H&I 4- Pearson Questions Final
After completing an assessment, the nurse determines that a client with cardiovascular disease would benefit from consultations with a physical therapist, dietitian, and psychologist. Which factors support the nurse's findings? (Select all that apply.) a) Client is an employee of the Internal Revenue Service b) Client sleeps 7 to 8 hours each night c) Client smokes 1 to 2 packs of cigarettes per day d) Client eats fast food for breakfast and lunch e) Client sits at a desk for 10 hours each day
a) Client is an employee of the Internal Revenue Service c) Client smokes 1 to 2 pack of cigarettes per day d) Client eats fast food for breakfast and lunch e) Client sits at a desk for 10 hours each day
A nurse is assessing the victim of an automobile accident to check for possible injury to the brain and central nervous system. The client's family is relieved to learn that the client's neurological responses are normal. For which part of the ABCDE priority is the nurse checking? a) D (disability) b) C c) B d) E
a) D
A nurse is providing education about heart failure to a community group. Which risk factors should the nurse include in the presentation? (Select all that apply.) a) Diabetes mellitus b) Coronary heart disease c) Pituitary adenoma d) Hypertension e) Sleep apnea
a) Diabetes mellitus b) Coronary heart disease d) Hypertension e) Sleep apnea
While waiting for morning report, the nurse is called to help in the room of a client with an alteration in perfusion. Which actions can the nurse perform independently? (Select all that apply.) a) Explain why the client is on a no-added-salt diet b) Administer a dose of a nitrate c) Measure urine output d) Measure peripheral blood pressure e) Assess radial pulse
a) Explain why the client is on a no-added salt diet c) Measure urine output d) Measure peripheral blood pressure e) Assess radial pulse
A nurse case manager is working with a family that has been reported to authorities due to evidence of elder abuse. With which possible positive perspectives can the nurse view the crisis situation? (Select all that apply.) a) Families can be more motivated to adopt new behaviors b) The crisis can be a trigger for relocating older adults c) The crisis can lead to the involvement of lawyers and the police d) The crisis can be a window of opportunity for change e) Families can be more open to get help
a) Families can be more motivated to adopt new behaviors b) The crisis can be a trigger for relocating older adults d) The crisis can be a window of opportunity for change e) Families can be more open to get help
The nurse is caring for a child who is diagnosed with type 2 diabetes mellitus (DM). The parents want to know how this happened to their child. Which items in this child's history will the nurse share with the parents as risk factors for developing this type of DM? (Select all that apply.) a) Family history of DM b) Active lifestyle c) Race d) Obesity e) High-fat diet
a) Family history of DM c) Race d) Obesity e) High-fat diet
A nurse is caring for a client newly diagnosed with heart failure. The client is placed on venous pressure monitoring. Which information about the heart function does venous pressure monitoring provide? (Select all that apply.) a) Fluid status b) Left ventricular and cardiac functioning c) Normal range, 2 to 6 mmHg d) Right heart filling pressures e) Direct and continuous arterial blood pressures
a) Fluid Status c) Normal range, 2 to 6 mmHg d) Right heart filling pressures
The nurse is caring for a 70-year-old client admitted for possible type 2 diabetes mellitus. When obtaining the client's history, which conditions are potential indicators of diabetes mellitus in this older client? (Select all that apply.) a) Gastroparesis (delayed gastric emptying) b) Impotence c) Glaucoma d) Periodontal disease e) Hypertension
a) Gastroparesis b) Impotence c) Glaucoma d) Periodontal disease
A nurse is describing the pathophysiology of heart failure to a client. Which changes caused by compensatory mechanisms in the development of heart failure should the nurse describe? (Select all that apply.) a) Hypertension causes the cardiac muscles to overstretch and cause temporarily increased cardiac output b) Increased cardiac output causes the aortic baroreceptors to stimulate the sympathetic nervous system c) The ventricles in the heart remodel and develop hypertrophy because of the chronic increase in fluid volume d) The kidneys release renin to retain sodium and water in an attempt to maintain cardiac output e) Atrial natriuretic peptide is released by the cardiac cells to help delay cardiac decompensation
