AIDS. RE

Parkland Formula for Fluid Replacement in Burns

-4 ml/kg per % TBSA of burn in 24 hours. One half of the total volume is given in the first 8 hours post burn. The second half is administered over the following 16 hours. -72 kg x 4 mL x 50% then divide by 2

Living Will/Advance Directives

-Always honor the patient's wishes. -Patients can change it whenever, doesn't have to be done by a court, can be anyone, -A written statement detailing a person's desires regarding their medical treatment in circumstances in which they are no longer able to express informed consent, especially an advance directive.

Angiotensin Receptor Blockade (ARB)

-Angiotensin II receptor blockers help relax your veins and arteries to lower your blood pressure and make it easier for your heart to pump blood. -Angiotensin II receptor blockers block the action of angiotensin II. As a result, the medication allows your veins and arteries to widen (dilate). -'tan drugs. -In addition to treating high blood pressure, angiotensin II receptor blockers may prevent, treat or improve symptoms in people who have: chronic kidney diseases, heart failure, kidney failure in diabetes

Beta Blockers

-Beta blockers, also known as beta-adrenergic blocking agents, are medications that reduce your blood pressure. Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. -Beta blockers cause your heart to beat more slowly and with less force, which lowers blood pressure. Beta blockers also help open up your veins and arteries to improve blood flow. -'lol drugs -Beta blockers are used to prevent, treat or improve symptoms in people who have: irregular heart rhythm (arrhythmia), heart failure, chest pain (angina), heart attacks, migraine, certain types of tremors -Decreases cardiac workload and oxygen consumption

Calcium Channel Blockers

-Calcium channel blockers lower your blood pressure by preventing calcium from entering the cells of your heart and arteries. Calcium causes the heart and arteries to contract more strongly. By blocking calcium, calcium channel blockers allow blood vessels to relax and open. -Some calcium channel blockers have the added benefit of slowing your heart rate, which can further lower your blood pressure, relieve chest pain (angina) and control an irregular heartbeat. -Calcium channel blockers are also called calcium antagonists -'pine drugs -In addition to high blood pressure, doctors prescribe calcium channel blockers to prevent, treat or improve symptoms in a variety of conditions, such as: coronary artery disease, chest pain (angina), irregular heartbeats (arrhythmia), some circulatory conditions, such as Raynaud's disease -Increases blood supply to the myocardium

Ishihara Chart

-Checks color blindness -The circle with a bunch of little circles and has "hidden" numbers and letters

Syndrome of Inappropriate Antidiuretic Hormone (SIADH) in Cancer

-Common with lung cancer -Body makes too much ADH which causes the body to retain too much water -This process disrupts sodium especially -Treatments include fluid restriction and possibly medications to balance electrolytes -May need diuretics -May cause hyponatremia

Immunosuppression in Kidney Transplant

-Immunosuppression drugs are given for transplants so the body does not attack the new organ and kill it. -Use precautions like contact precautions because the pt is immunocompromised and get sick easy -They don't need to be in large crowds.

Late Septic Shock

-Late SEPTIC Shock symptoms include shallow respirations, lethargic mental status, and decreased urine output.

Second Degree Type II Heart Block (Mobitz II)

-More p's than QRS, PR intervals stay the same

Pain (Background, Breakthrough, Procedural, Referred)

-Procedural pain is associated with therapeutic activities such as wound care and physical therapy. -Background pain is the underlying pain from the primary injury that is continuous and ongoing. -Breakthrough pain is pain related to specific episodes associated with activities of daily living (ADL) such as walking. -Referred pain occurs in a part of the body other than its actual source.

Electrical Conduction of the Heart (including each pacemaker and its intrinsic rate)

-SA- 60-100 -AV- 40-60 -Bundle- 20-40 -Purkinje- less than 20

Cushing's Triad

-Three primary signs that indicate increased intracranial pressure -Increased systolic BP, decreased pulse, and decreased respirations -Hypertension, bradycardia, and irregular respirations (Cheyne-Stokes) -Cushing's Triad is a grouping of symptoms that indicate an elevation in intracranial pressure (ICP). The triad consists of hypertension (with widening pulse pressure), Bradycardia, and slow irregular breathing, Other signs present with increased ICP are: headache, vomiting, restlessness and irritability, decreased level of consciousness (LOC), confusion, double vision, unequal pupils, seizures, contralateral hemiparesis, etc.

ptosis

-Upper eyelid drooping due to muscle dysfunction or nerve issue -Can be fixed with surgery and pts like it bc it makes them look younger

*14. The client diagnosed with schizophrenia spectrum disorder is prescribed an antipsychotic. Which client symptoms, related to the side effects of this medication, should prompt a nurse to intervene immediately? 1. Sore throat and malaise 2. Light-colored urine and bradycardia 3. Anosognosia and avolition 4. Dry mouth and urinary retention

1

*3. An adolescent diagnosed with schizophrenia spectrum disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which response should the nurse make? 1. "Your child has a chemical imbalance of the brain, which leads to altered perceptions." 2. "Your child's hallucinations are caused by medication interactions." 3. "Your child has too little serotonin in the brain, causing delusions and hallucinations." 4. "Your child's abnormal hormonal changes have precipitated auditory hallucinations."

1

1. During a home visit the nurse suspects that someone in the family has hearing loss. What did the nurse observe to come to this conclusion? 1) Television volume on loud 2) Patient sitting in the kitchen 3) Music playing in the background 4) Family member cooking at the stove

1

1. The nurse is caring for a patient with acquired immunodeficiency syndrome (AIDS) who is in antiretroviral therapy. The patient reports nausea, fever, severe diarrhea, and anorexia. Which prescribed medication does the nurse anticipate in order to relieve the anorexia and to stimulate the patient's appetite? 1) Dronabinol (Marinol) 2) Abacavir (Ziagen) 3) Ciprofloxacin (Cipro) 4) Zidovudine (Retrovir, AZT)

1

10. A medical-surgical unit is expecting a large volume of patient admissions after a train derailment. Which member of the nursing care team will prioritize care for the unit? 1) Charge nurse 2) Nurse supervisor 3) Licensed practical nurse 4) Unlicensed assistive personnel

1

10. A nurse is caring for a patient who was involved in a motor vehicle accident who has lost approximately 1,500 mL of blood. Based on this data, which type of shock is the patient experiencing? 1) Hypovolemic 2) Cardiogenic 3) Distributive 4) Obstructive

1

11. A patient is admitted to the emergency department in a sickle cell crisis. The nurse assesses the patient and documents the following clinical findings: temperature 102°F, O2 saturation of 89%, and complaints of severe abdominal pain. Based on the assessment findings, which intervention is the greatest priority? 1) Apply oxygen per nasal cannula at 3 L/minute. 2) Assess and document peripheral pulses. 3) Administer morphine sulfate 10 mg IM. 4) Administer Tylenol 650 mg by mouth.

1

11. A patient with a hearing disorder just underwent a CT scan with contrast. What should the nurse emphasize to the patient after the test? 1) Increase oral fluids 2) Avoid caffeinated beverages 3) Take nothing by mouth for three hours 4) Avoid over-the-counter analgesics

1

11. A patient with acute kidney injury is complaining of a metallic taste in the mouth and has no appetite. Based on this data, which intervention by the nurse is the most appropriate? 1) Provide mouth care before meals 2) Administer an antiemetic as prescribed 3) Restrict fluids 4) Encourage the intake of protein, salt, and potassium

1

11. A patient with several deep partial-thickness burns asks how long it will take for the burn to heal. What should the nurse respond to this patient? 1) "More than two weeks." 2) "Within one to two weeks." 3) "Within 24 to 72 hours." 4) "You will need skin grafts."

1

11. The nurse is concerned that a patient admitted for a total hip replacement is at risk for thrombus formation and pulmonary embolism. Which assessment finding supports the nurse's concern? 1) Body mass index (BMI) 35.8 2) Former cigarette smoker 3) Blood pressure 132/88 mm Hg 4) Age 45 years

1

12. A patient with systemic lupus erythematosus (SLE) is being treated with immunosuppressant drugs and corticosteroids. Which patient statement indicates the need for further education after teaching? 1) "I can go to events with large crowds." 2) "I should avoid getting the flu shot." 3) "I will use contraception to avoid pregnancy." 4) "I will report any symptoms of infection immediately."

1

13. A nurse is caring for a patient with systemic lupus erythematosus (SLE). The patient begins to cry stating, "I am afraid I will be disfigured because of all of these lesions." Which intervention does the nurse plan to teach this patient to minimize skin infections associated with SLE? 1) Use sunscreen with an SPF of 15 or greater 2) Remain indoors on sunny days 3) Avoid swimming in a pool or the ocean 4) Decrease sun exposure between 3:00 p.m. and 5:00 p.m.

1

13. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient presents with a fever without other notable symptoms. Which is the most likely cause of this data? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

1

13. Which assessment data would a school nurse recognize as a sign of physical neglect in a child? 1. The child is often absent from school and seems apathetic and tired. 2. The child is very insecure and has poor self-esteem. 3. The child has multiple bruises on various body parts. 4. The child has sophisticated knowledge of sexual behaviors.

1

14. A child diagnosed with severe autism spectrum disorder has the nursing diagnosis disturbed personal identity. Which outcome would best address this client diagnosis? 1. The client will name own body parts as separate from others by day five. 2. The client will establish a means of communicating personal needs by discharge. 3. The client will initiate social interactions with caregivers by day four. 4. The client will not harm self or others by discharge.

1

15. A patient with heart failure is prescribed an angiotensin-converting enzyme inhibitor. What should the nurse explain as being the purpose of this medication? 1) Reduce afterload 2) Decrease preload 3) Increase contractility 4) Control sympathetic nervous system response to decreased cardiac output

1

16. The nurse is assessing a patient who is diagnosed with human immunodeficiency virus (HIV) who presents with a rash. Which assessment question is most appropriate? 1) "Are you taking Bactrim?" 2) "Have you recently used a new soap?" 3) "What have you eaten in the last few days?" 4) "Did you have unprotected sex within the last week?"

1

16. The nurse is preparing to discharge a patient with chronic kidney disease. The nurse is teaching the patient and family about administering calcium acetate tablets by mouth with each meal at home. Which explanation about this medication is the most appropriate? 1) "The calcium acetate will lower your serum phosphate levels." 2) "The calcium acetate helps to neutralize your gastric acids." 3) "The calcium acetate will help to stimulate your appetite." 4) "The calcium acetate will decrease your serum creatinine levels."

