sample questions

1. Akathesia 2. Dystonia 3. Tardive Dyskenisia 4. Akinesia

1. Restless 2. Upward gaze of eyes 3. Movement of tongue/face 4. Lack of movement

Deep Tendon Reflex Scale

0 - absent +1 - trace +2 - normal +3 - brisk +4 - non sustained clonus +5 - sustained clonus

The unit charge nurse is responsible for reporting all Healthcare Associated Infections. Which client condition needs to be reported? 1) 36 year old diagnosed with Clostridium Difficile while receiving IV antibiotics. 2) 24 year old admitted with an apparent spider bite grows Methicillin-resistant Staphylococcus aureus from a culture. 3) 47 year old with Ulcerative Colitis exhibiting diarrhea. 4) 75 year old with a fever of 100.2º two days post gastrectomy.

1) 36 year old diagnosed with C. Diff while receiving IV antibiotics. C. Diff is a spore forming bacterium that has significant Healthcare-associated infections (HAI) potential. A more virulent strain has affected healthcare facilities throughout the US. NO: 24 year old admitted with an apparent spider bite grows Methicillin-resistant Staphylococcus aureus from a culture. (evidence indicates that this is a community acquired infection) Ulcerative Colitis- diarrhea normal Low grade fever- expected after surgery **HOSPITAL ACQUIRED INFXN vs. COMMUNITY ACQUIRED INFXN**

A RN on the general pediatric unit has been reassigned to the spinal/neurology unit. What assignment by the charge nurse would be appropriate for the RN? 1) A child with spina bifida with a previous shunt revision, and an adolescent that is 4 days post op from a spinal fusion. 2) A child with a ventriculoperitonial shunt one day post op, and a child with spinal muscle atrophy that is ventilator assisted. 3) A child with cerebral palsy that had a tracheostomy performed this am, and a child with closed head injury from an accident 3 days ago. 4) A child with an intracranial screw whose ICP is stable, and a child with myelomeningocele that had a skin graft due to a decubitus ulcer in the sacral area.

1) A child with spina bifida with a previous shunt revision, and an adolescent that is 4 days post op from a spinal fusion. The shunt revision and the 4 day post op spinal fusion will be the most stable and will require the least skill level when compared with the other 3 choices. On a general pediatric unit the nurse would be familiar with checking for increased ICP which would be necessary for caring for the shunt revision. Also, the adolescent with spinal fusion would require special turning and assessment of lungs to prevent and observe for congestion/pneumonia. This would be skills the nurse has and expected when working on a general floor. Clients in the other assignments are more acute and require higher skill level. Intracranial Screw (measures subarachnoid pressure)

Twelve hours post coronary artery bypass surgery (CABG), the nurse notes the client's level of consciousness has decreased from alert to somnolent. BP 88/50, HR 130 and thready, Resp 32, urinary output (U/O) has dropped from 100 ml one hour earlier to 20 mL this hour. What would be the nurse's first action? 1) Administer high flow oxygen per mask. 2) Lower the head of the bed in order to raise BP. 3) Give the ordered Lasix to increase urinary output. 4) Re-check the BP in the other arm.

1) Administer high flow oxygen per mask. This client has developed signs of CARDIOGENIC SHOCK, one of the complications post CABG. Cardiac output is decreased, so the client needs more oxygen for the circulating blood volume. The primary healthcare provider also needs to be notified STAT. Lowering the HOB will not help in cardiogenic shock, but will actually make it harder for the heart to pump.

Which are risk factors for post-influenza complications? SATA 1) Age > 65 years. 2) Midlle age client living alone 3) Diabetes. 4) Renal disease. 5) Clients who reside in a nursing home.

1) Age > 65 years. 3) Diabetes. 4) Renal disease. 5) Clients who reside in a nursing home.

The client has been taking divalproex for the management of bipolar disorder. The nurse should give priority to monitoring which laboratory test? 1) Alanine aminotransferase (ALT) 2) Serum glucose 3) Serum creatine 4) Serum electrolytes

1) Alanine aminotransferase (ALT) ALT levels will increase primarily in Liver damage/disorders. A side effect of administering divalproex is drug induced hepatitis. Divalproex (Depakot) antiseizure/mood stabilizer.

