302 Modules 5-8

What are the signs and symptoms of right-side heart failure

+JVD w/h.o.b. elevated at 45* -Dependent edema

What lab tests/results are used to evaluate heart failure?

- B-Natriuretic Protein (BNP) >100 -B-Natriuretic Peptide Brain natriuretic peptide

You accept care of a client, and when you go into their room, you note that they have oxygen going at 9 liters/nasal cannula. What is the nursing action?

-Assess patient and check order for oxygen - Regular nasal cannula should not have a liter flow greater than 6L/min

What are phenomena, signs and symptoms of left-side heart failure?

-Decreased cardiac output -Moist lung sounds "Blood back up from L. ventricle" "Blood traffic jam"

What is the definition of Orthopnea and what does it indicate? What is a nursing intervention?

-It is a classic sign of Respiratory Distress and is difficulty in breathing that occurs when lying down and is relieved upon changing to an upright position. -"Straight breathing," or "Straight-up Breathing." - Elevate H.O.B -Semi-Fowlers

A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1c, a measure of blood sugar control over the past 90 days, has increased by saying, "The hemoglobin A1c is wrong. My blood sugar levels have been excellent for the last 6 months." Which defense mechanism is the patient using? 1. Denial 2. Conversion 3. Dissociation 4. Displacement

1

Matching: 1. ventilation 2. Perfusion 3. Diffusion A. The process of circulating blood B. The process of moving gases into and out of the lungs C. The exchange of respiratory gases in the alveoli and capillaries

1 = B 2 = A 3 = C

A 45-year-old woman who is obese tells a nurse that she wants to lose weight. Which assessment findings may be contributing factors to the woman's obesity? (Select all that apply.) 1. The woman works in an executive position that is very demanding. 2. The woman says that she has little time to prepare meals at home and eats out at least four nights a week. 3. The woman works out at the corporate gym at 5 AM three mornings per week. 4. The woman says that she tries to eat "low-cholesterol" foods to help lose weight. 5. The woman says that she vacations annually to reduce stress.

1, 2

Which of the following are examples of the conventional reasoning form of cognitive development? (Select all that apply.) 1. A 35-year-old woman is speaking with you about her recent diagnosis of a chronic illness. She is concerned about her treatment options in relation to her ability to continue to care for her family. As she considers the options and alternatives, she incorporates information, her values, and emotions to decide which plan will be the best fit for her. 2. A young father is considering whether or not to return to school for a graduate degree. He considers the impact the time commitment may have on the needs of his wife and infant son. 3. A teenage girl is encouraged by her peers to engage in shoplifting. She decides not to join her peers in this activity because she is afraid of getting caught in the act. 4. A single mother of two children is unhappy with her employer. She has been unable to secure alternate employment but decides to quit her current job. 5. A young man drives over the speed limit regularly because he thinks he is an excellent driver and will not get into a car accident.

1, 2

A nurse is caring for a patient with chronic arthritis pain. The patient wants to add some complementary therapies to help with pain management. Which therapies might be most effective for controlling pain (Select all that apply): 1. Biofeedback 2. Acupuncture 3. Therapeutic touch 4. Chiropractic therapy 5. Herbal medicines

1, 2, 3

To best assist a patient in the grieving process, which factors are most important for the nurse to assess? (Select all that apply.) 1. Previous experiences with grief and loss 2. Religious affiliation and denomination 3. Ethnic background and cultural practices 4. Current financial status 5. Current medications

1, 2, 3

The nurse recognizes that which factors influence a person's approach to death? (Select all that apply.) 1. Culture 2. Spirituality 3. Personal beliefs 4. Previous experiences with death 5. Gender 6. Level of education

1, 2, 3, 4

Chronic illness (e.g., diabetes mellitus, hypertension, rheumatoid arthritis) may affect a person's roles and responsibilities during middle adulthood. When assessing the health-related knowledge base of both the middle-age patient with a chronic illness and his or her family, the assessment should include which of the following? (Select all that apply.) 1. Medical course of the illness 2. Prognosis for the patient 3. Coping mechanisms of the patient and family 4. Socioeconomic status 5. Need for community and social services.

1, 2, 3, 5

Which comments to a patient by a new nurse regarding palliative care needs are correct? (Select all that apply.) 1. "Even though you're continuing treatment, palliative care is something we might want to talk about." 2. "Palliative care is appropriate for people with any diagnosis." 3. "Only people who are dying can receive palliative care." 4. "Children are able to receive palliative care." 5. Palliative care is only for people with uncontrolled pain.

1, 2, 4

A 36-year-old patient newly diagnosed with type 1 diabetes shares with you that he is frustrated with the time it takes to prepare meals and monitor his exercise and blood sugar. He also is having trouble understanding his insulin schedule. Which of the following suggestions would be most appropriate? (Select all that apply.) 1. Provide patient education materials that are easy to read. 2. Refer this patient to a diabetes support group. 3. Refer the patient to his endocrinologist. 4. Suggest that the patient make an appointment with a registered dietitian. 5. Suggest ways to modify his schedule.

1, 2, 4, 5

The nurse manager of a community clinic arranges for staff in-services about various complementary therapies available in the community. What is the purpose of this training? (Select all that apply.) 1. Nurses play an essential role in the safe use of complementary therapies. 2. Nurses are often asked for recommendations and strategies that promote well-being and quality of life. 3. Nurses learn how to provide all of the complementary modalities during their basic education. 4. Nurses play an essential role in patient education to provide information about the safe use of these healing strategies. 5. Nurses appreciate the cultural aspects of care and recognize that many of these complementary strategies are part of a patient's life.

1, 2, 4, 5

When planning care for a dying patient, which interventions promote the patient's dignity? (Select all that apply.) 1. Providing respect 2. Viewing the patient as a whole 3. Providing symptom management 4. Showing interest 5. Being present 6. Inserting a straight catheter when the patient has difficulty voiding

1, 2, 4, 5

A nurse sees a 76-year-old woman in the outpatient clinic. She states that she recently started to notice a glare in the lights at home. Her vision is blurred, and she is unable to play cards with her friends, read, or do her needlework. Which of the following nursing interventions are appropriate? (Select all that apply.) 1. Refer her to an ophthalmologist. 2. Suggest large-print books and playing cards. 3. Reassure her that this is part of normal aging. 4. Suggest lower-wattage light bulbs to decrease glare. 5. Assess her home environment for safety.

1, 2, 5

While assessing an older woman who is recently widowed, the nurse suspects that this woman is experiencing a developmental crisis. Which questions provide information about the impact of this crisis? (Select all that apply.) 1. With whom do you talk on a routine basis? 2. What do you do when you feel lonely? 3. Tell me what your husband was like. 4. I know this must be hard for you. Let me tell you what might help. 5. Have you experienced any changes in lifestyle habits, such as sleeping, eating, smoking, or drinking?

1, 2, 5

The nurse is caring for a 50-year-old woman visiting the outpatient medicine clinic. The patient has had type 1 diabetes since age 13. She has numerous complications from her disease, including reduced vision, heart disease, and severe numbness and tingling of the extremities. Knowing that spirituality helps patients cope with chronic illness, which of the following principles should the nurse apply in practice? (Select all that apply.) 1. Pay attention to the patient's spiritual identity throughout the course of her illness. 2. Select interventions that you know scientifically support spiritual well-being. 3. Listen to the patient's story each visit to the clinic, and offer a compassionate presence. 4. When the patient questions the reason for her long-time suffering, try to provide answers. 5. Consult with a spiritual care adviser, and have the adviser recommend useful interventions.

1, 3

A crisis intervention nurse is working with a mother whose child with Down syndrome has been hospitalized with pneumonia and who has lost her child's disability payment while the child is hospitalized. The mother worries that her daughter will fall behind in her classes during hospitalization. Which strategies are effective in helping this mother cope with these stressors? (Select all that apply.) 1. Referral to social service process reestablishing the child's disability payment 2. Sending the child home in 72 hours and having the child return to school 3. Coordinating hospital-based and home-based schooling with the child's teacher 4. Teaching the mother signs and symptoms of a respiratory tract infection 5. Telling the mother that the stress will decrease in 6 weeks when everything is back to normal

1, 3, 4

Which are examples of positive health habits that may prevent the development of chronic illness later in life? (Select all that apply.) 1. Routine screening and diagnostic tests 2. Unprotected sexual activity 3. Regular exercise 4. Consistent seat belt use 5. Excess alcohol consumption

1, 3, 4

Which actions by the nurse help grieving families? (Select all that apply.) 1. Encourage involvement in nonthreatening group social activities. 2. Follow up with the family in their home. 3. Remind them that feelings of sadness or pain can return around anniversaries. 4. Encourage survivors to ask for help. 5. Look for overuse of alcohol, sleeping aids, or street drugs.

1, 3, 4, 5

A nurse is completing an assessment on a 27-year-old female patient. Which questions best assess the psychosocial aspects of this young woman's health? (Select all that apply.) 1. Do you feel safe in your home and at work? 2. How many fruits and vegetables do you typically eat every day? 3. Describe your relationship with your family. 4. Have you had the vaccine to prevent HPV? 5. What are your long-term career goals?

