Nursing textbooks medical-surgical practice questions, set 12
Nursing textbooks · medical-surgical
Nursing textbooks medical-surgical practice questionsset 12
You practice adult health stems across systems, then name the action that changes the outcome. Five of the 15 questions include the correct answer and rationale. The other ten keep answers in the study hub. Continue with the Nursing textbooks exam guide or more Nursing textbooks practice questions.
Five medical-surgical questions with answers
Cover the key. Write the first action. Then open the rationale and name why the other choices fail.
Question 1
A nurse who is considered a servant leader is working in an economically depressed community setting up a free mobile health clinic. Which actions best exemplify a servant leader? Select all that apply.
A. Motivating coworkers to solicit funding to set up the clinic
B. Setting only realistic goals that are present oriented and easily achieved
C. Forming an autocratic governing body to keep the project on track
D. Spending time with supporters to help them grow in their roles
E. Ensuring that other's lowest priority needs are served
Show answer and rationale
Correct answer: A — Motivating coworkers to solicit funding to set up the clinic
To serve as servant leaders, nurses need to invest in those who support the organization's values, show passion, can play to their strengths, and demonstrate a positive attitude. They should develop their vision to see the future related to a current anticipated need and motivate others to follow and engage. They also need to provide ongoing opportunities for collaborations, sharing, reflection, encouragement, and celebration as well as hard work. The servant leader allows others to have a voice, to exercise control, and to practice leading themselves. The servant first makes sure that other people's highest priority needs are being served.
Question 2
The nurse is caring for a long-term care patient with moderate dementia who develops increased restlessness and agitation. Which of the following actions should the nurse implement initially?
A. Reorient the patient to time, place, and person.
B. Administer the PRN dose of lorazepam.
C. Assess for factors that might be causing discomfort.
D. Have a nursing assistant stay with the patient to ensure safety.
Show answer and rationale
Correct answer: C — Assess for factors that might be causing discomfort.
Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors like pain, so the nurse's initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning a nursing assistant to stay with the patient also may be necessary, but any physical changes that may be causing the agitation should be addressed first.
Question 3
A female client comes to the clinic and tells the nurse, 'I think I have another vaginal infection and I also have some wart-like lesions on my vagina. This is happening quite often.' Which nursing action is the priority for this client?
A. Recommend abstinence or safer-sex practices.
B. Offer information on human immunodeficiency virus (HIV) testing.
C. Provide a prescribed topical antifungal agent to treat the client's vaginal infection.
D. Refer the client to a support group with others experiencing the same symptoms.
Show answer and rationale
Correct answer: B — Offer information on human immunodeficiency virus (HIV) testing.
In women, gynecologic problems may be the focus of the chief complaint for clients who are HIV positive but not yet diagnosed. Abnormal results of Papanicolaou tests, genital warts, pelvic inflammatory disease, and persistent vaginitis may also correlate with HIV infection. Based on this information, the priority nursing action is to offer information on HIV testing to the client. Although recommending abstinence or safer-sex practices, providing a prescribed topical antifungal agent to treat the client's vaginal infection, and referring to a support group may be appropriate, the priority is to determine the source of the client's symptoms.
Question 4
A home health nurse is caring for a patient discharged home after pancreatic surgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than Body Requirements on the care plan based on the potential complications that may occur after surgery. What are the most likely complications for the patient who has had pancreatic surgery?
A. Proteinuria and hyperkalemia
B. Hemorrhage and hypercalcemia
C. Weight loss and hypoglycemia
D. Malabsorption and hyperglycemia
Show answer and rationale
Correct answer: D — Malabsorption and hyperglycemia
The nurse arrives at this diagnosis based on the complications of malabsorption and hyperglycemia. These complications often lead to the need for dietary modifications. Pancreatic enzyme replacement, a low-fat diet, and vitamin supplementation often are also required to meet the patients nutritional needs and restrictions. Electrolyte imbalances often accompany pancreatic disorders and surgery, but the electrolyte levels are more often deficient than excessive. Hemorrhage is a complication related to surgery, but not specific to the nutritionally based nursing diagnosis. Weight loss is a common complication, but hypoglycemia is less likely.
Question 5
A patient experiencing severe anxiety suddenly begins running and shouting, 'I'm going to explode!' The nurse should implement which intervention to best maximize the patient's safety?
