NUR 115- Evolve Questions- Exam 7

A patient has experienced the recent death of a spouse. During a conversation with a nurse, the patient begins to cry. An appropriate response from the nurse is to

hand a tissue to the patient.

Who identified the five stages of the dying process?

Kübler-Ross

Which statement is true regarding pain control in the dying patient?

The goal is to allow a pain-free death.

Which clinical sign or symptom is common in a dying patient being medicated with an opiate?

Constipation

A patient is approaching death and is growing physically weaker. What should the nurse expect?

Respirations sounding moist.

A report to a coroner would be required in which situation?

A death due to a stroke that occurred 12 hours after admission to a hospital

When the parents of a child who is on life support ask what indicates brain death, the nurse responds that brain death occurs when

there is an absence of EEG waves

The nurse caring for a terminally ill patient with renal failure would question an order for pain control that prescribed

meperidine.

Which is considered to be a violation of the American Nurses Association’s (ANA’s) Code for Nurses? (Select all that apply.)

• Active euthanasia

• Assisted suicide

Which are grief indications? (Select all that apply.)

• Denial

• Anger

• Acceptance

• Depression

Which is a function of the respiratory system?

Oxygen diffuses across the alveolar membrane into the blood.

What is the function of the diaphragm?

Relaxation of the diaphragm causes air to move out of the lungs.

The most common cause of respiratory insufficiency is

obstruction.

What is the most common cause of airway obstruction in the unconscious person?

Tongue

A patient with chronic lung disease requires continuous oxygen per nasal cannula at home and reports significant dryness of the nose and mouth. Which is most appropriate?

Humidifier

An older asult has had an acute stroke and is unable to ventilate on their own. Which airway is recommended?

Endotracheal

A nurse is nasopharyngeal suctioning an adult patient to remove thick secretions. The nurse will

use a 14-Fr catheter.

A nurse is teaching a post-surgical cardiac patient about interventions to prevent respiratory problems. The nurse should include

use of an incentive spirometer can prevent or relieve atelectasis.

When assessing the lungs of a patient, the nurse assesses a musical sound on inspiration. This finding is documented as

stridor.

Which organs are most susceptible to slight changes in oxygenation? (Select all that apply.)

• Brain

• Retina

• Heart

Which age-related change in the urinary system should a nurse expect?

Reduced rate of renal filtration

A nurse should notify the primary care provider if the 24 hour urine output is

650 mL.

Which bacterium is most often responsible for cystitis?

Escherichia coli

A nurse is collecting a voided specimen for urinalysis. When giving the patient the speciment cup, the nurse should

tell the patient that only about 1.5 inches of urine is needed.

A female patient has had a knee replacement and is experiencing difficulty voiding. What should the nurse recommend?

Pour warm water over the perineum while patient attempts to void.

Catheterization is an appropriate intervention in which situation?

Dilation of urethral stricture

When intermittently catheterizing an older adult biological female patient, the nurse may

position the patient on their side.

A nurse is educating a group of older adult patients in an assisted-living facility about urinary incontinence. Information offered during the encounter may include

condom catheters may be used by males.

A patient is being assessed for a possible urinary tract infection in the outpatient clinic. Before sending a urinalysis specimen to the laboratory, the nurse collects a small amount of urine to perform a dipstick test in order to detect

leukocytes.

What are the functions of the urinary structures for elimination? (Select all that apply.)

• Urine output is related to the amount of fluid intake.

• Waste products are diluted with water and excreted as urine.

• Bladder signals need to urinate

What is the function of the small intestine?

Processes chyme into a liquid state

What initiates peristalsis?

Gastrocolic reflex

The nurse reports that the patient’s stools are black and tarry. The nurse should document the stool as

melena.

An older adult patient reports having a poor diet and chronic constipation. The best recommendation from the nurse would be

fiber supplement daily.

Fecal incontinence may be caused by what illness?

Stroke

A nurse notes that a patient has not had a stool for 2 days. The initial action of the nurse should be to

ask about the patient’s normal bowel pattern.

What information should be included in the nursing care plan of a patient with constipation?

Consume 1 to 3 tablespoons of bran mixed with applesauce

Interventions for a patient with diarrhea include

clear liquid diet.

Which of the following medical conditions may require an ostomy? (Select all that apply.)

• Colon cancer

• Ulcerative colitis

• Congenital bowel malformation

The patient with the new colostomy is concerned about how to control diarrhea of the effluent. The nurse suggests that diarrhea can be controlled by the intake of (Select all that apply”

• cheese.

• creamy peanut butter.

What is now assessed along with vital signs?

Pain

The gate control theory concludes that pain transmission is controlled by a gate mechanism in the

central nervous system (CNS).

A patient with diabetes presents to the clinic with a 1 month history of tingling, altered sensation, and pain in the distal lower extremities. This type of pain is

neuropathic pain.

The third phase of nociceptive pain is

perception.

Which clinical finding may be assessed in a patient with pain?

Nausea

An elderly, confused, post-surgical patient is moaning and crying and is restless. The patient may be experiencing

pain.

A patient with chronic back pain is prescribed a transcutaneous electrical nerve stimulation (TENS) unit for pain management. Which statement is true regarding the TENS unit?

The patient can control the intensity and interval of the current.

A patient with apnea has a visible respiratory effort and then arouses briefly to draw a breath before falling back asleep. The patient’s primary care provider has recommended a continuous positive airway pressure (CPAP) device. The patient has which type of apnea?

Obstructive

A nurse preparing a young adult patient for home care following cancer treatment is discussing the use of the fentanyl patch. Which of the following would be the most important instruction regarding safety?

Store fentanyl patches in a locked cabinet.

Noninvasive methods implemented for pain management include (Select all that apply.)

• music therapy.

• biofeedback.

• hypnosis.

• Transcutanwous electrical nerve stimulation (TENS)