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PNLE: Fundamentals in Nursing Exam 2 (PM)
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Question 1
When providing a continuous enteral feeding, which of the following action is essential for the nurse to do?
A
Attach the feeding bag to the current tubing.
B
Place the client on the left side of the bed.
C
Elevate the head of the bed.
D
Cold the formula before administering it.
Question 1 Explanation:
Elevating the head of the bed during an enteral feeding prevents aspiration. The patient may be placed on the right side to prevent aspiration. Enteral feedings are given at room temperature to lessen GI distress. The enteral tubing should be changed every 24 hours to limit microbial growth.
Question 2
The nurse is aware that Bell’s palsy affects which cranial nerve?
A
7th CN (Facial)
B
4th CN (Trochlear)
C
3rd CN (Occulomotor)
D
2nd CN (Optic)
Question 2 Explanation:
Bells’ palsy is the paralysis of the motor component of the 7th caranial nerve, resulting in facial sag, inability to close the eyelid or the mouth, drooling, flat nasolabial fold and loss of taste on the affected side of the face.
Question 3
A skin lesion which is fluid-filled, less than 1 cm in size is called:
A
papule
B
macule
C
bulla
D
vesicle
Question 3 Explanation:
Vesicle is a circumscribed circulation containing serous fluid or blood and less than 1 cm (ex. Blister, chicken pox).
Question 4
Van Fajardo is a 55 year old who was admitted to the hospital with newly diagnosed hepatitis. The nurse is doing a patient teaching with Mr. Fajardo. What kind of role does the nurse assume?
A
talker
B
doer
C
thinker
D
teacher
Question 4 Explanation:
The nurse will assume the role of a teacher in this therapeutic relationship. The other roles are inappropriate in this situation.
Question 5
When performing an admission assessment on a newly admitted patient, the nurse percusses resonance. The nurse knows that resonance heard on percussion is most commonly heard over which organ?
A
intestine
B
thigh
C
liver
D
lung
Question 5 Explanation:
Resonance is loud, low-pitched and long duration that’s heard most commonly over an air-filled tissue such as a normal lung.
Question 6
Pia’s serum sodium level is 150 mEq/L. Which of the following food items does the nurse instruct Pia to avoid?
A
cabbage
B
sardines
C
tomatoes
D
broccoli
Question 6 Explanation:
The normal serum sodium level is 135 to 145 mEq/L, the client is having hypernatremia. Pia should avoid food high in sodium like processed food. Broccoli, cabbage and tomatoes are good source of Vitamin C.
Question 7
Nurse Cherry is teaching a 72 year old patient about a newly prescribed medication. What could cause a geriatric patient to have difficulty retaining knowledge about the newly prescribed medication?
A
Patient has no interest on learning
B
Absence of family support
C
Decreased plasma drug levels
D
Decreased sensory functions
Question 7 Explanation:
Decreased in sensory functions could cause a geriatric patient to have difficulty retaining knowledge about the newly prescribed medications. Absence of family support and no interest on learning may affect compliance, not knowledge retention. Decreased plasma levels do not alter patient’s knowledge about the drug.
Question 8
To assess the adequacy of food intake, which of the following assessment parameters is best used?
A
regularity of meal times
B
3-day diet recall
C
food preferences
D
eating style and habits
Question 8 Explanation:
3-day diet recall is an example of dietary history. This is used to indicate the adequacy of food intake of the client.
Question 9
It is the gradual decrease of the body’s temperature after death.
A
livor mortis
B
algor mortis
C
rigor mortis
D
none of the above
Question 9 Explanation:
Algor mortis is the decrease of the body’s temperature after death. Livor mortis is the discoloration of the skin after death. Rigor mortis is the stiffening of the body that occurs about 2-4 hours after death.
Question 10
What is the characteristic of the nursing process?
A
stagnant
B
asystematic
C
goal-oriented
D
inflexible
Question 10 Explanation:
The nursing process is goal-oriented. It is also systematic, patient-centered, and dynamic.
Question 11
The nurse is assessing the endocrine system. Which organ is part of the endocrine system?
