Hesi review

By which age should hearing loss be detected to maximize the child's potential to achieve normal language development?

3 months

Which sign in the newborn infant would reflect an Apgar score of 1 in the category of respiration? 1. Good cry 2. Grimace 3. Absent respiration 4. Slow, weak cry

4. Slow, weak cry

During an annual physical assessment, a client reports not being able to smell coffee and most foods. Which cranial nerve function would the nurse assess? A. I B II C X D. VII

A I

Which koror off sound represents the diastolic blood pressure in an adolescent? A. First B. Third C. Fifth D. Fourth

C. Fifth

Which decreased hormone level may cause a client's anemia? Bradykinin Prostaglandin Erythropoietin Activated vitamin D

Erythropoietin

Which type of cast or splint would the nurse expect to see on a child with a fractured femur?

Hip spica

An infant is found to have developmental dysplasia of the hip (DDH) 6 weeks after birth. The parents ask a nurse at the clinic why their infant must be restrained in a harness at such an early age. How should the nurse respond?

Infants' hip joints are cartilaginous, allowing molding of the acetabulum.

Which task must a 30 year old client work through based on Erikson's psychosocial stages of development

Intimacy vs isolation

An increase in which blood component is responsible for the acidosis related to untreated diabetes mellitus?

Ketones

The nurse is assessing a toddler with plumbing (lead poisoning) which organ system is most concern because of the condition's irreversible effects?

Nervous (damaged nerve cells do not regenerate)

Which mechanism of action would the nurse identify for levodopa therapy prescribed to a client diagnosed with Parkinson's disease?

Restores the dopamine levels in the brain

Which sport would the nurse suggest as therapeutic for a 13 year old adolescent with idiopathic scoliosis while considering that exercise and avoidance of fatigue are essential components of care?

Swimming

Which initial objective with the nurse established with the client when a healthcare provider prescribes a diagnostic work up for a client who may have myasthenia gravis

The client will maintain present muscle strength

Which reason explains why so many psychiatric clients are give benztropine or trihexyphendiyl in conjunction with phenothiazine-derivative neuroleptic medications?

They combat the extrapyramidal side effects of the neuroleptic medication

For which purpose is a goniometer used?

To assess range of motion

The home health nurse provides education for a client with cancer of the tongue who will begin Gastrostomy feedings at home. Which client statement indicates effective teaching?

Before i start the procedure i will measure the residual volume

A child has a respiratory tract infection with a low-grade fever. When teaching the parents, which intervention would the nurse emphasize?

Giving small amounts of clear liquids frequently to prevent dehydration

Which type of rehabilitation is an essential component to a client's recovery from Guillain-Barre Syndrome? Physical therapy Speech exercises Fitting with a vertebral brace Follow up on cataract progression

Physical Therapy Rehabilitation needs for a client with Guillain-Barre syndrome focuses on physical therapy and exercise for lower extremities because of muscle weakness and discomfort.

Which nursing intervention with the nurse implement for a client newly diagnosed with myasthenia gravis, who voiced concerns about fluctuations in physical condition, and generalized weakness?

Preplan the spacing of activities throughout the day

According to Erikson's which behavior would the nurse anticipate when assessing an adolescent?

Questioning their identity

Which characteristic occurs after the transition from infancy to toddlerhood?

Reduced need for sleep

Which area of the client's body would the nurse consider a high risk for developing a pressure injury when caring for an older adult with Alzheimer type dementia who consistently sleeps in a semi-Fowler position in bed?

Sacrum

Which nursing intervention would the nurse implement for a hospitalized client with multiple sclerosis who voices a concern about generalized weakness and fluctuating physical status?

Space activities throughout the day.

Which site would the nurse assess first for the amount of drainage from a client discharged from the postanesthesia care (PACU)? A. Foley catheter B. Nasogastric tube C. Intravenous (IV) catheter D. Surgical incision

D. Surgical incision

Which behavior would an adolescent exhibit? A. Temper tantrums B. Attempting to control situations C. Synchronization of moral skills D. Eagerness of formal education.

