course point question a-d

A nurse is assessing a client brought to the emergency room by his daughter. Which statement by the daughter would most likely lead the nurse to suspect that the client may have an infection?

All of a sudden my dad seemed to become confused."

Which of the following could be a possible cause of cyanosis?

Low tissue oxygenation

A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client's home environment, the nurse should focus on which nursing diagnosis?

Risk for injury

In which position would a client undergoing a lumbar puncture be placed?

Side-lying, knees to chest

Scabies are spread by which type of transmission?

Skin-to-skin contact

A client reports chest pain and palpitations during and after jogging in the mornings. The client's family history reveals a history of coronary artery disease (CAD). What should the nurse recommend to minimize cardiac risk?

Smoking cessation

A client is admitted with a gastrointestinal bleed. What client symptom may indicate a peptic ulcer perforation to the nurse?

Sudden, severe upper abdominal pain

Which of the following actions helps the nurse to determine the quality of the skin turgor?

Grasping the skin

A young baseball player was fielding a ground ball when it bounced and struck the player in the left eye, leaving a large ecchymosis and edema. In client education, after applying an ice pack, the nurse explains the functions of the various structures of the eye. What glands, contained in the eyelids, produce tears?

lacrimal

Which characteristic is a risk factor for colorectal cancer?

polyps

Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention?

. oxygen saturation of 82%

A client who has suffered a compound fracture is preparing for discharge to home. During the teaching session, the client asks why he needs antibiotics for a broken bone. Which response by the nurse is most appropriate?

"Antibiotic therapy has been prescribed as a precaution because your bone was exposed to the environment at the time of your injury."

A young female client smokes two packs of cigarettes and drinks a six-pack of beer each day. The nurse is attempting to teach the client about smoking cessation and decreasing alcohol intake. The client states, "My grandmother lived to be in her 90s, and she smoked and drank. I come from good genes." What is the most appropriate statement the nurse can make in response?

"Certain illnesses can be traced to common risk factors and can be prevented."

A nurse is teaching a client with osteoporosis about dietary selections. What client statement indicates the teaching was effective?

"I will eat more dairy products to increase my calcium intake."

The nurse is completing a preoperative assessment. The nurse notices the client is tearful and constantly wringing their hands. The client states, "I'm really nervous about this surgery. Do you think it will be ok?" What is the nurse's best response?

"What are your concerns?"

A client tells the nurse that she will be researching an alternative method of treatment for her disease. What is the most appropriate response by the nurse?

"You are within your right to search for other methods of treatment. Just be sure to inform your physician what treatments you are using."

The nurse is assigned to a client admitted with advanced Parkinson's disease. What type of gait correlates with Parkinson's disease?

- shuffling

The nurse is establishing a visual test using the Snellen chart for a client experiencing visual changes. At which distance should the nurse instruct the client to stand?

A 20-feet distance

A nurse is caring for a client with a cardiac disorder who is prescribed diuretics. What important factor should the nurse include in this client's teaching plan?

A discussion of the signs and symptoms of electrolyte and water loss.

The nurse is providing education about angina pectoris to a hospitalized client who is about to be discharged. What instruction does the nurse include about managing this condition? Select all that apply.

A. Balance rest with activity. B. Carry nitroglycerin at all times. C. Stop smoking.

Which term refers to chest pain brought on by physical or emotional stress and relieved by rest or medication?

Angina pectoris

Which diagnostic test would be used if a malignancy is suspected?

Biopsy

The nurse is assessing a client with a bleeding gastric ulcer. When examining the client's stool, which characteristic would the nurse be most likely to find?

Black and tarry appearance

Which common problem of the upper extremity results from entrapment of the median nerve at the wrist?

Carpal tunnel syndrome

A client has just been diagnosed with prehypertension. What would the nurse instruct this client to do to restore blood pressure below hypertensive levels?

Decrease sodium intake.

When teaching a client about hypertension and lifestyle changes what does the nurse emphasizes should be included in the diet?

Fresh fruits and vegetables

A client with venous insufficiency is instructed to exercise, apply elastic stockings, and elevate the extremities. Which is the primary benefit for this nursing management regime?

Improve venous return

A client is reporting problems with constipation. What dietary suggestion can the nurse inform the client may help facilitate the passage of stool?

Increase dietary fiber.

A client is in Buck's traction after fracturing his right hip. The nurse should include which action in the care plan?

