Final Exam 203

The school nurse has provided an instructional session about impetigo to the parents of the children attending school. Which statement, if made by a parent, indicates a need for further instruction?

"Lesions most often are located on the arms and chest"

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. 1. Monitor vital signs. 2. Maintain NPO status. 3. Provide a safe environment. 4. Address hallucinations therapeutically. 5. Provide stimulation in the environment. 6.Provide reality orientation as appropriate

* 1. Monitor vital signs. * 3. Provide a safe environment. * 4. Address hallucinations therapeutically.. * 6.Provide reality orientation as appropriate

Identify the serum lithium level for maintenance and safety.

0.5-1.5

A 4-month-old infant is brought to the emergency department with severe dehydration. The heart rate is 180, blood pressure is 68/38. The infant's anterior fontanel is sunken. The nurse notes the infant does not cry when the intravenous line is inserted. The child's parents state she has not 'held anything down in 18 hours.' Which of the following does the nurse include in the plan of care? (Select all that apply). 1. Place the child on strict I&O. 2. Offer the child an oral rehydration solution such as Pedialyte. 3. Administer intravenous potassium supplement. 4. Provide supplemental oxygen therapy. 5. Administer a bolus of intravenous normal saline.

1 Place the child on strict I&O. 4. Provide supplemental oxygen therapy. 5. Administer a bolus of intravenous normal saline

A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse?: 1. "Are you having thoughts of suicide?" 2. "I am not sure I understand what you are trying to say." 3. "Try to stay hopeful. Things have a way of working out." 4. "Tell me more about what interested you before you became depressed."

1. "Are you having thoughts of suicide?"

A school nurse is speaking to the mother of a 16 year old male adolescent. The mother has concerns about her son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?: 1. "His favorite teacher committed suicide a few weeks ago." 2. "He has slept 9 hours each night for the past 2 years." 3. "He is very religious and attends services twice a week." 4. "He spends most of his time with his two school friends."

1. "His favorite teacher committed suicide a few weeks ago."

A client who has bipolar disorder is to be discharged home with a prescription for Lithium. Which statement indicates that the client has received effective teaching?: 1. "I should eat a regular diet with normal amounts of salts and fluids." 2. "I should discontinue the Lithium when I begin to feel better." 3. "I need to be careful to avoid becoming addicted to the Lithium." 4. "I can skip a dose of medication if my stomach is upset."

1. "I should eat a regular diet with normal amounts of salts and fluids."

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings does the nurse expect to note? Select all that apply. 1. Dental decay 2. Moist oily skin 3. Loss of tooth enamel 4. Electrolyte imbalances 5. Body weight well below ideal range

1. Dental decay 3. Loss of tooth enamel 4. Electrolyte imbalances

A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administer first?: 1. Diazepam 5 mg IV bolus 2. Clonidine 0.1 mg transdermal patch 3. Naltrexone 380 mg IM 4. Bupropion 150 mg PO

1. Diazepam 5 mg IV bolus

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? 1. Setting limits on the client's behavior 2. Asking the client to leave the group session 3. Asking another nurse to escort the client out of the group session 4. Telling the client that they will not be able to attend any future group session

1. Setting limits on the client's behavior

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1. The adolescent gives away a DVD and a cherished autographed picture of a performer 2. The adolescent runs out of the therapy group, swearing at the group leader, and to her room. 3. The adolescent becomes angry while speaking on the telephone and slams down the receiver 4. The adolescent gets angry with the roommate when the roommate borrows the client's clothes without asking

1. The adolescent gives away a DVD and a cherished autographed picture of a performer

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1. communicate expected behaviors to the client 2. ensure that the client knows that they are not in charge of the nursing unit 3. assist the client in identifying ways of setting limits on personal behaviors 4. follow through about the consequences of behavior in a non punitive manner 5. enforce rules by informing the client that he/she will not be allowed to attend therapy groups 6. have the client state the consequences for behaving in ways that are viewed as unacceptable

1. communicate expected behaviors to the client 3. assist the client in identifying ways of setting limits on personal behaviors 4. follow through about the consequences of behavior in a non punitive manner 6. have the client state the consequences for behaving in ways that are viewed as unacceptable

A nurse is performing a psychosocial assessment on an adolescent client. Which of the following should indicate to the nurse a potential risk for suicide? (Select all that apply): 1. death of a parent at a young age 2. recent or impending move 3. low parental expectations 4. volunteering at a community center after school 5. sudden decline in school performance

1. death of a parent at a young age 2. recent or impending move 3. low parental expectations 5. sudden decline in school performance

A client's medication sheet contains a prescription for sertraline. To ensure safe administration of the medication, how should the nurse administer the dose? 1. On an empty stomach 2. At the same time each evening 3. Evenly spaced around the clock 4. PRN when the client complains of depression

2. At the same time each evening

The nurse is teaching a client who is being started on imipramine about the medication. The nurse should inform the client to expect maximum desired effects at which time period following initiation of the medication? 1. In 2 months 2. In 2-3 weeks 3. During the first week 4. During the 6th week of administration

2-3 weeks

A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The client is doing calisthenics in the client dining room during lunchtime instead of eating. Which of the following statements should the nurse make?: 1. "You are already too thin and exercise is not good for you. Go sit down somewhere and eat something." 2. "Come with me. Here is a milkshake to drink." 3. "We need you to decide what activities you will do today." 4. "You will need to leave the dining room right now and go somewhere else to exercise."

2. "Come with me. Here is a milkshake to drink."

The nurse is monitoring a client for evidence of a hypoglycemic reaction. The client received Humulin R insulin at 7 AM. The nurse anticipates that the client will need to be most closely monitored for evidence of a hypoglycemic reaction at which time? 1. 3:00 PM to 6:00 PM 2. 9:00 AM to 11:00 AM 3. Noon to 3:00 PM 4. 8:00 PM to Midnight

2. 9:00 AM to 11:00 AM

After a change-of-shift report, which patient will the nurse assess first? 1. A 19-yr-old patient with type 1 diabetes who was admitted with dawn phenomenon 2. A 60-yr-old patient with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa 3. A 35-yr-old patient with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL 4. A 68-yr-old patient with type 2 diabetes who has severe peripheral neuropathy and reports burning foot pain

2. A 60-yr-old patient with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa

A nurse is reviewing medications for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following client prescriptions should the nurse realize is expected to reduce the client's mania?: 1. Fluvastatin 2. Carbamazepine 3. Lorazepam 4. Propranolol

2. Carbamazepine

A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? Select all that apply: 1. imbalanced nutrition: more than body requirements 2. disturbed thought processes 3. sleep deprivation 4. chronic confusion 5. social isolation

