CDC B part 3
問題一覧
1
Situation: Tien, a 70-year-old Filipino Chinese, was presented to the outpatient clinic for a glaucoma evaluation.
Patient awareness is very important. When teaching Tien about the disease process related to glaucoma, which statement is most appropriate?
"There is a decrease in amount in terms of drainage of the aqueous humor in the eye, causing pressure damage to the optic nerve."
2
Additionally, the physician discussed the nerve affectation with glaucoma. To confirm patient’s understanding about the disease process, the physician asked Mr. Tien about the specific nerve affected. He is correct when he answers:
Optic Nerve
3
This test is used primarily to assess for an increase in IOP and potential glaucoma?
Tonometry
4
Betaxolol hydrochloride eye drops have been prescribed for Mr. Tien. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medication?
Monitoring blood pressure
5
After confirming the glaucoma diagnosis, the nurse was tasked to accomplish a teaching plan for Tien. Which instruction should the nurse emphasize?
Administration of eye medications for life
6
More medications were prescribed to Mr. Tien. Which medication, if prescribed for the client with glaucoma, would the nurse question?
Atropine sulfate
7
A miotic medication has been prescribed for the client with glaucoma, and the client asks the nurse about the purpose of the medication. Which response would the nurse provide to the client?
“The medication causes the pupil to constrict and will lower the pressure in the eye.”
8
When planning care for a patient with disturbed sensory perception related to increased intraocular pressure caused by primary open-angle glaucoma, what should the nurse focus on?
Encouraging compliance with drug therapy
9
Mallory began developing akinesia while ambulating. Which suggestion would the nurse provide to the client to alleviate this problem?
Consciously think about walking over imaginary lines damage to the optic nerve." on the floor.
10
Mallory began developing akinesia while ambulating.The nurse is instructing Mallory about preventing falls especially with her signs and symptoms. Which client statement reflects a need for further teaching?
“I don’t need anybody’s help to get to the bathroom.”
11
Carbidopa-levodopa is prescribed for Mallory. Which side effects would the nurse monitor?
Impaired voluntary movements
12
Chlamydial conjunctivitis is diagnosed. On the basis of this diagnosis, the nurse determines that which requires further investigation?
Possible sexual abuse
13
Having a history of alcohol use disorder, what is the most important assessment that the emergency nurse should take?
When the patient last had alcohol intake
14
Damage to internal organs often requires surgery. The patient was then scheduled for an immediate and emergency. Having a positive brief screening test result for an alcohol use disorder, which initial action is most appropriate?
Complete a detailed alcohol use assessment.
15
A patient in alcohol withdrawal has a nursing diagnosis of ineffective protection related to sensorimotor deficits, seizure activity, and confusion. Which nursing intervention is most important for the patient?
Monitor vital signs frequently to detect an extreme autonomic nervous system response.
16
The patient’s confusion and restlessness indicate acute alcohol withdrawal. A more thorough assessment reveals a score of 11 on the Clinical Institute Withdrawal Assessment for Alcohol Scale. To prevent alcohol delirium, which medication should be given basing on the physician’s orders?
IV thiamine
17
During admission to the emergency department, a patient with chronic alcoholism is intoxicated and very disoriented and confused. Which drug will the nurse administer first?
IV thiamine
18
What is an important postoperative intervention indicated for the patient with AUD who is alcohol intoxicated and is undergoing emergency surgery?
Closely monitor for signs of withdrawal and respiratory and cardiac problems.
19
Which of the following is NOT a possible cause of death for a patient suffering from alcohol withdrawal delirium?
Cerebral hemorrhage
20
Situation: A woman suspected of rape was brought to the emergency room after being found in an abandoned park. Upon arriving at the emergency room, the woman is huddled in the corner and seems stunned.
During physical examination, what should the nurse be aware of?
A paper bag would be useful at this time
21
Situation: A woman suspected of rape was brought to the emergency room after being found in an abandoned park. Upon arriving at the emergency room, the woman is huddled in the corner and seems stunned.
