Tacara Berrain Submitted Name Status Score Instructions

4/22/12 5:02 PM Nur 223 Adv HA Exam 2 Apr 10, 2012 Completed 92 out of 100 points

Question 1
2 out of 2 points When assessing an IV site, which of the following indicacte abnormal findings? Answer Selected Answers: swelling redness cool skin

Correct Answers: swelling redness cool skin

Question 2
0 out of 2 points Select all of the following that are functions of the integumentary system. Answer Selected Answers:

functions to sense tempereature, pain, and touch

helps to regulate temperature of the body

vitamin D production

Correct Answers: functions to sense tempereature, pain, and touch

helps to regulate temperature of the body

vitamin D production

protection against trauma and infection protects from loss of water and electrolytes

Question 3
0 out of 2 points A full thickness pressure ulcer that goes throw to bone is classified as a stage ______ wound. Answer Selected Answer: IV Correct Answer: I

Question 4
2 out of 2 points

Match the description with the term. Answer Question skin that has tenting skin that has itching, wheals skin that is red, swollen, tender, and warm skin that has itching

Correct Match Selected Match D. dehydration D. dehydration

A. A. allergic reaction allergic reaction C. inflamed B. pruritus C. inflamed B. pruritus

Question 5
2 out of 2 points Match the description to the appropriate definition. Answer Question skin wound that is draining serous fluid skin wound that is drainage sanguinous fluid skin wound that is draining sero-sanguineous fluid skin wound that is draining purulent exudate Correct Match B. clear yellow A. bloody D. blood mixed with yellow, clear exudate C. infected Selected Match B. clear yellow A. bloody D. blood mixed with yellow, clear exudate C. infected

Question 6
2 out of 2 points Select all of the following that place the patient at risk for developing impaired skin integrity. Answer Selected Answers: tanning in the sun between the hours of 11am and 3pm

patient immobilized due to a hipfracture decreased albumin and protein levels in the blood frequent or constant exposure to moisture

Correct Answers: tanning in the sun between the hours of 11am and 3pm patient immobilized due to a hipfracture decreased albumin and protein levels in the blood frequent or constant exposure to moisture

Question 7
2 out of 2 points Match the associated lesion with the name or treatment. Answer Question Correct Match C. caused by herpes virus Selected Match C. caused by herpes virus

D. ringworm treat with griseofulvin-monitor liver enzymes

D. ringworm treat with griseofulvin-monitor liver enzymes

A. immunocompromised patients, treat with nystatin swish and swallow B. after a course of antibiotics

A. immunocompromised patients, treat with nystatin swish and swallow B. after a course of antibiotics

Question 8
2 out of 2 points Your patient has an open lesion on his left ear. Select all of the following that would support a nursing diagnosis of "Impaired skin integrity" related to ineffective tissue perfusion. Answer Selected Answers: patient has been lying on left side for 4 hours without turning patient has HR 56 patient has BP 90/50

Correct Answers: patient has been lying on left side for 4 hours without turning patient has HR 56 patient has BP 90/50

Question 9
2 out of 2 points

Select all of the following that are abnormal findings in the skin. Answer Selected Answers: jaundiced cyanotic pale

Correct Answers: jaundiced cyanotic pale

Question 10
2 out of 2 points Match the intervention with the rationale for a client with impaired skin integrity. Answer Question reposition every 90 minutes to 2 hours keep skin dry and clean, avoid rubbing reddened areas Correct Match Selected Match A. A. removes pressure and allows removes pressure and allows normal blood return response normal blood return response D. moisture softens the skin ; rubbing in an area of nonblanching erythema (doesn't turn white when you push in on it) will cause further tissue damage C. the higher the head of the D. moisture softens the skin ; rubbing in an area of nonblanching erythema (doesn't turn white when you push in on it) will cause further tissue damage C. the higher the head of the

elevate head of the bed no more

than 30 degrees

bed, the more likely shearing bed, the more likely shearing forces will be present making forces will be present making the wound worse the wound worse B. will provide moisture to the wound which encourages healing; will prevent the sheets from rubbing on the area thus decreasing friction B. will provide moisture to the wound which encourages healing; will prevent the sheets from rubbing on the area thus decreasing friction

use a moisture barrier ointment over the wound at least 3 times a day

Question 11
2 out of 2 points Select all of the following that are true with findings in assessing the skin. Answer Selected Answers: white patches on a person of genetic African descent are known as vitiligo jaundice, yellowing, is associated with liver or bile disease or hemolytic (breaking apart of red blood cells) anemia which manifests as increased bilirubin levels

