Exam 3 Medsurge Questions

Question 1

Violence, Physical Abuse, and Neglect

Answer 1

*

Question 2

61. The female client presents to the emergency department with facial lacerations and
    contusions. The spouse will not leave the room during the assessment interview.
    Which intervention should be the nurse’s first action?
62. Call the security guard to escort the spouse away.
63. Discuss the injuries while the spouse is in the room.
64. Tell the spouse that the police will want to talk to him.
65. Escort the client to the bathroom for a urine specimen.

Answer 2

4

By escorting the client to a bathroom for
any reason, the nurse can get the client to a
safe area out of the hearing of the spouse.
This is the most innocuous way to get the
client alone.

Question 3

62. The elderly male client is admitted to the medical unit with a diagnosis of senile dementia. The client is 74 inches tall and weighs 54.5 kg. The client lives with his son and daughter-in-law, both of whom work outside the house. Which referral would be the most important for the nurse to implement?
63. Adult Protective Services.
64. Social worker.
65. Medicare ombudsman.
66. Dietitian.

Answer 3

2

1. Adult protective services should be called only
   if it is determined that willful neglect or abuse
   of the client is occurring.
2. The nurse should arrange for the social
   worker to see the client and family to determine
   if some arrangements could be made
   to provide for the client’s safety and for the
   client to be provided with nutritious meals
   while the adult children are at work. A
   long-term care facility or adult day care
   may be needed.
3. The Medicare ombudsman is a person who
   represents a Medicare client in a long-term
   care facility.
4. The dietitian could see this client to determine
   eating preferences (74 inches ! 6 foot 2 inches
   and 54.5 kg ! 120 pounds), but the most
   appropriate is safety.

Question 4

63. The nurse working in a homeless shelter identifies an adolescent female that is sexually aggressive toward some of the males in the shelter. Which is the most common cause for this behavior?
64. The client is acting in a learned behavior pattern to get attention.
65. The client had to leave home because of promiscuous behavior.
66. The client has a psychiatric disorder called nymphomania.
67. The client is a prostitute and is trying to get customers.

Answer 4

1

1. Research suggests that at least 67% of
   adolescents who are runaways or homeless
   have been abused in the home. This represents
   a learned behavior pattern that gets
   the female adolescent attention.
2. One reason adolescents of both sexes run away
   from home is abuse in the home. Nothing in
   the stem indicates that the client was turned
   out of the home for any behavior.
3. This has the nurse medically diagnosing the
   client.
4. This is a judgmental statement.

Question 5

64. The adolescent female comes to the school nurse of an intermediate school and tells the nurse she thinks she is pregnant. During the interview the client states that her
    father is the baby’s father. Which should the nurse do first?
65. Complete a rape kit.
66. Notify Child Protective Services
67. Call the parents to come to the school.
68. Arrange for the client to go to a free clinic.

Answer 5

2

1. The school nurse is not a Sexual Assault Nurse
   Examiner (SANE) nurse, and this child thinks
   she is pregnant, suggesting that the abuse has
   been occurring for a period of time or at least
   in some months past. The child should be
   taken for examination to a hospital.
2. Child Protective Services should be notified
   to protect the child from further abuse and
   to initiate charges against the father. An
   intermediate school nurse would be caring
   for children in the 4th, 5th, 6th, or 7th
   grades, depending on the school district.
3. This would bring the abuser to the school.
4. Sending the child to a free clinic would not
   negate the nurse’s responsibility to report
   suspected child abuse.

Question 6

65. The nurse in an outpatient rehabilitation facility is working with convicted child abusers. Which characteristics would the nurse expect to observe in the abusers? Select all that apply.
66. Calls the child a liar.
67. Has a tendency toward violence.
68. Exhibits a high self-esteem.
69. Is unable to admit the need for help.
70. Was spoiled as a child.

Answer 6

1, 2, 4

1. Frequently child abusers will deny the
   child’s reports of abuse and say that the
   child is a habitual liar.
2. Child abusers believe that violence is an
   acceptable way to reduce tension. They
   tend to have a low tolerance for frustration
   and have poor impulse control.
3. Child abusers have a tendency toward feelings
   of helplessness and hopelessness.
4. Child abusers tend to blame the child for
   the abuse and not admit that the problem is
   their own.
5. The child abuser may have been abused as a
   child, but there is no evidence of the child
   abuser being spoiled as a child.

Question 7

66. The nurse is teaching a class about rape prevention to a group of women at a community
    center. Which information is not a myth about rape?
67. Women who are raped asked for it by dressing provocatively.
68. If a woman says no, it is a come on and she really does not mean it.
69. Rape is an attempt to exert power and control over the client.
70. All victims of sexual assault are women; men can’t be raped.

