RN mix hesi 3

What should nursing care for a child admitted with acute glomerulonephritis be directed toward? Multiple choice question Enforcing bed rest Promoting diuresis Encouraging fluids Removing dietary salt

What should nursing care for a child admitted with acute glomerulonephritis be directed toward? Multiple choice question Enforcing bed rest Promoting diuresis Encouraging fluids Removing dietary salt

A client with a head injury is admitted to the hospital. Which assessment finding alerts the nurse to increasing intracranial pressure? Multiple choice question Hypervigilance Constricted pupils Increased heart rate Widening pulse pressure

Pressure on the vital centers in the brain causes an increase in the systolic blood pressure, widening the difference between the systolic and diastolic pressures. The client will be lethargic and have a lowered level of consciousness. The pupils will be unequal or dilated, not constricted. Pressure on the vital centers in the brain results in a decreased, not increased, heart rate.

Which test helps a primary healthcare provider distinguish between conductive and sensorineural hearing loss? Multiple choice question Whisper test Weber test Tympanometry Electrocochleography

weber test - has tuning forks

Which instructions should the nurse include in the teaching plan for a client with hyperlipidemia who is being discharged with a prescription for cholestyramine? Multiple choice question "Increase your intake of fiber and fluid." "Take the medication before you go to bed." "Check your pulse before taking the medication." "Contact your healthcare provider if your skin or sclera turn yellow."

Fiber and fluids help prevent the most common adverse effect of constipation and its complication: fecal impaction. The medication should be taken with meals. The pulse is not affected. Cholestyramine binds bile in the intestine; therefore, it reduces the incidence of jaundice.

Which statement demonstrates that a psychiatric nurse has fostered the most therapeutic nurse-client relationship? Multiple choice question "My clients and I are partners in the planning that helps meet their physical and mental health needs." "Nurses and clients must develop a therapeutic relationship if appropriate mental and physical care is to be provided." "Mental health is best achieved and maintained when the nurses and the clients exhibit respect and caring for each other." "Without a mutually satisfying relationship between nurse and client, the process needed to maximize mental and physical wellness is greatly hindered."

"My clients and I are partners in the planning that helps meet their physical and mental health needs."

Which drug may lead to bruxism? Multiple choice question Vilazodone Isocarboxazid Clomipramine Levomilnacipran

Serotonin reuptake inhibitors and serotonin/epinephrine reuptake inhibitors may lead to bruxism. Levomilnacipran is a serotonin/epinephrine reuptake inhibitor that may cause bruxism. Vilazodone is an atypical antidepressant that does not cause bruxism. Isocarboxazid is a monoamine oxidase inhibitor that does not cause bruxism. Clomipramine is a tricyclic antidepressant that does not cause bruxism.

The nurse is providing preoperative teaching for a client who is to have cataract surgery. Which is appropriate for the nurse to include concerning what the client should do after surgery? Multiple selection question Do not blow your nose. Remain flat for three hours. Eat a soft diet for two days. Breathe and cough deeply. Avoid bending from the waist.

Do not blow your nose. Avoid bending from the waist. The client needs to avoid activities that cause a sudden rise in intraocular pressure, such as bending from the waist, blowing the nose, sneezing, and coughing. It is not necessary to remain flat in bed for three hours after surgery, and the diet is not restricted.

The nurse is caring for a client admitted with fluid overload. Which tasks are most appropriate to be delegated to the patient care associate? Multiple selection question Documenting vital signs Documenting urine output Assessing the laboratory findings Administering diuretic intravenously Repositioning the client every one or two hours

Documenting vital signs Documenting urine output Repositioning the client every one or two hours Patient care associates are unlicensed assistive personnel whose scope of practice includes documenting vital signs and urine output and repositioning the client every one or two hours. Assessing the laboratory findings should be carried out by the registered nurse only. Intravenous medications should be administered the registered nurse. Administration of oral and topical medications can be delegated to the licensed practical or vocational nurse.

A nurse is caring for a client admitted to the hospital with primary hyperparathyroidism. Which action should be included in this client's plan of care? Multiple choice question Ensuring a large fluid intake Providing a high-calcium diet Instituting seizure precautions Encouraging complete bed rest

Ensuring a large fluid intake Fluids help prevent the formation of renal calculi associated with high levels of serum calcium. Additional calcium intake may increase the already high levels of serum calcium. Seizures are associated with low, not high, levels of serum calcium. Bed rest is contraindicated because it accelerates bone destruction.

The nurse is caring for a client in labor whose medical report states posterior pituitary hormone deficiency. Which medication administration is required for the client considering the medical condition? Multiple choice question Oxytocin to promote uterine contractions Prolactin to promote breast milk ejection Luteinizing hormone to promote painless labor Follicle-stimulating hormone to promote estrogen secretion

Oxytocin to promote uterine contractions Oxytocin is a posterior pituitary hormone that acts on the uterus to stimulate uterine contractions. Therefore the nurse should administer oxytocin to the client. Prolactin is an anterior pituitary hormone that promotes breast milk production, not milk ejection. Luteinizing hormone is an anterior pituitary hormone that stimulates progesterone secretion and ovulation and does not promote painless labor. Follicle-stimulating hormone is secreted by the anterior pituitary and is involved in estrogen secretion and follicle maturation.

The nurse assesses a client's eyes and notices that the pupils are unequal in size and constricted. What condition would be found in the client's medical record? Multiple choice question Cataracts Blepharitis Anisocoria Exophthalmos

Anisocoria

Which conditions may result from immunoglobulin IgE antibodies on mast cells reacting with antigens? Multiple selection question Asthma Hay fever Sarcoidosis Myasthenia gravis Rheumatoid arthritis

Asthma Hay fever Clinical conditions such as asthma and hay fever are considered type I hypersensitive reactions that are mediated by a reaction between IgE antibodies with antigens. It results in the release of mediators such as histamines. Type IV hypersensitivity reactions such as sarcoidosis result from reactions between sensitized T cells with antigens. Myasthenia gravis results from a type II hypersensitivity reaction that occurs due to an interaction between immunoglobulin IgG and the host cell membrane. Rheumatoid arthritis is a type III hypersensitivity reaction that results from the formation of immune complexes between antigens and antibodies that results in inflammation.

The school nurse is working with a child with a hearing deficit. The child arrives at school today without hearing aids. When the nurse talks with the child about the reasons for not wearing the aids, the nurse will need to ensure that the child understands what is being said. What actions by the nurse will promote effective communication? Multiple selection question Speaking slower, louder than normal, and excessively fast Facing the child directly when talking to the child Avoiding chewing gum while communicating with the child Avoiding using facial expressions that could interfere with lip reading Moving from side to side while talking to the child to keep the child looking at the nurse

Facing the child directly when talking to the child Avoiding chewing gum while communicating with the child

A client with a history of stabbing pain in the eyes and blurring and gradual loss of vision is examined by an ophthalmologist, a neurologist, and an internist, all of whom find no organic cause. When eye complaints increase, the client is admitted to a mental health unit. What is the priority nursing intervention? Multiple choice question Encouraging involvement in group activities Requesting a description of the eye discomfort Exploring feelings about possible impending blindness Focusing on daily activities while avoiding discussion of the eye discomfort

Focusing on daily activities while avoiding discussion of the eye discomfort The client's eye problems are a conversion reaction. Avoiding discussion of the physical problems prevents the client from using this topic to avoid an exploration of feelings. Focusing on the safe topic of activities may eventually progress to a discussion of emotion-laden topics such as feelings. It is too early for encouraging involvement in group activities; the client is too introspective to become involved with group activities at this time. Focusing on the physical problem allows the client to avoid feelings. The data do not indicate that the client has an organic problem and is going blind.

Which laboratory finding should alert the nurse to the need for further assessment? Multiple choice question Hemoglobin of 10 g/dL (100 mmol/L) Urine specific gravity of 1.020 Glucose level of 1+ in the urine White blood cell count of 9000/mm 3 (9 × 10 9/L)

Hemoglobin of 10 g/dL (100 mmol/L) This hemoglobin reading suggests a true anemia. The lowest hemoglobin resulting from physiologic anemia of pregnancy is 12 g/dL (120 mmol/L). This type of anemia occurs because the plasma volume increases to a greater extent than the red blood cells during pregnancy. A white blood cell count of 9000/mm 3 (9 × 10 9/L) is within the expected range of 5000 to 10,000/mm 3 (5 to 10 × 10 9 mmol/L). It may increase to 15,000/mm 3 during the second half of pregnancy. A urine specific gravity of 1.020 is within the expected range of 1.010 to 1.030. A 1+ urine glucose level is not unusual during pregnancy because of the lowered renal threshold for glucose during pregnancy; if it increases to 2+, further investigation for diabetes should be undertaken.

Which medication will cause the nurse to monitor the client closely for hemolytic anemia? Multiple choice question Tacrolimus Methyldopa Azathioprine Procainamide

Hemolytic anemia is an autoimmune disorder in which red blood cells are destroyed and removed from the bloodstream before the end of their normal life span. It may result after administration of methyldopa. Tacrolimus may cause adverse effects such as nephrotoxicity, lymphoma, and leukopenia. Azathioprine is administered as an immunosuppressant, which may cause bone marrow suppression. Procainamide can induce the formation of antinuclear antibodies and cause a lupus-like syndrom

A child is diagnosed with classic hemophilia. A nurse teaches the child's parents how to administer the plasma component factor VIII through a venous port. It is to be given three times a week. When should the parents administer this therapy? Multiple choice question Whenever a bleed is suspected In the morning on scheduled days At bedtime while the child is lying quietly in bed On a regular schedule at the parents' convenience

In the morning on scheduled days Factor VIII has a short half-life; therefore prophylactic treatment involves administering the factor on the scheduled days in the morning so the child will get the most benefit during the day, while he is most active. Prophylactic treatment is administered on a scheduled basis to prevent bleeds from occurring. Administering the drug at bedtime will limit its effectiveness because bleeds are more common when the child is active. Administering the medicine on a regular schedule at the parents' convenience does not take into consideration the properties of the drug.

An agitated, acting-out, delusional client is receiving large doses of haloperidol, and the nurse is concerned because this drug can produce untoward side effects. Which clinical manifestations will alert the nurse to stop the drug immediately? Multiple selection question Jaundice Dizziness Tachycardia Lethargic behavior Extrapyramidal symptoms

Jaundice Tachycardia Jaundice signifies liver function interference and requires that the medication be stopped. Tachycardia, QT-interval prolongation, and cardiac arrest are life-threatening cardiovascular effects of haloperidol (Haldol). Dizziness due to orthostatic hypotension usually subsides after several weeks of treatment. Lethargy and drowsiness usually subside after several weeks of treatment. Extrapyramidal symptoms usually require that the dose be reduced or can be treated with other medications; if symptoms do not subside, then the drug is stopped.

