Immersion Remediation

A client is diagnosed with myasthenia gravis. Which response does the nurse expect the client to demonstrate? 1 Partial improvement of muscle strength with mild exercise 2 Fluctuating weakness of muscles innervated by the cranial nerves 3 Little or no change of muscle strength regardless of therapy initiated 4 Dramatic worsening of muscle strength with anticholinesterase drugs

2. Fluctuating weakness of muscles innervated by cranial nerves Muscle use reduces strength, and rest increases strength; eyelid movement, chewing, swallowing, speech, facial expression, and breathing often are affected [1] [2]. Muscle strength increases with rest and decreases with activity. Anticholinesterase drugs improve muscle strength. Anticholinesterase drugs increase, not decrease, muscle strength.

When a nurse is admitting an older client to the mental health unit, it is important to identify any signs of dementia. What signs and symptoms denote the presence of dementia of the Alzheimer type? Select all that apply. 1 Ambivalence 2 Forgetfulness 3 Flight of ideas 4 Loose associations 5 Expressive aphasia

2. Forgetfulness 5. Expressive aphasia

Respiratory distress syndrome (RDS) develops 6 hours after birth in a neonate born at 33 weeks' gestation. What would the nurse's assessment of the newborn at this time reveal? 1. High-pitched cry 2. Intercostal retractions 3. Heart rate of 140 beats/min 4. Respirations of 30 breaths/min

2. Intercostal retractions

The nurse is using non-verbal active listening skills during a clinical therapeutic encounter with a client. Which non-verbal action best conveys engagement in this client interaction? 1 Sitting with a relaxed posture 2 Leaning toward the client 3 Making eye contact 4 Facing the client

2. Leaning in toward the client Leaning toward the client during a therapeutic communication encounter is the best way to convey engagement in a client interaction.

The nurse is educating a client who is being discharged after insertion of a coronary artery stent. For what signs and symptoms should the nurse instruct the client to seek immediate medical attention? Select all that apply. 1. Dyspnea on exertion 2. Unexplainable profuse diaphoresis 3. Indigestion not relieved by antacids 4. Fatigue the day after a rigorous walk 5. Acute chest pain after rigorous exercise 6. Nonremitting chest pain after three sublingual nitroglycerine tablets

2,3, 5 &6

The nurse is advising a client with acquired immunodeficiency syndrome (AIDS) to avoid the consumption of undercooked meat. Which infection can be prevented in the client by following this measure? 1 Tuberculosis 2 Cryptococcosis 3 Cryptosporidiosis 4 Toxoplasmosis encephalitis

4. Toxoplasmosis Toxoplasmosis encephalitis is caused by Toxoplasma gondii, which may occur due to the ingestion of infected undercooked meat or by contact with contaminated cat feces

Which response should a nurse expect a client diagnosed with cerebellum dysfunction to exhibit? 1 Dysphagia 2 Hemiplegia 3 Visual disturbances 4 Uncoordinated movements

4. Uncoordinated movements CEREBELLUM = BALANCE

Based on the assessment of a full-term infant, the nurse suspects a cardiac anomaly. Which clinical manifestation does the nurse identify that indicates a cardiac anomaly? 1. Projectile vomiting 2. Irregular respiratory rhythm 3. Hyperreflexia of the extremities 4. Unequal peripheral blood pressures

4. Unequal peripheral blood pressures A discrepancy in blood pressures from the arms to the legs indicates arterial stenosis caused by coarctation of the aorta. Projectile vomiting commonly results from pyloric stenosis; it is not of cardiac origin and does not occur immediately after birth. An irregular respiratory rhythm is common and expected in the healthy newborn. Hyperreflexia of the extremities may be indicative of a neurologic, not cardiac, problem.

A lithotripsy to break up renal calculi is unsuccessful, and a nephrolithotomy is performed. Which postoperative clinical indicator should the nurse report to the primary healthcare provider? 1. Passage of pink-tinged urine 2. Pink drainage on the dressing 3. Intake of 1750 mL in 24 hours 4. Urine output of 20 to 30 mL/hr

4. Urine output of 20 to 30 mL/hr Output should be at least 30 mL/hr or more; a decreased output may indicate obstruction or impaired kidney function. Blood, tinting the urine pink, is expected. Drainage on the dressing may be pink; bright red drainage should be reported. The intake of 1750 mL in 24 hours is adequate; however, a higher intake usually is preferred (e.g., 2000 to 3000 mL).

Four clients are admitted to a hospital with different symptoms associated with depression. Which client would benefit from mirtazapine? client 1: fatigue client 2: insomnia client 3: chronic pain client 4: sexual dysfunction

Client 2 Mirtazapine causes substantial sedation. Therefore, client 2 would benefit from mirtazapine. Client 1 requires a central nervous system stimulant such as fluoxetine. Client 3 will benefit from duloxetine, which is a drug relieves chronic pain. Client 4 would benefit from bupropion, which enhances a person's libido.