Correct Answers:

white patches on a person of genetic African descent are known as vitiligo jaundice, yellowing, is associated with liver or bile disease or hemolytic (breaking apart of red blood cells) anemia which manifests as increased bilirubin levels

Question 12
2 out of 2 points A patient has an open lesion on the heal. Select all of the following that supports a nursing diagnosis of "Impaired skin integrity related to impaired nutrition." Answer

Selected Answers: albumin level of 1.5 patient is underweight and malnourished

Correct Answers: albumin level of 1.5 patient is underweight and malnourished

Question 13
2 out of 2 points Select all the following that are correct related to interventions/risk factors to prevent pressure ulcers. Answer Selected Answers: for a client with decreased mobility and poor nutrition -provide adequate nutritional and fluid intake; consult a dietitian for nutritional evaluation to avoid friction and sheer, use a drawsheet and lift off surface; position at a 30 degree lateral turn; provide a trapeze to facilitate movement for a person with decreased sensory perception - assess pressure points for signs of nonblanching reactive hyperemia (doesn't turn white, then red when released) and provide a pressure resdistribution surface for a person that is moist frequently - cleanse area and provide a moisture barrier to the skin especially after incontinent episodes

Correct Answers:

for a client with decreased mobility and poor nutrition -provide

adequate nutritional and fluid intake; consult a dietitian for nutritional evaluation to avoid friction and sheer, use a drawsheet and lift off surface; position at a 30 degree lateral turn; provide a trapeze to facilitate movement for a person with decreased sensory perception - assess pressure points for signs of nonblanching reactive hyperemia (doesn't turn white, then red when released) and provide a pressure resdistribution surface for a person that is moist frequently - cleanse area and provide a moisture barrier to the skin especially after incontinent episodes

Question 14
2 out of 2 points To assess skin turgor in the elderly, pull the skin Answer Selected Answer: on the chest Correct Answer: on the chest

Question 15
2 out of 2 points Which of the following is a Stage II pressure ulcer? Answer Selected Answer:

Correct Answer:

Question 16
2 out of 2 points Select all of the following that are functions of the skin. Answer Selected Answers: sensory organ for touch sensory organ for temperature regulator of body temperature

Correct Answers: sensory organ for touch sensory organ for temperature regulator of body temperature

Question 17
2 out of 2 points Select all of the following that would support a nursing diagnosis of "Impaired skin integrity related to infection". Answer Selected Answers: edges of wound red and warm, not approximated

yellow, foul-smelling drainage from the wound presence of wound or a break in skin integrity

Correct Answers: edges of wound red and warm, not approximated yellow, foul-smelling drainage from the wound presence of wound or a break in skin integrity

Question 18
2 out of 2 points Cool, clammy skin occurs when surface blood vessels constrict shunting blood to interior organs. Answer Selected Answer: Correct Answer: True True

Question 19
2 out of 2 points Match the skin condition with the associated term. Answer Question yellowish tent to sclera and skin Correct Match F. liver or bile problem, increased bilirubin, hemolytic anemia ( red blood cells split apart and liver is unable to process them quickly) C. anemia and decreased red blood cells Selected Match F. liver or bile problem, increased bilirubin, hemolytic anemia ( red blood cells split apart and liver is unable to process them quickly) C. anemia and decreased red blood cells

pale skin, nailbeds and conjunctiva

bluish tent to skin skin that is "red as a beet" skin that is cold and clammy

A. problem with oxygenation B. flushed skin with blood flow and dilated vessels E. skin with blood vessels constricted and blood is shunted to the inner organs

A. problem with oxygenation B. flushed skin with blood flow and dilated vessels E. skin with blood vessels constricted and blood is shunted to the inner organs D. dead skin that needs to be debrided

skin that is D. black, necrotic dead skin that needs to be debrided

Question 20
2 out of 2 points Match the description of the lesion with the description or treatment. Answer Question rounded area with intense itching caused by fungus, commonly known as ringworm, treated with antifungal such as lotrimin or nystatin painful recurring blusters caused by a virus with shortening of symptoms treated by Acyclovir linear, itching lesions caused by a mite - treat with Kwell or lindane - contact isolation, wash clothing, bedding in hot water, Correct Match B. tinea D. herpes F. scabies Selected Match B. tinea D. herpes F. scabies C. impetigo G. lice

honey colored lesions caused by strep skin infection, C. treat with antibiotic impetigo head or body infestation caused by organisms that G. leaves eggs known as nits - treat with Kwell, Rid, or lice lindane and wash all clothes and bedding in hotwater - place in contact isolation inflammation of skin caused by contqact with material that one is allergic to- treat by excising or with chemotherapeutic drugs dark, irregular, elevated lesion with assymetric E. contact dermatitis A.