a) Hypertension causes the cardiac muscles to overstretch and cause temporarily increased cardiac output c) The ventricles in the heart remodel and develop hypertrophy because of the chronic increase in fluid volume d) The kidneys release renin to retain sodium and water in an attempt to maintain cardiac output e) Atrial natriuretic peptide is released by the cardiac cells to help delay cardiac decompensation
A client is diagnosed with type 2 diabetes mellitus. Which information about type 2 diabetes mellitus should the nurse include when providing client education? a) Insulin resistance occurs in peripheral tissues b) The liver suppresses the release of glucose c) Metabolism of dietary carbohydrates is enhanced d) The onset of hyperglycemia is rapid
a) Insulin resistance occurs in peripheral tissues
The nurse is assisting a client with type 2 diabetes mellitus to plan to meet nutritional needs. Which general rules should the nurse include in the plan? (Select all that apply.) a) Intake of 45-65% of carbohydrates b) Intake of 10% protein c) Intake of 20% protein and 10% fat d) 15 grams of carbohydrate for every 1 unit of regular insulin e) Intake of 20% fat
a) Intake of 45-65% of carbohydrates c) Intake of 20% protein and 10% fate d) 15 grams of carbohydrate for every 1 unit of regular insulin
The nurse in the emergency department is caring for a woman of Asian descent who was brought in by a neighbor. The right side of the client's face is swollen, bruised, and bleeding. She has multiple bruises on her arms. The client's husband arrives and does not let her speak; he answers questions for her. The nurse should suspect which type of abuse? a) Intimate partner violence b) Financial abuse c) Elder abuse d) Rape
a) Intimate partner violence
A client has questions about surgery to replace the need to take insulin several times a day. Which is a surgical intervention that can be considered for clients with diabetes mellitus? (Select all that apply.) a) Islet cell transplantation b) Replacing pancreatic cells c) Removing the spleen d) Replacing the pancreas e) Replacing a part of the liver
a) Islet cell transplantation b) Replacing pancreatic cells d) Replacing the pancreas
Which is a specific recommendation for exercise for a client with diabetes mellitus? (Select all that apply.) a) Keep the exercise brief and moderate b) Stay hydrated during exercise c) Exercise at least 150 minutes per week d) Keep sessions short, as prolonged sessions cause hypoglycemia e) Exercise no more than 60 minutes a week
a) Keep the exercise brief and moderate b) Stay hydrated during exercise c) Exercise at least 150 minutes per week
A client with diabetes mellitus is being taught to monitor the blood glucose level. Which factor that affects accurate glucose monitoring should the nurse include in the instruction? (Select all that apply.) a) Low hematocrit level b) Creatinine level c) WBC count d) Overdose medications e) High hematocrit level
a) Low hematocrit level d) Overdose medications e) High hematocrit level
A nurse is assessing an older adult client who was being abused and neglected. The nurse should assess the client for which characteristics? (Select all that apply.) a) Malnutrition b) Chronic fatigue c) Trauma to sexual organs d) Withdrawn behavior e) Bruises or burns
a) Malnutrition c) Trauma to sexual organs d) Withdrawn behavior e) Bruises or burns
A client was recently diagnosed with acute heart failure. The nurse anticipates that which cardiac disorder led to this diagnosis? a) Myocardial infarction b) Valvular disease c) Cardiomyopathy d) Coronary heart disease
a) Myocardial infarction
While assessing peripheral pulses in a 2-week-old infant, the nurse is unable to palpate the radial and pedal pulses. What action should the nurse take? a) Nothing because this is a normal finding (normally low blood pressure and rapid heart rate, other distal pulses may be hard to feel; may be able to palpate brachial, popliteal, and femoral pulses) b) Notify the health care provider immediately c) Prepare the infant for emergency cardiac catheterization d) Insert a venous access device for intravenous cardiac medications
a) Nothing because this is a normal finding
A nurse is preparing a community teaching presentation on prevention of abuse. Which levels of prevention should be included in the nurse's presentation? (Select all that apply.) a) Parental b) Individual c) Historical d) Societal e) Community
a) Parental b) Individual d) Societal e) Community
The nurse is caring for a child who is hospitalized for the treatment of diabetic ketoacidosis (DKA). The child's parents ask why their child is receiving potassium. What is the best answer for the nurse to provide to this child's parents? a) "Potassium is administered to treat hypokalemia." b) "Potassium is administered to decrease blood glucose levels." c) "Potassium is administered to treat acidosis." d) "Potassium is administered to treat cerebral edema."