The nurse suspects that a client is in the chronic persistent stage of Lyme disease. Which symptoms support the nurse's suspicion? Select all that apply. 1. Arthritis 2 Dyspnea 3 Dizziness 4 Chronic fatigue 5 Erythema migrans

arthritis & chronic fatigue Lyme disease is a systemic infectious disease caused by the spirochete Borrelia burgdorferi. The symptoms of the chronic persistent stage are arthritis and chronic fatigue. Dyspnea and dizziness are the symptoms of the early disseminated stage. Erythema migrans is observed in the localized stage.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

what are the fat soluble vitamins?

vitamin A, D, E & K

A nurse is obtaining a health history from the parents of a toddler who has recently been diagnosed with acute lymphocytic leukemia. Which early physiologic changes does the nurse expect the parents to report? Select all that apply. 1 Pale skin 2 Loss of hair 3 Eating less food 4 Sores in the mouth 5 Purplish spots on the skin

1, 3 & 5 Pallor is a presenting sign of leukemia and reflects anemia because of decreased erythrocytes. Lack of appetite (anorexia) resulting in the consumption of less food is a presenting symptom of leukemia; it may be the result of enlarged lymph nodes and areas of inflammation in the intestinal tract. Decreased platelet production with petechiae and bleeding is a presenting sign of leukemia. Alopecia results from chemotherapy, not the leukemia. Sores in the mouth are not a presenting sign but often result from chemotherapy.

The blood lab work for a client with purpuric lesions on the skin shows a thrombocyte count of 100,000 cells per microliter. Which nursing intervention would be priority in this client to reduce the risk of bleeding? 1. Advising the client to drink plenty of fluids 2. Advising the client to perform bending exercises 3. Advising the client to use superabsorbent tampons 4. Advising the client to use alcohol-based mouthwashes

1. Advise the client to drink plenty of fluids A client with purpuric lesions and a thrombocyte count of 100,000 cells per microliter has thrombocytopenia. Drinking plenty of fluids helps to prevent constipation and straining while having a bowel movement, thereby preventing bleeding. Performing bending exercises may lead to bleeding from the nose, and it is contraindicated. Usage of superabsorbent tampons may increase the chance of toxic shock syndrome (TSS) and result in severe infection or death. Usage of alcohol-based mouthwashes can dry the gums and increase bleeding.

A client is receiving hydrochlorothiazide. What should the nurse monitor to best determine the effectiveness of the client's hydrochlorothiazide therapy? 1 Blood pressure 2 Decreasing edema 3 Serum sodium level 4 Urine specific gravity

1. Blood pressure Diuretics promote urinary excretion, which reduces the volume of fluid in the intravascular compartment, thus lowering blood pressure.

Which clients should be considered for assessing the carotid pulse? Select all that apply. 1 Client with cardiac arrest 2 Client indicated for Allen test 3 Client under physiologic shock 4 Client with impaired circulation to foot 5 Client with impaired circulation to hand

1. Client in cardiac arrest 3. Client under physiologic shock

A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client? 1. Encouraging a fluid intake of 3 L daily 2. Suctioning via the tracheostomy every hour 3. Applying an occlusive dressing over the surgical site 4. Using cotton balls to cleanse the stoma with peroxide

1. Encouraging a fluid intake of 3 L daily

When a client is expressing severe anxiety by sobbing in the fetal position on the bed, what is the nurse's priority? 1. Ensuring a safe therapeutic milieu 2. Monitoring and documenting vital signs 3. Eliminating the cause of the client's anxiety 4. Ensuring that the client's physical needs are met

1. Ensuring a safe therapeutic milieu PATIENT SAFETY IS #1

What potentially dangerous adverse effect of an intravenous titrated drip of lidocaine should the nurse immediately report to the healthcare provider? 1. Tremors 2. Anorexia 3. Hypertension 4. Tachycardia

1. Tremors Tremors are a precursor to the major adverse effect of seizures. Although anorexia may occur, it is not a dangerous side effect. Bradycardia, which may lead to heart block, may occur, not tachycardia. Hypotension, not hypertension, may occur.

