Questions and Rationales Given in Class 211 NVCC Fall 2020

The nurse is caring for a 10-year-old child who has meningitis and is delirious. Which is a priority nursing diagnosis for this client? 1.Anxiety 2.Risk for Injury 3.Ineffective Airway Clearance 4.Activity Intolerance

2.Risk for Injury Risk for Injury is a priority diagnosis for any client who is confused.

The nurse is caring for a 22-year-old female client who is diagnosed with schizophrenia. The nurse would anticipate which family member is at highest risk for having the disorder? 1. Maternal uncle 2.Younger brother 3.First-degree cousin 4.Paternal grandmother

2.Younger brother An individual who has an affected first-degree relative such as a parent or sibling has a risk of schizophrenia that jumps to as much as 50%. Individuals with an affected third-degree relative such as a cousin have a risk of 2%. Individuals with an affected second-degree relative such as an aunt, uncle, half sibling, or grandparent have a risk of 2% to 6%.

What to watch out for with patient on Aricept? (Donepezil)

Cardiovascular Issues Donepezil is an acetylcholinesterase inhibitor- may cause Bradycardia

A patient thinks the T.V. can steal her thoughts. Which symptom is she having?

Dulusions. = Rigid, false beleifs

At group therapy, the family of an Alzheimer's patient is sad because she perceives the loss of family. What is an appropriate response?

How have others dealt with this sense of loss? This will facilitate discussion.

Which manifestation is the first usually seen in Alzheimer's disease?

Subtle memory deficits are initial signs of AD. Later manifestations are: -Inability to perform ADL's -Sundowning -Communication problems

In the presence of inflammation, a client's erythrocyte sedimentation rate (ESR)

increases due to the increased proportion of fibrinogen in the blood

The nurse is caring for the older adult client and is aware that many conditions can cause signs and symptoms of delirium. Which factor in the older adult client is least likely to cause delirium? 1.Urinary tract infection 2.Dehydration 3.Gout 4.Urinary retention

Gout would be the least likely to cause signs and symptoms of delirium in the older adult client. Urinary retention, urinary tract infection, and dehydration, as well as a respiratory tract infection, adverse drug effects, pain, and stroke could all possibly cause signs and symptoms of delirium in the older adult client.

Which intervention would the nurse expect to administer first to a client experiencing hypersensitivity? 1.Inhalation 2.Prick test 3.Intradermal injection 4.Subcutaneous injection

2.Prick test The order for administering antigens in allergy testing is based on prevention of anaphylaxis. The prick test has the lowest risk for anaphylaxis. If the client does not respond to the prick test and there is evidence that the client is sensitive to an allergen, then an intradermal test is given. Inhalation and subcutaneous testing are not used because the risk of anaphylaxis is too great.

A 63-year-old client with Alzheimer disease is brought to the emergency department (ED) with pressure sores and severe dehydration. Upon further assessment, the nurse notices bruises on the client's neck, arms, and legs. Which question should the nurse ask the client's spouse? 1. "What kind of support do you have at home to care for your spouse?" 2."Have you considered placing your spouse in a nursing home?" 3."How often do you turn your spouse while your spouse is in bed?" 4."How long do you leave your spouse at home alone?"

1. "What kind of support do you have at home to care for your spouse?" Asking about support at home will assess the support system and ability of the spouse to care for the client in a safe manner. This question also indicates that the nurse is aware of possible stress on the caregiver without accusing the spouse of abuse. Asking about placing the client in a nursing home subtly implies the spouse is abusing the client and is unable to care for the client properly. The nurse first assesses the client before planning interventions. Asking about turning the client in bed does not assess the possibility of caregiver strain nor does it offer support to the caregiver. Asking about the length of time the client is alone assumes that the client's injuries are signs of neglect or abuse.

A client is admitted to the nursing unit with fever and dehydration, which have caused the client to experience delirium. The nurse expects which treatment to be ordered for this client? 1. Acetaminophen and IV fluids 2.Provide a stimulating environment 3.Psychotropic medications 4.Drugs to assist the memory

1. Acetaminophen and IV fluids Delirium is a state caused by a disease or some other condition that must be treated for the confusion to abate. In this case, acetaminophen is given for fever and IV fluids are given to rehydrate the client. Medications of any kind do not treat delirium; the underlying cause is treated. This client does not have evidence of a mental disorder or memory loss. A stimulating environment can potentially negatively impact the client's confusion and delirium.

A client admitted to the hospital for a recent suicide attempt has been taking antidepressants as prescribed and attending group therapy. The client is sleeping 6 hours per night and reports a significant improvement in mood. The client states, "I have lots of things to do when I get home, and I don't really need to be in the hospital anymore." Which response by the nurse would be most appropriate? 1."Are you still having thoughts of suicide?" 2."Are you willing to sign a 'no-harm' contract before you leave?" 3."How would you rate your mood on a scale of 1 to 10?" 4."How can we be sure you won't hurt yourself when you go home?"

1."Are you still having thoughts of suicide?" It is necessary to assess the client's continued risk for suicide before discharge is considered. The client remains at risk; with improvement, the client may have more energy and capacity to act on suicidal thoughts. Although a no-harm contract is appropriate while in the hospital, the client may have decided on a specific plan for suicide and should not be discharged until suicidal thoughts are managed appropriately. Rating mood is relevant, but does not assess for the presence of suicidal thoughts. "How can we be sure you won't hurt yourself when you go home?" indicates a lack of trust and damages the rapport between client and nurse. The use of vague terms such as hurt or harm may cause the client to react negatively.

A client with systemic lupus erythematosus (SLE) asks the nurse what medications are used to cure autoimmune diseases. The nurse should respond with which statement? 1."Autoimmune diseases are not curable." 2."Autoimmune diseases are temporary and do not need medications." 3."The NSAIDs provide a cure for autoimmune diseases." 4."Antibiotics are used to treat autoimmune diseases."

