NP4 -2

95問 • 1年前

問題一覧

Situation 1 - Nurse Yolan cares for a terminally ill client with cancer. 1. Nurse Yolan assesses the client for depression. Which of the following is a key indicator for clinical depression?

Inability to care for one's physical self

The client has difficulty sleeping. Which of the following interventions is LEAST helpful for Nurse Yolan to incorporate in her care plan?

Instruct the client to drink black tea

The care plan for the client includes family support. Which of the following is MOST appropriate for the family to establish a relationship with the health care team? Nurse Yolan should

Provide a brief explanation to the family member about the care being delivered to the client

The client appears to be dehydrated. The family members are discussing whether their loved one should be given intravenous fluid. Which of the following concepts about dehydration in terminally ill clients should guide Nurse Yolan?

All interventions for terminally ill client should be directed towards comfort and reduction of symptoms

The client show signs of imminent death. Nurse Yolan recognizes cardiovascular indicators of imminent death which are the following EXCEPT

tachycardia

A 65 year old male is admitted for prostate cancer. On assessment, the nurse determines that the patient has experienced incontinence. The nurse knows that incontinence is the first most common symptom of prostate cancer. 6. Based on information gathered, the nurse writes a nursing diagnosis. Which of the following diagnoses is MOST appropriate?

Risk for impaired urinary elimination

To help manage incontinence, the nurse instructs the patients to do which of the following:

Perform perineal muscle exercises

The patient asks for treatment option for his condition. The Nurse explains that treatment options are based on which of the following:

grade and stage of the disease

The nurse recalls the staging and classification of prostate cancer. Which of the following statements is TRUE?

The normal prostate specific antigen (PSA) range under 40 years of age is less than 4 to 6 ng/mL.

The patient asks the nurse what the physician meant about his prostate cancer as Stage C or T3. The nurse explains that the tumor is

palpable and has spread beyond the prostate but not to other organs.

You are oriented on health care economics. The study of economics focuses on how choices are made to overcome a scarcity of resources. Which of the following statements BEST illustrates health care economics? Select all the apply

Providing less health care services that is optimal in order to contain costs., Providing adequate or appropriate care minimize risk of expensive utilization

Which of the following statement is TRUE regarding health care economics?

Contemporary health care is characterized as a business struggling to balance cost and quality.

You understand that a key factor that influence client care is the cost involved in the delivery of health services. Which of the following resources is NOT required to support the services delivered by nurses?

Client's environment

You are aware that there is a need for you to understand how to manage the cost of client care as it relates to clinical practice. Which of the following are nurses accountable for?

Decision regarding cost effective practices.

While touring the department where you are assigned, you noticed that the supply room is stacked with medical supplies and equipment. Which of the following is the BEST action you will take?

Take an inventory of the supplies and equipment.

A 34 year old female client complains of experiencing double vision and frequent headaches. The client claims to be forgetful and has mood swings. A diagnosis of right frontal lobe lesion was made and the client was admitted for craniotomy The client claims to have a diagnostics work up in the outpatient unit before she was admitted. The admitting nurse prepares the client for which of the procedure that will MOST likely confirm the presence of brain tumor?

CT Scan

A 34 year old female client complains of experiencing double vision and frequent headaches. The client claims to be forgetful and has mood swings. A diagnosis of right frontal lobe lesion was made and the client was admitted for craniotomy While the client is being interviewed, she had a seizure. The initial intervention of the nurse must be directed towards:

Protecting the client

A 34 year old female client complains of experiencing double vision and frequent headaches. The client claims to be forgetful and has mood swings. A diagnosis of right frontal lobe lesion was made and the client was admitted for craniotomy After surgery, it is important for the nurse to position the head of the client properly to:

Maintain patent airway

The Nurse is aware that one of the measures listed below is contraindicated in post-operative pulmonary toilet.