Answer 7

3

1. This is a myth that has been believed by some
   people. Many individuals are raped ranging in
   age from infants to the 90s, male and female,
   heterosexuals and homosexuals. No one asks to
   be raped.
2. If a person says they are not interested in any
   type of sexual activity it means no and anything
   else is forced and it is rape. No means no. It is
   considered rape if a prostitute says no.
3. Rape is an act of violence motivated by the
   rapist’s desiring to overpower and control
   the victim.
4. Men and children can be victims of rape. Sexual
   arousal and orgasm do not imply consent; it
   may be a pathological response to stimulation.

Question 8

67. The nurse working in the emergency department is admitting a 34-year-old female client for one of multiple admissions for spousal abuse. The client has refused to leave her husband or to press charges against him. Which action should the nurse implement?
68. Insist that the woman press charges this time.
69. Treat the wounds and do nothing else.
70. Tell the woman that her husband could kill her.
71. Give the woman the number of a woman’s shelter.

Answer 8

4

1. The nurse can encourage the client to press
   charges but has no right to insist.
2. The nurse should treat the wound and may
   find it frustrating that the client will not press
   charges, but the nurse is obligated to give the
   client information that will help the client to
   get to a safe place.
3. The woman is more aware of this fact than the
   nurse.
4. The nurse should help the client to devise
   a plan for safety by giving the client the
   number of a safe house or a woman’s shelter.

Question 9

68. The 84-year-old female client is admitted with multiple burn marks on the torso and under the breasts along with contusions in various stages of healing. When questioned by the nurse the woman denies any problems have occurred. The woman lives with her
    son and does the housework. Which is the most probable reason the woman denies being abused?
69. There has not been any abuse to report.
70. The client is ashamed to admit being abused.
71. The client has Alzheimer’s disease and can’t remember.
72. The client has engaged in consensual sex.

Answer 9

2

1. This client has signs of ongoing abuse:multiple
   burns and contusions in different stages of
   healing.
2. Many times the elderly are ashamed to
   report abuse because they raised the abuser
   and feel responsible that their child became
   an abuser. The elder parent may feel financially
   dependent on the child or be afraid of
   being placed in a long-term care facility.
   Forty-seven states have Adult Protective
   Services (APS) created by the states to
   protect elder citizens.
3. There is no evidence in the stem that the
   client is not mentally competent and there
   is evidence in the stem of physical abuse.
   This client is performing activities of daily
   living.
4. Consensual sex does not involve the physical
   abuse noted in the assessment.

Question 10

69. Which is an appropriate interview question for the nurse to use with clients involved
    in abuse?
70. “I know you are being abused. Can you tell me about it?”
71. “How much does your spouse drink before he hits you?”
72. “What did you do that caused your spouse to get mad?”
73. “Do you have a plan if your partner becomes abusive?”

Answer 10

1

1. Unless the nurse is being personally abused
   in the same manner the client is being abused
   and has seen the abuse taking place, the nurse
   cannot “know” the client is being abused.
2. Alcohol and drugs are implicated in the abuse
   of many clients, but not all abusers use alcohol
   or drugs.
3. This is agreeing with the abuser that the client
   caused the abuse.
4. This statement assesses the abused client’s
   safety (or a plan for safety).

Question 11

70. The client who was abused as a child is diagnosed with post-traumatic stress disorder (PTSD). Which intervention should the nurse implement when the client is resting?
71. Call the client’s name to awaken him or her, but don’t touch the client.
72. Touch the client gently to let him or her know you are in the room.
73. Enter the room as quietly as possible to not disturb the client.
74. Do not allow the client to be awakened at all when sleeping.

Answer 11

1

1. Clients diagnosed with PTSD are easily
   startled and can react violently if awakened
   from sleep by being touched.
2. Touching the client can cause the client to
   become afraid, to believe himself or herself to
   be under attack, and to react violently. The
   nurse should not touch a sleeping client diagnosed
   with PTSD.
3. If the client awakes with the nurse in the room,
   the client could become fearful and react to the
   fear.
4. There may be times when the nurse must
   awaken the client to determine if the client is
   physically stable.

Question 12

71. The emergency department nurse writes the problem of “ineffective coping” for a client who has been raped. Which intervention should the nurse implement?
72. Encourage the client to take the “morning after” pill.
73. Allow the client to admit guilt for causing the rape.
74. Provide a list of rape crisis counselors.
75. Discuss reporting the case to the police.