C. Synchronization of moral skills (adolescents synchronize physical, psychosocial, cognitive, and moral skills to become an accepted member of society)

Which hormone levels do not require monitoring during the administration of menotropins for infertility? A. Estrogen B. Luteinizing hormone C. Follicle-stimulating hormone D. Gonadotropin-releasing hormone

D. Gonadotropin-releasing hormone (they act as the hypothalamic level)

An older retired client tells the nurse about the The great life she has lived in the activities that she enjoys at the senior center. Which developmental conflict has the client resolved according to Ericksons psychosocial stages of development?

Integrity vs despair

An adult client with low-functioning Down syndrome (trisomy 21) appears in the emergency department via ambulance after an accident. Which assessment method would be the best instrument to use when determining this clients level of pain

Using the Wong-Baker FACES Pain Rating Scale

Which tissue connects the client's tibia to the femur at the knee joint?

ligaments

A client reports to the nurse, "I've been using St. John's wort to try and feel more like myself again. I'm not sure whether it's going to work." Which symptom would the nurse further assess? A. Depression B. Sleep depression C. Diminished cognitive ability D. Sensory- perceptual disturbances

A. Depression

Which action would the school nurse take first when a child reports a sore throat? A. Examine the throat B. Have the child sent home C. Take the child's temperature D. Secure a prescription for an oral analgesic

A. Examine the throat (significant swelling can creat potential for airway obstruction.)

Which action would the nurse suggest when a client reports feeling faint and lightheaded upon rising to a standing position after a discectomy and fusion surgery? A. Have the client sit on the edge of the bed so the nurse can hold the client upright B. Have the client slide to floor with assistance to avoid injuring the client because of a fall C. Have the client bend forward to increase blood flow to the brain D. Have the client lie down immediately so the nurse may obtain the clients BP

A. Have the client sit on the edge of the bed so the nurse can hold the client upright

In which settings would the nurse perform developmental assessments for pediatric clients? SATA. One, some, or all A. Home B. School C. Hospital D. Daycare center E. Assisted living center

A. Home B. School C. Hospital. D. Daycare

Which would the nurse identify as the most widely used off label medication for cervical ripening and the enhancement of uterine muscle tone? A. Misoprostol B. Mifepristone C. Dinoprostone D. Methylergonovine

A. Misoprostol

Which atypical antipsychotics is approved for long-term use to prevent the recurrence of mood episodes in clients with bipolar disease? SATA one Some or all A. Olanzapine B.quetiapine C. Ziprasidone D. Risperidone E. ARIPIPRAZOLE

A. Olanzapine C. Ziprasidone E. Aripiprazole

Which organism is a common opportunistic infection in a client with human immunodeficiency virus (HIV)? A. Oropharyngeal candidiasis B. Cryptosporidiosis C. Toxoplasmosis encephalitis D. Pneumocystis jiroveci pneumonia

A. Oropharyngeal candidiasis

which behavioral response to a disaster would the nurse treat first, in an attempt to avoid mass hysteria? A. Panic B. Coma C. Euphoria D. Depression

A. Panic

Which structure is included in the external genitalia of the male anatomy? SATA. One, some, or all A. Penis B. Testes C. Scrotum D. Urethra E. Seminal vesicles

A. Penis C. Scrotum

Which key feature is associated with a stage 2 pressure ulcer? A. Presence of nonintact skin B. Development of sinus tracts C. Damage to the subcutaneous tissues D. Appearance of a reddened area over a bony prominence

A. Presence of nonintact skin

Which is the most common teratogenic effect associated with thalidomide? A. Shortened limbs B. Growth delay C. Neural tube defects D. Cleft lip with cleft palate

A. Shortened limbs

Which feature is associated with the "maturation phase" of normal wound healing? A. The scare is firm and inelastic on palpation. B. Fibrin strands form a scaffold or framework C. White blood cells migrate into the wound D. Epithelial cells are grown over the granulation tissue bed

A. The scar is firm and inelastic on palpation

While conducting an eye examination, the ophthalmologist shines a light into the client's pupil and observes that there is a slow recovery of the pupil size. Which muscular atrophy is responsible for this condition? A. Iris dilator muscle B. Iris sphincter muscle C. Medial rectus muscle D. Lateral rectus muscle

A.iris dilator muscle

Which description describes a coalesced type of skin lesion configuration? A. Lesions are well defined with sharp borders B. Lesions merge together and appear confluent. C. Lesions are ring like around flat centers of skin D. Lesions have wavy borders that resemble a skin.