Suctioning

The surgeon orders glucocorticoid Dexamethasone (Decadron) to be given following craniotomy. The nurse recognizes that this drug:

Reduces cerebral edema thus reducing ICP

a nurse in the intensive care unit attends to a 20-year old female who was involved in a vehicular accident three days prior to admission. The prognosis is very poor. No brain activity was detected after 2 electro encephalograms (EEGs) were taken. 21. The family decides to wean the patient from the ventilator support. The family talks to the nurse about their decision to get the nurses' support. Which of the following actions is NOT appropriate?

Tells the family that death will occur almost immediately after the patient is removed from the ventilator support.

Two hours after the ventilator support was discontinued, the patient dies. The nurse discusses with the family the possibility of donating the deceased person's organs. The following are guidelines in organ or tissue donation. Which of the guidelines should the nurse observe?

Religious beliefs in organ donation and transplantation must be respected., Donors must be free of infectious disease and cancer, Consent or written orders by the physician are necessary for referral to an organ procurement organization , The family of the deceased should be offered an opportunity to speak with a knowledgeable organ procurement coordinator , The person requesting for organ donation does not have to believe in the benefits of organ donation but should support the process with a positive attitude

The legal definition of death that facilitate organ donation is the cessation of:

Function of the entire brain

The patient is pronounced dead by the physician. Which of the following nursing actions VIOLATES the standards of care for a dead person?

Keeping the dead person in a sitting position until the family has arrived and said their goodbyes

The family goes through the stages of grieving. What are the stages in the grieving process? 1. Acceptance 2. Depression 3. Denial 4. Bargaining 5. Anger

3, 5, 4, 2, 1

A male teenager was wheeled in the Emergency Department (ED) for injured. The nurse assesses the patient for complications. Which are the MOST COMMON complications? 1. Urinary leakage 2. Delayed bleeding from damage 3. Abscess formation 4. Paralytic ileus 5. Renal failure

2 & 3

The nurses knows that with renal trauma, further complications may occur such as: Which are the POSSIBLE complications? 1. Secondary hemorrhage usually due to infections 2. Renal artery stenosis 3. Renal atrophy 4. Hypotension 5. Hydronephrosis

1, 2, 3, 5

The nurse assesses the patient to determine the extent of injury. Which of the following signs is a CARDINAL sign of renal trauma?

Hematuria

The nurse writes a nursing diagnosis for the patient with stab wound. The MOST appropriate nursing diagnosis is

Acute pain in the lumbar area related to renal trauma

The physician prescribes Magnetic Resonance Imaging (MRI) of both kidneys to confirm clinical suspicion and determine the severity of the injury. Which of the following activities is a PRIMARY nursing consideration in preparing the patient for MRI?

Coordinate the MRI with other patient care activities and inform the patient about the test.

Nurse Kyla understands the importance of continuing professional development. Which of the following is the MAIN purpose of continuing professional development? To

Update one's professional knowledge and competence

Nurse Kyla reads that the drug Cyclophosphamide (Cytoxan) is given to patients with breast cancer. Nurse Ashley understand that this drug is ______:

Cell cycle phase-non-specific

Nurse Kyla reads in the literature that a patient with breast cancer taking Cytoxan should observe the following. Given a case what should nurse Ashley instruct a patient to do?

Increase fluid intake 2000 to 3000 mL daily

Nurse Ashley understands that patients receiving antineoplastic medications should do which of the following? 1. drinks beverages containing alcohol in moderate amounts 2. consult with the physician before receiving immunizations 3. be sure to receive flu and pneumonia immunizations 4. take aspirin (Acetylsalicylic Acid, ASA) as for headache

2 only

An incident was described in the literature where a patient developed stomatitis after receiving a course of antineoplastic medications. Which of the following actions would be BEST for a nurse to do?

Rinse the mouth with diluted baking soda or saline

the head nurse of a trauma unit introduce changes to improve the quality of care of trauma patients. 36. The head nurse presented a set of goals to the staff nurses. Which of the following goals is NOT relevant to improving quality of care? No_

Legal suits.