Which clinical indicators can the nurse expect when assessing a client with Cushing syndrome? . Multiple selection question Lability of mood Slow wound healing A decrease in the growth of hair Ectomorphism with a moon face An increased resistance to bruising

Lability of mood Slow wound healing Excess adrenocorticoids cause emotional lability, euphoria, and psychosis. Hypercortisolism impairs the inflammatory response, slowing wound healing. Increased secretion of androgens results in hirsutism. Although a moon face is associated with corticosteroid therapy, ectomorphism is a term for a tall, thin, genetically determined body type and is unrelated to Cushing syndrome. There is increased bruising because capillary fragility results in multiple ecchymotic areas.

A client is scheduled for a lumbar puncture. What nursing care should be implemented after the procedure? Multiple choice question Maintaining the client in the supine position for several hours Encouraging the client to ambulate every hour for at least 6 hours Keeping the client in the Trendelenburg position for at least 2 hours Placing the client in the high-Fowler position immediately after the procedure

Maintaining the client in the supine position for several hours

A 30-year-old female client asks the nurse to change her room, stating that she hates her roommate and can't stand to be in the same room with her. Just as she finishes speaking, her roommate enters and the client tells her she missed her and has been all over the unit looking for her. What does the nurse recognize the client to be using? Multiple choice question Projection Sublimation Reaction formation Passive aggression

Reaction formation The client's expressed feelings are opposite the client's behavior and are an acceptable substitute for repressed antisocial feelings when facing the roommate. The client's feelings are expressed to the nurse, not projected or attributed to others. The client has expressed real feelings to the nurse and has made no attempt to make an instinctual, socially unacceptable impulse into an acceptable behavior. The client has not masked covert hostility with overt compliance.

A recently married 22-year-old woman is brought to the trauma center by the police. She has been robbed, beaten, and sexually assaulted. The client, although anxious and tearful, appears to be in control. The primary healthcare provider prescribes 0.25 mg of alprazolam for agitation. The nurse will administer this medication when what event occurs? Multiple choice question The client's crying increases. The client requests something to calm her. The nurse determines a need to reduce her anxiety. The primary healthcare provider is getting ready to perform a vaginal examination.

The client requests something to calm her. Because a sexual assault is a threat to the sense of control over one's life, some control should be given back to the client as soon as possible. Crying is a typical way to express emotions; the client should be told that medication is available if desired. The nurse determining a need to reduce the client's anxiety or administering the medication when the primary healthcare provider is getting ready to do a vaginal examination takes control away from the client; the client may view these actions as an additional assault on the body, which increases feelings of vulnerability and anxiety and does not restore control.

A nursing student is recalling the various stages of health behavior change. What are the characteristics of the preparation stage? Multiple selection question The client requires assistance to plan changes in health behavior. The client intends to make changes in health behavior in the next 6 months. The client becomes actively engaged in strategies to change health behavior. The client understands that the advantages of health behavior change exceed the disadvantages. The client makes small changes in health behavior in preparation for major changes in the next month.

The client requires assistance to plan changes in health behavior. The client understands that the advantages of health behavior change exceed the disadvantages. The client makes small changes in health behavior in preparation for major changes in the next month. In the preparation stage, the client may need assistance in planning for the health behavior change. At this stage, the client understands that advantages of health behavior change exceed the disadvantages. The client, therefore, makes small changes to prepare for major health behavior change in the next month. In the contemplation stage of health behavior change, the client intends to make changes in health behavior in the next 6 months. In the preparation stage, the client becomes actively engaged in strategies to change his or her health behavior.

Who undertakes the responsibility of identifying the need for and calling of different specialty-trained providers to care for clients in a disaster? Multiple choice question Triage officer Public information officer Medical command physician Hospital incident commander

The medical command physician focuses on determining the number, acuity, and medical resource needs available for the clients in a disaster event. They are responsible for identifying the need for and calling specialty-trained providers to care for clients in the hospital. The triage officer re-evaluates the acuity for appropriate disposition within the hospital best suited to meet the client's medical needs. The public information officer serves as a liaison between the healthcare facility and the media. The hospital incident commander's role is to take a global view of the entire situation and facilitate client movement through the system.

Which nursing action indicates that the nurse is actively listening to the client? Multiple choice question The nurse states his or her own opinions when the client is speaking. The nurse refrains from telling his or her own story to the client. The nurse reads the client's health record during the conversation. The nurse interprets what the client is saying and reiterates in his or her own words.

The nurse interprets what the client is saying and reiterates in his or her own words. The nurse is listening actively if he or she is able to take in what the client says. A nurse who is listens attentively interprets and reiterates what the client is saying in his or her own words. A nurse who states his or her own opinions when the client is speaking is being judgmental. A good listener should be able to reach out by exchanging his or her own stories with the client. If a nurse reads the client's health record during the conversation, it is an indication that the nurse is not really interested in the conversation.

Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client? Multiple choice question Hazy Yellow Brown Colorless

The yellow color of CSF can be attributed to the hemolysis of the red blood cells (RBC), which leads to increased production of bilirubin. Other causes include subarachnoid hemorrhage, jaundice, increased CSF protein, hypercarotenemia, or hemoglobinemia. Hazy or unclear CSF is indicative of an elevated white blood cell count due to infections. If the CSF has a brown color it is indicative of the presence of methemoglobin, indicating a previous meningeal hemorrhage. A colorless color indicates a normal finding.

A client who has just had an adrenalectomy is told about a death in the family and becomes very upset. What concern about the client requires the nurse to notify the primary healthcare provider? Multiple choice question Analgesia and mild sedation will be required to ensure rest. Steroid replacement medication therapy will have to be reduced. There is a decreased ability to handle stress despite steroid therapy. Feelings of exhaustion and lethargy may result from the emotional stress.

There is a decreased ability to handle stress despite steroid therapy. Clients with adrenocortical insufficiency who are receiving steroid therapy usually require increased amounts of medication during periods of stress because they are unable to produce the increased levels of glucocorticoids needed by the body at this time. Although sedation may be prescribed, the major concern is the regulation of glucocorticoids in the presence of emotional or physiologic stress. Increased stress requires increased glucocorticoids. Although feelings of exhaustion and lethargy may occur and may be minimized by an increase in glucocorticoids, the primary reason for an adjustment in dosage is to assist the body's ability to adapt to stress.

A young adult sustained a spinal cord injury at the level of T5 a week ago and is now incontinent of feces. When the nurse tries to give a bath and change the linens, the client says, "Leave me alone. It's worse having you change me than it is to lie in this mess." What is the best response by the nurse? Multiple choice question "Do you want me to get someone else to change you?" "You shouldn't be embarrassed; this is part of my job." "I'll be back in a little while; why don't you rest until then?" "While I'm bathing you I'll start teaching you about bowel training."

"While I'm bathing you I'll start teaching you about bowel training." - gives a matter of fact and you have to stay with him and then help resolve the issue

During a well-baby clinic visit the nurse assesses an 18-month-old's growth and development. What observation indicates that the toddler is within the expected range? Multiple choice question Pedals a tricycle easily Climbs up several stairs Says 150 different words Builds a tower of eight blocks

Climbing stairs is expected developmental behavior for 18-month-old toddlers; however, they may have difficulty coming back down the stairs. Pedaling a tricycle, having a 150-word vocabulary, and building a tower of eight blocks are above the ability level of an 18-month-old child.

A 55-year-old client who has a long history of drug and alcohol abuse mentions taking ginkgo biloba. The nurse knows that ginkgo biloba is taken to treat what condition? Multiple choice question Insomnia Depression Memory impairment Anxiety and nervousness

Ginkgo biloba is an herb used to treat age-related memory impairment and dementia. It has not been shown to be effective in treating insomnia, depression, or anxiety.

The nurse is analyzing the client's rhythm when the nurse notes multiple premature ventricular contractions (PVCs). Each PVC occurs in no particular pattern and looks like all other PVCs. How will the nurse interpret this finding? Multiple choice question Multifocal Unifocal Bigeminal Couplet

Unifocal A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical in shape and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal) and every third beat (trigeminal). Two consecutive PVCs are called a couplet.

The parents of a 6-year-old child tell a nurse at the pediatric clinic that their child is weak and lethargic, has headaches, has no appetite, and has dark, cloudy urine. The nurse suspects acute poststreptococcal glomerulonephritis (APSGN). What should the nurse ask the mother? Multiple choice question "Has your child lost weight recently?" "Did your child have a sore throat during the past 3 weeks?" "Does your child have migratory pains in the shoulders and knees?" "Has your child had a rash on the palms and soles in the past 2 weeks?"

"Did your child have a sore throat during the past 3 weeks?" If the response to the question indicates a recent sore throat, the healthcare provider may decide to prescribe specific tests to confirm a diagnosis of ASPGN. Weight loss usually occurs in children with type 1 diabetes, not glomerulonephritis. This kind of pain is reported in rheumatic fever and scarlet fever, which do not result in the smoky urine associated with hematuria. A rash on the palms and soles is not associated with APSGN.

A nurse is educating a client about the use of tretinoin cream for acne. Which of these statements by the client indicate a need for further teaching? Multiple selection question "I should only apply this medication at night." "I should use a sunscreen with a sun-protection factor of 15." "I should avoid using a daily moisturizer while taking this medication." "I should apply the medication right after I get done washing my face." "I should start by applying a pea-sized dot of the cream to each of the three main areas of my face."

"I should avoid using a daily moisturizer while taking this medication." "I should apply the medication right after I get done washing my face." The client should use a daily moisturizer to help prevent dryness of the skin. The medication should be applied 20 to 30 minutes after the client washes her face, not immediately after. The medication should be applied at night. A sunscreen with an SPF of 15 should be used to ameliorate the severity of acne. The client should begin by dispensing one pea-sized dot of the cream, dividing it among the three main areas of the face, and gently rubbing the cream into the skin. A pea-sized dot for each area is too much medication.

The nurse provides instructions to a client who is prescribed bromocriptine for hyperpituitarism. Which statement made by the client indicates effective learning? Multiple selection question "I should take the drug with a meal." "I should avoid the drug if I get pregnant." "I should check my blood pressure regularly." "I should monitor body temperature regularly." "I should report immediately if I experience chest pain."

"I should take the drug with a meal." "I should avoid the drug if I get pregnant." "I should report immediately if I experience chest pain." Bromocriptine is associated with gastric irritation and nausea. Therefore, the nurse should advise the client to take the drug with meals to avoid side effects. Bromocriptine may cause serious effects to the fetus. Therefore, the drug should be avoided during pregnancy. Bromocriptine may cause serious complications, such as cardiac dysrhythmias and cerebrospinal leakage. Therefore, the clients should be told to report to their primary health care provider immediately if there is any such complication. Clients are not typically instructed to monitor blood pressure and body temperature because bromocriptine does not cause hypertension and fever-like symptoms.

During a routine 32-week prenatal visit, a client tells the nurse that she has had difficulty sleeping on her back at night. Which guidance should the nurse provide regarding sleeping position? Multiple choice question "Turn from side to side." "Try to sleep on your stomach." "Elevate the head of the bed on blocks." "Place two pillows under your knees for sleep."

