Rasmussen MDC 1 Exam 2 Questions and Answers (Graded A), Exams of Physiology

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Rasmussen MDC 1 Exam 2 Questions

and Answers (Graded A)

Ways to prevent Osteoporosis - ANSWER-Avoid alcohol, tobacco, and caffeine Increase Vitamin D and Calcium At least 5 min. of sun exposure Weight bearing exercise 3-5 times a wk The person takes on the values, beliefs, and behaviors of the dominant culture - ANSWER-Assimilation Providing for a client's basic care and comfort needs while taking consideration the values, beliefs and definitions of health and illness of each individual within our diverse society. - ANSWER-culturally competent care Assuming the characteristics of the new culture through a learning process called - ANSWER-acculturation Student nurse introduces self, role in the relationship, determines the name the client wishes to be addressed by and establishes the rapport. - ANSWER-Orientation phase Marks the end of the relationship whether at the end of the shift or discharge. Summarizing all of the work done during the relationship is a good way to end the shift.

• ANSWER-termination phase You walk in and a patient is on the floor after a fall. Which should you do first? A. Wash hands B. Use call light for assistance C. Obtain Vitals D. Put her in bed - ANSWER-B. Use call light for assistance Range of motion- Bending a hinge joint at 90 degrees. A. Adduction B. Circumduction C. Flexion D. Extension - ANSWER-C. Flexion You walk in on a patient who fell and is lying on the floor complaining of hip pain. After getting help, what should be your next step A. Re-position client for comfort B. Assess the comfort level C. Assess for groin pain or pain in back of knee

D. Measure legs to see if one is shorter - ANSWER-Assess comfort level Coordinated use of the body to safely transfer clients from place to place. Use lift equipment to protect the care provider from injury. A. Body mechanics B. Coordination C. Body alignment D. Balance - ANSWER-A. Body mechanics When you move you shoulder away from your body what ROM is being performed? - ANSWER-Abduction Touching the thumb to each finger of the hand is what kind of joint movement. - ANSWER-Opposition Bringing the patients arm towards his body represent what joint movement. - ANSWER- Adduction Where do you place a transfer belt on a patient to help ambulate. A. Under armpits above breasts B. Around the clients waist C. Across the hips. - ANSWER-B. around the waist Your patient has difficulty with mobility. As a nurse you need to help improve their mobility. Select all choices that will help improve patient mobility. A. Use assistive devices when walking B. Range of motion exercises C. Use hand weights D. Dangling E. use a mechanical lift - ANSWER-A. use assistive devices when walking B. Range of motion exercises D. Dangling. Immovable joints are called A. Diarthroses B. Amphiarthroses C. Synarthrosis - ANSWER-C. Synarthroses Where are condyloid joints found? A. Knee and elbow B. Shoulder C. Carpal D. Wrist - ANSWER-D. Wrist Damage to this area of the body can cause problems with a patient's coordination A. Condyloid

B. Cerebellum C. Cerebral cortex D. Acromion process - ANSWER-B. Cerebellum A patient cut off his fingers while doing yard work and wrapped his hand in a towel to stop the bleeding. The patient comes into the ER with the towel still wrapped around his hand. When should the nurse remove the towel? A. Immediately when he enters the ER B. After receiving the order from the doctor C. In the operating room D. After giving him an IV - ANSWER-B. After receiving the order from the doctor A patient on bedrest has what percentage of muscle loss per week? - ANSWER-7-10% How often should a patient do the incentive spirometer when awake? - ANSWER-Every 2 hours How does immobility affect the gastrointestinal system? Select all that applies A. Paralytic Illeus B. Constipation C. Bowel obstruction D. Slows peristalsis E. Diarrhea - ANSWER-A. Paralytic Illeus B. Constipation D. Slows Peristalsis What are nursing interventions to help immobile patients not have musculoskeletal system? Select all that apply. A. Reposition every 2 hours. B. Incentive spirometer every 4 hours C. Perform Passive or active ROM D. Administer Heparin - ANSWER-A. Reposition every 2 hours C. Perform passive or active ROM Immobility effects the respiratory system. Select all that apply. A. Respiratory depth decreases. B. Increases Secretion. C. Osteoporosis D. Decreases all muscle strengths including lungs E. Atelectasis - ANSWER-A. Respiratory depth decreases. B. Increases Secretion. D. Decreases all muscle strengths including lungs E. Atelectasis What are the 5 Ps of compartment syndrome? - ANSWER-Pain Pulse