The head nurse reviews reports on nurse staffing. The following findings result to better patient outcomes EXCEPT: A higher

Nurse to patient ratio increases costs

The head nurse determines to reduce medication errors in the trauma unit. She recognizes that medication errors often occur in relation to the following EXCEPT:

Failure to identify non-therapeutic client responses

The head nurse suggests that to reduce medication errors, several measures will be instituted. Which of the following is MOST appropriate?

Use point-of-care technology to access drug reference information.

The head nurse is aware that managing and improving quality care in the trauma unit requires which of the following?

All of the choices.

Nurse Mirasol is the attending nurse of a 40-year old female admitted in the medical unit with a probable diagnosis of Scleroderma. The patient complains of pain in her fingertips and pallor followed by blanching of the extremities and redness. Nurse Mirasol knows that these symptoms are characteristic of which of the following disorders?

Raynaud's phenomenon

Nurse Mirasol is the attending nurse of a 40-year old female admitted in the medical unit with a probable diagnosis of Scleroderma. Nurse Mirasol assesses the skin of the patient. Which phase of skin changes occur FIRST and are usually painless and symmetrical?

Edematous

Nurse Mirasol is the attending nurse of a 40-year old female admitted in the medical unit with a probable diagnosis of Scleroderma. Nurse Mirasol writes a nursing diagnosis for the patient. Which of the following is a PRIORITY nursing diagnosis?

Impaired skin integrity

Nurse Mirasol is the attending nurse of a 40-year old female admitted in the medical unit with a probable diagnosis of Scleroderma. Nurse Mirasol assists the patient in coping with the disorder. During the early stages of a chronic disease, patients tend to focus on which of the following behaviors?

Interpretations of symptoms

Nurse Mirasol is the attending nurse of a 40-year old female admitted in the medical unit with a probable diagnosis of Scleroderma. Nurse Mirasol prepares a discharge plan of care for the patient. Which of the following objectives are MOST appropriate? The patient should _______________. 1. Try to prevent breakdown of the skin and ulceration 2. Avoid activities that trigger pain 3. Modify diet to include legumes 4. Avoid exposure to extreme cold temperature

1, 2, 4

Nurse Bessie is a nurse manager of trauma unit. She supervises the staff and regularly holds conferences with them and other unit personnel. In one meeting she re orients the staff nurses on their various functions. She cites clinical situations related to a nurse dependent, interdependent, and collaborative functions. An interdependent function of nurse is when the nurse _______:

Helps a client choose foods rich in protein from an ordered diet

A nurse decides to give a partial bath to a client instead of a complete bath. The nurse is working

Independently

A nurse works with a skin care team. The nurse is functioning

Interdependently

A nurse initiates a visit from member of the clergy for a terminally ill client. The nurse is functioning

Independently

When a nurse uses a straight catheter to obtain a urine specimen for laboratory test, the nurse is functioning

Dependently

One of her patients is a 50-year old female named Marcela is in the terminal stage of breast cancer. She tells Nurse Marie. "I have given responses of Nurse Marie is MOST therapeutic?

"You have given up hope?"

Marcela says to Nurse Marie. "I don't like to spend my final days on earth in a hospital." The BEST response of Nurse Marie would be:

"Can you please tell me more how you are feeling right now?"

Nurse Marie has another patient, Cena who was recently diagnosed with ductal cell carcinoma of the breast. Her oncologist described Cena's cancer as T2, N1, Mx. Cena asked Nurse Marie to repeat to her what "all those letters and numbers mean." Nurse Marie replies that it means the following:

One tumor present, which is larger than 2.5 centimeters,nodal involvement in one region, and metastasis was unable to be determined

Patient Cena tells Nurse Marie "How did I acquire breast cancer?" Nurse Marie explains that there are risk factors that may have contributed to her condition. Which of the following statements is TRUE concerning the risk factors for breast cancer?

Ethnicity is a risk factor.

