Exam 2 Rotating Case Studies

In addition to developing over a period of hours or days, the nurse should assess delirium as distinguishable by which of the following characteristics? 1. Disturbances in cognition and consciousness that fluctuate during the day. 2. The failure to identify objects despite intact sensory functions. 3. Significant impairment in social or occupational functioning over time. 4. Memory impairment to the degree of being called amnesia.

1

The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is: A) Normal B) Indicates the presence of infection C) Indicates the need for increasing oral fluids D) Indicates the need for increasing ambulation

B

The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as: A) delusions. B) hallucinations. C) loose associations. D) neologisms.

B

A 4-year old female client is brought to the emergency room after waking up with bark-like cough and stridor. On arrival to the ER, she has respiratory distress and is afebrile. The diagnosis is croup. What instruction should you give the parents? a) perform percussion and postural drainage before putting the child to bed and before meals b) run a cool mist vaporizer in patient's room during the day c) encourage the child to do coughing and deep breathing exercises d) bring the child to the bathroom and have the tap run with warm water during acute episodes of cough

B

A nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On admission assessment, which data would the nurse expect to obtain when asking the mother about the child's symptoms? a) watery diarrhea b) projectile vomiting c) increased urine output d) vomiting large amounts of bile

B

The child with croup is in a mist tent. Which of the following toys will be appropriate for the child? a) stuffed toys b) drawing book c) plastic ball d) coloring book

C

A client with persistent, severe schizophrenia has been treated with phenothiazines for the past 17 years. Now the client's speech is garbled as a result of drug-induced rhythmic tongue protrusion. What is another name for this extrapyramidal symptom? A) Dystonia B) Akathisia C) Pseudoparkinsonism D) Tardive dyskinesia

D

A patient who overdosed on oxycodone is given naloxone. When assessing the patient, the healthcare provider would anticipate which of these clinical manifestations of opioid withdrawal? A) Hyperthermia and euphoria B) Depressed respirations and somnolence C) Bradycardia and hyporthermia D) Irritability and nausea

D

A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F. Which of the following actions would be most appropriate? A) Retake the temperature in 15 minutes B) Notify the physician C) Document the findings D) Increase hydration by encouraging oral fluids

D

A student nurse was asked which of the following best describes dementia. Which of the following best describes the condition? A) Memory loss occurring as part of the natural consequence of aging B) Difficulty coping with physical and psychological change C) Severe cognitive impairment that occurs rapidly D) Loss of cognitive abilities, impairing ability to perform activities of daily living

D

After expulsion of the placenta in a client who has six living children, an infusion of lactated ringer's solution with 10 units of pitocin is ordered. The nurse understands that this is indicated for this client because: A) She had a precipitate birth B) This was an extramural birth C) Retained placental fragments must be expelled D) Multigravidas are at increased risk for uterine atony

D

A client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 1 qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition? A. Vomiting, diarrhea, and bradycardia B. Dehydration, temperature above 101° F (38.3° C), and pruritus C. Hypertension, diaphoresis, and seizures D. Diaphoresis, tremors, and nervousnes

D

A 71-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. variable ability to perform simple tasks. c. difficulty eating and swallowing. d. loss of recent and long-term memory.

D

A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia? a. The patient is disoriented to place and time but oriented to person. b. The patient has a history of increasing confusion over several years. c. The patient's speech is fragmented and incoherent. d. The patient was oriented and alert when admitted.

D

Nurse reinforces instructions to mother of a child who has been hospitalized w/croup. Which of following statements by mom would indicate further instruction?

I will give my child cough syrup if a cough develops

A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? a.) Evaluate urine specific gravity b.) Anticipate treatment for renal failure c.) Provide emollients to the skin to prevent breakdown d.) Slow down the IV fluids and notify the physician

a.) Evaluate urine specific gravity Rationale: Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There's no evidence that the client is experiencing renal failure. Providing emollients to prevent skin breakdown is important, but doesn't need to be performed immediately. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? a.) Complete set of vital signs b.) Palpation and auscultation of the abdomen c.) Brief neurologic assessment d.) Initiation of pulse oximetry

c.) Brief neurologic assessment Rationale: A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are considered part of the secondary survey.