Pallor Paresthesia Paralysis Which ethnic group has the highest rate of dwarfism? A. Irish B. Egyptians C. Amish D. African Americans - ANSWER-C. Amish You can not obtain a pedal pulse manually. What piece of equipment would you get to check blood flow? A. Mechanical Lift B. Xray C. Doppler D. CT scan - ANSWER-C. Doppler Muscle strength of a patient is reported at level 3. What does level 3 mean? A. No evidence of muscle strength B. Normal ROM C. Fair: Can complete ROM against gravity D. Poor: can complete ROM with no gravity E. Good: Can complete ROM against gravity with some resistance - ANSWER-C. Fair: Can complete ROM against gravity Paget's disease effects what body system? - ANSWER-Musculoskeletal Which lab result would you look for to see if your patient's most accurate nutrition status? A. Calcium B. Phosphate C. Pre Albumin D. Albumin - ANSWER-C. Pre Albumin what does SPICE stand for? - ANSWER-Sleep disorders Problems with eating or feeding Incontinence Confusion Evidence of falls Skin breakdown Which is a priority intervention to decrease risk of pressure ulcer? A. Provide rest and comfort measures B. Use a draw sheet to slide the patient C. Reposition the pt every two hours. D. Sit the pt in chair - ANSWER-D. Reposition the pt every two hours

Which range below shows a low risk for a Braden Scale? A. 13- B. 15- C. 10- D. 19-23 - ANSWER-B. 15- The nurse removes a dressing and assesses yellow, foul smelling drainage. How would the nurse document this finding? A. Purulent B. Serous C. Serosanguineous D. Sanguineous - ANSWER-A. Purulent The nurse performs a focused musculoskeletal assessment on a patient with a hip fracture. Which should the nurse include for this type of assessment? Select all that applies A. Muscle weakness B. Joint tenderness C. Gait D. Range of motion E. Pain - ANSWER-B. Joint tenderness D. Range of motion E. Pain Devices such as pillows, trapeze bars, special mattresses, and trochanter rolls are used for what purpose? A. Facilitate ADLs B. Alleviate pressure and maintain proper body alignment C. Provide patient comfort D. Facilitate ROM - ANSWER-B. Alleviate pressure and maintain proper body alignment A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take? A. Use a 10mL syringe B. Attach a 22 gauge catheter to the syringe C. Warm the irrigating solution to 37 degrees Celsius D. Administer an analgesic 10 min before the irrigation - ANSWER-C. Warm the irrigating solution to 37 degrees Celsius A nurse is screening a client who has an S-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of which musculoskeletal issue? - ANSWER-scoliosis Which represents a clear liquid diet? A. Cream of rice

B. Cottage cheese C. Gelatin D. Ice Cream - ANSWER-C. Gelatin A nurse is planning care for a client who has a single lumen nasogastric tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? A. Set the suction machine at 120 mmHg. B. Provide oral hygiene frequently. C. Measure the amount of drainage from the NG tube. D. Secure the NG tube to the client's gown. E. Apply petroleum jelly to the clients nares. - ANSWER-B, C, D What does PQRST stand for? - ANSWER-Provokes Quality Radiates Severity Time Which action should a nurse take to decrease risk of fall? A. Use a gait belt during ambulation B. Ensure the client is wearing socks before ambulating. C. Instruct the client to sit on the edge of the bed for 15 sec before ambulating. D. Walk 2 ft behind the client during ambulation. - ANSWER-A. Use a gait belt during ambulation A nurse is providing teaching about crutches to a pt with a fracture. What teaching should the nurse include? A. When you go up a flight of stairs, place your right foot on the first step. B. Keep the rubber crutch tips securely in place. C. When standing, keep the crutches 12in in front of you and 12in to the side. D. Place your weight on the crutch pads at your armpits. - ANSWER-B. Keep the rubber crutch tips securely in place. What kind of side effects happen when a pt uses Timolol? Select all that apply A. Hypoglycemia B. Narrow airways C. Bradycardia D. Hypovolemia - ANSWER-A, B, C Which foods promote eye health? Select all A. Kale B. Bananas C. Carrots D. Ground Beef E. Shellfish