1

16. The nurse is providing care for a newly married woman with systemic lupus erythematosus (SLE). Which patient statement indicates an appropriate understanding of the plan of care? 1) "I will take birth control pills while I am taking cytotoxic medications." 2) "I do not need to contact the doctor if I develop a fever or rash." 3) "I plan to go to the movies this weekend so that I get out of the house." 4) "I can take aspirin as indicated for pain."

1

17. A patient asks why sunglasses need to be worn when out of doors. What health problem should the nurse say is reduced when responding to this patient? Cataracts Glaucoma Detached retina Corneal abrasions

1

19. A middle-aged patient avoids eating out in restaurants because of the inability to hear dining partners talk. What should the nurse realize that this patient is describing? 1) Presbycusis 2) Mixed hearing loss 3) Conductive hearing loss 4) Sensorineural hearing loss

1

19. A patient recovering from 25% total body surface area burns has a low-grade fever. What should the nurse do to reduce this patient's risk of developing an infection? 1) Follow contact precautions 2) Implement protective isolation 3) Use sterile technique for all dressing changes 4) Administer prophylactic antibiotics as prescribed

1

19. The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a patient who is experiencing hypovolemic shock due to a penetrating wound? 1) Red 2) Black 3) Green 4) Yellow

1

2. The nurse is caring for an adolescent Asian patient with a strong family history of breast cancer. What should the nurse teach the patient regarding cancer prevention? 1) Perform monthly breast self-examination. 2) Teach the side effects of cancer treatment. 3) Talk to family members who have the disease. 4) Discuss cancer fears with the health-care provider.

1

20. During a home visit, the nurse is concerned that an older adult patient is developing chronic kidney disease. The patient has no history of cardiovascular disease. Which data in the patient's assessment caused the nurse to have this concern? 1) Progressive edema 2) Complaints of hip joint pain 3) Recent increase in hunger and thirst 4) Warm moist skin

1

21. A patient with 35% total body surface area burns is in the rehabilitative phase of care. Which approach should be used to reduce the risk of developing contractures? 1) Apply splints 2) Physical therapy two hours a day 3) Passive range of motion exercises 4) Occupational therapy one hour every other day

1

21. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is less than 200 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

1

23. An older adult patient with renal failure is diagnosed with anemia. Based on this data, which cause of anemia will the nurse plan for when providing care? 1) Loss of the kidney hormone erythropoietin 2) A loss of appetite related to elevated blood urea nitrogen (BUN) and creatinine levels 3) The renal dialysis used to treat the chronic renal failure 4) Loss of blood through the urine because the failing kidney does not function properly

1

3. The nurse is discharging a pediatric patient who was recently diagnosed with acquired immunodeficiency syndrome (AIDS). When discussing appropriate health promotion activities for this child, which immunization is contraindicated? 1) Varicella vaccine 2) Haemophilus influenzae type B (HIB conjugate vaccine) 3) Hepatitis B vaccine (hep B) 4) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)

1

3. The nurse is planning care for the patient with acute kidney injury. The nurse plans the patient's care based on the nursing diagnosis of Excess Fluid Volume. Which assessment data supports this nursing diagnosis? 1) Pitting edema in the lower extremities 2) Bowel sounds positive in four quadrants 3) Wheezing in the lungs 4) Generalized weakness

1

3. The nurse is teaching a client diagnosed with bulimia nervosa about the symptom of tooth enamel deterioration. Which explanation for this complication of bulimia nervosa should the nurse provide? 1. The emesis is acidic and corrodes the tooth enamel. 2. Purging causes the depletion of dietary calcium. 3. Food is rapidly ingested without proper mastication. 4. Poor dental and oral hygiene leads to dental caries.

1

3. Which information would be included in a lesson about domestic violence? 1. Power and control are central to the dynamic of domestic violence. 2. Poor communication and social isolation are central to the dynamic of domestic violence. 3. Erratic relationships and vulnerability are central to the dynamic of domestic violence. 4. Emotional injury and learned helplessness are central to the dynamic of domestic violence.

1

5. After an adolescent diagnosed with attention deficit/hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy, a nurse notes that the adolescent loses 10 pounds in a 2-month period. Which is the best explanation for this weight loss? 1. The pharmacological action of Ritalin causes a decrease in appetite. 2. Hyperactivity seen in ADHD causes increased caloric expenditure. 3. Side effects of Ritalin cause nausea, and, therefore, caloric intake is decreased. 4. Increased ability to concentrate allows the client to focus on activities rather than food.

1

5. The nurse is caring for a patient who is diagnosed with acute kidney injury. When reviewing the patient's laboratory data, which finding indicates that a patient has met the expected outcomes? 1) Decreasing serum creatinine 2) Decreasing neutrophil count 3) Decreasing lymphocyte count 4) Decreasing erythrocyte count

1

5. The nurse is caring for a patient who is newly diagnosed with human immunodeficiency virus (HIV). The patient asks the nurse if there are ways to protect the patient's life partner from getting the HIV virus. After educating the patient, which statement indicates the need for further education? 1) "I know to use an oil-based lubricant to prevent spread of the disease to my partner." 2) "I can still kiss and hug my partner to show affection." 3) "I will not share my razor with my partner." 4) "I know I have to practice safer sex with my partner by using a latex condom."

1

5. Which observation made by the nurse indicates that the patient might be experiencing a hearing disorder? 1) Answers most questions incorrectly 2) Sits with the hands folded in the lap 3) Looks at the nurse's face when talking 4) Takes a few extra seconds before responding

1

7. A patient seeks treatment for a corneal abrasion that occurred the previous week. What should the nurse expect to be prescribed to reduce this patient's risk of developing a complication? 1) Tetanus vaccination 2) Topical steroid drops 3) Systemic pain medication 4) Topical antihistamine drops

1

7. The nurse is administering albumin 5% to a patient in shock. Which nursing action is appropriate when assessing this patient? 1) Auscultate breath sounds for crackles 2) Auscultate breath sounds for hyperresonance 3) Auscultate breath sounds for inspiratory stridor 4) Auscultate for an absence of breath sounds in the lower lobes

1

8. A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy, which client statement would indicate to a nurse that the student is handling this situation in a healthy manner? 1. "I know that it was not my fault." 2. "My boyfriend has trouble controlling his sexual urges." 3. "If I don't put myself in a dating situation, I won't be at risk." 4. "Next time I will think twice about wearing a revealing dress."

1

8. The nurse explains the purpose of an infusion of albumin 5% to a patient recovering from hypovolemic shock. Which statement indicates that the patient understands the instructions? 1) "It is a protein that pulls water into my blood vessels." 2) "It is a protein that causes my kidneys to conserve fluid." 3) "It is a super-concentrated salt solution that helps me conserve body fluid." 4) "It is a liquid that has electrolytes in it to pull water into my blood vessels."

1

9. The nurse is teaching about the differences between the symptoms of anorexia nervosa and the symptoms of bulimia. Which information should the nurse include? 1. Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not. 2. Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not. 3. Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not. 4. Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not.

1

13. Which member of the health-care team, when using the team nursing approach, is responsible for prioritizing patient care? 1) Team leader 2) Charge nurse 3) Licensed practical nurse 4) Unlicensed assistive personnel

1 -The Emergency Severity Index (ESI) is a triage tool to assist in the prioritization of care. Consists of levels 1-5. 1 is highest need, 5 is lowest need. 5- nonurgent (rash), 4-less urgent (simple cut or dysuria), 3- urgent (abd pain, high fever w cough, 2- emergent (cardiac, chest pain, asthma attack), 1- resuscitation (cardiac arrest, severe bleeding. -The charge nurse coordinates care and assignments and may ultimately be the only person familiar with all the need of any individual patient; therefore, it is this member of the team that will prioritize care for the patients who are being admitted. -When using the team nursing approach, the team leader, who is a registered nurse, is responsible for coordinating a group of licensed and unlicensed personnel to provide patient care to a small group of patients, including the prioritization of patient care. -Setting priorities is an essential nursing skill for the triage, or assessment process that occurs in the emergency department (ED).

26. The nurse instructs a group of community members on the difference between benign and malignant neoplasms. Which participant statements indicate that teaching has been effective? Select all that apply. 1) "Malignant tumors can grow back." 2) "Benign tumors stay in one area." 3) "Benign tumors grow slowly." 4) "Malignant tumors are easy to remove." 5) "Malignant tumors push other tissue out of the way."

1 2 3

27. The nurse is concerned that an older adult patient is at risk for developing acute kidney injury. Which information in the patient's history supports the nurse's concern? Select all that apply. 1) Diagnosed with hypotension 2) Recent aortic valve replacement surgery 3) Prescribed high doses of intravenous antibiotics 4) Total hip replacement surgery five years ago 5) Taking medication for type 2 diabetes mellitus

1 2 3

26. The nurse suspects that a patient is experiencing a corneal abrasion. What did the nurse assess to come to this conclusion? Select all that apply. 1) Tearing 2) Eye pain 3) Squinting 4) Photophobia 5) Purulent drainage

1 2 3 4

24. The nurse is caring for a patient who sustained chemical burns. What would have caused these injuries? Select all that apply. 1) Lime 2) Gasoline 3) Bleach 4) Fabric softener 5) Hydrofluoric acid

1 2 3 5

27. The nurse is preparing information about cataracts for a community health fair. What should the nurse include about risk factors for the disorder? Select all that apply. 1) Obesity 2) Age over 60 3) Family history 4) Alcohol intake 5) Chronic health problems

1 2 3 5

15. In planning care for a woman who presents as a survivor of domestic abuse, a nurse would be aware of which of the following data? (Select all that apply.) 1. It often takes several attempts before a woman leaves an abusive situation. 2. Substance abuse is a common factor in abusive relationships. 3. Until children reach school age, they are usually not affected by abuse between their parents. 4. Women in abusive relationships usually feel isolated and unsupported. 5. Economic factors rarely play a role in the decision to stay.

1 2 4

17. Which of the following student statements indicate that learning has occurred regarding intimate partner violence? (Select all that apply.) 1. "Intimate partner violence is a pattern of abusive behavior that is used by an intimate partner." 2. "Intimate partner violence is used to gain power and control over the other intimate partner." 3. "Fifty-one percent of victims of intimate violence are women." 4. "Women ages 25 to 34 experience the highest per capita rates of intimate violence." 5. "Victims are typically young married women who are dependent housewives."