A
Sinus
B
Thymus
C
Thyroid
D
Heart
Question 11 Explanation:
The thyroid is part of the endocrine system. Heart, sinus and thymus are not.
Question 12
Immunization for healthy babies and preschool children is an example of what level of preventive health care?
A
Secondary
B
Primary
C
Tertiary
D
Curative
Question 12 Explanation:
The primary level focuses on health promotion. Secondary level focuses on health maintenance. Tertiary focuses on rehabilitation. There is n Curative level of preventive health care problems.
Question 13
Presty has terminal cancer and she refuses to believe that loss is happening ans she assumes artificial cheerfulness. What stage of grieving is she in?
A
depression
B
denial
C
bargaining
D
acceptance
Question 13 Explanation:
The client is in denial stage because she is unready to face the reality that loss is happening and she assumes artificial cheerfulness.
Question 14
Claire is admitted with a diagnosis of chronic shoulder pain. By definition, the nurse understands that the patient has had pain for more than:
A
3 months
B
9 months
C
6 months
D
1 year
Question 14 Explanation:
Chronic pain s usually defined as pain lasting longer than 6 months.
Question 15
Which of the following is considered significant enough to require immediate communication to another member of the health care team?
A
Diminished breath sounds in patient with previously normal breath sounds
B
Weight loss of 3 lbs in a 120 lb female patient.
C
Patient stated, “I feel less nauseated.”
D
Change of heart rate from 70 to 83 beats per minute.
Question 15 Explanation:
Diminished breath sound is a life threatening problem therefore it is highly priority because they pose the greatest threat to the patient’s well-being.
Question 16
Which of the following is appropriate nursing intervention for a client who is grieving over the death of her child?
A
Tell her not to cry and it will be better.
B
Discourage the client in expressing her emotions.
C
Encourage her to accept or to replace the lost person.
D
Provide opportunity to the client to tell their story.
Question 16 Explanation:
Providing a grieving person an opportunity to tell their story allows the person to express feelings. This is therapeutic in assisting the client resolve grief.
Question 17
Which of the following is a nursing diagnosis?
A
Diabetes Mellitus
B
Angina
C
Hypethermia
D
Chronic Renal Failure
Question 17 Explanation:
Hyperthermia is a NANDA-approved nursing diagnosis. Diabetes Mellitus, Angina and Chronic Renal Failure are medical diagnoses.
Question 18
Which of the following statements regarding the nursing process is true?
A
It progresses in separate, unrelated steps.
B
It provides the solution to all patient health problems.
C
It focuses on the patient, not the nurse.
D
It is useful on outpatient settings.
Question 18 Explanation:
The nursing process is patient-centered, not nurse-centered. It can be use in any setting, and the steps are related. The nursing process can’t solve all patient health problems.
Question 19
During application of medication into the ear, which of the following is inappropriate nursing action?
A
Warm the medication at room or body temperature.
B
Instill the medication directly into the tympanic membrane.
C
In an adult, pull the pinna upward.
D
Press the tragus of the ear a few times to assist flow of medication into the ear canal.
Question 19 Explanation:
During the application of medication it is inappropriate to instill the medication directly into the tympanic membrane. The right thing to do is instill the medication along the lateral wall of the auditory canal.
Question 20
A patient is wearing a soft wrist-safety device. Which of the following nursing assessment is considered abnormal?
A
Bluish fingernails, cool and pale fingers
B
Capillary refill within 3 seconds
C
Palpable ulnar pulse
D
Palpable radial pulse
Question 20 Explanation:
A safety device on the wrist may impair blood circulation. Therefore, the nurse should assess the patient for signs of impaired circulation such as bluish fingernails, cool and pale fingers. Palpable radial and ulnar pulses, capillary refill within 3 seconds are all normal findings.
Question 21
When assessing a patient’s level of consciousness, which type of nursing intervention is the nurse performing?
A
Professional
B
Dependent
C
Collaborative
D
Independent
Question 21 Explanation:
Independent nursing interventions involve actions that nurses initiate based on their own knowledge and skills without the direction or supervision of another member of the health care team.
