NUR 211 Final

The healthiest form of communication is the ________ style.

Assertive Assertive communicators are honest and direct while valuing and respecting other individuals' views and seeking a win-win solution without the use of manipulation or game-playing.

A nurse teaches a client to perform total skin self-examinations on a monthly basis. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Look for asymmetry of shape and irregular borders. b. Assess for color variation within each lesion. c. Examine the distribution of lesions over a section of the body. d. Monitor for edema or swelling of tissues. e. Focus your assessment on skin areas that itch.

A,B Clients should be taught to examine each lesion following the ABCDE features associated with skin cancer: asymmetry of shape, border irregularity, color variation within one lesion, diameter greater than 6 mm, and evolving or changing in any feature.

What strategies should the nurse implement to increase nutritional intake for the child receiving chemotherapy? (Select all that apply.) a. Allow the child any food tolerated. b. Fortify foods with nutritious supplements. c. Allow the child to be involved in food selection. d. Encourage the parents to place pressure on the importance of eating. e. Encourage the child to eat favorite foods during infusion of chemotherapy medications.

A,B,C To increase nutritional intake for the child receiving chemotherapy, the nurse should allow the child any food tolerated, fortify foods with nutritious supplements, and allow the child to be involved in food selection. The parents should be encouraged to reduce pressure placed on eating. Some children develop aversions to certain foods if they are eaten during chemotherapy. It is best to refrain from offering the child's favorite foods while the child is receiving chemotherapy.

A woman has been using acupuncture to treat nausea and vomiting caused by the side effects of chemotherapy for breast cancer. Which conditions would cause the nurse to recommend against further use of acupuncture? (Select all that apply.) a. Lymphedema b. Bleeding tendencies c. Low white blood cell count d. Elevated serum calcium e. High platelet count

A,B,C Acupuncture could be unsafe for the client if there is poor drainage of the extremity with lymphedema or if there was a bleeding tendency and low white blood cell count. Coagulation would be compromised with a bleeding disorder, and the risk of infection would be high with the use of needles. An elevated serum calcium and high platelet count would not have any contraindications for acupuncture.

The nurse working with oncology clients understand that interacting factors affect cancer development. Which factors does this include? (Select all that apply.) a. Exposure to carcinogens b. Genetic predisposition c. Immune function d. Normal doubling time e. State of euploidy

A,B,C The three interacting factors needed for cancer development are exposure to carcinogens, genetic predisposition, and immune function.

A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a TBI. What actions should the nurse include in the clients care? (Select all that apply) A. Assess tube placement per agency policy B. Keep the head of the bed elevated at least 30 degrees C. Listen to lung sounds at least every 4 hours D. Run continuous feedings on a feeding pump E. Use blue dye to determine proper placement

A,B,C,D All of these options are important for client safety when continuous enteral feedings are in use. Blue dye is not used because it can cause lung injury if aspirated.

A student nurse is learning about human immunodeficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with stage 1 HIV disease are not infectious to others.

A,B,C,D In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease.

The nurse is teaching a womans group about gynecologic cancers. Which does the nurse teach are risk factors? (Select all that apply.) a. Nulliparity b. Multiple sex partners c. Obesity d. Smoking e. Delayed first intercourse

A,B,C,D Nulliparity, smoking, and obesity are risk factors for uterine cancer. Risk factors for cervical cancer include multiple sex partners, obesity, and smoking. Early age at first intercourse (before 18) is a risk factor for cervical cancer.

A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the UAP? (Select all that apply) A. Applying a cool washcloth to the head B. Assisting the client with a position of comfort C. Keeping voices soft and soothing D. Maintaining low lighting in the room E. Providing antipyretics for fever

A,B,C,D The client with meningitis often has a high fever, pain, and some degree of confusion. Cool washcloths to the forehead are comforting and help with pain. Allowing the client to assume a position of comfort also helps to manage pain. Keeping voices low and lights dimmed also helps convey caring in a nonthreatening manner. The nurse provides antipyretics for fever.

The nurse is conducting preoperative teaching to parents and their child about an external fixation device. What should the nurse include in the teaching session? (Select all that apply.) a. Pin care b. Crutch walking c. Modifications in activity d. Observing pin sites for infection e. Full weight bearing will be allowed after 24 hours

A,B,C,D The device is attached surgically by securing a series of external full or half rings to the bone with wires. Children and parents should be instructed in pin care, including observation for infection and loosening of pins. Partial weight bearing is allowed, and the child needs to learn to walk with crutches. Alterations in activity include modifications at school and in physical education. Full weight bearing is not allowed until the distraction is completed and bone consolidation has occurred.

What factors should be considered as a possible trigger for a palliative care consult? (Select all that apply.) A. Multiple hospitalizations over a short period of time B. Cognitive impairment C. Multifaceted care needs Correct D. Metastatic cancer E. An established advanced care plan

A,B,C,D The triggers for a palliative care consult includes multiple hospitalization over a short period of time, presence of cognitive impairment, multiple care needs, metastatic cancer, and the lack of an advance care plan.

A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immunodeficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the prevention of perinatal HIV transmission? (Select all that apply.) a. Clean drinking water b. Cultural beliefs about illness c. Lack of antiviral medication d. Social stigma e. Unknown transmission routes

A,B,C,D Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids during birth, and through breast-feeding.

The nurse is performing a medical history and physical assessment for a client. Which assessment findings lead the nurse to conclude that the client is at risk for development of osteoporosis? (Select all that apply.) a. Client is a white woman with a body mass index (BMI) of 19.4. b. Client fractured her wrist badly in a fall last year. c. Client drinks at least four cans of diet cola every day. d. Client does tai chi exercises for 45 minutes every morning. e. Client has smoked two packs of cigarettes a day for 40 years. f. Client has taken estrogen (Premarin) 0.625 mg daily since menopause.

A,B,C,E Risk factors for osteoporosis include white race, female gender, small body frame, large intake of caffeinated carbonated drinks, and smoking cigarettes. Recent fracture after a fall indicates that the clients bones may be soft and/or thin. Hormone replacement therapy, late onset of menopause, and regular exercise helps reduce the risk of osteoporosis.

The nurse is taking the history of a 24-year-old client diagnosed with cervical cancer. What possible risk factors would the nurse assess? (Select all that apply.) a. Smoking b. Multiple sexual partners c. Poor diet d. Nulliparity e. Younger than 18 at first intercourse

A,B,C,E Smoking, multiple sexual partners, poor diet, and age less than 18 for first intercourse are all risk factors for cervical cancer. Nulliparity is a risk factor for endometrial cancer.

A nurse is providing community education on the seven warning signs of cancer. Which signs are included? (Select all that apply.) a. A sore that does not heal b. Changes in menstrual patterns c. Indigestion or trouble swallowing d. Near-daily abdominal pain e. Obvious change in a mole

A,B,C,E The seven warning signs of cancer can be remembered with the acronym CAUTION: changes in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere; indigestion or difficulty swallowing, obvious change in a wart or mole, and nagging cough or hoarseness. Abdominal pain is not a warning sign.

Which factors are considered to be indicative of a moderately increased risk of a clients developing breast cancer? (Select all that apply.) a. High postmenopausal bone density b. Ionizing radiation c. Family history of one first-degree relative d. Genetic factors e. First child born after age 30 f. Biopsy-confirmed atypical hyperplasia

A,B,C,F Factors considered to be indicative of a moderately increased risk of a clients developing breast cancer include high postmenopausal bone density, ionizing radiation, family history of one first-degree relative, and biopsy-confirmed atypical hyperplasia. Female gender and genetic factors are indicative of high increased risk. The first child born after age 30 is indicative of low increased risk of developing breast cancer.

The nurse is preparing to administer a medication when the client states, Im allergic to that. How will the nurse proceed? (Select all that apply.) a. Check the chart for allergies. b. Notify the health care provider. c. Ask what reaction the client gets. d. Continue to give the medication. e. Perform a skin test first. f. Notify the pharmacist. g. Document the allergy on the chart.

A,B,C,F,G If a client states that he or she has an allergy to a medication, the nurse should not administer the medication. The nurse should find out what reaction the client experiences from the medication and then should notify the health care provider and the pharmacist of the client's response. The nurse should document the allergy on the chart, including the reaction to the medication and notification of the provider and the pharmacist, and should indicate what other drug was ordered in its place. Before administering any drug, the nurse should have already checked the chart for allergies.

Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 or less than 14% b. Infection with Pneumocystis jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immunodeficiency virus (HIV) d. Presence of HIV wasting syndrome e. Taking antiretroviral medications

A,B,D A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic infection such as Pneumocystis jiroveci and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics.

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

A,B,D Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner and wheelchair cushion are comfort measures but do not help increase independence.

A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery for a right hip fracture. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Elevate heels off the bed with a pillow. b. Ambulate the client on the first postoperative day. c. Push the clients patient-controlled analgesia button. d. Reposition the client every 2 hours. e. Use pillows to encourage subluxation of the hip.

A,B,D Postoperative care for a client who has ORIF of the hip includes elevating the clients heels off the bed and repositioning every 2 hours to prevent pressure and skin breakdown. ***It also includes ambulating the client on the first postoperative day, and using pillows or an abduction pillow to prevent subluxation of the hip.*** The nurse should teach the client to use the patient-controlled analgesia pump, but the nurse should never push the button for the client.

A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.) a. Client who exhibits extreme emotional lability b. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Client with mild forgetfulness and a slight limp d. Client who has a past hospitalization for a suicide attempt e. Client who is unable to walk or eat 3 weeks post-stroke

A,B,D,E

A client who previously had a bacillus Calmette-Gurin (BCG) vaccine has a positive tuberculosis (TB) test. What symptoms assist in determining that the client has active disease? (Select all that apply.) a. Nausea b. Weight loss c. Insomnia d. Ankle edema e. Night sweats f. Increased urination

A,B,E TB symptoms include nausea and weight loss, as well as night sweats. Inability to sleep and ankle edema are not typical symptoms. Increased urination also is not a typical symptom.

A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.) a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower.

A,B,D,E Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step into the bathtub leading with the operative side. Stepping into a bathtub may also require the client to bend the hip more than the allowed 90 degrees.

The client is undergoing treatment for ovarian cancer. Which common nutritional problems are related to gynecologic cancers and the treatment thereof? (Select all that apply.) a. Stomatitis b. Constipation c. Increased appetite d. Diarrhea e. Nausea and vomiting

A,B,D,E Altered taste, stomatitis, constipation, anorexia, diarrhea, and nausea and vomiting are all possible nutritional complications related to gynecologic cancers and their treatment. The nurse must assess accordingly and adapt the client's plan of care. To ensure recovery, these women should consume a diet high in iron and protein, drink plenty of fluids, and eat foods high in vitamins C, B, and K.

What situation is considered a barrier to palliative care? (Select all that apply.) A. Poor of understanding of the role and nature of the care B. Insufficient numbers of appropriately trained professionals C. The need to delivery care only in home settings D. How palliative care is paid for E. Ineffective communication with potential palliative care patients

A,B,D,E Barriers to the delivery of palliative care to those illegible include poor communication about the role and nature of the care and the information potential patients need to arrive at the decisions appropriate for themselves. The issue of payment for the care and the training of palliative care professionals are also barriers to the implementation of such care. The care can be delivered in a variety of setting and is not limited to only home care.

A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.) a. Alcohol b. Caffeine c. Fat d. Carbonated beverages e. Vitamin D

A,B,D,E Dietary components that affect the development of osteoporosis include alcohol, caffeine, high phosphorus intake, carbonated beverages, and vitamin D. Tobacco is also a contributing lifestyle factor. Fat intake does not contribute to osteoporosis.

The focus of quality health care should be on which of the following items? (Select all that apply.) a. Excellent services b. Comprehensive communication c. Private hospital rooms d. Health team collaboration e. Culturally competent care

A,B,D,E Excellent services, communication, collaboration, and culturally competent care brings quality to the health care delivered to the patient. Private hospital rooms may be a preference by some patients, but they do not add to the quality of care.

A nurse is teaching a female client with rheumatoid arthritis (RA) taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.) a. Avoid acetaminophen in over-the-counter medications. b. It may take several weeks to become effective on pain. c. Pregnancy and breast-feeding are not affected by MTX. d. Stay away from large crowds and people who are ill. e. You may find that folic acid, a B vitamin, reduces side effects.

A,B,D,E MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take 4 to 6 weeks for effectiveness. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while on this drug.

The nurse is assisting with application of a synthetic cast on a child with a fractured humerus. What are the advantages of a synthetic cast over a plaster of Paris cast? (Select all that apply.) a. Less bulky b. Drying time is faster c. Molds readily to body part d. Permits regular clothing to be worn e. Can be cleaned with small amount of soap and water

A,B,D,E The advantages of synthetic casts over plaster of Paris casts are that they are less bulky, dry faster, permit regular clothes to be worn, and can be cleaned. Plaster of Paris casts mold readily to a body part, but synthetic casts do not mold easily to body parts.

A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Tape a halo wrench to the clients vest. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the clients oral fluid intake. e. Assess the chest and back for skin breakdown.

A,B,E A special halo wrench should be taped to the clients vest in case of a cardiopulmonary emergency. The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse should also increase fluids and fiber to decrease bowel straining and assess the client's chest and back for skin breakdown from the halo vest.

What are the major attributes of healthcare quality? (Select all that apply.) a. Conforms to standards b. Sound decision making c. High acuity patients d. Low health care costs e. Identifies adverse events

A,B,E Major attributes of healthcare quality include confirmation to standards set by regulatory agencies, sound decision making regarding care, and identifying potential adverse events. High acuity of patients does not contribute to quality health care, because the care demand is increased, and low health care costs mean fewer services may be available.

The nurse is working with clients who have connective tissue diseases. Which disorders are correctly paired with their manifestations? (Select all that apply.) a. Dry, scaly skin rash Systemic lupus erythematosus (SLE) b. Esophageal dysmotility Systemic sclerosis c. Excess uric acid excretion Gout d. Foot Drop and paresthesias Osteoarthritis e. Vasculitis causing organ damage Rheumatoid arthritis

A,B,E A dry, scaly skin rash is the most frequent dermatologic manifestation of SLE. Systemic sclerosis can lead to esophageal motility problems. Vasculitis leads to organ damage in rheumatoid arthritis. Gout is caused by hyperuricemia; the production of uric acid exceeds the excretion capability of the kidneys. Footdrop and paresthesias occur in rheumatoid arthritis.

The nurse is taking a history of a 68-year-old woman. What assessment findings would indicate a high risk for the development of breast cancer? (Select all that apply.) a. Age greater than 65 years b. Increased breast density c. Osteoporosis d. Multiparity e. Genetic factors

A,B,E The high risk factors for breast cancer are age greater than 65 with the risk increasing until age 80; an increase in breast density because of more glandular and connective tissue; and inherited mutations of BRCĀ and/or BRCÁ genes. Osteoporosis and multiparity are not risk factors for breast cancer. A high postmenopausal bone density and nulliparity are moderate and low increased risk factors, respectively.

A nurse assesses a client with a brain tumor. Which newly identified assessment findings alert the nurse to urgently communicate with the health care provider? (Select all that apply) A. GCS of 8 B. Decerebrate posturing C. Reactive pupils D. Uninhibited speech E. Diminished cognition

A,B,E The nurse should urgently communicate changes in a clients neurologic status, including a decrease in the GCS, abnormal flexion or extension, changes in cognition or speech, and pinpointed, dilated, and nonreactive pupils

In teaching a 16-year-old adolescent who was recently diagnosed with systemic lupus erythematosus (SLE), what statements should the nurse include? (Select all that apply.) a. You should use a moisturizer with a sun protection factor (SPF) of 30. b. You should avoid pregnancy because this can cause a flare-up. c. You should not receive any immunizations in the future. d. You may need to be on a low-protein, high-carbohydrate diet. e. You should expect to lose weight while taking steroids. f. You may need to modify your daily recreational activities.

A,B,F Teaching for an adolescent with SLE should foster adaptation and self-advocacy and include using a moisturizer with an SPF of 30, avoiding pregnancy because it can produce a flare-up, and modifying recreational activities but continuing with daily exercise as an essential part of the treatment plan. The adolescent should continue to receive immunizations as scheduled, should expect to gain weight while on steroid therapy, and would not have a specialized diet.

After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the clients electronic medical record? (Select all that apply.) a. Peau d'orange b. Dense breast tissue c. Nipple retraction d. Mobile mass at two oclock e. Nontender axillary nodes

A,C,D In the documentation of a breast mass, skin changes such as dimpling (peau d'orange), nipple retraction, and whether the mass is fixed or movable are charted. The location of the mass should be stated by the face of a clock. Dense breast tissue and nontender axillary nodes are not abnormal assessment findings that may indicate breast cancer.

Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.) a. Uninsured or underinsured status b. Easy access to health screenings c. High cost of medications d. Inadequate nutrition

A,C,D Individuals of low socioeconomic status tend to be part of the underinsured or uninsured population. Lack of insurance decreases accessibility to health care in general and health screening services specifically. High costs of medication and nutritious food also make this population at higher risk for infection.

A nurse cares for older clients who have TBI. What should the nurse understand about this population (Select all that apply) A. Admission can overwhelm the coping mechanisms for older adults B. Alcohol is typically involved in most traumatic brain injuries for this age group C. These clients are more susceptible to systemic and wound infections D. Other medical conditions can complicate treatment for these clients E. Very few traumatic brain injuries occur in this age group.

A,C,D Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decrease protective mechanisms, they are more susceptible to both local and systemic infections. other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to TBI in this population; such injury is most often from falls or MVCs. The 65-76-year-old age group has the second highest rate of brain injuries compared to other age groups

The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.) a. Type I Examples include hay fever and anaphylaxis b. Type II Mediated by action of immunoglobulin M (IgM) c. Type III Immune complex deposits in blood vessel walls d. Type IV Examples are poison ivy and transplant rejection e. Type V Examples include a positive tuberculosis test and sarcoidosis

A,C,D Type I reactions are mediated by immunoglobulin E (IgE) and include hay fever, anaphylaxis, and allergic asthma. Type III reactions consist of immune complexes that form and deposit in the walls of blood vessels. Type IV reactions include responses to poison ivy exposure, positive tuberculosis tests, and graft rejection. Type II reactions are mediated by immunoglobulin G, not IgM. Type V reactions include Graves disease and B-cell gammopathies.

The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) a. Alcohol intake b. Diabetes c. High-fat diet d. Obesity e. Smoking

A,C,D,E Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.

Chemotherapy with multiple drug agents is used in the treatment of recurrent and advanced breast cancer with positive results. Which side effects would the nurse anticipate for the client once treatment has begun? (Select all that apply.) a. Hair loss b. Severe constipation c. Anemia d. Leukopenia e. Thrombocytopenia

A,C,D,E Because chemotherapeutic agents rapidly kill reproducing cells, treatment also affects normal cells that frequently reproduce. The side effects that the nurse would anticipate and on which the nurse will provide education include partial or full hair loss, gastrointestinal effects (e.g., nausea, vomiting, anorexia, mucositis), leukopenia, neutropenia, thrombocytopenia, and anemia.

Which medications can be taken by postmenopausal women to treat and/or prevent osteoporosis? (Select all that apply.) a. Calcium b. NSAIDs c. Fosamax d. Actonel e. Calcitonin

A,C,D,E Calcium, Evista, Fosamax, Actonel, and Calcitonin can be used by postmenopausal women to treat or prevent osteoporosis. Parathyroid hormone and estrogen may also be of value. NSAIDs may provide pain relief; however, these medications neither prevent nor treat osteoporosis.

The nursing process involves which of the following steps in the clinical decision-making process? (Select all that apply.) a. Identifying patient needs b. Diagnosing the disease process c. Determining priorities of care d. Setting goals e. Performing nursing interventions f. Evaluating effectiveness of medical treatments

A,C,D,E Diagnosing disease is not a nursing action. Evaluating the effectiveness of medical treatments is not a nursing action either. Nurses are to use the nursing process to evaluate the effectiveness of nursing interventions, not medical treatments. Identifying patient needs, determining priorities of care, setting realistic goals, and implementing nursing interventions are all steps in the clinical decision-making process.

A nurse working with clients with sickle cell disease teaches about self-management to prevent exacerbations and sickle cell crisis. What factors should clients be taught to avoid? (Select all that apply) A. Dehydration B. Exercise C. Extreme stress D. High altitudes E. Pregnancy

A,C,D,E Several factors cause RBCs to sickle in SCD, including dehydration, extreme stress, high altitudes, and pregnancy. Strenuous exercise can also cause sickling, but not unless it is very vigorous.

A student studying leukemias learns the risk factors for developing this disorder. Which risk factors does this include? (Select all that apply.) a. Chemical exposure b. Genetically modified foods c. Ionizing radiation exposure d. Vaccinations e. Viral infections

A,C,E Chemical and ionizing radiation exposure and viral infections are known risk factors for developing leukemia. Eating genetically modified food and receiving vaccinations are not known risk factors.

The nurse recognizes a potential health threat to an alcoholic patient who is using the drug disulfiram (Antabuse) when the nurse reads in the health record that the patient is also which of the following? (Select all that apply.) a. On blood thinners b. Taking diphenhydramine (Benadryl) tablets c. Ingesting alcohol d. On penicillin e. Using mouthwash

A,C,E Disulfiram increases the effect of anticoagulants such as warfarin (Coumadin). Ingesting alcohol may cause headache, nausea, vomiting, tachycardia, chest pain, or dizziness. Mouthwash can have alcohol as one of the main ingredients and should be checked prior to using.

An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply an abduction pillow to the client's legs. b. Assess the skin under the abduction pillow straps. c. Place pillows under the heels to keep them off the bed. d. Monitor cognition to determine when the client can get up. e. Take and record vital signs per unit/facility policy.

A,C,E The UAP can apply an abduction pillow, elevate the heels on a pillow, and take/record vital signs. Assessing skin is the nurses responsibility, although if the UAP notices abnormalities, he or she should report them. Determining when the client is able to get out of bed is also a nursing responsibility.

A client started on therapy for tuberculosis infection is reporting nausea. What does the nurse teach this client? (Select all that apply.) a. Eat a diet rich in protein, iron, and vitamins. b. Do not drink fluids with medications. c. Take medications at bedtime. d. Space medications 12 hours apart. e. Take medications with milk. f. Take an antiemetic daily.

A,C,F Taking the daily dose of medications at bedtime may help to decrease nausea. A well-balanced diet with foods rich in iron, protein, and vitamins C and B also helps to decrease nausea. Antiemetics are often prescribed. Drinking fluids with medications should not influence the nausea; neither should taking medications with milk. Spacing medications 12 hours apart is not recommended therapy.

The nurse is precepting a new graduate nurse at an ambulatory pediatric hematology and oncology clinic. What cardinal signs of cancer in children should the nurse make the new nurse aware of? (Select all that apply.) a. Sudden tendency to bruise easily b. Transitory, generalized pain c. Frequent headaches d. Excessive, rapid weight gain e. Gradual, steady fever f. Unexplained loss of energy

A,C,F The cardinal signs of cancer in children include a sudden tendency to bruise easily; frequent headaches, often with vomiting; and an unexplained loss of energy. Other cardinal signs include persistent, localized pain; excessive, rapid weight loss; and a prolonged, unexplained fever.

After hip replacement surgery, a client receives two doses of enoxaparin (Lovenox) during the day shift. What orders does the nurse anticipate for the client? (Select all that apply.) a. Laboratory draw for platelet count b. Laboratory draw for prothrombin time (PTT) c. Laboratory draw for international normalized ratio (INR) d. Order for protamine sulfate e. Order for vitamin K

A,D Lovenox is a low molecular-weight heparin. Side effects can include thrombocytopenia. The antidote for all heparin products is protamine sulfate, although it will not be as effective for Lovenox as it is for unfractionated heparin.

A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.) a. Discharging the client on a statin medication b. Providing the client with comprehensive therapies c. Meeting goals for nutrition within 1 week d. Providing and charting stroke education e. Preventing venous thromboembolism

A,D,E Core Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thromboembolism. The client must be assessed for therapies but may go elsewhere for them. Nutrition goals are not part of the Core Measures.

The nurse is planning care for a child with chickenpox (varicella). Which prescribed supportive measures should the nurse plan to implement? (Select all that apply.) a. Administration of acyclovir (Zovirax) b. Administration of azithromycin (Zithromax) c. Administration of Vitamin A supplementation d. Administration of acetaminophen (Tylenol) for fever e. Administration of diphenhydramine (Benadryl) for itching

A,D,E Chickenpox is a virus, and acyclovir is ordered to lessen the symptoms. Benadryl and Tylenol are prescribed as supportive treatments. Vitamin A supplementation is used for treating rubeola. Zithromax is an antibiotic prescribed for bacterial infections such as pertussis.

The nurse is caring for a 14-year-old child with systemic lupus erythematous (SLE). What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Arthralgia b. Weight gain c. Polycythemia d. Abdominal pain e. Glomerulonephritis

A,D,E Clinical manifestations of SLE include arthralgia, abdominal pain, and glomerulonephritis. Weight loss, not gain, and anemia, not polycythemia, are manifestations of SLE.

Researchers have found a number of common risk factors that increase a woman's chance of developing a breast malignancy. It is essential for the nurse who provides care to women of any age to be aware of which risk factors? (Select all that apply.) a. Family history b. Late menarche c. Early menopause d. Race e. Nulliparity or first pregnancy after age 40 years

A,D,E Family history, race, and nulliparity or the first pregnancy after age 40 years are known risk factors for the development of breast cancer. Other risk factors include age, personal history of cancer, high socioeconomic status, sedentary lifestyle, hormone replacement therapy, recent use of oral contraceptives, never having breastfeed a child, and drinking more than one alcoholic beverage per day. Early menarche and late menopause are not risk factors for breast malignancy.

The nurse is formulating a teaching plan according to evidence-based breast cancer screening guidelines for a 50-year-old woman with low risk factors. Which diagnostic methods should be included in the plan? (Select all that apply.) a. Annual mammogram b. Magnetic resonance imaging (MRI) c. Breast ultrasound d. Breast self-awareness e. Clinical breast examination

A,D,E Guidelines recommend a screening annual mammogram for women ages 40 years and older, breast self-awareness, and a clinical breast examination. An MRI is recommended if there are known high risk factors. A breast ultrasound is used if there are problems discovered with the initial screening or dense breast tissue.

A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply) A. A client with a moderate trauma may need hospitalization B. A GCS of 10 indicates mild brain injury C. Only open head injuries can cause a severe TBI D. A client with a GCS of 3 had severe TBI E. The terms mild BTI and concussion have similar meanings

A,D,E Mild TBI is a term used synonymously with the term concussion. A moderate TBI has a GCS of 9-12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS of 3-8.

The nurse is caring for a child immobilized because of Russel traction. What interventions should the nurse implement to prevent renal calculi? (Select all that apply.) a. Monitor output. b. Encourage the patient to drink apple juice. c. Encourage milk intake. d. Ensure adequate fluids. e. Encourage the patient to drink cranberry juice.

A,D,E To prevent renal calculi in a child who is immobilized, a nurse should monitor output; ensure adequate fluids; and encourage cranberry juice, which acidifies urine. Apple juice and milk alkalize the urine, so they should not be encouraged.

A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best? A. 0.45% normal saline B. 0.9% normal saline C. Dextrose 50% (D50) D. Lactated Ringers solution

A. 0.45% normal saline Because clients in sickle cell crisis are often dehydrated, the fluid of choice is a hypotonic solution such as 0.45% normal saline. ).9% normal saline and lactated ringers solution are isotonic. D50 is hypertonic and not used for hydration.

A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority? A. Administer oxygen B. Apply an oximetry probe C. Give pain medication D. Start an IV line

A. Administer oxygen All actions are appropriate, but remembering the ABCs, oxygen would come first. The main problem in a sickle cell crisis is tissue and organ hypoxia, so providing oxygen helps halt the process.

After performing a physical assessment on a 75-year-old client, the nurse notes that the client has a hypoactive response to a test of deep tendon reflexes. Which intervention does the nurse include in this client's plan of care? A. Assist the client with ambulation B. Elevate the clients lower extremities C. Apply elastic support hose D. Massage the clients legs

A. Assist the client with ambulation The older adult experiences certain neurological changes associated with aging. hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse or assistive personal should assist this client with ambulation to prevent injury. The other interventions do not address the clients problem.

A nurse teaches a client who is scheduled for a positron emission tomography scan of their brain. Which statement should the nurse include in this clients teaching? A. Avoid caffeine-containing substances for 12 hours before the test B. Drink at least 3 liters of fluid during the 24 hours after the test C. Do not take your cardiac medication the morning of the test D. Remove your dentures and any metal before the test begins

A. Avoid caffeine-containing substances for 12 hours before the test Caffeine-containing liquids and foods are central nervous system stimulants ad may alter the test results. No contrast is used; therefore, the client does not need to increase fluid intake. Th client should take cardiac medications as prescribed. Metal does not have to be removed; this is done for MRI.

The nurse is assessing the deep tendon reflexes of a client with long-standing diabetes mellitus. Which clinical manifestations does the nurse expect to see? A. Bilateral hypoactive reflexes B. Bilateral hyperactive reflexes C. Asymmetric reflex response D. Bilateral ankle clonus

A. Bilateral hypoactive reflexes Long-standing diabetes mellitus causes peripheral neuropathy. Hypoactive responses or no response to stimulation of deep tendon reflexes is one manifestation of diabetes-induced peripheral neuropathy. Other responses are not related to complications of diabetes.

A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60, pulse pressure increase from 26-40, and respiratory irregularities. What action by the nurse takes priority? A. Call the provider and Rapid Response Team B. Incase the rate of the IV fluid administration C. Notify respiratory therapy for a breathing treatment D. Prepare the give IV pain medication

A. Call the provider or Rapid Response Team These manifestations indicate Cushing's Triad, a potentially life-threatening increase in ICP, which is an emergency. immediate medical attention is necessary, so the nurse notifies the provider, or Rapid Response Team. Increasing fluids would increase ICP. The client does not need a breathing treatment or pain medication.

The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would be A. Change in level of consciousness B. Inability to focus visually C. Loss of primitive reflexes D. Unequal pupil size

A. Change in level of consciousness A change in the level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the GCS, which assess eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refers to those reflexes found in a normal infant that disappear with maturation. These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be a reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS.

A nurse is caring for four clients in the neurologic ICU. After receiving the hand-off report, which client should the nurse see first? A. Client with a GCS that was 10 and is now 8 B. Client with a GCS that was 9 and is now 12 C. Client with a moderate brain injury who is amnesic for the event D. Client who is requesting pain medication for a headache

A. Client with a GCS that was 10 and is now 8 A 2-point decrease in GCS is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requisition pain medication should be seen after the one with the declining GCS.

A nurse caring for a client with sickle cell disease (SCD) reviews the client's laboratory work. Which finding should the nurse report to the provider? A. Creatinine: 2.9 B. Hematocrit: 30% C. Sodium: 147 D. WBC: 12,000

A. Creatinine: 2.9 An elevated creatinine indicates kidney damage, which occurs in SCD. A hematocrit level of 30% is an expected finding, as is a slightly elevated white blood cell count. A sodium of 147, although slightly high, is not concerning

During a neurologic assessment of a client, the nurse notes that the client's arms, wrists, and fingers have become flexed, and internal rotation and plantar flexion of the legs are evident. How does the nurse document these findings? A. Decorticate posturing B. Decerebrate posturing C. Atypical hyperreflexia D. Spinal cord degeneration

A. Decorticate posturing This client is demonstrating decorticate posturing, which is seen with interruption in the corticospinal pathway, This finding is abnormal and is a sing that the client's condition has deteriorated. The physician, the charge nurse, and other health care team members should be notified immediately of this change in status. Decerebrate posturing consists of external rotation and extension of the extremities. The other two options are inaccurate.

A nurse assesses a client who demonstrates a positive Romberg's sign with eyes closed but not with eyes open. Which condition does the nurse associate with this finding? A. Difficulty with proprioception B. Peripheral motor disorder C. Impaired cerebella function D. Positive pronator drift

A. Difficulty with proprioception The client who sways with eyes closed (positive Romberg's sign) but not with eyes open most likely has a disorder of proprioception and uses vision to compensate for it. The other options do not describe a positive Romberg's sign

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The client's spouse is very frustrated, stating that the client's personality has changed and the situation is intolerable. What action by the nurse is best? A. Explain that personality changes are common following brain injuries B. Ask the client why he or she is acting out and behaving differently C. Refer the client and spouse to a head injury support group D. Tell the spouse this is expected and he or she will have to learn to cope.

A. Explain that personality changes are common following brain injuries Personality and behavior often change permanently after head injury. The nurse should explain this to the spouse. Asking the client about his or her behavior isn't useful because the client probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to leant to cope belittle the spouses concerns and feelings.

A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best? A. Give the client pain medication if it is time for another dose. B. Instruct the client not to request pain medication too early. C. Request the provider to leave a prescription for a placebo D. Tell the client it is too early to have more pain medication

A. Give the client pain medication it it is time for another dose. Clients with sickle cell crisis often have severe pain that is managed with up to 48 hours of IV opioid analgesics. Even if the client is addicted and drug seeking, he or she is still in extreme pain. If the client can receive another doe of medication, the nurse should provide it, The other options are judgmental and do not address the client's pain. Giving placebos is unethical.

A school-age child is admitted in vasooclusive sickle cell crisis (pain episode). The child's care should include which therapeutic interventions? A. Hydration and pain management B. Oxygenation and factor VIII replacement C. Electrolyte replacement and administration of heparin D. Correction of alkalosis and reduction of energy expenditure

A. Hydration and pain management The management of crises include adequate hydration, pain management, minimization of energy expenditures, electrolyte replacement, and blood component therapy if indicated. Factor VIII is not indicated in the treatment of vaso-occlusive sickle cell crisis. Oxygen may prevent further sickling, but it is not effective in reversing sickling because it cannot reach the clogged blood vessels. Also, prolonged oxygen can reduce bone marrow activity. heparin is not indicated in the treatment of vaso-occlusive sickle cell crisis. electrolyte replacement should accompany hydration. The acidosis will be corrected as the crisis is treated. Energy expenditure should be minimized to improve oxygen utilization. Acidosis, not alkalosis, results from hypoxia, which also promotes sickling.

When caring for the patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes A. Hypertension, and bradycardia B. Hypertension, and tachycardia C. Hypotension, and bradycardia D. Hypotension, and tachycardia

A. Hypertension, and Bradycardia Hypertension with widening pulse pressure, bradycardia, and respiratory changes are the ominous late stages of increased ICP and indications of impending herniation (Cushing's trail). It is bradycardia, not tachycardia, which is the component of this ominous trait. It is hypertension, not hypotension, which is the component of the ominous triad.

