HESI FUNDIES PRATICE

Which of the following statements shows a client's understanding of living with a newly implanted pacemaker?

"I should wear a Medic Alert bracelet and carry an identification card."

While employed by a family practitioner, the RN is assigned to teach clients regarding their medications. A client who is started on estrogen replacement therapy is receiving instructions. Which of the following would the RN say that would help her understand the possible complications of estrogen therapy?

"Make sure you keep your gynecologic check-up appointment."

A daughter of an elderly client who has schizophrenia calls the office and talks to the nurse about how her mother was acting the past couple of days. Which of the following statements would indicate the client is showing early signs have relapse for schizophrenia?

"My mom is very mean. She is normally nice and has kind words. Yesterday, she told me 'I don't need you here everyday taking care of me. Why don't you go to your house for a change? I need privacy sometimes you know."

You are working in a crisis center and counseling a female victim of a sexual assault. The client conveys that she feels "as though the rape just happened yesterday" even though it was several months ago. The appropriate nursing response would be what?

"Tell me more about the incident that causes you to feel like the rape just occurred."

A client is prescribed zaleplon (Sonata) for insomnia. This medication has a half-life of:

1 hour

Many times before administering medication, a nurse must convert the dosage amount for the appropriate weight. Which of the following metric conversions is correct for 1,000 grams?

1 kilogram.

Concepts of death change from infancy to old age. At about what age do children see death as inevitable?

10 years Preschool children do not understand the finality of death. Children aged 5 to 6 see death as reversible. Children aged 6 to 9 begin to accept death as a final event. Children at about the age of 10 years realize that death is inevitable.

The Glasgow Coma Scale score for a patient who opens his eyes when told to, moves away from a painful stimulus, and tells you the incorrect year is which of the following?

11 The Glasgow Coma Scale rates eye opening response, motor response and verbal response. A patient who opens his eyes when told to, moves away from a painful stimulus, and tells you the incorrect year has a score of 11. Eye opening is rates from 1 - 4. Opening eyes when told to is a 3 on the scale. Motor response is rated from 1 - 6. Moving away from a painful stimulus is a 4 on the scale. Verbal response is rated from 1 - 5. Telling you the incorrect year rates a 4 on the scale. Therefore, the total score for this patient is 11.

The nurse should begin screening for lead poisoning when a child reaches which age?

18 months

The nurse should instruct a client who is self-administering Atropine (Atropisol) to wait how long between instilling the first drop and instilling the second drop?

2 to 3 minutes.

in a pregnant woman the fundus reaches the location of the umbilicus at about: check all answers that apply

20 - 22 weeks

You are caring for an infant born to a diabetic mother. The infant is receiving IV medication to manage blood glucose levels. Which of the following blood glucose levels would cause you concern? check all answers that apply

35 mg/dL 75 mg/dL

Which of the following ages fall into middle adulthood?

42 59

You are providing an educational session to new employees and the topic is elder abuse. It is important to stress which client is the most typical victim of abuse?

A 90 year old woman with advanced Parkinson's disease.

A client had unprotected sex 8 hours ago. The client asks the nurse what she can use to prevent pregnancy. What should the nurse tell the client?

A copper IUD is an option. Let me tell you about it.

The RN working on a pulmonary unit is caring for several clients with respiratory illnesses. Which of the following clients is at the lowest risk for infection with tuberculosis?

A man who works as a mail carrier.

During the recovery facet of mental health rehabilitation, which goal does the nurse choose to assist the client in realistic mental health management?

Adapting to the disease

Which of the following medications is most appropriate for a client with autism?

Adderall

The nurse is caring for a client with anorexia nervosa. Which of the following is the first priority?

Address fluid volume deficit

All of the following statements about heart rate are accurate EXCEPT :check all answers that apply

An increase in heart rate decreases oxygen consumption., Sinus bradycardia is a rate more than 100 beats/minute.

A client with a myocardial infarction (MI) develops pulmonary crackles and dyspnea. A chest X-ray shows evidence of pulmonary edema. The specific type of MI the client had is MOST LIKELY what?

Anterior.

In a client who has burns on the legs, which nursing intervention helps prevent contractures?

Applying knee splints.

The nurse interviews a 28-year-old client with a new medical diagnosis of endometriosis. Which of the following questions is MOST appropriate?

Are you experiencing pain during intercourse?"

When assessing a newborn's need for oxygen, which value should the nurse assess as it is the best indicator of low oxygen levels in the baby

Arterial p02

A nurse is working on the east wing of a psychiatric hospital for children. The hospital has a total of three units that are located in three different buildings of the campus. The nurse hears the alarm go off but she does not hear the hospital's code '09' indicating that one of the client's on the unit is attempting to escape through one of the locked doors. Which of the following is the best nursing action in this situation?