A nurse is admitting a client who has been diagnosed with PTSD. Which of the following symptoms might the nurse expect to assess? (Select all that apply.) 1. Feelings of guilt that precipitate social isolation 2. Aggressive behavior that affects job performance 3. Relationship problems 4. High levels of anxiety 5. Escalating symptoms lasting less than one month

1, 2, 3, 4

A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate (Prolixin Decanoate) by I.M. injection. Three days later, the client has muscle contractions that contort the neck. This client is exhibiting which extrapyramidal reaction? A) Dystonia B) Akinesia C) Akathisia D) Tardive dyskinesia

A

A client with paranoid schizophrenia is admitted to the psychiatric unit of a hospital. Nursing assessment should include careful observation of the client's: A) thinking, perceiving, and decision-making skills. B) verbal and nonverbal communication processes. C) affect and behavior. D) psychomotor activity.

A

A client with schizophrenia who receives fluphenazine (Prolixin) develops pseudoparkinsonism and akinesia. What drug would the nurse administer to minimize extrapyramidal symptoms? A) benztropine (Cogentin) B) dantrolene (Dantrium) C) clonazepam (Klonopin) D) diazepam (Valium)

A

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which of the following nursing interventions would be most appropriate initially? A) Massage the fundus until it is firm B) Elevate the mothers legs C) Push on the uterus to assist in expressing clots D) Encourage the mother to void

A

After taking chlorpromazine (Thorazine) for 1 month, a client presents to an emergency department (ED) with severe muscle rigidity, tachycardia, and a temperature of 105oF (40.5C). The nurse expects the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome and treat by discontinuing Thorazine and administering dantrolene (Dantrium) B. Neuroleptic malignant syndrome and treat by increasing Thorazine dosage and administering an antianxiety medication C. Dystonia and treat by administering trihexyphenidyl (Artane) D. Dystonia and treat by administering bromocriptine (Parlodel)

A

An 8-month-old infant is admitted to the pediatric unit with a respiratory syncytial virus (RSV) infection and bronchiolitis. During the admission assessment, which of these signs should the healthcare provider recognize as an early sign of respiratory distress? A) Tachycardia B) Anxiety C) Nasal flaring D) Intercostal retractions

A

If clozapine (Clozaril) therapy is being considered, the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life-threatening side effect? A. White blood cell count B. Liver function studies C. Creatinine clearance D. Blood urea nitrogen

A

If continued bleeding occurs during the third stage with a contracted uterus, the cause is most likely to be: A) Cervical and perineal Lacerations B) Placental abruption C) Uterine atony D) Cervical Polyp

A

Methergine or pitocin are prescribed for a client with PP hemorrhage. Before administering the medication(s), the nurse contacts the health provider who prescribed the medication(s) in which of the following conditions is documented in the client's medical history? A) Peripheral vascular disease B) Hypothyroidism C) Hypotension D) Type 1 diabetes

A

Nurse Dorothy is evaluating care of a client with schizophrenia, the nurse should keep which point in mind? A) Frequent reassessment is needed and is based on the client's response to treatment. B) The family does not need to be included in the care because the client is an adult. C) The client is too ill to learn about his illness. D) Relapse is not an issue for a client with schizophrenia.

A

Positive symptoms of schizophrenia include which of the following? A) Hallucinations, delusions, and disorganized thinking B) Somatic delusions, echolalia, and a flat affect C) Waxy flexibility, alogia, and apathy D) Flat affect, avolition, and anhedonia

A

Which assessment finding is most consistent with early alcohol withdrawal? A. Heart rate of 120 to 140 beats/minute B. Heart rate of 50 to 60 beats/minute C. Blood pressure of 100/70 mm Hg D. Blood pressure of 140/80 mm Hg

A

Which statement should indicate to a nurse that an individual is experiencing a delusion? A. "There's an alien growing in my liver." B. "I see my dead husband everywhere I go." C. "The IRS may audit my taxes." D. "I'm not going to eat my food. It smells like brimstone."

A

Important teaching for clients receiving antipsychotic medication such as haloperidol (Haldol) includes which of the following instructions? Select all that apply. A) Use sunscreen because of photosensitivity. B) Take the antipsychotic medication with food. C) Have routine blood tests to determine levels of the medication. D) Abstain from eating aged cheese.