Answer 12

3

1. This plan for the client to take RU 486 or the
   morning-after pill prevents pregnancy from
   occurring, but it does not directly address
   coping skills.
2. The client may talk about “what if I had not
   done,” but the client is not guilty of causing
   the rape.
3. The client should be provided the phone
   number of a rape crisis counseling center
   or counselor to help the client deal with the
   psychological feelings of being raped.
4. This is a legal issue

Question 13

72. The nurse writes a nursing diagnosis of “risk for injury as a result of physical abuse by spouse” for a client. Which would be an appropriate goal for this client?
73. The client will learn not to trust anyone.
74. The client will admit the abuse is happening and get help.
75. The client will discuss the nurse’s suspicions with the spouse.
76. The client will choose to stay with the spouse.

Answer 13

2

1. The nurse should attempt to develop a relationship
   in which the client feels that he or she
   can trust the nurse (males are abused by significant
   others too).
2. The first step in helping a client who has
   been abused is to get the client to admit
   that the abuse is happening.
3. This could cause the abuse to escalate.
4. This is what the nurse is trying to get the client
   to avoid.

Question 14

Urinary Incontinence (Genitourinary disorders) Comprehensive Examination

Answer 14

*

Question 15

1. The elderly client being seen in the clinic has complaints of urinary frequency, urgency,
   and “leaking.” Which intervention should the nurse implement?
2. Ensure communication is nonjudgmental and respectful.
3. Set the temperature for comfort in the examination room.
4. Speak loudly to ensure the client understands the nurse.
5. Discuss incontinence problems with female clients only.

Answer 15

1

1. Clients who have urinary incontinence are
   hesitant to discuss this problem because
   they may be embarrassed. Many clients will
   try to hide this condition from others, so it
   is the responsibility of the nurse to approach
   this subject with respect and consideration.
2. The temperature of the room is not pertinent
   to the client’s physical examination.
3. The nurse should not assume that elderly
   clients have hearing difficulty. If the client is
   “hard of hearing,” the nurse should speak
   clearly and concisely but should not shout.
4. Incontinence is experienced by both sexes and
   by all ages. All adult clients may experience this
   and should be questioned at least initially.

Question 16

2. The client is experiencing urinary incontinence. Which intervention should the nurse
   implement?
3. Teach the client to drink prune juice weekly.
4. Encourage the client to eat a high-fiber diet.
5. Discuss the need to urinate every six (6) hours.
6. Administer diuretics at 2100 every day.

Answer 16

2

1. Prune juice is given to prevent constipation but
   should be taken daily, not weekly.
2. Clients experiencing incontinence should
   eat a high-fiber diet to avoid constipation.
3. Bladder training is used to assist with urinary incontinence by voiding every two (2) to three (3) hours, not every six (6) hours.
4. Diuretics should be taken in the morning to allow for rest during the night.

Question 17

3. Which information would indicate to the nurse that teaching about treatment of urinary incontinence has been effective?
4. The client prepares a scheduled voiding plan.
5. The client verbalizes the need to increase fluid intake.
6. The client explains how to perform pelvic floor exercises.
7. The client attempts to retain the vaginal cone in place the entire day.

Answer 17

1

1. There are several plans for training the
   bladder to decrease frequency and incontinence.
   One plan is to schedule each voiding
   two (2) to three (3) hours apart, and when
   the client has remained consistently dry,
   the interval is increased by about 15
   minutes.
2. Managing the fluid intake is an important part
   of assisting the client with incontinence. The
   daily fluid intake is usually limited to 1500 mL,
   the majority of which should be drunk early in
   the day to prevent nocturia.
3. Pelvic floor exercises (Kegel) should be performed
   two (2) to three (3) times daily with
   repetitions of 10 to 30 each session, but this is
   recommended for stress incontinence, not urinary
   incontinence.
4. A series of vaginal weights can be used to
   increase the muscle tone. The time is usually
   only 15 minutes, not all day.

Question 18

4. Which intervention should the nurse implement first for the client diagnosed with urinary incontinence?
5. Palpate the bladder after an incontinent episode to assess for urinary retention.
6. Administer oxybutynin, an anticholinergic agent, to decrease bladder contractions.
7. Prepare the client for surgical intervention to repair the problem.
8. Administer a cognitive function examination to determine abilities to function.

Answer 18

1

1. The nurse should assess first to determine
   the etiology of the incontinence before the
   treatment plan can be formulated. By palpating the bladder after voiding, the nurse can determine if the incontinence was the result of overdistention of the bladder.

