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Exam 1

MedSurg Exam 1

QuestionAnswer
Which view is the traditional view of health? Views health and illness as separate concepts.
Which view of health is the current view? Includes mental, physical, social, and emotional adaptation to the environment.
During the initial gathering of data, a patient reveals a weight loss of 17 lb since the death of his spouse 5 weeks earlier. He says that he is not sleeping and has no appetite. Which category of unmet needs in Maslow’s hierarchy of needs? Physiologic
Which is the major advantage of using Maslow’s hierarchy of needs when planning nursing care for patients? Prioritizes patient care.
A nurse points out that a physiologic response to stress involves the total body. Which syndrome is this considered? General adaptation
Which term(s) describe the ability to solve problems and to maintain self-confidence and the willingness to accept criticism incorporated in according to Maslow? Self-actualization
A patient returning from surgery complains of incisional pain that is now rated 7 in intensity on the 1-to-10 pain scale. Which syndrome or response should the nurse be aware that pain exemplifies? Local adaptation syndrome
A nurse clarifies that a neuroendocrine response involves both the autonomic nervous system and the endocrine system. Which syndrome is this considered? General adaptation
Which syndrome includes the alarm reaction stage, resistance stage, and exhaustion stage? General adaptation syndrome
A nurse gives the example of when an individual becomes frightened and experiences an increased heart rate and mental activity along with increased blood flow to the skeletal muscles and dilated pupils. Fight-or-flight response
A patient is being discharged from same-day surgery after a tonsillectomy. The nurse is aware that the patient will be in the phase of general adaptation syndrome, in which the body begins to heal after injury. Which stage is this considered? Resistance stage
An anxious co-worker who is to present a comprehensive report to the hospital board on innovative staffing patterns sits down at a table in the lunchroom and begins to tell you what will be presented in the report. Which coping strategy is used? Event rehearsal
Which diagnosis is the best example for a nurse to use when explaining chronic illness? Asthma
A nurse assesses that smoking, drinking alcohol, and exercising compulsively may occur as responses to a stressful situation. Which type of response should this be considered? Internal
Which type of response is demonstrated when an individual seeks help from family, friends, or a community resource during a time of stress? External
Which term describes activities directed toward maintaining or enhancing well-being against illness? Health promotion
A home health nurse is assisting a patient who is chronically ill with congestive heart failure to reorder time. Which intervention is best to assist this patient? Developing a daily schedule that allows time for activities, as well as for medical regimens
Which type of illnesses are the common cold, appendicitis, and urinary tract infections considered? Acute
Which step comes first f when helping patients to increase adaptability? Assess past methods of coping with stress.
Which assessment describes a patient who has a functional interaction of the cognitive, affective, behavioral, and social dimensions of his personality? Mentally healthy
A nurse assesses that a 42-year-old patient lives with her parents and is dependent on them for decisions about her life. Which mental health characteristic is this patient lacking? Autonomous behavior
Which example is indicative of a positive stressor? Test anxiety
Which action is an example of a person attempting to maintain homeostasis as a newcomer in a community? Joins a local church.
Which behavior best exemplifies developmental activities in a 13-year-old teenager? Going out with a group of friends
In which stage of development is introspection a major characteristic? Older-age adult
A nurse hears a 5-year-old patient who just started kindergarten uses rude vocabulary. Which response to this behavior is the best? Praise him when he speaks properly.
Which patient is most likely to experience the greatest cultural impact on his coping with a chronic debilitating illness? A 26-year-old Latino man with a family
A patient with low back pain confesses that he drinks heavily each night to help him sleep and control pain. Which situation does this behavior exemplify? Using a maladaptive coping method
Which information should a nurse provide to a Native American patient taking herbal remedies and nutritional supplements? If herbs and vitamins are not harmful, then they will be integrated into the plan of care.
When a patient is given a diagnosis of cancer, his first statement is, “What did I ever do to deserve God punishing me?” Which terminology correctly identifies what this scenario exemplifies? Spiritual distress
A star quarterback on the high school football team is injured in a motorcycle accident. He will be unable to play football again. Which patient problem is most appropriate when planning care specific to coping? Immobility
A wife of a critically injured husband has been at his bedside constantly for 2 days. As the nurse speaks to the wife, the wife sobs, “This is awful. I can’t take it anymore.” Which response is the wife experiencing? Stress
Which statement correctly describes how fear differs from anxiety? Fear is a response to a specific threat.