B. Lesions merge together and appear confluent

Which information would the nurse include in his or her teaching for a class on breast health?

Breast awareness will help a client know if there are changes in her breasts.

Which nursing intervention has the highest priority when providing care to a client after an arthroscopy? A. Elevating the client to perform exercises B. Elevating the affected extremity for 12-24 hours C. Assessing the neurovascular status of the client's affected limb D. Administering analgesics as prescribed by the health care provider

C. Assessing the neurovascular status of the client's affected limb

Which organism is responsible for a client's localized bacterial infection of mucous membranes? A. Giardia B. Aspergillus fumigatus C. Corynebacterium diphtheria D. Myobacterium tuberculosis

C. Corynebacterium diphtheria (infection of mucous membranes or skin) **giardia travelers diarrhea **aspergillus lung disease ** mycobacterium tuberculosis (tb)

According to Erikson's developmental stages, which characteristic would the nurse anticipate When assessing a pre-school age child? A. Being engaged in tasks B. Questioning sexual identity C. Having highly imaginative thoughts D. Wanting to participate in organized activities

C. Having highly imaginative thoughts

Which symptom indicates that a client with inhalation anthrax is in the fulminant stage? A. Low grade fever B. Dry cough C. Hypoxia D mild chest pain

C. Hypoxia

Which description is associated with fissures? A. Deep erosions that extend beneath the epidermis B. Thinning of the skin surface with a loss of skin markings C. Linear cracks in the epidermis that extend into the dermis D. Thickened areas of epidermis with accentuated skin markings.

C. Linear cracks in the epidermis that extend into the dermis

Which of these assessments would be the highest priority for the nurse to complete on a client who arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and bilateral lower extremities? A. Level of consciousness B. Characteristics of pain C. Quality of respirations D. Observation of abdominal contusions

C. Quality of respirations

A client on hospice is receiving palliative treatment. Which is the goal of palliative care for this client? A. Restore the client's health B. Promote the client's recovery C. Relieve the client's discomfort D. Support the client's significant others.

C. Relieve the client's discomfort

Which volume of solution would be prepared when the nurse receives an order to prepare a solution for administering a cleansing enema for an adolescent client? A. 150 to 250 ml B. 250 to 350 ml C. 300 to 500 ml D. 500 to 750 ml

D. 500 to 750 ml

Nursing actions after a client has had general anesthesia are directed at preventing which postoperative respiratory complication? A. Pleural effusion B. Empyema C. Pneumothorax D. Atelectasis.

D. Atelectasis (complete or partial lung collapse due to anesthesia)

Which hormone may cause vaginal carcinoma in a female child after birth? A. Estrogen B. Progesterone C. Androgens D. Diethylstilbestrol

D. Diethylstilbestrol

Which part of the electrocardiogram (ECG) represents depolarization of the ventricles? A. P wave B. T wave C. PR interval D. QRS interval

D. QRS interval

While assessing a client for the dorsalis pedis pulse, the nurse documents the reading as 1+. Which conclusion can be inferred from this finding?' A. There is absence of a pulse B. The pulse strength is normal C. The pulse strength is bounding D. The pulse strength is barely palpable.

D. The pulse strength is barely palpable

Which nutrients would the nurse teach the parents of a child with celiac disease to avoid? A. Saturated oils and fats B. Milk and hard cheeses C. Corn and rice products D. Wheat and oat products

D. Wheat and oat products

Which test would the nurse identify as specific for the diagnosis of myasthenia gravis?

Edrophonium chloride

Which test would the nurse identify as specific for the diagnosis of myasthenia gravis?

Edrophonium chloride test

Which intervention with the nurse implement after determining that a client, Josefina cerebrovascular accident needs assistance with eating for optimum nutrition?

Encourage the client to participate in the feeding process

Which primary purpose does the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) serve?