A child is admitted to the hospital with a temp of 102.2ºF/ 39.0ºC, lethargic, and no urinary output in 6 hours. Which prescription would be PRIORITY for this child? 1) Blood cultures times two 2) Rocephin 250 mg every 12 hours 3) Start IV & monitor site. 4) ½ normal saline at 40 mL/hr

1) Blood cultures times two Immediate blood cultures should be obtained on a child, as sepsis is suspected with any temperature this high. IV can be started at any point, but should be done after the cultures. Fluids will be started after the cultures and after the IV is started. Start abx after cultures.

Which assessment measures would be appropriate to review as a health promotion plan is developed for a client trying to improve his eating habits? SATA 1) Body mass index 2) Waist circumference 3) Serum cholesterol, triglycerides 4) Calcium, sodium, potassium, iron 5) Cortisol levels

1) Body mass index 2) Waist circumference 3) Serum cholesterol, triglycerides 4) Calcium, sodium, potassium, iron Mineral levels are important indicators of nutritional status. Cortisol levels indicate levels of stress which indirectly affect intake of food. This would not be assessed routinely for nutritional status.

A school nurse is planning a session on the effects of cannabis use for a high school health class. Which information does the nurse need to include? SATA 1) Cannabis ingestion can cause tachycardia. 2) Inhaled cannabis produces a greater amount of tar than tobacco. 3) Cannabis smoke contains more carcinogens than tobacco smoke. 4) It is not possible to overdose on cannibis. 5) Orthostatic hypotension can be caused by cannabis injections.

1) Cannabis Ingestion can cause Tachycardia. 2) Inhaled cannabis produces a greater amount of tar than tobacco. 3) Cannabis smoke contains more carcinogens than tobacco smoke. 5) Orthostatic hypotension can be caused by cannabis injections. It is possible to overdose on cannabis. Symptoms include fatigue, paranoia, delusions, hallucinations, and possible psychosis.

Which interventions should the nurse include when planning care for a client diagnosed with paranoid personality? SATA 1) Develop a trusting relationship. 2) Be honest when communicating with the client. 3) Initiate group therapy. 4) Have the client clean the day room daily. 5) Give clear explanations of procedures before hand.

1) Develop a trusting relationship. 2) Be honest when communicating with the client. 5) Give clear explanations of procedures before hand. These clients are not open and suspect everyone of causing problems for them. They suspect that others are using or exploiting them.

The nurse determines that a client does not have an advance directive. The daughter is designated to make health care decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate for this client? SATA 1) Document the client's statement in the client's own words. 2) Provide information on advance directives to the client. 3) Inform the client that personnel are available to assist with completing an advance directive. 4) Avoid inquiring about a client's advance directive as this could cause the client anxiety and concern. 5) Ask the daughter if she agrees with her mother's decision.

1) Document the client's statement in the client's own words. 2) Provide information on advance directives to the client. 3) Inform the client that personnel are available to assist with completing an advance directive. The nurse should document the client's statement in the client's own words. The nurse should provide the client with information on advance directives and reassurance that there are hospital personnel to assist with completing the advance directive.

The nurse has just received report and is going to enter the room of a newly admitted client with nephrotic syndrome. Which findings are expected? SATA 1) Edema 2) Hyperalbuminemia 3) Protenuria 4) Malaise 5) Urolithiasis

1) Edema 3) Protenuria 4) Malaise Hypoalbuminemia occurs in nephrotic syndrome. Kidney stones are not expected finding with nephrotic syndrome.

What information should be included in the health promotion plan for parents of toddlers and the promotion of adequate bowel elimination in toddlers? SATA 1) Include adequate fiber in the diet through whole grains and fruits. 2) Increase intake of water daily. 3) Provide toileting opportunities that are free from distractions. 4) Encourage the toddler to go to the bathroom at least three times daily. 5) Take away attention from the toddler if he cannot potty.

1) Include adequate fiber in the diet through whole grains and fruits. 2) Increase intake of water daily. 3) Provide toileting opportunities that are free from distractions. The toddler should be taken to the bathroom after meals & bedtime to encourage adequate elimination. Don't take away attention if he can't potty. Embarrassment or punitive measures will not yield positive results. Rather, the toddler should be praised for using the potty.