When the nurse starts asking questions, the woman answers in a monotone voice with single words and exhibits a blunt affect. How should the nurse interpret this clients’ responses?
The client may be demonstrating a controlled response pattern.
22
The nurse knows that this type of abuse can be the most difficult to treat effectively?
Emotional
23
Women and their children are protected against violence under what republic act?
RA 9262
24
Situation: One of the basics of nursing practice is the theoretical knowledge and understanding about Cranial Nerves.
How is cranial nerve (CN) III, originating in the midbrain, assessed by the nurse for an early indication of pressure on the brain stem?
Test pupillary reaction to light
25
Which cranial nerve is tested with tongue protrusion?
CN XII
26
Situation: The newly opened medical ward is step by step evaluated for quality improvement.
Which of the following is not included in the fundamental elements of quality improvement?
Care Control
27
Several nurses on the Medical Ward 2 are asked to participate in data collection on hand hygiene for the unit. What purpose will it serve for the nurse to cooperate with this request?
Participate in the quality improvement process
28
Standards of care is an important topic to be adhered to in the unit. Which comment made by the newly hired nurse indicates the need for further education about the standards of care?
"Process standards focus on human resources, and general organizational structure."
29
The bedside nurse is giving the due medications for the patient who had a bypass surgery. What part of the nursing process is in place?
Nursing intervention
30
Situation: A nurse is caring for a newly admitted patient named Sophie who was admitted with weakness, fatigue, and shortness of breath. Laboratory testing has revealed that Sophie has anemia. Her attending physician has ordered one unit of packed red blood cells to be transfused once available.
After picking up one unit of packed red blood cells at the hospital blood bank, the nurse arrived back at the station at exactly 6:00 pm. At what time must the blood transfusion start?
6:10 pm
31
The nurse reads the order again for Sophie. The prescribed time for the administration of one unit of packed red blood cells should not exceed how many hours?
4 hours
32
What intravenous solution should be used when giving blood transfusions?
0.9% Sodium Chloride Solution
33
Before explaining the procedure to the client, what question should the nurse starting the blood transfusion ask Sophie?
"Have you ever had a blood transfusion before?"
34
Just before beginning the transfusion, what assessment should the nurse prioritize?
Vital Signs
35
Seven minutes into the transfusion, the patient complains that she is having trouble catching her breath. She also feels as if her heart is racing. What should the nurse do?
Stop the transfusion
36
Another patient with an O+ blood is in need of an emergency transfusion. Unfortunately, there is a shortage of blood products with an O+ blood type. Which potential unit of blood could be given to the client?
O- unit
37
Lifelong regular blood transfusions can happen to people with certain disorders. Iron overload is a common effect of the transfusions. Which medication would the nurse anticipate being prescribed to correct iron overload from these transfusions?
Deferoxamine
38
A student nurse is worried about finding a solution for his patient’s problems. Which should be the nursing instructor's best response?
"Our patients are the ones responsible for their own choices and decisions."
39
Touch plays a special role in communicating. One of the student nurses is learning about the appropriate use of touch when communicating with clients diagnosed with psychiatric disorders. Which statement best provides information about this aspect of therapeutic communication?
"Touch carries a different meaning for different individuals."
40
The nurse–client relationship requires trust. Phoebe, another nursing student, always makes sure to match her words and her actions. When she says that she will be back at a certain time, she then, indeed returns at that said time to her client. What component of therapeutic communication is Phoebe demonstrating to her client?
Congruence
41
Another student nurse was tasked to care for a patient with obsessive-compulsive disorder (OCD) who washes his hands continually. This behavior prevents the patient from joining the activities prepared by the students. Which statement by the student nurse best addresses this situation?
“Let's figure out a way for you to attend unit activities and still wash your hands."
42
Giving recognition is a great way to foster therapeutic communication in nursing. Which nursing statement is a good example of giving recognition?
"I notice you are wearing a new dress and you have tied your hair."
