Final Exam Questions

A nurse is reviewing the laboratory reports of a client and notes an elevated thyroid-stimulating hormone (TSH) level. Which of the following findings should the nurse expect? a. Bradycardia b. Tremors c. Low-grade fever d. Diaphoresis

A. CORRECT - Elevated TSH levels indicate hypothyroidism (high TSH, low T3 and T4), which is characterized by low and slow effects - bradycardia, depression, cold intolerance. B. Incorrect - Tremors are manifestations of Graves' disease, or hyperthyroidism, in which TSH levels are decreased. C. Incorrect - Graves' disease manifestation. D. Incorrect - Graves' disease manifestation.

A nurse is conducting a home visit for an older adult client who has diabetes mellitus and takes regular insulin subcutaneously before each meal. The client appears disoriented and weak and has slurred speech. Which of the following conditions should the nurse consider first when responding to these manifestations? a. Hyperglycemia b. Hypoglycemia c. Infection d. Transient ischemic attack

A. Incorrect B. CORRECT - The nurse should first check for hypoglycemia by drawing a blood glucose level. A client with hypoglycemia can have slurred speech, disorientation, weakness, and confusion near meal time each day because regular insulin peaks in 2-4 hours, causing a drop in blood glucose. Other manifestations include irritability, mental confusion, double vision, hunger, tachycardia, diaphoresis, and palpitations. C. Incorrect D. Incorrect

A nurse is caring for a client who has tardive dyskinesia. Which of the following tools should the nurse use in performing an assessment on the client? a. CAGE Assessment b. Hamilton Anxiety Rating Scale c. Abnormal Involuntary Movement Scale (AIMS) d. SAFE-T Tool

A. Incorrect - The CAGE (Cut Annoyed Guilty Eye-opener) assessment is used to diagnose alcohol use disorder. This assesses alcohol dependency. B. Incorrect - The Hamilton Anxiety Rating Scale measures psychological distress and physical symptoms associated with anxiety. C. CORRECT - The AIMS is an assessment tool that identifies and tracks involuntary movements in clients who have tardive dyskinesia (TD). Examples of involuntary movements are lip smacking or tongue protruding. D. Incorrect - The SAFE-T (Suicide Assessment Five-step Evaluation and Triage) tool assesses the client's risk factors for suicide.

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? a. Increase the oxygen flow b. Assist the client to Fowler's position c. Promote removal of pulmonary secretions d. Obtain a specimen for arterial blood gas

A. Incorrect - This is not the priority action, although there might be a need to increase oxygen. B. CORRECT - Using the ABC framework and least restrictive/most restrictive framework, changing the bed to Fowler's position is the priority action. Fowler's position facilitates maximal lung expansion and thus optimizes breathing. Lying flat causes abdominal contents to press against the diaphragm and cause difficulty breathing. C. Incorrect - There might be a need to suction the airway, but there is another priority action. D. Incorrect - Check the client's oxygenation status. But there is another priority action. Nurses must address the concern before obtaining lab specimens.

A nurse is caring for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following actions should the nurse take? a. Administer ibuprofen b. Limit daily fluid intake c. Apply cold compresses to painful joints d. Withhold live virus immunizations

A. CORRECT - Administer ibuprofen or acetaminophen (nonopioid analgesics) for mild to moderate pain. If pain is not relieved, the nurse should administer an opioid analgesic. B. Incorrect - The nurse should encourage the child to increase daily fluid intake to reduce blood viscosity and prevent sickling of red blood cells. C. Incorrect - Cold compresses increase vasoconstriction, thereby increasing pain. Warm compresses should be applied instead. D. Incorrect - Ensure that the child receives all immunizations to prevent infection. Infection is a major cause of death in children who have sickle cell anemia since infection increases oxygen demand on the body. The spleen, which is impaired in sickle cell anemia, also fights invading germs in the blood and controls WBC levels.

A nurse is caring for a client who has type 2 diabetes mellitus and is displaying manifestations of hyperglycemia. Which of the following findings indicates the client has hyperglycemia? a. Hunger b. Increased urination c. Cold, clammy skin d. Tremors

A. Incorrect - Increased hunger is a manifestation of hypoglycemia due to central glucose deprivation. The body needs more glucose and is sending hunger signals. B. CORRECT - Increased urination is a sign of hyperglycemia due to an insulin deficiency, leading to osmotic diuresis. C. Incorrect - Cold, clammy skin is a sign of hypoglycemia. D. Incorrect - Tremors are a sign of hypoglycemia.

A nurse is assessing a client who has Addison's disease. Which of the following skin manifestations should the nurse expect to find? a. Purple striae on the chest and abdomen b. Butterfly rash across the bridge of the nose c. Bronze pigmentation of the skin d. Jaundice of the face and sclera

A. Incorrect - Purple striae is a sign of Cushing's disease. B. Incorrect C. CORRECT - Patients with Addison's disease will have a darkening of the skin due to a hormone deficiency caused by damage to the outer layer of the adrenal cortex. D. Incorrect - Can be seen in pancreatitis, cholecystitis, and cirrhosis.

A nurse is caring for a client who is in labor. Which of the following assessment findings should the nurse report to the provider? a. Fetal heart rate baseline of 90 bpm b. Maternal temperature of 37.8 degrees C (100 degrees F) c. Uterine relaxation for 1 minute between contractions d. Uterine contractions increasing in intensity

A. CORRECT - A fetal heart rate baseline of 90 bpm is considered bradycardia (normal: 110-160 bpm) and should be reported to the provider. B. Incorrect - The nurse should report a maternal temperature of 38 degrees C (100.4 degrees F) or higher. It is expected that the mother's temperature will raise a little to increase metabolic demands. C. Incorrect - There should be at least 1 minute of resting time between contractions to allow adequate placental perfusion. Less than 1 minute of resting time can lead to fetal hypoxia. D. Incorrect - As labor progresses, uterine contractions are expected to increase in intensity and frequency.

A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse provide? (Select all that apply) a. Take allopurinol as prescribed b. Exercise several times a week c. Limit intake of foods high in purine d. Decrease daily fluid intake e. Avoid citrus juices

A. CORRECT - Allopurinol is the drug of choice for chronic gout and decreases uric acid levels. B. CORRECT - Immobility is a risk factor for stone formation; therefore, the client should maintain a healthy lifestyle that includes exercise to also reduce obesity risk. C. CORRECT - Purine-rich foods increase the risk of uric acid formation. When purines are degraded, they break down into uric acid. Meats, alcohol, seafood, and some vegetables (spinach, cauliflower, asparagus) are high in purine. D. Incorrect - Maintaining adequate fluid intake reduces the risk for stone formation. E. Incorrect - Citrus juices alkalinize the urine, preventing stone formation. Patients should be taught to increase vitamin C rich foods, which are antioxidants that prevent unwanted inflammation (which gout can cause).

A nurse is reviewing the laboratory values of a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? a. Decreased calcium b. Decreased potassium c. Increased potassium d. Increased calcium

A. CORRECT - Calcium is necessary for nerve conduction and muscle contractions. When calcium levels are below 8.5 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the client's ear. If facial muscle twitching follows the stimulus, it is a positive Chvostek's sign and an indication of hypocalcemia. B. Incorrect - A positive Chvostek's sign is not seen in hypokalemia, in which muscle weakness and other clinical manifestations occur. C. Incorrect - The nurse should assess for muscle weakness, cardiac dysrhythmias, and other manifestations of hyperkalemia. Chvostek's sign is not observed. D. Incorrect - The nurse should assess for lethargy, weakness, and other manifestations in clients with hypercalcemia.

A nurse is checking laboratory values to determine if a client with diabetes mellitus is adhering to the treatment plan. Which of the following tests should the nurse use to make this determination? a. Glycosylated hemoglobin levels b. Urine sugar and acetone levels c. Glucose tolerance test d. Fasting serum glucose

A. CORRECT - Checking HbA1c is an accurate method to determine routine compliance. Glycosylated hemoglobin refers to hemoglobin that is connected to glucose. HbA1c measures the average blood sugar level from the past 3 months. Since the lifespan of a RBC is 3 months, this value will not be affected by recent changes in diet or medication. B. Incorrect - Urine sugar and acetone levels reflect how well-controlled the client has been for the last few hours. C. Incorrect - A glucose tolerance test is used to diagnose type 2 diabetes mellitus and gestational diabetes. D. Incorrect - A fasting serum glucose provides information about the previous 24 hours.

A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? (Select all that apply) a. REM sleep provides cognitive restoration b. It is difficult to awaken a person in REM sleep c. Sleepwalking occurs during REM sleep d. Vivid dreams are common during REM sleep

A. CORRECT - Cognitive and brain tissue restoration occur during REM sleep. B. CORRECT - It is difficult awakening a patient during REM sleep. C. Incorrect - Sleepwalking and sleep talking tend to occur during stage 3 of non-REM sleep. D. CORRECT - Dreaming does occur in other stages, but it less vivid and possibly less colorful.

A nurse is caring for a client who is experiencing an acute gout attack. The nurse should anticipate a prescription from the provider for which of the following medications? a. Colchicine b. Allopurinol c. Probenecid d. Pegloticase

A. CORRECT - Colchicine is one of the medications of choice for an acute gout attack. If a patient reports severe pain upon admission, the priority is medicating the patient. NSAIDs and glucocorticoids can also be used for acute attacks. B. Incorrect - Allopurinol is the medication of choice for chronic gout. It is a cheap over-the-counter medication with a decent therapeutic range to manage the symptoms of gout. C. Incorrect - Treats chronic gout. D. Incorrect - Treats chronic gout.

A nurse is teaching a client who has a colostomy about ways to reduce flatus and odor. Which of the following strategies should the nurse include? a. Eat crackers and yogurt regularly b. Chew minty gum throughout the day c. Drink orange juice every day d. Put an aspirin in the pouch

A. CORRECT - Crackers, toast, and yogurt can help reduce flatus, which contributes to odor. B. Incorrect - Chewing any type of gum can increase flatus, contributing to odor. C. Incorrect - Cranberry juice and buttermilk, not orange juice, can help prevent odor. D. Incorrect - Aspirin, an NSAID, in the pouch can cause stoma ulceration.

