問題一覧
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37. Older client notes a BP reading of 150/88, no other symptoms or medical illness, which of the following instructions should you give to the client
Follow up with their primary care doctor for further diagnositcs and treatment.
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40. 75 year old has diabetes and want to teach them about nutrition therapy when taking their antidiabetic drugs, which of the statements requires further teaching
if the client states “I need to stick to food allowed in my diet except for special occasions”
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31. Taking care of a client with heart failure, asks if they should get an pneumonia shot
Anyone with heart failure is at greater risk for complications so yes they should
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46. Client with diabetes ask the nurse why more than one injection of regular insulin is required each day, what is the best response
Single dose of insulin will not match the blood insulin levels and food intake patterns closely enough.
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22. Client experienced stroke, what would you identify as the leading predisposing factor for a hemorrhagic stroke
Nonadherence to hypertension medication
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30. Caring for a client with asthma who has not responded well to the medication. Patient says “why am I not doing better”. The best response by the nurse
There are many triggers for asthma and can make treatment difficult.
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38. Assessing a client with pneuomonia, you assess decreased lung sounds on the left side, and decreased lung expansion, what is the best action by the nurse
Check the o2 sat and contact provider right away
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29. COPD patient, is tachycardic, dysrhythmia, admitted for nebulizer treatment, IV steroids, and antibiotics. What nursing diagnosis is priority for this client
Impaired gas exchange
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8. Hypertensive patient teaching, it is important to try in life
Low sodium diet, exercise, treat underlying depression
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4. A1C of 7, what is the best explanation for this?
This is high, poorly controlled
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15. Caring for a client determining between delirium or depression
The nurse would expect to see if the clients experiencing depression with an onset related to a recent life change, loss of a spouse, moving into an assisted living
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19. Older client with dementia observe behavior that is not usual for this client , sudden outbursts, pacing the halls, which of the following nursing interventions should the nurse implement in response to the anger
Check the MAR to ensure that the patient has been receiving their medications, and on time
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20. Client who was diagnosed with early, mild Alzheimer’s which of the following should the nurse ensure is completed at the time of diagnosis
Discuss with patient about their desire of treatment, what are their wishes
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3. Patient with diabetes, why is it important to keep bg no lower than 60
Hypoglycemic shock
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17. Older client in the neuro ICU is sedated and on the ventilator, what should the nurse do to prevent delirium
Maintain adequate sedation, maintain adequate pain medication
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44. Type 2 diabetic has a BG level of 44, what action by the nurse is priority
Give orange juice
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26. Recently diagnosed alzheimers, nurse understands that which of the following factors place client at greatest risk for disease
Age
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33. Caring for a patient with parkinsons, what do you want to make sure they do about their appointments
Make sure appointments are made in early afternoon and not in the late afternoon. (Powerpoint says: Schedule appointments later in the day to prevent rushing patient, this is a good one to miss because of the wording)
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23. Patient with stroke only brushing right side of hair and cleaning right side of face, what is the best nursing intervention to address this situation?
Remind patient to address the left side of their face and hair to reorient them.
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35. Caring for a client recovering from a mild stroke, which intervention best supports the client report of feeling a loss of control after the stroke
Encourage to perform as many tasks as possible and participate in decision making for as long as possible.
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48. Older client with pneumonia , asking how this happened since they never had respiratory issues in the past , best response
Untreated dental caries, periodontal disease can make it easier to develop pneuomonia as a secondary infection
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18. Long term care facility, completed rounds an hour before getting off shift, client is trying to climb out first floor window, after assisting patient back to bed what does the nurse do next
Sit down and talk to them to figure out the reason why they tried to do this
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36. Client with CAD (coronary artery disease), expect to see which symptoms that CAD is worsening
Excessive fatigue, unusual defecation patterns, dizziness
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41. 85 year old newly diagnosed with type 2 diabetes, on metformin , clients regarding diet and exercise, what is the priority nursing action is priority
Contact the PCP regarding most recent orders (doesn’t make sense question, good to miss)
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14. Which of the following alterations in sensory function should the nurse address as a potential side effect of a type 2 diabetic that has problem maintaining blood sugars
Check their glasses, make sure they are using their glasses, if they are able to read labels , if they are able to read
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2. Type 1 Diabetes, urinary incontinence what could be the cause?
Hyperglycemia, sugar, too much glucose in the urine
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9. COPD patient education
Before any type of exercise or activity they should use their bronchodilator at least 30 minutes before
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5. Patient and teaching coworkers, what is important to include about diabetes
Diabetes precursors into cardiovascular disease, diabetic retinopathy, kidney issues
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32. What findings indicates a client has class 3 heart failure
Comfortable when resting
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47. Older client, as the nurse you are aware of signs and symptoms of heart failure are
fatigue, dyspnea with exertion.
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21. Careplan for a client with parkinsons, most appropriate nursing intervention for client who keeps spilling food with meals
Weighted utensils for all meals and snacks
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25. Caring for a client with delirium , was found standing in a busy street in their night clothes, what is the best way to communicate
Explain all the steps you are taking in simple words to keep them oriented
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43. Care plan for an older client with type 2 diabetes , include in plan of care
Teach how to prevent hyperglycemia, emphasize role in physical exercise, review manifestations of complications of diabetes, instruct on self monitoring of blood glucose levels
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16. Different types of aphasia, client speaks easily but uses long sentences that don’t make sense
Wernicke (fluent aphasia)
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39. Attending a conference on heart disease, you will train your colleagues that the pathophysiology of an MI
Ischemia that completely blocks the delivery of oxygen to the heart and muscles.
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34. Client on warfarin for ischemic stroke, what lab value requires immediate intervention by the nurse
Potassium level of 5.5
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42. Providing care to older client with suspected type 2 diabetes, you are aware that the following is the cause of delay diagnosis in the older population
Type 2 usually has very few symptoms in older clients so there is already organ damage done.
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12. Diabetic education
Food should be consumed at a scheduled time each day, snacks and meals same time each day
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24. Client has parkinsons, which statement indicates family requires further teaching regarding changes in motor movement
“I should remind my family member to concentrate on their feet while walking.”
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1. What do you want to tell a patient that has diabetes type 2 about foot care?
Check their feet, ask family for help or use a mirror to examine a feet
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10. Caring for a type 2 diabetic, To prevent them getting microvascular and macrovascular problems we want them to do what
Prevent hyperglycemia, diet is key
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27. Client with right hemisphere stroke 3 years ago and sensory perception deficit, best nursing intervention
To keep personal items within their visual field
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28. Caring for a client with moderate dementia, frequently forget room number, what is the best nursing intervention
Easily established recognized landmarks for them.
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7. Elderly client with respiratory problems , or any infections
Need to intervene immediately, higher risk of falling
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11. Diabetic foot care
Make sure new shoes fit well, not too tight, not too lose, footwear fits well and has even patterns, walking properly
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6. A patient with a pulmonary infection what action would you take first?
Assess Level of consciousness
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13. Patient with diabetes become acutely ill like flu or cold and not eating
Educate patient if they cannot eat they cannot continue to take their medicine and need to call their doctor.
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45. Client with type 2 diabetes getting education, what is the priority to educate on
Tell them what to do when a hypoglycemic episode occurs , what they will feel like/what they want to do about it