1."Autoimmune diseases are not curable." The nurse should respond that autoimmune diseases are not curable by medications or by any other means. The client should be instructed on health promotion and management of symptoms with pharmacologic and nonpharmacologic methods. Antibiotics are used when the client with an autoimmune disease acquires an infection.

A client who attempted suicide 5 years ago with an overdose was brought to the emergency department by a friend. The client states, "I just don't feel like living anymore. No one would care if I lived or died." What question should the nurse ask next? 1."Do you have a plan for suicide at this time?" 2."What major losses have you experienced in the past 6 months?" 3."Have you experienced any major life crises in the past 6 months?" 4."Do you feel angry, overwhelmed, or hopeless?"

1."Do you have a plan for suicide at this time?" Asking whether the client has a plan ascertains whether the client is planning another suicide attempt. The best clinical predictors for suicide risk are previous attempts and a sense of hopelessness or desperation. Information about major losses or crises is not as important as determining the client's immediate suicide risk. The most important question to ask is about the client's present status, not events of the past months. Asking whether the client feels angry, overwhelmed, or hopeless would be unnecessary given the client's statements clearly expressing feelings of hopelessness.

A nursing student is studying physical changes that occur in older adults. This week's lecture is on age-related changes in the ear. Which statement, if made by the nursing student, demonstrates a good understanding of these changes? 1."Older adults may have a buildup of cerumen in the auditory canal." 2."High-frequency sounds intensify and low-frequency sounds decrease." 3."Muscles and ligaments in the middle ear weaken and relax over time." 4."In the inner ear, there is an increased blood supply and an increase in hair cells."

1."Older adults may have a buildup of cerumen in the auditory canal." Older adults may have a buildup of cerumen in the auditory canal. High-frequency sounds are lost, not intensified, and low-frequency sounds may also be lost or decreased. Muscles and ligaments weaken and stiffen, and do not relax, over time. In the inner ear, there is a loss of hair cells and a decrease, not an increase, in blood supply.

A client receiving treatment for generalized anxiety disorder reports having stopped the prescribed buspirone (BuSpar) because the medication does not seem to be working after taking it for a week. What is the nurse's best response to the client's statement? 1."The medication takes approximately 2 to 3 weeks to exert its therapeutic effect." 2."The healthcare provider may have prescribed a drug dose that is too low." 3."The client should be taking the medication on an empty stomach." 4."The medication is more effective in clients with obsessive-compulsive disorder."

1."The medication takes approximately 2 to 3 weeks to exert its therapeutic effect." Clients taking buspirone (BuSpar), an anxiolytic used in treatment of general anxiety disorder (GAD), should be advised that the medication requires daily administration for at least 2 weeks to produce antianxiety effect. The adequacy of the dose cannot be assessed until after the drug has been taken for 2 to 3 weeks. The bioavailability of the drug is increased when taken with food. Antidepressants (SSRIs and TCAs) are the most effective pharmacologic treatments for OCD.

The nurse in the clinic is teaching a school-aged child and the parents about how an allergic response may feel to the child. The nurse would include which priority response in her teaching? 1."You may feel like your tongue has hair on it." 2."You may want to take a nap." 3."You may feel hungry." 4."You may not be able to focus in school."

1."You may feel like your tongue has hair on it." Although the school-aged child may feel tired, hungry, or be unable to focus in school, the nurse should focus on teaching and sharing symptoms in words that the child will understand. Explaining to the child that his or her tongue feels like it has hair on it would be the best teaching reply because the teaching is focused on the child. Other symptoms could be explained as "bugs in your ears" for itching ears and "a frog in your throat" for swelling in the throat.

The nurse is giving a community presentation at a local college to an audience of young adults. The nurse would not consider which information as important in maintaining an effective immune system? 1.Adequate amounts of strenuous exercise 2.Appropriate amount of quality sleep 3.Stress reduction and management techniques 4.Healthy eating behaviors and weight management

1.Adequate amounts of strenuous exercise The nurse would include the topics of exercise, nutrition, sleep, and stress management in the presentation. Moderate exercise, not strenuous exercise, is important for the immune system. Moderate exercise has been shown to prevent and even reverse many chronic disease processes. Moderate exercise assists the immune system to pump the lymph fluid more effectively throughout the body. Strenuous exercise may have an impact on reducing the immune system.

A client in the hospital in a hypomanic state comes to the common room dressed in a sexually suggestive manner and is making sexual remarks and gestures. What is the appropriate nursing action? 1.Approach the client calmly and escort the client back to the client's room. 2.Insist that the client leave the common room. 3.Confront the client regarding dress and mannerisms in the common room. 4.Tell the other clients to ignore the behavior.

1.Approach the client calmly and escort the client back to the client's room. The individual experiencing mania lacks insight and judgment. The best response is calm and distracting so that the client can be assisted with dressing appropriately. Confrontational responses will lack meaning for the client. Ignoring the behavior is inappropriate because the behavior will continue and other clients may be upset.

The nurse is working with an older adult client and is aware that symptoms of depression may be related to life changes. With which life change would the nurse be most likely to be concerned as being related to depression? 1.Death of a spouse 2.Purchasing a new car 3.Friends moving away 4.Change in activity level

1.Death of a spouse The nurse is aware that symptoms of depression ma be related to life changes, such as death of a spouse. Friends moving away or a change in activity level are not the most likely compared to death of a spouse. Purchasing a new car would be the least likely to cause symptoms of depression.

The chief nursing officer stated at the nursing orientation that "our facility has a zero-tolerance policy regarding horizontal violence." The newly licensed nurse knows that this refers to which definition? 1.Hostile or aggressive behavior from an individual or group of nurses toward another nurse will not be tolerated. 2.Hostile or aggressive behavior from a physician toward a nurse will not be tolerated. 3.Hostile or aggressive behavior from a nurse toward a client or family member will not be tolerated. 4.Hostile or aggressive behavior from a client or family member toward a nurse will not be tolerated.