2. disturbed thought processes 3. sleep deprivation

The nurse is caring for a female client who was admitted to mental health until recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? 1. Interrupt the client and weigh her immediately 2. Interrupt the client and offer to take her for a walk 3. Allow the client to complete her exercise program 4. Tell the client that she is not allowed to exercise rigorously

2. Interrupt the client and offer to take her for a walk

A nurse is assessing a patient who has major depressive disorder and has been receiving Amitriptyline for 1 week. Which of the following should the nurse expect?: 1. rapid improvement in affect within 30-60 mins after taking the medication 2. greater risk of attempting suicide as affect and energy improve 3. onset of frequent loose stools 4. development of physiologic dependence on the medication

2. greater risk of attempting suicide as affect and energy improve

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?: 1. provide a stimulating environment 2. have consistent unit routines 3. discourage daytime napping 4. schedule daily seclusion times

2. have consistent unit routines

A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?: 1. watching a video with a group in the day room 2. walking with the nurse in the courtyard 3. participating in a basketball game in the gym 4. joining a group discussion about a local election

2. walking with the nurse in the courtyard

The plan of care for a patient in the manic state of bipolar disorder should include which interventions? Select all that apply: 1. touch the patient to provide reassurance 2. invite the patient to lead a community meeting 3. provide a structured environment for the patient 4. ensure that the patient's nutritional needs are met 5. design activities that require the patient's concentration

3. provide a structured environment for the patient 4. ensure that the patient's nutritional needs are met

A nurse is evaluating teaching for a client who has newly diagnosed depression and a new prescription for Bupropion. Which of the following statements by the client indicates understanding of the teaching?: 1. "I may develop a slow heartbeat while taking Bupropion." 2. "I can drink one glass of wine with dinner each day while taking Bupropion." 3. "I may not notice a lifting of my mood for at least 2 weeks." 4. "I should watch for increased salivation and drooling while taking Bupropion."

3. "I may not notice a lifting of my mood for at least 2 weeks."

A patient receives aspart (NovoLog) insulin at 8:00 AM. At which time would the nurse anticipate the highest risk for hypoglycemia? 1. 12:00 AM 2. 4:00 PM 3. 10:00 AM 4. 2:00 PM

3. 10:00 AM

After receiving a change-of-shift report about the following four patients, which should the nurse assess first? 1. A 53-year-old male patient who has Addison's disease and is due for a prescribed dose of hydrocortisone (Solu-Cortef) 2. A 22-year-old male patient admitted with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 130 mEq/L 3. A 70-year-old female patient taking levothyroxine (Synthroid) who has a new onset of irregular pulse of 134 4. A 31-year-old female patient with Cushing syndrome and a blood glucose level of 244 mg/dL

3. A 70-year-old female patient taking levothyroxine (Synthroid) who has a new onset of irregular pulse of 134

A nurse in a mental health clinic is caring for a patient who has bipolar disorder and reports that she stopped taking Lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the patient to stop taking the medication?: 1. sore throat 2. photophobia 3. hand tremors 4. constipation

3. hand tremors

A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? 1. Place the client in seclusion for 30 minutes 2. Tell the client that the behavior is inappropriate 3. Escort the client to their room, with the assistance of other staff 4. Tell the client that their telephone privileges are revoked for 24 hours

3. Escort the client to their room, with the assistance of other staff

What information will a review of a patient's glycosylated hemoglobin (A1C) results provide to the nurse? 1. Glucose levels 2 hours after a meal 2. Fasting pre-prandial glucose levels 3. Glucose control over the past 90 days 4. Hypoglycemic episodes in the past 3 months

3. Glucose control over the past 90 days

The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?: 1. auditory hallucinations 2. delusions of grandeur 3. poor personal hygiene 4. psychomotor agitation

3. poor personal hygiene

A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?: 1. the client's spouse reports that the client has recently gained weight 2. the client is dressed in all black 3. the client responds to questions with disorganized speech 4. the client reports that voices are telling him to write a novel

3. the client responds to questions with disorganized speech

A nurse in an acute mental health facility is assessing a client who has bipolar disorder. Which of the following findings indicates the client is at risk for suicide?: 1. the client has begun playing basketball with several other clients during the past month 2. the client identifies with problems expressed by other clients 3. the client's behavior has become impulsive in the past few weeks 4. the client states that she wants to go home to be with her children and partner

3. the client's behavior has become impulsive in the past few weeks

Which client behavior validates the need for involuntary hospitalization?: 1. beliefs about FBI surveillance 2. diagnosis of schizophrenia 3. violence towards father 4. guarded and suspicious

3. violence towards father

A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next? 1. Prepare for endotracheal intubation. 2. Begin thyroid hormone replacement. 3. Plan for emergency tracheostomy. 4. Administer IV calcium gluconate.

4. Administer IV calcium gluconate.

The nurse is caring for a patient who has a massive burn injury and possible hypovolemia. Which assessment data should be of most concern to the nurse? 1. Oral fluid intake is 100 mL for 8 hours. 2. Skin tenting over the sternum is prolonged. 3. Urine output is 30 mL/hr. 4. Blood pressure is 90/40 mm Hg.

4. Blood pressure is 90/40 mm Hg.

A client with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication? 1.) "You have everything to live for" 2.) "Why do you see yourself as a failure?" 3.) "Feeling like this is all part of being depressed" 4.) "You've been feeling like a failure for a while?"

4.) "You've been feeling like a failure for a while?"

A nurse is planning care for a patient who is to undergo electroconvulsive therapy (ECT). Which actions should be included in the plan of care?: 1. administer Phenytoin 30 min prior to the procedure 2. instruct the client to expect a headache following the procedure 3. place the client in four point restraints prior to the procedure 4. monitor the client's cardiac rhythm during the procedure

4. monitor the client's cardiac rhythm during the procedure

The nurse is administering risperidone to a client who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client? 1. Get adequate sunlight 2. Continue driving as usual 3. Avoid foods rich in potassium 4. Get up slowly when changing positions

4. Get up slowly when changing positions

When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse plans care based on the purpose of this approach? 1. Providing a supportive environment 2. Examining intrapsychic conflicts and past issues 3. Emphasizing social interaction with clients who withdraw 4. Helping the client to examine dysfunctional thoughts and beliefs

4. Helping the client to examine dysfunctional thoughts and beliefs

A nurse in a primary care clinic is assessing a client who take lithium carbonate (Lithotabs.) for the treatment of bipolar disorder. The nurse should recognize which of the following findings as a possible indication of toxicity to this medication? A. Severe hypertension B. Coarse tremors C. Constipation D. Urinary retention

B. Coarse tremors

The health care provider diagnoses impetigo in a patient who has crusty vesicopustular lesions on the lower face. Which instructions should the nurse include in the teaching plan?

