WorksheetsMS1 Pretest
Total questions: 60
Worksheet time: 2hrs 32mins
Which action by the nurse will facilitate relaxation of the abdominal muscles during exam of the abdomen?
Flex the client's legs by placing a pillow under the knees.
Avoid the use of pillow under the head during exam.
Provide privacy to the client and instruct him to relax.
Raise the client's arms or fold them behind the head.
Nurse Obet is caring for a client with distended abdomen. Which parameter should Nurse Obet measure to assess for improvement?
Perform percussion for tympany.
Palpate the abdomen.
Auscultate the bowel sounds.
Measure abdominal girth.
Nurse Caloy observes tenderness over the costovertebral angle on the right side. He recognizes that this is an abnormal finding of which organ?
liver
gallbladder
kidney
spleen
Which change in auscultation of bowel sounds should the nurse recognize as a sign of an intestinal obstruction?
A soft click every 5-15 seconds.
An increase in the pitch.
Increase in the frequency of gurgles.
No sound heard in one minute.
Nurse Juana is performing light palpation of the abdomen and feels prominent, non-tender, pulsating mass above the umbilicus that measures approximately 6cm. What is an appropriate action by Nurse Juana?
Assist the client to the bathroom to empty the bladder.
Stop the palpation and notify the health care provider.
Auscultate over the same area for the presence of a bruit.
Use percussion to determine the solidity of the structure
A client reports severe pain in the LLQ for 3 days duration. How should the nurse conduct palpation of the abdomen due to this history?
Encourage the client to relax to minimize pain.
Medicate for pain before beginning the assessment.
The LLQ is palpated last.
This area should be avoided completely
The nurse is preparing to assess the abdomen of a hospitalized client 2 days after abdominal surgery. The nurse should first:
Palpate the incision site.
Auscultate for bowel sounds.
Percuss for tympany.
Inspect the abdominal area.
The nurse is planning to assess the abdomen of an adult male client. Before the nurse begins assessment, the nurse should:
ask the client to empty his bladder.
place the client in a side lying position.
ask the client to hold his breath for a few seconds.
tell the client to raise his arms above his head.
During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should:
palpate the abdomen before auscultation.
listen in each quadrant for 15 seconds.
use the diaphragm of the stethoscope.
begin auscultation in the left upper quadrant.
The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should:
perform this abdominal assessment first.
ask the client to assume a side-lying position.
palpate lightly while slowly releasing pressure.
palpate deeply while quickly releasing pressure.
The hospitalized client with GERD is complaining of chest discomfort that feels like heartburn following a meal. After administering an ordered antacid, the nurse encourages the client to lie in which of the following positions?
Supine with the head of bed flat.
On the stomach with the head flat.
On the left side with the head of the bed elevated 30 degrees.
On the right side with the head of the bed elevated 30 degrees.
Nurse Juana is planning to teach the client with GERD about substances that will increase the lower esophageal sphincter pressure. Which of the following items would Nurse Juan include on this list?
Fatty foods
Nonfat milk
Chocolate
Coffee
Bethanechol has been ordered for a client with GERD. The nurse should evaluate the client for which of the following side effects?
Constipation
Urinary urgency
Hypertension
Dry oral mucosa
Your client has been diagnosed with GERD and has attended two sessions with the dietitian to learn about diet modifications. The teaching would be considered successful if the client says that she will decrease her intake of which of the following foods?
Fats
High sodium foods
Carbohydrates
High calcium foods
You are an ER nurse performing an admission assessment on a client diagnosed with GERD. Which signs and symptoms would indicate GERD?
Pyrosis, globus, and flatulence
Weight loss, dysarthria and diarrhea
Decreased abdominal fat, proteinuria, diarrhea
Midepigastric pain, (+) H.pylori test and melena
A patient is taking Bethanechol for treatment of GERD. This is known as what type of drug?