Ask all of the children on the unit to move into the main area of the building and perform a roll call

When you take the blood pressure of your patient with an automatic blood pressure machine the reading is 80/60 Hg with a pulse of 55 beats per minute. Considering this reading what is the first thing that you should do for this patient?

Assess the patient for dizziness and cold, clammy skin.

Which task can the nurse delegate to a nursing assistant?

Assisting a client who had surgery three days ago walk down the hallway.

The nurse prepares to perform postural drainage. How should the nurse ascertain the best procedure to facilitate clearing the lungs?

Auscultation.

You are educating a pregnant woman about things to do during the pregnancy. Which of the following would you advise her to do? check all answers that apply

Avoid exercise in hot and humid weather. Eat no raw shellfish or raw meat.

Which of the following would NOT be an appropriate nursing intervention for a preterm newborn? check all answers that apply

Avoid touching the infant as much as possible.

Which of the following statements about determination of BUN level in a client is accurate? check all answers that apply

BUN levels indicate the extent of renal clearance of urea nitrogenous waste products. Intake of a high-protein diet can elevate the BUN level. Elevated serum creatinine and BUN levels suggest renal dysfunction.

You are working with a client who has anorexia nervosa. Which of the following are appropriate interventions for this client? check all answers that apply

Be accepting and nonjudgmental. Implement behavior modification techniques. Establish a one-to-one therapeutic relationship with the client.

The nurse is caring for a newborn in the NICU. Which of the following conditions is a chronic illness and is a complication of care given in the NICU?

Bronchopulmonary dysplasia.

What medication may be used safely in a pregnant woman with cardiovascular disease?

Cardiac glycosides.

The community nurse notices the increased motivation of the patients to learn new information or use new resources regarding their specific disease or illness. This is most likely due to which of the following?

Change in cognitive status

A woman in labor does not continue to dilate. The physician decides to perform a cesarean section. A healthy 7 lb. 12 oz baby boy is delivered. What is the most essential nursing intervention in the immediate postpartum period?

Check the fundus for firmness.

Which intervention does NOT apply when dealing with an upper G.I endoscopy?

Clear liquids only for 24 hours after procedure.

Which of the following statements about communication theory is accurate? check all answers that apply

Communication theory emphasizes the interaction of individuals that is both verbal and nonverbal. Communication functions include emotional support, shared information and instruction.

Which of the following is NOT a component of a normal EKG?

D wave.

During auscultation of the abdomen with the diaphragm of the stethoscope, a high pitched, tinkling, rushing and growling bowel sound is heard. These sounds indicate which of the following?

Diarrhea.

You are instructing an elderly client on home safety during her discharge process. The client is at high risk for falls due to her neurological status. Which of the following will NOT be an appropriate measure to prevent falls?

Discuss keeping her bed up high to allow for ease of rising.

Which of the following defense mechanisms is when an individual deals with an emotional issue through a short-term change in identity

Dissociation.

The nurse notes that a client with Type I diabetes mellitus has lipodystrophy on both upper thighs. The nurse would appropriately inquire about:

Does the client rotate sites for injection?

Which of the following is NOT a sign of a patient with suspected pulmonary embolus?

Dry mouth.

After a gastrectomy, the nurse should evaluate the client carefully for which of the following complications?

Dumping syndrome.

our patient is often bothered by canker sores. The health care provider has prescribed a topical steroid. You would tell the patient which of the following about this medication? check all answers that apply

Eat a bland, soft diet during lesion eruptions. Use at the first sign of tingling to abort the eruption.

Using the proper fire extinguisher in the case of an emergency is very important. Which of the following materials requires the use of a Class C extinguisher?

Electrical equipment.

Which of the following is NOT an intervention of autonomic dysreflexia?

Elevate the bed 45 degrees

You are caring for a patient who has just been diagnosed with type 1 diabetes. This patient needs to be educated as to how to be able to cope with this diagnosis. What is the first thing that you should do for this patient?

Evaluate what this patient already knows about diabetes and the administration of insulin.

Which of the following statements about colorectal cancer is NOT accurate? check all answers that apply

Exploratory surgery is needed to confirm the colorectal cancer diagnosis.

Which of the following is NOT a social role related to European (White) Americans?

Extended family is not important.

The nurse understands that good hand hygiene involves washing the hands ___.

For at least 15 seconds.

The nurse is caring for a laboring woman who is receiving an epidural anesthesia. What should be included when assessing this woman?

Frequent assessment of maternal blood pressure

A goal of the post-operative phase of abdominal surgery is to advance the diet as tolerated. The client has thus far tolerated ice chips and clear liquids. What would be the next phase in the client's diet?

Full liquids.

A couple demonstrates understanding of the consequences of not treating Chlamydia when they state what?

He could get an infection in the tube that carries out the urine."