The nurse is caring for a client with hyperparathyroidism. The nurse will monitor the client for which complications? SATA 1) Kidney stones 2) Diarrhea 3) Osteoporosis 4) Tetany 5) Fluid volume deficit

1) Kidney stones 3) Osteoporosis Hypercalcemia. Too much calcium in blood = too much calcium in urine and increased risk of kidney stones. PTH is pulling the calcium from the bones leaving them weak. Hyperparathyroidism leads to constipation not diarrhea. Tetany is s/s of hypoparathyroidism. FVD doesn't apply.

Which nursing interventions are appropriate for a client hospitalized with Dissociative Amnesia? SATA 1) Obtain client likes and dislikes from family members. 2) Flood the client with data regarding the forgotten past. 3) Expose client to stimuli that was a happy memory of the past. 4) Hypnotize the client to help restoration of memory. 5) Ensure client safety.

1) Obtain client likes and dislikes from family members. 3) Expose client to stimuli that was a happy memory of the past. 5) Ensure client safety.

The nurse notes that a stroke client has impaired swallowing. Which interventions are appropriate for the nurse to include in the plan of care? SATA 1) Sit the client up at a 90 degree angle during meals. 2) Assist the client to hyperextend the head when preparing to swallow. 3) Encourage the client to sit up for 30 minutes after eating. 4) Educate a family member on the Heimlich maneuver. 5) Start the client on a thin liquid diet.

1) Sit the client up at a 90 degree angle during meals. 3) Encourage the client to sit up for 30 minutes after eating. 4) Educate a family member on the Heimlich maneuver. The client should position the head in forward flexion in preparation for swallowing: called the "CHIN TUCK".

The nurse is planning health promotion strategies for a 31 year-old single mother who is trying to increase her physical activity level and expresses a lack of time. Which interventions would help the client get more regular physical activity into her day? SATA 1) Suggest that she walk up and down steps at her home several times each morning and evening. 2) Suggest that she park further away from the car when completing grocery shopping or errands. 3) Take the girls walking with her in the evening instead of watching TV with them. 4) Suggest that she awaken one hour early in the morning to go to the gym. 5) Suggest that she walk for 30 minutes with a buddy each afternoon before she leaves work.

1) Suggest that she walk up & down steps at her home several times each morning and evening. 2) Suggest that she park further away from the car when completing grocery shopping or errands. 3) Take the girls walking with her in the evening instead of watching TV with them. NO: Suggest that she walk for 30 minutes with a buddy each afternoon before she leaves work (This plan would only increase time demands and possibly financial demands if the children have to be cared for by someone else at an extra charge each day)

1. Dysphagia 2. Dysphasia/Apashia

1. Dysphagia = difficulty swallowing 2. Dysphasia/Apashia = impairment of speech/comprehension of speech

The family of an elderly woman asks the nurse how to help their mother sleep better. The family's sleep is disturbed as a result and the family is concerned that their mother is not getting restful sleep. Which questions would be important for the nurse to ask? SATA 1.) Has there been any change in your mother's state of health? 2.) Can family members take naps during the day? 3.) Does she take routine diuretics? 4.) Has there been an increase in noise levels? 5.) Can the family take turns in managing the mother's sleep problems?

1.) Has there been any change in your mother's state of health? 3.) Does she take routine diuretics? 4.) Has there been an increase in noise levels? The focus is to help the mother of the family to sleep better. There may be a physical reason for the difficulty sleeping, perhaps pain or presence of an infection. Diuretics should be scheduled early in the day so as not to interfere with sleep. Perhaps there has been a change in medication schedule. Changes in the sleep environment, such as an additional TV in the home or other noise may impact sleep.

The oncoming nurse has just received report and is preparing to make her initial rounds. Which postpartum client should the nurse see first? 1) A primipara 6 hours postpartum saturating one peripad every two hours 2) A multigravida 1 hour postpartum and complaining of intense perineal pain 3) A primigravida 12 hours postpartum with the uterine fundus at the umbilicus 4) A multigravida 72 hours postpartum with a brownish pink lochia discharge.

2) A multigravida 1 hour postpartum and complaining of intense perineal pain Intense perineal pain is a symptom of a perineal hematoma (a localized collection of blood outside the blood vessels), which is a medical emergency. Other choices, expected findings for the postpartum period described.

When should the primary healthcare provider be notified by the nurse in the event of a medication incident? SATA 1) All of the time 2) Client is harmed or dies. 3) Medication incident is a near miss. 4) Nurse administers an incorrect dosage. 5) Client questions the medication color.