Question 22
Jason, 3 years old vomited. His mom stated, “He vomited 6 ounces of his formula this morning.” This statement is an example of:
A
objective data from a primary source
B
objective data from a secondary source
C
subjective data from a secondary source
D
subjective data from a primary source
Question 22 Explanation:
Jason is the primary source; his mother is a secondary source. The data is objective because it can be perceived by the senses, verified by another person observing the same patient, and tested against accepted standards or norms.
Question 23
Prolonged deficiency of Vitamin B9 leads to:
A
pernicious anemia
B
pellagra
C
megaloblastic anemia
D
scurvy
Question 23 Explanation:
Prolonged Vitamin B9 deficiency will lead to megaloblastic anemia while pernicious anemia results in deficiency in Vitamin B12. Prolonged deficiency of Vitamin C leads to scurvy and Pellagra results in deficiency in Vitamin B3.
Question 24
Which is an example of a subjective data?
A
Productive cough
B
Vomiting for 3 days
C
Temperature of 38 0C
D
Patient stated, “My arms still hurt.”
Question 24 Explanation:
Subjective data are apparent only to the person affected and can or verified only by that person.
Question 25
Kussmaul’s breathing is;
A
Increased rate and depth of respiration.
B
Shallow breaths interrupted by apnea.
C
Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea.
D
Prolonged gasping inspiration followed by a very short, usually inefficient expiration.
Question 25 Explanation:
Kussmaul breathing is also called as hyperventilation. Seen in metabolic acidosis and renal failure. Shallow breaths interrupted by apnea refers to Biot’s breathing. Prolonged gasping inspiration followed by a very short, usually inefficient expiration is apneustic breathing and marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea is the Cheyne-stokes breathing.
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PNLE: Fundamentals in Nursing Exam 2 (EM)
Choose the letter of the correct answer. You got 25 minutes to finish the exam .Good luck!
Start
Congratulations - you have completed PNLE: Fundamentals in Nursing Exam 2 (EM).
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
Which of the following is a nursing diagnosis?
A
Diabetes Mellitus
B
Hypethermia
C
Chronic Renal Failure
D
Angina
Question 1 Explanation:
Hyperthermia is a NANDA-approved nursing diagnosis. Diabetes Mellitus, Angina and Chronic Renal Failure are medical diagnoses.
Question 2
What is the characteristic of the nursing process?
A
goal-oriented
B
asystematic
C
inflexible
D
stagnant
Question 2 Explanation:
The nursing process is goal-oriented. It is also systematic, patient-centered, and dynamic.
Question 3
When performing an admission assessment on a newly admitted patient, the nurse percusses resonance. The nurse knows that resonance heard on percussion is most commonly heard over which organ?
A
intestine
B
thigh
C
lung
D
liver
Question 3 Explanation:
Resonance is loud, low-pitched and long duration that’s heard most commonly over an air-filled tissue such as a normal lung.
Question 4
Prolonged deficiency of Vitamin B9 leads to:
A
pellagra
B
megaloblastic anemia
C
scurvy
D
pernicious anemia
Question 4 Explanation:
Prolonged Vitamin B9 deficiency will lead to megaloblastic anemia while pernicious anemia results in deficiency in Vitamin B12. Prolonged deficiency of Vitamin C leads to scurvy and Pellagra results in deficiency in Vitamin B3.
Question 5
Immunization for healthy babies and preschool children is an example of what level of preventive health care?
A
Secondary
B
Tertiary
C
Primary
D
Curative
Question 5 Explanation:
The primary level focuses on health promotion. Secondary level focuses on health maintenance. Tertiary focuses on rehabilitation. There is n Curative level of preventive health care problems.
Question 6
A skin lesion which is fluid-filled, less than 1 cm in size is called:
A
macule
B
bulla
C
papule
D
vesicle
Question 6 Explanation:
Vesicle is a circumscribed circulation containing serous fluid or blood and less than 1 cm (ex. Blister, chicken pox).
Question 7
Presty has terminal cancer and she refuses to believe that loss is happening ans she assumes artificial cheerfulness. What stage of grieving is she in?
A
bargaining
B
denial
C
acceptance
D
depression
Question 7 Explanation:
The client is in denial stage because she is unready to face the reality that loss is happening and she assumes artificial cheerfulness.
