H&I NCLEX Qs

The clinic nurse assesses a client with a history of transient ischemic attacks (TIA) who was advised to lose weight, change diet to lower cholesterol, and maintain treatment of hypertension. The client has chosen not to take this advice, leading the nurse to conclude the client is at increased risk for: 1.Cerebrovascular accident (CVA). 2.Aneurysm. 3.Vasovagal syndrome. 4.Myasthenia gravis.

1. CVA

The admitting orders for a client with acute bacterial pneumonia include: intravenous antibiotic every 8 hours; oxygen per nasal cannula at 5 L/min; continuous pulse oximetry monitoring; bed rest with bathroom privileges and chair at bedside as desired; diet as tolerated; sputum specimen for culture and sensitivity (C&S); complete blood count (CBC); urinalysis; and chemistry panel. Which order should the nurse carry out first? 1.Start the oxygen per nasal cannula. 2.Insert an intravenous catheter and start the prescribed antibiotic. 3.Provide a dinner tray to the client. 4.Obtain the sputum specimen.

1. Start the oxygen per nasal cannula.

The parents of an infant with bronchiolitis ask the nurse why their baby's room has a sign on the door that states "Contact Precautions" and why all the nurses wear gowns and gloves when they hold him. What is the nurse's best response? 1."The virus that usually causes bronchiolitis can spread to other babies if extra precautions are not taken." 2."Your baby is very ill and should be touched or held only when necessary." 3."It's because your baby is in isolation." 4."We always wear gowns when babies are coughing."

1."The virus that usually causes bronchiolitis can spread to other babies if extra precautions are not taken."

65-year-old client begins to have chest pain, decreasing oxygen saturation, and dyspnea after surgery. The nurse expects the physician to order which of the following for a definitive diagnosis? 1.Chest x-ray and ECG 2.MRI 3.Electrolyte panel 4.Complete blood count

1.Chest x-ray and ECG

The most important nursing interventions to prevent acute renal failure in the critically ill client include: 1.Maintaining fluid volume and cardiac output. 2.Avoiding all potentially nephrotoxic drugs. 3.Administering antihypertensive drugs. 4.Assessing for a history of diabetes or systemic lupus erythematosus.

1.Maintaining fluid volume and cardiac output.

The physician orders morphine 2-5 mg IV as needed for pain and dyspnea for a client with pulmonary edema from heart failure. The nurse appropriately: 1. Questions the order because the order does not have a time interval. 2. Administers the drug as ordered, monitoring respiratory function. 3. Withholds the medication until respiratory status improves. 4. Administers the drug only when the client complains of chest pain.

2. Administers the drug as ordered, monitoring respiratory function.

The client with a fractured femur is upset and agitated about her injury and its treatment. She says, "How can I stay like this for weeks? I can't even move!" Which of the following is the most appropriate nursing diagnosis? 1. Impaired physical mobility related to traction. 2. Ineffective coping related to prolonged immobility. 3. Deficient diversional activity related to prolonged hospitalization. 4. Activity intolerance related to impaired mobility.

2. Ineffective coping related to prolonged immobility.

The nurse and a client with suspected Parkinson disease are discussing the client's symptoms. The client asks what causes the symptoms. The best response by the nurse is that the manifestations are the result of: 1.Autoimmune response to a viral infection. 2. The failure of dopamine to inhibit acetylcholine. 3.Effects of a neurotoxin. 4.A genetic defect.

2. The failure of dopamine to inhibit acetylcholine.

A child in the early stages of impaired gas exchange often experiences which of the following diagnoses as well? 1.Risk for Injury related to fatigue and dehydration 2.Anxiety related to hypoxia 3.Risk for Development: Delayed related to hypoxia 4.Fatigue related to air trapping

2.Anxiety related to hypoxia

A client who is pregnant and had a child die from sudden infant death syndrome (SIDS) asks the nurse whether there are measures that can be taken to prevent the second child from dying of SIDS. The nurse advises the client to do which of the following? 1.Breastfeed the infant. 2.Buy a firm mattress for the infant. 3.Feed the baby only small amounts at a time. 4.Buy only stuffed animals for the bed.

2.Buy a firm mattress for the infant.