1 2 4

26. A patient is diagnosed with several superficial partial-thickness burns. What treatment would be indicated for this patient? Select all that apply. 1) Apply bacitracin ointment 2) Cover with a nonadherent bandage 3) Apply mafenide acetate 10% cream 4) Wash with antiseptic soap and warm water 5) Apply collagenase and cover with roll gauze

1 2 4

17. Which modalities should a nurse recognize as integral parts of a treatment program when planning care for clients diagnosed with schizophrenia spectrum disorder? (Select all that apply.) 1. Group therapy 2. Medication management 3. Deterrent therapy 4. Supportive family therapy 5. Social skills training

1 2 4 5

24. The nurse is preparing a teaching tool on hearing for a community fair. Which medication classifications should the nurse identify as potentially causing hearing problems? Select all that apply. 1) Diuretics 2) Antibiotics 3) Vasodilators 4) Chemotherapy agents 5) Nonsteroidal anti-inflammatory drugs (NSAIDs)

1 2 4 5

27. A patient has been recovering for 18 months from burns that affected 60% total body surface area. For which problems should the nurse anticipate providing continuing care to this patient? Select all that apply. 1) Anxiety 2) Depression 3) Spiritual distress 4) Body image disorder 5) Post-traumatic stress disorder (PTSD)

1 2 4 5

26. A patient with a history of anemia has started a vegan diet. Which addition to meals should the nurse recommend to help ensure that this patient has adequate amounts of iron in the diet? Select all that apply. 1) Legumes 2) Orange juice 3) Brewer's yeast 4) Okra 5) Peas

1 2 5

26. A patient with frequent urinary tract infections is seen in the urology clinic and is at risk for acute kidney injury. The nurse reviews the patient's medical history. Which item supports the patient's being at risk for acute kidney injury? Select all that apply. 1) Dehydration 2) Renal calculi 3) Ineffective wound healing 4) Low serum albumin 5) Hypertension

1 2 5

30. Which nursing actions during a mass casualty incident should be included in the triage portion of an organizational disaster plan? Select all that apply. 1) Treatment 2) Stabilization 3) Evaluation of interventions 4) Formulation of nursing diagnosis 5) Decontamination for suspected contamination

1 2 5 -Emergency Severity Index -Setting priorities is an essential nursing skill for the triage, or assessment process that occurs in the emergency department (ED). -Simple Triage and Rapid Treatment (START) uses physiological parameters and is designed to be completed in 60 seconds or less. It is based on three observations: 1) respirations, 2) perfusion (pulse), 3) mental status. The mnemonic RPM is used as a memory aid. START allows for only two interventions during the triage process. 1) direct pressure to control bleeding and 2) basic airway-opening maneuvers.

23. The nurse is caring for a client diagnosed with generalized anxiety disorder. Which activities would the nurse encourage for this client? (Select all that apply.) 1. Recognize the signs of escalating anxiety. 2. Avoid any situation that causes stress. 3. Employ newly learned relaxation techniques. 4. Cognitively reframe thoughts about situations that generate anxiety. 5. Avoid caffeinated products.

1 3 4 5

26. A patient is experiencing manifestations of infective endocarditis. Which diagnostic tests should the nurse expect to be prescribed for this client? Select all that apply. 1) Blood cultures 2) Ejection fraction 3) Electrocardiogram 4) Transthoracic echocardiogram (TTE) 5) Transesophageal echocardiogram (TEE)

1 3 4 5 A transesophageal echocardiogram (TEE) is a type of ultrasound test. Your doctor puts a tube down your esophagus with an ultrasound device that takes a series of moving pictures of your heart. It can show if it makes clots when it pumps blood.

19. Place the spectrum of schizophrenic and other psychotic disorders as described by the DSM-5 on a gradient of psychopathology from least to most severe (1-4). (Enter the number of each disorder in the proper sequence, using comma and space format, such as: 1, 2, 3, 4) 1. Delusional disorder 2. Schizophrenia 3. Schizophreniform disorder 4. Substance-induced psychotic disorder

1 4 3 2

21. The client has been diagnosed with generalized anxiety disorder (GAD). Which symptoms would the nurse observe upon assessment? (Select all that apply.) 1. Muscle tension 2. Paresthesia 3. Hyperventilation 4. Restlessness 5. Procrastination

1 4 5

26. A nurse is working in a summer camp for children. One of the children comes to the clinic with several bee stings. Which clinical manifestations would necessitate the need to inject the child with epinephrine (EpiPen)? Select all that apply. 1) Skin that is cold and clammy to the touch 2) Skin that is warm and dry to the touch 3) The child is hyperactive and hyperverbal. 4) Complaints of thirst 5) Restlessness and confusion

1 4 5

28. The nurse is preparing to administer hemodialysis treatment for a patient with chronic kidney disease. Which laboratory values does the nurse anticipate prior to the patient's treatment? Select all that apply. 1) Increased blood urea nitrogen (BUN) 2) Decreased potassium 3) Decreased phosphorus 4) Increased urine osmolality 5) Increased creatinine

1 5

6. The nurse has completed a seminar teaching a group in the community about ways to reduce cancer risks. The nurse returns a month later to evaluate the effectiveness of the seminar. Which statements made by members of the group indicate retention and application of the material presented by the nurse to reduce the risk of developing cancer? 1) "I stopped using tanning booths." 2) "I have reduced my intake of fiber." 3) "I have increased the amount of lean red meat in my diet." 4) "I began drinking two glasses of red wine a day with dinner."

1 Decreased red meat, stop smoking, use sunscreen, healthy weight, and being active

18. The client is prescribed alprazolam (Xanax) for acute anxiety. Which client finding should cause a nurse to question this order? 1. History of alcohol use disorder 2. History of personality disorder 3. History of schizophrenia 4. History of hypertension

1 Deficiencies of minerals such as calcium, magnesium, iron, and zinc are common in alcoholics

9. The nurse is preparing to assess a patient's near vision. Which tool should the nurse use for this assessment? Jaegar card Snellen chart Ishihara chart Confrontation test

1 just a handheld card with sentences in different sizes to read

5. During a treatment meeting on an oncology unit, the nurse learns that a patient is scheduled for chemotherapy before surgery. What are the purposes for this patient to receive chemotherapy at this specific time? 1) Shrink the tumor 2) Improve wound healing 3) Eradicate all cancer cells 4) Allow the immune system to kill cancer cells

1 kills fast growing cancer cells

18. Which is the priority action for a nurse who is exposed to a needle-stick injury while providing patient care? 1) Washing the injury under running water 2) Squeezing the site to remove the patient's blood 3) Taking two or three drugs for 28 days 4) Consenting to a human immunodeficiency virus (HIV) test

1 milk site, wash hands or run under water, report and do prophylactic measures

20. A nurse is caring for a patient with leukemia who is neutropenic. Which intervention will the nurse implement to ensure this patient's safety? 1) Place patient in reverse isolation 2) Place patient in standard precaution isolation 3) Administer a prophylactic gram-negative antibiotic 4) Administer neutrophil colony-stimulating factor (N-CSF) as ordered

1 place in reverse isolation low neutrophils monitor who can come in, meticulous hand washing

26. Human immunodeficiency virus (HIV) infects and destroys CD4 cells. List the following events in the order in which they occur for a patient who is HIV-positive. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Virus invades helper T cell 2) Viral RNA converts with reverse transcriptase to viral DNA 3) Viral DNA integrates with host cell DNA. 4) Virus remains latent, or actively replicates 5) Virus sheds protein coat

13452

*12. The nurse is caring for a client with schizophrenia spectrum disorder who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia? 1. Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia. 2. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia. 3. Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia. 4. Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.

2

*9. Which action would the nurse take to establish a trusting relationship with a client diagnosed with schizophrenia spectrum disorder? 1. Establish personal contact with family members 2. Be reliable, honest, and consistent during interactions 3. Share limited personal information 4. Sit close to the client to establish rapport

2

1. A client with schizophrenia spectrum disorder presents with bizarre behaviors and delusions. Which nursing action should be prioritized to maintain this client's safety? 1. Monitor for medication nonadherence. 2. Note escalating behaviors immediately. 3. Interpret attempts at communication. 4. Assess triggers for bizarre, inappropriate behaviors.

2

1. The nurse is caring for a patient admitted with a diagnosis of acute kidney injury. The patient asks the nurse, "Are my kidneys failing? Will I need a kidney transplant?" Which response by the nurse is the most appropriate? 1) "No, don't think that. You're going to be fine." 2) "Your condition can be reversed with prompt treatment and usually will not destroy the kidney." 3) "Kidney transplantation is likely, and it would be a good idea to start talking to family members." 4) "When the doctor comes to see you, we can talk about whether you will need a transplant."

2

10. A patient has full-thickness burns over 30% of total body surface area. Which intervention will least likely provide comfort initially to this patient? 1) Elevate injured extremities 2) Medicate for pain around the clock 3) Apply medicated ointment to all areas 4) Elevate the head of the bed 30 degrees

2

10. A preschool child is admitted to a psychiatric unit with a diagnosis of autism spectrum disorder. To help the child feel more secure on the unit, which intervention would a nurse include in this client's plan of care? 1. Encourage and reward peer contact. 2. Provide consistent caregivers. 3. Provide a variety of safe daily activities. 4. Maintain close physical contact throughout the day.

2

10. Which amount of time is appropriate for nurse to spend triaging each patient during a mass casualty incident? 1) Less than 10 seconds 2) Less than 15 seconds 3) Less than 30 seconds 4) Less than 60 seconds

2

11. The nurse performs a full physical health assessment on an older adult client admitted with a diagnosis of major depressive disorder. What is the rationale for the nurse's assessment? 1. The attention during the assessment is beneficial in decreasing social isolation in the elderly. 2. Depression can generate somatic symptoms that can mask actual physical disorders. 3. Physical health complications are likely to arise from antidepressant therapy. 4. Depressed geriatric clients avoid addressing physical health and ignore medical problems.