A nurse is discussing gout with a client who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors for this disease? (Select all that apply) a. Diuretic use b. Obesity c. Deep sleep deprivation d. Depression e. Cardiovascular disease

A. CORRECT - Diuretics facilitate removal of fluid from the body via urine, leaving the remaining fluid more concentrated and prone to stone formation. B. CORRECT - Obesity increases the risk of an elevated serum uric acid level. C. Incorrect - Clients with gout may struggle with receiving adequate sleep because of pain, but this is not a risk factor for gout. D. Incorrect - Depression does not increase the risk of developing gout, but those with gout may develop depression as a result of their condition. E. CORRECT - Elevated serum uric acid levels are associated with higher incidences of hypertension. Diuretics may also be used for CVD.

A nurse is assessing a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances? a. Hypokalemia b. Hyponatremia c. Hypercalcemia d. Hypermagnesemia

A. CORRECT - Furosemide is a potassium-wasting diuretic. Manifestations of hypokalemia include muscle weakness and bradycardia. B. Incorrect - Manifestations of hyponatremia include seizures, lethargy, confusion. C. Incorrect - Hypercalcemia symptoms include tachycardia, hypertension, and muscle weakness. D. Incorrect - Hypermagnesemia symptoms include hypotension and decreased deep tendon reflexes.

A nurse is providing teaching to a client who has type 1 diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include in the teaching? a. Shakiness b. Urinary frequency c. Dry mucous membranes d. Excess thirst

A. CORRECT - Hypoglycemia produces neurological symptoms, which includes shakiness, headaches, difficulty thinking, irritability, etc. The brain, which uses only glucose for energy, is starving for energy and will cause neurological issues. B. Incorrect - Increased urination is associated with hyperglycemia as the body attempts to rid itself of excess glucose. C. Incorrect - Dry mucous membranes are associated with dehydration, which hyperglycemia causes d/t excessive urination. D. Incorrect - Excessive thirst is associated with hyperglycemia because the body is ridding itself of large amounts of glucose, and it is attempting to restore fluid volume.

A nurse is assessing a client who has Addison's disease. Which of the following findings should the nurse expect? a. Hypotension b. Weight gain c. Sugar craving d. Pale skin tone

A. CORRECT - Hypotension is a critical sign of Addison's disease, and the nurse should monitor blood pressure closely. If an Addisonian crisis occurs, the client's hypotension can become severe due to blood volume depletion caused by aldosterone loss (increased sodium and water excretion). B. Incorrect - Weight loss is expected. C. Incorrect - Salt craving is expected as the client is experiencing hyponatremia from decreased aldosterone production, which normally regulates sodium reabsorption. D. Incorrect - Hyperpigmentation is expected. A pale skin tone is seen in Cushing's.

A nurse is teaching a client who has seasonal affective disorder (SAD) about the use of light therapy. Which of the following statements should the nurse make? a. "Light therapy suppresses the natural nighttime release of melatonin." b. "You should plan your light therapy session before going to bed." c. "You should begin with 2-minute light therapy sessions and gradually progress to 10-minute sessions." d. "Light therapy is less effective at treating SAD than antidepressant medications."

A. CORRECT - Melatonin is produced nocturnally by the pineal gland; larger amounts are produced during months containing more hours of darkness. These large amounts of melatonin seem to cause SAD in clients who are susceptible to this disorder. Light therapy is thought to improve depression by suppressing melatonin production and increasing serotonin production. B. Incorrect - Exposure to light therapy (think of smartphones) before bedtime can cause insomnia. C. Incorrect - Begin light therapy with 10-15-minute sessions and gradually progress to sessions lasting 30-45 minutes. D. Incorrect - Light therapy is the primary treatment for SAD.

A nurse is communicating with a client who was admitted for treatment of a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication? a. Offering advice b. Reflecting c. Listening attentively d. Giving information

A. CORRECT - Offering advice to a client should be avoided. Advice tends to interfere with the client's ability to make personal decisions and choices. In addition, it is not about what the nurse thinks the client should be doing. B. Incorrect - Reflection directs the focus back to the client for the client to examine their feelings. C. Incorrect - Active listening helps to understand the message that the client is trying to convey. D. Incorrect - Giving information informs the client of needed information to assist in the treatment planning process.

A nurse is planning to care for a client who has suicidal ideation and is being transferred to the mental health unit. Which of the following interventions should the nurse include in the plan of care? a. Search the client and his belongings upon arrival b. Assign the client to a private room near the nurses' station c. Instruct the assistive personnel to check on the client every 15 minutes d. Keep the door to the client's room closed

A. CORRECT - Plan to search the client and all his belongings upon arrival. The search is conducted for the client's safety so that the nurse can identify and remove any objects that increase the risk of injury or suicide. Potentially harmful objects include razors, shoelaces, necklaces, hygiene products, and tweezers. B. Incorrect - Assign a semi-private room to decrease the risk of suicide. The client should always be in view of the hospital staff. C. Incorrect - Implement 1:1 observation of the client as part of suicide precautions to decrease the risk for suicide. The client should always be directly visible while on suicide precautions. D. Incorrect - Keep the door to the client's room open as part of suicide precautions.

A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply) a. Restlessness b. Tachypnea c. Bradycardia d. Confusion e. Hypertension

A. CORRECT - Restlessness is an early indication for hypoxia. Think about being underwater and needing to come back up for air. The panicking feeling is similar to restlessness. B. CORRECT - Tachypnea is a compensatory mechanism in hypoxia to increase oxygenation. C. Incorrect - Bradycardia is a late manifestation of hypoxia. In early stages, the body compensates by increasing the HR. D. CORRECT - Confusion (level of consciousness changes) is an early sign of hypoxia. The brain is starving for oxygen and will produce neurological symptoms like confusion. E. CORRECT - Hypertension is a compensatory mechanism in hypoxia to increase hemoglobin transfer across the body.

A nurse is caring for a school-aged child who has sickle cell anemia and was admitted for a vaso-occlusive crisis. Which of the following findings should the nurse report to the provider immediately? a. Slurred speech b. Hemoglobin level of 9 g/dL c. Hematuria d. Pain level of 7 on FACES scale

A. CORRECT - Slurred speech in a child with sickle cell anemia is an indication of stroke. The clumping of RBCs may be trapped in blood vessels transporting oxygen-carrying hemoglobin to important organs. The nursing should report this finding immediately. B. Incorrect - A Hgb level of 9 g/dL is below the expected reference range of 10-15.5 g/dL and is an expected finding for a child with sickle cell anemia. C. Incorrect - Hematuria is an expected finding of a vaso-occlusive crisis. D. Incorrect - Pain is an expected finding and the nurse should implement interventions to promote the child's level of comfort, such as around-the-clock opioid/ibuprofen/acetaminophen medications, nonpharmacologic interventions, adequate nutrition and hydration, and therapeutic communication.

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume? a. Sodium b. Calcium c. Potassium d. Magnesium

A. CORRECT - Sodium regulates extracellular fluid balance, nerve impulse transmission, acid-base balance, etc. B. Incorrect - Calcium supports bone and tooth formation and facilitates nerve impulse transmission. While calcium exists in the ECF, it does not affect extracellular fluid volume. C. Incorrect - Potassium affects glycogen storage, nerve impulse transmission, cardiac conduction, and smooth muscle contraction. It is the major cation of the ICF. D. Incorrect - Magnesium affects enzyme and neurochemical activities and the excitability of cardiac and skeletal muscles. However, it does not affect extracellular fluid volume (also part of ICF).

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurse's priority? a. Placing the client on one-to-one observation b. Assisting the client to perform ADLs c. Encouraging the client to participate in counseling d. Teaching the client about medication adverse effects

A. CORRECT - The greatest risk for a client with MDD and comorbid anxiety is injury due to self-harm (safety). This is the highest priority. B. Incorrect - The client who has MDD may require assistance with ADLs, especially if they feel like they cannot get out of bed, but this does not pose the greatest risk to the client's physiological integrity and is not the highest priority. C. Incorrect - Encourage the client who has MDD to participate in counseling. However, there is another priority intervention. D. Incorrect - Teach the client who has MDD about medication adverse effects. However, there is another priority action.

A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? a. Assist the client into the left-lateral position b. Apply a fetal scalp electrode c. Insert an IV catheter d. Perform a vaginal exam

A. CORRECT - The greatest risk to the fetus during late decelerations is uteroplacental insufficiency. The initial nursing action should be to place the client into the left-lateral position to increase uteroplacental perfusion. Think ABC's. B. Incorrect - The application of a fetal scalp electrode will assist in the assessment of fetal well-being, but this is not the first action to take. C. Incorrect - Inserting an IV catheter is an intervention for late decelerations, but this is not the first action to take. D. Incorrect - The nurse may perform a vaginal exam to assess dilation, but this is not the first action to take.

A nurse is planning care for a client who has type 2 diabetes mellitus. Which of the following interventions should the nurse include in the plan? a. Encourage the client to control weight b. Inspect the client's feet once each week c. Restrict the client's activity d. Apply moisturizer between the client's toes

A. CORRECT - The nurse should encourage weight control to stabilize the client's blood glucose and improved glycosylated hemoglobin levels. Obesity is a risk factor for type 2 diabetes, and moderate calorie restriction can improve diabetes control. B. Incorrect - The nurse should inspect the feet daily. The client is at risk for foot injury/infection due to impaired circulation and reduced sensation in the lower extremities. C. Incorrect - The nurse should seek to increase physical activity to reduce weight and improve blood glucose control. D. Incorrect - The nurse should not apply moisturizer between the client's toes due to the risk of skin breakdown from excess moisture.

