Qbank #3
A client states to the nurse, "I am having difficulty seeing". Which cranial nerve will the nurse test first? 1. CN II 2. CN IV 3. CN VI 4. CN VIII
ANSWER: 1 (CN II controls vision. The nurse should use a snellen chart to test far vision and have the client read a newspaper to test near vision). CN IV: controls downward and inward movement of the eyes. CN VI: Controls lateral movement of the eyes. CN VIII: Controls sense of hearing and balance.
The employee-health nurse encourages all employees to use a newly opened physical exercise and wellness area in the workplace. Which level of health promotion is the nurse demonstrating in this situation? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Passive prevention
ANSWER: 1 (This type of prevention works to precede disease and alter unhealthy behaviors)
The nurse provides care to a client diagnosed with sinus arrhythmia. The nurse uses which site to assess the client's pulse? 1. Apical 2. Radial 3. Femoral 4. Carotid
ANSWER: 1 (apical pulse assessment is indicated for use during initial cardiac examination or if the client's pulse is irregular. Sinus arrhythmia, which is most common among children and young adults, refers to minor variations in pulse regularity that occur in relationship to the respiratory cycle. In infants and children up to 3 years old, the apical pulse is the routine site for cardiac assessment. Apical pulse assessment is also indicated prior to administration of certain medications, such as digoxin).
The nurse in a well-baby clinic assesses several infant clients. Which infant will the nurse identify as needing to be seen by the HCP? 1. 3-month old who does not smile when played with. 2. 5-month old who does not hold own bottle. 3. 7-month old who does not have a moro reflex 4. 9-month old who does not release objects at will.
ANSWER: 1 (at 2 months of age, an infant should demonstrate a social smile. This infant should be the priority to follow up with the HCP). Why 2 is wrong: an infant should hold the bottle by 6 months of age. Why 3 is wrong: the moro reflex disappears at 4 months of age. Why 4 is wrong: infants are not expected to release objects until 11 months of age.
The nurse provides care for a client diagnosed with hypocalcemia. The nurse teaches the client about calcium supplements. Which vitamin is essential for the absorption of calcium in the GI tract and should be included in teaching? 1. Vitamin D 2. Vitamin K 3. Vitamin A 4. Vitamin C
ANSWER: 1 (vitamin D stimulates absorption of calcium from the GI tract) Vitamin K: essential for blood clotting Vitamin A: Essential for night vision Vitamin C: essential for would healing and IRON absorption
A client develops an obstruction of the lower intestine. Which finding does the nurse anticipate when assessing the client? 1. Nausea, vomiting, abdominal distention 2. Explosive, irritating diarrhea 3. Abdominal tenderness with rectal bleeding 4. Mid-epigastric discomfort, tarry stools
ANSWER: 1 (with an obstruction of the lower intestine, the nurse can expect distention above the level of the obstruction, and hyperactive bowel sounds upon initial assessment. There would be no stool, as motility distal to (below) the obstruction would cease. The obstruction causes the client to develop nausea, vomiting, and abdominal distention due to the lack of movement of GI contents). Why 2 is wrong: diarrhea is not a symptoms of a lower intestinal obstruction. Why 3 is wrong: There is no rectal bleeding with obstruction of the lower intestine. The abdomen would be distended but non-tender. Why 4 is wrong: Mid-epigastric discomfort and tarry stools are associated with GI bleeding, neither of which are symptoms of lower intestinal obstruction.
The nurse conducts a class for clients in their first trimester of pregnancy. Which information is appropriate for the nurse to include? SATA. 1. Quickening should occur around 16-20 weeks gestation. 2. The fundal height is the measurement from the top of the symphysis pubis to the top of the fundus. 3. Toddlers should be informed of the mother's pregnancy early on in the pregnancy. 4. Expected weight gain is 10-15 pounds in the first trimester. 5. Nausea usually ends by 14-16 weeks.
ANSWER: 1, 2, 5 Why 3 is wrong: since toddlers have little perception of time, many parents delay telling them that a baby is expected until shortly before the birth. Why 4 is wrong: pregnant clients should not gain much weight in the first trimester. The majority of weight gain should occur in the second and third trimesters, at approx. 1 pounds per week. For a client whose pre-pregnancy BMI fell within normal limits, the total weight gain in pregnancy should be only 25-35 pounds.
