Examsrevision

MULTIPLE CHOICE 1. The nurse is caring for a 90-year-old resident in a long-term care facility who is becoming progressively confused and irritable. What should the nurse do next? a. Request an order for a urinalysis. b. Hold the patient’s antihypertensive medications. c. Assess the patient for fecal impaction. d. Notify the charge nurse. ANS: A Sudden confusion and irritability may indicate a urinary tract infection (UTI) in the older adult. There is no supportive information indic...

MULTIPLE CHOICE 1. Intake of which nutrients directly impacts thyroid hormone production? a. Protein and iodine b. Fats and vitamins c. Carbohydrates and minerals d. Sodium and potassium ANS: A The production of thyroid hormone is dependent on the intake of protein and iodine. PTS:1 DIF: Cognitive Level: Comprehension REF: 821 OBJ:2 (theory) TOP: Thyroid Hormone Production KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2...

DeWit: Medical Surgical Nursing: Concepts & Practice, 3rd Edition Chapter_ 21_22_23_24_25_26_27_28_29_30_

Chapter 21: The Neurologic System deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition

MULTIPLE CHOICE 1. A patient has come to the ambulatory care clinic with a sprain. The nurse correctly differentiates a grade 2 sprain from a grade 3 sprain with the assessment of which finding? a. Pain b. Swelling c. Bleeding into the joint d. Minor loss of function ANS: D The minor loss of function is the differentiating factor. Pain, swelling, and bleeding into the joint are true of both grade 2 and grade 3 sprains. A grade 3 sprain has loss of function of the joint. PTS:1 DIF: ...

MULTIPLE CHOICE 1. An 85-year-old patient who has been NPO since midnight last night for diagnostic testing just completed the procedure. Which intervention is most important? a. Inform the patient about the test results. b. Obtain the patient’s weight for comparison to the morning value. c. Turn the patient every 2 hours. d. Offer 4 ounces of water or juice every hour. ANS: D Offering small amounts of fluid every hour will rehydrate the older adult without resorting to intravenous ...

MULTIPLE CHOICE 1. The nurse is discussing actions that can be taken to best prevent osteoporosis with a patient. Which information should the nurse include? a. Take an extra calcium supplement. b. Eat a balanced diet. c. Exercise throughout life. d. Increase daily intake of milk products. ANS: C A lifetime of even mild daily exercise will delay or prevent osteoporosis. PTS:1 DIF: Cognitive Level: Comprehension REF: 720 OBJ:4 (theory) TOP: Osteoporosis: Supplement KEY: Nursing...

MULTIPLE CHOICE 1. Which type of hernia can lead to necrosis? a. Strangulate d hernia b. Indirect hernia c. Direct hernia d. Irreducible hernia ANS: A The incarcerated hernia may become strangulated, which cuts off the blood supply and can lead to necrosis of the trapped bowel loop. Hernias are classified as reducible, which means the protruding organ can be returned to its proper place by pressing on the organ, and irreducible, which means that the protruding part of the organ is tig...

MULTIPLE CHOICE 1. The nurse cautions that constant stress can cause which alteration to the gastrointestinal (GI) system? a. Slowed GI mobility resulting in constipation b. Reversed peristalsis resulting in projectile vomiting c. Increased digestive juices resulting in a gastric ulcer d. Decreased digestive juices resulting in ineffective metabolism ANS: C Stress increases the gastric secretions, which irritate and finally ulcerate the gastric mucosal lining. PTS:1 DIF: Cognitive L...

MULTIPLE CHOICE 1. Which component in the eye refracts light rays to be directed to the lens? a. Pupil b. Cornea c. Retina d. Ciliary body ANS: B The cornea bends or refracts the light rays onto the retina. The pupil acts to regulate the entrance of light into the eye. The ciliary body helps to change the shape of the eye for far and near vision. The retina is the inner coat of the eyeball and is found in the posterior portion of it. The retina contains several layers. The layer wit...