When caring for a client experiencing symptoms for peripheral arterial disease, the nurse monitors the client for which of the following signs and symptoms consistent with tissue ischemia? 1.Widened pulse pressure 2.Leg pain while walking 3.Brownish discoloration to the skin on the leg 4.Peripheral edema

2.Leg pain while walking

The nurse is caring for a child diagnosed with glomerulonephritis. Which of the following findings will the nurse expect in this client? 1. Hypotension 2.Red-brown urine 3. Low blood urea nitrogen (BUN) level 4. A urine specific gravity of 1.000

2.Red-brown urine

The nurse is caring for a child diagnosed with nephrotic syndrome. Which of the following is the most appropriate nursing diagnosis for the child? 1.Activity Intolerance 2.Risk for Impaired Skin Integrity 3.Ineffective Coping 4.Risk for Loneliness

2.Risk for Impaired Skin Integrity

The nurse is examining a client in the clinic for follow-up care for heart failure. Which of the following, if reported by the client, would not be associated with exacerbating heart failure? 1. Recent upper respiratory infection 2. Nutritional anemia 3. Peptic ulcer disease 4. Atrial fibrillation

3. Peptic ulcer disease

When admitting a client with a fractured extremity, the nurse should first focus the assessment on which of the following? 1. The area proximal to the fracture. 2. The actual fracture site. 3. The area distal to the fracture. 4. The opposite extremity for baseline comparison.

3. The area distal to the fracture.

When providing care for a client with glomerular disorders, the nurse teaches the client which of the following? 1."You will be cured when you leave the hospital." 2."You will face activity restrictions for the rest of your life." 3."Healing takes a long time, so you will learn self-management." 4."You will be free of infection in the future."

3."Healing takes a long time, so you will learn self-management."

The nurse determines the client with venous stasis ulcers has understood dietary teaching when the client states: 1."I have increased my carbohydrate intake." 2."I have reduced my sugar intake." 3."I have increased my protein intake." 4."I have decreased my fat intake."

3."I have increased my protein intake."

The nurse is evaluating the communication abilities of a client with Parkinson disease and determines that outcomes have been met when the client does which of the following? 1.Takes 10 minutes to speak the nurse's name 2.Does not talk because it is frustrating 3.Brings a slate and chalk to the visit 4.Lets a family member speak for the client

3.Brings a slate and chalk to the visit

A 76-year-old client has been brought to the emergency department by ambulance with a suspected stroke. Initial vital signs are BP 150/100, pulse 90, and respirations 20. After 30 minutes, vital signs have changed to BP 170/90, pulse 78 and respirations 24. Which of the following should the nurse initiate next? 1.Ask how the client feels. 2.Check the client's phenytoin (Dilantin) level. 3.Get an order to decrease IV fluids. 4.Offer the client clear liquids to prevent dehydration.

3.Get an order to decrease IV fluids.

The nurse is caring for a client admitted for exacerbation of Crohn disease. Which nursing diagnosis should the nurse address as a priority? 1.Fatigue related to decreased nutritional intake 2.Deficient Knowledge related to disease process 3.Imbalanced Nutrition: Less Than Body Requirements related to diarrhea 4.Anxiety related to alterations in health status

3.Imbalanced Nutrition: Less Than Body Requirements related to diarrhea

Which nursing actions are instituted for the client with kidney trauma? 1.Monitor level of consciousness and urine output. 2.Monitor vital signs for hypotension and bradycardia. 3.Observe for hypertension and check urine for hematuria. 4.Observe urine for oliguria and proteinuria

3.Observe for hypertension and check urine for hematuria.

The emergency department nurse is working with the family of a newborn who died of sudden infant death syndrome (SIDS). Which of the following interventions will the nurse initiate for the family? 1.Take the baby to the morgue. 2.Tell the family they can have another baby. 3.Provide literature and information about a local support group. 4.Provide food and drink for the family.

3.Provide literature and information about a local support group.

In assessing a client admitted 24 hours ago with heart failure, the nurse notes that the client has lost 2.5 pounds, heart rate is down from 105 to 88, and there are fine crackles only in the bases of the lungs. The nurse correctly interprets these data as indicating: 1.The client's condition is unchanged. 2.A need for more aggressive treatment. 3.The treatment regimen is achieving the desired effect. 4.Heart failure has resolved.

3.The treatment regimen is achieving the desired effect.

A client with a fracture develops compartment syndrome. Which of the following signs should alert the nurse to impending organ failure? 1. Crackles. 2. Jaundice. 3. Generalized edema. 4. Dark, scanty urine.

