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Question 1 of 10
1. Question
An adolescent is admitted to the spinal rod orthopedic nursing unit insertion for scoliosis treatment. Which evaluations are the most important? When considering the neurovascular status of the patient, is it important in the immediate postoperative period? Select all that is applicable.
Correct
Altered neurovascular status is a possible complication when the spinal column is manipulated during surgery; therefore, neurovascular status checks should be performed, including circulation, sensation, and motion, at least every 2 hours at a time. Postoperative pain levels and urinary output are important assessments, but more important is neurovascular status.
Incorrect
Altered neurovascular status is a possible complication when the spinal column is manipulated during surgery; therefore, neurovascular status checks should be performed, including circulation, sensation, and motion, at least every 2 hours at a time. Postoperative pain levels and urinary output are important assessments, but more important is neurovascular status.
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Question 2 of 10
2. Question
The Glasgow Coma Scale is performed by the nurse while evaluating a patient with an injury to the brainstem. Which additional measures should the nurse be willing to implement? Select all that is applicable.
Correct
Evaluation should be specific to the area of the brain involved. In a patient with a brain stem injury, the assessment of respiratory status and cranial nerve function is a critical part of the evaluation process because the respiratory center is located in the brain stem.
Incorrect
Evaluation should be specific to the area of the brain involved. In a patient with a brain stem injury, the assessment of respiratory status and cranial nerve function is a critical part of the evaluation process because the respiratory center is located in the brain stem.
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Question 3 of 10
3. Question
Reports that a patient diagnosed with myxedema has experienced lack of energy, puffiness around the eyes and face. The nurse plans care realizing that these clinical manifestations are caused by a lack of hormone production? Select all that is applicable.
Correct
Although all of these hormones originate from the anterior pituitary, the patient’s symptoms are associated with only T3 and T4. Myxedema results from insufficient levels of thyroid hormones (T3 and T4).
Incorrect
Although all of these hormones originate from the anterior pituitary, the patient’s symptoms are associated with only T3 and T4. Myxedema results from insufficient levels of thyroid hormones (T3 and T4).
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Question 4 of 10
4. Question
When determining whether a patient diagnosed with respiratory disease can tolerate and profit from active progressive relaxation, what should the nurse consider? Select all that is applicable.
Correct
Active progressive relaxation training teaches the patient how to rest and decrease tension in the body effectively. The physiological and psychological status of the patient is some important considerations when choosing the type of relaxation technique. Because active progressive relaxation training requires moderate energy expenditure, the nurse needs to consider the functional status of the patient, medical diagnosis, and energy expenditure ability.
Incorrect
Active progressive relaxation training teaches the patient how to rest and decrease tension in the body effectively. The physiological and psychological status of the patient is some important considerations when choosing the type of relaxation technique. Because active progressive relaxation training requires moderate energy expenditure, the nurse needs to consider the functional status of the patient, medical diagnosis, and energy expenditure ability.
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Question 5 of 10
5. Question
For a patient experiencing urgent urinary incontinence, the nurse develops a care plan. For this type of incontinence, which interventions would be helpful? Select all that is applicable.
Correct
Urge incontinence, after a strong sense of the urgency to void, is the involuntary passage of urine. It is characterized by urinary urgency, often with frequency (more often than every 2 hours); spasm or contraction of the bladder; and voiding in small quantities (less than 100 mL) or in large quantities (greater than 500 mL).
Incorrect
Urge incontinence, after a strong sense of the urgency to void, is the involuntary passage of urine. It is characterized by urinary urgency, often with frequency (more often than every 2 hours); spasm or contraction of the bladder; and voiding in small quantities (less than 100 mL) or in large quantities (greater than 500 mL).
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Question 6 of 10
6. Question
After a Billroth II operation, a patient resumes a diet. Which actions should the nurse teach the patient in order to minimize complications associated with eating? Select all that is applicable.
Correct
A patient who has had a procedure for Billroth II is at risk of dumping syndrome. In order to avoid this syndrome, the patient should lie down after eating and avoid drinking liquids with food. The patient should be placed on a high-protein, moderate-fat, and low-carbohydrate dry diet. Frequent small dishes are encouraged, and concentrated sweets should be avoided by the patient.
Incorrect
A patient who has had a procedure for Billroth II is at risk of dumping syndrome. In order to avoid this syndrome, the patient should lie down after eating and avoid drinking liquids with food. The patient should be placed on a high-protein, moderate-fat, and low-carbohydrate dry diet. Frequent small dishes are encouraged, and concentrated sweets should be avoided by the patient.