A healthcare provider would like to give the nurse a verbal telephone prescription for a client. Which action does the nurse take to properly receive the prescription? SATA 1. Clarify the client's name 2. Explain that verbal prescriptions are only accepted in emergency situations. 3. Transcribe the prescription into the client's medical record as soon as possible. 4. Read back the prescription and get confirmation from the HCP. 5. Have another nurse also listen as the HCP gives the verbal prescription. 6. Record the prescription as "pending until written prescription provided"
ANSWER: 1, 3, 4 (the healthcare provider and nurse should clarify the name, diagnosis, and other identifying data about the client to ensure both are speaking about the same client. Verbal or telephone prescriptions should be transcribed into the client's medical record as soon as feasible. Verbal or telephone prescriptions must be told back to the HCP to ensure accuracy). Why 2 is wrong: verbal/telephone prescriptions can be given outside of emergency situations. Why 5 is wrong: it is not necessary for another nurse to listen Why 6 is wrong: verbal or telephone prescriptions will be indicated as such according to agency policy.
The nurse provides care for a client who has a chest tube in place for a hemothroax. The drainage from the chest tube has suddenly decreased over the past hour. Which action does the nurse take when caring for the chest tube? SATA. 1. Examine the tubing for clots. 2. Periodic milking and striping of the tubing. 3. Determine the presence of tidaling. 4. Check tubing for kinks. 5. Assess dressing around the chest tube insertion site.
ANSWER: 1, 3, 4, 5 - If the nurse notices clots in the tubing, this may be the reason why there is a decrease in chest tube drainage. If there are visable clots, the nurse should squeeze hand over hand along the tubing to promote movement on the clots. - Tidaling is fluctuation in the water seal chamber with respiratory effort. Water level rises with inspiration and decreases with expiration. If there is an absence of tidaling, this may indicate that the tube is kinked or occluded. - Tubing needs to be free of kinks and fluid-filled dependent loops. - The nurse needs to check the dressing around the insertion site for abnormal drainage. Excessive or abnormal drainage on the dressing may indicate that the chest tube is occluded. Why 2 is wrong: milking and stripping the tubing is contraindicated because it generates extreme negative pressures in the tubing. This negative pressure can harm pleural membranes and surrounding tissues.
The nurse cares for a client who weighs 400 lbs and is on bed rest. The nurse must assist the client to move up to the head of the bed with the use of a drawsheet. Which technique, if performed by the nurse, ensures proper lifting of the client? SATA. 1. The nurse keeps own spine, neck, and back straight and aligned throughout the lift. 2. The nurse maintains a narrow stance before pulling the client upward. 3. The nurse remains an arms-length distance from the client while puling the client upawrd. 4. The nurse pivots feet in the direction of the move prior to moving the client. 5. The nurse requests that one other nurse assist. 6. The nurse places the bed in Trendelenburg position prior to moving the client.
ANSWER: 1, 4, 6
The nurse prepares to administer immunizations to a 4-year-old child. Which immunization is appropriate for the nurse to administer? SATA. 1. Inactivated poliovirus (IPV) 2. Pneumocoocal conjugate (PCV13) 3. Haemophilus influenza type b (Hib) 4. Rotavirus (RV) 5. Measles, mumps, rubella (MMR)
ANSWER: 1, 5 (the child should receive four doses of the IPV. The first dose at 2 months, a second at 4 months, third dose between 6-18 months, and the fourth dose between 4-6 years. The child should receive two doses of MMR, the first dose at 12-15 months and the second dose between 4-6 years).
The nurse provides care for a client diagnosed with bulimia nervosa. Which intervention does the nurse initiate as part of the client's plan of care? SATA 1. Monitor the client for an hour after meals. 2. Assist the client in identifying situations that produce anxiety. 3. Provide a quiet, non-stimulating environment for the client. 4. Weigh the client every morning on the same scale. 5. Establish the treatment plan with the client.
ANSWER: 1,2,3,4,5 - When caring for a client diagnosed with bulimia, it is essential for the nurse to monitor the client for at least an hour after meals to prevent the client from purging. - When caring for this client, the goal is to identify situations that produce anxiety that may cause the client to binge-eat. - The goal here is to decrease situations that produce anxiety. Providing a quiet, non-stimulating environment will assist in decreasing the client's anxiety. - The nurse should obtain the client's weight every day at the same time using the same scale. - Establishing a client treatment plan is important. The plan encourages the client to assume responsibility for actions, should include an agreement about binge eating, purging or vomiting, and hoarding of food.
