practice questions for final
having requested it as a part of a comprehensive treatment program, the client is to receive disulfiram. which statement should the nurse include when teaching the client about this drug? a. inhaling fumes from paints and wood stains may cause a disulfiram reaction b. eating adequately cooked seafood may lead to disulfiram resistance. c. taking disulfiram will reduce your physical craving for alcohol d. if you consume alcohol while taking disulfiram, rapid intoxication will occur
A
The nurse is caring for a client with peritonitis. What assessment findings would the nurse expect? (select all that apply) A. Nausea and vomiting B. Distended rigid abdomen C. Abdominal pain D. Bradycardia E. Decreased urinary output F. Fever
A, C, D, E, F
A client is prescribed sertraline, an SSRI. Which adverse effects would the nurse review when creating a medication teaching plan? Select all that apply. A Agitation B. Agranulocytosis C. Sleep disturbance D. Persistent cough E. Dry mouth F. Seizures
A, C, E
The nurse plans care for a client with Crohn disease who has a heavily draining fistula. Which intervention would be the nurse's priority action? A. Low-fiber diet B. Skin protection C. Antibiotic administration D. Intravenous glucocorticoids
B
A 77 yr old client is brought to the emergency department by her son. The client has a severe headache and lack of sleep because "I am so worried about everything." Her sons says that she has heart failure and chronic schizophrenia. In addition to all of her heart medicines, she's on aripiprazole, which was increased to 30 mg by her health care provider 3 days ago. In addition to documenting all of the client's medications and exact dosages, the nurse should particularly investigate which factors? (select all that apply) A. The qualifications of the client's HCP B. The client's symptoms of schizophrenia C. The dose of ariprprazole D. The client's symptoms of heart failure E. The client's relationship with her son
B, C, D
A client is having an EGD and has been given midazolam hydrochloride The clients respiratory rate is 8 breaths/min. what action by the nurse is appropriate? a. Administer naloxone b. Call a rapid c. Provide physical stimulation d. Ventilate with a bag-valve-mask
C
the nurse is caring for a client who is diagnosed with a complete SBO. for what priority problem is this client most likely at risk? a. abdominal distension b. nausea c. electrolyte imbalance d. obstipation
C
The nurse is assessing a client who has undernutrition. what signs and symptom(s) would the nurse expect? a. alopecia b. stomatitis c. muscle wasting d. peripheral edema e. anemia f. dry, scaly skin
all of them
The nurse assesses a client who has appendicitis. Which assessment finding would the nurse expect? A. Severe, steady right lower quadrant pain B. Abdominal pain associated with Nausea and vomiting C. Marked peristalsis and hyperactive bowel sound D. Abdominal pain that increases with knee flexion
A
When developing the plan of care for a client diagnosed with personality disorder, the nurse plans to assist the client PRIMARILY with what factor? A. Specific dysfunction behaviors B. Psychopharmacologic compliance C. Examination of developmental conflicts D. Manipulation of the environment
A
a client with panic disorder is taking alprazolam 1mg PO TID. the nurse understands this medication is effective in blocking the symptoms of panic because of its specific action on which neurotransmitter? a. gamma-neurotransmitters b. serotonin c. dopamine d. norepinepherine
A
A client had an ERCP . the nurse teaches the client and family about the signs of potential complications which include what problems? SATA a. Cholangitis b. Pancreatitis c. Perforation d. Renal lithiasis e. Sepsis
A, B, C, E
the nurse understands that undernutrition can occur in hospitalized clients for several reasons. which of the following factors are possible reasons for this complication to occur? a. cultural food preferences b. family bringing snacks c. increased need for nutrition d. need for NPO status e. staff shortages
A, C, D, E
The nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members would the nurse collaborate to provide appropriate nutrition to this client? SATA A. Registered dietician B. Nursing assistant C. Clinical pharmacist D. Certified herbalist E. Primary health care provider
A, C, E
when caring for an older adult client who has hypothyroidism, what assessment findings will the nurse expect? a. lethargy b. diarrhea c. low body temp d. tachycardia e. slowed speech f. weight gain
A, C, E, F
a client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report? a. Nausea and vomiting b. Severe boring abdominal pain c. Jaundice and itching d. Elevated temperature
B
a nurse assesses a female client who presents with hirsutism. which question would the nurse ask when assessing this client? a. how do you plan to pay for your treatment? b. how do you feel about yourself? c. what medications are you prescribed? d. what are you doing to prevent this from happening?