"Turn from side to side." The side-lying position will relieve back pressure; it also promotes uterine perfusion and fetal oxygenation. At 32 weeks' gestation the abdomen is too distended for the pregnant woman to lie in the prone position. Elevating the head of the bed will not relieve back pressure; it is used to limit gastroesophageal reflux. Lying on the back is contraindicated because it puts pressure on the vena cava, resulting in hypotension and uteroplacental insufficiency. Pillows under the knees are contraindicated because they place pressure on the popliteal area, which compresses the venous circulation, increasing the risk of thrombophlebitis.

Which client is at greatest risk for the development of a venous thrombosis? Multiple choice question A 76-year-old female with a 100-pack-per-year smoking history and hypertension A 68-year-old male on bed rest following a left hip fracture A 59-year-old male who is an intravenous drug user with hyperlipidemia A 42-year-old female with Factor V Leiden mutation on warfarin

A 68-year-old male on bed rest following a left hip fracture Venous thrombosis is the result of inflammation to a vein, hypercoagulability, venous stasis, or a combination of the three, known as Virchow triad. Bed rest and hip fracture are two major risk factors for the development of a thrombosis. While the other options present risk factors (cigarette smoking, drug abuse, and clotting disorders), the combination of the two (venous stasis and vessel injury) results in greatest risk for thrombus development.

What are the purposes of public health laws? Multiple selection question Advocating for the rights of people Prohibiting the purchase or sale of organs Regulating health care and healthcare financing Ensuring professional accountability for the care provided Encouraging healthcare professionals to assist in emergencies

Advocating for the rights of people Regulating health care and healthcare financing Ensuring professional accountability for the care provided The primary purposes of public health laws are advocating for the rights of people, regulating health care and healthcare financing, and ensuring professional accountability for care that is provided. Public health laws help protect the health of the public. The National Organ Transplant Act of 1984 prohibits the purchase or sale of organs. Good Samaritan laws are enacted to encourage health care professionals to assist in emergencies.

A client's laboratory report shows elevated IgE levels and positive skin tests. The nurse suspects an allergic reaction. Upon assessment the nurse discovers skin lesions (vesicles), which are widespread. Which condition will the nurse most likely observe written in the client's medical record? Multiple choice question Allergic rhinitis Atopic dermatitis Contact dermatitis Goodpasture syndrome

Atopic dermatitis Elevated IgE levels and positive skin tests occur in individuals with atopic dermatitis. The skin is characterized by the presence of lesions that spread widely over the skin, unlike in contact dermatitis where they occur locally. Contact dermatitis is a red itchy rash that involves mediators such as cytokines, resulting in a delayed hypersensitivity reaction. Allergic rhinitis may occur yearly or seasonally and involves mediators such as histamine and mast cells that result in an IgE-mediated hypersensitivity reaction. Goodpasture syndrome is an autoimmune disorder involving lungs and kidneys, and does not cause edematous papules or lesions; it involves mediators such as complement lysis and tissue macrophages that cause type II cytotoxic hypersensitivity reaction.

A client with the diagnosis of personality disorder with antisocial behavior is hospitalized. The client is openly discussing interpersonal difficulties with family members and the boss at work from whom the client has stolen money. The client is facing criminal charges. Which behavior indicates that the client is meeting treatment outcomes? Multiple choice question Expression of feelings of resentment toward the employer Discussion of plans for each of the possible outcomes of a trial Expression of resignation about difficult relationships with the spouse and children Discussion of the decision to file a grievance against the employer after discharge from the hospital

Because the legal difficulties were a precipitating event for hospitalization, if the client can realistically examine the possible outcomes of the trial, then some benefit has been gained from the therapy. Freely expressing resentment and claiming victimization by the employer and authority figures do not show improvement or insight. The client has been discussing the problems since admission, so expressing resignation does not indicate the development of insight. Deciding to file a grievance indicates unrealistic planning and does not demonstrate the development of insight.

A 1-year-old infant is in the pediatric unit for management of AIDS. One of the medications that has been prescribed for the child is zidovudine. What clinical finding indicates to the nurse that the infant is experiencing life-threatening zidovudine toxicity? Multiple choice question Fatigue and lethargy Increased urine output Progressive weight loss Bruises on the limbs and trunk

Bruises on the limbs and trunk Zidovudine can cause life-threatening blood dyscrasias, including thrombocytopenia. With zidovudine toxicity the infant will demonstrate agitation, restlessness, and insomnia, not fatigue and lethargy. Urine output is unrelated to zidovudine toxicity; decreased urine output may be related to decreased fluid intake, vomiting, and diaphoresis associated with the illness. Weight loss is usually a response to the illness rather than to the therapy.

A nursing instructor asks a nursing student about the formal operations stage of Piaget's theory of cognitive development. Which of these statements by the student indicate a need for further teaching? Multiple selection question During this stage, the individual engages in risk-taking. During this stage, there's an absence of egocentric thought. During this stage, reversibility in thought is the primary characteristic. During this stage, the individual's thinking moves toward abstract theory. During this stage, the individual develops the capacity to reason with respect to possibilities.

During this stage, there's an absence of egocentric thought. During this stage, reversibility in thought is the primary characteristic. During the formal operations stage, egocentric thought prevails. During the concrete operation stage, reversibility is the primary characteristic of the thought. Reversibility refers to the ability to recognize that numbers or objects can be changed and returned to their original conditions. When the student says that there is no egocentric thought in adolescents and reversibility is the primary characteristic in the formal operation stage, this indicates a need for further teaching. During the formal operations stage, the adolescent is preoccupied by the thought that he or she is invulnerable and engages in risk-taking behavior. As adolescents mature, their thinking moves to abstract and theoretical subjects. During the formal operations stage, individuals develop the capacity to reason with respect to possibilities.

Health promotion efforts within the healthcare system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Multiple selection question Encouraging regular dental checkups Facilitating smoking cessation programs Administering influenza vaccines to older adults Teaching the procedure for breast self-examination Referring clients with a chronic illness to a support group

Encouraging regular dental checkups Teaching the procedure for breast self-examination Encouraging regular dental checkups is a secondary prevention activity because it emphasizes early detection of health problems, such as dental caries and gingivitis. Teaching the procedure for breast self-examination is a secondary prevention activity because it emphasizes early detection of problems of the breast, such as cancer. Facilitating smoking cessation programs is a primary prevention activity because it emphasizes health protection against heart and respiratory diseases. Administering influenza vaccines to older adults is a primary prevention activity because it emphasizes health protection against influenza. Referring clients with a chronic illness to a support group is a tertiary prevention activity because it emphasizes care that is provided after illness already exists.

A pregnant client's last menstrual period was on February 11. A physical assessment on July 18 should reveal the top of the fundus to be where? Multiple choice question Even with the umbilicus Just above the symphysis pubis Two fingerbreadths above the umbilicus Halfway between the symphysis and umbilicus

Even with the umbilicus Around the 22nd week of gestation the top of the fundus is at the level of the umbilicus. Just above the symphysis pubis is too low for a pregnancy between the fifth and sixth months of gestation. Two fingerbreadths above the umbilicus is too high for 20 to 22 weeks' gestation. Halfway between the symphysis pubis and umbilicus is too low for a pregnancy between the fifth and sixth months of gestation.

The nurse is planning discharge instructions for a client who had a thyroidectomy. What signs/symptoms will the client exhibit with surgically induced hypothyroidism? Multiple selection question Fatigue Dry skin Insomnia Excitability Weight loss Intolerance to heat

Fatigue Dry skin Fatigue results from the decreased metabolic rate associated with hypothyroidism. Dry skin is caused by decreased glandular function. Insomnia is associated with hyperthyroidism because of the increased metabolic rate. Lethargy, not excitability, is associated with hypothyroidism because of the decreased metabolic rate. Weight gain, not loss, is associated with hypothyroidism because of the decreased metabolic rate. Intolerance to heat is associated with hyperthyroidism.

While assessing a knee injury, the nurse asks the client to flex the knee to 30 degrees, pulling the tibia forward while the femur is stabilized. Which test is the nurse performing? Multiple choice question Drop arm test Lachman's test McMurray's test Straight-leg-raising test

Lachman's test In Lachman's test, the knee is flexed 15 to 30 degrees, pulling the tibia forward while the femur is stabilized; this test helps determine anterior cruciate ligament tear. The drop arm test involves abducting the arm to 90 degrees and slowly lowering the arm to the other side; this test helps determine rotator cuff injury. McMurray's test involves flexing, rotating, and extending the knee which produces pain; this test helps determine a torn meniscus. The straight-leg-raising test is performed in a client who is supine by raising the leg to 60 degrees; this test helps determine intervertebral disc prolapse and herniation.

The nurse is teaching a client with a furuncle about preventing the spread of infection. Which statement made by the client indicates effective learning? Multiple choice question "I will dress the wound occlusively." "I will apply warm compresses to the furuncle." "I will use an antibacterial soap while bathing." "I will gently remove crusts before applying the medication."

Skin care with proper cleansing may help to prevent the spread of infection; therefore the client should use an antibacterial soap while bathing. Occlusive dressings promote microorganism growth due to the presence of excessive moisture. Applying warm compresses to a furuncle helps in providing comfort. Removal of crusts before applying the drug helps in easy absorption of medication.

A client with diabetes asks the nurse whether the new forearm stick glucose monitor gives the same results as a finger stick. What is the nurse's best response to this question? Multiple choice question "There is no difference between readings." "These types of monitors are meant for children." "Readings are on a different scale for each monitor." "Faster readings can be obtained from a finger stick."

The forearm glucose monitor is calibrated to be consistent with results obtained from a finger stick. Individuals of all ages can use these glucose monitors. A different scale is not used for each monitor; accompanying literature will indicate whether the monitor reading reflects venous blood values even though capillary blood is used. There is no difference in the time required to complete the test.

A client who had a myocardial infarction receives a prescription for a nitroglycerin patch. What does the nurse identify as the purpose of the nitroglycerin patch? Multiple choice question Decreased heart rate lowers cardiac output. Increased cardiac output increases oxygen demand. Decreased cardiac preload reduces cardiac workload. Peripheral venous and arterial constriction increases peripheral resistance.

Decreased cardiac preload reduces cardiac workload. Nitroglycerin reduces cardiac workload by decreasing the preload of the heart by its vasodilating effect. It decreases blood pressure, not heart rate (which may increase to compensate for the decreased blood pressure). It decreases, not increases, oxygen demand. Nitroglycerin dilates, not constricts, peripheral veins and arteries.