The outpatient clinic nurse administers a tuberculin skin test (TST) to four adult clients. The nurse anticipates which client will likely demonstrate a false-positive response to the TST? 1. A client who received a herpes zoster (shingles) vaccine last week. 2. A client who recieved a bacille calmette-geurin (BCG) vaccine 1 month ago. 3. A client who regularly takes corticosteroid medication. 4. A client who was recently diagnosed with AIDS.
ANSWER: 2 (Clients who receive a BCG vaccine, which prevents against the development of TB, may demonstrate a false-positive response to a TST). Why 1 is wrong: Recent administration of a live vaccine may cause a false negative, not a false positive result. It is recommended to either administer the live vaccine the same day as the TST or wait 4-6 weeks after administration of the live vaccine. Why 3 is wrong: Corticosteroid medications suppress the immune response and are more likely to demonstrate a false-negative. Why 4 is wrong: AIDS suppresses the immune system and are more likely to demonstrate a false-negative.
The nurse notes that a toddler client has numerous bruises, a possible fractured left humerus, and several lacerations. Which action will the nurse take first? 1. Report findings to CPS 2. Ask the parents what caused the injuries. 3. Review the client's previous medical records. 4. Observe the interaction between the parents and client.
ANSWER: 2 (asking the parents what caused the injuries helps determine if the explanation is compatible with the injuries observed). The nurse should complete the assessment before reporting any findings.
The nurse provides care for a client with a radium implant. Which action is most important for the nurse to take? 1. Evaluate the position of the applicator every 2 hours. 2. Place the client on a low-residue diet to decrease bowel movements. 3. Encourage the use of the bedside commode every 1-2 hours. 4. Decrease fluid intake to decrease radiation in the bladder.
ANSWER: 2 (bowel movements can dislodge the radium implant. This diet will decrease the amount of stool and number of bowel movements). Why 1 is wrong: the position of the applicator should be checked every 8 hours, not every 2. Why 3 is wrong: a client is on strict bed rest to prevent dislodging the radium implant. Why 4 is wrong: decreasing fluids will not alter exposure to radiation. A client should have a high fluid intake.
The nurse assesses the need for further teaching for a client considering cognitive therapy. Which client statement informs the nurse that the client understands the therapy? 1. "My therapist will just rapidly expose me to things that cause me anxiety so that I can learn to tolerate them better" 2. "My therapist will help me examine my thoughts and feelings to understand how they play a part in my struggle" 3. "My therapist will teach me new ways of relaxing through art therapy, so I can develop new coping skills" 4. "My therapist will help me understand the events in my past that contributed to my present problems"
ANSWER: 2 (cognitive therapy focuses on the immediate thought processes and seeks to show the relationship between how the person interprets or perceives experiences and how the person feels or behaves). Why 1 is wrong: This describes flooding Why 3 is wrong: This describes art therapy Why 4 is wrong: This describes psychodynamic therapy
A client with ongoing rehabilitation needs is being discharged from the hospital. Which intervention best ensures continuity of care for this client? 1. Connecting with the client's next-door neighbor. 2. Communicating with the primary health care provider. 3. Ensuring home physical therapy is prescribed. 4. Contacting the home care agency.
ANSWER: 2 (continuity of care will best occur when the discharge team coordinates care planning with the primary health care provider. When the primary HCP is aware of the client's ongoing home care needs, they are better equipped to manage that client's care at home). Why 1 is wrong: The next-door neighbor is not involved in the client's health care needs. This is not an appropriate action. Why 3 is wrong: While communication with home physical therapy is required, the best method for achieving continuity to care is to communicate with the primary HCP. Why 4 is wrong: Contacting the home care agency is important, yet the client's primary health care provider is the one responsible for continuity of care after discharge.
A client is diagnosed with meningococcal meningitis with Neisseria meningitidis as the potential pathogen. The nurse must obtain a blood sample. Prior to entering the client's room, which transmission-based precaution is appropriate? 1. N95 mask and face shield 2. Surgical mask and face protection 3. Gown and surgical mask 4. Gown, shoe covers, and surgical mask
ANSWER: 2 (droplet precautions are needed when caring for clients with meningitis. They include a surgical mask and a face shield to protect the eyes. Standard precautions are utilized while drawing labs on a client diagnosed with meningitis).