An older Italian woman has an egg yolk in a bowl under her bed that she believes is absorbing the evil of her illness and making her feel better. Which action should a nurse implement? Include maintenance of the egg in the nursing care plan.
When a 25-year-old woman who had a hysterectomy 1 day earlier tearfully tells the nurse that she is grieving for the children she will never have. Which information correctly describes what grief allows this patient to achieve? Reappraise her values for the future.
A 5-year-old patient was in an accident in which his cousin was killed. The patient starts to wet the bed at night. Which question should the nurse ask the mother when she confirms that it has been several years since difficulty with bedwetting? “Do you think this is related to the accident?”
A 24-year-old man scheduled for brain surgery in the morning constantly listens to music with his headphones on. Which assessment does the nurse make regarding this behavior? Conscious coping strategy
When a patient is asked whether he wants his pain medication, he says to you, “I don’t know; whatever you think is best.” Which term correctly describe s s this maladaptive coping mechanism? Powerlessness
Which patient diagnosis and behavior should lead a nurse to conclude the patient is using the defense mechanism of denial? A patient with emphysema continues to smoke.
Which goal of nursing care should be implemented for the patient with a chronic illness? Help the patient manage the illness.
Which nursing action should be implemented when dealing with a patient who is an alcoholic in denial and claims to only drink in social situations? Help the patient investigate ways to reduce drinking.
Which actions describe how the nurse can assist when a caregiver is frustrated and is complaining of being overwhelmed? (Select all that apply.) Referring the caregiver to a support group Seeking assistance from a home health agency Listening to the caregiver’s concerns Assisting in making a daily schedule for the caregiver to follow
Which reasons identify why a person who is ill should be allowed to adopt the “sick role.” (Select all that apply.) Exempt from usual roles Expected to get well Actively seeking remedy
Which factors are known to influence coping strategies? (Select all that apply.) Age Role expectations Personal values Cultural expectations
Which information should a nurse evaluate to assess the social dimension of a patient’s persona? (Select all that apply.) Interaction with family Presentation of self to community
Which characteristics make up a healthy person according to Maslow? (Select all that apply.) Acceptance of self Reality orientation Spontaneity Effective problem-solving skills
A patient in early labor says to the nurse, “I will pass on protection from diseases, and the baby will not ever need any shots.” Which response by the nurse is the best response? “Babies are born with immunoglobulin E (IgE), an antibody that crosses the placenta, but it only briefly protects the baby.”
A school nurse starts a clean-up campaign at a local elementary school in an effort to combat allergens. Which allergic response disorder is the most common? Asthma
A nurse is discussing the body’s first and second lines of defense against infection with a community group. Which is considered the body’s first line of defense? Sweat
A nurse explains that a medication given to a patient with a severe inflammatory response mimics a hormone secreted by the adrenal cortex. Which hormone is the nurse explaining? Cortisol
With the exposure to an antigen, a nurse explains that the initiator of the inflammatory response is the presence of histamine. Which blood component is responsible for releasing histamine? Basophils
A nurse is bathing a patient who is immunodeficient and has a Cryptococcus infestation. Which classification applies to this organism? Fungus
Which mode of transmission occurs when a mosquito or a fly carries an organism that infects another living organism? Vector
Which method is the most effective to control the spread of communicable disease? Demonstrate and monitor a return demonstration of a good hand washing technique by the family.
An air conditioner duct cleaning is recommended by a home health nurse. Which type of organism spread is prevented by using this precaution in the patient’s home? Fungi
A school nurse cautions a group of parents about children playing barefoot on dirt. To which infectious agents can this action expose the children? Helminthes
A large, heavy, patient has a stroke and develops an infected decubitus ulcer on the sacrum during the hospital stay. Two weeks after the patient has gone home, the patient returns to the hospital with pneumonia. Which statement ? The decubitus ulcer is termed a health care–associated infection, and pneumonia is termed a community-acquired infection.