1.Hostile or aggressive behavior from an individual or group of nurses toward another nurse will not be tolerated. Although hostile or aggressive behavior from one person to another at any level should not be tolerated by management, horizontal violence refers to violence at the same level of job description. It is usually nonviolent, but can cause psychological or emotional damage to employees. Behaviors may include sabotage, criticism, and harassment.

The nurse is caring for a client who is manic and exhibiting psychomotor agitation. Which nursing action would be most effective? 1.Implement limit setting with the client. 2.Explore causes of the manic behavior. 3.Administer antidepressants as ordered. 4.Discuss alternative behaviors with the client.

1.Implement limit setting with the client. A client who is manic and exhibiting psychomotor agitation requires limit setting within a provided structure and space. This intervention will promote safety of the client and other individuals around the client. A manic client is minimally able to have insight into behaviors; therefore, exploring causes and discussing alternative behaviors will not be as effective. Mood stabilizers (such as lithium), not antidepressants, are given to clients with manic episodes.

The therapeutic team has identified the need to formulate strategies for dealing with a client's inappropriate behavior and maintaining a safe environment for the other clients on the unit. Which intervention strategy must be initiated immediately? 1.Monitor the client's behavior. 2.Identify the client's thought process that leads to this behavior. 3.Help the client to identify why the client demonstrates this behavior. 4.Teach appropriate interpersonal skills to the client.

1.Monitor the client's behavior. Monitoring the client's behavior is the intervention strategy that must be initiated immediately. The unit must be maintained as a safe environment for the client and the other clients; therefore, the client should never have unsupervised time on the unit. The other interventions may be appropriate after specific behaviors are noted.

A 76-year-old client presents to the nurse with symptoms that seem to indicate hearing loss, especially in large groups. It has become difficult for the client to tell where sounds are coming from, and words often sound "mixed up." What should the nurse suspect as the cause for this change? 1.Presbycusis 2.Tinnitus 3.Noise-induced hearing loss 4.Scarring of the tympanic membrane

1.Presbycusis Hearing loss is common in older adults. With aging, the hair cells of the cochlea degenerate, producing a progressive sensorineural hearing loss. In age-related hearing loss, or presbycusis, hearing acuity begins to decrease in early adulthood and progresses as long asthe individual lives. Higher pitched tones and conversational speech are lost initially. The other options could play a part in the hearing loss, but with age-related hearing loss, the nurse should consider presbycusis first.

The nurse would assess which finding in a client who is being evaluated for systemic lupus erythematosus (SLE)? 1.Rash on the face across the nose 2.Fatigue 3.Fever 4.Elevated red blood cell count

1.Rash on the face across the nose Rash on the face across the nose is the classic sign of SLE. Fever and fatigue are symptoms that occur during exacerbations. The client with SLE is apt to be anemic.

The nurse is caring for a client in the out-patient setting who states that he is color blind. The nurse knows that which type of color blindness is more common? 1.Red-green 2.Blue-yellow 3.Gray only 4.Green-blue

1.Red-green Color blindness affects approximately 1 in 10 men but very few women. It occurs when one or more pigments are missing within the cones in the retina. The most common variant of color blindness is the inability to distinguish between red and green. Less common is the inability to distinguish between blue and yellow. Achromatopsia is a rare form of color blindness in which the individual cannot distinguish any color at all and sees only shades of gray. There is not a specific green-blue color blindness.

A client arrives at the emergency department in a severe state of panic following a motor vehicle crash. What is the best intervention by the nurse? 1.Remain with the client. 2.Put the client in a room alone. 3.Teach the client relaxation breathing exercises. 4.Encourage the client to talk about the experience.

1.Remain with the client. Remaining with the client may help decrease the panic level. Leaving the client in a room alone may elicit feelings of abandonment and increase panic levels. The client in a state of panic is not ready for teaching. The client is not encouraged to talk about the experience initially, because this will reinforce the panic. When the panic has decreased and some distance has occurred, then the client is better able to process the trauma.

Which information about the prescribed sulfasalazine is most appropriate for the nurse to instruct the client with inflammatory bowel disease? 1.Use sunscreen while taking the medication. 2.Take the medication on an empty stomach. 3.Limit fluid to 1,500 mL or less per day. 4.Take vitamin C while on this medication.

1.Use sunscreen while taking the medication. Sulfasalazine makes the client more susceptible to sunburn, so the client is instructed to use sunscreen when outside. The medication is best tolerated with food, and fluids should be increased to a minimum of 2,000 mL per day. There is no known reason to take vitamin C while on this medication.

When assessing a client, the nurse notes absence of the red reflex in the client's right eye. On questioning, the client responds, "Oh, yes, my doctor told me I have cataracts. When should I have them removed?" How should the nurse respond? 1."It appears that the right eye is due for surgery." 2."Are you having difficulty reading or doing activities you enjoy?" 3."Are you starting to experience frequent headaches or pain in your right eye?" 4."Cataracts can be removed any time that it is convenient for you."

2."Are you having difficulty reading or doing activities you enjoy?" Cataract surgery is an elective surgery, generally performed when visual impairment interferes with daily activities. The nurse would first determine whether the client is having difficulties before making a suggestion. Telling the client that the right eye is ready for surgery is not helpful without a rationale. Cataracts do not cause pain or headaches. Cataracts can be removed any time the client chooses, but this answer does not respond to the client's question.

The spouse of a client who is experiencing delirium from dehydration is concerned about taking the client home in a confused state. The nurse would respond with which correct statement? 1."I'll teach you how to make your home safe." 2."Once the dehydration is corrected, your spouse will no longer be delirious." 3."We'll be ordering a home health aide to help you." 4."Oh, it won't be so bad; the client is harmless."