1, 3, 5

A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for her grandchildren as needed, and belongs to numerous church committees. What are the major concerns for this patient? (Select all that apply.) 1. The loss of his work role 2. The risk of social isolation 3. A determination on whether the wife will need to start working 4. How the wife expects household tasks to be divided in the home in retirement 5. The age the patient chose to retire

1, 4

A 71-year-old patient enters the emergency department after falling down stairs at church. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not exercise regularly and states that he experiences weakness in his legs when climbing stairs. He is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this patient? (Select all that apply.) 1. Impaired vision 2. Residence design 3. Blood pressure 4. Leg weakness

1, 4

A patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his marriage of 15 years and has been praying daily to help him through this difficult time. He does not have a primary health care provider because he has never really been sick, and his parents never took him to a physician when he was a child. Which external variables influence the patient's health practices? (Select all that apply.) 1. Difficulty paying his bills 2. Praying daily 3. Age of patient (46 years) 4. Stress from the divorce and the loss of a job 5. Family practice of not routinely seeing a health care provider

1, 5

A nurse is caring for a man who is recently retired and who appears withdrawn. He says he is "bored with life." The nurse helps this individual find meaning in life by: 1. Encouraging him to reflect on his relationships with others. 2. Encouraging relocation to a new city. 3. Explaining the need to simplify life. 4. Encouraging him to adopt a new pet.

1.

A nurse is conducting a home visit with a new mom and her three children. While in the home the nurse weighs each family member and reviews their 3-day food diary. She checks the mom's blood pressure and encourages the mom to take the children for a 15- to 30-minute walk every day. The nurse is addressing which level of need, according to Maslow? 1. Physiological 2. Safety and security 3. Love and belonging 4. Self-actualization

1.

The nurse is caring for a patient who has just had a near-death experience (NDE) following a cardiac arrest. Which intervention by the nurse best promotes the spiritual well-being of the patient after the NDE? 1. Allowing the patient to discuss the experience 2. Referring the patient to pastoral care 3. Having the patient talk to another patient who had an NDE 4. Offering to pray for the patient

1.

When taking care of patients, a nurse routinely asks whether they take any vitamins or herbal medications, encourages family members to bring in music that the patient likes to help the patient relax, and frequently prays with her patients if that is important to them. The nurse is practicing which model? 1. Holistic 2. Health belief 3. Transtheoretical 4. Health promotion

1.

Which of the following statements best explains therapeutic touch (TT)? 1. Intentionally mobilizes energy to balance, harmonize, and repattern the recipient's biofield 2. Intentionally heals tissue damage or corrects certain disease symptoms 3. Is overwhelmingly effective in many conditions 4. Is completely safe and does not warrant any special precautions

1.

The nurse assesses the risk factors for coronary artery disease (CAD) in a female patient. Which of these factors are classified as genetic and physiological? (Select all that apply.) 1. Sedentary lifestyle 2. Mother died from CAD at age 48 3. History of hypertension 4. Eats diet high in sodium 5. Elevated cholesterol level

2, 3, 5

Lab value for specific gravity? What does a high level mean?

1.005-1.030 is normal A high level would indicate dehydration

Blood, Urea, Nitrogen (BUN) normal lab value? What is its implication?

10-20 mg/dL Kidney Function

A 44-year-old male patient has just been told that his wife and child were killed in an auto accident while coming to visit him in the hospital. Which of the following statements are assessment findings that support a nursing diagnosis of Spiritual Distress related to loss of family members? (Select all that apply.) 1. "I need to call my sister for support." 2. "I have nothing to live for now." 3. "Why would my God do this to me?" 4. "I need to pray for a miracle." 5. "I want to be more involved in my church."

2, 3

Which complementary therapies are most easily learned and applied by a nurse? (Select all that apply.) 1. Traditional Chinese medicine 2. Progressive relaxation 3. Breathwork and guided imagery 4. Therapeutic touch

2, 3

A nurse is participating in a health and wellness event at the local community center. A woman approaches and relates that she is worried that her widowed father is becoming more functionally impaired and may need to move in with her. The nurse asks about his ability to complete activities of daily living (ADLs). ADLs include independence with: (Select all that apply.) 1. Driving. 2. Toileting. 3. Bathing. 4. Daily exercise. 5. Eating.

2, 3, 5

A nurse is preparing to teach an older adult who has chronic arthritis how to practice meditation. Which of the following strategies are appropriate? (Select all that apply.) 1. Encourage family members to participate in the exercise. 2. Have patient identify a quiet room in the home that has minimal interruptions. 3. Suggest the use of a quiet fan running in the room. 4. Explain that it is best to meditate about 5 minutes 4 times a day. 5. Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer.

2, 3, 5

A patient's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center? (Select all that apply.) 1. The center needs to be clean, and rooms should look like a hospital room. 2. Adequate staffing is available on all shifts. 3. Social activities are available for all residents. 4. The center provides three meals daily with a set menu and serving schedule. 5. Staff encourage family involvement in care planning and assisting with physical care.

2, 3, 5

Which interventions does a nurse implement to help a patient at the end of life maintain autonomy while in a hospital? (Select all that apply.) 1. Use therapeutic techniques when communicating with the patient. 2. Allow the patient to determine timing and scheduling of interventions. 3. Allow patients to have visitors at any time. 4. Provide the patient with a private room close to the nurses' station. 5. Encourage the patient to eat whenever he or she is hungry.

2, 3, 5

A nurse is caring for a patient experiencing a stress response. The nurse plans care with the knowledge that systems respond to stress in what manner? (Select all that apply.) 1. Always fail and cause illness and disease 2. Cause negative responses over time 3. React the same way for all individuals 4. Protect an individual from harm in the short term 5. Tolerate the stress response indefinitely

2, 4

A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks whether the patient is dying and now in "hospice." What does the nurse tell the family member about palliative care? (Select all that apply.) 1. Palliative care and hospice are the same thing. 2. Palliative care is for any patient, any time, any disease, in any setting. 3. Palliative care strategies are primarily designed to treat the patient's illness. 4. Palliative care relieves the symptoms of illness and treatment. 5. Palliative care selects home health care services.

2, 4

During a home health visit a nurse talks with a patient and his family caregiver about the patient's medications. The patient has hypertension and renal disease. Which of the following findings place him at risk for an adverse drug event? (Select all that apply.) 1. Taking two medications for hypertension 2. Taking a total of eight different medications during the day 3. Having one physician who reviews all medications 4. Patient's health history of renal disease 5. Involvement of the caregiver in helping with medication administration

2, 4

A nurse working on a medical patient care unit states, "I am having trouble sleeping, and I eat nonstop when I get home. All I can think of when I get to work is how I can't wait for my shift to be over. I wish I felt happy again." What are the best responses from the nurse manager? (Select all that apply.) 1. "I'm sure this is just a phase you are going through. Hang in there. You'll feel better soon." 2. "I know several nurses who feel this way every now and then. Tell me about the patients you have cared for recently. Did you find it difficult to care for them?" 3. "You can take diphenhydramine over the counter to help you sleep at night." 4. "Describe for me what you do with your time when you are not working." 5. "The hospital just started a group where nurses get together to talk about their feelings. Would you like for me to e-mail the schedule to you?"

2, 4, 5

A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing: 1. Dementia. 2. Depression. 3. Delirium. 4. Anxiety.

2.

A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. The patient is very thin and unkempt, has a stage 3 pressure injury on her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son, who accompanied her to the hospital. What is the nurse's next step? 1. Call social services to begin nursing home placement. 2. Ask the son to step out of the room so that she can complete her assessment. 3. Call adult protective services because you suspect elder mistreatment. 4. Assess the patient's cognitive status.

2.

A nurse is completing a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer's disease 1 year ago but became extremely confused last evening and was hallucinating. She was unable to calm her, and her mother thought she was a stranger. On the basis of this history, the nurse suspects that the patient is experiencing: 1. Normal aging. 2. Delirium. 3. Depression. 4. Worsening dementia.

2.

A patient has just learned she has been diagnosed with a malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. The nurse has been caring for her for only 2 hours but has a good relationship with her. What is the most appropriate intervention for support of her spiritual well-being at this time? 1. Make a referral to a professional spiritual care adviser. 2. Sit down and talk with the patient; have her discuss her feelings and listen attentively. 3. Move the patient's Bible from her bedside cabinet drawer to the top of the over-bed table. 4. Ask the patient whether she would like to learn more about the implications of having this type of tumor.

2.

As part of a faith community nursing program in her church, a nurse is developing a health promotion program on breast self-examination for the women's group. Which statement made by one of the participants is related to the individual's accurate perception of susceptibility to an illness? 1. "I have a door hanging tag in my bathroom to remind me to do my breast self-examination monthly." 2. "Since my mother had breast cancer, I know that I am at increased risk for developing breast cancer." 3. "Since I am only 25 years of age, the risk of breast cancer for me is very low." 4. "I participate every year in our local walk/run to raise money for breast cancer research."

2.

In addition to a thorough patient assessment, when a nurse uses one of the nursing-accessible complementary therapies, he or she must ensure that which of the following has occurred? 1. The family has provided permission. 2. The patient has provided permission and consent. 3. The health care provider has given approval or provided orders for the therapy. 4. The nurse has received specialized training in the therapeutic technique.

2.

A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. Tea includes which of the following ingredients? ATI 243 A) Chamomile B) Ginseng C) Ginger D) Echinacea

A)

A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take? ATI 243 A) Offer information on a relaxation technique and ask the client if they are interested in trying it B) Request a social worker see the client to discuss meditation C) Attempt to use biofeedback techniques with the client. D) Tell the client many people feel the same way before surgery and to think of something else.