A, B

Select the appropriate interventions for caring for the client in alcohol withdrawal. Select all that apply. A) Monitor vital signs B) Provide stimulation in the environment C) Maintain NPO status D) Provide reality orientation as appropriate E) Address hallucinations therapeutically

A, D, E

A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss? A) A temperature of 100.4*F B) An increase in the pulse from 88 to 102 BPM C) An increase in the respiratory rate from 18 to 22 breaths per minute D) A blood pressure change from 130/88 to 124/80 mm Hg

B

The nurse examines a woman one hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to: A) Place her on a bedpan to empty her bladder B) Massage her fundus C) Call the physician D) Administer Methergine 0.2 mg IM which has been ordered prn

B

Which nursing diagnosis would best describe the problems evidenced by the following client symptoms: avoidance, poor concentration, nightmares, hypervigilance, exaggerated startle response, detachment, emotional numbing, and flashbacks? A. Ineffective coping B. Post-trauma syndrome C. Complicated grieving D. Panic anxiety

B

Which of the following assessment findings in a patient's health history supports a diagnosis of substance dependence? A) Numerous legal problems and interpersonal conflicts B) Withdrawal symptoms when not using the substance C) Impaired judgment and risk-taking behaviors D) Continued tardiness and absenteeism from work

B

Which of the following nursing actions would be included in a care plan for a client with PTSD who states the experience was "bad luck"? A) Encourage the client to verbalize the experience B) Assist the client in defining the experience C) Work with the client to take steps to move on with his life D) Help the client accept positive and negative feelings

B

A client who is a veteran of the Gulf War is being assessed by a nurse for post-traumatic stress disorder (PTSD). Which of the following client symptoms would support this diagnosis? (Select all that apply.) A. The client has experienced symptoms of the disorder for 2 weeks. B. The client fears a physical integrity threat to self. C. The client feels detached and estranged from others. D. The client experiences fear and helplessness. E. The client is lethargic and somnolent.

B, C, D

Nurse Arya assesses for evidence of positive symptoms of schizophrenia in a newly admitted client. Which of the following symptoms are considered positive evidence? Select all that apply. A) Anhedonia B) Delusions C) Flat affect D) Hallucinations E) Loose associations F) Social withdrawal

B, D, E

A client is admitted to the psychiatric unit with active psychosis. The physician diagnoses schizophrenia after ruling out several other conditions. Schizophrenia is characterized by: A) loss of identity and self-esteem. B) multiple personalities and decreased self-esteem. C) disturbances in affect, perception, and thought content and form. D) persistent memory impairment and confusion.

C

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? A. Tactile hallucinations B. Tardive dyskinesia C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices

C

Which of the following teachings should be given to the mother when her child is in a mist tent for liquefication of secretions? a) give the child a stuff toy inside the mist tent b) avoid nylon blanket inside the mist tent c) advise mother to let the child stay in the mist tent d) give the child coloring book inside the mist tent

C

A client diagnosed with chronic schizophrenia presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The nurse would expect the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome and treat by discontinuing antipsychotic medications B. Agranulocytosis and treat by administration of clozapine (Clozaril) C. Extrapyramidal symptoms and treat by administration of benztropine (Cogentin) D. Tardive dyskinesia and treat by discontinuing antipsychotic medications

D

In which of these cases could you diagnose PPH following vaginal delivery: 1. > 500 blood loss over 24 hrs 2. hypotension 3. tachycardia A) 1 & 3 B) 2 C) 3 D) 1

D

The nurse is caring for a client with a closed head injury. Which of the following would contribute to intracrainal hypertension? a.) hypoventilation b.) elevating the head of the bed c.) hypernatremia d.) quiet darkened environnent

a.) hypoventilation Rationale: Hypoventilation leads to vasodilation and increased intracranial pressure.

Which of the following would the nurse expect to assess in a client diagnosed with posttraumatic stress disorder? Select all that apply. 1. Dissociative events. 2. Intense fear and helplessness. 3. Excessive attachment and dependence toward others. 4. Full range of affect. 5. Avoidance of activities that are associated with the trauma.

1, 2 ,5

A nurse would recognize which of the following as the best predictors of PTSD in Vietnam veterans? (Select all that apply.) 1. The severity of the stressor 2. The degree of ego strength 3. The degree of psychosocial isolation in the recovery environment 4. The attitudes of society regarding the experience 5. The presence of preexisting psychopathology

1, 3

A client with early dementia exhibits disturbances in her mental awareness and orientation to reality. The nurse should expect to assess a loss of ability in which of the following other areas? 1. Speech. 2. Judgment. 3. Endurance. 4. Balance.

