1. The main goal of treatment for acute glomerulonephritis is to:
encourage activity. encourage high protein intake. maintain fluid balance. teach intermittent urinary catheterization.
2. Nursing diagnoses mostly differ from medical diagnoses, in that they are:
dependent upon medical diagnoses for the direction of appropriate interventions. primarily concerned with caring, while medical diagnoses are primarily concerned with curing. primarily concerned with human response, while medical diagnoses are primarily concerned with pathology. primarily concerned with psychosocial parameters, while medical diagnoses are primarily concerned with physiologic parameters.
3. A patient who received spinal anesthesia four hours ago during surgery is transferred to the surgical unit and, after one and a half hours, now reports severe incisional pain. The patient’s blood pressure is 170/90 mm Hg, pulse is 108 beats/min, temperature is 99oF (37.2oC), and respirations are 30 breaths/min. The patient’s skin is pale, and the surgical dressing is dry and intact. The most appropriate nursing intervention is to:
medicate the patient for pain. place the patient in a high Fowler position and administer oxygen. place the patient in a reverse Trendelenburg position and open the IV line. report the findings to the provider.
4. To prevent a common, adverse effect of prolonged use of phenytoin sodium (Dilantin), patients taking the drug are instructed to:
avoid crowds and obtain an annual influenza vaccination. drink at least 2 L of fluids daily, including 8 to 10 glasses of water. eat a potassium-rich, low sodium diet. practice good dental hygiene and report gum swelling or bleeding.
5. The most common, preventable complication of abdominal surgery is:
atelectasis. fluid and electrolyte imbalance. thrombophlebitis. urinary retention.
6. A 78-year-old patient is scheduled for transition to home after treatment for heart disease. The patient’s spouse, who has chronic obstructive pulmonary disease, plans to care for the patient at home. The spouse says that their grown children, who live nearby, will help. The best approach to discharge planning is to:
arrange nursing home placement for the couple. consult the spouse’s healthcare provider about the spouse’s ability to care for the patient. contact the children to ascertain their commitment to help. discuss community resources with the spouse and offer to make referrals.
7. During an assessment of a patient who sustained a head injury 24 hours ago, the medical-surgical nurse notes the development of slurred speech and disorientation to time and place. The nurse’s initial action is to:
continue the hourly neurologic assessments. inform the neurosurgeon of the patient’s status. prepare the patient for emergency surgery. recheck the patient’s neurologic status in 15 minutes.
8. For the evaluation feedback process to be effective, the medical-surgical nurse who is a manager:
conducts weekly meetings with staff members. considers staff members’ interests and abilities when delegating tasks. informs staff members regularly of how well they are performing their jobs. provides goals for staff members to meet.
9. An 80-year-old patient is placed in isolation when infected with methicillin-resistantStaphylococcus aureus. The patient was alert and oriented on admission, but is now having visual hallucinations and can follow only simple directions. The medical-surgical nurse recognizes that the changes in the patient’s mental status are related to:
a fluid and electrolyte imbalance. a stimulating environment. sensory deprivation. sundowning.