Final Exam

A client with myasthenia gravis becomes increasingly weaker. The physician injects a dose of edrophonium (Tensilon) to determine whether the client is experiencing a myasthenia crisis or a cholinergic crisis. The nurse expects that the client will have which of the following reactions if the client is in cholinergic crisis? B. A temporary worsening of the condition

B

The nurse is assessing a client with long-term rheumatoid arthritis (RA) who has been taking prednisone for 10 years. For which complications of chronic drug therapy would the nurse assess? (Select all that apply.) a. Osteoporosis b. Diabetes mellitus c. Glaucoma d. Hypertension e. Hypokalemia f. Decreased immunity 1. A,B,C,D,E,F 2. B,C,D,E 3. C,D,E,F 4. A,B,C,D

1

A nurse is reading the laboratory results for a client being treated with carbamazepine (Tegretol) for prophylaxis of complex-partial seizures. The nurse interprets that which of the following values is consistent with an adverse reaction to this medication? A. White blood cell count 3200/mm3

A

A nurse is teaching a wilderness survival class. Which statements would the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.) a. "Wear synthetic clothing instead of cotton to keep your skin dry." b. "Wear sunglasses to protect skin and eyes from harmful rays." c. "Know your physical limits. Come in out of the cold when limits are reached." d. "Change your gloves and socks if they become wet." 1. A,B,C 2. A,B,C,D 3. B,C,D 4. C,D

2

The nurse is caring for a client who has possible hypothyroidism. What possible risk factors can cause this health problem? (Select all that apply.) a. Lithium drug therapy b. Thyroid cancer c. Autoimmune thyroid disease d. Iodine deficiency e. Pituitary tumors 1. A,B,C,D 2. A,B,C 3.A,D,E 4. A,B,C,D,E

4

A nurse assesses a client with Cushing disease. Which assessment findings would the nurse expect? (Select all that apply.) a. Moon face b. Weight loss c. Muscle atrophy d. Muscle rigidity 1. A,B,C 2.A,B,C,D 3. A,B 4.B,C,D

1

An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions does the nurse include in this patient's plan of care? (Select all that apply.) a. Administer oxygen via mask or nasal cannula. b. Give Potassium c. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. d. Obtain baseline serum electrolytes and cardiac enzymes. 1. C,D 2. A,C,D 3. B,C,D 4.A,B,C

2

Levothyroxine sodium is prescribed for a client with hypothyroidism, and the nurse provides information to the client about the medication. The nurse realizes teaching was effective if the client selects which symptom to report to the health care provider? Select all that apply. A. Lethargy B. Chest pain C. Palpitations D. Weight gain E. Constipation F. Rapid heart rate 1. A,B,C,D 2.B,C,F 3. A,B,C,F 4. A,B,C,D,E,F

2

The nurse assesses a client with long-term rheumatoid arthritis (RA) for late signs and symptoms. Which assessment findings will the nurse document as late signs and symptoms of RA? (Select all that apply.) a. Anorexia b. Felty syndrome c. Joint deformity d. Low-grade fever e. Weight loss 1. A,B,D 2. B,C,E 3. A,B,C,D 4.

2

The nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Have suction equipment with an airway at the bedside. d. Have oxygen administration set at the bedside. c. Ensure that the client has IV access. d. Wear a surgical mask 1. A,B 2. A,B,C 3. A,B,C,D 4. A,C

2

A new graduate nurse has started working on a medical-surgical unit. What actions would the nurse take to be prepared for a disaster? (Select all that apply.) a. Know the institution's Emergency Response Plan. b. Participate in the institution's disaster drill. c. Develop a personal preparedness plan. d. Understand that nurses play a role in every phase of a disaster. e. Be willing to be flexible working during a crisis situation. 1. B,C,D,E 2. A,B,C 3. A,B,C,D,E 4. A,D,E

3

Benztropine mesylate is prescribed for a client with Parkinson's disease. For which gastrointestinal (GI) side effects of the medication does the nurse monitor the client? Select all that apply. A. Mucositis B. Dry mouth C. Constipation D. Increased appetite E. Hyperactive bowel sounds 1.A,B,C 2.C,D 3. B,C 4. A,B,C,D

3

Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b. Unconscious unresponsive c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Bruising and pain in the right lower abdomen 1. B,C,D,E 2. A,B,C 3. A,C,D,E 4. A,C,D

