EXIT K 9
A client who has been diagnosed with acute lymphocytic leukemia will be receiving doxorubicin (Adriamycin) infusions as part of a chemotherapy regimen. The nurse monitors the client for signs and symptoms of doxorubicin toxicity. What clinical finding indicates that toxicity has occurred?
Abnormalities in cardiac rhythm
The nurse is caring for a client who has an occlusion of the left femoral artery and is scheduled for an arteriogram. Which clinical finding is most significant when assessing the left extremity before the arteriogram?
Absence of the pedal pulse
Which medication should the nurse anticipate the health care provider will prescribe to relieve the pain experienced by a client with rheumatoid arthritis?.
Acetylsalicylic acid (Aspirin)
Which prescribed medication should the nurse expect to administer to a female client who exhibits the genital lesions presented in the illustration at
Acyclovir sodium (Zovirax)
A client has been taking lithium carbonate (Eskalith) for 3 days. The nurse has the client's lithium level checked before administering the medication and finds it to be 0.3 mEq/L. The nurse should:
Administer the medication.
A client is found to have paranoid schizophrenia, and the practitioner prescribes a typical antipsychotic medication. After a 1-month hospitalization the client is discharged home with instructions to continue the antipsychotic and a referral for weekly mental health counseling. This picture illustrates the client's physical status as observed by the nurse on the client's first visit to the community mental health clinic. What extrapyramidal side effect has developed?
Akathisia
A client calls the emergency department of the hospital after taking 24 sleeping pills. Which statement best describes the psychodynamics of calling the emergency department during the very act of a suicide attempt?
Ambivalence about dying
A mental health nurse is admitting a client with anorexia nervosa. When obtaining the history and physical assessment, the nurse expects the client's condition to reveal:
Amenorrhea
A client's cardiac monitor indicates ventricular tachycardia. The nurse assesses the client and identifies an increase in apical pulse rate from 100 to 150 beats per minute. An appropriate treatment plan includes:
Amiodarone bolus.
What are the "four As" for which nurses should assess clients with suspected Alzheimer disease?
Amnesia, apraxia, agnosia, aphasia
A nurse counsels the parents of an 8-month-old infant to remove small objects from the floor when their child is crawling on it. What is the best rationale for this instruction?
An 8-month-old infant can pick up small objects easily.
An infant with hypertrophic pyloric stenosis is admitted to the pediatric unit. What does the nurse expect to find when palpating the infant's abdomen?
An olive-sized mass in the right upper quadrant.
A client with bipolar disorder, manic episode, has a superior, authoritative manner and constantly instructs other clients in how to dress, what to eat, and where to sit. The nurse should intervene because these behaviors eventually will cause the other clients to feel:
Angry,
A client who was in an automobile accident is admitted to the hospital with multiple injuries. Approximately 14 hours after admission, the client begins to experience signs and symptoms of withdrawal from alcohol. Which signs and symptoms should the nurse connect to alcohol withdrawal? Select all that apply.
Anxiety Diaphoresis Psychomotor agitation
A nurse is assessing a client with chronic schizophrenia. Which effects will the client most likely exhibit? Select all that apply.
Apathy Flatness
During auscultation of the heart, the nurse expects the first heart sound (S1) to be the loudest at the:
Apex of the heart
A client who is suspected of having leukemia has a bone marrow aspiration. Immediately after the procedure, the nurse should:
Apply brief pressure to the site
A client with a history of heart failure and hypertension is admitted with reports of syncope. Which prescribed medication should the nurse prepare to administer based on the ECG rhythm strip image?
Atropine
A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse's best intervention?
Attempt to identify the client's concerns.
The nurse is providing instructions to a client on how to reduce the dietary intake of sodium. What should the nurse include in the instructions?
Avoid carbonated beverages
A nurse is caring for a client who is scheduled to have an abdominal perineal resection for colorectal cancer. A type and cross match is done because of a concern about blood loss. The client has type B-negative blood. The blood type that can be used for this client is:
B negative
A nurse is performing a neurological assessment of a 7-month-old infant. What reflex should the nurse be able to elicit?
Babinski.
A nurse is teaching a client who is taking a loop diuretic (e.g., furosemide [Lasix]) about foods that are high in potassium. Which foods should the nurse emphasize? Select all that apply.
Bananas Beef stew Baked potatoes
A client with alcohol dependence is admitted to the detoxification unit. Which class of medication does the nurse anticipate that the practitioner will prescribe?