A)

A charge nurse is conducting a nutritional class for a group of newly licensed nurses regarding basal metabolic rate (BMR). The charge nurse should inform the class that which of the following factors increases BMR? (SATA) A) Lactation B) Prolonged stress C) Malnutrition D) Puberty E) Age older than 6 years

A) B) D)

When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, what is the first assessment the nurse conducts? 1. The amount of family support 2. A 3-day diet recall 3. A thorough physical assessment 4. Threats to safety in her home

3

While planning care for a patient, a nurse understands that providing integrative care includes treating which of the following? 1. Disease, spirit, and family interactions 2. Desires and emotions of the patient 3. Mind-body-spirit of patients and their families 4. Muscles, nerves, and spine disorders

3

A nurse is completing an assessment on a male patient, age 24. Following the assessment, the nurse notes that his family history is not significant for chronic illnesses, and his physical and laboratory findings are within normal limits. Because of these findings, nursing interventions are directed toward activities related to: (Select all that apply.) 1. Instructing him to return in 2 years. 2. Instructing him in secondary prevention. 3. Instructing him in health promotion activities. 4. Instructing him about routine screenings. 5. Instructing him about proper vaccinations.

3, 4, 5

The nurse is interviewing a patient in the community clinic and gathers the following information about her: she is intermittently homeless, a single parent with two children who have developmental delays. She has had asthma since she was a teenager. She does not laugh or smile, does not volunteer any information, and at times appears close to tears. She has no support system and does not work. She is experiencing an allostatic load. As a result, which of the following would be present during complete patient assessment? (Select all that apply.) 1. Post-traumatic stress disorder 2. Rising hormone levels 3. Chronic illness 4. Insomnia 5. Depression

3, 4, 5

The nurse is evaluating how well a patient newly diagnosed with multiple sclerosis and psychomotor impairment is coping. Which statements indicate that the patient is beginning to cope with the diagnosis? (Select all that apply.) 1. "I'm going to learn to drive a car, so I can be more independent." 2. "My sister says she feels better when she goes shopping, so I'll go shopping." 3. "I'm going to let the occupational therapist assess my home to improve efficiency." 4. "I've always felt better when I go for a long walk. I'll do that when I get home." 5. "I'm going to attend a support group to learn more about multiple sclerosis."

3, 5

A 50-year-old woman has elevated serum cholesterol levels that increase her risk for cardiovascular disease. One method to control this risk factor is to identify the patient's current diet trends and describe dietary changes to reduce the risk. This nursing activity is a form of: 1. Referral. 2. Counseling. 3. Health education. 4. Stress-management techniques.

3.

A nurse used spiritual rituals as an intervention in a patient's care. Which of the following questions is most appropriate to evaluate its efficacy? 1. Do you feel the need to forgive your wife over your loss? 2. What can I do to help you feel more at peace? 3. Did either prayer or meditation prove helpful to you? 4. Should we plan on having your family try to visit you more often in the hospital?

3.

A patient discharged a week ago following a stroke is currently participating in rehabilitation sessions provided by nurses, physical therapists, and registered dietitians in an outpatient setting. In what level of prevention is the patient participating? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Transtheoretical prevention

3.

When providing postmortem care, which actions are necessary for the nurse to complete? 1. Locating the patient's clothing 2. Calling the funeral home 3. Providing culturally and religiously sensitive care in body preparation 4. Providing postmortem care to protect the family of the deceased from having to view the body

3.

Which factor affects a middle-age adult's adherence to a treatment plan? 1. Gender 2. Lifestyle 3. Motivation 4. Family history

3.

A 34-year-old single father who is anxious, tearful, and tired from caring for his three young children tells the nurse that he feels depressed and doesn't see how he can go on much longer. Which statement would be the nurse's best response? 1. "Are you thinking of suicide?" 2. "You've been doing a good job raising your children. You can do it!" 3. "Is there someone who can help you during the evenings and weekends?" 4. "Tell me what you mean when you say you can't go on any longer."

4

A 34-year-old female executive has a job with frequent deadlines. She notes that when the deadlines appear, she tends to eat high-fat, high-carbohydrate foods. She also explains that she gets frequent headaches and stomach pain during these deadlines. After receiving health education from the nurse, the executive decides to try yoga. In this scenario yoga is used as a(n): 1. Outpatient referral. 2. Counseling technique. 3. Health promotion activity. 4. Stress-management technique.

4.

Dave reports being happy and satisfied with his life. What do we know about him? 1. He is in one of the later developmental periods, concerned with reviewing his life. 2. He is atypical, since most people in any of the developmental stages report significant dissatisfaction with their lives. 3. He is in one of the earlier developmental periods, concerned with establishing a career and satisfying long-term relationships. 4. It is difficult to determine Dave's developmental stage since most people report overall satisfaction with their lives in all stages.

4.

Older adults frequently experience a change in sexual activity. Which best explains this change? 1. The need to touch and be touched is decreased. 2. The sexual preferences of older adults are not as diverse. 3. Medication side effects often impact sexual functioning. 4. Frequency and opportunities for sexual activity may decline.

4.

When planning patient education, it is important to remember that patients with which of the following illnesses often find relief in complementary therapies? 1. Lupus and diabetes 2. Ulcers and hepatitis 3. Heart disease and pancreatitis 4. Chronic back pain and arthritis

4.

A nurse in a health clinic is caring for a 21-year-old client who tells the nurse that their last physical exam was in high school. Which of the following health screenings should the nurse expect the provider to perform for this client? ATI87 A. Testicular examination B. Blood glucose C. Fecal occult blood D. Prostate-specific antigen

A)

A nurse is assessing a client who has urosepsis. Which of the following findings should the nurse expect? A) Decreased heart rate B) Decreased urinary output C) Increased blood pressure D) Increased motility

B)

Plan of care: Nursing Process: Define/Describe a client centered goal/outcome

A client-centered goal is - Singular, Observable, Measurable, Time-limited Mutual, and Realistic

A client hospitalized with a terminal illness is experiencing pain and has asked for a Reiki Master to help alleviate the pain. Which of the following responses by the nurse is most appropriate? A) "Complementary therapy has been beneficial to many clients." B) "Folk medicine is not practiced in the hospital." C) "Modern medicine has come a long way to promote health since faith healers." D) "Your doctor will need to write the order in your medical record."

A)

A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? A) Check to see whether the catheter is patent B) Reassure the client that it is not possible for them to urinate C) Recatheterize the bladder with a larger-gauge catheter D) Collect a urine specimen for analysis

A)

A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine? 239 A) Presence of associated manifestations B) Location of the pain C) Pain quality D) Aggravating and relieving factors

A)

A nurse is caring for a client who has a prescription for a 24 hr urine collection. Which of the following actions should the nurse take? A) Discard the first voiding B) Keep the urine in a single container at room temperature C) Dispose the last voiding D) Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container

A)

A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client's role problem? ATI 187 A) Role conflict B) Role overload C) Role ambiguity D) Role strain

A)

A nurse is caring for a male client who has an upper urinary tract infection. The nurse should identify that the infection is in which of the following portion of the urinary tract? A) Kidney B) Bladder C) Prostate D) Urethra

A)

A nurse is conducting a nutrition class at a local community center. Which of the following information should the nurse include in the teaching? A) Progress toward limiting saturated fat to 7% of total daily intake. B) Good bowel function requires 35g/day of fiber for females. C) Limit cholesterol consumption to 400mg/day D) Normal functioning cardiac systems depends on B-complex vitamins

A)

A nurse is conducting a nutritional class on minerals and electrolytes. The nurse should include which of the following foods as a major source of magnesium? A) Tuna B) Tomatoes C) Eggs D) Oranges

A)

A nurse is discussing the use of a low-profile gastrostomy device with the guardian of a child who is receiving an enteral feeding. Which of the following is an appropriate statement by the nurse? A) "The device is usually comfortable for children." B) "Checking residual is much easier with this device." C) "This access requires less maintenance than a traditional nasal tube." D) "Mobility of the child is limited with this device."

A)

A nurse is teaching about food safety and foodborne illness to a group of adults at a local community center. Which of the following information should the nurse include? A) "Unpasteurized fruit juice is a common cause of foodborne illness." B) "Store hard-boiled eggs in the refrigerator for up to 2 weeks." C) "The recommended cooking temperature for ground beef is 145 degrees F." D) "The onset of norovirus is 5 to 7 days after exposure to the bacteria."

A)

A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? 357 A) A client with nasogastric suctioning B) A client who has chronic constipation C) A client who has syndrome of inappropriate antidiuretic hormone D) A client who took a toxic dose of sodium bicarbonate antacids

A)

A woman has learned that her ex-husband has died and her initial reaction was stunned silence, followed by anger that he left no insurance money for their young children. Based on this situation, what is most important for the nurse to understand? A) This woman is experiencing a normal bereavement reaction. B) To help explain this woman's reaction, the nurse needs more information about the relationship and breakup. C) The children and the injustice done to them by their father's death are this woman's main concerns. D) This woman is not reacting normally to the news.

A)

An advancing diet should progress in which order? A) Clear liquids, full liquids, light diet, regular diet B) Light diet, full liquids, regular diet, clear liquids C) Regular diet, light diet, full liquids, clear liquids

A)

Unable to make it to bathroom in time due to decreased ambulation. A) Functional Incontinence B) Retention or Overflow Incontinence C) Stress Incontinence D) Urge Incontinence

A)

Which action can a nurse delegate to assistive personnel (AP)? 1147 A) Performing glucose monitoring every 6 hours on a patient. B) Teaching the client about the need for enteral feeding. C) Administering enteral feeding bolus after tube placement has been verified. D) Evaluating the patient's tolerance of the enteral feeding.

