NRSG 2300 Exam 3 Questions With Complete Solutions
A client has a newly created colostomy. After participating in
counseling with the nurse and receiving support from the
spouse, the client decides to change the colostomy pouch
unaided. Which behavior suggests that the client is beginning to
accept the change in body image?
The client asks the spouse to leave the room.
The client touches the altered body part.
The client closes his or her eyes when the abdomen is exposed.
The client avoids talking about the recent surgery.
The client touches the altered body part.
By touching the altered body part, the client recognizes the body
change and establishes that the change is real. Closing his or her
eyes, not looking at the abdomen when the colostomy is
exposed, or avoiding talking about the surgery reflects denial,
instead of acceptance of the change. Asking the spouse to leave
the room signifies that the client is ashamed of the change and
not coping with it.
A client with acquired immunodeficiency syndrome (AIDS)
develops Pneumocystis cariniipneumonia. Which nursing
diagnosis has the highest priority?
,Activity intolerance
Impaired gas exchange
Impaired oral mucous membranes
Imbalanced nutrition: Less than body requirements
Impaired gas exchange
Although all of these nursing diagnoses are appropriate for a
client with AIDS, Impaired gas exchange is the priority nursing
diagnosis for a client with P. carinii pneumonia. Airway,
breathing, and circulation take top priority for any client.
During a community health fair, a nurse is teaching a group of
seniors about promoting health and preventing infection. Which
intervention would best promote infection prevention for senior
citizens who are at risk of pneumococcal and influenza
infections?
Drink six glasses of water daily
Receive vaccinations
Take all prescribed medications
Exercise daily
Receive vaccinations
Identifying clients who are at risk for pneumonia provides a
means to practice preventive nursing care. The nurse encourages
,clients at risk of pneumococcal and influenza infections to
receive vaccinations against these infections.
A client presents to the emergency department with complaints
of acute GI distress, bloody diarrhea, weight loss, and fever.
Which condition in the family history is most pertinent to the
client's current health problem?
Hypertension
Gastroesophageal reflux disease
Appendicitis
Ulcerative colitis
Ulcerative colitis
A family history of ulcerative colitis, particularly if the relative
affected is a first-degree relative, increases the likelihood of the
client having ulcerative colitis. Although hypertension has
familial tendencies, the client's symptoms aren't related to
hypertension. A family history of gastroesophageal reflux
disease or appendicitis isn't a significant factor in the client
history because these conditions aren't considered familial traits.
A nurse is providing care for a client who has a diagnosis of
irritable bowel syndrome (IBS). When planning this client's
care, the nurse should collaborate with the client and prioritize
what goal?
Client will accurately identify foods that trigger symptoms.
Client will adhere to recommended guidelines for mobility and
activity.
, Client will demonstrate appropriate care of his ileostomy.
Client will demonstrate appropriate use of standard infection
control precautions.
Client will accurately identify foods that trigger symptoms.
A major focus of nursing care for the client with IBS is to
identify factors that exacerbate symptoms. Surgery is not used to
treat this health problem and infection control is not a concern
that is specific to this diagnosis. Establishing causation likely is
more important to the client than managing physical activity.
The nurse at a long-term care facility is assessing each of the
residents. Which resident mostlikely faces the greatest risk for
aspiration?
A resident with severe and deforming rheumatoid arthritis
A 92-year-old resident who needs extensive help with ADLs
A resident who suffered a severe stroke several weeks ago
A resident with mid-stage Alzheimer disease
A resident who suffered a severe stroke several weeks ago
Aspiration may occur if the client cannot adequately coordinate
protective glottic, laryngeal, and cough reflexes. These reflexes
are often affected by stroke. A client with mid-stage Alzheimer
disease does not likely have the voluntary muscle problems that
occur later in the disease. Clients that need help with ADLs or
have arthritis should not have difficulty swallowing unless it
exists secondary to another problem.
Crohn's disease is a condition of malabsorption caused by which
pathophysiological process?