The nurse sees 4 clients for an annual health assessment. To which of these clients does the nurse offer the meningococcal immunization? 1. A 60-year old who works as a LPN in a skilled nursing facility 2. A first-year college student who lives in a residence hall. 3. A 30-year old who is sexually active, but HIV negative. 4. A retired military veteran who served combat duty.
ANSWER: 2 (due to past outbreaks of bacterial meningitis in dorms, previously unimmunized first-year college students living in a residence hall should be immunized against the meningococcal bacteria). Why 1 is wrong: working in a skilled nursing facility is not a risk for bacterial meningitis Why 3 is wrong: being sexually active is not a risk factor, however, being HIV positive is. Why 4 is wrong: active military personnel who live in crowded situations are at risk, however, retired military veterans are not at risk.
A client care team consists of the nurse, LPN, and two UAPs. Which client will be assigned to the nurse? 1. Client recovering from a surgical repair of hypospadias. 2. Client recovering from excision of malignant melanoma. 3. Client diagnosed with MI and requiring assistance to the bathroom. 4. Client diagnosed with urolithiasis and recovering from lithotripsy.
ANSWER: 2 (the client recovering from the excision of malignant melanoma may have a wide excision wound that required the nurse to anticipate the need for analgesic medications. Psychological support is also necessary because of the diagnosis of cancer. This client requires assessment, teaching, and nursing judgement and should be assigned to the nurse).
The nurse provides care for multiple clients in a long-term care facility. Which client does the nurse see first for pressure injury assessment? 1. An ambulatory client diagnosed with 1+ edema in the lower extremities. 2. An older adult client who is malnourished and on bed rest. 3. An overweight client who needs help to get in and out of a wheelchair. 4. A client experiencing urinary incontinence who frequently gets up from bed.
ANSWER: 2 (this client has three risk factors- older age, being on bed rest, and malnutrition)
The nurse manager makes decisions for the group, gives orders, and is concerned with task accomplishments. Which leadership style does the nurse manager use? 1. Democratic leadership 2. Autocratic leadership 3. Laissez-faire leadership 4. Transformational leadership
ANSWER: 2 (this description describes autocratic (authoritarian) leadership. It is a "top-down" style where the leader controls the followers). Democratic: share leadership, important decisions are made with the team, and the leader is primarily concerned with human relations and teamwork. Laissez-faire: do very little planning or decision-making and fail to encourage others to do so. It is a "bottom-up" style where workers choose the goals and the means they will be met. Transformational: Leaders communicate their vision in a manner that is so meaningful and exciting that it reduces negativity and inspires commitment in the people with whom they work.
The nurse discovers twice the prescribed dose of medication has been administered to a client. Which action is appropriate? SATA 1. Hold the next dose of the prescribed medication. 2. Notify the client's HCP of the error. 3. Assess the client after calling the charge nurse. 4. Inform the charge nurse of the medication error. 5. Complete the medication variance report.
ANSWER: 2, 4, 5 (assess the client and then notify the client's HCP of the error. All incidents, irregular occurrences, or medication variances should be reported to the charge nurse. Documentation on any type of incident or variance report should include the facts concerning the incident). Why 1 is wrong: medication doses are not held without the HCP's direction. Why 3 is wrong: The client should be assessed immediately to ensure client safety.
The nurse plans a physical assessment of a 4-month old client. The client sits quietly on the parent's lap as the nurse approaches. In which order should the nurse conduct the physical assessment? 1. Examine eyes, ears, and mouth 2. Auscultate heart and lungs 3. Test for the moro (startle) reflex 4. Palpate and percuss the abdomen 5. Record heart and respiratory rates.
ANSWER: 2, 5, 4, 1, 3 Explanation: Auscultate the heart and lungs. This is done initially when the infant is quiet. Record heart and RR after auscultating. Results should be recorded before proceeding to more disturbing assessments. Next, the nurse should palpate and percuss the abdomen after auscultating. Examine the eyes, ears, and mouth immediately before testing moro reflex. Test for the moro reflex last because it is a more disturbing assessment. (reminder: the moro reflex disappears after 3-4 months)
The nurse provides care for an infant diagnosed with human immunodeficiency virus (HIV). Which laboratory study does the nurse expect the HCP will prescribe to monitor the progression of the HIV infection? 1. Chest x-ray 2. p24 antigen assay 3. CD4+ count 4. Western blot
ANSWER: 3 (CD4+ count is used, along with viral load, to monitor the progression of HIV. When the CD4_ T cell count falls below 200 cells/uL, acquired immune deficiency syndrome (AIDS) is diagnosed). Why 1 is wrong: Chest x-rays evaluate the presence of other manifestations, such as pneumonia, that are associated with HIV infection. Why 2 is wrong: p24 antigen, in most cases, is undetectable after seroconversion because of antibody production; after sufficient antibodies to HIV have been produced and become bound to the p24 protein, the protein is eliminated from the blood. The p24 test is typically only positive for a number of weeks to months after infection with HIV. Why 4 is wrong: western blot confirms the presence of HIV antibodies.