4. Dark, scanty urine.

An expected assessment finding by the nurse in a client with peripheral atherosclerosis would be which of the following? 1. Pallor of the legs and feet when dependent 2. Increased hair growth on the affected extremity 3. Higher blood pressure readings in the affected extremity 4. Impaired sensation in the affected extremity

4. Impaired sensation in the affected extremity

The nurse working with a client with an anxiety disorder should explain that the success of cognitive behavioral therapy is based on the client's understanding that: 1. Antecedents of anxiety are childhood traumas 2. Symptoms are related to delusional thoughts 3. The problems are all in the client's mind 4. Symptoms are learned responses to thoughts

4. Symptoms are learned responses to thoughts

The client admitted for pneumonia asks the nurse why a sputum sample is needed. Which response by the nurse is most accurate? 1."A total of three sputum samples will be collected." 2."The results from the test will help rule out atelectasis." 3."Coughing up sputum will expectorate the secretions." 4."The results will help with determining the antibiotic treatment."

4."The results will help with determining the antibiotic treatment."

A client in skeletal traction suddenly develops right-sided chest pain and shortness of breath. Which of the following interventions is the priority for the nurse? 1.Check for Homan sign. 2.Start oxygen per nasal cannula. 3.Administer the prescribed analgesic. 4.Elevate the head of the bed 45 degrees.

4.Elevate the head of the bed 45 degrees.

A nurse is caring for a client with hyperkalemia who received sodium polystyrene sulfonate (Kayexalate) orally. What evaluation finding by the nurse would indicate that the client had an effective response to the intervention? 1.Tall, peaked T waves 2.Decreased urine output 3.Increased blood pressure 4.Frequent bowel movements

4.Frequent bowel movements

A nurse is caring for the client with Crohn disease who was admitted last night. Which of the following manifestations would the nurse NOT expect to note for this client? 1.Constipation 2.Diarrhea 3.Bloody stools 4.Frothy stools

4.Frothy stools

The nurse is caring for a client diagnosed with heart failure who is taking digoxin and furosemide. Which of the following laboratory values will the nurse monitor closely? 1.Calcium 2.Sodium 3.Phosphorus 4.Potassium

4.Potassium

When assessing a client diagnosed with left-sided heart failure, the nurse anticipates which of the following findings? 2. Abdominal distention 3. Liver enlargement 4. Edema of the feet and ankles 5. Shortness of breath

5. Shortness of breath

The nurse, caring for a 10-year-old client with symptoms of juvenile idiopathic arthritis (JIA), should include which of the following when teaching the family about the child's illness? Symptoms are different for children and adults. The child will need hospitalization. About 70% of children experience permanent remission by adulthood. The child will grow normally

About 70% of children experience permanent remission by adulthood.

A nurse is providing health teaching for a group of clients. Which of the following clients is at risk for developing peripheral arterial disease (PAD)? A. A client with hypothyroidism B. A client with diabetes C. A client whose daily caloric intake consists of 25% fat D. A client who consumes two bottles of beer a day

B. A client with diabetes

A nurse is preparing to administer oral medications to a client who has dysphagia. Which of the following is an appropriate action by the nurse? A. Have the client drink water from a straw after taking medications B. Instruct the client to lift his chin upward when swallowing medications C. Offer each med one at a time D. Place the med in the client's mouth

C. Offer each med one at a time

A nurse is caring for a client who has bacterial pneumonia. The nurse should expect which of the following assessment findings? A. Decreased fremitus B. SaO2 95% on room air C. Temperature 38.8 C (101.8 F) D. Bradypnea

C. Temperature 38.8 C (101.8 F)

A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the priority? A. Provide a quiet environment B. Encourage use of the incentive spirometry every 1-2 hrs C. Initiate continuous cardiac monitoring D. Administer heparin via continuous IV infusion

D. Administer heparin via continuous IV infusion

A nurse is giving an end of shift report about a client admitted earlier that day with pneumonia. Which of the following pieces of information is most essential to provide? A. Admitting diagnosis B. Diagnostic test results C. Body temperature D. Breath sounds

D. Breath sounds

A nurse is caring for a client who has a history of DVT and is receiving warfarin (Coumadin). Which of the following client findings provides the nurse with the best evidence regarding the effectiveness of therapy? A. Hemoglobin 14 B. Minimal bruising of extremities C. Reduced circumference of affected extremity D. INR 2.5

D. INR 2.5

Which is the most accurate indicator of fluid volume status in the oliguric or anuric client? Intake and output Weight changes Level of thirst BUN and creatinine levels

Weight changes

At an inpatient facility, the client with obsessive compulsive disorder (OCD) counts the number of tiles on the floor each morning before going to breakfast. This ritual takes the client 30 minutes and the client always misses breakfast. Which interventions by the nurse can assist the client in arriving to breakfast prior to the meal ending? Select all that apply. a) Allow additional time in the client's morning routine to include ritual before breakfast. b) Escort the client to the dining area and place in restraints. c) Cancel breakfast and make the client wait until lunch to eat. d) Interrupt the client's ritual and demand that he go to breakfast now. e) Set limits on the amount of time the client performs the ritual.

a) Allow additional time in the client's morning routine to include ritual before breakfast. e) Set limits on the amount of time the client performs the ritual.