Clean the infected areas with soap and water

A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patient's arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness

D) Full-thickness

A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol? A. Chlordiazepoxide (Librium) B. Bupropion (Zyban) C. Disulfiram (Antuse) D. Carbamazepine (Tegretol)

Disulfram

what is the number one sign of portal hypertension

GI bleeding

Identify behaviors that would appropriately describe the following statement made by an experienced nurse in a mentoring role. "I want to convey to my patients that I am interested in them and that I want to listen to what they have to say."

Rapport and trust with the nurse

what is the number one cause of gastroenteritis

Rotavirus

A nurse in a provider's office is assessing a client who has severe sunburn. Which of the following classifications should the nurse use to document this burn? Superficial thickness Superficial partial thickness Deep partial thickness Full thickness

Superficial thickness

Which focused data should the nurse assess after identifying 4+ pitting edema on patient who has cirrhosis? a. Hemoglobin b. Temperature c. Activity level d. Albumin level

albumin level

Which is an accurate description of a Kasai procedure? a. A palliative procedure in which the bile duct is attached to a loop of bowel to assist with bile drainage. b. A curative procedure in which the bile duct to avoid liver transplant. 6. A curative procedure in which the bile duct is banded to prevent bile leakage. d. A palliative procedure in which the bile duct is banded to prevent bile leakage.

a. A palliative procedure in which the bile duct is attached to a loop of bowel to assist with bile drainage.

Which manifestation would the nurse expect to see in a 4-week-old infant with biliary atresia in the early phase? a. Abdominal distention, dark yellow urine, jaundiced sclera, and hepatomegaly. b. Abdominal distention, multiple bruises, bloody stools, and hematuria. c. Jaundiced sclera and skin tones, excessively oily skin, and prolonged bleeding times. d. Splenomegaly and irritability.

a. Abdominal distention, dark yellow urine, jaundiced sclera, and hepatomegaly.

A 7-month-old is admitted to the pediatric unit following a surgical repair for a cleft lip and palate. The nurse is preparing a plan of care. Which of the following are to be included? (Select all that apply) a. Application of elbow immobilizers. b. Analgesia for pain management. c. Feeding resumed when tolerated. d. Rectal temperature checks. e. Oral pacifiers for restlessness.

a. Application of elbow immobilizers. b. Analgesia for pain management. c. Feeding resumed when tolerated. d. Rectal temperature checks.

Which action should the nurse take to evaluate effectiveness of Buck's traction for a patient who has an intracapsular fracture of the right femur? a. Assess for hip pain b. Check for contractures c. Palpate peripheral pulses d. Monitor for hip dislocation

a. Assess for hip pain

A nurse is caring for an infant diagnosed with Hirschsprung disease. Which of the following clinical manifestations would the nurse anticipate? (Select all that apply) a. Constipation. b. Ribbonlike, foul-smelling stools. c. Abdominal Distention. d. Visible peristalsis. e. Easily palpable fecal mass.

a. Constipation. b. Ribbonlike, foul-smelling stools. c. Abdominal Distention. d. Visible peristalsis. e. Easily palpable fecal mass.

Nurse educators in the orthopedic trauma unit are reviewing safe and effective use of traction with some recent nursing graduates. What principle should the educator promote? a. Knots in the rope should not be resting against pulleys b. Weights should rest against the bed rails c. End of the limb in traction should be braced by the footboard of the bed d. Skeletal traction may be removed for brief periods to facilitate patient's independence

a. Knots in the rope should not be resting against pulleys

A patient who had open reduction and internal fixation (ORIF) of left lower leg fractures continued to report severe pain in the leg 15 minutes after receiving prescribed IV morphine. The nurse determines pulses are faintly palpable and the foot is cool to touch. Which action should the nurse take next? a. Notify health care provider b. Assess the incision for redness c. Reposition the left leg on pillows d. Check the patient's blood pressure

a. Notify health care provider

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? a. Patient is alert and oriented b. Patient denies nausea or anorexia c. Patient's bilirubin level decreases d. Patient has at least one stool daily

a. Patient is alert and oriented

Which patient should the nurse assess first after receiving a change-of-shift report? a. Patient with esophageal varices who has rapid heart rate b. Patient with history of gastrointestinal bleeding who has melena c. Patient with nausea who has dose of metoclopramide (Reglan) due d. Patient who is crying after diagnosis of esophageal cancer

a. Patient with esophageal varices who has rapid heart rate

A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (select all) a. auditory hallucination b. lack of motivation c. use of clang associations d. delusion of persecution e. constantly waving arms f. flat affect

a. auditory hallucination c. use of clang associations d. delusion of persecution e. constantly waving arms

What behaviors are expected to be displayed by a patient diagnosed with bipolar disorder in the manic phase in social interactions?

abnormally upbeat, jumpy, or wired increased activity, energy, or agitation exaggerated sense of well-being & self-confidence/euphoria

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is least likely to be helpful to this client at this time?

acknowledge the client's behaviors assist the client to an area that is quiet maintain a safe distance from the client

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first?

auscultate the patient's lungs

​​A patient diagnosed with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene, avolition and motor agitation. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?

avolition & poor personal hygiene

A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following responses should the nurse make? a. "Why do you think you feel the need to give money away?" b. "I am here to provide care and cannot accept this from you" c. "I can request that your case manager discuss appropriate charity options with you" d. "You should know that giving away your money is inappropriate"

b. "I am here to provide care and cannot accept this from you"

​​After the change of shift report, which patient will the nurse assess first? a. 40-year-old woman whose parenteral nutrition infusion bag has 30 minutes of solution left b. 30-year-old man with continuous enteral feedings who has developed pulmonary crackles c. 30-year-old man with 4t generalized pitting edema and severe protein- calorie malnutrition d. 30-year-old woman whose gastrostomy tube is plugged after crushed medications were administered

b. 30-year-old man with continuous enteral feedings who has developed pulmonary crackles

What action should the nurse complete before administering alendronate (Fosamax) to a patient with osteoporosis? a. Ask about any leg cramps or hot flashes b. Assist patient to sit up at the bedside c. Be sure the patient has recently eaten d. Administer the ordered calcium carbonate

b. Assist patient to sit up at the bedside

The patient's lithium level is 3.5 mEq/L. What interventions should the nurse anticipate when the provider is notified of this level? Select all that apply. a. No intervention is needed because this is a therapeutic level. b. Augment lithium excretion using aminophylline, mannitol, or urea. c. Gastric lavage to remove oral lithium d. Monitor and assist respiratory and circulatory systems. e. Hemodialysis may be ordered to augment removal from the circulatory system. f. IV fluids containing saline and electrolytes

b. Augment lithium excretion using aminophylline, mannitol, or urea. c. Gastric lavage to remove oral lithium d. Monitor and assist respiratory and circulatory systems. e. Hemodialysis may be ordered to augment removal from the circulatory system. f. IV fluids containing saline and electrolytes

A nurse is assessing an infant admitted to the pediatric unit with suspected hypertrophic pyloric stenosis. Which of the following findings would the nurse expect to see? (Select all that apply) a. Steady weight gain since birth. b. Chronic hunger. c. Projectile vomiting after feedings. d, Distended upper abdomen. f. Visible gastric peristaltic waves.

b. Chronic hunger. c. Projectile vomiting after feedings. d, Distended upper abdomen.

