Exam 4

Question 1

Which area of the cerebrum is likely to be affected in a patient with loss of voluntary motor function following a head injury?

Answer 1

Frontal lobes

Question 2

Which communication method would be implemented by the nurse when communicating with a patient who has expressive aphasia?

Answer 2

Offer pictures or a communication board so the patient can point

Question 3

For a middle-aged adult patient needing surgical removal of an inflamed gallbladder, the nurse would anticipate the surgeon prescribing what screening tests?

Answer 3

ECG/EKG, & chest x-ray

Question 4

The nurse teaches perineal care to the caregiver of a female patient. The nurse instructs the caregiver to clean the vulva using the downward strokes with a clean washcloth. Which complication is the nurse trying to prevent by providing this instructions?

Answer 4

Urinary tract infections

Question 5

Which complication of dysphagia might the nurse observe in a 70-year-old patient admitted to the hospital post stroke who has right-sided hemiplegia and dysphagia?

Answer 5

Aspiration pneumonia

Question 6

An unlicensed assistive personnel (UAP) requests help transferring a patient a patient who is 125lbs (56.8kg) from the bed to a wheelchair. The patient is unable to assist. To maintain the safety of the patient and the caregivers, what response would the nurse make?

A. “As long as we use proper body mechanics, no one will get hurt.”
B. “The patient only weighs 125lbs. You don’t need my assistance.”
C. “We will work together and use the full-body sling lift.”
D. “The two of us can easily lift the patient.”

Answer 6

C. “ We will work together and use the full-body sling lift.”

Question 7

A patient is admitted to the hospital for a scheduled cataract surgery. While assessing the patient, the nurse realizes that the patient has a progressive hearing disorder. Which condition would the nurse document in the electronic health record?

Answer 7

Presbycusis

Question 8

Which common postoperative complication is likely to occur among patients who are obese?

Answer 8

Pneumonia, infection, & hypoxemia

Question 9

What parameter is being assessed when a nurse is performing a Mini-mental state examination (MMSE) on an alcoholic patient?

Answer 9

orientation and cognitive function

Question 10

What instruction would the nurse give a patient who has reduced taste sensation and is finding food less appealing?

Answer 10

“Avoid blending or mixing foods.”

Question 11

What symptom is in the effect of taste bud atrophy in older adults?

Answer 11

Difficulty differentiating flavors

Question 12

What technique would help to restore a sense of time, place, and person for an older adult after an acute hospitalization?

Answer 12

Reality orientation

Question 13

A patient on extended bed rest is unable to dorsiflex the feet. What condition would the nurse associate with this finding?

Answer 13

Footdrop

Question 14

What action would the nurse avoid when assisting an older adult with dysphagia to eat?

Answer 14

Giving large bites to stimulate swallow reflex

Question 15

What type of exercise is walking?

Answer 15

isotonic

Isotonic refers to active movement w/ constant muscle contraction

Question 16

For a child with cerebral palsy, which assessment finding would the nurse expect to observe?

Answer 16

Spasticity

—a condition in which there is an abnormal increase in muscle tone or stiffness of muscle, which might interfere with movement, speech, or be associated with discomfort or pain.

Question 17

What findings are characteristics of stage III surgical anesthesia?

Answer 17

Depressed reflexes, regular breathing, and relaxed skeletal muscles

Question 18

For a patient recovering from hip surgery, what device would the nurse use to reduce the risk of external hip rotation?

Answer 18

Trochanter roll

Question 19

What objective datum is a sign of good nutrition in a patient?

Answer 19

Pink gingiva in mouth

Question 20

What postoperative risk would be increased among older adult patients?

Answer 20

Hemorrhage, increased systolic BP, increased diastolic BP

Question 21

Which condition is MOST commonly associated with damage to the lower spinal cord?

Answer 21

paraplegia

Question 22

Which action by the nurse will provide relief to the caregiver of a patient with cognitive alterations and in the terminal stages of cancer after learning that the patients caregiver is extremely stressed and has not been able to take time for a personal life?

Answer 22

Helping the caregiver set a regular time for respite

Question 23

Which part of the body would the nurse examine when assessing a patient’s peripheral vascular system?

Answer 23

Fingernails

Question 24

What assessment strategy performed by the nurse helps determine the spatial perception of the patient?

Answer 24

Having the patient draw the face of a clock

Question 25

What risk is a patient with peripheral neuropathy likely to encounter?

Answer 25

Pt may be vulnerable to injury

Peripheral neuropathy—happens when the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged

Question 26

A patient presents with itching and a reddened scalp from head lice. What precautions would the nurse take to prevent the spread of lice?

Answer 26

Contact

Question 27

What device assists in preventing venous stasis in the lower extremities of a patient on bed rest?

Answer 27

Antiembolism hose

Question 28

What patient condition is the nurse trying to prevent by providing a thickened liquid diet while caring for a geriatric patient with dysphagia?

Answer 28

Aspiration

Question 29

What symptoms does the nurse expect in a patient under the influence of cocaine?

Answer 29

Impulsive behavior, increased heart rate, impaired coordination

Question 30

What condition would the nurse associate with myopia?

Answer 30

Ability to see only a short distance

—nearsightedness.

Question 31

What first line medication does the nurse anticipate administering to a postop patient who has a productive cough, chest pain, dyspnea, fever, and adventitious breath sounds?

Answer 31

Antibiotic

Fever=more than likely infection

Question 32

the nurse is caring for a 78-year-old patient who is terminally ill and needs end-of-life care. Which type of care would alleviate pain and other symptoms?

Answer 32

Hospice care

Question 33

What type of diet decreases risk for cancer and cardiovascular diseases?

Answer 33

Mediterranean diet

Question 34

Use of energy to change simple materials into complex body substances and tissue; promotes cell growth

Answer 34

Anabolism-metabolism

Question 35

Serve as fat storage molecules

Answer 35

Glycerides