The nurse provides care for a client diagnosed with a stroke located in the left hemisphere. Which client characteristic does the nurse expect to have the greatest influence on the client's emotional response to this situation? 1. The client's ability to understand the illness and treatment. 2. The client's perception of the care received during the illness. 3. The client's coping mechanisms and general health prior to the stroke. 4. The client's prognosis based on the type of lesion from the stroke.
ANSWER: 3 (a client's past experiences, coping mechanisms, and general health prior to the stroke are major factors in determining a client's reaction to having a stroke. These factors affect how well the client accepts and participates in the recovery phase).
The nurse is teaching a group of clients who are all over the age of 45 years about the screening tests for colorectal cancer. Which screening recommendation does the nurse include in the teaching? 1. Annual prostate-specific antigen 2. Fecal occult blood every 3 years 3. Colonoscopy every 10 years 4. Barium enema every year
ANSWER: 3 (clients who are 45 years+ should have a colonoscopy every 10 years). Why 1 is wrong: prostate-specific antigen is a test, which may be used to help screen for prostate cancer. Why 2 is wrong: If fecal occult blood testing is selected as a screening for colorectal cancer, it should be done every year. Why 4 is wrong: if a barium enema is selected as a screening for colorectal cancer, it should be done every 5 years.
The antepartum nurse is planning care for several clients who are waiting to be seen for a prenatal examination. Which client does the nurse assess first? 1. The client who reports nosebleeds at 8 weeks gestation. 2. The client who reports vulva and rectal varicosities at 16 weeks gestation. 3. The client who reports abdominal pain at 24 weeks gestation. 4. The client who reports leg craps when reclining at 32 weeks gestation.
ANSWER: 3 (persistent or severe abdominal or epigastric pain could indicate ectopic pregnancy (if early), worsening preeclampsia, or abruptio placentae. This client should be assessed first). Why 1 is wrong: The client may has nasal stuffiness, epistaxis (nosebleeds), and changes in voice due to elevated progesterone levels in pregnancy. These are normal occurrences in pregnancy and not priority to assess. Why 2 is wrong: The pressure of the enlarging uterus causes pressure on veins, resulting in development of varicosities in the vulva, rectum, and legs. These are normal occurrences in pregnancy and not the priority assessment. Why 4 is wrong: leg cramps are common in the third trimester.
The nurse assesses a client receiving furosemide. Which finding is the most important for the nurse to report to the HCP? 1. Blood glucose 180 2. Report of hearing loss 3. Potassium 3.2 4. Uric acid 8.5
ANSWER: 3 (potassium level of 3.2 is below expected range and places the client at risk for fatal dysrhythmias). Why 2 is wrong: the nurse should report the client's hearing loss, which is usually transient, but is not the priority concern.
Four clients undergo admission at the same time to the medical unit. Which client will the nurse assign to a private room? 1. A client diagnosed with Escherichia coli gastroenteritis 2. A client diagnosed with hepatitis A 3. A client diagnosed with scabies 4. A client diagnosed with cirrhosis
ANSWER: 3 (scabies is a contagious skin disease caused by mites. It is transmitted by close contact, either directly person to person or via contaminated personal items such as clothing or bedding. It requires a private room and contact precautions). Why 1 is wrong: Bacterial gastroenteritis caused by E.coli is an acute diarrheal illness, which is transmitted by fecal-oral route. Standard infection control procedures are sufficient unless the client is diapered or incontinent, in which case contact precautions are required. Why 2 is wrong: Hep. A is a form of viral hepatitis transmitted by fecal-oral route. Standard infection control procedures are sufficient unless the client is diapered and incontinent, in which case contact precautions are required. Why 4 is wrong: Cirrhosis is not an active infectious process and does not require transmission-based precautions.