2

When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? 1. Cancer of any kind. 2. Impaired hearing. 3. Prescription drug intoxication. 4. Heart failure.

3

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately? A. Sore throat, fever, and malaise B. Akathisia and hypersalivation C. Akinesia and insomnia D. Dry mouth and urinary retention

A

Ramsay is diagnosed with schizophrenia paranoid type and is admitted in the psychiatric unit of Nurseslabs Medical Center. Which of the following nursing interventions would be most appropriate? A) Establishing a non demanding relationship B) Encouraging involvement in group activities C) Spending more time with Ramsay D) Waiting until Ramsay initiates interaction

A

The 4 "T's" of PPH are: 1. Trauma 2. Toxins 3. Travel 4. Tissue 5. Threads 6. Thrombin 7. Tears 8. Tone A) 1, 4, 6 & 8 B) 1, 5 7 & 8 C) 1, 2, 3 & 6 D) 3, 4, 5 & 6

A

A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance dependence? A. Narcotic pain medication is contraindicated for all clients with active substance-abuse problems. B. Clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. C. There is no need to assess the client for substance dependence. There is an obvious PCA malfunction. D. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.

B

A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia? A. Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia. B. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia. C. Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia. D. Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.

B

Methergine or pitocin is prescribed for a woman to treat PP hemorrhage. Before administration of these medications, the priority nursing assessment is to check the: A) Amount of lochia B) Blood pressure C) Deep tendon reflexes D) Uterine tone

B

When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate? A) Document the findings B) Notify the physician C) Reassess the client in 2 hours D) Encourage increased intake of fluids

B

A client diagnosed with schizophrenia states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing reply? A. "Did you take your medicine this morning?" B. "You are not going to hell. You are a good person." C. "I'm sure the voices sound scary. The devil is not talking to you. This is part of your illness." D. "The devil only talks to people who are receptive to his influence."

C

To be considered a PPH, what would the estimated blood loss have to be for a C-section? A) < 550 ML B) > 600 ML C) > 1000 ML D) < 900 ML

C

Which nonantipsychotic medication is used to treat some clients with schizoaffective disorder? A) phenelzine (Nardil) B) chlordiazepoxide (Librium) C) lithium carbonate (Lithane) D) Cimipramine (Tofranil)

C

Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol). Today, the nurse notices that the client is holding his head to one side and complaining of neck and jaw spasms. What should the nurse do? A) Assume that the client is posturing. B) Tell the client to lie down and relax. C) Evaluate the client for adverse reactions to haloperidol. D) Put the client on the list for the physician to see tomorrow.

C

Which of the following classifications of medications would be MOST often used for clients with schizophrenia? A) Anxiolytics B) Anti-depressants C) Mood stabilizers D) Neuroleptics

D

Which of the following signs and symptoms of increased ICP after head trauma would appear first? a.) Bradycardia b.) Large amounts of very dilute urine c.) Restlessness and confusion d.) Widened pulse pressure

c.) Restlessness and confusion Rationale: The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.

A family asks the nurse why their son was diagnosed with PTSD and others in the accident were not. Which of the following information should the nurse offer? (Select all that apply.) 1. An individual's religious affiliation can affect response to trauma. 2. Responses are affected by how an individual handled previous trauma. 3. Protectiveness of family and friends can help an individual deal with trauma. 4. Control over the possibility of recurrence can affect the response to trauma. 5. The time in which the trauma occurred can affect the individual's response.

2, 3, 4, 5

A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that one is: A) highly important or famous. B) being persecuted. C) connected to events unrelated to oneself. D) responsible for the evil in the world.

A

A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse immediately report to the client's attending psychiatrist? A. Respirations of 22 beats/minute B. Weight gain of 8 pounds in 2 months C. Temperature of 104F (40C) D. Excessive salivation

C

Which of the following should the nurse expect to include as a priority in the plan of care for a client with delirium based on the nurse's understanding about the disturbances in orientation associated with this disorder? 1. Identifying self and making sure that the nurse has the client's attention. 2. Eliminating the client's napping in the daytime as much as possible. 3. Engaging the client in reminiscing with relatives or visitors. 4. Avoiding arguing with a suspicious client about his perceptions of reality.

