NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 20, Exams of Nursing

Download NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 20 and more Exams Nursing in PDF only on Docsity! NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED 1. A patient is in the primary infection stage of HIV. What is true of this patient's current health status? a. The patient is infected with HIV but lacks HIV-specific antibodies. 2. A nurse is admitting a patient with an immunodeficiency to the medical unit. In planning the care of this patient, the nurse should assess for what common sign of immunodeficiency? a. Chronic diarrhea 3. A nurse is caring for a patient who has an immunodeficiency. What assessment finding should prompt the nurse to consider the possibility that the patient is developing an infection? a. Persistent diarrhea 4. The nurse is applying standard precautions in the care of a patient who has an immunodeficiency. What are key elements of standard precautions? Select all that apply. a. Using appropriate personal protective equipment b. Using safe injection practices c. Performing hand hygiene 5. A home health nurse is reinforcing health education with a patient who is immunosuppressed and his family. What statement best suggests that the patient has understood the nurse's teaching? a. “My family needs to understand that I'll probably need lifelong treatment.” 6. The nurse is preparing to administer IVIG to a patient who has an immunodeficiency. What nursing guideline should the nurse apply? a. Administer pretreatment medications as ordered 30 minutes prior to infusion. 7. A nurse has created a plan of care for an immunodeficient patient, specifying that care providers take the patient's pulse and respiratory NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED 13. A patient has been diagnosed with AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate for this patient? a. Obtain a stool culture to identify possible pathogens. 14. An 18-year-old pregnant female has tested positive for HIV and asks the nurse if her baby is going to be born with HIV. What is the nurse's best response? a. “It's possible that your baby could contract HIV, either before, during, or after delivery.” 15. Since the emergence of HIV/AIDS, there have been significant changes in epidemiologic trends. Members of what group currently have the greatest risk of contracting HIV? NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED a. Gay, bisexual, and other men who have sex with men 16. A hospital patient is immunocompromised because of stage 3 HIV infection and the physician has ordered a chest radiograph. How should the nurse most safely facilitate the test? a. Arrange for a portable x-ray machine to be used 17. A patient's current antiretroviral regimen includes nucleoside reverse transcriptase inhibitors (NRTIs). What dietary counseling will the nurse provide based on the patient's medication regimen? a. Take this medication without regard to meals. 18. A nurse is performing the admission assessment of a patient who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply. a. Current medication regimen b. Identification of patient's support system c. Immune system function d. History of sexual practices 19. A nurse is aware of the need to assess patients' risks for anaphylaxis. What health care procedure constitutes the highest risk for anaphylaxis? a. Computed tomography with contrast solution 20. A patient with multiple food and environmental allergies tells the nurse that he is frustrated and angry about having to be so watchful all the time and wonders if it is really worth it. What would be the nurse's best response? a. “I can only imagine how you feel. Would you like to talk about it? NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED 21. A nurse is caring for a patient who has allergic rhinitis. What intervention would be most likely to help the patient meet the goal of improved breathing pattern? a. Modify the environment to reduce the severity of allergic symptoms. 22. The nurse in an allergy clinic is educating a new patient about the pathology of the patient's health problem. What response should the nurse describe as a possible consequence of histamine release? a. Contraction of bronchial smooth muscle 23. A patient has presented with signs and symptoms that are consistent with contact dermatitis. What aspect of care should the nurse prioritize when working with this patient? a. Identifying the offending agent, if possible 24. A nurse is educating a patient with gout about lifestyle modifications that can help control the signs and symptoms of the disease. What recommendation should the nurse make? a. Limiting intake of alcohol NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED pneumonia at least one time per year for the last 10 years. What does the nurse suspect the patient is developing? a. Bronchiectasis 12. A nurse is admitting an adolescent patient with a diagnosis of ataxia- telangiectasis. Which of the following nursing diagnoses should the nurse include in the patient's plan of care? a. Risk for Falls Due to Loss of Muscle Coordination 13. A 20-year-old patient with an immunodeficiency is admitted to the unit with an acute episode of upper airway edema. This is the fifth time in the past 3 months that the patient has had such as episode. As the nurse caring for this patient, you know that the patient may have a deficiency of what? a. C1esterase inhibitor 14. A patient with Wiskott-Aldrich syndrome is admitted to the medical unit. The nurse caring for the patient should prioritize which of the following? a. Protective isolation 15. The nurse is admitting a patient to the unit with a diagnosis of ataxia- telangiectasia. The nurse's assessment should reflect the patient's increased risk for what complication? a. Cancer 16. The nurse is working with the interdisciplinary team to care for a patient who has recently been diagnosed with severe combined immunodeficiency disease (SCID). What treatment is likely of most benefit to this patient? a. Hematopoietic stem cell transplantation (HSCT) 17. A patient has been admitted with a phagocytic cell disorder and the nurse is reviewing the most common health problems that accompany these disorders. The nurse should identify which of the following? Select all that apply. NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED a. Chronic otitis media b. Cutaneous abscesses c. Pneumonia 18. A nurse is caring for a patient with a phagocytic cell disorder. The patient states, ìMy specialist says that I will likely be cured after I get my treatment tomorrow. To what treatment is the patient most likely referring? a. Hematopoietic stem cell transplantation 19. A nurse educator is explaining that patients with primary immunodeficiencies are living longer than in past decades because of advances in medical treatment. This increased longevity is associated with an increased risk of what? a. Cancer 20. The nurse educator is differentiating primary immunodeficiency diseases from secondary immunodeficiencies. What is the defining characteristic of primary immunodeficiency diseases? a. They have a genetic origin 21. The nurse is caring for a patient with an immunodeficiency who has experienced sudden malaise. The nurse's colleague states, ìI'm pretty sure that it's not an infection, because the most recent blood work looks fine.