Maintaining correct body alignment

The nurse is conducting a health history of a preoperative client. The client shares that she experienced vaginal itching and burning and labial swelling after her partner tried a new brand of condoms. The nurse suspects that the client:

May have a latex allergy.

During an initial assessment, the nurse notes a symptom of a mild case of bacterial conjunctivitis and documents in the electronic medical record that the client is displaying which of the following ?

Mucopurulent ocular discharge

A nurse is teaching a community class about how to decrease the risk of cancer. Which food should the nurse recommend?

Oranges

A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention?

Oxygen saturation (SaO2) of 85%

Medical management of cardiac failure uses similar methodology whether it is right-sided or left-sided. Measures such as dietary modification, lifestyle changes, medications to reduce dyspnea and relieve anxiety, etc. are all used with one primary intention. The primary goal in the medical management of heart failure is to reduce:

Reducing cardiac workload

Since normal aging results in changes in cognition, how should the nurse teach an elderly patient to administer insulin?

Repeat the information frequently for reinforcement.

A nurse is teaching a client taking digoxin about checking the pulse rate daily. The client counts her radial pulse as 64 beats/min. The nurse counts at the same time and assesses the rate as 58 beats/min. When evaluating response to treatment, the nurse would chart that the client

Requires another opportunity for practice

The nurse teaches the client who demonstrates herpes zoster (shingles) that

The infection results from reactivation of the chickenpox virus.

A nurse is caring for a client who had a three-vessel coronary bypass graft 4 days earlier. The client's cholesterol profile is as follows: total cholesterol 265 mg/dl, low-density lipoprotein (LDL) 139 mg/dl, and high-density lipoprotein (HDL) 32 mg/dl. The client asks the nurse how to lower his cholesterol. What is the best response by the nurse?

The nurse will ask the dietitian to talk with the client about modifying the diet.

Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective?

Vital signs within normal limits; absence of chills and cough

The nurse is evaluating care provided to a client with hemiplegia. Which client statement indicates that care has been effective?

can put on socks by advice help- independently

A registered nurse who is responsible for coordinating and documenting client care in the operating room is a

circulating nurse.

What is a modifiable risk factor for the development of atherosclerosis?

consumption of a high-fat diet ?

A client has a fractured femur and is being seen in the emergency department. The nurse assessing the area notices there is a grating sound that is suspected to be bone ends moving over one another. This would be called:

crepitus.

A nurse is interviewing a client about past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?

d. Polyps

Which condition is characterized by a decline in intellectual functioning?

dementia

A patient is admitted with suspected cardiomyopathy. What diagnostic test will the nurse need to teach the client about for identification of this disease?

echocardiogram

The nurse is transitioning to a home health setting. What factor has resulted in a shift in the health care delivery setting?

growing number of elderly clients

A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following?

hypoxia

The nurse is caring for a patient with Parkinson's disease and is preparing to administer medication. What does the nurse administer to the patient that is considered the most effective drug currently given for the tremor of Parkinson's?

levodopa

At a public health fair, a nurse teaches a group of women about breast cancer awareness. Possible signs of breast cancer include:

nipple discharge and a breast nodule.

Primary prevention of osteoporosis includes:

optimal calcium intake and estrogen replacement therapy.

A nurse who works in an oncology practice prepares patients for the side effects of adjuvant hormonal therapy to treat breast cancer. Which of the following is the hormonal agent that has an increased risk of pulmonary embolism and deep vein thrombosis?

patients for the side effects of adjuvant hormonal therapy to treat breast cancer. Which of the following is a hormone agent that has him increased risk of pulmonary embolism and deep vein thrombosis? Tamoxifen

The nurse is planning care for a group of assigned clients. Which client will the nurse expect to need an assistive device to perform self-care activities over the long term?

stroke pt

The nursing student says to the instructor. " I always hear about critical thinking and how to develop it. How will this benefit me as a nurse?" What is the best response by the instructor? A. If you have critical thinking skills, you wont make mistakes B. You will never make it through nursing school without those skills C. Without good critical thinking skills, you wont be able to make a decision D. Acquiring critical thinking skills will help you become more efficient and effective at resolving problems

Acquiring critical thinking skills will help you become more efficient and effective at resolving problems.

You are caring for a client with shock. You are concerned about hypoxemia and metabolic acidosis with your client. What finding should you analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?

Arterial blood gas (ABG) findings

A nonverbal client has just finished undergoing a bronchoscopy procedure and writes that he want to eat lunch now. Which intervention is necessary for the nurse to complete at this time?

Assess for a cough reflex.

