Test 1 Flashcards
Which of the following nursing actions would be most appropriate for a patient who is receiving diuretic therapy for cardiac failure?
a. monitor for hypotension
b. monitor for edema reduction in lower legs
c. have the patient sit straight up
d. ensure the patient is receiving IV fluid replacement
Monitor for hypotension
The patient has returned from surgery after a total parathyroidectomy, the nurse should assess for which of the following complications after surgery
a. post nasal drip
b. tetany
c. tremors in the arms and legs
d. watery eyes
tetany
which of the following statements is true of the pathophysiology of HIV?
a. the virus does not change human DNA
b. HIV can be cured
c. HIV requires a host cell, such as CD4+ to reproduce
d. it is contagious through physical touching of the skin
The DNA of HIV requires a host cell, such as CD4+, to reproduce
A cardiac catheterization is ordered most commonly for which purpose ?
a. unclogs blocked arteries
b. for PICC line insertion
c. the assessment of coronary artery patency
d. to assess arterial blood pressure
the assess coronary artery patency
a patient comes to the health clinic complaining of tremors and hyperexcitability. The nurse observes the patient has exophthalmos. The patient is exhibiting signs and symptoms of which of the following?
a. hypothyroidism
b. hyperthyroidism
c. Cushing’s syndrome
d. Addison’s disease
Hyperthyroidism
a nurse is attending an immunology conference. after learning about the function of the immune system, the nurse knows that B cells are responsible for?
a. DNA replication
b. production of antibodies
c. production of memory cells
d. replication of T-cells
production of antibodies
assessment of a patient who has experienced massive emesis during the last 24 hours indicated that he may be in the compensatory stage of shock. How should the nurse position the patient?
a. trendelenburg
b. supine
c. lateral recumbent
d. semi fowlers
Later recumbent (Sim’s)
patients started on thyroid replacement therapy are watched for which of the following?
a. increase of the effect of anticoagulant
b. retraction of bulging eyes
c. mouth tremors
d. decreased effect of levothyroxine
increase of the effect of anticoagulant
a patient is diagnosed with Grave’s disease. the nurse is aware that the patient may have which of the following physical characteristics?
a. swelling of the eyes
b. bulging eyes
c. hyper extension of the hands
d. dry lips
bulging eyes
a nurse is explaining to a patient the common features of leukemia, which is…
a. high platelet counts
b. decrease in production of RBC
c. decrease in production of WBC
d. unregulated proliferation of macrophages
decrease in production of white blood cells/
unregulated proliferation of white blood cells
which of the following assessment findings would the nurse consider to be most indicative of right sided heart failure?
a. a patient experiencing recent weight gain and complains of swollen ankles
b. increase headaches and dizziness
c. numbness and tingling to the left arm
d. stomach ache
a patient experiencing recent weight gain and complains of swollen ankles
when performing an assessment on a patient who is admitted with unstable angina, the nurse notes that the patient’s nail beds and lips have a bluish tinge. The nurse would chart this as?
a. raynodes disease
b. peripheral cyanosis
c. systemic cyanosis
d. decreased O2 demands
peripheral cyanosis
which of the following should be the nurses priority nursing diagnosis in the care for a patient with acute leukemia ?
a. increased risk for fatigue
b. risk for falls
c. risk for bleeding and infection
d. increased need for nutrients
Risk for bleeding and infection
the nurse notes that there are changes in the ECG of a patient who experienced an MI. A change that may indicate that ischemia is occurring is?
a. prolonged Q wave
b. shortened S valleys
c. T-wave inversion
d. R-S peak inversion
T-wave inversion
what causes hypovolemic shock ?
a. increased fluid buildup in the peritoneal cavity
b. decrease in blood flow through the heart
c. fluid circulating in the blood stream decreases
d. fluid in the veins is stagnant
fluid circulating in the blood stream decreases
a nurse is assessing a patient for symptoms of neurogenic shock after a spinal cord injury. what should the nurse be monitoring the patient for?
a. bladder spasms
b. bradycardia
c. tachycardia
d. hypotension
bradycardia
which of the following may develop in the patient when ketone bodies accumulate in excessive amounts?