Which of the following is a typical physical characteristic of a toddler? check all answers that apply

Head circumference increases about 1 inch between ages 1 and 2. Normal height changes include a growth of about 3 inches per year. "Pot belly" is noted.

The nurse assesses a 80-year-client with hot, dry skin that is flushed. Which of the following best identifies the client's condition?

Heatstroke.

A client is seen in the emergency department with a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps. With each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?

Helicopod.

Which of the following statements about herbal therapies is NOT accurate? check all answers that apply

Herbs can be helpful if trying to get pregnant. Herbs can be taken in any dosage; they are not toxic.

The nurse notices that a client with obsessive-compulsive disorder dresses and undresses numerous times each day. Which comment by the nurse would be most therapeutic?

I saw you change clothes several times today; that must be very tiring.

A woman in the clinic is at 32 weeks gestation and has the diagnosis of pregnancy induced hypertension (PIH). You are the RN who is to perform client instructing. Which of the following statements, made by the client, indicates to the nurse that further instruction is required?

I will have to keep my room darkened and not watch much television."

A client is admitted to the emergency department with an acute asthma attack. The physician prescribes ephedrine sulfate, 25 mg subcutaneously (S.C.). How soon should the ephedrine take effect?

In 20 minutes.

When discussing the Food Guide Pyramid with a 75-year-old client, the nurse should remember that the guide has been modified for older people. Unlike the standard Food Guide Pyramid, what is true of the version for elderly individuals?

Includes eight 8 oz. glasses of water at the base of the pyramid.

Which sign and symptom suggest that a client's abdominal aortic aneurysm is extending?

Increased abdominal and back pain. Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.

Which of the following is defined as the length of time between the contact with an infection and the manifestation of the disease?

Incubation.

Which of the following IV fluids is as equally concentrated as the body's natural intracellular fluid?

Isotonic.

Morphine has which of the following effects on a patient?

It decreases the body's demand for oxygen.

Your patient is a 75-year-old woman. You are assessing her to see whether she has any needs or care deficits. The correct tool to use for this assessment is which of the following?

Katz Index of Activities of Daily Living

Which of the following is a brand name for Phentermine?

Lonamin.

Which of the following is NOT a screening tool to assess a substance abuse disorder?

MME he MME is the mini-mental exam and is used to screen for cognitive impairment; not for substance abuse disorder. The other three tools are used to assess for a substance abuse disorder.

Which of the following is an infection control method that is also known as clean technique?

Medical asepsis.

Which of the following is defined as slowing down the spread of infectious microorganisms?

Medical asepsis.

Which of the following created rights for the mentally ill patient?

Mental Health Systems Act

You are caring for a client with a nasogastric tube attached to low suction. The nurse monitors the client, understanding that this client is at risk for which acid-base disorder?

Metabolic alkalosis.

While caring for a client who has been recently diagnosed with Amyotrophic Lateral Sclerosis, the nurse should understand what?

Mood changes may occur. Clients with amyotrophic lateral sclerosis may experience mood changes such as a sudden outburst of laughter one minute and crying spells the next. Further, irregular spasmodic twitching of the small muscle groups may occur instead of regular spasmodic twitching. Then, underactive deep tendon reflexes is incorrect as clients with this disorder typically experience overactive deep tendon reflexes. Also, the client will not have heavy breathing. Instead, the client will experience difficulties in breathing and mechanical ventilation may be warranted to help support respiratory function.

A client is undergoing an extensive diagnostic workup for suspected muscular dystrophy. The nurse knows that muscular dystrophy has many forms, but that one assessment finding is common to all forms. Which finding belongs in this category?

Muscle weakness.

The nurse is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common?

Muscle weakness.

Nurse Jones conducts a carotid pulse check of her patient. On what part of the body is this done?

Neck

The RN is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse use to dilute this medication?

Normal saline (0.9%) solution.

A patient who was diagnosed with diabetes while in the hospital will be discharged tomorrow. He has been educated on how to administer insulin to himself. What would be the best action for the nurse to take in regard to this before the patient is discharged?

Observe the patient as he gives himself an insulin shot.

A 50-year-old male is admitted to the hospital with a stroke. Which of the following actions should the nurse delegate to a nursing assistant?

Offer the client a bedpan every 2 hours

Which of the following statements from the Patient's Bill of Rights adopted by the American Hospital Association is NOT stated correctly?check all answers that apply

Patients have the right to examine and receive an explanation of their bill if insurance does not cover the cost. Patients must be afforded privacy when they ask for it

Glasgow's coma scale does NOT measure which of the following?

Peripheral vision.

A client has undergone an ileostomy. Which of the following postoperative care approaches is the nurse's top priority?

Place the client in the physician ordered position.