Benzodiazepine
A client reports a history of bilateral blanching and pain in the fingers on exposure to cold. When rewarmed, the fingers become bright red and "tingly" with a slow return to their usual color. The client smokes one to two packs of cigarettes per day. The nurse determines that the client has Raynaud's disease and not Raynaud's phenomenon because of the:
Bilateral involvement...
A client returns from a cardiac catheterization procedure and is to remain in the supine position for four hours with the affected leg straight. The nurse explains that these measures are to prevent:.
Bleeding at the arterial puncture site
A client who is receiving atenolol (Tenormin) for hypertension frequently reports feeling dizzy. What effect of atenolol should the nurse consider may be responsible this response?
Blocking the adrenergic response
The nurse is evaluating a client who received intravenous morphine. Which life-threatening response indicates the need to notify the healthcare provider?
Bradycardia
A client has a bone marrow aspiration performed. After the procedure, what is the first nursing action?
Briefly apply pressure over the aspiration site
A nurse in the mental health unit is working with a group of adolescent girls with the diagnosis of anorexia nervosa. The nurse recalls that the major health complication associated with intractable anorexia nervosa is:
Cardiac dysrhythmias resulting in cardiac arrest
The health care provider prescribes enalapril maleate (Vasotec). Which instruction should the nurse include when educating the client about the new medication?
Change positions slowly.
A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first?
Check for a pulse
A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. The nurse determines that the client understands the dietary instructions when the client identifies the following foods. Select all that apply.
Chicken broth Enriched whole milk Red meats, such as beef Liver and other glandular organ meats
Which paired drugs does the nurse expect the practitioner to prescribe for a client admitted for acute alcohol detoxification?
Chlordiazepoxide (Librium) and thiamine
A nurse is assessing a client with a diagnosis of primary insomnia. Which findings from the client's history may be the cause of this disorder? Select all that apply.
Chronic stress Excessive caffeine Environmental noise/distractors
A Foley catheter was placed with an urimeter for an 85-year-old client with a history of congestive heart failure. The output is 45 mL/hour, cloudy, and has sediment. These findings indicate:
Cloudy urine may be indicative of infection.
What should the nurse include in the teaching plan for parents of an infant with phenylketonuria (PKU)?
Cognitive impairment occurs if PKU is untreated.
After undergoing a cardiac catheterization, the client complains of tingling sensations in the affected leg. To determine the cause of the tingling, the nurse should:
Compare femoral, popliteal, and pedal pulses in both legs
When the nurse is communicating with a client with substance-induced persisting dementia, the client cannot remember facts and fills in the gaps with imaginary information. The nurse identifies this as:
Confabulation
A client who has had a myocardial infarction experiences a noticeably decreased pulse pressure. What does this indicate to the nurse?
Decreased force of contraction
A nurse is assessing a client and suspects diabetic ketoacidosis (DKA). What clinical findings support this conclusion?
Deep respirations and fruity odor to the breath
A nurse is planning care for a client with substance-induced persisting dementia resulting from long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain tissue, has contributed to substance-induced persisting dementia?
Deficiency of thiamine
A client in the mental health clinic tells the nurse, "The FBI is out to kill me." What should the nurse document that the client is experiencing?
Delusion of persecution
A mental health nurse is working on a unit where many clients have the diagnosis of alcoholism. The nurse identifies that the defense mechanism most commonly used by clients who are alcoholics is:
Denial
The nurse is assessing a client with the diagnosis of chronic heart failure. Which clinical finding should the nurse expect the client to experience?
Dependent edema in the evening
When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestations? Select all that apply.
Dependent rubor Ulcers on the toes Delayed capillary refill
One morning a client tells the nurse, "My legs are turning to rubber because I have an incurable disease called schizophrenia." The nurse identifies that this as an example of:
Depersonalization
A client's antidepressant medication therapy has recently been modified to substitute a tricyclic antidepressant for the monoamine oxidase inhibitor (MAOI) prescribed 2 years ago. In light of this assessment data, collected during the follow-up appointment, the nurse should first:
Determine exactly when the client began taking the amitriptyline (Elavil).
A nurse is caring for a client with vascular dementia. What does the nurse expect of this client's mental status?
Difficulty recalling recent events related to cerebral hypoxia
A nurse is caring for a client exhibiting compulsive behaviors. The nurse concludes that the compulsive behavior usually incorporates the use of:
Displacement
What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess?