2) Client is harmed or dies. 4) Nurse administers an incorrect dosage. The primary healthcare provider should be notified if harm is brought to the client or death occurs as a result of the medication incident. The primary healthcare provider should be notified if the nurse administers an incorrect dosage to the client. An incident report needs to be completed in this situation. **Near misses (unplanned event, that DID NOT result in injury) & all med events, do not need to be reported to the PCP**

The nurse is planning discharge teaching regarding safety for a client with thrombocytopenia. Which points should the nurse include? SATA 1) Floss between teeth twice a day. 2) Do not eat hard food. 3) Take a laxative every day to prevent straining 4) Wear shoes with firm soles while ambulating. 5) If bumped, apply ice to site for 20 minutes.

2) Do not eat hard food. 4) Wear shoes with firm soles while ambulating. 5) If bumped, apply ice to site for 20 minutes. Hard food can cause bleeding as it passes through the esophagus. Can cause gums to bleed. Firm soles on shoes can prevent puncture wounds while ambulating. Ice will prevent hematoma formation and stop bleeding. A LAXATIVE is too harsh and can cause irritation and bleeding. A STOOL SOFTENER should be TAKEN DAILY to prevent a hard stool.

A homeless person has been admitted to the medical unit and placed on airborne precautions for suspected Pulmonary Tuberculosis. The nurse will assess for which signs and symptoms? SATA 1) Weight gain. 2) Fatigue. 3) Bloody sputum 4) Diaphoresis during sleep 5) Anorexia.

2) Fatigue. 3) Bloody sputum 4) Diaphoresis during sleep 5) Anorexia.

The client is admitted with a period of unobserved loss of consciousness and now has an EEG scheduled this am. What intervention should the nurse implement? 1) Keep NPO and hold medication. 2) Hold sedatives, but allow client to have breakfast and give other meds. 3) Administer meds, but hold anticonvulsants. 4) Give additional fluids and some caffeine prior to the test.

2) Hold sedatives, but allow client to have breakfast and give other meds. prior to an EEG we want the client to eat so the blood sugar does not drop and take medications, except sedatives, prior to the EEG.

The ED called the LDR to give report on a 24 year old primigravida at term and having contractions every 5-8 minutes. The unit is very busy, and all the RNs are with other clients. What action by the charge nurse would be most appropriate? 1) Request that the ED hold the client until one of the RNs is available to do the initial assessment. 2) Instruct the LPN to obtain initial vital signs and connect the client to a fetal monitor, then report this data to the charge nurse. 3) Assign an LPN to complete the nursing history and an initial obstetric assessment on this client. 4) Inform one of the RNs that a client is coming from the ED and that a nursing history should be completed as soon as possible.

2) Instruct the LPN to obtain initial VS and connect the client to a fetal monitor, then report this data to the charge nurse. Obtaining VS and placing clients on electronic fetal monitors are within the scope of practice of LPNs. The ED is not staffed to care for a client in labor. LPNs are not qualified to perform assessments.

The nurse sees that the new medication noted in a recent medication prescription is on the client's list of allergies. In the role of client advocate, what actions should the nurse take to ensure client safety? SATA 1) Document the medication with times and doses to be given, then administer the medication as ordered. 2) Notify the primary healthcare provider immediately that the medication ordered is on the client's list of medication allergies. 3) Discontinue the medication on the client's medication administration record. 4) Check the client's allergy band against the list of client allergies documented in the medical record. 5) Call the pharmacy to see if the medication needs to be changed.

2) Notify the primary healthcare provider immediately that the medication ordered is on the client's list of medication allergies. 3) Discontinue the medication on the client's medication administration record. 4) Check the client's allergy band against the list of client allergies documented in the medical record. No, the primary healthcare provider, not the pharmacy, should be notified for medication changes.

An elderly client has suffered a cerebrovascular accident (CVA) and as a result has left homonymous hemianopia. Based on this fact, what measure will the nurse include in the client's initial plan of care? 1) Approach the client from his left side. 2) Place the client's meal on the right side of the over bed table. 3) Request a consult for an ophthalmologist. 4) Stand directly in front of the client when addressing.