B
the nurse is caring for a client who has a post op paralytic ileum following abdominal surgery. what drug is appropriate to manage this nonmechanical bowel obstruction? a. alosetron b. alvimopan c. amitiptyline d. amlodipine
B
A client diagnosed with borderline personality disorder has self-inflicted cuts on the arms. The nurse is assessing the client for the risk of suicide. What should the nurse ask the client FIRST? A. About medication the client has taken recently B. If the client is taking antidepressants C. If the client has a suicide plan D. Why the client self-inflicted the cuts.
C
A client diagnosed with major depression is being considered for electroconvulsive therapy (ECT). Which client teaching should the nurse prioritize? A. Empathize with the client about fears regarding ECT. B. Monitor for any cardiac alterations to prevent possible negative outcomes. C. Discuss with the client and family expected short-term memory loss. D. inform the client that injury related to induced seizure commonly occurs
C
A client diagnosed with paranoid personality disorder is hospitalized for physically threatening his wife because he suspects her of having an affair with a coworker. What approach should the nurse employ with this client? A. Authoritarian B. Parenteral C. Matter of fact D. Controlling
C
A client seen in the emergency department is experiencing irritability, pressured speech, and increased levels of anxiety. Which would be the nurse's priority intervention? A. Place the client on a one-to-one observation to prevent injury B. Ask the physician for a psychiatric consultation C. Assess vital signs and complete a physical assessment D. Reinforce relaxation techniques to decrease anxiety.
C
After teaching a client who has diverticulitis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? A. I'll ride my bike or take a long walk at least three times a week B. I must try to include at least 25 g of fiber in my diet every day. C. I will take a laxative nightly at bedtime to avoid becoming constipated. D. I should use my legs rather than my back muscles when I lift heavy objects.
C
A young adult client is admitted to a psychiatric unit with a diagnosis of alcohol abuse and personality disorder. the client's mother states "he's always in trouble, just like when he was a boy. Now he's just a bigger prankster and out of control." In view of the client's history, which intervention is most important initially? a. letting the client know the staff has the authority to subdue him if he gets unruly b. keeping the client isolated from other clients until he is better known by the staff c. emphasizing to the client that he will have to pay for any damage he causes d. closely observing the client's behavior to establish a baseline pattern of functioning
D
when teaching a client who is to receive methadone therapy for opioid addiction, the nurse should instruct the client that methadone is useful primarily for what reason? a. it in not an addictive substance b. a maintenance dose is taken twice a day c. the client will no longer be addicted to opioids d. the client may work and live normally
D
A client is receiving TPN. on assessment, the nurse notes that the client's pulse is 128 Beats/min, blood pressure is 98/56 mm Hg, skin is dry, and skin turbot is poor. what action should the nurse perform next? a. assess the 24-hour I&O b. assess the clients oral cavity c. prepare to hang a normal saline bolus d. increase the infusion rate of the TPN
A
A nurse reviews the electronic health record of a client who has Crohn disease and a draining fistula. Which documentation would alert the nurse to urgently contact the primary health care provider for additional prescriptions? A. Serum potassium of 2.6 mEq/L (2.6 mmol/L) B. Client ate 20% of breakfast meal C. White blood cell count of 8200 D. Client's weight decreased by 3 lb
A
A nursing student reports to the nurse that he has observed several types of behavior among the patients. Which patient needs priority assessment? A. A patient who is having command hallucinations. B. A patient who is demonstrating clang associations. C. A patient who is verbalizing ideas of reference. D. A patient who is using neologisms.
