3rd Semester Final Review

A couple reveals that they are going to tell both their biological children and adoptive children they are filing for a divorce. Prior to having this family discussion,, they met with a counselor about the possible impact this may have on the children. The counselor suggests to be on the lookout for which possible consequences on the adoptive children related to the divorce

-Adoptive children may feel they are the cause of the divorce. -Adoptive children experience insecurity for a second time.

The nursing student is preparing a teaching presentation on disaster preparedness for a nursing class assignment. Which action(s) would the student include in the presentation?

-Affix a tag to a pet's collar with contact information. -Store a supply kit with extra batteries, flashlight, and radio. -create a network of persons who can provide support during and after the disaster.

A client is developing increasing symptoms of anxiety disorder and reports having urges to self harm. The nurse secures admission to a residential treatment facility and the client begins to shout at the nurse for betraying trust and ruining the clients life. What is the nurse's role in this situation?

-Assuring the clients safety -Helping the client problem-solve -modifying communication -All of the above.

Forms of communication by the LVN should include:

-Charting on the nurse's noted. -Reading the patient's chart, including physician progress notes. -Taking notes during a staff meeting. -Including all pertinent information when reporting off to the next shift. -All of the above.

The mother of a 4-yr-old is concerned her child is not eating well. In addressing the concerns of this mother, which foods should the nurse point out are high in protein? Select all that apply.

-Cheese and crackers -Whole grain granola with yogurt -Turkey sandwich.

The nurse is educating a group of student nurses on symptoms of sexually abused women. What symptoms will the nurse include in the teaching? Select

-Chronic pelvic pain -substance use disorder -social withdrawal

The emergency department nurse manager is orienting the new nurse regarding bioterrorism. The nurse manager would include which indicator(s)

-Clusters of sick people form a shared locale -High outbreak of similar symptoms among previously healthy people

A pt. is having diagnostic testing for suspected hyperthyroidism. Which of the following diagnostics correlate with this endocrine disorder? Select all that apply.

-Decrease in serum TSH. -Increased T3 -Increased T4 -Increase in radioactive iodine uptake

In caring for clients, a healthcare team often uses critical pathways. Which of the following are reasons critical pathways are used. Select all that apply.

-Decreases cost for the client and hospital. -Helps establish a trusting relationship with clients. -Is followed by all members of the health team. -Provides organization for the care of the client -Includes all treatments and procedures.

A client has just learned of having a terminal illness. Which assessment finding(s) indicate to the nurse that the client is experiencing a sympathetic nervous system response to this diagnosis? Select all that apply.

-Dilated pupils. -HR 112. -BP 170/90 -Glucose 140 -RR 26 and shallow.

The nurse removed a clients indwelling urinary catheter 24hrs after the cesarean birth. Four hrs later, the client has not yet voided. The client reports 6/10 incisional pain and no urge to void. The nurse can palpate a full bladder. What action(s) will the nurse take? Select all that apply.

-Encourage increased oral fluid intake. -Perform in-and-out catheterization

The school nurse is concerned that a young girl is being sexually abused. which assessment finding supports this concern? Select all that apply.

-Expresses fear about going home -reports frequent urinary tract infections -is socially isolated and immature -demonstrates low self-esteem

The nurse in the emergency department is caring for a client who has an elevated BP and elevated RR. The nurse is aware that the client may be experiencing withdrawal from heroin if the client displays which other s/sx? Select all that apply.

-Goosebumps. -Diarrhea.

Passive aggressive behaviors is demonstrated by the nurse who:

-Gossips about other people. -Constantly complains during shift report. -Complains to everyone except the right person. -All of the above.

A school- aged child is in isolation at the hospital and her family members ask what they can do to help the child feel less lonely. What would the nurse suggest to this family? Select all that apply.

-Have the child's classmates send cards -have parents bring the child's electronic game system. --Draw a smile on the nurse's mask before entering the room.

A community-based nurse is precepting a student nurse. The student nurse asks the preceptor to explain a communal family. How would the nurse respond? Select all that apply.

-In a communal family, all members share the responsibilities for homemaking. -All members living in a communal family are responsible for childbearing the children. -Communal families are seen in many cultures.

Which of the following assessment findings is most important in determining the presence of alcohol dependency in a client? Select all that apply. .

-Patterns of use. -Fluctuation in appetite. -Absenteeism from work. -Blurred vision.

A postpartum woman is concerned about constipation following delivery. What factor(s) contribute to this problem? Select all that apply..

-Perineal pain. -Hemorrhoidal discomfort -Iron Supplements

A nurse is developing a program for families to promote spending more time together. Which cause(s) of decreased family togetherness will the nurse incorporate into the program? Select all that apply.

-Rise in children participating in extracurricular activities. -Increase in television use over discussion among family members. -Greater focus on material things rather than relationships.

In which situation(s) will the nurse anticipate client admission tot he labor and delivery unit? Select all that apply.

-The client reports experiencing regular contractions every 5 minutes. -The nurse notes that the cervix has thinned with 7cm dilation.

The nurse is observing a nursing assistant transfer a client form bed to chair. Which observation needs correction? Select all that apply.

-The nursing assistant stands with feet close together, and knees and back straight when helping the client to move. -The nursing assistant tells the client to grab on to her any place during the transfer. -The nursing assistant lifts the client up by tugging on the clients arms. -The nursing assistant assists the client to stand and pivot to get into the chair.

The nurse is planning care for a family whose 3-yr-old child is in the final stages of dying. Which outcome demonstrates that the interventions have been successful? Select all that apply.

-The parents identify coping measures that are helping -the family prepares a scrapbook with favorite photos. -the child remain free of pain during the end stage of life -The parents identify a support group for their family.

A 6-yr-old has been administered a hypnotic before going to surgery. The child remains kicking and screaming. The nurse is considering whether restraints should be used in this situation. Which guidelines should the nurse follow in this instance? Select all that apply.

-Use the least amount of restraint necessary -obtain a primary care provider's prescription for restraint -Explain to the parents the need to restrain their child. -Explain calmly to the child that he is being punished for his poor bx.