Distended jugular veins
A nurse expects that a client with right-sided heart failure will exhibit:
Distended neck veins
A client is found to have a mood disorder, hypomanic episode. To support the diagnosis, the nurse should identify the signs and symptoms associated with this disorder. Select all that apply.
Distractibility Flight of ideas
A client who is in a manic phase of bipolar disorder threatens staff and clients on a psychiatric acute care unit. Place the following interventions in priority order, from the least to the most restrictive.
Diversional activities Limit-setting Medication administration Seclusion Restraints
The nurse believes that an emotionally disturbed client is ready to begin participating in therapeutic activities. What should the nurse initially suggest?
Drawing pictures with the nurse
For which common complication of myocardial infarction (MI) should the nurse monitor the client that has been admitted to the coronary care unit for two days?
Dysrhythmia
A nurse recalls that language development in the autistic child resembles:
Echolalia
The nurse reviews the information gathered on a client with bipolar disorder who has been prescribed lithium (Eskalith). In light of this information, the nurse determines that the priority nursing intervention is:
Educating the client regarding the management of hypothyroidism
A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline at 125 mL/hr has been started. One hour after the IV initiation the client begins screaming, "I can't breathe!" The nursing priority action is:
Elevate the head of the bed and obtain vital signs
An electrocardiogram (ECG) is prescribed for a client who reports chest pain. What early finding does the nurse expect on the lead over the infarcted area?
Elevated ST segments
A client who has been experiencing chest pain and vomiting for several hours is admitted to the hospital with a diagnosis of myocardial infarction. The client is transferred immediately to the cardiac intensive care unit. The client's potassium level is below the expected range. Considering the laboratory result, the nurse should monitor the client's electrocardiogram (ECG) for:
Elevated U and flattened T waves
A nurse is caring for a client with a history of hypertension and aphasia. A family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the client's aphasia. What is a common cause of this type of occlusion?
Emboli associated with atrial fibrillation
To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care?
Encourage early mobility.
The nurse manager is evaluating a primary nurse who is working with a hospitalized adolescent client with the diagnosis of conduct disorder. Which intervention by the primary nurse should the nurse manager question?
Encouraging the verbalization of negative feel
The nurse is working with a client who has a diagnosis of borderline personality disorder. What personality traits should the nurse expect the client to exhibit? Select all that apply.
Engaging Manipulative
A client comes to the clinic for a physical and asks to be tested for acquired immunodeficiency syndrome (AIDS). Which test should the nurse explain will be used for the initial screening for HIV?
Enzyme-linked immunosorbent assay (ELISA)
A client with vascular dementia (formerly known as multiinfarct dementia) has signs and symptoms that are different from dementia of the Alzheimer type. What characteristics unique to vascular dementia should the nurse expect when assessing a client with this diagnosis? Select all that apply. Exaggerated deep tendon reflexes
Episodic progression of symptoms
Exaggerated deep tendon reflexes
Episodic progression of symptoms
A client has the diagnosis of histrionic personality disorder. Which behavior should the nurse expect when assessing this client?
Extroverted and dramatic
A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The parents ask how this could happen in addition to many other questions. Hemophilia A is linked to a deficiency in:
Factor VIII
A client comes to the mental health clinic for treatment of a phobia of large dogs. The nurse should anticipate that this client will demonstrate:
Fear of discussing the phobia
A 45-year-old man who recently completed alcohol detoxification states that he plans to begin using disulfiram (Antabuse) as part of his alcoholism treatment regimen. Important client teaching by the nurse regarding this drug is that:
Foods, medications, and any topical preparation containing alcohol should be avoided.
What is an appropriate behavior modification goal for a client with anorexia nervosa?
Gaining 1 lb of weight a week,
A blood transfusion of packed cells has been prescribed for a client. The transfusion started five minutes ago and the client is complaining of chest pain and nausea, having difficulty breathing, and chills. The blood pressure has dropped from 140/88 to 110/60 mm Hg, temperature is 99.2 degrees, and the client seems less alert. The nurse suspects:
Hemolytic reaction.
A client is admitted to the emergency department with a contaminated wound. The client is a poor historian, and the nurse realizes that it is impossible to determine whether the client is immunized against tetanus. Because it will produce passive immunity for several weeks with minimal danger of an allergic reaction, the nurse expects that what medication will be prescribed?
Human tetanus antitoxin
Which topic should the nurse determine is most appropriate when presenting health-related instruction to clients from an African-American community?