43
The nursing student started his conversation with the words, “What can we do to help you?". The clinical instructor looked proud. What is the purpose of this therapeutic communication technique?
To explore a subject, idea, experience, or relationship
44
Situation: Amara, a thirty-year-old accountant, was diagnosed to have major depressive disorder after the death of her child a few years ago. Nurse Dwight was assigned to take care of her.
Amara is seen to have a flat affect and depressed mood. The nurse on duty attempts to engage the client in an interaction but the client does not respond to the nurse. What should the nurse say to the patient”?
"I'll sit here with you for 15 minutes."
45
During a group session, Amara finally opened up about losing her job. Which of the following responses by the nurse is best?
"It must have been very upsetting for you. Can you tell me more?"
46
Amara was prescribed to shift her medications to Parnate last week. Which statement by the client indicates an important understanding of the side effects of Parnate?
"I must refrain from eating aged cheese or yeast products."
47
Amara’s best friend was also prescribed 30 mg of Cymbalta twice daily because of her signs and symptoms. Amara began disclosing her bestfriend’s pattern of drinking which consists of drinking more than five packs of beer daily for the past few seven years to help with sleep. What should the nurse do first?
Report the client's beer consumption to the physician
48
Nurse Dwight is also a part time lecturer. He plans to talk about Horowitz's Stages of Loss and Adaptation for his next lecture. According to Horowitz’s division of grief, what term is used to describe the first realization of the loss?
Outcry
49
Situation: A pregnant client diagnosed with mania is Nurse Agatha’s patient for today.
During the daily group session, Nurse Agatha’s client consistently disrupts the group’s interactions. Which intervention would the nurse initially implement
Setting limits on the client’s behavior
50
Which term typifies the speech of a person in the acute phase of mania?
Flight of ideas
51
The pregnant client was supposed to be prescribed Lithium. Which of the following information regarding Lithium should be emphasized to the pregnant client?
Lithium can cross the placenta
PALMR
PALMR
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100問 • 2年前問題一覧
1
Situation: Tien, a 70-year-old Filipino Chinese, was presented to the outpatient clinic for a glaucoma evaluation.
Patient awareness is very important. When teaching Tien about the disease process related to glaucoma, which statement is most appropriate?
"There is a decrease in amount in terms of drainage of the aqueous humor in the eye, causing pressure damage to the optic nerve."
2
Additionally, the physician discussed the nerve affectation with glaucoma. To confirm patient’s understanding about the disease process, the physician asked Mr. Tien about the specific nerve affected. He is correct when he answers:
Optic Nerve
3
This test is used primarily to assess for an increase in IOP and potential glaucoma?
Tonometry
4
Betaxolol hydrochloride eye drops have been prescribed for Mr. Tien. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medication?
Monitoring blood pressure
5
After confirming the glaucoma diagnosis, the nurse was tasked to accomplish a teaching plan for Tien. Which instruction should the nurse emphasize?
Administration of eye medications for life
6
More medications were prescribed to Mr. Tien. Which medication, if prescribed for the client with glaucoma, would the nurse question?
Atropine sulfate
7
A miotic medication has been prescribed for the client with glaucoma, and the client asks the nurse about the purpose of the medication. Which response would the nurse provide to the client?
“The medication causes the pupil to constrict and will lower the pressure in the eye.”
8
When planning care for a patient with disturbed sensory perception related to increased intraocular pressure caused by primary open-angle glaucoma, what should the nurse focus on?
Encouraging compliance with drug therapy
9
Mallory began developing akinesia while ambulating. Which suggestion would the nurse provide to the client to alleviate this problem?
Consciously think about walking over imaginary lines damage to the optic nerve." on the floor.
10
Mallory began developing akinesia while ambulating.The nurse is instructing Mallory about preventing falls especially with her signs and symptoms. Which client statement reflects a need for further teaching?
“I don’t need anybody’s help to get to the bathroom.”