A nurse has been working in the hospital setting and has decided to change careers to the community-based setting. What skill(s) will this nurse need to be successful in the new role? Select all that apply.

-Use the nursing process for the family instead of the individual. -Apply educational theory and techniques. -Develop communication techniques with family members. -Become an advocate for the family.

The nurse is admitting a pediatric client for a common pediatric surgical procedure. When completing the domestic violence screening, which statements require clarification? Select all that apply.

-We stay out of moms way when she is in a bad mood -I see my dad drive by our new house to see who is here. -My mom will hit my dad when she is drunk but it doesn't hurt.

A nurse is making an initial home visit to a child requiring home IV antibiotic therapy for tx of a bone infection. When assessing the home environment, which area(s) is the priority for the nurse to assess? Select all that apply.

-electricity -refrigeration -storage areas

A family that regularly takes in foster children is visiting the junior high school nurse to inform the staff that there will be a new 8th grade foster child beginning school the following week. The school nurse should monitor this new student for which psychosocial response to being moved to the foster care system? -High lvl of insecurity. -Aggressive bx as the child acts out feelings.

1 (or 2)

A nurse is educating a client about the benefits of fruit versus fruit juice in the diabetic diet. The client states, what difference does it make if you drink the juice or eat the fruit? It is all the same. What are the best responses by the nurse? Select all that apply. -Eating the fruit instead of drinking the juice decreases the glycemic index by slowing absorption. -The fruit has less sugar than the juice.

1 and 5.

A young couple are asking the nurse for suggestion on the best way to help their newborn develop properly. Which is the best response by the nurse? -Provide nutritional supplements. -Provide a variety of brightly colored toys.

1 or 4.

The nurse is assisting a 30-yr-old client in scheduling an appointment for a cervical biopsy. The nurse would recommend that the client schedule the testing at which time?

1 week after completion of the clients menstrual cycle.

A nurse is working with the burn clinic at a local hospital. Which types of burns would the nurse address with the health care provider and social worker? Select all that apply. -Small, round burns. -Hand burns with a pattern -Linear pattern burns

1, 2, and 3.

A nurse is conducting a home care assessment of a pediatric client and the home. Which aspects might the nurse include to determine any safety concerns? Select all that apply. -Client medications -Home layout -Developmental status -Family member at home

1, 3, 4, and 5.

Lately, a 75-year-old man is having difficulty emptying his bladder. He is unable to empty it completely and yet it feels full, causing discomfort. The physician suspects prostate cancer. Which question(s) would you expect the physician to ask the client? Select all that apply. -"Do you pass blood in your urine?" -"Do you have difficulty urinating?" -"Do you have a family history of prostate cancer?"

1, 3, and 5.

A nurse is providing a community seminar about eating disorders. Which age group would the nurse be most likely to target because of their increased risk?

12 to 25

How much notice should you give your employer when terminating your employment?

2 weeks.

A woman arrives at the prenatal clinic and is accompanied by her partner. Which bx's would be suggestive of intimate partner violence? Select all that apply. -The partner answers questions for the pregnant client. -The partner is overly protective of the pregnant client. -Poor weight gain during the pregnancy and low-birth-weight infant.

2, 3, and 4.

A client with diabetes comes to the clinic for a follow-up visit. The nurse reviews the clients glycosylated hemoglobin test results. Which result would indicate to the nurse that the clients blood glucose lvl has been well controlled?

6.5%

All of the following adults are admitted to the surgical unit. Which client should the nurse prepare for immediate surgery? -A 56 yr old woman who is having right scapular pain after eating. -A 48yr old woman who has had moderate vaginal bleeding for 2 wks. -A 28 yr old man who has severe RLQ pain and a WBC of 14. -A 45 yr old man with an irreducible inguinal hernia.

A 28yr old man who has severe RLQ pain and a WBC of 14.

The nurse is caring for four clients on the pediatric unit. Which client scenario provides the highest concern of suspected abuse?

A 7 month old with multiple bruises on the legs. (Accepted #4)

A suspicious breast lump is noted on a mammogram. The client asks the nurse which diagnostic test confirms if the lump is cancerous or benign. What is the best answer from the nurse?

A biopsy.

A nurse teaching family members about the brain's connection to behaviors commonly seen in mental illnesses is using the tern neurotransmitter. The nurse should explain that a neurotransmitter is: -

A chemical that is released in the brain.

An LVN is planning the client assignments for the day. Which of the following is the most appropriate assignment for the CNA?

A client who needs assistance with eating meals because of right-sided weakness.

A nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department for treatment on the evening shift. The nurse would assign the highest priority to which of the following clients?

A client with chest pain who states that he just ate pizza that was made with a very spicy sauce.

A 10-yr-old child is receiving end of life care at home. The home care nurse recommends repositioning the client every 2 hrs. The caregiver responds, My child has been through so much already! Why can't we just let the child stay in a comfortably position? How will the nurse address the parents' concerns? -A pressure injury could cause additional pain; we can gently reposition your child to reduce this risk.

A pressure injury could cause additional pain; we can gently reposition your child to reduce this risk.

A client has gained 100 lbs over the past 20 yrs, and wants to lose weight.

A sensible weight loss regimen prescribed by a dietitian.

You have just taken report on four clients this morning, it's 6:30am. In what order will you assess your clients starting with the most critical? -The CNA reports that her 56yr old pt in room 27 has a blood sugar of 476. His NPH insulin is due at 7am. -A 72yr old client in room 24 tells the aid that she is having chest pain that does not radiate at a pain scale of 6/10. She is having no difficulty breathing and is not diaphoretic. -A 21 yr old MVA victim of 2 days ago with multiple long bone fractures with sudden onset of SOB, c/o chest pain at 9/10 and O2 sats of 87%. -A 67 yr old male with c/o being unable to void for four hrs who states that his bladder feels really full.

A=3, B=2, C=1, D=4.

A client is being treated for alcoholism. Which organization can be recommended to assist the FAMILY in coping with this disease?