Hypertension
The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of:
Hypokalemia.
A client takes isosorbide dinitrate (Isordil) daily. The client states, "I would like to start taking sildenafil (Viagra) for erectile dysfunction. I was told I can't take sildenafil and isosorbide dinitrate at the same time." The nurse explains that taking both of these medications concurrently may result in severe:
Hypotension
A hospitalized client hurriedly approaches the nurse, saying that it sounds like there is a roaring fire in the bathroom. In reality, the client's roommate has just turned the shower on full force. What term best describes this experience?
Illusion,
A nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor. What intervention is the priority?
Immediate defibrillation
A nurse is concerned when an 11-month-old infant is brought to the pediatric clinic weighing 9 lb 3 oz. The nurse suspects that the infant is suffering from physical and emotional neglect. What observations lead the nurse to suspect maltreatment? Select all that apply.
Inappropriate clothing Social unresponsiveness Frequent rocking motions
A nurse is discussing dietary guidelines to help reduce a client's risk for heart disease. What should the nurse teach the client?
Increase complex carbohydrates.
During a home visit to an older adult, the nurse observes a change in behavior and suspects delirium. The nurse assesses the client for one of several conditions that may have precipitated the delirium. Select all that apply.
Infection Dehydration Urine retention
The primary health care provider prescribes a transfusion of two units of packed red blood cells for a client. When administering blood, the priority nursing intervention is to:
Infuse the blood at a slow rate during the first 15 minutes
A client who recently was diagnosed as having myelocytic leukemia discusses the diagnosis by referring to statistics, facts, and figures. The nurse determines that the client is using the defense mechanism known as:
Intellectualization
A client is receiving warfarin (Coumadin). Which test result should the nurse use to determine if the daily dose of this anticoagulant is therapeutic?
International normalized ratio (INR)
A client with a history of alcoholism is found to have Wernicke encephalopathy associated with Korsakoff syndrome. What does the nurse anticipate will be prescribed
Intramuscular injections of thiamine
When discussing the therapeutic regimen of vitamin B12 for pernicious anemia with a client, the nurse explains that:
Intramuscular injections once a month will maintain control
The client is admitted with supraventricular tachycardia at a rate of 140 beats per minute. The client's blood pressure is 110/55 mm Hg, and he is asymptomatic except for a "fluttering feeling" in his chest. Which of the following treatments would be appropriate? Select all that apply:
Intravenous adenosine (Adenocard) Intravenous beta blockers Intravenous calcium channel blockers OJO Intravenous amiodarone
The nurse caring for a client with diabetic ketoacidosis (DKA) can expect to implement which of the following?.
Intravenous administration of regular insulin
A client is admitted to a mental health facility for depression. What action should a nurse take to help the client develop a positive self-regard?
Involve the client in activities that promote success.
The personality characteristics of a client with an antisocial personality disorder make it difficult for family members to interact and maintain a healthy relationship. What are common characteristics of an antisocial personality? Select all that apply.
Irresponsible Manipulative
Within a few hours of alcohol withdrawal the nurse should assess the client for the presence of:
Irritability and tremors
A nurse spends time in individual sessions helping a depressed, suicidal client verbalize feelings. For what themes should the nurse particularly listen? Select all that apply.
Isolation Hopelessness
A hospitalized, depressed, suicidal client has been taking a mood-elevating medication for several weeks. The client's energy is returning and the client no longer talks about suicide. What should the nurse do in response to this client's behavior?
Keep the client under closer observation.
Schizophrenia is associated with negative symptoms. In the assessment of a client with schizophrenia, which symptoms are classified as negative symptoms? Select all that apply.
Lack of energy Poor grooming
For which clinical indication should a nurse observe a child in whom autism is suspected?
Lack of eye contact
An infant who has been found to have developmental dysplasia of the hip (DDH) is being examined in the pediatric clinic. What clinical finding does the nurse expect to identify during the physical assessment?
Limited abduction of the affected hip.
A nurse is assessing an adolescent client with the diagnosis of schizophrenia, undifferentiated type. Which signs and symptoms should the nurse expect the client to experience?
Loosened associations and hallucinations
What should the nurse include in the plan of care for a client with dementia of the Alzheimer type, stage 2 (moderate dementia)?
Maintain a daily routine of living.
A client in a mental health facility is demonstrating manic-type behavior by being demanding and hyperactive. What is the nurse's major objective?