2

11. Which is a potentially life-threatening condition found during the primary triage survey that would necessitate priority nursing care? 1) Cystitis 2) Concussion 3) Lacerated arm 4) Fractured femur

2

12. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient has lost 15% of body weight since the last appointment. Which reason should the nurse include in a teaching session for this patient regarding this occurrence? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

2

12. The nurse is providing discharge instructions to an older adult patient who is going home after having a total knee replacement. Which will the nurse include in the discharge teaching to decrease the patient's risk for developing a thrombosis or pulmonary embolism? 1) Place pillows under the knees when in bed 2) Use compression stockings 3) Limit ambulation 4) Limit fluids

2

13. A patient is experiencing a new onset of reduced hearing. Which medication should the nurse suspect is causing this patient's disorder? 1) Prilosec 2) Gentamycin 3) Dexamethasone 4) Calcium supplement

2

13. The nurse is providing care to a patient who is receiving treatment for sickle cell disease. The patient is at risk for infection. Which medication does the nurse expect to administer to this patient? 1) Acetaminophen 2) Penicillin 3) Morphine sulfate 4) Tamoxifen

2

13. Which characteristic would help a nurse distinguish between dysthymia and major depressive disorder (MDD)? 1. Dysthymia is associated with the menstrual cycle. 2. Dysthymia is a chronically depressed mood. 3. MDD lasts for at least 2 years. 4. MDD does not have delusions or hallucinations.

2

14. A nurse is reviewing the stat laboratory data of a client in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? 1. 50 mg/dL 2. 100 mg/dL 3. 250 mg/dL 4. 300 mg/dL

2

14. An emergency department nurse is caring for a child in a sickle cell crisis. The nurse suspects the etiology of the crisis as being thrombotic in nature due to which clinical manifestations? 1) The patient has profound pallor and fatigue. 2) The patient is in extreme pain. 3) The patient has profound hypotension and shock. 4) The patient's chest CT reveals a pulmonary infarct.

2

14. The nurse is caring for a patient diagnosed with discoid lupus erythematosus. The nurse is collaborating with the patient to set goals for the nursing plan of care. Which is an appropriate goal for this patient? 1) Work through the stages of death and dying 2) Compliance with a sun protection plan 3) Gain weight to within 10 pounds of normal for height 4) Report pain no higher than 4 on a scale of 1-10

2

15. The nurse has instructed a patient recovering from a pulmonary embolism on long-term anticoagulant therapy. Which patient statement indicates that instruction has been effective? 1) "I will expect bloody sputum when I brush my teeth." 2) "I need to use a soft toothbrush and an electric razor, and avoid injuries." 3) "I need to eat a well-balanced diet with green salads." 4) "I can expect to be bruised, since this is normal."

2

15. The nurse is planning care for an adolescent patient who has systemic lupus erythematosus (SLE). Which action by the patient indicates the implemented plan of care is appropriate? 1) Refusing to attend school 2) Discussing skin changes with a good friend 3) Refraining from attending any social functions 4) Discussing skin changes with the health-care provider

2

17. Which is the essential nursing skill for the triage process in the emergency department? 1) Evaluating care 2) Setting priorities 3) Formulating diagnoses 4) Implementing interventions

2

18. The nurse is caring for a patient with 70% total body surface area chemical burns. Which approach should the nurse anticipate to meet this patient's nutritional needs? 1) Parenteral nutrition 2) Duodenal tube feedings 3) Nasogastric tube feedings 4) Six small high-calorie meals per day

2

18. The nurse is providing care to several patients on a medical-surgical unit. Which patient is at highest risk for a nonthrombotic pulmonary embolism? 1) The patient who is receiving intravenous pain medication 2) The patient who is postoperative from a femur fracture repair 3) The patient with a primary lung tumor 4) The patient who uses intravenous illicit drugs

2

18. The nurse is reviewing data in a patient's medical record. Which information increases the patient's risk for developing Ménière's disease? 1) Follows a gluten-free diet 2) Allergic to house dust and pet dander 3) Works as a computer science technician 4) Treated for a pinched nerve in the lower back

2

19. A patient is demonstrating signs of a detached retina. What is the reason this occurred? 1) Blood vessels in the eye spasm 2) Inner layers of the retina separate 3) Overgrowth of vessels damages vision 4) Drainage of vitreous humor is blocked

2

20. A patient comes into the emergency department with manifestations of retinal detachment. What should the nurse do to minimize this patient's eye movements? 1) Provide a sedative 2) Loosely cover both eyes 3) Elevate the head of the bed 45 degrees 4) Apply an eye patch over the affected eye

2

20. The nurse is evaluating nutritional teaching provided to a patient recovering from 24% total body surface area burns. Which information indicates that teaching has been effective? 1) Weight loss 3 kg 2) Serum protein level 7.1 g/dL 3) Serum albumin level 2.8 g/dL 4) +1 pitting edema of lower extremities

2

20. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is currently 480 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

2

20. Which emergency medical system (EMS) first responders can perform triage during mass casualty incidents? 1) Unlicensed assistive personnel 2) Nurses appointed to a field team 3) A physician who survives the incident 4) Community response team members

2

21. The nurse is providing care to a patient admitted with a spinal cord injury. The patient is bradycardic, hypotensive, and has cold and clammy skin. Which is the priority nursing action for this patient? 1) Starting two large intravenous catheters 2) Notifying the Rapid Response Team 3) Calling the patient's physician to report the changes 4) Placing oxygen on the patient

2

21. While caring for a patient with chronic kidney disease, the nurse tracks the patient's serum albumin level. For which nursing diagnosis is the action most indicated? 1) Excess Fluid Volume 2) Imbalanced Nutrition: Less Than Body Requirements 3) Risk for Ineffective Perfusion 4) Risk for Infection

2

3. A child has been diagnosed with autism spectrum disorder. The distraught mother cries out, "I'm such a terrible mother. What did I do to cause this?" Which nursing response is most appropriate? *1. "Researchers really don't know what causes autism spectrum disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored." 2. "Poor parenting doesn't cause autism spectrum disorder. Research has shown that abnormalities in brain structure or function are to blame. This is beyond your control." 3. "Research has shown that the mother appears to play a greater role in the development of autism spectrum disorder than the father." 4. "Lack of early infant bonding with the mother has shown to be a cause of autism spectrum disorder. Did you breastfeed or bottle-feed?"

2

4. Which nursing action is appropriate for a client brought to the emergency department after being raped? 1. Discourage the client from discussing the rape, because this may lead to further emotional trauma. 2. Remain nonjudgmental while actively listening to the client's description of the rape event. 3. Meet the client's self-care needs by assisting with showering and perineal care. 4. Probe for further, detailed description of the rape event.

2

5. A nurse is providing discharge instructions to a patient with iron-deficiency anemia who is experiencing glossitis. Which patient statement indicates the need for further education? 1) "I will monitor my lips and tongue daily." 2) "I will use an alcohol-based mouthwash twice per day." 3) "I will apply a petroleum-based lubricating ointment to my lips." 4) "I will use a soft toothbrush when brushing my teeth each day."

2

6. A home health nurse is conducting home visits for several patients who are diagnosed with acquired immunodeficiency syndrome (AIDS). Which patient would the nurse see first? 1) A patient who is receiving lamivudine (Epivir) because of a diagnosis of a low CD4 cell count 2) A patient with Pneumocystis carinii pneumonia (PCP) who called the office this morning to report a new onset of fever, cough, and shortness of breath 3) A patient with wasting syndrome who needs modifications and education regarding dietary changes 4) A patient who is receiving IV antibiotics daily for toxoplasmosis

2

7. Which finding would a nurse expect when assessing a child diagnosed with separation anxiety disorder? 1. The child has a history of antisocial behaviors. 2. The child's mother was stressed during the pregnancy. 3. The child previously had an extroverted temperament. 4. The child's mother and father have an inconsistent parenting style.

2

8. A client with a history of alcohol use disorder is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 48 hours. When the nurse reports to the ED physician, which client sign or symptom should be the nurse's first priority? 1. Hearing and visual impairment 2. Blood pressure of 180/100 mm Hg 3. Mood rating of 2/10 on numeric scale 4. Dehydration

2

9. A patient contemplating cataract surgery asks if there are any risk factors. How should the nurse respond? 1) Blindness 2) Detached retina 3) Corneal abrasion 4) Macular degeneration

2

9. A son is seeking advice about his mother who seems to worry unnecessarily about everything. The son states, "Should I seek psychiatric help for my mother?" Which is an appropriate nursing response? 1. "My mother also worries unnecessarily. I think it is part of the aging process." 2. "Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning." 3. "From what you have told me, you should get her to a psychiatrist as soon as possible." 4. "Worry and anxiety are complex phenomena and are effectively treated only with psychotropic medications."

2

9. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of 500 cells/L. Which classification of HIV should the nurse document for this patient? 1) Stage 0 2) Stage 1 3) Stage 2 4) Stage 3

2

28. The nurse is reviewing the laboratory values of a patient who is newly diagnosed with acquired immunodeficiency syndrome (AIDS). Which values should be reported to the patient's health-care provider? Select all that apply. 1) CD4 cell count 1,100/mm3 2) T4 cell count 150 3) CD4 lymphocytes 12% 4) Viral load 11,500 copies/mL 5) WBC 6,500

2 3 4

29. A nurse educator is teaching a group of parents how to prevent a crisis in the child with sickle cell disease. What should the nurse instruct about the precipitating factors that could contribute to a sickle cell crisis? Select all that apply. 1) Increased fluid intake 2) Altitude 3) Fever 4) Vomiting 5) Regular exercise

2 3 4

23. The nurse is preparing teaching materials for a group of senior citizens. What information should the nurse include as risk factors for hearing loss? Select all that apply. 1) Diet 2) Heredity 3) Medications 4) Recreational noise 5) Occupational noise

2 3 4 5

30. Which parental statements regarding precipitating factors for sickle cell disease indicate correct understanding of the discharge information presented by the nurse? Select all that apply. 1) "My child should avoid regular exercise." 2) "We should provide acetaminophen or ibuprofen to treat fever." 3) "Our child needs to drink lots of fluid to avoid dehydration when playing sports." 4) "High altitudes can cause exacerbation and should be avoided." 5) "Fluid restriction is necessary to avoid exacerbations from occurring."