A health care team is involved in caring for a client with advanced Alzheimer's disease. During a team conference, a newly hired nurse indicates that she has never cared for a client with advanced Alzheimer's disease. Which key point about the disease should the charge nurse include when teaching this nurse?

Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment.

The nurse recommends which type of therapeutic bath for its antipruritic action?

Colloidal (oatmeal)

A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?

Cough or change in chronic cough

The nurse is caring for a client with the diagnosis of colon cancer with metastasis to the liver. Which statement made by the client indicates an understanding of the diagnosis?

D) "My cancer has now spread to my liver."

A nurse is teaching a client who will soon be discharged with a prescription for warfarin (Coumadin). Which statement should the nurse include in discharge teaching?

Don't take aspirin while you're taking warfarin."

A client with Parkinson's disease has been receiving levodopa as treatment for the past 7 years. The client comes to the facility for an evaluation and the nurse observes facial grimacing, head bobbing, and smacking movements. The nurse interprets these findings as which of the following?

Dyskinesia

A nurse educator is providing information about hypertension to a small group of clients. A participant asks "What can I do to decrease my blood pressure and thus my risk for heart problems?" The nurse describes modifiable and nonmodifiable risk factors. Which of the following risk factors can the client modify?

Dyslipidemia

The nurse has assessed a client's superficial fungal infection that began in the skin between the toes and has spread to the soles of the feet. How would the nurse document this finding?

Tinea pedis

Which of the following superficial fungal infections begins in the skin between the toes and spreads to the soles of the feet?

Tinea pedis

Which instruction should a nurse provide a client with a history of rheumatic fever before the client has any dental work done?

To take prophylactic antibiotics

The nurse determines that a client would benefit from changing a lifestyle factor that adversely affects health. Which statement indicates to the nurse that the client takes responsibility for the health problem created by the lifestyle factor?

a. "It doesn't mean that you'll get the disease, just that the odds are greater for you."

A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be obtained from the right arm, and the client's left arm and hand should be elevated as much as possible to prevent which condition?

a. Lymphedema

Discharge planning begins during which portion of a client's hospital stay?

admission

The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of

anemia.

A client taking metronidazole for the treatment of H. pylori states that the medication is causing nausea. What teaching should the nurse provide to the client to alleviate the nausea?

Take the medication with meals to decrease the nausea.

A nurse who works in the oncology practice prepares patients for the side effects of adjuvant hormonal therapy to treat breast cancer. Which of the following is a hormone agent that has him increased risk of pulmonary embolism and deep vein thrombosis?

Tamoxifen

After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/mm3. What term should the nurse use to describe this low platelet count?

Thrombocytopenia

Goal of OSHA

To ensure the employers have safe work environments for employees.

A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing?

Turn the client to the side during a seizure and do not restrain movements

A client presents to the emergency department with complaints of acute GI distress, bloody diarrhea, weight loss, and fever. Which condition in the family history is most pertinent to the client's current health problem?

Ulcerative colitis

A nurse is performing a skin assessment and observes symmetrical patchy, milky white spots bilaterally. The nurse interprets these lesions as suggesting which of the following?

Vitiligo

The nurse is teaching the client to instill eye drops. Which statement is correct?

Wash your hands before and after instilling eye drops and do not touch the tip of the bottle.

Which nursing assessment finding would be indicative of compartment syndrome in the client with a cast applied to the left forearm 3 hours earlier?

Capillary refill of left fingers greater than 3 seconds

A patient's skin is examined and the nurse notes the presence of herpes simplex/zoster skin lesions. The nurse describes the lesions as:

Circumscribed and elevated masses >0.5 cm. Pus-filled vesicles; circumscribed and elevated masses >0.5 cm.

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?

Face the client and establish eye contact.

The nurse is aware that loss of consciousness occurs with which type of anesthesia?

General anesthesia

An elderly client who lives in a retirement community has been having a mild depressive episode over the past few weeks. What should the nurse recommend for the client?

Participation in a social activity

The emergency department nurse teaches clients with sports injuries to remember the acronym PRICE. This acronym stands for which combination of treatments?

Protection, rest, ice, compression, elevation

A hospitalized client with heart failure puts on the call light and states, "I've become very short of breath, and I've been coughing up this pink frothy sputum." The nurse immediately suspects which of the following complications?

Pulmonary edema

A client sprains an ankle while playing tennis and is brought to the emergency department. What is the priority action by the nurse?

