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NUR2214 / NUR 2214 EXAM 2 (Latest 2023 /
2024): Nursing Care of the Older Adult -
Rasmussen
Two nursing students are shadowing a neurology nurse and together they observe a patient who is lying in the supine position with their arms and legs extended forming an “E-shape.” What does this patient’s position indicate? A. Damage to the pons or brain stem B. Damage to the spinal tract C. Damage to the cerebral hemisphere D. Damage to the lumbar spine A. Damage to the pons or brain stem Rationale: The patient appears to be in a decerebrate position, which involves damage to the pons or brain stem. A patient with osteoporosis is prescribed Risedronic (Actonel). What teaching should go along with this medication? Select all that apply: A. Take medication 30 minutes before breakfast B. Take medication 2 hours after breakfast C. Take medication with an 8 oz glass of water D. Take medication right before going to bed E. Take medication during lunch F. Take medication while sitting up G. Take medication in the supine position A. Take medication 30 minutes before breakfast
C. Take medication with an 8 oz glass of water F. Take medication while sitting up A patient with multiple sclerosis (MS) has an acute exacerbation. What medication does the nurse anticipate the HCP ordering? A. Diphenhydramine (Benadryl) B. Metoprolol (Lopressor) C. Amoxicillin (Moxatag) D. Methylprednisolone (Solu-Medrol) D. Methylprednisolone (Solu-Medrol) What are some likely medications for a patient with osteoarthritis? A. Antibiotics B. Anticholinergics C. NSAIDs D. Antihypertensive C. NSAIDs Rationale: NSAIDs are the most effective treatment for patients with osteoarthritis. Cox-2 Inhibitors are a very common NSAID used for osteoarthritis A nursing student observes a PA working in a cardiology clinic. The PA and the student assess an infant patient with a "machine-like heart murmur." The student notices the patient has a bounding heart pulse. The PA knows the teaching has been successful when the student is able to identify the condition as: A. Pulmonary embolism B. Patent Ductus Arteriosus
C. 15 - 30
D. 20 - 30
A. 5 - 15
Rationale: millimeters of mercury is how this is measured What are some nursing interventions for a child suffering from Tetralogy of Fallot (TOF)? Select all that apply: A. Decrease stimuli B. Place child in high fowler's position C. Weigh child at various times throughout the day D. Check peripheral pulses, including capillary refill E. Check for edema F. Prevent child from playing A. Decrease stimuli D. Check peripheral pulses, including capillary refill Rationale: Children should still be allowed to play, just not in a way that will cause over-exertion. These patients should be placed in the semi-fowler's position. In addition, these patients should be weighed every day, at the same time, and ideally before breakfast. A student nurse receives education on how changes in mobility will occur throughout a person's lifespan. What are these expected changes considered to be part of? A. Family Systems Theory B. Sedentary lifestyle C. Growth and development D. Rare physiological changes
C. Growth and development A nursing instructor describes this heart defect as one the easiest ones to diagnose. It can often be identified on a chest-X-Ray because of its "boot-like" appearance. A. Coarctation of the aorta B. Right Ventricular Hypertrophy C. Pulmonary Stenosis D. Overriding Aorta B. Right Ventricular Hypertrophy Rationale: This is one of the four heart defects associated with Tetralogy of Fallot (TOF). A nurse and a cardiology nurse practitioner discuss nursing interventions for a patient with an aorta that is positioned directly above a ventricular septal defect (VSD). This condition allows blood from both ventricles to enter the aorta. What is this specific phenomenon known as? A. Ventricular Septal Defect (VSD) B. Right Ventricular Hypertrophy C. Pulmonary Stenosis D. Overriding Aorta D. Overriding Aorta Rationale: This is one of the four heart defects associated with Tetralogy of Fallot (TOF). A graduate nurse hears the term "palliative interprofessional core team." The nurse should know this includes the specific disciplines of: Select all that apply: A. Nursing
C. Coarctation of Aorta D. Tetralogy of Fallot D. Tetralogy of Fallot A 62-year-old female Caucasian patient has been diagnosed with osteoporosis. Which medication(s) is the HCP likely to prescribe? Select all that apply: A. Alendronate B. Atropine C. Risedronate (Actonel) D. Ibandronate E. Prednisolone F. Zoledronic A 62-year-old female Caucasian patient has been diagnosed with osteoporosis. Which medication(s) is the HCP likely to prescribe? Select all that apply: A. Alendronate C. Risedronate (Actonel) D. Ibandronate F. Zoledronic Rationale: Risedronate (Actonel) is commonly used to treat patients with osteoporosis. Prednisolone is a corticosteroid and should be withheld from patients with osteoporosis. Corticosteroids have a major impact on how the body uses calcium and can actually cause bone loss. While auscultating a newborn's chest, the nurse appreciates a heart murmur. An electrocardiogram (EKG) confirms the murmur occurs as blood passes through the left and right ventricles. What condition does the newborn most likely have?
