NUR 209 MEDICINE-SURGERY EXAM 3 PROFESSIONAL QUESTIONS AND CORRECT ANSWERS GRADED A+| VERIFIED ANSWERS

NUR 209 MEDICINE-SURGERY EXAM 3 PROFESSIONAL QUESTIONS AND CORRECT ANSWERS GRADED A+| VERIFIED ANSWERS A nurse is engaged in diagnostic reasoning to propose appropriate nursing diagnosis for a client. Place the steps in the order that they would occur from first to last during this process. - Answer Correct response: Organizing the existence of cues, Generating possible diagnoses, Comparing cues to possible diagnoses, Conducting a focused data collection, Validating diagnoses Which activity is the clearest example of the evaluation step in the nursing process? - Answer Correct response: checking the client's blood pressure 30 minutes after administering captopril. A nurse arrives at the home of an older adult client. The agency was called because a neighbor noticed that the client was home alone. The nurse finds the client alone in the living room. When asked about the client's daughter who lives there and has been caring for her, the client says, "She went on vacation for about a month. She'll be back soon." Further assessment reveals that there are no other family members or services currently involved. The nurse would identify this situation as: - Answer abandonment During a home health care visit, the nurse identifies a nursing diagnosis of Caregiver Role Strain for a parent who is caring for a child dependent on a ventilator. What subjective assessment data would support the nurse's diagnosis? - Answer The parent states, "I cannot allow anyone else to help because they won't do it right." The night shift RN is caring for a hospitalized adult client who reports being unable to sleep. The client states, "I just can't sleep here. I miss my home. There are too many lights and it is too hot." Which would be the best nursing diagnosis for this client? - Answer Disturbed sleep pattern The nurse is performing an admission assessment on a young client admitted to the unit. Which of the following are considered objective data? Select all that apply. - Answer 38-year-old man height 6' (1.82m) weight 195 lb (89kg) A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to: - Answer complete postoperative assessment. During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue? - Answer The nurse should determine the reason for the client's refusal. When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed? - Answer Focused A nurse designs a care plan to improve walking mobility in an older adult client. When encouraged to implement the new strategies for ambulation the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome? - Answer developing the plan without client input Which statement appropriately identifies an at-risk nursing diagnosis for a woman 78 years of age who is confined to bed? - Answer Risk for impaired skin integrity related to bed rest A student takes an adult client's pulse and counts 20 beats/min. Knowing this is not the normal range for an adult pulse, what should the student do next? - Answer Ask the instructor or a staff nurse to take the pulse. The nurse would promote which lifestyle modifications for a 39-year-old male patient who is diagnosed with prehypertension - Answer - smoking cessation -aerobic exercises -low fat diet Immediate therapeutic measures given to a patient with an acute myocardial infarction include: - Answer -morphine sulfate, oxygen therapy, nitroglycerin, aspirin immediate post operative nursing care of a patient who has undergone open heart surgery include: - Answer -assess cardiac rate & rhythm, check chest tubes for drainage, manage pain a 40-year-old woman complains of leg pains that are associated with fullness when walking. She describes itching on the lower leg and on inspection has a twisted appearing swelling in her legs. Pt will most likely be treated for: - Answer varicose veins The nurse reinforce discharge instructions to a patient who is diagnosed with chronic venous insufficiency. Which instructions should be included (Select All That Apply) - Answer -take low dose aspirin everyday -consider swimming for exercise -avoid wearing tight clothing -reapply elastic wraps in the afternoon -elevate legs above heart level as much as possible If a patient complains of intermittent claudication, the nurse would expect which clinical finding - Answer rubor when legs are dependent A patient diagnosed with a venous disorder ask "what is scleropathy an accurate explanation would be - Answer an injection of a medication that shrinks the vein a patient is started on an antihypertensive medication. which patient statement indicates effectiveness of teaching - Answer sudden changes in position may cause dizziness The nurse is receiving a patient who had femoral-popliteal bypass surgery. which nursing intervention would take priority in the immediate postoperative period - Answer monitoring vital signs of bleeding The nurse is reinforcing the physicians instructions to an elderly woman who is newly diagnosed with hypertension. the patient doesn't speak the nurses language and is legally blind. what is the best