35-year old female client presents herself in the outpatient Department with complaints of rashes particularly on the face, across the bridge of the nose and on the cheeks. The client is suspected of having systematic lupus erythematous (SLE). She is admitted to the female medical unit.

inflammatory disease of collagen contained in connective tissues.

The nurse includes in the care plan dietary instructions. Which of the food items should the nurse instruct the client to AVOID?

steak

The nurse is aware that fatigue is experienced by patients with SLE. Which of the following activities should be a component in the care plan for the client to manage fatigue? To ________. 1. sit whenever possible 2. take a hot shower in the morning 3. avoid long periods of rest 4. engage in moderate low impact exercise when not fatigued 5. maintain a balance diet

1, 4, 5

The physician schedules the client for plasmapheresis. The client asks the nurse what is plasmapheresis. The nurse explains that it is a method that will __

remove antibody-antigen complexes from circulation

The nurse monitors the client undergoing plasmapheresis. Which of the following reactions should the nurse observe?

transfusion reactions

The nurse assists in the care of clients with chronic obstructive pulmonary disease (COPD). The nurse is aware that clients with COPD are at risk for ineffective respirations EXCEPT which of the following _________?

Clients with fluid volume deficit

Nursing interventions for clients with respiratory acidosis include the following EXCEPT to _

administer sedation as ordered by the physician to relax the client

The nurse understands that excess acid in the body acts as CNS depressant. Clients with acidosis may exhibit which of the following symptoms: 1. reduced level of consciousness 2. confusion 3. lethargy 4. coma

all of the options

The goal for treatment for respiratory acidosis is to improve ventilation. Which of the following measures is appropriate for clients with COPD experiencing respiratory acidosis?

Spirometers

The nurse understands that respiratory acidosis occurs when _

the body retains too much carbon dioxide

Nurse Mark is assigned in the oncology unit of a tertiary hospital. He is aware of the increase in number of colorectal cancer patient in his unit. He and a colleague plan to conduct a study of the incidence of colorectal cancer in the Philippines. Nurse Mark formulates a possible title for the study. Which of the following is the MOST appropriate title?

"Incidence of Colorectal Cancer in the Philippines"

What research design is the MOST suitable to gather data for the study?

Descriptive study

Nurse Mark formulates an assumption for the study. Which of the following is MOST acceptable?

More Filipinos regardless of gender are diagnosed with colorectal cancer.

Incidence of Colorectal Cancer in the Philippines Which of the following is the MOST appropriate recommendation Nurse Mark should propose?

DOH only should intensify its campaign on colorectal cancer awareness.

The nurses cares for a 30 year old patient who is admitted for severe vomiting. The diagnosis of the patient is hypernatremia. The nurse reads the laboratory results. Which of the following values indicate that the patient is experiencing hypernatremia?

Serum osmolality above 295mOsm/kg

The nurse monitors the patient for signs and symptoms of complications. The nurse knows that one of the PRIMARY risks when treating hypernatremia is

cerebral edema

In planning the care for this patient the nurse includes the following interventions. Which of the following actions should the nurse NOT include in the plan of care?

restrict fluids to 1,200 mL per day

The nurse understands that a patient with hyperatremia is at high risk for seizure. Which of the following safety measures is MOST appropriate? Use of __

padded side rails

HYPERNATREMIA , SEVERE VOMITING The nurse formulates a nursing diagnosis for the patient. Which of the following nursing diagnoses is NOT appropriate for this patient?

imbalanced Nutrition, more that body requirements, related to excess intake of foods rich in sodium

You are oriented on the hospital policy that when a patient is readmitted, the patient's file maybe retrieved from the hospital records department. From which file may be a readmitted patient's record be retrieved?

master patient index file.

You orient your staff on the common system used in recording nursing interventions. The system used is a nursing index card or Kardex. What information is NOT included in the Kardex?

Progress notes of the physician.

