Test III Health and Illness III

Which condition is identified as a cause of the development of delirium? Select all that apply.

- infection - opioid use - hypoxia

A client's son states that since his mother's diagnosis of dementia he has felt irritable and fatigued. The nurse suspects caregiver role strain. Which of the following are associated with caregiver role strain?

- insomnia - excessive sleeping - weight gain - headaches

The nurse is caring for a child with Down syndrome. The nurse is aware that this condition may increase risk of developing which complication(s)? Select all that apply.

- leukemia - gastroesophegial reflux - spinal problems

Which of the following are signs/symptoms of Alzheimer's disease? Select all that apply.

- memory loss - confusion - agitation - inability to preform self care - personality changes

Which clinical manifestation alerts the registered nurse (RN) of the presence of catatonic schizophrenia? Select all that apply.

- negativism - staring off into space

The nurse is assessing the client for factors related to an increased risk of breast cancer. Which is/are considered risk factor(s) for breast cancer? Select all that apply.

- obesity - alcoholism - history of smoking - over the age of 50 - use of oral contraceptive

While providing care for a client diagnosed with catatonic schizophrenia, which intervention will the registered nurse (RN) implement? Select all that apply.

- offer to eat foods frequently - offer milk shakes frequently - assist with daily body care

Which clinical manifestation will the registered nurse (RN) identify as a presentation of cognitive symptoms in a client diagnosed with schizophrenia? Select all that apply.

- problems with abstract thinking - difficulty understanding others feelings - difficulty with problem solving

Which of the following nursing interventions are effective for a client with dementia? Select all that apply.

- redirecting to new activities - interacting calmly - maintaining a consistent caregiver schedule

While assessing a client diagnosed with schizophrenia, what action by the client will the registered nurse (RN) identify as a presentation of preservation?

- responds with the same answer for each question asked by the RN

Which descriptive term(s) reflect(s) common characteristics associated with autism spectrum disorder (ASD)? Select all that apply.

- ritualistic - repetitive

While providing education to a client prescribed tamoxifen, the registered nurse (RN) will include which point? Select all that apply.

- this drug is given over 5-10 yrs - take this drug each day as prescribed - report if heavy vaginal bleeding occurs - report pain, heat, or tenderness to calf

Which of the following clients are exhibiting signs of colon cancer? Select all that apply.

- unexplained weight loss - hemoglobin drop from 12 to 9 - blood stools and change in bowel habits

Which action by the client diagnosed with schizophrenia will the registered nurse (RN) recognize as a presentation of a negative symptom of schizophrenia? Select all that apply.

- walking out of a room if anyone else tries to enter room - being anxious if anyone tries to sit next to them - refusing to eat meal in common areas

A young autistic client is being assigned a room. Which room assignment is best?

A private room away from the nurses station to lower noise and activity

A client whose mother has Alzheimer disease was reading her mother's medical history and asked the nurse what the medical term "agnosia" means. Which is the best answer by the nurse?

Agnosia is the inability to recognize familiar objects

What is the most common disease associated with a diagnosis of dementia?

Alzheimer's disease

What statement made by the client receiving tamoxifen for the treatment of breast cancer, will require further education by the registered nurse (RN)?

I am concerned that the drug dose is to high as I am now having hot flashes

Which of the following has been associated with the development of dementia?

Traumatic brain injury

Which of the following causes delirium tremens from it's withdrawal?

alcohol

What is the primary goal for a client who may be an alcoholic?

- identify triggers for alcohol abuse

A client with paranoid schizophrenia tells the nurse, "There are people in my room telling me they are going to kill me. I am really afraid." What is the most therapeutic response of the nurse?

"I do not hear the voices but I know they are frightening to you."

The nurse is caring for a schizophrenic client. The client stated, "I am not going to eat the food because voices told me it was poisoned and I would die if I ate it." Which is the best response of the nurse?

"I know the voices are real to you, but I do not hear the voices."

A schizophrenic client is pacing around the hallways of the unit. The nurse asked the client why he was pacing. The client stated, "Those people behind me are trying to catch me to stab me. Don't you see them with their knives?" What is the nurse's best response?

"I know you must be frightened. I don't see anybody behind you at all."

What statement made by the client alerts the registered nurse (RN) of the occurrence of paranoid schizophrenia?

"Keep that door closed tightly, otherwise, demons will kill me."

A family member of an Alzheimer's client is very frustrated about their mother's confusion and seeks advice from the nurse. Which statement is most therapeutic?

"Seeing these changes in your mother must be very difficult for you."

The nurse is caring for a schizophrenic client. The client states, "Do you see those cameras? The government is watching me." What is the nurse's best response?

"The camera's are scarring you. We use those camera's to make sure our patients are safe."

What education point will the registered nurse (RN) provide to the client diagnosed with schizophrenia who receives a new prescription for risperidone?