nursing action - Answer recruit a translator to provide instructions a 54-year-old man complains of pain when walking and lower extremity numbness on examination. the nurse notes both extremities are pale and cool to touch. the highest nursing priority diagnosis is - Answer ineffective peripheral tissue perfusion pt with peripheral arterial disease is prescribed a daily dose of aspirin. the nurse accurately explains the prescription by stating - Answer aspirin helps prevent the formation of clots the nurse promotes lifestyle modifications to a 39-year-old male diagnosed with prehypertension. it is recommended (Select All) - Answer -smoking cessation -exercise 30 minutes per day most of the week -limit alcohol intake to two drinks per day -low fat diet -stress reduction measures the nurse is about to administer the first dose of torsemide (Demadex) to a patient diagnosed with heart disease. which assessment findings indicate a possible side effect of this drug (Select all) - Answer -muscle weakness -light-headedness the patient is admitted with a cardiac dysrhythmia. the morning lab values show potassium as 5.8 mg/dL. what action is most important to take - Answer notify the physician immediately _________ is the delivery of a mild electrical shock at a specific time of the cardiac cycle to interrupt an abnormal rhythm and to possibly initiate a normal rhythm - Answer cardioversion after pacemaker implantation, it is important to teach the patient to - Answer count her pulse regularly a 48-year-old patient is admitted for tachycardia, SOB, and chest pain eased by sitting up and leaning forward. the nurse auscultates a high-pitched scratchy sound at the left sternal border of the chest. the patient most likely has - Answer pericarditis which assigned patient would take priority for immediate attention - Answer the patient with dysrhythmia whose heart rate has dropped to 42 bpm and is dizzy the patient has heart failure and atherosclerosis. which patient statement regarding healthy food choices demonstrates a need for further assisting - Answer I need to watch red meat intake, but can have all the cheese I want the nurse explains the importance of reducing salt in the diet to a Hispanic man who was recently diagnosed with heart failure. the nurse realizes that the relatives are at the bedside with the patient. the appropriate nursing action would be - Answer determine who does the cooking in the family in discussing heart failure with a patient, the physician explains that the underlying weakness of the left ventricle results in reduced cardiac output and backup of fluid in the pulmonary system. the nurse anticipates which sign/symptom - Answer crackles in the lungs the patient asks "why am I taking lisinopril (Zestril)?" an accurate statement by the nurse would be - Answer the medication helps prevent vasoconstriction after reviewing risk factors for cardiac disease, the patient is prescribed atorvastatin (Lipitor) to reduce cholesterol levels. the nurse must include which instruction(s) (Select All) - Answer report any muscle weakness -avoid exposure to sunlight -keep appointments for lab work he patient asks "what causes angina pectoris?" an accurate response by a nurse would be - Answer it is caused by a decreased blood flow to the myocardium die to partial obstruction of the coronary arteries a patient is diagnosed as having attacks of angina pectoris. as part of the discharge instructions, the patient is instructed on the appropriate storage and use of sublingual nitroglycerin. which of the following patient statements includes a need for further instructions - Answer I can take the tablet every 15 minutes for angina pains a 44-year-old patient is admitted with a sudden, severe chest tightness unrelieved by rest or nitroglycerin, and profuse sweating. which test would exhibit and elevated level only if the patient has had an MI - Answer serum troponin immediate therapeutic measures provided for a patient entering the hospital with an acute MI include which measure(s) (Select All) - Answer -morphine sulfate, oxygen therapy, nitroglycerin, aspirin which food has been found to reduce cholesterol levels - Answer garlic treatment options for a Hispanic woman diagnosed with occlusion of multiple coronary vessels. Before signing an informed consent, he patient is most likely to defer her health care decisions to her - Answer husband the patient has experienced an MI and has ST-segmented elevation on the ECG. The priority nursing diagnosis would be - Answer ineffective tissue perfusion immediate post operative nursing care of a patient who has undergone coronary artery bypass grafts includes which intervention(s) (Select All) - Answer -assessing cardiac rate and rhythm -checking chest tubes for drainage -managing pain after change of shift report, which of the following assigned patients should the nurse attend to first? the patient with - Answer unstable angina who is having chest pain, SOB, nausea, and anxiety Mrs. Dunn is being discharged from the hospital after being treated for arterial insufficiency in both lower extremities. What findings do