î What principle should guide the nurse's response to the colleague? a. Immunodeficient patients will usually exhibit subtle and atypical signs of infection 22. A patient with a diagnosis of primary immunodeficiency informs the nurse that he has been experiencing a new onset of a dry cough and occasional shortness of breath. After determining that the patient's vital signs are within reference ranges, what action should the nurse take? NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED a. Assess the patient for signs and symptoms of infection 23. A nurse is preparing to administer a scheduled dose of IVIG to a patient who has a diagnosis of severe combined immunodeficiency disease (SCID). What medication should the nurse administer prior to initiating the infusion? a. Diphenhydramine 24. An immunocompromised patient is being treated in the hospital. The nurse's assessment reveals that the patient's submandibular lymph nodes are swollen, a finding that represents a change from the previous day. What is the nurse's most appropriate action? a. Inform the patient's primary care provider of this finding 25. A nurse caring for a patient who has an immunosuppressive disorder knows that continual monitoring of the patient is critical. What is the primary rationale behind the need for continual monitoring? a. So that early signs of impending infection can be detected and treated 26. A nurse is planning the care of a patient who requires immunosuppression to ensure engraftment of depleted bone marrow during a transplantation procedure. What is the most important component of infection control in the care of this patient? a. Thorough and consistent hand hygiene 27. A home health nurse is caring for a patient who has an immunodeficiency. What is the nurse's priority action to help ensure successful outcomes and a favorable prognosis? a. Encourage the patient and family to be active partners in the management of theimmunodeficiency 28. A nurse is preparing to discharge a patient with an immunodeficiency. When NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED to the onset of what complication? a. HIV encephalopathy 2. A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority? a. Tachypnea and restlessness 3. A patient has come into the free clinic asking to be tested for HIV infection. The patient asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the AIDS virus are present in the blood, this indicates what? a. The patient has been infected with HIV 4. The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the patient? a. Can you tell me what concerns you most about dying? 5. The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees? a. Hold the condom by the cuff upon withdrawal 6. A nurse is planning the care of a patient with AIDS who is admitted to the unit with Pneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this patient? a. Ineffective Airway Clearance 7. A public health nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. The nurse should prioritize which of the following interventions? a. Educational programs that focus on control and prevention NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED 8. During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection? a. Pneumocystis pneumonia 9. A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the patient's gastrointestinal system and analyzing the data, what is most likely to be the priority nursing diagnosis? a. Diarrhea 10.A A patient with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond? a. Many patients with HIV use some type of alternative therapy and, as with most health treatments, there are benefits and risks 11.A A patient was tested for HIV using enzyme immunoassay (EIA) and results were positive. The nurse should expect the primary care provider to order what test to confirm the EIA test results? a. Western blot test 12. The nurse's plan of care for a patient with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin Integrity Related to Candidiasis. What nursing intervention best addresses this risk? a. Providing thorough oral care before and after meals 13.A A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea? a. Administer antidiarrheal medications on a scheduled basis, as ordered NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED a. Viral set point 20.A A patient with HIV will be receiving care in the home setting. What aspect of self- care should the nurse emphasize during discharge education? a. Importance of personal hygiene 21.A A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of successful therapy? a. Addressing possible barriers to adherence 22. The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently ìcoughed up some blood.î What is the nurse's most appropriate action? a. Place the patient on respiratory isolation and inform the physician (Note: this is a sign of possible TB) 23.A A patient has come into contact with HIV. As a result, HIV glycoproteins have fused with the patient's CD4+ T-cell membranes. This process characterizes what phase in the HIV life cycle? a. Attachment 24. An HIV-infected patient presents at the clinic for a scheduled CD4+ count. The results of the test are 45 cells/μL, and the nurse recognizes the patient's increased risk for Mycobacterium avium complex (MAC disease). The nurse should anticipate the administration of what drug? a. Azithromycin 25.A A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this patient should expect the physician to order NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED what drug for the management of the patient's diarrhea? a. Sandostatin 26.A A patient with AIDS is admitted to the hospital with AIDS-related wasting syndrome and AIDS-related anorexia. What drug has been found