NUR 254 EXAM 5 2024
x x x x x
x
an ximmunologic xdefense xagainst xtissue xinjury, xinfections, xor xallergy x
x
A. inflammation x
B. sepsis x
C. chain xof xprevention x
D. antibotics x- xA. xInflammation x
x
The xmajority xof xexudate/drainage xis xcomposed xof xwhich xtype xof xWBC xduring xa xchronic
xinflammatory xresponse x? x(select xall xthat xapply) x
x
A. macrophages x x
B. neutrophils x x
C. eosinophils x x
D. lymphocytes x- xA. xmacrophages x x
D. xlymphocytes x
x
Healing xdepends xon x(select xall xthat xapply) x x
x
A. re-injury x x
B. renewed xinflammation x
C. diet xlow xin xprotein x x
D. immune xsystem xstrength x- xA. xre-injury x x
B. xrenewed xinflammation x
D. ximmune xsystem xstrength x
x
a xstate xor xquality xof xbeing xmobile xor xmovable x x
x
A. mobility x x
B. Immobility x
C.Impaired xphysical xmobility x
D. xdeconditioned x- xA. xmobility x
x
a xloss xof xphysical xfitness x
x
A. mobility x x
B. Immobility x
C.Impaired xphysical xmobility x
D. xdeconditioned x- xD. xdeconditioned x
x
This xapplies xnot xonly xto xan xathlete xwho xfails xto xmaintain xan xoptimal xlevel xof xtraining xbut
xalso xto xan xindividual xwho xdoes xnot xmaintain xoptimal xphysical xactivity. x
x
refers xto xan xinability xto xmove x
x
A. mobility x x
B. Immobility x
C.Impaired xphysical xmobility x
,D. xdeconditioned x- x. xImmobility x
x
Elderly xpatients xare xat xrisk xfor ximpaired xmobility xdue xto xall xthe xfollowing xEXCEPT: x
x
A. kyphosis x x
B. decreased xbone xdensity x x
C. increased xelasticity xof xligaments x
D. reduced xmuscle xtone x- xC. xincreased xelasticity xof xligaments x
x
x
spinal xcolumn, xa xthinning xof xvertebral xdisks, xshortening xof xthe xspinal xcolumn, xand xonset xof
xkyphosis xwith xspinal xcolumn xcompression xoccur. xBone xdensity xdecreases xand xbecomes
xbrittle x(particularly xin xfemales), xleaving xolder xadults xmore xsusceptible xto xfracture. xCartilage
xbecomes xrigid xand xfragile, xand xthere xis xa xloss xof xresilience xand xelasticity xof xligaments.
xMuscle xmass xand xtone xreduce xsignificantly xin xlate xadult xyears. xCumulatively, xthese xchanges
xresult xin xmobility ximpairment xattributable xto xreduced xrange xof xmotion xand xpain xin xjoints,
xreduced xmuscle xstrength, xand xincreased xrisk xfor xbone xfracture.4 x
D. xreduced xmuscle xtone x
x
In xregards xto xthe xurinary xsystem xa xpatient xwho xis ximmobile xis xat xmost xlikely xat xrisk xfor
xEXCEPT: x
x
A. Renal xcalculi x
B. Incontinence x x
C. Urinary xstasis x
D. Infection x- xB. xIncontinence x
x
Nurse xis xcaring xfor xan ximmobile xpatient. xWhat xare xsome xconsequence xof ximmobiltiy xin
xwhich xshe xshould xmonitor xfor x(select xall xthat xapply) x x
x
A. Orthostatic xhypotension x
B. Constipation x x
C. Skin xbreak xdown x
D. Contracture xof xjoints x
E. Diarrhea x x
F. Crackles x- xA. xOrthostatic xhypotension x
B. Constipation x x
C. Skin xbreak xdown x
D. Contracture xof xjoints x
F. xCrackles--> xAtelectasis x( xpneumonia....breath xsounds xare xcrackles) x
x
Major xreason xpeople xseek xhealth xcare x
x
A. Immobility x x