1

A 69-year-old client is admitted and diagnosed with delirium. Later in the day, he tries to get out of the locked unit. He yells, "Unlock this door. I've got to go see my doctor. I just can't miss my monthly Friday appointment." Which of the following responses by the nurse is most appropriate? 1. "Please come away from the door. I'll show you your room." 2. "It's Tuesday and you are in the hospital. I'm Anne, a nurse." 3. "The door is locked to keep you from getting lost." 4. "I want you to come eat your lunch before you go the doctor."

2

When treating individuals with posttraumatic stress disorder, which variables are included in the recovery environment? 1. Degree of ego strength. 2. Availability of social supports. 3. Severity and duration of the stressor. 4. Amount of control over reoccurrence.

2

Which of the following is essential when caring for a client who is experiencing delirium? 1. Controlling behavioral symptoms with low-dose psychotropics. 2. Identifying the underlying causative condition or illness. 3. Manipulating the environment to increase orientation. 4. Decreasing or discontinuing all previously prescribed medications.

2

A newly admitted client is diagnosed with posttraumatic stress disorder. Which behavioral symptom would the nurse expect to assess? 1. Recurrent, distressing flashbacks. 2. Intense fear, helplessness, and horror. 3. Diminished participation in significant activities. 4. Detachment or estrangement from others.

3

A nurse has been caring for a client diagnosed with PTSD. Which realistic goal should be included in this client's plan of care? 1. The client will have no flashbacks. 2. The client will be able to feel a full range of emotions by discharge. 3. The client will not require zolpidem (Ambien) to obtain adequate sleep by discharge. 4. The client will refrain from discussing the traumatic event.

3

Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium? 1. Explain the experience of having delirium. 2. Resume a normal sleep-wake cycle. 3. Regain orientation to time and place. 4. Establish normal bowel and bladder function.

3

A newly admitted client diagnosed with posttraumatic stress disorder is exhibiting recurrent flashbacks, nightmares, sleep deprivation, and isolation from others. Which nursing diagnosis takes priority? 1. Posttrauma syndrome R /T a distressing event AEB flashbacks and nightmares. 2. Social isolation R /T anxiety AEB isolating because of fear of flashbacks. 3. Ineffective coping R /T flashbacks AEB alcohol abuse and dependence. 4. Risk for injury R /T exhaustion because of sustained levels of anxiety.

4

A nursing instructor is teaching about trauma and stressor-related disorders. Which student statement indicates that further instruction is needed? 1. "The trauma that women experience is more likely to be sexual assault and child sexual abuse." 2. "The trauma that men experience is more likely to be accidents, physical assaults, combat, or viewing death or injury." 3. "After exposure to a traumatic event, only 10 percent of victims develop post-traumatic stress disorder (PTSD)." 4. "Research shows that PTSD is more common in men than in women."

4

A client is admitted to the psychiatric unit with a diagnosis of alcohol intoxication and suspected alcohol dependence. Other assessment findings include an enlarged liver, jaundice, lethargy, and rambling, incoherent speech. No other information about the client is available. After the nurse completes the initial assessment, what is the first priority? A. Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output B. Checking the client's medical records for health history information C. Attempting to contact the client's family to obtain more information about the client D. Restricting fluids and leaving the client alone to "sleep off" the episode

A

What are four risk factors for PPH (arising during pregnancy)? A) Previous PPH; polyhydramnios; multiple pregnancy; anaemia conditions B) Abruptio placenta; mollydominos, grand multi; iron deficiency C) Intrauterine death; abracadabra placenta, previous pph, iron deficiency. D) Placenta praevia; polyhydramnios, outeruterine death, hyroplanes E) A & C

A

When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include? a. Reminding the patient frequently about being in the hospital b. Placing suction at the bedside to decrease the risk for aspiration c. Providing complete personal hygiene care for the patient d. Repositioning the patient frequently to avoid skin breakdown

A

When planning the care of a client who is experiencing post-traumatic stress disorder, the nurse identifies which of the following as an appropriate goal? The client will report: A) A decrease in flashbacks and nightmares. B) A decrease in hearing voices. C) Spending less time on ritualistic behavior. D) Having more energy.

A

Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been plated in the unit walls. Which action would be the most therapeutic response? A) Confront the delusional material directly by telling Gio that this simply is not so. B) Tell Gio that this must seem frightening to him but that you believe he is safe here. C) Tell Gio to wait and talk about these beliefs in his one-on-one counselling sessions. D) Isolate Gio when he begins to talk about these beliefs.