The nurse is performing a sterile dressing change on a postoperative client. Which actions would indicate that sterile technique has been broken? (Select all that apply). a. Cleaning the wound from the midline to outer edges. b. Cleaning the wound from outer edges to midline. c. Lipping the normal saline bottle. d. The patient touches the nurse's gloved hand. e. A piece of dust falls on the sterile field when the air conditioning kicks on.

b. Cleaning the wound from outer edges to midline. d. The patient touches the nurse's gloved hand. e. A piece of dust falls on the sterile field when the air conditioning kicks on.

Patient with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relation to the patient's cast care? a. Cover cast with a blanket until cast dries b. Keep your right leg elevated above heart level c. Use a clean object to scratch itches inside the cast d. A foul smell from the cast is normal after the first few days

b. Keep your right leg elevated above heart level

Nurse is caring for a patient who has cirrhosis. Which data obtained by a nurse during assessment will be of most concern? a. Patient reports right upper quadrant pain with palpation b. Patient's hands flap back and forth when arms are extended c. Patient has ascites and a 2kg weight gain from previous day d. Patient's abdominal skin has multiple spider-shaped blood vessels

b. Patient's hands flap back and forth when arms are extended

What action should a nurse take after assisting with a needle biopsy of the liver at the patient's bedside? a. Elevate head of the bed to facilitate breathing b. Place patient on right side with bed flat c. Check patient's post-biopsy coagulation studies d. Position a sandbag over the liver to provide pressure

b. Place patient on right side with bed flat

A nurse is caring for an infant with a confirmed diagnosis of cleft lip and palate. The nurse is creating a plan of care for the infant. Which of the following are included? (Select all that apply). a. Explain to the mother it is best for her to observe the nurse feed the infant. b. Position the infant in an upright position for feedings. c. Pause during feedings to burp the infant. d Use a tongue blade to assess the palate for bleeding. e. Utilize a bottle with a narrow-based nipple.

b. Position the infant in an upright position for feedings. c. Pause during feedings to burp the infant.

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (Select all that apply) a. use caffeine in moderation to prevent relapse b. difficulty sleeping can indicate a relapse c. begin taking your medications as soon as a relapse begins d. participating in psychotherapy can help prevent a relapse e. anhedonia is a clinical manifestation of a depressive relapse

b. difficulty sleeping can indicate a relapse d. participating in psychotherapy can help prevent a relapse e. anhedonia is a clinical manifestation of a depressive relapse

Describe treatment of a patient that is suffering from delirium tremens.

begins at the hospital after 48 hours of last drink give a benzo to calm the hyperactive CNS can also benefit from IV fluids with vitamins and minerals due to dehydration & f&e loss

A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding? a. "ECT is the recommended initial treatment for bipolar disorder" b. "ECT is contraindicated for clients who have suicide ideation" c. "ECT is effective for clients who are experiencing severe mania" d. "ECT is prescribed to prevent relapse of bipolar disorder"

c. "ECT is effective for clients who are experiencing severe mania"

​​During the change of shift report, the nurse learns about the following four patients. Which patient requires assessment first? a. 58-year-old patient who has compensated cirrhosis and reports anorexia b. 40-year-old patient with chronic pancreatitis who has gnawing abdominal pain c. 55-year-old patient with cirrhosis and ascites who has oral temperature of 102-degree F d. 36-year-old patient recovering from laparoscopic cholecystectomy who has shoulder pain

c. 55-year-old patient with cirrhosis and ascites who has oral temperature of 102-degree F

Which information should the nurse include in discharge instructions for patients with comminuted left forearm fractures and a long-arm cast? a. Keep left shoulder elevated on pillow or cushion b. Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) c. Call health care provider for numbness of the hand d. Keep hand immobile to prevent soft tissue swelling

c. Call health care provider for numbness of the hand

Nurse is caring for a patient who has a leg cast. The nurse observes that the patient uses a pencil to scratch skin under the edge of the cast. How should the nurse respond to this observation? a. Allow patient to continue to scratch inside cast with a pencil but encourage him to be cautious b. Give patient sterile tongue depressor to use for scratching instead of pencil c. Encourage patient to avoid scratching, and obtain order for antihistamine if severe itching persists d. Obtain order for sedative, such as lorazepam (Ativan), to prevent patient from scratching

c. Encourage patient to avoid scratching, and obtain order for antihistamine if severe itching persists

The parent of a 5-year-old states that the child has been having diarrhea for 24 hours, vomited twice 2 hours ago, and now claims to be thirsty. The parent asks what to offer the child because the child is refusing Pedialyte. Select the nurse's most appropriate response. a. You can offer clear diet soda such as Sprite. b. Pedialyte is really the best thing for your child, who if thirsty enough, will eventually drink it. c. Pedialyte is really the best thing for your child. Allow your child choices in the way to take it such as offering small amounts in a medicine cup. d. It really does not matter what your child drinks as long as it is kept down.

c. Pedialyte is really the best thing for your child. Allow your child choices in the way to take it such as offering small amounts in a medicine cup.

When a patient arrives in the emergency department with a facial fracture, which action should the nurse take first? a. Assess for nasal bleeding and pain b. Apply ice to the face to reduce swelling c. Use cervical collar to stabilize the spine d. Check patient's alertness and orientation

c. Use cervical collar to stabilize the spine

A hospitalized client is started on phenelzine for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply. A. Figs B. Yogurt C. Crackers D. Aged cheese E. Tossed Salad F. Oatmeal raisin cookies

crackers & salad

A nurse in an acute mental health facility is caring for a client who has bipolar disorder. Which of the following is the priority nursing action? a. set consistent limits for expected client behavior b. administer prescribed medications as scheduled c. provide the client with step-by-step instructions during hygiene activities d. monitor the client for escalating behavior

d. monitor the client for escalating behavior

symptoms of pyloric stenosis

dehydration f&e imbalance weight loss puking small stools

How is rotavirus transmitted?

fecal-oral

only one way to get rid of the barium in the bowel

increase fluids

Why is feces in pyloric stenosis not bile colored?

