Test 4 Flashcards
To evaluate your Activity tolerance nursing plan for Mrs Gonzales, at the end of 12 weeks an indication of its effectiveness would be that Mrs. Gonzales:
- Has lot 15 Pounds
- Has full range of motion to all joints without experiencing pain.
- Jogs 5 city blocks twice a week
- Participates in an exercise program at the YWCA 3 days a week.
- Participates in an exercise program at the YWCA 3 days a week.
- Dehiscence”
- Dehiscence
While caring for a 27-yr-old man on a mechanical ventilator, the ventilator alarms sound. On entering the patient’s room, the nurse notes that he is very agitated and his skin is ashen and diaphoretic. His pulse oximeter shows an oxygen saturation of 78%. The nurse is unable to identify any obvious problems with the ventilator. The first step the nurse should take is to:
1 Assess his breath sounds
2 Call the respiratory therapist to troubleshoot the probem
- manually ventilate him with an Ambu-bag
4 Contact the physician
- manually ventilate him with an Ambu-bag
The duration of sleep is regulated by the:
- Electrical impulses transmitted from the cerebral cortex to the cerebellum
- Person’s innate biorhythms
- Amount of sleep a person usually requires.
4 Reticular activating system
4 Reticular activating system
The head of the bed of a patient who is receiving enteral feedings is elevated to 30 degrees. Which complication associated with enteral feedings does this intervention help prevent?
- Aspiration
- Diarrhea
- Infection
- Electrolyte imbalane
- Aspiration
Which of the following goals is appropriate for a client without underlying cardiopulmonary disease who is being monitored with continuous pulse oximetry?
- Patient will refrain from movement while monitored in order to ensure accurate readings.
2 oxygen saturation will remain at 80%-90% during hospitalization
3 Patient will report pain as less than 3 on a scale of 1-10 during monitoring
4 Oxygen saturation will remain at 95%-100% while monitored.
4 Oxygen saturation will remain at 95%-100% while monitored.
Respiratory function involves which four body systems?
1 Respiratory, neurological, endocrine, and cardiovascular
2 Respiratory, cardiovascular, neurological, and integumentary
3 Respiratory, cardiovascular, neurological, and musculoskeletal
4 respiratory, musculosckeletal, cardiovascular, and endocrine
3 Respiratory, cardiovascular, neurological, and musculoskeletal
The most appropriate nursing diagnosis for Mr Jerome, who developed a fistula, at this time would be:
- Risk for infection related to dehiscence of wound
2 Body Image Disturbance related to nonhealing surgical wound
3 Risk for impaired skin integrity related to wound drainage
4 Pain related to surgical incision.
3 Risk for impaired skin integrity related to wound drainage
Mrs Ray is a 50-yr-old woman who had a surgical repair of a fracture of her right tibia 2 days ago. She has been using crutches for ambulation and must remain non-weight bearing on her right leg, but must learn to use the steps leading into her house. The nurse should instruct Mrs Ray to:
1 Lay the crutches down and hop on the left leg when going up or down the stairs
2 Use the crutches, maintaining toe-touch weight-bearing on the right leg when going up or down the stairs
3 Have someone carry her up and down the stairs
4 Lead with the left leg when going up steps, and lean with the right leg when going down steps.
4 Lead with the left leg when going up steps, and lean with the right leg when going down steps.
The nurse is caring for a 14-yr-old boy with a history of asthma. He is currently being treated for acute bronchitis. A thorough nursing assessment of his pulmonary status will include (select all that apply)
- Skin color and temperature
2 Auscultation of breath sounds
3 Testing of cough reflex
4 Chest x-ray
- Skin color and temperature
2 Auscultation of breath sounds
To obtain the most accurate culture information of a chronic wound, the nurse would recommend:
1 Tissue biopsy
2 swab culture
3 sterile culture
4 Needle aspiration culture
1 Tissue biopsy
Mr Jerome had a colon resection 1 week ago. When assessing the abdominal incision, the nurse notes foul-smelling brown drainage seeping from the middle of the incision site. The nurse suspects Mr Jerome has:
1 An infected wound
2 Wound dehiscence
3 A hematoma
4 A fistula
4 A fistula
A 10-yr-old boy fell on the playground. He is complaining of pain in his right forearm. The nurse notes that the boy’s arm is swelling and tender to touch. There is an area of protrusion on the lateral aspect of his arm, which upon palpation is very firm. The nurse suspects a fracture; however, her suspicion cannot be confirmed until
- A venous and arterial Doppler are obtained
- The boy demonstrates that he cannot use his arm
3 The swelling is decreased by applying ice
4 An X-ray is obtained
4 An X-ray is obtained
What signs and symptoms might the nurse expect to see in a patient experiencing hypxia?