A client who had a severe traumatic brain injury is being discharge home, where the spouse will be a full-time caregiver. What statement by the spouse would lead to the nurse to provide further education on home care? A. I know I can take care of all these needs by myself B. I need to seek counseling because I am very angry C. Hopefully things will improve gradually over time D. With respite care and support, I think I can do this.

A. I know I can take care of all these needs by myself This caregiver has unrealistic expectations about being able to do everything without help. Acknowledging anger and seeking counseling show a realistic outlook and plans for accomplishing goals. Hoping for improvement over time is also realistic, especially with the inclusion of the word hopefully. Realizing the importance of respite care and support also is a realistic outlook.

A client has a brain abscess and is receiving phenytoin. The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best? A. Increased pressure from the abscess can cause seizures B. Preventing febrile seizures with an abscess is important C. Seizures always occur in client with Brian abscesses D. This drug is used to sedate the client with an abscess

A. Increase pressure from the abscess can cause seizures Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenytoin is not used to prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This rug is not used for sedation.

What pain medication is contraindicated in children with sickle cell disease (SCD)? A. Meperidine B. Hydrocodone C. Morphine sulfate D. Ketorolac

A. Meperidine Meperidine is not recommended. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when is accumulates with repetitive dosing. Patients with SCD are particularly at risk for normeperidine-induced seizures.

A 5-year-old child is admitted to the hospital in a sickle cell crisis. The child has been alert and oriented but in severe pain. The nurse notes that the child is complaining of headache and is having unilateral hemiplegia. What action should the nurse implement? A. Notify the health care provider B. Place the child on bed rest C. Administer a dose of hydrocodone (Vicodin) D. Start Ó per the hospitals protocol.

A. Notify the health care provider Any number of neurologic symptoms can indicate a minor cerebral insult, such as headache, aphasia, weakness, convulsions, visual disturbances, or unilateral hemiplegia. Loss of vision is usually the result of progressive retinopathy and retinal detachment. The nurse should notify the health care provider.

A nurse assesses a client recovering from a cerebral angiography via the clients femoral artery. Which assessment should the nurse complete? A. Palpate bilateral lower extremity pulses B. Obtain orthostatic blood pressure readings C. Perform a funduscopic examination D. Assess the gag reflex prior to eating

A. Palpate bilateral lower extremity pulses Cerebral angiography is performed by threading a catheter through the femoral or brachial artery. The extremity is kept immobilized after the procedure. The nurse checks the extremity for adequate circulation by noting skin color and temperature, presences and quality of pulses distal to the injection site, and capillary refill. Clients usually are on bedrest; therefore, orthostatic blood pressure readings cannot be performed. The funduscopic examination would be affected by cerebral angiography. The client is given analgesics but not conscious sedation; therefore, the clients gag reflex would not be compormised.

The most conservative approach for early breast cancer treatment involves lumpectomy followed by which procedure? a. Radiation b. Adjuvant systemic therapy c. Hormonal therapy d. Chemotherapy

A. Radiation Radiation therapy, in the form of either brachytherapy or accelerated breast radiation, is the standard therapy after lumpectomy for the treatment of early-stage breast cancer. Chemotherapy administered soon after surgical removal of the tumor is referred to as adjuvant chemotherapy. Not all women are candidates for hormonal therapy. After the entire tumor or portion is removed by excision, a receptor assay must be performed. Chemotherapy with multiple-drug combinations is used in the treatment of recurrent and advanced breast cancer with positive results.

A nurse performs an assessment of pain discrimination on an older adult client. The client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action should the nurse take next? A. Touch the pin on the same area of the left hand B. Contact the provider with the assessment results C.Ask the client about current medications D. Continue the assessment on the clients feet.

A. Touch the pin on the same area of the left hand If testing is begun on the right hand and the client correctly identifies the pain stimulus, the nurse should continue the assessment on the left hand. This is a normal finding and does not need to be reported to the provider, but instead documented in the client's chart. Medication do not need to be assessed in response to this finding. The nurse should assess the hand prior to assessing the feet.

The nurse recognizes that the risk of osteoporosis is higher in an individual with which risk factor? A. White or Asian race B. African-American race C. History of participation in active sports D. Obesity

A. White or Asian race Risk factors for postmenopausal osteoporosis include white or Asian descent, slender body build, early estrogen deficiency, smoking, alcohol consumption, low-calcium diet, sedentary lifestyle, and family history of osteoporosis.

Breast cancer is the most frequently staged according to the tumor size (T), involvement of regional nodes (N), and distance and spread of the disease (M). Match the stage of breast cancer with the appropriate clinical manifestation. a. Tumor 2 to 5 cm with positive node b. Carcinoma in situ c. Any distant metastasis d. Tumor less than 2 cm with negative nodes e. Tumor of any size with extension to chest wall 1. Stage 0 2. Stage I 3. Stage IIb 4. Stage IIIb 5. Stage IV

A=3 B=1 C=5 D=2 E=4

The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that apply.) a. It affects single joints only. b. Antibodies lead to inflammation. c. It consists of an autoimmune process. d. Morning stiffness is rare. e. Permanent damage is inevitable.

B,C RA is a chronic autoimmune systemic inflammatory disorder leading to arthritis-type symptoms in the joints and other symptoms that can be seen outside the joints. Antibodies are created that lead to inflammation. Clients often report morning stiffness. Permanent damage can be avoided with aggressive, early treatment.

A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a. Blood urea nitrogen (BUN): 19 mg/dL b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L e. White blood cell (WBC) count: 72,000/mm3

B,C Rifampin can cause liver damage, evidenced by the clients high INR and prothrombin time. The BUN and WBC count are normal. The sodium level is low, but that is not related to this clients problem.

What are favorable prognostic criteria for acute lymphoblastic leukemia? (Select all that apply.) a. Male gender b. CALLA positive c. Early preB cell d. 2 to 10 years of age e. Leukocyte count 750,000/mm3

B,C,D Favorable prognostic criteria for acute lymphoblastic leukemia include CALLA positive, early preB cell, and age 2 to 10 years. Leukocyte count less, not greater, than 50,000/mm3 and female, not male, gender are favorable prognostic criteria.

A child has had a short-arm synthetic cast applied. What should the nurse teach to the child and parents about cast care? (Select all that apply.) a. Relieve itching with heat. b. Elevate the arm when resting. c. Observe the fingers for any evidence of discoloration. d. Do not allow the child to put anything inside the cast. e. Examine the skin at the cast edges for any breakdown.

B,C,D,E Cast care involves elevating the arm, observing the fingers for evidence of discoloration, not allowing the child to put anything inside the cast, and examining the skin at the edges of the cast for any breakdown. Ice, not heat, should be applied to relieve itching.

A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assessing the client's fluid and electrolyte status b. Assisting the client to get out of bed to prevent falls c. Obtaining a bedside commode if the client is weak d. Providing gentle perianal cleansing after stools e. Reporting any perianal abnormalities

B,C,D,E The UAP can assist the client with getting out of bed, obtain a bedside commode for the clients use, cleanse the clients perianal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status.

A client in the family practice clinic reports a 2-week history of an allergy to something. The nurse obtains the following assessment and laboratory data: Physical Assessment Data Laboratory Results Reports sore throat, runny nose, headache Posterior pharynx is reddened Nasal discharge is seen in the back of the throat Nasal discharge is creamy yellow in color Temperature 100.2 F (37.9 C) Red, watery eyes White blood cell count: 13,400/mm3 Eosinophil count: 11.5% Neutrophil count: 82% About what medications and interventions does the nurse plan to teach this client? (Select all that apply.) a. Elimination of any pets b. Chlorpheniramine (Chlor-Trimeton) c. Future allergy scratch testing d. Proper use of decongestant nose sprays e. Taking the full dose of antibiotics

B,C,D,E This client has manifestations of both allergic rhinitis and an overlying infection (probably sinus, as evidenced by purulent nasal drainage, high white blood cells, and high neutrophils). The client needs education on antihistamines such as chlorpheniramine, future allergy testing, the proper way to use decongestant nasal sprays, and ensuring that the full dose of antibiotics is taken. Since the nurse does not yet know what the client is allergic to, advising him or her to get rid of pets is premature.

The nurse is administering a medicate to ancient that stimulate the sympathetic division of the autonomic nervous system. Which clinical manifestation doe sth inures monitor for? (Select all that apply) A. Decreased heart rate B. Increased heart rate C. Decreased force of contraction D. Increased force of contraction E. Decreased respirations

B,D Stimulation of the sympathetic nervous system initiates the fight-or-flight response, increasing both the heart rate and the force of contraction. The other three options do not occur with sympathetic nervous system stimulation.

A client is admitted for a cardiac catheterization. It is essential for the nurse to ask the client about which allergies? (Select all that apply.) a. Penicillin b. Latex c. Iodine d. Shellfish e. Keflex f. Dilantin g. Bananas

B,C,D,G It is important to check for all allergies, but for a cardiac catheterization, the nurse needs to question about shellfish, iodine, latex, and bananas specifically. The contrast used contains iodine, and the equipment in the laboratory frequently contains latex. Information concerning these allergies needs to be passed on to laboratory personnel before the client goes to the laboratory. This will prevent the client from having an anaphylactic reaction during the procedure.

Strategies that a nurse could use in a motivational interview to increase the chances of change include which of the following? (Select all that apply.) a. Educating the patient on the physical damage the substance is causing b. Encouraging the patient to think of ways to change environmental triggers to abuse substances c. Asking the patient how they think substance abuse affects their family life d. Explaining to the patient that substance abuse affects everyone in the family and give examples e. Asking the patient what methods they think would work and encouraging participating in self-help groups

B,C,E Empowering the patient by helping them see what effect the abuse has on their life is a key component of motivation. Educating the patient is too much like lecturing and may cause resistance. Explaining how the family responds to the problem may elicit guilt and resistance.

A client has Hodgkin's lymphoma, Ann Arbor stage Ib. For what manifestations should the nurse assess the client? (Select all that apply.) a. Headaches b. Night sweats c. Persistent fever d. Urinary frequency e. Weight loss

B,C,E In this stage, the disease is located in a single lymph node region or a single non lymph node site. The client displays night sweats, persistent fever, and weight loss. Headache and urinary problems are not related.

The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.) a. Anorexia b. Felty's syndrome c. Joint deformity d. Low-grade fever e. Weight loss

B,C,E Late manifestations of RA include Felty's syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in the course of the disease.

A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? (Select all that apply.) a. Demonstrating breast self-examination methods to women b. Instructing people on the use of chemoprevention c. Providing vaccinations against certain cancers d. Screening teenage girls for cervical cancer e. Teaching teens the dangers of tanning booths

B,C,E Primary prevention aims to prevent the occurrence of a disease or disorder, in this case cancer. Secondary prevention includes screening and early diagnosis. Primary prevention activities include teaching people about chemoprevention, providing approved vaccinations to prevent cancer, and teaching teens the dangers of tanning beds. Breast examinations and screening for cervical cancer are secondary prevention methods.

A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply oral anesthetic gels before meals. b. Assist the client with oral care every 2 hours. c. Offer the client frequent sips of cool drinks. d. Provide the client with alcohol-based mouthwash. e. Remind the client to use only a soft toothbrush.

B,C,E The UAP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and should not be used.

What interventions does the nurse recommend for a client who is to be discharged home following total hip replacement surgery? (Select all that apply.) a. Continuous passive motion machine b. Elevated toilet seat c. Walker d. Crutches e. TED hose f. Heating pad

B,C,E The client will be using a walker, crutches are used only by younger clients. TED hose should be worn until the client regains full mobility and Coumadin is discontinued. A walker will be needed until the client regains full strength and is able to walk with full weight bearing on the operative side. Crutches are not used because they do not provide enough support for the client during ambulation and pose a risk for falls. Heating pads increase blood flow to the area and may increase pain. Ice packs should be used instead, as needed. Continuous passive motion machines are not used after hip surgery.

The nurse is caring for a hospitalized client who has AIDS and is severely immunocompromised. Which interventions are used to help prevent infection in this client? (Select all that apply.) a. Use sterile gloves and gowns whenever the nursing staff is in contact with the client. b. Provide an incentive spirometer to encourage coughing and deep breathing by the client. c. Keep a blood pressure cuff, thermometer, stethoscope in the client's room for his or her use only. d. Use N95 respirators (all nursing staff) when in the client's room. e. Request that the family take home the fresh flowers that are at the client's bedside. f. Assist the client with meticulous oral care after meals and at bedtime.

B,C,E,F The nursing staff should encourage coughing and deep breathing to prevent pneumonia, and incentive spirometry will be helpful. Assessment equipment such as thermometers and blood pressure cuffs should be kept in the room only for the use of this client, rather than being used by other clients on the unit as well. Fresh flowers can harbor microorganisms and should be removed from the room. Meticulous oral care will help to prevent infection by Candida.

Guidelines for breast cancer screening continue to evolve as new evidence is generated. Which examination or procedure and frequency would be recommended for a 31-year-old asymptomatic client? (Select all that apply.) a. Annual mammography b. Clinical breast examination every 3 years c. Annual MRI d. Breast self-examination e. Mammography every 3 years

B,D A 31-year-old client with no risk factors and who is asymptomatic should perform a breast self-examination on a regular basis and have a clinical breast examination every 3 years. Women who are 40 years of age and older require both mammography and clinical breast examination annually. High-risk women 30 years and older should have an annual MRI and mammogram.

After administering a medication that stimulates the sympathetic division of the autonomic nervous system, the nurse assesses the client. For which clinical manifestations should the nurse assess? (Select all that apply) A. Decreased respiratory rate B. Increased heart rate C. Decreased level of consciousness D. Increased force of contraction E. Decreased blood pressure

B,D Stimulation of the sympathetic nervous system initiates the fight-or-flight response, increasing heart rate and force of contraction. A medication that stimulates the sympathetic nervous system would also increase the client's respiratory rate, blood pressure, and level of consciousness

A nurse is dismissing a client from the emergency department who has a mild TBI. What information obtained from the client represents a possible barrier to self-management? (Select all that apply) A. Does not want to purchase a thermometer B. Is allergic to Acetaminophen C. Laughing, says strenuous? What's that? D. Lives alone and is new in town with no friends E. Plans to have a beet and go to bed once home

B,D,E Clients should take acetaminophen for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen, which should be avoided. The client needs neurologic checks every 1-2 hour, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.

The nurse is teaching a client with rheumatoid arthritis (RA) about joint protection principles. What information does the nurse include? (Select all that apply.) a. Use smaller joints to rest the larger ones. b. Hold objects with two hands, not one. c. Sit most often in a reclining chair. d. Use assistive-adaptive devices. e. Bend at your knees to lift objects.

B,D,E Clients with RA should use large joints to protect smaller ones, should hold objects with two hands instead of one, should sit in chairs with straight backs, should not bend at the waist but rather bend the knees while keeping the back straight, and should use assistive-adaptive devices wherever possible.

The nurse is preparing to admit a 1-year-old child with pertussis (whooping cough). Which clinical manifestations of pertussis should the nurse expect to observe? (Select all that apply.) a. Earache b. Coryza c. Conjunctivitis d. Low-grade fever e. Dry hacking cough

B,D,E The clinical manifestations of pertussis include coryza, a low-grade fever, and a dry hacking cough. The child does not have an earache or conjunctivitis.

The nurse is preparing to admit a 5-year-old child who developed lesions of varicella (chickenpox) 3 days ago. Which clinical manifestations of varicella should the nurse expect to observe? (Select all that apply.) a. Nonpruritic rash b. Elevated temperature c. Discrete rose pink rash d. Vesicles surrounded by an erythematous base e. Centripetal rash in all three stages (papule, vesicle, and crust)

B,D,E The clinical manifestations of varicella include elevated temperature, vesicles surrounded by an erythematous base, and a centripetal rash in all three stages (papule, vesicle, and crust). The rash is pruritic, and a discrete pink rash is seen with exanthema subitum, not varicella.

A patient has been taking disulfiram (Antabuse) as part of his rehabilitation therapy. However, this evening, he attended a party and drank half a beer. As a result, he became ill and his friends took him to the emergency department. The nurse will look for which adverse effects associated with acetaldehyde syndrome? (Select all that apply.) A. Euphoria B. Severe vomiting C. Diarrhea D. Pulsating headache E. Difficulty breathing F. Sweating

B,D,E,F Acetaldehyde syndrome results when alcohol is taken while on disulfiram (Antabuse) therapy. Adverse effects include CNS effects (pulsating headache, sweating, marked uneasiness, weakness, vertigo, others); GI effects (nausea, copious vomiting, thirst); and difficulty breathing. Cardiovascular effects also occur; see Table 17-2. Euphoria and diarrhea are not adverse effects associated with acetaldehyde syndrome.

A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse is assessing the patient's risk for falls so that falls prevention can be implemented if necessary. Select all the risk factors that apply from this patient's history and physical. (Select all that apply.) a. Being a woman b. Taking more than six medications c. Having hypertension d. Having cataracts e. Muscle strength 3/5 bilaterally f. Incontinence

B,D,E,F Adverse effects of medications can contribute to falls. Cataracts impair vision, which is a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine or stool increases risk for falls. Men have a higher risk for falls. Hypertension itself does not contribute to falls. Dizziness does contribute to falls.

A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply) A. Long-term memory loss B. Slower processing time C. Increased sensory perception D. Decreased risk for infection E. Change in sleep patterns

B,E Normal changes in the nervous system related to aging include recent memory loss, slower processing time, decreased sensory perception, an increased risk for infection, changes in sleep patterns, changes in perception of pain, and altered balance and/or decreased coordination.

A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position.

B,E The UAP can take and document vital signs, including oxygen saturation, and keep the clients head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.

After shunt procedure, the nurse would monitor the patient's neurologic status by using the a. electroencephalogram. b. GCS. c. National Institutes of Health Stroke Scale. d. Monro-Kellie doctrine.

B. GCS The GCS gives a standardized numeric score of the neurologic patient assessment. An electroencephalogram is used in diagnosing and localizing the area of seizure origin. This scale is an example of one type of specific tool for nurses to use when assessing a patient following stroke. The Monroe-Kellie doctrine is not an assessment or monitoring strategy; it describes the interrelationship of volume and compliance of the three cranial components, brain tissue, cerebrospinal fluid, and blood.

A patient undergoing alcohol rehabilitation decides to accept disulfiram (Antabuse) therapy to avoid impulsively responding to drinking cues. Which information should be included in the discharge teaching for this patient? Select all that apply. a. Avoid aged cheeses. b. Read the labels of all liquid medications. c. Wear sunscreen and avoid bright sunlight. d. Maintain an adequate dietary intake of sodium. e. Avoid breathing fumes of paints, stains, and stripping compounds.

B,E The patient must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne; smelling alcohol-laden fumes; and eating foods prepared with wine, brandy, beer, or spirits of any sort may also trigger reactions. The other options do not relate to hidden sources of alcohol.

The nurse is providing patient teaching for a patient who is starting antitubercular drug therapy. Which of these statements should be included? (Select all that apply.) A. "Take the medications until the symptoms disappear." B. "Take the medications at the same time every day." C. "You will be considered contagious during most of the illness and must take precautions to avoid spreading the disease." D. "Stop taking the medications if you have severe adverse effects." E."Avoid alcoholic beverages while on this therapy." F. "If you notice reddish-brown or reddish-orange urine, stop taking the drug andcontact your doctor right away." G. "If you experience a burning or tingling in your fingers or toes, report it to yourprescriber immediately." H. "Oral contraceptives may not work while you are taking these drugs, so you willhave to use another form of birth control."

B,E,G,H Medications for tuberculosis must be taken on a consistent schedule to maintain blood levels. Medication therapy for tuberculosis may last up to 24 months, long after symptoms disappear, and patients are infectious during the early part of the treatment. Compliance with antitubercular drug therapy is key, so if symptoms become severe, the prescriber should be contacted for an adjustment of the drug therapy. The medication must not be stopped. Because of potential liver toxicity, patients on this drug therapy must not drink alcohol. Discoloration of the urine is an expected adverse effect, and patients need to be warned about it beforehand. Burning or tingling in the fingers or toes may indicate that peripheral neuropathy is developing, and the prescriber needs to be notified immediately. A second form of birth control must be used because antitubercular drug therapy makes oral contraceptives ineffective.

The nurse is preparing to administer morning medications to a patient who has been newly diagnosed with tuberculosis. The patient asks, "Why do I have to take so many different drugs?" Which response by the nurse is correct? A. "Your prescriber hopes that at least one of these drugs will work to fight thetuberculosis." B. "Taking multiple drugs reduces the chance that the tuberculosis will become drugresistant." C. "Using more than one drug can help to reduce side effects." D. "Using multiple drugs enhances the effect of each drug."

B. "Taking multiple drugs reduces the chance that the tuberculosis will become drugresistant." The use of multiple medications reduces the possibility that the organism will become drug resistant. The other options are incorrect.

A client with human immunodeficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first? a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.

B. Assess the client for adherence to the drug regimen.

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best? A. Assess the clients magnesium level B. Assess the client sodium level C. Increase the rate of IV infusion D. Provide oral care every hour

B. Assess the clients sodium level This client has manifestations of hypernatremia, which is a possible complication after craniotomy. The nurse should assess the client's serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.

A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death? A. Client with a core temp of 95 F (35 C) for 2 days B. Client in coma for 2 weeks from MVC C. Client who is found unresponsive in a remote area of field by hunter D. Client with systolic BP of 92 since admission

B. Client in a coma for 2 weeks from MVC IN order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near-normal core temp, 3) normal systolic blood pressure, and 4) at least one neurologic examination. The client who was in the car crash meets two of these criteria. The client with the lower temperature and lower blood pressure only have one of these criteria. there is no data to support assessment of brain death in the client found by the hunter.

The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe? A. Aligning the neck with the body B. Clustering many nursing activities C. Elevating the head of the bed 30 degrees D. Providing stool softeners or laxatives as ordered

B. Clustering many nursing activities It is important to minimize stress and activities that could increase ICP. Combining many nursing activities could increase oxygen demand and ICP. This would not be safe. Interventions which can promote venous outflow can help decrease ICP. The stress of constipation or bowel movements can increase ICP; stool softener or laxatives can minimize this.

A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer? A. Carbamazepine B. Dexmedetomidine C. Diazepam D. Mannitol

B. Dexmedetomidine Dexmedetomidine is often used to manage agitation in the client with traumatic brain injury. Carbamazepine is an anti seizure drug. Diazepam is a benzodiazepine. Mannitol is an osmotic diuretic.

A nurse obtained a focused health history for a client who is scheduled for magnetic resonance angiography. Which priority question should the nurse ask before the test? A. Have you had a recent blood transfusion? B. Do you have allergies to iodine or shellfish? C. Are you taking any cardiac medications? D. Do you currently use oral contraceptives?

B. Do you have allergies to iodine or shellfish? Allergies to iodine and/or shellfish need to be explored because the client may have a similar reaction t the dye used in the procedure. In some cases, the client ay need to be medicated with antihistamines or steroid before the test is given. A recent blood transfusion or current use of cardiac medications or oral contraceptives would not affect the angiography

A child with sickle cell disease is vase-occlusive crisis. What nonpharmacologic pain intervention should the nurse plan? A. Exercise as a distraction B. Heat to the affected area C. Elevation of the extremity D. Cold compresses to the affected area

B. Heat to the affected area Frequently, heat to the affected area is soothing. Cold compresses are not applied to the area because doing so enhances vasoconstriction and occlusion. bed rest is usually well tolerated during a crisis, altho the actual ret obtained depends a great deal on pain alleviation and the use of organized schedules of nursing care. Although the objective of bed rest s to minimize oxygen consumption, some activity, particularly passive range of motion exercises, is beneficial to promote circulation. Usually the best course is to let children determine their activity tolerance. elevating the extremity will not help in sickle cell disease.

Before electroencephalography, a client asks, why will I be asked to take deep breaths during the procedure? How does the nurse respond? A. Hyperventilation causes cerebral vasodilation and increases the likelihood of seizure activity B. Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity C. Deep breathing will keep you relaxed and will lower the seizure threshold. D. Deep breathing will make you hypoxemic

B. Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity Hyperventilation produces cerebral vasoconstriction and alkalosis, which increases the likelihood of seizure activity. the client is asked to breathe deeply 20-30 times for 3 minutes. Th other responses are not appropriate.

A client admitted for sickle cell crisis is distraught after learning her child also has the disease. What response by the nurse is best? A. Both you and the father are equally responsible for passing it on. B. I can see you are upset. I can stay here with you awhile if you like C. It's not your fault; there is no way to know who will have this disease D. There are many good treatments for sickle cell disease these days.

B. I can see you are upset. I can stay here with you awhile if you like. The best response is for the nurse to offer self, a therapeutic communication technique that uses presence. Attempting to assign blame to both parents will not help the client feel better. There is genetic testing available, so it is inaccurate to state there is no way to know who will have the disease. Stating that good treatments exist belittles the client's feelings.

The nurse is assessing a client's remote memory. Which statement by the client confirms that remote memory is intact? A. Mary had a little lamb whose fleece was white as snow B. I was born on April 3rd, 1967, in Johnstown Community Hospital C. Apple, chair, and pencil are the words you just stated D. My sister brought me to the clinic for this appointment

B. I was born on April 3rd, 1967, I Johnstown Community Hospital Asking clients about certain facts from the past that can be verified assesses remote, or long-term, memory. The client's ability to make up a rhyme tests not memory, but rather a higher level of cognition. The other statements indicate immediate and recent memory.

The nurse assesses a client who has trauma to the cerebrum. Which clinical manifestation does the nurse expect to observe? A. Poor coordination B. Memory loss C. Hyperthermia D. Slurred speech

B. Memory loss The cerebrum is the largest part of the brain and controls intelligence, creativity, and memory. Poor coordination, hyperthermia, and slurred speech are cause by other parts of the brain.

A child with sickle ell anemia develops severe chest pain and back pain, fever, cough, and dyspnea. What should be the first action by the nurse? A. Administer 100% oxygen to relieve hypoxia B. Notify the practitioner because chest syndrome is suspected C. Infuse intravenous antibiotics as soon as cultures are obtained D. Give ordered pain medication to relieve symptoms of pain episode

B. Notify the practitioner because chest syndrome is suspected These are the symptoms of chest syndrome, which is a medical emergency. Notifying the practitioner is the priority action. Oxygen may be indicated; however, it does not reverse the sickling that has occurred. Antibiotics are not indicated initially. Pain medications may be required, but evaluation by ht practitioner is the priority.

A clients mean arterial pressure is 60 mm Hg and the ICP is 20 mm Hg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client? A. Impending brain herniation B. Poor prognosis and cognitive function C. Probable complete recovery D. Unable to tell from this information

B. Poor prognosis and cognitive function The cerebral perfusion pressure (CPP) is the ICP - MAP (60-20=40). For optimal outcomes, CPP should be at least 70 mm Hg. This client has a very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery.

A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this client's plan of care? A. Check bath water temperature wit a thermometer B. Provide the client with assistance when ambulating C. Place elastic support hose on the client's legs D. Assess the client's feet for wounds each shift.

B. Provide the client with assistance when ambulating Hypoative deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse should plan to provide the client with ambulation assistance to prevent injury. The other interventions do not address the clients problem.

What condition occurs when the normal adult hemoglobin is partly or completely replaced by abnormal hemoglobin? A. Aplastic anemia B. Sickle cell anemia C. Thalassemia major D. Iron deficiency anemia

B. Sickle cell anemia Sickle cell anemia is one of the group of diseases collectively called hemoglobinopathies, in which normal adult hemoglobin is replaced by abnormal hemoglobin. Aplastic anemia is a lack of cellular elements being produced. Thalassemia major refers to a variety of inherited disorders characterized by deficiencies in production of certain globulin chains. Iron-deficiency anemia affects red blood cell size and depth of color but does not involve abnormal hemoglobin.

The regulation of red blood cell production is thought to be controlled by which physiologic factor? A. Hemoglobin B. Tissue hypoxia C. Reticulocyte count D. Number of RBCs

B. Tissue hypoxia Hemoglobin does not directly control RBC production. If there is insufficient hemoglobin to adequately oxygenate the tissue, then erythropoietin may be released. When tissue hypoxia occurs, the kidneys release erythropoietin into the bloodstream. This stimulates the marrow to produce new RBCs. Reticulocytes are immature RBCs. The metic count can be used to monitor hematopoiesis. The number of RBCs does not directly control production. In congenital cardiac disorders with mixed blood flow or decreased pulmonary blood flow, RBC production continues secondary to tissue hypoxia.

Which statement(s) might the nurse appropriately include when teaching a client about calcium intake for osteoporosis? (Select all that apply.) a. You should try to increase your protein intake when you are taking calcium. b. It is best to take calcium in one large dose. c. Tums are the most soluble form of calcium. d. You should take calcium with vitamin D because vitamin D helps your body better absorb calcium. e. Its okay to take calcium if you have had a history of kidney stones.

C,D Teaching the client to take calcium with vitamin D is accurate. Excessive protein should be avoided. Calcium is best taken in divided doses to increase absorption. Calcium should be taken with vitamin D to increase absorption. Calcium is contraindicated in women with a history of kidney stones.

A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Surgical discomfort b. Redness and itching at the incision site c. Incisional bulging d. Clear drainage on the dressing e. Sudden and severe headache

C,D,E Bulging at the incision site or clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. Loss of cerebrospinal fluid may cause a sudden and severe headache, which is also an emergency situation. Pain, redness, and itching at the site are normal.

A nurse is providing education to a community women's group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.) a. Cut down on tobacco product use. b. Limit alcohol to two drinks a day. c. Strengthening exercises are important. d. Take recommended calcium and vitamin D. e. Walk 30 minutes at least 3 times a week.

C,D,E Lifestyle changes can be made to decrease the occurrence of osteoporosis and include strengthening and weight-bearing exercises and getting the recommended amounts of both calcium and vitamin D. Tobacco should be totally avoided. Women should not have more than one drink per day.

The nurse studying osteoporosis learns that which drugs can cause this disorder? (Select all that apply.) a. Antianxiety agents b. Antibiotics c. Barbiturates d. Corticosteroids e. Loop diuretics

C,D,E Several classes of drugs can cause secondary osteoporosis, including barbiturates, corticosteroids, and loop diuretics. Antianxiety agents and antibiotics are not associated with the formation of osteoporosis.

A client has received a bone marrow transplant and is waiting for engraftment. What actions by the nurse is most appropriate? (Select all that apply.) a. Not allowing any visitors until engraftment b. Limiting the protein in the clients diet c. Placing the client in protective precautions d. Teaching visitors appropriate hand hygiene e. Telling visitors not to bring live flowers or plants

C,D,E The client waiting for engraftment after bone marrow transplant has no white cells to protect him or her against infection. The client is on protective precautions and visitors are taught hand hygiene. No fresh flowers or plants are allowed due to the standing water in the vase or container that may harbor organisms. Limiting protein is not a healthy option and will not promote engraftment.

A patient who has started drug therapy for tuberculosis wants to know how long he will be on the medications. Which response by the nurse is correct? A. "Drug therapy will last until the symptoms have stopped." B. "Drug therapy will continue until the tuberculosis develops resistance." C. "You should expect to take these drugs for as long as 24 months." D. "You will be on this drug therapy for the rest of your life."

C. "You should expect to take these drugs for as long as 24 months." Drug therapy commonly lasts for 24 months if consistent drug therapy has been maintained. The other options are incorrect.

A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his name, mumbles in response to questions, and follows simple commands. How should the nurse document the client's assessment using the GCS? A. 8 B. 10 C. 12 D. 14

C. 12 The client opens his eyes to speech (Eye opening: to sound = 3), mumbles in response to questions (Verbal response: Inappropriate words = 3), and follows simple commands (Motor response: Obey commands = 6). Therefore, the clients GCS is: 3+3+6 = 12

A client is newly diagnosed with sickle cell anemia. Which information does the nurse include in the clients discharge instructions? A. Eat a diet high in iron B. Take hydoxyurea every morning C. Be aware of the early symptoms of crisis D. Do not use any oral contraceptives

C. Be aware of the early symptoms of crisis Clients need to know the early symptoms of crisis so that treatment can be started early to prevent pain, complications, and permanent tissue damage. The iron level is not low in sickle cell anemia. Hydroxyurea is used in the hospital during sickle cell crisis. The use of oral contraceptives is controversial because they kay enhance clot formation, predisposing the client to crisis.

A client who has sickle cell anemia is admitted to the hospital. The client reports severe pain. Which action will the nurse take first? A. Administer one unit of packed red blood cells B. Administer prescribe hydroxyurea C. Begin intravenous fluids at 250 mL/hr D. Prepare for bone marrow transplantation

C. Begin intravenous fluids at 250 mL/hr All of these are treatments for sickle cell anemia. However, the client in severe pain is likely to be in sickle cell crisis. To prevent further sickling of the red blood cells, adequate hydration of at least 200 mL/hr is needed during a crisis. the other interventions should be implemented after the fluids are started

In a child with sickle cell anemia, adequate hydration is essential to minimize sickling and delay the vaso-occlusion and hypoxiaischemia cycle. What information should the nurse share with parents in a teaching plan? A. Encourage drinking B. Keep accurate records of output C. Check for moist mucous membranes D. Monitor the concentration of the child's urine

C. Check fr moist mucous membranes. Children with SCA have impaired kidney function and cannot concentrate urine. Parents are taught signs of dehydration and ways to minimize loss of fluid of fluid to the environment. Encouraging drinking is not specific enough for parents. The nurse should give the parents and child a target fluid amount for each 24-hour period. Accurate monitoring of output may not reflect the child's fluid needs. Without the ability to concentrate urine, the child needs additional intake to compensate. Dilute urine and specific gravity are not valid signs of hydration status in children with SCA.

The parents of a child with sickle cell anemia are concerned about subsequent children having the disease. What statement most accurately reflects inheritance of SCA? A. SCA is not inherited B.All siblings will have SCA C. Each sibling has a 25% chance of having SCA D. There is a 50% chance of siblings having SCA

C. Each sibling has a 25% chance of having SCA SCA is inherited as an autosomal recessive disorder. In this inheritance pattern, each child born to these parents has a 25% chance of having the disorder, a 25% chance of have neither SCA nor the trait, and a 50% chance of being heterozygous for SCA. SCA is an inherited hemoglobinopathy

A nurse asks a client to take deep breaths during electroencephalography. The client asks, Why are you asking me to do this? How should the nurse respond? A. Hyperventilation causes vascular dilation of cerebral arteries, which decreases electoral activity in the brain B. Deep breathing helps you relax and allows the electroencephalogram to obtain a better waveform C. Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity D. Deep breathing will help you to blow off carbon dioxide and decreases intracranial pressure

C. Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity Hyperventilation produces cerebral vasoconstriction and alkalosis, which increases the likelihood of seizure activity. The client is asked to breath deeply 20-30 times for 3 minutes. the other responses are not accurate.