MULTIPLE CHOICE 1. The nurse notices that the patient must hold the newspaper at arm’s length and squint to read. The nurse understands that this finding is consistent with which eye problem? a. Myopia b. Hyperopia c. Presbyopia d. Astigmatism ANS: B The person with hyperopia is farsighted; the patient cannot see things up close and must change the distance from the eyes in order to focus. The person with myopia cannot see things in the distance. Presbyopia refers to the hardening ...

MULTIPLE CHOICE 1. The nurse is caring for a patient who recently suffered a cerebrovascular accident (CVA). Family members ask the nurse why their father had a seizure. Which response is best for the nurse to make? a. “The seizure was most likely caused by brain cells being deprived of oxygen due to a blood clot in the brain.” b. “The stroke generated a toxin that excites the brain cells.” c. “The stroke causes an alteration in the cells adjacent to the blood clot.” d. “The...

MULTIPLE CHOICE 1. The nurse is explaining Parkinson disease to the student nurse. Which statement indicates that the student nurse correctly understands the pathophysiology of the disease? a. “Regardless of the actual etiology, Parkinson disease is caused by depletion of dopamine and excess of acetylcholine.” b. “The pathophysiology of the disease is caused by the deterioration of the myelin sheath of the basal ganglia.” c. “Excess dopamine and deficient acetylcholine are the ca...

MULTIPLE CHOICE 1. The nurse is caring for a patient who recently suffered a cerebrovascular accident (CVA). Family members ask the nurse why their father had a seizure. Which response is best for the nurse to make? a. “The seizure was most likely caused by brain cells being deprived of oxygen due to a blood clot in the brain.” b. “The stroke generated a toxin that excites the brain cells.” c. “The stroke causes an alteration in the cells adjacent to the blood clot.” d. “The...

MULTIPLE CHOICE 1. The nurse explains that the diagnosis of morbidly obese is reserved for people who exceed which percentage of their recommended weight? a. 50% b. 70% c. 90% d. 100% ANS: D Those people who weigh 100% over their recommended weight are considered morbidly obese. PTS:1 DIF: Cognitive Level: Comprehension REF: 645 OBJ:1 TOP: Obesity: Morbid Obesity KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. The nurse calculates th...

MULTIPLE CHOICE 1. The nurse is providing discharge teaching for a patient who underwent a laparoscopic cholecystectomy. Which statement indicates that the nurse’s teaching has been successful? a. “I should call my doctor if I have any pain.” b. “I should be able to go back to work tomorrow.” c. “I should avoid fatty foods for a few weeks.” d. “I should let these Steri-Strips fall off on their own.” ANS: D The nurse should teach the patient to remove the bandages fro...

MULTIPLE CHOICE 1. The nurse describes a concussion as a closed head injury in which: a. The brain tissue is bruised. b. No loss of consciousness occurs. c. There is amnesia related to the incident. d. There are no subsequent symptoms. ANS: C A concussion is a closed head injury in which there is a brief disruption of consciousness, amnesia, and subsequent headaches that may last for several weeks. PTS:1 DIF: Cognitive Level: Comprehension REF: 501, Figure 22-1 OBJ:1 (theory) TOP:...

deWit: Medical-Surgical Nursing: Concepts and Practice, 3rd Edition Chapters _11_12_13_14_15_16_17_18_19_20_

MULTIPLE CHOICE 1. The nurse is caring for a patient with angina pectoris who asks what happens to make his body experience pain. The nurse explains that pain results from which underlying causative factor? a. Congestion that backs up into the lungs b. Inadequate blood flow and poor oxygen supply c. Edema from fluid overload d. Inflammation in the vessels ANS: B Angina pectoris (chest pain) occurs when blood supply to the heart is decreased or totally obstructed. Pain results from isc...

MULTIPLE CHOICE 1. The nurse is caring for a patient with suspected right-sided heart failure. Which manifestation best supports this potential diagnosis? a. Wheezing b. Orthopnea c. Edema d. Pallor ANS: C Right-sided heart failure leads to edema from systemic backup. Wheezing, orthopnea, and pallor are indicative of left-sided failure. PTS:1 DIF: Cognitive Level: Comprehension REF: 426, Table 19-2 OBJ:1 (theory) TOP: Heart Failure: Right Side KEY: Nursing Process Step: Assessment...