AI-Anon

When a staff member makes a mistake, the nurse manager should:

Accept that the person made a mistake and help the person learn from the mistake.

The nurse is spending time with a client who has just learned, unexpectedly, that she is pregnant. Which initial task should the nurse assist the client to focus on? -Accepting the pregnancy. -

Accepting the pregnancy.

When you, as the nurse manager, hold staff members responsible for their actions and require them to document, on flow sheets, such items as intake and output, and personal care, which of the following terms applies?

Accountability.

A nurse understands that for the parathyroid hormone to exert its effect, what must be present?

Adequate vitamin D lvl

The family of a client stung by a bee, rushed the client to the emergency room. The client is experiencing hives and redness at the site. Upon arrival, the client states, "I feel a lump in my throat and I am sweating. I can't breathe. I think I am going to die!" The nurse anticipates which emergency treatment next? -

Administer an injection of epinephrine IV stat.

The nurse explains to the clients family the alcoholic's recovery. What is the first step in recovering from excessive alcohol use?

Admitting an inability to control drinking.

Which of the following is the primary hormone for the long-term regulation of sodium balance?

Aldosterone

A 5-yr-old child is brought to the emergency room with an open chin laceration following a bike accident. The child appears extremely frightened and asks if he will bleed to death. Which nursing action should the nurse prioritize to best assist this child?

Allow him to sit on his parents lap until time to suture the laceration.

Which of the following is the result of progressive deterioration of the brain?

Alzheimer's

You have received morning report and are getting ready to assess your clients. which of the following would you assess first?

An asthmatic pediatric client with inspiratory-expiratory wheezes.

Which would be included in the teaching plan for a client diagnosed with DM?

An elevated blood glucose concentration contributes to complications of diabetes, such as diminished vision.

To prepare the community for the possible threat of anthrax, a nurse must teach that:

Anthrax can infect integumentary, GI, and respiratory systems.

A 3-yr-old client has been hospitalized for 1 week with her mother rooming in; however, the mother has gone home to tend to other family responsibilities for a few days. After being inconsolable for the first 24 hrs after the mothers departure, the nurse notes the child is now lying quietly in bed sucking her thumb. Which response should the nurse prioritize in this situation?

Are you feeling sad? Your mom didn't want to leave, but she will be back after two more breakfasts.

The nurse is conducting a health history when a middle aged client states that her last menstrual period was 6 months ago. Upon further questioning, the client also states that symptoms of hot flashes and mood fluctuations are present. Which question should the nurse ask next? -

Are you taking any hormone replacement therapy?

The nurse discharging a newly delivered mother and her newborn infant needs to assess the mothers knowledge about how to take care of herself and her baby. This is her second child. Which approach would be best to verify the -Ask her questions and observe her caring for her baby.

Ask her questions and observe her caring for her baby.

The nurse is assessing a child of a different cultural background. Which nursing action should the nurse prioritize when providing nursing care?

Ask the family for input into their care based on their cultural beliefs.

Your boss has decided that you were behaving inappropriately and talked to you about it in front of your co-workers. What is the most appropriate way to handle this situation?

Ask to have the discussion somewhere private.

The nurse is assigned a client who is admitted for complications after a scheduled abortion. The nurses personal standards value adoption over abortion and will best serve the client by:

Asking the charge nurse for an alternative assignment.

Before an LVN can delegate a function to the CNA, he/she must:

Assess the pt. carefully.

A nurse is preparing to asses a family that recently went through a divorce. the family now consists of a 40-yr-old female, her 16-yr-old sone, and 5-yr-old daughter. The mother will continue as the primary wage earner with her current employment and has full custody of the children. Which action should the nurse prioritize with this family?

Assess the son for emotional trauma.

In a managed care environment, the nurse has an ethical responsibility to the pt. to:

Assume the role of the pt. advocate

One way an LVN can expand practice without becoming an RN is to:

Attain certification in a specific are, such as IV therapy.

A client experiences a cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?

Autocratic.

Which of the following instructions should a nurse provide a client with alcohol dependence who is prescribed disulfiram?

Avoid mixing disulfiram and alcohol.

In providing culturally competent care to clients, the home care nurse should assess health care practices. What should be included in the home care nurse's assessment? Select all that apply.

Barriers to health care -cultural practices -Health promotion behaviors -health care compliance -Education lvl

To develop a therapeutic relationship with an anxious client, the nurse looks for ways to build trust. What nursing intervention is most likely to help the nurse gain the clients trust?

Be available and attentive to the clients requirements.

The nurse is providing information about foot care to a client with diabetes. Which of the following would the nurse include?

Be sure to apply a moisturizer to feet daily.

It is important for a nurse not to argue about the validity of a schizophrenic client's delusions or try and convince him or her that they are wrong because clients may:

Become more fixated on their delusions.

While making a home visit, the nurse suspects that a child is experiencing psychological maltreatment. What did the nurse observe in the home?

Belittling the child in front os the nurse and other siblings.

A 43 yr old, physically fit, healthy woman who is newly married tells the nurse that she and her husband would like to have a child. What is an appropriate first response? -You must know that's pretty risky. Have you thought about adopting instead? -Well, I'm sure you know there are some risks involved so it's helpful that you've been taking such good care of yourself. - You're in great shape now, but are you sure that at your age you'll have enough energy to care for a child? -If you got pregnant now you'd be at risk for multiple fetal pregnancies, chromosomal abnormalities, spontaneous abortion, and hypertension among other things. Are you ready to take that risk?

Book says #2, Gene says #4.

Communication occurs when:

Both the sender and the receiver have understood the meaning of the communication.

When teaching a client with generalized anxiety disorder, the nurse instructs the client to avoid which of the following?

Caffeine

A client is scheduled to have her first pap test and asks the nurse why this test is necessary. The nurse should tell the client that this test is used to detect early cancer of the:

Cervix

A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed?

Check blood glucose.

Your client is a 72-yr-old male who has just undergone a transurethral resection of the prostate (TURP) and is returned to the nursing unit with a 3-way catheter for administering bladder irrigation. Your client c/o bladder discomfort and a feeling of urgency to void. Which nursing action is best to take first?

