NUR2101 Exam 3 Review

NUR 2101 Exam 3 Review

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Question 1

Question 1 - Rationale

Correct Answer

A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client?

• Broth Fat
• free broth is an acceptable component of a clear liquid diet.
• Grape juice
• is an acceptable component of a clear liquid diet, along with apple juice and cranberry juice.
• Lemon Gelatin
• is an acceptable component of a clear liquid diet, along with sugar, honey, hard candy, and ice pops.

Question 1 - Rationale

Incorrect Answers

A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client?

• Nonfat milk
• is an acceptable component of a full liquid diet, not a clear liquid diet.
• Custard
• is an acceptable component of a full liquid diet, not a clear liquid diet

Question 2

Question 2 - Rationale

Correct Answer

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation?

• Ignoring the urge to defecate
• Anything that prevents the client from responding to the urge to defecate and disrupts regular habits can cause alterations in bowel habits.
• Inadequate fluid intake
• Reduced fluid intake slows the passage of food through the intestine and can result in hardening of stool.

Question 2 - Rationale

Incorrect Answers

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation?

• Increased fiber in the diet:
• Increased fiber promotes more efficient bowel emptying.
• Increased activity:
• promotes bowel emptying.

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Question 3

Question 3 - Rationale

Correct Answers

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

• Leave a nightlight on in the patient's room.
• This is an appropriate action for keeping the patient safe. Night vision may be impaired in older adult patients. If the patient awakens in the night, a nightlight may help the patient to recognize the surroundings, decreasing the likelihood of disorientation. It will also help to decrease the possibility of a fall on the way to the bathroom because the path will be illuminated, and the patient will be less likely to trip over objects in the room.

Question 3 - Rationale

Incorrect Answers

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

• Limit the patient's fluid intake in the evening. This is not an appropriate nursing action.
• Obtain a bedside commode for the patient's use. This is not an appropriate nursing action.
• Put the side rails up and tell the patient to call the nurse before voiding. This is not an appropriate nursing action.

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Question 4

Question 4 - Rationale

Correct Answer

A nurse is caring for a client whose partner was recently hospitalized with COVID-19. The client is experiencing manifestations related to the alarm stage of the general adaptation syndrome (GAS). For which of the following manifestations should the nurse assess for?

• Body image
• Role performance
• Identity
• Self-esteem

The four main components of self-concept include body image, self-esteem, role performance, and identity.

Question 4 - Rationale

Incorrect Answers

A nurse is caring for a client whose partner was recently hospitalized with COVID-19. The client is experiencing manifestations related to the alarm stage of the general adaptation syndrome (GAS). For which of the following manifestations should the nurse assess for?

• Health promotion
• Health promotion is incorrect. While health promotion is a focus of nursing interventions within the plan of care, it is not considered a component of self-concept.

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Question 6

Question 6 - Rationale

Correct Answer

A client working at home due to COVID-19 restrictions reports abdominal cramping and bloating with diarrhea and states, “I am completely stressed out from working at home.” The nurse should identify the client is experiencing symptoms of

• Irritable bowel syndrome
• Irritable bowel syndrome is a condition often triggered by stress and characterized by abdominal discomfort, cramping, bloating, and diarrhea.

Question 6 - Rationale

Incorrect Answers

• Food poisoning
• Some of the symptoms the client is describing might mimic food poisoning; however, food poisoning is not a stress-related condition.
• Panic disorder
• Panic disorder is a type of anxiety disorder characterized by sudden feelings of terror.
• Major depressive disorder
• Major depressive disorder is a mental health disorder characterized by persistently depressed mood and loss of interest in activities.

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Question 7

A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, “It is too late for me to quit.” Which of the following actions should the nurse take?

Question 7 - Rationale

Correct Answer

A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, “It is too late for me to quit.” Which of the following actions should the nurse take?

• Assist the client in finding local smoking cessation programs.

• Smoking cessation slows the progression of COPD. It is not too late for this client to stop smoking and the nurse should encourage the client to do so.

Question 7 - Rationale

Incorrect Answers

A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, “It is too late for me to quit.” Which of the following actions should the nurse take?