"This drug can cause weight gain, so it will be important to eat a healthy diet."

A parent brings a child with Down syndrome to the clinic for a well check-up. The parent asks for insight related to how to address the child's behavior problems. Which response is best?

"consider using a visual chart and reward stickers to reinforce positive behavior.

A client's daughter is distressed by her father's unusual behavior, stating that he never acted this confused in earlier hospitalizations. Which of the following is the nurse's best response?

"this may be upsetting for you to see him unlike himself."

While providing care for a client diagnosed with schizophrenia, which statement made by the client will alert the registered nurse (RN) to the presence of delusions? Select all that apply.

- I can only drink bottled water because the state is trying to poison me - I don't turn on the television because that is how the government sees what im doing - I must be cleaned up soon I am having dinner with the president

The registered nurse (RN) provides which response to the client diagnosed with schizophrenia who was prescribed clozapine one week ago and is experiencing increased drowsiness? Select all that apply.

- The drowsiness will stop once your body begins to tolerate the drug - avoid driving or operating machinery when you are drowsy from the drug

Which of the following clients are at a high risk of developing colorectal cancer? Select all that apply.

- a client diagnosed with diverticulitis - a client diagnosed with ulcerative collitis - family history of CRC - excess alcohol

lWhich assessment finding(s) of a child would cause the nurse to suspect autism spectrum disorder (ASD)? Select all that apply.

- a sibling with autism - repetitive hand gestures - no eye contact - delayed speech

Which intervention will the registered nurse (RN) implement for the client diagnosed with schizophrenia that reports hearing voices at various times during the day? Select all that apply.

- acknowledge that the client believes he is hearing voices - provide a distraction from the voices with music and earphones - explain to the patient that the RN doesn't hear the voices

Which of the following are risk factors for developing Alzheimer's disease? Select all that apply.

- advancing age - family history/genetics - alcohol and smoking usage - cardiovascular disease

A client with alcohol abuse is admitted to the hospital. It has been 24 hours since her last drink. Which symptoms does the nurse expect the client to be exhibiting? Select all that apply.

- anxiety - insomnia - palpitations

Which intervention will the registered nurse (RN) implement for the client who states "the people hiding in the ceiling are trying to kill me in my sleep"? Select all that apply.

- avoid arguing with the client about their beliefs that they will be killed - reinforce to the patient that they do have the thought that someone is trying to kill them - reinforce to the patient that though these thoughts exist, the client is safe from harm

A client with a known history of alcohol abuse is at risk for what issues? Select all that apply.

- balance problems - poor nutrition - hypoglycemia -cns depression -death

A client is admitted with alcoholic cirrhosis. The client had his last drink 48 hours ago. Which medications may be ordered to help prevent delirium tremens? Select all that apply.

- diazepam - lorazepam - atenolol - clonidine

The nurse is planning pre-operative teaching information for a client who is scheduled for a left radical mastectomy. Which statement(s) is/are correct? Select all that apply.

- elevate your arm above your heart to avoid swelling - wear a compression sleeve on affected arm to avoid swelling - you may have numbness for up to a year after surgery

A client suffering with alcohol abuse had a motor vehicle accident that nearly killed an entire family. The client has been sober for two weeks. He arrives at the outpatient clinic seeking help to remain sober. Which of the following interventions may be implemented? Select all that apply

- find a sponsor to sponsor him - allow him to vent his feelings - promoting abstinence of alcohol - obtaining a prescription of disulfiram - set up support groups with recovering alcoholics

While providing care for the client diagnosed with schizophrenia and admitted to the hospital, which assessment will the registered nurse (RN) monitor after the administration of ziprasidone hydrochloride? Select all that apply.

- hypotension -widened qt interval

Which statement is correct regarding the presentation of delirium? Select all that apply.

- identifiable causes - usually reversible - acute,transient

Which intervention will the registered nurse (RN) implement for the client who states "the people hiding in the ceiling are trying to kill me in my sleep"? Select all that apply. explain to the client that these are just thoughts in their head and not real avoid arguing with the client about their beliefs that they will be killed reinforce to the client that they do have this thought that someone is trying to kill them explain to the client that the ceiling has been checked and there is no one there that can cause the client harm reinforce to the client that though these thoughts exist, the client is safe from harm

-avoid arguing with the client about their beliefs that they will be killed -reinforce to the client that they do have this thought that someone is trying to kill them - reinforce to the client that though these thoughts exist, the client is safe from harm

A client was brought to the emergency department after having a motor vehicle accident and was found in a ditch. The police suspect the client was laying in the ditch for two days. The client has a history of alcohol abuse. Which of the following symptoms does the nurse expect the client may be experiencing from the lack of alcohol?