A client has a newly created colostomy. After participating in
counseling with the nurse and receiving support from the
spouse, the client decides to change the colostomy pouch
unaided. Which behavior suggests that the client is beginning to
accept the change in body image?
The client asks the spouse to leave the room.
The client touches the altered body part.
The client closes his or her eyes when the abdomen is exposed.
The client avoids talking about the recent surgery.
The client touches the altered body part.
By touching the altered body part, the client recognizes the body
change and establishes that the change is real. Closing his or her
eyes, not looking at the abdomen when the colostomy is
exposed, or avoiding talking about the surgery reflects denial,
instead of acceptance of the change. Asking the spouse to leave
the room signifies that the client is ashamed of the change and
not coping with it.
A client with acquired immunodeficiency syndrome (AIDS)
develops Pneumocystis cariniipneumonia. Which nursing
diagnosis has the highest priority?
,Activity intolerance
Impaired gas exchange
Impaired oral mucous membranes
Imbalanced nutrition: Less than body requirements
Impaired gas exchange
Although all of these nursing diagnoses are appropriate for a
client with AIDS, Impaired gas exchange is the priority nursing
diagnosis for a client with P. carinii pneumonia. Airway,
breathing, and circulation take top priority for any client.
During a community health fair, a nurse is teaching a group of
seniors about promoting health and preventing infection. Which
intervention would best promote infection prevention for senior
citizens who are at risk of pneumococcal and influenza
infections?
Drink six glasses of water daily
Receive vaccinations
Take all prescribed medications
Exercise daily
Receive vaccinations
Identifying clients who are at risk for pneumonia provides a
means to practice preventive nursing care. The nurse encourages
,clients at risk of pneumococcal and influenza infections to
receive vaccinations against these infections.
A client presents to the emergency department with complaints
of acute GI distress, bloody diarrhea, weight loss, and fever.
Which condition in the family history is most pertinent to the
client's current health problem?
Hypertension
Gastroesophageal reflux disease
Appendicitis
Ulcerative colitis
Ulcerative colitis
A family history of ulcerative colitis, particularly if the relative
affected is a first-degree relative, increases the likelihood of the
client having ulcerative colitis. Although hypertension has
familial tendencies, the client's symptoms aren't related to
hypertension. A family history of gastroesophageal reflux
disease or appendicitis isn't a significant factor in the client
history because these conditions aren't considered familial traits.
A nurse is providing care for a client who has a diagnosis of
irritable bowel syndrome (IBS). When planning this client's
care, the nurse should collaborate with the client and prioritize
what goal?
Client will accurately identify foods that trigger symptoms.
Client will adhere to recommended guidelines for mobility and
activity.
, Client will demonstrate appropriate care of his ileostomy.
Client will demonstrate appropriate use of standard infection
control precautions.
Client will accurately identify foods that trigger symptoms.
A major focus of nursing care for the client with IBS is to
identify factors that exacerbate symptoms. Surgery is not used to
treat this health problem and infection control is not a concern
that is specific to this diagnosis. Establishing causation likely is
more important to the client than managing physical activity.
The nurse at a long-term care facility is assessing each of the
residents. Which resident mostlikely faces the greatest risk for
aspiration?
A resident with severe and deforming rheumatoid arthritis
A 92-year-old resident who needs extensive help with ADLs
A resident who suffered a severe stroke several weeks ago
A resident with mid-stage Alzheimer disease
A resident who suffered a severe stroke several weeks ago
Aspiration may occur if the client cannot adequately coordinate
protective glottic, laryngeal, and cough reflexes. These reflexes
are often affected by stroke. A client with mid-stage Alzheimer
disease does not likely have the voluntary muscle problems that
occur later in the disease. Clients that need help with ADLs or
have arthritis should not have difficulty swallowing unless it
exists secondary to another problem.
Crohn's disease is a condition of malabsorption caused by which
pathophysiological process?