Rest, ice, compression, and elevation

The nurse is educating the patient about administering nitroglycerin prior to discharge from the hospital. What information should the nurse include in the instructions?

Take a nitroglycerin and repeat every 5 minutes if the pain is not relieved until a total of 3 are taken. If pain is not relieved, activate the emergency medical system.

The nurse is caring for a patient admitted to the hospital with a brain abscess that developed from an untreated case of otitis media. What assessment data is a priority to alert the nurse to changes in intracranial pressure?

level of consciousness

When providing education to the patient with a chronic illness, what is a priority intervention for the nurse to perform?

Adapt teaching strategies and materials to the individual patient.

A client was playing softball and was hit in the right ankle by the ball sustaining a contusion. What is the first action taken to help alleviate pain and swelling?

Apply a cold pack to the ankle.

A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. Which nursing action is the first priority?

Applying a sterile, moist dressing

The nurse is providing teaching to a client with a mild case of bunions. Which suggestion would be most important for the nurse to give this client?

Don proper footwear.

A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client's diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing?

Help the client sit upright when eating and feed slowly

A client with vitamin D deficiency is receiving education from the nurse. What would be an appropriate recommendation by the nurse? Promote intake of clear fluids. Spend time outdoors at least twice per week. Increase intake of leafy green vegetables. Eat red meat at least once per week.

Increase intake of leafy green vegetables.

A nurse is developing a nursing care plan for a client with peripheral arterial disease. Which of the following will be the priority nursing diagnosis?

Ineffective peripheral tissue perfusion

Which of the following is the most common complaint related to a diagnosis of head lice?

Itching

A client has been diagnosed with liver disease. The nurse would expect which skin variation?

Jaundice

A nurse is conducting a health assessment and interviewing a patient. Which of the following would be MOST appropriate for the nurse to do?

Listen carefully to patient responses

The nurse is caring for an elderly client who has a large unhealed sacral wound. The client is thin and malnourished. The client informs the nurse that today, (the client) must fast due to religious reasons. The nurse is aware that the client requires good nutrition and extra protein to heal. Which of the following would be the best way for the nurse to respond to the client?

"In order for your wound to heal, you need to eat, but I will respect your decision."

A nurse is performing discharge teaching for an elderly client diagnosed with osteoporosis. Which statement about home safety should the nurse include?

"Most falls among the elderly occur in the home. These clients should remove throw rugs and install bathroom grab bars."

The public health nurse is presenting a workshop on hypertension for the Parent Teacher Organization of the local elementary school. A parent asks the nurse who is at risk for hypertension. What would be the nurse's best answer?

"People at highest risk for hypertension include those with diabetes."

A nurse is caring for a client who is recovering from a myocardial infarction (MI). The cardiologist refers the client to cardiac rehabilitation. Which statement by the client indicates an understanding of cardiac rehabilitation?

"Rehabilitation will help me function as well as I physically can."

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement?

"TIA is a warning sign. Let's talk about lowering your risks."

A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) immediately following confirmed diagnosis of acute myocardial infarction. The client is overtly anxious and crying. Which response by the nurse is most appropriate?

"Tell me what concerns you most."

The RICE acronym is helpful for remembering treatment interventions for musculoskeletal injuries. Which of the following are components of the RICE acronym? Select all that apply.

-Rest-Ice-Compression-Elevation

An older adult female has a bone density test that reveals severe osteoporosis. What does the nurse understand can be a problem for this client due to the decrease in bone mass and density?

Compression fractures

Which statement provides accurate information regarding cancer of the colon and rectum?

Colorectal cancer is the third most common site of cancer in the United States.

Which component of the nursing process results in the determination of a client's responses to nursing interventions and the extent to which outcomes have been achieved?

Evaluation

Health teaching for a patient diagnosed with Raynaud's phenomenon would include advising the patient to avoid the most common factor known to trigger episodes. Which of the following is the most common factor?

Cold and stress

The nurse is conducting a community education program using the American Cancer Society's colorectal screening and prevention guidelines. The nurse determines that the participants understand the teaching when they identify that people over the age of 50 should have which screening test every 10 years?

Colonoscopy

The nurse has come on shift to find that a client newly admitted to the ICU is confused and persistently trying to get out of bed despite being comforted and re-oriented by the nurse. The client begins to pull on the peripheral intravenous line in the hand and speaking in non-sensical terms. The client's history indicates a sudden onset of neurological symptoms after developing a bacterial infection. The nurse anticipates providing care for which health problem?