A
All but which of the following are initial goals for treating the severely malnourished client with anorexia nervosa? A. Correction of bogy imagine disturbance B. Correction of electrolyte imbalances C. Nutritional rehabilitation D. Weight restoration
A
During a home visit for a client diagnosed with paranoid schizophrenia discharged 1 week ago, the client's mother tearfully states, I can hardly sleep because I'm so worried about my daughter. I'm afraid to leave her alone in the house. What if something should happen while I am gone? Which caregiver problem would be the MOST inclusive one for the nurse to incorporate into the client's plan of care? A. Caregiver rold strain B. Anxiety C. Fear D. Disturbed sleep pattern
A
In caring for a patient who is admitted to a medical surgical unit for treatment of anorexia nervosa, which task can be delegated to unlicensed assistive personnel? A. Sitting with the patient during meals and for 1 to 1.5 hours after meals. B. Observing for and reporting ritualistic behaviors related to food. C. Obtaining special food for the patient when she requests it. D. Weighing the patient daily and reinforcing that she is underweight.
A
The nurse attempts to draw blood from a client with a diagnosis of delirium who was admitted last evening. The client yells out, "Stop! Leave me alone! What are you trying to do to me? What's happening to me?" Which response by the nurse is MOST appropriate? A. The tests of your blood will hep us figure out what's happening to you B. Please hold still so i don't have to stick you a second time C. After I get your blood, I'll get some medicine to help you calm down D. I'll tell you everything after I get your blood tests to the laboratory
A
The nurse documents the following note in the medical record. The client has bruising on the upper arms in the shape of finger marks. Bruising in various degrees of resolution are noted on the lower back and abdomen. When the client is asked about the marks, the client states, I fell down the steps. Which communication is BEST to determine if domestic abuse is occurring? A. Do you feel safe in your living situation? B. I hope that you would tell me if abuse at your home is occurring C. Living in an abusive situation is terrible. I know personally D. Do you also have children who have bruises like this?
A
The nurse is performing an initial assessment and notes that the client weighs 186.4lb. six months ago, the client weighed 211.8lb. what action by the nurse is appropriate? a. Ask the client if the weight loss was intentional b. Determine if there are food allergies or intolerances c. Perform a comprehensive nutritional assessment d. Perform a rapid bedside blood glucose test
A
The nurse is working with a client with anorexia nervosa. Even through the client has been eating all her meals and snacks, her weight has remained unchanged for 1 week. Which of the following interventions is indicated? A. Supervise the client closely for 2 hours after meals and snacks. B. Increase the daily caloric intake from 1500 to 2000 calories. C. Increase the client's fluid intake. D. Request an order from the physician for fluoxetine.
A
The nurse teaches a client who has viral gastroenteritis. Which dietary instruction would the nurse include in the health teaching? A. Drink plenty of fluids to prevent dehydration B. You should only drink 1L of fluids daily C. Increase your protein intake by drinking more milk D. Sips of cola or tea may help to relieve your nausea
A
When working with a depressed client who has suicidal ideation, the nurse anticipates that the client may be overwhelmed by personal problems. With this in mind, the nurse should take which action to best assist the client to cope more effectively? A. Encourage the client to make a list of problems from most urgent to least urgent. B. Support the client's decision to put off problem solving until outpatient therapy has begun. C. Encourage the client to work on problems only in group therapy D. Take a directive approach and advise the client how to prioritize personal problems.
A
a client brought to the ED is perspiring profusely, breathing rapidly, and having dizziness and palpitations. problems of the cardiovascular nature are rules out, and the clients diagnosis is tentatively listed as a panic attack. after the symptoms pass, the client states "I thought I was going to die." which is the nurse's best response? a. it was very frightening for you b. we would not have let you die c. I would have felt the same way d. but you are okay now
A
the nurse is talking with a client who has been diagnosed with antisocial personality disorder about how to socialize during activities without being seductive. the nurse should focus the discussion on which area? a. explaining the negative reactions of others toward his behaviors b. suggesting he apologize to others for his behavior c. asking him to explain the reasons for his seductive behavior d. discussing his relationship with his mother
A
which behavior indicated to the nurse that the client diagnosed with avoidant personality disorder is improving? a. interacting with two other clients b. listening to music with headphones c. sitting at a table and painting d. talking on the telephone
A
which client statement indicates to the nurse that the client needs further teaching about disulfiram? a. I can drink one or two beers and not get sick while on this med b. I can take this med at bedtime if it makes me sleepy c. a metallic or garlic taste in my mouth is normal when starting this med d. ill read the labels on cough syrup and mouthwash for possible alcohol content
A
a nurse assesses a client with IBS. which questions would the nurse include in this clients assessment? SATA a. which food types cause an exacerbation of symptoms? b. where is your pain or discomfort and what does it feel like? c. have you lost a significant amount of weight lately? d. are your stools soft, watery, and black? e. do you often experience nausea and vomiting?