Check that the urinary drainage catheter is patent and not kinked.

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determine the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?

Check the identification badge of any health care worker before releasing baby from room.

Effective delegation involves which of the following? -

Clear identification of the needs of the delegated task

What changes if any, should the nurse expect in the dietary patterns of a client who is clinically depressed?

Client either overeats excessively or under eats with little nutritional input.

Which type of therapy assists the clients to alter their irrational thinking? -Psychopharmacology

Cognitive therapy

You have an employee that is always 5-10 minutes late. What should you do about it?

Collect all pertinent information with documentation and call him/her privately to give a verbal warning with consequences if he/she doesn't comply.

Which of the following is an important role of the nurse manager?

Coordinate the units activities and needs.

The nurse is caring for a victim of a chemical disaster. Medications given in the treatment of this client include amyl nitrate, sodium nitrite, and sodium thiosulphate. Which chemical agent does the nurse know this client has been exposed to?

Cyanide.

A postpartum client tells the nurse that she feels like crying for no apparent reason and is unable to sleep well. What should the nurse point out to the client that this may be related to?

Decreased progesterone lvls.

A nurse assigns an unlicensed assistive personnel (UAP) to take 2 Tylenol tablets to a pt. c/o a headache. In assigning this task the nurse is:

Delegating an inappropriate task to ancillary personnel.

When referred to a podiatrist, a client newly diagnosed with diabetes mellitus asks, "Why do you need to check my feet when I'm having a problem with my blood sugar?" The nurse's most helpful response to this statement is:

Diabetes can affect the sensation in your feet and you can hurt yourself without realizing it.

A controlled type 2 diabetic client states, "The doctor said if my blood sugars remain stable, I may not need to take any medication." Which response is most appropriate?

Diet, exercise, and weight loss can eliminate the need for medication.

The nurse is caring for a client who has recently lost a spouse. Which question asked by the nurse is essential in guarding the clients immune system?

Do you have friends and family to support you?

While the nurse is recording the health history of a client who is scheduled for a thyroid test, the client informs the nurse about an allergy to seafood. What is the nurse's most appropriate response?

Document the allergy and inform the physician.

Impaired balance and uncontrolled tremors of parkinson's disease is correlated with which neurotransmitter?

Dopamine

There are many things you can do to prepare for your job interview. Which of the following is critical to your success?

Dress in clothing that demonstrates a professional appearance.

Which action would the nurse include in a primary prevention program in the community to help reduce the incidence of HIV infection?

Educate clients on how to practice safe sex.

How can nurses help the nation achieve its 2020 national health goals related to violence in the family? Select all that apply.

Educate parents about effective parenting skills -Acute care and clinic nurses will identify victims of abuse. -Refer parents for counseling when under severe stress. -Report suspected abuse to the appropriate protective services.

A client at 27wks gestation still walks daily but reports "terrible" heartburn at night. Which action should the nurse point out will best address this situation?

Elevate the HOB.

In order to gain the cooperation of staff members, the manager asks for their input on pt. care and to share information regarding patient care. These actions are examples of doing what for the staff?

Empowerment

The nurse is working with a 12-yr-old who is hospitalized with a chronic illness. Which action by the nurse might help the chronically ill preteen thrive while hospitalized? -Encourage the client to wear his or her own clothes, talk to friends on the phone, and interact with other clients who have similar illnesses.

Encourage the client to wear his/her own clothes, talk to friends on the phone, and interact with other clients who have similar illnesses.

A culture indicates that your client has nonspecific urethritis from chlamydia Trachomatis, a sexually transmitted infection. Which nursing intervention is best to provide to the client to prevent a recurrence of the infection?

Encourage your sexual partners to be tested and treated.

A group of students is reviewing material about endocrine system function. The students demonstrate an understanding of the information when they identify which of the following as secreted by the adrenal medulla.?

Epinephrine

A pt is noted to be anemic. Which hormone will affect the development of RBCs in this pt?

Erythropoietin.

A client with bulimia nervosa tells a nurse she was doing well until last week when she had a fight with her father. Which nursing intervention would be most helpful?

Examining the relationship between feelings and eating.

What is a clinical manifestation of diabetes insipidus?

Excessive thirst.

A young client tells the nurse, "I have the best family in the world." When questioned about who is in the family, the client replies, "I have lots of people in my family... my mom, my dad, two brothers, grandma and grandpa, two uncles, two aunts, and three cousins." This client is describing which type of family?

Exteneded

A nurse is providing care to a client and actively involves the clients family members in the care planning and implementation, dealing with the client and family as a unit. The nurse is engaging in:

Family-centered care.

In which manner is the fetal status best assessed during the active and transition stages of labor?

Fetal heart rate at the peak of contraction.

The nursing instructor is teaching a class on the nutritional needs of the pregnant client. The instructor determines the session is successful when the students correctly choose which supplement as being known to prevent up to 70% of CNS birth defects? -Folic Acid

Folic Acid

The nurse is educating a couple who has had difficulty with conception. The client asks about the hormone, which is responsible for the production of eggs. The nurse answers that this hormone is called?

Follicle-Stimulating Hormone (FSH)

As part of the first prenatal visit, the nurse is assessing a pregnant woman's obstetrical history, which includes an 18-month old daughter, born 2 days after her estimated due date; a 3 yr old son born at 35wks, and two lost pregnancies, one at 12wks, and one at 21 wks. How should the nurse document the history?

G5 T1 P2 A1 L2

One role of the nurse in a community-based setting focuses on primary prevention. An example of primary prevention would be:

Giving an information session on bicycle safety in an after-school program.

The nurse is caring for a client with diabetes who has developed hypoglycemia. What can the nurse administer to the client to raise the blood sugar lvl?

Glucagon

When working in a long-term care facility, which one of the following actions would be considered unethical and is a HIPPA violation?

Going to the dementia unit and lookin at your neighbors chart.

