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SP22 Exam 3 Review

Total questions: 25

Worksheet time: 51mins

Name
Class
Date
1.

Which patient below is at most risk for a hemorrhagic stroke?

a)

Which patient below is at most risk for a hemorrhagic stroke?

b)

A 89 year old female with atherosclerosis.

c)

A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago.

d)

A 55 year old female with atrial flutter.

2.

The RN supervising a senior nursing student is discussing methods for preventing acute kidney injury (AKI). Which points would the RN be sure to include in this discussion? Select all that apply.

a)

Encourage patients to avoid dehydration by drinking adequate fluids.

b)

Record intake and output and weigh patients daily.

c)

Monitor laboratory values that reflect kidney function.

d)

Immediately report a urine output of less than 2 mL/kg/hr.

e)

Instruct patients to drink extra fluids during periods of strenuous exercise.

3.

A patient with Hepatitis A asks you about the treatment options for this condition. Your response is?

a)

Antiviral medications

b)

Interferon

c)

Supportive care

d)

Hepatitis A vaccine

4.

A patient is admitted to the ER with signs and symptoms of painful mid-epigastric pain felt in the back, elevated glucose, fever, and vomiting. During the head-to-toe assessment, bluish discoloration around the belly button is noted. What is this called?

a)

Grey-Turner’s Sign

b)

McBurney’s Sign

c)

Homan’s Sign

d)

Cullen’s Sign

5.

A client was brought into the ER for a stroke, but did not receive tissue plasminogen activator (tPA). Which answer below is the best rationale for this?

a)

Client is already on aspirin

b)

Client was brought in 4 hours after onset of symptoms

c)

Client experienced an ischemic stroke

d)

Client experienced hemorrhagic stroke

6.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

a)

A blood glucose level of 480 mg/dl

b)

A right-sided carotid bruit

c)

A blood pressure of 220/120 mmHg

d)

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

7.

You’re providing education to a patient with an active Hepatitis B infection. What will you include in their discharge instructions? Select all that apply:

a)

“Take acetaminophen as needed for pain.”

b)

“Eat large meals that are spread out through the day.”

c)

“Follow a diet low in fat and high in carbs.”

d)

“Do not share toothbrushes, razors, utensils, drinking cups, or any other type of personal hygiene products.”

e)

“Perform aerobic exercises daily to maintain strength.”

8.

What action by the nurse should require the most caution when caring for a patient with hepatitis A?

a)

Inserting an IV

b)

assessing oral mucus mucosa

c)

emptying a patient’s bed pan after a bowl movement

d)

changing the bed linens due to left-over food crumbs on the sheets.

9.

Which is the most common cause of acute encephalitis in the United States?

a)

Human immunodeficiency virus (HIV)

b)

Western equine bacteria

c)

Lyme Disease

d)

Herpes simplex virus (HSV)

10.

A client newly admitted to an in-patient psychiatric unit is diagnosed with obsessive-compulsive disorder. Which behavioral symptom would the nurse expect to assess?

a)

The client uses excessive hand washing to relieve anxiety

b)

The client rates anxiety at 8/10

c)

The client uses breathing techniques to decrease anxiety

d)

A client newly admitted to an in-patient psychiatric unit is diagnosed with obsessive-compulsive disorder. Which behavioral symptom would the nurse expect to assess?

11.

A 34-year-old female undergoes an emergency open cholecystectomy due to severe inflammation with her gallbladder. What is the priority nursing intervention you would provide to this client?

a)

request the UAP empty the NG tube Q3 hours and report output to RN

b)

Encourage deep breathing using the incentive spirometer Q2 hours to avoid post-op atelectasis.

c)

observe incision site for approximation and no signs and symptoms of infection.

d)

administer pain meds PRN

12.

A client is admitted with a possible diagnosis of pancreatitis. Which of the following is a strong indicator for this diagnosis?

a)

Pain in the RUQ of the abdomen

b)

Elevated lipase and amylase levels

c)

Hyperactive bowel sounds

d)

Oxygen saturation level of 95%

13.