2) Place the client's meal on the right side of the over bed table. Hemianopia is blindness in ½ of the visual field. The client has lost half of the visual field in the Left eye. To avoid startling the client and so the client can better view the food, the nurse knows to approach the client from the right side. Standing in front of the client does not address the client's visual field deficit. Standing in front of the client is appropriate for clients who have tunnel vision, but not for clients with homonymous hemianopia.

The Health Insurance Portability and Accountability Act (HIPAA) was federal legislation enacted in 1996. What are some of the components of HIPAA? SATA 1) Gives every person access to free health care. 2) Provides the public more widespread access to health insurance. 3) Provides protection and privacy of health information. 4) Designates a surrogate for the client if he becomes unable to make informed health care decisions. 5) Establishes legal requirements for appropriate sharing of client's personal health information.

2) Provides the public more widespread access to health insurance. 3) Provides protection and privacy of health information. 5) Establishes legal requirements for appropriate sharing of client's personal health information. HIPAA provides that every person is guaranteed access to health care but does not provide for free health care.

The nurse working in a high school educates the students about car accident prevention. The nurse tells the students that teenagers at highest risk for a motor vehicle crash are those who: 1) Have just turned 19 years of age. 2) Recently acquired a driver's license. 3) Car-pool to the senior prom. 4) Drive to weekly football games.

2) Recently acquired a driver's license. crash risk is particularly high during the first year that teenagers are eligible to drive. While teenagers who are 19 years old, car-pooling to the senior prom, and driving to weekly football games are also at risk for a motor vehicle crash, they are not the highest-risk teenage group.

The client arrives in the emergency department with crushing substernal chest pain radiating down the left arm. You are at the bedside with emergency equipment available. Which measure would you initiate first? 1) Cardiac monitor 2) Supplemental oxygen 3) IV line 4) Call the emergency department primary healthcare provider to the bedside

2) Supplemental oxygen Not Cardiac Monitor- Looking & Watching as pt. dies Getting IV line ready is good, but start with O2 Yes, the ED PCP will be there shortly, but get started with O2

A client was admitted to the SNF approximately 3 months ago. Since admission, the client has lost 8 pounds. There have been no documented changes in the client's physical health. Which strategy may help to improve caloric intake for this client? 1) Encourage the client to eat meals in the room. 2) Take the client to the dining room for all meals. 3) Provide a high protein supplement 30 minutes before meals. 4) Ask the unlicensed assistive personnel to feed the client at each meal.

2) Take the client to the dining room for all meals. The client may be lonely and miss the interaction with others. Eating with others may help to improve appetite and intake of food. A high protein supplement may increase caloric intake; however, to give that to the client 30 minutes before a meal will interfere with food intake at mealtime.

Which situation would the nurse respond to first? 1) X-ray confirms that the newly placed central venous catheter's tip is located in the internal jugular. 2) The intravenous tubing is disconnected from a client's central line catheter 3) Purulent drainage at the exit site of a tunneled Groshong central line catheter. 4) Blood cannot be aspirated from a short-term central venous catheter.

2) The intravenous tubing is disconnected from a client's central line catheter The IV tubing being separated from the client's central line catheter would cause the client to lose blood and/or air to enter. If the tubing is not reconnected or the catheter clamped, the client could lose a large amount of blood quickly. Also air could enter the system causing emboli. This situation would need to be dealt with first to prevent life-threatening problems. Cath Tip in Internal Jugular- This would need to be reported to the primary healthcare provider so that the catheter can be correctly placed. The nurse would not use the central line until correct placement is confirmed by X-ray. Of the situations presented here, it does not have to be dealt with first. Not being able to aspirate blood from a central line catheter could mean that a fibrin sheath has formed at the end of the catheter. This situation would have to be dealt with but not before dealing with the IV tubing being separated from the central line catheter.

A client requires assistance to ambulate and needs to use the bathroom. The call light has been left out of reach rendering the client unable to summon staff for assistance. Which client right is violated? 1) The right to participate in the plan of care and treatment decisions 2) The right to freedom from unreasonable restraint 3) The right to privacy 4) The right to considerate and respectful care

2) The right to freedom from unreasonable restraint A client requiring assistance for any ADL needs access to call for assistance from the health care staff. Denial of access to care by removal of access devices is unreasonable restraint.

