NUR215 EXAM 4 LATEST UPDATE
VERIFIED QUESTIONS & DETAILED
EXPLANATIONS GRADED A+
Professional Academic Assistance Services
The female client states to the nurse, "I'm so distressed. It
seems like every time I laugh hard, I wet myself." The nurse
knows that this condition is known as:
A.Stress incontinence
B.Urge incontinence
C.Functional incontinence
D.Unconscious incontinence - Answer: A.Stress incontinence
Stress incontinence results from increased pressure within the
abdominal cavity.
The nurse prepares to insert an indwelling urinary catheter.
Which statement least explains the reason for this intervention?
A.Empty your bladder prior to your procedure.
B.Treat your problem of leaking urine.
C.Obtain a sterile urine specimen for culture.
D.Measure the amount of urine left after you emptied your
bladder. - Answer: B.Treat your problem of leaking urine.
Insertion of a urinary catheter is not a "treatment" for
incontinence.
,There is a 24-hr urine collection in process for a client. The
unlicensed assistive personnel (UAP) inadvertently empties one
specimen into the toilet instead of the collection "hat." The
nurse should:
A.Continue with the collection of urine until the 24-hr time
period is finished.
B.Make a note to the lab to inform them that one specimen was
missed during the collection.
C.Begin filling a new collection container and take both
containers to the lab at the end of the collection period.
D.Dispose of the urine already collected and begin an entirely
new 24-hr collection. - Answer: D.Dispose of the urine already
collected and begin an entirely new 24-hr collection.
Once one specimen is missed during a 24-hr urine collection, the
results of the laboratory test will be inaccurate, and the
collection must be restarted.
Mrs. Addie is 70 years old. While the nurse is gathering
admission assessment data, the patient states, "I've taken a
tablespoon of Milk of Magnesia every day for 3 years." Which
nursing diagnosis is most appropriate for the nurse to use in
their plan of care?
A.Diarrhea
B.Constipation
C.Risk for Ineffective Therapeutic Regimen
,D.Perceived Constipation - Answer: D.Perceived Constipation
Daily laxative use by the patient might suggest that she
perceives she is constipated, and the nurse would gather further
assessment data related to the client's bowel pattern. There is
not enough data to infer actual constipation.
You are caring for a patient with a colostomy. In order to
provide safe care, you understand that when irrigating a
colostomy a proper fitting cone is needed to prevent:
A.Introducing air into the colon
B.Leaking the solution around the stoma
C.Administering the solution too rapidly
D.Introduction of bacteria from the stoma - Answer: B.Leaking
the solution around the stoma
A proper fitting cone prevents leakage of the solution around
the stoma that may cause irritation and damage to the skin
surrounding the stoma.
The nurse is assisting the client in caring for their ostomy. The
client states, "Oh, this is so disgusting. I'll never be able to touch
this thing." The nurse's best response is:
A."I'm sure you will get used to taking care of it eventually."
B."Yes, it is pretty messy, so I'll take care of it for you today."
C."It sounds like you are really upset."
D."You sound very angry. Should I call the chaplain for you?" -
, Answer: C."It sounds like you are really upset."
This statement reflects the principles of therapeutic
communication.
A patient who is obese is admitted with a diagnosis of
congestive heart failure. The nursing history reveals the patient
has diabetes, smokes 2 packs of cigarettes daily, and is
noncompliant with diet, exercise, and medications. The student
nurse assigned to the patient states, "Let's focus on making
them compliant, which will solve all the problems. Otherwise,
we can't help them." What is the most appropriate response?
A."Let's explore reasons for the noncompliance."
B."This statement shows a bias against the patient."
C."Let's discuss how you derived your priority of care."