You are caring for a 4 year old with the diagnosis of human immunodeficiency virus (HIV) infection. With consideration of this child's psychosocial needs, the nurse expects that:

Pneumococcal and influenza vaccines are recommended.

Which of the following is a brand name for Repaglinide?

Prandin.

A woman is being treated for severe depression. During the acute phase of her illness, which of these measures should have priority in the client's care?

Providing her with physical care

What is a characteristic of hyperthyroidism that should alert the nurse that a client is in a thyroid crisis?

Pulmonary edema.

A client with vaginal cancer asks the nurse, "What is the usual treatment for this type of cancer?" Which treatment should the nurse name?

Radiation.

A nurse has a patient who is confined to bed and who needs to have her position changed periodically. The nurse has asked an assistant to help her turn the woman. What is the first thing that they should do before they help the woman into a new position?

Raise the bed to the level of their waists before moving the patient.

Which of the following is a brand name for Metoclopramide HCL?

Reglan.

Which of the following actions is appropriate to take in the case of sudden external hemorrhage? check all answers that apply

Remove any clothing covering the injury. Apply firm, direct pressure to the injury.

The nurse is treating a patient who has been raped. How should the nurse treat the patient's clothes from the event?

Remove the clothes carefully to preserve evidence.

The nurse is planning caregiver teaching regarding applying bandages. Which of the following should the nurse instruct the client's caregiver to do?

Report redness of the skin and pain.

The nurse is administering prescribed medication to her patient. The patient sees the medication and tells the nurse that it does not look like what he has been taking. What action should the nurse take?

Report what the patient said to her supervisor.

When caring for a client with chest pain, which of the following should the nurse assess as an indictor of pain?

Rubbing of the jaw

In terms of the etiology of schizophrenia, which of the following statements is accurate? check all answers that apply

Schizophrenia typically manifests early in adulthood. Schizophrenia becomes chronic or recurrent in at least 80% of those who develop it It is believed that schizophrenia occurs when multiple inherited gene abnormalities combine with nongenetic factors.

A 75-year-old woman who has limited mobility tells you that she has trouble getting to sleep at night and is easily awakened during the night. She asks if it would help her to take a sleeping pill at night. What is the best response to her question?

Sleeping pills can help you sleep but may create problems for you in terms of disorientation.

You want to make sure that your patient will not suffer from pressure ulcers because he is not able to position himself effectively. You would do which of the following as part of an early intervention? Check all answers that apply

Take steps to reduce shearing and friction. Clean skin as soon as it becomes wet. Use the sheet to lift or reposition the patient in bed.

A patient in the surgical unit with moderate pain as a result of surgery has been in the same nurse's care for a week. A physician has prescribed a dosage of pain reliever that the nurse feels is too strong for the patient. What is the best thing for her to do in this situation? Check all answers that apply

Talk to the health care provider or physician about her concerns.

A client with panic disorder is having difficulty falling asleep. Which nursing intervention should be performed first?

Teach the client relaxation/meditation techniques The client needs to learn skills to calm himself. This might be done through relaxation/meditation instead of using medication as a first resort.

A nurse is teaching a group of fifth grade girls about their reproductive systems. When they reach the subject of menstruation a 12 year old girl expresses concerns that all of her friends have started menstruating but she hasn't. What is the best reply to this girl?

The average age for the onset of menstruation is 12.5 years. Some girls start earlier and some later.

A 20- year- old male client is in seclusion and restraints. Earlier, the client grabbed a therapist and pushed her into a table that was located in the center of the therapy room. Which of the following indicates the client is ready for release?

The client is calm and appears relaxed

As a community health care nurse, you met with several elders to address their concerns regarding the onset of Alzheimer disease. What are the onset signals of Alzheimer?

The first signal would be progressive memory lost

You have a patient whose blood pressure is consistently high. The doctor has decided that the best way to control the hypertension is through medication. You know that it is important to teach this patient all about the medications that he is taking because

The more patients know about their antihypertensive medications, the more likely they are to take them.

A nurse who is preparing a patient for eye surgery takes his intraocular pressure. She finds that the pressure in the right eye is 12 mm Hg and the pressure in the left eye is 17 mm Hg. The nurse would tell the patient that

The pressure in both eyes is normal

In what way does Schizophrenia differ culturally?

The prevalence of schizophrenia is higher in some countries than in others. The form of expression of schizophrenia varies across cultures. The stressors that trigger the onset of schizophrenia may be culturally specific, such as fearing that one is the victim of witchcraft. All of the above statements are true.

A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and intervention, what would be the MOST desirable outcome?

The student accepts a referral to a substance abuse counselor

Which of the following is NOT an accurate statement regarding a ventricular septic defect (VSD) in an infant?

There is no present nonsurgical intervention for this condition.