2 3 4 give oxygen, pain killers, and fluid

27. The nurse is planning care for a pediatric patient diagnosed with human immunodeficiency virus (HIV). The nurse selects Risk for Infection as a priority nursing diagnosis for this pediatric patient. Based on this nursing diagnosis, which actions by the nurse are appropriate? Select all that apply. 1) Administering tuberculosis skin tests every six months 2) Teaching proper food-handling techniques to the family 3) Instructing on the importance of consuming ample fresh fruits and vegetables 4) Assessing the health status of all visitors 5) Monitoring hand-washing techniques used by the family

2 4 5

12. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient has lost 15% of body weight since the last appointment. Which reason should the nurse include in a teaching session for this patient regarding this occurrence? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

2 HIV progresses to AIDS acute, chronic, then AIDS

17. A nurse is caring for a patient with systemic lupus erythematous (SLE) who is taking hydroxychloroquine (Plaquenil). When providing care for this patient, the nurse monitors for which adverse effect associated with the prescribed medication? 1) Renal toxicity 2) Retinal toxicity 3) Cushingoid effects 4) Pulmonary fibrosis

2 characterized by a butterfly rash

16. A patient has been experiencing a gradual loss of central vision. Which tool should the nurse use when assessing this patient? 1) Jaeger card 2) Amsler grid 3) Snellen chart 4) Ishihara chart

2 literally a grid with a black dot in the middle

*13. The aging client takes an antipsychotic for schizophrenia spectrum disorder and a beta-adrenergic blocking agent for hypertension. Based on an understanding of the combined side effects of these drugs, which statement by a nurse is most appropriate? 1. "Make sure you concentrate on taking slow, deep, cleansing breaths." 2. "Watch your diet and try to engage in some regular physical activity." 3. "Rise slowly when you change position from lying to sitting or sitting to standing." 4. "Wear sunscreen and try to avoid midday sun exposure."

3

*2. A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be included in the nurse's teaching? 1. The side effects of medications 2. Deep breathing techniques to decrease stress 3. How to make eye contact when communicating 4. Behaviors needed to be a leader

3

*4. Parents ask a nurse how they should reply when their son, diagnosed with schizophrenia spectrum disorder, tells them that voices command him to harm others. Which nursing response is appropriate? 1. "Tell him to stop discussing the voices." 2. "Ignore what he is saying, while attempting to discover the underlying cause." 3. "Focus on the feelings generated by the hallucinations and present reality." 4. "Present objective evidence that the voices are not real."

3

*6. A client diagnosed with schizophrenia spectrum disorder states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing response? 1. "Did you take your medicine this morning?" 2. "You are not going to hell. You are a good person." 3. "The voices must sound scary, but I do not hear any voices." 4. "The devil only talks to people who are receptive to his influence."

3

1. A victim of a house fire is brought to the emergency department for burn treatment. What assessment finding indicates that the patient may have an inhalation injury? 1) Coughing 2) Soot on the face 3) Singed facial hair 4) Heart rate 98 bpm

3

10. The client diagnosed with schizophrenia spectrum disorder tells the nurse, "I'm sad that the voice is telling me to stop seeing my psychiatrist." Which symptom is the client exhibiting? 1. Magical thinking 2. Persecutory delusions 3. Command hallucinations 4. Altered thought processes

3

10. The nurse caring for a patient recovering from an abdominal hysterectomy suspects the patient is experiencing a pulmonary embolism. Which clinical manifestation supports the nurse's suspicion? 1) Nausea 2) Decreased urine output 3) Dyspnea and shortness of breath 4) Activity intolerance

3

10. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of 300 cells/L. Which classification of HIV should the nurse document for this patient? 1) Stage 0 2) Stage 1 3) Stage 2 4) Stage 3

3

11. A preschool child diagnosed with autism spectrum disorder has been engaging in constant head-banging behavior. Which nursing intervention is appropriate? 1. Place client in restraints until the aggression subsides. 2. Sedate the client with antipsychotic medications. 3. Hold the client's head steady and apply a helmet. 4. Distract the client with a variety of games and puzzles.

3

11. The client presents with symptoms of alcohol withdrawal and states, "I haven't eaten in three days." The nurse's assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry mucous membranes and poor skin turgor. What should be the priority nursing diagnosis? 1. Denial 2. Fluid volume excess 3. Imbalanced nutrition: less than body requirements 4. Ineffective individual coping

3

11. The psychiatrist prescribes haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg at bedtime for a client with schizophrenia spectrum disorder. Which client behavior would warrant the nurse to administer benztropine? 1. Tactile hallucinations 2. Tardive dyskinesia 3. Muscle rigidity 4. Reports of hearing disturbing voices

3

12. A client's wife has been making excuses for her alcoholic husband's work absences. In family therapy, she states, "His problems at work are my fault." Which response by the nurse is therapeutic? 1. "Why do you assume responsibility for his behaviors?" 2. "I think you should start to confront his behavior." 3. "Your husband needs to deal with the consequences of his drinking." 4. "Do you understand what the term enabler means?"

3

12. A patient is demonstrating manifestations of a detached retina. For which diagnostic test should the nurse prepare this patient? MRI CT scan Ultrasound Radioisotope scan

3

12. A survivor of rape presents in an emergency department crying, pacing, and cursing her attacker. A nurse would recognize these client actions as which behavioral defense? 1. Controlled response pattern 2. Compounded rape reaction 3. Expressed response pattern 4. Silent rape reaction

3

12. The nurse is caring for a patient with chronic kidney disease who is pale and experiencing fatigue. The nurse attributes these symptoms to anemia secondary to chronic kidney disease. The patient's spouse asks why the patient is anemic. Which response by the nurse is the most appropriate? 1) "Your spouse has a genetic tendency for the development of anemia." 2) "The increased metabolic waste products in the body depress the bone marrow and cause anemia." 3) "There is a decreased production by the kidneys of the hormone erythropoietin, which is the cause of anemia." 4) "The patient is not eating enough iron-rich foods, which is causing anemia."

3

12. The nurse notes that a patient is diagnosed with primary open-angle glaucoma. What diagnostic test would have been used to diagnose this health problem? 1) MRI 2) CT scan 3) Tonometry 4) Ultrasound

3

13. A patient diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. Which is the priority nursing diagnosis for this patient? 1) Ineffective Tissue Perfusion 2) Anxiety 3) Impaired Gas Exchange 4) Impaired Physical Mobility

3

13. The nurse is caring for a patient with 45% total body surface area thermal burns. Which laboratory value change would be expected? 1) Increased pH 2) Increased sodium 3) Increased potassium 4) Decreased hematocrit

3

14. During an assessment the nurse becomes concerned that a patient is at risk for a hearing loss. What information caused the nurse to have this concern? 1) Age 35 years 2) Lives with spouse and two children 3) Works for a lawn and garden service 4) Has a ranch-style home in the country

3

14. The nurse is planning care for a patient with a pulmonary embolism. Which intervention would assist with the patient's decrease in cardiac output? 1) Provide oxygen 2) Keep protamine sulfate at the bedside 3) Monitor pulmonary arterial pressures 4) Assess for bleeding

3

14. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient reports night sweats. Which is the most likely reason for this clinical manifestation? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

3

15. A nurse is planning care for a patient with sickle cell disease and chooses Acute Pain as the nursing diagnosis. Which intervention is inappropriate for the nurse to include in this plan of care? 1) Administer ordered analgesic medications around the clock 2) Place patient in position of comfort 3) Use heat or cold packs as tolerated 4) Support the patient's joints and extremities with pillows

3

15. The nurse is planning care for a patient with chronic kidney disease and osteoporosis. After reviewing the patient's medical record, which is the priority nursing diagnosis for this patient? 1) Anxiety 2) Disturbed Body Image 3) Risk for Injury 4) Risk for Bleeding

3

17. A child diagnosed with aplastic anemia is admitted to the hospital. The parents ask the nurse what aplastic anemia is. Which response by the nurse is accurate? 1) "Aplastic anemia causes a proliferation of white blood cells." 2) "Aplastic anemia is characterized by abnormally shaped red blood cells." 3) "Aplastic anemia is caused by the bone marrow producing inadequate cells." 4) "Aplastic anemia is a disorder that occurs after a viral illness."

3

17. The nurse is preparing to discharge a patient recovering from a pulmonary embolism. Which topics are appropriate for the nurse to include in the teaching session? 1) Resume the use of any over-the-counter medications 2) Diet to include green leafy vegetables 3) Anticoagulant administration schedule 4) Resume normal activity level

3

18. It is documented in the medical record that a patient has a rhegmatogenous detached retina. How should this diagnosis be explained to the patient? 1) Eye trauma causes the retinal to detach from the retinal pigment epithelium (RPE). 2) Eye inflammation causes vitreous fluid leaks into the area under the retina. 3) Vitreous fluid moves under the retina and separates the retina from the pigmented cell layer. 4) Scar tissue on the retina causes the retina to separate from the retinal pigment epithelium (RPE).

3

18. The ear-nose-and-throat health-care professional documents that a patient has a stiff tympanic membrane. What should this information indicate to the nurse? 1) Antibiotics should be prescribed 2) Progressive hearing loss will occur 3) Middle ear changes affect the patient's hearing 4) Special care is required to protect the ears when showering

3

18. The nurse is providing care for a patient diagnosed with chronic kidney disease who is experiencing hyperkalemia. When planning meals for this patient, which choice would be most appropriate for this patient? 1) Hamburger on a bun, banana 2) Cold cuts with bun with fresh pears 3) Spaghetti and meat sauce, breadsticks 4) Carrots and green, leafy vegetables

3

19. A patient with a history of hypertension is diagnosed with chronic kidney disease. When the patient asks the nurse how this occurred, which response by the nurse is the most appropriate? 1) "Thickening of the kidney structures and gradual death of nephrons has caused this diagnosis." 2) "Cysts compress renal tissue that destroys the kidneys, causing this diagnosis." 3) "High blood pressure reduces renal blood flow and harms the kidney tissue, causing this diagnosis." 4) "Immune complexes form in the kidney tissue that causes inflammation, causing this diagnosis."

3

19. The nurse is caring for a patient with leukemia who is experiencing neutropenia as a result of chemotherapy. Which action should the nurse include in the plan of care for this patient? 1) Restrict fluid intake 2) Replace hand hygiene with gloves 3) Restrict visitors with communicable illnesses. 4) Insert an indwelling urinary catheter to prevent skin breakdown

3

19. Which is the priority teaching point for the nurse to include in the discharge instructions for the parents of a child who was admitted to the hospital in a sickle cell crisis? 1) Rapid weaning of pain medications 2) A diet high in protein 3) Adequate hydration 4) Restriction of activities

3

2. Which information would a nurse include in client teaching about social anxiety disorder? 1. Obsessions are the underlying reason for clients to avoid social situations. 2. These people avoid social interactions because of a perceived physical flaw. 3. Individuals with social anxiety disorder avoid performing in front of others. 4. People with this disorder avoid social gatherings because of fear of separation.