it doesnt pass into the small intestine

positioning for colonscopy

left lateral position

what does cullens sign mean

pancreatitis

What to watch for when increasing buopropion

seizure activity

A nurse is teaching a client who has depression about electroconvulsive therapy (ECT). Which of the following information should the nurse include in the teaching?: 1. temporary memory loss is the most common adverse effect of ECT 2. medications are given to prevent seizure activity during ECT 3. the greatest risk of ECT is brain damage 4. ECT is effective in the treatment of substance use disorders

temp. memory loss

Know how to know rather or not patient understands teaching regarding application of corticosteroid cream to area of contact dermatitis

thinning of the skin is normal they do not use neosporin apply creams in a thin layer only side effects specific to safety

What are symptoms that would indicate acute dystonic reaction to antipsychotic medications?

tilted head w tongue & lower jaw stuck out w drooling NOT relaxation of the pharynx

A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings?: 1. amenorrhea 2. lanugo 3. cold extremities 4. tooth erosion

tooth erosion

A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg orally twice daily for 3 weeks. What symptoms if assessed by the nurse would indicate Pseudoparkinsonism?

tremor mask-like facies drooling rigidity stiff gait NOT hypertension or hyperthermia

How to do therapeutic communication

use open-ended questions then silence

Charge nurse is watching new nurse care for burn patient, know if seen which action new nurse does requires immediate intervention by charge nurse

use sterile gloves only to care for a burn wound NOT clean gloves

What are the behaviors of patients that would most likely be admitted involuntarily to a psychiatric unit?

violence against self or others

The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and the effect is belligerent. Based on these observations, which is the nurse's immediate priority of care? 1. Provide safety for the client and other clients on the unit 2. Provide the clients on the unit with a sense of comfort and safety. 3. Assist the staff in caring for the client in a controlled environment 4. Offer the client a less stimulating area in which to calm down and gain control

1. Provide safety for the client and other clients on the unit

A nurse is admitting a patient who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care?: 1. encourage the client to drink 125 mL of fluid each hour while awake 2. allow the client to eat independently in his room 3. weight the client twice weekly 4. measure the client's vital signs once each day

1. encourage the client to drink 125 mL of fluid each hour while awake

A nurse is caring for a client who is to undergo electroconvulsive therapy (ECT) for the treatment of depression. Which of the following actions should the nurse take prior to the scheduled ECT? (Select all that apply): 1. request an ECG 2. witness the informed consent 3. check the client's blood pressure 4. obtain a serum parathyroid hormone level 5. obtain a urine specimen

1. request an ECG 2. witness the informed consent 3. check the client's blood pressure

A nurse is caring for a client who has bipolar disorder. Which of the following actions by the nurse should the nurse interpret as displaying manic behavior? (Select all that apply): 1. talking in rapid, continuous speech 2. interacting with others in a flirtatious way 3. spending large sums of money 4. sleeping for long periods of time 5. dressing in black or gray clothing

1. talking in rapid, continuous speech 2. interacting with others in a flirtatious way 3. spending large sums of money

A nurse is caring for a client who has bipolar disorder and is taking Lithium. The client reports blurred vision and ataxia. Which of the following actions should the nurse take?: 1. withhold the medication 2. prepare to administer Propranolol 3. administer the next dose as prescribed 4. plan to administer Levothyroxine

1. withhold the medication

A nurse is preparing a teaching plan for a female client who has bipolar disorder and a new prescription for carbamazepine. Which of the following instructions should the nurse include in the teaching?

"Eliminate grapefruit juice from your diet." "You will need to have a complete blood count and carbamazepine levels drawn periodically." "Notify your provider if you develop a rash." "Avoid driving for the first few days after starting this medication."

A nurse is counseling several patients. Which of the following patient statements should the nurse identify as expected for factitious disorder imposed on another? A. "I had to pretend I was injured to get disability benefits." B. "I know that my abdominal pain is caused by a malignant tumor." C. "I needed to make my child sick so that someone else would take care of them for a while." D. "I became deaf when I heard that my partner was having an affair with my best friend."

"I needed to make my child sick so that someone would take care of them for a while."

​​The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 1. "You need to stop that behavior now." 2. "You will need to be placed in seclusion." 3. "You seem restless; tell me what is happening." 4. "You will need to be restrained if you do not change your behavior."

. "You seem restless; tell me what is happening."

A client is to receive Humalog (Lispro) insulin at breakfast. The nurse plans to administer the insulin _____ breakfast. 1. 30 minutes after 2. 5 minutes before 3. 30 minutes before 4. 15 minutes after

. 5 minutes before

The nurse observes that a client with bipolar disorders is pacing in the hall, talking loudly and rapidly and using elaborate hand gestures. The nurse concludes that the client is demonstrating which of the following A. Aggression B. Anger C. Anxiety D. Psychomotor agitation

. Psychomotor agitation

A nurse on a med-surg unit is assessing a patient who sustained injuries 12 hrs ago following a motor-vehicle crash. The blood alcohol level was 325 mg/dL. Which of the following findings indicate the client is experiencing alcohol withdrawal?: 1. somnolence 2. blood pressure 154/96 mm Hg 3. pinpoint pupils 4. blood glucose 210 mg/dL

. blood pressure 154/96 mm Hg

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for Lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause Lithium toxicity?: 1. experiencing diarrhea 2. exercising moderately 3. increasing sodium intake 4. drinking green tea

. experiencing diarrhea

A nurse is reviewing routine labs for several patients who are taking lithium carbonate. Which of the following clients should be further assessed for findings indicating lithium toxicity?: 1. a client who has a fasting blood glucose of 80 mg/dL 2. a client who has a sodium level of 128 mEq/L 3. a client who has a BUN of 18 mg/dL 4. a client who has a potassium level of 3.6 mEq/L

2. a client who has a sodium level of 128 mEq/L

A charge nurse is admitting a client who has bipolar disorder and who is in the manic phase. Which of the following room assignments should the nurse give the client?: 1. a semi-private room across from the day room 2. a private room across the nurse's station 3. a private room across from the exercise room 4. a semi-private room across from the snack area

2. a private room across the nurse's station

A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as: 1. echolalia 2. an idea of reference 3. a delusion of infidelity 4. an auditory hallucination

2. an idea of reference

A nurse is caring for a client who has bipolar disorder. The client states, "I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator." Which of the following findings is this client exhibiting?: 1. flight of ideas 2. grandiosity 3. reality testing 4. derealization

2. grandiosity

A nurse is caring for a group of clients in an acute mental health facility. Which of the following clients has the legal right to refuse treatment?: 1. a 16-year-old client whose parents have requested treatment 2. an adult client who has delusions and refuses treatment for religious reasons 3. an older adult client who was voluntarily admitted 4. a client who is competent but was involuntary admitted