Maintaining a supportive, structured environment
When developing a plan of care for a client who had a cardiac catheterization via a femoral insertion site, the nurse should include:
Maintaining the supine position for a minimum of four hours
A client with a history of chronic alcoholism is admitted to the mental health unit. What does the nurse identify as the cause of a client's use of confabulation?
Marked loss of memory
A 65-year-old man is admitted to a mental health facility with a diagnosis of substance-induced persisting dementia resulting from chronic alcoholism. When conducting the admitting interview, the nurse determines that the client is using confabulation. The nurse recalls that the use of confabulation is precipitated by a client's:
Marked memory loss
A client is in profound (late) hypovolemic shock. The nurse assesses the client's laboratory values. Clients that are in late shock develop:
Metabolic acidosis
A nurse reviews the laboratory test results of a client with emphysema who is recovering from a myocardial infarction. The nurse obtains the client's vital signs and performs a physical assessment. Which prescribed medication should the nurse consider the priority at this time?
Metoprolol (Lopresor)
A nurse is auscultating a client's heart sounds. Which valves close when the first heart sounds are produced?
Mitral and tricuspid
A nurse is preparing to administer the prescribed digoxin (Lanoxin) intravenously (IV) to a client. Which nursing interventions are associated with IV digoxin administration? Select all that apply.
Monitor the heart rate closely Check the blood levels of digoxin Monitor the serum potassium level
A nurse is providing postprocedure care to a client who had a cardiac catheterization via a brachial artery. For the first hour after the procedure, what is the priority nursing intervention?
Monitor the vital signs every 15 minutes
A child with a congenital heart defect has a cardiac catheterization. What is an essential element of nursing care after this procedure?
Monitoring the extremity distal to the insertion site
A nurse is caring for depressed older adults. What precipitating factors for depression are most common in the older adult without cognitive problems? Select all that apply.
Multiple losses Declines in health
During an assessment interview the client reports overwhelming, irresistible attacks of sleep. Which sleep disorder does the nurse conclude that the client is experiencing?
Narcolepsy
nurse is assigned to care for a group of clients who have been found to have depression. Which clinical manifestations does the nurse anticipate? Select all that apply.
Neglect of personal hygiene "I don't know" answers to questions Apathetic response to the environment
The client's atrial and ventricular heart rates are equal at 88 beats/min. The PR interval is 0.14 seconds and the QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. The client's rhythm is:
Normal sinus rhythm (NSR).
A client who had surgery 24 hours ago reports pain in the calf. Assessment reveals redness and swelling at the site of discomfort. What should the nurse do?
Notify the health care provider.
*An adolescent who was admitted to the hospital with ketoacidosis is stable and receiving Novolin R subcutaneously. One hour after its administration the nurse enters the room and notes that the adolescent is diaphoretic and irritable. What is the nurse's priority intervention?
Obtaining a blood glucose reading.
An expectant couple asks the nurse about the cause of low back pain in labor. The nurse replies that this pain occurs most often when the position of the fetus is:
Occiput posterior
A low-dose intravenous dopamine hydrochloride (Dopamine) infusion drip is prescribed for a client in acute renal failure (ARF). What is the most appropriate way for the nurse to administer this intravenous medication to the client?
Peripherally inserted central line catheter (PICC) line-
A nurse performs an assessment of a 3-day-old infant. What finding should the nurse report to the health care provider?
Petechiae covering the chest
A client develops a nosebleed (epistaxis) and seeks treatment at a first-aid station. The nurse can help control the bleeding by:
Pinching the nostrils together
A client with a diagnosis of bipolar disorder, manic episode, is admitted to the mental health unit. Because the environment is important, what should the nurse do?
Place the client in a private room to provide a quiet atmosphere.
Which is the priority intervention for the dependant client with peptic ulcer disease (PUD) who is vomiting bright red blood?
Place the client in a side-lying position.
The nurse is reassessing a newborn who had an axillary temperature of 97° F (36° C) and was placed skin to skin with the mother. The newborn's axillary temperature is still 97° F (36° C) after 1 hour of skin-to-skin contact. Which intervention should the nurse implement next?
Placing the newborn under a radiant warmer in the nursery
A child is found to have attention deficit-hyperactivity disorder (ADHD). What strategy should the nurse teach the parents to help them cope with this disorder? Reward appropriate conduct.
Play
A complete blood count is ordered for a 5-month-old infant with tetralogy of Fallot. What does the nurse expect to see when reviewing the laboratory results?
Polycythemia.