Proton-pump inhibitor
Histamine receptor blocker
Prokinetic
Mucosal Healing Agent
Nurse Bea is preparing the patient with GERD for surgery. Which of the following assessment findings should be reported to the attending physician?
The client's Bernstein esophageal test was positive.
The client's abdominal x ray shows hiatal hernia.
The client's WBC count is 14.0 x109/L.
The client's Hgb is 13.8g/dL.
The client with peptic ulcer disease needs dietary modification to reduce episodes of epigastric pain. The nurse tells the client that which of the following items does not need to be limited or eliminated with the disease?
Pink Moscato
Kenny Rogers Classic healthy plate
Vietnamese coffee
Fruit platter
A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid?
My antacid will be most effective if I take it whenever I experience stomach pains.
It is best for me to take my antacid 1 to 3 hours after meals.
I should take my antacid before I take my other medications.
I need to decrease my intake of fluids so that I don't dilute the effects of my antacid.
Your patient is experiencing a flare-up with Crohn's Disease. A complete bowel rest is ordered by the physician. You are administering TPN (total parental nutrition) per physician order. When developing the patient's nursing plan of care, which nursing diagnosis is MOST important to include in the care plan?
Risk for allergy response
Risk for unstable blood glucose level
Risk for imbalance nutrition: more than body requirements
Risk for imbalances nutrition: less than body requirements
Which of the following hormones would be expected to increase if you were studying all day for a test and skipped breakfast and lunch?
Glucagon
Calcitonin
Insulin
Growth Hormone
Growth factors and histamine are chemical agents released in small amounts that act locally on neighboring cells. Which of the following best describes the function of growth factors and histamine?
Endocrine function
Autocrine function
Paracrine function
None of the above
Which of the following is both an endocrine and exocrine gland?
Parathyroid glands
Adrenal glands
Liver
Thyroid glands
The primary role of the parathyroid gland is:
To maintain metabolic homeostasis
To regulate serum calcium levels
To send hormonal signals to other endocrine organs
To receive hormonal signals from the hypothalamus
All of the following are true of posterior pituitary hormones except:
They include direct and tropic hormones
They are released from the posterior pituitary
A nerve signal from the hypothalamus stimulates their release
They include antidiuretic hormone and oxytocin
Identify an endocrine gland within the brain.
Adrenal gland
Pancreas
Pituitary gland
Parathyroid glands
ADH will stimulate ______ water reabsorption by the kidneys and _____of the blood vessels; thus ______ blood pressure.
decrease: constriction: increase
decrease: dilatation: decrease
increase: constriction: increase
increase: dilation: decrease
When blood calcium levels are high, ____ is released from the thyroid gland to deposit the excess calcium into the bones.
parathyroid hormone
calcitonin
oxytocin
glucagon
Which of the following patients are at risk for developing Cushing's Syndrome?
A patient with a tumor on the pituitary gland which is causing too much ACTH to be secreted.
A patient taking glucocorticoids for several weeks.
A patient with a tuberculosis infection.
A patient who is post-opt from an adrenalectomy
A patient with Cushing's syndrome will be undergoing an adrenalectomy. Which of the following will be included in the patient's discharge teaching after the procedure?
Glucocorticoid replacement therapy
Avoiding avocadoes and pears
Declomycin therapy
Signs and symptoms of Grave's disease
During assessment of the patient with acromegaly, the nurse would expect the patient to report:
infertility
dry, irritated skin
undesirable changes in appearance
an increase in height of 2-3 inches per year
Nurse Philip is planning care for a client with a growth hormone deficiency. Which action should the nurse Philip include in this client's plan of care?
Avoid intramuscular medications.
Place the client on protective isolation
Use the lift sheet to re-position the client
Assist the client to dangle before rising
The nurse asks the client to state her name as soon as she regains consciousness post-operatively after a subtotal thyroidectomy and at each assessment. The nurse does this primarily to monitor for signs of which of the following?