A, B
The nurse is teaching a client diagnosed with generalized anxiety disorder how to effectively cope with severe distress. which interventions would the nurse use to promote effective coping with anxiety? SATA a. discuss previous methods that were effective in handling stress b. encourage the client to limit to a mutually decided amount of time spent on worrying c. help the client establish a goal and develop a plan to meet their goal d. teach the client how to label feelings and hot to express them e. discuss ways to examine the reality of fears f. assist the client to acknowledge the major consequences of blaming others.
A, B, C, D
The nurse is assessing a client for a neurocognitive disorder such as dementia. What history findings would the nurse anticipate while talking with the client and family? (select all that apply) A. The progression of symptoms has been slow B. The client admits to feelings of wanting to be alone C. The client acts apathetic and pessimistic D. The family cannot determine when the symptoms first appeared E. The client has been exhibiting basic personality changes F. The client has great difficulty paying attention to others
A, B, C, D, E, F
The nurse is caring for a client who has possible acute pancreatitis. What serum laboratory findings would the nurse expect for this client? SATA A. Elevated amylase B. Elevated lipase C. Elevated glucaose D. Decreased calcium E. Elevated bilirubin F. Elevated leukocyte count
A, B, C, D, E, F
A nurse cares for an older adult who is admitted to the hospital with complications of diverticulitis. Which actions would the nurse include in the client's plan of care? ( select all that apply) A. Administer pain medications as prescribed B. Palpate the abdomen for distention C. Assess for sudden changes in mental status. D. Provide the client with a high-fiber diet. E. Evaluate stools for occult blood.
A, B, C, E
A nurse prepares to discharge a client who is newly diagnosed with a chronic inflammatory bowel disease. Which questions would a nurse ask in preparation for discharge? (select all that apply) A. Does your gym provide yoga classes? B. When should you contact your provider? C. What do you plan to eat for dinner? D. Do you have a scale for daily weights? E. How many bathrooms are in your home?
A, B, C, E
when working with older adults to promote good nutrition, what actions by the nurse are most appropriate? a. allow uninterrupted time for eating b. assess dentures (if worn) for appropriate fit c. ensure that the client has glasses on or contracts in when eating d. provide salty or highly spicy foods that the client can taste e. serve high-calorie, high-protein snacks one to two times a day
A, B, C, E
When beginning a client on newly prescribed anti-psychotic medications, which symptoms are commonly seen within the first few weeks of treatment? (select all that apply) A. Acute dystonia reactions B. Akathisia C. Tardive dyskinesia D. Neuroleptic malignant syndrome E. Hearing loss F. Orthostatic hypotension
A, B, D, F
which symptoms are expected indications that a client has alcohol withdrawal delirium? SATA a. tachycardia b. tachypnea c. dry, flushed skin d. thirst e. hypertension f. abdominal cramping
A, B, E
A nurse in employed at an outpatient rehabilitation facility caring for clients withdrawing from opioids. when assessing clients who present for their counseling session, which findings are anticipated at this time? SATA a. abdominal cramps b. dry, warm skin c. rhinorrhea d. dilated pupils e. hypersomnia f. feelings of hunger
A, C, D
When administering certain anti-psychotic drugs, the nurse monitors for extrapyramidal effects such as (Select all that apply) A. Tremors B. Elation and a sense of well-being C. Painful muscle spasms D. Motor restlessness E. Bradycardia
A, C, D
which nursing intervention approaches would the nurse take that may be effective when caring for a client with body dysmorphic disorder who is preoccupied with a mole on her face? SATA a. teach the client meditation and breathing relaxation techniques b. explain to the client that her perception of the mole is absolutely a misperception, and that it is all in her head c. respect the clients preoccupation with the perceived physical defect. d. encourage the client to participate in a self-help group e. focus on the client's positive relationships with family members
A, C, D, E