Your patient has had hip replacement surgery. She is being discharged and along with other instructions you advise her not to lift her leg upward from a lying position or elevate the knee when sitting. The primary reason for this is which of the following?

This type of action may pop the prosthesis out of the socket.

A client is scheduled for an magnetic resonance imaging (MRI). What should the nurse explain to the client regarding the test's purpose?

To identify conditions of the brain.

Which of the following stages of development is a child most likely to have increased ear infections?

Toddler

For a patient who is suffering from Huntington's disease, all of the following are true EXCEPT: check all answers that apply

Treatment to cure the disease includes Navane and Haldol. Antidepressants should not be used.

A client is in the third stage of labor. Which finding indicates impending placental separation?

Umbilical cord lengthening.

Vasogenic or distributive shock may be caused by which of the following? check all answers that apply

Vasogenic or distributive shock may be caused by which of the following? check all answers that apply

The nurse is to administer an intramuscular (IM) injection to a six-month-old. What is the most appropriate site to utilize?

Vastus lateralis

All of the following are common adverse effects of chemotherapy except:

Weakening of teeth.

Which of the following questions is a closed end question? check all answers that apply

What did you eat for dinner? Who brought you here?

A 23-year-old female has kidney stones. She is scheduled for an intravenous pyelogram. Which of the following client statements should stand out as a concern to the nurse?

When I eat crab meat, I get short of breath."

You have a patient with advanced breast cancer who has been admitted to the hospital for palliative care. You understand that this means which of the following?

You have a patient with advanced breast cancer who has been admitted to the hospital for palliative care. You understand that this means which of the following? The patient will receive care to relieve pain and symptoms without hastening or postponing the patient's death.

Which of the following patients would be most likely to perceive direct eye contact as a show of hostility or aggression? check all answers that apply

a 30-year-old Appalachian male

Which of the following clients would have a higher risk of delivering a newborn with Down Syndrome?

a 45 year old female

Which of the following patients do NOT have a problem that would be considered a priority need? check all answers that apply

a patient whose family refuses to visit her

A nurse has several patients in her care. Which of the following patients will be limited in their right to autonomy? check all answers that apply

a patient with an intestinal parasitic infection who refuses treatment

A nurse is asked to find a suitable room for a patient who is being admitted for chest pains and is also disoriented and restless. Which of the following would be the safest room assignment for this patient?

a private room within view of the nurse's station

Which of the following clients should the nurse care for first?

a woman who needs to be turned every two hours and was last turned two hours ago The person who needs turning should be attended to first. This will help to prevent skin breakdown and respiratory complications. Turning usually can be done fairly quickly and the nurse can get on to the others who need attention.

The nurse is caring for a client traumatized by the sudden death of a brother who was murdered. The nurse understands the client's loss is what?

actual

Bleuler's four A's are used to help remember the important characteristics of schizophrenia. Which of the following is NOT one of the four A's?

actualities

Which of the following nursing interventions would be appropriate for a patient who is suffering from hypocalcemia? check all answers that apply

administer IV calcium as prescribed administer vitamin D supplementation as prescribed administer a phosphate-binding antacid

A 55-year-old male has come to the emergency room suffering a heart attack. He has a laceration on the head from falling when he first felt the pain of the attack. He also has type II diabetes and is being treated for arthritis. Which of the following actions takes priority in caring for this patient?

administration of O2

The nurse obtains a health history from the following clients. To which should she give priority in regard to teaching about cervical cancer prevention?

age 30, treated for PID

Documentation for a female patient indicates an android pelvis. Upon examination of the pelvic area of this patient you would expect to find which of the following? check all answers that apply

angulated pelvis narrow pelvic planes

Neurological impairment takes on many forms. The loss of ability to use language is which of the following? check all answers that apply

aphasia

Your patient was admitted after suffering a stroke. The patient's family is concerned that the patient is unable to speak. You tell them that the patient is suffering from which of the following losses?

aphasia

The nurse is educating a family on violence and assault. The nurse explains what?

assault is the mental or physical threat of violence

Which of the following indicates the nurse's role during diagnostic testing for bowel disorders?

assess for medications that may change the results of the test

Which of the following nursing actions would be performed as part of the surgical skin preparation process?

assess the skin of the surgical site for moles

Which of the following factors might increase the incidence of and susceptibility to depression? check all answers that apply

being under 40 having a substance abuse problem

The nurse understands that the components of electrolytes in the blood are

bicarbonate

There are several nonpharmacologic techniques for management of pain. The method that teaches patients to control involuntary body mechanisms, such as heart rate, muscle spasms, and circulation is which of the following? check all answers that apply

biofeedback

You are taking the pulse of a hospitalized patient. You find that the pulse is 55 beats per minute. This is considered which of the following? check all answers that apply

bradycardia

Which of the following items would be classified as part of the general assessment of a patient during a physical examination? check all answers that apply

breath and body odor general appearance

For a patient with a vitamin B12 deficiency, you might suggest foods rich in this vitamin. This would include all of the following foods EXCEPT: check all answers that apply

carrots ,green peppers

Of the following disorders which one is NOT a disorder of nerve impulse transmission? check all answers that apply

cerebral palsy

For which of the following eye infections and/or inflammation is incision and drainage an option? check all answers that apply

chalazion stye These two infections might be treated by incision and drainage. For a stye, warm compresses and antibiotics are also used.

