Nursing Concepts 6 Practice Test Flashcards

Terms Definitions
The nurse is obtaining a sputum specimen for acid-fast bacillus. Which action will best protect the nurse during this procedure?
Place the specimen container in a sealed plastic bag.
Which nursing diagnosis should receive priority in the plan of care for a three-month-old infant who has a salmonella infection?
fluid volume deficit
The nurse is assessing a three-year-old patient with upper respiratory symptoms. Which clinical manifestation is indicative of rubeola (measles)?
Koplik's spots on the buccal mucosa
Which is the drug of choice for the treatment of streptococcal pharyngitis?
penicillin V potassium (Pen-Vee K)
A three-year-old patient is admitted with sepsis and possible Haemophilus influenzae meningitis. Which action should the nurse take prior to initiating the prescribed antibiotic therapy?
Ensure that blood, urine, and cerebrospinal fluid (CSF) cultures are obtained.
Why is it particularly important for the nurse interviewing a patient with gonorrhea to identify the patient's sexual contacts?
Gonorrhea may be asymptomatic.
Which health problem often precedes the occurrence of rheumatic fever?
streptococcal pharyngitis
The nurse reviews the nutritional history of a 10-year-old child who developed a salmonella infection. Which food is most likely to be the cause of the infection?
cookie dough
Which vaccine is contraindicated for a child who is HIV seropositive and severely immunocompromised?
rubella
A positive response to which diagnostic test is the best indicator that a patient who is HIV seropositive has tuberculosis?
sputum specimen
Which observation indicates a urinary tract infection (UTI) in a school-age child?
enuresis
Which infectious disease can be diagnosed through the use of blood studies
syphilis
A patient with chills uses accessory neck muscles to breathe. Chest movement is restricted and inspiratory crackles are heard on auscultation. Which acute condition should the nurse suspect?
pneumonia
A patient with a urinary tract infection is taking sulfisoxazole (Gantrisin). Why should the nurse increase this patient's fluid intake?
to prevent crystalluria
A patient with a urinary tract infection (UTI) is seen at a community health center and amoxicillin trihydrate (Amoxil) is prescribed. Three days later, the laboratory report on the patient's urine specimen reads, "Bacterial count 150,000 colonies pe
The bacterial count is excessive and Amoxil should be continued.
Which is a clinical manifestation of herpes zoster (shingles)?
vesicles along one side of the thorax
Which symptoms in a patient with AIDS are most characteristic of Pneumocystis carinii pneumonia infection?
fever, dyspnea, and nonproductive cough
The nurse is planning discharge instructions for a patient who has acquired immunodeficiency syndrome (AIDS). The nurse should stress that disinfection can be effectively achieved in the home by cleaning contaminated surfaces with which substance?
a dilute solution of sodium hypochlorite
What is natural immunity?
protection induced by actually contracting the causative agent of the disease
How does the herpes simplex virus, type 2 (HSV-2) survive in the body? The virus
invades nerve ganglia when its replication diminishes.
Which person is most likely to have a significant positive response (greater than 9 mm) to the Mantoux test?
a person who has a history of tuberculosis
Which information in a patient's health history indicates that the patient is at risk for infection from hepatitis B?
employed as a dentist
Which clinical manifestation is most indicative of Lyme disease in children?
ring-shaped rash
What are the initial clinical manifestations of shigella infection?
fever and abdominal cramping
Which measure should be included in the nursing management of a patient with pelvic inflammatory disease (PID)?
Maintain semi-Fowler's position.
A nurse has given home care instructions to the husband of a 78-year-old woman who is going home after an open reduction and internal fixation of a hip fracture. The nurse realizes that the patient's husband needs further instruction when the husband make
I have put a hospital bed in the dining room so that I do everything for her more easily
Which condition has clinical manifestations similar to those of systemic lupus erythematosus (SLE)?
rheumatoid arthritis
The community health nurse arrives at a patient's home to find the patient lying on the floor. The patient is oriented to person, time, and place. The patient's right leg is shorter than the left and is adducted. The nurse suggests that the patient be tra
The nurse suspects a fracture of the femoral neck.
The nurse has provided pin site care for a patient in skeletal traction who has a Steinmann pin in place. Which observation should the nurse be certain to include in the nurse's report?
heat and swelling at the pin site
Which are primary goals for a patient scheduled for orthopedic surgery?
pain relief, tissue perfusion, health maintenance, improved mobility, and improved self-concept
Which is the best indicator of circulatory complications in a patient who underwent a right total hip replacement 3 days ago? The patient experiences pain upon
dorsiflexion of the right ankle.