A new client on the psychiatric unit has been diagnosed with depression and obsessive compulsive personality disorder. During visiting hours, her husband states to the nurse that he does not understand the OCPD and what can be done about it. What information should the nurse share with the client and her husband? SATA a. perfectionism and overemphasis on tasks usually interfere with friendships and leisure time b. it will help to interrupt her tasks and tell her you are going out for the evening c. there are medicines, such as clomipramine or fluoxetine, that may help. d. remind your wife that it is ok to be hum and make mistake e. reinforce with her that she is not allowed to expect the whole family to be perfect too f. this disorder typically involves inflexibility and a need to be in control
A, C, D, F
a nurse is caring for a client who has been diagnosed with a SBO. which assessment findings would the nurse correlate with this diagnosis? SATA a. serum potassium of 2.8 b. loss of 15lb without dieting c. abdominal pain in upper quadrants d. low pitched bowel sounds e. serum sodium of 121
A, C, E
A nurse is caring for a client diagnosed with persistent depressive disorder. Which defining characteristics are associated with this disorder? Select all that apply. A. Insomnia or hypersomnia B. Delusions or hallucinations C. Loss of interest in daily activities D. Onset of symptoms within a 2-week period E. Symptoms that occur in the winter and resolve in spring F. Appetite disturbance
A, C, F
A nurse is preparing discharge instructions for a client with resistant depression who was prescribed a new medication regimen that includes phenelzine, a MAOI. If the teaching was successful, what foods would that client state that he or she needs to void? (Select all that apply) A. Aged Cheese B. Cottage cheese C. Milk D. Wine E. Salami F. Grapefruit
A, D, E
the nurse is caring for a client who has a NG tube. which actions would the nurse take for client care? SATA a. asses for proper placement of the tube Q4Hrs per agency policy b. flush the tube with water every hour to ensure patency c. secure the NG tube to the clients chin d. disconnect suction when auscultating bowel peristalsis e. monitor the clients skin around the tube site for irritation
A, D, E
The nurse needs to teach a client about newly prescribed sertraline (Zoloft). Which information is essential to include in the teaching? (select all that apply) A. Sertraline is most often taken as a morning dose. B. Constipation is a common side effect of sertraline C. Fever and flu-like symptoms are bothersome but not dangerous side effects of sertraline D. Clients taking sertraline will usually recognize improvement within one week. E. It is possible that sexual side effects will occur
A, E
A client is diagnosed with antisocial personality disorder has a potential for violence and aggressive behavior. which short-term client outcome is most appropriate for the nurse to include in the plan of care? a. use humor when expressing anger b. discuss feelings of anger with staff c. ask the nurse for medication when upset d. use indirect behaviors to express anger
B
A client is recovering from an EGD and requests something to drink. What action by the nurse is appropriate? a. Allow the client cool liquids only b. Assess the clients gag reflex c. Remind the client to remain NPO d. Tell the client to wait 4 hours
B
A nurse is reviewing laboratory values for several clients. which value indicates a need for a nutritional assessment? a. client with an albumin of 3.5 g/dl b. client with a cholesterol of 142 mg/dl c. client with a hemoglobin of 9.8 mg/dl d. client with a pre albumin of 28 mg/dl
B
An adolescent female client who has been treated for an anxiety disorder since middle school with behavioral treatment and PRN anxiety medication is preparing to go to college. the parents are concerned that she will experience an exacerbation of symptoms if she attends college out of town and want their daughter to attend the local community college and live at home. the girl believes she can handle the challenge of leaving home for college. how should the nurse in the outpatient clinic respond to the family's concern? a. your parents have a point; transitions have been hard for you in the past b. there are many pros and cons here that we all need to discuss together c. every high school graduate deserves the chance to take on new challenges d. it may be premature for you to think of college at this point in time.