A patient's record contains information of the medications and treatments administered, and observations of the patient's condition. Which of the following data MUST be filled up in the patient's chart when he/she is discharged from the hospital?

Final medical diagnosis

You are familiar with the ethical aspects of patients and hospital records. Which of the following statements is NOT true?

Health records are the property of the locality where the patient is treated.

Ms. Gina is a staff nurse in a medical unit of x hospital. She collaborate with other members of the health team to provide safe and quality patient care. Which of the following statements BEST explains the role of the nurse in collaborating with others to plan for the patient's care? The nurse

collaborates with colleagues and the patient's family to provide combined expertise in planning care.

Nurse Gina is aware that collaborative interventions are therapies that require the following: Which of the collaborative interventions is the MOST therapeutic?

Multiple health care professionals

To initiate an intervention in collaboration with the health team, Nurse Gina must be competent in which of the following areas?

Leadership, autonomy, and skills

Nurse Gina is aware that there are nursing activities that may be delegated to other health care team members. Which principle should guide the nurse in delegating tasks?

The nurse has the primary responsibility for the quality of patient care

Nurse Gina is a potential team leader of the health team. Which of the following skills should she develop?

Collaborative skills

Nurse Rolly, a triage nurse admits clients in the Emergency Department (ED) of X hospital. The following are situations in the ED Nurse Rolly encounters. Four victims are brought to the ED after a motor vehicle crash. Who among the following victims require the HIGHEST priority for the treatment?

62 year-old female with palpitation and chest pain

Four victims of a car crash are brought to the ED. Nurse Rolly assesses the victims. Select who among the following has the HIGHEST priority for treatment.

Absence of peripheral pulses

Nurse Rolly performs primary assessment on one of the trauma victims, and determines that the client has a patent airway. The NEXT assessment by Nurse Rolly should be to

observe/assess client's breathing or respiratory effort

Jerome, 65 years old who works as a carpenter fell from a ladder while fixing the roof of a neighbor. He was brought to the ED by family members. He is unconscious. Nurse Rolly does a primary assessment on client Jerome which is to:

Obtain a Glasgow Coma Scale Score

A 30 year-old female is admitted for fever,fatigue, lymphadenopathy, thrush, diarrhea and muscle and joint pains. She also has a rash in her torso and arms. The nurse assesses the client. What question should she ask to determine the client's possible exposure to HIV?

"Do you practice safe sex?"

The nurse writes a care plan for the client. Included in the care plan is to provide health teachings. Before the nurse performs any teaching, what should the nurse do FIRST?

Assess the client's immediate clinical status.

The client is being treated for thrush. The patient asks if there are any side effects of the medication she is receiving for thrush. Which of the following should the nurse include in her teaching?

"Nausea, vomiting, and diarrhea are common side effects."

The client complains of increasing pain in her feet and legs. The nurse realizes that the client is demonstrating a/an _________:

nervous system manifestation of the disease

An adult male is wheeled in the Emergency Department with complaints of nausea and vomiting, abdominal pain and lower back pain. The physician writes a medical diagnosis of abdominal aortic aneurysm (AAA) The nurse assesses the patient with AAA. Which of the assessment findings is related to the aneurysm?

Pulsatile abdominal mass, Systolic bruit over the area of the mass, Subjective sensation of "heart beating" in the abdomen

The nurse auscultates the abdominal area of the patient with AAA. Which of the following sounds can be DISTINCTLY heard over the area?

Bruit

The nurse recalls specific anatomic sites for aneurysm. The most common sites are the aortic arch, thoracic aorta and abdominal aorta. Which of the following areas is an AAA most commonly located?

Distal to the renal arteries

The patient complains of severe lower back pain. Which of the following is the PRIORITY action by the nurse?

notify the physician

The nurse is aware that rupture of the aneurysm is a life-threatening emergency. Which of the following groups of symptoms indicates a ruptured AAA?

Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count

Astignars random QS

Kyla Angelique Son · 19問 · 1年前

Astignars random QS