On a visit to administer the fifth in a series of 10 antibiotic doses, a home health nurse is told that the patient is now complaining about a bothersome vaginal discharge. Which is the most likely cause of the vaginal discharge? Superinfection response to the antibiotic medication
Which patient diagnosis is most likely related to acquiring a health care–associated infection? Urinary infection after the insertion of a Foley catheter
A community picnic is held. A number of the attendees become ill after the picnic. Which vehicle identifies how this pathogen was acquired? Common vehicle
A nurse caring for a patient who is immunosuppressed is diligent about protecting the patient from infection. Which item should be prohibited when visitors come in? Potted plant
Which drugs reduce inflammation but also hinder the body’s immune response? Bronchodilators and corticosteroids
A patient has had several increasingly severe allergic reactions during last year’s pollen season. This year, the patient comes regularly to the office to receive some antigen injections. Which education will the nurse provide regarding these injections? They will increase tolerance to the antigen.
A patient who is receiving daily steroids for the control of a condition calls the nurse to ask advice about whether a small child who has been exposed to influenza should come and visit because she has not had any symptoms. Which response ? “No, the child should not visit. Infectious diseases are often most communicable in the short period before the child actually becomes ill.”
A patient with the diagnosis of Clostridium difficile infection asks what has caused the diarrhea. Which is the best response by the nurse? It is caused by a long-term antibiotic therapy.
A patient receiving a large intramuscular dose of antibiotic was asked to please wait 20 to 30 minutes before checking out. Which is the correct reason for this request? Antibiotics are a common source of severe allergic reactions within the first few minutes after an injection.
Which action should the nurse take first when, after receiving an injection of penicillin, a patient undergoes an anaphylactic reaction? Administer oxygen.
The Centers for Disease Control and Prevention (CDC) has issued new guidelines for infection control. Which protocol is mainly addressed by nursing care plans for patients with infection? Standard Precautions guidelines
Which vitamin can enhance wound healing? C
A patient is hospitalized with cryptococcal pneumonia and AIDS. Which standard precaution for the health care team is the most important to implement? Hands are washed before and after gloving.
Which organ, in addition to the tonsils, spleen, and lymph nodes, is involved in immunity? Liver
Which action is required by medical asepsis that is not required by surgical asepsis? Good hand washing technique
The daughter of an 89-year-old resident in a long-term care facility asks if she may give her father an over-the-counter (OTC) antihistamine that she uses for seasonal allergy. Which is the nurse’s most appropriate response? “No. Many antihistamines cause confusion in the older adult.”
Which of the following is the correct order of events of an antibody-mediated immunity response? Antibodies seek out and bind with specific antigen, antigen binds to a B lymphocyte, circulating antibody–antigen complexes are destroyed, antibodies are produced, and 1ntibodies are replenished.
Which occurrences of disease is the school nurse required to report to the health department? (Select all that apply.) Rubella Lyme disease Clostridium difficile
A nurse assesses that a patient’s urine has become much more concentrated. Which hormone is most likely the cause for the change? Aldosterone
Which assessment finding should a nurse anticipate when the water absorption in the renal tubules becomes greater than normal? More concentrated urine
Which process occurs when oxygen is directed out of the arteries and into the capillaries? Diffusion
A patient’s intravenous (IV) injection has been infusing at a very high rate. Which assessment indicates fluid volume overload in this patient? Pulmonary edema
A small child is hospitalized with severe metabolic acidosis after ingesting a whole bottle of baby aspirin approximately 8 hours earlier. Which nursing action is the most appropriate? Frequently assessing the mental and neurologic status
Which medium is primarily responsible for carrying fluids with nutrients and wastes on a random basis throughout the body? Extracellular fluid
A nurse clarifies that electrolytes, such as sodium and potassium (K+), break down into smaller particles when dissolved. Which term describes the smaller particles? Ions
A nurse assists a patient with dyspnea to sit in a high Fowler position. Which process allows gravity to help move oxygen from the pulmonary capillaries into the blood when the patient is in this position? Diffusion
A nurse evaluates the laboratory reports on electrolyte values carefully to assess the balance between positive and negative ions. Which of the following is responsible for the regulation of this process? Diffusion
Which term identifies what is being administered when a nurse hangs an IV bag with Na+, K+, and Cl–? Electrolytes
Each compartment of the body has a water-fluid distribution movement of its own. Which process allows these fluids to move and distribute themselves among compartments? Osmosis
A (LPN/LVN) is preparing to add a new IV of 5% dextrose in water (D5W) with potassium (K+ ) to an existing line. The LPN/LVN notices that only 25 mL of urine has been collected over the past hour. Which intervention is the most appropriate? Avoid hanging the IV with K +and inform the registered nurse (RN) of the urine output.