3

The nurse is caring for a client in late-stage Alzheimer's disease. Which assessment finding(s) will the nurse anticipate? (Select all that apply.) a. Immobile b. ADL dependent c. Incontinent d. Possible seizures 1. A,B,C 2. B,D 3. A,B,C,D 4. C,D

3

Which of the following statements is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Tooth brushing is performed every 2 hours for the greatest effect. b. Implementing a comprehensive oral care program is an intervention for preventing VAP. c. Oral care protocols should include oral suctioning and brushing teeth. d. Protocols that include chlorhexidine gluconate have been effective in preventing VAP. 1. A,B,C 2. B,C 3. B,C,D 4. C,D

3

A client is admitted with a possible diagnosis of diabetes insipidus (DI). What assessment findings would the nurse expect? (Select all that apply.) a. Hypotension b. Increased urinary output c. Poor skin turgor d. Weight loss 1.A,B 2.C,D 3.A,B,C,D 4. A,B,C

4

A nurse is in charge of a first-aid tent at an all-day outdoor sports event on a hot and humid day. A participant comes to the tent reporting a headache, weakness, and nausea. What actions would the nurse take? (Select all that apply.) A. Have the client lie down in a cool place. B. Apply cold packs to neck, arm pits, and groin. C. Encourage drinking a sports drink. 1. A,B 2. A,C 3. B,C 4. A,B,C

4

A nurse is providing dietary instructions to a client with chronic obstructive pulmonary disease (COPD) who is experiencing a loss of appetite and complains of feeling "too full to eat." The nurse realizes the instructions were effective if the client verbalizes making which changes? A. Avoid drinking fluids before and during meals B. Eat a variety of dark-green vegetables, such as broccoli C. Have snacks, such as crackers and cheese, between meals D. Select foods that are easy to chew and are not gas forming Consume high-calorie drinks, such as milkshakes, between meals Select all that apply. 1.AB 2.ABD 3.BC 4.AD

4

A nurse teaches a client with Cushing disease. Which dietary requirements would the nurse include in this client's health teaching? (Select all that apply.) a. Low Fat b. Low carbohydrate c. Low calories d. Low sodium 1. A,B,C,D 2. A,B,C 3. A,B 4. B,C,D

4

The nurse assesses a client who has Parkinson disease. Which signs and symptoms would the nurse recognize as a key feature of this disease? (Select all that apply.) The nurse assesses a client who has Parkinson disease. Which signs and symptoms would the nurse recognize as a key feature of this disease? (Select all that apply.) a. Flexed trunk b. Muscle weaknesS c. Slow movements d. Uncontrolled drooling 1. A,B 2. A,B,C 3. A,B,C,D 4. A,B,D

4

The nurse assesses a client who has meningitis. Which sign(s) and symptom(s) would the nurse anticipate? (Select all that apply.) a. Photophobia b. Decreased level of consciousness c. Severe headache d. Fever and chills 1. A,B 2. C,D 3. B,C,D 4. A,B,C,D

4

The nurse assesses clients on a medical-surgical unit. Which clients would the nurse identify as at risk for secondary seizures? (Select all that apply.) a. A 26-year-old woman with a left temporal brain tumor b. A 38-year-old male client in an alcohol withdrawal program c. A 42-year-old football player with a traumatic brain injury 1. A,B 2. A,C 3.B,C 4. A,B,C,

4

The nurse is teaching participants in a family-oriented community center ways to prevent their older relatives and friends from getting heat-related illnesses. What information does the nurse include? (Select all that apply.) a. Rest b. Take cool baths or showers after outdoor activities. c. Check on the older adult daily in hot weather. d. Drink plenty of liquids throughout the day. 1. C,D 2. B,C 3. A,B,C 4. B,C,D

4

A client has just been admitted with a diagnosis of myxedema coma. If all of the following interventions were prescribed, the nurse would place highest priority on completing which of the following first? A. Administering oxygen as ordered

A

A client hospitalized with an abdominal aortic aneurysm (AAA) suddenly complains of severe back and flank pain. The nurse notes on the cardiac monitor that the client's heart rate has increased from 80 to 110 beats/min. The nurse should take which action first? A. Immediately contact the health care provider B. Administer pain medication to the client C. Continue to monitor the client's vital signs D. Evaluate urine output during the previous shift

A

A nurse is constructing a personal preparedness plan in case of a disaster. What does the nurse consider in making this plan? a. Store basic supplies to last for at least 3 days.