The nurse provides care for a client in the clinic. The HCP's prescription reads, "sulindac 200mg PO bid for 14 days". Which symptoms does the nurse instruct a client to report immediately to the HCP? 1. Nervousness 2. Photophobia 3. Ecchymosis of the extremities 4. Mild edema of the feet
ANSWER: 3 (sulindac is a NSAID. A client taking sulindac should notify the HCP if they begin to bruise easily or experience prolonged bleeding). Why 1 is wrong: Nervousness can be an adverse effect of sulindac, but it does not require immediate notification to the HCP. Why 2 is wrong: Photophobia is not an adverse effect of this medication. Why 4 is wrong: Sulindac does cause sodium retention, which can cause peripheral edema. This adverse effect does not require immediate notification of the HCP.
The nurse on the med-surg unit just received report. Which client does the nurse see first? 1. A young adult female undergoing peritoneal dialysis with outflow that appears red-tinged. 2. An adult male client diagnosed with acute post-infectious glomerulonephritis with BP 150/90. 3. A middle-age adult female client diagnosed with P. jiroveci pneumonia and who is turning restlessly in bed. 4. An older adult male client diagnosed with angina and who is scheduled for discharge today.
ANSWER: 3 (this client has an opportunistic infection associated with AIDS, which causes progressive hypoxemia and cyanosis. Restlessness, along with agitation and confusion, are early signs of hypoxemia). Why 1 is wrong: this finding is not unusual in a female client of childbearing age. Because of the tonicity of dialysate, endometrial lining may be pulled through the fallopian tubes and into the solution during the menstrual cycle. Why 2 is wrong: In the client diagnosed with glomerulonephritis, HTN is caused by fluid volume overload. While this requires treatment, the client is currently stable. Why 4 is wrong: This client is stable and awaiting discharge.
A preschooler client diagnosed with croup suddenly becomes restless and reports difficulty breathing. Which nursing intervention is an essential part of the plan of care for this client? 1. Administer inhaled hot steam or humidified air. 2. Provide oxygen by placing the mask directly on the client's face. 3. Administer nebulized racemic epinephrine as prescribed. 4. Assess the airway by performing a throat examination.
ANSWER: 3 (this medication alleviates symptoms of croup by producing bronchodilation, which in turn widens the lumen of the airway). Why 1 is wrong: studies have not demonstrated a significant improvement in croup symptoms with this intervention. Why 2 is wrong: placing the mask directly on the client's face to deliver oxygen may increase agitation. To prevent this, the nurse should hold the oxygen mask 2 inches away from the client's face while waving it side-to-side (blow-by technique). Why 4 is wrong: This intervention can irritate the client and cause further closure of the airway and asphyxiation.
The nurse provides care for a client who had a positive urine pregnancy test. The client states the last normal menstrual period began on October 11, 2019 and ended on October 18, 2019. What is the client's estimated date of delivery according to the naegele rule? 1. July 4, 2020 2. July 11, 2020 3. July 18, 2020 4. July 24, 2020
ANSWER: 3 (using the naegele rule, subtract 3 months from the data of the first day of last normal menstrual period. (october-3 months = july). next, add 7 days (july 11 + 7 = july 18), lastly, add one year).
A parent brings a 10-month-old client to the health clinic. The parent asks the nurse when the client will be ready to begin toilet training. Which response by the nurse is accurate? 1. Your child is ready now. 2. Your child will be ready in 2 months. 3. Your child will be ready in another 8-12 months. 4. Your child will tell you when your child is ready.
ANSWER: 3 (voluntary control over sphincters is achieved at 18-24 months of age).
A client diagnosed with depression states, "my boss is angry at me for not doing my job as well as I used to". Which is the best response by the nurse? 1. I dont think your boss is angry with you. 2. Why do you think your boss would be angry when he knows you're depressed? 3. Once your medication begins to work, you will feel much better. 4. It must be hard to keep up with work when you're feeling depressed.
ANSWER: 4 (clients diagnosed with depression often have impaired self-esteem. Showing empathy helps encourage the client to speak more about feelings and shoes that the nurse cares).
The nurse provides care for a client in an outpatient clinic and who reports vaginal itching. Which recommendation to the client by the nurse is appropriate? 1. Supplement your diet with yogurt and dairy products 2. Douche with an over-the-counter preparation. 3. Wash the area with soup and water several times a day. 4. Wear underwear that is lined with a cotton crotch.