3

20. A patient develops hypovolemic shock secondary to pancreatitis. Which action by the nurse is most appropriate? 1) Starting an 18-gauge intravenous catheter in the patient's nondominant hand 2) Ordering a type and cross-match of packed red blood cells 3) Preparing to assist with central line placement 4) Inserting a nasogastric tube

3

20. The nurse is planning care for a newly admitted patient diagnosed with pulmonary embolism. The nurse anticipates the patient will need anticoagulant therapy. What is true regarding this therapy for the treatment of this condition? 1) It is considered second-line treatment. 2) Major hemorrhage is common. 3) Heparin and warfarin (Coumadin) are usually initiated at the same time. 4) Heparin alters the synthesis of vitamin K-dependent clotting factors, preventing further clots.

3

22. A patient is ending the first year of recovery after having burns to both legs. Which observation indicates that the patient needs to be encouraged to wear the pressure garment? 1) Skin warm and moist 2) Pedal pulses present but faint 3) Scattered areas of scarring noted 4) Nonpitting edema of both ankles

3

22. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is greater than 500 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

3

22. The nurse suspects that patient is experiencing undiagnosed Ménière's disease. Which assessment finding supports the nurse's clinical decision? 1) Facial pain 2) Nasal drainage 3) Positive Romberg test 4) Decreased deep tendon reflexes

3

24. A nurse is educating a patient with anemia about the pathophysiological mechanisms of anemia. Which should be excluded in the nurse's teaching plan for this patient? 1) Altered hemoglobin synthesis 2) Altered DNA synthesis 3) Decreased hemolysis 4) Bone marrow failure

3

24. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). Which patient statement indicates the need for further education regarding HIV management? 1) "I will eat small, frequent meals." 2) "I will use condoms for every sexual encounter." 3) "I will take my medications when others can see me, even if that means taking them late." 4) "I will ask my spouse to clean the cat litter to decrease my risk for developing toxoplasmosis."

3

3. On the first day of a client's alcohol detoxification, which nursing intervention should take priority? 1. Strongly encourage the client to attend 90 Alcoholics Anonymous (AA) meetings in 90 days. 2. Educate the client about the biopsychosocial consequences of alcohol abuse. 3. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. 4. Provide thiamin supplements to prevent Wernicke-Korsakoff syndrome.

3

4. In planning care for a child diagnosed with autism spectrum disorder, which would be a realistic client outcome? 1. The client will communicate all needs verbally by discharge. 2. The client will participate with peers in a team sport by day four. 3. The client will establish trust with at least one caregiver by day five. 4. The client will perform most self-care tasks independently.

3

4. Which medication treatment should the nurse administer to clients diagnosed with generalized anxiety disorder (GAD)? 1. Long-term treatment with diazepam (Valium) 2. Acute symptom control with propranolol (Inderal) 3. Long-term treatment with buspirone (BuSpar) 4. Acute symptom control with ziprasidone (Geodon)

3

5. A client who has been raped answers a nurse's questions in a monotone voice with single words, appears calm, and exhibits a blunt affect. How would the nurse interpret this client's responses? 1. The client may be fabricating details of the incident. 2. The client may be experiencing a silent rape reaction. 3. The client may be demonstrating a controlled response pattern. 4. The client may be having a compounded rape reaction.

3

5. An older adult patient is experiencing hypovolemic shock. Which is the priority intervention for this patient? 1) Assessing the cause of bleeding 2) Providing replacement of volume 3) Establishing invasive cardiac monitoring 4) Administering analgesics for control of pain

3

6. The client with major depressive episode is experiencing command hallucination for self-harm. Which intervention should be the nurse's priority at this time? 1. Obtaining an order for locked seclusion until client is no longer suicidal 2. Conducting 15-minute checks to ensure safety 3. Placing the client on one-to-one observation while continuing to monitor suicidal ideations 4. Encouraging client to express feelings related to suicide

3

6. The nurse is administering peritoneal dialysis to a patient with acute kidney injury. The nurse notes the presence of a cloudy dialysate return. After notifying the health-care provider, which action by the nurse is the most appropriate? 1) Measure abdominal girth 2) Document the cloudy dialysate 3) Culture the dialysate return 4) Increase dialysate instillation

3

7. The client diagnosed with bulimia nervosa has been attending an outpatient mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change? 1. Gained two pounds in one week 2. Focused conversations on nutritious food 3. Demonstrated healthy coping mechanisms that decreased anxiety 4. Verbalized an understanding of the etiology of the disorder

3

7. The client diagnosed with schizophrenia spectrum disorder tells a nurse about voices commanding him to kill his ex-spouse. Which nursing diagnosis is priority for this client? 1. Disturbed sensory perception 2. Altered thought processes 3. Risk for violence: directed toward others 4. Risk for injury

3

7. The nurse assesses a client with major depressive disorder. Which assessment finding would the nurse observe? 1. Sadness subsides quickly 2. Promiscuous behaviors 3. Unable to feel any pleasure 4. Excessive spending sprees

3

8. A patient comes into the emergency room seeking treatment for radiation burns. What should be considered prior to providing care to this patient? 1) Pathway of flow through the body 2) Duration of contact with the agent 3) Type, dose, and length of exposure 4) Temperature to which the skin is heated

3

9. A patient asks the nurse if there are any conditions that can exacerbate systemic lupus erythematosus (SLE). Which response by the nurse is the most appropriate? 1) "Conditions causing hypotension can often exacerbate SLE." 2) "GI upset is often associated with SLE exacerbation." 3) "Pregnancy is often associated with an SLE exacerbation." 4) "Fever is a known trigger for an SLE exacerbation."

3

9. A patient being treated for hypovolemic shock is prescribed a low dose of dopamine. Which outcome does the nurse anticipate for this patient? 1) Increased cardiac output 2) Stabilization of fluid loss 3) Urinary output of at least 30 mL/hour 4) Vasoconstriction and increased blood pressure

3

9. The nurse is a first responder for a health-care organization for a mass casualty incident. Which injury would the nurse tag as yellow during the triage process? 1) Ankle sprain 2) Hypovolemic shock 3) Open femur fracture 4) Massive head trauma

3

A nurse working in an intensive care unit (ICU) is assigned a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Based on this data, which type of precaution does the nurse implement when providing direct care? 1) Droplet 2) Reverse 3) Standard 4) Contact

3

29. The nurse is concerned that a patient is demonstrating early signs of hypovolemic shock. Which assessment findings support the nurse's concern? Select all that apply. 1) Rapid weak pulse 2) Normal respirations 3) Normal blood pressure 4) Slight increase in pulse 5) Prolonged capillary refill time

3 4 5 Early signs of HYPOVOLEMIC Shock include normal blood pressure, slight increase in pulse rate, prolonged capillary refill time and normal respirations use low dose dopamine or albumin

22. The nurse notes that a patient has Level III Usher's syndrome. What should the nurse expect when assessing this patient? Select all that apply. 1) Deafness 2) Unilateral hearing loss 3) Variable vestibular dysfunction 4) Profound sensorineural hearing loss 5) Progressive sensorineural hearing loss

3 5

9. A patient being treated for hypovolemic shock is prescribed a low dose of dopamine. Which outcome does the nurse anticipate for this patient? 1) Increased cardiac output 2) Stabilization of fluid loss 3) Urinary output of at least 30 mL/hour 4) Vasoconstriction and increased blood pressure

3 When a patient is in hypovolemic shock, the HCP may prescribe a "low dose" dopamine infusion. The purpose of "low dose" dopamine is to stimulate the dopaminergic receptors, ESPECIALLY in the kidneys, leading to vasodilation and an increased blood flow through the kidneys. This decreases the likelihood and severity of acute kidney injury (AKI) from poor perfusion. Because of the effect on the kidneys, the expectation is a minimum of 30 ml/hr of urine. The "low dose" dopamine does NOT increase the blood pressure or cardiac output; that occurs at a higher dose.

25. Parents of a newborn infant are concerned that their baby may have sickle cell disease. The nurse reviews the medical record and finds that both parents have the sickle cell trait. Which is the best response for the nurse to give the parents? 1) "Since neither of you actually has sickle cell disease, your baby is not at risk." 2) "Your baby has the disease, as you both carry the trait." 3) "As you both have the sickle cell trait, your baby will be tested for the disease" 4) "Have you talked to a genetic counselor about your concerns?"

3 kidney bean or crescent shaped RBCs, clot and stick together easily, chronically low oxygen

*12. The nurse is preparing an antidepressant medication for a 13-year-old client who is experiencing major depressive disorder. Which FDA-approved medication should the nurse administer? 1. Paroxetine (Paxil) 2. Sertraline (Zoloft) 3. Citalopram (Celexa) 4. Escitalopram (Lexapro)

4

*5. The nurse asks the client with schizophrenia spectrum disorder, "Do you receive special messages from certain sources, such as the television or radio?" The nurse is assessing which potential symptom of this disorder? 1. Loose associations 2. Paranoid delusions 3. Magical thinking 4. Delusions of reference

4

*8. Which nursing intervention would be most appropriate when caring for an agitated, suspicious client diagnosed with schizophrenia spectrum disorder? 1. Supply neon lights and soft music. 2. Maintain continual eye contact throughout the interview. 3. Use therapeutic touch to increase trust and rapport. 4. Provide personal space to respect the client's boundaries.

4

10. A patient agrees to receive long-term hemodialysis to treat chronic kidney disease. For which surgical procedure should the nurse instruct this patient? 1) Insertion of a double-lumen catheter into the subclavian artery 2) Placement of a peritoneal catheter 3) Insertion of a subarachnoid-peritoneal shunt 4) Placement of an arteriovenous fistula

4

10. A patient in sickle cell crisis reports taking a recent skiing trip that caused a respiratory infection from the cold weather. Which nursing diagnosis is a priority for this patient? 1) Fluid Volume Excess 2) Risk for Self-Mutilation 3) Knowledge Deficit 4) Acute Pain

4

10. The nurse holds the hand of a client who is experiencing alcohol withdrawal. The nurse is assessing for which condition? 1. Emotional strength 2. Wernicke-Korsakoff syndrome 3. Tachycardia 4. Coarse tremors

4

10. The nurse is caring for a patient recovering from cataract removal surgery. Which action should the nurse take to reduce intraocular pressure (IOP)? 1) Restrict fluids 2) Position on the operative side 3) Administer mydriatic eye drops 4) Elevate the head of the bed 45 degrees

4

10. The nurse is providing health education to a diverse group at a neighborhood community center. Why does the nurse plan to include signs and symptoms of systemic lupus erythematosus (SLE)? 1) The neighborhood is composed of many young female children. 2) The audience has asked the nurse to include the information. 3) The audience is mainly composed of Caucasian women. 4) The audience is mainly females of Asian-American descent.