1 Altered level of consciousness
2 Peripheral pitting edema
3 Cyanosis of skin and mucous membranes
4 Weak or absent peripheral pulses
1 Altered level of consciousness
3 Cyanosis of skin and mucous membranes
4 Weak or absent peripheral pulses
4 Impaired skin integrity related to fecal drainage”
2 Disturbed body image related to colostomy
The nurse is assessing an ischial pressure ulcer on a client. She observes that the pressure ulcer is 3cm X 2cm X 1cm and involves only subcutaneous tissue. The nurse also notes an area extending 3 cm from 12 o’clock to 3 o’clock under the wound edges. The nurse would document this as:
1 State IV pressure ulcer with undermining of 3 cm from 12:00 to 3:00
- State III pressure ulcer with undermining of 3 cm from 12:00 to 3:00
- Stage IV pressure ulcer with sinus tract from 12:00 to 3:00
- Stage III pressure ulcer with sinus tract from 12:00 to 3:00
- State III pressure ulcer with undermining of 3 cm from 12:00 to 3:00
Depression, hyperthyroidism, hypothyroidism, pain, and sleep apnea are examples:
1 Disorders that are provoked by sleep
2 Parasomnias
3 Conditions that cause secondary sleep disorders
4 Disorders associated with narcolepsy
3 Conditions that cause secondary sleep disorders
4 Impaired Physical Mobility related to limited range of motion, secondary to obesity”
- Activity intolerance related to morbid obesity and dyspnea secondary to sedentary lifestyle.
Which of the following nursing interventions would be appropriate for Mrs Gonzales who has a diagnosis of activity intolerance? Encourge Mrs Gonzales to (select all that apply)
1 Participate in a scheduled exercise program
2 Participate in activities outside of the home
3 Increase her fluid intake
4 Increase the length of time between rest periods
1 Participate in a scheduled exercise program
2 Participate in activities outside of the home
4 Increase the length of time between rest periods
Langerhans cells are:
1 Protein-containing cells that give the skin strength and elasticity
2 Cells that provide protection from ultra light
3 Mobile and able to phagocytize foreign material
4 Located in the dermal layer of the skin
3 Mobile and able to phagocytize foreign material
Mr Cannes developed a wound 16 days ago. When performing a wound assessment, the nurse notes the formation of granulation tissue in the wound bed and recognizes that Mr Cannes is in this stage of wound healing
- Proliferative phase
- Maturation phase
- Aggregation phase
- Inflammatory phase
- Proliferative phase
Mr Vann has a 3.0 cm X 2.0 eschar on the right heel. The best treatment choice for this wound is:
1 Elevate the right heel off the bed
2 Request a surgical consult for debridement of the area
3 Apply a hydrocolloid to promote autolytic debridement of the wound
4 Request an order for an enzymatic debridement medication
1 Elevate the right heel off the bed
The nurse is planning goals for activity intolerant Mrs Gonzales. Which of the following NOC outcome(s) relate(s) directly to the above nursing diagnosis; that is, which outcome(s), if achieved, would demonstrate resolution of her problem? Select all that apply.
- Endurance
- Activity Tolerance
- Active Joint Movement
- Mobility Level
- Endurance
- Activity Tolerance
The nurse will know interventions were successful when Mrs Lore:
- Demonstrates the proper method of cleansing her skin
- Demonstrates proficiency when providing treatment to excoriated skin
- States she will start caring for the colostomy after she gets home
- Proficiently performs colostomy care prior to discharge
- Proficiently performs colostomy care prior to discharge