E. contact dermatitis A.

borders and variegated colors

melanoma

melanoma

Question 21
2 out of 2 points Hemolytic anemia occurs when red blood cells lyse ( break apart) and liver cannot process them quickly. Hemoglobin and other pigments are deposited in the skin and the broken apart RBCs clump together in trying to get through the blood vssels. Select all of the following that would be seen in a client with hemolytic anemia. Answer Selected Answers: pain from clumping of the cells in the blood vessels jaundice from deposition of bilirubin

Correct Answers: pain from clumping of the cells in the blood vessels jaundice from deposition of bilirubin

Question 22
2 out of 2 points A cardiac catherization is a procedure in which the catheter is inserted into the heart to obtain information about what is happening in the heart. Which of the following should the nurse assess after the procedure? Answer Selected Answer: Correct Answer: assess the site for possible bleeding and check distal pulses to assure blood flow to extremities assess the site for possible bleeding and check distal pulses to assure blood flow to extremities

Question 23

2 out of 2 points Select all of the following that are functions of bloodl Answer Selected Answers: helps regulate fluid/electrolyte and acid-base balance transport metabolic wastes products from cells to lungs, liver, and kidneys transport nutrients from GI tract to cells transport oxygen from lungs to cells regulate body temperature protects by combating invasion of pathogens and other foreign substances

Correct Answers:

helps regulate fluid/electrolyte and acid-base balance transport metabolic wastes products from cells to lungs, liver, and kidneys transport nutrients from GI tract to cells transport oxygen from lungs to cells regulate body temperature protects by combating invasion of pathogens and other foreign substances

Question 24
2 out of 2 points Match the lymph nodes with the appropriate area for assessing them. Answer Question under the chin under the jaw infection in front of the ear infection in the back of the head infection in the lower arm infection in the breast Correct Match Selected Match A. submental E. submandibular B. preauricular C. occipital D. epitrochlear F. axillary A. submental E. submandibular B. preauricular C. occipital D. epitrochlear F. axillary

Question 25
2 out of 2 points Select all of the following that are clinical manifestations of anemia. Answer Selected Answers: fatigue

pallor palpitations, dyspnea

Correct Answers: fatigue

pallor palpitations, dyspnea

Question 26
2 out of 2 points Fatigue is a subjective complaint with both acute and chronic illnesses. Select all of the following that would be contributing factors in a nursing diagnosis of fatigue. Answer Selected Answers: sleep deprivation stress medication side effects hemoglobin of 9 hematocrit of 30

Correct Answers: sleep deprivation stress medication side effects hemoglobin of 9 hematocrit of 30

Question 27

0 out of 2 points Select all of the following that the nurse would find in a patient with occlusive venous disease in the leg. Answer Selected Answers: cold extremity brown, pigmented skin from deposits of hemoglobin in the skin

Correct Answers: warm extremity brown, pigmented skin from deposits of hemoglobin in the skin

Question 28
2 out of 2 points Select all of the following that are clinical manifestations/descriptions of sickle cell anemia. Answer Selected Answers: genetic disease sickling of cells causes clumping that blocks flow in the blood vessels resulting in pain illness and dehydration precipitates sickle cell crises keep hydrated and treat pain

Correct

Answers:

genetic disease sickling of cells causes clumping that blocks flow in the blood vessels resulting in pain illness and dehydration precipitates sickle cell crises keep hydrated and treat pain

Question 29
2 out of 2 points Select all of the following that are involved in blood clotting. Answer Selected Answers: platelet aggregation clotting factors such as prothrombin and thrombin

Correct Answers: platelet aggregation clotting factors such as prothrombin and thrombin

Question 30
2 out of 2 points Select all of the following that are found in the normal physical assessment of the cardiovascular system. Answer Selected Answers: + S1, S2 heart sounds

PMI (point of maximal intensity) is palpable in 4th intercostal space, midclavicular line absence of murmurs no pedal edema

Correct Answers:

+ S1, S2 heart sounds PMI (point of maximal intensity) is palpable in 4th intercostal space, midclavicular line absence of murmurs no pedal edema

Question 31
2 out of 2 points Select all of the following that would be found in an arterial occlusive disorder in the legs. Think of what happens when an artery is blocked and blood can't get through. Answer Selected Answers: hairless area decreased pulses cold extremity distal to the occlusion

