Rasmussen MDC 1 Exam 2 with Complete Solutions, Exams of Nursing

Download Rasmussen MDC 1 Exam 2 with Complete Solutions and more Exams Nursing in PDF only on Docsity! Rasmussen MDC 1 Exam 2 with Complete Solutions 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 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 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 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. 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. 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?" 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 lens opacity that distorts an image is called A. Glaucoma B. Cataract C. Exopthalamus D. Enopthalamus - ANSWER-B. Cataract 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 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 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 B. Increases Secretion. D. Decreases all muscle strengths including lungs E. Atelectasis Immovable joints are called A. Diarthroses B. Amphiarthroses C. Synarthrosis - ANSWER-C. Synarthroses 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 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 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 Range of motion- Bending a hinge joint at 90 degrees. A. Adduction B. Circumduction C. Flexion D. Extension - ANSWER-C. Flexion 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 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. 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." 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 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 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 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 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 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 person takes on the values, beliefs, and behaviors of the dominant culture - ANSWER-Assimilation 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 Touching the thumb to each finger of the hand is what kind of joint movement. - ANSWER-Opposition 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 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 What are some findings for osteoporosis? Select All that apply 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 ethnic group has the highest rate of dwarfism? A. Irish B. Egyptians C. Amish D. African Americans - ANSWER-C. Amish 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 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 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 Which range below shows a low risk for a Braden Scale? A. 13-14 B. 15-18 C. 10-12 D. 19-23 - ANSWER-B. 15-18 Which represents a clear liquid diet? A. Cream of rice B. Cottage cheese C. Gelatin D. Ice Cream - ANSWER-C. Gelatin 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." 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 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 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 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.