4

10. The nurse notes that a patient's left pupil constricts when the right pupil is exposed to a bright light. What response did the nurse observe? Ocular movements Corneal light reflex Pupillary light reflex Consensual light reflex

4

11. During a vision test, the nurse notes that a patient has decreased peripheral vision of both eyes. Which health problem should the nurse suspect that this patient is experiencing? 1) Secondary glaucoma 2) Acute angle glaucoma 3) Normal-tension glaucoma 4) Primary open-angle glaucoma

4

11. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of less than 200 cells/L. Which classification of HIV should the nurse document for this patient? 1) Stage 0 2) Stage 1 3) Stage 2 4) Stage 3

4

11. Which advice would the nurse in an employee assistance program provide to an employee who exhibits symptoms of domestic physical abuse? 1. Have ready access to a gun and learn how to use it. 2. Research lawyers that can aid in divorce proceedings. 3. File charges of assault and battery. 4. Access to the number of a safe house for battered women.

4

12. The nurse is assisting with the secondary survey of a patient with 50% total body surface area electrical burns. Which test would be a priority for this patient? 1) Chest x-ray 2) Bronchoscopy 3) CT scan of the head 4) 12-lead electrocardiogram

4

12. The nurse is caring for a patient who was admitted to a medical-surgical unit in a sickle cell crisis. Which medication should the nurse expect to administer to this patient? 1) Acetaminophen 2) Ibuprofen 3) Meperidine 4) Hydroxyurea

4

13. The nurse is caring for a patient from another country who was admitted with hypertension and chronic kidney disease. The patient is receiving hemodialysis three times a week. The nurse is assessing the client's diet, and the patient reports the use of salt substitutes. When teaching the patient to avoid salt substitute, which rationale supports this teaching point? 1) They will increase the risk of AV fistula infection. 2) They will cause the patient to retain fluid. 3) They will interact with the client's antihypertensive medications. 4) They can potentiate hyperkalemia.

4

14. The nurse is caring for an older adult patient diagnosed with chronic kidney disease. The patient reports no bowel movement in the past two days. Based on this data, which condition is the patient at an increased risk for developing? 1) Metabolic acidosis 2) Hypocalcemia 3) Increased serum creatinine levels 4) Hyperkalemia

4

14. The nurse is reviewing teaching provided to a patient with glaucoma. Which patient statement indicates that teaching has been effective? 1) "I should consider surgery to cure this disorder." 2) "I should use the eye drops when my vision blurs." 3) "I should cut down on eating salty and high-fat foods." 4) "I should call my doctor before taking any over-the-counter medications."

4

15. A patient is being prepared for corneal staining. Which health problem is this patient most likely experiencing? Cataracts Glaucoma Detached retina Corneal abrasions

4

15. The nurse is evaluating care provided to a patient with burns during the emergent phase. Which data indicates that additional fluid resuscitation is required? 1) Blood pH 7.39 2) Heart rate 112 bpm 3) Blood pressure 110/60 mm Hg 4) Central venous pressure 2 mm Hg

4

15. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient has shortness of breath when walking, but no problems breathing at rest. Which is the most likely cause for this clinical manifestation? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

4

15. The nurse is teaching a client diagnosed with anxiety about treatment options. Which statement by the client indicates effective teaching? 1. "There is nothing that I can do to that will reduce anxiety." 2. "Medication is available, but only for those who have had anxiety for a year or more." 3. "If I ignore the symptoms of anxiety, it will go away." 4. "Practicing yoga or meditation may help reduce my anxiety."

4

17. A nurse evaluating the therapeutic effect of the drug sodium polystyrene sulfonate (Kayexalate) for a patient diagnosed with chronic kidney disease. Which therapeutic effect from the medication does the nurse anticipate? 1) Decreased serum sodium 2) Increased stool excretion 3) Decreased urine specific gravity 4) Decreased serum potassium

4

17. The nurse is providing care to a patient diagnosed with hypovolemic shock. Which nursing action is appropriate for this patient during the initial compensatory phase? 1) Placing a cool blanket over the patient 2) Raising the patient's head to a 30-degree angle 3) Positioning the patient in the left-lateral recumbent position 4) Turning the patient's head to one side if no neck injury is suspected

4

19. A nurse caring for a patient with a pulmonary embolism expects to find which diagnostic result? 1) Patchy infiltrates on chest x-ray 2) Metabolic alkalosis on arterial blood gas 3) Elevated CO2 level found on end-tidal carbon dioxide monitor 4) Tachycardia and nonspecific T-wave changes on EKG

4

19. A patient with Ménière's disease is admitted for intravenous fluid administration. What additional manifestation is seen in this disease process? 1) Muscle cramps 2) Drop in blood pressure 3) Capillary glucose 90 mg/dL 4) Uncontrollable eye movements

4

19. The nurse is providing care to several patients in the emergency department. Which patient is the priority when using the three-tiered triage system? 1) A patient with a simple fracture 2) A patient experiencing renal colic 3) A patient with severe abdominal pain 4) A patient with chest pain and diaphoresis

4

19. Which patient should the nurse offer the opportunity for human immunodeficiency virus (HIV) testing during an annual physical examination? 1) A 66-year-old male patient 2) A 75-year-old female patient 3) An 8-year-old school-age child 4) An 18-year-old young adult patient

4

2. A nurse is performing an admission assessment on a patient with symptoms that indicate human immunodeficiency virus (HIV). Which question from the nurse addresses a major risk factor for contracting HIV? 1) "Has your partner been experiencing these symptoms?" 2) "When was your first sexual experience?" 3) "Have you had any fever, diarrhea, or chills over the last 48 hours?" 4) "Have you ever experimented with intravenous drugs?"

4

2. A young school-age patient is in the hospital with acute kidney injury following a streptococcus infection. The parents are Spanish-speaking and speak little English. The parents, through an interpreter, ask the nurse what mistake they made that caused the child to be so sick. Which response by the nurse is the most appropriate? 1) "Your child does not have enough dietary protein." 2) "Your child has a congenital defect that led to renal failure." 3) "Your child's renal failure has been caused by a low calcium level." 4) "Your child's recent infection may have caused the renal failure."

4

2. The nurse is caring for a patient with 50% total body surface area burns. Which finding indicates that burn shock is resolving? 1) Heart rate 112 bpm 2) Respirations 24 per minute 3) Blood pressure 90/60 mm Hg 4) Urine output 800 mL over 2 hours

4

21. A patient with severe Ménière's disease is considering a labyrinthectomy. What should the nurse emphasize as a complication of this procedure? 1) Long-term tinnitus 2) Chronic otitis media 3) Rupture of the tympanic membrane 4) Complete hearing loss of the affected ear

4

21. Which patient injury would receive a black tag by the triage nurse during a mass casualty incident? 1) Concussion 2) Ankle sprain 3) Open femur fracture 4) Full-thickness body burns

4

22. The nurse instructs a patient with chronic kidney disease on the prescribed medication furosemide (Lasix). Which patient statement indicates that teaching has been effective? 1) "I will take this medication to keep my calcium balance normal." 2) "This medication will make sure I have enough red blood cells in my body." 3) "I will take this pill to keep the protein level in my body stable." 4) "This pill will reduce the swelling in my body and get rid of the extra potassium."

4

23. A patient with chronic kidney disease is experiencing manifestations of anemia. Based on this data, which treatment does the nurse anticipate for this patient? 1) Begin fluid restriction. 2) Administer intravenous glucose and insulin. 3) Begin a low-sodium diet. 4) Epoetin injections

4

23. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is currently 250 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

4

3. Which guideline should the nurse use to help differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)? 1. GAD is acute in nature, and panic disorder is chronic. 2. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders. 3. Depression is a common symptom in GAD and rare in panic disorder. 4. Depersonalization is absent in GAD but is commonly seen in panic disorder.

4

4. A patient is admitted for a suspected inhalation injury. What should the nurse emphasize when caring for this patient? 1) Increase oral fluids 2) Turn in bed every two hours 3) Monitor strict intake and output 4) Deep breathing and coughing every hour

4

4. The nurse is instructing a patient with iron-deficiency anemia about appropriate menu choices. Which diet choice indicates that teaching has been effective? 1) Tofu with mixed vegetables in curry, milk, whole-wheat bun 2) Broiled fish, lettuce salad, grapefruit half, carrot sticks 3) Pork chop, mashed potatoes and gravy, cauliflower, tea 4) Roast beef, steamed spinach, tomato soup, orange juice

4

5. The nurse is caring for a patient who sustained electrical burns. Why should the nurse monitor this patient for compartment syndrome? 1) Potential for undiagnosed injuries 2) Injuries from being thrown bruise soft tissue 3) Electrical current alters integrity of blood vessels 4) Fluid seeps from intravascular spaces into the interstitium

4

6. A cab driver, stuck in traffic, becomes lightheaded, tremulous, diaphoretic, tachycardic, and dyspneic. A work-up in an emergency department reveals no pathology. Which nursing diagnosis should be the nurse's first priority? 1. Fear 2. Powerlessness 3. Altered role performance 4. Anxiety

4

6. A patient is diagnosed with a corneal abrasion. Which diagnostic test was used to confirm this diagnosis? 1) MRI 2) CT scan 3) Ultrasound 4) Fluorescein stain

4

6. Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant to a client with alcohol withdrawal? 1. Antagonist treatment 2. Deterrent therapy 3. Codependency therapy 4. Medication-assisted treatment

4

7. A client diagnosed with chronic alcohol addiction is being discharged from an inpatient treatment facility after detoxification. Which client outcome, related to Alcoholics Anonymous (AA), would be most appropriate for a nurse to discuss with the client during discharge teaching? 1. To immediately attend AA meetings at least weekly. 2. To rely on an AA sponsor to help control alcohol cravings. 3. To incorporate family in AA attendance. 4. To seek appropriate deterrent medications through AA.