B. Infections x
C. Pain x
D. Signs xof xinflammation x- xC. xPain x
x
True xor xfalse: x
x
,A xpatient xwho xis xunconscious xcan xstill xexperience xpain x- xFALSE x x
x
(power xpoints) x x
x
Pain xis xa xconscious xexperience xthat xrequires xan xawareness xand xsensation xvia xan xintact
xnervous xsystem x
x
*Why xis xthe xolder xpopulation xat xrisk xfor xchronic xpain x(select xall xthat xapply) x x
x
A. ability xto xtolerate xpain xincreases x x
x
B. frequent xrecipients xof xsurgical xprocedures x x
x
C. More xlikely xto xsuffer xfrom xconditions xsuch xas xDJD xand xarthritis x x
x
D. unable xto xverbalize xpain x
x
E. part xof xthe xaging xprocess x
x
F. increase xrisk xof xfalls x- xB, xC, xD, xF x
x
-Chronic xpain xis xNOT xa xnormal xpart xof xaging x x
x
-ability xto xtolerate xpain xdecreases x x
x
-Suffer xfrom xmany xconditions xassociated xwith xpain→ x( xarthritis, xchanges xin xspine,
xmusculoskeletal xdisorders) x x
x
-Frequent xrecipients xof xsurgical xprocedures x x
x
-Increase xrisk xof xfalls xand xtrauma x
x
-Under-treatment xof xpain x→ xunable xto xverbalize xpain xdue xto xcognitive ximpairment xor xmay
xbe xreluctant xto xreport xpain x
x
Social xfactors xthat xinfluence xaccess xtreatment xto xpain x(select xall xthat xapply) x x
x
A. income x x
B. education x x
C. geographic xlocation x
D. gender x- xA. xincome x x
B. education x x
C. geographic xlocation x
x
Patients xwho xare xat xrisk xfor xbeing xunder-treated xfor xpain xdue xto xinability xto xcommunicate x-
xcognitively ximpaired x x
-infants/toddlers x
-anesthetized x x
-critically xill x
-comatose x x
-imminently xdying x
x
The xnurse xis xtrying xto xasses xfor xACUTE xpain xin xa xpatient xwith xdementia xwhat xshould xshe
xlook xfor x(select xall xthat xapply) x
, x
A. Increased xblood xpressure x
B. Increased xheart xrate x
D. xfrequent xpositition xchanges x x
C. xIncreased xrespiratory xrate x- xA. xIncreased xblood xpressure x
B. Increased xheart xrate x
C. Increased xrespiratory xrate x
x
x
chronic xpain xyou xwont xsee xthese xchanges xand xyou xmust xmonitor xyour xpatient xfor xsubtle
xchanges x
x
True xor xFalse x
x
The xjoint xcommission xadopted xthe xconcept xof xpain xas xthe xfifth xvital xsign x- xTRUE x
x
A xclient xwho xhad xa xmyocardial xinfarction xreceives x15 xmg xof xmorphine xsulfate xfor xchest
xpain. xFifteen xminutes xafter xreceiving xthe xdrug, xthe xclient xcomplains xof xfeeling xdizzy. xWhat
xaction xshould xthe xnurse xtake? x
x
A.Determine xif xthis xis xan xallergic xreaction. x
x
B. Elevate xthe xclient's xhead xand xkeep xthe xextremities xwarm. x
x
C. Place xthe xclient xin xthe xsupine xposition xand xtake xthe xvital xsigns. x
x
D. Tell xthe xclient xthat xthis xis xnot xa xtypical xsensation xafter xreceiving xmorphine xsulfate. x- xC.
xPlace xthe xclient xin xthe xsupine xposition xand xtake xthe xvital xsigns. x
x
Vertigo xis xa xsymptom xof xhypotension, xa xside xeffect xof xmorphine xsulfate. xThe xsupine xposition
xincreases xvenous xreturn, xincreases xcardiac xoutput, xand xincreases xblood xflow xto xthe xbrain.