After interacting with a client, a nurse finds that a 23-year-old client has never undergone a Papanicolaou (Pap) test. What should the nurse suggest to the client? Multiple choice question Schedule a Pap test immediately Schedule a Pap test during menses Schedule a Pap test every five years Schedule a Pap test and human papillomavirus test

Schedule a Pap test immediately The Papanicolaou test (Pap test) is a cytologic study performed annually after the age of 21 years. The nurse should advise a 23-year-old client to undergo a Pap test immediately to rule out precancerous and cancerous cells within the client's cervix. Undergoing a Pap test during menses may interfere with laboratory analysis and results. A human papillomavirus test is performed every 5 years. Pap tests and human papillomavirus tests are recommended in clients between the ages of 30 and 65 years.

What are the roles of an unlicensed assistive personnel in skin care? Multiple selection question To assist the client in bathing To apply wet dressings to the skin To report changes in the skin appearance To reinforce teaching as done by the registered nurse To determine whether the client is taking a drug that increases photosensitivity

To assist the client in bathing To apply wet dressings to the skin To report changes in the skin appearance The unlicensed assistive personnel may be responsible for assisting the client in bathing, applying wet dressings to the skin, and reporting changes in the skin appearance. Teaching done by the registered nurse can be reinforced by a licensed practical nurse or a vocational nurse. The registered nurse would be responsible for determining whether the client is taking a drug that increases photosensitivity.

Which client would have relatively smaller tidal volumes due to limited chest wall movement? Multiple choice question A client with asthma A client with pneumonia A client with pulmonary fibrosis A client with phrenic nerve paralysis

A client with phrenic nerve paralysis Some respiratory conditions such as phrenic nerve paralysis may limit the diaphragm or chest wall movement and may result in smaller tidal volumes. In this condition, the lungs do not fully inflate, and the gas exchange may be impaired. Exacerbations of asthma may cause expiration to become an active labored process. Pneumonia may result in decreased lung compliance due to an accumulation of fluid in the lungs. As the lung tissue becomes less elastic or distensible, the client with pulmonary fibrosis may have decreased lung compliance.

A client who had a subtotal thyroidectomy asks how hypothyroidism may develop when the problem was hyperthyroidism. What should the nurse consider when formulating a response? Multiple choice question Hypothyroidism is a gradual slowing of the body's function. A decrease in pituitary thyroid-stimulating hormone (TSH) will occur. Less thyroid tissue is available to supply thyroid hormone after surgery. Atrophy of tissue remaining after surgery reduces secretion of thyroid hormones.

A decrease in pituitary thyroid-stimulating hormone (TSH) will occur. After a thyroidectomy, thyroxine output usually is inadequate to maintain an appropriate metabolic rate. Hypothyroidism is decreased thyroid functioning, not a slowing of functions of the entire body. With hypothyroidism, the level of TSH from the pituitary usually is increased. Thyroid tissue remaining after surgery does not atrophy.

Which characteristics observed in a five-year-old child are appropriate? Multiple selection question Involvement in parallel play Finicky eating habits Ability to swim and skate Interest in trying new foods Ability to draw triangles and diamonds

Ability to swim and skate Interest in trying new foods Ability to draw triangles and diamonds Five-year-old children may begin to swim and skate. They are interested in trying new foods and can easily draw triangles and diamonds. Toddlers may get involved in parallel play. Four-year-old children have finicky eating habits.

A school nurse is teaching a group of parents about age-related issues in 5-year-old children. What should the nurse include as a major concern of children of this age? Multiple choice question Fear of separation Anxiety about body integrity Apprehension regarding strangers Threats to their dependency needs

Anxiety about body integrity

A client is recovering from a kidney transplant. Which medications should the nurse expect to be prescribed for this client's maintenance therapy? Multiple selection question Basiliximab Azathioprine Prednisone Cyclosporine Antithymocyte globulin-equine

Azathioprine Prednisone Cyclosporine Antithymocyte globulin-equine Maintenance therapy is the continuous immunosuppression used after a solid organ transplant. The drugs used for routine therapy after solid organ transplantation include an antiproliferative agent such as azathioprine, a corticosteroid such as prednisone, and a calcineurin inhibitor such as cyclosporine. Baxiliximab is a monoclonal antibody used to treat acute rejection episodes. Antithymocyte globulin-equine is a polyclonal antibody used to treat acute rejection episodes.

The nurse is assessing a client suspected of having hypersecretion of growth hormone. Which question should the nurse ask the client? Multiple choice question "Have you noticed thickening of your lips?" "Do you experience excessive thirst?" "Did you notice increase in frequency of urination?" "Do you experience pain during sexual intercourse?"

Excessive secretion of growth hormone results in several skeletal and soft-tissue changes. A common manifestation of increased levels of growth hormone in the body is the thickening of the client's lips. Asking the client about increased thirst and frequency of urination helps assess the status of diabetes insipidus, which is a disorder of water loss. Hypersecretion of prolactin is assessed by asking the client about difficulty during intercourse because excess of prolactin results in difficulties in sexual function.

The nurse is caring for a client with vaginal bleeding caused by placenta previa. What is the priority nursing intervention at this time? Multiple choice question Maintaining bed rest Planning for an ultrasound test Preparing for a nonstress test Administering oxygen by way of a mask

Gravitational pull on an already stressed placenta may cause further bleeding; bed rest limits stress on the fetus and may prolong the pregnancy. Planning for an ultrasound test or a nonstress test provides for fetal assessment; it will not delay the birth. Unless the fetal heart rate is decelerating, oxygen supplementation is not necessary.

Which is an example of a nurse-initiated intervention? Multiple choice question Preparing a client for endoscopy Coordinating with an x-ray technician for imaging Starting an intravenous line for a blood transfusion Keeping edematous lower extremities elevated on pillows

Keeping edematous lower extremities elevated on pillows

The legal authority has delegated the tasks according to the model of analysis type of care. Which statements are true regarding the model analysis? Multiple selection question Model analysis improves client satisfaction. Model analysis is a cost-effective idea for client care. Quality control is better in the model analysis type of care. Model analysis promotes organizational decision-making at lower levels. Model analysis promotes adequate communication among the staff members.

Model analysis improves client satisfaction. Model analysis is a cost-effective idea for client care. Model analysis promotes organizational decision-making at lower levels. Model analysis is a type of care that benefits clients in terms of satisfaction of care being provided. In model analysis, the team nursing method is followed. It is a cost-effective system because it works with an expected ratio of unlicensed to licensed personnel. Organizational decision making occurs at lower levels in model analysis. Control of quality is lower in model analysis. There may be inadequate communication among staff members due to the higher potential for fragmentation of care.

The nurse is educating a client about protease inhibitors. What statement about protease inhibitors is true? Multiple choice question Protease inhibitors prevent viral replication. Protease inhibitors prevent the interaction between viral material and the CD4+ T-cell. Protease inhibitors prevent viral and host genetic material integration. Protease inhibitors prevent the clipping of the viral strands into small functional pieces.

Protease inhibitors act by preventing viral replication and release of viral particles. NRTIs inhibits the transformation of viral single-stranded ribonucleic acid into host double-stranded deoxyribonucleic acid (DNA) by the action of the enzyme reverse transcriptase. Entry inhibitor drugs prevent the binding of the virus to the CD4 receptors. Integrase inhibitor drugs prevent the integration of viral material into the host's DNA by the action of the enzyme integrase.

An adolescent with leukemia is to be sent home on a protocol that includes several antineoplastic agents. Before discharge, what medication instructions should the nurse give the parents? Multiple choice question Limit contact with all peers and family members. Withhold medications when nausea occurs to prevent vomiting. Schedule laboratory blood tests to evaluate response to the medication. Return weekly for a bone marrow aspiration to monitor effectiveness of therapy.

Schedule laboratory blood tests to evaluate response to the medication. Blood tests indicate response to therapy; if the white blood cell count drops precipitously, therapy may be halted temporarily. These children undergo therapy for extended periods, and prolonged separation from their peers may lead to social isolation. Contact with children who have active infections should be avoided. Although nausea commonly occurs with this therapy, antiemetic measures are instituted; the drug is not withdrawn for this reason. A bone marrow aspiration is a painful procedure and is performed selectively (e.g., to confirm the diagnosis), not routinely.

A client reports painful and bleeding gingivae, increased saliva with metallic taste, fetid mouth odor, decreased hunger, fever, and general malaise. Upon assessment, the nurse finds eroding necrotic lesions of the interdental papillae and bleeding ulcerations in the mouth. Which microorganism is responsible for this condition? Multiple choice question Candida species Spirochetes Herpes simplex viruses Staphylococcus species

Spirochetes - vincent infection

The primary healthcare provider prescribes medication to prevent transplant rejection from increased concentration of interleukin-2. Which drugs could the nurse most likely administer? . Multiple selection question Sirolimus Tacrolimus Cyclosporine Azathioprine Mycophenolate

Tacrolimus Cyclosporine Tacrolimus and cyclosporine are calcineurin inhibitors that stop the production and secretion of interleukin-2 and prevent the activation of lymphocytes involved in transplant rejection. Therefore tacrolimus and cyclosporine are most suitable for the client. Sirolimus, azathioprine, and mycophenolate are antiproliferative medications that inhibit something essential to DNA synthesis and prevent cell division in activated lymphocytes; thus they are effective for lessening transplant rejection involving DNA synthesis, not interleukin-2.

A client has an anaphylactic reaction after receiving intravenous penicillin. What does the nurse conclude is the cause of this reaction? Multiple choice question An acquired atopic sensitization occurred. There was passive immunity to the penicillin allergen. Antibodies to penicillin developed after a previous exposure. Potent antibodies were produced when the infusion was instituted.

Antibodies to penicillin developed after a previous exposure. Hypersensitivity results from the production of antibodies in response to exposure to certain foreign substances (allergens). Earlier exposure is necessary for the development of these antibodies. This is not a sensitivity reaction to penicillin; hay fever and asthma are atopic conditions. It is an active, not passive, immune response. Antibodies developed when there was a previous, not current, exposure to penicillin.

While assessing a client, the nurse observes solar lentigines on the face and back of the hands. What changes in the skin may the nurse suspect to be the reason for the client's symptoms? Multiple choice question Increased permeability Decreased extracellular water Decreased activity of sebaceous glands Increased focal melanocytes in the basal layer with pigment accumulation

Increased focal melanocytes in the basal layer with pigment accumulation Solar lentigines on the face and back of the hands may occur due to the increased focal melanocytes in the basal layer with pigment accumulation. Increased permeability may be associated with bruising. Decreased extracellular water may result in dry and flaked skin. Dried skin with minimal perspiration and uneven skin color may be related to the decreased activity of sebaceous glands.

A client is admitted to a psychiatric hospital because of a recurrent mental health problem. During admission the nurse determines the expected client outcomes. The nurse concludes that these outcomes can be described in what way? Multiple choice question Long-term goals Variances of care Clinical pathways Measurable objectives

Measurable objectives Expected outcomes are the desirable projected responses to therapeutic interventions that consider the client's present and potential capabilities; they are measurable and realistic. Expected outcomes may be either short-term or long-term, not only long-term. A variance is when a client's response to interventions is different from what usually is expected. Expected client outcomes are a component of a clinical pathway; a clinical pathway is a written standardized process that details essentials steps in the care of patients and describes the patient's expected clinical course.