4

8. The emergency department nurse is triaging patients. Which patient should be prioritized? 1) An adult patient experiencing mild chest pain 2) An adolescent patient with a possible fractured wrist 3) An older adult patient with a hip fracture who is in pain 4) A school-age patient with asthma presenting with dyspnea

4

8. The nurse suspects that a patient is developing a cataract. What finding did the nurse use to make this clinical decision? 1) Itching of both eyes 2) Tearing of both eyes 3) Redness of the sclera 4) Double vision in one eye

4

8. The patient enters the outpatient clinic and states to the triage nurse, "I think I have the flu. I'm so tired, I have no appetite, and everything hurts." The triage nurse assesses the patient and finds a butterfly rash over the bridge of nose and on the cheeks. Based on this data, which diagnosis does the nurse anticipate? 1) Gout 2) Lyme disease 3) Fibromyalgia 4) Systemic lupus erythematosus

4

9. A patient with atrial fibrillation is being considered for cardioversion. Which diagnostic test should the nurse anticipate being prescribed prior to this procedure being completed? 1) Chest x-ray 2) CT scan of the chest 3) 12-lead electrocardiogram 4) Transesophageal echocardiogram (TEE)

4

9. It is documented that a patient has superficial partial-thickness burns over both anterior lower arms. What should the nurse expect when assessing this patient? 1) Dry with no blisters 2) Waxy appearance and cherry red in color 3) Dry leathery appearance and pale or brown in color 4) Open or closed blisters, mild edema, easily blanches

4

9. A patient with atrial fibrillation is being considered for cardioversion. Which diagnostic test should the nurse anticipate being prescribed prior to this procedure being completed? 1) Chest x-ray 2) CT scan of the chest 3) 12-lead electrocardiogram 4) Transesophageal echocardiogram (TEE)

4 -Only consider cardioversion after atria have been evaluated for clots by a TEE -Cardioversion- at peak of R wave, tachy dysrhythmias with a pulse, start with low J and work up -Defib- anywhere in cardiac cycle, tachy dysrhythmias with no pulse, immediately start at 200J

26. Prioritize the depressive disorders and their predominant affective symptoms from least to most severe (1-4). (Enter the number of each disorder in the proper sequence, using comma and space format, such as 1, 2, 3, 4.) 1. Dysthymic disorder (helplessness, powerlessness, pessimistic outlook, low self-esteem) 2. Uncomplicated grieving (feelings of anger, anxiety, guilt, helplessness) 3. Major depressive episode (total despair, worthlessness, flat affect, apathy) 4. Transient depression (sadness, dejection, feeling downhearted, having "the blues")

4 2 1 3

3. A patient recovering from a motor vehicle crash develops hypotension and jugular distension with a tracheal deviation. Based on this data, which should the nurse suspect occurred? 1) Hemorrhage 2) Compensatory shock 3) Hypovolemic shock 4) Tension pneumothorax

4 A tension pneumothorax is life threatening and requires immediate intervention. On inspiration, air enters the pleural space, does not escape on expiration, and increases the intrapleural pressure. The pressure collapses the injured lung and shifts the mediastinal contents, compressing the heart, great vessels, trachea, and eventually the uninjured lung. The pressure must be released or the patient will experience cardiac tamponade, respiratory arrest, and death. A chest tube will be placed to release the air and allow re-expansion of the lung.

3. A victim of a car fire is confused, dizzy, and nauseated. What diagnostic test should be done to determine if this patient is experiencing carbon monoxide poisoning? 1) Chest x-ray 2) Bronchoscopy 3) Pulse oximeter 4) Carboxyhemoglobin level

4 Carbon monoxide binds to the hemoglobin molecule more easily than does oxygen; therefore, it will replace oxygen on the hemoglobin molecule resulting in tissue hypoxia. Carboxyhemoglobin level blood test will detect the amount of carbon monoxide in the patient. A patient with carbon monoxide poisoning will exhibit symptoms such as headache, confusion, dizziness, and nausea. If one succumbs to carbon monoxide poisoning, even though hypoxic, the skin may be pink because the hemoglobin is saturated. If using a pulse oximeter, it may read high 90s to 100% because of carbon monoxide saturating the hemoglobin—the oximeter does not know the difference between oxygen and carbon monoxide.

13. The nurse is conducting medication teaching for a patient who is prescribed an epi-pen. Which statements made by the patient indicates the need for additional instruction? 1) "I will carry an epi-pen with me at all times." 2) "I will check the expiration date on my epi-pen regularly." 3) "I should hold the epi-pen in place for 10 seconds after injection." 4) "I should use the epi-pen to inject the drug into my abdominal wall."

4 Patients who are susceptible to severe allergic reactions are often prescribed an Epi-pen. The patient should carry the Epi-pen at ALL times, check the expiration date regularly, and should hold it in place for a minimum of 10 seconds after injection to ensure receipt of the full dose. The medication is administered subcutaneously, NOT IM, and through the clothing.

16. A patient scheduled for surgery is being instructed in leg exercises and the pneumatic compression device. The nurse includes these instructions to decrease which postoperative complication? 1) Infection 2) Delayed wound healing 3) Contractures 4) Deep vein thrombosis

4 don't massage the area of the clot, can break off and go to the lungs

2. A patient is brought into the emergency department after being assaulted. It is suspected that the patient has a spinal cord injury. Which diagnostic test does the nurse anticipate based on the data collected? 1) Computed tomography (CT) scan 2) X-ray 3) Ultrasound 4) Magnetic resonance imaging (MRI)

4 keep head/neck from moving

18. During the initial stage of shock, which clinical manifestation should the nurse monitor for when assessing the patient? 1) Lethargy 2) Hypotension 3) Respiratory alkalosis 4) Subtle changes in heart rate

4 subtle or no clinical manifestations are anticipated

25. Place the progression of human immunodeficiency virus (HIV) in sequential order. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) AIDS 2) Death 3) Seroconversion 4) Viral transmission 5) Acute viral infection 6) Asymptomatic chronic infection

435612

Isolation Precautions

AIDS gets standard precautions

Ventricular Tachycardia (Monomorphic)

Big Vs, all look the same

Lactate Levels

Elevated levels confirm anaerobic metabolism

??????????????? disorder is manifested by signs and symptoms of schizophrenia, along with a strong element of symptomatology associated with the mood disorders (depression or mania).

Schizoaffective

18. A nurse has been providing a young adult patient with a history of hypersensitivity reactions. The nurse is preparing instructions on the correct methods for using an EpiPen. Which patient statement indicates understanding of the proper technique? "I make sure the EpiPen is always available." "No one else in my family knows how to use the EpiPen." "It's fine to leave the EpiPen out in the sun." "I don't need a medical alert tag."

a

80. The nurse provides care to a patient who is diagnosed with increased intracranial pressure (ICP). Which finding indicates the need for immediate intervention? Contralateral hemiparesis Lethargy Sluggish pupillary response to light Confusion

a Proper positioning for a patient with increased ICP includes: placing the head in a neutral position and raising the head of bed (HOB) 45—60 degrees. Flexion of the hips or lying the patient supine will increase the ICP further. cushing's triad Other signs present with increased ICP are: headache, vomiting, restlessness and irritability, decreased level of consciousness (LOC), confusion, double vision, unequal pupils, seizures, contralateral hemiparesis, etc. Pupillary size and reaction assesses cerebral function in patients in a coma with ICP

10. When assessing her patient the nurse finds symptoms of poor perfusion. On what symptoms did she base this finding? (Select All That Apply) Dizziness/Lightheadedness Hypotension Chest Pain/Shortness of Breath Shortness of Breath Anxiety Hypertension

a b c d e

29. The nursing instructor is explaining causes o thrombus (DVT) to the students. She knows the a student understands when she identifies which of the following factors contribute and make-up Virchow's Triad. (Select All That Apply) Intimal Damage of Vessels Hypervolemia Hypercoagulability Venous Stasis

a c d intimal damage of vessels, hypercoagulability, and venous stasis shows causes of DVT

ventricular fibrillation

all over the place, nothing discernable

Antianxiety drugs are also called ???? and minor tranquilizers

anxiolytics

19. A pediatric patient with a history of anaphylactic hypersensitivity reactions will be discharged with a prescription for an EpiPen. Which statement is appropriate for the nurse to include in the discharge instructions for this patient and family? "Keep the medication in one location that is easy to remember." "Frequently check the expiration date of the medication." "This medication does not come prefilled and must be measured." "Keep the medication in the car at all times."

b

24. The nurse provides care to several patients with a history of hypersensitivity reactions. Which patient requires education regarding a type I reaction? The patient with a suspected latex allergy The patient with allergic rhinitis The patient with rheumatoid arthritis The patient with myasthenia gravida

b

43. Which clinical manifestations does the nurse anticipate when providing care to a patient experiencing a histamine-mediated hypersensitivity reaction? Select all that apply. A low blood pressure Wheezing upon auscultation The presence of hives A report of itching The presence of vomiting

b c d e

19. A pattern of coercive control founded on and supported by physical and/or sexual violence or threat of violence of an intimate partner is termed ?????????.

battering

13. A nurse is caring for a pediatric patient who is receiving an infusion of intravenous antibiotic at the ambulatory clinic. Which clinical manifestation indicates that the patient is experiencing a type I hypersensitivity reaction? Erythema Fever Hypotension Joint pain

c

14. The nurse is assessing a patient who is receiving intravenous (IV) antibiotics. Which item in the patient's health history increases the risk for experiencing a hypersensitivity reaction? Caucasian race 26 years of age Concurrent chronic illness Previous antibiotic therapy

d

20. A nurse is caring for a patient with seasonal hypersensitivity reactions. What teaching would the nurse provide to improve this patient's comfort? Keep doors and windows open on high-allergen days to circulate air. Take antihistamine and leukotriene medication as ordered Stop taking oral corticosteroids immediately once symptoms disappear. Maintain a clean, dust-free environment.

d

Asystole

don't shock flatline do CPR and use a vasopressor like Epi

Suicide prevention

know the signs, never dismiss or discredit threats, listen, ask if they;re suicidal, don't ever leave them alone

20. Physical ??????? of a child includes refusal of or delay in seeking health-care, abandonment, expulsion from the home or refusal to allow a runaway to return home, and inadequate supervision.

neglect

To rid the body of excessive calories, a client diagnosed with bulimia nervosa may engage in ??????? behaviors, which include self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

purging

Snellen Chart

the typical eye chart in the doctors office with the big E