A patient with Hepatitis B is being discharged in 2 days. In the discharge teaching plan, the nurse should include instructions to:

a)

Avoid alcohol for the first 3 weeks

b)

Use a condom during sexual intercourse

c)

. Have family members receive the Hep B vaccine

d)

Follow a low-protein, moderate-carb, moderate-fat diet

14.

A patient with AKI has a urinary output of 350 mL/day. In addition, morning labs showed an increased BUN and creatinine level along with potassium level of 6 mEq/L. What type of diet ordered by the physician is most appropriate for this patient?*

a)

Low-sodium, high-protein, and low-potassium

b)

High-protein, low-potassium, and low-sodium

c)

Low-protein, low-potassium, and low-sodium

d)

High-protein and high-potassium

15.

A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. Which theoretical principle best explains the etiology of this client's depressive symptoms?

a)

According to psychoanalytic theory, depression is a result of anger turned inward

b)

According to object-loss theory, depression is a result of abandonment.

c)

According to learning theory, depression is a result of repeated failures.

d)

According to cognitive theory, depression is a result of negative perceptions.

16.

A client with a history of severe depression and anxiety is in the hospital after attempting suicide. Which evidence would most likely be seen that indicates a crisis in a person with a mental illness? Select all that apply.

a)

The client has not slept for several nights in a row

b)

The client is socially withdrawn

c)

The client has increased interest in personal hygiene

d)

The client is crying

17.

For a client diagnosed with anorexia nervosa, which goal takes priority?

a)

Establishing adequate daily nutritional intake

b)

Developing a contract with the nurse that sets a target weight

c)

Identifying self-perceptions about body size as unrealistic

d)

Verbalizing the possible physiologic consequences of self-starvation

18.

You’re providing education to a patient with an active Hepatitis B infection. What will you include in their discharge instructions? Select all that apply:

a)

“Take acetaminophen as needed for pain."

b)

“Eat large meals that are spread out through the day.”

c)

“Follow a diet low in fat and high in carbs.”

d)

“Do not share toothbrushes, razors, utensils, drinking cups, or any other type of personal hygiene product.”

e)

“Perform aerobic exercises daily to maintain strength.”

19.

A patient is being admitted to the Neuro ICU following an acute head injury. The patient has cerebral edema. The nurse would expect to administer what priority medication to reduce the swelling?

a)

Hydro Diuril

b)

Lasix

c)

Mannitol

d)

Aldactone

20.

Clients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia?

a)

Hypotension

b)

Warm moist skin

c)

Bradycardia

d)

Polyuria

21.

A client has just experienced the loss of her mother and says, “God, why did you have to take my mother away, bring her back? I need to talk to her one last time.” What stage is the client experiencing in Kubler Ross’s stages of Grief?

a)

Denial

b)

Bargaining

c)

Depression

d)

Acceptance

22.

A patient diagnosed with acute kidney failure had a urine output of 1560 mL for the past 8 hours. The LPN/LVN who is caring for this patient under the RN's supervision asks how a patient with kidney failure can have such a large urine output. What is the RN's best response?

a)

“The patient's kidney failure was caused by hypovolemia, and we have given him IV fluids to correct the problem.”

b)

“Acute kidney failure patients go through a diuretic phase when their kidneys begin to recover and may put out as much as 10 L of urine per day.”

c)

“With that much urine output, there must have been a mistake in the patient's diagnosis.”

d)

“An increase in urine output like this is an indicator that the patient is entering the recovery phase of acute kidney failure.”

23.

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply

a)

Dental decay

b)

Moist, oily skin

c)

Loss of tooth enamel

d)

Electrolyte imbalances

e)

Bodyweight well below the ideal range

24.

What is a clinical manifestation of meningitis?

a)

Neck Mobility

b)

Negative Brudzinski Sign

c)

Photophobia

d)

Negative Kernig Sign

25.

A 13-year-old client returns to the clinic for follow up for Major Depressive Disorder. The client states, I do not feel like going on with life, I wish things would just end now”. As the nurse, what is the correct response to ensure safety?

a)

“it’s okay, you are very young. Things will get better soon”.

b)

“How long have you had these thoughts.”

c)

“Do you have a plan to kill yourself?”

d)

“So, you do not feel like going on with life?”