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

Answer Question Correct Match C. caused by herpes virus D. caused by herpes virus Selected Match C.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. ringworm treat with griseofulvin-monitor liver enzymes D. ringworm treat with griseofulvin-monitor liver enzymes .

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 . treat with nystatin swish and swallow B. immunocompromised patients. Select all of the following that would support a nursing diagnosis of "Impaired skin integrity" related to ineffective tissue perfusion.A. 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.

removes pressure and allows removes pressure and allows normal blood return response normal blood return response D. A. 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 . the higher the head of the elevate head of the bed no more . Answer Question reposition every 90 minutes to 2 hours keep skin dry and clean.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. avoid rubbing reddened areas Correct Match Selected Match A. rubbing in an area of nonblanching erythema (doesn't turn white when you push in on it) will cause further tissue damage C. moisture softens the skin .

will provide moisture to the wound which encourages healing. yellowing. Select all of the following that supports a nursing diagnosis of "Impaired skin integrity related to impaired nutrition. Answer Selected Answers: white patches on a person of genetic African descent are known as vitiligo jaundice. yellowing." Answer .than 30 degrees bed. the more likely shearing forces will be present making forces will be present making the wound worse the wound worse B. will prevent the sheets from rubbing on the area thus decreasing friction B. 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. will provide moisture to the wound which encourages healing. the more likely shearing bed. 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. 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.

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 . position at a 30 degree lateral turn.Selected Answers: albumin level of 1.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 . provide a trapeze to facilitate movement for a person with decreased sensory perception . consult a dietitian for nutritional evaluation to avoid friction and sheer.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.5 patient is underweight and malnourished Correct Answers: albumin level of 1. use a drawsheet and lift off surface. Answer Selected Answers: for a client with decreased mobility and poor nutrition -provide adequate nutritional and fluid intake.

position at a 30 degree lateral turn.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. provide a trapeze to facilitate movement for a person with decreased sensory perception . 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: . then red when released) and provide a pressure resdistribution surface for a person that is moist frequently .assess pressure points for signs of nonblanching reactive hyperemia (doesn't turn white. consult a dietitian for nutritional evaluation to avoid friction and sheer.adequate nutritional and fluid intake. use a drawsheet and lift off surface.

not approximated .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.

increased bilirubin.yellow. clammy skin occurs when surface blood vessels constrict shunting blood to interior organs. anemia and decreased red blood cells pale skin. Answer Question yellowish tent to sclera and skin Correct Match F. hemolytic anemia ( red blood cells split apart and liver is unable to process them quickly) C. increased bilirubin. not approximated yellow. Answer Selected Answer: Correct Answer: True True • Question 19 2 out of 2 points Match the skin condition with the associated term. nailbeds and conjunctiva . hemolytic anemia ( red blood cells split apart and liver is unable to process them quickly) C. liver or bile problem. foul-smelling drainage from the wound presence of wound or a break in skin integrity Correct Answers: edges of wound red and warm. anemia and decreased red blood cells Selected Match F. liver or bile problem. foul-smelling drainage from the wound presence of wound or a break in skin integrity • Question 18 2 out of 2 points Cool.

herpes F.treat with Kwell or lindane . flushed skin with blood flow and dilated vessels E.contact isolation. 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. problem with oxygenation B. Answer Question rounded area with intense itching caused by fungus. treat with antibiotic impetigo head or body infestation caused by organisms that G. . itching lesions caused by a mite . problem with oxygenation B. Rid. treated with antifungal such as lotrimin or nystatin painful recurring blusters caused by a virus with shortening of symptoms treated by Acyclovir linear. scabies C. impetigo G. contact dermatitis A. tinea D.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. Correct Match B. lice honey colored lesions caused by strep skin infection. bedding in hot water. skin with blood vessels constricted and blood is shunted to the inner organs A. tinea D. wash clothing. black.treat with Kwell. C. irregular. herpes F. leaves eggs known as nits . scabies Selected Match B.bluish tent to skin skin that is "red as a beet" skin that is cold and clammy A. commonly known as ringworm. 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. flushed skin with blood flow and dilated vessels E. E. or lice lindane and wash all clothes and bedding in hotwater . elevated lesion with assymetric 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. 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. Hemoglobin and other pigments are deposited in the skin and the broken apart RBCs clump together in trying to get through the blood vssels. 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 .

