MED-SURG/ADULT
HEALTH 220 QS AND
ANSWERS 2023/2024
An older client is apprehensive about being hospitalized. The
nurse realizes that one of the stresses of hospitalization is the
unfamiliarity of the environment and activity. How can the nurse
best limit the client's stress?
1. Use the client's first name.
2. Visit with the client frequently.
3. Explain what the client can expect.
4. Listen to what the client has to say. - answer3
Explaining procedures and routines should decrease the client's
anxiety about the unknown. The nurse should not confuse roles of
professional and friend; the client should be called by an
appropriate title (Mr., Miss, Ms., Mrs., etc.) unless the client
requests otherwise. The nurse should not confuse the role of
professional with that of being a friend; "visiting" has a social
connotation. Although listening to the client is therapeutic, this
does not change the fact that the hospital environment is strange
to the client and the client needs information.
The nurse recognizes that a common conflict experienced by the
older adult is the conflict between:
1. Youth and old age
,2. Retirement and work
3. Independence and dependence
4. Wishing to die and wishing to live - answer3
A common conflict confronting the older adult is between the
desire to be taken care of by others and the desire to be in charge
of one's own destiny. The conflict between the young and old age
may occur but is not common. The conflict between the retired
and working may occur but is not common. The conflict between
those wishing to die and those wishing to live may occur but is not
common.
A primary nurse receives prescriptions for a newly admitted client
and has difficulty reading the health care provider's writing. Who
should the nurse ask for clarification of this prescription?
1. Nurse practitioner
2. House health care provider that is on-call
3. Health care provider who wrote the prescription
4. Nurse manager familiar with the health care provider's writing -
answer3
The health care provider who wrote the prescription should be
called for clarification. The nurse is liable and responsible if the
prescription is misinterpreted. Only the health care provider who
wrote an undecipherable prescription can correctly clarify the
prescription.
,A client is admitted with metabolic acidosis. The nurse considers
that two body systems interact with the bicarbonate buffer system
to preserve healthy body fluid pH. What two body systems should
the nurse assess for compensatory changes?
1. Skeletal and nervous
2. Circulatory and urinary
3. Respiratory and urinary
4. Muscular and endocrine - answer3
Increased respirations blow off carbon dioxide (CO2), which
decreases the hydrogen ion concentration and the pH increases
(less acidity). Decreased respirations result in CO2 buildup, which
increases hydrogen ion concentration and the pH falls (more
acidity). The kidneys either conserve or excrete bicarbonate and
hydrogen ions, which helps to adjust the body's pH. The buffering
capacity of the renal system is greater than that of the pulmonary
system, but the pulmonary system is quicker to respond. Skeletal
and nervous systems do not maintain the pH, nor do muscular
and endocrine systems. Although the circulatory system carries
fluids and electrolytes to the kidneys, it does not interact with the
urinary system to regulate plasma pH.
A 2 g sodium diet is prescribed for a client with stage 2
hypertension, and the nurse teaches the client the rationale for
this diet. The client reports distaste for the food. The primary
nurse hears the client request that the family "bring in a ham and
cheese sandwich and fries." What is the most effective nursing
intervention?
1. Discuss the diet with the client and family.
, 2. Tell the client why salty foods should not be eaten.
3. Explain the dietary restriction to the client's visitors.
4. Ask the dietitian to teach the client and family about sodium
restrictions. - answer1
The client and significant family members should be included in
dietary teaching; families provide support that promotes
adherence. The client already has received information about why
salty foods should not be eaten. Explaining the dietary restriction
to the client's visitors could violate confidentiality. The client
should be involved in his or her own care; the client ultimately will
assume the responsibility. The dietitian is a resource person who
can give specific, practical information about diet and food
preparation once there is a basic understanding of the reasons for
the diet.
The nurse should place the client in which position to obtain the
most accurate reading of jugular vein distention?
1. Upright at 90 degrees
2. Supine position
3. Raised to 30 degrees
4. Raised to 10 degrees - answer3
Jugular vein pressure is measured with a centimeter ruler to
obtain the vertical distance between the sternal angle and the
point of highest pulsation. This procedure is most accurate when
the head of the bed is elevated between 30 and 45 degrees. The
internal and external jugular veins should be inspected while the
client is gradually elevated from a supine position to an upright
HEALTH 220 QS AND
ANSWERS 2023/2024
An older client is apprehensive about being hospitalized. The
nurse realizes that one of the stresses of hospitalization is the
unfamiliarity of the environment and activity. How can the nurse
best limit the client's stress?