Facilitates classification of mental disorders and guides the determination of diagnosis

Which example is classified as a flat bone? SATA 1. Sacrum 2. Scapula 3. Sacrum 4. Humerus 5. Mandible

2. Scapula 3. Sacrum

Which procedure involves the examination of the ureters and the renal pelvises? A. Cystogram B. Pyelogram C. Urethrogram D. Voiding cystourethrogram

B. Pyelogram

Which joint is an example of a gliding joint?

Sacroiliac

After teaching a male client about measures to maintain sexual health and prevent transmission of sexually transmitted infections (STIs) which client statement indicates effective learning?

"I will consult with my primary health care provider when there is a rash or ulcer on my genitalia"

How much sleep should a preschooler get each day?

12 hours

Which respiratory rate is the minimum normal in an adolescent?

16

Which percentage of his or her adult weight does an individual gain during adolescent years?

50

Which substance is the CAGE questionnaire used to screen? A. Alcohol B. Barbiturates C. Hallucinogens D. Multiple drugs

A. Alcohol

Which type of joint permits movement in any direction? A. Pívot B. Hinge C. Biaxial D. Ball-and-socket

D. Ball-and-socket

While providing care for a client with a second degree left ankle sprain, the nurse raises the injured part above heart level. Which statement describes the rationale behind this nursing action?

To prevent further edema

Which sexually transmitted infection is caused by chlamydia trachomatis? A. Cervicitis B. Gonorrhea C. Genital warts D. Genital herpes

A. Cervicitis

Which intervention would the nurse recommend if a teenager being discharged with a cast experiences pruritus around the cast edges? A. Scratch the itchy area gently B. Put an ice pack on the affected area C. Sprinkle a layer of powder around the itchy spots D. Ask your doctor for a prescription for an antihistamine

B. Put an ice pack on the affected area.

When developing the plan of care for a client with rheumatoid arthritis, which client consideration would the nurse include? A. Surgery B. Comfort C. Education D. Motivation

B.comfort

Which hormone is crucial in maintaining the implanted ovum at its site? A. Inhibin B. Estrogen C. Progesterone D. Testosterone

C. Progesterone

Attainment of which skills would be expected in a 7 month old? A. The child pulls themself to Stand or sit B. The child is able to pick up small objects C. The child can sit alone without support D. The child can place objects into containers

C. The child can sit alone without support

Which complication is the nurse's main priority during the early postoperative period after a subtotal throidectomy? A. Hemorrhage B. Thyrotoxic crisis C. Airway obstruction D. Hypocalcemic tetany

C.airway obstruction

Which electrical activity of the cardiac conduction system is reflected in the P wave? A. Atrial depolarization B. Atrial repolarization C. Ventricular depolarization D. Ventricular repolarization

A. Atrial depolarization

Which hormonal deficiency causes diabetes insipidus in a client? A. Prolactin B. Thyrotropin C. Luteinizing hormone D. Antidiuretic hormone

D. Antidiuretic hormone

Which rationale would the nurse use to explain they cane's purpose to a client with hemiparesis who voices a reluctance to use a cane?

Maintain balance to improve stability

A 55-year old female client reports cessation of menstrual periods for a year during An annual exam. Which term would the nurse use to describe the client's condition? A. Menarche B. Menopause C. Dyspareunia D. Menorrhagia

B menopause

Which school age client would the nurse anticipate will experience rivalry as a source of stress? A. 6 year old B. A 7 year old C. An 8 year old D. A 9 year old

A. A 6 year old

Which characteristic would a nurse expect to be exhibited by an adolescent? SATA. One, some, or all. A. A belief in their own invulnerability B. Personal fable C. Temper tantrums D. Attempts to control situations E. Eagerness for formal education

A. A belief in their own invulnerability B. Personal fable

The nursing is caring for a client who is having difficulty digesting fatty foods. To which deficiency would the nurse attribute this problem? A. Bile B. Lipase C. Amylase D. Cholesterol

A. Bile

Which activity would the nurse ask an older adult client to do when testing short term memory? A. Subtract serial sevens from 100 B. Copy one simple geometric figure C. State three random words mentioned earlier in the examination D. Name two common objects when the nurse points to them

C. State three random words mentioned earlier in the examination

By which age does the anterior fontanel of the skull close? A. 12-18 months B. 20-24 months C. 26-30 months D. 32-36 months

