Tiêu đề PRE-INTENSIVE - NP4 - SC ✅

C. The client is asked to stand at a distance of 40ft. from the chart and is asked to read the largest line on the chart. D. The client is asked to stand at a distance of 40 ft. from the chart and to read the line than can be read 200 ft. away by an individual with unimpaired vision. 13. The result of the Snellen’s test for the older client is documented as 20/60. The nurse interprets this as: A. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet. B. The client can read at a distance of 60 feet what a client with normal vision cannot read at 20 feet. C. The client can read at a distance of 20 feet what a client with normal vision cannot read at 60 feet. D. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet. 14. Nurse Nicole notes that the physician has documented a diagnosis of presbyopia to the older client’s chart. She expects to assess for the presence of? A. Age-related nearsightedness B. Age-related farsightedness C. Age-related central vision loss D. Age-related peripheral vision loss 15. Nurse Nico is caring for another older client who has impaired hearing. Which of the following approaches will facilitate communication? A. Speak frequently B. Speak loudly C. Speak directly into the impaired ear D. Speak in a normal tone 16. Within how many seconds should he check if the pulse of the patient is present? A. 5 seconds B. 10 seconds C. 5 seconds D. 20 seconds 17. Should Antonio confirm that the child is not breathing but the pulse rate is approximately 80 beats per minute, which of the following should he do next? A. Check for the pulse of the patient every 3 minutes. B. Give additional chest compressions to assist the heart of the patient. C. Provide rescue breathing: 1 breath every 3-5 seconds. D. Shout for nearby help. 18. If in case Antonio determine that the patient’s pulse is no longer palpable, what should he do? A. Perform CPR using cycles of 15 compressions and 2 breaths. B. Shout for nearby help. C. Activate the emergency response team. D. Perform CPR using cycles of 30 compressions and 2 breaths. 19. Should Nurse Antonio’s initial assessment reveal that the child is not breathing and that there is no definite pulse, what should he do next after giving 2 minutes of CPR? A. Continue performing CPR using the 30:2 ratio of chest compressions and rescue breaths. B. Utilize the emergency response system. C. Pray for the child. D. Continue performing CPR but make the ratio of chest compressions and rescue breaths to 60:4. 20. The nurse was able to retrieve the AED and it revealed that the rhythm was shockable. After delivering 1 shock, what should Antonio do next? A. Resume CPR for about 2 minutes. B. Check for the pulse of the patient. C. Leave the patient to activate the emergency response team. D. Provide rescue breathing giving 1 breath every 3-5 seconds. 21. A nurse is caring for client with acute pancreatitis who has history of alcoholism. The client monitors the client for paralytic ileus, knowing which data indicate this complication of pancreatitis? A. Inability of pass flatus B. Loss of anal sphincter control C. Severe, constant pain with rapid onset D. Firm, non-tender mass palpable at the lower right costal margin 22. Patient Robert is diagnosed with cholecystitis. The nurse reviews the client’s medical record, expecting to note documentation of which manifestations of this disorder? Select all that apply. 1. Dyspepsia 2. Dark stools 3. Light colored urine and clear urine 4. Feelings of abdominal fullness 5. Rebound tenderness in the abdomen 6. Upper abdominal pain that radiates to the right shoulder A. II, III, IV, V B. I, III, IV, V, VI C. I, IV, V, VI D. All of the above 23. Which of the following diet is required few days after cholecystectomy? A. High fat B. Low fat C. Clear liquid D. Fill liquid 24. Patient Jake who undergone cholecystectomy was found to have a T-Tube inserted after surgery, what is the purpose of this tube? A. To maintain patency of common bile duct B. To drain excess bile C. To serve as temporary gall bladder D. To concentrate bile 25. As the nurse performs teaching to a group of nursing student, which of the following types of liver cirrhosis has the highest incidence? A. Laennec cirrhosis B. Biliary tract cirrhosis C. Cardiac cirrhosis D. Post herpetic cirrhosis 26. Which manifestation is related to liver cirrhosis? A. Fetor hepaticus B. Urea breath C. Uremic frost D. Nevus flammeus 27. Patient Romana suffers from Hepatitis C which developed into liver failure and GIT hemorrhage. Which of the following blood products would bring hemostasis to the client? A. Whole blood and albumin B. Platelets and RBCs C. Whole blood and FFP D. Cryoprecipitate and FFP 28. Patient Sherwin has a recent history of rectal bleeding is being prepared for colonoscopy. How should the nurse position the patient initially? A. Lying on the right side with legs bent B. Lying on the left side with legs straight C. Lying on the left side with legs bent D. Lying on the right side with legs straight 29. Patient Dante is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, which of the following should be taught to the client? A. Increasing OFI to prevent dehydration B. Wearing a pouch at bedtime only C. Eating food low in protein D. Eating a diet high in root crops 30. Nurse Daenerys is taking care of a patient with liver cirrhosis. Which of the following assessment findings is consistent with the complication of deficient clotting factors? A. Dyspnea and fatigue B. Ascites C. Purpura D. Gynecomastia 31. When evaluating a male client for potential complications of pancreatitis, which of the following should be monitored? A. Increased ICP B. Decreased urine output C. Bradycardia D. Hypertension 32. What laboratory finding is the primary diagnostic indicator for pancreatitis? A. Increased WBC B. Elevated BUN 2 | Page

