NURSING1
FUNDAMENTALS
FUNDAMENTALS
A 73-year-old patient who sustained a right hip fracture in a fall requests pain medication from the nurse. Based on his injury, which type of pain is this patient most likely experiencing?
1) Phantom 2) Visceral 3)Deep somatic
4) Referred
3) Deep somatic
Rationale:
Deep somatic pain originates in ligaments, tendons, nerves, blood vessels, and bones. Therefore, a hip fracture causes deep somatic pain. Phantom pain is pain that is perceived to originate from a part that was removed during surgery. Visceral pain is caused by deep internal pain receptors and commonly occurs in the abdominal cavity, cranium, and thorax. Referred pain occurs in an area that is distant to the original site.
A 78-year-old does not want to eat lunch and complains that the food that is serve does not taste good. Consistent with knowledge about age-related changes to taste, the nurse may find that the client is more willing to eat.
A) Greasy foods
B) Sour foods
C) Sweet foods
D) Salty foods.
C = the older adults' taste buds retain their sensitivity to carbohydrates. In addition, carbohydrates. Tend to be food items that are easy to chew. Older adults lose their sensitivity to sour and salty foods. Older adults may find greasy foods harder to digest and therefore may avoid them; however, preference for greasy foods is not related to changes in taste associated with age.
The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy?
a. Painless vaginal bleeding
b. Abdominal cramping
c. Throbbing pain in the upper quadrant
d. Sudden, stabbing pain in the lower quadrant
Answer D is correct. The signs of an ectopic pregnancy are vague until the fallopian tube ruptures. The client will complain of sudden, stabbing pain in the lower quadrant that radiates down the leg or up into the chest. Painless vaginal bleeding is a sign of placenta previa, abdominal cramping is a sign of labor, and throbbing pain in the upper quadrant is not a sign of an ectopic pregnancy, making answers A, B, and C incorrect.
Which behavior demonstrates the nurse's competency as an emotionally intelligent leader?
1. The nurse is proficient in technical skills.
2. The nurse relies on policies, not options.
3. The nurse supports team members.
4. Productivity is not a major concern.
Answer:
3. The nurse supports team members.
Rationale:
1: While technical skill is important for all nurses, it is not a hallmark of a competent leader.
2: Chaos theory states that solutions are not always clear and policies might not always be applied easily; other options might need to be considered.
3: In Emotional Intelligent theory, team members support each other and feel supported by the team leader.
4: This statement reflects the country club leadership style.
You are taking the history of a 14 year old girl who has a (BMI) of 18. The girl reports inability to eat, induced vomiting and severe constipation. Which of the following would you most likely suspect?
A: Multiple sclerosis
B: Anorexia nervosa
C: Bulimia
D: Systemic sclerosis
(B) All of the clinical signs and systems point to a condition of anorexia nervosa.
Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis?
1) Ibuprofen (Motrin)
2) Celecoxib (Celebrex)
3) Aspirin (Ecotrin)
4) Indomethacin (Indocin)
3) Aspirin (Ecotrin)
Rationale:
Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin therapy is commonly administered to decrease the risk of thrombophlebitis, myocardial infarction, and stroke. Ibuprofen, celecoxib, and indomethacin are NSAIDs, but they do not inhibit platelet aggregation.
The nurse is preparing a discharge plan to a female client with peptic ulcer for the dietary modification she will need to follow at home. Which of the following statements indicates that the client understands the instruction of the nurse?
A) "I should not drink alcohol and caffeine."
B) "I should eat a bland, soft diet."
C) "It is important to eat six small meals a day."
D) "I should drink several glasses of milk a day.
A = caffeinated beverages and alcohol should be avoided because they stimulate gastric acid production and irritate gastric mucosa.
The client should avoid foods that cause discomfort; however, there is no need to follow a soft, bland diet.
Eating six small meals daily is no longer a common treatment for peptic ulcer disease.
Milk in large quantities is not recommended because it actually stimulates further production of gastric acids.