to promote significant weight gain in AIDS patients by increasing body fat stores? a. Megestrol 27.A A nurse is completing a nutritional status of a patient who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply. a. Serum albumin level b. Weight history c. BMI d. BUN level 28.A A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces? a. Peri-anal region and oral mucosa 29.A A hospital nurse has experienced percutaneous exposure to an HIV-positive patient's blood as a result of a needlestick injury. The nurse has informed the supervisor and identified the patient. What action should the nurse take next? a. Report to the emergency department or employee health department 30. The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care? a. Keep the patient's bed linens free of wrinkles NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED 31.A A patient who has AIDS is being treated in the hospital and admits to having periods of extreme anxiety. What would be the most appropriate nursing intervention? a. Teach the patient guided imagery 32.A A patient who has AIDS has been admitted for the treatment of Kaposi's sarcoma. What nursing diagnosis should the nurse associate with this complication of AIDS? a. Impaired Skin Integrity Related to Kaposi's Sarcoma b. (This is a disease that involves the endothelial layer of blood and lymphatic vessels. This malignancy does not directly affect swallowing or bowel motility and it doesn’t constitute a risk for disuse syndrome) CHP 38 1. A patient with a family history of allergies has suffered an allergic response based on a genetic predisposition. This atopic response is usually mediated by what immunoglobulin? a. Immunoglobulin E 2. An office worker takes a cupcake that contains peanut butter. He begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? a. Anaphylactic (type 1) 3. A patient is learning about his new diagnosis of asthma with the asthma nurse. What medication has the ability to prevent the onset of acute asthma NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED by IgE antibodies and requires previous exposure to the specific antigen. Skin reactions are more commonly type IV and myasthenia gravis is thought to be a type II reaction. Rheumatoid arthritis is not a type I hypersensitivity reaction. 9. A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patient's discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self- administer epinephrine in what site? a. Thigh 10.A A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a patient's plan of care. The presence of what chronic health problem would most likely prompt this diagnosis? a. Spina bifida 11.A A patient has a documented history of allergies presents to the clinic. She states that she is frustrated by her chronic nasal congestion, anosmia (inability to smell) and inability to concentrate. The nurse should identify which of the following nursing diagnoses? a. Ineffective Individual Coping with Chronicity of Condition and Need for Environmental Modification 12.A A patient's decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies the patient's health problem? a. The patient's body has mistakenly identified a normal constituent of the body as foreign 13. A child is undergoing testing for food allergies after experiencing NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED unexplained signs and symptoms of hypersensitivity. What food items would the nurse inform the parents are common allergens? a. Eggs and wheat The most common causes of food allergies are seafood (lobster, shrimp, crab, clams, fish), legumes (peanuts, peas, beans, licorice), seeds (sesame, cottonseed, caraway, mustard, flaxseed, sunflower seeds), tree nuts, berries, egg white, buckwheat, milk, and chocolate. 14.A A patient has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the patient will present with what alteration in laboratory values? a. Increased eosinophils 15. After the completion of testing, a child's allergies have been attributed to her family's cat. When introducing the family to the principles of avoidance therapy, the nurse should promote what action? a. Removing the cat from the family's home 16. The nurse is providing health education to the parents of a toddler who has been diagnosed with food allergies. What should the nurse teach this family about the child's health problem? a. Many children outgrow their food allergies in a few years if they avoid the offending foods 17.A A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic reaction. What is a priority for health education? a. The need for the parents to carry an epinephrine pen 18. An adolescent patient's history of skin hyperreactivity and inflammation has been attributed to atopic dermatitis. The nurse should recognize that this patient NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED severity of a patient's anaphylactic reaction. What would be the nurse's best response? a. The faster the onset of symptoms, the more severe the reaction 25.A A nurse knows of several patients who have achieved adequate control of their allergy symptoms using over-the-counter antihistamines. Antihistamines would be contraindicated in the care of which patient? a. A pregnant woman at 30 weeks' gestation 26.A A patient has been living with seasonal allergies for many years, but does not take antihistamines, stating, ìWhen I was young I used to take antihistamines, but they always put me to sleep.î How should the nurse best respond? a. The newer antihistamines are different than in years past, and cause lesssedation 27.A A child has been transported to the emergency department (ED) after a severe allergic reaction. The ED nurse is evaluating the patient's respiratory status. How should the nurse evaluate the patient's respiratory status? Select all that apply. a. Assess breath sounds b. Measure the child’s oxygen saturation by oximeter c. Monitor the child’s respiratory pattern d. Assess the child’s respiratory rate 28.A A nurse at an allergy clinic is providing education for a patient starting immunotherapy for the treatment of allergies. What education should the nurse prioritize? a. The importance of keeping appointments for desensitization procedures (b/c dosages are adjusted on a weekly basis, and missed appts may interfere w/the dosage adjustment) 29.A A patient was prescribed an oral antibiotic for the treatment of sinusitis. The NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED patient has now stopped, stating she developed a rash shortly after taking the first dose of the drug. What is the