3. an older adult client who was voluntarily admitted

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder?: 1. delusions 2. neologisms 3. anhedonia 4. echopraxia

3. anhedonia

A nurse is caring for a client who has bipolar disorder and a new prescription for Valproate. Which of the following instructions should the nurse give the client about the use of this medication?: 1. thyroid function tests should be performed every 6 months 2. a pretreatment electroencephalogram (EEG) will be done "of this medication?: 1. thyroid function tests should be performed every 6 months 2. a pretreatment electroencephalogram (EEG) will be done 3. liver function tests must be monitored 4. high serum sodium levels can cause toxic levels of Valproate

3. liver function tests must be monitored

A nurse is planning care for a patient who has bipolar disorder and is experiencing mania. Which intervention should the nurse include in the plan of care?: 1. encourage the client to participate in group therapy 2. instruct the client to avoid napping during the day 3. offer the client high-calorie finger foods frequently 4. decrease the client's daily fiber intake

3. offer the client high-calorie finger foods frequently

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? SATA A delay in growth may occur after a burn injury An immature immune system presents an increased risk of infection for infants and young children. Infants and young children are at increased risk for protein and calorie deficiency, because they have smaller muscle mass and less body fat than adults.

A delay in growth may occur after a burn injury An immature immune system presents an increased risk of infection for infants and young children. Infants and young children are at increased risk for protein and calorie deficiency, because they have smaller muscle mass and less body fat than adults.

When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? SATA An irregularly shaped lesion A small papule with a dry, rough scale A firm, nodular lesion topped with crust A pearly papule with a central crater and a waxy border Location in the bald spot atop the head that is exposed to outdoor sunlight

A pearly papule with a central crater and a waxy border Location in the bald spot atop the head that is exposed to outdoor sunlight

A patient has a new order for carbamazepine (Tegretol). What does the nurse know is a contraindication to administration of carbamazepine? A) Bone marrow depression B) Bipolar disorder C) Allergy to sulfonamides D) Diabetes

A) Bone marrow depression

The nurse is collecting assessment data on a client who is suspected to be a victim of violence. Which assessment data would support the suspicion that the client is a victim of abuse? Select all that apply. A) The client has few friends. B) The client holds a dominant role in the family. C) The client is in charge of the family finances. D) There is a moderate amount of alcohol use in the home. E) The client reports that the father was abusive during childhood.

A) The client has few friends. D) There is a moderate amount of alcohol use in the home. E) The client reports that the father was abusive during childhood.

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? SATA A. Restating B. Active listening C. Asking the client why D. Maintaining neutral responses E. Providing acknowledgement and feedback F. Giving advice and approval or disapproval

A, B, D, E

A nurse is assessing a patient who has generalized anxiety disorder. Which of the following findings should the nurse expect? SATA A. Excessive worry for 6 months B. Impulsive decision making C. Delayed Reflexes D. Restlessness E. Sleep disturbance

A, D, E

A nurse is providing discharge teaching to a client who is to begin taking fluoxetine (Prozac) for posttraumatic stress disorder. Which fo the following statements is appropriate for the nurse to include in the teaching? A. "You may have a decreased desire for intimacy while taking this medication." B. "You should take this medication at bedtime to help promote sleep." C. "You will have fewer urinary adverse effects if you urinate just before taking this medication." D. "You'll need to wear sunglasses when outdoors due to the light sensitivity caused by this medication."

A. "You may have a decreased desire for intimacy while taking this medication."

A client with bipolar disorder begins taking lithium carbonate (lithium), 300 mg four times a day. After 3 day of therapy, the client says, "My hands are shaking." The best response by the nurse is which of the following? A. "fine motor tremors are in early effect of lithium therapy than usually subsides in a few weeks" B. "It is nothing to worry about unless it continues for the next month" C. "Tremors can be an early sign of toxicity, but we'll keep monitoring your lithium level to make sure you're okay" D. "You can expect tremors with lithium. You seem very concerned about such a small tremor"

A. "fine motor tremors are in early effect of lithium therapy than usually subsides in a few weeks"

Which of the following would indicate an increase suicidal risk? select all that apply A. An abrupt Improvement in mood B. Calling family members to make amends. C. Crying when discussing sadness D. Feeling overwhelmed by simple daily tasks. E. Statements such as "I'm such a burden for everyone." F. Statements such as "everything will be better soon"

A. An abrupt Improvement in mood B. Calling family members to make amends. F. Statements such as "everything will be better soon"

A nurse is preparing to perform a follow-up assessment on a client who takes chlorpromazine (Thorazine) for the treatment of schizophrenia. The nurse should expect to find the greatest improvement in which of the following manifestations? (Select all that apply.) A. Disorganized speech B. Bizarre behavior C. Impaired social interactions D. Hallucinations E. Decreased motivation

A. Disorganized speech B. Bizarre behavior D. Hallucinations

A charge nurse is planning a staff education session to discuss medications used during the care of a client experiencing alcohol withdrawal. Which if the following medications should the charge nurse include in the discussions? (select all that apply) A. Lorazepam B. Diazepam C. Disulfiram D. Naltrexone E. Acamprosate

A. Lorazepam B. Diazepam

A nurse is caring for a client who has a new prescription for phenelzine (Nardil) for the treatment of depression. Which of the following indicates that the client is experiencing an adverse effect of this medication? A. Orthostatic hypotension B. Respiratory depression C. Gastrointestinal bleeding D. Weight loss

A. Orthostatic hypotension

A nurse is reviewing laboratory findings and notes that a client's plasma lithium level is 2.1 mEq/L. Which of the following is an appropriate action by the nurse? A. Perform immediate gastric lavage. B. Prepare the client for hemodialysis. C. Administer an additional oral dose of lithium. D. Request a stat repeat of the laboratory test.

A. Perform immediate gastric lavage.

What are the most common types of side effects from SSRIs? A. dizziness, drowsiness, and dry mouth B. convulsions and respiratory difficulties C. diarrhea and weight gain D. jaundice and agranulocytosis

A. dizziness, drowsiness, and dry mouth

Which of the following activities would be appropriate for a client with mania? select all that apply A. drawing a picture B. modeling clay C. playing bingo D. playing table tennis E. stretching exercises F. stringing beds

A. drawing a picture B. modeling clay E. stretching exercises

Which of the following typifies the speech of a person in the acute phase of mania? A. flight of ideas B. Psychomotor retardation C. Hesitant D. Mutism

A. flight of ideas

A client with mania begins dancing around the room. When she twirled her skirt in front of the male client's, it was obvious she had no underpants on. The nurse distracts her and takes her in the room to put on underpants. The nurse acted as she did to A. minimize the client's embarrassment about her present behavior B. keep her from dancing with other client's C. avoid embarrassing the male client's who are watching D. teach her about proper attire and hygiene

A. minimize the client's embarrassment about her present behavior

A patient has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the patient's subsequent care? A) Teaching the patient to safely and effectively administer immunosuppressants B) Helping the patient identify and avoid the offending agent C) Teaching the patient how to maintain meticulous skin hygiene D) Helping the patient perform wound care in the home environment

B) Helping the patient identify and avoid the offending agent

A school nurse has sent home four children who show evidence of pediculosis capitis. What is an important instruction the nurse should include in the note being sent home to parents? A) The child's scalp should be monitored for 48 to 72 hours before starting treatment. B) Nits may have to be manually removed from the child's hair shafts. C) The disease is self-limiting and symptoms will abate within 1 week. D) Efforts should be made to improve the child's level of hygiene.