11
Carbidopa-levodopa is prescribed for Mallory. Which side effects would the nurse monitor?
Impaired voluntary movements
12
Chlamydial conjunctivitis is diagnosed. On the basis of this diagnosis, the nurse determines that which requires further investigation?
Possible sexual abuse
13
Having a history of alcohol use disorder, what is the most important assessment that the emergency nurse should take?
When the patient last had alcohol intake
14
Damage to internal organs often requires surgery. The patient was then scheduled for an immediate and emergency. Having a positive brief screening test result for an alcohol use disorder, which initial action is most appropriate?
Complete a detailed alcohol use assessment.
15
A patient in alcohol withdrawal has a nursing diagnosis of ineffective protection related to sensorimotor deficits, seizure activity, and confusion. Which nursing intervention is most important for the patient?
Monitor vital signs frequently to detect an extreme autonomic nervous system response.
16
The patient’s confusion and restlessness indicate acute alcohol withdrawal. A more thorough assessment reveals a score of 11 on the Clinical Institute Withdrawal Assessment for Alcohol Scale. To prevent alcohol delirium, which medication should be given basing on the physician’s orders?
IV thiamine
17
During admission to the emergency department, a patient with chronic alcoholism is intoxicated and very disoriented and confused. Which drug will the nurse administer first?
IV thiamine
18
What is an important postoperative intervention indicated for the patient with AUD who is alcohol intoxicated and is undergoing emergency surgery?
Closely monitor for signs of withdrawal and respiratory and cardiac problems.
19
Which of the following is NOT a possible cause of death for a patient suffering from alcohol withdrawal delirium?
Cerebral hemorrhage
20
Situation: A woman suspected of rape was brought to the emergency room after being found in an abandoned park. Upon arriving at the emergency room, the woman is huddled in the corner and seems stunned.
During physical examination, what should the nurse be aware of?
A paper bag would be useful at this time
21
Situation: A woman suspected of rape was brought to the emergency room after being found in an abandoned park. Upon arriving at the emergency room, the woman is huddled in the corner and seems stunned.
When the nurse starts asking questions, the woman answers in a monotone voice with single words and exhibits a blunt affect. How should the nurse interpret this clients’ responses?
The client may be demonstrating a controlled response pattern.
22
The nurse knows that this type of abuse can be the most difficult to treat effectively?
Emotional
23
Women and their children are protected against violence under what republic act?
RA 9262
24
Situation: One of the basics of nursing practice is the theoretical knowledge and understanding about Cranial Nerves.
How is cranial nerve (CN) III, originating in the midbrain, assessed by the nurse for an early indication of pressure on the brain stem?
Test pupillary reaction to light
25
Which cranial nerve is tested with tongue protrusion?
CN XII
26
Situation: The newly opened medical ward is step by step evaluated for quality improvement.
Which of the following is not included in the fundamental elements of quality improvement?
Care Control
27
Several nurses on the Medical Ward 2 are asked to participate in data collection on hand hygiene for the unit. What purpose will it serve for the nurse to cooperate with this request?
Participate in the quality improvement process
28
Standards of care is an important topic to be adhered to in the unit. Which comment made by the newly hired nurse indicates the need for further education about the standards of care?
"Process standards focus on human resources, and general organizational structure."
29
The bedside nurse is giving the due medications for the patient who had a bypass surgery. What part of the nursing process is in place?
Nursing intervention
30
Situation: A nurse is caring for a newly admitted patient named Sophie who was admitted with weakness, fatigue, and shortness of breath. Laboratory testing has revealed that Sophie has anemia. Her attending physician has ordered one unit of packed red blood cells to be transfused once available.
After picking up one unit of packed red blood cells at the hospital blood bank, the nurse arrived back at the station at exactly 6:00 pm. At what time must the blood transfusion start?
6:10 pm
31
The nurse reads the order again for Sophie. The prescribed time for the administration of one unit of packed red blood cells should not exceed how many hours?