nurse's most appropriate response? a. Refer the woman to her primary care provider to have the medication changed 30.A A patient has sought care, stating that she developed hives overnight. The nurse's inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed? a. Type I 31. The nurse is providing care for a patient who has a diagnosis of hereditary angioedema. When planning this patient's care, what nursing diagnosis should be prioritized? a. Risk for Impaired Gas Exchange Related to Airway Obstruction 32.A A junior nursing student is having an observation day in the operating room. Early in the day, the student tells the OR nurse that her eyes are swelling and she is having trouble breathing. What should the nurse suspect? a. Anaphylaxis due to a latex allergy 33. The nurse is creating a care plan for a patient suffering from allergic rhinitis. Which of the following outcomes should the nurse identify? a. Improved coping with lifestyle modifications 34.A A 5-year-old boy has been diagnosed with a severe food allergy. What is an important parameter to address when educating the parents of this child about his allergy and care? a. Wear a medical identification bracelet 35. A patient is brought to the emergency department (ED) in a state of NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED consistent with the clinical presentation of RA? a. Joint stiffness, especially in the morning 7. A patient has a diagnosis of rheumatoid arthritis and the primary care provider has now prescribed cyclophosphamide (Cytoxan). The nurse's subsequent assessments should address what potential adverse effect? a. Infection 8. A clinic nurse is caring for a patient newly diagnosed with fibromyalgia. When developing a care plan for this patient, what would be a priority nursing diagnosis for this patient? a. Fatigue Related to Pain 9. A nurse is assessing a patient for risk factors known to contribute to osteoarthritis. What assessment finding would the nurse interpret as a risk factor? a. The patient's body mass index is 34 (obese). 10.A A patient is undergoing diagnostic testing to determine the etiology of recent joint pain. The patient asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? a. OA is a considered a noninflammatory joint disease. RA is characterized byinflamed, swollen joints 11.A A patient with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the patient has understood health education when the patient makes what statement? a. I'll make sure to monitor my body temperature on a regular basis 12.A A patient with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on the medical unit. The nurse observes that the patient NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED expresses angerand irritation when her call bell isn't answered immediately. What would be the most appropriate response? a. "You seem like you're feeling angry. Is that something that we could talk about?" 13.A A nurse is caring for a 78-year-old patient with a history of osteoarthritis (OA). When planning the patient's care, what goal should the nurse include? a. The patient will express satisfaction with her ability to perform ADLs 14.A A patient who has been newly diagnosed with systemic lupus erythematosus (SLE) has been admitted to the medical unit. Which of the following nursing diagnoses is the most plausible inclusion in the plan of care? a. Fatigue Related to Anemia 15. The nurse is preparing to care for a patient who has scleroderma. The nurse refers to resources that describe CREST syndrome. Which of the following is a component of CREST syndrome? a. Raynaud's phenomenon 16. Allopurinol (Zyloprim) has been ordered for a patient receiving treatment for gout. The nurse caring for this patient knows to assess the patient for bone marrow suppression, which may be manifested by which of the following diagnostic findings? a. Decreased platelets 17.A A patient with rheumatic disease is complaining of stomatitis. The nurse caring for the patient should further assess the patient for the adverse effects of what medications? a. Gold-containing compounds (Stomatitis is associated with gold therapy) NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED a. Managing Raynaud’s-type symptoms b. Smoking cessation c. The importance of vigilant skin care 30.A A 40-year-old woman was diagnosed with Raynaud's phenomenon several years earlier and has sought care because of a progressive worsening of her symptoms. The patient also states that many of her skin surfaces are ìstiff, like the skin is being stretched from all directions.î The nurse should recognize the need for medical referral for the assessment of what health problem? a. Scleroderma Scleroderma starts insidiously with Raynaud's phenomenon and swelling in the hands. Later, the skin and the subcutaneous tissues become increasingly hard and rigid and cannot be pinched up from the underlying structures. This progression of symptoms is inconsistent with GCA, FM, or RA 31.A A patient with rheumatoid arthritis comes to the clinic complaining of pain in the joint of his right great toe and is eventually diagnosed with gout. When planning teaching for this patient, what management technique should the nurse emphasize? a. Restrict consumption of foods high in purines 32.A A clinic nurse is caring for a patient diagnosed with rheumatoid arthritis (RA). The patient tells the nurse that she has not been taking her medication because she usually cannot remove the childproof medication lids. How can the nurse best facilitate the patient's adherence to her medication regimen? a. Encourage her to have her pharmacy replace the tops with NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED alternatives that are easier to open 33.A A nurse's plan of care for a patient with rheumatoid arthritis includes several exercise-based interventions. Exercises for patients with rheumatoid disorders should have which of the following goals? a. Preserve and increase range of motion while limiting joint stress 34.A A patient has just been told by his physician that he has scleroderma. The physician tells the patient that he is going to order some tests to assess for systemic involvement. The nurse knows that priority systems to be assessed include what? a. Gastrointestinal 35.A A nurse is providing care for a patient who has a rheumatic disorder. The nurse's comprehensive assessment includes the patient's mood, behavior, LOC, and neurologic status. What is this patient's most likely diagnosis? a. Systemic lupus erythematosus (SLE) 36.A A patient with rheumatoid arthritis comes