Medical-Surgical Nursing- Assessment and Management of Clinical Problems (GRADED A)

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Test Bank For Medical-Surgical Nursing- Assessment and Management of Clinical Problems An adult patient who arrived at the triage desk in the emergency department (ED) with minor facial lacerations a... fter a motor vehicle accident has a blood pressure (BP) of 182/94. Which action by the nurse is appropriate? a. Start an IV line to administer antihypertensive medications. b. Recheck the blood pressure after the patient has been assessed. c. Discuss the need for hospital admission to control blood pressure. d. Teach the patient about the stroke risk associated with uncontrolled hypertension. 2. A female patient who initially came to the clinic with incontinence was recently diagnosed with endometrial cancer. She is usually well organized and calm, but the nurse who is giving her preoperative instructions observes that the patient is irritable, has difficulty concentrating, and yells at her husband. Which action should the nurse take? a. Ask the health care provider for a psychiatric referral. b. Focus teaching on preventing postoperative complications. c. Try to calm the patient before repeating any information about the surgery. d. Encourage the patient to combine the hysterectomy with surgery for bladder repair. An adult patient who is hospitalized after a motorcycle crash tells the nurse, “I didn’t sleep last night because I worried about missing work at my new job and losing my insurance coverage.” Which nursing diagnosis is appropriate to include in the plan of care? a. Anxiety c. Ineffective denial b. Defensive coping d. Risk prone health behavior A patient is extremely anxious about having a biopsy on a femoral lymph node. Which relaxation technique would be the best choice for the nurse to facilitate during the procedure? a. Yoga stretching c. Relaxation breathing b. Guided imagery d. Mindfulness meditation 5. A patient who has frequent migraines tells the nurse, “My life feels chaotic and out of my control. I could not manage if anything else happens.” Which response should the nurse make initially? a. “Regular exercise may get your mind off the pain.” b. “Guided imagery can be helpful in regaining control.” c. “Tell me more about how your life has been recently.” d. “Your previous coping resources can be helpful to you now.” 6. A nurse prepares an adult patient with a severe burn injury for a dressing change. The nurse knows that this is a painful procedure and wants to try providing music to help the patient relax. Which action is best for the nurse to take? a. Use music composed by Mozart. b. Play music that does not have words. c. Ask the patient about music preferences. d. Select music that has 60 to 80 beats/minute. 7. The nurse teaches a patient who is experiencing stress at work how to use imagery as a relaxation technique. Which statement by the nurse would be appropriate? a. “Think of a place where you feel peaceful and comfortable.” b. “Place the stress in your life into an image that you can destroy.” c. “Repeatedly visualize yourself experiencing the distress in your workplace.” d. “Bring what you hear and sense in your work environment into your image.” n obese female patient who had enjoyed active outdoor activities is stressed because osteoarthritis in her hips now limits her activity. Which action by the nurse will bestassist the patient to cope with this situation? a. Have the patient practice frequent relaxation breathing. b. Ask the patient what outdoor activities she misses the most. c. Teach the patient to use imagery for reducing pain and stress. d. Encourage the patient to consider weight loss to improve symptoms. 9. A hospitalized patient with diabetes tells the nurse, “I don’t understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up. This is so frustrating.” Which response by the nurse is accurate? a. “The liver is not able to metabolize glucose as well during stressful times.” b. “Your diet at the hospital is the most likely cause of the increased glucose.” c. “The stress of illness causes release of hormones that increase blood glucose.” d. “It is probably coincidental that your blood glucose is higher when you are ill.” 10. A middle-aged male patient with usually well-controlled hypertension and diabetes visits the clinic. Today he has a blood pressure of 174/94 mm Hg and a blood glucose level of 190 mg/dL. What patient information may indicate that additional intervention by the nurse is needed? a. The patient states that he takes his prescribed antihypertensive medications daily. b. The patient states that both of his parents have high blood pressure and diabetes. c. The patient indicates that he does blood glucose monitoring several times each day. d. The patient reports that he and his wife are disputing custody of their 8-yr-old son. 11. A patient who is taking antiretroviral medication to control human immunodeficiency virus (HIV) infection tells the nurse about feeling mildly depressed and anxious. Which additional information about the patient is most important to communicate to the health care provider? a. The patient takes vitamin supplements and St. John’s wort. b. The patient recently experienced the death of a close friend. c. The patient’s blood pressure has increased to 152/88 mm Hg. d. The patient expresses anxiety about whether the drugs are effective. MULTIPLE RESPONSE 1. A patient who is hospitalized with a pelvic fracture after a motor vehicle accident just received news that the driver of the car died from multiple injuries. What actions should the nurse take based on knowledge of the physiologic stress reactions that may occur in this patient (select all that apply)? a. Assess for bradycardia. b. Observe for decreased appetite. c. Ask about epigastric discomfort. d. Monitor for decreased respiratory rate. e. Check for elevated blood glucose levels. [Show More]

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