a) Potassium is administered to treat hypokalemia
The nurse is providing care to a child diagnosed with patent ductus arteriosus who is exhibiting symptoms of congestive heart failure. Which intervention is appropriate to decrease the cardiac workload of the client? (Select all that apply.) a) Provide frequent rest periods while feeding b) Weigh child once a week c) Strictly measure intake and output d) Burp child frequently during feeding e) Offer three large feedings
a) Provide frequent rest periods while feeding c) Strictly measure intake and output d) Burp child frequently during feeding
Which actions are appropriate nonpharmacologic treatments of a neglected or abused child? (Select all that apply.) a) Providing a safe environment for the child b) Reporting the abuse or neglect to the appropriate agency c) Family therapy for the parents d) Play therapy e) Pain medication for the child's injuries
a) Providing a safe environment for a child b) Reporting the abuse or neglect to the appropriate agency c) Family therapy for the parents d) Play therapy
The nurse who is caring for a client who was a victim of intimate partner violence (IPV) is aware that recovery from this type of relationship can be a long and difficult process. Which should the nurse identify as the victim's main goal in reconstructing her life? a) Regaining a sense of empowerment and safety b) Resolving grief over any losses c) Getting through the shock and confusion of the act d) Getting back into work and home routines
a) Regaining a sense of empowerment and safety
A client with cardiovascular disease has a new onset of lethargy. Assessment data includes a blood pH of 7.31 and a respiratory rate of 8 breaths per minute. What should the nurse do to help this client? (Select all that apply.) a) Review medications for analgesics provided b) Provide rest periods between activities c) Assess for jugular vein distention d) Raise the head of the bed e) Measure urine output
a) Review medications for analgesics provided e) Measure urine output
A victim of an automobile crash is diagnosed with fractures of the axial skeleton. For which bone fractures should the nurse anticipate providing care for this client? (Select all that apply.) a) Ribs b) Arm c) Lower leg d) Femur e) Vertebra
a) Ribs e) Vertebra
The results of diagnostic tests indicate that a client with coronary artery disease has cardiomyopathy. Which clinical manifestations should the nurse expect to assess in this client? (Select all that apply.) a) Shortness of breath when walking b) Nosebleeds c) Fatigue d) Morning headache e) Lower extremity edema
a) Shortness of breath when walking c) Fatigue e) Lower extremity edema
A client reports weakness, fatigue, and decreased exercise tolerance. Based on the reported symptoms, the nurse anticipates that the healthcare provider will diagnose the client as having which classification of heart failure? a) Systolic b) Diastolic c) Right-sided d) Left-sided
a) Systolic
The nurse is planning care for a client with diabetes mellitus and addressing the potential problem of risk of infection. Which intervention will best assist in addressing this risk? a) Teaching the client to use lukewarm water and soap for foot and skin care b) Promoting smoking cessation c) Monitoring sensation in extremities daily d) Instructing the client to have an oral examination yearly
a) Teaching the client to use lukewarm water and soap for foot and skin care
A case management nurse is working with a familiar client, a proven victim of repeated and severe domestic abuse. The client has chosen to return for the third time to live with the abuser. What must the nurse remember in this frustrating situation? (Select all that apply.) a) The client feels unable to leave an unsafe situation b) The client's decisions should not be judged by the nurse c) The client's choice should be supported by the nurse d) The client will never make other living arrangements e) The client has the case manager's contact information
a) The client feels unable to leave an unsafe situation b) The client's decisions should not be judged by the nurse c) The client's choice should be supported by the nurse e) The client has the case manager's contact information
The nurse is preparing teaching material for a client newly diagnosed with coronary artery disease. What should the nurse include when explaining the disease process to the client? (Select all that apply.) a) The coronary vessels supply oxygen and nutrients to the heart muscle b) Heart rate controls the flow of blood through these vessels c) It is a low-pressure system that begins with the right side of the heart d) Aortic pressure controls the flow of blood through these vessels e) It is a high-pressure system needed to move oxygenated blood to body tissues
a) The coronary vessels supply oxygen and nutrients to the heart muscle b) Heart rate controls the flow of blood through these vessels d) Aortic pressure controls the flow of blood through these vessels
A nurse is assessing a client with heart failure. The nurse is concerned the client is experiencing poor tissue perfusion based on which assessment findings? (Select all that apply.) a) Urinary output is 20 mL/hour for the past 2 hours b) Level of consciousness is decreasing c) Capillary refill time is increasing d) Blood pressure is 126/72 mmHg e) Oxygen saturation is 93% on room air
a) Urinary output is 20 mL/hour for the past 2 hours b) Level of consciousness is decreasing c) Capillary refill time is increasing
The nurse is planning care for an 18-month-old child diagnosed with tetralogy of Fallot. Which intervention should the nurse implement to assist in managing hypercyanosis? (Select all that apply.) a) Use opioids to manage pain b) Avoid administering dopamine c) Administer packed red blood cells d) Apply oxygen e) Place child in supine position
a) Use opioids to manage pain c) Administer packed red blood cells d) Apply oxygen
A nurse is providing care to a client diagnosed with heart failure. Which interventions should the nurse implement when monitoring the client's fluid volume? (Select all that apply.) a) Weigh the client daily b) Auscultate lung sounds every 4 hours c) Allow for rest periods d) Record hourly urine outputs e) Monitor intake and output
a) Weigh the client daily b) Auscultate lung sounds every 4 hours d) Record hourly urine outputs e) Monitor intake and output
The nurse instructs a client with hypercholesterolemia on the medication lovastatin. Which client statement indicates that teaching has been effective? a) "I should expect to have muscle cramps and pain while taking this medication." b) "I should not drink any alcohol while taking this medication." c) "I need to weigh myself every day while taking this medication." d) "I should take this medication at bedtime so I won't get dizzy."
b) "I should not drink any alcohol while taking this medication."