xDizziness xis xa xsymptom xof xhypotension xthat xis xa xside xeffect, xnot xan xallergic xresponse, xto
xmorphine xsulfate. xRaising xthe xclient's xhead xmay xaggravate xdizziness. xDizziness xis xa xtypical
xside xeffect xof xmorphine xsulfate. x
x
A xclient xpresents xto xthe xhealthcare xfacility xwith xabdominal xpain. xWhich xquestion xshould xthe
xnurse xask xthe xclient xto xobtain xinformation xabout xconcomitant xsymptoms? x
x
A. "Can xyou xdescribe xthe xpain?" x
x
B. "Where xexactly xdo xyou xfeel xthe xpain?" x
x
C. "Which xactivities xmake xthe xpain xworse?" x
x
D. "What xother xdiscomfort xdo xyou xexperience?" x- x"What xother xdiscomfort xdo xyou
xexperience?" x
x
x
Symptoms xthat xaccompany xthe xprimary xsymptom xof xthe xillness xand xworsen xthe xhealth
xcondition xare xcalled xconcomitant xsymptoms. xAn xexample xis xnausea xthat xmay xaccompany xthe
xprimary xsymptom xof xpain. xThe xnurse xassesses xthe xquality xof xthe xpain xby xasking xthe xclient
xto xdescribe xit. xThe xnurse xgathers xinformation xabout xthe xlocation xof xthe xillness xby xasking xthe
x x x x x
x
an ximmunologic xdefense xagainst xtissue xinjury, xinfections, xor xallergy x
x
A. inflammation x
B. sepsis x
C. chain xof xprevention x
D. antibotics x- xA. xInflammation x
x
The xmajority xof xexudate/drainage xis xcomposed xof xwhich xtype xof xWBC xduring xa xchronic
xinflammatory xresponse x? x(select xall xthat xapply) x
x
A. macrophages x x
B. neutrophils x x
C. eosinophils x x
D. lymphocytes x- xA. xmacrophages x x
D. xlymphocytes x
x
Healing xdepends xon x(select xall xthat xapply) x x
x
A. re-injury x x
B. renewed xinflammation x
C. diet xlow xin xprotein x x
D. immune xsystem xstrength x- xA. xre-injury x x
B. xrenewed xinflammation x
D. ximmune xsystem xstrength x
x
a xstate xor xquality xof xbeing xmobile xor xmovable x x
x
A. mobility x x
B. Immobility x
C.Impaired xphysical xmobility x
D. xdeconditioned x- xA. xmobility x
x
a xloss xof xphysical xfitness x
x
A. mobility x x
B. Immobility x
C.Impaired xphysical xmobility x
D. xdeconditioned x- xD. xdeconditioned x
x
This xapplies xnot xonly xto xan xathlete xwho xfails xto xmaintain xan xoptimal xlevel xof xtraining xbut
xalso xto xan xindividual xwho xdoes xnot xmaintain xoptimal xphysical xactivity. x
x
refers xto xan xinability xto xmove x
x
A. mobility x x
B. Immobility x
C.Impaired xphysical xmobility x
,D. xdeconditioned x- x. xImmobility x
x
Elderly xpatients xare xat xrisk xfor ximpaired xmobility xdue xto xall xthe xfollowing xEXCEPT: x
x
A. kyphosis x x
B. decreased xbone xdensity x x
C. increased xelasticity xof xligaments x
D. reduced xmuscle xtone x- xC. xincreased xelasticity xof xligaments x
x
x
spinal xcolumn, xa xthinning xof xvertebral xdisks, xshortening xof xthe xspinal xcolumn, xand xonset xof
xkyphosis xwith xspinal xcolumn xcompression xoccur. xBone xdensity xdecreases xand xbecomes
xbrittle x(particularly xin xfemales), xleaving xolder xadults xmore xsusceptible xto xfracture. xCartilage
xbecomes xrigid xand xfragile, xand xthere xis xa xloss xof xresilience xand xelasticity xof xligaments.
xMuscle xmass xand xtone xreduce xsignificantly xin xlate xadult xyears. xCumulatively, xthese xchanges
xresult xin xmobility ximpairment xattributable xto xreduced xrange xof xmotion xand xpain xin xjoints,
xreduced xmuscle xstrength, xand xincreased xrisk xfor xbone xfracture.4 x
D. xreduced xmuscle xtone x
x
In xregards xto xthe xurinary xsystem xa xpatient xwho xis ximmobile xis xat xmost xlikely xat xrisk xfor
xEXCEPT: x
x
A. Renal xcalculi x
B. Incontinence x x
C. Urinary xstasis x
D. Infection x- xB. xIncontinence x
x
Nurse xis xcaring xfor xan ximmobile xpatient. xWhat xare xsome xconsequence xof ximmobiltiy xin
xwhich xshe xshould xmonitor xfor x(select xall xthat xapply) x x
x
A. Orthostatic xhypotension x
B. Constipation x x
C. Skin xbreak xdown x
D. Contracture xof xjoints x
E. Diarrhea x x
F. Crackles x- xA. xOrthostatic xhypotension x
B. Constipation x x
C. Skin xbreak xdown x
D. Contracture xof xjoints x
F. xCrackles--> xAtelectasis x( xpneumonia....breath xsounds xare xcrackles) x
x
Major xreason xpeople xseek xhealth xcare x
x
A. Immobility x x