A. State, 'I'm not sure what you mean. Give me an example.'
B. Chase after the patient while giving instructions to stop running.
C. Retrain the patient in a basket-hold to increase feelings of control.
D. Assemble several staff members and state, 'We will help you regain control.'
Show answer and rationale
Correct answer: D — Assemble several staff members and state, 'We will help you regain control.'
The safety needs of the patient and other patients are a priority. The patient is less likely to cause self-harm or hurt others when several staff members take responsibility for providing limits. The explanation given to the patient should be simple and neutral. Simply being told that others can help provide the control that has been lost may be sufficient to help the patient regain control. Running after the patient will increase the patient's anxiety. More than one staff member is needed to provide physical limits if they become necessary. Asking the patient to give an example is futile; a patient in panic processes information poorly.
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Question 6
The nurse is admitting and preparing the client for surgery. Following administration of lorazepam 2 mg orally, one time dose, which safety measure is most appropriate?
A. Place the client in a semi-Fowler's position.
B. Place the side rails in the up position.
C. Remove the water pitcher from the bedside.
D. Instruct the family to call for any client needs.
Correct answer:
Lorazepam is a common hypnotic administered to reduce preoperative anxiety. The most appropriate safety measure is to limit the client's ability to get out of bed following administration of a preoperative sedative. Assistance is needed to maintain client safety. Placing the client in a semi-Fowler's position aids in gas exchange, but this is not indicated as a concern in this question and does not relate to a safety concern associated with this medication. Water should not be at the bedside for a client in the preoperative phase. Families can be helpful support for the client; however, it is the nurse's responsibility to maintain safety.
A laboring mother asks the nurse if the baby will have immunity to some illnesses when born. What type of immunity does the nurse understand that the newborn will have?
A. Naturally acquired active immunity
B. Artificially acquired active immunity
C. Passive immunity transferred by the mother
D. There is no immunity passed down from mother to child.
Correct answer:
Passive immunity develops when ready-made antibodies are given to a susceptible person. The antibodies provide immediate but short-lived protection from the invading antigen. Newborns receive passive immunity to some diseases for which their mothers have manufactured antibodies. Naturally acquired active immunity occurs as a direct result of infection by a specific microorganism. An example is the immunity to measles that develops after the initial infection. Not all invading microorganisms produce a response that gives lifelong immunity. Artificially acquired immunity is obtained by receiving a killed or weakened microorganism or toxoid.
The nurse is administering intravenous vancomycin to a patient who has had gastrointestinal surgery. Which nursing measures are appropriate? (Select all that apply.)
A. Monitoring serum creatinine levels
B. Restricting fluids while the patient is on this medication
C. Warning the patient that a flushed feeling or facial itching may occur
D. Instructing the patient to report dizziness or a feeling of fullness in the ears
E. Reporting a trough drug level of 11 mcg/mL and holding the drug
Correct answer:
Constant monitoring for drug-related neurotoxicity, nephrotoxicity, ototoxicity, and superinfection remains critical to patient safety. Monitor for nephrotoxicity by monitoring serum creatinine levels. Ototoxicity may be indicated if the patient experiences dizziness or a feeling of fullness in the ears, and these symptoms must be reported immediately. Vancomycin infusions may cause red man syndrome, which is characterized by flushing of the neck and face and a decrease in blood pressure. Optimal trough blood levels of vancomycin are 10 to 20 mcg/mL; therefore, the drug should not be administered when there is a trough level of 24 mcg/mL.
The nurse is caring for a patient who has a BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which of the following actions should the nurse take first?
A. Elevate the head of the patient's bed to 60 degrees.
B. Document the BP and ICP in the patient's record.
C. Report the BP and ICP to the health care provider.
D. Continue to monitor the patient's vital signs and ICP
Correct answer:
The patient's cerebral perfusion pressure is 56 mm Hg (using the calculation CPP = MAP - ICP). This is below the normal range of 70-100 mm Hg and approaching the level of ischemia and neuronal death as a minimum of 50-60 mm Hg is necessary for adequate cerebral perfusion. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation also will be done, but they are not the first actions that the nurse should take.
The nurse is caring for a group of hospitalized patients with various psychiatric diagnoses. The nurse identifies which patient as having the greatest risk for a suicide attempt?