The parents of a preterm infant are preparing to take their baby home. How should the nurse best evaluate the parents' competency in infant care? Multiple choice question Ask the parents what they plan to do at home. Determine the rationales behind the parents' actions. Observe the parents while they are giving care to their infant. Demonstrate care before having the parents give a return demonstration.

Observe the parents while they are giving care to their infant. Observing the care that the parents actually give the infant provides direct validation of their skills and comfort level. Asking the parents what they plan to do at home is helpful for providing anticipatory guidance, but it is a small part of a competency evaluation. Although determining the rationales behind the parents' actions is helpful in identifying empirical knowledge, it does not test the parents' skills or comfort level. Demonstrating care before having the parents give a return demonstration does not provide enough evidence of the parents' competency.

Which responses should alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia? Multiple choice question Flaccid paralysis and numbness Absence of sweating and pyrexia Escalating tachycardia and shock Paroxysmal hypertension and bradycardia

Paroxysmal hypertension and bradycardia When autonomic dysreflexia[1][2] is identified, immediate intervention is necessary to prevent serious complications. Paralysis is related to transection, not to dysreflexia; the client will have no sensation below the injury. Profuse diaphoresis occurs. Bradycardia occurs. These clinical findings occur as a result of exaggerated autonomic responses.

A health care provider prescribes ranitidine for a client with heartburn. During a teaching session, which information will the nurse share with the client about how this drug works? Multiple choice question Ranitidine increases gastrointestinal peristalsis. Ranitidine reduces gastric acidity in the stomach. Ranitidine neutralizes the acid that is present in the stomach. Ranitidine stops production of hydrochloric acid in the stomach.

Ranitidine reduces gastric acidity in the stomach. Ranitidine (Zantac) inhibits histamine at H 2 receptor sites in the stomach, resulting in reduced gastric acid secretion. Ranitidine reduces, rather than neutralizes, gastric acidity. Ranitidine does not increase gastrointestinal peristalsis, and it does not completely stop production of hydrochloric acid in the stomach.

An adolescent girl who participated in unprotected intercourse requires an emergency contraception. Which drugs could be prescribed? Multiple selection question Uliprestel Misoprostol Mifepristone Methotrexate Levonorgestrel

Uliprestel Levonorgestrel Food and Drug Administration (FDA) approved drugs for emergency contraception include uliprestel, levonorgestrel, and a combination of estrogen and progestin. Misoprostol, mifepristone, and methotrexate are used to induce abortion after a pregnancy is confirmed.

A nurse is reviewing medication instructions with the parents of an infant who is receiving digoxin and spironolactone. What parental response concerning their infant's care indicates that the instructions have been understood? Multiple choice question Activity should be restricted. Orange juice or other high-potassium drinks must be offered daily. Vomiting should be reported to the healthcare provider. Antiinflammatory drugs will not be given with spironolactone.

Vomiting is a classic sign of digoxin toxicity, and the healthcare provider must be notified. Infants regulate their own activity according to their energy level. Orange juice is rarely needed because spironolactone spares potassium. There is no restriction on antiinflammatory drugs with spironolactone.

A nurse in the clinic is assessing a teenager with a tentative diagnosis of primary syphilis. What is an early sign of this infection? Multiple choice question Rash Genital lesion Genital discharge Multiple gummatous lesions

Genital lesion A chancre is the earliest sign of syphilis; a dark-field examination of a scraping will reveal the Treponema organism. A rash occurs in the secondary stage of syphilis. A genital discharge is associated with gonorrhea. Multiple lesions are late manifestations of syphilis.

A nurse is caring for a client with type 1 diabetes who developed ketoacidosis. Which laboratory value supports the presence of diabetic ketoacidosis? Multiple choice question Decreased serum glucose levels Decreased serum calcium levels Increased blood urea nitrogen levels Increased serum bicarbonate levels

Increased blood urea nitrogen levels With diabetic ketoacidosis blood urea nitrogen level generally is increased because of dehydration. With diabetic ketoacidosis, the serum glucose levels are generally above 300 mg/dL (16.7 mmol/L). The calcium level is unrelated to diabetic ketoacidosis. Serum bicarbonate levels are below 15 mEq/L (15 mmol/L).

A nurse is volunteering on the community crisis hotline. What is the final objective of the counseling process? Multiple choice question Reducing anxiety Exploring feelings Developing constructive coping skills Accomplishing the debriefing process

Past coping behaviors have been inadequate in resolving the current crisis; new coping skills are needed to manage anxiety-producing conflicts. Reduction of anxiety is an early objective. Exploration of feelings is an immediate objective. Accomplishment of the debriefing process is an early objective.

A nurse is caring for a client with scoliosis of the thoracic spine and lumbar spine. Which risk does the nurse suspect in the client? Multiple choice question Osteoarthritis Muscle spasticity Intervertebral disc prolapse Cardiac function impairment

Scoliosis can lead to cardiac function impairment. A client with an S-shaped thoracic and lumbar spine, and unequal shoulder and scapula height, may have scoliosis. A thoracic rib prominence in the lumbar spine deformity of 45 degrees indicates that the client is at a risk of lung and cardiac function impairment. Osteoarthritis is an inflammatory joint condition that is uncommon in a client with scoliosis of the thoracic spine and lumbar spine. Muscle spasticity, an increased muscle tone that may interfere with gait, movement, and speech, is uncommon in the client with scoliosis of the thoracic and lumbar spine. Passively raising the client's leg 60 degrees or less during a straight-leg-raising test indicates nerve root irritation due to intervertebral disc prolapse.

What manifestations does the nurse expect to identify when taking a health history from a client with moderate dementia? Multiple selection question Sundowning Hypervigilance Increased inhibition Exaggeration of premorbid traits Inability to recognize family members

Sundowning Exaggeration of premorbid traits

A 3-year-old child is admitted to the pediatric unit with a diagnosis of nephrotic syndrome. The child has ascites, oliguria, respirations of 40 breaths/min, and a recent weight gain of 10 lb (4.5 kg). What nursing intervention may help ease the child's respiratory difficulty? Multiple choice question Providing six small meals daily Maintaining a well-ventilated room Ensuring bed rest in the low Fowler position Administering oxygen at 2 L/min by way of nasal cannula

The low Fowler position decreases pressure on the diaphragm from the abdominal organs and the ascites, thereby increasing respiratory excursion. Frequent feedings may lead to fatigue and quickened respiration, which will further distress the child. Placing the child in a well-ventilated room will not alleviate the cause of the respiratory problem, which is pressure on the diaphragm from the ascites. Oxygen therapy is not necessary; the dyspnea results from pressure on the diaphragm, not lack of oxygen.

Which diagnostic study is used to investigate the cause of an inflamed joint and determines a client's response to antiinflammatory drug therapy? Multiple choice question Duplex venous Doppler Plethysmography Thermography Somatosensory evoked potential

Thermography uses an infrared detector that measures the degree of heat radiating from the skin's surface. Therefore it is used to investigate the cause of an inflamed joint and in determining the client's response to antiinflammatory drug therapy. Plethysmography is used to record variations in volume and pressure of blood passing through tissues. Duplex venous Doppler records blood flow abnormalities to the lower extremities, which helps to detect deep vein thrombosis. Somatosensory evoked potential is used to identify subtle dysfunction of lower motor neuron and primary muscle disease.

A client with schizophrenia is actively psychotic, and a new medication regimen is prescribed. A student nurse asks the primary nurse, "Which of the medications will be the most helpful against the psychotic signs and symptoms?" What response will the nurse give? Multiple choice question Citalopram Ziprasidone Benztropine Acetaminophen with hydrocodone

Ziprasidone is a neuroleptic, which will reduce psychosis by affecting the action of both dopamine and serotonin. Citalopram is a selective serotonin reuptake inhibitor antidepressant. Benztropine is an anticholinergic. Acetaminophen with hydrocodone is an analgesic/opioid.

The nurse cares for a client with schizophrenia and who is receiving ziprasidone. Which conditions in the client may indicate discontinuation of the drug? Multiple selection question Leukopenia Tachycardia Hypokalemia Hypermagnesemia Prolonged QT interval

leukopenia, hypokalemia, prolonged QT interval Ziprasidone is a second generation antipsychotic drug indicated for schizophrenia. The drug may cause leukopenia, hypokalemia, and hypomagnesemia. This drug may cause a prolonged QT interval, which indicates torsades de points. Bradycardia may occur in torsades de pointes, but not tachycardia.

A client comes to the emergency department because of minimal urinary output despite drinking adequate fluid. The client's blood pressure is 190/94 mm Hg. For what additional clinical manifestation associated with this data should the nurse assess the client? Multiple choice question Thirst Weight gain Urinary retention Urinary hesitancy

weight gain If urine is not being produced in the presence of an average daily intake, fluid will be retained and reflected in weight gain. Oliguria is decreased urinary output. One liter of fluid weighs 2.2 pounds (1 kg). Excess fluid contributes to an increase in circulating blood volume, causing hypertension. Thirst is associated with dehydration, not hypertension and oliguria. Urinary retention is unrelated to hypertension. Urinary retention is the inability to empty the bladder. Urinary hesitancy is an involuntary delay in initiating urination and is unrelated to hypertension and oliguria.

A client is prone to hyponatremia. Which factors should the nurse identify that can precipitate hyponatremia? Multiple selection question Wound drainage Diuretic therapy Gastrointestinal (GI) suction Parenteral infusion of 0.9% sodium chloride Inappropriate anti-diuretic hormone (ADH) secretion

Wound drainage Diuretic therapy Gastrointestinal (GI) suction Inappropriate anti-diuretic hormone (ADH) secretion Wound drainage can result in hyponatremia from loss of sodium ions. Most diuretics interfere with sodium reabsorption in the nephrons and have the side effect of hyponatremia. Gastrointestinal fluids are rich in sodium ions, which are lost by GI suction. With the syndrome of inappropriate anti-diuretic hormone (SIADH), high levels of the anti-diuretic hormone (ADH) are produced, causing the body to retain water instead of excreting it normally in the urine. Parenteral infusion of 0.9% sodium chloride, an isotonic solution, should be compatible with body fluids; if given in excess, it may lead to hypernatremia.

The mother of a 10-year-old boy with mild scoliosis asks the nurse, "How long will my son have to continue his exercises before he's better?" How should the nurse respond? Multiple choice question "At your son's age the exercise program is done for several months." "Wearing a brace daily will probably result in quicker improvement." "Surgery may be necessary, but it will be less involved if the exercises are done." "Even if he keeps doing the exercises, we won't know how much he's improved until he's fully grown."

"Even if he keeps doing the exercises, we won't know how much he's improved until he's fully grown." As the child grows the curvature may progress despite the exercise program. The child should be checked often, because a brace or surgery may become necessary. The younger the child is, the longer he or she will need to exercise; the program should be continued until growth is complete. A brace or surgery may or may not be necessary; specific daily exercises may be all that are necessary to correct functional scoliosis. Maintaining the exercise program does not guarantee that if surgery becomes necessary, it will be less involved.