2."Once the dehydration is corrected, your spouse will no longer be delirious." Delirium is a temporary state that is corrected once the underlying cause is treated. The client will be rehydrated and the delirium will dissipate. It is not necessary to teach home safety because the client will not be confused at discharge. A home health aide will not be needed. Telling the spouse that the client is harmless may increase fears and decrease trust in the nurse.

The nurse is caring for the postpartum mother and baby in the hospital. The mother is concerned that the baby does not appear to notice visitors as they come into the room. What would be the most appropriate response from the nurse regarding the mother's concern? 1."The newborn is overwhelmed with stimuli at this point. Do not be worried." 2."The newborn can only focus on things that are within 8-10 inches at the present time." 3."Thank you for sharing this with me. We will have your healthcare provider order a vision consult for the baby." 4."The newborn's vision is fully developed, but is more interested in things nearby."

2."The newborn can only focus on things that are within 8-10 inches at the present time." The nurse would communicate with the mother that newborns can only focus on objects 8-10 inches away from them at birth. This will adjust quickly so that the baby notices more objects farther away.

The nurse is working with a woman 4 weeks after childbirth who is experiencing mild depression. The woman's partner asks the nurse whether there is anything he can do to help the new mother during this transition. What is the nurse's best response? 1.Take the client to be admitted to the psychiatric facility. 2.Schedule an evening out once a week to focus on their relationship. 3.Give the mother extra tasks so she won't think about depression. 4.Send the mother to her mother's home for the duration.

2.Schedule an evening out once a week to focus on their relationship. The partner is encouraged to be supportive of the new mother and to find ways to decrease her stress and provide her with some pleasurable activities. This client does not need to be in the hospital. Giving the mother more work may deepen the symptoms. The couple needs to work this out together and not send the mother away, which could lower her self-esteem.

The spouse of a client on lithium for bipolar disorder tells the nurse that the client is experiencing slurred speech, muscle weakness, and diarrhea. The spouse reports the client's lithium level is 2.0 mEq/L. What should the nurse tell the spouse to assist with coping? 1."This level is sub-therapeutic and an increase in the medication will need to be made to reach the therapeutic range." 2."This level is above the therapeutic range and the client's symptoms are related to this level." 3."This level is within therapeutic range but may need to be higher to meet the client's individual needs." 4."There is not a therapeutic range for lithium. It is dosed to address the symptoms that the client is exhibiting."

2."This level is above the therapeutic range and the client's symptoms are related to this level." The symptoms reported by the client's spouse are related to lithium toxicity. There is a specific but narrow therapeutic range with lithium. The therapeutic level for each client is individualized, related to the signs and symptoms exhibited by the client and signs of possible toxicity.

The nurse is attending a conference on child abuse. The nurse is aware that which situation is a potential form of child abuse? 1.Not having yearly physical exams and screenings for school-aged child 2.A school-aged child's lack of appropriate clothing and no coat during a cold winter 3.Not allowing sugar-filled sodas and snacks in the child's home 4.Withholding age-appropriate vaccines from school-aged child

2.A school-aged child's lack of appropriate clothing and no coat during a cold winter Seasonal inappropriate clothing and no coat during a cold winter could possibly be neglect, one type of child abuse. Not giving a child a vaccine is not considered child abuse because state laws vary, but generally allow a parent to not vaccinate on personal or religious grounds. Not having sweets and sugar-filled sodas in the home is not potential child abuse. Not having yearly physical exams and screenings would not be potential child abuse, because all individuals do not have easy access to affordable healthcare and health promotion visits may not be possible.

The nurse is performing a routine vision screening test on a 50-year-old client and plans to examine the eye after the test. If the client is diagnosed with exudative macular degeneration, which manifestations would the nurse expect to find? 1.Green-yellow drainage from the eye 2.Bleeding in the eye 3.Increased intraoptical pressure 4.Floaters and spots

2.Bleeding in the eye In exudative macular degeneration, new vessels are formed in the eye, which are prone to leaking blood. Green-yellow drainage is a sign of conjunctivitis and is on the outside of the eye. Increased pressure in the eye is glaucoma, and floaters and spots are manifestations of a detached retina.

A nurse is caring for the client with Crohn disease who was admitted last night. Which manifestation would the nurse expect to note for this client? 1.Constipation 2.Diarrhea 3.Bloody stools 4.Frothy stools

2.Diarrhea The client with Crohn disease is likely to have diarrhea with no blood in the stools. Constipation, bloody stools, and frothy stools are not manifestations of Crohn disease.

Which medication would the nurse expect to administer to a client who is experiencing ritualistic behavior that interferes with job performance and activities of daily living? 1.Fluphenazine (Prolixin) 2.Fluoxetine (Prozac) 3.Lorazepam (Ativan) 4.Carbamazepine (Tegretol)

2.Fluoxetine (Prozac) Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that corrects the imbalance of serotonin in anxiety disorders such as obsessive-compulsive disorder. Fluphenazine is an antipsychotic and not appropriate for anxiety disorders. Lorazepam is a sedative with central nervous system depressive side effects that is used mostly for sedation and to manage status epilepticus. Tegretol is used mainly for seizure disorders.

Which laboratory measurement should the nurse assess as a reliable indicator of lymphocyte status in a client with HIV infection? 1.B lymphocytes 2.Helper T cells (CD4) 3.Natural killer cells (NK) 4.Cytotoxic T cells

2.Helper T cells (CD4) CD4 cells are indicative of a client's HIV status. As the disease progresses, the helper T cells decrease in number and lose their ability to function. B lymphocytes indicate the status of humoral activity. NK cells and cytotoxic T cells are not directly related to HIV.