The nurse is caring for a client who had a CT of the head with contrast medium. Which priority intervention does the nurse implement? A. Maintain bedrest with the head of the bed elevated less than 30 degrees B. Apply a pressure dressing to the site of injection C. Increase fluid intake after the procedure D. Maintain sedation for 8 hours post procedure

C. Increase fluid intake after procedure If a contrast medium is used, IV fluid may be given to promote excretion of the contrast medium. Contrast medium also may act as a diuretic, resulting in the need for fluid replacement. Th client will not be sedated for the procedure and will not require bedrest. Contrast is injection through a peripheral IV.

The clinical manifestations of sickle cell anemia (SCA) are primarily the result of which physiologic alteration? A. Decreased blood viscosity B. Deficiency in coagulation C. Increased RBC destruction D. Greater affinity for oxygen

C. Increased RBC destruction The clinical features of SCA are primarily the result of increased RBC destruction and obstruction caused by the sickle-shaped RBCs. When the sickle cells change shape, they increase the viscosity in the area where they are involved in the microcirculation. SCA dose not have a coagulation deficit. Sickled red cells have decreased oxygen-carrying capacity and transform into the sickle shape in conditions of low oxygen tension

A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the UAP? A. Apply ice packs to the client's legs B. Elevate the clients legs on pillows C. Keep the lower extremities warms. D. Place elastic bandage wraps on the client's legs.

C. Keep the lower extremities warm During a sickle cell crisis, the tissue distal to the occlusion has decreased blood flow and ischemia, leading to pain. Due to decreased blood flow, the clients legs will be cool or cold. The UAP can attempt to keep the clients legs warm. Ice and elevation will further decrease perfusion. Elastic bandage wraps are not indicated and may constrict perfusion in the legs

The nurse is caring for a client during a sickle cell crisis. Which intervention does the nurse implement for the client? A. Administer acetaminophen as needed B. Administer intravenous fluids to keep the vein open C. Keep the room temperature at 80F D. Transfuse red blood cells (RBCs)

C. Keep the room temperature at 80 F Keeping the room warm can be used as a complementary therapy to relieve the pain of a sickle cell crisis. Cold can act as a factor in causing a crisis. Analgesia is an important prt of receiving pain. The analgesia routine should be followed on an around-the-clock basis and should consist of IV opioids for severe pain, followed by treatment with oral doses of opioids of NSAIDs. High-volume intravenous fluids be administered to minimize pain during sickle cell crisis.

When admitting a patient with a suspected diagnosis of chronic alcohol use, the nurse will keep in mind that chronic use of alcohol might result in which condition? A. Renal failure B. Cerebrovascular accident C. Korsakoff's psychosis D. Alzheimer's disease

C. Korsakoff's psychosis A variety of serious neurologic and mental disorders, such as Korsakoff's psychosis and Wernicke's encephalopathy, as well as cirrhosis of the liver, may occur with chronic use of alcohol. Renal failure, cerebrovascular accident, and Alzheimer's disease are not associated directly with chronic use of alcohol.

The nurse assesses a client's GCS and determines it to be a 12 (4 in each category). What care should the nurse anticipate fo this client? A. Can ambulate independently B. May have trouble swallowing C. Needs frequent re-orientation D. Will need near-total care

C. Needs frequent re-orientation This client will most likely be confused and need frequent re-orientation. The client may not be able to ambulate at all but should do so independently, not because of mental status Swallowing is not assessed by GCS. The client will not need near-total care.

The nurse is transfusing red blood cells to a client who has sickle cell disease. Which laboratory result indicates that the nurse should discontinue the transfusion? A. Hematocrit: 32% B. Hemoglobin 88% C. Serum iron level: 300 D. WBC: 12,000

C. Serum iron level: 300 Clients with sickle cell disease are anemic but are not iron deficient. Transfusions are prescribed cautiously to prevent iron overload with repeated transfusions. Iron overload damages the heart, liver, and endocrine organs. monitor the client's serum ferritin, serum iron, and total iron-binding capacity during transfusion therapy. the other laboratory values should not result in discontinuation of the transfusion by the nurse.

A client has a traumatic brain injury and a positive halo sign. Th client is in the Icu, sedated and on a ventilator, and is in a critical but stable condition. What collaborative problem takes priority at this time? A. Inability to communicate B. Nutritional deficit C. Risk for acquiring an infection D. Risk for skin breakdown

C. The positive halo sign indicates a leak of CSF. This places the client at a high risk of acquiring an infection. Communication and nutrition are not priorities compared to preventing brain infection. The client has a definite risk for skin breakdown, but it is not the immediate danger a brain infection would be.

A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, Snakes are crawling on my bed. I've gotta get out of here. What is the most accurate assessment of the situation? The patient: a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. C. has symptoms of alcohol withdrawal delirium. D. is having a recurrence of an acute psychosis.

C. has symptoms of alcohol withdrawal delirium. Symptoms of agitation, elevated pulse, and perceptual distortions point to alcohol withdrawal delirium, a medical emergency. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for: a. slurred speech, excessive drowsiness, and bradycardia. b. paranoid delusions, tactile hallucinations, and panic. C. runny nose, yawning, insomnia, and chills. D. anxiety, agitation, and aggression.

C. runny nose, yawning, insomnia, and chills. Early signs and symptoms of narcotic withdrawal resemble symptoms of onset of a flu like illness, but without temperature elevation. The incorrect options reflect signs of intoxication or CNS depressant overdose and CNS stimulant or hallucinogen use.

A nurse is teaching a client with cerebellar function impairment. Which statement should the nurse include in this clients discharge teaching? A. Connect a light to flash when your doorbell rings B. Label your faucet knobs with hot and cold signs C. Ask a friend to drive you to your follow-up appointments D. Use a natural gas detector with an audible alarm

C.Ask a friend to drive you to your follow-up appointments Cerebellar function enables the client to predict distance or gauge the speed with which is one approaching an object, control voluntary movement, maintain equilibrium, and shift from one skilled movement to another in an orderly sequence. A client who has cerebellar function impairment should not be driving. The client would not have difficulty hearing, distinguishing between hot and cold, or smelling.

While caring for a patient with a methamphetamine overdose, which tasks are the priorities of care? Select all that apply. a. Administration of naloxone (Narcan) b. Vitamin B12 and folate supplements c. Restoring nutritional integrity d. Prevention of seizures e. Reduction of fever

D,E Hyperpyrexia and convulsions are common when a patient has overdosed on a CNS stimulant. These problems are life threatening and take priority. Naloxone (Narcan) is administered for opiate overdoses. Vitamin B12 and folate may be helpful for overdoses from solvents, gases, or nitrates. Nutrition is not a priority in an overdose situation.

A nurse assesses an older adults skin. Which findings require immediate referral? (Select all that apply.) a. Excessive moisture under axilla b. Increased hair thinning c. Increased presence of fungal toenails d. Lesion with various colors e. Spider veins on legs f. Asymmetric 6-mm dark lesion on forehead

D,F The lesion with various colors, as well as the asymmetric 6-mm dark lesion, fits two of the American Cancer Society's hallmark signs for cancer according to the ABCD method. Other manifestations are variants of normal seen in various age groups.

A patient newly diagnosed with tuberculosis (TB) has been taking antitubercular drugs for 1week calls the clinic and is very upset. He says, "My urine is dark orange! What's wrong with me?" Which response by the nurse is correct? A. "You will need to stop the medication, and it will go away." B. "It's possible that the TB is worse. Please come in to the clinic to be checked." C. "This is not what we usually see with these drugs. Please come in to the clinic tobe checked." D. "This is an expected side effect of the medicine. Let's review what to expect."

D. "This is an expected side effect of the medicine. Let's review what to expect." Rifampin, one of the first-line drugs for TB, causes a red-orange-brown discoloration of urine, tears, sweat, and sputum. Patients need to be warned about this side effect. The other options are incorrect.

The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? A. Client with a CPP of 72 B. Client with a GCS of 12 C. Client with a PaCÓ of 36 who is on a ventilator D. Client who has a temp of 102 F (38.9 C)

D. Client who has a temp of 102 F (38.9 C) A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. GCS of 12, PaCÓ of 36, and CPP of 72 are all desired outcomes.

A client admitted the previous day for a suspected neurologic disorder becomes increasingly lethargic. Which is the best nursing action? A. Promote a quite atmosphere for sleep and rest to treat the clients sleep deprivation B. Explain to the family that this is a normal age-related decline in mental processing C. Consult a psychiatrist to treat the clients hospital-acquired depression D. Complete a full neurologic assessment and notify the neurologist

D. Complete a full neurologic assessment and notify the neurologist A change in the clients level of consciousness is the first indication of a decline in central neurologic functioning. The nurse should conduct a thorough assessment and then should notify the neurologist (or other provider). The other intervention are inappropriate

A nurse cares for a client who is experiencing deteriorating neurologic functions. The client states, I am worried I will not be able to care for my young children. How should the nurse respond? A. Caring for your young children is a priority. You may not want to ask for help, but you have too. B. Our community has resources that may help you with some household tasks so you have energy to care for your children. C. You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status? D. Give me more information about what worries you, so we can see if we can do something to make adjustments.

D. Give me some more information about what worries you, so we can see if we can do something to make adjustments Investigate specific concerns about situational or role changes before providing additional information. The nurse should not tell the client what is or is not a priority for him or her. Although community resources may be available, they may not be appropriate for the client. Consulting a psychologist would not be appropriate without obtaining further information from the client related to current concerns.

The nurse will assess the patient for which potential contraindication to antitubercular therapy? A. Glaucoma B. Anemia C. Heart failure D. Hepatic impairment

D. Hepatic impairment Results of liver function studies (e.g., bilirubin level, liver enzyme levels) need to be assessed because isoniazid and rifampin may cause hepatic impairment; severe liver dysfunction is a contraindication to these drugs. In addition, the patient's history of alcohol use needs to be assessed.

A nurse assesses a client's recent memory. Which client statement confirms that the clients remote memory is intact? A. A young girl wrapped in a shroud fell asleep on a bed of clouds B. I was born on April 3rd, 1967, in Jonhstown Community Hospital C. Apple, chair, and pencil are the words you just stated D. I ate oatmeal with wheat toast and orange juice for breakfast

D. I ate oatmeal with wheat toast and orange juice for breakfast Asking clients about recent events that can be verified, such as what the client ate for breakfast, assesses the client's recent memory. The client's ability to make up a rhyme tests not memory, bu rather a higher level of cognition. Asking clients about certain facts from the past can be verified assesses remote or long-term memory. Asking the client to repeat words assesses the client's immediate memory.

A nurse obtained a focused health history for a client who is scheduled for an MRI. Which condition should alert the nurse to contact the provider and cancel the procedure? A. Creatine phosphokinase of 100 B. Atriventricular graft C. BUN of 50 D. Internal insulin pump

D. Internal insulin pump Metal devices such as internal pumps, pacemakers, and prostheses interfere with accuracy of the image and can become displaced by the magnetic force generated by an MRI procedure. An artioventricular graft does not contain any metal. CPK and BUN levels have no impact on an MRI procedure

The nurse is discussing adverse effects of antitubercular drugs with a patient who has active tuberculosis. Which potential adverse effect of antitubercular drug therapy should the patient report to the prescriber? A. Gastrointestinal upset B. Headache and nervousness C. Reddish-orange urine and stool D. Numbness and tingling of extremities

D. Numbness and tingling of extremities Patients on antitubercular therapy should report experiencing numbness and tingling of extremities, which may indicate peripheral neuropathy. Some drugs may color the urine, stool, and other body secretions reddish-orange, but this is not an effect that needs to be reported. Patients need to be informed of this expected effect. The other options are incorrect.

The nurse is teaching a client who has sickle cell disease and was admitted for splenomegaly and abdominal pain. Which instruction does the nurse include in the clients discharge teaching? A. Avoid drinking large amounts of fluids B. Eat six small meals daily instead of large meals C. Engage in aerobic 3 days a week D. Receive a yearly influenza vaccination

D. Receive a yearly influenza vaccination Abdominal pain and a palpable spleen could indicate blood trapped in the spleen. Over time, the spleen may become nonfunctional, which the client at risk for infection. An annual influenza vaccination helps prevent infection. A client with sickle cell disease should not become dehydrated or engage in strenuous physical activity because this could precipitate a crisis. Eating smaller meals has no impact on sickle cell disease of infection.

A patient has been taking antitubercular therapy for 3 months. The nurse will assess for what findings that indicate a therapeutic response to the drug therapy? A. The chronic cough is gone. B. There are two consecutive negative purified protein derivative (PPD) results over 2months. C. There is increased tolerance to the medication therapy, and there are fewer reportsof adverse effects. D. There is a decrease in symptoms of tuberculosis along with improved chest x-raysand sputum cultures.

D. There is a decrease in symptoms of tuberculosis along with improved chest x-raysand sputum cultures. A therapeutic response to antitubercular therapy is manifested by a decrease in the symptoms of tuberculosis, such as cough and fever, and by weight gain. The results of laboratory studies (culture and sensitivity tests) and the chest radiographic findings will be used to confirm the clinical findings of resolution of the infection.

A 51-year-old woman will be taking selective estrogen receptor modulators (SERMs) as part of treatment for postmenopausal osteoporosis. The nurse reviews potential contraindications, including which condition? A. Hypocalcemia B. Breast cancer C. Stress fractures D. Venous thromboembolism

D. Venous thromboembolism SERMs such as raloxifene are contraindicated in women with venous thromboembolic disorder, including deep vein thrombosis, pulmonary embolism, or a history of such disorders. The other options are incorrect.

Components of the GCS the nurse would use to assess a patient after a head injury include A. Blood pressure B. Cranial nerve function C. Head circumference D. Verbal responsiveness

D. Verbal responsiveness Components of GCS include eye opening, motor responsiveness , and verbal responsiveness. The nurse would want to assess the blood pressure, but this is not a component of comma scale. Assessment of cranial nerve function is appropriate as alterations such as cranial nerve VI palsies may occur, but this is not part of the coma scale. Increases in head circumference are associated with alterations in ICP in infants, but this is not part of the coma scale.

Primary prevention strategies to reduce the occurrence of head injuries would include A. Blood pressure control B. Smoking cessation C. Maintaining a healthy weight D. Violence prevention

D. Violence prevention Injury prevention measures such as wearing a seat belt, helmet use, firearm safety, and violence prevention programs reduce the risk of traumatic brain injuries. Blood pressure control and exercising can decrease the risk of vascular disease, impacting the cerebral arteries, rather than head injuries. Smoking cessation is one primary prevention strategy which can decrease the risk of vascular disease. Maintaining a healthy weight can decrease the risk of vascular disease.

A client with sickle cell disease (SCD) takes hydroxyurea (Droxia). The client presents to the clinic reporting an increase in fatigue. What laboratory result should the nurse report immediately? A. Hematocrit: 25% B. Hemoglobin: 9.2 C. Potassium: 3.2 D. WBC: 38,000

D. WBC: 38,000 Although individuals with SCD often have elevated WBC counts, this extreme elevation could indicate leukemia, a complication of taking hydoxyurea. The nurse should report this finding immediately. Alternatively, it could indicate infection, a serious problem for clients with SCD. Hematocrit and hemoglobin levels are normally low in people with SCD. The potassium level, while slightly low, is not worrisome as the WBCs.

When assessing a patient who has ingested flunitrazepam (Rohypnol), the nurse would expect: a. acrophobia. b. hypothermia. C. hallucinations. D. anterograde amnesia.

D. anterograde amnesia. Flunitrazepam is known as the date rape drug. It produces disinhibition and a relaxation of voluntary muscles, as well as anterograde amnesia for events that occur. The other options do not reflect symptoms commonly observed after use of this drug.

A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is: a. jaundiced. b. dependent on alcohol. C. healthy but underweight. D. microcephalic and cognitively impaired.

D. microcephalic and cognitively impaired. Fetal alcohol syndrome is the result of alcohol inhibiting fetal development in the first trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder. Alcohol use during pregnancy is not likely to produce the findings listed in the distractors.

Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction? a. methadone (Dolophine) b. bromocriptine (Parlodel) C. disulfiram (Antabuse) D. naltrexone (Revia)

D. naltrexone Naltrexone is useful for treating both opioid and alcohol addictions. As an opioid antagonist, it blocks the action of opioids. Because it blocks the mechanism of reinforcement, it also reduces or eliminates alcohol craving.

A patient comes to an outpatient appointment obviously intoxicated. The nurse should: a. explore the patient's reasons for drinking today. b. arrange admission to an inpatient psychiatric unit. C. coordinate emergency admission to a detoxification unit. D. tell the patient, We cannot see you today because you've been drinking.

D. tell the patient, We cannot see you today because you've been drinking. One cannot conduct meaningful therapy with an intoxicated patient. The patient should be taken home to recover and then make another appointment. Hospitalization is not necessary.

***The nurse is caring for a young client who has acquired immune deficiency syndrome (AIDS) and a very low CD4+ cell count. The nurse is teaching the client how to avoid infection at home. Which statement by the client indicates that additional teaching is needed? a. I will let my sister clean my pet iguanas cage from now on. b. My brother will change the kitty litter box from now on. c. It will seem funny but I'll run my toothbrush through the dishwasher. d. I will not drink juice that has been sitting out for longer than an hour.

I will let my sister clean my pet iguanas cage from now on. Immunocompromised clients should avoid having reptiles or turtles as pets and should avoid changing cat litter to help prevent opportunistic infections. Drinking juice that has been at room temperature for longer than 1 hour can lead to opportunistic infection and should be avoided. Clients should clean their toothbrushes daily by running them in the dishwasher or rinsing them in liquid laundry bleach.

The nurse is planning a cancer education event in an Asian community center. The nurse plans to present information specifically on which types of cancer? a. Breast and colorectal b. Skin and lymphoma c. Liver and stomach d. Uterine and ovarian

a. Breast and colorectal Asians have higher rates of breast, colorectal, prostate, lung, and stomach cancers than are seen in the general population.

A client who has had total hip replacement surgery asks the nurse when she will be able to use a regular-height toilet seat again. What is the nurse's best response? a. As soon as you are able to walk without a limp. b. As soon as the staples are removed from the incision. c. When you are off pain medication and warfarin (Coumadin). d. When you can hold your leg 6 inches off the bed for 5 full minutes.

a. As soon as you are able to walk without a limp. When the client is able to walk without a limp, the artificial joint is seated sturdily enough in place that it will not be dislocated or dislodged by overflexing it. At that time, the client will no longer need assistive devices or ambulatory aids. With staples removed, holding the leg off the bed and taking Coumadin do not affect readiness to bend the hip enough to use a regular toilet seat.

The nurse is caring for a client who is disoriented as the result of a stroke. Which action will the nurse implement to help orient this client? a. Ask the family to bring in pictures familiar to the client. b. Turn on the television to a 24-hour news station. c. Maintain a calm and quiet environment by minimizing visitors. d. Provide auditory and visual stimulation simultaneously.

a. Ask the family to bring in pictures familiar to the client. For the client with disorientation, the nurse can request that the family bring in pictures or objects that are familiar to the client. The nurse explains what the object or picture represents in simple terms. These stimuli can be presented several times daily. Visitors can also be familiar stimuli to reorient the client. Too much stimuli and constant stimuli can lead to further confusion.

A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a. Ask the spouse to explain the fear of visiting in further detail. b. Inform the spouse the precautions are meant to keep other clients safe. c. Show the spouse how to follow the isolation precautions to avoid illness. d. Tell the spouse that he or she has already been exposed, so it's safe to visit.

a. Ask the spouse to explain the fear of visiting in further detail. The nurse needs to obtain further information about the spouses specific fears so they can be addressed. This will decrease stress and permit visitation, which will be beneficial for both client and spouse. Precautions for TB prevent transmission to all who come into contact with the client. Explaining isolation precautions and what to do when entering the room will be helpful, but this is too narrow in scope to be the best answer. Telling the spouse it's safe to visit is demeaning of the spouses feelings.

The nurse is caring for a postoperative client on the medical-surgical unit following a total left hip replacement the previous day. During the assessment, the nurse notes that the client's left leg is cool, with weak pedal pulses. What is the nurse's first action? a. Assess circulatory status of the right leg. b. Notify the surgeon immediately. c. Measure leg circumference at the calf. d. Check for bilateral Homans signs.

a. Assess circulatory status of the right leg. The symptoms may represent impaired circulation or may be normal for this client. Before the surgeon is notified, the status of the nonoperative leg should be assessed and assessment findings on both legs compared with the client's baseline. Homans sign (pain in the calf on dorsiflexion of the foot) is not always indicative of a deep vein thrombosis and should not be evaluated until other assessments are made. Measuring calf circumference would provide additional data related to deep vein thrombosis.

Which instruction does the nurse include in the discharge teaching plan for a client who has osteoporosis? a. Avoid using scatter rugs. b. Avoid weight-bearing exercises. c. Use a cane when walking outside. d. Reduce the amount of protein in your diet.

a. Avoid using scatter rugs. To avoid falls, the client should keep a hazard-free environment, including avoiding scatter rugs, cluttered rooms, and wet floor areas. Weight-bearing exercises help prevent bone resorption. A cane is not needed unless the client has a physical disability. A protein deficiency should be avoided because it might cause a reduction in bone density.

What is the most common reproductive tract cancer associated with pregnancy? a. Cervical b. Uterine c. Ovarian d. Fallopian tube

a. Cervical The incidence of cervical cancer concurrent with pregnancy is reported to be 1 in 2000 pregnancies making it the most common reproductive tract cancer associated with pregnancy. Uterine cancer is rarely diagnosed during pregnancy. Ovarian cancer is the second most frequent cancer diagnosis in pregnancy. At an incidence rate of approximately 1%, fallopian tube cancer remains a rare occurrence. The peak incidence of tubal cancer is between the ages of 50 and 55 years; for this cancer to be concurrent with pregnancy is only a remote possibility.

Which instruction is most important for the RN to provide to the nursing assistant assigned to care for a client with primary osteoporosis? a. Clean up the clutter in the room. b. Encourage the client to bathe herself or himself. c. Monitor urinary output. d. Perform passive range-of-motion exercises.

a. Clean up the clutter in the room. Clients with osteoporosis are at risk for fracture when they fall. Clutter in the room is a risk factor for falls. The other choices have nothing to do with prevention of bone fracture in a client with primary osteoporosis.

A nursing instructor needs to evaluate students' abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructors needs? a. Concept mapping b. Reflective journaling c. Reading assignment with a written summary d. Lecture and discussion

a. Concept mapping Concept maps challenge the student to synthesize data and identify relationships between nursing diagnoses. Reflective journaling involves thinking back to clarify concepts. Reading assignments and lecture do not best provide an instructor the ability to evaluate students' abilities to synthesize data.

Critical thinking characteristics include a. Considering what is important in a given situation. b. Accepting one, established way to provide patient care. c. Making decisions based on intuition. d. Being able to read and follow physician's orders.

a. Considering what is important in a given situation. Critical thinking involves being able to decipher what is relevant and important in a given situation and to make a clinical decision based on that importance. Patient care can be provided in many ways. Clinical decisions should be based on evidence and research. Following physicians orders is not considered a critical thinking skill.

The nurse is assessing a patient's functional performance. What assessment parameters will be most important in this assessment? a. Continence assessment, gait assessment, feeding assessment, dressing assessment, transfer assessment b. Height, weight, body mass index (BMI), vital signs assessment c. Sleep assessment, energy assessment, memory assessment, concentration assessment d. Healthy individual, volunteers at church, works part time, takes care of family and house

a. Continence assessment, gait assessment, feeding assessment, dressing assessment, transfer assessment Functional impairment, disability, or handicap refers to varying degrees of an individual's inability to perform the tasks required to complete normal life activities without assistance. Height, weight, BMI, and vital signs are physical assessment. Sleep, energy, memory, and concentration are part of a depression screening. Healthy, volunteering, working, and caring for family and house are functional abilities, not performance.

A woman has preinvasive cancer of the cervix. Which modality would the nurse discuss as an available option for a client with this condition? a. Cryosurgery b. Colposcopy c. Hysterectomy d. Internal radiation

a. Cryosurgery Cryosurgery, laser surgery, and loop electrosurgical excision procedure (LEEP) are several techniques used to treat preinvasive lesions. Colposcopy is an examination of the cervix with a stereoscopic binocular microscope that magnifies the view of the cervix. This examination would have already been performed as part of the diagnosis of preinvasive cancer of the cervix. A hysterectomy is performed if the cancer has extended beyond the cervix. Women with positive pelvic nodes (indicating invasive cancer) usually receive whole pelvis irradiation.

The nurse is worried that a client who is not entirely reliable is being discharged home on therapy for multidrug-resistant tuberculosis. What strategy is the best to use for this client? a. Directly observed therapy b. IV drug administration c. Remaining in the hospital d. Isolation

a. Directly observed therapy If a client is not reliable, the risk is that the client will not take medications as required, causing spread of an organism that may become more drug resistant. The other answers are not correct.

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity

a. Educating the client on adherence to the treatment regimen The treatment regimen for TB ranges from 6 to 12 months, making adherence problematic for many people. The nurse should stress the absolute importance of following the treatment plan for the entire duration of prescribed therapy. The other options are appropriate topics to educate this client on but do not take priority.

As part of the diagnostic evaluation of a child with cancer, biopsies are important for staging. What statement explains what staging means? a. Extent of the disease at the time of diagnosis b. Rate normal cells are being replaced by cancer cells c. Biologic characteristics of the tumor or lymph nodes d. Abnormal, unrestricted growth of cancer cells producing organ damage

a. Extent of the disease at the time of diagnosis Staging is a description of the extent of the disease at the time of diagnosis. Staging criteria exist for most tumors. The stage usually relates directly to the prognosis; the higher the stage, the poorer the prognosis. The rate that normal cells are being replaced by cancer cells is not a definition of staging. Classification of the tumor refers to the biological characteristics of the tumor or lymph nodes. Abnormal, unrestricted growth of cancer cells producing organ damage describes how cancer cells grow and can cause damage to an organ.

The nurse is caring for a client with HIV who has been prescribed didanosine (Videx EC). Which action by the nurse is most appropriate? a. Help the client plan specific meal and dosing times. b. Explain that the client will have frequent complete blood counts (CBCs) drawn. c. Advise the client to take Videx EC with milk or a small meal. d. Tell the client to take Tylenol (acetaminophen) for any abdominal pain.

a. Help the client plan specific meal and dosing times. Videx EC must be taken on an empty stomach 30 minutes before or 2 hours after a meal. The nurse should assist the client in planning a daily schedule that includes meals and drug doses. Videx does not affect bone marrow, so frequent CBCs are not needed. A client on this drug who reports abdominal pain should be assessed for pancreatitis, a common adverse effect.

Which intervention is most important for the nurse to teach the client who is recovering from an allergic reaction to a bee sting? a. How to use an EpiPen b. Wearing a medical alert bracelet c. Avoiding contact with the allergen d. Keeping diphenhydramine (Benadryl) available

a. How to use an EpiPen If an anaphylactic reaction starts, the client will need to self-medicate very rapidly with the EpiPen. He or she should carry it at all times and should be proficient in its assembly and use. This is the highest priority intervention. The client should get a medical alert bracelet and keep away from bees if at all possible. It is also advised that diphenhydramine be kept on hand in case of a less severe reaction.

After chemotherapy is begun for a child with acute leukemia, prophylaxis to prevent acute tumor lysis syndrome includes which therapeutic intervention? a. Hydration b. Oxygenation c. Corticosteroids d. Pain management

a. Hydration Acute tumor lysis syndrome results from the release of intracellular metabolites during the initial treatment of leukemia. Hyperuricemia, hypocalcemia, hyperphosphatemia, and hyperkalemia can result. Hydration is used to reduce the metabolic consequences of the tumor lysis. Oxygenation is not helpful in preventing acute tumor lysis syndrome. Allopurinol, not corticosteroids, is indicated for pharmacologic management. Pain management may be indicated for supportive therapy of the child, but it does not prevent acute tumor lysis syndrome.

An older adult client is scheduled for knee replacement surgery. Which statement by the client indicates a need for further preoperative instruction? a. I need to keep my leg positioned away from my body. b. I may have a continuous passive motion machine for a few days. c. I may need more pain medicine than I did with my hip replacement. d. I probably can get back to work within 2 to 3 weeks.

a. I need to keep my leg positioned away from my body. Dislocation is not a problem with knee replacement surgery, so the client does not need to keep his or her leg abducted. The other statements indicate accurate understanding of the instructions.

The nurse is teaching a community health class about health promotion techniques. Which statement by a student indicates a strategy to help prevent the development of osteoarthritis? a. I will keep my BMI under 24. b. I will switch to low-tar cigarettes. c. I will start jogging twice a week. d. I will have a family tree done.

a. I will keep my BMI under 24. Obesity increases the stress on weight-bearing joints and contributes to the development of degenerative joint disease. Smoking does not decrease risk for osteoarthritis. Jogging increases the risk because of increased wear and tear on the joints. There is a genetic link to osteoarthritis; creating a family tree might help the client discover if there is any familial link but will not help prevent the disorder.

The nurse is assessing a client who had a stroke in the right cerebral hemisphere. Which neurologic deficit does the nurse assess for in this client? a. Impaired proprioception b. Aphasia c. Agraphia d. Impaired olfaction

a. Impaired proprioception A stroke to the right cerebral hemisphere causes impaired visual and spatial awareness. The client may present with impaired proprioception and may be disoriented as to time and place. The right cerebral hemisphere does not control speech, smell, or the client's ability to write.

A client has experienced a stroke resulting in damage to Wernicke's area. Which clinical manifestation does the nurse monitor for? a. Inability to comprehend spoken words b. Communication with rote speech only c. Slurred speech d. Inability to make sounds

a. Inability to comprehend spoken words The client with damage to Wernicke's area cannot understand spoken or written words. If the client speaks, the language is meaningless, with the client using made-up words. Damage to Wernicke's area does not cause slurred speech, nor will the client communicate with habitual speech only.

The nurse correlates initiation in cancer development with which action? a. Inflicting mutations that lead to excessive cell division b. Increasing the capacity of the transformed cell for error-free DNA repair c. Stimulating contact inhibition in cells damaged by a carcinogen d. Making cancer cells appear more normal to escape immune surveillance

a. Inflicting mutations that lead to excessive cell division The process of initiation induces changes in the genes that allow proto-oncogenes to be activated to oncogene status and to be expressed.

In preparing a cancer risk reduction pamphlet for African-American clients, it is most important that the nurse include information on prevention and early detection for which types of cancer? a. Lung and prostate b. Bone and leukemia c. Skin and lymphoma d. Stomach and esophageal

a. Lung and prostate African Americans have higher incidences of lung, prostate, breast, colorectal, and uterine cancers than are seen in the general population.

What is appropriate mouth care for a toddler with mucosal ulceration related to chemotherapy? a. Mouthwashes with plain saline b. Lemon glycerin swabs for cleansing c. Mouthwashes with hydrogen peroxide d. Swish and swallow with viscous lidocaine

a. Mouthwashes with plain saline Administering mouth care is particularly difficult in infants and toddlers. A satisfactory method of cleaning the gums is to wrap a piece of gauze around a finger; soak it in saline or plain water; and swab the gums, palate, and inner cheek surfaces with the finger. Mouth rinses are best accomplished with plain water or saline because the child cannot gargle or spit out excess fluid. Avoid agents such as lemon glycerin swabs and hydrogen peroxide because of the drying effects on the mucosa. Lidocaine should be avoided in young children.

What does impetigo ordinarily results in? a. No scarring b. Pigmented spots c. Atrophic white scars d. Slightly depressed scars

a. No scarring Impetigo tends to heal without scarring unless a secondary infection occurs.

A client with rheumatoid arthritis had abdominal surgery and has returned to the postoperative nursing unit. The client is unable to use the incentive spirometer correctly, demonstrating limited lung volume and fatiguing easily. What action by the nurse takes priority? a. Notify the physician immediately. b. Have respiratory therapy re-instruct the client. c. Assess for pain and medicate if necessary. d. Let the client rest for a few hours.

a. Notify the physician immediately. Clients with rheumatoid arthritis can have cervical spine involvement resulting in subluxation. This may lead to decreased respiratory function and can be life threatening. This client was recently intubated for an operation and so is at a higher risk for this problem. The nurse should notify the physician immediately and continue assessing the client.

A client recently had a mammogram. Which statement by the client indicates a need for clarification regarding the importance or purpose of this procedure? a. Now that I have had a mammogram, my risk of getting breast cancer is reduced. b. I will still do a breast self-examination monthly even after the mammogram. c. Yearly mammograms can reduce my risk of dying from breast cancer. d. The amount of radiation exposure from a mammogram is very low.

a. Now that I have had a mammogram, my risk of getting breast cancer is reduced. Regular or yearly mammography does not decrease the incidence of breast cancer. It only assists in early detection and diagnosis and decreases the mortality rate from breast cancer. The client should be instructed that the mammogram uses a very small amount of radiation in the test, and that consistent scheduling of a mammogram, along with a breast self-examination performed at least monthly, can reduce the client's risk of dying from breast cancer.

A client with a history of breast cancer is admitted through the emergency department with shortness of breath, weakness, fatigue, and new lower extremity edema. The client's oxygen saturation is 88%. After stabilizing the client, which action by the nurse is most important? a. Obtain a list of the client's medications. b. Orient her to her room and surroundings. c. Place the client on intake and output. d. Assess the clients family cardiac history.

a. Obtain a list of the client's medications. Some chemotherapeutic drugs, such as doxorubicin (Adriamycin) and trastuzumab (Herceptin), are known to be cardiotoxic. Although all other actions are appropriate, the nurse (and the provider) must know the medications the client is on, with specific emphasis on assessing for causative agents.

A client had a total knee replacement this morning and has a continuous passive motion (CPM) machine. What activity related to the CPM does the RN delegate to the unlicensed assistive personnel? a. Placing controls out of the reach of confused clients b. Assessing the client's response to the CPM c. Teaching the clients family the rationale for the CPM d. Assessing neurovascular status of the leg in the CPM

a. Placing controls out of the reach of confused clients All activities are appropriate for the client with a CPM, but the nurse can delegate only the task of keeping controls out of reach of the confused client. All other activities would need to be performed by the RN.