A nurse is caring for a client who is in active labor. The cervix is dilated to 5 cm, and the membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes an FHR of 115-125 bpm with occasional increases up to 150-155 bpm that last for 25 seconds and have moderate variability. There is no slowing of the FHR from the baseline. The client is exhibiting manifestations of which of the following? (Select all that apply) a. Moderate variability b. FHR accelerations c. FHR decelerations d. Normal baseline FHR e. Fetal tachycardia

A. CORRECT - There is moderate variability between each acceleration in relation to uterine contractions. B. CORRECT - FHR accelerations are present with increases up to 150-155 bpm lasting for 25 seconds. C. Incorrect - There are no FHR decelerations because the FHR does not slow down. D. CORRECT - This is a normal baseline FHR of 115-125 bpm that falls within the expected range of 110-160 bpm. E. Incorrect - There is no evidence of fetal tachycardia because the FHR is within the expected reference range of 115-125 bpm.

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia? a. The client watches television in her bed during the day b. The client drinks warm milk before bedtime c. The client goes to bed at 2200 every night d. The client gets up to use the bathroom once during the night

A. CORRECT - To promote sleep hygiene, the client should avoid watching television in bed. She should only use the bed for sleep and sexual activities. B. Incorrect - Warm milk produces L-tryptophan, an amino acid that promotes sleep. C. Incorrect - General sleep strategies include establishing a regular sleep schedule. A nightly bedtime everyday of 2200 can promote sleep. D. Incorrect - Although this can cause nighttime disruptions, waking once or twice to use the bathroom at night is common. Adults who do not have insomnia fall back to sleep readily.

A nurse is teaching a client who has a prescription for long-term use of oral prednisone for treatment of chronic asthma. The nurse should instruct the client to monitor for which of the following manifestations as an adverse effect of this medication? a. Weight gain b. Nervousness c. Bradycardia d. Constipation

A. CORRECT - Weight gain and fluid retention are adverse effects of oral prednisone, a glucocorticoid, due to the effect of sodium and water retention. B. Incorrect - Nervousness and insomnia are adverse effects of beta agonists, not glucocorticoids. C. Incorrect - Tachycardia, not bradycardia, are adverse effects of prednisone. D. Incorrect - Diarrhea is an adverse effect of prednisone, not constipation.

A nurse is assessing a female client who reports severe joint pain. The nurse should identify that which of the following factors places the client at risk for gout? a. Perimenopause b. Migraine headaches c. Diuretic use d. Irritable bowel syndrome

A. Incorrect B. Incorrect C. CORRECT - Diuretics are a risk factor for gout. Diuretics increase urination, which reduces the amount of fluid in your body. But the remaining fluid is more concentrated, which increases the chance of crystal formation. Some diuretics also reduce the kidneys' excretion of urate (uric acid) as well. D. Incorrect

A nurse in the pediatric unit is caring for a group of clients. Which of the following findings should be the nurse's priority? a. A child who has asthma and a pulse oximetry of 94% b. A child who has nephrotic syndrome and 1+ protein on urine dipstick c. A child who has sickle cell anemia and a urine specific gravity of 1.030 d. A child who has insulin-dependent diabetes mellitus and a fingerstick glucose reading of 110 mg/dL

A. Incorrect - A child who has asthma should have a pulse oximetry reading at 90% or greater; therefore, this is not the nurse's priority finding. B. Incorrect - A child with nephrotic syndrome typically has moderate to large amounts of protein in the urine; therefore, this is not the priority finding. C. CORRECT - A child who has sickle cell anemia must maintain adequate hydration because dehydration could cause sickle cell crisis that can occlude the child's circulation and transfer of oxygen into tissues and organs. Sickled cells are sticky, and hydration helps with blood viscosity. D. Incorrect - A blood glucose level of 110 mg/dL is within the expected reference range for this child (70-110 mg/dL); therefore, this is not the priority.

A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching? a. "Because most of my colon is still intact and functioning, my stool will be formed." b. "My stoma will appear large at first, but it will shrink over the next several weeks." c. "My colostomy will begin to function in 2-6 days after surgery." d. "I will have to consume a soft diet after surgery."

A. Incorrect - A colostomy placed at the descending or sigmoid colon produces stool that is fairly solid and resembles what is normally expelled in the rectum. B. Incorrect - The stoma is edematous at first because of trauma from surgery and colon manipulation, but it will shrink within 6-8 weeks after surgery as the edema decreases. C. Incorrect - Because of the lack of bowel peristalsis after surgery and the client's NPO status, it is not unusual for only mucus or blood to drain from the ostomy until 2-6 days after surgery. D. CORRECT - After surgery, the client can quickly return to a regular diet, and there are no food restrictions for colostomies unless the client chooses to decrease the intake of foods that increase gas or odor.

A nurse is assessing a client who has a history of alcohol use disorder and is experiencing alcohol withdrawal. Which of the following findings should the nurse identify as a manifestation of severe alcohol withdrawal? a. Decreased appetite b. Slurred speech c. Insomnia d. Hallucinations

A. Incorrect - A decreased appetite is a manifestation of mild to moderate alcohol withdrawal. B. Incorrect - Slurred speech is a manifestation of alcohol withdrawal. C. Incorrect - Insomnia is a manifestation of mild to moderate alcohol withdrawal. D. CORRECT - Hallucinations (delirium tremens) are a manifestation of SEVERE alcohol withdrawal, along with diaphoresis, hyperthermia, and tachycardia. Note that this is life-threatening and may potentially kill the patient. Unlike opioid withdrawal which does not kill the patient, alcohol withdrawal can.

A nurse is providing discharge teaching about foot care to a client with diabetic neuropathy. Which of the following statements by the client demonstrates an understanding of the teaching? a. "I can use a heating pad on my feet to keep them warm." b. "I can go barefoot as long as I stay inside the house." c. "I will wash my feet daily and apply lotion, except between my toes." d. "I will trim my toenails every morning by rounding the corners."

A. Incorrect - A heating pad can place the client at risk of a thermal injury. B. Incorrect - Going barefoot is not recommended due to the inability to feel injury, increasing the risk of infection. Protective shoes should be worn. C. CORRECT - Diabetic neuropathy is a risk factor for extremity amputation. The client should inspect the feet daily to recognize early injury. The client should also clean the feet daily with mild soap and warm water. Lotion is applied to prevent drying and cracking, but should not be applied between the toes as this can provide a moist environment that favors bacterial growth. D. Incorrect - The client should trim the toenails as needed when the nailbeds are softened after a bath or shower. The toenails should be cut evenly, straight across. Nails that are cut into the corners of the toe put the client at risk of an ingrown toenail, leading to infection.

A nurse in the emergency department is assessing a newly admitted infant. Which of the following findings is an early indication of hypoxemia? a. Nonproductive cough b. Hypoventilation c. Tachypnea d. Nasal stuffiness

A. Incorrect - A nonproductive cough is a manifestation of a respiratory infection and oxygen toxicity. B. Incorrect - Hypoventilation is a manifestation of oxygen toxicity. C. CORRECT - Tachypnea is an early indication of hypoxemia in an infant because their body is compensating to be more oxygenated by breathing more. D. Incorrect - Nasal stuffiness is a manifestation of a respiratory infection.

A nurse is monitoring a client who has Graves' disease for the development of thyroid storm. The nurse should report which of the following findings to the provider? a. Constipation b. Headache c. Bradycardia d. Hypertension

A. Incorrect - A patient experiencing a thyroid storm (hyperthyroidism) will have diarrhea in response to thyroid hormone overproduction. B. Incorrect - Restlessness and confusion are indicative of hyperthyroidism and thyroid storm. C. Incorrect - Tachycardia is indicative of hyperthyroidism and thyroid storm. D. CORRECT - A patient experiencing thyroid storm will have an exaggerated condition of hyperthyroidism associated with hypertension, tachycardia, and more (everything is high).

A nurse is caring for an adolescent client who has a prescription for opioids. Which of the following findings should the nurse recognize as an adverse effect of opioids? a. Dilated pupils b. Tremors c. Yawning d. Pruritis

A. Incorrect - Dilated pupils are manifestations of opioid withdrawal. B. Incorrect - Tremors are manifestations of opioid withdrawal. C. Incorrect - Yawning is a manifestation of opioid withdrawal. D. CORRECT - Pruritis is an adverse effect of opioids. Constipation, respiratory depression, nausea, vomiting, agitation, orthostatic hypotension, and hallucinations are also adverse effects of opioids.

A nurse is teaching the guardian of a school-age child who has diabetes mellitus how to recognize diabetic ketoacidosis (DKA). Which of the following findings should the nurse identify as a manifestation of this complication? a. Slow heart rate b. Protruding eyeballs c. Deep, rapid respirations d. Decreased urinary output

A. Incorrect - A rapid heart rate is a manifestation of DKA. B. Incorrect - Sunken eyeballs are a manifestation of DKA resulting in dehydration. Protruding eyeballs, or exophthalmos, are indicative of Graves' disease (hyperthyroidism). C. CORRECT - Deep and rapid respirations, or Kussmaul respirations, is a manifestation of DKA. This respiratory pattern is caused by the body's attempt to rid itself of excess carbon dioxide that results from the presence of ketones. Ketones are produced when the body uses fat for energy because there is insufficient use of glucose. These breaths can be fruity smelling due to the body's attempt to eliminate ketones via the respiratory system. D. Incorrect - Increased urinary output is a manifestation of hyperglycemia which may lead to DKA. Decreased urinary output is associated with hypoglycemia. The body is attempting to rid of excess glucose via the urine.

A nurse is a reviewing the laboratory results of a client who has diabetes mellitus. Which of the following results indicates that the client's diabetes is controlled? a. HbA1c 8.5% b. Postprandial blood glucose 190 mg/dL c. Casual blood glucose 205 mg/dL d. Fasting blood glucose 95 mg/dL

A. Incorrect - An HbA1c of 8.5% is above the expected range of <6.5% and does not indicate diabetes control. B. Incorrect - The postprandial blood glucose expected range is <160 mg/dL. 190 mg/dL is too high. C. Incorrect - The casual blood glucose expected range is <200 mg/dL. 205 mg/dL is too high. D. CORRECT - A fasting blood glucose of 95 mg/dL is within the expected reference range of 70-110 mg/dL.