you expect on physical examination of Mrs. Dunn legs? - Answer - feet cool to touch -pedal pulses absent or diminished -skin on legs shiny/lack of hair -brittle or thick toenails -presence of ulcerations What medication and treatment do you expect the physician to prescribe? Why are these prescribed? - Answer -apply dressings to ulcers, if present, to achieve healing and prevent infections -Vasodilators may be prescribed; however, their effectiveness is questionable. Antiplatelet agents or platelet inhibitors may be prescribed. -Modify the diet to lower cholesterol, thus slowing arteriosclerosis/atherosclerosis. -Elevate the legs as often as possible to prevent pooling of blood. List 5 priority teaching points for Mrs. Dunn - Answer -Walk as much as possible to improve circulation. -Stop smoking, if this is an issue. -Keep follow-up appointments. -Avoid injury to lower extremities. -Avoid wearing constricting clothing. Ms. Yao, age 27, developed DVT in her left thigh after surgery to repair a fractured right femur. She is receiving Heparin IV and will begin enoxaparin subQ the following morning. Describe the pathophysiology of DVT & how does her diagnosis relate to the development of DVT - Answer Deep venous thrombosis (DVT) may occur following surgical procedures if the patient is immobile for a period of time. DVT results when circulation is slowed and clots form in the deep veins, causing pain and inflammation at the site of the clot. The location becomes edematous, and the patient is at risk for embolus formation. Identify essential information you need to safely administer the medications prescribed - Answer Teach to report any chest pain, shortness of breath, dizziness, or change in level of consciousness. Ask him to report increasing pain or swelling or pain or swelling in the other extremity. Any bleeding from gums or body orifice should be reported as well as excessive bruising from the anticoagulant medication. Develop a teaching plan for Ms. Yao - Answer -Signs and symptoms of recurrence of DVT -Signs of complications (shortness of breath, chest pain, apprehension) -Need to avoid rubbing or massaging the affected leg -Need to ambulate as soon as directed by physician -Side effects of medications and symptoms to report -Procedure for compresses, if appropriate -Need to keep appointments for follow-up laboratory work and to see the physician Mr. Thompkins, age 66, who is hypertensive and only recently quit smoking, has been diagnosed with a 3-cm abdominal aortic aneurysm. what treatment would you expect for him? - Answer Expect a "watch and wait" treatment, with monitoring of the aneurysm every 3 to 6 months. He would be reminded to adhere to the lifestyle modifications for hypertension, such as maintaining normal weight; decreasing stress; eating a low-sodium, low-fat diet; getting regular exercise; and not smoking. His blood pressure should be monitored daily, and antihypertensive medications should be taken regularly. what signs & symptoms of complications would you teach him? - Answer He should report any sudden back pain, a feeling of pressure in the abdomen, or numbness or weakness in the legs. what measures could he take to help prevent the aneurysm from growing & rupturing - Answer The only thing he can do to help prevent the aneurysm from growing or rupturing is to keep his blood pressure within normal limits of 119/79 mm Hg. Mr. Jenkins, age 56, is admitted to the telemetry unit with a diagnosis of a fib. Physical assessment reveals a restless, apprehensive man with an irregular heart rate of 145 and dyspnea. describe the rhythm you expect to note on the telemetry monitor - Answer Irregular, rapid atrial rate, with a fast ventricular response what treatment do you expect the physician to prescribe for Mr. Jenkins - Answer Cardiac medications to see if the arrhythmia will convert to a sinus rhythm. Cardioversion, digoxin, warfarin (Coumadin), oxygen, and diuretics may be prescribed. List 5 priority teaching points you should establish for Mr. Jenkins - Answer -Take your pulse for a full minute. -Notify the physician if your pulse rate is consistently less than 60 beats/min, above 100 beats/min, or outside the parameters set by the physician. -Observe for and report signs of unusual bruising or bleeding. -Take your medications as prescribed and at the same time daily. Report missed doses to the physician. -Keep all laboratory appointments for measurement of prothrombin time (PT) and international normalized ratio (INR). -Weigh yourself daily. Report sudden weight gain. Mr. Zulic, age 76, received a permanent pacemaker to correct complete heart block. He is 1 day post-op and preparing for discharge. what are indications for a pacemaker - Answer Emergency situations, such as open heart surgery, symptomatic bradycardia, complete heart block, and atrial fibrillation, are indications for the placement of a pacemaker. describe the types of pacemakers and indications for their use - Answer -Single chamber: pacing wire placed in heart (atrium or ventricle) -Dual chamber: one lead in atrium, one in ventricle; close to natural pacemaker ...