Which is the most abundant intracellular positively charged electrolyte? Potassium
Which compensatory condition should the nurse carefully assess for when the patient with metabolic acidosis is hyperventilating? Respiratory alkalosis
The K+ laboratory report shows a level of 5.2 mEq/L. Which assessment is the most important for the nurse to make? Irregular heartbeat
A patient has renal damage because of diabetes. Which outcome puts the patient at the highest risk? Hyperkalemia
Which diagnosis is usually associated with hyperchloremia? Metabolic acidosis
Older adults are at risk for dehydration because of reduced thirst and aging kidneys. Which assessment would the nurse observe as an early indicator of dehydration? Constipation
A nurse has two newly admitted patients with dehydration. One patient is dehydrated from heat exhaustion, and the other is dehydrated from an overdose of Lasix. Which finding should be present in both patients? Increased laboratory values of hemoglobin and hematocrit
Which two systems mainly monitor fluid balance in the body? Circulatory and renal
Which electrolyte primarily maintains extracellular fluid osmolarity? Sodium
Which method explains how the healthy kidney adjusts the volume and composition of filtrate that prevents excessive fluid loss? Tubular reabsorption
Which process involves blood being brought by the incoming capillaries into the kidney, which contains nitrogenous substances to be excreted as waste? Filtration
Which primary intervention and focus should occur when a patient is hypovolemic? Extracellular fluid deficit and encouraging fluid intake
Which situation in the body causes a patient to be frequently thirsty? Too much sodium and too little water in the body
Which instruction should be provided to a patient with a K+ level of 6.2 to avoid? (Select all that apply.) Bananas Carrots Tomatoes Celery
Which statement best defines concepts to be included in a teaching plan for a patient with cancer? Cancer is a group of diseases. The cancer cells are different from the cells in the tissue of its origin in both the growth and spreading of abnormal cells.
A nurse explains that the seven warning signs of cancer written by the American Cancer Society (ACS) can be recalled by the acronym CAUTION. Which term is represented by the A in the acronym? A sore that will not heal
A home health nurse is compiling a patient profile on a 23-year-old obese woman who smokes one-half pack of cigarettes a day and drinks 1 beer a week. blah blah Which number represents how many risk factors for cancer apply to this patient? 3
Which phase is considered the latent period before the period of rapid growth of tumors? Promotion
Which information is true about both malignant tumors and benign tumors? Both may press on nearby surrounding tissues, such as nerves and blood vessels, causing pain.
A patient newly diagnosed with cancer says, “I feel like I’ve lost my future. I feel so much harm has been done to me that I’m overwhelmed.” To which type of coping strategy should the nurse recognize this attitude will most likely lead the patient? Avoidant
A patient has a cancer that has been TNM staged as T3 (1-4, size of primary tumor), N2 (0-3, degree of spread to regional lymph nodes), and M2 (0-1, presence of metastasis).He has an as needed order of 4 mg of morphine intramuscularly every 3 to 4 hours. Give the morphine and evaluate the results of pain relief. Arrange for the physician to evaluate for breakthrough pain.
A patient is scheduled for a chemotherapy treatment in approximately 30 minutes. Breakfast trays have arrived and are being served on the unit. Which action is the best intervention? Listen attentively to any concerns that the patient expresses regarding the treatment. Offer to hold his tray until after the treatment.
A nurse explains that drugs such as cannabinoids, Benadryl, and Vistaril are frequently ordered for patients with cancer who are taking chemotherapy. Which action do these types of drugs accomplish? Control nausea, vomiting, and taste disorders caused by the therapy.