A

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question would the nurse ask? a. "Do you live in a crowded residence?"

A

A nurse teaches assistive personnel (AP) about how to care for a client with Parkinson disease. Which statement would the nurse include as part of this teaching? a. "Allow the client to be as independent as possible with activities."

A

A primary health care provider prescribes a rewarming bath for a client who presents with Grade 3 frostbite. What action would the nurse take prior to starting this treatment? a. Administer intravenous morphine.

A

A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV infection. Forty-eight hours after administration, the nurse checks the test site (see image). The nurse documents the result of the test as: A. Positive B. Negative C. Insignificant D. Indeterminate

A

The nurse is teaching a family caregiver about how best to communicate with the client who has been diagnosed with Alzheimer disease. Which statement by the caregiver indicates a need for further teaching? a. "I will avoid communicating with the client to prevent agitation."

A

The nurse observes a client with late-stage Alzheimer disease eat breakfast. Afterward the client states, "I am hungry and want breakfast." What is the nurse's best response? a. "I see you are still hungry. I will get you some toast."

A

The result of two enzyme-linked immunosorbent assays (ELISA) performed to detect HIV is positive. Which diagnostic test does the nurse anticipate will be prescribed next? A. Western blot B. CD4+ T-cell count C. Bone marrow biopsy D. T-helper lymphocyte count

A

A client has rheumatoid arthritis (RA) and the nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.) a. Grab bars to reach high items b. Long-handled bath scrub brush c. Soft rocker-recliner chair d. Toothbrush with built-up handle e. Wheelchair cushion for comfort 1. 2. A,B,C 3. A,B,D 4.

A,B,D

A nurse is reviewing care for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) with assistive personnel. What statement by the AP indicates understanding of this client's care? a. "I will weigh the client carefully before breakfast and compare with yesterday's weight."

A.

The nurse is caring for a client who is diagnosed with diabetes insipidus (DI). For what common complication will the nurse monitor? A. Dehydration B. Hypothyroidism C. Hyperkalemia D. Fluid overload

A. Dehydration

A client who recently began medication therapy with levodopa (Larodopa) for Parkinson's disease complains of nausea. The nurse reminds the client to do which of the following to best manage this problem? B. Eat a snack before taking the medication.

B

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic intervention does the nurse recommend? a. Heating pad b. Ice packs c. Splint d. Paraffin dip

B

A nurse assesses a group of clients who have rheumatoid arthritis (RA). Which client would the nurse see first? a. Client who reports jaw pain when eating b. Client with a red, hot, swollen right wrist c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit

B

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication would the nurse anticipate to prepare for administration? b. Lorazepam

B

A nurse cares for a client who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The client's serum sodium level is 114 mEq/L (114 mmol/L). What nursing action would be appropriate? B. Restrict the client's fluid intake to 600 mL/day.

B

A nurse cares for a client who presents with bradycardia secondary to hypothyroidism. Which medication does the nurse prepare to administer? b. Levothyroxine

B

A nurse plans care for a client admitted with a snakebite to the right leg. With whom would the nurse collaborate? b. The poison control center

B

A primary health care provider prescribes diazepam to a client who was bitten by a black widow spider. The client asks, "What is this medication for?" How does the nurse respond? b. "It will relieve your muscle rigidity and spasms."

B

Cyclophosphamide is prescribed for a client with a diagnosis of breast cancer. The nurse has provided instructions to the client regarding the medication. Which statement by the client indicates an understanding of this chemotherapeutic regimen? A. "I need to take the medication with food." B. "I need to increase my fluid intake to 2000 to 3000 mL a day." C. "I'll eat a banana and drink a glass of orange juice every day." D. "I should try to avoid salty foods while I'm taking this medication."

B

The nurse cares for a client with middle-stage (moderate) Alzheimer disease. The client's caregiver states, "She is always wandering off. What can I do to manage this restless behavior?" What is the nurse's best response? b. "Engage the client in scheduled activities throughout the day."