Which statements by a client with hyperemesis gravidarum would confirm that the client requires further teaching? Multiple selection question "I'll start drinking protein shakes." "I'll start drinking plenty of fluids." "I'll start limiting my carbohydrates." "I'll lie down for at least 2 hours after I eat." "I'll be sure to schedule rest periods throughout the day so I won't get tired."

"I'll start drinking protein shakes." "I'll start limiting my carbohydrates." "I'll lie down for at least 2 hours after I eat." During pregnancy the cardiac sphincter may relax, which allows food to come back up into esophagus when supine. Not lying down for up to 2 hours after eating should provide time for digestion so that food is not regurgitated. The client should not decrease carbohydrate intake. Hyperemesis gravidarum can be aggravated by stress and fatigue. Rest periods may reduce the client's stress level and fatigue and promote relaxation. The client should be encouraged to drink plenty of fluids to help prevent dehydration. Drinking protein shakes can help provide protein needed to decrease the chance of a negative nitrogen balance.

The parents of a preschooler ask the nurse for advice on how to deal with the child's sleep terrors. Which intervention does the nurse recommend the parents follow? Multiple choice question "Do not make the child go back to bed." "Professional counselling might be needed for recurrent episodes." "Sit with the child and offer comfort, assurance, and sense of protection." "It is a normal, common phenomenon that requires relatively little intervention."

"It is a normal, common phenomenon that requires relatively little intervention." The nurse should stress to the parents that sleep terrors are a normal, common phenomenon in preschoolers that requires relatively little intervention. The nurse may advise the parents to guide the child back to bed, if needed, after an episode of sleep terrors. In case the child has a nightmare, the parents should avoid forcing the child back to bed. Professional counselling might be needed for recurrent episodes of nightmares; sleep terrors, on the other hand, are natural in preschoolers. For episodes of nightmares, the nurse would advise the parents to sit with the child and offer comfort, assurance, and sense of protection. For episodes of sleep terrors, the parents should be instructed to intervene only if necessary to protect the child from injury.

A mother complains that her three year old still performs thumb sucking. What should the nurse suggest to the mother? Multiple selection question "Try to engage child in more play activities." "Try to identify if the child is experiencing stress." "Consult a pediatrician immediately because this habit can be harmful to your child." "Be strict with the child whenever he or she sucks his or her thumb.

"Try to engage child in more play activities." "Try to identify if the child is experiencing stress." The nurse should suggest that the mother engage the child in more play activities because playing can help the child release his or her frustration. In a preschooler, thumb sucking may be a sign of stress. Therefore, the mother should try to identify any sources of stress. A pediatrician should be consulted only if thumb sucking occurs past the preschool age. Thumb sucking in preschoolers is not a normal habit although it is a normal coping mechanism for many children.

The primary healthcare provider has prescribed rifampin to a client with tuberculosis. Which instructions by the nurse will be beneficial to the client? Multiple selection question "You should report any yellow tinge to your skin." "Your soft contact lenses will be stained permanently." "You should report any reddish orange tinge to your secretions." "You need to drink at least 8 ounces of water with the medication." "You should report any increased tendency to bruising or bleeding."

"You should report any yellow tinge to your skin." "Your soft contact lenses will be stained permanently." "You should report any increased tendency to bruising or bleeding." Rifampin is a first-line drug in the treatment of tuberculosis and clients should report any yellow tinge to the skin because this may be a sign of liver toxicity or failure. Staining of bodily fluids such as tears, urine, and sweat, is commonly associated with rifampin, so warning the client that contact lenses will be stained will be beneficial. The client should be instructed to immediately report any increased tendency to bruising or bleeding because this may indicate liver toxicity or damage. The need to drink at least 8 ounces of water with the medication is beneficial information for a client prescribed pyrazinamide. A reddish orange tinge to secretions is common with rifampin and not harmful, so it need not be reported.

The nurse is teaching growth and development activities to the parents of a 3-month-old infant. Which statements does the nurse include in the teaching plan? Multiple selection question "Your child should be able to show the grasp reflex." "Your child should be able to coo, babble, and chuckle." "Your child should be able to pull at blankets or clothes." "Your child should be able to put the feet into the mouth when supine." "Your child's head can come up to a 45- to 90-degree angle from the table."

"Your child should be able to coo, babble, and chuckle." "Your child should be able to pull at blankets or clothes." "Your child's head can come up to a 45- to 90-degree angle from the table." Cooing, babbling, and chuckling in a 3-month-old infant indicate normal development. A 3-month-old infant can pull at blankets or clothes and can raise his or her head to a 45- to 90-degree angle from the table. The grasp reflex generally disappears by the age of 3 months. A 3-month-old infant may not able to put his or her feet in the mouth when lying in the supine position. Generally a 5-month-old infant can put his or her feet in the mouth when lying in the supine position.

While performing a physical assessment, the nurse notices a minute, nonpalpable change in the skin color of a client. What might be the type of skin lesion involved? Multiple choice question Wheal Papule Vesicle Macule

A macule is a flat, nonpalpable change in skin color, which is smaller than 1 cm. A wheal is a localized edema, usually caused by a mosquito bite. Wheals are irregular in shape and have elevated surfaces. Papules are palpable, circumscribed solid elevations in the skin, smaller than 1 cm. Vesicles are small, circumscribed skin elevations, filled with serous fluid.

During resuscitation of a critically injured client in a bomb blast, the nurse finds the client is breathing spontaneously. Which nursing intervention would the nurse perform in this situation? Multiple choice question Inserting an endotracheal tube Providing non-rebreather mask Providing mechanical ventilation Providing bag-valve-mask (BVM) ventilation

A non-rebreather mask is used in spontaneously breathing clients. Providing an endotracheal tube and mechanical ventilation is beneficial in clients with significantly impaired consciousness. A client who needs ventilatory assistance during resuscitation requires a BVM ventilation with an appropriate airway adjunct and a 100 percent oxygen source.

The nurse is assessing a Latino-Caribbean patient who was brought to the hospital by family members. The family reports the patient started crying, shouting, trembling, had uncontrolled jerking of the extremities, and then fell into a trance-like state. What condition does the nurse suspect? Multiple choice question Bulimia nervosa Anorexia nervosa Shenjing shuairuo Ataque de nervios

Ataque de nervios is a Latino-Caribbean culture-bound syndrome that usually happens in response to specific stressors. This culture-bound syndrome is characterized by crying, uncontrollable spasms, trembling, shouting, dissociation, and trance-like states. Bulimia nervosa and anorexia nervosa are culture-bound syndromes in the form of eating disorders, but they are not characterized by crying, spasms, and shouting. Shenjing shuairuo is not associated with the Latino-Caribbean culture; instead, it is associated with Chinese culture.

A client on a telemetry unit develops paroxysmal atrial fibrillation. When planning care for this client, what should the nurse consider? Multiple choice question That this condition is rare. That it is frequently is transient. That it requires cardioversion. That it may be life threatening.

Atrial fibrillation increases the risk for a brain attack even without underlying heart disease; the risk is greater with structural heart disease, hypertension, and increasing age. Atrial fibrillation is a common dysrhythmia. Atrial fibrillation may be chronic or intermittent. Antidysrhythmic medications are used initially; cardioversion is used only if the client does not respond to medication.

Thirty minutes after administering fluphenazine to a client, the nurse notes that the client's jaw is rigid, the client is drooling, and speech is slurred. There are a number of as-needed prescriptions in the client's chart. Which will the nurse administer? Multiple choice question Diazepam, 10 mg by mouth Trihexyphenidyl, 1 mg by mouth Haloperidol, 2 mg intramuscularly (IM) Benztropine, 2 mg IM

Benztropine, 2 mg IM Benztropine is an anticholinergic, antiparkinsonian drug used to treat drug-induced extrapyramidal symptoms associated with phenothiazine therapy; the IM route will relieve symptoms more rapidly. Haloperidol is also an antipsychotic and may produce parkinsonism, not relieve it. Diazepam is not effective in reducing extrapyramidal side effects. Although trihexyphenidyl is an appropriate medication, swallowing pills may be difficult for the client; the oral medication should not be administered.

Which organism is responsible for causing Lyme disease in clients? Multiple choice question Phthirus pubis Sarcoptes scabiei Borrelia burgdorferi Pediculushumanus var. corporis

Borrelia burgdorferi Lyme disease is a bacterial infection caused by Borrelia burgdorferi, which is transmitted by ticks. Phthirus pubis causes pediculosis. Scabies is caused by Sarcoptes scabiei. Pediculushumanus var. corporis also causes pediculosis.

Which client is suspected to have an increased risk of hyperlipidemia? Multiple selection question Client with corneal arcus Client with periorbital edema Client with decreased skin turgor Client with paleness of conjunctivae Client with yellow lipid lesions on eyelids

Client with corneal arcus Client with yellow lipid lesions on eyelids The presence of corneal arcus, which is the whitish opaque ring around the junction of the cornea and sclera, indicates that the client has hyperlipidemia. Yellow lipid lesions on the eyelids refer to xanthelasma, which indicates a client has hyperlipidemia. The presence of periorbital edema indicates the client may have kidney disease. Decreased skin turgor may be due to dehydration. Paleness of the conjunctivae indicates anemia.

The nurse is examining the wound of a client and notes greenish-blue pus. What should the nurse interpret from this finding? Multiple choice question Colonization with Proteus Colonization with Pseudomonas Colonization with Staphylococcus Colonization with aerobic coliform and Bacteroides

Colonization with Pseudomonas Greenish-blue pus is formed due to colonization with Pseudomonas bacteria. Beige pus is formed from colonization by Proteus bacteria. Creamy-yellow pus indicates colonization of Staphylococcus bacteria. Brownish pus is a result of colonization with aerobic coliform and Bacteroides.

The nurse is caring for a client who underwent intestinal surgery 3 days ago and notices brownish pus with a fecal odor draining from the incision. What should the nurse infer from this finding? Multiple choice question Colonization with Proteus Colonization with Pseudomonas Colonization with Staphylococcus Colonization with aerobic coliform and Bacteroides

Colonization with aerobic coliform and Bacteroides A client who underwent intestinal surgery is more susceptible to developing colonization of aerobic coliform and Bacteroides, which results in brown pus with a fecal odor. Beige pus that has a fishy odor is formed due to colonization with Proteus. Greenish-blue pus that has a fruity smell is formed due to colonization with Pseudomonas. Creamy-yellow pus indicates a colonization of Staphylococcus.