A)

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older adult client? A) Assist client to cough, turn, and deep breathe every 2 hours. B) Encourage client to drink through a straw to prevent aspiration. C) Discontinue humidification delivery device and keep excess fluid from lungs. D) Monitor oxygen saturation, and frequently assess lung bases.

A)

Which statement made by the patient indicates an understanding of sleep-hygiene practices? A) "I usually drink a cup of warm milk in the evening to help me sleep." B) "If I exercise right before bedtime, I will be tired and fall asleep faster." C) "I know it does not matter what time I go to bed as long as I am tired." D) "If I use hypnotics for a long time, my insomnia will be cured."

A)

The nurse has just witnessed her patient go into cardiac arrest. What priority interventions should the nurse perform at this time? SATA 976 A) Perform chest compressions B) Ask someone to bring the defibrillator to the room for immediate defibrillation C) Apply oxygen via nasal cannula D) Place the patient in the high Fowler's position E) Educate the family about the need for CPR

A) B)

A nurse in a senior center is counseling a group of older adults about their nutritional needs & considerations. Which of the following info should the nurse include? SATA A. Older adults are more prone to dehydration than younger adults are B. Older adults need the same amount of most vitamins & minerals as younger adults do C. Many older men & women need calcium supplementation D. Older adults need more calories than they did when they were younger E. Older adults should consume a diet low in carbs

A) B) C)

A nurse is performing dietary needs assessments for a group of clients. A blenderized liquid diet is appropriate for which of the following clients? SATA A) A client who has a wired jaw due to a motor vehicle crash. B) A client who is 24 hours postoperative following temporomandibular joint repair. C) A client who has difficulty chewing due to oral surgery. D) A client who has hypercholesterolemia due to coronary artery disease E) A client who is scheduled for a colonoscopy the next morning.

A) B) C)

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps shoudl the nurse take? SATA ATI 249 A) Warm the enema solution prior to instillation B) Position the client on the left side with the right leg flexed forward C) Lubricate the rectal tube or nozzle D) Slowly insert the rectal tube about 5cm (2in) E) Hang the enema container 61 cm (24in) above the client's anus

A) B) C)

Which sleep-hygiene actions at bedtime can the nurse delegate to the nursing assistant? (Select all that apply.) A) Giving the patient a backrub B) Turning on quiet music C) Dimming the lights in the patients room D) Giving the patient a cup of coffee E) Monitoring for the effect of the sleeping medication that was given

A) B) C)

A nurse is discussing essential nutrients for normal functioning of the nervous system with a client. Which of the following should the nurse include in the teaching? SATA A) Calcium B) Thiamin C) Vitamin B6 D) Sodium E) Phosphorus

A) B) C) D)

A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? SATA ATI87 A) Help the client see the benefits of their actions. B) Identify the client's support systems. C) Suggest and recommend community resources. D) Devise and set goals for the client. E) Teach stress management strategies.

A) B) C) E)

A school nurse is teaching a group of students how to read food labels. Which of the following is a required component of food labels that the nurse should include in the teaching? SATA A) Total carbohydrates B) Total fat C) Calories D) Magnesium E) Dietary fiber

A) B) C) E)

A nurse is administering bolus enteral feedings to a client who has malnutrition. Which of the following are appropriate nursing interventions? SATA A) Verify the presence of bowel sounds. B) Flush the feeding tube with warm water. C) Elevate the head of the bed 20 degrees. D) Administer the feeding at room temperature. E) Instill the formula over 60 min.

A) B) D)

A school nurse is teaching a high school health class about the possible causes of a negative nitrogen balance. Which of the following causes should the nurse include in the teaching? SATA A) Illness B) Malnutrition C) Adolescence D) Trauma E) Pregnancy

A) B) D)

A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? SATA 331 A) Restlessness B) Tachypnea C) Bradycardia D) Confusion E) Hypertension

A) B) D) E)

A nurse is performing a nutrition assessment on a client. Which of the following clinical findings are suggestive of malnutrition? SATA A) Poor wound healing B) Dry hair C) Blood pressure 130/80 mmHG D) Weak hand grips E) Impaired coordination

A) B) D) E)

A nurse is talking with a client about ways to help sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? SATA A) Practice muscle relaxation techniques. B) Exercise each morning. C) Take an afternoon nap. D) Alter the sleep environment for comfort. E) Limit fluid intake at least 2 hours before bed.

A) B) D) E)

A nurse is teaching a group of female clients about risk factors for developing osteoporosis. Which of the following risk factors should the nurse include? SATA A) Inactivity B) Family History C) Obesity D) Hyperlipidemia E) Cigarette smoking

A) B) E)

Which statements from a patient indicate an understanding of behaviors that will promote sleep? SATA A) "I will not watch television in bed." B) "I will not drink caffeine later in the day." C) "A short nap late in the evening will lead to a more restful night of sleep." D) "I am going to start eating dinner closer to my bedtime." E) "I will start to exercise regularly during the day."

A) B) E)

A nurse is providing teaching about food allergies to a group of new patients. Infants who react to which of the following foods typically outgrow the sensitivity? SATA A) Soy B) Wheat C) Cow's milk D) Eggs E) Fish

A) C)

A nurse who is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration? SATA 357 A) Hct 55% B) Blood osmolarity 260 mOsm/kg C) Urine specific gravity 1.035 D) Blood creatinine 0.6 mg/dL

A) C)

A nurse is providing teaching to a client who follows vegan dietary practices. The nurse should instruct the client that there is a risk of having a deficit in which of the following nutrients? SATA A) Vitamin D B) Fiber C) Calcium D) Vitamin B12 E) Whole grains

A) C) D)

A nurse is reviewing CDC immunization recommendations with a young adult client. Which of the following vaccines should the nurse recommend as routine, rather than catch-up, during young adulthood? SATA ATI 116 A) Influenza B) Measles, Mumps, Rubella C) Pertussis D) Tetanus E) Polio

A) C) D)

A nurse is teaching a group of newly licensed nurses on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage them to use? SATA ATI 243 A) Guided imagery B) Massage therapy C) Meditation D) Music therapy E) Therapeutic touch

A) C) D)

Which nursing intervention(s) best promote(s) effective sleep in an older adult? SATA A) Limit fluids 2 to 4 hours before sleep. B) Ensure that the room is completely dark. C) Ensure that the room temperature is comfortably cool. D) Provide warm covers. E) Encourage walking an hour before going to bed.

A) C) D)

A nurse in a provider's office is caring for a client who states that, for the past week, "I have felt tired during the day and cannot sleep at night." Which of the following responses should the nurse ask when collecting data about the client's difficulty sleeping? (SATA) A) "Have your working hours changed recently?" B) "Do you feel confused in the late afternoon?" C) "Do you drink coffee, tea or other caffeinated drinks? If so, how many cups per day?" D) "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" E) "Tell me about any personal stress you are experiencing?"

A) C) D) E)

A nurse is planning care for a client receiving treatment for malnutrition. The client is scheduled for discharge to their home where they live alone. Which of the following actions should the nurse include in the plan of care? SATA A) Consult social services to arrange home meal delivery. B) Encourage the client to purchase nonperishable boxed meals. C) Advise the client to purchase frozen fruits and vegetables. D) Recommend drinking a supplement between meals. E) Educate the client on how to read nutrition labels.

A) C) D) E)

A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? SATA ATI 120 A) Eye examination every 1 to 3 years B) Decrease intake of calcium supplements C) DXA screening for osteoporosis D) Increase intake of carbohydrates in the diet E) Screening for depressive disorders

A) C) D) E)

A nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? SATA ATI 125 A) Increase protein intake to increase muscle mass. B) Decrease fluid intake to prevent urinary incontinence C) Increase calcium intake to prevent osteoporosis D) Limit sodium intake to prevent edema E) Increase fiber intake to prevent constipation

A) C) D) E)

A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find diseases in which of the following physiologic functions? SATA ATI 120 A) Metabolism B) Ability to hear low pitched sounds C) Gastric secretions D) Far vision E) Glomerular filtration

A) C) E)

A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining REM sleep, which of the following characteristics should the nurse include? SATA A) REM sleep provides cognitive restoration. B) REM sleep lasts about 90 min. C) It is difficult to awaken a person in REM sleep. D) Sleepwalking occurs during REM sleep. E) Vivid dreams are common during REM sleep.

A) C) E)

A nurse is reviewing complementary and alternative therapies with a group of newly licensed nurses. Which of the following interventions are mind-body therapies? SATA ATI 243 A) Art therapy B) Acupressure C) Yoga D) Therapeutic touch E) Biofeedback

A) C) E)

A nurse is developing a plan for a patient who was diagnosed with narcolepsy. Which interventions should the nurse include on the plan? SATA A) Take brief, 20 min naps no more than twice a day. B) Drink a glass of wine with dinner. C) Eat a large meal at lunch rather than dinner. D) Establish a regular exercise program.

A) D)

A nurse is reviewing the effect of culture on nutrition during a staff in-service. Which of the following groups prescribes eating specific foods to balance forces in the body during illness? SATA A) Asian culture B) African culture C) Roman Catholicism D) Hispanic/Latinx culture E) Buddhism

A) D)

A nurse is consoling the partner of a client who just died after a long battle with liver cancer. The grieving partner states, "I hate them for leaving me." Which of the following statements should the nurse make to facilitate mourning for the partner? (Select all that apply.) ATI 207 A. "Would you like me to contact the chaplain to come and speak with you?" B. "You will feel better soon. You have been expecting this for a while now." C. "Let's talk about your children and how they are going to react." D. "You know, it is quite normal to feel anger toward your loved one at this time." E. "Tell me more about how you are feeling."