Internal hemorrhage
Decreasing level of consciousness
Laryngeal nerve damage
Upper airway obstruction
A 60-year-old woman is diagnosed with hypothyroidism. Signs and symptoms of hypothyroidism include:
Tachycardia
Weight gain
Diarrhea
Anorexia
Appropriate nursing diagnoses for a client with hypothyroidism would probably include which of the following?
Risk for Injury (corneal abrasion) related incomplete closure of eyelid.
Imbalanced Nutrition: Less Than Body Requirements related to hypermetabolism
Deficient fluid volume related to diarrhea
Activity intolerance related to fatigue associated with the disorder
Which statement should the nurse make when teaching the client about taking oral glucocorticoids?
"Take your medication with full glass of water"
"Take your medication on an empty stomach."
"Take your medication at bedtime to increase absorption."
"Take your medication with meals or with an antacid."
A client has been found to have an adrenal tumor and is scheduled for a bilateral adrenalectomy. The nurse begins pre-operative teaching, which includes the importance of deep breathing. Which of the following would be the most accurate instructions?
"Sit in an upright position and take a deep breath."
"Hold your abdomen firmly with a pillow and take several deep breaths"
"Tighten your stomach muscles as you inhale and breathe normally"
"Raise your shoulders to expand your chest."
A patient is recovering from a thyroidectomy. The patient starts to complain of tingling and numbness in the face, toes, and fingers. Which of the following findings below warrants attention?
Ca+ level: 6mg/dL
Na level: 145 mg/dL
K+ level: 3.5 mg/dL
Phosphate level: 4.3 mg/dL
Fill in the blank regarding the negative feedback loop for thyroid hormone production: The ______________ produces TRH (Thyrotropin-Releasing Hormone) which causes the anterior pituitary gland to produce _______________ which in turn causes the thyroid gland to release _______ and _______.
A. Thalamus, CRH (Corticotropin-releasing hormone), TSH (thyroid-stimulating hormone) and T4.
B. Hypothalamus, TSH (thyroid-stimulating hormone), T3 and T4
C. Posterior pituitary gland, TSH (thyroid-stimulating hormone), T3 and T4.
Hypothalamus, CRH (Corticotropin-releasing hormone), TSH (thyroid-stimulating hormone), T3 and TSH.
The nurse is reviewing laboratory results for the clinic patients to be seen today. Which patient meets the diagnostic criteria for diabetes mellitus?
A 48- year- old woman with a hemoglobin A1C of 8.4%
A 58- year- old man with a fasting blood glucose level of 111 mg/dl
A 68- year- old woman with a random plasma glucose of 190 mg/dl
A 78- year- old man with a 2 hour glucose tolerance plasma glucose of 184 mg/dl
The nurse teaches a 38-year-old man who was recently diagnosed with type 1 diabetes mellitus about insulin administration. Which statement by the patient requires an intervention by the nurse?
"I will discard any insulin bottle that is cloudy in appearance."
"The best injection site for insulin administration is in my abdomen."
"I can wash the site with soap and water before insulin administration."
"I may keep my insulin at room temperature (75° F) for up to a month."
The nurse is evaluating a 45-year-old patient diagnosed with type 2 diabetes mellitus. Which symptom reported by the patient is considered one of the classic clinical manifestations of diabetes?
Excessive thirst
Gradual weight gain
Overwhelming fatigue
Recurrent blurred vision
What is the priority action for the nurse to take if the patient with type 2 diabetes complains of blurred vision and irritability?
call the physician
administer insulin as ordered
check the patient's blood glucose level
assess for other neurologic symptoms
Which of the following symptoms is not present in hyperglycemia?
extreme thirst
hunger
blood glucose <60mg/dl
Glycosuria
A patient with diabetes asks you about what type of exercise they should perform throughout the week. The best response is:
Lifting weights
Sprinting
Swimming
Jumping
A patient is scheduled to take 5 units of Humulin R and 10 units of NPH. What is the proper way of mixing these insulins?