Question 8
When providing a continuous enteral feeding, which of the following action is essential for the nurse to do?
A
Place the client on the left side of the bed.
B
Cold the formula before administering it.
C
Elevate the head of the bed.
D
Attach the feeding bag to the current tubing.
Question 8 Explanation:
Elevating the head of the bed during an enteral feeding prevents aspiration. The patient may be placed on the right side to prevent aspiration. Enteral feedings are given at room temperature to lessen GI distress. The enteral tubing should be changed every 24 hours to limit microbial growth.
Question 9
Which of the following statements regarding the nursing process is true?
A
It is useful on outpatient settings.
B
It progresses in separate, unrelated steps.
C
It provides the solution to all patient health problems.
D
It focuses on the patient, not the nurse.
Question 9 Explanation:
The nursing process is patient-centered, not nurse-centered. It can be use in any setting, and the steps are related. The nursing process can’t solve all patient health problems.
Question 10
Van Fajardo is a 55 year old who was admitted to the hospital with newly diagnosed hepatitis. The nurse is doing a patient teaching with Mr. Fajardo. What kind of role does the nurse assume?
A
talker
B
teacher
C
thinker
D
doer
Question 10 Explanation:
The nurse will assume the role of a teacher in this therapeutic relationship. The other roles are inappropriate in this situation.
Question 11
Claire is admitted with a diagnosis of chronic shoulder pain. By definition, the nurse understands that the patient has had pain for more than:
A
3 months
B
6 months
C
1 year
D
9 months
Question 11 Explanation:
Chronic pain s usually defined as pain lasting longer than 6 months.
Question 12
The nurse is assessing the endocrine system. Which organ is part of the endocrine system?
A
Sinus
B
Thyroid
C
Thymus
D
Heart
Question 12 Explanation:
The thyroid is part of the endocrine system. Heart, sinus and thymus are not.
Question 13
Which of the following is considered significant enough to require immediate communication to another member of the health care team?
A
Patient stated, “I feel less nauseated.”
B
Change of heart rate from 70 to 83 beats per minute.
C
Weight loss of 3 lbs in a 120 lb female patient.
D
Diminished breath sounds in patient with previously normal breath sounds
Question 13 Explanation:
Diminished breath sound is a life threatening problem therefore it is highly priority because they pose the greatest threat to the patient’s well-being.
Question 14
It is the gradual decrease of the body’s temperature after death.
A
none of the above
B
rigor mortis
C
livor mortis
D
algor mortis
Question 14 Explanation:
Algor mortis is the decrease of the body’s temperature after death. Livor mortis is the discoloration of the skin after death. Rigor mortis is the stiffening of the body that occurs about 2-4 hours after death.
Question 15
Nurse Cherry is teaching a 72 year old patient about a newly prescribed medication. What could cause a geriatric patient to have difficulty retaining knowledge about the newly prescribed medication?
A
Decreased sensory functions
B
Decreased plasma drug levels
C
Absence of family support
D
Patient has no interest on learning
Question 15 Explanation:
Decreased in sensory functions could cause a geriatric patient to have difficulty retaining knowledge about the newly prescribed medications. Absence of family support and no interest on learning may affect compliance, not knowledge retention. Decreased plasma levels do not alter patient’s knowledge about the drug.
Question 16
To assess the adequacy of food intake, which of the following assessment parameters is best used?
A
eating style and habits
B
regularity of meal times
C
food preferences
D
3-day diet recall
Question 16 Explanation:
3-day diet recall is an example of dietary history. This is used to indicate the adequacy of food intake of the client.
Question 17
A patient is wearing a soft wrist-safety device. Which of the following nursing assessment is considered abnormal?
A
Palpable radial pulse
B
Palpable ulnar pulse
C
Bluish fingernails, cool and pale fingers
D
Capillary refill within 3 seconds
Question 17 Explanation:
A safety device on the wrist may impair blood circulation. Therefore, the nurse should assess the patient for signs of impaired circulation such as bluish fingernails, cool and pale fingers. Palpable radial and ulnar pulses, capillary refill within 3 seconds are all normal findings.
Question 18
When assessing a patient’s level of consciousness, which type of nursing intervention is the nurse performing?