4 hours
32
What intravenous solution should be used when giving blood transfusions?
0.9% Sodium Chloride Solution
33
Before explaining the procedure to the client, what question should the nurse starting the blood transfusion ask Sophie?
"Have you ever had a blood transfusion before?"
34
Just before beginning the transfusion, what assessment should the nurse prioritize?
Vital Signs
35
Seven minutes into the transfusion, the patient complains that she is having trouble catching her breath. She also feels as if her heart is racing. What should the nurse do?
Stop the transfusion
36
Another patient with an O+ blood is in need of an emergency transfusion. Unfortunately, there is a shortage of blood products with an O+ blood type. Which potential unit of blood could be given to the client?
O- unit
37
Lifelong regular blood transfusions can happen to people with certain disorders. Iron overload is a common effect of the transfusions. Which medication would the nurse anticipate being prescribed to correct iron overload from these transfusions?
Deferoxamine
38
A student nurse is worried about finding a solution for his patient’s problems. Which should be the nursing instructor's best response?
"Our patients are the ones responsible for their own choices and decisions."
39
Touch plays a special role in communicating. One of the student nurses is learning about the appropriate use of touch when communicating with clients diagnosed with psychiatric disorders. Which statement best provides information about this aspect of therapeutic communication?
"Touch carries a different meaning for different individuals."
40
The nurse–client relationship requires trust. Phoebe, another nursing student, always makes sure to match her words and her actions. When she says that she will be back at a certain time, she then, indeed returns at that said time to her client. What component of therapeutic communication is Phoebe demonstrating to her client?
Congruence
41
Another student nurse was tasked to care for a patient with obsessive-compulsive disorder (OCD) who washes his hands continually. This behavior prevents the patient from joining the activities prepared by the students. Which statement by the student nurse best addresses this situation?
“Let's figure out a way for you to attend unit activities and still wash your hands."
42
Giving recognition is a great way to foster therapeutic communication in nursing. Which nursing statement is a good example of giving recognition?
"I notice you are wearing a new dress and you have tied your hair."
43
The nursing student started his conversation with the words, “What can we do to help you?". The clinical instructor looked proud. What is the purpose of this therapeutic communication technique?
To explore a subject, idea, experience, or relationship
44
Situation: Amara, a thirty-year-old accountant, was diagnosed to have major depressive disorder after the death of her child a few years ago. Nurse Dwight was assigned to take care of her.
Amara is seen to have a flat affect and depressed mood. The nurse on duty attempts to engage the client in an interaction but the client does not respond to the nurse. What should the nurse say to the patient”?
"I'll sit here with you for 15 minutes."
45
During a group session, Amara finally opened up about losing her job. Which of the following responses by the nurse is best?
"It must have been very upsetting for you. Can you tell me more?"
46
Amara was prescribed to shift her medications to Parnate last week. Which statement by the client indicates an important understanding of the side effects of Parnate?
"I must refrain from eating aged cheese or yeast products."
47
Amara’s best friend was also prescribed 30 mg of Cymbalta twice daily because of her signs and symptoms. Amara began disclosing her bestfriend’s pattern of drinking which consists of drinking more than five packs of beer daily for the past few seven years to help with sleep. What should the nurse do first?
Report the client's beer consumption to the physician
48
Nurse Dwight is also a part time lecturer. He plans to talk about Horowitz's Stages of Loss and Adaptation for his next lecture. According to Horowitz’s division of grief, what term is used to describe the first realization of the loss?
Outcry
49
Situation: A pregnant client diagnosed with mania is Nurse Agatha’s patient for today.
During the daily group session, Nurse Agatha’s client consistently disrupts the group’s interactions. Which intervention would the nurse initially implement
Setting limits on the client’s behavior
50
Which term typifies the speech of a person in the acute phase of mania?
Flight of ideas
51
The pregnant client was supposed to be prescribed Lithium. Which of the following information regarding Lithium should be emphasized to the pregnant client?
Lithium can cross the placenta