The nurse is teaching a child with diabetes and her family about sick day guidelines. Which statement by the family indicates appropriate understanding of the material presented? a) "We will test for ketones when the blood glucose level is 160 mg/dL." b) "We will test for ketones when the blood glucose level is 220 mg/dL." c) "We will test for ketones when the blood glucose level is 200 mg/dL." d) "We will test for ketones when the blood glucose level is 180 mg/dL."
b) "We will test for ketones when the blood glucose level is 220 mg/dL."
The home care nurse is talking to an entire family when caring for their oldest member, an 88-year-old client with multiple health issues. The rest of the family includes a 48-year-old, a 28-year-old, an 18-year-old, and an 8-year-old. Which individuals are in age groups less likely to report or admit to being the victims of violence? (Select all that apply.) a) 18 year-old b) 88 year-old c) 28 year-old d) 48 year-old e) 8 year-old
b) 88 year-old e) 8 year-old
The nurse is planning care for a school-age client diagnosed with type 2 diabetes mellitus (DM). Which task will the nurse plan at the first annual visit for this child? a) Establish baseline HbA1C b) Administer influenza vaccine c) Administer a psychosocial assessment d) Assess dietary needs
b) Administer influenza vaccine
The nurse is talking with a client who just had a beautiful potted flower delivered. Suddenly the client starts to cry and stares out the window. The client has a history of abuse by her husband. Which response should the nurse include in the plan of care for this client? a) Tell the client that the abuse was in the past b) Assess if the client is having a flashback of previous abuse c) Tell the client to enjoy the flowers and that she will feel better in a little while d) Give the client some time and return later
b) Assess if the client is having a flashback of previous abuse
At the completion of a health history and physical assessment, the nurse is concerned that a middle-aged adult client is at risk for developing cardiovascular disease. What did the nurse most likely assess in this client? (Select all that apply.) a) Plays racquet ball 4 times a week for 1 hour b) Body mass index 31.4 c) Smokes 1 pack per day of cigarettes d) Blood pressure 158/96 mmHg e) Fasting blood glucose 86 mg/dL
b) Body mass index 31.4 c) Smokes 1 pack per day of cigarettes d) Blood pressure 158/96 mmHg
A nurse at a geriatric clinic notices bruises on the arms and legs of a frail older client. If the bruises are caused by abuse, who might be possible perpetrators? (Select all that apply.) a) Meals-on-wheels volunteers b) Children visiting a parent c) Client's spouse d) Prescriber of anticoagulants e) Caregiver living in home
b) Children visiting a parent c) Client's spouse e) Caregiver living in home
The nurse is caring for a pediatric client who is experiencing diabetic ketoacidosis (DKA). Which assessment finding indicates the need for the nurse to monitor this client for cardiac arrhythmias? a) Elevated blood glucose level b) Decreased potassium level c) Decreased urine output d) Decreased albumin level
b) Decreased potassium level
A newborn recently diagnosed with coarctation of the aorta is admitted to the neonatal intensive care unit (NICU). For which clinical manifestation should the nurse monitor the client? a) Warm extremities b) Delayed capillary refill c) Increased urinary output d) Loud murmur
b) Delayed capillary refill
A nurse is looking at the professional literature about children with similar risks of environmental exposure to violence. Which outcomes would the nurse read about? (Select all that apply.) a) Lethargy b) Depression c) Nonproblematic behaviors d) Hypertension e) Violence
b) Depression c) Nonproblematic behaviors e) Violence
A 5-year-old girl who has been physically abused is having difficulty putting her feelings into words. Which nursing intervention best enables the child to express her feelings? a) Reporting the abuse to a prosecutor b) Engaging in play therapy c) Role-playing d) Giving the child's drawings to the abuser
b) Engaging in play therapy
The nurse identifies that a client who sits for 10 hours a day during work is at risk for hip contracture formation. What should the nurse instruct the client to do, in order to reduce this risk? (Select all that apply.) a) Consider losing weight and increasing activity b) Follow the prescribed exercises provided by the physical therapist c) Perform stretching exercises as instructed by the physical therapist d) Remove scatter rugs from the home e) Clear all walkways from obstructions in the home
b) Follow the prescribed exercises provided by the physical therapist c) Perform stretching exercises as instructed by the physical therapist d) Remove scatter rugs from the home e) Clear all walkways from obstruction in the home
The nurse is caring for a child with type 1 diabetes mellitus (DM) who is experiencing hypoglycemia. In reviewing the child's history, what item most likely caused the hypoglycemia? a) Lack of growth b) Inaccurate insulin dose c) Too many calories d) Decreased exercise
b) Inaccurate insulin dose
The nurse is caring for a client diagnosed with a congenital heart defect. Which item will the nurse include in the psychosocial portion of the nursing assessment? a) Blood pressure b) Parental coping skills c) Respiratory rate d) Maternal prenatal history
b) Parental coping skills
Immediately after the birth of an infant, the nurse is completing a physical assessment. Which manifestation indicates the infant may have a heart defect associated with decreased pulmonary blood flow? a) Fatigue b) Profound cyanosis that does not respond to oxygen c) Poor feeding d) Clubbing of fingers and toes
b) Profound cyanosis that does not respond to oxygen