The nurse is talking to a pre-teen group of students at a community center. The nurse explains the importance of a student reporting to an adult when a friend states the thought of committing suicide. What is the reason the nurse would include this information? 1.This is so the student with the thought of suicide can be reported to the police. 2.Many students who tell someone follow through with suicide plans and actions can be put in place to protect the student. 3.The student with thoughts of suicide should be admitted to an inpatient psychiatric facility immediately. 4.Data is being collected for a local and state study of pre-teen suicide attempts.

2.Many students who tell someone follow through with suicide plans and actions can be put in place to protect the student. A quarter of children who committed suicide discussed their intent to do so with someone else prior to their death. Reporting this information to an adult could potentially prevent a student from attempting or committing suicide.

The nurse is caring for a 4-year-old child with posttraumatic stress disorder. The nurse is aware that the child is exhibiting age-appropriate manifestations of posttraumatic stress disorder when the child exhibits which behavior? 1.Guilt 2.Nocturnal enuresis 3.Attempted suicide 4.Poor concentration

2.Nocturnal enuresis It is common for children under 6 years old to re-experience the trauma through play, or by drawing pictures that symbolize the trauma.The young child may experience nocturnal enuresis (nighttime bedwetting), or being greatly clingy or needy.

The nurse is planning care for a newly admitted client who is experiencing hypomania. The nurse selects the nursing diagnosis of Risk for Injury based on which finding? 1.Good defensive abilities of the client 2.Possible attacks by other clients 3.Good judgment by the client 4.Lack of impulsivity of the client

2.Possible attacks by other clients The client in a hypomanic phase has a tendency to annoy other clients with the client's outbursts or behavior and is at risk for violence from others. The client experiencing hypomania has poor defensive abilities, poor judgment, and is very impulsive, which also place the client at increased risk for injury.

The nurse is reviewing the record of a client who has cataracts. Which manifestation of cataracts does the nurse expect to be noted? 1.Eye pain 2.Floating spots 3.Blurred vision 4.Diplopia

3.Blurred vision A gradual, painless blurring of central vision is the chief clinical manifestation of cataracts. Spots are not associated with cataracts.

The nurse is talking with an older adult client and the client's child in the outpatient clinic. The nurse is explaining obstacles regarding the older adult client taking the eye drop medications for glaucoma. The nurse would include which piece of information related to the aging process? 1.The client does not always understand the importance of inserting the eye drops. 2.Tremors and cognitive decline can impact the client remembering to insert and use eye drops. 3.The client does not like the side effects of the eye drops and chooses not to use them. 4.The client feels they are too expensive and does not want to pay for them.

2.Tremors and cognitive decline can impact the client remembering to insert and use eye drops. The older adult may have aging process issues such as tremors in the hands and cognitive decline that would impact the client being able to insert the eye drops or remembering to take the eye drops. The medications do not have side effects that the patient would be concerned about. The client may not understand the importance, but that is not the priority answer. The cost may be prohibitive, but this is not related to the aging process, as the question asks.

The nurse is caring for a client admitted for exacerbation of Crohn disease. Which nursing diagnosis should the nurse address as a priority? 1. Fatigue related to decreased nutritional intake 2. Deficient Knowledge related to disease process 3. Imbalanced Nutrition: Less Than Body Requirements related to diarrhea 4. Anxiety related to alterations in health status

3. Imbalanced Nutrition: Less Than Body Requirements related to diarrhea The priority nursing diagnosis the nurse should address is Imbalanced Nutrition: Less Than Body Requirements. This problem can lead to other complications such as anemia, weight loss, fatigue, and impaired immune system, which can prolong the client's recovery. The other nursing diagnoses are appropriate, butare not considered as priority given the choices provided.

The school nurse teaches elementary school teachers about occurrences of violence toward children. The nurse knows that further teaching is necessary if a teacher makes which statement? 1. "Poor hygiene and inappropriate clothing are possible signs of child abuse." 2."Physically abused children may appear overly submissive and eager to please their teacher." 3."Children with special needs are less vulnerable to physical abuse than other children." 4."Children who are physically abused by their parents are more likely to abuse siblings."

3."Children with special needs are less vulnerable to physical abuse than other children." Caregiver stress and frustration may lead to abuse or even homicide of children with special needs. Children who are physically abused by their parents are more likely to abuse siblings; sibling abuse is the most unrecognized form of abuse. Physically abused children may appear overly submissive and eager to please their teacher; abused children are frequently overly compliant in response to all adults. Inadequate physical care or lack of care for a child may be a sign of child abuse.

The nurse working with the family of a client with suicidal ideations is asked whether the antipsychotic medication the client is taking will prevent suicide. What is the nurse's best response? 1."Clients who take the medication as prescribed are at decreased risk for suicide." 2."Medication helps treat an underlying mood disorder associated with suicidal thinking and therefore prevents suicide." 3."Medication helps decrease the frequency and intensity of suicidal thoughts." 4."The client states that no more attempts will be made at suicide, so you don't need to worry."

3."Medication helps decrease the frequency and intensity of suicidal thoughts." Antipsychotic medications will help decrease the frequency and intensity of suicidal thoughts. Medications may treat the underlying cause but do not necessarily reduce the risk for suicide. Medication does not prevent suicide; in fact, many times when clients regain their energy from medications, they are at increased risk for suicide. A client may not be at risk currently because of medication, but that does not rule out an attempt in the future, so the nurse should not tell the family not to worry.

The nurse is seeing a pregnant client in the clinic at the beginning of influenza season. The client asks about the influenza vaccine and if she needs to receive one. What is the most appropriate response by the nurse? 1."It is acceptable not to take the vaccine if you do not want to have it." 2."No, you cannot take the influenza vaccine while you are pregnant." 3."Your immune system is altered during pregnancy and the influenza vaccine is strongly encouraged." 4."If you usually take the influenza vaccine, it would be a good idea to continue it this year."