A) D) E)

A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has a recurrent UTIs. Which of the following factors should the nurse include? SATA A) Frequent sexual intercourse B) Lowering of testosterone levels C) Wiping from front to back to clean the perineum D) Location of the urethra closer to the anus E) Frequent catheterization

A) D) E)

A nurse is caring for a client who has a fractured humerus and received an opioid medication intravenously 1 hr ago for pain. Which of the following questions should the nurse ask to determine the intensity of the client's pain at this time? A) "On a scale from 0 to 10, how do you rate your pain?" B) "How often do you feel the pain?" C) "Can you point to where you have pain?" D) "What does your pain feel like?"

A) "On a scale from 0 to 10, how do you rate your pain?" The nurse should ask the client to rate his pain using a pain scale to assess the intensity of the pain.

A nurse is preparing to administer acetaminophen 1,000 mg PO every 12 hr for a client who has arthritic pain. The nurse should monitor the client for which of the following adverse effects? A) Hepatotoxicity B) Salicylism C) Respiratory Depression D) Gastrointestinal Bleeding

A) Hepatotoxicity. The nurse should monitor the client for hepatotoxicity. The client should not receive more than 4 g/day of acetaminophen to prevent damage to the liver.

What are some recommendations to promote normal bowel function and safety in the older adult? SATA A.) "increase your exercise and activity as much as you can tolerate" B.) "decrease intake of fibrous foods to avoid abdominal pain" C.) "everyone should use a laxative everyday to improve bowel health" D.) "increase your intake of water and keep well hydrated" E.) "make sure you defecate when the urge presents"

A,D,E

Your patient has BMI of 22 and serum albumin= 4.2 what is their status? a.) Patient is normal weight and well nourished (in the context of protein) b.) Patient is overweight and well nourished c.) Patient is normal weight and malnourished d.) Patient is normal weight and low albumin levels

A.

If a person is hyperventilating, they may experience symptoms of numbness, tingling, and potential loss of consciousness. These symptoms are caused by: A. Hypocapnea B. Hypoxia C. Hyperoxia D. Anoxia E. Hyperkalemia

A. Hypocapnia Rapid respiration = "Blowing off" excessive CO2

You are caring for a client who had a colostomy placed approximately 8 hours ago. In assessing the newly create stoma -you note that the stoma itself is red-pink, the area around the stoma is intact without signs of irritation or skin breakdown, and the pouch is full of blood. What is your nursing action? A.) Notify Provider B.) Change pouch and educate client on proper care C.) Notify your charge nurse D.) Change pouch and then notify Provider

A.)

If patient is in shock and kidneys aren't perfused, what does this lead to?

Acute Renal Failure

If your patient exhibits those S/S (hypoxia), what is my NEXT assessment?

Assessment, particularly oxygen saturation (O2 sat) Nursing 'Testology' 101: First, assure airway patency!

In order to promote and maintain normal bowel elimination patterns, it is important to complete a nursing history that reviews a client's :(SATA) A.) Usual bowel pattern and habits B.) Any changes in appetite C.) Medication history D.) Stool characteristics E.) History of surgery or illnesses affecting the GI tract

All of the above

The nurse is caring for a client who had abdominal surgery 3 days ago. The client states they prefer to stay in bed and rest. Upon assessment, the nurse notes that the surgical incision is well approximated, with no s/s of infection. Vital signs: T100.8*F (O), P=88, R=20, shallow, BP=118/78, O2 sat=92% RA. Auscultating the patient's lung fields, the nurse notes crackles at the bases. What is the priority nursing action?

Assist to ambulate, cough and deep breathe; incentive spirometer

A female employee is called into her supervisor's office to discuss her deteriorating work performance since the loss of her husband 2 years ago. The employee begins sobbing and states she is "falling apart" at home as well. The supervisor escorts this employee to the nurse's office for further assessment. The nurse recognizes that this employee's symptoms best correlate with which of the following? A) Normal grief B) Complicated grief C) Disenfranchised grief D) Perceived grief

B)

A nurse at a health department is planning strategies related to heart disease. Which of the following activities should the nurse include as part of primary intervention. ATI87 A) Providing cholesterol screening B) Teaching about a healthy diet C) Providing information about antihypertensive medications D) Developing a list of cardiac rehabilitation programs

B)

A nurse at a provider's office is talking about routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? ATI87 A) "So I don't need the colon cancer procedure for another 2 or 3 years" B) "For now, I should continue to have a mammogram each year." C) "Because the doctor just did a Pap smear, I'll come back next year for another one. D) "I had my blood glucose test last year, so I won't need it again for 4 years."

B)

A nurse educator is teaching a class on culture and food to a group of newly hired nurses. Which of the following statements by a nurse indicates an understanding of the teaching? A) "Most clients who practice Roman Catholicism do not drink caffeinated beverages." B) "Most clients who practice orthodox Judaism do not eat meat with dairy products." C) "Most clients who are Mormon eat only the protein of animals that are slaughtered under strict guidelines." D) "Most clients who practice Hinduism do not eat dairy products."

B)

A nurse is caring for a client who has multiple sclerosis and requires liquids with honey-like thickness. Which of the following foods can the client consume without adding a thickening agent? A) Ice cream B) Yogurt C) Buttermilk D) Cream of chicken soup

B)

A nurse is caring for a client who is at risk for aspiration. Which of the following actions should the nurse take? A) Give the client thin liquids. B) Instruct the client to tuck their chin when swallowing. C) Have the client use a straw. D) Encourage the client to lie down and rest after meals.

B)

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? 331 A) Increase the oxygen flow. B) Assist the client to Fowler's position. C) Promote removal of pulmonary secretions. D) Obtain a specimen for arterial blood gases.

B)

A nurse is caring for a client who is to receive a level 2 dysphagia diet due to a recent stroke. Which of the following dietary selections is most appropriate? A) Turkey sandwich B) Poached eggs C) Peanut butter crackers D) Granola

B)

A nurse is caring for a client whose partner passed away 4 months ago. The client has a recent diagnosis of diabetes mellitus. The client is tearful and states, "How could you possibly understand what I am going through?" Which of the following responses should the nurse make? ATI 187 A) "It takes time to get over the loss of a loved one." B) "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling." C) "Why don't you try something to take your mind off your troubles, like watching a funny movie." D) "I might not share your exact situation, but I do know what people go through when they deal with a loss."

B)

A nurse is caring for several clients in an extended care facility. Which of the following clients is the highest priority to observe during meals? A) A client who has decreased vision. B) A client who has Parkinson's disease. C) A client who has poor dentition. D) A client who has anorexia.

B)

A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? ATI 120 A) "I am struggling to accept that my parents are aging and need so much help." B) "It's been so stressful for me to think about having intimate relationships." C) "I know I should volunteer my time for a good cause, but maybe I'm just selfish." D) "I love my grandchildren, but my child expects me to relive my parenting days"

B)

A nurse is discussing how the body processes food with a client during a routine provider's visit. Which of the following statements should the nurse include? A) Glycerol can be broken down into glucose for use by the body. B) The liver converts unused glucose into glycogen. C) Excess fatty acids are stored in the muscle tissue. D) The body uses glycogen for fat before using available ATP.

B)

A nurse is discussing the plan of care for a client who reports following Islamic practices. Which of the following statements by the nurse indicates culturally responsive care to the client? ATI 201 A) "I will make sure the menu includes kosher options." B) "I will ask the client if they want to schedule some time to pray during the day." C) I will avoid discussing care when the client's family is around." D) "I will make sure daily communion is available for this client."

B)

A nurse is educating a client who has anemia about dietary intake of iron. Which of the following is a non-heme source of iron? A) Ground beef B) Dried beans C) Salmon D) Turkey

B)

A nurse is instructing a client who has narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A) "I'll add plenty of carbohydrates to my meals." B) "I'll take a short nap whenever I feel a little sleepy." C) "I'll make sure I stay warm when I am at my desk at work." D) "It's okay to drink alcohol as long as I limit it to one drink per day."

B)

A nurse is instructing a young adult client about health promotion and illness prevention. Which of the following statements indicates understanding? ATI 116 A) "I already had my immunizations as a child, so I'm protected in that area." B) "It is important to schedule routine health care visits even if I am feeling well." C) "I will just go to an urgent care center for my routine medical care." D) "There's no reason to seek help if I am feeling stressed because it's just part of life."

B)

A nurse is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend? ATI 249 A) Macaroni and cheese B) One medium apple with skin C) One cup of plain yogurt D) Roast chicken and white rice

B)

A nurse is reviewing dietary recommendations with a group of clients at a health fair. Which of the following information should the nurse include? A) "Fats should be 5% to 15% of daily calorie intake." B) "Make protein 10% to 35% of total calories each day." C) "Consume 1,500 mL of water from liquids and solids daily." D) "The body needs 40mg of iron each day."

B)

A nurse is reviewing prescribed medications for a newly admitted client. Which of the following medications increases the body's rate of metabolism? A) Morphine B) Levothyroxine C) Phenobarbital D) Dilaudid

B)

A nurse is teaching a client who is starting continuous feedings about the various types of enteral nutrition (EN) formulas. Which of the following should the nurse include in the teaching? A) Formula rich in fiber is recommended when starting EN. B) Standard formula contains whole protein. C) Hydrolyzed formula is recommended for a full-functioning GI tract. D) The high-calorie formula has increased water content.