While bathing a patient with cancer, a nurse assessed several large new bruises on the patient’s upper arms and thighs. Which understanding of the possible causes and the correct nurse’s actions for these findings is the most accurate? The patient may have disseminated intravascular coagulation. The size, shape, location, color, and tenderness must be reported and recorded fully.
Which manifestations might be assessed by a nurse when a patient is diagnosed with the oncologic emergency hypercalcemia? Fatigue, confusion, and weakness
A female college student has had a melanoma of the forehead surgically removed and given a course of chemotherapy. Which comment demonstrates an understanding of the treatments and prognosis? “My spring dance is only 3 weeks away. Do you think I could find a wig to cover my head where the hair fell out from the chemo?”
A patient whose cancer has been staged at T4 N2 M2 has been assigned for care. Which interpretation of this staging information should be used in planning care for this patient? The primary tumor is quite large and has extended to lymph glands and distant areas. Gentle touch and therapeutic listening will be especially helpful.
Which symptom reported by a patient taking doxorubicin (Adriamycin) should be considered a priority for intervention? Rapid heartbeat
A diagnosis of breast cancer is first made at stage T1 N0 M0. Which patient problem would be appropriate? “Anxiety, related to outcome of treatments.”
Which is the most common site of cancer in adult women? Breast
Which complaint should a nurse Consider a warning sign for cancer? Persistent indigestion associated with difficulty swallowing
Which is the most common site of cancer in adult men? Prostate
Which patient assessment should lead a nurse to conclude a patient diagnosed with cancer is beginning the acceptance stage? Inquires about support groups
A family is concerned about the possibility of addiction as a result of the frequent doses of Roxanol. Which is the nurse’s best response? “This is a low-dose drug, and it controls pain without the problems of addiction.”
Which cytologic test, usually performed in outpatient settings, suggests the probability of a need for further testing for cancer cells? Papanicolaou (Pap) test
Which cause is the reason for cell death when a patient receives radiation as a treatment for cancer? Damage of the cell membrane
Which is the best menu choice for a patient with nausea who is undergoing radiation treatments every other day? Broiled chicken with rice, 1-oz slice of plain American cheese, one-quarter cup of spinach, one-half ripe banana, and 8 oz of grape juice
A patient is close to death with terminal liver cancer with widespread metastases and calls the nursing staff to his room every 5 minutes. Which interventions will be most supportive and in the best interest of the patient? Use fixed interval and cocktail medication administration. Frequently evaluate for breakthrough pain and anxieties. Answer the call bell quickly on the intercom or in person.
Which statement by a patient should lead the nurse to conclude that the pre-colonoscopy instruction provided has been effective? “I know that the lighted tube he will use will help the doctor look at my tumor, and he might take a small piece of tissue to look at in the lab.”
Which of the following lists the tumors in order based on the following tissue of origin: 1, fat; 2, fibrous; 3, smooth muscle; 4, glands; 5, bone? Lipoma, carcinoma, leiomyoma, fibroma, sarcoma
Which conditions of middle-aged persons promote the formation of malignant cells? (Select all that apply.) Increasing age Hormonal changes Chronic irritation of tissue e. Diet
Which recommendations should a nurse make to a visitor of a patient who has an internal radiation implant? (Select all that apply.) Avoid visitation if you are pregnant. Limit your visitation time. Stay at least 6 feet away from bedside.
Why is adjuvant therapy given to patients with cancer who are free of signs of the disease? (Select all that apply.) Ensures eradication of undetected cells. Diminishes recurrence of breast cancer.
Which action should a nurse implement if an intravenous vesicant cancer drug has extravasated? (Select all that apply.) Stop the infusion. Notify the charge nurse.
Which statement indicates when a surgical remedy for cancer is most successful? (Select all that apply.) Cancer is detected early. Lymph glands have not been involved.
Which maximum time period is correct for heat to be applied to an injured hip of a patient? 30 minutes.
A patient with an extensive abdominal surgical procedure is assessed by the nurse as having predictable pain. How often should the nurse administer analgesics to this patient to be most effective? Around the clock
Which sympathetic responses to pain might be assessed by the nurse? Increased blood pressure, increased pulse, and increased respiratory rate
A health care provider has prescribed both heat and cold treatments for an older adult patient with a leg injury. The nursing care plan reflects secondary diagnoses of (PVD), diabetes, and an allergy to latex. Which treatment and why? The nurse will use heat treatment because cold is contraindicated for patients with PVD.