The nurse observes an adult client pacing the room and wringing his hands. The client checks the lock on the exam room door 12 times after the nurse enters the room. Which assessment questions would be appropriate when evaluating this client? Select all that apply. a) How old were you when you first started this behavior? b) Does anyone in your family suffer from depression? c) "Are you easily annoyed?" d) Does this behavior interfere with your daily life? e) "What would happen if you were dead?"

a) How old were you when you first started this behavior? d) Does this behavior interfere with your daily life?

Which intervention should be the nurse's priority action when caring for a client experiencing severe and panic anxiety? a) Stay with the client. b) Alert security personnel. c) Darken lighting in the room. d) Identify coping mechanisms.

a) Stay with the client.

The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is at most risk for developing this type of allergy? a) hairdressers b) the homeless c) children in day care centers d) individuals living in a group home

a) hairdressers

A nurse is caring for a client with acute pyelonephritis. Which of the following is an appropriate respond by the nurse regarding home care? a. "you should complete the entire cycle of antibiotic therapy" b. "you should maintain complete bedrest until manifestations decrease" c. "you should drink 1,000 ml fluid/ day" d. "you should weigh yourself daily"

a. "you should complete the entire cycle of antibiotic therapy"

A health care provider aspirates synovial fluid from a knee joint of a client with rheumatoid arthritis. The nurse reviews the laboratory analysis of the specimen and would expect the results to indicate which finding? a. Cloudy synovial fluid b. Presence of organisms c. Bloody synovial fluid d. Presence of urate crystals

a. Cloudy synovial fluid

The nurse if reviewing the record of a client with Crohn's Disease. Which stool characteristics should the nurse expect to note documented in the client's record? a. Diarrhea b. Chronic constipation c. Constipation alternating with diarrhea d. Stool constantly oozing from the rectum

a. Diarrhea

The nurse is conducting a teaching clinic for Older adults about risk factors for stroke. Although the nurse includes all of the following as risk factors, which of the following presents the greatest risk for stroke? a. Hypertension b. Heart disease c. Diabetes d. High cholesterol level

a. Hypertension

The nurse is planning care for a client with acute glomerulonephritis. Which problem is priority for the nurse to address when caring for this client? a. Impaired fluid balance b. Impaired skin integrity c. Fatigue d. Impaired nutrition

a. Impaired fluid balance

A nurse is caring for a client with a possible diagnosis of glomerulonephritis. Which laboratory values would the nurse pay particular attention to when monitoring for manifestations of this condition? Select all that apply. a. Increased creatinine b. Increased BUN c. Decreased urine creatinine d. Positive ASO titer e. Decreased ESR

a. Increased creatinine b. Increased BUN c. Decreased urine creatinine d. Positive ASO titer

A nurse is caring for a client with nephritis who also has ascites due to excess fluid volume. Which action by the nurse is the best way to monitor the client's degree of ascites? a. Measure abdominal girth b. Monitor I&O c. Monitor BP d. Measure CVP

a. Measure abdominal girth

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency. The nurse would incorporate which of the following as a priority in the plan of care? a. Protecting the client for infection b. Providing emotional support to decrease fear c. Encouraging discussion about lifestyle changes d. Identifying factors that decreased the immune function

a. Protecting the client for infection

Which interventions would apply in the care of a client is admitted who has a high risk for an allergic reaction to a latex allergy? Select all that apply. a. Use non latex gloves b. Use medications from glass ampules c. Place the client in a private room only d. Avoid the use of medication vials that have rubber stoppers e. Keep a latex safe supply cart available in the client's area f. Use a blood pressure cuff from an electronic device only to measure the blood pressure

a. Use non latex gloves b. Use medications from glass ampules d. Avoid the use of medication vials that have rubber stoppers e. Keep a latex safe supply cart available in the client's area

A nurse is providing discharge teaching to a client who has HF. The nurse should instruct the client to report which of the following findings immediately to the provider? a. Weight gain of 0.9kg (2lbs) in 24 hrs b. Increased of 10 mm Hg in SBP c. Dyspnea on exertion d. Dizziness when rising quickly.

a. Weight gain of 0.9kg (2lbs) in 24 hrs

A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck's skin traction and screams, "Don't hurt me with that hangman's noose." The patient is experiencing: a. an illusion. b. a delusion. c. hallucinations. d. hypnagogic phenomenon.

a. an illusion.