B

The nurse is teaching a client with mild rheumatoid arthritis (RA) about how to protect synovial joints. Which health teaching will the nurse include? (Select all that apply.) a. "Use small joints rather than larger ones during tasks." b. "Use both hands instead of one with holding objects." c. "When getting out of bed or a chair, use the palms of your hands." d. "Bend your knees instead of your waist and keep your back straight." e. "Do not use multiple pillows under your head to prevent neck flexion." f. "Use a device or rubber grip to open jars or bottle tops." g. "Use long-handled devices such as a hairbrush with an extended handle."

B,C,D,E,F,G

A client diagnosed with diabetes insipidus is beginning medication therapy with lypressin. The nurse teaches the client that this medication is taken: C. Intranasally to promote water reabsorption

C

A client has long-term rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is appropriate? a. "Let's ask your provider about increasing your pain pills." b. "Hold ice bags against your hands before quilting." c. "Try a paraffin wax dip 20 minutes before you quilt." d. "You need to stop quilting before it destroys your fingers."

C

A client who exhibits fatigue, lack of energy, constipation, and depression is diagnosed with hypothyroidism. The physician prescribes levothyroxine (Synthroid). To increase the likelihood of medication compliance in the early course of treatment, the nurse plans to alert the client that: C. Full therapeutic effect may take 1 to 3 weeks.

C

A client with newly diagnosed Cushing's syndrome expresses concern about personal appearance, specifically about the "buffalo hump" that has developed at the base of the neck. When counseling the client about this manifestation, the nurse should incorporate the knowledge that: C. It may slowly improve with treatment of the disorder.

C

A nurse assesses a client recently bitten by a coral snake. Which assessment would the nurse complete first? c. Cardiopulmonary status

C

A nurse cares for a client who has hypothyroidism as a result of Hashimoto thyroiditis. The client asks, "How long will I need to take this thyroid medication?" How would the nurse respond? c. "You'll need thyroid pills for life because your thyroid won't start working again."

C

A nurse cares for victims during a community-wide disaster drill. One of the victims asks, "Why are the individuals with black tags not receiving any care?" How does the nurse respond? c. "In a disaster, extensive resources are not used for one person at the expense of many others."

C

A nurse has provided dietary instructions to a client with viral hepatitis whose laboratory results indicate liver impairment. The nurse realizes that teaching has been effective if the client verbalizes the need to make which change? A. To increase intake of foods high in protein to promote healing B. To consume mainly high-fat foods because they are better tolerated C. That most calorie intake should consist of foods high in carbohydrates D. That snacks, particularly those that are salty, are an important part of the diet

C

A nurse has taught a client with chronic obstructive pulmonary disease (COPD) about positions that will ease breathing during dyspneic episodes. Which statement by the client indicates a need for further instruction? A. "I should sit up and lean on a table." B. "I should stand and lean against a wall." C. "I should lie flat on my side in a fetal position." D. "I should sit up with my elbows resting on my knees."

C

A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation? a. Emergency tracheostomy and mechanical ventilation b. Mechanical ventilation via an endotracheal tube c. Noninvasive positive-pressure ventilation (NPPV) d. Oxygen at 100% via bag-valve-mask device

C

The nurse is preparing to give tolvaptan for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). For which potentially life-threatening adverse effect would the nurse monitor? c. Rapid-onset hypernatremia

C

The nurse is teaching a group of college students about the importance of preventing meningitis. Which health promotion activity is the most appropriate for preventing this disease? c. Obtaining the recommended meningitis vaccination and boosters.

C

The nurse is teaching the daughter of a client who has middle-stage Alzheimer disease. The daughter asks, "Will the sertraline my mother is taking improve her dementia?" How would the nurse respond about the purpose of the drug? c. "It will not improve her dementia but can help control emotional responses."

C

The nurse teaches assistive personnel (AP) about how to care for a client with early-stage Alzheimer disease. Which statement would the nurse include? c. "Reorient the client to the day, time, and environment with each contact."

C

The nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. What action would the nurse take first? c. Turn the client's head to the side.

C

The primary health care provider prescribes methotrexate (MTX) for a client with a new diagnosis of rheumatoid arthritis. The nurse provides health teaching about the drug. What statement by the nurse is appropriate to include about methotrexate? a. "It will take at least 1 to 2 weeks for the drug to help relieve your symptoms." b. "The drug is very expensive but there are pharmacy plans to help pay for it." c. "The drug can increase your risk for infection, so you should avoid crowds." d. "It's OK for you to drink about 2 to 3 glasses of wine each week while taking the drug."