A community health nurse prepares a presentation about decreasing the risk of spreading influenza in the community. The presentation most likely includes which information? 1) The flu is transmitted via the flu vaccine. 2) Use a shirtsleeve when coughing or sneezing if tissue is not available. 3) Tissues are not effective in decreasing the spread of the flu. 4) Antibiotics are effective in treating the flu.

2) Use a shirtsleeve when coughing or sneezing if tissue is not available. The flu vaccine contains a dead virus that is not capable of causing the flu. Clients may experience flu-like symptoms from the flu vaccine, but they won't contract the full-fledged virus.The flu is treated with antipyretics, fluids, and rest.

A nurse has responded to the scene of a natural disaster and starts to triage clients. The nurse would tag the client with which problem as BLACK? 1.) One with a traumatic amputation to the left lower leg. 2.) One with 2nd and 3rd degree burns over 75 % of the body. 3.) One suffering from a fracture of the humerus. 4.) One with a BP of 90/40 and lethargic.

2.) One with 2nd and 3rd degree burns over 75 % of the body. 2nd and 3rd degree burns over 60% of the body puts the client in the triage category of black- expectant: injuries are extensive and chances of survival are unlikely

A client who has a history of major depression is in the emergency room. Which statement would demonstrate a risk for suicide or self-directed injury? 1) "I can't do anything right anymore." 2) "I am not sure what to do anymore." 3) "I just cannot take this loneliness anymore." 4) "No one cares about me."

3) "I just cannot take this loneliness anymore." This statement indicates that the person cannot tolerate the current situation so this should alert the nurse to carefully watch this client. •Can't do anything right = low self esteem •I'm not sure what to do anymore= indecisive •No one cares about me = social isolation/low self esteem

While the postpartum nurse was in report, four of her clients called the nurse's station for assistance. Which client should the nurse see first? 1) A client with three dime sized clots on her perineal pad. 2) A breastfeeding client who is complaining of uterine cramping. 3) A client complaining of blood running down her legs upon standing. 4) A client who had an epidural and is now complaining of a headache.

3) A client complaining of blood running down her legs upon standing. Check her fundus. If the fundus is boggy, a fundal massage will need to be done. If the fundus is not boggy (contracted), the blood running down the legs is normal as blood pools in the vagina while the client is lying down. The peripad can not contain all the blood upon standing. 3 dime size clots normal. Worry about nickel size clots (5 cents) A post epidural headache can be an indication of inadvertent puncture of the dural membrane. This client will need to be positioned PRONE, PUSH FLUIDS, GIVEN CAFFEINE and may need a BLOOD PATCH to seal the dural leak.

Which pediatric client should the nurse see first? 1) A six year old with a femur fracture. 2) A two year old with a fever of 102 degrees F. 3) A three year old with wheezes in right lower lobe. 4) A two year old whose gastrostomy tube came out.

3) A three year old with wheezes in right lower lobe. The child having respiratory difficulty should be seen first. Is important to see, but is no interference with an immediate vital function such as airway and breathing.

A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What statement made by the client indicates that teaching has been effective regarding safe needle disposal? 1) No special handling of the syringes is necessary. 2) A hospital issued biohazard container must be used. 3) Any hard plastic container with a screw-on cap may be used. 4) The needles must be brought to the nearest hospital for disposal.

3) Any hard plastic container with a screw-on cap may be used. At home, needles, syringes, and sharps may be disposed of in a hard plastic container placed into the regular trash. This protects the sanitation engineers from becoming injured by the sharps. The hospital need not be involved in sharps disposal in the home.

Which medications below are used to help decrease tremors for clients with hyperthyroidism? 1) Steroids 2) Anticonvulsants 3) Beta blockers 4) Iodine compounds

3) Beta blockers Anticonvulsants- No! Tremor is not a seizure Iodine compounds- decrease production of Thyroid hormones, but doesn't help tremors

An elderly client receives instructions regarding the use of warfarin sodium. Which statement indicates the client understands the possible food interactions which may occur with this medication? 1) I'm going to miss having my evening glass of wine now. 2) I told my daughter to buy bananas for me. I'll have to eat more of those now. 3) I will have to watch my intake of salads, something that I really love. 4) I am going to begin eating more fish and pork and leave beef alone now.

3) I will have to watch my intake of salads, something that I really love. Clients taking warfarin sodium must watch their intake of vitamin K, which is present in leafy green vegtables, tomatoes. Wines does not affect the use of warfarin sodium.