B)

A nurse on an orthopedic unit is reviewing data for a client who sustained trauma in a motor-vehicle crash. Which of the following values indicates the client is in a catabolic state (using protein faster than protein is being synthesized)? A) Blood albumin is 3.5 g/dL B) Negative nitrogen balance C) BMI of 18.5 D) Blood prealbumin 15mg/dL

B)

A nurse sees an assistive personnel (AP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention by the nurse? 1147 A) Fastening tube to the gown with new tape. B) Placing client supine while giving a bath. C) Monitoring the client's weight as ordered. D) Ambulating patient with enteral feedings still infusing.

B)

A patient is recovering from a major surgery. Which nutrient should be increased to help with healing? A) Carbohydrates B) Protein C) Fats D) Sugars

B)

Bladder palpates as tight or full. A) Functional Incontinence B) Retention or Overflow Incontinence C) Stress Incontinence D) Urge Incontinence

B)

Difficulty swallowing increases the risk for aspiration. What is this condition called? A) Dyspepsia B) Dysphagia C) Dyspnea D) Dyslexia

B)

The goal of client education is to help clients achieve which of the following? A) Compliance with meeting the standards of the Nurse Practice Act. B) Optimal level of health. C) Dependence on the health care team. D) Self-care only while in the hospital.

B)

The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing, and unable to clear secretions. What should the nurse do first? 975 A) Start oxygen at 2 L/min via nasal cannula B) Elevate the head of the bed to 45 degrees C) Encourage the patient to use the incentive spirometer D) Notify the health care provider

B)

The nurse is obtaining the health history from a client whose background differs from the nurse's. To develop culturally acceptable strategies for nursing care, the nurse should assess which client factor? A) Marital status B) Cultural influences C) Financial resources D) Community involvement

B)

The nurse is reviewing the medical record of an older adult male client. The nurse should identify that which of the following findings places the client at risk for developing a urinary tract infection (UTI)? A) The client has a history of a left-sided stroke. B) The client has prostate disease. C) The client admits to drinking six alcoholic beverages each day,

B)

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? ATI 249 A) Have the client hold their breath briefly and bear down B) Clamp the enema tubing C) Remind the client that cramping is common at this time D) Raise the level of the enema fluid container

B)

A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid retention? 357 A) A client who has a new diagnosis of adrenal insufficiency B) A client who has heart failure C) A client who is receiving treatment for diabetic ketoacidosis D) A client who has abdominal ascites

B) Anticipate a client who has heart failure to require fluid and sodium restriction to reduce the workload on the heart.

A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? 357 A) Administer antihypertensive on schedule. B) Check the client's weight each morning. C) Notify the provider of a urine output greater than 30 mL/hr. D) Encourage independent ambulation four times a day.

B) Include obtaining the client's weight each day in the plan of care. To ensure accuracy the client's weight should be obtained at the same time each day using the same scale. By determining the client's weight gain or loss each day the nurse can evaluate the client's response to treatment.

A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action to take before attempting this particular mind-body intervention? ATI 243 A) Tell the client the goal of the therapy is to promote healing. B) Ask whether the client is comfortable using prayer C) Encourage the client participate actively for best results D) Instruct the client to relax during the therapy

B) The first action to take using the nursing process is to assess or collect data from the client.

A nurse is instructing a client on how to administer cyclic enteral feedings at home. Which of the following information should the nurse include? SATA A) "Give a feeding every 6 hours" B) "Set the feeding up before you go to bed." C) "Weigh yourself daily." D) "Flush the tube with a carbonated beverage to dislodge clogs." E) "Ensure your head is elevated to 15 degrees during administration."

B) C)

A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect? SATA ATI 249 A) Bradycardia B) Hypotension C) Elevated temperature D) Poor skin turgor E) Peripheral edema

B) C) D)

A nurse is preparing to administer intermittent enteral feeding to a client. Which of the following are appropriate nursing interventions? SATA A) Fill the feeding bag with 24 hr worth of formula. B) Discard feeding equipment after 24 hr. C) Place any unused formula in open cans in the refrigerator. D) Flush the feeding tube every 4 hours. E) Elevate the head of the client's bed for 15 min after administration.

B) C) D)

A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? SATA A) Restrict the client's intake of fluids during the daytime. B) Have the client record urination times. C) Gradually increase the urination intervals D) Remind the client to hold urine until the next scheduled urination time E) Provide a sterile container for urine.

B) C) D)

A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? SATA ATI 116 A) Install bath rails and grab bars in bathrooms B) Wear a helmet while skiing C) Install a carbon monoxide detector D) Secure firearms in a safe location E) Remove throw rugs from the home

B) C) D)

The nurse is caring for a patient with pneumonia, who has severe malnutrition. The nurse should assess the patient for which of the following assessment findings? SATA 1147 A) Heart Disease B) Sepsis C) Hemorrhage D) Skin Breakdown E) Diarrhea

B) C) D)

Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention? SATA A) SpO2 value of 95% B) Retractions C) Respiratory rate of 28 breaths per minute D) Nasal flaring E) Clubbing of fingers

B) C) D)

A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? SATA ATI 125 A) Human Papillomavirus virus (HPV) immunization B) Pneumococcal immunization C) Yearly eye examination D) Periodic mental health screening E) Annual fecal occult blood test

B) C) D) E)

A nurse is providing teaching for a client who has a new diagnosis of hypertension and a prescription for a low-sodium diet. Which of the following client statements indicate an understanding of the teaching? SATA A) "I should select organic canned vegetables." B) "I need to read food labels when grocery shopping." C) "I will stop eating frozen dinners for lunch at work." D) "I know that deli meats are usually high in sodium." E) "I can refer to the American Heart Association's website for dietary guidelines."

B) C) D) E)

A nurse is assisting a client who has a prescription for a mechanical soft diet with food selections. Which of the following are appropriate selections by the client? SATA A) Dried prunes B) Ground Turkey C) Mashed carrots D) Fresh strawberries E) Cottage cheese

B) C) E)

A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? SATA ATI 187 A) Suggest coping skills for the client to use in this situation B) Allow the client to provide input in the treatment plan C) Assist the client with time management, and address the client's priorities D) Provide extensive instructions on the client's treatment regimen. E) Encourage the client in the expression of feelings and concerns

B) C) E)

A nurse is collecting data to evaluate a middle adult's psychosocial developmental. The nurse should expect middle adults to demonstrate which of the following developmental tasks? SATA ATI 120 A) Develop an acceptance of diminished strength and increased dependence on others B) Spend time focusing on improving job performance C) Welcome opportunities to be creative and productive D) Commit to finding friendship and companionship E) Become involved with community issues and activities

B) C) E)

A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? SATA A) Limit total daily fluid intake B) Decrease or avoid caffeine C) Take calcium supplements D) Avoid drinking alcohol E) Use the Crede maneuver

B) D)

A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? SATA ATI 125 A) Skin thickening B) Decreased height C) Increased saliva production D) Nail thickening E) Decreased bladder capacity

B) D) E)

A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and family members? SATA ATI 201 A) Talk to the interpreter about the family while the family is in the room B) Determine client understanding several times during the conversation C) Look at the interpreter when asking the family questions D) Use lay terms if possible E) Do not interrupt the interpreter and the family as they talk.

B) D) E)

Which nursing interventions are appropriate to use in a plan of care to promote sleep for patients who are hospitalized? SATA A) Give patients a cup of coffee one hour before bedtime. B) Plan vital signs to be taken before the patients are asleep. C) Turn television on 15 minutes before bedtime. D) Have patients follow at-home bedtime schedule. E) Close the door to patient's rooms at bedtime.

B) D) E)

A nurse is caring for a client following an appendectomy who has a postoperative prescription that reads "discontinue NPO status; advance diet as tolerated." Which of the following are appropriate for the nurse to offer the client initially? SATA A) Applesauce B) Chicken broth C) Sherbet D) Wheat toast E) Cranberry juice

B) E)

A nurse is discussing health problems associated with nutrient deficiencies with a group of clients. Which of the following conditions is associated with a deficiency of vitamin C? SATA A) Dysrhythmias B) Scurvy C) Pernicious anemia D) Megaloblastic anemia E) Bleeding gums

B) E)

What is a normal Serum albumin level? a.) 3.3-5.0 b.) 3.5-5.0 c.) 3.2-5.0 d.) 2.7-3.4

B.

The nurse notes that their patient's H&H is 27% Hct and Hgb=8.8. This result may indicate that the patient will have: A. Hypovolemia B. Hypoxia C. Increased lung compliance D. Crackles at the bases

B. Hypoxia

Which form of pain is more intense. i.e., "hurts more?" A. Acute B. Chronic

Based on the information presented, "Cannot be ascertained". Acute and Chronic relate to time, how long the pain has persisted, not the intensity of pain.

Describe a healthy stoma in an ileostomy, colostomy, and urostomy?

Beefy red

Signs and Symptoms of urinary tract infections

Bladder Urgency Urinary frequency Cloudy urine Foul smelling

A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse include as a developmental task for a young adult? ATI 116 A) Becoming actively involved in providing guidance to the next generation. B) Adjusting to major changes in roles and relationships due to losses. C) Devoting time to establishing an occupation D) Finding oneself "sandwiched" between and being responsible for two generations.