The nurse is triaging victims during a mass casualty incident. The nurse uses which color tag for a victim whose care can be delayed.?

Green

A family in the second phase of divorce are actually separating and moving to new homes and perhaps new schools. The school-age children may experience which type of feeling at this phase in the divorce?

Grief for the missing parent.

The nurse is helping a family explore the various options available to provide health care for a child who will require medical assistance. The nurse will point out that individuals with which conditions can be safely cared for by qualified professionals in the home environment? Select all that apply.

HIV -Ventilator dependence -Postoperative orthopedic corrective surgery

The nurse is instructing an adolescent who is not sexually active on potential vaccinations available. Which vaccination would the nurse state that decreases the risk of cervical cancer? -Hep B -HPV -Herpes Zoster -Meningococcal

HPV

A woman delivered her infant 2 hrs ago and calls to tell the nurse that she needs to go to the bathroom. When the nurse arrives, the mother is getting -Have the client sit dangling her legs off the side of the bed for 5 minutes.

Have the client sit dangling her legs off the side of the bed for 5 minutes.

A client arrives at the mental health clinic. He had been ordered a tricyclic antidepressant about a month ago. The client states that he has been taking it correctly every day. What observation below would indicate that the client is actually taking the medication?

He arrives at the clinic on time for his appointment with a neat appearance and clean clothes.

The nurse is preparing to assess a toddler during a routine health maintenance visit. Which assessment will the nurse perform to determine the child's growth milestone?

Height and Weight.

The parents are bonding with their newborn when the nurse notes the infant's axillary temperature is 97.2 an hour after birth. Which intervention should the nurse prioritize for this family?

Help the mother provide skin-to-skin (kangaroo care).

The nurse is providing education via phone to a client who called stating that the newly prescribed imipramine(Tofranil) is not working as depression is still a problem. Which question is most important to ask first?

How long have you been taking the medication?

A nurse is preparing to discharge a client with coronary artery disease and HTN who is at risk for Type II DM. Which information is important to include in the discharge teaching?

How to control blood glucose through lifestyle modification with diet and exercise.

A home care nurse is visiting with a teenage client of home care during cancer treatments. Which statement by the clients mother warrants intervention by the home care nurse?

I don't let her drink too many fluids since the bathroom is downstairs.

Which statement by the child who is being bullied demonstrates appropriate behavior?

I will have a teacher accompany me to the bus so I am protected.

The nurse is assessing a client for potential 23-e. Which statement by the client indicated that they will be able to take a medication that is prescribed three times a day?

I will take one pill before breakfast, before lunch, and before dinner.

What statement by the mother of a preschooler indicates the need for further education by the nurse? -If food falls on the floor, my child should pick it up quickly and wipe it off before eating it.

If food falls on the floor, my child should pick it up quickly and wipe it off before eating it.

A client with Cushing syndrome is admitted to the hospital. During the initial assessment, the client tells the nurse, "The worst thing about this disease is how awful I look. I want to cry every time I look in the mirror." Which s

If treated successfully, the major physical changes will disappear with time.

Severe levels of anxiety can result in what?

Impaired ability to concentrate.

The nurse is relating health education to students when asked where sperm is actually made. Which location is most correct?

In the testes within the scrotum

A client who binges on alcohol during the weekends denies having an alcohol dependency problem. Which is the best understanding, by the nurse, in regards to binge drinking? -Drinking only on weekends does not constitute a dependency problem. -Binge drinking can lead to daily drinking so needs to be monitored. -Inability to control drinking is a sign of dependency. -Binge drinkers are social drinkers not alcoholics.

Inability to control drinking is a sign of dependency.

A nurse presenting an educational event for a local community group is addressing premenstrual syndrome (PMS). What treatment guideline should the nurse teach this group?

Increase the frequency and intensity of exercise.

A school nurse is visiting with a father who has custody of his children. Prior to this, the father provided child support for the children but had not been involved in the day-to-day raising of the kids. The father has never had to take children to school before. The priority diagnosis of the father during this conversation would include which potential effect on the change in his parenting role?

Ineffective role performance.

Anthrax is acquired by which method develops into the most severe form?

Inhalation

A single mother has been staying with her 8 month old daughter admitted for dehydration secondary to gastroenteritis. During the third hospital day, the exhausted mother states she would like to go home to shower and get clean clothes but does not want to leave her daughter. What would the best option for the nurse to say?

Inquire if another family member is available to stay in her absence.

The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize?

Instill 0.5% ophthalmic erythromycin.

A client is experiencing an increase in blood glucose lvls. The nurse understands that which of the following hormones would be important in lowering the clients blood glucose lvl?

Insulin.

Which condition is the most common cause of anemia in pregnancy? -iron-deficiency anemia

Iron-deficiency anemia.

The nurse understands that a single dose of azithromycin as treatment for a chlamydia infection is prescribed by the health care provider for what reason?

It can be administered to the client at the health care providers office.

The nurse is teaching a prenatal class on the functions of the various structures involved with a pregnancy., The nurse determines the class is successful when the class correctly chooses which function for amniotic fluid? -It helps cushion the baby. -

It helps to cushion the baby.

One week ago, the client was prescribed Buspirone for anxiety. The client phones the office and reports the medication has not eliminated the symptoms. Which is the best response by the nurse?

It may take up to 4 wks for full therapeutic response.

A nursing student asks the instructor why the pituitary gland is called the master gland. What is the best response by the instructor?

It regulates the function of other endocrine glands.

A resume should include:

Jobs that are relevant to the job for which you are applying or that use skills that could apply to this job.

What hormone causes the ovary to release an ovum during ovulation?

LH (Luteinizing Hormone)

During a visit to the prenatal clinic, a pregnant woman asks the nurse, "What causes labor to start?" Which response by the nurse would be appropriate? -

Labor starts from a combination of several maternal and fetal hormones working together.

Which comes first? -Management -Leadership -Organization -Participation

Leadership

A child who is immobile states, "I am sad because I cannot do what my friends do." which response by the nurse is appropriate?

Lets try to figure out how you can do more.