An older adult client is talking to the nurse about his Vietnam experiences and shares that he still has flashbacks. While assessing him the nurse notices that he is jumpy and exhibits startle reactions and poor concentration. The nurse identifies these as symptoms of:
Posttraumatic stress disorder (PTSD)
A client is receiving furosemide (Lasix) to help treat congestive heart failure. Which of the laboratory results warrants notifying the health care provider?
Potassium 3.0mEq/L
A nurse is planning care for a client admitted to the unit with a diagnosis of bipolar disorder, manic phase. In which type of room should the nurse tell the admissions clerk to place this client?
Private
An infant is found to have hydrocephalus. Which assessment finding alerts the nurse to suspect increasing intracranial pressure?
Projectile vomiting.
Which relationship does the nurse consider reflective of the relationship of naloxone (Narcan) to morphine sulfate?
Protamine sulfate to parenteral heparin
A client at 36 weeks' gestation is admitted to the high-risk unit because she gained 5 lb in the previous week and there is a pronounced increase in blood pressure. What is the initial intervention in the client's plan of care?.
Providing a dark, quiet room with minimal stimuli
A client paces back and forth across the floor, speaks incoherently, and continually talks to and verbally fights with people who are not present. What is the nurse's initial therapeutic intervention?
Providing emotional support while demonstrating acceptance of the client
A client who complains of memory loss, nervousness, insomnia, and fear of leaving the house is admitted to the hospital after several days of increasing incapacitation. What nursing action is the priority in light of this client's history?
Providing the client with a sense of security and safety,
chronic obstructive pulmonary disease (COPD). What is the priority nursing intervention when the client becomes short of breath during the care?
Put the client in a high Fowler's position.
Two depressed clients are sharing a room. The health team has established a goal of increased socialization for each client. Which action will be most effective in facilitating interaction between these two clients?.
Putting a puzzle together with them in their room
Ventricular depolarization is shown on the rhythm strip as a:
QRS complex.
After surgery for repair of a myelomeningocele, the nurse places the infant in a side-lying position with the head slightly elevated. The main reason the nurse places the infant in this position after this particular surgery is that it:
Reduces intracranial pressure.
A 6-year-old child has been wetting the bed at night since the birth of a baby brother. What defense mechanism is the child using to cope with the stress of accepting a new family member?
Regression
A client receives a prescription for morphine via patient-controlled analgesia (PCA). Before beginning administration of this medication, what should the nurse assess first?
Respirations
A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock?
Restlessness
A man has completed an alcohol detoxification program and is setting goals for rehabilitation. When setting goals it is important for this client to understand the need to:
Restructure his life without alcohol.
The nurse is caring for a client newly diagnosed with diabetes. When preparing the teaching plan about the importance of yearly eye examinations, the nurse should plan to instruct the client on which eye problem most associated with diabetes?,
Retinopathy
What is the priority nursing intervention in the planning of nursing care for an adolescent client with anorexia nervosa?
Rewarding weight gain by increasing privileges
The parents of an infant with tetralogy of Fallot ask the nurse to explain what is wrong with their baby's heart. Before explaining the problem in a way that they will understand, the nurse remembers that tetralogy of Fallot includes:
Right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding of the aorta.
The primary objective of nursing intervention for clients with dementia, delirium, and other cognitive disorders is to maintain:
Safety within the environment
A client is admitted to the hospital for a thyroidectomy. In which position should the nurse maintain the client after this surgery?
Semi-Fowler
The mother of a newborn with exstrophy of the bladder tells the nurse that the primary health care provider said that her child may develop an unusual gait when learning to walk. What does the nurse tell the mother is the cause of waddling gait?
Separation of the pubic bones
At 10 pm a client with a personality disorder is in the lounge playing cards. When the nurse enters, the client requests a sleeping pill. The nurse responds, "First go to bed and try to sleep." The nurse's response is directed toward:
Setting limits
After surgery a client's fever does not respond to antipyretics. The health care provider prescribes that the client be placed on a hypothermia blanket. A response to hypothermia therapy that the nurse should prevent is:
Shivering
A client presents to the emergency department with severe epistaxis. Which position is most beneficial?
Sitting with head tilted slightly forward
A nurse is assessing a client and attempting to distinguish between dementia and delirium. Which factors are unique to delirium? Select all that apply.
Slurred speech Visual or tactile hallucination A fluctuating level of consciousness
When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is:
Sodium
The parents of a 6-month-old infant ask the nurse about the best toy to buy for their baby. What type of toy should the nurse suggest?