3."Your immune system is altered during pregnancy and the influenza vaccine is strongly encouraged." The immune system of the pregnant woman is altered during the pregnancy. The influenza virus is especially dangerous to the client. A study by Stanford University supports that this is not due to immune suppression, but to a strong immune reaction to the influenza virus itself. The healthcare provider should strongly encourage the client to receive this immunization if not contraindicated.

Which action by the nurse is most appropriate when providing care for a client who is hearing impaired? 1.Speak with a raised voice. 2.Exaggerate facial expressions. 3.Articulate words when speaking. 4.Speak toward the impaired side.

3.Articulate words when speaking. When caring for an individual with impaired hearing, the nurse should speak slowly and articulate words clearly. The nurse should speak in a normal tone of voice, because raising the voice increases the pitch and poses difficulty hearing for the client. Exaggerated facial expressions do not facilitate lip-reading by the client. The nurse should speak toward the less-impaired side, where the client can hear better.

The nurse is documenting an interaction with a client and is describing the intensity of emotions displayed in the client's affect. What word would the nurse use to describe that the client's emotions are dulled or muted given the situation? 1.Moderate 2.Overreactive 3.Blunted 4.Flat

3.Blunted The client is displaying blunted affect when emotions are dulled or muted given the situation. Overreactive would be used to describe the individual's level of emotion that is disproportionate or extreme given the situation. Flat would be used to describe a client who provides no visible cues to his or her emotions. Moderate would be used to describe a client who displays a level of emotion that is appropriate to the situation.

The nurse is preparing to remove the nasogastric tube from a client with inflammatory disease who had an obstruction. The client has tolerated clamping of the tube without problem. Which assessment will the nurse check before removing the NG tube? 1.Proper placement of the tube 2.Serum electrolytes 3.Bowel sounds in all four abdominal quadrants 4.pH of gastric drainage

3.Bowel sounds in all four abdominal quadrants The nurse checks for the return of bowel function by listening for positive bowel sounds in all four quadrants. Serum electrolytes, pH of gastric drainage, and placement of the tube are important to check when the client's tube is in place, not when it is ready to be removed.

Which assessment should be considered as priority by the nurse caring for a client with major depression? 1.Client's current mood and affect 2.Client's response to medications 3.Client's risk for suicidal behaviors 4.Client's decision-making abilities

3.Client's risk for suicidal behaviors The nurse should promote client safety and prevent self-harm. Therefore, the nurse's priority assessment is to determine the client's risk for suicidal behaviors. While the client's cognitive functioning, current mood and affect, and response to medication therapy are important aspects of the assessment, suicide risk takes priority in clients diagnosed with major depressive disorder.

The nurse, caring for a client with AIDS experiencing nausea and weight loss, would initiate which intervention for this client? 1.Drink liquids with meals. 2.Eat high-fat foods. 3.Eat small, frequent meals. 4.Lie down after eating.

3.Eat small, frequent meals. Small, frequent meals help lessen nausea because they require less work of digestion, they do not overwhelm the client with food odors, and they take less time to eat than a larger meal. High-fat foods are more difficult to digest and may distend the stomach. Drinking liquids with meals gives a feeling of fullness, so the client does not eat as much. Lying down after meals can encourage reflux.

The nurse is promoting a therapeutic environment for a client with delirium and congestive heart failure. Which intervention will the nurse initiate for this client? 1.Keep the drapes over the windows closed at all times. 2.Avoid medicating client with any type of pain medication. 3.Maintain appropriate levels of noise in the room to avoid overstimulation. 4.Discourage family and loved ones visiting the client.

3.Maintain appropriate levels of noise in the room to avoid overstimulation. The client who is confused needs no extra stimulation, which would add to the confusion. The television or radio may be appropriate to keep turned on, but that would depend on the individual client. The nurse would encourage the family and loved ones to visit often because they are familiar to the client. The client should be medicated if needed for pain, because pain itself can cause delirium. Drapes in the room should be left open, especially during the day, so the client can be aware of the day/night cycle.

The nurse is talking with the nursing students on the unit. The nurse explained to the students that what percentage of hearing loss in children is genetic? 1.Less than 10% 2.Approximately 25% 3.More than 50% Approximately 95%

3.More than 50% More than 50% of hearing loss in children is genetic. Congenital hearing loss can be associated with dominant, recessive, or X-linked genes.

The nurse assesses a cough, shortness of breath, and tachypnea in a client diagnosed with AIDS. For which infection will the nurse expect to treat the client? 1.Toxoplasmosis 2.Cytomegalovirus 3.Pneumocystis jiroveci pneumonia 4.Cryptococcus neoformans

3.Pneumocystis jiroveci pneumonia Of these disease processes, only Pneumocystis jiroveci pneumonia (PCP) can cause the respiratory symptoms of cough, shortness of breath, and tachypnea.

The nurse, instructing a client scheduled for prick tests for allergies, should include which information? 1.With the prick test, it is possible to rule out two specific antigens. 2.The prick test is the most sensitive allergy test. 3.Results can be obtained in 15 to 20 minutes. 4.The prick test involves drawing a small amount of blood from the client.

3.Results can be obtained in 15 to 20 minutes. A drop of diluted allergenic extract is placed on the skin and the skin is then pricked or punctured through the drop. A localized pruritic wheal and erythema indicates a positive test. The response is maximal at 15 to 20 minutes.

The nurse is caring for a pregnant client with a history of bipolar disorder. What does the nurse know about the pregnant client's risk of a bipolar episode while she is pregnant? 1.Pregnant women do not have bipolar episodes due to their estrogen levels during pregnancy. 2.Most pregnant women with bipolar disorder experience at least one manic episode while pregnant. 3.The pregnant client is 5-10 times more likely to have a bipolar episode during pregnancy. 4.If the pregnant client continues to take the same dosage of medication, there is no risk of a bipolar episode.