A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
a. Her contractions are 2 minutes apart.
b. She has back pain and a bloody discharge.
c. She experiences abdominal pain and frequent urination.
d. Her contractions are 5 minutes apart.
Answer D is correct.
The client should be advised to come to the labor and delivery unit when the contractions are every 5 minutes and consistent. She should also be told to report to the hospital if she experiences rupture of membranes or extreme bleeding. She should not wait until the contractions are every 2 minutes or until she has bloody discharge, so answers A and B are incorrect. Answer C is a vague answer and can be related to a urinary tract infection
Describe the primary focus of a manager in a knowledge work environment.
1. Developing the most effective teams.
2. Taking risks.
3. Routine work.
4. Understanding the history of the organization.
Answer:
1. Developing the most effective teams.
Rationale:
1: The most important focus of this manager is on developing and supporting effective teams, utilizing the knowledge of many.
2: Risk taking is a part of knowledge work, but is not the most important of this manager's tasks.
3: Knowledge work is a combination of routine and non-routine work, so the manager will have focus on the routine. This is not the manager's most important focus.
4: Understanding the history of the organization is important as it will help the manager work within the organization, but it is not the most important focus.
Rho gam is most often used to treat____ mothers that have a ____ infant.
A: RH positive, RH positive
B: RH positive, RH negative
C: RH negative, RH positive
D: RH negative, RH negativ
(C) Rho gam prevents the production of anti-RH antibodies in the mother that has a Rh positive fetus.
The nurse assesses clients' breath sounds. Which one requires immediate medical attention? A client who has:
1) Crackles
2) Rhonchi
3) Stridor
4) Wheezes
Answer:
3) Stridor
Rationale:
Stridor is a sign of respiratory distress, possibly airway obstruction. Crackles and rhonchi indicate fluid in the lung; wheezes are caused by narrowing of the airway. Crackles, rhonchi, and wheezes indicate respiratory illness and are potentially serious but do not necessarily indicate respiratory distress that requires immediate medical attention.
A client has disabling attacks of vertigo. The nurse suspects that the client has Meniere's disease. The nurse is aware that the diet of the client must be modified. Which of the following is the best diet for the client?
A) High protein
B) Low Carbohydrates
C) Low Sodium
D) Low Fat
C = A low sodium diet is frequently an effective mechanism for reducing the frequency and severity of the disease episodes.
About three-quarters of clients with Meniere's disease respond to treatment with a low salt diet
A 21y.o. client has been diagnosed with hydatidiform mole. Which of the following factors is considered a risk factor for developing hydatidiform mole?
1. age in 20s or 30s
2. high in SES
3. Primigravida
4. prior molar gestation
4.
previous molar gestation increases risk for developing subsequent molar gestation by 4-5 times. Adolescents and women ages 40+ are at increased risk for molar pregs. MULTIGRAVIDAS, esp women with prior preg loss, and women with LOWER SES are at increased risk for this problem.
The nurse manager is making patient assignments for the shift. What should be the primary guiding factor in these assignments?
1. Number of staff available.
2. Skill mix of the staff.
3. Patient needs.
4. Physical layout of the unit.
Answer:
3. Patient needs.
Rationale 1: This is an important determinant of staff assignments, but is not the most important factor.
Rationale 2: This is an important determinant of staff assignments, but is not the most important factor.
Rationale 3: The most important factor in any decision made by any health care provider should be patient needs.
Rationale 4: This is an important determinant of staff assignments, but is not the most important factor.
A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present?
A: Slow pulse rate
B: Weight gain
C: Decreased systolic pressure
D: Irregular WBC lab values
(B) Weight gain is associated with CHF and congenital heart deficits.
The nurse suspects that a patient is being physically abused at home. What is the best environment in which to discuss the possibility of abusive events?
1) The patient's shared semiprivate room
2) The hallway outside the patient's room
3) An empty corner at the nurse's station
4) A conference room at the end of the hall
Answer:
2) Positive self-talk
Rationale:
The nurse engaging in positive self-talk is using intrapersonal communication—conscious internal dialogue. Staff meetings, shift report, and a committee meeting are all examples of group or interpersonal communication.
