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Nursing 220 Final Exam Review
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Nursing 220 Final Exam Review
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Nursing 220 Final Exam Review_______________ syndrome is a neurotoxic disorder that has been linked to febrile
illness and aspirin use in children less than 18 years of age. - ANS-Reye
A 1-year-old child grabs an Easter egg and attempts to throw it across the room. The
nurse knows that the child is exhibiting which scheme according to Piaget? -
ANS-Assimilation
A 14-year-old male is upset because he is shorter in stature and smaller in build than
the other boys in his class. He is concerned about never growing. How should the nurse
address his concern? - ANS-Reassure him that males often do not stop growing until
they are 18-20 years old.
A 15-year-old female gymnast is hospitalized with the diagnosis of bulimia nervosa.
Which data would the nurse anticipate finding in the patient's admission history and
physical assessment? - ANS-Excessive food intake, self-induced vomiting, and use of
laxatives
A 16-year-old male patient has been involved in a motor vehicle accident. Every time
the nurse enters his room, there are at least 4-5 friends laughing and talking with the
patient. The nurse is frustrated in trying to get things done. What is the nurse's best
action? - ANS-Work with the boy and his friends to plan and coordinate activities to
minimize interruptions.
A 2-year-old child insists on having a drink of water and having a story read to him and
says "Good night, sleep tight" at bedtime every night. The nurse knows the child is
exhibiting which type of behavior? - ANS-Ritualism
A 20-year-old patient is concerned that he may have the same illness (acute myeloid
leukemia [AML]) as a 65-year-old male relative. Which influencing factor about which
the nurse is aware may alleviate this patient's concern? - ANS-Age
A 25-year-old female patient demands that her mother or father be present during all
blood testing. Which defense mechanism could the nurse document as being used by
this patient? - ANS-Regression
,A 40-year-old patient complains of 4 days of frequent loos stools with abdominal
cramping. What is the priority nursing diagnosis for this patient? - ANS-Risk for
Imbalanced Fluid Volume
A 58-year-old male is admitted for a small-bowel obstruction late Saturday night. The
nurse obtains admitting orders, which include the need to place a nasogastric (NG) tube
to low intermittent suction. During the assessment, the nurse determines that the patient
does not speak English. What should the nurse do before placing the NG tube? -
ANS-Assess the presence of any family members who may speak English and the
patient's native language.
A 61-year-old male is undergoing an emergency cardiac catheterization when the nurse
gives his wife a packet of registration paperwork and asks her to complete the forms.
Which observed actions may indicate a health literacy issue? - ANS-Asking someone in
the waiting area to read the forms to her "because I need to get new glasses—these
just don't work"
Waiting until her daughter arrives to begin the paperwork so that her daughter can
complete the forms
Returning the forms only partially filled out, with missing or inaccurate information
A 65-year-old male patient has been a one-pack-per-day smoker for 40 years. He was
recently diagnosed with early-stage chronic obstructive pulmonary disease (COPD) and
would like to attend a smoking cessation class. The nurse recognizes smoking
cessation as which level of prevention for this patient? - ANS-Tertiary prevention
A Buddhist patient has end-stage pancreatic cancer. In what spiritual practice would this
patient most likely engage? - ANS-Meditating on the meaning of life
A client with metastatic cancer shares with the clinic nurse that he has only days or
weeks to live. What type of community service would be most appropriate for the nurse
to suggest to this client? - ANS-Hospice care
A famous rock star has just been admitted to Unit 12A after an automobile accident. A
nurse on Unit 12B who is a fan of the musician uses the electronic health record (EHR)
to find out how the patient is doing. Which is true regarding the use of a patient's EHR?
- ANS-Only staff caring for the patient should access this record.
A father is upset because his preschool son has told him he wishes he were gone and
pushes him and his wife apart whenever they are together. What advice should the
nurse give the father? - ANS-This is normal at this age and should resolve on its own.
,A female Muslim patient is admitted to the hospital and informs the nurse that it is the
month of Ramadan. What action by the nurse is most appropriate in caring for this
patient? - ANS-Check on the potential effect fasting until sundown will have on the
patient's condition.
A female patient has had urinary tract infections. Which statement by the patient
indicates that the nurse's teaching on prevention has been effective? - ANS-"I will wipe
from the front to the back after voiding"
A Jewish patient who adheres to a kosher diet is diagnosed with type 1 diabetes. What
would be the best response of the nurse when the patient refuses to take insulin,
stating, "Insulin contains pork and i do not eat pork." - ANS-"All of the insulin used today
is made synthetically."
A kindergartener's mother is concerned because the child has had two bouts of
respiratory infections in the past three months since school started. What is the nurse's
best response? - ANS-"He is exposed to more germs now that he is in school. Let's go
over good handwashing."
A male patient is told that he may have colon cancer. Which response by the patient
best indicates that his initial appraisal of the situation is primarily a challenge to be met?
- ANS-Requesting information on various treatment options
A newborn's mother is concerned about Sudden Infant Death Syndrome (SIDS). What
would the nurse advise her is the best way to prevent SIDS? - ANS-To place the infant
supine to sleep
A nurse assigned to the neonatal intensive care unit (NICU) has spent most of a day
working with a critically ill infant, with the mother standing by. The infant experiences a
cardiac arrest and does not survive. The mother spends an hour crying and holding the
baby, saying good-bye. Which spiritual care intervention(s) is/are most appropriate for
the nurse to implement? - ANS-If desired, briefly hold the baby to say good-bye after the
mother leaves.
Call the family spiritual adviser or the chaplain.
Ask the mother if you could call a family member or friend to be with her.
A nurse delegates a bed bath to an unlicensed assistive personnel (UAP). After lunch,
the patient rings for the nurse and complains that he has not yet been cleaned up. He is
, very upset and angry. What should the nurse's next action be? - ANS-Assist the patient
in getting cleaned up
A nurse in an oncology unit has used the available resources. She has also considered
other relevant factors such as specific isolation requirements when determining who can
care for this patient. This is a demonstration of what right of delegation? - ANS-Right
circumstance
A nurse is caring for a patient in the acute care setting who has a do-not-resuscitate
order in place. The family approaches the nurse as he or she is walking down the hall
and says, "I think my mother has died." To facilitate acceptance of the death by the
family, an important nursing intervention is to - ANS-assess the patient for pulse,
respirations, or blood pressure with the family present.
A nurse is caring for a patient with a diagnosis of pellagra resulting from niacin
deficiency who complains of fatigue, loss of appetite, headache, weight loss, scaly
sores, and neurological deterioration. The nurse performs a dietary assessment for
which of the following vitamins? - ANS-Vitamin B3
A nurse is making outpatient assignments for the day. One of the LPNs is newly
returned from a medical leave due to a back injury. Which patient would be the most
appropriate to assign to this nurse? - ANS-Mr. D., a confused patient who is ambulatory
and requires assistance with feeding
A nurse is volunteering in the community to educate parents to increase the number of
children in the school district who are immunized. The nurse oversees the activities of a
group of volunteers. Which role best describes the nurse's activity in this situation? -
ANS-Leadership
A nurse manager is trying to improve patient satisfaction ratings for her area of
responsibility. The manager meets with the staff and forms an ad hoc committee to
address the issues around the problem. This is an example of what style of leadership?
- ANS-Democratic
A nurse manager receives two vacation requests from staff for the same days off. Unit
policy states that only one person may be off at a time. The manager decided to allow
the staff the time off anyway. What type of leadership is the manager demonstrating? -
ANS-Laissez-faire
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