Which action should the nurse take when caring for clients through a Community-Based Care Transition Program (CCTP)? Multiple choice question Asking a pharmacist to review expected effects of a medication to a client Contacting the client and physician through a conference call line to discuss medication issues Reporting that a client's temperature has increased while receiving a unit of packed red blood cells Directing unlicensed assistive personnel (UAP) to measure vital signs and pass linen on an assigned group of clients

Contacting the client and physician through a conference call line to discuss medication issues One activity within a Community-Based Care Transition Program (CCTP) is assisting with communication between the client and primary and specialty caregivers. Contacting the client and physician through a conference call line to discuss medication issues would be an example of this activity. Asking a pharmacist to review medication effects would be a part of the client-focused care delivery system. Reporting a client's change in vital signs would be an activity conducted by a nurse providing care in a variety of delivery systems. Directing unlicensed assistive personnel (UAP) to measure vital signs and pass linen would be direction provided by a team leader.

A nurse expects a client with a herniated intervertebral disk to report a sudden increase in pain with which activities? . Multiple selection question Coughing or sneezing Sitting on cold surfaces Standing for extended periods Lying supine while flexing the knees Straining when having a bowel movement

Coughing or sneezing Straining when having a bowel movement Coughing or sneezing, as well as lifting and straining, cause an increase in the intraspinal pressure, resulting in pain. Straining when having a bowel movement increases intraspinal pressure, causing pain. Sitting on cold surfaces does not affect the intraspinal pressure and should not cause pain. Although pain with prolonged standing may increase as a result of compression of the vertebrae, the increase is gradual, not sudden. Flexing the knees and hips relieves intraspinal pressure and pain.

The nurse asks the client to shrug the shoulders and to turn the head against passive resistance. Which cranial nerve is involved in this action? Multiple choice question Cranial nerve II Cranial nerve XI Cranial nerve VI Cranial nerve VII

Cranial nerve XI (the spinal accessory nerve) is the motor nerve that coordinates the movement of head and shoulders. Cranial nerve II (optic nerve) is a sensory nerve for visual acuity. Cranial nerve VI (abducens nerve) is a motor nerve that coordinates the lateral movement of eyeballs. Cranial nerve VII or (auditory nerve) is a sensory nerve which coordinates the hearing sense.

The nurse is creating a discharge teaching plan for a client who had a subtotal gastrectomy. The nurse should include what instructions about minimizing dumping syndrome? Multiple selection question Drink fluids with meals. Eat small, frequent meals. Lie down for one hour after eating. Chew food five times before swallowing. Select foods that are low in fiber.

Eat small, frequent meals. Lie down for one hour after eating. Small, frequent meals keep the volume within the stomach to a minimum at any one time, limiting dumping syndrome. Lying down delays emptying of the stomach contents, which will limit dumping syndrome. Fluids should be taken between meals to decrease the volume within the stomach at one time. Dumping syndrome occurs after eating because of the rapid movement of food into the jejunum without the usual digestive mixing in the stomach and processing in the duodenum. Chewing a set number of times before swallowing is not pertinent to solving this problem. High fiber, complex carbohydrates, moderate fats, and high protein in small, frequent meals are recommended to prevent dumping syndrome.

Which condition may lead to collapse of the walls of the bronchioles and alveolar air sacs? Multiple choice question Asthma Emphysema Chronic bronchitis Centrilobular emphysema

Emphysema is a condition in which a dysregulation of lung proteases may lead to the collapse of the walls of the bronchioles and alveolar air sacs. Asthma is a condition that involves a reversible airflow obstruction in the airways. In chronic bronchitis, infections or bronchial irritants cause increased secretions, edema, bronchospasm, and impaired mucociliary clearance. Centriacinar or centrilobular emphysema affect the respiratory bronchioles most severely.

The nurse is working with a client who has a diagnosis of borderline personality disorder. What personality traits should the nurse expect the client to exhibit? Multiple selection question Engaging Indecisive Withdrawn Manipulative Perfectionistic

Engaging Manipulative Clients with borderline personality disorders initially tend to be engaging and to establish intense relationships. They may be manipulative because they are opinionated and want people to conform to their agendas. These clients are often decisive and opinionated, have a pronounced intolerance for being alone, and are usually quite social. These clients are not perfectionists.

A child with pulmonary edema is treated with opioids and furosemide. Which nursing interventions should be performed to promote safe drug administration? Multiple selection question Following the principle of atraumatic care Administering oral drugs with food or snacks Documenting the client's age, weight, and height Exposing the child to sunlight for healthy growth Administering medications if the client reports dizziness or drowsiness

Following the principle of atraumatic care Administering oral drugs with food or snacks Documenting the client's age, weight, and height A local anesthetic should be applied at the injection site to promote atraumatic care. Administering drugs with food reduces gastric discomfort. The client's age, weight, and height should be documented to help ensure correct calculation of the drug dose. A child who is undergoing treatment with diuretics should not be exposed to sunlight because this can cause fluid volume loss and exhaustion. If the client reports dizziness or drowsiness, medications should not be administered until an order is prescribed by the primary healthcare provider.

After assessing the muscle functionality of a client, the nurse assigns a grade of F (fair) on the Lovett scale in the client. What is the muscle functionality of the client? Multiple choice question Full range of motion with gravity Full range of motion with gravity eliminated Full range of motion against gravity with full resistance Full range of motion against gravity with some resistance

Full range of motion with gravity In the Lovett scale, grade F (fair) is given to clients who exhibit a full range of motion with gravity. Full range of motion in passive motion is assigned a P (poor) score. When a client exhibits full range of motion against gravity with full resistance, the client is given an N (normal) score. When a client exhibits full range of motion against gravity with marginal resistance, the client is given a score of G (good).

A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how gamma globulin provides passive immunity? Multiple choice question It increases production of short-lived antibodies. It accelerates antigen-antibody union at the hepatic sites. The lymphatic system is stimulated to produce antibodies. The antigen is neutralized by the antibodies that it supplies.

Gamma globulin, which is an immune globulin, contains most of the antibodies circulating in the blood. When injected into an individual, it prevents a specific antigen from entering a host cell. Gamma globulin does not stimulate antibody production. It does not affect antigen-antibody function.

Which antiinfective agent may lead to blindness if not used correctly by the client in prescribed amounts? Multiple choice question Bromfenac Natamycin Trifluridine Gentamicin

Gentamicin is an antiinfective agent that can lead to blindness if not used in prescribed amounts. The nurse should instruct clients to take this only as prescribed, because bacterial and fungal eye infections may worsen rapidly and can lead to blindness if not treated adequately. Bromfenac is a nonsteroidal antiinflammatory (NSAID) agent and does not lead to blindness. Natamycin is an antifungal agent and trifluridine is a topical antiviral agent; both do not cause blindness.

Which activity performed by the registered nurse (RN) indicates effective supervision of the delegatee? Multiple choice question Assigning the task to the delegatee Taking responsibility of the delegated task Guiding the delegatee while he or she is performing the task Understanding the nurse practice of the state

Guiding the delegatee while he or she is performing the task

A client who is human immunodeficiency virus (HIV) positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissible through what means? Multiple selection question Feces Blood Semen Urine Sweat Tears

HIV, which is the virus that causes acquired immunodeficiency syndrome (AIDS), is transmitted through infected blood, semen, and bloody bodily fluids. HIV is not spread casually. Although HIV may be found in other bodily secretions, including feces, urine, sweat, tears, saliva, sputum, and emesis, the amount of virus is likely not sufficient enough to be transmitted.

A client reports to the hospital with skin lesions. Upon physical examination, the nurse notices circumscribed elevations of the skin, measuring about 0.5 × 0.5 cm. The lesions are filled with serous fluid. What is the suspected cause of these skin lesions? Multiple selection question Venous stasis ulcer Arterial insufficiency Staphylococcal infection Herpes simplex infection

Herpes simplex infection Circumscribed elevated skin lesions filled with serous fluid smaller than 1 cm are called vesicles. Vesicles are found in conditions such as herpes simplex infection and chicken pox. Venous stasis ulcers are characterized by deep loss of skin surface that extends to the dermis and is associated with frequent bleeding. The appearance of shiny and translucent skin with loss of normal furrow indicates arterial insufficiency. In a staphylococcal infection, the skin lesion is similar to that of vesicle, but is filled with pus instead of serous fluid.

An adolescent client who reports bleeding from vagina for 2 months is diagnosed with dysfunctional uterine bleeding. Which assessment findings in the adolescent's history may be relevant? Multiple selection question History of trauma to the vagina Presence of malignant lesions Family history of vaginal bleeding Medical history indicating iatrogenic causes History of early menarche

History of trauma to the vagina Presence of malignant lesions Medical history indicating iatrogenic causes Trauma to the vagina and malignant lesions can cause dysfunctional uterine bleeding as can iatrogenic injuries (i.e., those caused by physician's activity or medical treatment). Family history and early menarche may not be relevant in this condition.

A client admitted to the hospital with a small bowel obstruction is to have an intestinal tube inserted. When preparing the client for the procedure, what action should the nurse take? Multiple choice question Place the client in the right side-lying position Instruct the client about techniques for mouth breathing Spray the client's oropharynx with a local anesthetic solution Reassure the client that the procedure will not cause discomfort

Instruct the client about techniques for mouth breathing Mouth breathing helps to decrease the gag reflex, thereby easing the passage of the intestinal tube. Lying on the right side does not take advantage of gravity and makes the client's naso-oral cavity less accessible to tube passage. Spraying the oropharynx with a local anesthetic solution will make it more comfortable, but it will interfere with swallowing, which is necessary during passage of an intestinal tube. Reassuring the client that passage of an intestinal tube will not cause discomfort is false reassurance; the procedure is not painful, but it is uncomfortable.

Which characteristic does the nurse associate with a punch biopsy? Multiple choice question It is usually indicated for superficial or raised lesions. It is more uncomfortable than other biopsies while healing. It is performed using a circular cutting instrument 2 to 6 mm in diameter. It removes only the portion of the skin that rises above the surrounding tissue.

It is performed using a circular cutting instrument 2 to 6 mm in diameter. Punch biopsy is a common technique that involves the use of a small circular cutting instrument with a diameter of 2 to 6 mm. Shave biopsies are usually recommended for superficial or raised lesions. Excisional biopsies are comparatively more uncomfortable than punch or shave biopsies. Shave biopsies remove the skin portion that rises above surrounding tissues.

A 16-year-old high school student who has anorexia nervosa tells the school nurse that she thinks she is pregnant even though she has had intercourse only once, more than a year ago. What is the most appropriate inference for the nurse to make about the student? Multiple choice question Using magical thinking Submitting to peer pressure Lying about the last time she had intercourse Lacking knowledge that anorexia can cause amenorrhea

Lacking knowledge that anorexia can cause amenorrhea The loss of body fat from anorexia can cause amenorrhea; the client needs information. No data are available to support the fact that the client is using magical thinking, which is characterized by the belief that thinking or wishing something can cause it to occur; in light of the client's diagnosis of anorexia, this is not the first conclusion. Submitting to peer pressure is not related to this type of concern. Although the nurse should question the timeline again, the client's nutritional status should be explored first.