The nurse is caring for a client who is HIV positive. The client has become confused over the course of the shift, and the client's pupils are no longer reacting to light equally. The nurse anticipates an order for which medication? a. Prednisone (Deltazone) b. Trimethoprim/sulfamethoxazole (Bactrim) c. Pentamidine isethionate (Pentam) d. Ketoconazole (Nizoral)

a. Prednisone (Deltazone) Confusion and changes in pupillary assessment in an HIV-positive client indicate increased intracranial pressure (ICP). Increased ICP in these clients is managed with corticosteroids like prednisone. Bactrim is an antibiotic, Pentam is an antiprotozoal, and Nizoral is an antifungal medication.

When performing a clinical breast examination on a client, the nurse palpates a thickened area where the skin folds under the breast. Which is the nurses best action? a. Proceed with the examination. b. Determine whether the thickness is bilateral. c. Ask how long the thickness has been present. d. Change the client's position and reassess.

a. Proceed with the examination. A thickened area where the skin folds under the breast is the inframammary ridge, a normal anatomic finding. Clients should be taught to identify this ridge and not confuse it with the presence of a lump or abnormal tissue thickening. Because this is a normal finding, no concern is necessary about whether it is present bilaterally or occurs in a different position, or how long the finding has been notable.

Which diagnostic test should the nurse anticipate being ordered for this client? a. Punch skin biopsy b. Viral cultures c. Wood's lamp examination d. Diascopy

a. Punch skin biopsy This lesion is suspicious for skin cancer and a biopsy is needed. A viral culture would not be appropriate. A Woods lamp examination is used to determine if skin lesions have characteristic color changes. Diascopy eliminates erythema, making skin lesions easier to examine.

When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After one year of drinking, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur? a. Tolerance develops. b. The alcohol is less potent. c. Antagonistic effects occur. d. Hypomagnesemia develops.

a. Tolerance develops. Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects would account for this change.

A young child with leukemia has anorexia and severe stomatitis. What approach should the nurse suggest that the parents try? a. Relax any eating pressures. b. Firmly insist that the child eat normally. c. Serve foods that are either hot or cold. d. Provide only liquids because chewing is painful.

a. Relax any eating pressures. A multifaceted approach is necessary for children with severe stomatitis and anorexia. First, the parents should relax eating pressures. The nurse should suggest that parents try soft, bland foods; normal saline or bicarbonate mouthwash; and local anesthetics. Insisting that the child eat normally is not suggested. For some children, not eating may be a way to maintain some control. This can set the child and caregiver in opposition to each other. Hot and cold foods can be painful on ulcerated mucosal membranes. Substitution of high-calorie foods that the child likes and can eat should be used.

A client is scheduled for surgery after a recent breast cancer diagnosis. The nurse is discussing the procedure with the client. To allay her fears, which explanation best describes a skin-sparing mastectomy? a. Removal of the breast, nipple, and areola, leaving only the skin b. Removal of the breast, nipple, areola, and axillary node dissection c. Incision on the outside of the breast, leaving the nipple intact d. Removal of both breasts in their entirety

a. Removal of the breast, nipple, and areola, leaving only the skin A skin-sparing mastectomy is a special procedure that keeps the outer breast of the skin intact. The breast, nipple, and areola are removed. A tissue expander may be placed for later reconstruction. A modified radical mastectomy also removes the axillary lymph nodes. The nipple-sparing mastectomy is reserved for a small number of women during which the areola is removed leaving the nipple intact. Women who test positive for the BRCĀ or BRCÁ gene mutation may have both breasts removed to reduce the risk of cancer and is most commonly known as a prophylactic or preventative mastectomy.

***The nurse is caring for a young woman at the primary health care clinic. Which assessment finding leads the nurse to question the client about risk factors for HIV? a. Six vaginal yeast infections in the last 12 months b. Unable to become pregnant for the last 2 years c. Severe cramping and irregular periods d. Very heavy periods and breakthrough bleeding

a. Six vaginal yeast infections in the last 12 months Persistent or recurrent vaginal candidiasis may be the first symptom of HIV in women. Decreased immune function allows overgrowth of this fungus. Infertility, heavy periods, and cramping are not generally indicative of HIV.

A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. What technique should the nurse suggest to remove this material? a. Soak in a bathtub. b. Vigorously scrub the leg. c. Carefully pick material off the leg. d. Apply powder to absorb the material.

a. Soak in a bathtub.

A student athlete was injured during a basketball game. The nurse observes significant swelling. The player states he thought he heard a pop, that the pain is pretty bad, and that the ankle feels as if it is coming apart. Based on this description, the nurse suspects what injury? a. Sprain b. Fracture c. Dislocation d. Stress fracture

a. Sprain Sprains account for approximately 75% of all ankle injuries in children. A sprain results when the trauma is so severe that a ligament is either stretched or partially or completely torn by the force created as a joint is twisted or wrenched. Joint laxity is the most valid indicator of the severity of a sprain. A fracture involves the cross-section of the bone. Dislocations occur when the force of stress on the ligaments disrupts the normal positioning of the bone ends. Stress fractures result from repeated muscular contraction and are seen most often in sports involving repetitive weight bearing such as running, gymnastics, and basketball.

The nurse is caring for a client who is 1 day post total hip replacement. The nurse is instructing the client about how to perform quadriceps-setting exercises correctly. Which direction does the nurse provide to the client? a. Straighten your legs and push the back of your knees into the mattress. b. Straighten your legs and bring each leg separately off the mattress 6 inches. c. Raise each leg 10 inches off the bed, keep it straight, and make ankle circles. d. Bend each knee, and rapidly point your toes downward and then upward.

a. Straighten your legs and push the back of your knees into the mattress. Quadriceps-setting exercises are done by straightening the leg as much as possible by attempting to push the back of the knees into the mattress. The other exercises may be performed by the client as tolerated, but these items do not describe quadriceps-setting exercises.

During a staff meeting, a nurse who is mentoring new BSN graduate states, "We are lucky to have a new nurse join our staff who is a BSN graduate from our local university." Another staff nurse is heard saying, "BSN. BSN is you don't have a BSN you aren't valued. You don't see anyone welcoming any nurses with associate degrees—we are not valued." The conversation places the mentor in a negative position when her intention was simply to welcome the new employee. The staff nurse's negative response represents which logical fallacy? a. Straw man b. Appeal to tradition c. Confusing Cause and Effect d. Appeal to Common Practice

a. Straw man Straw man occurs when a person's position on a topic is misrepresented.

During history-taking, a patient tells the nurse that he is addicted to alprazolam (Xanax) and that he takes six 1 mg tablets a day. He quit cold turkey yesterday and now presents with extreme agitation, increased heart rate, and panic. The nurse suspects which disorder? a. Stress reaction b. DTs c. Overdose d. Relapse

a. Stress reaction Stress reaction is a withdrawal symptom that can occur when detoxing too quickly. DTs are usually associated with alcohol withdrawal. Overdose of alprazolam would present with extreme drowsiness, confusion, muscle weakness, and loss of balance or coordination. The effects of alprazolam are dizziness, drowsiness, dry mouth, and lightheadedness.

A client had a mastectomy nearly a year ago and is distressed over continued tingling and burning in the ipsilateral arm. What orders does the nurse prepare to implement? a. Teach the client about gabapentin (Neurontin). b. Demonstrate the use of heat therapy to the axilla. c. Discuss ways to prevent constipation with pain meds. d. Reassure the client that this will disappear shortly.

a. Teach the client about gabapentin (Neurontin). Injury to nerves causes paresthesias such as burning, tingling, pins and needles, and numbness after a mastectomy. These sensations are usually gone by the end of the year. Because this clients symptoms are distressing and have lasted so long, the nurse should anticipate an order for Neurontin. Narcotic pain medications will not be helpful or needed. Heat therapy may or may not be helpful, and reassuring the client at this point will sound unbelievable.

A client who is receiving highly active antiretroviral therapy (HAART) tells the nurse, The doctor said that my viral load is reduced. What does this mean? What is the nurse's best response? a. The HAART medications are working well right now. b. You are not as contagious as you were anymore. c. Your HIV infection is becoming resistant to your medications. d. You are developing an opportunistic infection.

a. The HAART medications are working well right now. The fact that the amount of virus is reduced means that the HAART regimen is working well to suppress viral replication. The risk of becoming infected by an HIV-positive person is always present. The reduced viral load is not related to an opportunistic infection or resistance to medication.

What important, immediate postoperative care practice should the nurse remember when caring for a woman who has had a mastectomy? a. The blood pressure (BP) cuff should not be applied to the affected arm. b. Venipuncture for blood work should be performed on the affected arm. c. The affected arm should be used for intravenous (IV) therapy. d. The affected arm should be held down close to the woman's side.

a. The blood pressure (BP) cuff should not be applied to the affected arm. The affected arm should not be used for BP readings, IV therapy, or venipuncture. The affected arm should be elevated with pillows above the level of the right atrium.

A client with a history of rheumatoid arthritis will be starting drug therapy with etanercept (Enbrel). What is most important for the nurse to teach the client? a. The correct technique for subcutaneous injections b. How to self-monitor blood glucose levels c. How to set up and prime the IV tubing d. How to calculate the dosage based on symptoms

a. The correct technique for subcutaneous injections Enbrel is a parenteral medication that is given by subcutaneous injection. The client and/or the family will need to be taught how to give a subcutaneous injection correctly. Blood glucose levels should not be affected by this medication. The medication is not administered IV. Drug dosages are not changed and recalculated by the client.

A client who first experienced symptoms related to a confirmed thrombotic stroke 2 hours ago is brought to the intensive care unit. Which prescribed medication does the nurse prepare to administer? a. Tissue plasminogen activator b. Heparin sodium c. Gabapentin (Neurontin) d. Warfarin (Coumadin)

a. Tissue plasminogen activator The client who has had a thrombotic stroke has a 3-hour time frame from the onset of symptoms to receive recombinant tissue plasminogen activator (rt-PA) to dissolve the cerebral artery occlusion and re-establish blood flow. Clients must meet eligibility criteria for the administration of this therapy. The other medications do not assist in the re-establishment of blood flow for a client with a confirmed thrombotic stroke.

A client with aphasia presents to the emergency department with a suspected brain attack. Which clinical manifestation leads the nurse to suspect that this client has had a thrombotic stroke? a. Two episodes of speech difficulties in the last month b. Sudden loss of motor coordination c. A grand mal seizure 2 months ago d. Chest pain and nuchal rigidity

a. Two episodes of speech difficulties in the last month Thrombotic stroke is characterized by a gradual onset of symptoms that often are preceded by transient ischemic attacks (TIAs), causing a focal neurologic dysfunction. Two episodes of speech difficulties would correlate with TIAs. The other manifestations are not related to a thrombotic stroke.

A client has undergone cryosurgery for stage I cervical cancer. Which precaution or action does the nurse teach this client? a. Use sanitary napkins to manage discharge for the next several weeks. b. Avoid sexual intercourse or becoming pregnant for the next 12 months. c. If you should become pregnant, you will be at an increased risk for preterm labor. d. Your next menstrual cycle will be delayed because of this procedure.

a. Use sanitary napkins to manage discharge for the next several weeks. The effects of cryosurgery include a heavy, watery vaginal discharge for 3 to 6 weeks after the procedure. Clients are cautioned to avoid the use of tampons and intercourse during this time to reduce the risk for infection. The other statements are inaccurate.

The nurse is preparing an airborne infection isolation room for a patient. Which communicable disease does the patient likely have? a. Varicella b. Pertussis c. Influenza d. Scarlet fever

a. Varicella An airborne infection isolation room is the isolation for persons with a suspected or confirmed airborne infectious disease transmitted by the airborne route such as measles, varicella, or tuberculosis. Pertussis, influenza, and scarlet fever require droplet transmission precautions.

The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The client's surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best? a. Assess neurovascular status in both legs. b. Elevate the affected leg and apply ice. c. Prepare to administer pain medication. d. Try to place the affected leg in abduction.

a. Assess neurovascular status in both legs. This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse should thoroughly assess the client.

A staff nurse reports a medication error, failure to administer a medication at the scheduled time. An appropriate response of the charge nurse would be a. We'll do a root cause analysis. b. That means you'll have to do continuing education. c. Why did you let that happen? d. You'll need to tell the patient and family.

a. We'll do a root cause analysis. In a just culture the nurse is accountable for their actions and practice, but people are not punished for flawed systems. Through a strategy such as root cause analysis the reasons for errors in medication administration can be identified and strategies developed to minimize future occurrences. Requiring continued education may be an appropriate recommendation but not until data is collected about the event. Telling the patient is part of transparency and the sharing and disclosure among stakeholders, but it is generally the role of risk management staff, not the staff nurse.

A client recently diagnosed with lung cancer is being taught by the nurse. What information does the nurse teach the client? a. You will receive 6 weeks of daily radiation therapy. b. Lung cancer has a very good prognosis. c. Further testing is not needed because lung cancer rarely metastasizes. d. It is very likely that surgery will be curative.

a. You will receive 6 weeks of daily radiation therapy. This is the only statement that is accurate. Small doses of radiation given over long periods are an effective routine treatment. Lung cancer does not have a good prognosis, and it often metastasizes. Surgery often is only palliative.

The nurse preparing to care for a patient after a suspected stroke would question an order for a(n) a. antihypertensive. b. antipyretic. c. osmotic diuretic. d. sedative.

a. antihypertensive. Anti-hypertensive medications may be detrimental because the mean arterial pressure must be adequate to maintain cerebral blood flow and limit secondary injury. Fever can worsen the outcome after a stroke, and antipyretics can promote normothermia. Osmotic diuretics such as mannitol can decrease interstitial volume and decrease intracranial pressure. Short-acting sedatives can decrease intracranial pressure by reducing metabolic demand. Long-acting sedatives would be avoided to provide times for periodic neurologic assessments.

Controlling pain is important to promoting wellness. Unrelieved pain has been associated with a. prolonged stress response and a cascade of harmful effects system-wide. b. large tidal volumes and decreased lung capacity. c. decreased tumor growth and longevity. d. decreased carbohydrate, protein, and fat destruction.

a. prolonged stress response and a cascade of harmful effects system-wide. Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrates, protein, and fat destruction, which can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevity are not associated with unrelieved pain. Decreased carbohydrate, protein, and fat are not associated with pain or stress response.

A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke? a. A 27-year-old heavy cocaine user b. A 30-year-old who drinks a beer a day c. A 40-year-old who uses seasonal antihistamines d. A 65-year-old who is active and on no medications

a. A 27-year-old heavy cocaine user Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this client uses them seasonally and there is no information that they are abused or used heavily. The 65-year-old has only age as a risk factor.

A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching? a. Acetaminophen (Tylenol) b. Cyclobenzaprine hydrochloride (Flexeril) c. Hyaluronate (Hyalgan) d. Ibuprofen (Motrin)

a. Acetaminophen All of the drugs are appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug.

A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The client's vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpÓ 88%. Which action should the nurse take first? a. Administer oxygen via nasal cannula. b. Re-position to a high-Fowler's position. c. Increase the intravenous flow rate. d. Assess response to pain medications.

a. Administer oxygen via nasal cannula. The client is at high risk for a fat embolism and has some of the clinical manifestations of altered mental status and dyspnea. Although this is a life-threatening emergency, the nurse should take the time to administer oxygen first and then notify the health care provider. Oxygen administration can reduce the risk for cerebral damage from hypoxia. The nurse would not restrain a client who is confused without further assessment and orders. Sitting the client in a high-Fowler's position will not decrease hypoxia related to a fat embolism. The IV rate is not related. Pain medication most likely would not cause the client to be restless.

What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement? a. Administer preoperative antibiotics as ordered. b. Assess the client's white blood cell count. c. Instruct the client to shower the night before. d. Monitor the client's temperature postoperatively.

a. Administer preoperative antibiotics as ordered. To prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery. Simply taking a shower will not help prevent infection unless the client is told to use special antimicrobial soap. The other options are processes to monitor for infection, not prevent it.

A client suffered an episode of anaphylaxis and has been stabilized in the intensive care unit. When assessing the client's lungs, the nurse hears the following sounds. What medication does the nurse prepare to administer? a. Albuterol (Proventil) via nebulizer b. Diphenhydramine (Benadryl) IM c. Epinephrine 1:10,000 5 mg IV push d. Methylprednisolone (Solu-Medrol) IV push

a. Albuterol (Proventil) via nebulizer The nurse has auscultated wheezing in the client's lungs and prepares to administer albuterol, which is a bronchodilator, or assists respiratory therapy with administration. Diphenhydramine is an antihistamine. Epinephrine is given during an acute crisis in a concentration of 1:1000. Methylprednisolone is a corticosteroid.

A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care? a. Allow the client to be as independent as possible with activities. b. Assist the client with frequent and meticulous oral care. c. Assess the client's ability to eat and swallow before each meal. d. Schedule appointments early in the morning to ensure rest in the afternoon.

a. Allow the client to be as independent as possible with activities Clients with Parkinson disease do not move as quickly and can have functional problems. The client should be encouraged to be as independent as possible and provided time to perform activities without rushing. Although oral care is important for all clients, instructing the UAP to provide frequent and meticulous oral is not a priority for this client. This statement would be a priority if the client was immune-compromised or NPO. The nurse should assess the client's ability to eat and swallow; this should not be delegated. Appointments and activities should not be scheduled early in the morning because this may cause the client to be rushed and discourage the client from wanting to participate in activities of daily living.

After a stroke, a client has ataxia. What intervention is most appropriate to include on the client's plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform post-void residuals.

a. Ambulate only with a gait belt. Ataxia is a gait disturbance. For the clients safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding.

A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best? a. Arrange a home safety evaluation. b. Ensure the client has a walker at home. c. Help the client look into assisted living. d. Refer the client to Meals on Wheels.

a. Arrange a home safety evaluation. This client has several risk factors that place him or her at a high risk for falling. The nurse should consult social work or home health care to conduct a home safety evaluation. The other options may or may not be needed based upon the client's condition at discharge.

A group of nursing students has entered a futuristic science contest in which they have developed a cure for cancer. Which treatment would most likely be the winning entry? a. Artificial fibronectin infusion to maintain tight adhesion of cells b. Chromosome repair kit to halt rapid division of cancer cells c. Synthetic enzyme transfusion to allow rapid cellular migration d. Telomerase therapy to maintain chromosomal immortality

a. Artificial fibronectin infusion to maintain tight adhesion of cells Cancer cells do not have sufficient fibronectin and so do not maintain tight adhesion with other cells. This is part of the mechanism of metastasis. Chromosome alterations in cancer cells (aneuploidy) consist of having too many, too few, or altered chromosome pairs. This does not necessarily lead to rapid cellular division. Rapid cellular migration is part of metastasis. Immortality is a characteristic of cancer cells due to too much telomerase.

A client has been advised to perform weight-bearing exercises to help minimize osteoporosis. The client admits to not doing the prescribed exercises. What action by the nurse is best? a. Ask the client about fear of falling. b. Instruct the client to increase calcium. c. Suggest other exercises the client can do. d. Tell the client to try weight lifting.

a. Ask the client about fear of falling. Fear of falling can limit participation in activity. The nurse should first assess if the client has this fear and then offer suggestions for dealing with it. The client may or may not need extra calcium, other exercises, or weight lifting.

A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best? a. Assess medication records for steroid use. b. Facilitate a consultation with physical therapy. c. Measure the range of motion in both hips. d. Notify the health care provider immediately.

a. Assess medication records for steroid use. Chronic steroid use is seen in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should determine if the client has been taking a steroid. Physical therapy may be beneficial, but there is not enough information about the client yet. Measuring range of motion is best done by the physical therapist. Notifying the provider immediately is not warranted.

A client has just been diagnosed with human immunodeficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best? a. Assess the client for support systems. b. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.

a. Assess the client for support systems. This client needs the assistance of support systems. The nurse should help the client identify them and what role they can play in supporting him or her. A clergy member may or may not be welcome. Legal requirements about disclosing HIV status vary by state. Telling the family for the client is enabling, and the client may not want the family to know.

A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best? a. Assess the client's culture more thoroughly. b. Discuss options for performing duties. c. See if the client will call a community meeting. d. Suggest the client give up the role of elder.

a. Assess the client's culture more thoroughly. The nurse needs a more thorough understanding of the client's culture, including the meaning of illness and the ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any possible solutions. If the nurse does not understand the consequences of what is suggested, the client may simply be unwilling to listen or participate in problem solving. The other options may be reasonable depending on the outcome of a better cultural understanding.

A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immunodeficiency virus (HIV) antibodies. The test is negative and the client states Whew! I was really worried about that result. What action by the nurse is most important? a. Assess the client's sexual activity and patterns. b. Express happiness over the test result. c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months.

a. Assess the client's sexual activity and patterns.

A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immunodeficiency virus (HIV) antibodies. The test is negative and the client states Whew! I was really worried about that result. What action by the nurse is most important? a. Assess the client's sexual activity and patterns. b. Express happiness over the test result. c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months.

a. Assess the client's sexual activity and patterns. The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 36 months. The nurse needs to assess the client's sexual behavior further to determine the proper response. The other actions are not the most important, but discussing safer sex practices is always appropriate.

A client with a stroke has damage to Broca's area. What intervention to promote communication is best for this client? a. Assess whether or not the client can write. b. Communicate using yes-or-no questions. c. Reinforce speech therapy exercises. d. Remind the client not to use neologisms.

a. Assess whether or not the client can write. Damage to Broca's area often leads to expressive aphasia, wherein the client can understand what is said but cannot express thoughts verbally. In some instances the client can write. The nurse should assess to see if that ability is intact. Yes-or-no questions are not good for this type of client because he or she will often answer automatically but incorrectly. Reinforcing speech therapy exercises is good for all clients with communication difficulties. Neologisms are made-up words often used by clients with sensory aphasia.

A client has frequent hospitalizations for leukemia and is worried about functioning as a parent to four small children. What action by the nurse would be most helpful? a. Assist the client to make sick day plans for household responsibilities. b. Determine if there are family members or friends who can help the client. c. Help the client inform friends and family that they will have to help out. d. Refer the client to a social worker in order to investigate respite child care.

a. Assist the client to make sick day plans for household While all options are reasonable choices, the best option is to help the client make sick day plans, as that is more comprehensive and inclusive than the other options, which focus on a single item.

A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The client's mental status is deteriorating. What action by the nurse is most appropriate? a. Attempt to find the family to sign a consent. b. Inform the provider that the procedure cannot occur. c. Nothing; no consent is needed in an emergency. d. Sign the consent form for the client.

a. Attempt to find the family to sign a consent. The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent, a life-saving procedure can be performed without formal consent. The nurse should not just sign the consent form.

The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are being met? a. Attends meetings of a book club b. Has a positive outlook on life c. Takes medication as directed d. Uses assistive devices to protect joints

a. Attends meetings of a book club All of the activities are appropriate for a client with RA. Clients who have a poor body image are often reluctant to appear in public, so attending public book club meetings indicates that goals for this client problem are being met.

The nurse caring for oncology clients knows that which form of metastasis is the most common? a. Bloodborne b. Direct invasion c. Lymphatic spread d. Via bone marrow

a. Bloodborne Bloodborne metastasis is the most common way for cancer to metastasize. Direct invasion and lymphatic spread are other methods. Bone marrow is not a medium in which cancer spreads, although cancer can occur in the bone marrow.

A nurse works in an allergy clinic. What task performed by the nurse takes priority? a. Checking emergency equipment each morning b. Ensuring informed consent is obtained as needed c. Providing educational materials in several languages d. Teaching clients how to manage their allergies

a. Checking emergency equipment each morning All actions are appropriate for this nurse; however, client safety is the priority. The nurse should ensure that emergency equipment is available and in good working order and that sufficient supplies of emergency medications are on hand as the priority responsibility. When it is appropriate for a client to give informed consent, the nurse ensures the signed forms are on the chart. Providing educational materials in several languages is consistent with holistic care. Teaching is always a major responsibility of all nurses.

A nurse is caring for four clients with leukemia. After hand-off report, which client should the nurse see first? a. Client who had two bloody diarrhea stools this morning b. Client who has been premedicated for nausea prior to chemotherapy c. Client with a respiratory rate change from 18 to 22 breaths/min d. Client with an unchanged lesion to the lower right lateral malleolus

a. Client who had two bloody diarrhea stools this morning The client who had two bloody diarrhea stools that morning may be hemorrhaging in the gastrointestinal (GI) tract and should be assessed first. The client with the change in respiratory rate may have an infection or worsening anemia and should be seen next. The other two clients are not a priority at this time.

A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first? a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 F (39.1 C) b. Client with Bruton's agammaglobulinemia who is waiting for discharge teaching c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia

a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 F (39.1 C) A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client.

A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the AIDS guy and wondering how the client contracted the disease. What action by the nurse is best? a. Confront the staff members about unethical behavior. b. Ignore the behavior; they will stop on their own soon. c. Report the behavior to the units nursing management. d. Tell the client that other staff members are talking about him or her.

a. Confront the staff members about unethical behavior. The professional nurse should be able to confront unethical behavior assertively. The staff should not be talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything.

The treatment team plans care for a person diagnosed with schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning? a. Consider each disorder primary and provide simultaneous treatment. b. The person will benefit from treatment in a residential treatment facility. c. Withdraw the person from cannabis, and then treat schizophrenia. d. Treat schizophrenia first, and then establish the goals for the treatment of substance abuse.

a. Consider each disorder primary and provide simultaneous treatment. Dual diagnosis (co-occurring disorders) clinical practice guidelines for both outpatient and inpatient settings suggest that the substance disorder and the psychiatric disorder should both be considered primary and receive simultaneous treatments. Residential treatment may or may not be effective.

The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immunodeficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands HIV+ d. Wearing a mask within 3 feet of the client

a. Consistent use of Standard Precautions According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact.

A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best? a. Consult with a health care provider about administering both drugs to the client. b. Inform the client that the celecoxib will be started when he or she goes home. c. Teach the client that, since morphine is stronger, celecoxib is not needed. d. Tell the client he or she should not take both drugs at the same time.

a. Consult with a health care provider about administering both drugs to the client. Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help with postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. The other responses are not warranted, as the client should be restarted on this medication postoperatively.

A client is placed on a medical regimen of doxorubicin (Adriamycin), cyclophosphamide (Cytoxan), and fluorouracil (5-FU) for breast cancer. Which side effect seen in the client should the nurse report to the provider immediately? a. Shortness of breath b. Nausea and vomiting c. Hair loss d. Mucositis

a. Shortness of breath Doxorubicin (Adriamycin) can cause cardiac problems with symptoms of extreme fatigue, shortness of breath, chronic cough, and edema. These need to be reported as soon as possible to the provider. Nausea, vomiting, hair loss, and mucositis are common problems associated with chemotherapy regimens.

A nurse is assessing an older client and discovers back pain with tenderness along T2 and T3. What action by the nurse is best? a. Consult with the provider about an x-ray. b. Encourage the client to use ibuprofen (Motrin). c. Have the client perform hip range of motion. d. Place the client in a rigid cervical collar.

a. Consult with the provider about an x-ray. Back pain with tenderness is indicative of a spinal compression fracture, which is the most common type of osteoporotic fracture. The nurse should consult the provider about an x-ray. Motrin may be indicated but not until there is a diagnosis. Range of motion of the hips is not related, although limited spinal range of motion may be found with a vertebral compression fracture. Since the defect is in the thoracic spine, a cervical collar is not needed.

A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The clients partner is listed as the emergency contact, but the clients mother insists that she should be listed instead. What action by the nurse is best? a. Contact the social worker to assist the client with advance directives. b. Ignore the mother; the client does not want her to be involved. c. Let the client know, gently, that nurses cannot be involved in these disputes. d. Tell the client that, legally, the mother is the emergency contact.

a. Contact the social worker to assist the client with advance directives. The client should make his or her wishes known and formalize them through advance directives. The nurse should help the client by contacting someone to help with this process. Ignoring the mother or telling the client that nurses cannot be involved does not help the situation. Legal statutes vary by state; as more states recognize gay marriage, this issue will continue to evolve.

A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling? a. Conveying understanding that pressures associated with nursing practice underlie substance abuse. b. Pointing out that work problems are the result, but not the cause, of substance abuse. c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing. d. Providing health teaching about stress management.

a. Conveying understanding that pressures associated with nursing practice underlie substance abuse. Enabling denies the seriousness of the patients problem or support the patient as he or she shifts responsibility from self to circumstances. The incorrect options are therapeutic and appropriate.

The nurse is caring for a client diagnosed with human immunodeficiency virus. The clients CD4+ cell count is 399/mm3. What action by the nurse is best? a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals.

a. Counsel the client on safer sex practices/abstinence. This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease.

The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further? a. Creatinine: 3.9 mg/dL b. Platelet count: 210,000/mm3 c. Red blood cell count: 5.2/mm3 d. White blood cell count: 4400/mm3

a. Creatinine: 3.9 mg/dL Lupus nephritis is the leading cause of death in clients with SLE. The creatinine level is very high and the nurse needs to perform further assessments related to this finding. The other laboratory values are normal.

The nurse is caring for a client with leukemia who has the priority problem of fatigue. What action by the client best indicates that an important goal for this problem has been met? a. Doing activities of daily living (ADLs) using rest periods b. Helping plan a daily activity schedule c. Requesting a sleeping pill at night d. Telling visitors to leave when fatigued

a. Doing activities of daily living (ADLs) using rest periods Fatigue is a common problem for clients with leukemia. This client is managing his or her own ADLs using rest periods, which indicates an understanding of fatigue and how to control it. Helping to plan an activity schedule is a lesser indicator. Requesting a sleeping pill does not help control fatigue during the day. Asking visitors to leave when tired is another lesser indicator. Managing ADLs using rest periods demonstrates the most comprehensive management strategy.

A woman diagnosed with breast cancer had these laboratory tests performed at an office visit: Alkaline phosphatase 125 U/L Total calcium 12 mg/dL Hematocrit 39% Hemoglobin 14 g/dL Which test results indicate to the nurse that some further diagnostics are needed? a. Elevated alkaline phosphatase and calcium suggests bone involvement. b. Only alkaline phosphatase is decreased, suggesting liver metastasis. c. Hematocrit and hemoglobin are decreased, indicating anemia. d. The elevated hematocrit and hemoglobin indicate dehydration.

a. Elevated alkaline phosphatase and calcium suggests bone involvement. The alkaline phosphatase (normal value 30 to 120 U/L) and total calcium (normal value 9 to 10.5 mg/dL) levels are both elevated, suggesting bone metastasis. Both the hematocrit and hemoglobin are within normal limits for females.

When working with a patient beginning treatment for alcohol abuse, what is the nurses most therapeutic approach? a. Empathetic, supportive b. Strong, confrontational c. Skeptical, guarded d. Cool, distant

a. Empathetic, supportive Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses.

What information does the nurse teach a women's group about osteoporosis? a. For 5 years after menopause you lose 2% of bone mass yearly. b. Men actually have higher rates of the disease but are underdiagnosed. c. There is no way to prevent or slow osteoporosis after menopause. d. Women and men have an equal chance of getting osteoporosis.

a. For 5 years after menopause you lose 2% of bone mass yearly. For the first 5 years after menopause, women lose about 2% of their bone mass each year. Men have a slower loss of bone after the age of 75. Many treatments are now available for women to slow osteoporosis after menopause.

In what significant ways is the therapeutic environment different for a patient who has ingested D-lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)? a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided. b. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained. c. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high-level stimulation is provided. d. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented.

a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided. Patients who have ingested LSD respond well to being talked down by a supportive person. Patients who have ingested PCP are very sensitive to stimulation and display frequent, unpredictable, and violent behaviors. Although one person should perform care and talk gently to the patient, no one individual should be alone in the room with the patient. An adequate number of staff members should be gathered to manage violent behavior if it occurs.

A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important? a. Have adequate help to transfer the client. b. Provide socks so the client can slide easier. c. Tell the client full weight bearing is allowed. d. Use a footstool to elevate the client's leg.

a. Have adequate help to transfer the client. The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the leg greater than 90 degrees is not allowed.

***A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement? a. I always wear long sleeves, pants, and a hat when outdoors. b. I try not to use cosmetics that contain any type of sunblock. c. Since I tend to sweat a lot, I use a lot of baby powder. d. Since I can't be exposed to the sun, I have been using a tanning bed.

a. I always wear long sleeves, pants, and a hat when outdoors Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, avoiding drying agents such as powder, and avoiding tanning beds.

Which statement most accurately describes substance addiction? a. It is a lack of control over use. Tolerance, craving, and withdrawal symptoms occur when intake is reduced or stopped. b. It occurs when psychoactive drug use interferes with the action of competing neurotransmitters. c. Symptoms occur when two or more drugs that affect the central nervous system (CNS) have additive effects. d. It involves using a combination of substances to weaken or inhibit the effect of another drug.

a. It is a lack of control over use. Tolerance, craving, and withdrawal symptoms occur when intake is reduced or stopped. Addiction involves a lack of control over substance use, as well as tolerance, craving, and withdrawal symptoms when intake is reduced or stopped.

A patient asks for information about Alcoholics Anonymous (AA). Which is the nurse's best response? a. It is a self-help group with the goal of sobriety. b. It is a form of group therapy led by a psychiatrist. c. It is a group that learns about drinking from a group leader. d. It is a network that advocates strong punishment for drunk drivers.

a. It is a self-help group with the goal of sobriety. AA is a peer support group for recovering alcoholics. The goal is to maintain sobriety. Neither professional nor peer leaders are appointed.

A nurse reviews prescriptions for an 82-year-old client with a fractured left hip. Which prescription should alert the nurse to contact the provider and express concerns for client safety? a. Meperidine (Demerol) 50 mg IV every 4 hours b. Patient-controlled analgesia (PCA) with morphine sulfate c. Percocet 2 tablets orally every 6 hours PRN for pain d. Ibuprofen elixir every 8 hours for first 2 days

a. Meperidine 50 mg IV every 4 hours Meperidine should not be used for older adults because it has toxic metabolites that can cause seizures. The nurse should question this prescription. The other prescriptions are appropriate for this clients pain management.

Select the nursing intervention necessary after administering naloxone (Narcan) to a patient experiencing an opiate overdose. a. Monitor the airway and vital signs every 15 minutes. b. Insert a nasogastric tube and test gastric pH. c. Treat hyperpyrexia with cooling measures. d. Insert an indwelling urinary catheter.

a. Monitor the airway and vital signs every 15 minutes. Narcotic antagonists such as naloxone quickly reverse CNS depression; however, because the narcotics have a longer duration of action than antagonists, the patient may lapse into unconsciousness or require respiratory support again. The incorrect options are measures unrelated to naloxone use.

A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered a test on my heart, how should the nurse respond? a. Most of these types of blood clots come from the heart. b. Some of the blood clots may have gone to your heart too. c. We need to see if your heart is strong enough for therapy. d. Your heart may have been damaged in the stroke too.

a. Most of these types of blood clots come from the heart. An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of clots is the heart. The other statements are inaccurate.