Which of the following is the most common surgical procedure for chronic otitis media?
A) Myringotomy
B) Ossiculoplasty
C) Mastoidectomy
D) Tympanoplasty
D
Tympanoplasty involves surgical reconstruction as the tympanic membrane and is done to re-establish middle ear function, close perforation, prevent recurrent infections.
- sew the tympanic membrane back up!
A client, 34 weeks pregnant, arrives at the ER with SEVERE abdominal pain, uterine tenderness and an increased uterine tone. The client denies vaginal bleeding. The external fetal monitor shows fetal distress with severe, variable decels. The client most likely has which of the following?
1. Abruptio placentae
a client w/ severe abruptio placentae will often have SEVERE abdominal pain. The uterus will have increased tone w/ little to no return to resting tone btw/ contractions.
The fetus will start to show signs of distress, with decels in the HR or even fetal death w/ large placental separation.
Placenta previa usually involves PAINLESS vaginal bleeding w/out UCs.
A molar preg. generally would be detected before 34 weeks gestation.
The manager has asked the staff to participate in the selection of new intravenous pumps for the unit. The manger has provided a list of choices and budget guidelines. This is an example of use of which management strategy?
1. Use of expert power.
2. Use of legitimate power.
3. Empowerment of staff.
4. Management persuasiveness.
Answer:
3. Empowerment of staff.
Rationale 1: This manager has used expert opinion, not expert power.
Rationale 2: Legitimate power is the type of power that is "awarded" with a position.
Rationale 3: This action enables others to act and provides others with the opportunity to participate and influence decisions.
Rationale 4: The manger would have used persuasiveness to convince the staff to adopt a particular kind of pump that the manager chose.
A patient asks a nurse, "My doctor recommended I increase my intake of folic acid. What type of foods contain folic acids?"
A: Green vegetables and liver
B: Yellow vegetables and red meat
C: Carrots
D: Milk
A) Green vegetables and liver are a great source of folic acid.
Which factor(s) in the patient's past medical history place(s) him at risk for falling? Select all that apply.
1) Orthostatic hypotension
2) Appendectomy
3) Dizziness
4) Hyperthyroidism
Answer:
1) Orthostatic hypotension
3) Dizziness
Rationale:
Orthostatic hypotension, cognitive impairment, difficulty with walking or balance, weakness, dizziness, and drowsiness from certain medications place the patient at risk for falling. A history of right appendectomy and hyperthyroidism do not place that patient at risk for falling.
A community health nurse is teaching smoking cessation program to a group of healthy adult smokers. What type of prevention activity is this?
A) Primary
B) Secondary
C) Tertiary
D) None of the above
A = primary cancer prevention targets healthy individuals and includes steps to avoid factors that might lead to the development of diseases.
When teaching an antepartal client about the passage of the fetus through the birth canal during labor, the nurse describes the cardinal mechanisms of labor. Place these events in the proper sequence in which they occur:
1. Flexion
2. External rotation
3. Descent
4. Expulsion
5. Internal Rotation
6. Extension
1. Descent
2. Flexion
3. Internal rotation
4. Extension
5. External rotation
6. Expulsion
Which is true about the termination process? (Select all that apply)
A. The manager can fire an employee after they are confident that everything possible was done to help correct the situation
B. The employee must be aware of the consequences following discussion about the issue at hand.
C. The nurse manager must consult her boss before terminating the individual.
D. The manager must verify that continuing employment would have negative effects on patient care.
Answer: A, B, D
Not C: The nurse does not need to consult her boss before terminating the individual. The manager must check with human resources to ensure termination is justifiable legally and the proper steps have been followed
A nurse is administering blood to a patient who has a low hemoglobin count. The patient asks how long to RBC's last in my body? The correct response is.
A: The life span of RBC is 45 days.
B: The life span of RBC is 60 days.
C: The life span of RBC is 90 days.
D: The life span of RBC is 120 days.
(D) RBC's last for 120 days in the body.