B

The 29-year-old client that was employed as a forklift operator sustains a traumatic brain injury secondary to a motor vehicle accident. The client is being discharged from the rehabilitation unit after 3 months and has cognitive deficits. Which goal would be more realistic for this client? A) The client will return to work within 6 months. B) The client is able to focus and stay on task for 10 minutes. C) The client will be able to dress self without assistance. D) The client will regain power and bladder control.

B

A client is admitted to the psychiatric hospital with a diagnosis of catatonic schizophrenia. During the physical examination, the client's arm remains outstretched after the nurse obtains the pulse and blood pressure, and the nurse must reposition the arm. This client is exhibiting: A) suggestibility. B) negativity. C) waxy flexibility. D) retardation.

C

A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurse's initial action should be to a. administer the PRN dose of lorazepam (Ativan). b. reorient the patient to time and place. c. assess the patient for anything that might be causing discomfort. d. have a nursing assistant stay with the patient to ensure safety.

C

A nurse is assessing a client in the 4th stage if labor and notes that the fundus is firm but that bleeding is excessive. The initial nursing action would be which of the following? A) Massage the fundus B) Place the mother in the Trendelenburg's position C) Notify the physician D) Record the findings

C

An agitated and incoherent client, age 29, comes to the emergency department with complaints of visual and auditory hallucinations. The history reveals that the client was hospitalized for paranoid schizophrenia from ages 20 to 21. The physician prescribes haloperidol (Haldol), 5 mg I.M. The nurse understands that this drug is used in this client to treat: A) dyskinesia. B) dementia. C) psychosis. D) tardive dyskinesia.

C

Parents ask a nurse how they should reply when their child, diagnosed with paranoid schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply? A. "Tell him to stop discussing the voices." B. "Ignore what he is saying, while attempting to discover the underlying cause." C. "Focus on the feelings generated by the hallucinations and present reality." D. "Present objective evidence that the voices are not real."

C

When administering a mental status examination to a patient with delirium, the nurse should a. give the examination when the patient is well-rested. b. reorient the patient as needed during the examination. c. choose a place without distracting environmental stimuli. d. medicate the patient first to reduce anxiety.

C

Which measure would be least effective in preventing postpartum hemorrhage? A) Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered B) Encourage the woman to void every 2 hours C) Massage the fundus every hour for the first 24 hours following birth D) Teach the woman the importance of rest and nutrition to enhance healing

C

Which of the following circumstances is most likely to cause uterine atony and lead to PP hemorrhage? A) Hypertension B) Cervical and vaginal tears C) Urine retention D) Endometritis

C

Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus? A) Retained placental fragments B) Urinary tract infection C) Cervical laceration D) Uterine atony

C

Jaime has a diagnosis of schizophrenia with negative symptoms. In planning care for the client, Nurse Brienne would anticipate a problem with: A) auditory hallucinations. B) Bizarre behaviors. C) Ideas of reference. D) Motivation for activities

D

The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? A) Assess neurological status. B) Monitor pulse, respiration, and blood pressure. C) Initiate an intravenous access. D) Maintain an adequate airway.

D

The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates such as morphine include: A. dilated pupils and slurred speech. B. rapid speech and agitation. C. dilated pupils and agitation. D. euphoria and constricted pupils.

D

The nurse is talking with a client who just had a beautiful bouquet of roses delivered. Suddenly the client becomes tearful and stares out the window. The client has a history of sexual abuse. Which of the following should the nurse include in the plan of care for this client? A) Tell the client to relax and enjoy the roses B) Tell the client that the sexual abuse was in the past C) Give the client some alone time and return later D) Assess if the client is having a flashback

D

What types of trauma during labour and birth would lead to PPH risk? A) Instrumental assisted birth (vacuum or forceps) B) C-Section C) Lacerations of the cervix or vaginal wall D) All of the above

D

Which of the following complications is most likely responsible for a delayed postpartum hemorrhage? A) Cervical laceration B) Clotting deficiency C) Perineal laceration D) Uterine subinvolution

D

Which of the following outcome criteria is appropriate for the client with dementia? A) The client will return to an adequate level of self-functioning. B) The client will learn new coping mechanisms to handle anxiety. C) The client will seek out resources in the community for support. D) The client will follow an established schedule for activities of daily living.

D