A Mexican immigrant family lives in an old, run-down apartment building situated close to a salvage yard in a poor neighborhood. Which area of assessment would be most important for the home health nurse? 1) Immunization status. 2) School-related problems. 3) Lead poisoning. 4) Signs of child abuse.

3) Lead poisoning. Lead may be found in the soil around rusted cars. Old paint contains lead. Chips of paint may be consumed by young teething children. Old run down apartments may also have pipes which contain lead. Consuming even small amounts of lead can be harmful. Although the nurse does need to check immunizations, the hints in the stem are indicating several problems that could lead to Lead poisoning which is the priority.

The nurse is to start administration of antimicrobial therapy to the client. Which would be a priority to include in the plan of care? 1) Accurate I&O throughout therapy 2) Monitor liver and blood tests throughout therapy 3) Teach client signs and symptoms of adverse reactions to report 4) Encourage the client to increase fluids to 8-10 glasses per day

3) Teach client signs and symptoms of adverse reactions to report According to the antimicrobial agent, there may be indication for monitoring blood and/or liver functions, but not the priority answer. The client should be taught signs and symptoms to report immediately including anaphylactic reactions since they rarely remain in the hospital for any length of time, if at all.

A client at 36 weeks gestation is receiving Magnesium Sulfate for treatment of pre-eclampsia. Which finding requires immediate action? 1) Respiratory rate of 12 2) Deep tendon reflexes of 3+ 3) Urinary output of 100cc/4hours 4) Fetal heart rate of 120

3) Urinary output of 100cc/4hours Magnesium Sulfate is a potent CNS depressant that is excreted through the Kidneys. Adequate kidney function is vital to prevent Magnesium toxicity. The urinary output must average at least 30cc/hr. FHR: normal range of 110-160 bpm, heart rate of 110-120: we are "worried and watching" but the range is acceptable.

A frightened client comes to the nurse's station during the night and reports hearing the voice of the devil speaking to the client. Which response by the nurse is priority? 1) Could you have overheard the staff talking at the desk? 2) I will get you some medication for anxiety. 3) What did the voice tell you? 4) You do not have to worry about this. You are safe.

3) What did the voice tell you? The most important thing the nurse needs to find out is what the voice was telling the client. This is a safety issue. No: Could you have overheard the staff talking at the desk? (this is not the priority response. This is voicing doubt and also presenting reality. This response could come later in the interaction)

A client has received 850 mL intravenously in less than 60 minutes. Which central venous pressure (CVP) reading indicates a problem related to the amount of intravenous fluids infused? 1) -2 mm of Hg 2) 3 mm of Hg 3) 6 mm of Hg 4) 12 mm of Hg

4) 12 mm of Hg Normal CVP: 5-10 mm of Hg low CVP: FVD high CVP: FVE

The nurse is caring for a client with jaundice, elevated liver enzymes and an elevated serum bilirubin. What color urine does the nurse expect to find? 1) Pink tinged 2) Straw colored 3) Clear 4) Dark amber

4) Dark amber The bilirubin will be excreted in the urine and discolor it dark. Pink Tinged = sx of bleeding Straw Colored= no bilirubin (obstructive jaundice)

A client has chronic kidney disease and just received his first dose of epoetin alfa.What is the priority nursing diagnosis for this client? 1) Decreased cardiac output related to hypovolemia 2) Risk for injury related to increased bleeding tendency 3) Risk for infection related to decreased antibody production 4) Impaired gas exchange related to decreased oxygen-carrying capacity

4) Impaired gas exchange related to decreased oxygen-carrying capacity Impaired gas exchange related to decreased oxygen-carrying capacity. Erythropoietin is a hormone produced in the kidneys. Epoetin alfa is the synthetic hormone administered to clients with renal failure. Clients with impaired renal function produce less erythropoietin. Erythropoietin stimulates the production of red blood cells. Any client with KIDNEY DZ will produce less red blood cells and suffer from ANEMIA. Risk for injury related to bleeding tendency refers to low platelets. Platelets most important function is to assist in clotting. With decreased platelets the client is at risk for bleeding. Platelets have nothing to do with gas exchange.