At a meeting for family members of alcoholics, a spouse says, "I did everything I could to help. I requested sick leave when my partner was too drunk to go to work." The nurse assesses this as: a. codependence. b. assertiveness. c. role reversal. d. homeostasis.

a. codependence.

A client is receiving cognitive-behavioral therapy for an anxiety disorder. The client describes a multitude of problems she faces and makes each one sound worse than the one before. Which of the following responses on the part of the nurse would be consistent with what is taught and learned in cognitive-behavioral therapy? a) Ask the client to describe one way of relaxing and to demonstrate it. b) Ask the client to identify the thinking errors and develop a more realistic way of thinking. c) Tell the client to stop these unhealthy thoughts immediately. d) Have the client list the problems in priority from most to least important.

b) Ask the client to identify the thinking errors and develop a more realistic way of thinking.

The home care nurse is assigned to visit a client who has returned home from the emergency room following treatment for a sprained ankle. The nurse notes that the client as sent home with crutches that have rubber axillary pads and needs instructions regarding crutch walking. On admission assessment, the nurse discovers that the client has an allergy to latex. Before providing instructions regarding crutch walking, the nurse should: a) contact the physician b) cover the crutch pads with cloth c) call the local medical supply store and ask for a cane to be delivered d) tell the client that the crutches must be removed from the house immediately

b) cover the crutch pads with cloth

When an outpatient is hospitalized in the psychiatric inpatient unit, a nurse will implement the recovery model by: a) assessing patient cognitive deficits. b) identifying and reinforcing patient strengths. c) reviewing the patient's former treatment plan for mistakes. d) considering lowering expectations when the patient is discharged.

b) identifying and reinforcing patient strengths.

Which of the following nursing measures should be included when caring for a client with Parkinson's disease? a) put color on rails in going upstairs b) provide high toilet seat c) provide soft mattress d) apply restraints to reduce tremors

b) provide high toilet seat

The nurse is caring for a patient experiencing auditory hallucinations who says, "When I first heard the voices they said nice things about me but now they say bad things." Which question will have an impact on the care this patient is initially provided? (Select all that apply.) a. "Do you trust me to help you with the voices?" b. "Are the voices commanding you to hurt yourself?" c. "How often during 24 hours do you hear the voices?" d. "Do you hear the voices if you're busy in a noisy environment?"

b. "Are the voices commanding you to hurt yourself?" c. "How often during 24 hours do you hear the voices?" d. "Do you hear the voices if you're busy in a noisy environment?"

The nurse demonstrates an understanding of dual diagnosis observed in a schizophrenic individual when asking: a. "Have you ever been diagnosed with an eating disorder?" b. "How often do you drink enough alcohol to get drunk?" c. "How old were you when you became sexually active?" d. "Would you describe yourself as being depressed?"

b. "How often do you drink enough alcohol to get drunk?"

A nurse is caring for a client who smokes cigarettes and asks the nurse about nicotine replacement therapy (NRT). Which statement made by the nurse is appropriate? a. "Combining the use of NRT and a smoking cessation program is no more effective than NRT use alone." b. "NRT does not address addictive behavior." c. "NRT helps to relieve the psychological and physiological effects of nicotine withdrawal." d. "Over-the-counter (OTC) NRTs include transdermal patches, gums, nicotine inhalers, and nasal sprays."

b. "NRT does not address addictive behavior."

Which question has highest priority when assessing a newly admitted patient with a history of alcohol abuse? a. "Have you ever had blackouts?" b. "When did you have your last drink?" c. "Has drinking caused you any problems?" d. "When did you decide to seek treatment?"

b. "When did you have your last drink?"

A nurse employed in the Emergency Department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign highest priority to which of the following clients? a. A client complaining of muscle aches, a headache, and malaise b. A client with chest pain who states that he just ate a pizza that was made with a very spicy sauce c. A client who twisted her ankle when she fell while rollerblading d. A client with a minor laceration on the index finger sustained while cutting an eggplant

b. A client with chest pain who states that he just ate a pizza that was made with a very spicy sauce

A patient with catatonic schizophrenia has been standing with his left arm upraised and his right foot off the floor for the majority of the last 20 hours, eating only when allowed to eat standing up. Which nursing activity has priority for this patient? a. Providing high-calorie drinks hourly b. Assessing for lower extremity edema bid c. Taking the patient to activities therapy once daily d. Encouraging the patient to sit or lie down for 30 minutes hourly

b. Assessing for lower extremity edema bid

Which of the following would alert the nurse that the client has experienced a transient ischemic attack (TIA)? a. Sudden severe pain over the left eye b. Numbness and tingling at the corner of the mouth c. Complete paralysis of the right arm and leg d. Loss of sensation and reflexes in both legs

b. Numbness and tingling at the corner of the mouth

A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention should be instituted? a. Check the patient every 15 minutes. b. Provide one-on-one supervision. c. Keep the room dimly lit. d. Rigorously encourage fluid intake.

b. Provide one-on-one supervision.

A clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (Immunization). Which of the following are general contraindications associated with receiving a live virus vaccine? (Select all that apply) a. The child with a cold b. The child had a previous anaphylactic reaction to the vaccine c. Mother reports that the child is having intermittent episodes of diarrhea d. Mother reports that the child has not had an appetite and been fussy e. The child has a disorder that caused a severely deficient immune system f. Mother reports that the child has recently been exposed to an infectious disease

b. The child had a previous anaphylactic reaction to the vaccine e. The child has a disorder that caused a severely deficient immune system

The nurse is teaching a client who will be discharged home on enoxaparin (Lovenox) about self-care at home. Which of the following will the nurse teach the client? a. Use a hard toothbrush and floss twice daily. b. Use an electric razor. c. Take aspirin for pain. d. Report blurred vision.

b. Use an electric razor.

A patient diagnosed with schizophrenia is standing naked after showering and appears dazed and indecisive. The nursing intervention that will be most helpful to promote dressing would be: a. saying, "These are your clothes. Please get dressed." b. saying, "These are your underpants. I'll help you put them on." c. asking, "Which of these two outfits would you like to wear now?" d. asking, "Is something the matter with your clothes that makes you not want to dress?"

b. saying, "These are your underpants. I'll help you put them on."

A patient in a psychiatric rehabilitation program mentions to a nurse, "I feel so guilty because my family gives me so much and I have so little to give in return." A therapeutic reply would be: a) "Your family feels good about giving to you." b) "Remember that, and don't bite the hand that feeds you." c) "Following your treatment plan and helping with household tasks are ways you can give back." d) "You can help most by keeping your feelings to yourself and not burdening the family when you feel upset."

c) "Following your treatment plan and helping with household tasks are ways you can give back."

Which of the following should the nurse provide when explaining therapeutic measures to a client prescribed methotrexate (Rheumatrex) for rheumatoid arthritis (RA)? a) Relief of symptoms will be assessed within 1 week of starting medication. b) Fluids are restricted to prevent formation of edema in the joints. c) Drug doses will be adjusted for optimum effect at the lowest dose once relief has been established. d) Six months of therapy will be adequate to stop disease progression.

c) Drug doses will be adjusted for optimum effect at the lowest dose once relief has been established.

Which intervention will have the greatest impact on reducing the stigma and rejection currently experienced by individuals with mental illness? a) Providing services to the mentally ill that minimize the need to rely upon the community. b) Holding activities at mental health facilities that are open to the community to foster acceptance. c) Educating local citizen groups on the needs and experiences of the mentally ill in their community d) Focusing on improving the socialization skills of mentally ill individuals living in the community

c) Educating local citizen groups on the needs and experiences of the mentally ill in their community

A toddler with acute otitis media (AOM) is taking amoxicillin. The nurse should instruct the parents about which of the following? a) If the AOM does not resolve with amoxicillin, a myringotomy will be necessary. b) If the child is older than 24 months, a shorter course of antibiotics is sufficient. c) If the child improves clinically, continue the entire duration of antibiotics (10 to 14 days). d) If the child experiences ear pain, alternate acetaminophen (Tylenol) and ibuprofen for pain control.

c) If the child improves clinically, continue the entire duration of antibiotics (10 to 14 days).

A patient experiencing panic suddenly began running and shouting, "I'm going to explode!" Select the nurse's best action. a) Ask, "I'm not sure what you mean. Give me an example." b) Capture the patient in a basket-hold to increase feelings of control. c) Tell the patient, "Stop running and take a deep breath. I will help you." d) Assemble several staff members and say, "We will take you to seclusion to help you regain control."

c) Tell the patient, "Stop running and take a deep breath. I will help you."