A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education? a. Participate in an exercise program to strengthen muscles. b. Purchase a mattress that allows you to adjust the firmness. c. Wear flat instead of high-heeled shoes to work each day. d. Keep your weight within 20% of your ideal body weight.

a. Participate in an exercise program to strengthen muscles. Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.

An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug? a. Truvada does not reduce the need for safe sex practices. b. This drug has been taken off the market due to increases in cancer. c. Truvada reduces the number of HIV tests you will need. d. This drug is only used for postexposure prophylaxis.

a. Truvada does not reduce the need for safe sex practices. Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human immunodeficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure prophylaxis.

In the emergency department, a patient's vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome. a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute. b. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department. c. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment. d. The patient will identify two community resources for the treatment of substance abuse by discharge.

a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute. Hydromorphone (Dilaudid) is an opiate drug. The correct answer is the only one that relates to the patient's physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The distractors are desired outcomes later in the plan of care.

A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Bucks traction and screams, Somebody tied me up with ropes. The patient is experiencing: a. an illusion. b. a delusion. C. hallucinations. D. hypnagogic phenomenon.

a. an illusion The patient is misinterpreting a sensory perception when seeing a noose instead of traction. Illusions are common in early withdrawal from alcohol. A delusion is a fixed, false belief. Hallucinations are sensory perceptions occurring in the absence of a stimulus. Hypnagogic phenomena are sensory disturbances that occur between waking and sleeping.

A patient's spouse was just diagnosed with lung cancer although there was no history of tobacco use. The spouse states, "I am so mad. How can you get cancer without smoking?" Which statement by the nurse represents empathy? a. "Research is identifying many risk factors for cancer besides smoking." b. "I understand how you could feel angry about the diagnosis." c. "He is still a good husband." d. "Why do you think he got cancer?"

b. "I understand how you could feel angry about the diagnosis." The nurse is placing herself in the wife's position and sharing her emotions.

What dose of epinephrine does the nurse prepare for a client in anaphylaxis who is 6 feet 3 inches tall and weighs 250 lb? a. 0.2 mL of a 1:1000 solution b. 0.5 mL of a 1:1000 solution c. 0.3 mL of a 1:10,000 solution d. 0.5 mL of a 1:10,000 solution

b. 0.5 mL of a 1:1000 solution Adult doses of epinephrine for anaphylaxis range between 0.3 and 0.5 mL of a 1:1000 solution. Because this client is large, the nurse should be prepared to give the higher dose initially.

Pertussis vaccination should begin at which age? a. Birth b. 2 months c. 6 months d. 12 months

b. 2 months The acellular pertussis vaccine is recommended by the American Academy of Pediatrics beginning at age 6 weeks. Infants are at greater risk for complications of pertussis. The vaccine is not given after age 7 years, when the risks of the vaccine become greater than those of pertussis. The first dose is usually given at the 2-month well-child visit. Infants are highly susceptible to pertussis, which can be a life-threatening illness in this age group.

An adult client's susceptibility to osteoporosis is caused by which aspect of his or her history? a. Fractured arm at age 16 b. Active smoking c. Vitamin D supplements d. Weight lifting

b. Active smoking A history of smoking has been identified as a risk factor for osteoporosis. A history of low-trauma fracture after the age of 50 has been identified as a risk factor. Vitamin D and weight lifting are measures that can be used to prevent this disease.

A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately? a. Albumin: 5.1 g/dL b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/mm3 d. White blood cell (WBC) count: 12,500/mm3

b. Alanine aminotransferase (ALT): 180 U/L INH can cause liver damage, especially if the client drinks alcohol. The ALT (one of the liver enzymes) is extremely high and needs to be reported immediately. The albumin and RBCs are normal. The WBCs are slightly high, but that would be an expected finding in a client with an infection.

A nurse gives Dilantin intravenously with lactated Ringer's solution containing multivitamins. The drug precipitates and obstructs the only existing line. When the team leader informs the nurse that these drugs cannot be mixed, the nurse states, "Everyone just pushes the medicine slowly. No one checks for compatibility. There isn't even a compatibility chart on the unit." Which type of logical fallacy has influenced the nurse? a. Ad hominem abusive b. Appeal to common practice c. Appeal to emotion d. Appeal to tradition

b. Appeal to common practice An appeal to common practice occurs when the argument is made that something is okay because most people do it.

The nurse is caring for a client who is immobile from a recent stroke. Which intervention does the nurse implement to prevent complications in this client? a. Position the client with the unaffected side down. b. Apply sequential compression stockings. c. Instruct the client to turn the head from side to side. d. Teach the client to touch and use both sides of the body.

b. Apply sequential compression stockings. To avoid complications of immobility, such as deep vein thrombosis, the nurse applies sequential compression stockings or pneumatic compression boots. Efforts are made to mobilize the client as much as possible, and the client should be repositioned frequently. The other interventions will not prevent complications of immobility.

A client who is positive for HIV presents with confusion, fever, headache, blurred vision, nausea, and vomiting. What does the nurse do first? a. Assess the client's deep tendon reflexes. b. Ask the client to place his chin on his chest. c. Start an IV line with normal saline. d. Assess the client's pupil reaction.

b. Ask the client to place his chin on his chest. The clients symptoms are associated with cryptococcal meningitis, so the nurse should first ask the client to place the chin on his or her chest. The presence of nuchal rigidity (pain when flexing the chin to the chest) helps confirm the diagnosis. An IV line may be started after the neurologic assessment is completed.

Which of these patient scenarios is most indicative of critical thinking? a. Administering pain relief medication according to what was given last shift b. Asking a patient what pain relief methods, pharmacological and nonpharmacological, have worked in the past c. Offering pain relief medication based on physician orders d. Explaining to the patient that his reports of severe pain are not consistent with the minor procedure that was performed

b. Asking a patient what pain relief methods, pharmacological and nonpharmacologica, have worked in the past Asking the patient what pain relief methods have worked in the past is an example of exploring many options for pain relief. Administering medication based on a previous assessment is not practicing according to standards of care. The nurse is to conduct an assessment each shift on his/her patient and intervene accordingly. Non Pharmacological pain relief methods are available, as are medications for pain. Pain is subjective. The nurse should offer pain relief methods based on the patients reports without being judgmental.

A new nurse is pulled from the surgical unit to work on the oncology unit. The nurse displays the critical thinking attitudes of humility and responsibility by a. Refusing the assignment. b. Asking for an orientation to the unit. c. Assuming that patient care will be the same as on the other units. d. Admitting lack of knowledge and going home.

b. Asking for an orientation to the unit. Humility and responsibility are displayed when the nurse realizes that lack of knowledge and requests an orientation to the unit. The other answer choices represent inappropriate actions in this situation and are not examples of humility and responsibility. The nurse should explore all options before refusing an assignment. The nurse should not make assumptions. Assuming is not an example of critical thinking. Admitting lack of knowledge is an example of humility, but going home does not illustrate an example of responsibility.

What is an appropriate nursing intervention when caring for a child in traction? a. Removing adhesive traction straps daily to prevent skin breakdown b. Assessing for tightness, weakness, or contractures in uninvolved joints and muscles c. Providing active range of motion exercises to affected extremity three times a day d. Keeping child prone to maintain good alignment

b. Assessing for tightness, weakness, or contractures in uninvolved joints and muscles

The nurse assesses for which clinical manifestation in a client with multiple sclerosis (MS) of the relapsing type? a. Absence of periods of remission b. Attacks becoming increasingly frequent c. Absence of active disease manifestations d. Gradual neurologic symptoms without remission

b. Attacks becoming increasingly frequent The classic picture of relapsing-remitting MS is characterized by increasingly frequent attacks. The other manifestations do not correlate with a relapsing type of MS.

What is most important for the nurse to teach the client with allergic rhinitis and glaucoma? a. If your heartbeat increases, be sure to contact your health care provider. b. Avoid allergy drugs containing pseudoephedrine or phenylephrine. c. Be sure to drink plenty of water with antihistamines. d. You should use an eye-moistening agent such as Restasis.

b. Avoid allergy drugs containing pseudoephedrine or phenylephrine. Ephedrine, phenylephrine, and pseudoephedrine may cause vasoconstriction, increased blood pressure, and increase intraocular pressure. The client should avoid these drugs. An increased heart rate is not a reason to call the health care provider. The client may be thirstier when on allergy medications, or the client may need an eye-moistening agent, but these are not the most important things for the nurse to teach.

Which statement made by a client about breast cancer indicates a correct understanding of the disease? a. Breast cancer is the leading cause of cancer deaths among women in the United States. b. Breast cancer is the leading type of cancer among women in North America. c. Late onset of menses and early menopause increase the risk for breast cancer. d. Breast cancer decreases with age, and very old women have virtually no risk.

b. Breast cancer is the leading type of cancer among women in North America. Breast cancer is the second most common form of cancer diagnosed in women (after skin cancer) and is the second leading cause of cancer deaths in women in the United States (after lung cancer). The incidence of breast cancer increases with age. Early onset of menses and late menopause increase the risk for breast cancer.

A client is admitted for a total hip replacement. Past medical history includes diabetes mellitus type 2, a heart attack 5 years ago, and allergies to sulfa drugs. The client currently takes insulin on a sliding scale and celecoxib (Celebrex). Before administering the client's medications, which action by the nurse is most appropriate? a. Take the client's blood pressure in both arms. b. Call the physician to clarify the orders. c. Schedule a preoperative electrocardiogram. d. Review the client's laboratory values.

b. Call the physician to clarify the orders. Celebrex is a cyclooxygenase (COX)-2 inhibitor. These drugs are thought to cause serious adverse reactions such as myocardial infarction and renal problems. This client already has coronary artery disease and a past myocardial infarction, so the nurse should discuss the order with the physician before giving the medication. Reviewing laboratory results could indicate renal impairment, but taking the client's blood pressure and scheduling an electrocardiogram (ECG) would not take priority over discussion with the physician.

The nurse is caring for a child receiving chemotherapy for leukemia. The child's granulocyte count is 600/mm3 and platelet count is 45,000/mm3. What oral care should the nurse recommend for this child? a. Rinsing mouth with water b. Daily tooth brushing and flossing c. Lemon glycerin swabs for cleansing d. Wiping teeth with moistened gauze or Toothettes

b. Daily tooth brushing and flossing Oral care is essential for children receiving chemotherapy to prevent infections and other complications. When the child's granulocyte count is above 500/mm3 and platelet count is above 40,000/mm3, daily brushing and flossing are recommended. Rinsing the mouth with water is not effective for oral hygiene. Lemon glycerin swabs are avoided because they have a drying effect on the mucous membranes, and the lemon may irritate eroded tissue and decay the child's teeth. Wiping teeth with moistened gauze or Toothettes is recommended when the child's granulocyte count is below 500/mm3 and platelet count is below 40,000/mm3.

An adult client who has a suspicious mammogram says that her mother died of bone cancer when she was around the same age. Which is the most important question for the nurse to ask this client? a. Have any other members of your family had bone cancer? b. Did your mother ever have any other type of cancer? c. How old were you when you started your periods? d. Did your mother have regular mammograms?

b. Did your mother ever have any other type of cancer? Breast cancer often spreads to the bone. Many laypersons do not understand that breast cancer in the bone is still breast cancer. It would be very important to know whether this clients mother had breast cancer because a genetic component is associated with it. Asking about other family members who have had bone cancer may give the nurse useful information but would not be as important as finding out about other cancers. Menstrual cycle and mammogram information also would not provide as relevant information as inquiring about other types of cancer, specifically breast cancer.

The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the patient's functional ability. What question would be the most appropriate? a. Are you able to shop for yourself? b. Do you use a cane, walker, or wheelchair to ambulate? c. Do you know what today's date is? d. Were you sad or depressed more than once in the last 3 days?

b. Do you use a cane, walker, or wheelchair to ambulate? Do you use a cane, walker, or wheelchair to ambulate? will assist the nurse in determining the patient's ability to perform self-care activities. A nutritional health risk assessment is not the functional assessment. Knowing the date is part of a mental status exam. Assessing sadness is a question to ask in the depression screening.

A parent tells the nurse that 80% of children with the same type of leukemia as his sons have a 5-year survival. He believes that because another child on the same protocol as his son has just died, his son now has a better chance of success. What is the best response by the nurse? a. It is sad for the other family but good news for your child. b. Each child has an 80% likelihood of 5-year survival. c. The data suggest that 20% of the children in the clinic will die. There are still many hurdles for your son. d. You should avoid the grieving family because you will be benefiting from their loss.

b. Each child has an 80% likelihood of 5-year survival. This is a common misconception for parents. The success data are based on numerous factors, including the effectiveness of the protocol and the child's response. These are aggregate data that apply to each child and do not depend on the success or failure in other children. The failure of one child in a protocol does not improve the success rate for other children. Although the son does face more hurdles, these are aggregate data, not specific to the clinic. It may be difficult for this family to be supportive given their concerns about their child. Families usually form support groups in pediatric oncology settings, and support during bereavement is common.

A 7-year-old child has just had a cast applied for a fractured arm with the wrist and elbow immobilized. What information should be included in the home care instructions? a. No restrictions of activity are indicated. b. Elevate casted arm when both upright and resting. c. The shoulder should be kept as immobile as possible to avoid pain. d. Swelling of the fingers is to be expected. Notify a health professional if it persists more than 48 hours.

b. Elevate casted arm when both upright and resting.

A client with lung cancer is lying flat in bed and reports shortness of breath. What action does the nurse take first? a. Notify the health care provider. b. Elevate the head of the bed. c. Assess oxygen saturation. d. Have the client take deep breaths.

b. Elevate the head of the bed. The nurses first action should be to elevate the head of the bed. Next, assessing oxygen saturation will help the nurse determine the client's status. If the oxygen is low, the nurse would increase oxygen flow and have the client take deep breaths. The provider could be notified after the nurse performs the interventions.

A client is in the clinic having had rhinorrhea and headache for the last 2 weeks. Which laboratory value alerts the nurse to the possibility of a type I hypersensitivity reaction? a. White blood cell count, 8900/mm3 b. Eosinophils, 10% c. Neutrophils, 65% d. Hemoglobin, 14 g/dL

b. Eosinophils, 10% An increase in eosinophils indicates an allergic reaction (type I) or allergic rhinitis. Normal eosinophil count is 1% to 2%. The other laboratory values are normal.

A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate? a. Arrange for immediate hospitalization. b. Facilitate polymerase chain reaction testing. c. Have the client produce a sputum sample. d. Obtain two sets of blood cultures.

b. Facilitate polymerase chain reaction testing. Polymerase chain reaction testing is used to diagnose pertussis, which this client is showing manifestations of. Hospitalization may or may not be needed but is not the most important action. The client may or may not be able to produce sputum, but sputum cultures for this disease must be obtained via deep suctioning. Blood cultures will be negative.

A teenage patient is using earphones to listen to hard rock music and is making gestures in rhythm to the music. The nurse assesses the amount of urine output in the Foley catheter and leaves the room. What communication technique is demonstrated in both of these situations? a. Blocking b. Filtration c. Empathy d. False assurance

b. Filtration Filtration is the unconscious exclusion of extraneous stimuli in communication.

A school-age child with leukemia experienced severe nausea and vomiting when receiving chemotherapy for the first time. What is the most appropriate nursing action to prevent or minimize these reactions with subsequent treatments? a. Administer the chemotherapy between meals. b. Give an antiemetic before chemotherapy begins. c. Have the child bring favorite foods for snacks. d. Keep the child NPO (nothing by mouth) until nausea and vomiting subside.

b. Give an antiemetic before chemotherapy begins. The most beneficial regimen to minimize nausea and vomiting associated with chemotherapy is to administer a 5-hydroxytryptamine-3 receptor antagonist (e.g., ondansetron) before the chemotherapy is begun. The goal is to prevent anticipatory signs and symptoms. The child will experience nausea with chemotherapy whether or not food is present in the stomach. Because some children develop aversions to foods eaten during chemotherapy, refraining from offering favorite foods is advised. Keeping the child NPO until nausea and vomiting subside will help with this episode, but the child will have discomfort and be at risk for dehydration.

A client is receiving an IV infusion of an antibiotic. The client calls the nurse about feeling uneasy and uncomfortable owing to congestion. Which action by the nurse is most appropriate? a. Elevate the head of the clients bed to 45 degrees. b. Have another nurse call the Rapid Response Team. c. Prepare to administer diphenhydramine (Benadryl). d. Slow the rate of the IV infusion.

b. Have another nurse call the Rapid Response Team. This client has early signs of anaphylaxis. The nurse must notify the Rapid Response Team but also needs to stay with the client in case of cardiovascular collapse. The nurses best action is to ask another nurse to call the Team while he or she continues to assess the client. The nurse will prepare to administer epinephrine. Slowing the IV rate will not help the situation; if the client is reacting to the antibiotic, the nurse should change the IV tubing and solution. If the client is not hypotensive, the nurse can raise the head of the bed.

Which client characteristic places her or him at high risk for latex hypersensitivity? a. Allergic to shellfish b. History of spina bifida c. Total hip replacement d. Taking oral contraceptives

b. History of spina bifida People who have spina bifida have lifelong exposure to latex products and frequently develop latex hypersensitivity. An allergy to shellfish does not put a person at increased risk for latex allergies. A total hip replacement will not place a client at risk for latex hypersensitivity, nor does the use of oral contraceptives.

The nurse is teaching a client how to prevent transmitting HIV to his sexual partner. Which statement by the client indicates that additional teaching is needed? a. I can throw the condoms in the trash after I have used them. b. I will store my condoms in my wallet so they are always handy. c. Water-based lubricants are best to prevent condom breakage. d. The condom needs to stay on until I withdraw my penis.

b. I will store my condoms in my wallet so they are always handy. Condoms should be stored in a cool, dry place. Wallets are not recommended because body heat can weaken the latex in the condom. The condom should stay on the penis until it is completely withdrawn. Condoms should be used only once and then discarded. Oil-based lubricants can weaken latex, possibly causing tearing or leakage, so only water-based lubricants are recommended.

The nurse is teaching a seminar about preventing the spread of HIV. Which statement by a student indicates that additional teaching is required? a. A woman can still get pregnant if she is HIV positive. b. I wont get HIV if I only have oral sex with my partner. c. Showering after intercourse will not prevent HIV transmission. d. People with HIV are still contagious even if they take HAART drugs.

b. I wont get HIV if I only have oral sex with my partner. HIV may be transmitted via oral sex when mucous membranes or nonintact skin comes in contact with infected body fluids (semen or vaginal secretions) or blood. Women who are HIV positive may get pregnant, and showering after intercourse will not reduce the risk of HIV transmission. HAART will lower viral loads, but the client will still be able to transmit the HIV virus to others.

To prevent Wernicke's encephalopathy from heavy alcohol use, the nurse anticipates an order for which medications? a. Benzodiazepine b. Thiamine and B complex IV c. Vitamins C and D3 d. Klonopin

b. Thiamine and B complex IV The B vitamins will prevent or reverse Wernickes if given early enough. Benzodiazepines are often used to prevent and treat DTs and to decrease respiratory depression and hypertension. Vitamins C and D3 are not related to alcohol withdrawal. Klonopin is administered for hypertension and anxiety related to withdrawal.

An adolescent comes to the school nurse after experiencing shin splints during a track meet. What reassurance should the nurse offer? a. Shin splints are expected in runners. b. Ice, rest, and nonsteroidal antiinflammatory drugs (NSAIDs) usually relieve pain. c. It is generally best to run around and work the pain out. d. Moist heat and acetaminophen are indicated for this type of injury.

b. Ice, rest, and nonsteroidal antiinflammatory drugs (NSAIDs) usually relieve pain. Shin splints result when the ligaments tear away from the tibial shaft and cause pain. Actions that have an antiinflammatory effect are indicated for shin splints. Ice, rest, and NSAIDs are the usual treatment. Shin splints are rarely serious, but they are not expected, and preventive measures are taken. Rest is important to heal the shin splints. Continuing to place stress on the tibia can lead to further damage.

The nurse is caring for an older adult client who will be discharged home to live with an adult daughter. The client will be given prescriptions for four new medications for rheumatoid arthritis. How does the nurse ensures that the client will be able to take the medications correctly at home? a. Monitor the client self-administering medications while in the hospital. b. Include the client's daughter when teaching the client about the medications. c. Provide the client with pamphlets and information about all the medications. d. Make a chart showing which medications the client should take at different times.

b. Include the client's daughter when teaching the client about the medications. Because the client will be living with the daughter, she should be included in the teaching plan about the medications. Providing pamphlets or charts about the medications does not ensure that the client knows how to take them correctly at home. Self-administering medications may or may not be permitted by hospital policy and might be helpful, but including the daughter would be the best option.

The nurse is caring for a client with AIDS who has just been diagnosed with cryptococcal meningitis. Which is the best nursing intervention for this client? a. Initiate respiratory isolation for the next 72 hours. b. Initiate seizure precautions with padded side rails. c. Thicken the clients liquids to honey consistency. d. Administer IV pentamidine isethionate (Pentam).

b. Initiate seizure precautions with padded side rails. Cryptococcosis is a debilitating form of meningitis that can cause seizures, so seizure precautions should be initiated. Respiratory isolation is not indicated. Dysphagia is not seen with cryptococcal meningitis, so thickened liquids are not indicated. Pentam is given for Pneumocystis jiroveci pneumonia (PJP).

A client is receiving warfarin (Coumadin) daily following total hip replacement surgery. Which laboratory value requires intervention by the nurse? a. Potassium (K+), 4.2 mEq/L b. International normalized ratio (INR), 5.1 c. Prothrombin time (PT), 13.4 seconds d. Hemoglobin (Hg), 16 g/dL

b. International normalized ratio (INR), 5.1 Blood levels of Coumadin will be monitored by checking daily PT and INR (in some places, only INR). The INR is critically high. The K+ is normal and is not monitored for Coumadin therapy. The PT is used in some facilities to monitor Coumadin therapy. Hemoglobin would be important to assess because a side effect of Coumadin is bleeding, and a dropping hemoglobin level would indicate that bleeding was occurring. PT and hemoglobin are within the normal range.

An adolescent will receive a bone marrow transplant (BMT). The nurse should explain that the bone marrow will be administered by which method? a. Bone grafting b. Intravenous infusion c. Bone marrow injection d. Intra Abdominal infusion

b. Intravenous infusion Bone marrow from a donor is infused intravenously, and the transfused stem cells migrate to the recipients marrow and repopulate it.

***A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? a. Beige freckles on the backs of both hands b. Irregular blue mole with white specks on the lower leg c. Large cluster of pustules in the right axilla d. Thick, reddened papules covered by white scales

b. Irregular blue mole with white specks on the lower leg This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Melanoma is an invasive malignant disease with the potential for a fatal outcome. Freckles are a benign condition. Pustules could mean an infection, but it is more important to take care of the potentially cancerous lesion first. Psoriasis vulgaris manifests as thick reddened papules covered by white scales. This is a chronic disorder and is not the priority.

The nurse is working with a client who has severe rheumatoid arthritis in her hands. The client states that she is frustrated at mealtime because it is difficult for her to manage cups and silverware. What is the nurse's best response? a. I'll have the nursing assistants set up your meal trays while you are in the hospital. b. Lets see if the occupational therapist can provide you with some utensils that are easier for you to use. c. I'll arrange for a home nursing assistant to help you with your meals after you are discharged from the hospital. d. Lets see if the physical therapist can suggest some muscle strengthening exercises for you.

b. Lets see if the occupational therapist can provide you with some utensils that are easier for you to use. The client wishes to be more independent at mealtimes; adaptive eating utensils from the occupational therapist will help her meet this goal. Muscle-strengthening exercises will not be as effective for the clients mealtime needs. The client wishes to remain as independent as possible, so a home nursing assistant should not be suggested.

An HIV-positive client is taking lopinavir/ritonavir (Kaletra) and reports nausea, abdominal pain, and diarrhea. What orders does the nurse anticipate? a. Renal function studies b. Liver enzymes c. Blood glucose monitoring d. Albumin and prealbumin

b. Liver enzymes Kaletra can cause liver complications, and clients taking it should have liver function studies. The clients symptoms could indicate a liver problem. Renal function and blood glucose are not affected by Kaletra. The client may have an albumin and prealbumin drawn if he or she has lost a great deal of weight and malnutrition is suspected, but the more common diagnostic test for a client taking Kaletra would be liver function studies.

The nurse is working with a client who has AIDS-related dementia and will soon be discharged to the care of family members. What teaching topic is best for the nurse to include in the discharge plan? a. Feed the client when he will not do it by himself. b. Make sure that a clock and a calendar are easily visible. c. Remove locks from bathroom and bedroom doors. d. Do not allow the client to smoke when he is alone.

b. Make sure that a clock and a calendar are easily visible. Having a clock and a calendar easily visible will help the client keep track of the date and time and will assist with reorientation. Banning smoking, removing locks, and feeding the client will not facilitate reorientation when the client is confused.

Jan is a 70-year-old retired nurse who is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. What options should you consider in her plan of care considering her expressed wishes? a. Stationary exercise bicycle, free weights, and spinning class b. Mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy c. Chamomile tea and IcyHot gel d. Acupuncture and attending church services

b. Mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy Mind-body therapies are designed to enhance the mind's capacity to affect bodily function and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others. Stationary exercise bicycle, free weights, and spinning are not mind-body therapies. They are classified as exercise therapies. Chamomile tea and IcyHot gel are not mind-body therapies per se. They are classified as herbal and topical thermal treatments. Acupuncture is an ancient Chinese complementary therapy, while attending church services is a religious prayer mind-body therapy capable of enhancing the minds capacity to affect bodily function and symptoms.

Why are the death rates from ovarian cancer so high? a. The causative oncovirus is resistant to chemotherapy and radiation. b. No symptoms are obvious during the early stages of this disorder. c. Radiation therapy is ineffective because the ovaries are located deep in the pelvis. d. Ovarian cancer occurs mostly in women over the age of 70 who have other health problems.

b. No symptoms are obvious during the early stages of this disorder. Ovarian cancer is poorly detected in its early stages, when the chances for cure or control are better. The other statements are inaccurate.

A 4-year-old child is placed in Buck extension traction for Legg-Calv-Perthes disease. He is crying with pain as the nurse assesses the skin of his right foot and sees that it is pale with an absence of pulse. What should the nurse do first? a. Reposition the child and notify the practitioner. b. Notify the practitioner of the changes noted. c. Give the child medication to relieve the pain. d. Chart the observations and check the extremity again in 15 minutes.

b. Notify the practitioner of the changes noted.

The nurse is caring for a client who has experienced a stroke. Which nursing intervention for nutrition does the nurse implement to prevent complications from cranial nerve IX impairment? a. Turn the clients plate around halfway through the meal. b. Place the client in high Fowler's position. c. Order a clear liquid diet for the client. d. Verbalize the placement of food on the clients plate.

b. Place the client in high Fowler's position. Cranial nerve IX, the glossopharyngeal nerve, controls the gag reflex. Clients with impairment of this nerve are at great risk for aspiration. The client should be in high Fowler's position and should drink thickened liquids if swallowing difficulties are present. The client would not have vision problems. Turning the plate around would not prevent a complication, nor would limiting the clients diet to clear liquids.

***Which characteristic is common to all types of hypersensitivity reactions? a. Decreased inflammatory responses b. Presence of tissue-damaging reactions c. Enhanced natural killer cell activity d. Inability to recognize extraneous cells

b. Presence of tissue-damaging reactions The defining difference between a normal immune response and that termed hypersensitivity is that the immune system reacts excessively or inappropriately, with resultant tissue damage and pathology.

An occupational health nurse is working with management in a firm that provides commercial building restoration, including asbestos removal. Which action does the nurse recommend to management? a. Provide annual screening chest x-rays for those exposed to asbestos. b. Purchase protective gear and develop policies mandating its use. c. Offer stop smoking programs on site several times a year. d. Routinely distribute testing kits for occult fecal blood.

b. Purchase protective gear and develop policies mandating its use. Asbestos is a powerful carcinogen. Chronic exposure, even to small amounts of loose asbestos fibers, increases the risk for development of lung cancer. Employees should wear personal protective gear when working with asbestos. Management should provide this gear and should develop policies requiring employees to use it. Stop-smoking programs would not be as beneficial in preventing cancer in this group of people as would limiting asbestos exposure. Routine chest x-rays and fecal occult blood testing will not prevent cancer.

What finding is characteristic of fractures in children? a. Fractures rarely occur at the growth plate site because it absorbs shock well. b. Rapidity of healing is inversely related to the childs age. c. Pliable bones of growing children are less porous than those of adults. d. The periosteum of a childs bone is thinner, is weaker, and has less osteogenic potential compared to that of an adult.

b. Rapidity of healing is inversely related to the childs age. Healing is more rapid in children. The younger the child, the more rapid the healing process. Nonunion of bone fragments is uncommon except in severe injuries. The epiphyseal plate is the weakest point of long bones and a frequent site of injury during trauma. Childrens bones are more pliable and porous than those of adults. This allows them to bend, buckle, and break. The greater porosity increases the flexibility of the bone and dissipates and absorbs a significant amount of the force on impact. The adult periosteum is thinner, is weaker, and has less osteogenic potential than that of a child.

The critical thinking skill of evaluation in nursing practice can be best described as a. Examining the meaning of data. b. Reviewing the effectiveness of nursing actions. c. Supporting findings and conclusions. d. Searching for links between data and the nurses assumptions.

b. Reviewing the effectiveness of nursing actions. Reviewing the effectiveness of interventions best describes evaluation. Examining the meaning of data is inference. Supporting findings and conclusions provides explanations. Searching for links between the data and the nurses assumptions describes analysis.

A client verbalizes a fear of contracting HIV because she has a history of intravenous substance abuse. What instructions does the nurse provide to the client to help minimize this risk? a. Boil all needles and syringes for at least 20 minutes before using them again and be sure not to share them. b. Rinse used needles and syringes with water followed by laundry bleach after using them. c. Rinse used needles and syringes with rubbing alcohol before and after using them. d. Run all needles and syringes through the dishwasher with an extra rinse cycle before using them again.

b. Rinse used needles and syringes with water followed by laundry bleach after using them. To minimize the risk for HIV transmission, needles should be cleaned with laundry bleach after use. Boiling needles and syringes and rinsing with alcohol are not recommended. Running needles and syringes through the dishwasher will not sanitize them sufficiently. The client should be encouraged not to share needles and syringes.

The nurse is caring for a newly diagnosed HIV-positive client who will be taking enfuvirtide (Fuzeon). Which precaution is important for the nurse to communicate to this client? a. Stop taking the medication if you develop a fever. b. Rotate the sites where you will be giving the injections. c. Take this medication with a snack or a small meal. d. Do not drive or operate machinery while taking this drug.

b. Rotate the sites where you will be giving the injections. Fuzeon is available only as a subcutaneous injection and can cause injection site reactions and nodules. The client should be taught the subcutaneous technique, including rotation of sites. The client should not stop taking this medication for fever, it can be given without regard to food, and the drug will not make the client sleepy or drowsy, so caution with driving or operating machinery is not needed.

A child with a hip spica cast is being prepared for discharge. Recognizing that caring for a child at home is complex, the nurse should include what instructions for the parents discharge teaching? a. Turn every 8 hours. b. Specially designed car restraints are necessary. c. Diapers should be avoided to reduce soiling of the cast. d. Use an abduction bar between the legs to aid in turning.

b. Specially designed car restraints are necessary.

In today's world of fast, effective communication, what is the most commonly used means of societal communication? a. Facial expression b. Spoken word c. Written messages d. Electronic messaging

b. Spoken word Verbal communication, which involves talking and listening, is the most common form of interpersonal communication. An important clue to verbal communication is the tone or inflection with which words are spoken and the general attitude used when speaking.

A female client with rheumatoid arthritis has taken Rheumatrex (methotrexate) for the past year to control her symptoms. The client comes to the clinic and tells the nurse that a home pregnancy test was positive. What is the nurse's best response? a. You need to schedule a prenatal appointment with your obstetrician right away. b. Stop taking Rheumatrex immediately. I'll tell the physician you are pregnant. c. Continue taking Rheumatrex, and increase the dose if you have a flare. d. See a genetic counselor to determine whether your baby will have rheumatoid arthritis.

b. Stop taking Rheumatrex immediately. I'll tell the physician you are pregnant. Rheumatrex is highly teratogenic and should not be taken during pregnancy. A prenatal appointment should be made right away, but the first priority is to stop taking methotrexate. Genetic counseling is not appropriate because the counselor will not be able to determine whether the baby will develop rheumatoid arthritis.

The nurse is administering an intravenous chemotherapeutic agent to a child with leukemia. The child suddenly begins to wheeze and have severe urticaria. What nursing action is most appropriate to initiate? a. Recheck the rate of drug infusion. b. Stop the drug infusion immediately. c. Observe the child closely for the next 10 minutes. d. Explain to the child that this is an expected side effect.

b. Stop the drug infusion immediately. When an allergic reaction is suspected, the drug is immediately discontinued. Any drug in the line should be withdrawn, and a normal saline infusion begun to keep the line open. The intravenous infusion is stopped to minimize the amount of drug that infuses. The infusion rate can be confirmed at a later time. Observation of the child for 10 minutes is essential, but it is done after the infusion is stopped. These signs are indicative of an allergic reaction, not an expected response.

***The nurse is working with a client who will be taking 20 mg of prednisone daily for rheumatoid arthritis. Which precautions does the nurse give the client about taking this medication? a. Take this medication at bedtime because it will make you sleepy. b. Take calcium and vitamin D supplements daily. c. Eat a high-fiber diet with lots of lean meats. d. Wash your face twice a day with an antibacterial soap.

b. Take calcium and vitamin D supplements daily. Long-term steroid use is associated with many complications, including diabetes, infection, and osteoporosis, among others. The client should be instructed to take calcium and vitamin D supplements to help prevent osteoporosis. Prednisone does not cause constipation, so increased fiber would not be helpful. Prednisone should be taken in the morning because it may interfere with sleep if taken at bedtime. Washing the face with antibacterial soap may cause skin dryness and breakdown.

Professional nurses are responsible for making clinical decisions to a. Prove traditional methods of providing nursing care to patients. b. Take immediate action when a patient's condition worsens. c. Apply clear textbook solutions to patients problems. d. Formulate standardized care plans for groups of patients.

b. Take immediate action when a patient's condition worsens. Professional nurses are responsible for making clinical decisions to take immediate action when a patient's condition worsens. Patient care should be based on evidence-based practice, not on tradition. Clear textbooks solutions to patient problems are not always available. Care plans should be individualized.

