Nursing: Medical-Surgical Revew Study Guide Rated A+
Which method elicits the most accurate information during a physical assessment of an older adult?
A. use reliable assessment tools for older adults
B. Review the past medical record for medications
C. Ask the client to recount one's health h...
Nursing: Medical-Surgical Revew Study Guide
Rated A+
1). Which method elicits the most accurate information during a physical assessment of an
older adult?
a. use reliable assessment tools for older adults
b. review the past medical record for medications
c. ask the client to recount one's health history
d. obtain the client's information from a caregiver
Ans: A. use reliable assessment tools for older adults
Specific assessment tools (D) for an older adult, such as Older Adult Resource Services
Center Instrument, mini-mental assessment, fall risk, depression, or skin breakdown risk,
consider age-related physiologic and psychosocial changes related to aging and provide
the most accurate and complete information. A and B are subjective and may vary in
reliability based on the client's memory and caregiver's current involvement. Although C is
a good resource to identify polypharmacy, a written record may not be available or
currently accurate.
2). A client who has just tested positive for hiv does not appear to hear what the nurse is
saying during post-test counseling. which information should the nurse offer to facilitate the
client's adjustment to hiv infection?
a. teach the client about the medications that are available for treatment
b. discuss retesting to verify the results, which will ensure continuing contact
c. identify the need to test others who have had risky contact with the client
d. inform the client how to protect sexual and needle-sharing partners
Ans: B. discuss retesting to verify results, which will ensure continuing contact
encouraging retesting supports hope and gives the client time to cope with the diagnosis.
Although post-test counseling should include education about A, B, and C, retesting
encourages the client to maintain medical follow-up and management.
3). The nurse is caring for a client with hiv infection who develops mycobacterium avium
complex (mac). what is the most significant desired outcome for this client?
a. free from injury of drug side effects
b. maintenance of intact perineal skin
c. adequate oxygenation
d. return to pre-illness weight
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, Ans: D. return to pre-illness weight
MAC is an opportunistic infection that presents as a TB like pulmonary process. MAC is a
major contributing factor to the development of wasting syndrome, so the most
significant desired outcome is the client's return to a pre-illness weight. drug schedules
and side effects remain a life-long management problem. Client outcomes for adequate
oxygenation are often dependent on management of anemia, maintenance of activities
without fatigue, and supplemental oxygen to prevent hypoxia. Skin integrity is dependent
upon resolution of diarrhea, which is not as significant as optimal nutrition.
4). A client who had abdominal surgery two days ago has prescriptions for intravenous
morphine sulfate 4 mg every 2 hours and a clear liquid diet. the client complains of feeling
distended and has sharp, cramping gas pains. what nursing intervention should be
implemented?
a. assist the client to ambulate in the hall
b. obtain a prescription for a laxative
c. administer the prescribed morphine sulfate
d. withhold all oral fluid and food
Ans: a. assist the client to ambulate in the hall
Post-operative abdominal distention is caused by decreased peristalsis as a result of
handling the intestine during surgery, limited dietary intake before and after surgery, and
anesthetic and analgesic agents. Peristalsis is stimulated and distention minimized by
implementing early and frequent ambulation. Based on the client's status, laxatives or
withholding dietary progression are not indicated at this time. although pain management
should be implemented, another analgesic prescription may be needed because morphine
reduces intestinal motility and contributes to the client's gas pains.
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, 5). A client with meniere's disease is incapacitated by vertigo and is lying in bed grasping the
side rails and staring at the television. which nursing intervention should the nurse
implement?
a. keep the head of the bed elevated 30 degrees
b. turn off the television and darken the room
c. encourage fluids to 3000 ml per day
d. change the client's position every two hours
Ans: B. turn off the television and darken the room
to decrease the client's vertigo during an acute attack of Meniere's disease, any visual
stimuli or rotational movement, such as sudden head movements or position changes,
should be minimized. Turning off the television and darkening the room minimize
fluorescent lights, flickering television lights, and distracting sound. The other are
ineffective in managing the client's symptoms.
6). A client who has a chronic cough with blood-tinged sputum returns to the unit after a
bronchoscopy. what nursing interventions should be implemented in the immediate post-
procedural period?
a. check vital signs every 15 minutes for 2 hours
b. allow the client nothing by mouth until the gag reflex returns
c. encourage fluid intake to promote elimination of the contrast media
d. keep the client on bed rest for 8 hours
Ans: B. allow the client nothing by mouth until the gag reflex returns
the nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior to
bronchoscopy, and the bronchoscope is coated with lidocaine gel to inhibit the gag reflex
and prevent laryngeal spasm during insertion. The client should be NPO until the client's
gag reflex returns to prevent aspiration from any oral intake or secretions. The others are
not indicated after bronchoscopy
7). The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing
spontaneously. to evaluate if the client can tolerate cuff deflation to promote speaking and
swallowing, what action should the nurse implement?
a. observe the client for coughing colored sputum after drinking a small amount of colored
water
b. ask the client to try to speak
c. auscultate for pulmonary crackles after the client drinks a small amount of clear water
d. assess for respiratory distress
Ans: A. observe the client four coughing colored sputum after drinking a small amount
of colored water
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