A nurse is caring for a client who has been taking metformin for 6 months. Which of the following finding should the nurse identify as an expected therapeutic effect of the medication? a. Decreased vitamin B12 levels b. Decreased blood glucose level c. Abdominal bloating and diarrhea d. Decreased LDL level

A. Incorrect - An adverse effect of metformin is decreasing the absorption of vitamin B12, which is not therapeutic. B. CORRECT - Metformin is a non-insulin medication for clients with type 2 diabetes mellitus used to treat elevated blood glucose levels. Metformin blocks the production of glucose by the liver and improves insulin sensitivity. C. Incorrect - Abdominal bloating and diarrhea is not a therapeutic effect of metformin, but an adverse one. D. Incorrect - Statins decrease LDL levels, not metformin.

A nurse is caring for an older adult client who has a new onset of type 2 diabetes mellitus. Which of the following physiological changes can contribute to the development of type 2 diabetes? a. Increased production of insulin by the pancreas b. Decreased sensitivity to circulating insulin c. Increased rate of glucose metabolism d. Decreased release of glycogen by the liver

A. Incorrect - An insufficient release of insulin by beta cells within the pancreas occurs in type 2 diabetes mellitus. B. CORRECT - Patients with type 2 diabetes mellitus demonstrates reduced tissue sensitivity to circulating insulin, or insulin resistance. C. Incorrect - A decreased rate of glucose metabolism occurs in older adult clients. D. Incorrect - Glucose is stored in the liver as glycogen. A decrease in the amount of glycogen will reduce blood glucose.

A nurse in a provider's office is documenting the results of a general survey of a client who is new to the practice. The client reports an inability to find pleasure in any activities she previously enjoyed. Which of the following terms should the nurse use to describe the client's mood? a. Anergia b. Flat affect c. Apathy d. Anhedonia

A. Incorrect - Anergia is a total passivity or lack of energy. B. Incorrect - A flat affect shows no facial expression at all. C. Incorrect - Apathy is indifference and a lack of interest in anything. D. CORRECT - Anhedonia is an inability to experience pleasure. This finding is especially concerning when the client no longer enjoys the activities that once produced pleasure.

A nurse is assessing a client who has advanced cirrhosis. The nurse should identify which of the following findings as indicators of hepatic encephalopathy? (Select all that apply) a. Anorexia b. Change in orientation C. Asterixis D. Weight gain E. Fetor hepaticus

A. Incorrect - Anorexia is present in a client with liver disease, but is not an indication of hepatic encephalopathy. B. CORRECT - A change in orientation indicates hepatic encephalopathy. A cirrhotic liver is unable to breakdown certain waste products (ammonia), increasing these substances in the blood and causing confusion. C. CORRECT - Asterixis, or a coarse hand flapping/tremor, is a late stage complication of cirrhosis and hepatic encephalopathy. D. Incorrect - Weight gain is not an indication. E. CORRECT - Fetor hepaticus (fruity, musty breath odor) is a finding of hepatic encephalopathy.

A nurse is caring for a client with bipolar disorder. The client states, "I am very rich, and I feel I must give 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 I 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."

A. Incorrect - Asking a "why" question is a nontherapeutic form of communication and can promote a defensive client response. B. CORRECT - This statement is matter of fact and concise, which is a therapeutic response for a client with bipolar disorder. Nurses should communicate in a firm, clear, concise, and honest matter. C. Incorrect - This statement does not recognize the possibility of poor judgment, which is associated with bipolar disorder. The nurse should also avoid enabling the manic behavior, and keep the situation matter-of-fact. D. Incorrect - This statement offers disapproval and can be interpreted by the client as aggressive, which promotes a defensive response.

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

A. Incorrect - Avoid the use of caffeine (and alcohol) in bipolar disorder because it can precipitate a relapse. B. CORRECT - The client should be alert for sleep disturbances, which can indicate a relapse. C. Incorrect - The client should take prescribed medications to prevent a relapse, not begin taking them when they occur. D. CORRECT - The client who has bipolar disorder can participate in psychotherapy to help prevent a relapse. E. CORRECT - Anhedonia, or the inability to experience pleasure in activities a client once enjoyed, is a manifestation of depression which can indicate a relapse of bipolar disorder.

A nurse is assessing a client who was recently admitted following a suicide attempt. Which of the following behaviors is the priority for the nurse to report to the adolescent's treatment team? a. Calling family members b. Spending time alone c. Giving away possessions d. Excessive crying

A. Incorrect - Calling family members indicates that the client has a support system. Therefore, another behavior is the priority. B. Incorrect - Spending time alone may indicate that the client is withdrawn from others. However, another behavior is the priority. C. CORRECT - Giving away possessions indicates the greatest risk for suicide. The nurse should have a relationship with the adolescent built upon trust and respect so that the nurse feels comfortable enough to ask the adolescent directly about suicidal thoughts and/or plans. D. Incorrect - Crying excessively indicates that the client is showing signs of increased depression. However, another behavior is the priority.

A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect? a. Pain in right upper quadrant b. Report of pain being worse when sitting upright c. Pain relieved with defecation d. Epigastric pain radiating to the left shoulder

A. Incorrect - Cholecystitis is characterized by right upper quadrant pain. Pancreatitis is epigastric and radiates. Much of the pancreas lies in the left upper quadrant and epigastric area, thus right upper quadrant pain is not expected. B. Incorrect - A client will report worsening pain when lying down. Sitting upright or in a fetal position somewhat makes the client feel better. C. Incorrect - Defecation does not relieve the pain. D. CORRECT - Clients with pancreatitis will report severe, boring epigastric pain radiating to the back, left flank, or left shoulder.

A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following statements indicates that the client understands the instructions? a. "I should try to drink at least 2 liters of fluid per day." b. "I can still fly out to visit my sister in Colorado for a while." c. "Physical activity is good for me, but I need to avoid overexertion." d. "I can still go skiing during the cold winter months."

A. Incorrect - Clients should drink 3-4 liters of fluid per day to prevent sickle cell crisis. Sickled RBCs are more likely to clump together when SCD patients are not well hydrated, increasing blood viscosity and occluding blood flow throughout the vessels. B. Incorrect - Clients should avoid traveling to high altitudes which increases oxygen demand, increasing the risk of sickle cell crisis. C. CORRECT - Clients should avoid overexertion which increases oxygen demand, increasing the risk of sickle cell crisis. D. Incorrect - Clients should understand that skiing may increase oxygen demand. Persistent exposure to cold weather causes the blood vessels to constrict, which does not help the problem seen in sickle cell crisis in which sticky RBCs are trapped.

A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care? a. Assign the client to a private room b. Document the client's behavior every hour c. Allow the client to keep perfume in their room d. Ensure that the client swallows their medication

A. Incorrect - Clients who are suicidal should not be assigned to a private room. Supervision is necessary to decrease the risk of harm. B. Incorrect - Client's behavior should be documented every 15 min or according to facility policy. C. Incorrect - Remove perfume from the client's room, as this is a safety hazard. Some perfumes are kept in glass bottles, which can be a hazard if it is shattered. D. CORRECT - Ensure that the client swallows their medication to prevent hoarding of medications for an attempt to exceed the prescribed dose as part of a suicide plan.

A nurse is reviewing the electronic monitor tracing of a client who is in active labor. A fetus receives more oxygen when which of the following appears on the tracing? a. Peak of uterine contraction b. Moderate variability c. FHR acceleration d. Relaxation between uterine contractions

A. Incorrect - Compression of the arteries to the uteroplacental intervillous spaces is most acute at the peak of a uterine contraction, resulting in a decrease in fetal circulation and oxygenation. B. Incorrect - Moderate variability does not indicate the fetus is receiving more oxygen, although it does indicate fluctuations in FHR. C. Incorrect - FHR accelerations indicate an intact fetal CNS and is not an indication the fetus is receiving more oxygen. D. CORRECT - A fetus is most oxygenated during the relaxation period during contractions. During contractions, the arteries to the uteroplacental intervillous spaces are compressed.

A nurse in a provider's office is collecting information from an older adult client who reports taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? a. Constipation b. Gastric ulcers c. Respiratory depression d. Liver damage

A. Incorrect - Constipation is an adverse effect of opioid analgesics. B. Incorrect - Gastric ulcers are an adverse effect of aspirin and other nonselective NSAIDs. C. Incorrect - Respiratory depression is an adverse effect of opioid analgesics. D. CORRECT - Acetaminophen in large doses can be toxic to the liver.

A nurse is teaching a child who has type 1 diabetes mellitus. Which of the following are manifestations of diabetic ketoacidosis? (Select all that apply) a. Blood glucose 58/dL b. Weight gain c. Dehydration d. Mental confusion e. Fruity breath

A. Incorrect - DKA is a symptom of hyperglycemia; classified as blood glucose level greater than 300 mg/dL. B. Incorrect - Children with DKA present with weight loss (cannot hold their weight whatsoever). C. CORRECT - DKA children experience polyuria (excessive urination). D. CORRECT - They may experience mental confusion because of the electrolyte imbalances from dehydration (and other factors). E. CORRECT - DKA children experience fruity breath because of the body's attempt to eliminate ketones via fat stores. Respiration is an insensible form of fluid loss that cannot be measured.