into the clinic for a routine check- up. On assessment the nurse notes that the patient appears to have lost some of her ability to function since her last office visit. Which of the following is the most appropriate action? a. Arrange for the patient to be assessed in her home environment 37.A A nurse is assessing a patient with rheumatoid arthritis. The patient expresses his intent to pursue complementary and alternative therapies. What fact should underlie the nurse's response to the patient? a. Evidence shows minimal benefits from most CAM therapies MedSurge Quiz 2 – 60 61 62 1. While assessing a dark-skinned patient at the clinic, the nurse notes the presence NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED lesions. The diagnosis is Kaposi's sarcoma. The nurse caring for this patient recognizes that this is what type of Kaposi's sarcoma? a. Immunosuppression-related 14.A A nurse practitioner is seeing a 16-year-old male patient who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications? a. Benzoyl peroxide and erythromycin (Benzamycin) 15.A A patient comes to the dermatology clinic requesting the removal of a port- wine stain on his right cheek. The nurse knows that the procedure especially useful in treating cutaneous vascular lesions such as port- wine stains is what? a. Laser treatment 16.A A nurse is providing care for a patient who has psoriasis. The nurse is aware of the sequelae that can result from this health problem. Following the appearance of skin lesions, the nurse should prioritize what assessment? a. Assessment of the patient’s joints for pain and decreased range of motion 17. An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury? a. The total body surface area (TBSA) affected by the burn b. The length of time since the burn c. The location of burned skin surfaces d. The source of the burn (Explanation: Systemic effects are a result of several variables. However, TBSA and wound severity are considered the major factors that affect the presence or absence of NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED systemic effects) 18. An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn? a. The causative agent b. The patient’s preinjury health status c. The patient’s prognosis for recovery d. The circumstances of the accident (Don’t get this question confused with the one before it. The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), temperature of the burning agent, duration of contact with the agent, and thickness of the skin. The patient's preinjury status, circumstances of the accident, and prognosis for recovery are important, but are not considered when determining the depth of the burn) 19.A A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? a. Assess the patient’s peripheral pulses distal to the dressing 20.A A home care nurse is performing a visit to a patient's home to perform wound care following the patient's hospital treatment for severe burns. While interacting with the patient, the nurse should assess for evidence of what complication? a. PTSD NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED a. “Are you allergic to any foods or medications” 7. A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning? a. By protecting older adults against shearing injuries 8. A patient is diagnosed with atrial fibrillation and the physician orders Coumadin (warfarin). For what skin lesion should the nurse monitor this patient? a. Ecchymosis 9. A new patient has come to the dermatology clinic to be assessed for a reddened rash on his abdomen. What diagnostic test would most likely be ordered to identify the causative allergen? a. Patch testing (performed to identify substances to which the pt has developed an allergy. Skin scrapings are done for suspected fungal lesions. A skin biopsy is completed to rule out malignancy and to establish an exact diagnosis of skin lesions. A Tzanck smear is used to examine cells from blistering skin conditions such as herpes zoster) 10.A A patient with a suspected malignant melanoma is referred to the dermatology clinic. The nurse knows to facilitate what diagnostic test to rule out a skin malignancy? a. Skin biopsy 11.A A nurse is explaining the importance of sunlight on the skin to a woman with decreased mobility who rarely leaves her house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin? a. Vitamin D 12. The outer layer of the epidermis provides the most effective barrier to NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED penetration of the skin by environmental factors. Which of the following is an example of penetration by an environmental factor? a. An insect bite 13.A A nurse in a dermatology clinic is reading the electronic health record of a new patient. The nurse notes that the patient has a history of a primary skin lesion. What is an example of a primary skin lesion? a. Pustule 14. An unresponsive Caucasian patient has been brought to the emergency room by EMS. While assessing this patient, the nurse notes that the patient's face is a cherry-red color. What should the nurse suspect? a. Carbon monoxide poisoning (causes a bright cherry red color in the face & upper torso in light-skinned persons. In dark-skinned persons, there will be a cherry red color to nail beds, lips, and oral mucosa. When anemia occurs in light-skinned persons, the skin has generalized pallor. Anemia in dark- skinned persons manifests as a yellow-brown coloration. Jaundice appears as a yellow coloration of the sclerae. Uremia gives a yellow-orange tinge to the skin) 15.A A nurse is providing an educational presentation addressing the topic of ìProtecting Your Skin.