B
An older adult client is admitted and diagnosed with delirium. Later in the day, he tries to get out of the locked unit. He yells, Unlock the door. I've got to go see my doctor. I just can't miss my monthly Friday appointment. Which of the following responses by the nurse is MOST appropriate? A. Please come away from the door I'll show you to your room B. It's 5 o'clock Tuesday, and you're in the hospital. I'm Anne, a nurse C. The door is locked to keep you from getting lost D. I want you to come eat your lunch before you go for your appointment
B
The parents of a 20-year old female client diagnosed with paranoid schizophrenia admitted 4 days ago are attending a family psycho education group in the hospital. Which statement by the mother indicates that she understands her daughter's illness and management A. I know that I'll have to do everything for my daughter when she comes home B. Tasks as simple as getting out of bed and showering in the morning may be difficult for her C. I know that visits from her friends at home should be discouraged for a while D. She won't experience a relapse as long as she takes her prescribed medication
B
The patient tells the nurse that he drinks 3 or 4 servings of alcohol evert day. he also reports frequently taking acetaminophen for stress related headaches. based on this information, which laboratory test results are the most important to follow up on? a. renal function test b. liver function test c. cardiac enzymes d. serum electrolytes
B
While assessing a client diagnosed with dementia, the nurse notes that her husband is concerned about what he should do when she uses vulgar language with him. What should the nurse tell the husband? A. Tell her that she is very rude B. Ignore the vulgarity and distract her C. Tell her to stop swearing immediately D. Say nothing and leave the room
B
a client is preparing to have a fecal occult blood test. what health teaching would the nurse include prior to the test? a. this test will determine whether you have colorectal cancer b. you need to avoid red meat and NSAIDS for 48 hours before the test c. you don't need to have this test because you can have a virtual colonoscopy d. this test can determine your genetic risk for developing colorectal cancer
B
a nurse is caring for ap patient who has excessive catecholamine release. which assessment finding would the nurse correlate with this condition? a. decreased BP b. increased pulse c. decreased RR d. increased urine output
B
after teaching a client with IBS, a nurse assesses the clients understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. ham sandwich on white bread, cup of applesauce, carbonated beverage b. broiled chicken with brown rice, steamed broccoli, glass of apple juice c. grilled cheese sandwich, small banana, cup of hot tea with lemon d. baked tilapia, fresh green beans, cup of coffee with low fat milk
B
the nurse is caring for a client who has been prescribed lubiprostone for IBS-C. what health teaching will the nurse include about taking this drug? a. this drug will make you very dry because it will decrease your diarrhea b. be sure to take this drug with food and water to help manage constipation c. avoid people who have infection as this drug will suppress your immune system d. include high-fiber foods in your diet to help produce more solid stools
B
A client, diagnosed with Alzheimer's disease, is a new resident in a long-term care facility. The client has difficulty finding his or her room and is seen wandering in to the room of others. When discussing the situation at a multidisciplinary conference, which client-centered actions would the nurse suggest?(select all that apply) A. Provide a map of the unit as a guide with the room highlighted B. Ensure that the client has prescribed hearing aids and glasses on throughout the day C. Place a box with familiar personal items outside the client's door for visual recognition D. Assign the client to a room close to the nursing station for closer monitoring E. Provide verbal cueing as to where the client's room is located F. Place the client with a roommate having similar cognitive deficits
B, C, D, E
A health care provider prescribes haloperidol p.o. 1 mg t.i.d. When assessing the client for extrapyramidal adverse effects, which nursing measures would be initiated? (select all that apply) A. Pad side rails in case of seizure activity. B. Closely monitor vital signs, especially temperature C. Observe for increased pacing and restlessness D. Reorient the client during delusions E. Provide the client with sugar-free hard candy F. Monitor for signs and symptoms of urticaria
B, C, E
A nurse is monitoring a client who appears to be hallucinating. The client is gesturing at a figure on the TV and appears agitated with speech containing paranoid content. Which nursing interventions are appropriate at this time? (select all that apply) A. In a firm voice, instruct the client to stop the behavior. B. Reassure the client that there is no danger C. Acknowledge the presence of the hallucinations. D. Instruct other team members to ignore the client's behavior E. Delegate client assessment to the LPN F. Give simple commands in a calm voice.