A
Independent
B
Collaborative
C
Professional
D
Dependent
Question 18 Explanation:
Independent nursing interventions involve actions that nurses initiate based on their own knowledge and skills without the direction or supervision of another member of the health care team.
Question 19
The nurse is aware that Bell’s palsy affects which cranial nerve?
A
4th CN (Trochlear)
B
3rd CN (Occulomotor)
C
7th CN (Facial)
D
2nd CN (Optic)
Question 19 Explanation:
Bells’ palsy is the paralysis of the motor component of the 7th caranial nerve, resulting in facial sag, inability to close the eyelid or the mouth, drooling, flat nasolabial fold and loss of taste on the affected side of the face.
Question 20
During application of medication into the ear, which of the following is inappropriate nursing action?
A
In an adult, pull the pinna upward.
B
Instill the medication directly into the tympanic membrane.
C
Warm the medication at room or body temperature.
D
Press the tragus of the ear a few times to assist flow of medication into the ear canal.
Question 20 Explanation:
During the application of medication it is inappropriate to instill the medication directly into the tympanic membrane. The right thing to do is instill the medication along the lateral wall of the auditory canal.
Question 21
Which of the following is appropriate nursing intervention for a client who is grieving over the death of her child?
A
Discourage the client in expressing her emotions.
B
Tell her not to cry and it will be better.
C
Encourage her to accept or to replace the lost person.
D
Provide opportunity to the client to tell their story.
Question 21 Explanation:
Providing a grieving person an opportunity to tell their story allows the person to express feelings. This is therapeutic in assisting the client resolve grief.
Question 22
Which is an example of a subjective data?
A
Productive cough
B
Patient stated, “My arms still hurt.”
C
Vomiting for 3 days
D
Temperature of 38 0C
Question 22 Explanation:
Subjective data are apparent only to the person affected and can or verified only by that person.
Question 23
Pia’s serum sodium level is 150 mEq/L. Which of the following food items does the nurse instruct Pia to avoid?
A
sardines
B
broccoli
C
cabbage
D
tomatoes
Question 23 Explanation:
The normal serum sodium level is 135 to 145 mEq/L, the client is having hypernatremia. Pia should avoid food high in sodium like processed food. Broccoli, cabbage and tomatoes are good source of Vitamin C.
Question 24
Jason, 3 years old vomited. His mom stated, “He vomited 6 ounces of his formula this morning.” This statement is an example of:
A
subjective data from a secondary source
B
objective data from a secondary source
C
objective data from a primary source
D
subjective data from a primary source
Question 24 Explanation:
Jason is the primary source; his mother is a secondary source. The data is objective because it can be perceived by the senses, verified by another person observing the same patient, and tested against accepted standards or norms.
Question 25
Kussmaul’s breathing is;
A
Prolonged gasping inspiration followed by a very short, usually inefficient expiration.
B
Shallow breaths interrupted by apnea.
C
Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea.
D
Increased rate and depth of respiration.
Question 25 Explanation:
Kussmaul breathing is also called as hyperventilation. Seen in metabolic acidosis and renal failure. Shallow breaths interrupted by apnea refers to Biot’s breathing. Prolonged gasping inspiration followed by a very short, usually inefficient expiration is apneustic breathing and marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea is the Cheyne-stokes breathing.
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1. A patient is wearing a soft wrist-safety device. Which of the following nursing assessment is considered abnormal?
Palpable radial pulse
Palpable ulnar pulse
Capillary refill within 3 seconds
Bluish fingernails, cool and pale fingers
2. Pia’s serum sodium level is 150 mEq/L. Which of the following food items does the nurse instruct Pia to avoid?
broccoli
sardines
cabbage
tomatoes
3. Jason, 3 years old vomited. His mom stated, “He vomited 6 ounces of his formula this morning.” This statement is an example of:
objective data from a secondary source
objective data from a primary source
subjective data from a primary source
subjective data from a secondary source
4. Which of the following is a nursing diagnosis?
Hypethermia
Diabetes Mellitus
Angina
Chronic Renal Failure
5. What is the characteristic of the nursing process?
stagnant
inflexible
asystematic
goal-oriented
6. A skin lesion which is fluid-filled, less than 1 cm in size is called:
papule
vesicle
bulla
macule
7. During application of medication into the ear, which of the following is inappropriate nursing action?
In an adult, pull the pinna upward.