A nurse teaches a client with newly diagnosed hypothyroidism about the need for thyroid hormone replacement therapy to restore the normal thyroid function. Which thyroid preparation if the agent of choice for thyroid HRT?

Levothyroxine (Synthroid)

The nurse is interviewing a client with major depression. Which of the following statements by the client would most indicate to the nurse that the client is at risk for suicide?

Life has just lost it's meaning for me.

The nurse is caring for a small child who has been admitted with a diagnosis of abusive head trauma (shaken baby syndrome). Which condition or concern often occurs with shaken baby syndrome?

Loss of vision and intellectual disability.

An important part of assertiveness for a nurse is to recognize that he/she has limitations. What are components that enable him/her to function safely on the job?

Make sure that he/she is oriented adequately if he/she has to do something he/she hasn't done before.

Four clients injured in an automobile accident enter the emergency department at the same time. The triage nurse evaluates them immediately. The nurse should assign the highest priority to the client with the:

Maxillofacial injury and gurgling respirations.

The caregiver of a 2-yr-old child reports to the nurse that the child vomits at least 5-6 times a day, sometimes continuously. The child is admitted for observation and the caregiver continues to report the child is vomiting, but the nurses never see the child vomit or any evidence the child has vomited.

Medical child abuse (Formerly Munchausen Syndrome by proxy)

After teaching a group of adolescent girls about female reproductive development, the nurse determines that teaching was successful when the girls state that menarche is defined as a women's first:

Menstrual period.

A client is seeking help for new onset of acne, scratches over face and arms, poor dentition, and stained rotten teeth. Which substance should the nurse suspect the client is using?

Methamphetamine.

The skull is the most important factor in relation to the labor and birth processes. The fetal skull must be small enough to travel through the bony pelvis. What feature of the fetal skull helps make this passage possible?

Molding

A client who has attempted to quit smoking and failed two times before is reluctant to make another attempt. Which response by the nurse is most appropriate?

Most people who have tried and failed ultimately do succeed.

The nurse is caring for a boy who states that his mother is a psychologist while his father is unemployed. His mother is the one who reminds him to take his medicine and also comforts his sister when she cries. Analyzing this description of his parent's roles, you would conclude that his:

Mother is the provider and nurturer.

You are a new leader and you want to develop specialized skills for your job that include making a personal analysis of all problems, making proposals to your group based on theses analyses, inviting comments and criticisms from the group, but making the final decision yourself. What type of leader are you?

Multicratic (participative)

A nurse is caring for an older female client whose husband died 6 months ago. Which behavior by the client indicates ineffective coping?

Neglecting her personal grooming and refusing to take showers/baths.

Why is networking important for the novice nurse?

Networking is an effective way to let people known informally about the nurses' goals, concerns, or desires.

A new mother asks the nurse when she should begin caring for her baby's teeth. Which response os the most appropriate for the nurse to make at this time?

Now.

What are the primary components of medical management for anorexia nervosa? Select all that apply. -All answers are correct. -

Nutritional therapy -Drug therapy -psychotherapy -family counseling.

A pregnant client reports difficulty sleeping well. Which suggestion for sleeping should the nurse prioritize to assist this client?

On her side with the weight of the uterus on the bed.

A nurse is providing home care to several families who live in a community with limited resources. Which action is an example of how the nurse can best "nurse the community?"

Organize a free flu vaccination in the community.

A client has a dysfunction in one of his glands that is causing a decrease in the lvl of calcium in the blood. What gland should be evaluated for dysfunction?

Parathyroid Gland

A nurse has delegated several nursing tasks to staff members. The nurse's primary responsibility after the delegation of the tasks is to?

Perform follow up with each staff member regarding the performance of the task and the outcomes related to the implementation of the task.

An older adult pt. that has type II DM comes to the emergency department with second-degree burns to the bottom of both feet and states, "I didn't feel too hot but my feet must have been too close to the heater." What does the nurse understand is most likely the reason for the decrease in temperature sensation?

Peripheral neuropathy.

The client recounts to the nurse an instance of jumping onto the hood of a car to avoid an approaching dog, and reports feeling embarrassed by this reaction. The client discloses suffering from a severe dog bite in childhood. The nurse classifies this symptom as which of the following?

Phobic Disorder.

The nurse is taking a nursing history on a client who has come to the clinic with c/o fatigue, weight gain, and constipation. The client states" i'm just depressed. The nurse knows that before the health care provider institutes therapy, the client will receive a full physical assessment for what reason?

Physical conditions such as hypothyroidism can mimic the symptoms of depression.

A client seeks treatment for disturbed sleep cycles and depressed mood. Which glans and hormone are involved in regulating sleep cycles and mood?

Pineal gland; melatonin

The nurse is caring for a client in active labor who states, "I need to go to the bathroom to have a bowel movement, now." Which action should the nurse take first? -

Position the client for and perform a cervical assessment.

A client was in a plane crash a year ago and several people were killed. The client is now experiencing nightmares, insomnia, headaches, loss of appetite, and fatigue. Which disorder is the client most likely experiencing?

Post-traumatic stress disorder.

Assessment for surfactant lvl via lecithin/sphingomyelin (L/S) ratio in the amniotic fluid is a primary estimation of fetal maturity. The purpose of surfactant is to:

Prevent alveoli from collapsing on expiration.

A client presents with symptoms of menstrual difficulties and infertility. Which hormone is essential in the maintenance of the endometrium?

Progesterone

What hormone would the nurse say when the client inquires about what makes breast milk production?

Prolactin.

Licensing laws (Nurse Practice Act) regulate the practice of nursing to:

Protect the public from injury.

"A client visits the physician's office complaining of agitation, restlessness, and weight loss. The physical examination reveals exophthalmos, a classic sign of Graves' disease. Based on history and physical findings, the nurse suspects hyperthyroidism. Exophthalmos is characterized by:

Protruding eyes and a fixed stare

Exposure to gamma radiation can be decreased by completing which action?

Providing distance from radiation source.

What is illegal for a potential job to ask you in an interview?