Case Vignette: Joseph is a 33-year-old Caucasian male who has hypertension and chronic low back pain after a car accident two years ago. He presents for a routine visit, and asks if you can prescribe him oxycodone for his back pain. His vital signs and physical exam are normal, and he has no other complaints. PCP has never prescribed him opioids in the past. a) Tell him that he has never required them before, and that he should try using acetaminophen or ibuprofen first b) Assist him for a referral to an orthopedic surgeon c) Use a structured screening tool to determine if he has a substance use disorder d) Obtain x-rays of his lumbosacral spine

c) Use a structured screening tool to determine if he has a substance use disorder

A client diagnosed with chronic depression appears sad and joyless when arriving at the mental health clinic for a scheduled appointment. The nurse best assesses the client's mood by: a) observing the client's posture, dress, and hygiene in detail. b) asking, "You seem very sad and forlorn; Are you depressed today?" c) asking, "On a scale of 0 to 10 with 10 being as happy as you can ever remember being, how do you feel today?" d) observing the way the client interacts with other staff to determine whether the client is demonstrating signs of depression.

c) asking, "On a scale of 0 to 10 with 10 being as happy as you can ever remember being, how do you feel today?"

During an assessment interview with a newly admitted client, the nurse identifies a sense of anger developing in response to the client's defiant statements. In order to maintain a therapeutic environment, the nurse: a) asks that another nurse continue the assessment. b) identifies for the client the inappropriateness of his statements. c) shares with the client that he appears angry about being admitted. d) postpones the remainder of the interview until the client is more cooperative.

c) shares with the client that he appears angry about being admitted.

A client is exhibiting behavioral symptoms of depression. Which charting entry would appropriately document these symptoms? a. "Rates mood as 4/10." b. "Express thoughts of poor self-esteem during group." c. "Become irritable and agitated on waking." d. "Rates anxiety as 2/10 after receiving lorazepam (Ativan)."

c. "Become irritable and agitated on waking."

A salesperson has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the salesperson was hospitalized after threatening a co-worker. When greeted by the nurse, the person shouts, "They're all plotting to destroy me. Isn't that true?" Select the nurse's most therapeutic response. a. "No, that is not true. People here are trying to help you if you will let them." b. "Everyone here is trying to help you. No one wants to harm you." c. "Thinking that people want to destroy you must be very frightening." d. "That is absurd. Staff members are health care workers, not members of the mob."

c. "Thinking that people want to destroy you must be very frightening."

A patient who has been unable to leave his home for more than a month because of symptoms of severe anxiety tells the nurse: "I feel really stupid, a grown man not being able to leave his house." The most therapeutic reply is: a. "I don't think it's stupid. You're afraid, it happens." b. "Many individuals share this situation with you." c. "You feel stupid because you're afraid to leave home." d. "I can see how you might feel that way."

c. "You feel stupid because you're afraid to leave home."

A nurse is caring for a client with Goodpasture syndrome who recently had plasmapheresis for treatment of this condition. The nurse notes petechiae and bruising to the client's abdomen and face. Which potential complications of plasmapheresis does the nurse suspect? a. Alteration of immunity b. Alteration of fluid volume c. Alteration of coagulation

c. Alteration of coagulation

A nurse is caring for a client who is suspected of a UTI. The provider prescribe a urinalysis. Which of the following findings confirm to the nurse that an upper UTI involving the kidney is present? a. Bacteria b. WBC c. Casts d. Ketones

c. Casts

A nurse is collecting a 24 hr creatinine clearance. During the collection the patient accidently discards a specimen. Which of the following is an appropriate action by the nurse? a. Continue the collection, noting the loss on the lab slip. b. Add 1 hr to the collection time. c. Discard the previously collected urine and start the collection again. d. Discontinue the collection and draw a serum creatinine.

c. Discard the previously collected urine and start the collection again.

The nurse is administering oxygen to a client experiencing a stroke in order to prevent hypoxia and hypercapnia. This will also lessen the risk for: a. Fluid accumulation in the lungs. b. Pulmonary emboli. c. Increased intracranial pressure (IICP). d. Rebleeding.

c. Increased intracranial pressure (IICP).

The nurse has completed gathering data on a client with esophageal cancer due to years of nicotine abuse. Which nursing diagnosis is a priority for this client? a. Disturbed Body Image b. Situational Social Isolation c. Ineffective Airway Clearance d. Decisional Conflict

c. Ineffective Airway Clearance

A nurse is caring for a client who has a renal tumor. The client will undergo a renal biopsy. Which of the following patient care should the nurse provide? a. Instruct the patient that they are NPO 8 hour following the procedure b. Assess the patient for a history of shellfish or iodine allergies prior to the procedure. c. Maintain bedrest 4-12 hours following the procedure d. Obtain a BUN and creatinine clearance prior to the procedure

c. Maintain bedrest 4-12 hours following the procedure

The difference between moderate and severe anxiety is that: a) severe anxiety centers on panic behavior. b) moderate anxiety motivates learning and creativity. c) the person experiencing severe anxiety is unable to focus on details of any kind. d) a person experiencing moderate anxiety can be redirected when instructed to do so.

d) a person experiencing moderate anxiety can be redirected when instructed to do so.