Delirium

A nurse is caring for a client who was admitted yesterday with myocarditis. The client takes insulin, digoxin, and metformin at home and continues these medications during hospitalization. During the morning assessment, the client reports anorexia, nausea, vomiting, headache, and disturbed color vision. An ECG strip shows a prolonged PR interval. What should the nurse suspect?

Digoxin toxicity

A patient suffering a stroke is having a difficult time swallowing. What would the nurse document this finding as?

Dysphagia

A nurse is inspecting the area of contusion and notes numerous areas of bruising. How would the nurse document this finding?

Ecchymosis

In which instance may a surgeon operate without informed consent?

Emergency situations

The nurse is caring for a client at risk for thrombosis. What is an appropriate nursing action when evaluating this client?

Examine the legs for color, capillary refill time, and tissue integrity.

A nurse is caring for a client with left-sided heart failure. What should the nurse anticipate using to reduce fluid volume excess?

Experiences exertional dyspnea when waling 3 feet states, "I cannot catch my breath."

Which particular area(s) should be examined to assess peripheral edema?

Feet, ankles

During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign?

Fluid retention

The nurse is caring for a patient who speaks only Spanish. To facilitate communication, which of the following is an appropriate action by the nurse?

Follow the agency's policies to obtain an interpreter.

A surgeon and nurse meet with their client to discuss knee replacement surgery, potential risks and benefits, the expected outcome, and consequences if the surgery is delayed or not performed. After listening and asking a few questions, the client signs a form indicating agreement to the surgery. What does the client's signature on the form represent?

Informed consent - know all you need to know about informed consent (purpose, role of nurses and surgeon).

During the admission history the client reports to the nurse of taking the usual dose of warfarin the previous day. What is an appropriate nursing action?

Notify the surgeon that the client took warfarin the day before surgery.

A nurse developed a program of increased ambulation for a patient with an orthopedic disorder. This goal setting is a component of the nursing process known as:

Planning

The nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand that bleed when picked off. What does the nurse suspect that this patient may have?

Psoriasis

When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe?

Red, swollen skin with inflammation spreading to surrounding tissues.

A nurse is practicing 730witCaring for Clients With Ear Disordershin a pediatric medicine group. What can the nurse do to maintain hearing within the pediatric client base?

Reduce frequency and severity of ear infections.

A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care?

Test all stools for occult blood.

Which act mandates that people with disabilities have access to job opportunities and to the community?

The Americans with Disabilities Act (ADA)

A client has constant pain and peripheral neuropathy following chemotherapy for cancer. The nurse assesses the following behavior as a common characteristic of a person with a chronic illness:

The client stops taking some medications due to side effects that are disturbing to the client

A client at an extended-care facility who has Alzheimer's disease is awake throughout the night. The nurse intervenes with activities that will promote sleep at night, which include

Walking the client in the facility yard during the day

The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?

Withhold the medication and notify the physician of the heart rate.

A middle-aged female client is overweight and sedentary, has slightly elevated blood pressure, and is seeking ways to begin exercise. The client wishes to lose weight and improve her blood pressure. The nurse plans an exercise program in which the client

b) Walks for 30 minutes three times this week and is re-evaluated

The nurse is collecting the history of a client diagnosed with a cataract and is performing a focused assessment. Which finding should the nurse anticipate?

blurred vision white pupils

A nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society guidelines, the nurse should recommend that the women:

have a mammogram annually.

Which of the following is the goal of patient and family education?

improve pt

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

pH, 7.25; PaCO2 50 mm Hg in respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 7.5 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. A ph value of 7.40 with a PaCO2 value of 35 mm Hg and a pH value of 7.35 with a PaCO2 value of 40 mm Hg represent normal ABG values, reflecting normal gas exchange in the lungs.

The nurse in an intensive care unit is caring for a client who requires blood work to assess for changes in blood coagulation due to heparin therapy. Which test should the nurse expect to see prescribed for this value to be assessed?

ptt

Which of the following would be a characteristic of a chronic illness?

slow, non curable, causes defecits later

A public health nurse administers influenza vaccines to a group of individuals during a community vaccination clinic. The nurse understands that this action is considered primary prevention due to which statement?

the vaccination focuses on health promotion and prevention of illness

Nurses assist clients to make knowledgeable choices about their health care by

understand all treatment option for pt to make his tx

A client is admitted to the hospital with an exacerbation of chronic gastritis. When assessing the client's nutritional status, the nurse should expect to find what type of deficiency?

vitamin B12