-seizures - unstable vital signs - hyperreflexia - hallucinations - mental confusion

A 75-year-old man is accompanied by his son who states that his father has been forgetful, confused, and aggressive over the past few months. The son says that his father has never had a history of these symptoms and has always been "sharp as a tack." Which of the following neurotransmitters are decreased as a result of the pathophysiology of Alzheimer's disease?

Acetylcholine

An Alzheimer's client keeps getting out of her bed and wandering around the hall and wringing her hands. Which intervention by the nurse would be most therapeutic?

Ask the patient to fold some towels beside her while she does her charging.

A client was admitted with severe unexplained weight loss of 10 pounds in one week and hemoglobin has dropped in two months from 9.0 g/dL to 7.0 g/dL. The client stated that her bowels have changed color and are a very dark maroon color. Which diagnosis would the nurse suspect the client is experiencing?

CRC

The nurse is caring for a client who is 24 hours status post right radical mastectomy. Which is the priority nursing assessment that should be reported to the health care provider (HCP) (HCP)?

HGB: 10

An Alzheimer's client is experiencing restlessness and agitation in the evening. Which suggestion by the registered nurse can help the client be more calm and satisfied during this time?

Having an increased lighting during the evening time.

Which of the following can cause delirium?

Hypoglycemia

What action will the registered nurse (RN) implement while providing care to a client diagnosed with schizophrenia?

Sit in the room with the patient for short, frequent times throughout the day

What is the most common clinical manifestation of delirium?

acute confusion

The registered nurse (RN) identifies what psychotic presentation during a conversation with a client diagnosed with schizophrenia who frequently states that the flittlebots are hiding under the table?

a presentation of neologism

The nurse is planning pre-operative teaching information for a client who is scheduled for a left radical mastectomy. Which statement(s) is/are correct? Select all that apply.

a round, immobile lump on my breast is just a benign finding- something to not be concerned about

Which diagnostic test is most accurate for diagnosing colorectal cancer?

colonoscopy

Which is most associated with a client with autism spectrum disorder (ASD)?

communication difficulties

What statement made by the student demonstrates a need for further education regarding dementia?

dementia is reversible with drug therapy

The pathophysiology behind the structural changes within the brain of a client with Alzheimer's disease includes:

deposition of amyloid plaques and neurofibrillary tangles

A family member of an Alzheimer's client requests something called in for her mother's drainage and cough. The client is taking memantine. Which prescription should the nurse question?

dextromethophan

The nurse is educating a parent of an older child with Down syndrome. Which information is most important to include in the teaching plan?

ensure that your Childs hearing and vision are tested frequently

While providing care for a client diagnosed with schizophrenia, the registered nurse (RN) notices involuntary facial muscle movement and attributes this assessment to what drug in the client's daily drug plan?

haloperidol

While obtaining a health history of a client diagnosed with breast cancer, what assessment finding will prompt the registered nurse (RN) to notify the healthcare provider (HCP) prior to initiation of tamoxifen drug therapy?

history of DVT

What statement made by the client receiving tamoxifen for the treatment of breast cancer, will alert the registered nurse (RN) to notify the healthcare provider?

it really hurts in my right calf to even try and walk across the room

A client with autism spectrum disorder (ASD) is preparing to order lunch. Which action would best assist this client?

limiting the number of choices

An 81-year-old client recently diagnosed with Alzheimer's disease has become forgetful and has been experiencing short-term memory loss. Which of the following effects of Alzheimer's is an indication of the next stage of the disease?

long-term memory loss

An infant with Down syndrome presents to the clinic for a well visit. Which statement indicates that the parent needs additional teaching about this condition?

my child will never meet any milestones like other children

An elderly client presents to the emergency department with a runny nose, diaphoresis, insomnia, and dilated pupils. The client has reported methadone use for opioid abuse. Which signs and symptoms are early warning signs of oxycodone toxicity?

nausea with frequent vommiting

What intervention will the registered nurse (RN) implement for the client diagnosed with schizophrenia to maintain proper hygiene?

redirect the client to the need to finish their meal

The nurse is caring for a child with Down syndrome. Which manifestations may be commonly displayed in clients with this condition?

short stature with flattened face, short neck and flat ears

What statement will the registered nurse (RN) implement to best explain the action of tamoxifen in the client diagnosed with breast cancer?

this drug helps prevent or stop breast cancer that feeds off of estrogen (a female hormone)

The nurse is assessing a client who is 48 hours status post right radical mastectomy. It is noticed the total output for the client's Jackson Pratt (JP) drain during the last 24 hour period is 125 mL. Which statement is true regarding this finding? "This is an expected finding." "This is a finding that requires reevaluation in 12 hours." "This is a finding that should be reported to the client's HCP" "This is a finding that suggests the drain should be discontinued soon."

this is a finding which should be reported to HCP This answer is correct because 125 mL of bright, red drainage from the client's JP drain in a 24 hour period should be reported to the client's HCP ASAP. This amount of drainage is excessive. This could be an early indication of hemorrhage.