î When discussing the anatomy of the skin with this group, the nurse should know that what cells are responsible for producing the pigmentation of the skin? a. Melanocytes 16.A A wound care nurse is reviewing skin anatomy with a group of medical nurses. Which area of the skin would the nurse identify as providing a cushion between the skin layers, muscles, and bones? a. Subcutaneous tissues NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED 17.A A young student comes to the school nurse and shows the nurse a mosquito bite. As the nurse expects, the bite is elevated and has serous fluid contained in the dermis. How would the nurse classify this lesion? a. Wheal 18. While assessing a 25-year-old female, the nurse notes that the patient has hair on her lower abdomen. Earlier in the health interview, the patient stated that her menses are irregular. The nurse should suspect what type of health problem? a. Hormonal imbalance 19.A A nurse is preparing to perform the physical assessment of a newly admitted patient. During which of the following components of the assessment should the nurse wear gloves? Select all that apply. a. Palpation of a rash on the patient’s trunk b. Palpation of a lesion on the patient’s upper back 20.A A patient with an exceptionally low body mass index has been admitted to the emergency department with signs and symptoms of hypothermia. The nurse should know that this patient's susceptibility to heat loss is related to atrophy of what skin component? a. Subcutaneous tissue 21. An 80-year-old patient is brought to the clinic by her son. The son asks the nurse why his mother has gotten so many ìspotsî on her skin. What would be an appropriate response by the nurse? a. “As people age, they normally develop uneven pigmentation in their skin” 22. An older adult patient is diagnosed with a vitamin D deficiency. What would be an appropriate recommendation by the nurse? NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED What nursing diagnosis should the nurse most likely associate with this health problem? a. Disturbed Body Image 30.A A patient is suspected of developing an allergy to an environmental substance and has been given a patch test. During the test, the patient develops fine blisters, papules, and severe itching. The nurse knows that this is indicative of what strength reaction? a. Moderately positive (the development of redness, fine elevations, or itching is considered a weak positive reaction; fine blisters, papules, and severe itching indicate a moderately positive reaction; and blisters, pain, and ulceration indicate a strong positive reaction) 31.A A dermatologist has asked the nurse to assist with examination of a patient's skin using a Wood's light. This test will allow the physician to assess for which of the following? a. Unusual patterns of pigmentation on the patient’s skin (this test makes it possible to differentiate epidermal from dermal lesions, and hypopigmented and hyperpigmented lesions from normal skin) 32.A A patient presents at the dermatology clinic with suspected herpes simplex. The nurse knows to prepare what diagnostic test for this condition? a. Tzanck smear (this test is used to examine cells from blistering skin conditions, such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. The secretions from a suspected lesion are applied to a glass slide, stained, and examined) NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED CHP 61 1. A nurse is caring for a patient who has been diagnosed with psoriasis. The nurse is creating an education plan for the patient. What information should be included in this plan? a. Use caution when taking nonprescription medications 2. A nurse is planning the care of a patient with herpes zoster. What medication, if administered within the first 24 hours of the initial eruption, can arrest herpes zoster? a. Acyclovir (Zovirax) 3. A patient with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention? a. Surgical excision 4. When writing a plan of care for a patient with psoriasis, the nurse would know that an appropriate nursing diagnosis for this patient would be what? a. Impaired Skin Integrity Related to Scaly Lesions 5. A patient who has sustained third-degree facial burns and a facial fracture is undergoing reconstructive surgery and implantation of a prosthesis. The nurse has identified a nursing diagnosis of Disturbed Body Image Related to Disfigurement. What would be an appropriate nursing intervention related to this diagnosis? a. Teaching the patient how to use and care for the prosthesis 6. While performing an initial assessment of a patient admitted with appendicitis, the nurse observes an elevated blue-black lesion on the patient's ear. The nurse knows that this lesion is consistent with what type of skin cancer? a. Malignant melanoma NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED spontaneously within 1 week) 18.A A patient has just been diagnosed with psoriasis and frequently has lesions around his right eye. What should the nurse teach the patient about topical corticosteroid use on these lesions? a. Cataract development is possible 19.A A nurse is caring for a patient who has a diagnosis of bullous pemphigoid and who is being treated on the medical unit. When providing hygiene for this patient, the nurse should perform which of the following actions? a. Apply cornstarch to the patient’s skin after bathing to facilitate mobility 20.A A nurse is caring for a patient admitted to the medical unit with a diagnosis of pemphigus vulgaris. When writing the care plan for this patient, what nursing diagnoses should be included? Select all that apply. a. Risk for Infection r/t Lesions b. Impaired Skin Integrity r/t Epidermal Blisters c. Disturbed Body Image r/t Presence of Skin Lesions d. Acute Pain r/t Disruption in Skin Integrity 21.A A patient's blistering disorder has resulted in the formation of multiple lesions in the patient's mouth. What intervention should be included in the patient's plan of care? a. Provide chlorhexidine solution for rinsing the patient's mouth (hypertonic solutions would be likely to cause pain and further skin disruptions) 22. When caring for a patient with toxic epidermal necrolysis (TEN), the critical care nurse assesses frequently for high fever, tachycardia, and extreme weakness NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED and fatigue. The nurse is aware that these findings are potential indicators of what? Select all that apply a. Epidermal necrosis b. Increased metabolic needs c. Possible gastrointestinal mucosal sloughing 23.A A nurse is assessing a teenage patient with acne vulgaris. The patient's mother states, ìI keep telling him that this is what happens when you eat as much chocolate as he does.