NR304 Final Exam Questions with Correct Answers

NR304 Final Exam Questions with Correct Answers During an assessment of an 80-year-old patient, the nurse notices the following: an inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate: a. CN dysfunction. b. Lesion in the cerebral cortex. c. Normal changes attributable to aging. d. Demyelination of nerves attributable to a lesion. - Answer-c. Normal changes attributable to aging. The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect? a. Hyperalgesia b. Hyperesthesia c. Peripheral neuropathy d. Lesion of sensory cortex - Answer-c. Peripheral neuropathy A 65-year-old patient remarks that she just cannot believe that her breasts sag so much. She states it must be from a lack of exercise. What explanation should the nurse offer her? After menopause: a. Only women with large breasts experience sagging. b. Sagging is usually due to decreased muscle mass within the breast. c. A diet that is high in protein will help maintain muscle mass, which keeps the breasts from sagging. d. The glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag. - Answer-d. The glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag. The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be: a. Gallbladder disease. b. Overuse of laxatives. c. Gastrointestinal bleeding. d. Localized bleeding around the anus. - Answer-c. Gastrointestinal bleeding. The nurse is performing an assessment on an adult. The adults vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next? a. Ask the patient about a history of frostbite. b. Suspect that the patient has venous insufficiency. c. Consider this a delayed capillary refill time, and investigate further. d. Consider this a normal capillary refill time that requires no further assessment. - Answer-c. Consider this a delayed capillary refill time, and investigate further. While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnosis should the nurse identify as being the priority in the client's care? A) Impaired tissue perfusion B) Alteration in body image C) Alteration in activity intolerance D) Impaired skin integrity - Answer-A) Impaired tissue perfusion During a visit to the clinic, a woman in her seventh month of pregnancy complains that her legs feel heavy in the calf and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings? a. Deep-vein thrombophlebitis b. Varicose veins c. Lymphedema d. Raynaud phenomenon - Answer-b. Varicose veins A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? A) Obtain a pair of slipper socks for the client B) Rub the clients feet briskly for several minutes C) Increase the client's oral fluid intake D) Place a moist heating pad unde the client's feet - Answer-A) Obtain a pair of slipper socks for the client During the assessment of an 18-month-old infant, the mother expresses concern to the nurse about the infants inability to toilet train. What would be the nurses best response? a. Some children are just more difficult to train, so I wouldnt worry about it yet. b. Have you considered reading any of the books on toilet training? They can be very helpful. c. This could mean that there is a problem in your baby's development. We'll watch her closely for the next few months. d. The nerves that will allow your baby to have control over the passing of stools are not developed until at least 18 to 24 months of age. - Answer-d. The nerves that will allow your baby to have control over the passing of stools are not developed until at least 18 to 24 months of age. While performing a rectal examination, the nurse notices a firm, irregularly shaped mass. What should the nurse do next? a. Continue with the examination, and document the finding in the chart. b. Instruct the patient to return for a repeat assessment in 1 month. c. Tell the patient that a mass was felt, but it is nothing to worry about. d. Report the finding, and refer the patient to a specialist for further examination. - Answer-d. Report the finding, and refer the patient to a specialist for further examination. Which of these statements is most appropriate when the nurse is obtaining a genitourinary history from an older man? a. Do you need to get up at night to urinate? b. Do you experience nocturnal emissions, or wet dreams? c. Do you know how to perform a testicular self-examination? d. Has anyone ever touched your genitals when you did not want them to? - Answer-a. Do you need to get up at night to urinate? You are assessing an adolescent boy. The first physical sign of puberty is: a. Height spurt b. Penis lengthening c. Sperm production d. Pubic hair development e. Testes enlargement - Answer-e. Testes enlargement