A nurse notices that a patient seems calm and peaceful despite an assessment that the patient’s injuries might be causing severe pain. The patient tells the nurse that using yoga and meditation lessens the perceptions of pain to tolerable levels. Music by a favorite artist
Which intervention of pain control exemplifies the gate control methods of pain relief? Giving a massage
To perform a nursing assessment correctly, a nurse must remember that pain perception involves several central nervous system (CNS) processes. Which examples relate to the CNS processes? Efferent pathways stimulate the spinal cord to recognize the location of pain.
A nurse is teaching a patient how to use a transcutaneous electrical nerve stimulation (TENS) unit and how it works. Which information is most appropriate for the nurse to relay? “This unit stimulates both the skin and the underlying tissues to decrease the intensity of the pain.”
Which intervention should greatly reduce postoperative pain for a patient about to undergo a hip replacement? Femoral nerve blocks
A patient continues to report pain after the administration of the prescribed analgesic. Which assessment indicates the nurse needs to change the nursing care plan? Patient’s pain threshold has lowered.
A nurse administers nalbuphine (Nubain), an opioid agonist–antagonist, to a 78-year-old patient. The family is worried about the patient and thinks that this drug is too strong and will cause harm. Blocks the side effects observed in opioid agonists
A patient admitted with the diagnosis of possible myocardial infarction complains of pain and tingling in the left arm and says, “How in the world could I be having a heart attack when it’s just my arm that is giving me trouble?” Referred pain
Every time the right arm is raised, a patient reports to the nurse that pain is triggered in the right shoulder. Which assessment information should the nurse use to document this description? Aggravating factor
A patient who had a myocardial infarction 2 days earlier has been eating well, is ambulating with assistance, and is receiving antibiotics and morphine by intravenous (IV) drip. The patient reports constipation this morning. Administration of an analgesic medication
A patient who is obviously in pain refuses the morphine that has been prescribed for pain control because of a fear of addiction. Which is the estimated percentage of patients taking prescribed pain protocols who become addicted? Less than 1%
Morphine sulfate (30 mg) IM PRN was prescribed for pain for an 80-year-old patient with emphysema who weighs 100 lb. Which action is the most appropriate for the licensed practical/vocational nurse (LPN/LVN) to implement? Tell the RN about the order.
Which assessment should a nurse make to evaluate the presence of pain in a patient who is cognitively impaired? Increasing confusion
Which steps should the LPN/LVN follow when performing a pain assessment? Assess location, quality, and intensity on an identified scale.
Two patients are hospitalized with the same diagnosis, but one is 23 years old, with acute recent pain from an injury, and the other is 64 years old, with pain of long-standing duration of several years. Older adult patients with chronic pain usually report lower levels of pain much less severe than they really are.
Which definition of the sensation of pain is correct according to the International Association for the Study of Pain? Unpleasant sensory and emotional experience
A nurse is notified when a patient, newly admitted with liver and gallbladder disease, reports pain in the right middle back and asks for some pain medication. Which is the best interpretation of this reported assessment by the nurse? The patient has referred pain sensations. The nurse should follow orders for administering pain medication.
Which result is the most common result of prolonged and unrelieved pain? Lowered pain threshold
A nurse is administering morphine IM, which was prescribed for a patient reporting severe pain. Which primary assessment focus should be used to evaluate the patient’s response to this drug? Sedative effects in the neurologic system
Which body area indicates Where the perception of pain originates in the gate control theory? Small nerve fibers
When a patient with sciatica seats themself in a chair, they gasp and complain of a burning and shooting pain in his hip. Which type of pain does this represent? Neuropathic
Which standards for pain management are published by The Joint Commission (TJC)? (Select all that apply.) Perform organized pain assessment. Record results of analgesia. Give adequate discharge instruction about pain relief. Teach patients about pain control methods.
Which instruction should the nurse provide to a patient who has had radiofrequency lesioning for leg pain? (Select all that apply.) Relief may not be permanent. The leg may tingle occasionally. Caution should be taken to prevent injury to the leg.
Created by: DrFeelgood
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