Question 19

5. The client recovering from a prostatectomy has been experiencing stress incontinence. Which independent nursing intervention should the nurse discuss with the client?
6. Establish a set voiding frequency of every two (2) hours while awake.
7. Encourage a family member to check every two (2) hours and assist the client to void.
8. Apply a transurethral electrical stimulator to relieve symptoms of urinary urgency.
9. Discuss the use of a “bladder drill,” including a timed voiding schedule.

Answer 19

4

1. Timed voiding is more helpful with neurogenic
   disorders, such as those related to diabetes.
2. A prompted voiding is useful with a client who
   does not have the cognitive ability to recognize
   the need.
3. The use of transvaginal or transurethral electrical
   stimulation to stimulate the pelvic floor
   muscles to contract is a collaborative intervention.
4. Use of the bladder training drill is helpful
   in stress incontinence. The client is
   instructed to void at scheduled intervals.
   After consistently being dry, the interval is
   increased by 15 minutes until the client
   reaches an acceptable interval.

Question 20

6. The nurse is preparing the plan of care for the client diagnosed with a neurogenic flaccid bladder. Which expected outcome would be appropriate for this client?
7. The client has conscious control over bladder activity.
8. The client’s bladder does not become overdistended.
9. The client has bladder sensation and no discomfort.
10. The client is able to check for bladder location in relation to the umbilicus.

Answer 20

2

1. In the flaccid neurogenic bladder, the client has lost the ability to recognize the need to void; therefore, this is not a realistic expected
   outcome.
2. The treatment goal of the flaccid bladder
   would be to prevent overdistention.
3. The sensation has been lost as a result of a lower motor neuron problem; therefore, there is no sensation to maintain and no discomfort, so this is not a realistic goal.
4. The client does not have to assess the bladder; this is a nursing intervention.

Question 21

7. Which intervention would be the most important before attempting to catheterize a client?
8. Determine the client’s history of catheter use.
9. Evaluate the level of anxiety of the client.
10. Verify that the client is not allergic to latex.
11. Assess the client’s sensation level and ability to void.

Answer 21

3

1. To determine if the client has had a catheter in
   place previously would assist with teaching and
   alleviating anxiety, but it is not the most
   important intervention.
2. Assessing the level of anxiety would be helpful
   in assisting the client, but it would not endanger
   the client; therefore it is not the most important
   intervention.
3. The nurse should always assess for allergies for latex prior to inserting a latex
   catheter or using a drainage system because if the client is allergic to latex, use of it could cause a life-threatening reaction.
   This is the most important intervention.
4. There are many reasons that the client would
   be catheterized regardless of the sensation and
   ability to void. The nurse would not need to
   assess this until the catheter is removed.

Question 22

8. Which client should not be assigned to an unlicensed nursing assistant (NA) working on a surgical floor?
9. The client with a suprapubic catheter inserted yesterday.
10. The client who has had an indwelling catheter for the past week.
11. The client who is on a bladder-training regimen.
12. The client who had a catheter removed this morning and is being discharged.

Answer 22

1

1. This client would require the most skill and knowledge because this client has the greatest potential for an infection; therefore the client should not be assigned to an NA.
2. The NA could care for a client with an indwelling Foley catheter because adherence to Standard Precautions is the only requirement
   for safe client care.
3. The NA cannot teach bladder training but can implement the strategies for the client on a
   bladder-training program.
4. The NA could care for this client because noting if the client voided after removal of the catheter is within the realm of the NA’s ability.

Question 23

9. The nurse is caring for an elderly client who has an indwelling catheter. Which data warrant further investigation?
10. The client’s temperature is 98.0!F.
11. The client has become confused and irritable.
12. The client’s urine is clear and light yellow.
13. The client has no discomfort or pain.

Answer 23

2

Question 24

10. The nurse is observing the unlicensed nursing assistant (NA) provide direct care to a client with a Foley catheter. Which data warrant immediate intervention by the nurse?
11. The NA secures the tubing to the client’s leg with tape.
12. The NA provides catheter care with the client’s bath.
13. The NA positions the collection bag on the client’s bed.
14. The NA cares for the catheter after washing the hands.

Answer 24

3

Question 25

14. The nurse is assessing a client diagnosed with urethral strictures. Which data support
    the diagnosis?
15. Complaints of frequency and urgency.
16. Clear yellow drainage from the urethra.
17. Complaints of burning during urination.
18. A diminished force and stream during voiding.

Answer 25

4

4. The client with urethral strictures will report a decrease in force and stream during voiding. The stricture is treated by dilation using small filiform bougies.

Question 26

16. Which intervention should the nurse include when assessing the client for urinary retention? Select all that apply.
17. Inquire if the client has the sensation of fullness.
18. Percuss the suprapubic region for a dull sound.
19. Scan the bladder with the ultrasound scanner.
20. Palpate from the umbilicus to the suprapubic area.
21. Insert an indwelling catheter in the bladder.