The presence of a diseased bone would make a patient more prone to which type of fracture?
pathologic
Which laboratory blood test result supports a diagnosis of systemic lupus erythematosus (SLE)?
positive for antinuclear antibodies
After teaching a patient with osteoporosis about nutritional needs, the nurse determines the patient understands high-calcium foods when the patient selects which meal?
tuna sandwich on whole wheat bread, one cup of fruit yogurt, and one cup of skim milk
Which is an alternative means to reduce the perception of pain?
back massage
A nurse is caring for a 29-year-old patient who is admitted with a spiral fracture of the femur resulting from a motor vehicle accident. The patient's pain seemed to decrease during the night. In the morning, the patient is restless and irritable. What fu
Get an order to obtain blood gas values.
What will cause a pressure bandage to become saturated with blood immediately following a below-the-knee amputation?
bleeding from a loosened suture
Which nursing intervention is appropriate to include in a plan of care for a patient in Buck's traction?
Remove the foam boot and inspect the skin three times daily.
Two days following multiple fractures, a patient reports shortness of breath and chest pain. Upon assessment, the nurse also finds the patient to be confused. The nurse should suspect which complication?
fat embolism
A patient complains of pain in the right great toe 24 hours after a right above-the-knee amputation. What is the nurse's first action?
Administer the prescribed narcotic analgesic.
A patient with rheumatoid arthritis of the hands asks the nurse why resting splints are necessary. The nurse explains that resting splints are used for which purpose? Resting splints
stabilize and immobilize joints in desired position when use of the hand is not required.
Which discharge instruction should the nurse provide to the parents of an 18-month-old child who is in a hip spica cast?
"Tuck a disposable diaper beneath the entire perineal opening of the cast to keep it clean."
Which injury of a child is most suggestive of physical abuse?
spiral fracture of the humerus
Which nursing action should receive priority for a patient who is recovering from a total hip replacement?
Position the patient using an abductor pillow.
Which instruction should the nurse give to a patient who is receiving prophylactic probenecid-colchicine (ColBENEMID) therapy?
Drink eight glasses of water a day.
A 60-year-old patient is admitted to the hospital with a fracture of the right femur. Which assessment should the nurse be most concerned about?
The patient pulls at the bed covers and talks to the wall.
The nurse teaches an adolescent client about management of scoliosis with a body brace. Which client statement indicates that the teaching was effective?
"Wearing the brace 23 hours a day will be hard for me."
Which action should the nurse take when caring for a patient with a newly applied cast?
Keep the cast uncovered.
What is the appearance of normal synovial fluid?
clear and straw-colored
Which nursing goal should receive priority for a patient in a full leg cast who is on prolonged bed rest?
Maintain skin integrity.
Which area of the brain is responsible for vision?
occipital
A patient with a newly diagnosed seizure disorder is started on phenytoin sodium (Dilantin). Which statement made by the patient indicates a need for further teaching related to the medication?
"I'll need to eat potassium-rich foods."
The nurse is assessing a patient who has a score of 6 on the Glasgow Coma Scale. Which level of response should the nurse expect to observe?
The patient withdraws the arms to painful stimuli.
How is the diagnosis of myasthenia gravis confirmed?
IV administration of edrophonium chloride (Tensilon test)
A patient with a head injury is scheduled for a magnetic resonance imaging (MRI) examination. To reduce the patient's anxiety, which health teaching would be most important to include?
The use of relaxation procedures will promote reduction of the claustrophobia associated with placement in the narrow tube.
What is the expected result of eliciting the biceps reflex in a patient?
elbow flexion
The nurse is taking care of a patient with breast cancer and chronic trigeminal neuralgia. The patient is complaining that the trigeminal neuralgia is bothering her and she would like treatment for it. What is the initial nursing intervention?
Assess corneal reflex.
A patient had a supratentorial craniotomy 24 hours ago. What is the rationale for maintaining this patient in semi-Fowler's position?
to promote drainage of venous and cerebrospinal fluids
A patient with a C5 spinal cord injury is entering the acute rehabilitative phase. Which is an appropriate long-term goal for this patient? The patient will
feed self with adaptive equipment and assistance in setup.
Which information should be included in the discharge teaching plan for a patient with epilepsy who experiences generalized tonic-clonic seizures?
Precipitating factors for seizure activity include increased stress, insomnia, and alcohol use
Which finding should the nurse expect when assessing a patient who exhibits agnosia after having a cerebrovascular accident? The patient will be unable to
recognize or interpret objects.
Which capability is impaired in a patient with myasthenia gravis?
motor function
Which nursing action should receive priority in the plan of care for a patient in the acute phase of a cerebrovascular accident?
Place the patient in a lateral position with the head of the bed elevated.