A nurse is caring for a client who has been diagnosed with an Addisonian crisis and has a blood pressure of 74/42 mmHg. Which of the following prescriptions should the nurse anticipate? a. Desmopressin b. Hydrocortisone c. Dopamine d. Furosemide

A. Incorrect - Desmopressin (analog of antidiuretic hormone, ADH) is the hormone replacement of choice for diabetes insipidus. B. CORRECT - Patients experiencing Addisonian crisis will require hydrocortisone (hormonal cortisol) to assist with replacing cortisol levels. Addison's disease is adrenal corticoid insufficiency due to the pituitary's inability to produce cortisol. Illness and stress can require steroids like hydrocortisone to restore hormone levels. C. Incorrect - Dopamine does not treat Addisonian crisis. D. Incorrect - Addisonian crisis necessitates fluid replacement due to volume loss. Furosemide, a loop diuretic, will make the problem worse.

A nurse is caring for a client at 26 weeks gestation and reports constipation. Which of the following responses by the nurse is appropriate? a. "You should drink 1 oz of mineral oil every morning." b. "You should walk for at least 30 min every day." c. "You should eat at least 3 oz of red meat per day." d. "You should stop taking your prenatal vitamin."

A. Incorrect - Do not consume mineral oil to treat constipation during pregnancy because this can lead to severe cramping, diarrhea, fluid loss, and preterm contractions. B. CORRECT - Participate in moderate physical activity, such as walking, every day. This activity increases intestinal peristalsis, which will help alleviate constipation. The three golden treatments for constipation is exercise, fluid intake, and fiber intake. C. Incorrect - Do not recommend a daily intake of red meat because it is high in iron and contributes to constipation. D. Incorrect - Instructing the client to stop taking the prescribed prenatal vitamin could harm the fetus.

A nurse is reviewing the admission laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect? a. Decreased blood lipase level b. Decreased blood amylase level c. Increased blood calcium level d. Increased blood glucose level

A. Incorrect - Due to pancreatic cell injury, there is an elevated blood lipase level. The pancreatic duct is inflamed or obstructed, causing amylase and lipase to be unable to get into the digestive tract to break down food. B. Incorrect - Due to pancreatic cell injury, there is an elevated amylase level. C. Incorrect - Due to fat necrosis, there is a decreased blood calcium level. D. CORRECT - Pancreatic cell injury impairs the metabolism of carbohydrates (glucose) because of the decreased release of insulin, elevating serum glucose levels.

A nurse is planning to 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 concerns e. Use a firm approach with communication

A. Incorrect - Establish consistent client behavior expectations to decrease the risk for client manipulation and create a milieu environment. Often in manic episodes, the client is sporadic and cannot focus or stay still. The nurse should provide firm and clear expectations to give the client structure. B. CORRECT - Offering concise explanations improves the client's ability to focus and comprehend the information. C. CORRECT - Establishing consistent limits decreases the risk for client manipulation. D. Incorrect - Respond to valid client concerns to foster a trusting nurse-client relationship. E. CORRECT - Using a firm approach with a client promotes structure and minimizes inappropriate client behaviors.

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? a. Extended periods of sleep b. Poor muscle tone c. Respiratory rate 50/min d. Exaggerated reflexes

A. Incorrect - Extended periods of sleep indicate CNS depression, not hyperactivity. B. Incorrect - A newborn with neonatal abstinence syndrome has increased muscle tone. Hypotonia is not an expected finding for a newborn who has narcotic withdrawal. C. Incorrect - Newborns with neonatal abstinence syndrome often experience respiratory distress, which is manifested as respirations >60/min. A respiratory rate of 50/min is within the expected reference range. D. CORRECT - A newborn who has neonatal abstinence syndrome usually exhibits clinical findings of hyperactivity within the CNS. Exaggerated reflexes are indicative of CNS irritability.

A nurse is caring for a client who has major depressive disorder. Which of the following should the nurse identify as a risk factor for depression? (Select all that apply) a. Male sex b. History of chronic bronchitis c. Recent death in client's family d. Family history of depression e. Personal history of panic disorder

A. Incorrect - Females are twice as likely as males to experience a depressive disorder. However, males are more at risk for completing suicide than females. B. CORRECT - Depressive disorders are more common in a client who has a chronic medical condition. C. CORRECT - Depressive disorders are more likely to occur in a client who is experiencing a high amount of stress, such as grieving over the death of a family member. D. CORRECT - Depressive disorders are more likely to occur in a client who has a family history of depression. E. CORRECT - A history of anxiety or personality disorder (comorbidities) increases the client's risk for depressive disorder.

A nurse is planning care for a client who has Cushing's syndrome due to chronic corticosteroid use. Which of the following actions should the nurse include in the plan of care? a. Check the client's blood glucose for hypoglycemia b. Check the client's urine specific gravity c. Weigh the client weekly d. Insert an indwelling urinary catheter for the client

A. Incorrect - Hyperglycemia is a sign of Cushing's syndrome. The body is secreting excess cortisol which releases stored glucose into the blood. B. CORRECT - The nurse should check the urine specific gravity to assess for fluid volume overload. There is excess aldosterone production in Cushing's, which helps retain sodium and water. Thus, clients will appear with trunk obesity, a "moon face," edema, and other characteristics of fluid retention. C. Incorrect - The nurse should weigh the client at the same time each day to determine fluid volume status, as well as treatment decisions. D. Incorrect - The nurse should save all urine output to record results every 24 hours. An indwelling catheter needlessly exposes the client to a potential UTI. Cushing's syndrome itself is not an indication for catheter use.

A nurse is reviewing the laboratory findings of a client who has chronic kidney disease. The client reports significant persistent nausea and muscle weakness. Which of the following findings should the nurse expect? a. Hypernatremia b. Hypomagnesemia c. Hypercalcemia d. Hyperkalemia

A. Incorrect - Hypernatremia indicates a sodium level greater than 145 mEq/L. Manifestations include dry mucous membranes, agitation, thirst, hyperreflexia, and convulsions. It is not associated with chronic kidney disease. B. Incorrect - Hypomagnesemia indicates a magnesium level below 1.3 mEq/L. Hypomagnesemia is present in patients with hyperthyroidism or diabetes and in clients who are pregnant. It is not associated with CKD. C. Incorrect - Hypercalcemia indicates a calcium level greater than 10.5 mg/dL. Hypercalcemia is present with some cancers but not associated with CKD. D. CORRECT - A patient with chronic kidney disease can have hyperkalemia, or a serum potassium level greater than 5.0 mEq/L. Vomiting and muscle weakness are characteristics of hyperkalemia.

A nurse assesses a client immediately following an ECT procedure. Which of the following findings should the nurse expect? (Select all that apply) a. Hypotension b. Paralytic ileus c. Memory loss d. Polyuria e. Confusion

A. Incorrect - Immediately following ECT, the client's blood pressure is expected to be elevated, which is why a blood pressure cuff is placed on the patient for monitoring purposes. B. Incorrect - Paralytic ileus is not an expected finding of ECT. C. CORRECT - Transient short-term memory loss is an expected finding immediately following ECT. D. Incorrect - Polyuria is not an expected finding of ECT. E. CORRECT - Confusion is an expected finding immediately following ECT. Small electrical currents may cause neurological symptoms, such as confusion or amnesia, but eventually resolves.

A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? a. "The newborn will have decreased muscle tone." b. "The newborn will have a continuous high-pitched cry." c. "The newborn will sleep for 2-3 hours after a feeding." d. "The newborn will have mild tremors when disturbed."

A. Incorrect - Increased muscle tone is seen in a newborn who has neonatal abstinence syndrome (CNS is hyperactive). B. CORRECT - A continuous high-pitched cry is often an indication of CNS disturbances in a newborn who has neonatal abstinence syndrome (hyperarousal, hyperexcitability). The gold standard for treatment is eat (adequate feeds), sleep (ensure undisturbed rest lasting longer than an hour), and console (limiting the cries and irritability). C. Incorrect - This newborn will experience sleep pattern disturbances and may not be fully able to get undisturbed sleep for even an hour. D. Incorrect - These newborns often experience moderate to severe tremors when undisturbed (CNS is hyperactive).

A nurse is teaching an adolescent who has diabetes mellitus about manifestations of hypoglycemia. Which of the following findings should the nurse include in the teaching? (Select all that apply) a. Increased urination b. Hunger c. Poor skin turgor d. Irritability e. Sweating and pallor f. Kussmaul respirations

A. Incorrect - Increased urination is a sign of hyperglycemia. The body is removing excess glucose in the blood through urination. B. CORRECT - Hunger results from increased adrenergic nervous system activity. The brain, the organ most significantly impacted by blood glucose, is "starving" for more energy. C. Incorrect - Poor skin turgor, indicating dehydration, is a sign of hyperglycemia. Polydipsia is a hallmark sign. The excessive urination causes the client to feel thirsty. D. CORRECT - Irritability is a sign of hypoglycemia because of depleted glucose in the CNS, causing neurological symptoms. E. CORRECT - Sweating and pallor are signs of hypoglycemia due to increased adrenergic nervous system activity. F. Incorrect - Kussmaul respirations are late-stage signs of hyperglycemia; may indicate DKA.

A nurse caring for a child who is receiving oxygen therapy and is on a continuous oxygen saturation monitor that is reading 89%. Which of the following actions should the nurse take first? a. Increase the oxygen flow rate b. Encourage the child to take deep breaths c. Ensure proper placement of the sensor probe d. Place the child in Fowler's position

A. Incorrect - Increasing the oxygen flow rate is important, but this is not the priority. B. Incorrect - Encouraging the child to take deep breaths to increase oxygenation is important, but this is not the priority. C. CORRECT - The first step of the nursing process is to assess. Ensuring the sensor probe is properly placed is the priority action. D. Incorrect - Placing the child in Fowler's position is important, but not the priority.

A nurse is providing instructions to a client who has a new prescription for albuterol, PO. Which of the following instructions should the nurse include? a. "You can take this medication to abort an acute asthma attack." b. "Tremors are an adverse effect of this medication." c. "Prolonged use of this medication can cause hyperglycemia." d. "This medication can slow skeletal growth rate."