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Question 7 of 10
7. Question
The nurse, for the first time after having abdominal surgery, ambulates a patient. What clinical manifestations should inform the nurse that orthostatic hypotension may be experienced by the patient? Choose all that apply
Correct
Orthostatic hypotension occurs when, while rising to an upright position, a normotensive individual develops symptoms of low blood pressure. There is a risk of orthostatic hypotension every time a nurse gets a patient up and out of a bed or chair. Iorthostatic hypotension is characterized by symptoms of nausea, dizziness, lightheadedness, tachycardia, pallor, and reports of visual spots.
Incorrect
Orthostatic hypotension occurs when, while rising to an upright position, a normotensive individual develops symptoms of low blood pressure. There is a risk of orthostatic hypotension every time a nurse gets a patient up and out of a bed or chair. Iorthostatic hypotension is characterized by symptoms of nausea, dizziness, lightheadedness, tachycardia, pallor, and reports of visual spots.
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Question 8 of 10
8. Question
A postpartum patient is screened for hepatitis B and the results indicate the presence of antigens in the maternal blood. Which treatment should the nurse expect to be prescribed for the newborn? Select all that is applicable.
Correct
A screen for hepatitis B is carried out to detect the presence of in maternal blood, antigens. If antigens are present, hepatitis B immune globulin and hepatitis B immune globulin should be given to the newborn within 12 hours after birth. Serum liver enzyme acquisition, maternal blood re-testing in a week, breastfeeding every 5 hours, and administering antibiotics are inappropriate actions and would not decrease the chance of the neonate contracting the hepatitis B virus.
Incorrect
A screen for hepatitis B is carried out to detect the presence of in maternal blood, antigens. If antigens are present, hepatitis B immune globulin and hepatitis B immune globulin should be given to the newborn within 12 hours after birth. Serum liver enzyme acquisition, maternal blood re-testing in a week, breastfeeding every 5 hours, and administering antibiotics are inappropriate actions and would not decrease the chance of the neonate contracting the hepatitis B virus.
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Question 9 of 10
9. Question
The nurse is advising a terminally ill client’s family about palliative care. Which objectives are identified by the nurse as those of palliative care? Select all that is applicable.
Correct
Palliative care is a total care philosophy. The objectives of palliative care include the following: providing a support system to help the patient live as actively as possible until death; providing pain relief and other distressing symptoms; improving the quality of life; Providing a support system to help families cope with the illness of the patient and their own deprivation; affirming life and dying as a normal process, neither hastening nor postponing death; and integrating patient care with psychological and spiritual aspects.
Incorrect
Palliative care is a total care philosophy. The objectives of palliative care include the following: providing a support system to help the patient live as actively as possible until death; providing pain relief and other distressing symptoms; improving the quality of life; Providing a support system to help families cope with the illness of the patient and their own deprivation; affirming life and dying as a normal process, neither hastening nor postponing death; and integrating patient care with psychological and spiritual aspects.
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Question 10 of 10
10. Question
The nurse is developing a care plan for a client who has suffered a pelvic fracture after a motor vehicle accident (MVC). To prevent skin breakdown, which interventions should be included in the nursing care plan? Select all that is applicable.
Correct
The patient is at high risk for pressure injury in this question. Pressure injury prevention interventions include minimizing the force and friction applied to the skin; conducting a systematic skin inspection at least once a day, paying special attention to the bony prominences; cleansing the skin at soiling time and at routine intervals; avoiding the use of hot water; Use of a mild cleansing agent which minimizes skin irritation and dryness. Pillows should be used to keep the knees from direct contact with each other and other bony prominences, as skin contact can promote breakdown. It can be harmful to at-risk skin surfaces to massage over bony prominences (especially vigorous).
Incorrect
The patient is at high risk for pressure injury in this question. Pressure injury prevention interventions include minimizing the force and friction applied to the skin; conducting a systematic skin inspection at least once a day, paying special attention to the bony prominences; cleansing the skin at soiling time and at routine intervals; avoiding the use of hot water; Use of a mild cleansing agent which minimizes skin irritation and dryness. Pillows should be used to keep the knees from direct contact with each other and other bony prominences, as skin contact can promote breakdown. It can be harmful to at-risk skin surfaces to massage over bony prominences (especially vigorous).