3.The pregnant client is 5-10 times more likely to have a bipolar episode during pregnancy. Pregnant woman with a history of bipolar disorder are 5-10 times more likely to have a bipolar episode while pregnant. Stopping medications can worsen symptoms; therefore, some healthcare providers will slowly taper the woman off medications, decrease the dose, or change the medication.

During a psychosocial assessment, the client tells the nurse, "My husband promised me he will stop abusing alcohol, so he can take me out to a nice dinner." The nurse recognizes that the client's situation is in which phase of the cycle of violence? 1.First phase 2.Second phase 3.Third phase 4.Fourth phase

3.Third phase The third phase of the cycle of violence is known as the honeymoon period, a time during which the aggressor may show love and affection and may also promise to change. In the first phase, tension builds between individuals in a relationship as communication fails. An abusive or threatening incident occurs in the second phase. During this phase, the victim feels traumatized and the aggressor blames the victim for the incident. The cycle of violence has only three phases.

Which outcome is most realistic and appropriate when planning care for a client newly diagnosed with an anxiety disorder? 1.Within 2 months, the client will discuss the reasons for episodes with significant others. 2.Within 2 months, the client will be episode-free. 3.Within 1 month, the client will experience decreased episodes. 4.Within 2 months, the client will establish two new relationships.

3.Within 1 month, the client will experience decreased episodes. This outcome may not occur, but it is the most realistic outcome listed. Within 1 month, with intervention, the client may experience a decrease in episodes. Discussing the reasons for the episodes may not be realistic because the information may be repressed and may take years to identify, if ever. An anxiety disorder is not cured in 2 months. Establishing new relationships is not directly relevant to anxiety.

A nurse comes to work with a black eye and a swollen lip. Coworkers have noticed that the partner calls the nurse at least 10 times during a 12-hour shift. The nurse has refused all invitations to go out with coworkers, saying that the partner will be there after work and doesn't like to wait. What is the most helpful response by the coworkers? 1.Convince the nurse to leave the partner. 2.Encourage the nurse to get a restraining order against the partner. 3.Enlist the parents' aid in getting the nurse away from the partner. 4.Encourage the nurse to talk to a professional.

4. Encourage the nurse to talk to a professional. The abused adult needs to be her own rescuer. Friends should encourage the nurse to ask for help directly. Trying to convince the abused adult to leave the abuser does not empower the adult. Friends and coworkers should provide support without telling the nurse what to do. Encouraging the nurse to get a restraining order against the partner is inappropriate because a restraining order may actually increase the violent behavior of the partner. Involving the parents may complicate the situation and result in more abuse, which further isolates the nurse from family and friends.

The white blood cell (WBC) count of a client with an immunity disorder shows a shift to the left. Which is the highest-priority nursing diagnosis for the nurse caring for this client? 1.Ineffective Health Maintenance 2. Impaired Skin Integrity 3. Ineffective Coping 4. Ineffective Protection

4. Ineffective Protection All of these diagnoses are appropriate for the client with an immunity disorder. However, the results of this client's WBC indicate that the client is at risk for infection due to the disease process or its treatments. Ineffective protection, then, is the highest priority of care for the nurse at this time.

The client states that taking medications causes sexual dysfunction. The client has not taken the prescribed antipsychotic drug for the past 2 weeks. The nurse anticipates which occurrence? 1.Hypertensive crisis may occur. 2.Muscle twitching may occur. 3.Parkinson-like symptoms may occur. 4.Agitation may occur.

4.Agitation may occur. Symptoms of psychosis are likely to return and manifest as agitation, distrust, and frustration. The other symptoms will not occur with withdrawal of the medication.

The nurse is speaking to a client who grew up with an aunt who had schizophrenia and asks the nurse to explain the genetic component of developing schizophrenia. What response accurately describes genetics and schizophrenia? 1.One single gene is responsible for producing schizophrenia. 2.There is strong evidence that genetic factors do not affect the risk of developing schizophrenia. 3.The chance of monozygotic (identical) twins both having schizophrenia is 100%, thus demonstrating the high level of genetic influence in schizophrenia. 4.An individual has an almost 50% chance of being diagnosed with schizophrenia if a sibling or parent has the disorder.

4.An individual has an almost 50% chance of being diagnosed with schizophrenia if a sibling or parent has the disorder.

A client with glaucoma has medication prescribed to decrease intraocular pressure. Which medication would the nurse understand is ineffective for glaucoma? 1.Timolol maleate (Timoptic) 2.Levobunolol (Betagan) 3.Pilocarpine HCl (Isopto) 4.Artificial tears

4.Artificial tears Timolol maleate, levobunolol, and pilocarpine are drugs usually prescribed for clients with glaucoma and increased intraocular pressure. Artificial tears are usually prescribed for individual persons with "dry eyes."

The nurse is caring for a client with HIV who has a CD4+ count of 220/mm3. Which outcome demonstrates that the nursing care interventions have been effective? 1.No signs of bleeding 2.Soft formed stools daily 3.Weight gain in 1 week 4.Free from opportunistic infections

4.Free from opportunistic infections Based on the given information related to the CD4+ count, the client is at risk for opportunistic infections. Therefore, the goal for this client is to be free from opportunistic infections. No information is provided in the question about the client's status related to coagulation, elimination, or nutritional intake.

During the 2-month postpartum checkup, a client who is a single mother tells the nurse that she's a terrible mother because she doesn't know what to do when her baby continues to cry after feeding and changing. She also reports insomnia, lack of energy, and anxiety. Which nursing diagnosis is appropriate for this client? 1.Disturbed Thought Processes 2.Risk for Self-Mutilation 3.Disturbed Sensory Perceptions 4.Ineffective Coping

4.Ineffective Coping The client is exhibiting signs of postpartum depression that have affected her ability to cope with the stressful situation of caring for a new baby on her own. The client does not exhibit signs of mental illness, self-mutilation, or disturbed sensory perceptions.