A. Incorrect - Inhaled albuterol is used to treat an acute asthma episode. Inhaled medication has a faster medication activation than oral medications, which has to be passed through the gastrointestinal tract. B. CORRECT - Tremors can occur due to excessive stimulation of beta-2 receptors of skeletal muscles. Beta-2 receptors also exist on the lungs, which is why albuterol treats asthmatic attacks. C. Incorrect - Prolonged use of glucocorticoids can cause hyperglycemia, not albuterol. D. Incorrect - Glucocorticoids slow skeletal growth rate in children and adolescents.

A nurse is conducting a class for a group of newly licensed nurses on caring for clients who are at risk of suicide. Which of the following information should the nurse include in the teaching? a. A client's verbal threat of suicide is attention-seeking behavior b. Interventions are ineffective for clients who really want to commit suicide c. Using the term suicide increases the client's risk for a suicide attempt d. A no-suicide contract decreases the client's risk for suicide

A. Incorrect - It is a myth that a suicide threat of attempt is attention-seeking behavior, adding to the stigma around mental health. B. Incorrect - It is a myth that interventions are ineffective for clients who really want to commit. Suicide precautions are shown to be effective in reducing the risk of a completed suicide, for example. C. Incorrect - Discuss suicide openly with the client, as it is a myth that mentioning suicide will increase their chances of attempting. D. CORRECT - No-suicide contracts decrease the risk for suicide by promoting and maintaining trust between the nurse and the client. However, it should not replace other suicide prevention strategies.

A nurse is assisting in the discharge planning for a client following alcohol detoxification. The nurse should expect prescriptions for which of the following medications to promote long-term abstinence from alcohol? (Select all that apply) a. Lorazepam b. Diazepam c. Disulfiram d. Naltrexone e. Acamprosate

A. Incorrect - Lorazepam is prescribed for short-term use during withdrawal, which occurs about 4-12 hours after the last drink. Once a client comes off the immediate withdrawal period, then long-term management of alcohol addiction can begin. B. Incorrect - Diazepam is prescribed for short-term use during withdrawal. C. CORRECT - Disulfiram promotes abstinence through aversion therapy by blocking the metabolism of alcohol. The client should avoid any products that contain alcohol (mouthwash, hand sanitizers, cannot drink) which will cause adverse interactions with disulfiram. D. CORRECT - Naltrexone promotes abstinence by suppressing the craving and pleasurable effects of alcohol by binding to mu-opioid receptors. E. CORRECT - Acamprosate (calcium) promotes abstinence by decreasing the unpleasant effects of abstinence by binding to glutamate receptors, acting as "artificial ETOH."

A nurse in a substance use disorder treatment facility is reviewing the medication records of a group of clients. The nurse should expect to administer methadone to a client who has a substance use disorder for which of the following substances? a. Amphetamines b. Opiates c. Barbiturates d. Alcohol

A. Incorrect - Methadone administration is not indicated for amphetamine use disorder. B. CORRECT - Methadone administration is indicated for opiate use disorder treatment. Opiates include opium, morphine, codeine, methadone, and heroin. Methadone is given as a substitute to prevent cravings and severe manifestations of opiate withdrawal. C. Incorrect - Methadone administration is not indicated for barbiturate use disorder. D. Incorrect - Methadone administration is not indicated for alcohol use disorder.

A nurse is assessing a child who is postoperative. Which of the following findings should the nurse identify as an indication that naloxone should be administered? a. Crackles in the lung bases b. Respiratory depression c. Nausea and vomiting d. Tachycardia

A. Incorrect - Monitor the child's lung sounds postoperatively. Crackles in the lung bases can indicate atelectasis, indicating the need to promote lung expansion. However, this is not an indication for the administration of naloxone. B. CORRECT - Plan to administer naloxone if respiratory depression is present. Naloxone is an opioid antagonist used to reverse the effects of opioids administered perioperatively. C. Incorrect - Nausea and vomiting postoperatively can occur because of abdominal distention, pain, or as an adverse effect of medications. However, this is not an indicator for administering naloxone. D. Incorrect - Monitor the child's heart rate and vital signs postoperatively. Tachycardia can be an indicator of pain, hemorrhage, or hypoxemia indicating the need for further assessment. However, tachycardia does not warrant naloxone administration.

A nurse is teaching about the adverse effects of morphine with a client who has acute pain. Which of the following statements should the nurse include in the teaching? a. "You might notice that you see better in dim areas." b. "You should increase your fluid intake." c. "You should expect to have excessive urination." d. "You might experience difficulty sleeping."

A. Incorrect - Morphine can cause pupillary constriction, making it difficult to see in a dim room. The patient's room should be kept well-lit to provide optimal visibility. B. CORRECT - An adverse effect of morphine is constipation. Therefore, the client should increase oral fluids to promote motility of the bowel. C. Incorrect - An adverse effect of morphine is urinary retention. The client should void at least once every 4 hours. D. Incorrect - Sedation and drowsiness are adverse effects of morphine. The client should stand up slowly when getting out of bed and alert the nurse of abnormal cognitive changes.

A nurse is assessing a client who is taking lithium to treat bipolar disorder and has a lithium level of 2.2 mEq/L. Which of the following findings should the nurse expect? a. Muscle weakness b. Oliguria c. Vomiting d. Blurry vision

A. Incorrect - Muscle weakness and fine hand tremors are early manifestations of lithium toxicity, common with lithium levels between 1.0-1.5 mEq/L. B. Incorrect - Lithium toxicity levels above 2.5 mEq/L include seizures and oliguria. C. Incorrect - Nausea, vomiting, diarrhea, and lethargy are early manifestations of lithium toxicity, common with lithium levels between 1.0-2.0 mEq/L. D. CORRECT - Lithium toxicity levels between 2.0-2.5 mEq/L include blurry vision, ataxia, clonic twitching, coma, severe hypotension, death, and polyuria.

A nurse is caring for a newborn who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect and report to the provider? a. Weak cry b. Absent Moro reflex c. Constipation d. Tremors

A. Incorrect - Newborns who have neonatal abstinence syndrome exhibit a shrill cry. B. Incorrect - Newborns who have neonatal abstinence syndrome exhibit an exaggerated Moro reflex. C. Incorrect - Newborns who have neonatal abstinence syndrome can exhibit diarrhea. D. CORRECT - Newborns who have neonatal abstinence syndrome can have tremors, tachypnea, nasal flaring, apnea, retractions, incessant crying, frequent yawning and sneezing, mottling of the skin, excessive sucking, vomiting, and fevers.

A nurse is demonstrating colostomy care to a client who has a new colostomy. Which of the following actions should the nurse teach the client to perform? (Select all that apply) a. Use antimicrobial ointment on the peristomal skin b. Empty the bag when it is one-third to one-half full c. Cut the skin barrier opening a little larger than the ostomy d. Wash the peristomal skin with mild soap and water e. Apply the skin barrier while the skin is slightly moist

A. Incorrect - Oil-based ointments on the skin disrupt adhesion, and antimicrobials are unnecessary unless prescribed by the provider to treat an infection. B. CORRECT - Allowing the bag to become too full can cause leakage, so empty the bag when it is one-third to one-half full. C. CORRECT - The client should cut an opening that is about 1/16-1/8 larger than the stoma to avoid applying any constricting pressure to the stoma. D. CORRECT - The client should wash the peristomal skin with mild soap and water. Avoid moisturizing soaps because lubricants can affect adhesion of the appliance. E. Incorrect - The skin must be dry before applying the skin barrier since the pouch will not adhere to moist skin.

A nurse is teaching a newly licensed nurse about pain management in clients aged 65 and older. Which of the following pieces of information should the nurse include in the teaching? a. Older adult clients experience a decreased ability to perceive pain compared to young adult clients. b. Older adult clients are reluctant to report pain. c. Older adult clients should not receive opioid narcotics. d. Older adult clients experience a shorter duration of action with medications than younger clients.

A. Incorrect - Older adult clients do not experience a decrease in pain perception. Neuropathy is not a normal sign of aging. B. CORRECT - Older adult clients are frequently reluctant to report pain because they might not want to bother or anger caregivers and might believe that pain is expected. C. Incorrect - Older adult clients can receive opioid narcotics for pain relief. However, these clients metabolize medications slowly and might require lower doses. D. Incorrect - Renal and liver function declines with age. Therefore, medications have a longer duration of action in older adult clients. The nurse should frequently monitor these clients for adverse effects and may need to administer a lower dosage at longer intervals.

A nurse is caring for a client who is receiving IV oxytocin for the induction of labor and notes repetitive early decelerations on the electronic fetal heart rate (FHR) tracing. Which of the following actions should the nurse take? a. Increase the rate of intravenous fluid infusion b. Discontinue the infusion of oxytocin c. Re-evaluate the FHR tracing in 15 minutes d. Request a prescription for an amnioinfusion

A. Incorrect - Oxytocin is given by starting a primary IV infusion and administering the medication through a secondary line. Therefore, the rate of IV fluids should be increased to improve uteroplacental perfusion if the client is experiencing late decelerations. B. Incorrect - The nurse should discontinue the oxytocin infusion in the presence of late or variable decelerations. This action is not appropriate for early decelerations. C. CORRECT - Early decelerations are a result of the compression of the fetal head during contractions. They are benign and require no specific intervention (Category I). The nurse should reassess the FHR and contraction pattern in 15 minutes to monitor effects of oxytocin. D. Incorrect - An amnioinfusion relieves intermittent umbilical cord compression resulting from variable decelerations.

A nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "I'll limit pushing the button, so I do not get an overdose." b. "If I push the button and still have pain after 2 minutes, I will push it again." c. "I will ask my niece to push the button when I am sleeping." d. "I can still use my transcutaneous electrical nerve stimulation unit while I am pushing the PCA button."