A woman has been told she has cervical polyps. Which statement by the client indicates a good understanding of the teaching the nurse provided? a. I hope my polyp doesn't turn cancerous like colon polyps can. b. These can be removed easily in the doctor's office with little pain. c. I will need to have more frequent screening for cervical cancer. d. I will need to finish all my medication before having sex again.

b. These can be removed easily in the doctor's office with little pain. Cervical polyps are benign growths. They can be removed easily in the physician's office with little to no pain. The other statements are inaccurate: Polyps are not related to cancer or to sexually transmitted diseases.

Which exercise does the nurse recommend to a client at risk for osteoporosis? a. High-impact aerobics 45 minutes once weekly b. Walking 30 minutes three times weekly c. Jogging 30 minutes four times weekly d. Bowling for 1 hour twice weekly

b. Walking 30 minutes three times weekly Weight-bearing, non jarring exercises have been proven to reduce or slow bone loss without causing vertebral compression. High-impact aerobics, jogging, and bowling are activities that actually could cause fracture in a client with osteoporosis. Walking would be the best choice as an exercise.

A 70-year-old patient is newly admitted to a skilled nursing facility with a diagnosis of Alzheimer's dementia, lipidemia, and hypertension, and a history of pulmonary embolism. Medications brought on admission included lisinopril, hydrochlorothiazide, warfarin, low-dose aspirin, ginkgo biloba, and echinacea. The nurse contacts the patient's medical provider over which potential drug-drug interaction? a. Lisinopril and echinacea b. Warfarin and ginkgo biloba c. Echinacea and warfarin d. Lisinopril and hydrochlorothiazide

b. Warfarin and ginkgo biloba Warfarin and blood thinners interact with ginkgo biloba as designed to improve memory. All herbal supplements should be evaluated with current pharmacological medications. The other options do not have drug interactions with each other.

The nurse is caring for a client who has undergone a spinal fusion. Which specific postoperative instructions does the nurse give this client? a. You may lift items up to 10 pounds. b. Wear your brace when you are out of bed. c. You must remain on bedrest for 48 hours after surgery. d. You will need to take steroids to prevent rejection of the bone graft.

b. Wear your brace when you are out of bed. Clients who undergo spinal fusion are fitted with a brace that they need to wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client does not need to remain on bedrest for the first 48 hours, should not lift anything, and will not take steroids for rejection prevention.

Which exercise plan or activity does the nurse teach the client for the first postoperative day after a modified radical mastectomy? a. Perform no movement or exercise today. Keep the arm supported and the elbow flexed, and as close to your body as possible. b. Without moving your shoulder, straighten your elbow three times hourly and squeeze a rubber ball with your fingers. c. Face the wall and extend your arm straight out to the wall. Walk your fingers as far above your head as your arm will reach, and then walk them back down. d. Hold your operative arm straight out from the shoulder to the side. Use your nonoperative arm to pull the operative arm completely straight above your head.

b. Without moving your shoulder, straighten your elbow three times hourly and squeeze a rubber ball with your fingers. Mild exercise begins on the first postoperative day. Exercises should not put stress on the incision and do not involve the shoulder at this point. Full extension of the elbow, with support, is important, as is using grip maneuvers for the hand on the affected side. Total immobility is not recommended. The other two exercises can be performed a few days after the operation.

Which client does the nurse encourage to seek genetic counseling regarding her risk for BRCĀ or BRCÁ gene mutation related breast cancer? a. Woman whose father had lung cancer and mother had leukemia b. Woman whose sister has breast cancer and mother has ovarian cancer c. Woman whose fraternal twin sister has breast cancer d. Older woman who has bilateral benign breast disease

b. Woman whose sister has breast cancer and mother has ovarian cancer The best-defined increased genetic risk for breast cancer is related to mutations in BRCĀ or BRCÁ gene. Families in which either of these genes is mutated have higher rates of breast and ovarian cancer in first-degree relatives. Being older is the primary risk factor for developing breast cancer but is not related to the genetic component; neither is benign breast disease. Lung cancer and leukemia are not genetically related to breast cancer. Having a twin with breast cancer does increase the genetic risk, but not as much as having two first-degree relatives with related cancers.

The nurse is teaching a postmenopausal client about the risk of acquiring HIV infection. The client states, I'm an old woman! I cannot possibly get HIV. What is the nurse's best response? a. Your vaginal walls become thicker after menopause, which increases your risk. b. Women in your age-group are the fastest growing population of AIDS clients today. c. Hormonal fluctuations after menopause make it harder to fight off infection. d. You might be right. How often do you engage in sexual activities?

b. Women in your age-group are the fastest growing population of AIDS clients today. Women are the fastest growing group with HIV infection and AIDS. Infection with HIV can occur at any age, and postmenopausal women experience thinning of vaginal tissue along with an age-related (not hormonal) decline in immune function. This places the older woman at higher risk of acquiring HIV infection. The frequency of sexual activity is not as relevant as the sexual activities the person practices.

The nurse is caring for a 6-year-old child with acute lymphoblastic leukemia (ALL). The parent states, My child has a low platelet count, and we are being discharged this afternoon. What do I need to do at home? What statement is most appropriate for the nurse to make? a. You should give your child aspirin instead of acetaminophen for fever or pain. b. Your child should avoid contact sports or activities that could cause bleeding. c. You should feed your child a bland, soft, moist diet for the next week. d. Your child should avoid large groups of people for the next week.

b. Your child should avoid contact sports or activities that could cause bleeding. A child with a low platelet count needs to avoid activities that could cause bleeding such as playing contact sports, climbing trees, using playground equipment, or bike riding. The child should be given acetaminophen, not aspirin, for fever or pain; the child does not need to be on a soft, bland diet or avoid large groups of people because of the low platelet count.

During height and weight assessments at a school's health fair, a child admits to drinking a cup of coffee with his mother every morning, and another child reports enjoying a morning cup of coffee on the commute to school. These two children are both below average on the height chart, and the nurse states, "Drinking coffee stunts a child's growth." This logical fallacy is referred to as: a. appeal to common practice. b. confusing cause and effect. c. ad hominem abusive. d. red herring.

b. confusing cause and effect. Cause and effect are confused when one assumes that a particular event must cause another just because the two events often occur together.

A patient who was admitted 24 hours ago has become increasingly irritable and now says there are bugs on his bed. The nurse suspects a. alcohol-induced psychosis. b. delirium tremens (DTs). c. neurologic injury related to a fall. d. posttraumatic stress reaction.

b. delirium tremens (DTs). During the 6 to 96 hours after last alcohol use, patients may experience DTs, as evidenced by disorientation, nightmares, abdominal pain, nausea, and diaphoresis, as well as elevated temperature, pulse rate, and blood pressure measurement and visual and auditory hallucinations.

A student nurse is talking with his instructor. The student asks how quality of care is evaluated. The best response by the instructor is Quality of care is evaluated a. by the patient getting well. b. on the basis of process and outcomes. c. by the physicians assessment. d. by the patients satisfaction.

b. on the basis of process and outcomes. Quality of care is evaluated by process and outcomes. If the outcomes are achieved, then the care has achieved what is was designed to do. The patient getting well may be an action of the body doing what it is supposed to do and not quality of care; the same can be said of the physician assessment. The patients satisfaction is subjective according to his or her perceptions and not the quality of care.

An 80-year-old male patient is in the ICU status fractured femur and MVA. You are making the rounds and notice he is somnolent, with no response to verbal or physical stimulation. He has been on round the clock opioids doses q 4 hours. The best immediate course of nursing action is to a. call a Code Blue. b. stop opioid; consider administering naloxone, call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status. c. call the primary hospitalist in charge of patient. d. call the anesthesia provider on call.

b. stop opioid; consider administering naloxone, call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status. Stop opioid; consider administering naloxone; call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status; notify primary or anesthesia provider; and monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory. Calling a Code Blue solely for a somnolent patient is not indicated as a solitary response. Calling the hospitalist assigned to the patient is an option only after the immediate treatment plan is enacted to reverse the opioid. Calling anesthesia is appropriate after stopping the opioid first.

During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, After discharge, I'm sure everything will be just fine. Which remark by the nurse will be most helpful to the spouse? a. It is good that you are supportive of your spouse's sobriety and want to help maintain it. b. Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol. c. It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection. d. Remember that alcoholism is a disorder of self-destruction. You will need to observe your spouse's behavior carefully.

b. Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol. During recovery, patients identify and use alternative coping mechanisms to reduce their reliance on alcohol. Physical adaptations must occur. Emotional responses, formerly dulled by alcohol, are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who should be given anticipatory guidance and accurate information.

A client with human immunodeficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first? a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.

b. Assess the client for adherence to the drug regimen. Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time. Since this clients viral load has increased dramatically, the nurse should first assess this factor. After this, the other assessments may or may not be needed.

A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition? a. Auscultating the lungs b. Assessing mucous membranes c. Listening to bowel sounds d. Performing a neurologic examination

b. Assessing mucous membranes Cryptosporidiosis can cause extreme loss of fluids and electrolytes, up to 20 L/day. The nurse should assess signs of hydration/dehydration as the priority, including checking the clients mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment.

A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this clients discharge teaching? a. Take warm baths to promote muscle relaxation. b. Avoid crowds and people with colds. c. Relying on a walker will weaken your gait. d. Take prescribed medications when symptoms occur.

b. Avoid crowds and people with colds. The client should be taught to avoid people with any type of upper respiratory illness because these medications are immunosuppressive. Warm baths will exacerbate the clients symptoms. Assistive devices may be required for safe ambulation. Medication should be taken at all times and should not be stopped.

A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak? a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) c. About 0200 on hospital day 3 (72 hours after drinking stopped) d. About 0200 on hospital day 4 (96 hours after drinking stopped)

b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) Alcohol withdrawal usually begins 6 to 8 hours after cessation or significant reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium.

A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client who reports jaw pain when eating b. Client with a red, hot, swollen right wrist c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit

b. Client with a red, hot, swollen right wrist All of the options are possible manifestations of RA. However, the presence of one joint that is much redder, hotter, or more swollen than the other joints may indicate infection. The nurse needs to see this client first.

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the clients neurologic examination is normal. About what drug should the nurse plan to teach the client? a. Alteplase (Activase) b. Clopidogrel (Plavix) c. Heparin sodium d. Mannitol (Osmitrol)

b. Clopidogrel (Plavix) This clients manifestations are consistent with a transient ischemic attack, and the client would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.

The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? a. Administering steroids for severe serum sickness b. Correctly identifying the client prior to a blood transfusion c. Keeping the client free of the offending agent d. Providing a latex-free environment for the client

b. Correctly identifying the client prior to a blood transfusion A classic example of a type II hypersensitivity reaction is a blood transfusion reaction. These can be prevented by correctly identifying the client and cross-checking the unit of blood to be administered. Serum sickness is a type III reaction. Avoidance therapy is the cornerstone of treatment for a type IV hypersensitivity. Latex allergies are a type I hypersensitivity.

While assessing a client who is 12 hours postoperative after thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first? a. Assess for drainage from the site. b. Cover the insertion site with sterile gauze. c. Contact the provider and obtain a suture kit. d. Reinsert the tube using sterile technique.

b. Cover the insertion site with sterile gauze. Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse should not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The site should only be assessed after the insertion site is covered. The provider should be called to reinsert the chest tube or prescribe other treatment options.

Which nursing diagnosis would likely apply both to a patient diagnosed with schizophrenia as well as a patient diagnosed with amphetamine-induced psychosis? a. Powerlessness b. Disturbed thought processes c. Ineffective thermoregulation d. Impaired oral mucous membrane

b. Disturbed thought processes Both types of patients commonly experience paranoid delusions; thus, the nursing diagnosis of Disturbed thought processes is appropriate for both. The incorrect options are not specifically applicable to both.

A nurse assesses the health history of a client who is prescribed ziconotide (Prialt) for chronic back pain. Which assessment question should the nurse ask? a. Are you taking a nonsteroidal anti-inflammatory drug? b. Do you have a mental health disorder? c. Are you able to swallow medications? d. Do you smoke cigarettes or any illegal drugs?

b. Do you have a mental health disorder? Clients who have a mental health or behavioral health problem should not take ziconotide. The other questions do not identify a contraindication for this medication.

A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important? a. Administer preoperative medications as prescribed. b. Ensure that a consent for transfusion is on the chart. c. Explain to the client how anemia affects healing. d. Teach the client about foods high in protein and iron.

b. Ensure that a consent for transfusion is on the chart. The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed. Administering preoperative medications is important for all preoperative clients and is not specific to this client. Teaching in the preoperative area should focus on immediate concerns.

An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate? a. Instruct the client to avoid large crowds. b. Prepare to administer epoetin alfa (Epogen). c. Teach the client about foods high in iron. d. Tell the client that all laboratory results are normal.

b. Prepare to administer epoetin alfa (Epogen). This client is anemic, which needs correction prior to surgery. While eating iron-rich foods is helpful, to increase the client's red blood cells, hemoglobin, and hematocrit within 2 months, epoetin alfa is needed. This colony-stimulating factor will encourage the production of red cells. The clients white blood cell count is normal, so avoiding infection is not the priority.

The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the client's blood glucose readings have been elevated. What question by the nurse is most appropriate? a. Are you compliant with following the diabetic diet? b. Have you been taking glucosamine supplements? c. How much exercise do you really get each week? d. You're still taking your diabetic medication, right?

b. Have you been taking glucosamine supplements? All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse should ask about its use. The other questions all have an element of nontherapeutic communication in them. Compliant is a word associated with negative images, and the client may deny being noncompliant. Asking how much exercise the client really gets is accusatory. Asking if the client takes his or her medications right? is patronizing.

A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best? a. Explain to the client that SLE is an unpredictable disease. b. Help the client create backup plans to minimize disruption. c. Offer to talk to the family and educate them about SLE. d. Tell the client to remain compliant with treatment plans.

b. Help the client create backup plans to minimize disruption. SLE is an unpredictable disease and acute exacerbations can occur without warning, creating chaos in the family. Helping the client make backup plans for this event not only will decrease the disruption but will give the client a sense of having more control. Explaining facts about the disease is helpful as well but does not engage the client in problem solving. The family may need education, but again this does not help the client to problem-solve. Remaining compliant may help decrease exacerbations, but is not as powerful an intervention as helping the client plan for such events.

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joints. What nonpharmacologic treatment does the nurse apply? a. Heating pad b. Ice packs c. Splints d. Wax dip

b. Ice packs Ice is best for acute inflammation. Heat often helps with joint stiffness. Splinting helps preserve joint function. A wax dip is used to provide warmth to the joint which is more appropriate for chronic pain and stiffness.

A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best? a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses.

b. Inform the student that the docusate should be given. Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea.

A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important? a. Assess the client's bedside glucose reading. b. Instruct the client not to get up without help. c. Monitor the client frequently for tachycardia. d. Record the clients intake, output, and weight.

b. Instruct the client not to get up without help. Antihistamines can cause drowsiness, so for the clients safety, he or she should be instructed to call for assistance prior to trying to get up. Hyperglycemia and tachycardia are side effects of sympathomimetics. Fluid and sodium retention are side effects of corticosteroids.

A 68-year-old male client is embarrassed about having bilateral breast enlargement. Which statement by the nurse is most appropriate? a. Breast cancer in men is quite rare. b. It is good that you came to be carefully evaluated. c. Gynecomastia usually comes from overeating. d. When you get older, the male breast always enlarges.

b. It is good that you came to be carefully evaluated. The most appropriate statement is the one that is supportive of the client. A breast mass should be carefully evaluated for breast cancer, even if it is not common. Gynecomastia as a symptom can be related to antiandrogen agents, aging, obesity, estrogen excess, or lack of androgens.

The nurse is taking the history of a client who is scheduled for breast augmentation surgery. The client reveals that she took two aspirin this morning for a headache. Which action by the nurse is best? a. Take the client's vital signs and record them in the chart. b. Notify the surgeon about the aspirin ingestion by the client. c. Warn the client that health insurance may not pay for the procedure. d. Teach the client about avoiding twisting above the waist after the operation.

b. Notify the surgeon about the aspirin ingestion by the client. The surgeon must be notified immediately since the aspirin could cause increased bleeding during the procedure. Vital signs should be recorded and postoperative teaching should be completed in the preoperative time frame, but these are not the priority since the procedure may be rescheduled. The warning about the clients health insurance is not appropriate at this time.

A nurse cares for an older adult client with multiple fractures. Which action should the nurse take to manage this clients pain? a. Meperidine (Demerol) injections every 4 hours around the clock b. Patient-controlled analgesia (PCA) pump with morphine c. Ibuprofen (Motrin) 600 mg orally every 4 hours PRN for pain d. Morphine 4 mg intravenous push every 2 hours PRN for pain

b. Patient-controlled analgesia (PCA) pump with morphine The older adult client should never be treated with meperidine because toxic metabolites can cause seizures. The client should be managed with a PCA pump to control pain best. Motrin most likely would not provide complete pain relief with multiple fractures. IV morphine PRN would not control pain as well as a pump that the client can control.

***A client has a bone density score of 2.8. What action by the nurse is best? a. Asking the client to complete a food diary b. Planning to teach about bisphosphonates c. Scheduling another scan in 2 years d. Scheduling another scan in 6 months

b. Planning to teach about bisphosphonates A T-score from a bone density scan at or lower than 2.5 indicates osteoporosis. The nurse should plan to teach about medications used to treat this disease. One class of such medications is bisphosphonates. A food diary is helpful to determine if the client gets adequate calcium and vitamin D, but at this point, dietary changes will not prevent the disease. Simply scheduling another scan will not help treat the disease either.

A nurse working at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurses drug use was evident? a. Accepting responsibility for medication errors. b. Seeking to be assigned as a medication nurse. c. Frequent complaints of physical pain. d. High sociability with peers.

b. Seeking to be assigned as a medication nurse. The nurse intent on diverting drugs for personal use often attempts to isolate him- or herself from peers rather than being sociable. The person seeks access to medications. Usually, the person will blame errors on others rather than accepting responsibility.

A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, cravings, poor concentration, and headache result. What does this scenario describe? a. Substance abuse b. Substance addiction c. Substance intoxication d. Recreational use of a social drug

b. Substance addiction Nicotine meets the criteria for a substance, the criterion for addiction (tolerance) is present, and withdrawal symptoms are noted with abstinence or a reduction of the dose. The scenario does not meet the criteria for substance abuse, intoxication, or recreational use of a social drug.

A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this client's postoperative instructions? a. Only lift items that are 10 pounds or less. b. Wear your brace whenever you are out of bed. c. You must remain in bed for 3 weeks after surgery. d. You are prescribed medications to prevent rejection.

b. Wear your brace whenever you are out of bed. Clients who undergo spinal fusion are fitted with a brace that they must wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client should not lift anything. The client does not need to remain in bed. Medications for rejection prevention are not necessary for this procedure.

Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.40 mg %). Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient: a. rarely drinks alcohol. b. has a high tolerance to alcohol. C. has been treated with disulfiram (Antabuse). D. has recently ingested both alcohol and sedative drugs.

b. has a high tolerance to alcohol. A non tolerant drinker would be in a coma with a blood alcohol level of 400 mg/dl (0.40 mg %). The fact that the patient is walking and talking shows a discrepancy between blood alcohol level and expected behavior. It strongly suggests that the patient's body has become tolerant to the drug. If disulfiram and alcohol are ingested together, then an entirely different clinical picture would result. The blood alcohol level gives no information about the ingestion of other drugs.

Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in one year. Before discharge, the patient will a. use rationalization in healthy ways. b. state, I see the need for ongoing treatment. C. identify constructive outlets for expression of anger. D. develop a trusting relationship with one staff member.

b. state, I see the need for ongoing treatment. The answer refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not provide enough information to know whether anger has been identified as a problem. A trusting relationship, although desirable, would not help the patient maintain sobriety.

What percentage of hip fractures are the result of falls? a. 50% b. 80% c. 90% d. 100%

c. 90% About 90% of falls end with a hip fracture.

The nurse is seeing clients at a drop-in primary health clinic. Which client does the nurse teach about the risks of acquiring HIV? a. Middle-aged woman with a new sexual partner b. Young male who has male sexual partners c. All clients who come to the clinic d. Young woman having her first gynecologic examination

c. All clients who come to the clinic All sexually active people should know their HIV status, and all people need to have education on their risk of acquiring HIV infection. Anyone who engages in sexual activity has some risk.

A mother brings her child to the clinic requesting genetic testing to determine whether her child suffers from the same multiple allergies as herself. What action by the nurse is most appropriate? a. Provide a referral to an allergist so the child can be tested. b. Refer the mother to a geneticist for genetic testing on the child. c. Ask the mother about specific symptoms the child may have had. d. Have the mother list her allergies and the symptoms they cause her.

c. Ask the mother about specific symptoms the child may have had. Allergic tendencies can be inherited, but no single gene has been identified that causes allergies, and allergies to specific items are not inherited. The nurse should ask the mother about any symptoms the child has that seem related to allergies. The child will not be tested by an allergist simply because the mother has allergies, and a geneticist will not be able to identify an allergy gene in the child. Because specific allergies are not inherited, having the mother list her allergies will not be beneficial.

It is most important that the nurse include which activity for the young adult client with Down syndrome? a. Encouraging more fruit and leafy green vegetables in the diet b. Teaching him how to perform a testicular self-examination c. Assessing the skin for unusual bruises and petechiae d. Testing the clients stool for occult blood

c. Assessing the skin for unusual bruises and petechiae All screening and prevention activities are appropriate. However, people with Down syndrome have an increased lifetime risk for the development of leukemia.

A child with leukemia is receiving intrathecal chemotherapy to prevent which condition? a. Infection b. Brain tumor c. Central nervous system (CNS) disease d. Drug side effects

c. Central nervous system (CNS) disease Children with leukemia are at risk for invasion of the CNS with leukemic cells. CNS prophylactic therapy is indicated. Intrathecal chemotherapy does not prevent infection or drug side effects. A brain tumor in a child with leukemia would be a second tumor, and additional appropriate therapy would be indicated.

The nurse has taught a client with lupus about skin protection in the clinic. Later, the nurse sees the client at an outdoor music festival. Which observation by the nurse indicates that the client requires further instruction? a. Client is wearing a thin, long-sleeved shirt. b. Client is wearing a hat with a full brim. c. Client is discussing her new perm. d. Client is seen applying sunscreen twice.

c. Client is discussing her new perm. Alopecia is common; the client should use gentle shampoo and avoid any harsh chemical treatments, such as a permanent wave. The other observations show good skin protection practices by the client.

A client is at high risk for developing skin cancer but will not perform total skin self-examination (TSSE) consistently. Which nursing intervention is the most important? a. Reinforce previous teaching on the TSSE technique. b. Teach the client the dangers of skin cancer. c. Determine whether the client has a partner to help. d. Carefully document all existing skin lesions.

c. Determine whether the client has a partner to help. Research shows that an important factor in compliance with TSSE is having a partner with whom to work while performing the assessment.

The nurse is preparing a child for possible alopecia from chemotherapy. What information should the nurse include? a. Wearing hats or scarves is preferable to a wig. b. Expose head to sunlight to stimulate hair regrowth. c. Hair may have a slightly different color or texture when it regrows. d. Regrowth of hair usually begins 12 months after chemotherapy ends.

c. Hair may have a slightly different color or texture when it regrows. Alopecia is a side effect of certain chemotherapeutic agents and cranial irradiation. When the hair regrows, it may be of a different color or texture. Children should choose the head covering they prefer. A wig should be selected similar to the child's own hairstyle and color before the hair loss. The head should be protected from sunlight to avoid sunburn. The hair usually grows back within 3 to 6 months after the cessation of treatment.

The nurse is assessing a patient using the CAGE Questionnaire. The patient answers yes to all of the questions. The nurse suspects alcoholism and feels the patient is in denial when the patient states which of the following? a. I go to meetings once a day and still drink. b. My family and friends have been avoiding me lately. c. I don't have a problem with alcohol. I can quit anytime I want to. d. I know it will be hard to quit, but I am willing to try.

c. I don't have a problem with alcohol. I can quit anytime I want to. The patient may need help admitting that there is a problem. The CAGE is designed to objectively assist in assessing problems related to alcohol use. A patient who states they are going to meetings is admitting they have a problem even if they still drink. Admitting that quitting is difficult is acceptance that there is a problem. Reality is setting in for a patient who can see that family and friends are avoiding them.

A client states that he is allergic to poison ivy. Which statement by the client indicates a good understanding of this type of sensitivity? a. Drinking 3 liters of water a day will prevent kidney damage. b. I will always wear a medical alert bracelet for this allergy. c. I need to try to avoid coming into contact with poison ivy. d. I should carry diphenhydramine (Benadryl) with me at all times.

c. I need to try to avoid coming into contact with poison ivy. Reactions to poison ivy are a type IV hypersensitivity reaction. They are cell mediated by T-lymphocytes in the skin. Avoidance of the offending allergen is the most appropriate intervention. The complexes do not form or precipitate in the kidney. This type of hypersensitivity does not represent an immediate life-threatening emergency and does not respond to histamine antagonists (diphenhydramine).

The nurse asks a young adult client if she is sexually active. The client asks why the nurse needs to know. What is the nurse's best response? a. I just need to make sure that the information you are providing is reliable. b. I have to fill in answers to all of the questions on the health history form. c. If you are sexually active, we should talk about ways to prevent getting HIV. d. I will have to notify your partner if you have a sexually transmitted disease.

c. If you are sexually active, we should talk about ways to prevent getting HIV. The nurse should assess whether the client is sexually active to determine whether it is appropriate to teach about safer sex practices. The nurse would not notify the clients sexual partners if a sexually transmitted disease were diagnosed.

Which of the following demonstrates a nurse utilizing self-reflection to improve clinical decision making? a. Uses an objective approach in all situations b. Obtains data in an orderly fashion c. Improves a plan of care while thinking back on interventions performed d. Provides evidence-based explanations for all nursing interventions

c. Improves a plan of care while thinking back on interventions performed Self-reflection utilizes critical thinking when thinking back on the effectiveness of interventions and how they were performed. The other options are not the best examples of self-reflection but do represent good nursing practice. Using an objective approach and obtaining data in an orderly fashion does not involve purposefully thinking back to discover the meaning or purpose of a situation. Providing evidence-based explanations for nursing interventions does not always involve thinking back to discover the meaning of a situation.

How does the type V hypersensitivity reaction differ from other reactions? a. It is cell mediated rather than antibody mediated. b. It is an immediate response rather than a delayed response. c. It produces a stimulatory response to normal tissues. d. It results in more severe tissue damage than is caused by other types of reactions.

c. It produces a stimulatory response to normal tissues. Type V hypersensitivity reactions are known as stimulatory responses. The classic example of type V hypersensitivity is Graves disease, in which the person makes a large amount of antibody that binds to the thyroid-stimulating hormone receptor antibody (TSHr-Ab) on thyroid tissue. The binding of this antibody to the TSH receptor activates the receptor, greatly stimulating the thyroid gland and causing severe hyperthyroid symptoms. This type of reaction is not cell mediated. It is not an immediate response, nor does it cause more severe tissue damage.

A client returns to the medical-surgical unit after a total hip replacement with a large wedge-shaped pillow between his legs. The client's daughter asks the nurse why the pillow is in place. What is the nurse's best response? a. It will help prevent bedsores from developing. b. It will help prevent nerve damage and foot drop. c. It will keep the new hip from becoming dislocated. d. It will prevent climbing out of bed if he becomes confused.

c. It will keep the new hip from becoming dislocated. Adduction of the operative leg beyond the midline could dislocate the new hip. The wedge pillow will help prevent this from happening. The wedge will not prevent bedsores from developing because it does not prevent pressure. The pillow will not prevent foot drop, because it is placed between the legs. The pillow is not a restraining device, and it will not prevent the client from climbing out of bed.

The nurse is caring for an older adult client who has fallen and fractured her hip. The client will have hip replacement surgery followed by extensive rehabilitation. The client confides in the nurse, I feel like I don't have any control over anything anymore now that I am old. What is the nurse's best response? a. I'll make sure that the physical and occupational therapists see you after surgery to help get your strength back. b. Its normal to feel this way, but hopefully you will be back on your feet after a stay in rehab. c. It's important to control what you can right now, like making out your menu every day and working with the therapists. d. I sense that you are feeling depressed about the situation. I will ask the doctor to prescribe an antidepressant for you.

c. It's important to control what you can right now, like making out your menu every day and working with the therapists. The nurse should support the clients self-esteem and increase feelings of competency by encouraging activities that assist in maintaining some degree of control, such as participation in decision making and performance of tasks that he or she can manage. The nurse should provide immediate control options for the client, rather than waiting until after rehabilitation. The clients desire for control does not indicate depression, so an antidepressant is not indicated. Therapy referrals are appropriate but do not address the client's desire for control.

An unknown unconscious client with an elevated temperature is ordered IV penicillin. What is the best action for the nurse to take? a. Administer the medication. b. Check the chart for allergies. c. Look for medical alert identification. d. Notify the nursing supervisor.

c. Look for medical alert identification. Allergies need to be identified before medications are administered. This client cannot talk and is unknown, so a chart cannot be retrieved. Clients with allergies are taught to carry medical alert identification.

The nurse is caring for a client who had a stroke. Which nursing intervention does the nurse implement during the first 72 hours to prevent complications? a. Administer prescribed analgesics to promote pain relief. b. Cluster nursing procedures together to avoid fatiguing the client. c. Monitor neurologic and vital signs closely to identify early changes in status. d. Position with the head of the bed flat to enhance cerebral perfusion.

c. Monitor neurologic and vital signs closely to identify early changes in status. Early detection of neurologic, blood pressure, and heart rhythm changes offers an opportunity to intervene in a timely fashion. Evidence is not yet sufficient to recommend a specific backrest elevation after stroke. Analgesics are often held during the first 72 hours to ensure that the clients neurologic status is not altered by pain medications. Preventing fatigue is not a priority in the first 72 hours.

An older client expresses concern about developing new age spots. Which instruction is most important for the nurse to provide to the client? a. Limit the time you spend in the sun. b. Monitor for signs of infection. c. Monitor spots for color change. d. Use skin cream to prevent drying.

c. Monitor spots for color change. The ABCDE method (check for asymmetry, border irregularity, color variation, diameter, and evolving [changing] in any feature) should be used to assess lesions for signs associated with cancer. Any positive findings using this method requires the lesion to be examined by a dermatologist or a surgeon. The other options are good instructions for clients too, but this client is worried about lesions that are already present.

A client is being treated with anastrozole (Arimidex) for breast cancer. The nurse is developing a plan of care for the client. Which intervention is the highest priority? a. Teach the client to weigh herself each day at the same time. b. Instruct the client to keep a symptom journal for menopausal symptoms. c. Monitor the client closely for evidence of osteoporosis. d. Review the client's dietary habits to prevent weight gain.

c. Monitor the client closely for evidence of osteoporosis. Arimidex is an aromatase inhibitor. A major side effect of aromatase inhibitors is loss of bone density. Fluid retention, menopausal symptoms, and weight gain are not primary side effects of Arimidex or other aromatase inhibitors.

Which diagnostic test is used to confirm a suspected diagnosis of breast cancer? a. Mammogram b. Ultrasound c. Needle-localization biopsy d. Magnetic resonance imaging (MRI)

c. Needle-localization biopsy When a suspicious mammogram is noted or a lump is detected, diagnosis is confirmed by either a core-needle biopsy or a needle-localization biopsy. Mammography is a clinical screening tool that may aid in the early detection of breast cancers. Transillumination, thermography, and ultrasound breast imaging are being explored as methods for detecting early breast carcinoma. An MRI is useful in women with masses that are difficult to find (occult breast cancer).

A client has known lung cancer and has been admitted for abdominal pain and jaundice. A computed tomography (CT) scan reveals tumors in the clients liver. The client is distraught and says, So now I have liver cancer too? Which response by the nurse is most appropriate? a. Yes, liver cancer is common in people who already have lung cancer. b. Yes, your chemotherapy left you vulnerable to a virus that causes liver cancer. c. No, the tumors are actually from your lung cancer, which has metastasized. d. No, having tumors in two different organs is rare; you probably have hepatitis.

c. No, the tumors are actually from your lung cancer, which has metastasized. When a cancer metastasizes to another organ, it is still the same cancer from the original spot. This client has lung cancer that has metastasized to the liver.

The nurse assesses the outcomes of a motivational interview on a patient with a dual diagnosis of alcoholism with DTs and determines that the communication was nontherapeutic. What should the nurses next priority be? a. Encourage the patient to think of ways to change environmental triggers to abuse substances. b. Ask the patient what methods they think would work and encourage participating in self-help groups. c. Notify provider to obtain order for oxazepam (Serax) and vitamin B infusion. d. Notify provider to obtain order for CT scan and psychologic consult.

c. Notify provider to obtain order for oxazepam (Serax) and vitamin B infusion. The patient will need to be treated for psychosis prior to conducting the motivational interview, because the patient can become violent and non receptive to the interventions. Oxazepam and vitamin B are the two therapies that work for DTs.

The home care nurse is making a follow-up visit to a client who had total hip replacement surgery 2 weeks ago. Which client statement indicates a need for clarification regarding postoperative routine? a. My daughter helps me put on my elastic TED (thromboembolic deterrent) hose every day. b. I take 200 mg of Motrin (ibuprofen) at bedtime so that I can sleep. c. Now that my hip doesn't hurt, I can cross my legs like a lady again. d. Each day, I try to increase my walking time by at least 10 minutes.

c. Now that my hip doesn't hurt, I can cross my legs like a lady again. Crossing the legs beyond midline can dislocate the new hip joint and should be avoided at all times. The other statements demonstrate correct behavior and understanding.

***A client is undergoing radiation therapy as a treatment for lung cancer and has developed esophagitis. Which is the best diet selection for this client? a. Spaghetti with meat sauce, ice cream b. Scrambled eggs, bacon, toast c. Omelet, whole wheat bread d. Pasta salad, custard, orange juice

c. Omelet, whole wheat bread Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. Toast is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic.

Having a genetic mutation may create an 85% chance of developing breast cancer in a woman's lifetime. Which condition does not increase a client's risk for breast cancer? a. BRCĀ or BRCÁ gene mutation b. Li-Fraumeni syndrome c. Paget disease d. Cowden syndrome

c. Paget disease Paget disease originates in the nipple and causes nipple carcinoma and exhibits bleeding, oozing, and crusting of the nipple. BRCĀ or BRCÁ, Li-Fraumeni syndrome, and Cowden syndrome are all genetic mutations that have different family pedigrees and increase the risk of breast cancer.