Soft stuffed animals.
What should the nurse suggest when parents ask what to do about their preschooler's stuttering?
Speak clearly and do not complete the child's sentences.
The nurse is providing teaching to a client with atrial flutter who has received a prescription for an oral anticoagulant. The client asks the nurse to provide a list of foods that are high in vitamin K and that should be avoided. What should the nurse include on the list? Select all that apply.
Spinach Broccoli
A client with a hemoglobin level of 6.2 g/dL is receiving packed red blood cells. Twenty minutes after the infusion starts, the client complains of chest pain, difficulty breathing, and feeling cold. What is the first action the nurse should take?
Stop the transfusion
A client with esophageal varices is admitted with hematemesis, and two units of packed red blood cells are prescribed. The client complains of flank pain halfway through the first unit of blood. The nurse's first action is to:
Stop the transfusion
A blood transfusion of packed cells has been prescribed for a client. The client shows signs of hemolytic reaction. Place the appropriate nursing actions in order.
Stop the transfusion Change IV administration set Run 0.9 normal saline at rapid rate Notify health care provider and blood bank
A client is receiving a unit of packed red blood cells (PRBC). The client experiences tingling in the fingers and headache. What is the nurse's priority action?
Stop the transfusion.
A depressed client reports feelings of helplessness and hopelessness. The nurse hears the client tell another client, "I'll be feeling better soon." In light of this comment, what factor should the nurse assess?
Suicidal thinking
A male client with paranoid schizophrenia wraps his legs in toilet paper, believing that this will protect him from deadly germs contaminating the floor. What is the best nursing intervention?
Talking with the client about anxiety that focuses on health
A female client with acute schizophrenia tells the nurse, "Everyone hates me." What is the best response by the nurse?
Tell me more about this.
A client who was forced into early retirement is found to have severe depression. The client says, "I feel useless, and I've got nothing to do." What is the best initial response by the nurse?
Tell me more about your feeling useless.
A 17-year-old mother is to sign the consent for her son's myringotomy. What should the nurse say to the mother about this procedure?
Tell me what you know about this procedure.
What should the nurse do when an adolescent girl with the diagnosis of anorexia nervosa starts to discuss food and eating?
Tell the client gently but firmly to direct her discussion of food to the nutritionist.
A client with a borderline personality disorder receives the wrong meal tray for lunch and angrily states, "The next time I see the dietitian, I'm going to throw this tray at her!" What is the most appropriate response by the nurse?
Telling the client that it is frustrating not to get the correct tray but that throwing the tray at the dietitian is unacceptable behavior
Knee-length elastic support stockings are prescribed for a client with varicose veins. What should the nurse teach the client about the elastic stockings?
The stockings should be applied before getting out of bed.
The mother of a 2-year-old girl expresses concern that her daughter's growth rate has slowed. What should the nurse explain to the mother about the growth of toddlers?
This growth pattern is typical at this age
A client is hospitalized because of severe depression. The client refuses to eat, stays in bed most of the time, does not talk with family members, and will not leave the room. The nurse attempts to initiate a conversation by asking questions but receives no answers. Finally the nurse tells the client that if there is no response, the nurse will leave and the client will remain alone. How should the nurse's behavior be interpreted?
This threat is considered assault, and the nurse should not have reacted in this manner.
After working for a week with an adolescent with anorexia nervosa, the adolescent becomes hostile and says to the nurse, "You're just like my mother. I hate you." What concept does the client's statement reflect?
Transference
A client with dehydration suddenly becomes diaphoretic, clammy, and pale. The client's blood pressure falls to 50/30. The nurse should place the patient is what position?
Trendelenburg
A client is admitted with the diagnosis of possible myocardial infarction, and a series of diagnostic tests are prescribed. Which blood level should the nurse expect will increase first if this client has had a myocardial infarction?
Troponin T (cTnT)
A nurse's best approach when caring for a confused older client is to provide an environment with:
Trusting relationships
A nurse is assessing growth and development in a 6-month-old infant. What behaviors does the nurse expect the infant to demonstrate?
Turning over completely, sitting momentarily without support, and reaching to be picked up.
A client who is scheduled for a modified radical mastectomy decides to have family members donate blood in the event it is needed. The client has type A negative blood. Blood can be used from relatives whose blood is:
Type A or O negative..
When talking with a female client with a history of panic disorder who is displaying many of the emotional and physiological symptoms of a panic attack, the nurse should do what?