A. Incorrect - PCA devices have a lockout mechanism that allows a preset minimum interval between medication doses and limits the total dose per hour. This safety feature prevents analgesic overdosing. B. Incorrect - PCA devices have a lockout mechanism that usually allows dosing every 6-8 minutes. If the client pushes the button after 2 minutes, the pump will not deliver any medication. C. Incorrect - The client is the only person who should operate the PCA pump. When someone else operates the pump, it bypasses a safety feature that requires the client to be awake and to decide whether more medication is needed. D. CORRECT - The nurse should encourage the client to utilize nonpharmacological methods of pain management such as transcutaneous electrical nerve stimulation (TENS) while using a PCA pump to reduce the amount of opioid dosing the client needs.

A nurse is teaching a client who has type 2 diabetes about a prescription for insulin lispro. Which of the following statements should the nurse include in the teaching? a. "The effects of the insulin lispro can last for 8-12 hours." b. "Administer insulin lispro 30-60 minutes before eating." c. "Insulin lispro has an onset of about 15 minutes." d. "This insulin can be given as a continuous intravenous bolus."

A. Incorrect - Patients taking insulin lispro can expect the medication effects to last for 3-6 hours. B. Incorrect - Patients taking insulin lispro should take the insulin within 15 minutes before eating because the onset of the medication is within 15 minutes. The patient should also take the insulin immediately after a meal. C. CORRECT - Insulin lispro is a rapid-acting insulin and has an onset of 15-30 minutes. D. Incorrect - Insulin lispro can be administered subcutaneously or through an insulin pump. It is never given intravenously.

A nurse is teaching a client who has hyperthyroidism about managing this disorder. Which of the following recommendations should the nurse include? a. Reduce total hours of sleep b. Keep the immediate environment warm c. Increase caloric intake with meals d. Gradually increase activity

A. Incorrect - Patients with hyperthyroidism often report an inability to sleep. Think high metabolism (energy) keeping them awake. A decreased attention span and hyperactivity are common. The nurse should suggest frequent periods of rest in a quiet environment. B. Incorrect - Patients with hyperthyroidism have heat intolerance accompanied by a low-grade fever and diaphoresis d/t their hypermetabolic state. C. CORRECT - Patients with excess thyroid hormone have increased protein, lipid, and carbohydrate metabolism. Meeting energy demands is often difficult, and weight loss is common. Muscle wasting and weakness can develop without adequate caloric and protein intake. D. Incorrect - Patients with hyperthyroidism are often restless and have an increased systolic blood pressure, tachycardia, and other dysrhythmias. During the acute phase, increased activity (therefore, increasing metabolic demand) is not recommended.

A nurse is teaching a client who has persistent cancer pain about the adverse effects of opioids. Which of the following statements should the nurse include in the teaching? a. "Opioids do not relieve pain without causing severe adverse effects." b. "Physical dependence is not the same as addiction." c. "Tolerance typically means that the medication will no longer be effective." d. "The most common adverse effect is respiratory depression with prolonged use."

A. Incorrect - Reassure the client that when opioids are correctly prescribed and used, they are both safe and effective. B. CORRECT - The nurse should explain that physical dependence can occur in all clients who take opioids, and the client may develop abstinence syndrome if the opioid is abruptly withdrawn. Physical dependence is not the same as addiction, but it can result in addiction. Addiction results when the opioid is continued despite physical or psychological harm. C. Incorrect - The dosage of the medication can increase when tolerance develops. A dosage increase will restore the effectiveness of the medication. D. Incorrect - The most DANGEROUS adverse effect of opioids is respiratory depression, which is uncommon with prolonged use.

A nurse is reviewing the medical record of a client who has a new prescription for bupropion for depression. Which of the following findings is the priority for the nurse to report to the provider? a. The client has a family history of seasonal pattern depression b. The client currently smokes 1.5 packs of cigarettes a day c. The client had a motor vehicle crash last year and sustained a head injury d. The client has a BMI of 25 and has gained 10 lb over the last year

A. Incorrect - Report family history information, although this information is not the most concerning priority to report. B. Incorrect - Report the current smoking status, although this is not the priority when addressing the greatest concern for taking bupropion. C. CORRECT - The client is at risk of developing seizures. Bupropion lowers the seizure threshold and should be avoided by clients who have a history of a head injury. D. Incorrect - Report the BMI and weight changes. However, this is not the greatest concern to report to the provider.

A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following? a. Retention b. Oliguria c. Diuresis d. Dysuria

A. Incorrect - Retention is an accumulation of urine in the bladder due to incomplete emptying of the bladder or a cessation of the ability to urinate. B. Incorrect - Oliguria is a diminishing urine output despite an acceptable fluid intake. C. CORRECT - Diuresis, or polyuria, is the excretion of excessive urine. This condition has many causes, including metabolic and hormonal imbalances and diuretic therapy for treating renal, cardiovascular, and pulmonary disorders. D. Incorrect - Dysuria is painful or difficult urination, often because of a UTI or injury.

A nurse 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

A. Incorrect - Set consistent limits for clients with bipolar disorder. However, this does not address the client priority need for safety. B. Incorrect - Administer prescribed medications as scheduled. However, this does not address the client priority need for safety. C. Incorrect - Provide the client with step-by-step instructions to assist with their self-care needs. However, this does not address the client priority need for safety. D. CORRECT - Monitoring for escalating behavior addresses the need for safety and is therefore a priority nursing action.

A nurse is providing teaching to a client who has heart failure and is taking spironolactone. Which of the following statements by the client indicates an understanding of the teaching? a. "I will increase my intake of citrus fruits, bananas, and potatoes." b. "I will use salt substitutes on my food." c. "I will drink as much water as I can while taking this medication." d. "I will watch for increased breast tissue growth while taking this medication."

A. Incorrect - Spironolactone is a potassium-sparing diuretic. Clients taking these diuretics should limit food intake high in potassium due to the risk of hyperkalemia. B. Incorrect - Clients taking potassium-sparing diuretics should not use salt substitutes because they contain potassium and may place client at risk of hyperkalemia. C. Incorrect - Drinking large amounts of water can be dangerous when taking spironolactone since electrolyte imbalances, such as hyponatremia, are common (further diluting blood sodium). Fluid restriction is indicated for heart failure to avoid overloading the heart. D. CORRECT - Spironolactone, derived from steroids, can cause adverse endocrine effects such as gynecomastia, impotence in men, and irregular menses and hirsutism in women.

A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply) a. Apply petroleum jelly around and inside the nares b. Remove the nasal cannula during mealtimes c. Check the position of the cannula frequently d. Report any nausea or difficulty breathing e. Post "No Smoking" signs in prominent locations

A. Incorrect - Teach the client to apply water-based lubricant to protect the nares from drying during oxygen therapy. Petroleum is an oily substance that does not react well with oxygen, potentially causing burns. B. Incorrect - Teach the client to leave the nasal cannula on while eating because this device does not interfere with eating. C. CORRECT - Teach the client that a disadvantage of the nasal cannula is that it dislodges easily. The client should form the habit of checking its position periodically and readjusting as necessary. D. CORRECT - Teach the client about oxygen toxicity, which is a complication of oxygen therapy from high concentrations or long durations. Manifestations include nausea, vomiting, and a nonproductive cough. To prevent toxicity, nurses should administer oxygen at the lowest setting that provides maximal therapeutic benefits. E. CORRECT - Teach the client that oxygen is combustible and thus increases the risk of fire injuries. No one in the house should smoke or use any device that might generate sparks in an area where oxygen is in use.

A nurse is tracking the outcomes of clients on the unit who have received postoperative pain management. This activity demonstrates which of the following competencies of the Quality and Safety Education for Nurses (QSEN) initiative? a. Safety b. Informatics c. Patient-centered care d. Quality improvement

A. Incorrect - The Safety QSEN competency uses national safety guidelines to provide safe client care. B. Incorrect - The Informatics QSEN competency involves navigating clients' EHR and using technology to effectively manage client care. C. Incorrect - The Patient-centered care QSEN competency determines clients' needs, preferences, and values while providing care. D. CORRECT - The Quality improvement QSEN competency uses data to track outcomes with the goal of devising processes to improve patient outcomes.

A nurse is caring for a client in labor whose cervix is dilated to 9 cm. She is experiencing strong contractions every 2 minutes lasting 75 seconds. The nurse should recognize that the client is in which of the following stages or phases of labor? a. Latent phase of first stage b. Active phase of first stage c. Second stage d. Transition phase of first stage

A. Incorrect - The latent phase is characterized by some cervical effacement and dilation from 0-3 cm, with little progress in the descent of the presenting part. B. Incorrect - The active phase is characterized by cervical dilation from 4-7 cm and significant descent of the presenting part. In this phase, the client has moderate to strong uterine contractions every 3-5 minutes lasting 40-70 seconds. C. Incorrect - The second stage begins with complete cervical dilation and ends with the birth of the newborn. D. CORRECT - These findings indicate the transition phase of the first stage of labor. The first stage ends with the transition phase in which the cervix dilates 8-10 cm. Uterine contractions are strong, occurring every 2-3 minutes and lasting 45-90 seconds.

A nurse is planning to care for a client who is in postpartum. Which of the following strategies should the nurse include in the plan to prevent bladder distention? a. Withhold analgesics to prevent urinary retention b. Run water in the sink while the client sits on the toilet c. Perform Crede's maneuver every 4 hours d. Restrict oral hydration

A. Incorrect - The nurse should administer analgesics as needed to decrease the client's pain during voiding. B. CORRECT - Running water in the sink can assist with spontaneous voiding. Nurses must strongly encourage postpartum clients to void frequently as part of the natural diuresis that happens immediately after birth. Frequent voiding decreases the risk of uterine displacement from an overdistended bladder. C. Incorrect - Crede's maneuver is used for clients who are not expected to regain voluntary bladder control. D. Incorrect - Clients who are postpartum will have an increased urine output and are at risk for bladder distention. Restricting oral hydration will not prevent distention.