Questions about your age, religion, and birthplace.

A mother tells the nurse that her toddler does not want to go to bed at night and keeps getting back up when she is put to bed. What recommendations would the nurse make to this mother to foster sleep in the toddler? -read the child a book in bed and take time to calm the child down before

Read the child a book in bed and take time to calm the child down before turning out the lights.

Following an explosion at a chemical plant, a nurse is triaging clients. One client has a penetrating abd. wound from a piece of shrapnel. What color coordinate would the nurse assign to this client?

Red

A client is admitted to an inpatient psychiatric unit for treatment of obsessive-compulsive symptoms. OCD is associated with:

Repetitive thoughts and recurring impulses.

A nurse just off orientation arrives at work and is told to float to the pediatric unit for the day because the unit is understaffed and needs another nurse. This nurse has never worked in the pediatric unit. Which of the following is the most appropriate response?

Report to the pediatric unit, request a 4hr orientation and identify tasks that he/she can safely perform.

The nurse is caring for an adult who was admitted for observation following an automobile accident. The client has several lacerations that were sutured in the emergency department and a fractures left leg that has been casted. The baseline V/S were BP 130/90, P 76, RR 16. One hr after arriving to your unit you note that his left pedal pulses were decreased and his repeat V/S were : BP 98/60, P 96, RR 22. Arrange the following steps in the proper order.

Reposition the leg and assess for pain Notify the physician of the changes Start an IV Give IV fluids Draw labs

A client in labor received an opioid close to the time of birth. At the time of the birth, the nurse will assess for which effect? -respiratory depression in the newborn

Respiratory depression in the newborn.

A nurse has been working with a bulimic college student to help control the eating disorder. Which recommendation by the nurse is most likely to be effective in helping the client control bulimia?

Restrict using the bathroom for at least 2 hrs after meals.

A group of nursing students are analyzing the various aspects of a family. At the end of the session the students correctly point out the family structure is illustrated best by which information?

Roles family members carry out.

The nurse is caring for a client who states he is not feeling very well. When asking the client for specific symptoms, the client is vague with details but does state feeling better when the sun is shining. With this information, the nurse would document which disorder as a possibility?

Seasonal Affective Disorder (SAD)

The nurse is assessing a client at her first prenatal visit and reports her LMP started December 1. Which date will the nurse predict for the EDD? -

September 8.

A nurse is interacting with a new mother whose infant is 6weeks old. The mother appears exhausted and anxious. Which of the following statements by the mother most indicates a potential risk for maltreatment of the child?

She cries all the time. I don't know what to do with her. She's just a bad baby, I guess.

A 16-yr-old girl has been diagnosed with gonorrhea and chlamydia and has been given a one-time IM dose of Rocephin and a prescription for doxycycline for 7 days to treat the chlamydia. Before leaving the clinic she asks the nurse "When can I be certain that I am no longer infectious?" The nurse correctly advises the client that she is still considered infectious until which time? -

She has negative cultures taken after being off antibiotics for at least 7 days.

A client with alcoholism has just completed a residential treatment program. What can this client reasonably expect?

She'll need ongoing support to remain abstinent.

The school nurse is aware that providing proper care involves cooperation from the adolescent. Which technique will the nurse prioritize to develop open communication with the adolescents?

Show interest in the adolescent and develop a rapport before asking questions.

A primigravida is 1cm dilated, in early latent labor, and interested in avoiding epidural anesthesia. After asking about which nonpharmacologic options for pain relief she can use at this time, which option(s) should the nurse point out to the client?

Simple breathing excersises -Effleurage -Walking and then using a birthing ball.

A 3-yr-old child is reverting to previous behavior and showing lvls of anxiety after his parents bring home his new baby sister. What advice given to the 3-

Spend some quality time alone with the older child.

The nurse is caring for a client who is being treated in the emergency department for a panic attack. Which of the following nursing interventions would be most appropriate? -

Stay with the client, emphasizing that he is safe and that you will remain with him.

A pregnant client is planning a vacation to a different state and questions the nurse concerning precautions. Which suggestion should the nurse prioritize for this client who will be traveling by automobile?

Stop and walk every 2 hrs.

A nurse explains to a client with thyroid disease that the thyroid gland normally produces?

T3, T4 (Thyroxine), and Calcitonin

The triage nurse receives a phone call from a client stating, "I was just raped and I need help. What should I do?" Which response by the nurse is a priority?

Tell me if you are in a safe location away from the assailant noe.

A client tells the nurse that drinking helps him cope with anxiety. Which response by the nurse would help the client view drinking more objectively?

Tell me what happened the last time you felt you were under a lot of stress and drinking to cope.

The nurse has completed assessing the vital signs of several clients who are form 36 to 48 hrs postpartum. For which set of vital signs should the nurse prioritize for interaction?

Temp: 98.6, HR 74, RR 16, BP 150/85.

A client with OCD describes all doorknobs as being contaminated with a variety of viruses. He cleans each knob 3 times with paper towels before use. Such behaviors allows the client to:

Temporarily reduce anxiety.

A teenage male client has not developed facial hair, a deeper voice, or other secondary sex characteristics. What hormone would the nurse expect would be checked for this client?

Testosterone

A nurse has performed disease prevention teaching with a client who has genital herpes. Which client behavior indicates that the teaching has been successful?

The client washes their hands before and after touching lesions.

An instructor is preparing a teaching plan for a group of students about reproductive structures and sexual arousal. Which female reproductive structure would the instructor include?

The clitoris

A client with bipolar disorder has been taking lithium, as prescribed, for the past 3 yrs. Today family members brought this client to the hospital because he hadn't slept, bathed, or changed clothes in 4 days. Had lost 10lbs in the past month, and woke the entire family at 4am with plans to fly them to Hawaii for a vacation. Based on this information, what may the nurse assume?

The lithium lvl should be measured before the client receives the next lithium dose.