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 .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.

Answer Selected Answers: fatigue pallor palpitations. submandibular B. 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.• Question 24 2 out of 2 points Match the lymph nodes with the appropriate area for assessing them. submental E. epitrochlear F. axillary A. axillary • Question 25 2 out of 2 points Select all of the following that are clinical manifestations of anemia. submandibular B. epitrochlear F. occipital D. preauricular C. dyspnea Correct Answers: fatigue . occipital D. preauricular C.

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 .

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

Answer Selected Answers: + S1. S2 heart sounds .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.

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

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 .triglycerides. 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. LDLs. 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 .hairless area decreased pulses cold extremity distal to the occlusion • Question 32 2 out of 2 points When cells are injured.

triglycerides. 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 . 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.increased risk of a first cardiac event elevated troponin and CK-MB (creatine kinase cardiac band) in heart attack serum lipids . LDLs.

Answer Question exercise stress test Correct Match B. 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. Answer Selected Answers: infection related to decreased WBCs low hemoglobin related to decreased RBC production bruising.) Select all of the following that are clinical manifestations of aplastic anemia. used to evaluation valve function. used to evaluation valve function.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. easy bleeding related to decreased platelets Correct Answers: infection related to decreased WBCs low hemoglobin related to decreased RBC production bruising. and ejection fraction ( how much blood ejected with each beat) of the heart echocardiogram . used to evaluate the effect of exercise on the heart C. easy bleeding related to decreased platelets • Question 35 2 out of 2 points Match the cardiac diagnostic test with the description.

injected IV contrast medium to obtain images of blood vessels and diagnose coronary artery disease A. 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. radioactive dye study used to evaluate heart function and valve function D. radioactive dye study used to evaluate heart function and valve function D.MUGA test multigated acquisition scan angiography A. 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. 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. (Outcomes. 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 .

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. She refuses to discuss the procedure and will not go out of the house. or dizziness verbalization of feeling less fatigued hemoglobin/hematocrit 12/39 . chest pain. Another term that can be used is goals. 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. diaphoresis. Select the appropriate nursing diagnosis. Outcomes are the exact opposite of the assessment finding indicating the need for care. Answer Selected Answers: abiltity to perform activities of daily living without exertional dyspnea and significant change in vital signs. Select all of the following that would be accepted goals for a client with a nursing diagnosis: Activity intolerance related to generalized weakness. She wears blouses that are three sizes too big.A 38 year old female refuses to look at her dressing after having a mastectomy for breast cancer. diaphoresis. chest pain.

which of the following would indicate a problem? Answer Selected Answers: constipation . which of the following would indicate a problem in the problem that the nurse would include on a problem list.• Question 43 2 out of 2 points In assessing diagnostic labs and procedures. 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.

not interventions) Answer Selected Answers: .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.

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. has not been able to keep anything down. Answer Selected Answer: Risk for aspiration Correct Answer: Risk for aspiration • Question 47 2 out of 2 points Patient has BP 90/50. He has a history of dysphagia (difficulty swallowing). has capillary refil > 3 seconds. and a depressed gag reflex. Select the . has lost 3 pounds in 2 days. dry oral mucous membranes.

appropriate nursing diagnosis. and yellow drainage from a wound swollen. which of the following would indicate that the person has an infection? Answer Selected Answers: cloudy urine redness. tender lymph nodes . 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. Answer Selected Answer: Fluid volume deficit Correct Answer: Fluid volume deficit • Question 48 2 out of 2 points In assessing the immune system. pain.

is unable to put clothes on without stopping for rest.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. 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: . Select the approprite nursing diagnosis. heart rate increases with activity. 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.increased erythrocyte sedimentation rate (ESR) .

2012 5:02:22 PM EDT . April 22.pulse oximetery > 94% RR 12-20 patient is alert and oriented x 3 apply oxygen to maintain pulse ox > 94% Sunday.

Sign up to vote on this title
UsefulNot useful