B. Infections x
C. Pain x
D. Signs xof xinflammation x- xC. xPain x
x
True xor xfalse: x
x
,A xpatient xwho xis xunconscious xcan xstill xexperience xpain x- xFALSE x x
x
(power xpoints) x x
x
Pain xis xa xconscious xexperience xthat xrequires xan xawareness xand xsensation xvia xan xintact
xnervous xsystem x
x
*Why xis xthe xolder xpopulation xat xrisk xfor xchronic xpain x(select xall xthat xapply) x x
x
A. ability xto xtolerate xpain xincreases x x
x
B. frequent xrecipients xof xsurgical xprocedures x x
x
C. More xlikely xto xsuffer xfrom xconditions xsuch xas xDJD xand xarthritis x x
x
D. unable xto xverbalize xpain x
x
E. part xof xthe xaging xprocess x
x
F. increase xrisk xof xfalls x- xB, xC, xD, xF x
x
-Chronic xpain xis xNOT xa xnormal xpart xof xaging x x
x
-ability xto xtolerate xpain xdecreases x x
x
-Suffer xfrom xmany xconditions xassociated xwith xpain→ x( xarthritis, xchanges xin xspine,
xmusculoskeletal xdisorders) x x
x
-Frequent xrecipients xof xsurgical xprocedures x x
x
-Increase xrisk xof xfalls xand xtrauma x
x
-Under-treatment xof xpain x→ xunable xto xverbalize xpain xdue xto xcognitive ximpairment xor xmay
xbe xreluctant xto xreport xpain x
x
Social xfactors xthat xinfluence xaccess xtreatment xto xpain x(select xall xthat xapply) x x
x
A. income x x
B. education x x
C. geographic xlocation x
D. gender x- xA. xincome x x
B. education x x
C. geographic xlocation x
x
Patients xwho xare xat xrisk xfor xbeing xunder-treated xfor xpain xdue xto xinability xto xcommunicate x-
xcognitively ximpaired x x
-infants/toddlers x
-anesthetized x x
-critically xill x
-comatose x x
-imminently xdying x
x
The xnurse xis xtrying xto xasses xfor xACUTE xpain xin xa xpatient xwith xdementia xwhat xshould xshe
xlook xfor x(select xall xthat xapply) x
, x
A. Increased xblood xpressure x
B. Increased xheart xrate x
D. xfrequent xpositition xchanges x x
C. xIncreased xrespiratory xrate x- xA. xIncreased xblood xpressure x
B. Increased xheart xrate x
C. Increased xrespiratory xrate x
x
x
chronic xpain xyou xwont xsee xthese xchanges xand xyou xmust xmonitor xyour xpatient xfor xsubtle
xchanges x
x
True xor xFalse x
x
The xjoint xcommission xadopted xthe xconcept xof xpain xas xthe xfifth xvital xsign x- xTRUE x
x
A xclient xwho xhad xa xmyocardial xinfarction xreceives x15 xmg xof xmorphine xsulfate xfor xchest
xpain. xFifteen xminutes xafter xreceiving xthe xdrug, xthe xclient xcomplains xof xfeeling xdizzy. xWhat
xaction xshould xthe xnurse xtake? x
x
A.Determine xif xthis xis xan xallergic xreaction. x
x
B. Elevate xthe xclient's xhead xand xkeep xthe xextremities xwarm. x
x
C. Place xthe xclient xin xthe xsupine xposition xand xtake xthe xvital xsigns. x
x
D. Tell xthe xclient xthat xthis xis xnot xa xtypical xsensation xafter xreceiving xmorphine xsulfate. x- xC.
xPlace xthe xclient xin xthe xsupine xposition xand xtake xthe xvital xsigns. x
x
Vertigo xis xa xsymptom xof xhypotension, xa xside xeffect xof xmorphine xsulfate. xThe xsupine xposition
xincreases xvenous xreturn, xincreases xcardiac xoutput, xand xincreases xblood xflow xto xthe xbrain.
xDizziness xis xa xsymptom xof xhypotension xthat xis xa xside xeffect, xnot xan xallergic xresponse, xto
xmorphine xsulfate. xRaising xthe xclient's xhead xmay xaggravate xdizziness. xDizziness xis xa xtypical
xside xeffect xof xmorphine xsulfate. x
x
A xclient xpresents xto xthe xhealthcare xfacility xwith xabdominal xpain. xWhich xquestion xshould xthe
xnurse xask xthe xclient xto xobtain xinformation xabout xconcomitant xsymptoms? x
x
A. "Can xyou xdescribe xthe xpain?" x
x
B. "Where xexactly xdo xyou xfeel xthe xpain?" x
x
C. "Which xactivities xmake xthe xpain xworse?" x
x
D. "What xother xdiscomfort xdo xyou xexperience?" x- x"What xother xdiscomfort xdo xyou
xexperience?" x
x
x
Symptoms xthat xaccompany xthe xprimary xsymptom xof xthe xillness xand xworsen xthe xhealth
xcondition xare xcalled xconcomitant xsymptoms. xAn xexample xis xnausea xthat xmay xaccompany xthe
xprimary xsymptom xof xpain. xThe xnurse xassesses xthe xquality xof xthe xpain xby xasking xthe xclient
xto xdescribe xit. xThe xnurse xgathers xinformation xabout xthe xlocation xof xthe xillness xby xasking xthe