B, C, F
A nurse assesses a client who has cholecystitis. Which sign or symptom indicates that this condition is chronic rather than acute? a. Temp of 100.1 b. Positive murphy signs c. Clay colored stools d. Upper abdominal pain after eating
C
A patient comes into the walk-in clinical and tells the nurse that he would like to be admitted to an alcohol rehab program. which question is the most important to ask? a. what made you decide to enter a program at this time b. how much alcohol do you usually consume in a day c. when was the last time you had a drink d. have you been in a rehab program before
C
A patient is displaying muscle spasms of the tongue, face, and neck, and his eyes are locked in an upward gaze. He is being prescribed haloperidol. What is the priority action? A. Encourage him to look at you and stay with him until the spasms pass B. Place the patient on aspiration precautions until the spasms subside C. Obtain an order for intramuscular or IV diphenhydramine D. Obtain an order for and administer an anti seizure medication
C
After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the clients understanding. Which statement by the client indicates a need for further teaching? a. The capsules can be opened and the powder sprinkled on applesauce if needed. b. I will wipe my lips carefully after I drink the enzyme preparation c. The best time to take the enzymes is immediately after I have a meal or a snack d. I will not mix the enzyme powder with food or liquids that contain protein
C
An older adult client was prescribed lorazepam 1 mg three times a day to help calm her anxiety after her husband's death. The next day, the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and insistence, the daughter calls the nurse to report her mother's behavior. Which findings would the nurse suspect as the cause of the mother's behavior, and what action would she suggest? A. The client is manic and may need a sleeping pill B. The client is experiencing a medication interaction and should go to the emergency department C. The client is experiencing a paradoxical reaction to the lorazepam an should stop the new medication immediately D. The client is overcome by grief and probably needs an antidepressant
C
An outpatient client who has a history of paranoid schizophrenia and chronic alcohol dependency has been taking risperidone for several months. She reports that she stopped drinking 4 days ago. The client is very frightened by the tactile hallucinations of bugs crawling under her skin. Which factor should the nurse incorporate into the plan of care when explaining the tactile hallucinations? A. Alcohol intoxication B. Ineffectiveness of risperidone C. Alcohol withdraw D. Interaction of alcohol and risperidone
C
The nurse assesses a client who is hospitalized with an exacerbation of Crohn disease. Which assessment finding would the nurse expect? A. Positive Murphy sign with rebound tenderness to palpitation B. Dull, hypoactive bowel sounds in the lower abdominal quadrants C. High-pitched, rushing bowel sounds in the right lower quadrant D. Reports of abdominal cramping that is worse at night
C
The nurse documents the vital signs of a client diagnosed with acute pancreatitis: Apical pulse- 116BPM Respirations- 28 breaths/min Blood pressure- 92/50 What complication of acute pancreatitis would the nurse suspect that the client might hae? A. Electrolyte imbalance B. Pleural effusion C. Internal bleeding D. Pancreatic pseudocyst
C
The nurse is assessing a client who recently began taking a typical antipsychotic medication. The client says, All of a sudden I can't breathe right. The nurse observes generalized body rigidity and diaphoresis. The body temperature is 103 F and the pulse is 130. What should the nurse do next? A. Administer the ordered prn anticholinergic medication B. Assess the client for indications of orthostatic hypotension C. Begin preparing the client for immediate transfer to an emergency department D. Arrange for an additional physician's visit later in the day
C
The nurse is assessing an older adult for signs of dementia. The nurse gives the client three words to remember: Cat, Crackers, and Toys. After having the client perform a short task, the nurse asks the client to repeat the words. The client says toys, boys, and joys. What should the nurse do next? A. Ask the client to repeat the original words one more time B. Note on the medical record that the client has echolalia C. Refer the client to a health care provider for further follow-up D. Repeat the test when a family member is present
C
The nurse reviews the laboratory results for a client who has possible appendicitis. Which laboratory test finding would the nurse expect? A. Decreased potassium level B. Increased sodium level C. Elevated leukocyte count D. Decreased thrombocyte count
C
The patient has a panic disorder, and it appears that he is having some problems controlling his anxiety. which symptoms are cause for greatest concern? a. his heart rate is increased, and he reports chest tightness b. he demonstrated tachypnea and carpopedal spasms c. he is pacing to and from and pounding his fists together d. he is muttering to himself and is easily startled