A nurse is caring for a client who has alcoholic use disorder. Following alcohol withdrawal, which of the following medications should the nurse expect to administer to the client during maintenance? a. Methadone b. Disulfiram c. Chlordiazepoxide d. Naloxone

A. Incorrect - The nurse should administer methadone to a client who has opioid withdrawal. B. CORRECT - The nurse should administer disulfiram as a deterrent to prevent future alcohol use. The nurse must ensure the client has not had any alcohol intake for at least 12 hours prior to administration. C. Incorrect - While chlordiazepoxide is used in alcohol withdrawal, it is not used to help with maintenance of an alcohol addiction. D. Incorrect - Administer naloxone to a client who is experiencing a narcotic overdose.

A nurse is caring for a client who is at 38 weeks gestation and in the active phase of the first stage of labor. The nurse notes 2 late decelerations of the fetal heart rate during the last 5 contractions. Which of the following actions should the nurse take? a. Slow the IV infusion rate b. Assist the client to a lateral position c. Assess the bladder for urinary retention d. Initiate an oxytocin infusion

A. Incorrect - The nurse should increase the IV infusion rate when managing late decelerations. B. CORRECT - A late deceleration is a variation in the fetal heart rate that results from uteroplacental insufficiency. Side-lying positioning helps improve uteroplacental blood flow. C. Incorrect - A full urinary bladder can displace the uterus after delivery, increasing the risk for postpartum hemorrhage, but does not cause late decelerations. D. Incorrect - In the presence of late decelerations, the nurse should stop the infusion if the client is receiving oxytocin.

A nurse is providing teaching about proper care to a client who has a new colostomy. Which of the following pieces of information should the nurse include in the teaching? a. Change the colostomy bag following breakfast b. Cleanse the skin around the stoma with warm water c. Change the pouch every day d. Place an aspirin in the ostomy pouch to decrease odor

A. Incorrect - The nurse should instruct the client to change the colostomy bag before a meal because drainage from the ostomy is less likely to occur. B. CORRECT - Instruct the client to cleanse the skin around the stoma with warm water (and mild soap that is completely washed off). Any residue on the skin can cause poor adherence of the pouch. C. Incorrect - Change the pouch every 3-7 days to avoid skin breakdown around the stoma. D. Incorrect - Do not place an aspirin in the ostomy pouch to decrease odor, as this can cause stoma bleeding.

A nurse is caring for a client with bipolar disorder who is experiencing mania. Which of the following actions is the nurse's priority? a. Offer the client finger foods every 2 hours b. Determine if the client is a danger to herself c. Monitor the client's vital signs every 2 hours d. Move the client to a quiet area

A. Incorrect - The nurse should offer the client finger foods frequently to encourage nutritional intake. However, another action is the priority. B. CORRECT - The greatest risk to this client is injury from hyperactivity or life-threatening exhaustion. Safety is the highest priority for mental health patients. Determine if the client has feelings of suicide and if the client is showing manifestations of exhaustion. C. Incorrect - Monitor vital signs every 1-2 hours to ensure the client is not experiencing physical exhaustion that can stress the cardiovascular system. However, another action is the priority. D. Incorrect - The nurse should stay with the client and move them to a quiet area with minimal stimulation to decrease excitability. However, another action is the priority.

A nurse is caring for a client in active labor. When last examined 2 hours ago, the client's cervix was 3 cm dilated, 100% effaced, membranes intact, and the fetus was at -2 station. The client suddenly states, "My water broke." The monitor reveals a FHR of 80-85 bpm and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first? a. Place the client in the Trendelenburg position b. Apply pressure to the presenting part with the fingers c. Administer oxygen at 10 L/min via a face mask d. Initiate IV fluids

A. Incorrect - The nurse should place the client in the Trendelenburg position, but there is another action to take first. B. CORRECT - According to EBP, applying pressure to the presenting part with the fingers will prevent further cord prolapse. C. Incorrect - The nurse should administer 10 L/min oxygen via a face mask. However, another action is the priority. D. Incorrect - The nurse should initiate IV fluids. However, another action is the priority.

A nurse is providing medication teaching for a client who has Addison's disease and is taking hydrocortisone. Which of the following instructions should the nurse include? (Select all that apply) a. Take the medication on an empty stomach b. Notify the provider of any illness or stress c. Report any manifestations of weakness or dizziness d. Do not discontinue the medication suddenly e. Eat a low-sodium diet

A. Incorrect - The patient should take hydrocortisone with food to decrease GI distress. Steroids (and NSAIDs) are also known to cause gastrointestinal disturbances. B. CORRECT - Physical and emotional stress can increase the need for hydrocortisone. The provider can increase the dosage when stress occurs. C. CORRECT - Weakness and dizziness are indicators of adrenal insufficiency. The client should report these findings to the provider. D. CORRECT - Rapid discontinuation can result in adverse effects, including Addisonian crisis. If hydrocortisone is to be discontinued, it should be tapered off. E. Incorrect - Addison's Disease causes hyponatremia. The client might require sodium supplementation, especially if experiencing diaphoresis or vomiting.

A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following pieces of information should the nurse include in the teaching? a. "Wear nylon socks with shoes." b. "Wear flip flops instead of going barefoot when outside." c. "Apply moisturizing cream between your toes." d. "Wash your feet daily using lukewarm water and soap."

A. Incorrect - The patient should wear cotton socks with shoes. Cotton socks allow the feet to breathe and prevent moisture from staying on the feet, which protects the skin from breaking down and forming ulcers. B. Incorrect - The patient should avoid wearing flip flops or open-toed sandals (and barefoot) when outside or inside. Patients with diabetes mellitus have poor sensation in their feet, and leaving toes exposed can lead to injury. C. Incorrect - The patient should apply moisturizing cream to the feet but not between the toes. This creates a moisture barrier allowing bacteria to develop and create an infection. D. CORRECT - A patient with diabetes mellitus should wash the feet daily with lukewarm water and soap. Keep the feet clean and free from dirt, which may cause infection, and inspect the feet daily for cuts and calluses that may form into an ulcer. Diabetes may cause neuropathy, decreasing pain sensations in the feet which would normally alert a person to seek treatment.

A nurse is caring for a client who is in the transition phase of labor and reports that they need to have a bowel movement with the peak of contractions. Which of the following actions should the nurse make? a. Assist the client to the bathroom b. Prepare for an impending delivery c. Prepare to remove a fecal impaction d. Encourage the client to take deep, cleansing breaths

A. Incorrect - The urge to have a bowel movement indicates fetal descent into the birth canal and complete dilation. Assisting the client to the bathroom is not an appropriate action in view of the impending birth. B. CORRECT - The urge to have a bowel movement indicates fetal descent. Preparing for an imminent birth is appropriate. The client is fully dilated and is about to enter stage 2. C. Incorrect - The nurse cleanses the perineal area to remove fecal matter that can be expelled due to the descent of the fetus. The nurse does not prepare to remove an impaction. D. Incorrect - Deep cleansing breaths are encouraged between contractions. The client will be encouraged to push because the sensation of a bowel movement indicates fetal descent.

A nurse is planning to administer a dose of lithium carbonate to a client who has bipolar disorder. The laboratory report indicates the client's current lithium level is 1.0 mEq/L. Which of the following actions should the nurse take? a. Contact the provider for a dosage increase b. Request a repeat of the lithium level c. Administer the medication d. Prepare the client for gastric lavage

A. Incorrect - There is no indication to contact the provider for an increased dose because the lithium level is within reference range. B. Incorrect - There is no indication to request a repeat of the lithium level, only when the level is a fine line between therapeutic and toxic since these parameters are close to each other. C. CORRECT - The nurse should administer the medication because the lithium level is within the expected reference range. D. Incorrect - There is no indication for gastric lavage, only when lithium levels are toxic.

A nurse is assessing a client's thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland? a. "Tilt your head slightly forward." b. "Keep your head straight and look ahead of you." c. "Tilt your head back and swallow." d. "Turn your head to the side of my hand."

A. Incorrect - Tilting the head forward inspects lymph nodes. B. Incorrect - Keeping the head straight aids in palpating the trachea for deviations. C. CORRECT - To examine the thyroid gland, the nurse should instruct the client to extend her head backward and to swallow. The nurse should be able to feel the thyroid gland ascend as the client swallows and observe any enlargement of the gland. D. Incorrect - Turning the head to the side of the nurse's hand assesses CN XI.

A nurse is caring for a client who experienced a spontaneous rupture of membranes and has prolonged decelerations on the fetal monitor. Which of the following conditions should the nurse expect? a. Uterine rupture b. Placental abruption c. Prolapsed umbilical cord d. Amniotic fluid embolus

A. Incorrect - Uterine rupture is not related to rupture of membranes. B. Incorrect - Rupture of membranes is not a contributing factor of placenta abruption. C. CORRECT - The nurse should identify that prolonged deceleration during a uterine contraction is a sign of cord prolapse. This is an emergent condition that should be reported to the provider immediately. The nurse should don gloves and stabilize the cord. D. Incorrect - Spontaneous rupture of membranes is not a contributing factor toward amniotic fluid bolus.

A nurse is providing teaching to the partner of a client who is at risk for alcohol withdrawal after 6 hours of cessation. Which of the following statements by the partner indicates an understanding of the teaching? a. "My partner might experience seizures after 3 days of abstinence." b. "Delirium tremens usually occurs within 24 hours." c. "Hypotension is a manifestation of alcohol withdrawal." d. "My partner might begin to shake."

A. Incorrect - Withdrawal seizures generally occur within 12-24 hours after alcohol cessation. The seizures are generalized and tonic-clonic. B. Incorrect - Withdrawal delirium, also known as delirium tremens (DTs), is a medical emergency that can result in death. DTs can occur anytime in the first 72 hours. Clients are at risk for DTs after cessation of heavy drinking for 3 days. Hallucinations and delusions can occur during this period. C. Incorrect - Hypertension, not hypotension, is a manifestation of alcohol withdrawal that occurs 6-8 hours after cessation. Both systolic and diastolic blood pressures increase. D. CORRECT - Tremulousness is the classic sign of alcohol withdrawal, commonly called "the shakes" or jitters. Tremulousness begins 6-8 hours after alcohol cessation.