Correct Answers:

hairless area decreased pulses cold extremity distal to the occlusion

Question 32
2 out of 2 points When cells are injured, they release enzymes and biomarkers useful in the diagnosis of cardiac disease. Select all of the following that are correct related to blood studies done to diagnose cardiac disease. Answer Selected Answers: b-type natriuretic peptide (BNP) is levated in congested heart failure elevated homocysteine levels are used to predict risk of an increased risk of a first cardiac event elevated troponin and CK-MB (creatine kinase cardiac band) in heart attack serum lipids - triglycerides, LDLs, cholesterol are elevated in coronary artery disease c-reactive protein is elevated and is used to predict risk for developing coronary artery disease

Correct Answers:

b-type natriuretic peptide (BNP) is levated in congested heart failure elevated homocysteine levels are used to predict risk of an

increased risk of a first cardiac event elevated troponin and CK-MB (creatine kinase cardiac band) in heart attack serum lipids - triglycerides, LDLs, cholesterol are elevated in coronary artery disease c-reactive protein is elevated and is used to predict risk for developing coronary artery disease

Question 33
2 out of 2 points Select all of the following associated with Coronary Artery Disease. Answer Selected Answers: increased cholesterol levels high fat diet atherosclerotic plaques in coronary (heart) blood vessels

Correct Answers: increased cholesterol levels high fat diet atherosclerotic plaques in coronary (heart) blood vessels

Question 34
2 out of 2 points

Aplastic anemia is a disease in which the patient has peripheral blood pancytopenial (decrease of al blood cell types due to problems with production in the bone marrow.) Select all of the following that are clinical manifestations of aplastic anemia. Answer Selected Answers: infection related to decreased WBCs low hemoglobin related to decreased RBC production bruising, easy bleeding related to decreased platelets

Correct Answers: infection related to decreased WBCs low hemoglobin related to decreased RBC production bruising, easy bleeding related to decreased platelets

Question 35
2 out of 2 points Match the cardiac diagnostic test with the description. Answer Question exercise stress test Correct Match B. used to evaluate the effect of exercise on the heart C. used to evaluation valve function, and ejection fraction ( how much blood ejected with each beat) of the heart Selected Match B. used to evaluate the effect of exercise on the heart C. used to evaluation valve function, and ejection fraction ( how much blood ejected with each beat) of the heart

echocardiogram

MUGA test multigated acquisition scan angiography

A. radioactive dye study used to evaluate heart function and valve function D. injected IV contrast medium to obtain images of blood vessels and diagnose coronary artery disease

A. radioactive dye study used to evaluate heart function and valve function D. injected IV contrast medium to obtain images of blood vessels and diagnose coronary artery disease

Question 36
0 out of 2 points Select all that are true related to iron deficiency anemia. Answer Selected Answers: results from deficiency in diet or extensive bleeding give liquid undiluted iron with a straw to avoid staining teeth glossitis (inflammation of the tongue) and chelitis (inflammation of the lips) pallor

Correct Answers:

results from deficiency in diet or extensive bleeding give liquid undiluted iron with a straw to avoid staining teeth give oral supplements of iron with a vitamin C source glossitis (inflammation of the tongue) and chelitis (inflammation of the lips)

pallor

Question 37
2 out of 2 points Select the following that are acceptable outcomes for a client with a nursing diagnosis Risk for Aspiration. (Outcomes, not interventions) Answer Selected Answers: breath sounds are clear

Correct Answers: breath sounds are clear

Question 38
2 out of 2 points In assessing the cardiac system, which of the following would indicate a problem ? Answer Selected Answers: patient's heart rate is 120 patient is unable to perform activities of daily living because of fatigue patient's hands and feet are cold from lack of circulation pt complains of chest pain that radiates to the jaw and left arm patient has BP of 90/50 patient has leg and ankle edema

Correct Answers: patient's heart rate is 120 patient is unable to perform activities of daily living because of fatigue patient's hands and feet are cold from lack of circulation pt complains of chest pain that radiates to the jaw and left arm patient has BP of 90/50 patient has leg and ankle edema

Question 39
2 out of 2 points In assessing the respiratory system, which of the following would indicate that the person has a problem in the respiratory system? Answer Selected Answers: oxygen saturation of 86% coughing up green secretions abnormal breath sounds can't speak more than 3 or 4 words without having to take a breath in

Correct Answers: oxygen saturation of 86%

coughing up green secretions abnormal breath sounds can't speak more than 3 or 4 words without having to take a breath in

Question 40
2 out of 2 points Select all that are appropriate outcomes for a client with nursing diagnosis of Infection. Answer Selected Answers: clear yellow urine WBC 5-10,000 T < 99 F