Instill the medication directly into the tympanic membrane.
Warm the medication at room or body temperature.
Press the tragus of the ear a few times to assist flow of medication into the ear canal.
8. Which of the following is appropriate nursing intervention for a client who is grieving over the death of her child?
Tell her not to cry and it will be better.
Provide opportunity to the client to tell their story.
Encourage her to accept or to replace the lost person.
Discourage the client in expressing her emotions.
9. It is the gradual decrease of the body’s temperature after death.
livor mortis
rigor mortis
algor mortis
none of the above
10. When performing an admission assessment on a newly admitted patient, the nurse percusses resonance. The nurse knows that resonance heard on percussion is most commonly heard over which organ?
thigh
liver
intestine
lung
11. The nurse is aware that Bell’s palsy affects which cranial nerve?
2nd CN (Optic)
3rd CN (Occulomotor)
4th CN (Trochlear)
7th CN (Facial)
12. Prolonged deficiency of Vitamin B9 leads to:
scurvy
pellagra
megaloblastic anemia
pernicious anemia
13. Nurse Cherry is teaching a 72 year old patient about a newly prescribed medication. What could cause a geriatric patient to have difficulty retaining knowledge about the newly prescribed medication?
Absence of family support
Decreased sensory functions
Patient has no interest on learning
Decreased plasma drug levels
14. When assessing a patient’s level of consciousness, which type of nursing intervention is the nurse performing?
Independent
Dependent
Collaborative
Professional
15. Claire is admitted with a diagnosis of chronic shoulder pain. By definition, the nurse understands that the patient has had pain for more than:
3 months
6 months
9 months
1 year
16. Which of the following statements regarding the nursing process is true?
It is useful on outpatient settings.
It progresses in separate, unrelated steps.
It focuses on the patient, not the nurse.
It provides the solution to all patient health problems.
17. Which of the following is considered significant enough to require immediate communication to another member of the health care team?
Weight loss of 3 lbs in a 120 lb female patient.
Diminished breath sounds in patient with previously normal breath sounds
Patient stated, “I feel less nauseated.”
Change of heart rate from 70 to 83 beats per minute.
18. To assess the adequacy of food intake, which of the following assessment parameters is best used?
food preferences
regularity of meal times
3-day diet recall
eating style and habits
19. Van Fajardo is a 55 year old who was admitted to the hospital with newly diagnosed hepatitis. The nurse is doing a patient teaching with Mr. Fajardo. What kind of role does the nurse assume?
talker
teacher
thinker
doer
20. When providing a continuous enteral feeding, which of the following action is essential for the nurse to do?
Place the client on the left side of the bed.
Attach the feeding bag to the current tubing.
Elevate the head of the bed.
Cold the formula before administering it.
21. Kussmaul’s breathing is;
Shallow breaths interrupted by apnea.
Prolonged gasping inspiration followed by a very short, usually inefficient expiration.
Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea.
Increased rate and depth of respiration.
22. Presty has terminal cancer and she refuses to believe that loss is happening ans she assumes artificial cheerfulness. What stage of grieving is she in?
depression
bargaining
denial
acceptance
23. Immunization for healthy babies and preschool children is an example of what level of preventive health care?
Primary
Secondary
Tertiary
Curative
24. Which is an example of a subjective data?
Temperature of 38 0C
Vomiting for 3 days
Productive cough
Patient stated, “My arms still hurt.”
25. The nurse is assessing the endocrine system. Which organ is part of the endocrine system?
Heart
Sinus
Thyroid
Thymus
Answers and Rationales
(D) Bluish fingernails, cool and pale fingers. A safety device on the wrist may impair blood circulation. Therefore, the nurse should assess the patient for signs of impaired circulation such as bluish fingernails, cool and pale fingers. Palpable radial and ulnar pulses, capillary refill within 3 seconds are all normal findings.