A nurse asks a patient to remember the following object, color, and address: pencil, red, and 15 Maple Street. After 15 minutes the nurse asks the patient to repeat the object, color, and address. The nurse is assessing: a) judgment. b) recent memory. c) ability to abstract. d) immediate recall.

d) immediate recall.

A client has been admitted with chronic obstructive pulmonary disease (COPD) and has asked the nurse for help and information regarding nicotine addiction and ways to quit smoking. The nurse will evaluate the treatment and determine that a goal has been met when the client states: a. "I will keep a pack of cigarettes in my closet in case I need it." b. "I will taper off smoking gradually." c. "I will eat a snack when I am feeling nervous." d. "I will chew sugar-free gum when I want a cigarette."

d. "I will chew sugar-free gum when I want a cigarette."

Family members of an individual undergoing a 30-day alcohol rehabilitation program ask, "How can we help?" Select the nurse's best response. a. "Alcoholism is a lifelong disease. Relapses are expected." b. "Use search and destroy tactics to keep the home alcohol-free." c. "Prevent embarrassment by covering for your loved one's lapses." d. "Make your loved one responsible for the consequences of his or her behavior."

d. "Make your loved one responsible for the consequences of his or her behavior."

A patient experienced alcohol withdrawal delirium, but now has a clear sensorium. The patient says, "Drinking helps me cope with being a single parent." Which response by the nurse would help the patient conceptualize the drinking more objectively? a. "Sooner or later, alcohol will kill you. Then what will happen to your children?" b. "I hear a lot of defensiveness in your voice. Do you really believe this?" c. "If you were coping so well, why were you hospitalized again?" d. "Tell me what happened the last time you drank."

d. "Tell me what happened the last time you drank."

A nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? a. A client scheduled for a chest x-ray b. A client requiring daily dressing changes c. A postoperative client preparing for discharge d. A client receiving nasal oxygen who had difficulty breathing during the previous shift

d. A client receiving nasal oxygen who had difficulty breathing during the previous shift

A 6-month old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The mother returns home and calls the clinic to report that the infant has developed swelling and redness at the site of infection. A nurse tells the mother to: a. Monitor the infant for a fever b. Bring the infant back to the clinic c. Apply a hot pack to the injection site d. Apply an ice pack to the injection site

d. Apply an ice pack to the injection site

An alcohol-dependent patient was hospitalized at 4 AM on Saturday. The patient's last drink was at 2 AM. When would the nurse expect withdrawal symptoms to peak then disappear or progress to delirium? a. Between 8 AM and 10 AM Saturday b. Between 10 AM and 4 PM Saturday c. Between 4 PM Saturday and 4 AM Sunday d. Between 2 AM Sunday and 2 AM Monday

d. Between 2 AM Sunday and 2 AM Monday

The client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? a. Folate deficiency b. Malabsorption Syndrome c. Intestinal obstruction d. Fluid and Electrolyte imbalance

d. Fluid and Electrolyte imbalance

Which assessment findings would prompt the nurse to suspect a disulfiram (Antabuse) reaction? a. Skin rash, itching, and urticaria b. Pallor, hypotension, and muscle cramping c. Dry skin, bradycardia, fatigue, and headache d. Headache, dyspnea, nausea, intense vomiting, and flushing

d. Headache, dyspnea, nausea, intense vomiting, and flushing

A nurse interviews the parents of a child recently diagnosed with glomerulonephritis. The nurse understands that which information collected during the assessment most often is associated with the diagnosis of glomerulonephritis? a. Child fell off a bike onto the handlebars b. Nausea and vomiting for the last 24 hours c. Urticarial and itching for 1 week before diagnosis d. Streptococcal throat infection 2 weeks before diagnosis

d. Streptococcal throat infection 2 weeks before diagnosis

The medical record of a patient diagnosed with schizophrenia states that the patient has cognitive dysfunction. From this statement, the nurse can expect to see evidence of: a. anxiety, fear, and agitation. b. aggression, anger, hostility, or violence. c. blunted or flat affect or inappropriate affective responses. d. impaired memory and attention as well as formal thought disorder.

d. impaired memory and attention as well as formal thought disorder.