a. acidosis
b. alkosis
c. urinary retention
d. ketoneacidosis
acidosis
which of the following patients would be characterized as experiencing a diagnosis other than circulatory shock?
a. a 56-year old type 1 diabetic who is experiencing insulin shock
b. a 33-year-old with chest pain
c. a 12-year-old with leg twitches
d. a 88-year old with Cushing’s syndrome experiencing pain behind the eyes
a 56-year old type 1 diabetic who is experiencing insulin shock
which of the following statements is true about viral load testing?
a. CD4 counts are indicators that viral load testing should be done
b. viral load testing is a better predictor of the risk of HIV progression than the CD4 count
c. viral load testing indicates that length of time before AIDS begins
d. CD4 counts are the only way to test for HIV, not viral load testing
Viral load testing is a better predictors of the risk of HIV progression than the CD4 count
a patient is diagnosed with thrombocytopenia. the nurse should explain to the pt that which of the following phenomena could have caused this condition?
a. decreased production of platelets
b. antiplatelet aggregation
c. increased flow of RBC
d. decreased presence of WBC in the blood stream
decreased production of platelets
the nurse is providing care for a patient who is on airborne precautions. the pt asks the nurse to leave his door open. how should the nurse best reply?
“i must keep your door shut at all times. I’ll open the curtains so that you don’t fell so closed in”
when discussing angina pectoris secondary to atherosclerotic disease with a pt they ask why they experience chest pain with exertion. the nurse informs the patient that exertion has which of the following effects?
increases in the hearts oxygen
which of the following actions should the nurse recommend to a diabetic patient to prevent hypoglycemia?
always carry a form of fast-acting sugar
which of the following assessment findings indicate right-sided cardiac failure?
distended neck veins
for a patient in irreversible shock, the nurse should encourage the patient’s family to do which of the following?
see, touch, and talk to the patient
a patient with autoimmune hemolytic anemia is not responding to conservative treatments. His condition is now becoming life-threatening. The nurse is aware that a treatment option in this case may included which of the following?
splenectomy
which of the following characteristics is associated with type 1 diabetes mellitus?
it is an inherited disease
the nurse is doing his morning rounds and finds a 54-year-old male client in respiratory distress. the nurse notes large quantities of frothy blood-tinged sputum, indicating which of the following?
severe pulmonary edema
a patients CBC has revealed the presence of myelodysplastic syndrome (MDS), a health problem of which both the care team and the patient were previously unaware. the nurse who is providing care for the patient should prioritize which of the following teaching points?
infection risk and strategies for avoiding infection
a 66-year-old male patient presents to the emergency department with complaints of midsternal chest pain that has lasted for the last 5 hours. the nurse is aware that because of the length of time the patient has been experiencing symptoms, if they are caused by an MI, the myocardium …
may have developed an increased area of infarction
a patient is receiving an initial dose of penicillin IV. during the infusion the patient becomes short of breath. what is the first thing the nurse should do?
stop the infusion of the medication
paramedics have reported their imminent arrival to the emergency department with a 61-year-old patient who is displaying signs and symptoms of an MI. what aspect of the patients problem is likely to contribute to cardiogenic shock?
destruction of the left ventricular myocardium that results in impaired circulation
a nurse in the emergency department has just initiated an insulin infusion that has been ordered for a patient who is displaying the s&s of diabetic ketoacidosis. the nurse would recognize that which of the following pathophysiologic phenomena underlies the patients diagnosis?
an increase in the patients breakdown of fat for energy
medical management of a patient with acute myeloid leukemia (AML) includes which of the following?
aggressive chemotherapy treatment
a nurse is caring for a patient who is being discharged after treatment for acute leukemia. To manage mucositis and painful mucous membranes, the nurse should instruct the patient to eat which of the following foods?
soft-textured foods, such as meat loaf
the nurse is assessing a client with possible Cushing’s syndrome, the nurse would expect to find?
deposits of adipose tissue in the trunk and dorsocervical area
which of the following criteria would indicate that a patient has AIDS (CDC category 3)?
the patient displays opportunistic infections associated with HIV infections
15 minutes after infusion of packed RBCs has begun, the patient complains of difficulty breathing and chest tightness. what is the most appropriate action for the nurse to first take?
to discontinue the transfusion immediately
a nurse is caring for a client with AIDS, while providing morning care, the nurse notices that the client has several skin lesions on the face and upper body. the nurse knows that the client has which of the following skin conditions common to patients?