F. Spinach - ANSWER-A, B, C, F A 44 year old client with Diabetes asks how often a visit to the eye doctor is recommended? A. Annually B. Every 6 months C. No examination necessary until 50 years old D. Every 2 years - ANSWER-A. Annually A lens opacity that distorts an image is called A. Glaucoma B. Cataract C. Exopthalamus D. Enopthalamus - ANSWER-B. Cataract The nurse is caring for a client who reports slow onset of a gradual loss of vision in the center of both eyes. The client describes vision as "foggy" and reports concerns of ongoing headaches from "trying to concentrate to see." What condition does the nurse anticipate? A. Cataract B. Glaucoma C. Conjunctivitis D. Retinal Detachment - ANSWER-B. Glaucoma The nurse is teaching a client who must instill multiple types of eyedrops before cataract surgery. Which client statement requires further teaching? A. "I will make a schedule for inserting the eyedrops." B. "Touching the dropper to my eye could cause contamination and infection." C. "If I can't remember when to take which drops, I'll just take them all at once." D. "If I have trouble instilling the drops, I will have my spouse put them in for me." - ANSWER-C. "If I can't remember when to take which drops, I'll just take them all at once." The nurse is caring for four clients. Which has the highest risk for development of age- related macular degeneration (AMD)? A. 25-year-old, 70 inches tall, with fracture of the right femur B. 38-year-old, 71 inches tall, who has just given birth to a healthy baby C. 45-year-old, 67 inches tall, who is a vegetarian D. 57-year-old, 60 inches tall, with hypertension - ANSWER-D. 57-year-old, 60 inches tall, with hypertension A client is being discharged after surgery to correct a retinal detachment. Which symptoms will the nurse teach the client to immediately report to the eye care provider? Select all that apply. A. Purulent discharge in the affected eye B. Fever of 102° F (38.9° C)

C. Pupil that constricts in response to light D. Improved visual acuity E. Pain in the eye - ANSWER-A, B, E Which action by a nurse is most likely to increase accurate communication with a client who has low vision? A. Speaking slowly and loudly B. Enhancing the talk using hand gestures C. Being very specific with descriptions and directions D. Marking the door of the client's room to indicate his or her vision status - ANSWER- C. Being very specific with descriptions and directions For which client will the nurse avoid performing an otoscopic examination? A. 29-year-old with abdominal pain B. 37-year-old with vertigo C. 45-year-old with new diagnosis of diabetes D. 59-year-old with confusion - ANSWER-D. 59-year-old with confusion The nurse is caring for a client with tinnitus. Which client statement requires nursing teaching? A. "I enjoy eating bananas every day for breakfast." B. "I've found several local support groups for people with tinnitus." C. "I take aspirin every day to help reduce my risk for having a stroke." D. "I'm seeing an audiologist who is fitting me for hearing aids." - ANSWER-C "I take aspirin every day to help reduce my risk for having a stroke." The nurse is caring for a client who has experienced an increased frequency in Ménière's disease attacks. When the client asks, "Will I have to have surgery?", what is the appropriate nursing response? Select all that apply. A. "If you eat a better balanced diet, you won't need surgery." B. "Surgery is not an option for this type of disorder." C. "You sound like you are concerned about having surgery." D. "It will be essential for you to have surgery if medications don't work." E. "Different types of surgery can be considered with your health care provider." - ANSWER-C. "You sound like you are concerned about having surgery." E. "Different types of surgery can be considered with your health care provider." How should the nurse communicate with a client who is deaf? A. By having the client read the nurse's lips B. By talking more loudly to the client C. By using pictures and writing, if the client can see D. By talking exclusively with the client's caregivers - ANSWER-C. By using pictures and writing, if the client can see