Situation: A 54-year-old man is brought to the emergency room unconscious. HR 100bpm, BP 100/60, Temp 37.2C, RR 22cpm. Hemorrhagic stroke is the primary impression. 52. The most common cause of subarachnoid hemorrhage is a rupture of a saccular aneurysm located in the circle of Willis. Which among the following vessels is not a part of the Circle of Willis? A. Anterior communicating artery B. Basilar artery C. Posterior communicating artery D. Posterior cerebral artery 53. What is the most common symptom that precedes hemorrhagic strokes? A. Projectile vomiting B. Sudden, severe headache C. Nuchal rigidity D. Ptosis 54. Which among the following drug orders for the patient will alert the nurse to ask the physician? A. Nicardipine B. Labetalol C. Coumadin D. Nitroprusside 55. Which acid-base balance is usually seen after subarachnoid hemorrhage? A. Hyponatremia B. Hypocalcemia C. Hyperphosphatemia D. Hypernatremia 56. In the presence of aneurysm, you institute the following interventions except: A. Raising the head of bed to 15 to 30-degree elevation B. Administering enema for constipation C. Providing dim lights in the patient’s room D. Instructing the patient to avoid straining or doing Valsalva Situation: In the United States, around 40,000 cases of endometrial cancer are documented annually. Gina is a 56-year-old female diagnosed with Stage II endometrial carcinoma, grade I. 57. Endometrial carcinoma is commonly preceded by which of the following conditions? A. HPV infection B. Chronic malnutrition C. Endometrial hyperplasia D. Early menopause 58. What is the most common type of endometrial carcinoma? A. Squamous cell carcinoma B. Adenocarcinoma C. Clear cell carcinoma D. Serous papillary carcinoma 59. Which among the following does not contribute to the development of endometrial CA? A. Use of oral combination contraceptives (estrogen + progestin) B. Nulliparity C. Diabetes mellitus D. Late onset of menopause 60. The patient underwent radical hysterectomy with bilateral lymph node dissection and removal of the upper third of the vagina. She asks you when she can have intercourse with her husband, fearing that she might have complications. Your best response would be: A. “Because of what was removed from you, I am afraid you can no longer have intercourse with your spouse again.” B. “You should avoid sexual intercourse for at least 6 weeks.” C. “Having intercourse as early as one week will no longer pose dangers.” D. “You may go ask your gynecologist about it.” 61. Which among the following signs and symptoms should the patient report after discharge? A. Occasional vaginal discharges B. Mild dyspareunia at the first intercourse C. Calf pain and tenderness D. All of the above SITUATION: Since 2012, there has been a shift of nursing core competency standards from eleven, it has been compressed into three. These are: Beginning role of nurses in client care (as a nurse generalist), in leadership & management, and in research. To be successful in the local boards, student-nurses must master PALMER concepts. The following questions apply. 62. During orientation, student-nurse Maxine learns that the nursing model of practice implemented in the facility is a primary nursing approach. When she attends a report on the medical unit, she will verify with the staff which of the following characteristics of primary nursing? A. critical paths are used when providing client care B. the nurse manager assigns tasks to the staff members C. a registered nurse leads nursing staff in providing care to a group of clients D. a single RN is responsible for planning and providing individualized nursing care to 4-6 clients 63. Maxine attends an in-service educational session for staff and student nurses about case management conducted by the unit’s nurse manager. The clinical nurse manager determines that a review of the material needs to be done if one of the staff nurse stated that case management: A. manages a client care by managing the client care environment B. maximizes hospital revenues while providing for optimal client care C. is designed to promote appropriate use of hospital personnel and material resources D. represents a primary health prevention focus managed by a single case manager 64. Now the nurse manager in the said nursing unit is reviewing the critical paths of the clients. She collaborates with each nurse assigned to the clients and performs a variance analysis. Which of the following indicate the need for further action and analysis? A. A client is performing his own colostomy care B. Purulent drainage is noted from a postoperative wound incision C. 1-day postoperative client has a temperature of 98.80F D. A client newly diagnosed with diabetes mellitus is preparing his own insulin for injection 65. The nurse manager is planning to implement a change in the nursing unit from team nursing to primary nursing. She anticipates that there will be resistance to the change during the change process. The primary technique that she should use in implementing this change is? A. Introduce the change gradually B. Confront the individuals involved in the change process C. Use coercion to implement that change D. Manipulate the participant in the change process. 66. A nursing assistant in the unit is resistant to the change and is not taking an active part in facilitating the process of change. Which of the following is the best approach of the nurse manager in dealing with the nursing assistant? A. Ignore the resistance B. Exert coercion with the nursing assistant C. Provide a positive reward system for the nursing assistant D. Confront the nursing assistant to encourage verbalization of feeling regarding the change Situation: A 55-year-old female patient is admitted due to profuse vaginal bleeding. She underwent ultrasound and laparoscopic examination. She was diagnosed with leiomyoma. 67. Which among the following is not true regarding leiomyoma? A. It is a tumor of the uterine endometrium. B. It is a slow-growing tumor. C. Leimyomas grow with estrogen stimulation. D. The tumor usually shrinks during the menopausal stage. 4 | Page