Which medication is used to decrease intracranial pressure (ICP) in a patient with a brain injury?
mannitol (Osmitrol)
Which sign is most characteristic of Parkinson's disease?
pill-rolling tremors
A patient who has sustained a complete spinal cord transection at level C4 will most likely have which condition?
quadriplegia
Which medication would a nurse anticipate immediately administering to a patient with a progressive brain attack (cerebrovascular accident [CVA]; stroke) who has a history of hypertension?
heparin IV
A 28-year-old patient with multiple sclerosis smiles and laughs almost constantly while awake. What is the pathophysiological basis for this clinical manifestation?
demyelination of the nervous system
Which information should the nurse provide to a school-age child prior to a noncontrast computerized axial tomography (CAT) scan?
"You will need to lie perfectly still while a big machine takes pictures."
A patient who has bacterial meningitis complains of severe headache and has a temperature of 39.2̊ C (102.6̊ F). What is the nurse's intervention?
Perform a neurological assessment on the patient.
Which long-term outcome is appropriate for a patient with early Parkinson's disease? The patient will
continue to participate in usual activities.
Which nursing measure is used to minimize pain in the affected arm of a patient who has had a cerebrovascular accident (CVA; brain attack; stroke)?
applying a sling
What can result from an injury to the frontal lobe of the cerebrum? A deficit in
sense of humor
A 10-year-old child with a neurogenic bladder has been taught to perform intermittent self-catheterization. Which data indicates that the child is achieving the goal of continence?
The child experiences no dribbling between catheterizations.
Which nursing action is appropriate when caring for a patient who is experiencing a generalized (grand mal) seizure?
Place the patient in a lateral position.
A patient who experienced a circumferential full-thickness (third-degree) burn of the left lower leg complains of numbness and tingling in the left foot. The nurse notes that the foot is cool to the touch and no pulse is palpable. What is the explanation
Edema formation under the eschar has occluded the blood supply to the foot.
Following major abdominal surgery, a patient's central venous pressure (CVP) decreases to 3 cm H2O. Based on this data, the nurse should continue to assess for which complication?
hypovolemic shock
Why is an injured person immobilized before being removed from the scene of a motor vehicle accident
to prevent further damage and loss of neurological function
A patient with malnutrition develops wound dehiscence following abdominal surgery. What is the most likely explanation for this problem?
Collagen production is diminished.
Which menu selection by a 10-year-old child with severe burns indicates that the nurse's nutritional instruction has been effective?
milk shake and peanut butter sandwich
Which patient should the nurse plan to monitor closely for postoperative complications of hypoventilation?
a 78-year-old patient who had an open cholecystectomy
The skin is most susceptible to excoriation from drainage following which surgical procedure?
ileostomy
Which measure should the nurse include in the plan of care for a patient with major burns to alleviate the patient's negative nitrogen balance?
Increase protein intake
Which side effect is associated with the combined use of skeletal muscle relaxants and general anesthesia?
respiratory arrest
Which ultrasound test result confirms cholelithiasis.
calculi in the gall bladder
Which assessment data are indicative of intraperitoneal injury in a patient who has sustained multiple injuries in an automobile accident?
Which assessment data are indicative of intraperitoneal injury in a patient who has sustained multiple injuries in an automobile accident?
How should the nurse position a postoperative patient in order to prevent aspiration?
sidelying
Which postoperative physiological process affects a patient's fluid and electrolyte balance?
a stimulation of antidiuretic hormone
Which instruction to parents is most effective in reducing the incidence of electrical burn injuries in toddlers? Eliminate a child's access to electrical sockets by
inserting child-proof covers in all electrical sockets.
Which outcome indicates adequate fluid resuscitation in a patient with a burn injury?
urinary output greater than 30 mL per hour
Which statement best describes the pain associated with a duodenal ulcer? It is localized in the
epigastrium and occurs 1 - 3 hours after meals.
Which manifestations occur following the ingestion of a corrosive chemical?
pain, inability to swallow, and drooling
What is the rationale for applying an elastic pressure garment to a patient who has sustained severe burn injuries?
to minimize hypertrophic scarring
The nurse is caring for a patient following an open cholecystectomy. The patient has a Penrose drain in place. Which action by the nurse should be included in the plan of care?
Place dressings around and over the drain
A patient who was severely burned two weeks ago eliminates a black stool. What does this finding indicate?
the development of a Curling's ulcer
Which is a common and early manifestation of diverticulitis?
crampy pain in the lower left quadrant
On the first day following a left below-the-knee amputation, a patient complains of pain in the left foot. Which nursing action is most appropriate initially?
Administer the ordered analgesic
Which laboratory finding would the nurse expect in a school-age child who has taken an overdose of acetaminophen (Tylenol)?
increased liver enzymes
Which food is permitted in the diet of a patient who has ulcerative colitis?
cottage cheese
The nurse should include which instruction in the discharge plan for a patient who has developed dumping syndrome following a gastrectomy?
"Eat small, frequent meals that are low in simple sugars."
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