The nurse on the pediatric unit is caring for a 3-year-old child who has dime-size burns on her legs and bruises in various stages of healing on her abdomen and back. Which is an appropriate nonpharmacologic treatment for this child? a) Give acetaminophen as ordered by the physician b) Refer the child for play therapy c) Treat the burns with silvadene ointment d) Assess the child's back and abdomen for any changes
b) Refer the child for play therapy
The nurse is educating a client newly diagnosed with type 1 diabetes mellitus. Which information should the nurse include in client education about the regular monitoring of glucose levels? a) Urine testing will assist in measuring hypoglycemia b) Self-monitoring of blood glucose should occur three or four times a day c) Self-monitoring of blood glucose is painless and noninvasive d) Urine testing is used only until glucose goals are achieved
b) Self-monitoring of blood glucose should occur three or four times a day
The school nurse is caring for a child who is experiencing hypoglycemia. The child is unconscious. What treatment options are most appropriate for this child? (Select all that apply.) a) Insulin injection b) Sugar gel or paste c) Glucagon d) Low-fat carbohydrate snack e) Glucose tablets
b) Sugar gel or paste c) Glucagon
The nurse is reviewing fasting serum blood glucose levels on several children on a pediatric medical-surgical unit. For which child does the nurse expect to provide information about treatment options for type 1 diabetes mellitus (DM)? a) The child with a fasting blood glucose of 100 mg/dL b) The child with a fasting blood glucose of 140 mg/dL c) The child with a fasting blood glucose of 80 mg/dL d) The child with a fasting blood glucose of 120 mg/dL
b) The child with a fasting blood glucose of 140 mg/dL
The school nurse is assessing a third-grade child for symptoms of sexual abuse. Which behavioral manifestations support the possibility of sexual abuse? a) Enuresis, impulsivity, and decline in school performance b) Thumb-sucking, isolating self from peers on playground, and excessive fear of strangers c) Hyperactivity, stuttering, and isolating self from peers on the playground d) Stuttering, impulsivity, and being the team leader when playing games with peers
b) Thumb-sucking, isolating self from peers on playground, and excessive fear of strangers
A nurse is reviewing diagnostic tests for a client newly diagnosed with heart failure. The nurse is concerned that the client is experiencing renal issues in addition to the heart failure. Which diagnostic tests would the nurse focus on to help determine renal function? (Select all that apply.) a) B-type natriuretic peptide (BNP) (related to heart failure, but not renal function; rises in response to stretch and overload of cardiac ventricles) b) Urinalysis c) Blood urea nitrogen (BUN) d) Serum creatinine e) Chest x-ray
b) Urinalysis c) Blood urea nitrogen (BUN) d) Serum Creatinine
While conducting a physical assessment, the nurse hears an additional heart sound immediately after the second sound. How should the nurse document this assessment finding? a) Friction rub b) Ventricular gallop c) Atrial gallop d) Diastolic murmur
b) Ventricular gallop
A pediatric nurse is conducting a health history on a newly admitted child. The nurse includes the fact that the child's family has been involved in a cycle of violence. What meaning could the nurse be conveying? a) The child has self-abusive behaviors b) Violence has occurred across multiple generations c) The child's parents have never committed violent acts d) Violence occurs unexpectedly and randomly in the child's family
b) Violence has occurred across multiple generations
The etiologies of interpersonal violence, abuse, and neglect relate to several different theories. Which explanation best describes the social learning theory? a) Some families, cultures, and communities value the subordination of women through power and privilege. b) Violence related to abuse and neglect is a learned behavior. c) The tendency to abuse, neglect, and become violent toward others is a result of genetic considerations and distortion in neurotransmitters. d) The cause of violence lies in the personality of the individual who commits abuse.
b) Violence related to abuse and neglect is a learned behavior
A public health nurse is the guest speaker at a PTA meeting. The nurse describes how parents' activities can decrease the risk of violence in their family. Which actions supported by CDC research will the nurse include? (Select all that apply.) a) Achieving financial success b) Watching the child's sports team play c) Regularly attending worship service together d) Rewarding good report cards e) Showing interest in the child's homework
b) Watching the child's sports team play c) Regularly attending worship services together d) Rewarding god report cards e) Showing interest in the child's homework
A nurse is conducting a nursing assessment interview of an individual with unexplained rib fractures. To check whether the person is a possible victim of domestic abuse, the nurse asks, "Has your partner ever struck you when feeling angry?" Which word in the nurse's phrasing of the question shows consideration? a) Using the word "partner" b) Using the word "ever" c) Using the word "stuck" d) Using the word "angry"
b) using the word "ever"
After a lecture by a health department nurse, some members of the audience came up to congratulate the nurse on an effective presentation. Which statements by the audience members would the nurse want to correct? (Select all that apply.) a) "Violence challenges coping efforts." b) "Eighty percent of domestic violence victims are women." c) "Elder abuse happens to people over 55 years old." d) "Domestic violence rates are increasing." e) "Violence is not preventable."