The nurse is teaching bladder training to a client who is incontinent after a stroke. Which instruction does the nurse include in this clients teaching? a. Decrease your oral intake of fluids to 1 liter per day. b. Use a Foley catheter at night to prevent accidents. c. Plan to use the commode every 2 hours during the day. d. Hold your bladder as long as possible to restore bladder tone.

c. Plan to use the commode every 2 hours during the day. To begin a bladder training program, teach the client to use the commode, bedpan, or urinal every 2 hours. If used frequently enough, this will prevent accidents and establish a routine. Fluid intake should be restricted at night, and a Foley catheter should be used only for urine retention. The client should empty his or her bladder when the urge occurs and should not hold the bladder.

The nurse is caring for a patient who is experiencing alcohol withdrawal. What is the main priority for this patient? a. Describe how the alcohol is causing the withdrawal effects. b. Leave the patient by him/herself so as not to cause agitation. c. Promote a safe, calm, and comfortable environment. d. Refer the patient to an alcohol-abuse counselor.

c. Promote a safe, calm, and comfortable environment. The main priority is the patients safety due to risk of harm from seizures, DTs, and anxiety. The nurse could provide referrals or discuss the relationship of alcohol to physical problems after the withdrawal period is over. Do not leave the patient alone, as many patients will need reassurance that they will survive the ordeal of withdrawal.

A client who has had a stroke with left-sided hemiparesis has been referred to a rehabilitation center. The client asks, Why do I need rehabilitation? How does the nurse respond? a. Rehabilitation will reverse any physical deficits caused by the stroke. b. If you do not have rehabilitation, you may never walk again. c. Rehabilitation will help you function at the highest level possible. d. Your doctor knows best and has ordered this treatment for you.

c. Rehabilitation will help you function at the highest level possible. The goal of rehabilitation is to maximize the clients abilities in all aspects of life. The other responses do not answer the clients questions appropriately.

A patient describes practicing a complementary and alternative therapy involving concentrating and controlling his respiratory rate and pattern, recognizing that breath work is to yoga as a. The zone is to acupressure. b. Massage therapy is to Ayurveda. c. Reiki therapy is to therapeutic touch. d. Prayer is to tai chi.

c. Reiki therapy is to therapeutic touch. This is an analogy that compares different therapies within specific categories. Both yoga and breath work are mind-body therapies, whereas both Reiki and therapeutic touch therapies are energy field therapies. The other options have different design structures; thus, they do not fit the analogy.

Professional standards influence a nurses clinical decisions by a. Bypassing the patients feelings to promote ethical standards. b. Establishing minimal passing standards for testing. c. Requiring the nurse to use critical thinking for the highest level of quality nursing care. d. Utilizing evidence-based practice based on nurses needs.

c. Requiring the nurse to use critical thinking for the highest level of quality nursing care. Upholding professional standards requires nurses to use critical thinking for the highest level of quality nursing care. Bypassing the patients feelings is not practicing according to professional standards. The primary purpose of professional standards is not to establish minimal passing standards for testing. Patient care should be based on patient needs, not on nurses needs.

The middle-aged client with lung cancer asks whether his adult children are at increased risk for this cancer. What is the nurse's best response? a. This disease is a random event and there is no way to prevent it. b. This disease is inherited, so your children have a 50% risk for developing it. c. Smoking is the main cause. Helping your children not smoke decreases their risk. d. They can avoid cancer by decreasing the fat they eat and by exercising more.

c. Smoking is the main cause. Helping your children not smoke decreases their risk. Long-term cigarette smoking is the major risk factor for lung cancer. Not smoking is the best way to prevent it.

A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect does the nurse monitor for in this client? a. Repeated syncope b. New-onset confusion c. Spontaneous ecchymosis d. Abdominal distention

c. Spontaneous ecchymosis Clopidogrel (Plavix) is an antiplatelet medication that can cause bleeding, bruising, and liver dysfunction. The nurse should be alert for signs of bleeding, such as ecchymosis, bleeding gums, and tarry stools. Plavix does not cause syncope, confusion, or abdominal distention.

When obtaining a sexual history from a client in a clinic setting, the nurse notes that the client appears very uncomfortable and pauses for long periods before answering the nurses questions. What is the nurse's best response? a. I am sorry that my questions are making you very uncomfortable. b. Don't worry. Well be done with these questions in no time at all. c. Take your time. I realize that this is a very private topic to talk about. d. These questions are making you uncomfortable, so we'll finish next time.

c. Take your time. I realize that this is a very private topic to talk about. The client should be given time to collect his or her thoughts and composure before answering questions. The nurse should not apologize for asking pertinent questions about the client's health history. The sexual history should not be deferred until the next appointment. Recognizing the difficulty the client may be experiencing is helpful in establishing a therapeutic relationship.

A patient is talking with the nurse about hip fractures. The patient would like to know the best approach to strengthen the bones. The nurse's best response is which of the following? a. Walk at least 5 miles every day for exercise. b. Wear proper fitting shoes to prevent tripping. c. Talk with your physician about a calcium supplement. d. Stand up slowly so you don't feel faint.

c. Talk with your physician about a calcium supplement. Calcium strengthens the bones. A calcium supplement will help strengthen bones as they may be affected by aging, illness, or trauma. Walking several miles will help strengthen the bones but a calcium supplement is a good addition. Wearing proper shoes and standing slowly to prevent dizziness is important but they will not prevent fractures.

The nurse is interested in primary prevention for cancer. Which activity does the nurse most likely participate in? a. Distributing occult fecal blood test kits to people at the shopping mall b. Arranging transportation volunteers for clients undergoing radiation therapy c. Teaching high school students the dangers of using tobacco d. Educating adolescent girls about getting an annual Papanicolaou (PAP) smear

c. Teaching high school students the dangers of using tobacco Primary prevention focuses on activities that occur before an illness, such as education and vaccinations. Occult fecal blood testing and PAP smears are secondary prevention activities designed for screening and early diagnosis. Arranging transportation for a client who is undergoing radiation therapy is tertiary prevention.

A nurse wants to apply open communication to obtain a thorough history and to determine cognitive function. Which question represents the use of open communication? a. Is today Wednesday? b. Do you know what day it is? c. Tell me what day of the week today is. d. Do you know what the first day of the week is?

c. Tell me what day of the week today is. The patient must be able to name the day of the week rather than use answer yes or no.

The newly employed nurse received a bacillus Calmette-Gurin (BCG) vaccine before moving to the United States. The nurse needs to receive a tuberculin (TB) test as part of the pre-employment physical. What does the nurse do? a. The nurse should not receive the tuberculin test. b. The nurse will need a two-step TB test. c. The nurse will need a chest x-ray instead. d. A physician should examine the nurse before the TB test is given.

c. The nurse will need a chest x-ray instead. The bacillus Calmette-Gurin (BCG) vaccine contains attenuated tubercle bacilli and is used in many countries to produce increased resistance to TB. The nurse will have a positive skin test. The client should be evaluated for TB with a chest x-ray. A physician examination is not necessary.

The nurse includes which information about benign tumors when presenting an in-service on cancer? a. They can wander far throughout the body. b. They are smaller than 2 cm. c. They retain a small nuclear-to-cytoplasmic ratio. d. They look different from the tissue they arose from.

c. They retain a small nuclear-to-cytoplasmic ratio. Benign tumors are made up of normal cells growing in the wrong place or growing when they are not needed. Benign tumors retain the characteristics of normal cells in that they do not migrate in the body, they retain a small nuclear-to-cytoplasmic ratio, and they look similar to the tissue from which they arose. Size is not related to malignancy or to being benign.

Which condition is a type II hypersensitivity reaction? a. Allergic rhinitis b. Positive purified protein derivative (PPD) test for tuberculosis c. Transfusion reaction to improper blood type d. Serum sickness after receiving immune globulin

c. Transfusion reaction to improper blood type Common clinical situations caused by type II hypersensitivities include hemolytic transfusion reactions. Type II hypersensitivity reactions are caused by antibodies directed against body tissues that have some form of non-self (foreign) protein attached to them. Allergic rhinitis is an example of a type I hypersensitivity. A positive PPD test is an example of a type IV reaction. Serum sickness is a type III reaction.

What description identifies the pathophysiology of leukemia? a. Increased blood viscosity b. Abnormal stimulation of the first stage of coagulation process c. Unrestricted proliferation of immature white blood cells (WBCs) d. Thrombocytopenia from an excessive destruction of platelets

c. Unrestricted proliferation of immature white blood cells (WBCs) Leukemia is a group of malignant disorders of the bone marrow and lymphatic system. It is defined as an unrestricted proliferation of immature WBCs in the blood-forming tissues of the body. Increased blood viscosity may result secondary to the increased number of WBCs. The coagulation process is unaffected by leukemia. Thrombocytopenia may occur secondary to the overproduction of WBCs in the bone marrow.

Nursing care of the child with myelosuppression from leukemia or chemotherapeutic agents should include which therapeutic intervention? a. Restrict oral fluids. b. Institute strict isolation. c. Use good hand-washing technique. d. Give immunizations appropriate for age.

c. Use good hand-washing technique. Good hand washing minimizes the exposure to infectious organisms and decreases the chance of infection spread. Oral fluids are encouraged if the child is able to drink. If possible, the intravenous route is not used because of the increased risk of infection from parenteral fluid administration. Strict isolation is not indicated. When the child is immunocompromised, the vaccines are not effective. If necessary, the appropriate immunoglobulin is administered.

A client with a family history of breast cancer tells the nurse that she has made several recent lifestyle changes. Which question by the nurse about these practices is most important? a. Are you a vegetarian? b. Do you drink green tea? c. What supplements do you use? d. Do you smoke cigarettes?

c. What supplements do you use? Soy supplements in high amounts should be avoided by women who have breast cancer or who are at high risk for breast cancer. Dietary soy, eaten in normal amounts, does not appear to present the same risk. The other activities do not have the same risk as taking large quantities of soy supplements.

A client has multidrug-resistant tuberculosis (TB). What is the most important fact for the nurse to teach the client? a. You will need to take medications longer than clients with other strains. b. You will need to remain in the hospital until cultures are negative. c. You will need to wear a mask when you go out in public. d. You will need to have drug cultures done weekly.

c. You will need to wear a mask when you go out in public. The client should wear a mask when out of the home environment and in crowds to prevent the spread of the infection. The other statements are not accurate.

The nurse is working with a client at a public health clinic. The client says to the nurse, The doctor said that my CD4+ count is 450. Is that good? What is the nurse's best response? a. Your count is high so you can cut back on your medication. b. Your count is normal because your medications are working well. c. Your count is a bit low and you are susceptible to infection. d. Your count is very low and you actually now have AIDS.

c. Your count is a bit low and you are susceptible to infection. A CD4+ T-cell count of 450 cells/mm3 of blood is low, and the client is at increased risk for developing an infection. Normal CD4+ counts range from 800 to 1000 cells/mm3. To be diagnosed with AIDS, a client must have a CD4+ T-cell count of <200 cells/mm3 (or a CD4+ T-cell percentage of <4%) and/or an opportunistic infection.

An elderly Chinese woman is interested in biologically based therapies to relieve osteoarthritis pain (OA). You are preparing a plan of care for her OA. Options most conducive to her expressed wishes may include a. Pilates, breathing exercises, and aloe vera. b. guided imagery, relaxation breathing, and meditation. c. herbs, vitamins, and tai chi. d. alternating ice and heat to relieve pain and inflammation.

c. herbs, vitamins, and tai chi. Nonpharmacologic strategies encompass a wide variety of nondrug treatments that may contribute to comfort and pain relief. These include the body-based (physical) modalities, such as massage, acupuncture, and application of heat and cold, and the mind-body methods, such as guided imagery, relaxation breathing, and meditation. There are also biologically based therapies which involve the use of herbs and vitamins, and energy therapies such as reiki and tai chi. Pilates, breathing exercises, aloe vera, guided imagery, relaxation breathing, meditation, and alternating ice and heat are multimodal therapies for pain management. They are not exclusively biologically based, which involves the use of herbs and vitamins.

A student nurse and clinical instructor are discussing quality in health care. The instructor knows the student understands when the student says, Quality is a. apparent in all health care. b. an outcome of health care. c. seen and unseen in health care. d. achieved by collaboration in health care.

c. seen and unseen in health care. Quality in health care is tangible and intangible. Quality in health care is not apparent in all health care, as many areas of health care are lacking. Quality of care does not always affect the outcome of care; the patient may recover no matter what care is given. Quality is not always achieved by collaboration.

A group of nurses are meeting to decide how to staff the upcoming holidays. Each of the four members freely expresses thoughts about fair staffing but is willing to listen to others thoughts and reconsider their first recommendations. The nurses are avoiding conflict and supporting professional communication through: a. empathy. b. positiveness. c. supportiveness. d. accommodation.

c. supportiveness. Supportive communication occurs when each person's opinion/position is valued and each participant has the freedom to express a position but is willing to change that opinion/position.

A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain? a. A 24-year-old female who is 25 weeks pregnant b. A 36-year-old male who uses ergonomic techniques c. A 45-year-old male with osteoarthritis d. A 53-year-old female who uses a walker

c. A 45-year-old male with osteoarthritis Osteoarthritis causes changes to support structures, increasing the client's risk for low back pain. The other clients are not at high risk.

A patient is admitted in a comatose state after ingesting 30 capsules of pentobarbital sodium. A friend of the patient says, Often my friend drinks, along with taking more of the drug than is prescribed. What is the effect of the use of alcohol with this drug? a. The drugs metabolism is stimulated. b. The drugs effect is diminished. c. A synergistic effect occurs. d. There is no effect.

c. A synergistic effect occurs. Both pentobarbital and alcohol are CNS depressants and have synergistic effects. Taken together, the action of each would potentiate the other.

What comfort measures can only be performed by a nurse, as opposed to unlicensed assistive personnel (UAP), for a client who returned from a left modified radical mastectomy 4 hours ago? a. Placing the head of bed at 30 degrees b. Elevating the left arm on a pillow c. Administering morphine for pain at a 4 on a 0-to-10 scale d. Supporting the left arm while initially ambulating the client

c. Administering morphine for pain at a 4 on a 0-to-10 scale Only the nurse is authorized to administer medications, but the UAP could inform the nurse about the rating of pain by the client. The UAP could position the bed to 30 degrees and elevate the client's arm on a pillow to facilitate lymphatic fluid drainage return. The client's arm should be supported while walking at first but then allowed to hang straight by the side. The UAP could support the arm while walking the client.

A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this client's plan of care? a. Encourage the client to stretch the back by reaching toward the toes. b. Massage the affected area with ice twice a day. c. Apply a heating pad for 20 minutes at least four times daily. d. Advise the client to avoid warm baths or showers.

c. Apply a heating pad for 20 minutes at least four times daily. Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will not promote healing, and there is no need to avoid warm baths or showers.

A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication would the nurse anticipate the health care provider will prescribe? a. Monoamine oxidase inhibitor, such as phenelzine (Nardil) b. Phenothiazine, such as thioridazine (Mellaril) c. Benzodiazepine, such as lorazepam (Ativan) d. Narcotic analgesics, such as morphine

c. Benzodiazepine, such as lorazepam (Ativan) This patient is experiencing alcohol withdrawal delirium. Sedation allows for the safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties. Antidepressant, antipsychotic, and opioid medications will not relieve the patient's symptoms.

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor? a. Peripheral edema b. Black tarry stools c. Bradycardia d. Nausea and vomiting

c. Bradycardia Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not adverse effects of fingolimod.

A nurse sees clients in an osteoporosis clinic. Which client should the nurse see first? a. Client taking calcium with vitamin D (Os-Cal) who reports flank pain 2 weeks ago b. Client taking ibandronate (Boniva) who cannot remember when the last dose was c. Client taking raloxifene (Evista) who reports unilateral calf swelling d. Client taking risedronate (Actonel) who reports occasional dyspepsia

c. Client taking raloxifene (Evista) who reports unilateral calf swelling The client on raloxifene needs to be seen first because of the manifestations of deep vein thrombosis, which is an adverse effect of raloxifene. The client with flank pain may have had a kidney stone but is not acutely ill now. The client who cannot remember taking the last dose of ibandronate can be seen last. The client on risedronate may need to change medications.

A 35-year-old woman is diagnosed with stage III breast cancer. She seems to be extremely anxious. What action by the nurse is best? a. Encourage the client to search the Internet for information tonight. b. Ask the client if sexuality has been a problem with her partner. c. Explore the idea of a referral to a breast cancer support group. d. Assess whether there has been any mental illness in her past.

c. Explore the idea of a referral to a breast cancer support group. Support for the diagnosis would be best with a referral to a breast cancer support group. The Internet may be a good source of information, but the day of diagnosis would be too soon. The nurse could assess the frequency and satisfaction of sexual relations but should not assume that there is a problem in that area. Assessment of mental illness is not an appropriate action.

The nursing instructor explains the difference between normal cells and benign tumor cells. What information does the instructor provide about these cells? a. Benign tumors grow through invasion of other tissues. b. Benign tumors have lost their cellular regulation from contact inhibition. c. Growing in the wrong place or time is typical of benign tumors. d. The loss of the characteristics of the parent cells is called anaplasia.

c. Growing in the wrong place or time is typical of benign tumors. Benign tumors are basically normal cells growing in the wrong place or at the wrong time. Benign cells grow through hyperplasia, not invasion. Benign tumor cells retain contact inhibition. Anaplasia is a characteristic of cancer cells.

A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met? a. Chooses preferred items from the menu b. Eats 75% to 100% of all meals and snacks c. Has clear lung sounds on auscultation d. Gains 2 pounds after 1 week

c. Has clear lung sounds on auscultation Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.

A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope with the long recovery period, what action by the nurse is best? a. Arrange a visitation schedule among friends and family. b. Explain that this process is difficult but must be endured. c. Help the client find things to hope for each day of recovery. d. Provide plenty of diversionary activities for this time.

c. Help the client find things to hope for each day of recovery. Providing hope is an essential nursing function during treatment for any disease process, but especially during the recovery period after bone marrow transplantation, which can take up to 3 weeks. The nurse can help the client look ahead to the recovery period and identify things to hope for during this time. Visitors are important to clients, but may pose an infection risk. Telling the client the recovery period must be endured does not acknowledge his or her feelings. Diversionary activities are important, but not as important as instilling hope.

With a history of breast cancer in the family, a 48-year-old female client is interested in learning about modifiable risk factors for breast cancer. After the nurse explains this information, which statement made by the client indicates that more teaching is needed? a. I am fortunate that I breast-fed each of my three children for 12 months. b. It looks as though I need to start working out at the gym more often. c. I am glad that we can still have wine with every evening meal. d. When I have menopausal symptoms, I must avoid hormone replacement therapy.

c. I am glad that we can still have wine with every evening meal. Modifiable risk factors can help prevent breast cancer. The client should lessen alcohol intake and not have wine 7 days a week. Breast-feeding, regular exercise, and avoiding hormone replacement are also strategies for breast cancer prevention.

A nurse is discharging a client after a total hip replacement. Which statement by the client indicates good potential for self-management? a. I can bend down to pick something up. b. I no longer need to do my exercises. c. I will not sit with my legs crossed. d. I won't wash my incision to keep it dry.

c. I will not sit with my legs crossed. There are many precautions clients need to take after hip replacement surgery, including not bending more than 90 degrees at the hips, continuing prescribed exercises, not crossing the legs, and washing the incision daily and patting it dry.

A nurse has taught a client about dietary changes that can reduce the chances of developing cancer. Which statement by the client indicates the nurse needs to provide additional teaching? a. Foods high in vitamin A and vitamin C are important. b. I'll have to cut down on the amount of bacon I eat. c. I'm so glad I don't have to give up my juicy steaks. d. Vegetables, fruit, and high-fiber grains are important.

c. I'm so glad I don't have to give up my juicy steaks. To decrease the risk of developing cancer, one should cut down on the consumption of red meat and animal fat. The other statements are correct.

The nurse is caring for a client with lung cancer who states, I don't want any pain medication because I am afraid I'll become addicted. How should the nurse respond? a. I will ask the provider to change your medication to a drug that is less potent. b. Would you like me to use music therapy to distract you from your pain? c. It is unlikely you will become addicted when taking medicine for pain. d. Would you like me to give you acetaminophen (Tylenol) instead?

c. It is unlikely you will become addicted when taking medicine for pain. Clients should be encouraged to take their pain medications; addiction usually is not an issue with a client in pain. The nurse would not request that the pain medication be changed unless it was not effective. Other methods to decrease pain can be used, in addition to pain medication.

A client is starting hormonal therapy with tamoxifen (Nolvadex) to lower the risk for breast cancer. What information needs to be explained by the nurse regarding the action of this drug? a. It blocks the release of luteinizing hormone. b. It interferes with cancer cell division. c. It selectively blocks estrogen in the breast. d. It inhibits DNA synthesis in rapidly dividing cells.

c. It selectively blocks estrogen in the breast. Tamoxifen (Nolvadex) reduces the estrogen available to breast tumors to stop or prevent growth. This drug does not block the release of luteinizing hormone to prevent the ovaries from producing estrogen; leuprolide (Lupron) does this. Chemotherapy agents such as ixabepilone (Ixempra) interfere with cancer cell division, and doxorubicin (Adriamycin) inhibits DNA synthesis in susceptible cells.

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? a. Avoid contact sports. b. Get plenty of calcium. c. Lose weight if needed. d. Engage in weight-bearing exercise.

c. Lose weight if needed. Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms once it occurs. Arthritis can be caused by contact sports, but this is less common than obesity. Calcium and weight-bearing exercise are both important for osteoporosis.

Which assessment findings best correlate to the withdrawal from central nervous system depressants? a. Dilated pupils, tachycardia, elevated blood pressure, elation b. Labile mood, lack of coordination, fever, drowsiness c. Nausea, vomiting, diaphoresis, anxiety, tremors d. Excessive eating, constipation, headache

c. Nausea, vomiting, diaphoresis, anxiety, tremors The symptoms of withdrawal from various CNS depressants are similar. Generalized seizures are possible.

Which finding in a female client by the nurse would receive the highest priority of further diagnostics? a. Tender moveable masses throughout the breast tissue b. A 3-cm firm, defined mobile mass in the lower quadrant of the breast c. Nontender immobile mass in the upper outer quadrant of the breast d. Small, painful mass under warm reddened skin

c. Nontender immobile mass in the upper outer quadrant of the breast Malignant lesions are hard, nontender, and usually located in the upper outer quadrant of the breast and would be the priority for further diagnostic study. The other lesions are benign breast disorders. The tender moveable masses throughout the breast tissue could be fibrocystic breast condition. A firm, defined mobile mass in the lower quadrant of the breast is a fibroadenoma, and a painful mass under warm reddened skin could be a local abscess or ductal ectasia.

A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important? a. Be sure you get enough sleep at night. b. Eat plenty of high-protein, high-iron foods. c. Notify your provider at once if you get a fever. d. Weigh yourself every day on the same scale.

c. Notify your provider at once if you get a fever. Fever is the classic sign of a lupus flare and should be reported immediately. Rest and nutrition are important but do not take priority over teaching the client what to do if he or she develops an elevated temperature. Daily weights may or may not be important depending on renal involvement.

A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find? a. Hyperresponsive reflexes b. Excessive somnolence c. Nystagmus d. Heat intolerance

c. Nystagmus Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.

A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first? a. Initiate Droplet Precautions for the client. b. Notify the provider about the CD4+ results. c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care.

c. Place the client under Airborne Precautions. Since this clients CD4+ cell count is low, he or she may have energy, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the provider about the low CD4+ count and requests alternative testing for TB. Droplet Precautions are not used for TB. Standard Precautions are not adequate in this case.

A nurse is caring for four clients. After the hand-off report, which client does the nurse see first? a. Client with osteoporosis and a white blood cell count of 27,000/mm3 b. Client with osteoporosis and a bone fracture who requests pain medication c. Post-microvascular bone transfer client whose distal leg is cool and pale d. Client with suspected bone tumor who just returned from having a spinal CT

c. Post-microvascular bone transfer client whose distal leg is cool and pale This client is the priority because the assessment findings indicate a critical lack of perfusion. A high white blood cell count is an expected finding for the client with osteoporosis. The client requesting pain medication should be seen second. The client who just returned from a CT scan is stable and needs no specific post procedure care.

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 has priority? a. Check the patient every 15 minutes. b. Rigorously encourage fluid intake. c. Provide one-on-one supervision. d. Keep the room dimly lit.

c. Provide one-on-one supervision. This patient is experiencing alcohol withdrawal delirium. One-on-one supervision is necessary to promote physical safety until sedation reduces the patients feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes illusions. Oral fluids are important, but safety is a higher priority.

A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed? a. Assess the distal circulation in 30 minutes. b. Change the settings based on range of motion. c. Raise the lower side rail on the affected side. d. Remind the client to do quad-setting exercises.

c. Raise the lower side rail on the affected side. Because the clients leg is strapped into the CPM, if it falls off the bed due to movement, the clients leg (and new joint) can be injured. The nurse should instruct the UAP to raise the side rail to prevent this from occurring. Assessment is a nursing responsibility. Only the surgeon, physical therapist, or specially trained technician adjusts the CPM settings. Quad-setting exercises are not related to the CPM machine.

The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement? a. Needs multiple dental fillings b. Over age 85 c. Severe osteoporosis d. Urinary tract infection

c. Severe osteoporosis Osteoporosis is a contraindication to joint replacement because the bones have a high risk of shattering as the new prosthesis is implanted. The client who needs fillings should have them done prior to the surgery. Age greater than 85 is not an absolute contraindication. A urinary tract infection can be treated prior to surgery.

A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a priority? a. Genetic testing b. Infection prevention c. Sperm banking d. Treatment options

c. Sperm banking All teaching topics are important to the client with lymphoma, but for a young male, sperm banking is of particular concern if the client is going to have radiation to the lower abdomen or pelvis.

A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, I feel terrible. Which analysis is correct? a. The patient is exhibiting a prodromal symptom of seizures. b. An idiosyncratic reaction to naloxone is occurring. c. Symptoms of opiate withdrawal are present. d. The patient is experiencing a relapse.

c. Symptoms of opiate withdrawal are present. The symptoms given in the question are consistent with narcotic withdrawal and result from administration of naloxone. Early symptoms of narcotic withdrawal are flu like in nature. Seizures are more commonly observed in alcohol withdrawal syndrome.

A client has just returned from a right radical mastectomy. Which action by unlicensed assistive personnel (UAP) would the nurse consider unsafe? a. Checking the amount of urine in the urine catheter collection bag b. Elevating the right arm on a pillow c. Taking the blood pressure on the right arm d. Encouraging the client to squeeze a rolled washcloth

c. Taking the blood pressure on the right arm Health care professionals need to avoid the arm on the side of the surgery for blood pressure measurement, injections, or blood draws. Since lymph nodes are removed, lymph drainage would be compromised. The pressure from the blood pressure cuff could promote swelling. Infection could occur with injections and blood draws. Checking urine output, elevation of the affected arm on a pillow, and encouraging beginning exercises are all safe postoperative interventions.

A client with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best? a. Gabapentin can be used as an antidepressant too. b. I have no idea why you should be taking this drug. c. This drug helps treat the pain from nerve irritation. d. You are at risk for seizures due to fungal infections.

c. This drug helps treat the pain from nerve irritation. Many classes of medications are used for neuropathic pain, including tricyclic antidepressants such as gabapentin. It is not being used as an antidepressant or to prevent seizures from fungal infections. If the nurse does not know the answer, he or she should find out for the client.

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

c. Try a paraffin wax dip 20 minutes before you quilt. Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. The nurse can suggest this comfort measure. Increasing pain pills will not help with movement. Ice has limited use unless the client has a hot or exacerbated joint. The client wants to finish her project, so the nurse should not negate its importance by telling the client it is destroying her joints.

A nurse coordinates care for a client with a wet plaster cast. Which statement should the nurse include when delegating care for this client to an unlicensed assistive personnel (UAP)? a. Assess distal pulses for potential compartment syndrome. b. Turn the client every 3 to 4 hours to promote cast drying. c. Use a cloth-covered pillow to elevate the client's leg. d. Handle the cast with your fingertips to prevent indentations.

c. Use a cloth-covered pillow to elevate the client's leg. When delegating care to a UAP for a client with a wet plaster cast, the UAP should be directed to ensure that the extremity is elevated on a cloth pillow instead of a plastic pillow to promote drying. The client should be assessed for impaired arterial circulation, a complication of compartment syndrome; however, the nurse should not delegate assessments to a UAP. The client should be turned every 1 to 2 hours to allow air to circulate and dry all parts of the cast. Providers should handle the cast with the palms of the hands to prevent indentations.

What is the first component of the critical thinking model for clinical decision making? a. Experience b. Nursing process c. Attitude d. A scientific knowledge base

d. A scientific knowledge base A scientific knowledge base is the first component for clinical decision making. After acquiring a sound knowledge base, the nurse can then apply knowledge to different clinical situations using the nursing process to gain valuable experience. A critical thinking attitude is a guideline for how to approach a problem and apply knowledge to make a clinical decision.

Which component of an e-mail shown below would be effective? a. Subject: A short concise subject line: Meeting b. Body: I would like you to answer these questions before the next meeting: Where would you like to meet? Do you want all the staff to attend? Can we serve refreshments? What is one goal for our unit? c. Body: Dear Staff, As you know, each department must reduce staff by 2%. We will need to discuss how to inform unlicensed staff about the downsizing efforts of the hospital. d. Body: The next staff meeting is scheduled for Tuesday, January 19, at 5:00PM in the first floor auditorium. Please send items for the agenda. Sally Smith, MSN, RN, [email protected] or ext. 5582

d. Body: The next staff meeting is scheduled for Tuesday, January 19, at 5:00PM in the first floor auditorium. Please send items for the agenda. Sally Smith, MSN, RN, [email protected] or ext. 5582 This provides a message that is concise and accurate with a clearly conveyed message for the reader and contact information from the sender, all of which are important components of effective email communication.

The nurse assesses a client receiving chemotherapy for lung cancer and notes red swollen mucous membranes and open sores in the mouth. The client reports mouth pain and difficulty swallowing. Which action does the nurse perform first? a. Document the size of the sores. b. Perform mouth hygiene. c. Have the client rinse his or her mouth. d. Call the health care provider and hold chemotherapy.

d. Call the health care provider and hold chemotherapy. Although the nurse should perform all interventions for mucositis, the priority is to call the health care provider and hold the chemotherapy. Mucositis may be a dose-limiting condition in chemotherapy. The nurse should call the provider, then should assist the client with mouth hygiene, rinsing the mouth, and obtaining pain relief. Documenting the size and location of ulcers is also important.

Which risk factor would the nurse recognize as being frequently associated with osteoporosis? a. African-American race b. Low Protein intake c. Obesity d. Cigarette smoking

d. Cigarette smoking Smoking is associated with earlier and greater bone loss and decreased estrogen production. Women at risk for osteoporosis are likely to be Caucasian or Asian. Inadequate calcium intake is a risk factor for osteoporosis. Women at risk for osteoporosis are likely to be small boned and thin. Obese women have higher estrogen levels as a result of the conversion of androgens in the adipose tissue. Mechanical stress from extra weight also helps preserve bone mass.

The nurse is providing discharge teaching to a client after a lumbar laminectomy. For which complication does the nurse instruct the client to return to the hospital? a. Pain at the incision site b. Decreased appetite c. Slight redness and itching at the incision site d. Clear drainage from the incision site

d. Clear drainage from the incision site The finding of clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. The client has in increased risk of meningitis with a spinal fluid leak. Pain, redness, and itching at the site are normal. The client should be encouraged to eat a healthy diet but does not need to return to the hospital for a decreased appetite.

Which client does the nurse assess more carefully for risk of developing primary osteoporosis? a. African-American client b. Residents of a nursing home c. Client who eats meat with every meal d. Client who drinks 6 cups of coffee daily

d. Client who drinks 6 cups of coffee daily Excessive consumption of caffeine and alcohol has been shown to be a risk factor for primary osteoporosis because of loss of calcium in the urine. Being white or Asian has been identified as causing a higher risk for developing osteoporosis at an earlier age compared with African-American ethnicity. Being a resident of a nursing home who is not exposed to sunlight could be a risk factor, but just being a resident does not predispose to osteoporosis. Meat is high in protein. Protein deficiency has been identified as a risk factor.

a nurse is caring for a client who has had rheumatoid arthritis (RA) for 5 years. Which laboratory value requires the most immediate intervention by the nurse? a. White blood cell count (WBC), 3800/mm3 b. Hemoglobin (Hg), 10.6 g/dL c. Blood urea nitrogen (BUN), 16 mg/dL d. Creatinine, 3.2 mg/dL

d. Creatinine, 3.2 mg/dL Clients with RA usually have pancytopenia, or a decrease in all cell types. WBC and hemoglobin are low, consistent with this condition. BUN is normal. Creatinine is very high; this indicates renal disease. This client may have renal consequences of his or her RA, which should be investigated.

A middle-aged client is having a physical examination and is worried about cancer risk. Which question is most important for the nurse to ask? a. How much time do you spend in the sun? b. How many servings of fruits and vegetables do you eat every day? c. How often do you eat processed meats like bologna? d. Do you smoke cigarettes or have you ever used tobacco products?

d. Do you smoke cigarettes or have you ever used tobacco products? Tobacco is related to about 30% of all cancers in North America and is the most important source of preventable carcinogen exposure. The other questions are related to carcinogenesis, but not to the degree that tobacco is.

A client is undergoing treatment for breast cancer and asks the nurse about natural treatments for her chemotherapy-induced nausea. Which is the most appropriate response by the nurse? a. Anything you can take will interfere with your chemotherapy. b. I dont know of any recommended complementary treatments for nausea. c. Black cohosh and flaxseed are good for combating nausea. d. Ginger has been used for nausea; would you consider taking it?

d. Ginger has been used for nausea; would you consider taking it? Up to 80% of women with breast cancer have used complementary therapies. Ginger, along with acupuncture, aromatherapy, hypnosis, progressive muscle relaxation, and shiatsu, has been used for nausea. Black cohosh and flaxseed are used for hot flashes. The client should check with her provider and other credible sources regarding any desired therapies to ensure that they won't interfere with the chemotherapy. Even if the nurse doesn't know of specific therapies, it is never appropriate to just say, I don't know. The nurse should investigate for the client.

When the history of a female client is taken, which client statement does the nurse refers to the health care provider? a. I had a fibroadenoma of the breast when I was 22 years old. b. I had my first child when I was 26 years old and my second child when I was 32. c. I stopped using oral contraceptives when I was no longer sexually active. d. I had my menopause 2 years ago and have started to have vaginal bleeding again.

d. I had my menopause 2 years ago and have started to have vaginal bleeding again. Vaginal bleeding that occurs after menopause can indicate cancer and should be promptly evaluated. The other statements by the client would not be cause for alarm and would not need to be reported to the provider.