A. 12-18 months

Which amount of time is appropriate for nurse to spend triaging each patient during a mass casualty incident? 1) Less than 10 seconds 2) Less than 15 seconds 3) Less than 30 seconds 4) Less than 60 seconds

2. Less than 15 seconds

Which term does the A of the mnemonic ABCDE of primary nursing survey stand for? A. Airway B. Allergies C. Assessment D. Aspiration

A. Airway

A client reports excessive tearing. Which disorders would the nurse suspect could be responsible for the client's condition? SATA A. Chalazion B. Entropion C. Hordelum D. Conjuntivitis E. Keratoconjunctivitis sicca

A. Chalazion B entropion C. Conjunctivitis

Which assessment finding would the nurse observe in a client with bipolar disorder, manic phase? A. Constant singing B. Ritualistic behavior C. Flat affect D. Apathetic demeanor

A. Constant singing

Damage to which cranial nerve may lead to decreased olfactory acuity? A. Cranial nerve I B. Cranial nerve X C. Cranial nerve V D. Cranial nerve VIII

A. Cranial nerve I

Which clinical manifestation is associated with cellulitis? A. Lymphadenopathy B. Occasional papeles C. Vesicles that evolve into pustules D. Isolated erythematous papules

A. Lymphadenopathy

A client with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with a tentative diagnosis of pleuritis. It is important for the nurse to perform which intervention? Administer opioids frequently Assess for signs of pneumonia Give medication to suppress coughing Limit fluid intake to prevent pulmonary edema

Assess for signs of pneumonia

Which data would the nurse use to determine a client's score on the braden scale to predict a client's risk for developing pressure injuries? SATA A. Age B. Anorexia C. Hemiplegia D. History of diabetes E. Urinary incontinence

B,C,D,E

Which part of the brain primarily regulates muscle functioning ad coordinates movement? A. Cerebrum B. Cerebellum C. Epithalamus D. Hypothalamus

B. Cerebellum

Which finding in a urinalysis indicated a urinary tract infection? A. Crystals B. Bilirubin C. Ketones D. Leukoesterase

D. Leukoesterase

An infant has been admitted with failure to thrive. The nurse knows that more education is needed when one of the parents makes which statement?

I can double the amount of water in the formula to save money

Which functioning level of trauma center is involved in providing a full continuum of trauma services?

Level I

A client is prescribed chlorpromazine. Which action will prevent life-threatening complications during administration when the client is anxious and restless? Provide adequate restraint Monitor the client's vital signs Protect against exposure to direct sunlight Watch the client For extrapyramidal side effects

Monitor the clients vital signs

The nurse identifies which category as reflective of a client's body mass index (BMI) of 25.5 kg

Overweight

When a client injures the amphiarthrodial joint, which joint did the client injure?

Pelvic joint

Which disease is caused by coronaviruses?

Severe acute respiratory syndrome

When a client expresses anxiety about being given anesthesia, which team member should sit with the person and provide comfort during the induction?

circulating nurse

At which stage of Kohlberg's theory does an individual want to fulfill the expectations of one's immediate group? A. Good boy-nice orientation B. Society-maintaining orientation C. Instrumental relativist orientation D. Universal ethical principle orientation

A. Good boy-nice orientation

The nurse is providing care to a family of a preschool age child who is diagnosed with sickle cell disease. Which sibling statement indicates to the nurse that parental education regarding discipline may be indicated?

"When i lie to my parents, i was punished for a week and my brother never gets punished"

Which statements regarding acne are correct? SATA 1. Acne is a hormonal disease 2. Acne may be caused by stress 3. Family history could be a reason for acne 4. Propionibacterium acne's causes acne. 5. Acne is commonly found on the face, chest, upper back, and neck

2. Acne may be caused by stress. 3.family history could be a reason for acne 4. Propionibacterium acne's causes acne. 5. Acne is commonly found on the face,chest,upper back, and neck.