A. Coarctation of the aorta (COA) B. Ventricle Septal Defect (VSD) C. Patent Ductus Arteriosus (PDA) D. Atrial Septal Defect (ASD) B. Ventricle Septal Defect (VSD) An HCP decides surgery is the best option for a patient with a patent ductus arteriosus (PDA). The parents ask what the purpose of this surgical procedure is. How should the nurse respond? A. The purpose is to prevent your child from developing diabetes later in life B. The purpose is to prevent your child's aorta from narrowing C. The purpose is to ensure oxygenated blood continues to go back to the lungs D. The purpose is to stop oxygenated blood from going back to the lungs D. The purpose is to stop oxygenated blood from going back to the lungs Which Glasgow Coma scale is most concerning to the nurse? A. 6 B. 8 C. 10 D. 13 A. 6 Rationale: Lowest possible score on Glasgow coma is 3 and the highest possible score is 15. The Glasgow Coma scale includes three categories: eye opening, verbal response, and motor function. A score of 8 or less is considered a severe neurological injury. A student nurse receives education on pain management and why it is important to prevent patients from having "long-term exposure to pain." The nursing educator deems the teaching to be successful after the student is able to verbalize:
A. Around the clock Demerol B. PRN ibuprofen C. Morphine IV 2hrs PRN D. Morphine PCA D. Morphine PCA Rationale: EBP says PCA control is the best way to control severe pain. The PCA reduces the patient's risk of overdose, too. Demerol is contraindicated in patients that are considered elderly and therefore should not be prescribed. A nurse cares for a patient who has ventricular septal defect (VSD). Which genetic anomaly is most commonly associated with this cardiac condition? A. Cystic Fibrosis B. Down Syndrome C. Fragile X Syndrome D. Marfan Syndrome B. Down Syndrome Rationale: Down syndrome (Trisomy 21) poses the greatest risk for heart defects in newborns. A nurse observes a 2-year-old patient with Tetralogy of Fallot (TOF) squatting. Why is the child most likely in this position? A. It relaxes the patients back muscles B. It improves the child's posturing C. It prevents the child from having a bowel movement D. It returns blood blow to the lungs D. It returns blood blow to the lungs
A graduate nurse is consulting with their nurse preceptor on how to care for patients with increased intracranial pressure (ICP). Which statement by the graduate indicates a need for further teaching? A. "My patient may require a stool softener in addition to their antiemetic." B. "I will try to cluster as many episodes of care as possible for this patient." C. "I will educate my patient on why the act of straining should be avoided." D. "My patient will remain in the semi-fowler's position." B. "I will try to cluster as many episodes of care as possible for this patient." Rationale: when caring for patients with increased intracranial pressure (ICP), nurses should space the care out as much as possible so they can reduce the number of stimuli the patient is exposed to. The goal is to not get patients with ICP overly worked up. Which patient population will NSAIDs most likely be used to treat patent ductus arteriosus (PDA)? A. Macrosomia infants B. Late full-term infants C. Premature infants D. Full-term infants C. Premature infants Rationale: NSAIDs can be used to care for premature infants. Surgical/ligation is significantly more likely to be used for late and full-term infants A student nurse receives education from a NP about osteoporosis. Which statement by the student nurse indicates the teaching has been successful? A. "Calcium helps with vitamin D absorption." B. "There is no way to treat osteoporosis after menopause." C. "For five years after menopause women will lose about 2% of bone mass each
B. Stool softener Rationale: The goal is to prevent straining for patients with ICP. The HCP does not want the patient bearing down so an antiemetic will prevent the patient from vomiting. However, a side effect of antiemetic is constipation, which could also encourage the patient to start bearing down. Therefore, a stool softener might be necessary. A nurse plans on discharging a 74-year-old female patient with osteoporosis who lives alone. What should be the nurse's first priority? A. Conduct a home risk assessment B. Encourage the patient to follow up with their HCP C. Instruct the patient to be careful walking around the house D. Tell the patient to call the HCP's office if she thinks she is a fall risk A. Conduct a home risk assessment An HCP instructs a nurse to provide education on using a transdermal patch. What should be included in the teaching? A. Always apply the new patch to same exact location B. Always remove the previous patch before applying a new one C. Do not keep on longer than 24 hours D. Always remove the patch by after 4 days Rationale: the patch should be changed every 72 hours (3 days) B. Always remove the previous patch before applying a new one Rationale: the patch should be changed every 72 hours (3 days) What is the lowest and highest possible score a patient can receive on the Glasgow Coma scale?