Which diagnostic procedure helps in the detection of uropathologic features in a client who has a urinary pouch or ileal conduit? Multiple choice question Loopogram Cystogram Computed tomography urogram Urethrogram

Loopogram helps in the detection of uropathologic features in a client who has a urinary pouch or ileal conduit. Cystogram helps to visualize the bladder and evaluates vesicoureteral reflux. A computed tomography (CT) urogram provides excellent visualization of kidneys and kidney size can be evaluated. When urethral trauma is suspected, an urethrogram is done before catheterization.

Which adverse effect is least likely to occur in a client who is prescribed clozapine? Multiple choice question Seizures Sedation Akathisia Myocarditis

Myocarditis Clozapine is a second-generation antipsychotic drug. Myocarditis is a very rare side effect caused by clozapine. Seizures, sedation, and akathisia are common side effects of clozapine.

What would be the behavioral characteristic of a slow-to-warm up child according to the theory related to temperament? Multiple choice question Highly active Irritable and irregular in habits Negative reaction to new stimuli A positive mild-to-moderately intense mood

Negative reaction to new stimuli A slow-to-warm up child may react negatively with mild intensity to any new stimuli or a change. A difficult child is highly active as well as irritable and irregular in habits. An easy child usually has a positive mild-to-moderately intense mood.

A client has non-pitting edema over the tibia. What could be the most possible cause of the client's condition? Multiple choice question Endocrine imbalance Inflammatory response Fluid and electrolyte imbalance Venous and cardiac insufficiency

Non-pitting edema occurs due to endocrine imbalance. Inflammatory response causes localized edema. Pitting edema occurs due to fluid and electrolyte imbalance and venous and cardiac insufficiency.

What should a nurse incorporate into the plan of care for a school-aged child hospitalized with acute glomerulonephritis (AGN)? Multiple selection question Weighing daily Restricting fluids Monitoring intravenous therapy Instituting isolation precautions Checking the blood pressure hourly

Weighing daily Restricting fluids Comparing daily weights is an objective measure of fluid balance and response to diuretic therapy. Fluids, as well as sodium, are restricted in the presence of oliguria. Intravenous therapy is not needed unless there is an emergency. Isolation is unnecessary because the illness is not communicable. Although the blood pressure is closely monitored, it need not be taken hourly.

A client has had two weeks of bile drainage from a T-tube following the client's cholecystectomy. To monitor for a lack of fat-soluble vitamins, the nurse should observe for what symptom? Multiple choice question Easy bruising Muscle twitching Excessive jaundice Tingling of the fingers

Phytonadione, a precursor for prothrombin, cannot be absorbed without bile. Muscle twitching is commonly related to electrolyte imbalances, not fat-soluble vitamin deficiency. Jaundice results from a backup of bile, not a deficiency of fat-soluble vitamins. Tingling of the fingers may be related to electrolyte imbalances or deficiency of B vitamins, which are water soluble.

What is the immediate nursing intervention for a client experiencing autonomic dysreflexia? Multiple choice question Administering an alpha blocker Placing the client in a sitting position Giving nifedipine or nitrate as prescribed Monitoring blood pressure every 15 minutes

Placing the client in a sitting position The immediate nursing intervention for a client experiencing autonomic dysreflexia is to place the client in sitting position to prevent falls. A client with recurrent autonomic dysreflexia is administered an alpha blocker as a prophylactic treatment. Nifedipine or nitrates are given after the client is placed in a stable sitting position. Blood pressure is monitored after the client is in a stable position.

The nurse accompanies a 3-year-old child to the playroom. The toddler seems afraid to select a toy or activity. What age-appropriate play materials should the nurse offer? Multiple selection question Plastic tea set Mold and clay Play telephone Pencil and paper Simple electronic game

Plastic tea set Mold and clay Play telephone Simple electronic game Toddlers are entering the developmental stage of creative and imaginative play. Holding an imaginary tea party is a safe, appropriate activity for a toddler. Using clay to make shapes, both with and without a mold, enhances toddlers' creativity and improves their fine motor coordination. Creative, imaginative, and imitative play is associated with toddlers. Simple electronic games and computer programs are especially valuable in helping children learn basic skills, such as letters and basic words. A 3-year-old child is too young to manipulate a pen or pencil and may cause self-injury or an injury to others.

Which components of a hospital service represent the process factor in the Avedis Donabedian model? Multiple selection question Promotion of continuity of care Adequacy of patient education Quality of interpersonal relations Adequacy of equipment and supplies Provider's knowledge and supervision

Promotion of continuity of care Adequacy of patient education Quality of interpersonal relations The Avedis Donabedian model contains three factors that affect the quality of health care. These include structure, process, and outcome. The process is the intermediating factor between the structure and the outcome of patient care. Process includes the quality of interpersonal relations between the patient and the staff, and among the health care team. Promotion of the continuity of care is another factor in process that affects the care once the patient leaves the health care facility. Adequacy of patient education is a process factor that promotes self-care in the patient. Adequacy of equipment and supplies and the provider's knowledge and supervision are the factors included in the structure attribute of the Avedis Donabedian model.

Which two factors would the nurse state influence the effectiveness of the leader? Multiple selection question Ability Attitude Readiness Willingness Assessment

Readiness & assessment Readiness and assessment are two of the factors that influence the effectiveness of the leader. Ability and willingness are the two factors that need to be assessed to determine the level of the leader's readiness. The attitude is related to the individual's willingness.

The bed alarm is ringing because an older adult client is attempting to get out of bed. A nurse enters the room and finds the client agitated and confused. The family member is upset and states, "He has never been like this. I don't know what to do." After getting the client back into bed, which nursing action is most appropriate? Multiple choice question Asking the family member to step out of the room so the client can rest Placing a vest restraint on the client to prevent the client from falling out of bed Explaining to the family that it is common for older clients to get confused while in the hospital Requesting the nursing assistant to stay with the client while the nurse calls the primary healthcare provider

Requesting the nursing assistant to stay with the client while the nurse calls the primary healthcare provider Because this is new for the client, the nurse should notify the primary healthcare provider. The client should be monitored continually for a while to prevent falling or injuring himself. This is an appropriate task to delegate to a nursing assistant. Since this is new for the client, reassuring the family that older adult clients often get confused in the hospital is not helpful. Evidence-based practice has shown that having a family member with the client is helpful. Therefore, the family member should be encouraged to stay with the client. Placing a restraint on the client should be done as a last resort and not instituted without a primary healthcare provider's prescription.

A newborn has just been admitted to the pediatric surgical unit from the birth hospital with a diagnosis of tracheoesophageal fistula. In what position should this child be maintained? Multiple choice question Prone, to reduce risk of aspiration Trendelenburg, to drain stomach contents Semi-Fowler, to reduce the risk of chemical pneumonia Supine, to reduce the risk of sudden infant death syndrome

Semi-Fowler, to reduce the risk of chemical pneumonia Because of the connection between the lower esophagus and the trachea, this child is maintained in a semi- to high Fowler position to reduce the risk of acidic stomach contents entering the trachea and causing inflammation of the lung tissues. Vomiting may or may not occur with this type of defect, because the esophagus does connect to the stomach. The semi-Fowler position would be more effective than the prone position in reducing aspiration. The Trendelenburg position will increase the risk of pneumonia. The concern is the tracheoesophageal fistula, not the risk of sudden infant death syndrome.

During administration of an enema, a client reports having intestinal cramps. What should the nurse do? Multiple choice question Discontinue the procedure. Instill the fluid at a slower rate. Lower the height of the container. Stop the fluid until the cramps subside.

Stop the fluid until the cramps subside. Administration of additional fluid when a client reports experiencing abdominal cramps adds to discomfort because of additional pressure. By clamping the tubing a few minutes, the nurse allows the cramps to subside, and the enema can be continued. Cramps are not a reason to discontinue the enema entirely; temporary clamping of the tubing usually relieves the cramps, and the procedure can be continued. Slowing the rate decreases pressure but does not reduce it entirely. Lowering the height of the container will reduce the flow of the solution, which will decrease pressure but not reduce it entirely.

Which assessment finding alerts the nurse to stop administering haloperidol to a client until further laboratory work is done? Multiple choice question Grimacing Shuffling gait Yellow sclerae Photosensitivity

Yellow sclerae Yellow sclerae is a sign of jaundice, indicating an increase of liver enzymes, which may be irreversible even if drug therapy is discontinued. Although grimacing may be a sign of a serious side effect, it may also just be a behavioral response of the disorder; the nurse should notify the primary healthcare provider rather than withhold the drug. Shuffling gait is a parkinsonian symptom that can be reversed with treatment; continuation of the medication is permitted. Photosensitivity is not a problem as long as the client is cautioned to stay out of the sun.

A nurse is caring for a client who is using paranoid ideation. How should the nurse begin to establish a trusting relationship? Multiple choice question Seeking the client out frequently to spend long blocks of time together Sitting in the unit and observing the client's behavior throughout the day Being available on the unit to meet with the client at mutually acceptable times Calling the client into the office to establish a contract for regular therapy sessions

The recommended approach for working with suspicious clients is to allow them to set the pace for the relationship. Seeking the client out to spend long blocks of time together, sitting and watching the client's behavior on the unit, or calling the client into the office to establish a contract may be perceived as threatening and add to the client's feelings of paranoia.

Which standards would the nurse explain are important for critical thinking? Multiple selection question Specific Fairness Relevant Confidence Independence

The standards important for critical thinking are specific and relevant knowledge about a task. Fairness, confidence, and independence are the attitudes required for critical thinking.

After several days of intravenous (IV) therapy for chloroquine-resistant malaria, the health care provider replaces the IV medication with oral quinine, 2 g per day in divided doses. The nurse advises the client to take this medication after meals for what purpose? Multiple choice question To delay its absorption To minimize gastric irritation To reduce its antidysrhythmic action To decrease stimulation of the appetite

To minimize gastric irritation

An older adult with a history of small cell lung carcinoma reports muscle cramping, thirst, and fatigue. The primary healthcare provider diagnoses the client with a pituitary disorder and is treating the client accordingly. Which is an effective outcome of the treatment? Multiple choice question Urine output of 10 L/day Urine specific gravity less than 1.025 Urine osmolarity of 80 mOsm/kg (80 mmol/kg) Serum osmolarity of 600 mOsm/kg (600 mmol/kg)

Urine specific gravity less than 1.025 Because the specific gravity is less than 1.025 after treatment, the outcome is considered positive. In syndrome of inappropriate antidiuretic hormone (SIADH), the specific gravity is greater than 1.025. Small cell lung cancer is a risk factor of SIADH. Muscle cramping, thirst, and fatigue are clinical manifestations of SIADH. A serum osmolarity of 600 mOsm/kg indicates central diabetes insipidus. A urine output 10 L/day and a urine osmolarity of 80 mOsm/kg indicate diabetes insipidus.

Which physiologic changes may occur during the first trimester of pregnancy? Multiple selection question Fatigue Increased libido Morning sickness Breast enlargement Braxton Hicks contractions

fatigue, morning sickness, breast enlargement