The nurse is teaching a client who has AIDS how to avoid infection at home. Which statement indicates that additional teaching is needed? a. I will wash my hands whenever I get home from work. b. I will make sure to have my own tube of toothpaste at home. c. I will run my toothbrush through the dishwasher every evening. d. I will be sure to eat lots of fresh fruits and vegetables every day.

d. I will be sure to eat lots of fresh fruits and vegetables every day. The client should avoid eating raw fruits, vegetables, and salads because of the risk of infection. Hands should be washed whenever returning home, and immunocompromised clients should not share toothbrushes or toothpaste. Toothbrushes should be run through the dishwasher nightly.

Which comment made by a client with breast cancer indicates correct understanding regarding cancer causes and prevention? a. I will prevent recurrence of my cancer by eating a low-fat diet from now on. b. If I had breast-fed my children, this would not have happened to me. c. I hope this doesn't increase my risk for bone cancer or lung cancer. d. I will have regular mammograms on my other breast to detect cancer early.

d. I will have regular mammograms on my other breast to detect cancer early. Regular mammography can help detect breast cancer at an early stage. Women who have had breast cancer have a greater risk of developing cancer in the other breast. The other statements are inaccurate.

The nurse is teaching a client who has osteoarthritis ways to slow progression of the disease. Which statement indicates that the client understands the nurses instruction? a. I will eat more vegetables and less meat. b. I will avoid exercising to minimize wear on my joints. c. I will take calcium with vitamin D every day. d. I will start swimming twice a week.

d. I will start swimming twice a week. Swimming is an excellent form of exercise for clients with arthritis because it involves minimal weight bearing and stress on the joints from gravity. Eating more vegetables will not decrease the progression of osteoarthritis. Taking calcium with vitamin D will decrease the risk of osteoporosis, not osteoarthritis. Gentle exercise is important to help slow progression of the disease.

***An older client with age spots is fearful of contracting skin cancer but wants to continue his hobby of outdoor gardening. Which statement by the client indicates a good understanding of the teaching about this issue? a. I will avoid staying outside during the day. b. I can only use oil-based tanning lotion. c. I have to start growing plants indoors. d. I will wear a hat and gloves when gardening.

d. I will wear a hat and gloves when gardening. Freckles, birthmarks, and age spots are caused by patches of melanin in the skin. Melanin protects against the harmful effects of sun exposure. Hyperpigmentation can occur in sun-exposed areas and can lead to skin cancer. For clients who spend time outdoors, the best protection from skin cancer is decreasing the amount of skin exposed to sunlight.

The nurse is caring for an older adult client who will be discharged after being hospitalized for a total hip replacement. Which statement indicates that arrangements may have to be made to have the client's medications supervised at home? a. I will take my Coumadin pill every day just before the evening news. b. My wife takes iron too, so we will take our pills together every morning. c. I prepare all my pills for the week and will place them in a labeled medi-set. d. If my legs get swollen, I will take an extra Coumadin pill that day.

d. If my legs get swollen, I will take an extra Coumadin pill that day. Warfarin (Coumadin) is an anticoagulant prescribed to prevent venous thromboembolism after joint replacement surgery. It is not used for edema. The other statements show that the client has an appropriate plan for self-administration of his medications.

A 45-year-old man is brought to the emergency department presenting with a respiratory rate of 6 breaths/min, and cardiac dysrhythmias. The most appropriate question the nurse should ask the patient's friend is a. Does he take amphetamines or uppers? b. Has he ever used LSD? c. Have you two been out of the country in the last 2 days? d. Is he using any opioids such as heroin?

d. Is he using any opioids such as heroin? The clinical manifestations of an opioid overdose include seizures, shock, respiratory depression, dysrhythmias, and altered level of consciousness. An opioid overdose is a medical emergency. Amphetamine overdose is ruled out because it causes hypertension and central nervous system disturbances such as paranoia, panic, and delusions. LSD overdose would also manifest with hypertension and tachypnea along with hallucinations and possible loss of contact with reality. Travel outside the country is unrelated.

A client receiving tamoxifen (Tamofen) asks how this therapy helps fight breast cancer. Which is the nurse's best response? a. This agent decreases estrogen levels. so the cancer stops growing. b. The drug causes you to secrete testosterone, which limits cancer growth. c. Tamoxifen kills estrogen-secreting cells and growth of blood vessels to cancer cells. d. It blocks estrogen receptors, and this limits cancer cell growth.

d. It blocks estrogen receptors, and this limits cancer cell growth. Tamoxifen is an estrogen antagonist-agonist. Its use in breast cancer is limited to cancers that express the estrogen receptor. Tamoxifen binds to estrogen receptors, inhibiting the binding of estrogen to receptors, thereby starving the cancer cells of an essential growth factor. The drug does not decrease circulating levels of estrogen, does not cause testosterone to be secreted instead of estrogen, and does not kill off estrogen-secreting cells.

Which precaution should the nurse take while caring for a client who is undergoing internal radiation therapy for cervical cancer? a. Wear gloves when assessing the cervical intracavitary implant. b. Instruct the client to urinate in the lead-lined bedpan or hat every 2 hours. c. Prepare the client for an enema before inserting the implant. d. Limit staff or visitor exposure to 30 minutes or less in an 8-hour period.

d. Limit staff or visitor exposure to 30 minutes or less in an 8-hour period. Staff and visitor exposure should be limited to 30 minutes or less in an 8-hour period to reduce the risk of overexposure to radiation. Nurses need to protect themselves from overexposure to radiation. Wearing a shield is one method of protection. An indwelling catheter is inserted to prevent urinary distention that could dislodge the applicator. No bowel preparation is necessary.

A client is suspected to have rheumatoid arthritis. Which manifestations does the nurse assess this client carefully for? a. Crepitus when the client moves the shoulders b. Numbness and tingling in the clients fingers c. Client has cool feet, with weak pedal pulses d. Low-grade fever, fatigue, anorexia with weight loss

d. Low-grade fever, fatigue, anorexia with weight loss Low-grade fever is common with rheumatoid arthritis because of the inflammatory response. Fatigue, anorexia, and weight loss are also common symptoms. Impaired neurological status, popping sounds with range of motion (ROM), and poor circulation are not common symptoms of rheumatoid arthritis.

The nurse needs a reminder of professional responsibility when performing which of these actions? a. Making an informed clinical decision b. Making an ethical clinical decision c. Making a clinical decision in the patient's best interest d. Making a clinical decision based on previous shift assessments

d. Making a clinical decision based on previous shift assessments The professional nurse is responsible for assessing patients each shift. Making informed, ethical decisions in the patient's best interest is practicing responsibly.

Malignant cell growth is uncontrolled because of which action? a. Cancer cells always divide more rapidly than normal cells. b. Mitosis of malignant cells usually produces more than two daughter cells. c. Malignant cells bypass one or more phases of the cell cycle during cell division. d. Malignant cells enter the cell cycle frequently, making cell division continuous.

d. Malignant cells enter the cell cycle frequently, making cell division continuous. Malignant cells have bypassed the normal control mechanisms that restrict entry into the cell cycle, so they re-enter the cell cycle as soon as they finish a round of cell division. Thus, cancer cell division is relentless.

A client who has discovered a lump in her breast becomes tearful when scheduling a mammogram. Which is the nurse's best response? a. All lumps are considered cancerous until proven otherwise. b. Unless you have a relative with breast cancer, this lump is probably benign. c. Diagnosing cancer at this early stage is most likely to result in a cure. d. Many women have breast lumps, and most of the lumps are benign.

d. Many women have breast lumps, and most of the lumps are benign. The finding of a breast lump or mass is a frightening experience. Clients should be reassured, until they can be seen or testing is done, that 90% of all breast lumps or masses are benign. It is inaccurate for the nurse to state that all lumps are considered cancerous until proven benign, or that the lump is probably benign unless the client has a relative with breast cancer. Diagnosing cancer at an early stage results in cure more often than when the cancer is in later stages, but such a comment before diagnosis will only scare the client more.

What immunization should not be given to a child receiving chemotherapy for cancer? a. Tetanus vaccine b. Inactivated poliovirus vaccine c. Diphtheria, pertussis, tetanus (DPT) d. Measles, mumps, rubella (MMR)

d. Measles, mumps, rubella (MMR) The vaccine used for MMR is a live virus and can cause serious disease in immunocompromised children. The tetanus vaccine, inactivated poliovirus vaccine, and DPT are not live vaccines and can be given to immunosuppressed children. The immune response is likely to be suboptimal, so delaying vaccination is usually recommended.

A client presents with an acute exacerbation of multiple sclerosis. Which prescribed medication does the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)

d. Methylprednisolone Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other medications are not appropriate.

What is a common clinical manifestation of Hodgkin disease? a. Petechiae b. Bone and joint pain c. Painful, enlarged lymph nodes d. Nontender enlargement of lymph nodes

d. Nontender enlargement of lymph nodes Asymptomatic, enlarged cervical or supraclavicular lymphadenopathy is the most common presentation of Hodgkin disease. Petechiae are usually associated with leukemia. Bone and joint pain are not likely in Hodgkin disease. The enlarged nodes are rarely painful.

Which is the highest priority problem for a client with late-stage lung cancer? a. Malnutrition b. Constipation c. Weakness and fatigue d. Pain

d. Pain Although all of these problems are important issues, effective pain management is the most important issue for this client and family. The nurse must serve as a client advocate and must ensure that all appropriate measures for the management of intractable, severe pain are implemented.

The nurse is caring for several clients on a respiratory floor. The nurse should place the client with which condition in isolation? a. Fever and weight loss b. Negative QuantiFERON TB gold test c. Negative acid-fast bacilli (AFB) stain d. Positive nucleic acid amplification test (NAAT)

d. Positive nucleic acid amplification test (NAAT) The NAAT is a new rapid test for the diagnosis of tuberculosis (TB). Results are available in less than 2 hours. A positive test is conclusive for TB, and the client should be placed in isolation per facility policy. A client with a negative QuantiFERON gold test would not have tuberculosis. Likewise, a client with a negative AFB would not have tuberculosis. The client with fever and weight loss could have tuberculosis, but diagnostic tests would be needed because these are nonspecific manifestations.

Total-body irradiation is indicated for what reason? a. Palliative care b. Lymphoma therapy c. Definitive therapy for leukemia d. Preparation for bone marrow transplant

d. Preparation for bone marrow transplant Total-body irradiation is used as part of the destruction of the child's immune system necessary for a bone marrow transplant. The child is at great risk for complications because there is no supportive therapy until engraftment of the donor marrow takes place. Irradiation for palliative care is done selectively. The area that is causing pain or potential obstruction is irradiated. Lymphoma and leukemia are treated through a combination of modalities. Total-body irradiation is not indicated.

The nurse inspects the site where a clients basal cell carcinoma has been treated with cryosurgery and finds that the area is red, with a blister in the center. Which action does the nurse take? a. Culture the site. b. Notify the surgeon. c. Apply hydrocortisone cream. d. Reassure the client.

d. Reassure the client. This skin reaction is the expected and normal response to cryosurgery. No other intervention is necessary other than continued assessment.

During a relaxation therapy skills group, the instructor discusses the cognitive skill of learning to tolerate uncertain and unfamiliar experiences. This best describes the skill of a. Mindfulness. b. Focusing. c. Passivity. d. Receptivity.

d. Receptivity. Receptivity is defined as the ability to tolerate and accept experiences that are uncertain, unfamiliar, or paradoxical. Passivity is the ability to stop unnecessary goal-directed and analytical activity. Focusing is the ability to identify, differentiate, maintain attention on, and return attention to simple stimuli for an extended period. Mindfulness is not a cognitive skill needed in relaxation therapy.

Which comment made by a client with breast cancer indicates a need for clarification regarding cancer causes and prevention? a. I will eat a low-fat, high-fiber diet from now on. b. Probably nothing I did or didn't do caused this cancer. c. I hope my daughter doesn't develop breast cancer. d. Regular mammograms on my other breast will prevent cancer.

d. Regular mammograms on my other breast will prevent cancer. Regular mammography can help detect breast cancer at an early stage, but it does not prevent breast cancer. For the most part, the specific cause of many cancers is unknown. Some associations have been noted with dietary habits. High fat, low fiber, high intake of red meat, and eating food with preservatives and other additives all have been suspected to contribute to carcinogenesis. Breast cancer has familial and hereditary forms.

The nurse has been exposed to HIV through splashing of urine from a client who is HIV positive with a low viral load. The urine came into contact with the nurses face. Which drug regimen does the nurse prepare to initiate? a. Retrovir (zidovudine) for 14 days b. Retrovir (zidovudine) for 28 days c. Retrovir (zidovudine) and Epivir (lamivudine) fōr4 days d. Retrovir (zidovudine) and Epivir (lamivudine) for 28 days

d. Retrovir (zidovudine) and Epivir (lamivudine) for 28 days The Centers for Disease Control and Prevention have developed guidelines for postexposure prophylaxis (PEP). This nurses exposure requires basic PEP with two drugs for 28 days.

Which client should the nurse refer for further testing? a. Left breast slightly smaller than right breast b. Eversion (elevation) of both nipples c. Faintly visible bilateral symmetry of venous network d. Small dimple located in the upper outer quadrant of the right breast

d. Small dimple located in the upper outer quadrant of the right breast A small dimple is an abnormal finding and should be further evaluated. Nipple retraction and a dimpling or pitting of the skin is suggestive of a locally advanced, aggressive form of breast cancer. In many women, one breast is smaller than the other, and eversion of both nipples is a normal finding. Faintly visible venous network is also a normal finding.

The nurse is instructing a client about management of discoid lupus erythematosus (DLE). Which statement indicates that the client requires additional teaching? a. I will be sure to apply sunscreen whenever I am outside. b. I will apply small amounts of the steroid cream to my face twice a day. c. I will take Plaquenil (hydroxychloroquine sulfate) with breakfast each morning. d. Steroids weaken the immune system, so I will wash my hands frequently.

d. Steroids weaken the immune system, so I will wash my hands frequently. Steroid creams used for the treatment of discoid lupus will not weaken the immune system because they should be applied in small amounts to affected areas. The client will be more sensitive to sun exposure while using the steroid cream, so sunscreen should be used whenever the client goes outside. The client should use only small amounts of the cream on her face. Plaquenil should be taken with meals or a glass of milk.

What side effect commonly occurs with corticosteroid (prednisone) therapy? a. Alopecia b. Anorexia c. Nausea and vomiting d. Susceptibility to infection

d. Susceptibility to infection Corticosteroids have immunosuppressive effects. Children who are taking prednisone are susceptible to infections. Hair loss is not a side effect of corticosteroid therapy. Children taking corticosteroids have increased appetites. Gastric irritation, not nausea and vomiting, is a potential side effect. The medicine should be given with food.

Which clinical manifestation in a client with invasive cervical cancer alerts the nurse to the possibility of metastasis? a. Amenorrhea b. Weight gain c. Breast tenderness d. Swelling of one leg

d. Swelling of one leg Leg pain or unilateral swelling of a leg is a symptom of disease progression as the tumor enlarges, or of recurrent disease.

Which nursing intervention is an example of primary prevention for lung cancer? a. Teaching clients with lung cancer how to cough and deep breathe b. Teaching clients with lung cancer to avoid infection c. Teaching clients about prophylactic antibiotics d. Teaching people about smoking and secondhand smoke

d. Teaching people about smoking and secondhand smoke Primary prevention for lung cancer focuses on reducing tobacco smoking. The other examples are examples of secondary prevention.

A nurse is providing education to a support group of women newly diagnosed with breast cancer. It is important for the nurse to discuss which factors related to breast cancer with the group? a. Genetic mutations account for 50% of women who will develop breast cancer. b. Breast cancer is the leading cause of cancer death in women. c. In the United States, 1 in 10 women will develop breast cancer in her lifetime. d. The exact cause of breast cancer remains unknown.

d. The exact cause of breast cancer remains unknown. The exact cause of breast cancer is unknown. Between 15% and 20% of these cancers are related to genetic mutations. Breast cancer is the second leading cause of cancer death in women ages 45 to 55 years. One in eight women in the United States will develop breast cancer in her lifetime.

The nurse is caring for an HIV-positive client. What assessment finding assists the nurse in confirming progression of the client's diagnosis to AIDS? a. Generalized lymphadenopathy b. HIV-positive status for 8 years c. Low-grade fever for the last 10 days d. Thick white patches on the clients tongue

d. Thick white patches on the clients tongue Candidiasis, which presents with thick white patches on the tongue and oral mucosa, is associated with the development of AIDS after HIV infection. The fact that the client has been positive for 8 years or has a low-grade fever is not significant.

A client who had a stroke combs her hair only on the right side of her head and washes only the right side of her face. How does the nurse interpret these actions? a. Poor left-sided motor control b. Paralysis or contractures on the right side c. Limited visual perception of the left fields d. Unawareness of the existence of her left side

d. Unawareness of the existence of her left side Clients who have experienced a right hemisphere stroke often have neglect syndrome, in which they are unaware of the existence of the paralyzed side, or the left side. This injury would not have an effect on the client's sight. This is not related to poor motor control or paralysis.

After the administration of each dose of zoledronic acid (Zometa), it is most important for the nurse to determine which finding? a. Capillary refill b. Pain relief c. Level of consciousness d. Urine output

d. Urine output Zoledronic acid is a bisphosphonate that helps protect bones and prevent fractures. Urine output and serum creatinine should be monitored because this drug can be toxic to the kidneys. Zometa does not relieve pain or affect capillary refill or level of consciousness.

***The RN has assigned a client with severe osteoporosis to an LPN. Which information about the care of the client is most important for the RN to provide the LPN? a. Provide passive range of motion (ROM) to all weight-bearing joints. b. Position the client upright to promote lung expansion. c. Place a pillow between the client's knees when in the side-lying position. d. Use a lift sheet to reposition the client.

d. Use a lift sheet to reposition the client. Severe osteoporosis causes such bone density loss that pathologic fractures can easily occur when lifting or pulling a client. Use of a lift sheet when positioning reduces this risk. Passive range of motion prevents contractures, but active weight-bearing exercise reduces bone resorption and is a better choice if possible. Positioning the client to promote lung expansion and positioning with a pillow for side-lying are important interventions for any client. The most important intervention for this client is to prevent bone fractures.

A new graduate nurse will make the best clinical decisions by applying the components of the nursing critical thinking model and which of the following? a. Drawing on past clinical experiences to formulate standardized care plans b. Relying on recall of information from past lectures and textbooks c. Depending on the charge nurse to determine priorities of care d. Using the nursing process

d. Using the nursing process Using the nursing process along with applying components of the nursing critical thinking model will help the new graduate nurse make the most appropriate clinical decisions. Care plans should be individualized, and recalling facts does not utilize critical thinking skills to make clinical decisions. The new nurse should not rely on the charge nurse to determine priorities of care.

An immunocompromised child has been exposed to chickenpox. What should the nurse anticipate to be prescribed to the exposed child? a. Acyclovir (Zovirax) b. Valacyclovir (Valtrex) c. Amantadine (Symmetrel) d. Varicella-zoster immune globulin

d. Varicella-zoster immune globulin The use of varicella-zoster immune globulin or immune globulin intravenous (IGIV) is recommended for children who are immunocompromised, who have no previous history of varicella, and who are likely to contract the disease and have complications as a result. The antiviral agent acyclovir (Zovirax) or valacyclovir may be used to treat varicella infections in susceptible immunocompromised persons. It is effective in decreasing the number of lesions; shortening the duration of fever; and decreasing itching, lethargy, and anorexia. Symmetrel is an antiviral used to treat influenza.

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting Nurses for directly observed therapy

d. Visiting Nurses for directly observed therapy Directly observed therapy is often utilized for managing clients with TB in the community. Meals on Wheels, job retraining, and home therapy may or may not be appropriate.

A healthy 60-year-old African-American woman regularly receives health care at her neighborhood clinic. She is due for a mammogram. At her first visit, her health care provider is concerned about the 3-week wait at the neighborhood clinic and made an appointment for her to have a mammogram at a teaching hospital across town. She did not keep her appointment and returned to the clinic today to have the nurse checked her blood pressure. What is the most appropriate statement for the nurse to make to this client? a. Do you have transportation to the teaching hospital so that you can get your mammogram? b. I'm concerned that you missed your appointment; let me make another one for you. c. Its very dangerous to skip your mammograms; your breasts need to be checked. d. Would you like me to make an appointment for you to have your mammogram here?

d. Would you like me to make an appointment for you to have your mammogram here? Offering to make an appointment for the client at the neighborhood location is nonjudgmental and gives her options as to where she may have her mammogram. Furthermore, it is an innocuous way to investigate the reasons the client missed her previous appointment. Mortality rates from breast cancer remain high for African-American women. Rather than reminding this woman that she has missed her appointment, discussing the evidence behind the recommendations for a mammogram might be preferable for the nurse. The nurse can offer to reschedule should the client agree to return for the test. Telling the client that it is dangerous to skip mammograms can be perceived as judgmental and derogatory and may alienate and embarrass the client.

To promote safety, the nurse manager sensitive to point of care (sharp end) and systems level (blunt end) exemplars works closely with staff to address the point of care exemplars such as a. care coordination. b. documentation. c. electronic records. d. fall prevention.

d. fall prevention. The most common safety issues at the sharp end include prevention of decubitus ulcers, medication administration, fall prevention, invasive procedures, diagnostic workup, recognition of/action on adverse events, and communication. These are the most common issues the staff nurse providing direct patient care encounters. Each of the other options are classified as systems level exemplars.

Mobility for the patient changes throughout the lifespan; this is known as the process of a. aging and illness. b. illness and disease. c. health and wellness. d. growth and development.

d. growth and development. Growth and development happens from infancy to death. Muscular changes are always happening, and these changes affect the individual and his or her performance in life. Aging, illness, health, and wellness do have an effect on a person, but they don't always affect mobility.

A sentinel event refers to an event that a. could have harmed a patient, but serious harm did not occur because of chance. b. harms a patient as a result of underlying disease or condition. c. harms a patient by omission or commission, not an underlying disease or condition. d. signals the need for immediate investigation and response.

d. signals the need for immediate investigation and response. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof called sentinel because they signal the need for immediate investigation and response. A near-miss refers to an error or commission or omission that could have harmed the patient, but serious harm did not occur as a result of chance. Harm that relates to an underlying disease or condition provides the rationale for the close monitoring and supervision provided in a health care setting. An adverse event is one that results in unintended harm because of the commission or omission of an act.

A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis? a. An 18-year-old male athlete with a fractured clavicle b. A 36-year old female with type 2 diabetes and fractured ribs c. A 55-year-old woman prescribed aspirin for rheumatoid arthritis d. A 74-year-old man who smokes and has a fractured pelvis

d. A 74-year-old man who smokes and has a fractured pelvis Deep vein thrombosis (DVT) as a complication with bone fractures occurs more often when fractures are sustained in the lower extremities and the client has additional risk factors for thrombus formation. Other risk factors include obesity, smoking, oral contraceptives, previous thrombus events, advanced age, venous stasis, and heart disease. The other clients do not have risk factors for DVT.

The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client taking celecoxib (Celebrex) and ranitidine (Zantac) b. Client taking etanercept (Enbrel) with a red injection site c. Client with a blood glucose of 190 mg/dL who is taking steroids d. Client with a fever and cough who is taking tofacitinib (Xeljanz)

d. Client with a fever and cough who is taking tofacitinib (Xeljanz) Tofacitinib carries a Food and Drug Administration black box warning about opportunistic infections, tuberculosis, and cancer. Fever and cough may indicate tuberculosis. Ranitidine is often taken with celecoxib, which can cause gastrointestinal distress. Redness and itchy rashes are frequently seen with etanercept injections. Steroids are known to raise blood glucose levels.

The nurse sees several clients with osteoporosis. For which client would bisphosphonates not be a good option? a. Client with diabetes who has a serum creatinine of 0.8 mg/dL b. Client who recently fell and has vertebral compression fractures c. Hypertensive client who takes calcium channel blockers d. Client with a spinal cord injury who cannot tolerate sitting up

d. Client with a spinal cord injury who cannot tolerate sitting up Clients on bisphosphonates must be able to sit upright for 30 to 60 minutes after taking them. The client who cannot tolerate sitting up is not a good candidate for this class of drugs. Poor renal function also makes clients bad candidates for this drug, but the client with a creatinine of 0.8 mg/dL is within normal range. Diabetes and hypertension are not related unless the client also has renal disease. The client who recently fell and sustained fractures is a good candidate for this drug if the fractures are related to osteoporosis.

An adult in the emergency department states, I feel restless. Everything I look at wavers. Sometimes Im outside my body looking at myself. I hear colors. I think I'm losing my mind. Vital signs are slightly elevated. The nurse should suspect a: a. cocaine overdose. b. schizophrenic episode. C. phencyclidine (PCP) intoxication. d. D-lysergic acid diethylamide (LSD) ingestion.

d. D-lysergic acid diethylamide (LSD) ingestion. The patient who has ingested LSD often experiences synesthesia (visions in sound), depersonalization, and concerns about going crazy. Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. PCP use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.

A patient admitted to an alcoholism rehabilitation program says, I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening. The patient is using which defense mechanism? a. Rationalization b. Introjection c. Projection d. Denial

d. Denial Minimizing ones drinking is a form of denial of alcoholism. The patient's own description indicates that social drinking is not an accurate name for the behavior. Projection involves blaming another for one's faults or problems. Rationalization involves making excuses. Introjection involves taking a quality into one's own system.

A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi's sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly

d. Disposing of soiled dressings properly All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital.

Which assessment findings will the nurse expect in an individual who has just injected heroin? a. Anxiety, restlessness, paranoid delusions b. Heightened sexuality, insomnia, euphoria c. Muscle aching, dilated pupils, tachycardia d. Drowsiness, constricted pupils, slurred speech

d. Drowsiness, constricted pupils, slurred speech Heroin, opiate, is a CNS depressant. Blood pressure, pulse, and respirations are decreased, and attention is impaired. The incorrect options describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine abuse.

A client is in the preoperative holding area prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best? a. Assess that the client has been NPO as directed. b. Communicate this information with dietary staff. c. Document the information in the client's chart. d. Ensure the information is relayed to the surgical team.

d. Ensure the information is relayed to the surgical team. A client with allergies to avocados, strawberries, bananas, or nuts has a higher risk of latex allergy. The nurse should ensure that the surgical staff is aware of this so they can provide a latex-free environment. Ensuring the clients NPO status is important for a client having surgery but is not directly related to the risk of latex allergy. Dietary allergies will be communicated when a diet order is placed. Documentation should be thorough but does not take priority.

A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled pentobarbital sodium. What is the nurse's first action? a. Test reflexes b. Check pupils c. Initiate vomiting d. Establish a patent airway

d. Establish a patent airway Pentobarbital sodium is a barbiturate. Maintaining a patent airway is the priority when the patient is unconscious. Assessing neurologic function by testing reflexes and checking pupils can wait. Vomiting should not be induced when a patient is unconscious because of the danger of aspiration.

A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? a. Chooses high-protein food b. Has decreased oral discomfort c. Eats 90% of meals and snacks d. Has a weight gain of 2 pounds/1 month

d. Has a weight gain of 2 pounds/1 month The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients.

After teaching the wife of a client who has Parkinson's disease, the nurse assesses the wifes understanding. Which statement by the client's wife indicates she correctly understands changes associated with this disease? a. His mask like face makes it difficult to communicate, so I will use a white board. b. He should not socialize outside of the house due to uncontrollable drooling. c. This disease is associated with anxiety causing increased perspiration. d. He may have trouble chewing, so I will offer bite-sized portions.

d. He may have trouble chewing, so I will offer bite-sized portions. Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the clients nutritional needs. A mask like face and drooling are common in clients with Parkinson disease. The client should be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the clients mask like face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson's disease and is associated with the autonomic nervous systems response.

A 37-year-old Nigerian woman is at high risk for breast cancer and is considering a prophylactic mastectomy and oophorectomy. What action by the nurse is most appropriate? a. Discourage this surgery since the woman is still of childbearing age. b. Reassure the client that reconstructive surgery is as easy as breast augmentation. c. Inform the client that this surgery removes all mammary tissue and cancer risk. d. Include support people, such as the male partner, in the decision making.

d. Include support people, such as the male partner, in the decision making. The cultural aspects of decision making need to be considered. In the Nigerian culture, the man often makes the decisions for the care of the female. Women with a high risk for breast cancer can consider prophylactic surgery. If reconstructive surgery is considered, the procedure is more complex and will have more complications compared to a breast augmentation. There is a small risk that breast cancer can still develop in the remaining mammary tissue.

A nurse plans care for a client with Parkinson's disease. Which intervention should the nurse include in this client's plan of care? a. Ambulate the client in the hallway twice a day. b. Ensure a fluid intake of at least 3 liters per day. c. Teach the client pursed-lip breathing techniques. d. Keep the head of the bed at 30 degrees or greater.

d. Keep the head of the bed at 30 degrees or greater. Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson's disease. Ambulation in the hallway is usually implemented to prevent venous thrombosis. Increased fluid intake flushes out toxins from the clients blood. Pursed-lip breathing increases exhalation of carbon dioxide.

A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)

d. Methylprednisolone Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other drugs are not used to treat acute exacerbations of MS. Interferon beta-1b is used to treat and control MS, decrease specific symptoms, and slow the progression of the disease. Baclofen and dantrolene sodium are prescribed to lessen muscle spasticity associated with MS.

A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like pins and needles and that the neck is very painful since returning from surgery. What action by the nurse is best? a. Assist the client to change positions. b. Document the findings in the client's chart. c. Encourage range of motion of the neck. d. Notify the provider immediately.

d. Notify the provider immediately. Clients with RA can have cervical joint involvement. This can lead to an emergent situation in which the phrenic nerve is compressed, causing respiratory insufficiency. The client can also suffer a permanent spinal cord injury. The nurse needs to notify the provider immediately. Changing positions and doing range of motion may actually worsen the situation. The nurse should document findings after notifying the provider.

Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant? a. Make physical contact by frequently touching the patient. b. Offer intellectual activities requiring concentration. c. Avoid manipulation by denying the patients requests. d. Observe for depression and suicidal ideation.

d. Observe for depression and suicidal ideation. Rebound depression occurs with the withdrawal from CNS stimulants, probably related to neurotransmitter depletion. Touch may be misinterpreted if the patient is experiencing paranoid tendencies. Concentration is impaired during withdrawal. Denying requests is inappropriate; maintaining established limits will suffice.

Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed? a. One-week detoxification program b. Long-term outpatient therapy c. Twelve-step self-help program d. Residential program

d. Residential program Residential programs and therapeutic communities have goals of complete change in lifestyle, abstinence from drugs, elimination of criminal behaviors, development of employable skills, self-reliance, and honesty. Residential programs are more effective than outpatient programs for patients with antisocial tendencies.

A patient admitted yesterday for injuries sustained in a fall while intoxicated believes snakes are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury

d. Risk for injury clouded sensorium, agitation, sensory perceptual distortions, and poor judgment increase the risk for injury. Disturbed sensory perception is an applicable diagnosis, but safety has a higher priority. The scenario does not provide data to support the other diagnoses.

A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder retention and/or incontinence. b. Listen to the client's lungs after eating or drinking. c. Prop the clients right side up when sitting in a chair. d. Rotate the clients meal tray when the client stops eating.

d. Rotate the clients meal tray when the client stops eating. This condition is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. The client may not see all the food on the tray, so the nurse rotates it so uneaten food is now within the visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control.

The nurse is caring for a client using a continuous passive motion (CPM) machine and has delegated some tasks to unlicensed assistive personnel (UAP). What action by the UAP warrants intervention by the nurse? a. Checking to see if the machine is working b. Keeping controls in a secure place on the bed c. Placing padding in the machine per request d. Storing the CPM machine under the bed after removal

d. Storing the CPM machine under the bed after removal For infection control (and to avoid tripping on it), the CPM machine is never placed on the floor. The other actions are appropriate.

A patient with a history of daily alcohol abuse says, Drinking helps me cope with being a single parent. Which response by the nurse would help the individual 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. The individual is rationalizing. The correct response will help the patient see alcohol as a cause of the problems, not the solution. This approach can also help the patient become receptive to the possibility of change. The incorrect responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurses frustration with the patient.

A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the clients white blood cell count (WBC) is high. What response by the registered nurse is best? a. If the WBCs are high, there already is an infection present. b. The client is in a blast crisis and has too many WBCs. c. There must be a mistake; the WBCs should be very low. d. Those WBCs are abnormal and don't provide protection.

d. Those WBCs are abnormal and don't provide protection. In leukemia, the WBCs are abnormal and do not provide protection to the client against infection. The other statements are not accurate.

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset

d. Time of symptom onset The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical.

Which statement about carcinogenesis is accurate? a. An initiated cell will always become clinical cancer. b. Cancer becomes a health problem once it is 1 cm in size. c. Normal hormones and proteins do not promote cancer growth. d. Tumor cells need to develop their own blood supply.

d. Tumor cells need to develop their own blood supply. Tumors need to develop their own blood supply through a process called angiogenesis. An initiated cell needs a promoter to continue its malignant path. Normal hormones and proteins in the body can act as promoters. A 1-cm tumor is a detectable size, but other events have to occur for it to become a health problem.

An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury? a. Administer mild sedation. b. Keep all four side rails up. c. Restrain the clients hands. d. Use an abduction pillow.

d. Use an abduction pillow. Older clients often have trouble metabolizing anesthetics and pain medication, leading to confusion or restlessness postoperatively. To prevent the hip from dislocating, the nurse should use an abduction pillow since the client cannot follow the directions at this time. Sedation may worsen the client's mental status and should be avoided. Using all four side rails may be considered a restraint. Hand restraints are not necessary in this situation.

A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection? a. Assess the client's white blood cell count. b. Culture any drainage from the wound. c. Monitor the client's temperature every 4 hours. d. Use aseptic technique for dressing changes.

d. Use aseptic technique for dressing changes. Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to change dressings or empty drains. The other actions do not prevent infection but can lead to early detection of an infection that is already present.

The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjogren's syndrome? a. Abdominal assessment b. Oxygen saturation c. Renal function studies d. Visual acuity

d. Visual acuity Sjgrens syndrome is seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in females. Visual disturbances can occur. The other assessments are not related to RA and Sjgrens syndrome.

A new patient in an alcoholism rehabilitation program says, I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening. Which response by the nurse will help the patient view the drinking more honestly? a. I see, and use interested silence. b. I think you may be drinking more than you report. c. Being a social drinker involves having a drink or two once or twice a week. d. You describe drinking steadily throughout the day and evening. Am I correct?

d. You describe drinking steadily throughout the day and evening. Am I correct? The answer summarizes and validates what the patient reported but is accepting rather than strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in treatment.