A nurse is performing a musculoskeletal assessment on an older adult living independently. What normal physiologic changes of aging does the nurse expect? Select all that apply. A. Muscle atrophy B. Slowed movement C. Scoliosis D. Arthritis E. Widened gait - ANSWER-A, B,D, E A client returns to the postanesthesia care unit (PACU) after an arthroscopy to repair a knee injury. What is the nurse's priority when caring for this client? A. Perform passive range-of-motion exercises. B. Keep the affected leg immobilized. C. Ensure that the patient uses the patient-controlled analgesia (PCA) pump. D. Check the neurovascular status of the affected leg and foot. - ANSWER-D. Check the neurovascular status of the affected leg and foot. Which additional assessment data will the nurse collect from an older Euro-American (white) woman to determine the client's risk for osteoporosis? Select all that apply. A. Tobacco use, especially smoking B. Alcohol use each day C. Exercise and activity level D. Dietary intake of vitamin D E. Use of calcium supplements F. Medication history - ANSWER-A, B, C, D, E, F Which statement by the client regarding lifestyle changes to prevent osteoporosis indicates a need for further teaching by the nurse? A. "I'm going to continue having my DXA scans as my doctor orders." B. "I'll drink only a half glass of wine occasionally to help me sleep." C. "I plan to increase calcium and vitamin D foods in my diet." D. "I'm going to jog every day for at least 30 minutes." - ANSWER-D. "I'm going to jog every day for at least 30 minutes." A client recently diagnosed with primary bone cancer states, "My life is over. I'll never get married now!" What is the nurse's best action at this time? A. Refer the client to a clergy member or spiritual leader. B. Ask the client what is meant by that statement. C. Listen while the client expresses feelings. D. Provide hope that marriage will happen. - ANSWER-C. Listen while the client expresses feelings. The nurse is caring for a client immediately after a bunionectomy. What is the nurse's priority action? A. Relieve or reduce the patient's pain. B. Assess neurovascular status in the affected foot.

C. Apply a hot compress to the surgical area. D. Check the surgical dressing for intactness. - ANSWER-B. Assess neurovascular status in the affected foot. A client who has a plaster leg splint reports a painful pressure sensation under the elastic wrap that is holding the splint in place. What is the nurse's best initial action? A. Remove the splint to reduce skin pressure. B. Perform a neurovascular assessment. C. Report the client's concern to the primary health care provider. D. Inspect the skin under the elastic bandage. - ANSWER-B. Perform a neurovascular assessment. A client has a synthetic cast placed for a right wrist fracture in the emergency department. Which priority health teaching is important for the nurse to provide for this client before returning home? Select all that apply. A. "Keep your right arm below the level of your heart as often as possible." B. "Use an ice pack for the first 24 hours to decrease tissue swelling." C. "Move the fingers of the right hand frequently to promote blood flow." D. "Report coolness or discoloration of your right hand to your doctor." E. "Don't place any device under the cast to scratch the skin if it itches." - ANSWER-B, C, D, E A client who had an elective below-the-knee amputation (BKA) reports pain in the foot that was amputated last week. What is the nurse's most appropriate response to the client's pain? A. "The pain will go away after the swelling decreases." B. "That's phantom limb pain, and every amputee has that." C. "Your foot has been amputated, so it's in your head." D. "On a scale of 0 to 10, how would you rate your pain?" - ANSWER-D. "On a scale of 0 to 10, how would you rate your pain?" What is the nurse's priority when doing an admission for a client who returned directly from the operating suite after a carpal tunnel repair? A. Monitor vital signs, including pulse oximetry. B. Check the surgical dressing to ensure that it is intact. C. Assess neurovascular assessment in the affected arm. D. Monitor intake and output. - ANSWER-A. Monitor vital signs, including pulse oximetry. What are some findings for osteoporosis? Select All that apply A. T score at or lower than -2. B. Caused from lack of calcium, estrogen, or testosterone C. Bone softening caused by lack of calcification D. High parathyroid hormone - ANSWER-A, B What is the normal Intra ocular pressure measurement?

A. 40mmHg B. 20mmHg C. 100mmHg D. 10mmHg - ANSWER-B. 20mmHg What is the most common type of Glaucoma? A. Cataract B. Primary open angle C. Associated D. Myopia E. Secondary - ANSWER-B. Primary open angle How would you explain myopia to a patient? - ANSWER-Myopia is nearsightedness vision. After cataract surgery what medications should the patient get? Select all. A. Steroids B. Warfarin C. Heparin D. Antibiotics - ANSWER-A and D What group is mostly affected by primary angle closure glaucoma? A. African American male B. Eastern Europeans C. Hispanic females D. Asian women - ANSWER-D. Asian women What group is most commonly affected by primary angle open glaucoma? Select all that apply A. African American B. Eastern Europeans C. Hispanic D. Asian - ANSWER-A. C. This test is used when elevation intraocular pressure is diagnosed to determine if the glaucoma is open angle or closed angle. Allows visualization of angle where the Otis meets the cornea. A. Ultrasonic imaging B. Gonioscopy C. Electroretinography D. Flourorescein angiography - ANSWER-B. Gonioscopy