c) "Elder abuse happens to people over 55 years old" d) "Domestic violence rates are increasing" e) "Violence is not preventable"
The nurse is evaluating teaching provided to a client with newly diagnosed hypertension. Which client statement indicates that teaching has been effective? a) "High blood pressure is the leading cause of death in the United States." b) "Half of the people with high blood pressure die within 5 years of diagnosis." c) "Uncontrolled high blood pressure can cause a heart attack or a stroke." d) "High blood pressure is the leading cause of disability in the United States."
c) "Uncontrolled high blood pressure can cause a heart attack or a stroke."
A college student is seen in the emergency department following an incident of date rape. The nurse documents that during her assessment of the student, the student describes the entire chain of events with a blank facial expression. She ends her comments by saying, "It's like it didn't happen to me at all." Which order will the nurse expect for this client? a) NSAIDs b) SSRIs c) Antibiotics d) Narcotics
c) Antibiotics
A school nurse is talking to a fifth-grade class about recognizing behavioral and psychological factors in themselves and their classmates that predispose them to violence. What characteristics should the nurse describe? (Select all that apply.) a) Living in a low-income community b) Having siblings who are heroin addicts c) History of being bullied d) History of bullying others e) Depression
c) History of being bullied d) History of bullying other e) Depression
A nurse is providing care for a client with pulmonary edema subsequent to heart failure. Which finding indicates that the interventions implemented have resolved the gas exchange problem? a) Client is restless and sitting upright to breathe b) Lung sounds indicate bilateral crackles and a cough productive of frothy, pink sputum c) Oxygen saturation is 94% with oxygen supplementation d) Client's respirations are 26 breaths/minute with intercostal retractions
c) Oxygen saturation is 94% with oxygen supplementation
The nurse is planning care for an older client with muscle atrophy and limited mobility. What actions should the nurse plan to promote comfort for this client? (Select all that apply.) a) Teach range-of-motion exercises (promotes joint mobility, not comfort) b) Coach in isometric exercises c) Pad joints d) Encourage ambulation e) Protect bony prominences
c) Pad joints e) Protect bony prominences
The nurse is explaining to a student nurse that left-to-right shunting of blood in the heart can lead to pulmonary overload and congestive heart failure. Which heart defect could the nurse use as an example in the explanation? a) Pulmonic stenosis b) Coarctation of the aorta c) Patent ductus arteriosus d) Tetralogy of Fallot
c) Patent ductus arteriosus
An alert and oriented older adult client is receiving home care services following a cerebrovascular accident that has left her with right-sided hemiparesis. She lives with her daughter and son-in-law. The nurse suspects that the client is being neglected when she observes that the client's hair and clothes are dirty and the client smells of urine. Which nonpharmacologic treatment would be a priority for this client? a) Interview the son-in-law to gain his perspective on the situation b) Confront the daughter with the suspicious c) Report the neglect to the appropriate agency d) Wait until enough trust has been developed to enable the client to approach the nurse first
c) Report the neglect to the appropriate agency
A client with diabetes mellitus is admitted to the medical unit for chronic complications. The nurse ensures that the client's room is free of clutter and has a night light, and checks the water temperature before bathing the client. Which potential problem do these interventions address when caring for this client? a) Ineffective coping b) Risk of infection c) Risk of injury d) Acute pain
c) Risk of injury
During a home visit, the nurse observes a client with back pain shouting at her children and banging cabinet doors in the kitchen while looking for a cooking utensil. Which concept should the nurse identify as being affected by this client's back pain? a) Perfusion b) Safety c) Stress d) Self-esteem
c) Stress
The nurse is reviewing the results of a client's electrocardiogram and notes changes in the QRS complex. What should this finding indicate to the nurse? a) There is a problem with the cardiac atria b) There is damage to the heart muscle c) There is a problem with the cardiac ventricles d) The impulse from the sinoatrial node is delayed
c) There is a problem with the cardiac ventricles
A 2-year-old is brought to the pediatric clinic with an upper respiratory infection. After assessing the child, the nurse suspects that this child may be a victim of child abuse. Which is a physical sign that usually indicates child abuse? a) Diaper rash b) A few bruises on shins c) Welts or bruises in various stages of healing on the child's back d) Scraped and scabbed knees
c) Welts or bruises in various stages of healing on the child's back
The nurse is caring for a child diagnosed with type 1 diabetes mellitus (DM). The nurse educates the child and parents that insulin dosing is based on which item? a) Weight b) Urine output c) Diet d) Age
c) diet
A nurse is doing discharge teaching with a client who has been newly diagnosed with diabetes mellitus type 2. Which statement from the client indicates the need for additional teaching? a) "I need to be alert for infections." b) "I need to stay hydrated during the day." c) "It is important to test my blood sugar at least four times a day." d) "As long as I'm in my house I can walk barefoot."
d) "As long as I'm in my house I can walk barefoot."