Use short sentences and an authoritative voice
While caring for a woman who has had a positive contraction stress test (CST), what complication does the nurse suspect?
Uteroplacental insufficiency
A nurse in the emergency department is assigned to care for four clients with serious health problems. Which health problem should the nurse identify as the priority?
Ventricular fibrillation
The nurse is caring for a client that experienced a myocardial infarction (MI). The nurse monitors for the most serious complication that occurs within 48 hours after an MI, which is:
Ventricular tachycardia
A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? Select all that apply.
Vomiting Muscle weakness Irregular heart rate
The serum lithium blood level of a client with a mood disorder, manic episode, is 2.3 mEq/L. What should the nurse expect when assessing this client?
Vomiting, diarrhea, and decreased coording
A client with the diagnosis of manic episode of bipolar disorder attends a mental health day treatment program. What supervised activity will be most therapeutic for this client during the early phase of treatment?
Walking around the facility with a nurse
A client was recently given a diagnosis of a manic episode of a bipolar I disorder. What activity is most therapeutic for this client at this time?
Walking around the unit with a nurse
A client with a history of heavy drinking is brought to a psychiatric facility in a stupor. On the day after admission the client is confused, disoriented, and delusional. The nurse concludes that the client may be experiencing alcoholic:
Withdrawal delirium
By identifying behaviors commonly exhibited by the client who has a diagnosis of schizophrenia, the nurse can anticipate:
Withdrawal, regressed behavior, and lack of social skills
After detoxification a client with a long history of alcohol abuse decides to attend Alcoholics Anonymous (AA) meetings at the hospital. On the day of the second meeting the client says, "I can't go to the AA meeting today because I'm expecting an important phone call." The most therapeutic response by the nurse is:
You are expected to go to the meeting.
A client who has severe anxiety starts to cry while talking with the nurse. The client is so upset that the crying becomes uncontrollable. What is the best response by the nurse?
"It's OK to cry; I'll just stay with you for now."
A client is admitted to the surgical unit with superficial wounds of both wrists, the result of a suicide attempt. When the nurse enters the room, the client says, "I suppose you're going to ask me about my suicide attempt." What is the best response by the nurse?
"Tell me how you feel about it."
A client with a bipolar mood disorder, manic episode, says to the nurse, "I don't know what I'm doing here. I never felt better in my life; I've got the world on a string around my finger." What is the nurse's most therapeutic response to this comment?
"You're feeling pretty elated right now."
Which instructions should the nurse include in the teaching plan for a client who will be taking simvastatin (Zocor) when discharged? Select all that apply.
- Avoid prolonged exposure to the sun. - Schedule regular ophthalmic examinations. - Contact your health care provider if skin becomes gray-bronze.
The nursing instructor determines that the student nurse understands the type(s) of hepatitis that most commonly are spread by consuming contaminated food and water or by fecal contamination if the student identifies which of the following? Select all that apply.
1. Hepatitis A 5. Hepatitis E
A nurse is performing cardiac compression on an adult client. How far must the nurse depress the lower sternum to maintain circulation until a defibrillator is available?
2 to 2 ½ inches
A nurse, planning care for a client who is an alcoholic, knows that the most serious life-threatening effects of alcohol withdrawal usually begin after a specific time interval. How many hours after the last drink do they occur?
24 to 72
Which intravenous fluid should the nurse classify as hypertonic?
5% dextrose in normal saline
Which client is considered at the highest risk for a dissecting aneurysm?.
55-year-old black male with uncontrolled hypertension
A client is seen in the clinic with sickle cell anemia. The hemoglobin range that is expected to be seen in this client in sickle cell crisis would be:
6--8g/100 mL
A client has been diagnosed with type 1 diabetes mellitus. When providing instructions on sharps disposal, the nurse should instruct the client to place the syringes in:
A plastic liquid detergent bottle with a screw-top lid
As a nurse prepares an older adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. What nursing action is most appropriate when targeting older adults' most frequent cause of falls?
instructing the client to call the nurse before going to the bathroom.
Postoperatively, a client asks the nurse, "Can I have a pillow under my knees? My legs feel stretched." What nursing response reinforces the client's preoperative teaching?
pillow under the knees slows blood flow and can cause clot formation."
The nurse is preparing to administer a subcutaneous dose of 15 units of lispro insulin (Humalog) to a client. Choose the proper syringe for this injection.
syringe 10-100