C

A client diagnosed with Parkinson disease will be starting ropinirole for symptom control. Which statement by the client indicates a need for further teaching? d. "I know the drug will probably make help me prevent constipation."

D

A client infected with HIV has a T4 count of 150/mm3 and a low CD4+/CD8+ ratio. On the basis of these values, the nurse prepares a plan of care that focuses on which aspect of care? A. The client's condition is gradually improving B. The client is developing a stronger immune system C. The client is not at risk for transmitting the infection to others D. The client is at risk for the development of an opportunistic infection

D

A client with Acquired Immunodeficiency Syndrome (AIDS) is admitted to the hospital with a diagnosis of histoplasmosis, and the nurse monitors the client for signs of progression of the disease. Which finding indicates progression of histoplasmosis? A. Headache B. Blurred vision C. Nuchal rigidity D. Enlargement of the lymph nodes

D

A nurse assesses a client admitted with a brown recluse spider bite. Which assessment does the nurse perform to identify complications of this bite? d. Monitor the client's temperature every 4 hours.

D

A nurse assesses a client on the medical-surgical unit. Which statement made by the client alerts the nurse to assess the patient for hypothyroidism? d. "I am always tired, even with 12 hours of sleep."

D

A nurse assesses a client who is prescribed levothyroxine for hypothyroidism. Which assessment finding alerts the nurse that drug therapy is effective? d. Heart rate is 76 beats/min and regular.

D

A nurse is assisting in the care of a client with Parkinson's disease who is receiving carbidopa/levodopa (Sinemet). The nurse plans to monitor the client for which of the following adverse effects, which could appear with elevated serum levels of this medication? D. Impaired voluntary movements

D

A nurse is field-triaging clients after an industrial accident. Which client condition would the nurse triage with a red tag? d. Multiple fractured ribs and shortness of breath

D

A nurse is monitoring a client with a head injury for signs of diabetes insipidus (DI). Which finding would cause the nurse to suspect that this complication is developing? A. Urine specific gravity 1.020 B. Serum osmolarity 200 mOsm/kg (200 mmol/kg) C. Urine output 30 mL/hr for past 4 hours D. Serum sodium level 155 mEq/L (155 mmol/L)

D

After teaching a client newly diagnosed with epilepsy, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? d. "If I am nauseated, I will not take my epilepsy medication."

D

After teaching a client who is diagnosed with new-onset epilepsy and prescribed phenytoin,the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? d. "Even when my seizures stop, I will continue to take this drug."

D

After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates that she correctly understands changes associated with this disease? D. "He may have trouble chewing, so I will offer bite-sized portions.

D

An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.

D

On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. What action would the nurse take? b. Start an intravenous line and infuse 0.9% saline solution.

D

The nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How would the nurse document this type of seizure? d. Tonic-clonic

D

The nurse assesses a client with rheumatoid arthritis (RA) and Sjögren syndrome. What assessment would be most important for this client? a. Abdominal assessment b. Oxygen saturation c. Breath sounds d. Visual acuity

D

The nurse plans care for a client with Parkinson disease. Which intervention would the nurse include in this client's plan of care? d. Keep the head of the bed at 30 degrees or greater.

D

The nurse prepares to discharge a client with early to moderate Alzheimer disease. Which statement to maintain client safety would the nurse include in the discharge teaching for the caregiver? d. "Install safety locks on all outside doors."

D

The primary health care provider prescribes donepezil for a client diagnosed with early-stage Alzheimer disease. What teaching about this drug will the nurse provide for the client's family caregiver? d. "Report any client dizziness or falls because the drug can cause bradycardia."

D

While at a public park, a nurse encounters a person immediately after a bee sting. The person's lips are swollen, and wheezes are audible. What action would the nurse take first? d. Administer an epinephrine and call 911

D

A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.) a. A 35-year-old female with severe chest pain: red tag b. A 60-year-old male with an open fracture with distal pulses: yellow tag 1. A 2. A,B 3. B

a,b

The nurse is caring for a client who has Alzheimer disease. The client's wife states, "I am having trouble managing his behaviors at home." Which questions would the nurse ask to assess potential causes of the client's behavior problems? (Select all that apply.) a. "Does your husband bathe and dress himself independently?" b. "Does your husband smoke? c. "Does his behavior become worse around large crowds?" d. "Do you use discipline to correct behavior?" e. "Do you have a clock and calendar in the bedroom and kitchen?" 1. A,C,E 2. A,B,C,D 3.A,C,D,E 4. B,C,D