C)

A noisy environment can affect sleep patterns and cause which of the following? A) Increased productivity B) Decreased blood pressure C) Delayed healing D) Skin breakdown

C)

A nurse enters the room of a client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take? ATI 201 A) Contact the hospital's spiritual services B) Ask what is making the client cry C) Ensure no visitors or staff enter the room for a short time period D) Turn on the television for distraction

C)

A nurse has been caring for a client who has been following the facility's routine and bathing in the morning. However, at home, the client always takes a warm bath just before bedtime. Now the client is having difficulty sleeping at night. Which of the following actions should the nurse take first? A) Rub the client's back 15 minutes before bedtime. B) Offer the client warm milk and crackers at 2100. C) Allow the client to take a bath in the evening. D) Ask the provider for a sleeping medication.

C)

A nurse is assisting a client with selecting food choices on a menu. Which of the following actions by the nurse demonstrates ethnocentrism? A) Asking the client about some favorite food choices B) Notifying the dietician to complete the menu. C) Recommending one's own favorite foods D) Asking the client's family to fill out the menu.

C)

A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)? ATI 187 A) Exhaustion Stage B) Resistance Stage C) Alarm Stage D) Recovery Stage

C)

A nurse is caring for a client who has hypertension. Which of the dietary patterns is sometimes followed by Asian clients and places clients at risk for this condition? A) Incorporation of plant-based foods in the diet. B) Consumption of raw foods. C) Preparation of foods using sodium. D) Focus on shellfish in the diet.

C)

A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my child's wedding." Based on the Kubler-Ross model, which stage of grief is the client experiencing? ATI 207 A) Anger B) Denial C) Bargaining D) Acceptance

C)

A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family? ATI 207 A) Allowing the client to function independently will strengthen muscles and promote healing. B) The client needs privacy at times for self-reflecting and organizing life. C) The client's sense of loss can be lessened through retaining control of some areas of life. D) Performing ADLs is a requirement prior to discharge from an acute facility.

C)

A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? 239 A) "I'll wait to use the device until it's absolutely necessary." B) "I'll be careful about pushing the button too much so I don't get an overdose." C) "I should tell the nurse if the pain doesn't stop while I am using this device." D) "I will ask my adult child to push the dose button when I am sleeping."

C)

A nurse is caring for a client who is transitioning to an oral diet following a partial laryngectomy. Which of the following actions should the nurse take to reduce the client's risk for aspiration? A) Request to have the client's oral medications provided in liquid form. B) Instruct the client to follow each bite of food with a drink of water. C) Encourage the client to tuck the chin when swallowing. D) Consult the dietician about providing the client with a thin liquid diet.

C)

A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A) Cooked barley B) Pureed broccoli C) Vanilla custard D) Lentil soup

C)

A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first? ATI87 A) Give the client information about immunization against meningitis. B) Tell the client to have a TB skin test every 2 years. C) Determine the client's health risks. D) Teach the client about exercise recommendations.

C)

A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients? ATI 201 A) Members of the same religion share similar feelings about their religion B) A shared religious background generates mutual regard for one another C) The same religious beliefs can influence individuals differently D) The nurse and client should discuss the differences and commonalities in their beliefs

C)

A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? 239 A) Ask the client what precipitates the pain B) Question the client about the location of the pain C) Offer the client a pain scale to measure their pain D) Use open-ended questions to identify the client's pain sensations

C)

A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following statements should the nurse identify as the priority to assess further? ATI 116 A) "I have my own apartment now, but it's not easy living away from my guardians." B) "It's been so stressful for me to even think about having my own family." C) "I don't even know who I am yet, and now I'm supposed to know what to do." D) "My partner is pregnant, and I don't think I have what it take to be a good parent."

C)

A nurse is taking a sleep history from a patient. Which statement made by the patient needs further follow up? A) "I feel refreshed when I wake up in the morning." B) "I use soft music at night to help me relax." C) "It takes me about 45 to 60 minutes to fall asleep." D) "I take the pain medication for my leg pain about 30 minutes before I go to bed."

C)

A nursing student is planning care for an older adult client who is experiencing pain. Which of the following statements made by the nursing student indicates the need for clarification by the clinical instructor? A) "Older clients often have difficulty determining what is causing their pain." B) "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the client's response to the medication." C) "As adults age, their ability to perceive pain decreases." D) "Clients who have dementia probably experience pain, and their pain is not always well controlled."

C)

Sudden intra-abdominal pressure. Changes due to coughing or sneezing. A) Functional Incontinence B) Retention or Overflow Incontinence C) Stress Incontinence D) Urge Incontinence

C)

The nurse is teaching students about pain assessment scales. Which statement by a student indicates correct understanding? A) "You cannot use a pain scale to compare the pain of my client with the pain of your client." B) "When clients say they don't need pain medication, they aren't in pain." C) "Pain assessment scales determine the severity and quality of a client's pain." D) "A client's behavior is more reliable than the client's report of pain."

C)

When using a bedpan, what position should the patient be in? A) Supine B) Semi Fowlers C) Fowlers

C)

A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? SATA ATI 207 A) Remove the dentures from the body. B) Make sure the body is lying completely flat. C) Apply fresh linens and place a clean gown on the body. D) Remove all equipment from the bedside. E) Dim the lights in the room.

C) D) E)

A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? SATA 239 A) Urinary incontinence B) Diarrhea C) Bradypnea D) Orthostatic hypotension E) Nausea

C) D) E)

A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? SATA ATI 357 A) Distended neck veins B) Hyperthermia C) Tachycardia D) Syncope E) Decreased skin turgor

C) D) E)

A nurse is providing teaching for an older adult client who has lost 4.5kg (9.9 lb) since the last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? SATA ATI 125 A) "Eat three large meals a day." B) "Eat your meals in front of the television." C) "Eat foods that are easy to eat, such as finger foods." D) "Invite family members to eat meals with you." E) "Exercise every day to increase appetite."

C) D) E)

A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? SATA 331 A) Apply petroleum jelly around and inside the nares. B) Remove the nasal cannula during mealtimes. C) Check the position of the cannula frequently. D) Report any nausea or difficulty breathing. E) Post "No Smoking" signs in prominent locations.

C) D) E)

A nurse is planning care for a client who has mechanical fixation of the jaw following a motorcycle crash. Which of the following actions should the nurse include in the plan of care? SATA A) Thicken liquids to honey consistency. B) Educate the client about the use of a nasogastric tube. C) Assist the client to use a straw to drink liquids. D) Ensure that the client receives ground meats. E) Encourage intake of fluids between meals.

C) E)

A nurse in a nutrition clinic is calculating body mass index (BMI) for several clients. The nurse should identify which of the following client BMIs as overweight? A) 24 B) 30 C) 27 D) 32

C) Overweight is defined as an increased body weight in relation to height, indicated by a BMI of 25 to 29.9.

While assessing a client with emphysema, which finding requires the nurse to follow up with the health care provider? A) Clubbing of the fingers B) Increased anterior-posterior diameter of the chest C) Hemoptysis D) Tachypnea

C) Hemoptysis is an abnormal occurrence of emphysema, and further diagnostic studies are needed to determine the cause of blood in the sputum.

A nurse is assessing a client's pain. Which of the following questions should the nurse ask the client to assess the quality of the pain? A) "When did the pain begin?" B) "How would you rate your pain on a scale from 0 to 10?" C) "What does your pain feel like?" D) "Can you show me where you have pain?"

C) "What does your pain feel like?" The nurse should assess the quality of the client's pain by asking him to describe how it feels.

Which are signs/symptoms of fluid overload? (SATA) A. Dark-colored urine B. Hypotension C. Pitting edema in the feet D. Dry mucus membranes E. Tachycardia F. Weight gain of 4lbs in 24 hrs G. Bounding Pulse H. Hypertension I. Tachypnea J. Head Ache

C) E) F) G) H) I) J) C. Pitting edema in the feet E. Tachycardia F. Weight gain of 4lbs in 24 hrs G. Bounding Pulse H. Hypertension I. Tachypnea J. Head Ache

A nurse is caring for a client who has a left hip fracture and is prescribed a morphine IV bolus as needed for pain. The nurse should monitor the client for which of the following adverse effects? A) Diarrhea B) Tachypnea C) Sedation D) Polyuria

C) Sedation. The nurse should monitor the client for sedation, which is an adverse effect of morphine and can lead to respiratory depression.

Best dietary choices essential for wound healing? a.) Green vegetables b.) Vitamin B12 c.) fish and chicken (meat) d.) Vitamin D

C.

If a client has a simple oxygen mask, the liter flow should be: A. 2-4L/min B. 4-8L/min C. 6-12L/min D. 15L/min

C. 6-12L/min

Which of the following is a client-centered outcome for patient experiencing acute pain? A. The nurse will administer ordered pain med q4hrs B. Staff will respond to pt's call bell within 5 minutes and measure/record vital signs. C. Client will report a decreased pain level of 2/10 within 30 minutes after pain med administration D. Client will be discharged to home on no pain medications.

C. Client will report a decreased pain level of 2/10 within 30 minutes after pain med administration

A noisy environment can affect sleep patterns and cause what problems? a.) risk for injury b.) grumpy patients c.) Delayed healing, prolonged hospitalization, lead to a grumpy, dissatisfied patient d.) prolonged hospitalization

C.)

Urine output is an indirect measurement of __________________ output as it 'perfuses' the kidneys.

Cardiac

What is the most accurate way for the nurse to assess a coherent, oriented, verbal client's pain?

Client rates pain using a 0/10 scale.

A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the nurse include as a developmental task for middle adulthood? ATI 120 A) The client evaluates their behavior after a social interaction B) The client states they are learning to trust others C) The client wishes to find meaningful friendships D) The client expresses concerns about the next generation

D)

A nurse is caring for a client who has a terminal illness. Death is expected within 24 hours. The client's family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse include? ATI 207 A) Regular breathing patterns B) Warm extremities C) Increased urine output D) Decreased muscle tone.