C
the nurse is teaching assistive personnel about hormones that are produced by the adrenal glands. which hormone has primary responsibility of maintaining fluid volume and electrolyte composition? a. sodium b. magnesium c. aldosterone d. renin
C
which person is displaying behaviors that most strongly suggest the need for additional screening for possible substance abuse? a. person with cancer progressively needs more pain medication achieve relief b. college student reports occasionally smoking marijuana during semester break c. stay at home mom reports drinking while her kids are in school and after they do to bed d. person with a fractured leg reports taking opioids and tapering off when pain subsides
C
A client is scheduled for a hepatobiliary iminodiacetic acid scan. What would the nurse include in client teaching about this diagnostic test? a. You'll have to drink a contrast medium right before the test b. You'll need to do a bowel prep the night before the test c. you'll be able to drink liquids up until the test begins d. you'll have a large camera close to you during the test
D
A nurse is assessing a client reporting RUQ abdominal pain. What technique would the nurse use to assess this client's abdomen? a. Auscultate after palpating b. Avoid any type of palpation c. Lightly palpate the RUQ first d. Lightly palpate the RUQ last
D
A patient diagnosed with paranoid schizophrenia tells the nurse that, Dr. Smith has killed several other patients, and now he is trying to kill me. What is the best response? A. I have worked here a long time. No one has died. You are safe here. B. What has Dr. Smith done to make you think he would like to kill you? C. All of the staff, including Dr. Smith, are here to ensure your safety. D. Whenever you are concerned or nervous, talk to me or any of the nurses.
D
After teaching a patient with diverticular disease, a nurse assesses the client's understanding. Which menu selection indicates the client correctly understood the teaching? A. Roasted chicken with rice pilaf and a cup of coffee with cream B. Spaghetti with meat sauce, a fresh fruit cup, and hot tea C. Garden salad with a cup of bean soup and a glass of low-fat milk D. Baked fish with steamed carrots and a glass of apple juice
D
During family teaching, the daughter of a client with dementia mentions to the nurse that her mother distorts things. The nurse understands that the daughter needs further teaching about dementia when she makes which statement? A. I tell her reality, such as that noise is the wind in the trees B. I understand the misperceptions are part of the disease C. I turn off the radio when we're in another room D. I tell her she's wrong, and then I tell her what's right
D
The nurse assesses a client with gastroenteritis. What risk factor would the nurse consider as the most likely cause of this disorder? A. Consuming too much fruit B. Consuming fried or pickled foods C. Consuming dairy products D. Consuming raw seafood
D
The nurse teaches a client about how to prevent transmission of gastroenteritis. Which statement by the nurse indicates a need for further teaching? A. I won't let anyone use my dishes or glasses B. I'll wash my hands with antibacterial soap C. I'll keep my bathroom extra clean D. I'll cook all the meals for my family
D
an adult client diagnosed with anxiety disorder becomes anxious when she touches fruits and vegetables. what should the nurse do? a. instruct the woman to avoid touching these foods b. ask the woman why she becomes anxious in these situations c. assist the woman to plan for her family to do the food shopping and preparation d. teach the woman to use cognitive behavioral approaches to manage her anxiety
D
for the client who has difficulty falling asleep at night because of withdrawal symptoms from alcohol, which are abating, which nurse intervention is likely to be most effective? a. inviting the client to play a board game with the nurse b. allowing the client to sit in the community room until the client feels sleepy c. advising the client to take multiple short naps during the day until symptoms improve d. teaching the client relaxation exercised to use before bedtime
D
the nurse is caring for a client with a large bowel obstruction due to fecal impaction. what position would be appropriate for the client while in bed? a. prone b. supine c. recumbent d. semi-fowlers
D
the nurse reviews the function of thyroid gland hormones. what is the primary function of calcitonin? a. sodium and potassium balance b. magnesium balance c. norepinephrine balance d. calcium and phosphorus balance
D
when the nurse is caring for a client experiencing delirium tremens, what is the most important nursing intervention? a. present psycho-education on the dangers of drug and alcohol use b. encourage the client to develop a relapse prevention plan c. administer anti-craving medications d. provide withdrawal care based on unit protocol
D