1

A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment would the nurse wear? (Select all that apply.) a. Face mask b. Surgical mask c. Gown d. Gloves 1. A,B,C 2. B,D 3. B,C,D 4. A,B,C,D

2

A nurse teaches the spouse of a client who has Alzheimer disease. Which statements should the nurse include in this teaching related to caregiver stress reduction? (Select all that apply.) a. "Establish advanced directives early." b. Establish Airway c. "Set aside time each day to be away from the client." d. "Use discipline to correct inappropriate behaviors." 1.A,B,C,D 2. A,C,D 3.A,B 4. A,D

2

An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at highest risk for heat-related illnesses? (Select all that apply.) a. Homeless individuals b. People with substance abuse disorders c. Infants d. Older adults e. Obese individuals 1. A,B,C,D,E 2. A,B,D,E 3. A,C,D 4. B,C,D,E

2

Which assessment findings would indicate to the nurse that a client has suffered from a heat stroke? (Select all that apply.) a. Confusion and bizarre behavior b. Hyperthyroidism c. Hypotension d. Tachycardia and tachypnea e. Body temperature more than 104° F 1. A,B,C,D 2. B,C,D 3. A,C,D,E 4. C,D,E

3

A client who has rheumatoid arthritis is prescribed etanercept. What health teaching by the nurse about this drug is appropriate? a. Giving subcutaneous injections b. Having a chest x-ray once a year c. Taking the medication with food d. Using heat on the injection site

A

A nurse assessing the skin of a client who is immobile notes this change in appearance of the skin in the sacral area: The nurse documents this finding in which manner? A. Stage I pressure ulcer B. Stage II pressure ulcer C. Stage III pressure ulcer D. Stage IV pressure ulcer

A

A nurse is administering a dose of oral pyridostigmine bromide to a client with myasthenia gravis. What does the nurse ask the client to do before administering the medication? A. Take sips of water B. Lie on her right side C. Ambulate to the bathroom to void D. Look at the ceiling for 30 seconds

A

A nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The health care provider gives a test dose of edrophonium (Tensilon). The nurse recalls that the client would have which of the following reactions if the client does actually have this disease? A. An increase in muscle strength within 1 to 3 minutes

A

A nurse is planning care for a client who has undergone transurethral resection of the prostate (TURP). The nurse includes interventions in order to relieve which most common cause of postoperative pain? A. Bladder spasms B. Bleeding within the bladder C. The location of the incision D. Tension on the Foley catheter

A

A nurse is providing dietary instructions to the spouse of a client with newly diagnosed Acquired Immunodeficiency Syndrome (AIDS) who is being discharged from the hospital. The nurse realizes teaching has been effective if the spouse indicates making which change in the diet? A. Serving foods at room temperature B. Adding spices to foods to make them more palatable C. Offering peanut butter and crackers as snacks to increase protein intake D. Increasing the amount of milk and milk products consumed on a daily basis

A

A nurse is reviewing the nursing care plan for a client who has seizure precautions in place. Which intervention documented in the plan of care should the nurse question? A. Have oxygen equipment at the bedside. B. Place suction equipment at the bedside. C. Keep a padded tongue blade at the bedside. Correct D. Maintain intravenous (IV) access in the client.

C

A nurse plans care for a client with hypothyroidism. Which priority problem does the nurse address first for this client? c. Depression and withdrawal

C

A client is found to have hypoparathyroidism. Which nutritional supplement does the nurse, teaching the client about measures to manage the disorder, tell the client to take on a daily basis? A. Vitamin C B. Phosphorus C. Beta-carotene D. Calcium carbonate with vitamin D

D

A client is newly diagnosed with hypothyroidism. Levothyroxine (Synthroid) is prescribed. The nurse who plans to teach this client about the medication should include that the appropriate method for taking the medication is: D. On an empty stomach

D

A client is being treated for diabetes insipidus (DI) with synthetic vasopressin (desmopressin). What is the priority health teaching that the nurse provides regarding drug therapy? A. Use skin protectant B. Have routine lab work C. Wear eyewear D. The need to weigh every day and report weight gain.

D.