These insulins cannot be mixed, therefore, should be drawn up in different syringes.
Draw-up the Humulin R insulin first and then the NPH insulin
Draw-up 2.5 units of NPH, then 10 units of Humulin R, and then finish drawing up 2.5 units of NPH.
Draw-up the NPH insulin first and then the Humulin R insulin.
A client newly diagnosed with diabetes mellitus has been stabilized with insulin injections daily. Nurse Gina prepares a discharge teaching plan regarding insulin. The teaching plan should reinforce which of the following concepts?
Increase the amount on insulin before unusual exercise
Ketones in the urine signify a need for less insulin
Always keep insulin vials refrigerated
Systematically rotate insulin injection sites
You're caring for a patient with Parkinson's Disease that has tremors. Select the option that is INCORRECT about tremors experienced in this disease:
The tremors are most likely to occur with purposeful movements.
A common term used to describe the tremors in the hands and fingers is called "pill-rolling".
Tremors are one of the most common signs and symptoms in Parkinson's Disease.
Tremors in this disease can occur in the hands, fingers, arms, legs and even the lips and tongue.
Which is the main pathology of Parkinson disease that causes changes in muscular and sensory function?
Reduction of acetylcholine in the brain
Reduction of dopamine in the brain
Genetic predisposition
Presence of Lewy bodies
When planning care for a patient with a cervical spinal cord injury (C5), which nursing diagnosis has the highest priority?
Impaired urinary elimination related to tetraplegia
Risk for impaired tissue integrity related to paralysis
Disabled family coping related to the extent of trauma
Ineffective airway clearance related to cervical spinal cord injury
When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority?
Assessment of respiratory rate and depth
Continuous cardiac monitoring for bradycardia
Application of pneumatic compression devices to both legs
Administration of methylprednisolone (Solu-Medrol) infusion
A patient is admitted to the emergency room with SCI at the level of T2. Which clinical finding is of most concern by the nurse?
SpO2 of 92%
heart rate of 42 bpm
BP of 88/60
loss of motor and sensory function in the arms and legs
A patient is admitted to the emergency room with a possible cervical SCI following an automobile crash. During admission of the patient, what is the highest priority for the nurse?
maintaining a patent airway
assessing the patient for head and other injuries
maintaining immobilization of the cervical spine
assessing the patient's motor and sensory function
A client has noticed recently having clearer vision at distance than up close. What is the term used to describe this client's visual condition?
Myopia
Hyperopia
Astigmatism
Emmetropia
A patient says she was diagnosed with astigmatism. When she asks what that is, what is the best explanation the nurse can give to the patient?
"It happens because the lens of the eye is absent."
"People with astigmatism have abnormally long eyeballs."
"The cornea of the eye is uneven or irregular with astigmatism."
"Astigmatism occurs because the eye muscles weaken with age."
The classic triad of symptoms associated with Meniere's disease is vertigo, tinnitus and:
headache
otitis media
fluctuating hearing loss
vomiting
A patient's MRI imaging shows damage to the cerebellum a week after the patient suffered a stroke. What assessment findings would correlate with this MRI finding?
vision problems
Balance impairment
Language difficulty
impaired short- term memory
You're assessing your patient's pupil size and vision after a stroke. The patient says they can only see half of the objects in the room. You document this finding as:
Hemianopia
Opticopsia
Alexia
Dystopic
A 85-year-old patient has an accidental fall while going to the bathroom without assistance. It appears the patient has sustained a bone fracture to the left leg. The leg's shape is deformed, and the patient is unable to move it. The patient is alert and oriented but in pain. What will you do FIRST after confirming the patient is safe and stable?
Apply an ice pack covered with a towel to the site.
Immobilize the fracture with a splint.
Administer pain medication
Elevate the extremity above heart level
BONUS QUESTION: "Former Philippine President Rodrigo Duterte was imprisoned at The Hague. Due to his illness, his family requested that he be placed under house arrest. What illness is Duterte suffering from?"