Children at highest risk for child abuse include all of the following EXCEPT:

children of high birth weight children over 5 years of age Children at highest risk for child abuse include children born prematurely; children of low birth weight; children under 3 years of age; and children with physical and/or mental disabilities. Child abuse includes intentional physical, emotional, and/or sexual misuse/trauma or intentional omission of basic needs.

Patients are coming into the emergency room as a result of an apartment house fire. You are examining a patient who is in distress but has no visible burn marks. You suspect that she is suffering from inhalation burns. Which of the following signs would NOT be associated with inhalation burns?

clear sputum

Which group of clients is at an increased risk for developing a wound infection?

clients who are undernourished

A patient comes to the doctor's office complaining that her heart skips beats sometimes. After determining that there is no underlying cardiac disease causing this, she is diagnosed with PVCs (premature ventricular contractions). In advising her as to what foods she should avoid which of the following would be included?

coffee tea cola

There are time when complementary and alternative medicine (CAM) may help a patient. One of the CAM therapies is mind-body therapy. Which of the following would be considered mind-body CAM methods? check all answers that apply

cognitive-behavioral therapy meditation clinical hypnosis

You have been assigned to be leader of a task that involves several other nurses and nursing assistants. You feel that connective leadership is the approach to use for this task. This means that you want to achieve results by which of the following? check all answers that apply

collaboration, cooperation

A nurse has an African-American patient whom he needs to check for cyanosis? Which of the following sites would be the best to check for this?

conjunctiva of the eye

The nurse is allowing the feeding for a female who has undergone a cholecystectomy to flow slowly at the prescribed rate. The nurse understands this will help prevent?

cramps

Which of the following is NOT part of the central nervous system (CNS)?check all answers that apply

cranial nerves spinal nerves These are not part of the CNS; they are part of the peripheral nervous system (PNS). The CNS is composed of the brain and spinal cord. They interpret incoming sensory information and send out instruction based on past experiences.

The nurse administers heparin to a female client. Which of the following is heparin used to treat?

deep vein thrombus

A client is scheduled for a dilation and curettage. The nurse instructs the client to come in a day before the scheduled procedure for the insertion of laminaria. The main reason for the laminaria insertion is to

dilate the cervix

A person with antisocial personality disorder would exhibit which of the following characteristics? check all answers that apply

disregard for the rights of others charming and intellectual appearance

The nurse is preparing a teaching plan for a client with a rib fracture. The nurse knows that a rib fracture will cause the most pain

during inspiration

You would see which of the following lab results for a person who has Graves' disease? check all answers that apply

elevated basal metabolic rate elevated T3 high titer anti-thyroid antibodies

You recognize that it is important to prevent the development of pneumonia in your patient who is immobile. Which of the following nursing interventions is the most likely to be used to prevent pneumonia in your patient?

elevating the head of the bed to feed

Which of the following solutions may consist of water in oil (w/o) or oil in water (o/w)?check all answers that apply

emulsion

You have a patient who is suspected of having esophageal cancer. You understand that which of the following is most likely to be used to confirm that diagnosis?check all answers that apply

endoscopy biopsy

Which of the following are involved in the planning aspect of nursing care?

establishing goals determining expected outcomes Collecting data and organizing data are part of the assessment process, not the planning process. Planning also involves setting priorities, and selecting appropriate interventions.

A 67 year old male is seen in the clinic with aplastic anemia. The nurse understands that with this condition the normal bone marrow is made with

fat The correct answer is fat. Aplastic anemia is a condition where the bone marrow is unable to not make all types of blood cells, which are the platelets, white blood cells and red blood cells. Instead, the bone marrow starts to make adipose or fat cells which in term stops the bone marrow from producing the blood cells.