Kaposi’s sarcoma
which of the following statements best captures the essence of shock?
cells lack an adequate blood supply and are deprived of oxygen and nutrients
an adult patient has had symptoms of unstable angina during admission to the hospital. What is the most appropriate nursing diagnosis for the discomfort associated with angina?
ineffective cardiac tissue perfusion secondary to CAD, as evidence by chest pain
when being discharged home, the nurse should instruct a patient with HF to monitor his or her fluid balance by?
monitoring daily weight
a patient is diagnosed as having an elevated cholesterol level. the nurse is aware that plaque on the inner lumen of arteries is composed chiefly of?
lipids and fibrous tissue
geriatric patients with diabetes are at an increased risk for poorly managing their diabetes, owing to which of the following reasons?
their appetite decreased and they have poor dentition
in type 2 DM, the patient demonstrates which of the following characteristics?
usually obesity at diagnosis
when discussing the patient’s elevated LDL and lowered HDL levels, the patient shows understanding of these levels by the statement?
Increased LDL and decreased HDL increase my risk of CAD
which of the following complications of DM is termed “macro vascular”?
CVA
a male patient with DM informs the nurse he is feeling nervous and hungry. the nurse further assess the patient and finds he is tachycardia and diaphoretic. the nurse should administer which of the following?
fruit juice
in addition to pain control, what is the rationale for administering morphine for cardiogenic shock?
it dilates the blood vessels
a patient is experiencing cardiogenic shock secondary to hypervolemia. the nurse should expect which of the following treatments to be ordered?
diuretics
the patient has returned after a thyroidectomy. how should the patient be positioned to promote comfort?
semi-fowlers with the head supported by 2 pillows
which of the following guidelines apply to periods of illness (sick day rules), in a diabetic patient?
do not eliminate insulin when nauseated and/or vomiting
the nurse is preparing to administer a unit of blood to a patient who is anemic. What is the… (cant remember the rest of the question but the answer is…)
4 hours
a 49-year-old client is diagnosed with hypercholesterolemia. the client is obese. the nurse needs to determine whether the client has other major risk factors for coronary artery disease (CAD). which factor would indicate the most increased risk for CAD>
a history of alcoholism
a patient is in the compensatory stage of shock. what is an early sign that accompanies this stage of shock?
cool, clammy skin
which of the following clinical syndromes of HIV is characterized by a progressive decline in cognitive behaviour and motor functions?
HIV encephalopathy
a patient with iron deficiency anemia states that he has minimal energy and finds it difficult to manage the household and work. what is the most appropriate intervention for the nurse to take to help the patient manage his fatigue?
to assist the patient to prioritize activities and establish an activity rest schedule
the nurse is working in a support group for patients with acquired immunodeficiency syndrome (AIDS). which point is the most important for the nurse to stress?
follow safer sex practices
a patient with thyroid cancer undergoes a thyroidectomy. after surgery the patient develops peripheral numbness and tingling and muscle twitching and spasms. the nurse should expect to administer what?
intravenous calcium gluconate
a 48-year old with longstanding dx of HIV has been admitted to hospital because of a recent exacerbation of his symptoms. which of the following S&S is typical of gastrointestinal manifestations of HIV
anorexia and diarrhea
a clinical nurse educator is orienting recent nursing graduates to the subacute geriatric unit of the hospital. which of the following teaching points regarding hypothyroidism in older adults should the educator emphasize to the new nurses?
older adults tend not to exhibit symptoms of hypothyroidism so they rely heavily on blood tests
the nurse is administering SL nitroglycerin to a patient immediately, what should the nurse assess for ?
throbbing headache and dizziness.