After a 4-year-old child undergoes craniotomy the nurse performs a neurologic assessment that includes level of consciousness, pupillary activity, and reflex activity. What else should the nurse include in this assessment? 1 Blood pressure 2 Motor function 3 Rectal temperature 4 Head circumference

2. Motor function

The nurse is assisting a primary health care provider perform an examination of the reproductive tract of a female client. Which nursing actions are beneficial for the client? SATA A. Providing nonjudgemental support to the client B. Instructing the client to hold both arms away from the body C. Asking the client to remove the drape while undergoing the test D. Asking the client to empty the bladder before the examination E. Assisting the client to a recumbent position on the examination table

A,D,E

Which radiographing test would be used to view the entire skeleton? A. Bone scale B. Gallium and thallium scan C. Computed tomography (ct) D. Magnetic resonance imaging (mri)

A. Bone scan (radioactive material injected to view entire skeleton)

A 26 year old woman whose sister recently had a lumpectomy for breast cancer calls the local women's health center and asks for an appointment for a mammogram. Which guidance would the nurse provide the client?

An appointment should be given for history, assessment, and indicated imaging

Which condition is likely in an adolescent displaying low self-esteem who complains of inflamed, red, and painful lesions on his forehead? A. Varioceles B. Acne Vulgaris C. Open comedones D. Closed comedones

B. Acne vulgaris

Which causative organism colonization signifies purulent exudates of greenish-blue pus with a fruity odor? A. Proteus B. Bacteriodes C. Pseudomonas D. Staphylococcus

C. Pseudomonas

Which feeling would the nurse anticipate a manic client with bipolar 1 disorder is likely experiencing? A. Guilt B. Grandeur C. Worthlessness D. Self-deprecation

b. grandeur

A young pregnant adolescent is diagnosed with an ectopic pregnancy. Which risk factors contribute to ectopic pregnancy? SATA one some-or all A. Habit of smoking B. Irregular menses C. Use of contraceptive pills D. Damage to the fallopian tubes E. History of pelvic inflammatory disease

A. Habit of smoking D. Damage to the fallopian tubes E. History of pelvic inflammatory disease

Which color according to the disaster triage tag system would be assigned to a client who has an immediate threat to life? A. Red B. Black C. Green D. Yellow

A. Red

Which term is used to indicate an absence of menstruation? A. Gonorrhea B. Amenorrhea C. Dysmenorrhea D. Ectopic pregnancy

B. Amenorrhea

Which clinical finding would the nurse anticipate when admitting a client with an extra cellular fluid volume excess? A. Rapid, threads pulse B. Distended jugular veins C. Elevated hematocrit level D. Increased serum sodium level

B. Distended jugular veins

Which skin infection would cause facial paralysis? A. Candidiasis B. Herpes zoster C. Herpes simplex D. Dermaophytosis

B. Herpes zoster (trigeminal nerve infected by varicella-zoster virus)

Which birth control agent requires administration once every three months? A. Progestin-only pills B. Intramuscular progestin C. Combination biphasic forms D. Combination monophasic forms

B. Intramuscular progestin

Which action is promoted by vasopressin? A. Sodium reabsorption B. Reabsorption of water C. Tubular secretion of sodium D. Red blood cell production

B. Reabsorption of water

Which mechanism of action would a nurse recall when using wet-to-Damp saline-moistened gauze from wound debridement? A. Promoting the dilution of viscous exudate B. Removing the necrotic tissue mechanically C. Causing a breakdown of the denatured protein of the Eschar. D. Promoting the spontaneous separation of necrotic tissue

B. Removing necrotic tissue mechanically.

Which parameter describes the maximum volume of air a client's lungs may contain? A. Vital capacity B. Total lung capacity C. Inspiratory capacity D. Functional residual capacity

B. Total lung capacity

Which adverse effect will the nurse assess for when caring for a client taking morphine sulfate for severe metastatic bone pain? A. Diarrhea B. Addiction C. Respiratory depression D. Diuresis

C. Respiratory depression

Which diagnostic exam would be used to detect muscle weakness? A. Arthroscopy B. Radiography C. Mylergraphy D. Electromyography

D. Electromyography

Which condition would be indicated by the presence of ketones in the urine of a client? A. Cystitis B. Heart failure C. Urinary calculi. D. Fat metabolism