You patient has fractures of multiple adjacent ribs. This is a cause of which of the following check all answers that apply

flail chest

A physician who works at the hospital has been taken into custody for representing that he had a valid license to practice medicine when in fact he has no license at all. This is known as which of the following? check all answers that apply

fraud

A young man has come to the office for a physical examination. The nurse documents his pulse as +3. Which of the following best describes this pulse?

full and brisk

A person's reaction to pain is subjective. It is influenced by certain factors. Which of the following are factors that may influence a patient's pain experience? check all answers that apply

gender culture religion

The official, established nonproprietary name assigned to a drug is which of the following?

generic

Communication with patients is a keystone of nursing. Nurses use therapeutic communication and avoid using nontherapeutic techniques. Which of the following is one of these non-therapeutic techniques? check all answers that apply

giving approval or disapproval challenging the client

The nurse understands an effective health care group

has a purpose

A nurse is caring for a teenage girl who has been in a motorcycle accident. The girl has deep abrasions on the right side of her body including on her face. In caring for this teenager, the nurse should know that the girl's primary concern will be

her body image

A client is in the recovery unit after having an ileostomy. The nurse finds the client has bulging surrounding the stoma. The nurse understands this is an abnormal finding as this may indicate

herniation

Which of the following diets is best for a patient with nephrotic syndrome

high protein, low sodium Nephrotic syndrome is a type of renal failure characterized by increased glomerular permeability, marked proteinuria, hypoalbuminemia, and edema. Drug treatment includes diuretics, angiotensin-converting enzyme inhibitors, and anti-lipid agents. The patient should also follow a high-protein, low-sodium diet.

A 45-year old woman tells the nurse that she is not getting enough sleep at night. She complains that it is affecting her work. What is the first thing that the nurse should determine with this complaint?

how many hours of sleep this woman would normally get before she had this current problem t is important to first determine what this woman considers a normal sleep pattern for herself. This will help the nurse to assess whether the client's recent sleep pattern deviates very far from her normal sleep pattern. The other choices may be considerations but not the first consideration.

Your patient is scheduled for amniocentesis to determine if the fetus has a genetic disorder. In monitoring the patient after the amniocentesis, you know that which of the following is least likely to be a complication of the procedure?

hypotension

A female client is scheduled for an abdominal ultrasound. The nurse instructs the client to not urinate until the ultrasound is finished. The nurse understands this will help

improve visualization

A patient of yours fell in the hallway while ambulating from his room to the nurse's station. He suffered no ill effects from the fall. This fall must be reported in which of the following forms of documentation?

incident report

An acute hemolytic reaction to blood transfusion would indicate which of the following? check all answers that apply

incompatibility

All of the following are side effects of streptomycin EXCEPT: check all answers that apply

increased appetite decreased thirst

You are speaking to a patient about her upcoming surgery. You nod your head to most of what the patient is saying. This is called acceptance. Acceptance involves which of the following? check all answers that apply

indication that you heard what the other person said non-judgmental action

Which of the following would NOT be an appropriate intervention for a client with a cognitive disorder such as Alzheimer's disease? check all answers that apply

keeping the environment as bare as possible

a nurse recognizes that one of the primary causes for malabsorption syndrome is what?

lactase deficiency

The nurse places a client in a lateral position. Which of the following is a potential problem for a client in the lateral position?

lateral flexion

Which of the following interventions for anxiety disorders would be likely to enhance the patient's self-esteem? check all answers that apply

making positive statements about the patient exploring the patient's previous achievements

Generativity versus stagnation occurs in which of Erikson's stages of psychosocial development? check all answers that apply

middle adulthood

The nurse is caring for a client under great stress. The client describes feeling nervous and having difficulty focusing on her work. Pulse and respiratory rate are slightly elevated. The nurse recognizes this client is experiencing what level of anxiety?

moderate anxiety

A primary care provider is performing an abdominal paracentesis. The nurse's role in the procedure will include which of the following?

monitoring the client for distress

The CAM tool is used to assess the development of delirium. It consists of nine factors. Which of the following are not factors of this tool? check all answers that apply

naming items following instructions

Abuse of alcohol results in multisystem physiological impairments including peripheral neuropathy. This impairment is characterized by which of the following?

nerve damage pain burning Peripheral neuropathy is characterized by peripheral nerve damage, pain, burning, tingling or prickly sensations of the extremities. Researchers believe it is the direct result of deficiencies in the B vitamins, particularly thiamine. Nutritional deficiencies are common in chronic alcoholics.

A nurse is assessing the neurological status of a patient. In the course of the assessment the nurse asks the patient to repeat three unrelated words that are spoken to him and after five minutes asks him to repeat these same words. The nurse is testing what type of memory? check all answers that apply

new memory

The nurse is reviewing the chart note from the physician's physical examination. The note indicates the client is a well developed, well nourished 1-year-old. On the last visit, the chart indicates the child's head is normocephalic. During the present visit, the nurse measures the 1- year-old's head and determines the child has a normal head circumference. A normal head circumference is called what?

normocephaly

A newborn's anterior fontanelle has which of the following characteristics?

open until 12-18 months diamond-shaped found along the coronal and sagittal sutures