A. 3 and 15 B. 5 and 20 C. 8 and 17 D. 10 and 21 A. 3 and 15 What is responsible for pushing oxygenated blood to the rest of the body? A. The left bronchus B. Right ventricle C. Left ventricle D. Both the right ventricle and the left ventricle C. Left ventricle A 5-year-old child with an atrial septal defect (ASD) has symptoms that appear to be getting worse. The child's cardiologist recommends cardiac catherization. What is the purpose of this procedure? A. To flatten against the septum on both sides and permanently seal the ASD B. To conduct a biopsy on the cardiac tissue C. Widen the opening of the ASD to promote blood flow D. To determine if the child is a candidate for a heart transplant A. To flatten against the septum on both sides and permanently seal the ASD A nursing instructor asks a student to provide an example of a "biologically based therapy." Select all that apply: A. Herbs B. Opioids C. Weightlifting D. SSRIs E. Vitamins F. Tai Chi
C. To surgically remove the patency of the ductus (PDA) D. Improve oxygenation and decrease pulmonary blood flow B. Improve oxygenation and increase pulmonary blood flow A nurse performs an assessment on a pulmonary patient who describes his condition as having an "excess of muscle mass" around the right side of his heart. Before checking his chart, what condition should the nurse assume the patient is referring to? A. Coarctation of the aorta (COA) B. Right Ventricular Hypertrophy C. Pulmonary Stenosis D. Overriding Aorta B. Right Ventricular Hypertrophy Rationale: This is one of the four heart defects associated with Tetralogy of Fallot (TOF). How should a patient with increased intracranial pressure (ICP) be positioned? A. Semi-Fowler's position B. Prone position C. High-Fowler's position D. Supine position A. Semi-Fowler's position Rationale: positioned upward at 30 degrees A 4-year-old patient has a heart defect. The defect involves an obstruction of blood flow from his right ventricle of the heart to the pulmonary artery. What condition does the child most likely have? A. Coarctation of the aorta
B. Right Ventricular Hypertrophy C. Pulmonary Stenosis D. Overriding Aorta C. Pulmonary Stenosis Rationale: This is one of the four heart defects associated with Tetralogy of Fallot (TOF). Thirty minutes after administering morphine to a 1-year-old patient, the nurse suspects the patient is having an overdose. Which action should the nurse perform first? A. Notify the HCP B. Call the rapid response team C. Administer IV fluids D. Administer Narcan D. Administer Narcan A nursing professor provides teaching on patent ductus arteriosus (PDA) in a newborn baby. What is the time frame for when the "shunt" should close? A. 24 hours B. 48 hours C. 72 hours D. 96 hours C. 72 hours A nursing professor conducts a lecture on assessment findings for patients with multiple sclerosis (MS). The professor asks the students to list the assessment findings associated with late onset of MS. Select all that apply: A. Excessive somnolence B. Heat intolerance
C. Patent Ductus Arteriosus (PDA) D. Atrial Septal Defect (ASD) D. Atrial Septal Defect (ASD) A neurology nurse observes a patient with their arms and legs flexed toward the body. What does this indicate to the nurse about the patient's condition? A. Damage to the spinal tract or cerebral hemisphere B. Damage to the brain stem C. Damage to the midbrain D. Damage to the pons A. Damage to the spinal tract or cerebral hemisphere Rationale: the patient appears to be in the decorticate position A graduate nurse and her preceptor provide care for an infant patient who has a history of Tetralogy of Fallot (TOF). The infant's skin appears blueish. The preceptor pushes the baby's knees to his chest. What is the baby experiencing? A. An infection B. A Tet-spell C. Hypoglycemic episode D. Ascites B. A Tet-spell The elderly population's thermoregulation begins to dimmish. What age does this start happening at? A. 60 B. 70 C. 80 D. 90
B. 70
Rationale: Thermoregulation starts diminishing at age 70 and it gets worse each decade after that. In elderly patients, it takes twice the amount of time for their temperature to return to its normal range (because of changes in metabolism). This means drastic temperature changes are more life-threatening for elderly patients. A patient who has been taking opioids complains of constipation. What dietary recommendations should the nurse make to the patient? Select all that apply: A. Bran foods B. Green leafy vegetables C. Cheese D. Steak E. Apples F. Prunes G. Peanuts A. Bran foods B. Green leafy vegetables E. Apples F. Prunes G. Peanuts A nurse interviews a 75-year-old male patient who says he has a condition where his body "cannot keep up with making enough cartilage and bone." Which disorder should the nurse assume the patient has? A. Osteoporosis