Correct Answers: clear yellow urine WBC 5-10,000 T < 99 F

Question 41
2 out of 2 points

A 38 year old female refuses to look at her dressing after having a mastectomy for breast cancer. She refuses to discuss the procedure and will not go out of the house. She wears blouses that are three sizes too big. Select the appropriate nursing diagnosis. Answer Selected Answer: Disturbed body image Correct Answer: Disturbed body image

Question 42
2 out of 2 points Outcomes are expectations to be generated from the care given. Another term that can be used is goals. Outcomes are the exact opposite of the assessment finding indicating the need for care. Select all of the following that would be accepted goals for a client with a nursing diagnosis: Activity intolerance related to generalized weakness. Answer Selected Answers: abiltity to perform activities of daily living without exertional dyspnea and significant change in vital signs; chest pain, diaphoresis, or dizziness verbalization of feeling less fatigued hemoglobin/hematocrit 12/39

Correct Answers:

abiltity to perform activities of daily living without exertional dyspnea and significant change in vital signs; chest pain, diaphoresis, or dizziness verbalization of feeling less fatigued hemoglobin/hematocrit 12/39

Question 43
2 out of 2 points In assessing diagnostic labs and procedures, which of the following would indicate a problem in the problem that the nurse would include on a problem list. Answer Selected Answers: glucose 50 hemoglobin 8 chest x-ray showing infiltrates in the lungs electrocardiogram (EKG) showing a HR of 125

Correct Answers: glucose 50 hemoglobin 8 chest x-ray showing infiltrates in the lungs electrocardiogram (EKG) showing a HR of 125

Question 44
2 out of 2 points In assessing the Gastrointestinal system, which of the following would indicate a problem? Answer Selected Answers: constipation

pain in the right upper quadrant blood in the stools diarrhea vomiting blood abdominal distention

Correct Answers: constipation pain in the right upper quadrant blood in the stools diarrhea vomiting blood abdominal distention

Question 45
2 out of 2 points Ineffective tissue perfusion results from a decrease in oxygen due to lack of perfusion (decreased blood flow) resulting in failure to nourish the tissues at the capillary level. Select all of the following that are desired outcomes for a client with Ineffective tissue perfusion (outcomes, not interventions) Answer Selected Answers:

BP within normal range urine output > 30 ml/hr capillary refil < 3 seconds extremities warm with absence of pallor and cyanosis

Correct Answers: BP within normal range urine output > 30 ml/hr capillary refil < 3 seconds extremities warm with absence of pallor and cyanosis

Question 46
2 out of 2 points A patient was admitted after going on a drinking binge. He has a history of dysphagia (difficulty swallowing), and a depressed gag reflex. Answer Selected Answer: Risk for aspiration Correct Answer: Risk for aspiration

Question 47
2 out of 2 points Patient has BP 90/50, dry oral mucous membranes, has lost 3 pounds in 2 days; has not been able to keep anything down, has capillary refil > 3 seconds. Select the

appropriate nursing diagnosis. Answer Selected Answer: Fluid volume deficit Correct Answer: Fluid volume deficit

Question 48
2 out of 2 points In assessing the immune system, which of the following would indicate that the person has an infection? Answer Selected Answers: cloudy urine redness, pain, and yellow drainage from a wound swollen, tender lymph nodes increased erythrocyte sedimentation rate (ESR) - taking a longer period of time for red blood cells to settle down in a test tube WBCs in the urine temperature of 101 F

Correct Answers:

cloudy urine redness, pain, and yellow drainage from a wound swollen, tender lymph nodes

increased erythrocyte sedimentation rate (ESR) - taking a longer period of time for red blood cells to settle down in a test tube WBCs in the urine temperature of 101 F

Question 49
2 out of 2 points Patient complains of fatigue; is unable to put clothes on without stopping for rest; heart rate increases with activity. Select the approprite nursing diagnosis. Answer Selected Answer: Activity intolerance Correct Answer: Activity intolerance

Question 50
2 out of 2 points Which of the following are anticipated outcomes for a nursing diagnosis of Impaired Gas exchange? (outcomes, not interventons) Answer Selected Answers: pulse oximetery > 94% RR 12-20 patient is alert and oriented x 3 apply oxygen to maintain pulse ox > 94%

Correct Answers:

pulse oximetery > 94% RR 12-20 patient is alert and oriented x 3 apply oxygen to maintain pulse ox > 94%

Sunday, April 22, 2012 5:02:22 PM EDT