D)

A nurse is caring for a client who tells the nurse that based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make? ATI 201 A) "I believe in this case you should really make an exception and accept the blood transfusion." B) "I know your family would approve of your decision to have a blood transfusion." C) "Why does your religion mandate that you cannot receive any blood transfusions?" D) "Lets discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.

D)

A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client? ATI 249 A) Eating more protein is optimal prior to testing B) One stool specimen is sufficient for testing C) A red color change indicates a positive test D) The specimen cannot be contaminated with urine

D)

A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? ATI 187 A) Prescribing tasks unilaterally B) Delegating care to one member C) Speaking to the primary client privately D) Convening a family meeting

D)

A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? ATI 125 A) "I spent my whole life dreaming about retirement, and now I wish I had my job back." B) "Its been so stressful for me to have to depend on my child to help around the house." C) "I just heard my friend Al died. That's the third one in three months." D) "I keep forgetting which medications I have taken during the day."

D)

A nurse is developing a plan of care for a client who has cystitis. Which of the following interventions should the nurse include in the plan? A) Insert an indwelling catheter. B) Monitor the client for bradycardia. C) Check the client's stools for occult blood. D) Provide the client with warm sitz baths.

D)

A nurse is discussing foods that are high in vitamin D with a client who is unable to be out in the sunlight. Which of the following should be included in the teaching? A) 1 cup steamed long-grain brown rice B) 6 medium raw strawberries C) 1/2 cup boiled brussels sprouts D) 2 large, poached eggs

D)

A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? 239 A) A client who has a broken femur and reports hip pain B) A client who has incisional pain 72 hr following pacemaker insertion C) A client who has food poisoning and reports abdominal cramping. D) A client who has episodic back pain following a fall 2 years ago

D)

A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? A) Fat B) Protein C) Glycogen D) Carbohydrates

D)

A nurse is providing teaching to a client who is to begin taking phenelzine. Consuming which of the following foods while taking this medication could cause a hypertensive crisis? A) Grapefruit juice B) Dark green vegetables C) Greek yogurt D) Smoked fish

D)

A nurse is teaching a client who has a urinary tract infection and a prescription for ciprofloxacin. Which of the following instructions should the nurse include in the teaching? A) "Limit the amount of fluids you drink while taking this medication." B) "Try to spend one hour each day outside in the sunshine." C) "Take this medication with milk to reduce your risk of stomach irritation." D) "You should not take an antacid within 2 hours of taking ciprofloxacin."

D)

Sudden urgent desire to pass urine, followed immediately by an incontinent episode. A) Functional Incontinence B) Retention or Overflow Incontinence C) Stress Incontinence D) Urge Incontinence

D)

The initial placement of a feeding tube should be confirmed by which method? A) Injecting air and listening for a "gurgle" B) Asking the patient C) Visualizing gastric juices D) Obtaining an X-Ray

D)

The nurse is caring for a client with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? 1147 A) Suction her mouth and throat. B) Turn her on her side. C) Put on oxygen at 2L nasal cannula. D) Stop feeding her.

D)

Which nursing action is best for a hospitalized client who is constantly upset with the staff, easily angers, and frequently shouts at the nurses? A) Request that the client be moved to another unit. B) Schedule a conference with the physician, nurse manager, and client about this behavior. C) Contact social services to meet with the client and family about the problem. D) Involve the client and family in the development of the care plan.

D)

A nurse is preparing to administer hydrocodone to a client who reports throbbing pain following a back injury. The nurse should document that the client is experiencing which of the following types of pain? A) Idiopathic B) Neuropathic C) Visceral D) Somatic

D) Somatic. The nurse should identify that the client who has a back injury is experiencing somatic pain, which affects the bones, joints, and muscles of the body.

After assessing the client and identifying the need for pain relief, the nurse administers an analgesic. What is the next priority nursing action for this client?

Evaluate - reassess in 30 min Using ADPIE - this will be the evaluation portion

Client receiving bolus feeding via NG tube. Pt position? How long should patient remain there? a.) semi-fowlers or fowlers and leave patient there for 30mins b.) supine and leave patient there for at least 2 hours c.) semi-fowlers or fowlers and leave patient there for 6 hours d.) semi- fowlers or fowlers and leave patient there for at least 2hours

D.)

Your patient has poor skin turgor, dry oral mucous membranes, and has been complaining of fatigue and weakness. Vital Signs: 99.8F (O), P 104, RR 20, BP 110/65 O2 Sat 94% on RA Urinalysis: Dark Amber pH 7.0 SG 1.045 Protein neg Glucose neg Ketones neg (all other urine chems and microscopics neg) Patient's problem is _________________ based on what lab values?

Dehydration, based on Dark Amber and SG 1.045

What are the signs and symptoms of Hypoxia?

Early signs: Restlessness, agitation, irritability, possibly tachypnea, subtly decreased LOC

Bed-wetting

Enuresis

The kidneys produce this. This stimulates red blood cell production and maturation of bone marrow. Patients with chronic kidney conditions are prone to anemia.

Erythropoietin

True or False Urinary incontinence is a normal aging change.

False

My patient has had diarrhea for 4 days. Lab work today shows the following: HgB 16, Hct 50%. What should we expect?

Hemoconcentration (increased concentration of cells and solids in the blood usually resulting from loss of fluid to the tissues)

Bowel Sounds: What does Hyperactive mean?

High pitched sounds that occur with small intestine obstruction and inflammatory disorders.

Creatinine normal lab value? What is its implication?

M 0.6-1.2 mg/dL F 0.5-1.1 mg/dL Kidney Function

Bowel Sounds: What does Hypoactive mean?

Maybe absent or hypoactive, such as after surgery. Patient should be NPO.

Are sterile gloves used for ostomy care?

No, just clean gloves. Ostomy/Stoma care: Inspect the area around the stoma before applying a new bag. The skin should be washed with warm water only as soap can cause drying and be too harsh. Sterile gloves are not needed as this is not a sterile procedure. The area around the stoma should be cleansed gently, not scrubbed, as this can cause problems with adhesion and skin breakdown.

Waking up at night to go pee. Causes: Excessive intake of fluids, especially coffee or alcohol before bedtime. Bladder obstruction, medication, or overactive bladder, cardiovascular disease, or UTI.

Nocturia

Bowel Sounds: What does Normoactive mean?

Normal bowel sounds occur every 5-15 seconds and last one to several seconds.

When assessing a young woman who was a victim of a home invasion 3 months earlier, the nurse learns that the woman has vivid images of the event whenever she hears loud yelling or a sudden noise. The nurse recognizes this as ____________.

PTSD

The process of circulating blood to all organs is called ____________________?

Perfusion

Lab tests/values needed to know for block 3?

Serum Albumin - 3.5-5 g/dL WBC - 4,000-10,000 mm3 RBC - 4.2-6.1 x 10 (6) micro/L Hematocrit - M: 40-52%, F: 37-47% Hemoglobin - M: 13-18, F: 12-15 BNP - <100

True or False Caffeine irritates bladder lining

True

True or False Risk for urinary incontinence increases with aging.

True

What type of O2 mask is this, and what is it's purpose?

Venturi mask. Accurately delivers a specific percentage of oxygen.

Describe and discuss obtaining a urine specimen for a culture and sensitivity

Wipe first, clean-catch midstream into a sterile container

The clients hemoglobin is 6.9g/dL and the hematocrit is 20%. Would oxygen supplementation be beneficial here?

Yes. O2 at 2-4L/min Nasal Cannula

The initial placement of a feeding tube should be confirmed by which method? a.) X-ray b.) Ultrasound c.) Feed the patient d.) Ask the charge nurse

a.)

What are the consequences of sleep deprivation? a.) Risk for injury b.) Risk for depression c.) Risk for pressure ulcers d.) Risk for developing anxiety

a.)

A nurse is assessing a patient with a BMI of 15, what is indicated by this BMI? a.) Patient is malnourished and should begin feeding immediately. b.) Patient is underweight c.) Patient is obese d.) Patient is in poor health overall

b.

Fostering, enabling, quality sleep in your hospitalized patient promotes what? a.) slows recovery and promotes good health b.) promoting good health and recovery from illness c.) Promotes patient to have a positive outlook and less likely to develop depression

b.)

A patient is recovering from major surgery. Which nutrient should be increased to help with healing? a.) carbohydrates b.) lipids c.) Protein d.) enzymes

c.)

What Nutrients are best energy source? a.) protein b.) lipids c.) carbohydrates d.) vitamins

c.)

You are assisting/feeding a patient with Dysphagia (due to hemiparesis) while eating. Dysphagia interventions? a.) lay patient down and feed quickly to prevent food from spoiling b.) sit patient up and feed in weaker side of the mouth slowly c.) sit client upright, feed slowly, and give food on stronger side of mouth. d.) sit client upright, feed quickly, and give food on stronger side of the mouth

c.)

Difficulty swallowing increases the risk for aspiration. What is this condition called? a.) Dyspnea b.) Aphasia c.) Dysphagia d.) Pneumonia

c.)Dysphagia

An advancing diet should progress in which order? ("diet: advance as tolerated") a.) Check patients allergies b.) Check bowel sounds c.) Check for aspirations d.) Check aspirations and bowel sounds. Proceed with ice chips, clear liquids, full liquids, light diet, regular diet

d.)