B) Nits may have to be manually removed from the child's hair shafts

A nurse is providing teaching for a male client who has schizophrenia and is taking risperidone. Which of the following instructions should the nurse include in the teaching? A. "Add extra snacks to your diet to prevent weight loss." B. "Notify the provider if you develop trouble sleeping C. "You may begin to have mild seizures while taking this medication" D. "This medication is likely to increase your libido"

B. "Notify the provider if you develop trouble sleeping

1. A nurse is teaching a client who has schizophrenia strategies to cope with anticholinergic effects of fluphenazine. Which of the following should the nurse suggest to the client to minimize anticholinergic effects? A. Take the medication in the morning to prevent insomnia. B. Chew sugarless gum to moisten the mouth. C. Use cooling measures to decrease fever. D. Take an antacid to relieve nausea.

B. Chew sugarless gum to moisten the mouth.

A nurse is providing teaching to a family of a client who has substance use disorder. Which of the following statements by a family member indicated understanding of the teaching? Select all that apply A. We need to understand that she is responsible for her disorder B. Eliminating any codependent behavior will promote her recovery C. She should participate in an al-anon group to help her recover D. The primary goal of her treatment is abstinence from substance use E. She needs to discuss her feelings about substance used to help her recover

B. Eliminating any codependent behavior will promote her recovery D. The primary goal of her treatment is abstinence from substance use E. She needs to discuss her feelings about substance used to help her recover

A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following is an expected finding? (Select all that apply.) A. Bradycardia B. Fine tremors of both hands C. Hypotension D. Vomiting E. Restlessness

B. Fine tremors of both hands D. Vomiting E. Restlessness

A nurse is involved in a serious prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder? (select all that apply) A. Avoid thinking about the incident when it is over B. Take breaks during the incident for food and water C. Debrief with others following the incident D. Avoid displays of emotion in the days following the incident. E. Take advantage of offered counseling

B. Take breaks during the incident for food and water C. Debrief with others following the incident E. Take advantage of offered counseling

The nurse is applying a topical corticosteroid to a client with eczema. The nurse understands that it is safe to apply the medication to which body areas? SATA Back Axilla Eyelids Soles of feet Palms of the hands

Back Soles of feet Palms of the hands

Which group of medications should the nurse expect to be used in the treatment of patients with acute anxiety?

Benzos

The pharmacology instructor is discussing drugs used for the treatment of partial seizures. What accurately describes the physiological action of carbamazepine? A) Reduces electrical activity B) Alters sodium and calcium channels C) Increases gamma-aminobutyric acid (GABA) activity and blocks sodium and calcium channels to stop action potentials D) Depresses conduction in the brainstem and cortex

C) Increases gamma-aminobutyric acid (GABA) activity and blocks sodium and calcium channels to stop action potentials

A charge nurse on a mental health unit is discussing client rights with a newly licensed nurse. Which of the following statements should the charge nurse make? A. "Clients can't refuse to take medications if they are admitted involuntarily." B. "You can notify a client's family if they are admitted involuntarily." C. "Clients who are admitted involuntarily maintain the right to give informed consent for procedures." D. "You can remove a client's privileges if they are admitted involuntarily and refuse to attend therapy sessions."

C. "Clients who are admitted involuntarily maintain the right to give informed consent for procedures."

A nurse is providing teaching to a client who has a new prescription for amitripyline (Elavil) for treatment of depression. Which of the following should the nurse include in the teaching? (Select all that apply.) A.Expect therapeutic effects in 24 to 48 hours. B. Discontinue the medication after a week of improved mood. C. Change positions slowly to minimize dizziness. D. Decrease dietary fiber intake to control diarrhea. E. Chew sugarless gum to prevent dry mouth.

C. Change positions slowly to minimize dizziness. E. Chew sugarless gum to prevent dry mouth.

A patient in an inpatient unit is awake at one a.m. and tells the nurse, "I can't sleep because of the light in the hall and the noise from the kitchen. I need to have another sleeping pill." What is the most appropriate nursing intervention? A. Administer PRN sedative B. Move the client to a quieter room C. Close the door to the client's room D. Allow the client to watch television for one hour

C. Close the door to the client's room

The patient who has a diagnosis of bipolar disorder has a new order for carbamazepine. What laboratory results should the nurse check?

CBC AST/ALT bone marrow density

A nurse is caring for a client who has a new prescription for lithium carbonate (Lithobid). When teaching the client about ways to prevent lithium toxicity, the nurse should advise the client to do which of the following? A. Avoid the use of acetaminophen for headaches. B. Restrict intake of foods rich in sodium. C. Decrease fluid intake to less than 1,500 mL daily. D. Limit aerobic activity in hot weather.

D. Limit aerobic activity in hot weather.

What is the rationale for a person taking lithium to have enough water and salt in his or her diet? A. salt and water are necessary to dilute lithium to avoid toxicity. B. Water and salt convert lithium into a usable solute. C. Lithium is metabolized in the liver, necessitating increased water and salt. D. Lithium is a salt that has a greater affinity for receptor sites than sodium chloride.

D. Lithium is a salt that has a greater affinity for receptor sites than sodium chloride.

The nurse in the ER receives a patient who sustained a severe burn injury. What is the priority action by the nurse in this situation? Establish a patent airway Insert an indwelling cath Replace fluids Administer pain medication

Establish a patent airway

According to Peplau's interpersonal therapy while working with an anxious, withdrawn patient. What should the nurse's interventions focus on?