A client is admitted for observation following an unrestrained MVA. A bystander stated that he lost consciousness for 1-2 minutes. On admit the client's Glasgow Coma Scale (GCS) was 14. The GCS is now 12. The nurse should: 1) Re-assess in 15 minutes 2) Stimulate the client with a sternal rub 3) Administer Tylenol with codeine for headache 4) Notify the PCP

4) Notify the PCP No Sternal Rub. Stimulating further will increase ICP. No Sedatives due to altering mental status and disrupting assessment. GCS: good = max 15 mod = 9-12 severe = 3-8

The PCP prescribes robinul (Glycopyrrolate) 0.2 mg IM thirty minutes prior to electroconvulsive therapy. What should be the nurse's response when the client asks why this drug is being given? 1) You wouldn't understand what it is for. Just roll over so I can give you the shot. 2) This drug will prevent you from having a seizure. 3) This medication will relax your muscles so that you do not break a bone. 4) Robinul will decrease secretions and could slow your heart rate.

4) Robinul will decrease secretions and could *slow*?? your heart rate. robinul (Glycopyrrolate) is an Anticholinergic. Should decrease secretions & INCREASE HR.

A mother tells the clinic nurse that her child has just been diagnosed with attention-deficit/hyperactivity disorder (ADHD) and asks the nurse what will be done to help her child. How should the nurse respond to the mother? 1) The primary healthcare provider will want to start your child on a CNS depressant in order to decrease hyperactivity and improve attention. 2) You will need to admit your child to the psychiatric behavioral unit so that group therapy can be initiated. 3) Children are often placed on CNS stimulants that improve behavior associated with ADHD. 4) The standard of care for children includes CNS stimulants along with behavior and family therapy

4) The standard of care for children includes CNS STIMULANTS along with behavior and family therapy Multimodal treatment of ADHD is the standard of care for children. There is a lot to be gained by supporting medication treatment with appropriate educational, psychosocial, and family interventions.

What kind of comments should the nurse expect from a client exhibiting clang associations? 1) Concrete explanations for abstract ideas 2) Reporting very small details when explaining something 3) Comments that are illogically associated 4) Use of rhymes when talking

4) Use of rhymes when talking CLANG ASSOCIATIONS- client may use rhyming words, such as dog, bog, cog, jog. •Reporting very small details when explaining something = Circumstantiality (can't get to the point, convo drifts) •Comments that are illogically associated = Loose Associations/Derailment

To avoid hypoglycemia in the diabetic client taking Lispro Insulin,what administration teaching is priority? 1) At bedtime 2) Twice daily, an AM and PM injection 3) One hour before meals 4) With meals

4) With meals Lispro is a rapid-acting insulin that should only be taken with food or within 15 minutes of a meal.

What are the best routine catheter care actions for the nurse to take while caring for a client with a foley catheter? 1) Encourage increased oral fluid intake and observe for any opacity in the urine suggesting bacterial infection. 2) Carefully wash the perineal area with soap and water after each bowel movement. 3) Avoid touching the tip of the spigot to any surfaces when emptying the collection bag. 4) Encourage the client to drink at least 2000 mL each day, wash the perineal area with soap and water twice daily and after each bowel movement.

4.) Encourage the client to drink at least 2000 mL each day, wash the perineal area with soap and water twice daily and after each bowel movement. Careful management of the drainage bag spigot, when emptying the urine, is a good infection control practice but is not part of routine catheter care.

Lithium: -acute mania -maintenance

Acute: 1-1.5 Maintain: 0.6-1.2

Neuroleptic Malignant Syndrome

Combo. of HYPERthermia, RIGIDITY, and AUTONOMIC DYSREGULATION that can occur as a serious complication of the use of antipsychotic drugs.

Naegele's Rule "My Daily Yawn"

Month: -3 Day: +7 (FIRST DAY of LMP, not the day it ended) Year: +1

lacto-ovo-vegetarian diet

NO animal flesh of any kind Dairy, Egg, Grain ok

Chlamydia, when to re-screen after abx tx??

Re-screen in 3 months after abx

Sx of Pregnancy: •Pre-sumptive •Probable •Positive

•PRESUMPTIVE: can be caused by conditions other than pregnancy (amenorrhea, breast tenderness, urinary freq) •PROBABLE: OBJECTIVE findings that can be documented by examiner •POSITIVE: only attributable to the presence of a fetus.