A nurse is working with a child she suspects may be a victim of maltreatment in her home. Which combination of characteristics related to the parent, child and the circumstances would most strongly indicate the risk for maltreatment of this child? -The mother was maltreated as a child; the child was born prematurely; the father recently lost his job, -The father drinks occasionally; The child is an only child; the mother has been ill recently. -The mother is a former drug abuser; the child was born with a birth defect; the family is lower income. -The father cares for the child at home; the child was born by cesarean section; the mother works full time.

The mother was maltreated as a child; the child was born prematurely; the father recently lost his job.

A 4-yr-old is brought to the emergency department by a grandparent who states, "His father beat him with a belt, and he has marks all over his back." What responsibility does the nurse have to report this incident?

The nurse has the responsibility to report the incident as suspected child abuse.

Licensed nurses have the authority to delegate duties. What gives nurses this authority?

The nurse practice act

After a nurse has gathered information about potential jobs, what should be done with that information?

The nurse should keep an organized list of potential employers with other important information.

The nurse observes a nursing assistant assigned to a client who just returned from having a bronchoscopy. Which action by the nursing assistant would prompt the nurse to intervene?

The nursing assistant offer the client some water.

A group of nursing students are preparing a presentation depicting the fetal circulation. The instructor determines the presentation is successful when the students correctly illustrate which route for the ductus arteriosus? -The pulmonary artery to the aorta.

The pulmonary artery to the aorta.

A nurse is caring or a client with social phobia. Which statement is most accurate regarding clients with social phobia?

They avoid social situations.

The parent of a toddler observes the child play next to another child but not with the child. What should the nurse explain to the parent about this type of play bx? -This is parallel play and is expected

This is parallel play and its expected.

The nurse is caring for a client with an immunodeficiency disorder. Lab results show that the client does not have an adequate number of T lymphocytes needed to improve immune function. Which gland should be investigated for dysfunction?

Thymus

A group of nursing students are doing a presentation on hormones. What hormone would the presentation show regulates the metabolic rate and influences the growth and development of the body?

Thyroid Hormone

A client has a blood alcohol lvl that is double the legal limit for driving yet does not exhibit behaviors of intoxication. The nurse knows that this is due to which effect?

Tolerance

During the second stage of labor, a women is generally:

Turning inward to concentrate on body sensations.

The greatest percentage of people have which type of diabetes?

Type 2.

A group of nursing students are analyzing the fetal circulation. After the session, the students correctly point out which fetal structure contains the highest concentration of oxygen? -Umbilical artery

Umbilical artery.

A client is being admitted for suspected toxic shock syndrome (TSS). Which of the following would be the most important for the nurse to determine?

Use of super absorbent tampons.

A client is in the third stage of labor. Which finding alerts the nurse that the placenta is separating?

Uterus becomes globular.

The nurse is caring for a client who has remained in stable condition at 37 wks gestation. The clients condition suddenly changes. Which assessment change should the nurse prioritize? -vaginal bleeding and no pain

Vaginal bleeding and no pain.

The nurse is completing discharge teaching with a client with hyperthyroidism who has been treated with radioactive iodine at an outpatient clinic. The nurse instructs the client to:

Watch for symptoms of hypothyroidism.

The nurse is caring for a male patient with gonorrhea. The pt. asks how he can reduce his risk of contracting another STI. The nurse should instruct the patient to do which of the following?

Wear a condom every time he has intercourse.

The nurse is instructing a couple in the early stages of infertility testing who has just found that the male has a slightly low sperm count. Which easy change can a nurse suggest to a male client?

Wear loose fitting underwear instead of tight ones.

A client with newly diagnosed type 2 diabetes is admitted to the metabolic unit. The primary goal for this admission is education. Which goal should the

Weight reduction through diet and exercise.

If a known substance abuser presents to the emergency department with tachycardia and chest pain, what is the most appropriate question for the nurse to ask?

When did you last use cocaine?

The client who has recently stopped smoking, is irritable and complaining of feeling hungry. The nurse would interpret this as which of the following?

Withdrawal.

Why is it important to be involve in local, state, or national organizations that support your profession?

You can become aware of laws and practices that affect your practice.

A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct?

You should not lift anything heavier than your infant in its carrier.

The nurse educator is planning a health promotion class with a focus on sexually transmitted infection. What points regarding risk factors for chlamydia and gonorrhea should the nurse educator include? Select all that apply.

Your chances of contracting these infections are higher the more sexual partners you have. -Young adults and teenagers are a high risk age group for both these infections.

A mother has come to meet with local school officials regarding admission of her child with spina bifida. The child requires catheterizations several times a day and the mother is requesting information on admission of the child for school and what accommodations can be made for the child's health care needs. What is the best response to the mother?

Your child may be mainstreamed into a regular classroom and assisted with catheterizations by the school nurse.

Who should be the first person you inform of termination of your employment?

Your nurse manager/boss.

The maternal health nurse is caring for a pregnant client with pre-existing heart disease. Which concept will the nurse identify as a priority?

balancing weight gain.

During a facility disaster drill, an 'injured client' presents to the emergency department with c//o dry mouth, inability yo focus his vision, and double vision. A nurse notes that the client has an unsteady gait and appears to be very weak. The client states, "My arms and legs feel like they just can't move." A nurse suspects the client may be a victim of bioterrorism with:

botulism

The school nurse observes an elementary school child arriving in the winter in shorts and a short sleeved shirt with no coat. The nurse would consider this as which type of abuse?

neglect

The pediatric nurse is aware that chronic illness can affect which of the following -

physical development -psychosocial development -cognitive development

ADH is secreted by which gland?

posterior pituitary gland

A 6-yr-old is brought to the emergency department numerous times over 3 months with the same symptoms of gastric upset and nightmares. The child acts very hostile with the nurses while there. What should the nurse suspect?

sexual abuse

Because of high divorce rates and separations in recent yrs, there has been a significant increase in the family structure termed:

single-parent

When preparing for an emergency bioterrorism drill, the nurse instructs the drill volunteers that each biological agent requires specific client management and medications to combat the virus, bacteria, or toxin. Which statement reflects the client management of variola virus (smallpox)?

smallpox spreads rapidly and requires immediate isolation.