Improving the patient's interaction skills

A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? SATA Limit visitors in the client's room Encourage fresh vegetables in the diet Increase protein intake Instruct the client to consume 2,000 calories/day Restrict fresh flowers in the room

Limit visitors in the client's room Increase protein intake Restrict fresh flowers in the room

The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage ll pressure injury in the sacral area. Which findings would the nurse expect to note on assessment of the clients sacral area? Intact skin Full-thickness skin loss Exposed bone, tendon, or muscle Partial-thickness skin loss of dermis

Partial-thickness skin loss of dermis

A nurse is providing teaching to the guardian of a child who has contact dermatitis. Which of the following information should the nurse include? Use fabric softeners dryer sheets when drying the child's clothing Apply a warm, dry compress to the rash areas Place child in a bath with colloidal oatmeal Leave child's hands uncovered during the night

Place child in a bath with colloidal oatmeal

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results for this patient: pH 7.48, PaO 2 85 mm Hg, PaCO 2 32 mm Hg, and HCO 3 25 mEq/L? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

Respiratory alkalosis

A child is admitted to the pediatric unit with suspected intussusception. The parents ask the nurse why their child is ordered an air enema. Select the nurse's most appropriate response. a. The enema will confirm the diagnosis. If the test result is positive, your child will need to have surgery to correct the intussusception. b. The enema will confirm the diagnosis. Although unlikely, the enema may help fix the intussusception so that your child will not immediately need surgery. c. The enema will help confirm the diagnosis and has a good chance of fixing the intussusception. d. The enema will help confirm the diagnosis and may temporarily fix the intussusception. If the bowel returns to normal, there is a strong likelihood that intussusception will recur.

The enema will confirm the diagnosis. Although unlikely, the enema may help fix the intussusception so that your child will not immediately need surgery.

examples of false imprisonment

The nurse restrains a patient from meeting loved ones & threatens that she would not give food or medicine if the patient does not abide by her restriction

The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching

The patient uses Neosporin ointment on minor cuts or abrasion

The hospitalized patient is in a manic phase of bipolar disorder. When developing the nursing care plan for this patient, how should the nurse expect the patient's behavior to be in social interactions?

Unpredictable, demanding, & competitive

A nurse is reviewing laboratory results for a client who has schizophrenia and is taking Clozapine. Which of the following values should the nurse identify as a contraindication for this medication?: 1. WBC 2,500/mm3 2. Hgb 11.5 mg/dL 3. platelets 150,00/mm3 4. RBC 3.5 million/mm3

WBC

The nurse is providing care for an adolescent with complex needs after surgical correction of a bowel obstruction. On entering the room, the nurse prioritizes care and decides to complete which task first? a. Change the central intravenous line dressing, which is loose and gaping. b. Empty the ileostomy bag, which is moderately full of liquid stool. c. Change the gauze dressing around the Jackson Pratt drain. d. Offer the adolescent ice chips to ease their dry mouth.

a. Change the central intravenous line dressing, which is loose and gaping.

Patients with right lower leg fracture will be discharged home with an external fixation device in place. Which statement should the nurse include in discharge teaching? a. Check and clean the pin insertion sites daily" b. Remove the external fixator for your shower c. Remain on bedrest until bone healing is complete d. Take prophylactic antibiotics until the fixator is removed

a. Check and clean the pin insertion sites daily"

A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? (select all that apply) a. provide flexible client behavior expectations b. offer concise explanations c. establish consistent limits d. disregard client complaints e. use a firm approach with communication

b. offer concise explanations c. establish consistent limits e. use a firm approach with communication

An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position; the lower jaw is thrust forward, and the patient is drooling. What intervention by the nurse is indicated? 1. administer Diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record 2. reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient 3. give Trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time 4. administer atropine sulfate 2 mg subcut from the PRN medication administration record

benadryl

Your client has started on Lithium. What are some side effects that you should be most concerned with?: 1. nausea 2. weight gain 3. thirst 4. blurred vision

blurred vision

A patient diagnosed with bipolar disorder and who takes lithium telephones the nurse at the clinic to say, "I've had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?"

come into the clinic ASAP

The nurse asks Bob if he has any allergies to medications. He reports an allergy to Haldol. The nurse asks him to describe the type of reaction he experienced. Bob states, "My neck got really stiff, and I couldn't move it." What type of reaction should the nurse suspect?: 1. akathisia 2. dystonia 3. parkinsonism 4. synergistic

dystonia

The nurse observes that a patient with paranoid schizophrenia is displaying signs that indicate increased agitation and could be followed by a violent reaction. What are the immediate priorities for the nurse to plan to institute?

escort to room or redirect to provide safety for self and others on unit do not whisper to them

The nurse is mindful of maintaining relationships with patients that are therapeutic. Certain characteristics of the relationships the nurse will foster include:

establishing boundaries for both the nurse and patient. maintaining a patient-focus at all times. avoiding concern with whether the patient likes the nurse

A nurse is caring for a client who has been taking sertraline (Zoloft) for the past 2 days. Which of the following assessment findings should alert the nurse to the possibility that the client is developing serotonin syndrome? A. Bruising B. Fever C. Abdominal pain D. Rash

fever

What assessments if made by the nurse would indicate that the patient has symptoms of serotonin syndrome?

fever

Know what step nurse should take first on patient coming into ER after extensive electrical burns

first line assessment is making sure they don't have injury to spinal cord & can still move & to do cardiac monitoring stabilize the cervical spine

The patient's lithium level has increased to a dangerous level. What interventions should the nurse anticipate when the provider is notified of this level?

gastric lavage lithium levels d/c med

What side effects of lithium can be expected at therapeutic levels?

hand tremors & polyuria

What is the pain like with intessusception

intense with knees brought up to the chest

The patient who has a diagnosis of bipolar disorder has a new order for carbamazepine. Before beginning to administer the medication, the nurse checks to see which laboratory results are in the patient's record?

liver function studies

A nurse is assessing a male client who recently began taking haloperidol (Haldol). Which of the following findings is the highest priority to report to the provider? A. Shuffling gait B. Neck spasms C. Drowsiness D. Impotence

neck spasms`

What are possible warnings or signals of abuse of the nurse-patient relationship?

nurse making exceptions to client keeping secrets inappropriate conversations in the nurse-client relationship

if the abdomen is rigid what does that mean

periotonitis

A nurse is creating a plan of care for a patient who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions is to be included in the plan?: 1. document the client's behavior every 8 hr 2. limit the client's fluid intake to 50 mL/hr 3. renew the prescription for the client every 4 hr 4. toilet the client every 4 hr

renew q4h

A patient experiencing mania has not eaten or slept for 3 days. Which nursing diagnosis has priority?

risk for injury

A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority?: 1. powerlessness 2. social isolation 3. risk for suicide

risk for suicide

What conditions would require the nurse to break patient confidentiality?

risk to themselves or others

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? 1. Chess 2. Writing 3. Ping pong 4. Basketball

solitary & requires a short attention span writing

What is the puke like with pyloric stenosis

sour

How would a nurse respond to a patient who was voluntarily admitted to the inpatient behavioral health facility that is refusing to take the prescribed antipsychotic medication?

suggest a long acting injection