1. Use the client's first name.
2. Visit with the client frequently.
3. Explain what the client can expect.
4. Listen to what the client has to say. - answer3
Explaining procedures and routines should decrease the client's
anxiety about the unknown. The nurse should not confuse roles of
professional and friend; the client should be called by an
appropriate title (Mr., Miss, Ms., Mrs., etc.) unless the client
requests otherwise. The nurse should not confuse the role of
professional with that of being a friend; "visiting" has a social
connotation. Although listening to the client is therapeutic, this
does not change the fact that the hospital environment is strange
to the client and the client needs information.
The nurse recognizes that a common conflict experienced by the
older adult is the conflict between:
1. Youth and old age
,2. Retirement and work
3. Independence and dependence
4. Wishing to die and wishing to live - answer3
A common conflict confronting the older adult is between the
desire to be taken care of by others and the desire to be in charge
of one's own destiny. The conflict between the young and old age
may occur but is not common. The conflict between the retired
and working may occur but is not common. The conflict between
those wishing to die and those wishing to live may occur but is not
common.
A primary nurse receives prescriptions for a newly admitted client
and has difficulty reading the health care provider's writing. Who
should the nurse ask for clarification of this prescription?
1. Nurse practitioner
2. House health care provider that is on-call
3. Health care provider who wrote the prescription
4. Nurse manager familiar with the health care provider's writing -
answer3
The health care provider who wrote the prescription should be
called for clarification. The nurse is liable and responsible if the
prescription is misinterpreted. Only the health care provider who
wrote an undecipherable prescription can correctly clarify the
prescription.
,A client is admitted with metabolic acidosis. The nurse considers
that two body systems interact with the bicarbonate buffer system
to preserve healthy body fluid pH. What two body systems should
the nurse assess for compensatory changes?
1. Skeletal and nervous
2. Circulatory and urinary
3. Respiratory and urinary
4. Muscular and endocrine - answer3
Increased respirations blow off carbon dioxide (CO2), which
decreases the hydrogen ion concentration and the pH increases
(less acidity). Decreased respirations result in CO2 buildup, which
increases hydrogen ion concentration and the pH falls (more
acidity). The kidneys either conserve or excrete bicarbonate and
hydrogen ions, which helps to adjust the body's pH. The buffering
capacity of the renal system is greater than that of the pulmonary
system, but the pulmonary system is quicker to respond. Skeletal
and nervous systems do not maintain the pH, nor do muscular
and endocrine systems. Although the circulatory system carries
fluids and electrolytes to the kidneys, it does not interact with the
urinary system to regulate plasma pH.
A 2 g sodium diet is prescribed for a client with stage 2
hypertension, and the nurse teaches the client the rationale for
this diet. The client reports distaste for the food. The primary
nurse hears the client request that the family "bring in a ham and
cheese sandwich and fries." What is the most effective nursing
intervention?
1. Discuss the diet with the client and family.
, 2. Tell the client why salty foods should not be eaten.
3. Explain the dietary restriction to the client's visitors.
4. Ask the dietitian to teach the client and family about sodium
restrictions. - answer1
The client and significant family members should be included in
dietary teaching; families provide support that promotes
adherence. The client already has received information about why
salty foods should not be eaten. Explaining the dietary restriction
to the client's visitors could violate confidentiality. The client
should be involved in his or her own care; the client ultimately will
assume the responsibility. The dietitian is a resource person who
can give specific, practical information about diet and food
preparation once there is a basic understanding of the reasons for
the diet.
The nurse should place the client in which position to obtain the
most accurate reading of jugular vein distention?
1. Upright at 90 degrees
2. Supine position
3. Raised to 30 degrees
4. Raised to 10 degrees - answer3
Jugular vein pressure is measured with a centimeter ruler to
obtain the vertical distance between the sternal angle and the
point of highest pulsation. This procedure is most accurate when
the head of the bed is elevated between 30 and 45 degrees. The
internal and external jugular veins should be inspected while the
client is gradually elevated from a supine position to an upright