(B) sardines. The normal serum sodium level is 135 to 145 mEq/L, the client is having hypernatremia. Pia should avoid food high in sodium like processed food. Broccoli, cabbage and tomatoes are good source of Vitamin C.
(A) objective data from a secondary source. Jason is the primary source; his mother is a secondary source. The data is objective because it can be perceived by the senses, verified by another person observing the same patient, and tested against accepted standards or norms.
(A) Hypethermia. Hyperthermia is a NANDA-approved nursing diagnosis. Diabetes Mellitus, Angina and Chronic Renal Failure are medical diagnoses.
(D) goal-oriented. The nursing process is goal-oriented. It is also systematic, patient-centered, and dynamic.
(B) vesicle. Vesicle is a circumscribed circulation containing serous fluid or blood and less than 1 cm (ex. Blister, chicken pox).
(B) Instill the medication directly into the tympanic membrane. During the application of medication it is inappropriate to instill the medication directly into the tympanic membrane. The right thing to do is instill the medication along the lateral wall of the auditory canal.
(B) Provide opportunity to the client to tell their story. Providing a grieving person an opportunity to tell their story allows the person to express feelings. This is therapeutic in assisting the client resolve grief.
(C) algor mortis. Algor mortis is the decrease of the body’s temperature after death. Livor mortis is the discoloration of the skin after death. Rigor mortis is the stiffening of the body that occurs about 2-4 hours after death.
(D) lung. Resonance is loud, low-pitched and long duration that’s heard most commonly over an air-filled tissue such as a normal lung.
(D) 7th CN (Facial). Bells’ palsy is the paralysis of the motor component of the 7th caranial nerve, resulting in facial sag, inability to close the eyelid or the mouth, drooling, flat nasolabial fold and loss of taste on the affected side of the face.
(C) megaloblastic anemia. Prolonged Vitamin B9 deficiency will lead to megaloblastic anemia while pernicious anemia results in deficiency in Vitamin B12. Prolonged deficiency of Vitamin C leads to scurvy and Pellagra results in deficiency in Vitamin B3.
(B) Decreased sensory functions. Decreased in sensory functions could cause a geriatric patient to have difficulty retaining knowledge about the newly prescribed medications. Absence of family support and no interest on learning may affect compliance, not knowledge retention. Decreased plasma levels do not alter patient’s knowledge about the drug.
(A) Independent. Independent nursing interventions involve actions that nurses initiate based on their own knowledge and skills without the direction or supervision of another member of the health care team.
(B) 6 months. Chronic pain s usually defined as pain lasting longer than 6 months.
(C) It focuses on the patient, not the nurse. The nursing process is patient-centered, not nurse-centered. It can be use in any setting, and the steps are related. The nursing process can’t solve all patient health problems.
(B) Diminished breath sounds in patient with previously normal breath sounds. Diminished breath sound is a life threatening problem therefore it is highly priority because they pose the greatest threat to the patient’s well-being.
(C) 3-day diet recall. 3-day diet recall is an example of dietary history. This is used to indicate the adequacy of food intake of the client.
(B) teacher. The nurse will assume the role of a teacher in this therapeutic relationship. The other roles are inappropriate in this situation.
(C) Elevate the head of the bed. Elevating the head of the bed during an enteral feeding prevents aspiration. The patient may be placed on the right side to prevent aspiration. Enteral feedings are given at room temperature to lessen GI distress. The enteral tubing should be changed every 24 hours to limit microbial growth.
(D) Increased rate and depth of respiration. Kussmaul breathing is also called as hyperventilation. Seen in metabolic acidosis and renal failure. Option A refers to Biot’s breathing. Option B is apneustic breathing and option C is the Cheyne-stokes breathing.
(C) denial. The client is in denial stage because she is unready to face the reality that loss is happening and she assumes artificial cheerfulness.
(A) Primary. The primary level focuses on health promotion. Secondary level focuses on health maintenance. Tertiary focuses on rehabilitation. There is n Curative level of preventive health care problems.
(D) Patient stated, “My arms still hurt.”. Subjective data are apparent only to the person affected and can or verified only by that person.
(C) Thyroid. The thyroid is part of the endocrine system. Heart, sinus and thymus are not.