ANSWER: 4 (cotton-lined underwear is more absorbent and allows for better circulation of air to the body. Dampness aggravates itching). Why 1 is wrong: these foods contain bacilli that naturally exist in the GI tract, but they have no effect on vaginal pH. Why 2 is wrong: Douching may alleviate discomfort of vaginal discharge, but would disrupt normal pH of the vagina and is not recommended. Why 3 is wrong: This frequency of washing would cause dryness and increase itching in the vaginal area.
The nurse assesses a neonatal client at birth. The neonates HR is 115. The neonate has regular respirations with a rate of 40 breaths/min with a virgorous cry. The neonate has some flexion of extremities and grimaces with reflective response. The nurse also notes that acrocyanosis is present. Which apgar score does the nurse assign the neonate? 1. 2 2. 3 3. 6 4. 7
ANSWER: 4 (the neonates apgar score is 7. The neonate is assigned 2 points for heart rate greater than 100, 2 points for respiratory effort, 1 point for muscle tone, 1 point for reflexes, and 1 point for color. Apgar score: 0-3 is poor, 4-6 is fair, and 7-10 is excellent.
A nurse provides care for a client who gave birth to a neonate 24 hours ago. The client and the newborn both have the AB negative blood type. Which action does the nurse implement based on this data? 1. Assess the need for Rh0(D) immune globulin. 2. Determine if the mother has any Rh antibodies. 3. Assess the blood type of the father. 4. Document the client and newborn's blood type.
ANSWER: 4 (the nurse should document the findings, as no further action is required). Why 1 is wrong: since both mother and newborn are Rh negative, there is no issue os Rh sensitization, so no further intervention is needed. Why 2 is wrong: Since both mother and newborn are Rh negative, there is no need to determine if the mother has any Rh antibodies. Why 3 is wrong: When the blood type of both the mother and the newborn are known, there is no need to assess the blood type of the father.
The nurse plans care for a client with a head injury. Which interventions will the nurse select to minimize the risk of increasing intracranial pressure? 1. Maintain a liquid diet, perform frequent tracheal suctioning, and turn the client every 2 hours. 2. Keep the head of the bed flat, turn the client every 2 hours, and perform nasotracheal suctioning every hour. 3. Keep the head of the bed elevated 90 degrees, keep the room dark and quiet, and place the call light within easy reach. 4. Keep the client's head from flexing or rotating, elevate the head of the bed 30 degrees, and avoid frequent suctioning.
ANSWER: 4 (the objective is to increase venous return and decrease cerebral edema. This is best accomplished by preventing the head from flexing or rotating, elevating the head of the bed at a 30-degree angle, and NOT suctioning the client). Why 1 is wrong: Tracheal suctioning should be done only as necessary because it will increase ICP. Why 2 is wrong: Tracheal suctioning should only be done as necessary because it will increase ICP. The head of the bed should be elevated and not flat. Why 3 is wrong: The head of the bed does not need to be elevated higher than 30 degrees. Keep the room dark and quiet does not affect ICP.
An older adult client asks the nurse to explain therapeutic massage since the HCP recommended it as treatment. Which response by the nurse is appropriate? 1. It decreases fluid retention 2. It helps to resolve blood clots in legs 3. It decreases hypertension 4. It improves circulation and muscle tone.
ANSWER: 4 (therapeutic massage will help improve circulation and muscle tone, particularly in older adult clients). Why 1 is wrong: therapeutic massage does not decrease fluid retention. Why 2 is wrong: Massage is contraindicated in any condition where manipulating damaged tissue can dislodge a blood clot. Why 3 is wrong: Therapeutic massage is not proven to affect hypertension.
A client on the psychiatric unit begins to pace and continuously wring hands, and the nurse notes the client's voice becoming louder and angrier. Which action does the nurse take? 1. Utilize an organized team to place the client in seclusion. 2. Allow time in the client's private assigned room for reflection. 3. Redirect the client to a quiet activity such as journaling. 4. Assist the client to express feelings of anger and frustration.
ANSWER: 4 (this behavior indicates increased agitation and may indicate impending violence. The nurse de-escalates the client's behavior. The nurse will help the client to verbalize feelings, avoid disagreeing with or threatening the client, and remove threatening components of the environment). Why 1 is wrong: the client may be placed in seclusion at a later time if escalating or violent behavior occurs. Why 2 is wrong: Do not leave the client alone, use threatening body language, or block the exit. While the client may benefit from decreased stimuli, it is not appropriate to leave this client unattended. Why 3 is wrong: During an acute episode of agitation is not the time for this type of reflective activity.