In the emergency department, a nurse is handing a doctor sterile supplies to suture several young people who reportedly got into a gang-related altercation. Which statement by the nurse best shows the need for more education for the nurse? a) "Gang members protect each other's identity." b) "Gang culture values violence as a rite of passage." c) "I should not have negative preconceived ideas about gangs." d) "Gang members always lie about the cause of their injuries."
d) "Gang members always lie about the cause of their injuries"
The nurse is caring for several clients diagnosed with diabetes mellitus. Which client would not require a sliding-scale insulin dose? a) A client who receives parenteral nutrition b) A client who receives corticosteroids c) A client who is under severe stress d) A client who missed a meal
d) A client who missed a meal
The nurse is caring for a child who is diagnosed with type 2 diabetes mellitus (DM). Which assessment finding specifically supports the diagnosis of type 2 DM vs type 1 DM? a) Blurred vision b) Ketosis c) Polyuria d) Acanthosis nigricans (hyperpigmentation and thickening of the skin)
d) Acanthosis nigricans (hyperpigmentation and thickening of the skin)
A nurse is preparing discharge teaching for a client newly diagnosed with heart failure. Which information should the nurse include in this teaching? a) Eat three large meals daily b) Restrict sodium intake to 3 g/day (1.5 to 2 g/day) c) Strenuous exercise is encouraged as manifestations improve d) Allow rest periods throughout the day
d) Allow rest periods throughout the day
The telephone advice nurse is fielding a complex question about possible intimate partner abuse. From the description that the caller is giving, it seems likely. What is the first priority of the advice nurse? a) Exploring the need for resources b) Giving information about helpful services c) Emphasizing that the caller is not to blame for the abuse d) Assuring safety from the partner's abuse
d) Assuring safety from the partner's abuse
An infant diagnosed with transposition of the great arteries is scheduled for a cardiac catheterization. The nurse prepares the infant for which procedure where a balloon is inserted to make the foramen ovale wider? a) Transcatheter closure b) Electrocardiogram c) Stent d) Atrial septostomy
d) Atrial septostomy
While measuring vital signs, the nurse discovers that a client's radial pulse rate is 70 and irregular. What should the nurse suspect is occurring with this client's heart? a) Heart muscle fiber tension at the end of diastole is damaged b) Cardiac muscle fibers are losing the ability to shorten c) The heart is not able to respond to changing demands d) Cardiac cells in the right atrium are damaged
d) Cardiac cells in the right atrium are damaged
The nurse is educating a women's community group about congenital heart disorders. Which factor should the nurse identify as placing a child at a greater risk for being born with a congenital heart disorder? a) Mother infected with gonorrhea b) Fetal exposure to a bacterial infection c) Young age of mother d) Chromosomal abnormality such as Down Syndrome
d) Chromosomal abnormality such as Down Syndrome
A nurse is reading a newspaper report about a 60% decrease in domestic violence over the past few years. What kind of factor does this statistic represent? a) Predisposing factor b) Protective factor c) Precipitating factor d) Influencing factor (defines trends)
d) Influencing factor
A newborn diagnosed with truncus arteriosus is prescribed prostaglandin E1(PGE1). The newborn's parents ask how this medication will help their newborn. The nurse bases the response on which rationale? a) Decreases preload b) Increases plasma aldosterone c) Improves myocardial contractility d) Maintains patency
d) Maintains patency
The parents of a teenager are talking with the nurse in the urgent care clinic about the injuries their son sustained in a physical fight during his high school lunch hour. What can the nurse tell them about fighting in adolescence? a) Its prevalence is not known b) It is an unexpected event in that age group c) It is due to the effect of hunger on teenagers d) One third of high school students get into physical fights
d) One third of high school students get into physical fights
Which nonpharmacologic treatment is appropriate in an abuse situation involving an older adult? a) Provide counseling to the person committing the abuse b) Protect the client's privacy by not documenting the abuse c) Provide counseling for the victim d) Report the situation to the proper agency, and provide support for the victim
d) Report the situation to the proper agency and provide support for the victim
The nurse is providing education to the parents of an infant diagnosed with aortic stenosis. About which procedure that will be performed via cardiac catheterization in an attempt to open the stenotic valve should the nurse educate the parents? a) Patent ductus arteriosus closure b) Transcatheter closure c) Atrial septostomy d) Valvuloplasty
d) Valvuloplasty
A nurse is checking the patency of the IV in a client who has suffered a major chest trauma. Since the vital signs are showing evidence of shock, the nurse expects the physician to order medication to treat that condition immediately. For which kind of medication should the nurse expect a stat order? a) An opioid like morphine b) An antibiotic like amoxicillin c) A mineral replacement like potassium d) A vasopressor like epinephrine