D. Fat metabolism

Which medication is administered to women after delivery to prevent post partum uterine atony and hemorrhage? A. Dinoprostone B. Mifepriston C. Indomethacin D. Methylergonovine

D. Methylergonovine

Which staff members would be the first to manage the care of victims from an accident at a nuclear power plants? A. Emergency medicine health care provider B. Emergency medical technicians C. Paramedics D. Prehospital care providers

D. Prehospital care providers

Which parameter would the nurse consider while assessing the psychologic status of a client with acquired immune deficiency syndrome (AIDS)? A. Sleep pattern B. Severity of pain C. Cognitive changes D. Presence of anxiety

D. Presence of anxiety

For which additional defect would the nurse assess an infant with exstrophy of the bladder? A. Imperforate anus B. Absense of one kidney C. Congenital heart disease D. Pubic bone malformation

D. Pubic bone malformation

Which organism would the nurse identify as causing syphilis? A. Treponema pallidum B. Campylobacter jejuni C. Trichomonas vaginalis D. Chlamydia Trachomatis

A. Treponema pallidum

Which action by the nurse would be priority for a male client with a history of schizophrenia who comes to the emergency department accompanied by his spouse? A. Observing and evaluating his behavior B. Writing a plan of care for the mental health team C. Obtaining a copy of the clients past medical records D. Meeting separately with his wife and exploring why he came to the hospital

A. Observing and evaluating his behavior

Which client condition would be prioritized by the nurse under the emergent classification? SATA A. Shock B. Contusion C. Open fracture D. Airway obstruction E. High cervical spinal cord injury

A. Shock C. Airway obstruction (immediate threat to life)

Which stage of the human immunodeficiency virus (HIV) disease is present in the client with a laboratory report revealing a CD4+ T-cell count of 520 cells/ mm 3, according to the centers for disease control and prevention (CDC)? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

A. Stage 1

Which parental description would the nurse recognize as characteristic of sleep terrors in a pre school age child? A. Sweating profusely B. Calling out after a dream C. Awakening during the second half of the night D. Being aware that others are in the room after awakening

A. Sweating profusely (sleep terror differentiates from a bad dream)

Which emotions should the nurse be especially alert to in order to further assess a clients suicidal potential? A. Anger and resentment B. Loneliness and anxiety C. Frustration and fear of death D. Helplessness and hopelessness

D. Helplessness and hopelessness

Which is the priority intervention for the infant with developmental dysplasia of the hip?

Abduction of the hip

Which action would promote psychological adjustment and early function after a teenager with a diagnosis of osteosarcoma has the affected leg amputated? A. Allow the client to change the first dressing B. Help the client adjust to the temporary prosthesis C. Assign the client to a room with another adolescent D. Have the client meet with a member of a cancer survivor organization

B. Help the client adjust to the temporary prosthesis

Which hormone would the nurse identify as inhibiting insulin and glucagon secretion? A. Amylin B. Somatostatin C. Triiodothronine T3 D. Pancreatic polypeptide

B. Somatostatin

Which action would the nurse take when a confused and anxious client voids on the floor in the sitting room of the mental health unit? A. Make the client mop the floor B. Restrict the client's fluids for the rest of the day C. Toilet the client more frequently with supervision D. Withhold the client's privileges each time the client voids on the floor

C. Toilet the client more frequently with supervision

A client is hospitalized with a left pneumothorax, and when assessing the left chest area, the nurse would expect to identify which finding? A. Dull sound on percussion B. Vocal fremitus on palpation C. Rales with rhonchi on auscultation D. Absence of breath sounds on auscultation

D. Absence of breath sounds on auscultation

Which surgery will a client undergo if the pituitary gland must be removed? A. Mastectomy B. Prostatectomy C. Thyroidectomy D. Hypophysectomy

D. Hypophysectomy

Which client statement indicates understanding of content taught about removing his or her three way in dwelling catheter and continuous bladder irrigation (CBI)? A. I probably will have diluted urine B. I probably will be unable to urinate C. I probably will produce dark red urine D. I probably will experience some burning on urination

D. I probably will experience some burning on urination.

Which goal is the priority for a client with asthma who has a prescription for an inhaled bronchodilator?

Demonstrates use of a metered-dose inhaler