• Tell the client that she will be alright after receiving medical care. -
• False reassurance
• Inform the client that she must stop smoking or the provider will not be able to care for her.
• Threatening the client
• Advocate for the client by supporting her statement about not quitting. -
• Not advocating the nurse is agreeing

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Question 8

A nurse is providing discharge teaching about improving gas exchange for a client who has COPD. Which of the following instructions should the nurse include in the teaching?

Question 8 - Rationale

Correct Answer

A nurse is providing discharge teaching about improving gas exchange for a client who has COPD. Which of the following instructions should the nurse include in the teaching?

• Use pursed-lipped breathing during periods of dyspnea.
• To slow expiration, increase airway pressure, and facilitate gas exchange.

Question 8 - Rationale

Incorrect Answers

A nurse is providing discharge teaching about improving gas exchange for a client who has COPD. Which of the following instructions should the nurse include in the teaching?

• Limit fluid intake to 1500 mL per day.
• Instruct the client to drink 2,000 to 3,000mL of fluid daily to thin secretions.
• Practice chest breathing each day.
• Encourage client to practice diaphragmatic or abdominal breathing to reduce the respiratory rate and increase alveolar ventilation.
• Wear home oxygen to maintain an SaO2 of at least 94%.
• The client should maintain an oxygen saturation of at least 88%. A saturation of 94% or greater could suppress the clients breathing.

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Question 9

Question 9 - Rationale

Correct Answer

The nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent?

• The meaning of disease can vary widely by cultures.
• A client may define and react to disease based on their unique cultural perspective. The nurse should seek to understand a client’s culture and life experiences in order to provide care that is effective, evidenced-based, and culturally congruent.

Question 9 - Rationale

Incorrect Answers

• Illness is not influenced by culture.
• Client’s culture affects the social determinates of health and contributes to how an individual defines illness.
• Assigning clients to specific cultural categories facilitates communication.
• The nurse cannot make assumptions that all clients within a specific culture have the same beliefs.
• Predetermined criteria should generate client care activities.
• The nurse should consider that patterns of daily life and meaning are generated by the client, not predetermined criteria.

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Question 10

Question 10 - Rationale

Correct Answers

A nurse is teaching a group of older adult clients about complementary and alternative therapies. Which of the following interventions should the nurse recommend to improve balance?

• Tai chi
• Tai chi is a Chinese martial art consisting of a series of slow, gentle, continuous movements. Older adult clients who take part in structured Tai chi programs improve their balance and physical strength, which reduces the risk of falls.

What are some other alternative therapies that can be used?

Question 10 - Rationale

Incorrect Answers

A nurse is teaching a group of older adult clients about complementary and alternative therapies. Which of the following interventions should the nurse recommend to improve balance?

• Naturopathic medicine
• Focuses on treating the whole client and promoting health
• Magnet therapy
• Can aid chronic pain and musculoskeletal disorders
• Progressive relation therapy
• Can lower blood pressure and heart rate, increase well-being, and decrease muscle tension

Question 11

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Question 11 - Rationale

Correct Answers

A nurse at an ophthalmology clinic is assessing the client referred by the provider for a potential cataract. Which of the following client reports is consistent with cataracts?

• Blurry or hazy vision
• Cataracts are a cloudy opaque area in the lens of the eye.

Question 11 - Rationale

Incorrect Answers

A nurse at an ophthalmology clinic is assessing the client referred by the provider for a potential cataract. Which of the following client reports is consistent with cataracts?

• Loss of peripheral vision
• Indicates open angle glaucoma
• Bright flashes of light and floaters
• Associated with Retinal detachment
• Eye strain and headaches with close work
• Associated with decreased visual acuity.

Question 12

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Question 12 - Rationale

Correct Answers

• A nurse is caring for a client experiencing insomnia. The statement that is an expected outcome is: "The client

• will identify sleep promotion strategies."
• This is the first thing the client should be able to in order to promote sleep.

Question 12 - Rationale

Incorrect Answers

A nurse is caring for a client experiencing insomnia. The statement that is an expected outcome is: "The client

• has a sleep pattern disturbance."
• Insomnia is a symptom rather than the name of a disease
• will have privacy when attempting to sleep."
• This will not affect the client’s ability to sleep
• will report an optimal balance of sleep and activity."
• While this is important the client needs to be able to identify techniques to induce sleep

Good Luck!