d) a vasopressor like epinephrine
A nurse is providing care for a client with heart failure. The client has weakened ventricular contractions and deceased cardiac output. The nurse anticipates an order for which medication to improve contractility? a) Digitalis glycosides b) Nitrates c) Loop diuretics d) Alpha-blockers
a) Digitalis glycosides
The nurse is caring for a client newly diagnosed with heart failure. Which medication order does the nurse anticipate receiving from the healthcare provider? a) Diuretic b) Proton pump inhibitor c) Selective serotonin reuptake inhibitor d) Benzodiazepine
a) Diuretic
The nurse is teaching a family about diabetic ketoacidosis (DKA). Which statement by the family indicates understanding of the symptoms that occur with DKA? a) Two separate glucose readings of greater than 400 mg/dL b) A single glucose reading of 400 mg/dL c) Three separate glucose readings greater than 200 mg/dL d) Four separate glucose readings greater than 200 mg/dL
a) Two separate glucose readings of greater than 400 mg/dL
A client is experiencing chest pain. What aggravating factors for this client should the nurse assess? (Select all that apply.) a) Does the chest pain change with activity? b) Does the chest pain change with breathing? c) How many minutes does the chest pain last? d) What have you done that relieves the chest pain? e) Is the chest pain continuous or episodic?
a) Does the chest pain change with activity? b) Does the chest pain change with breathing?
Which therapy is involved in the treatment of a client with diabetes? (Select all that apply.) a) Exercise b) Fluid restriction c) Medication d) Nutrition e) Daily weight checking
a) Exercise c) Medication d) Nutrition
The nurse is educating a group of children and their parents about risk factors for developing type 2 diabetes mellitus (DM). A parent asks the nurse to identify the most common age range for diagnosis. Which answer by the nurse is the most accurate? a) 10 to 19 years b) 3 to 9 years c) Birth to 2 years d) 16 to 18 years
a) 10 to 19 years
An older woman who has been physically and financially abused by her son tells the nurse, "I am not pressing charges against my son because I am afraid that he will put me out on the street and I will have no place to go." Which response should the nurse include in her interventions for this client? a) Assess the client's safety and help her develop a safety plan b) Instruct the client not to worry about her son because she is in the hospital, so he will not do it again c) Support the client's wishes to not press charges due to fear d) Encourage the client to move out of her son's home to avoid future encounters with him
a) Assess the client's safety and help her develop a safety plan
The nurse observes unlicensed assistive personnel measuring a client's blood pressure and is concerned that the reading is erroneously high. Which factors could have resulted in an erroneously high reading? (Select all that apply.) a) Blood pressure cuff was wrapped too loosely b) Blood pressure was assessed while the client was eating breakfast c) Blood pressure cuff was too wide d) Client's arm was unsupported e) Client's arm was above the level of the heart
a) Blood pressure cuff was wrapped too loosely b) Blood pressure was assessed while the client was eating breakfast d) Client's arm was unsupported
After reviewing data collected during a cardiovascular assessment, the nurse determines that an older client is demonstrating normal signs of aging. Which did the nurse assess to come to this conclusion? (Select all that apply.) a) Blood pressure dropping from a sitting to a standing position b) Heart murmur heard in early diastole c) Weak popliteal pulses bilaterally d) Dependent edema of both feet when sitting for several hours e) Elevated systolic blood pressure
a) Blood pressure dropping from a sitting to a standing position c) Weak popliteal pulses bilaterally d) Dependent edema of both feet when sitting for several hours e) Elevated systolic blood pressure
A client is newly admitted with chest tubes. Which type of intervention is the priority when providing nursing care to this client? a) Outputs b) Pressure supports c) Fluid supports d) Inputs
a) Outputs
The nurse is caring for a school-age client who has undergone cardiac catheterization for repair of an atrial septal defect. Which intervention should the nurse implement? a) Restrict oral fluids b) Observe for signs of decreased perfusion c) Maintain quiet, low exertion activity for 12 hours d) Keep on bed rest for 2 hours (bed rest for 4 to 6 hours, supine position)
b) Observe for signs of decreased perfusion
A nurse is working in an emergency department and is being trained on diagnostic tests used for various cases of abuse. Which diagnostic tests should be included for physical, not sexual, abuse? a) Vaginal swabs b) STD testing c) X-rays d) HIV testing
c) X-Rays
A newborn diagnosed with hypoplastic left heart syndrome is scheduled for a heart transplantation. The nurse informs the mother that the transplanted heart usually lasts for how long before another transplant is needed? a) 16 to 20 years b) 0 to 4 years c) 5 to 9 years d) 10 to 15 years
d) 10 to 15 years