Which of the following situations is an example of behavioral therapy? check all answers that apply

operant conditioning, desensitization

All of the following would be considered basic mobility aids in terms of durable medical equipment (DME) EXCEPT: check all answers that apply

ostomy care supplies ventilator

In the course of educating student nurses about pregnancy, labor, and delivery you cite the 5 Ps of a difficult birth (dystocia). You would include which of the following?

passenger passage psyche

When a client undergoes a tubal ligation, the nurse should teach the client about what possible complication?

perforation of the bowel

The meninges are three connective tissue membranes that cover the brain and spinal cord. Which of the following is NOT one of the membranes? check all answers that apply

pons

You are caring for a child with cerebral palsy. You are about to feed the child. Which of the following would be a priority for feeding the child?

preventing aspiration by position the child upright and supporting the lower jaw

Which of the following devices would the nurse use to identify hypoxemia?

pulse oximeter

A client who recently lost her mother tells the nurse, "I won't be stopping by my mother's house after work anymore. Maybe I can make plans with my sister in the evenings." Which of the following stages of grieving identified by Engle is the client exhibiting?

resolving the loss

A young child is brought into the emergency room. Her parents have told the medical personnel that she has been vomiting a lot and has had severe diarrhea for two days. The child was suffering hypovolemic shock and was put on mechanical ventilation (which has been effective) to treat oxygenation problems. Which of the following should the nurse consider a priority at this time?

risk for infection

Which of the following is classified as secondary lesions?

scars

A young child is brought to his pediatrician's office with flu-like symptoms. The nurse takes his temperature with a tympanic thermometer. In doing this the nurse should

set the thermometer to whichever type of measurement reading that she will be taking

A 25-year-old female patient complains that she is often nauseous and dizzy, and has trouble sleeping. She also says that she feels that nothing is right with her life and something terrible is probably going to happen. This person is diagnosed with anxiety disorder. Which level of anxiety is this person experiencing? check all answers that apply

severe The somatic symptoms of severe anxiety include headache, nausea, dizziness and insomnia which increase as the anxiety becomes severe. The person may experience hyperventilation and a sense of impending doom or dread.

You have just received a patient who has been admitted for an injury received in a fall. As you are assessing her condition she is wringing her hands, is very agitated and tells you that she is feeling very uneasy and tense. She states that she "needs help and can't stand the feeling of anxiety any more." At what level would you assess her anxiety?

severe anxiety

four-year-old is admitted with foreign body aspiration. Which of the following is commonly associated with foreign body aspiration?

small raw vegetables

In terms of borderline personality disorder, the ego defense mechanism that is manifested by an inability to integrate and accept both positive and negative feelings is which of the following?

splitting Splitting is a primitive ego defense mechanism that is common in people with borderline personality disorder. It arises from their lack of achievement of object constancy and is manifested by an inability to integrate and accept both positive and negative feelings. In their view people and life situations are either all good or all bad.

The nurse attends an onsite workshop that addresses new policies for the intentional threat to harm a group of people for religious or political reasons. The nurse understands the focus of the workshop is on which of the following?

terrorism

You have a patient with sickle cell anemia. You administer penicillin as a prophylactic. This is known as which of the following?

tertiary prevention

A 9-year-old has moderate persistence of asthma. The nurse knows this means what?

the client has daily coughing and wheezing

A client with Myasthenia Gravis is undergoing Plasmapheresis. Which of the following should the nurse not tell the client before the procedure?

the procedure will last between 2 to 5 hours

The responsibilities of a licensed practical nurse include all of the following EXCEPT: check all answers that apply

to advise patients about advance directives

You have a patient who came into the emergency room in great emotional distress saying that she cannot stand to feel the way she does anymore. She says she doesn't sleep well, can't eat, feels hopeless and does not want to go on like this anymore. You know that this patient is in crisis and you also know that after determining that she is not at risk for injury the primary goal in her care is

to get the patient back to a pre-crisis level of functioning

A nurse has 79-year-old patient with normal pressure hydrocephalus (NPH). This nurse can expect that which of the following measures will be taken to correct the problem? check all answers that apply

ventriculoperitoneal shunt

nurse has 79-year-old patient with normal pressure hydrocephalus (NPH). This nurse can expect that which of the following measures will be taken to correct the problem? check all answers that apply

ventriculoperitoneal shunt

A client will be undergoing a blood transfusion. Which of the following actions should the nurse perform first?

verify the physician order to determine what type of blood product is administered

All of the following are subjective data for assessment of a patient EXCEPT: check all answers that apply

vital signs hematuria

he nurse is instructing a client diagnosed with hypoparathyroidism about the regimen used to treat this disorder. The nurse should state that the physician probably will prescribe daily supplements of calcium and:

vitamin D

Your client becomes very angry when a technician who is drawing blood is unable to find a vein after several attempts. To cope with this angry client, which of the following should be done? check all answers that apply

watch the client's body language speak in a reassuring way