An older client in an assisted living facility complains to the nurse about having a stuffy head and ringing in the ears. What is the appropriate response by the nurse? 1.Make an appointment with the client's primary care physician. 2.Refer the client to an audiologist. 3.Prescribe eardrops for daily use. 4.Inspect the ear canals for patency.

4.Inspect the ear canals for patency. The client's symptoms could be due to impacted cerumen because older adults have a tendency to have cerumen buildup present, which causes hearing loss and tinnitus. The nurse is able to determine this on assessment and would not refer the client to the physician or audiologist until the assessment is complete. The nurse does not prescribe medications.

The nurse caring for older adult clients in the clinic setting is aware of this population being known as the "invisible population" in terms of HIV prevention. Why is this population known by this term? 1.There are few individuals diagnosed with HIV as an older adult. 2.The overall number of older adults with HIV are a small percentage of the overall HIV population. 3.Older adults do not have sexual practices that put them at risk for HIV. 4.Older adults are not taking preventive measures, are not aware of the need for testing, and healthcare providers do not have important conversations about HIV with this population.

4.Older adults are not taking preventive measures, are not aware of the need for testing, and healthcare providers do not have important conversations about HIV with this population. Adults over 55 account for approximately 26% of HIV/AIDS cases in the United States, and the number is increasing yearly. There are several reasons that this population is known as the "invisible population" in terms of HIV prevention. Manifestations of HIV may be overlooked by healthcare providers. Generally, healthcare providers do not have conversations with this population about HIV. Individuals may have a change in their relationship status, and not be in monogamous relationships as in the past. There is often a lack of knowledge by an older adult about transmission of HIV, taking preventive measures, and the importance of testing.

The nurse, planning care for a client diagnosed with AIDS who is in transmission-based precautions, sets psychosocial integrity as a goal. Which intervention will the nurse plan for to achieve a positive outcome for the client? 1.Letting the client sleep to build up stamina 2.Maintaining strict precautions so the client believes the best care is being given 3.Providing care in a limited timeframe to keep the client safe 4.Providing diversional activities to enhance sensory input

4.Providing diversional activities to enhance sensory input The client in transmission-based precautions experiences sensory deficits. The nurse plans activities that allow the client to experience sensory input such as music, television, and other activities. The other options are physiological interventions.

The nurse is working with a client during an annual physical examination. The client describes a new and rapid onset of signs of macular degeneration. What is the nurse's highest priority for this finding? 1.Conduct an eye test. 2.Schedule laser surgery. 3.Tell the client it is the result of aging. 4.Refer the client to an ophthalmologist.

4.Refer the client to an ophthalmologist. Macular degeneration is typically a slow-moving process that does not require immediate attention. However, some clients experience rapid onset and should be referred immediately because treatment may preserve a greater degree of vision. An eye test is unnecessary given the symptoms. Laser surgery is not done for all types of macular degeneration. Telling the client that this is a process of aging may not be accurate for rapid onset, so the client should not be told this prior to seeing a physician.

The nurse is caring for a woman who is one day postpartum, has a history of depression, and plans to breastfeed her baby. What does the nurse expect the physician to order? 1.Start the client on Fluoxetine (Prozac) and follow up in office in 3 days 2.Admit the client to the psychiatric unit for 72 hours of observation 3.Consult with child protective services to be sure the infant is safe 4.Referral to a mental health professional for follow-up

4.Referral to a mental health professional for follow-up The mother with a history of depression is referred to a mental health professional for assessment and follow-up. Fluoxetine (Prozac) is not recommended for breastfeeding mothers. Admission to the psychiatric unit or involving child protective services is not indicated by this scenario.

The nurse is assessing a client for hearing ability during a yearly checkup. The nurse finds that the client's bone conduction is greater than the air conduction. For which test is this an abnormal finding? 1.Weber test 2.Whisper test 3.Tympanogram 4.Rinne test

4.Rinne test To perform the Rinne test, place the base of a vibrating tuning fork on the client's mastoid bone. Ask the client to indicate when the sound is no longer heard. When the client does so, quickly reposition the tuning fork in front of the client's ear close to the ear canal. Ask whether the client can hear the sound. If the client says yes, ask the client to indicate when the sound is no longer heard. Repeat over the opposite mastoid bone. The client with no conductive hearing loss will hear the sound twice as long by air conduction as by bone conduction. Bone conduction is greater than air conduction in the ear with a conductive loss. The normal pattern is AC > BC (air conduction greater than bone conduction). The Weber test is performed by placing the base of a vibrating tuning fork on the midline vertex. The tympanogram measures the pressure of the middle ear with a device.

An 83-year-old client is in the emergency department and is acting in a bizarre manner. The client is being treated for otitis media. Which sign will the nurse recognize as indicating that the client is delirious? 1.Sundowning symptoms 2.Gradual onset of symptoms 3.Impaired thinking skills 4.Specific attention to detail

Impaired thinking skills The older client with delirium is difficult to distinguish from the client with dementia. Generally, the delirious client has an inability to pay attention and cannot focus well on a topic. The client with dementia has gradual onset of symptoms and could exhibit sundowning symptoms. The client with delirium would have impaired ability to stay focused or maintain attention.

What is the cause of Alzheimer's Disease?

Unknown cause. Amyloid plaques and neurofibrillary tangles have been found in the brain at autopsy.

The nurse is aware that the population that is most at risk for confusion and hallucinations related to dehydration, fever, infections, or anesthesia is which group?

Young Children Young Children have limitation in functional reserves required to prevent these.