Answer 26

1, 2, 3, 4,

1. The nurse needs to assess the client’s sensation
   of needing to void or feeling of fullness.
2. A dull sound heard when percussing the bladder indicates it is filled with urine.
3. A portable bladder scan is used to assess for the presence of urine, rather than using a straight catheter.
4. A distended bladder can be palpated.
5. Inserting a straight catheter or an in-and-out
   catheter is used to assess for residual urine, but
   not an indwelling catheter.

Question 27

17. The nurse has been assigned to train the unlicensed nursing assistant about prioritizing
    care. Which client should the nurse instruct the unlicensed nursing assistant to see first?
18. The client who needs both sequential compression devices removed.
19. The elderly woman who needs assistance ambulating to the bathroom.
20. The surgical client who needs help changing the gown after bathing.
21. The male client who needs the intravenous fluid discontinued

Answer 27

2

1. The client who needs a sequential compression
   device removed is not urgent.
2. The elderly woman has age-related changes
   that can cause this request to be met as
   soon as possible. The elderly female client
   has a decreased bladder capacity, can be
   incontinent if not emptied frequently, has
   weakened urinary sphincter muscles, and
   has shortened urethras. The client is at risk
   for falling while attempting to get to the
   bathroom.
3. Changing a gown does not have a high priority.
4. The client will not be harmed if the intravenous
   fluid infuses for a short time, and this
   task should not be delegated to an NA.

Question 28

20. The nurse is preparing the plan of care for a client with fluid volume deficit. Which
    interventions should the nurse include in the plan of care? Select all that apply.
21. Monitor vital signs every two (2) hours until stable.
22. Measure the client’s oral intake and urinary output daily.
23. Administer mouth care every eight (8) hours.
24. Weigh the client in the same clothing at the same time daily.
25. Assess skin turgor and mucous membranes every shift.

Answer 28

1, 3, 4, 5

1. Vital signs should be monitored every two
   (2) hours until stable and more frequently
   if the client is unstable.
2. Intake and output should be monitored more
   frequently than every 24 hours. Depending on
   the client’s condition, frequency may vary from
   every hour to every four (4) hours.
3. Mouth care should be given as often as
   needed. A minimum of care should be every
   eight (8) hours.
4. The client should be weighed daily at the
   same time wearing the same clothing to
   ensure the reliability of this indicator.
5. Skin turgor and mucous membranes should
   be assessed every shift or more often depending
   on the client’s condition.

Question 29

21. Which outcome should the nurse identify for the client diagnosed with fluid volume
    excess?
22. The client will void a minimum of 30 mL per hour.
23. The client will have elastic skin turgor.
24. The client will have no adventitious breath sounds.
25. The client will have a serum creatinine of 1.4 mg/dL.

Answer 29

3

1. Voiding a minimum of 30 mL of urine each
   hour would be appropriate for a client with
   fluid volume deficit.
2. Elastic skin turgor would indicate that the
   client has adequate fluid volume status. This
   would be an expected output for the client with
   fluid volume deficit.
3. The client with fluid volume excess has too
   much fluid. Excess fluid would be reflected
   by adventitious breath sounds. Therefore
   an expected outcome would be to have no
   excess fluid, as evidenced by normal, clear
   breath sounds.
4. The creatinine would be elevated in a client
   who is dehydrated. The normal male should
   have a creatinine of 0.6–1.2 mg/dL, and a
   female client’s normal creatinine is between 0.5
   and 1.1 mg/dL.

Question 30

26. The client on the medical unit is exhibiting peaked T waves on the electrocardiogram.
    Which interventions should the nurse implement? List in order of priority.
27. Assess the client for leg and muscle cramps.
28. Check the serum potassium level.
29. Notify the health-care provider.
30. Arrange for a transfer to the telemetry floor.
31. Administer Kayexalate, a cation resin.

Answer 30

1, 2, 3, 5, 4

In order of priority: 1, 2, 3, 5, 4
1. The nurse should assess to determine if the
client is symptomatic of hyperkalemia.
2. A peaked T wave is indicative of hyperkalemia;
therefore, the nurse should obtain
a potassium level.
3. Hyperkalemia is a life-threatening situation
because of the risk of cardiac dysrhythmias;
therefore the nurse should notify the
health-care provider.
5. Kayexalate is a medication that will help
remove potassium through the gastrointestinal
system and should be administered
to decrease the potassium level.
4. The client should be monitored continuously
for cardiac dysrhythmias so a transfer
to the telemetry unit is warranted