D."What do you know about congestive heart failure?" -
Answer:
On assessment of a patient with acute renal failure, the nurse
finds the following: distended neck veins, cool and pale skin, and
crackles in the lungs. The nurse should suspect the patient is
experiencing:
A.Hypocalcemia
B.Hypovolemia
C.Hypervolemia
D.Hypercalcemia - Answer: C.Hypervolemia
VERIFIED QUESTIONS & DETAILED
EXPLANATIONS GRADED A+
Professional Academic Assistance Services
The female client states to the nurse, "I'm so distressed. It
seems like every time I laugh hard, I wet myself." The nurse
knows that this condition is known as:
A.Stress incontinence
B.Urge incontinence
C.Functional incontinence
D.Unconscious incontinence - Answer: A.Stress incontinence
Stress incontinence results from increased pressure within the
abdominal cavity.
The nurse prepares to insert an indwelling urinary catheter.
Which statement least explains the reason for this intervention?
A.Empty your bladder prior to your procedure.
B.Treat your problem of leaking urine.
C.Obtain a sterile urine specimen for culture.
D.Measure the amount of urine left after you emptied your
bladder. - Answer: B.Treat your problem of leaking urine.
Insertion of a urinary catheter is not a "treatment" for
incontinence.
,There is a 24-hr urine collection in process for a client. The
unlicensed assistive personnel (UAP) inadvertently empties one
specimen into the toilet instead of the collection "hat." The
nurse should:
A.Continue with the collection of urine until the 24-hr time
period is finished.
B.Make a note to the lab to inform them that one specimen was
missed during the collection.
C.Begin filling a new collection container and take both
containers to the lab at the end of the collection period.
D.Dispose of the urine already collected and begin an entirely
new 24-hr collection. - Answer: D.Dispose of the urine already
collected and begin an entirely new 24-hr collection.
Once one specimen is missed during a 24-hr urine collection, the
results of the laboratory test will be inaccurate, and the
collection must be restarted.
Mrs. Addie is 70 years old. While the nurse is gathering
admission assessment data, the patient states, "I've taken a
tablespoon of Milk of Magnesia every day for 3 years." Which
nursing diagnosis is most appropriate for the nurse to use in
their plan of care?
A.Diarrhea
B.Constipation
C.Risk for Ineffective Therapeutic Regimen
,D.Perceived Constipation - Answer: D.Perceived Constipation
Daily laxative use by the patient might suggest that she
perceives she is constipated, and the nurse would gather further
assessment data related to the client's bowel pattern. There is
not enough data to infer actual constipation.
You are caring for a patient with a colostomy. In order to
provide safe care, you understand that when irrigating a
colostomy a proper fitting cone is needed to prevent:
A.Introducing air into the colon
B.Leaking the solution around the stoma
C.Administering the solution too rapidly
D.Introduction of bacteria from the stoma - Answer: B.Leaking
the solution around the stoma
A proper fitting cone prevents leakage of the solution around
the stoma that may cause irritation and damage to the skin
surrounding the stoma.
The nurse is assisting the client in caring for their ostomy. The
client states, "Oh, this is so disgusting. I'll never be able to touch
this thing." The nurse's best response is:
A."I'm sure you will get used to taking care of it eventually."
B."Yes, it is pretty messy, so I'll take care of it for you today."
C."It sounds like you are really upset."
D."You sound very angry. Should I call the chaplain for you?" -
, Answer: C."It sounds like you are really upset."
This statement reflects the principles of therapeutic
communication.
A patient who is obese is admitted with a diagnosis of
congestive heart failure. The nursing history reveals the patient
has diabetes, smokes 2 packs of cigarettes daily, and is
noncompliant with diet, exercise, and medications. The student
nurse assigned to the patient states, "Let's focus on making
them compliant, which will solve all the problems. Otherwise,
we can't help them." What is the most appropriate response?
A."Let's explore reasons for the noncompliance."
B."This statement shows a bias against the patient."
C."Let's discuss how you derived your priority of care."
D."What do you know about congestive heart failure?" -
Answer:
On assessment of a patient with acute renal failure, the nurse
finds the following: distended neck veins, cool and pale skin, and
crackles in the lungs. The nurse should suspect the patient is
experiencing:
A.Hypocalcemia
B.Hypovolemia
C.Hypervolemia
D.Hypercalcemia - Answer: C.Hypervolemia