A. Man with bipolar I disorder
B. Woman with acute stress disorder
C. Man with major depressive disorder
D. Woman with somatoform disorder
Correct answer:
Major depressive disorder is strongly associated with a high risk of suicide due to persistent feelings of hopelessness, worthlessness, and despair, which are core symptoms. Studies indicate that individuals with major depressive disorder have a significantly higher suicide risk compared to other psychiatric conditions. Bipolar I disorder (A) carries a risk, particularly during depressive episodes, but the risk is generally lower than in major depressive disorder. Acute stress disorder (B) is typically short-term and less associated with suicide. Somatoform disorder (D) focuses on physical symptoms and has a lower direct link to suicide.
A nurse is caring for a client who has just been diagnosed with glaucoma. What teaching should the nurse include with this client?
A. How long it will be necessary to wear dark glasses
B. The importance of regular bowel habits
C. What vegetables to eat
D. When it will be possible to read again
Correct answer:
Instructions for the client with glaucoma include the following: Obtain assistance from a family member, relative, or friend if having trouble instilling eye drops. Avoid all drugs that contain atropine. Check with physician or pharmacist before using any nonprescription drug. preparations for cold or allergy symptoms may contain an atropine-like drug. Maintain regular bowel habits; straining at stool can raise intraocular pressure (IOP). Avoid heavy lifting and emotional upsets (especially crying) because they increase IOP. Patients do not have to wear dark glasses. Vegetable consumption is not restricted. Reading does not increase IOP.
A male client is having sexual relations with another male as well as using methamphetamine and has contracted HIV. What concern does the nurse have for this client?
A. The client is a drug addict and needs to stop using.
B. The client may infect other people because of the drug use.
C. The client may develop AIDS in a shorter period of time.
D. The client will remain HIV positive for a longer period of time.
Correct answer:
A new strain of HIV, identified as 3-DCR HIV, was detected in a gay man in New York. Scientists consider this new strain highly virulent because it converted the man's initial HIV infection to full-blown AIDS in a matter of months; the new strain is highly drug resistant. The infected man also used methamphetamine, which scientists believe can accelerate the replication of the virus, especially in the brain. Although the drug addiction and the transmission of HIV to other people is a concern, it does not relate to what the question is asking. A positive outcome would be the client maintaining HIV status longer and not converting to AIDS.
The nurse is caring for a group of hospitalized patients with various psychiatric diagnoses. The nurse identifies which patient as having the greatest risk for a suicide attempt?
A. Man with bipolar I disorder
B. Woman with acute stress disorder
C. Man with major depressive disorder
D. Woman with somatoform disorder
Correct answer:
Major depressive disorder is strongly associated with a high risk of suicide due to persistent feelings of hopelessness, worthlessness, and despair, which are core symptoms. Studies indicate that individuals with major depressive disorder have a significantly higher suicide risk compared to other psychiatric conditions. Bipolar I disorder (A) carries a risk, particularly during depressive episodes, but the risk is generally lower than in major depressive disorder. Acute stress disorder (B) is typically short-term and less associated with suicide. Somatoform disorder (D) focuses on physical symptoms and has a lower direct link to suicide.
The nursing student observes the perioperative area and notes the unique functions of the circulating nurse, which include: (Select all that apply.)
A. Accounting for all sharps
B. Documenting all care given
C. Maintaining the sterile field
D. Monitoring traffic in the room
E. Anticipating needs of the surgical team
Correct answer:
The circulating nurse has several responsibilities, including maintaining client safety and privacy, monitoring traffic in and out of the operating room, assessing fluid losses, reporting findings to the surgeon and anesthesia provider, anticipating needs of the team, and communicating to the family. The circulating nurse and scrub person work together to ensure accurate counts of sharps, sponges, and instruments. The circulating nurse also documents care, but in the perioperative area, the preoperative or holding room nurse would also document. Maintaining the sterile field is a joint responsibility of all members of the surgical team.
What are the causes of somatic system disorders generally related to?
A. Faulty perceptions of body sensations
B. Traumatic childhood events
C. Culture-bound phenomena
D. Mood instability
Correct answer:
Structural or functional abnormalities of the brain have been suggested to lead to the somatic system disorders, resulting in disturbed processes of perception and interpretation of bodily sensations. Furthermore, cognitive theorists believe patients misinterpret the meaning of certain bodily sensations and then become excessively alarmed by them. Traumatic childhood events are related to the dissociative disorders. Culture-bound phenomena may explain the prevalence of some symptoms but cannot explain the cause. Somatic system disorders are not a facet of mood instability; however, depression may coexist with a somatic system disorder.
About these Nursing textbooks medical-surgical questions
Nursing textbooks medical-surgical practice questions, set 12 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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