î What aspect of the pathophysiology of acne should inform the nurse's response? a. Diet is thought of play a minimal role in the development of acne (it’s not believed to play a major role in acne therapy. A change in diet is not known to exacerbate symptoms) 24.A A nurse is providing self-care education to a patient who has been receiving treatment for acne vulgaris. What instruction should the nurse provide to the patient? a. Wash your face with water and gentle soap each morning and evening 25.A A patient has just undergone surgery for malignant melanoma. Which of the following nursing actions should be prioritized? a. Anticipate the need for, and administer, appropriate analgesic medications 26.A A patient has recently been diagnosed with advanced malignant melanoma and is scheduled for a wide excision of the tumor on her chest. In writing the plan of care for this patient, what major nursing diagnosis should the nurse include? a. Deficient Knowledge about Early Signs of Melanoma (the fact that the patient's disease was not reported until an advanced stage suggests that NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED patient's care, the nurse should include which of the following nursing diagnoses? a. Disturbed Body Image r/t Excess Sebum Production 32.A A nurse is working with a family whose 5 year-old daughter has been diagnosed with impetigo. What educational intervention should the nurse include in this family's care? a. Teaching about the importance of maintaining high standards of hygiene (Impetigo is associated with unhygienic conditions; educational interventions to address this are appropriate. The disease is contagious, thus vesicles should not be manually burst. Because of the bacterial etiology, corticosteroids are ineffective) CHP 62 1. A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patient's arm? a. Full-thickness 2. The current phase of a patient's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care? a. Acute (the acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED changes, wound dÈbridement, and wound grafting), pain management, and nutritional support are priorities at this stage. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling) 3. A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? a. Hyperkalemia, hyponatremia, elevated hct & metabolic acidosis 4. A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? a. Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream 5. An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to ìcool the burn.î How should the nurse cool the burn? a. Wrap cool towels around the affected extremity intermittently 6. A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED 16.A A patient's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? a. Inform the primary care provider promptly b/c the graft may need to be removed 17.A A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications? a. A 4-year-old scald victim burned over 24% of the body 18.A A patient is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what? a. Hemodynamic instability 19.A A patient with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the patient closely for what signs of the onset of burn shock? a. Decreased BP 20. An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patient's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? a. Administer IV fluids 21.A A patient's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? a. Lactated Ringer's NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED 22.A A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patient's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? a. Ischemia 23.A A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patient's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? a. Recognize that the patient is experiencing an expected onset of diuresis 24.A A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort? a. Education about home safety 25.A A nurse is performing a home visit to a patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following? a. Assess the patient's psychosocial state 26.A A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? a. Prevention of venous thromboembolism 27.A A patient is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED should teach the family that these responses are typically a result of what cause? You Selected: • Frustration around changes in function and communication Correct response: • Frustration around changes in function and communication Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1986. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1986 Question 3 See full question A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what? You Selected: • Evidence of hemorrhagic stroke Correct response: • Evidence of hemorrhagic stroke Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1977. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1977 Question 4 See full question NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patient's cardiac and neurologic status, the nurse monitors the patient for signs of what complication? You Selected: • Bleeding Correct response: • Bleeding Explanatio n: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1979. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1979 Question 5 See full question A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patient's safety during mobilization, the nurse should perform what action? You Selected: • Avoid mobilizing the patient in the early morning or late evening. Correct response: • Have a colleague follow the patient closely with a wheelchair. Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED Management of Patients With Cerebrovascular Disorders, p. 1982. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1982 Question 6 See full question The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke? You Selected: • White male, age 60, with history of uncontrolled hypertension Correct response: • White male, age 60, with history of uncontrolled hypertension Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1988. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1988 Question 7 See full question A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patient's family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family? You Selected: • The patient should mobilize as soon as she is physically able. Correct response: • The patient should mobilize as soon as she is physically able. Explanation: NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED You Selected: • The patient should be placed in a Trendelenberg position two to three times daily to promote cerebral perfusion. Correct response: • The patient should be placed in a prone position for 15 to 30 minutes several times a day. Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1982. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1982 Question 12 See full question After a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the immediate recovery period from an ischemic stroke should include which of the following? You Selected: • Positioning to avoid hypoxia Correct response: • Positioning to avoid hypoxia Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1979. Chapter 67: NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED Management of Patients With Cerebrovascular Disorders - Page 1979 Question 13 See full question A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patient's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patient's plan of care? You Selected: • Maintain the patient on complete bed rest. Correct response: • Maintain the patient on complete bed rest. Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1991. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1991 Question 14 See full question A patient has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? You Selected: • Generalized seizure Correct response: • Generalized seizure Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1968. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1968 Question 17 See full question A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patient's safety? You Selected: • Place the patient in a side-lying position. Correct response: • Place the patient in a side-lying position. Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1966. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1966 Question 18 See full question A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like the person in part B of the accompanying image. Which posturing is the patient exhibiting? You Selected: • Decorticate Correct response: NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED • Decerebrat e Explanatio n: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, pp. 1937-1938. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1937-1938 Question 19 See full question A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with a severe head injury. Upon entering the room, the nurse observes that the patient is positioned like part A of the accompanying image. Which posturing is the patient exhibiting? You Selected: • Decerebrate Correct response: • Decorticate Explanatio n: Reference: □ Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical- Nursing, 12th ed. Philadelphia: Lippincott Williams & Wilkins, 2010, Chapter 61: Management of Patients With Neurologic Dysfunction, pp. 1859- 1861. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1859-1861 Question 20 See full question A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED Question 22 See full question A patient is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the patient rates at 8 on a 10- point pain scale. What nursing action is most appropriate? You Selected: • Administer morphine sulfate as ordered. Correct response: • Administer morphine sulfate as ordered. Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1955. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1955 Question 23 See full question A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following? You Selected: • "There is a strong familial tendency." Correct response: • "There is a strong familial tendency." Explanation: Reference: NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1967. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1967 Question 24 See full question A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patient's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? You Selected: • Loss of brain stem reflexes Correct response: • Loss of brain stem reflexes Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1952. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1952 Question 25 See full question The nurse is caring for a patient whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this patient? You Selected: • Assessing the patient's verbal response Correct response: NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED Assessing the patient's verbal response MedSurg Quiz 4 – 68 69 70 Question 1 See full question A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patient's risk for orthostatic hypotension? You Selected: • Monitor the patient's BP before and during position changes. Correct response: • Monitor the patient's BP before and during position changes. Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2018. Chapter 68: Management of Patients With Neurologic Trauma - Page 2018 Question 2 See full question A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? You Selected: • An intracerebral hematoma Correct response: • An intracerebral hematoma Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED BP. Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2014. Chapter 68: Management of Patients With Neurologic Trauma - Page 2014 Question 5 See full question The nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action? You Selected: • Increase the frequency of ROM exercises. Correct response: • Increase the frequency of ROM exercises. Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2021. Chapter 68: Management of Patients With Neurologic Trauma - Page 2021 Question 6 See full question A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? You Selected: • Bradycardia and hypertension NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED Correct response: • Bradycardia and hypertension Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2010. Chapter 68: Management of Patients With Neurologic Trauma - Page 2010 Question 7 See full question A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patient's current health status is most likely to have precipitated this event? You Selected: • The patient's urinary catheter became occluded. Correct response: • The patient's urinary catheter became occluded. Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2017. Chapter 68: Management of Patients With Neurologic Trauma - Page 2017 Question 8 See full question The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? You Selected: NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST EXAM SOLUTION LATEST UPDATE 2021/2022 RATED/100% VERIFIED • Perform passive ROM exercises as ordered. Correct response: • Perform passive ROM exercises as ordered. Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2022. Chapter 68: Management of Patients With Neurologic Trauma - Page 2022 Question 9 See full question A male patient presents to the clinic complaining of a headache. The nurse notes that the patient is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the patient may have meningitis. What is another well-recognized sign of this infection? You Selected: • Positive Kernig's sign Correct response: • Positive Kernig's sign Explanation: Reference: □ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies, p. 2027. Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2027 NUR 4500All Med Surge Exams Quizzes & ANS 100% CORRECT BEST