The nurse is performing bedside sonography for a female client who underwent a hysterectomy. Which nursing intervention needs correction? 1 Using the female icon on the bladder scanner 2 Placing an ultrasound gel pad right above the pubic bone 3 Pointing the scan head so the ultrasound is projected towards the client's coccyx 4 Placing the midline of the probe over the abdomen about 1.5 inches (3.8 cm) above the pubic bone

1. Using the female icon on the bladder scanner Before performing a bedside sonography, the male or female icon on the scanner should be selected. The male icon should be selected for men and for women who have undergone a hysterectomy. An ultrasound gel pad should be placed right above the pubic bone. The scan head should be pointed in such a way that the ultrasound is projected towards the client's coccyx. The midline of the probe should be placed over the abdomen about 1.5 inches (3.8 cm) above the pubic bone.

A health care provider prescribes cholestyramine, an anion exchange resin, to treat a client's persistent diarrhea. What vitamin does the nurse anticipate may become deficient because cholestyramine reduces the absorption of fat? 1. vit A 2. vit B12 3. Vit B2 4. Vit B6

1. Vit A Cholestyramine is a fat-binding agent; it binds with and interferes with all the fat-soluble vitamins (A, D, E, and K). Thiamine is not a fat-soluble vitamin and is unaffected. Riboflavin is not a fat-soluble vitamin and is unaffected. Vitamin B6 is not a fat-soluble vitamin and is unaffected.

A client enters the emergency department reporting shortness of breath and epigastric distress. What should be the triage nurse's first intervention? 1 Assess vital signs. 2 Insert a saline lock. 3 Place client on oxygen. 4 Draw blood for troponins.

1. assess vital signs

An older adult who was in a motor vehicle collision is brought to the emergency department via ambulance. The client exhibits a decreased level of consciousness, and the nurse identifies serosanguineous drainage from the client's left ear. Which action should the nurse take? 1 Irrigate the ear with normal saline. 2 Place a sterile pad over the external ear. 3 Gently insert a cotton-tipped swab in the ear canal. 4 Pack a cotton ball in the external meatus of the ear.

2. Place a sterile pad over the external ear A lowered level of consciousness indicates a potential head injury, and drainage from an ear may be cerebrospinal fluid; a sterile pad gently affixed over the ear will absorb drainage and prevent infection and can help detect the halo sign. Irrigating the ear with normal saline is contraindicated if a cerebrospinal fluid leak is suspected. Packing a cotton ball in the external meatus of the ear or inserting a cotton-tipped swab may be traumatic and may injure the ear further; also, it will obstruct free flow of drainage.

A client experiencing chills and fever is admitted to the hospital. After assessing the client's vitals and medical history, the nurse concluded that the client's fever pattern is remittent. Which assessment finding led to this conclusion? 1. The client's temperature returns to an acceptable value at least once in the past 24 hours 2. The client's fever spikes and falls without a return to normal temperature levels 3. Periods of febrile episodes and periods with acceptable temperature values occur 4. The client has a constant body temperature continuously above 38°C with minimal fluctuation

2. The client's fever spikes and falls without a return to normal temperature levels In a remittent pattern of fever, the fever spikes and falls without a return to normal temperature levels. If the temperature returns to an acceptable value at least once in a 24 hour interval, the fever has an intermittent pattern.

A client has cholelithiasis with possible obstruction of the common bile duct. The nurse performs a nutritional assessment. What is the primary goal for this assessment? 1 To determine if follows a high fatty diet 2 To determine if deficient in vitamins A, D, and K 3 To determine if eats adequate amounts of dietary fiber 4 To determine if consumes excessive amounts of protein

2. To determine if deficient in vitamins A, D, & K (AKA FAT SOLUBLE VITAMINS) Bile promotes the absorption of the fat-soluble vitamins. An obstruction of the common bile duct limits the flow of bile to the duodenum and thus the absorption of these fat-soluble vitamins

A client reports facial lesions that are surrounded by redness and cause itching. On assessment, the lesions are found to be thick with a honey-colored crust and surrounded by erythema. Which infection is suspected by the primary healthcare provider? 1 Shingles 2 Impetigo 3 Folliculitis 4 Verruca vulgaris

2. impetigo Impetigo is a primary bacterial infection most common on the face. This is clinically manifested as vesiculopustular lesions that develop as thick, honey-colored crust surrounded by erythema. Shingles or herpes zoster is a viral infection that usually occurs unilaterally on the trunk, face, and lumbosacral areas.

The nurse is caring for a client who has an occlusion of the left femoral artery and is scheduled for an arteriogram. Which clinical finding is most significant when assessing the left extremity before the arteriogram? 1 Mottling of the leg 2 Coolness of the foot 3 Absence of the pedal pulse 4 Thickening of the toenails on the foot

3. Absence of the pedal pulse Absence of the left pedal pulse indicates inadequate circulatory status of the left lower extremity. Mottling of the left leg may indicate impaired circulation, but observation of both extremities for comparison is necessary. Coolness of the left foot is a less significant indication of arterial occlusive disease than the absence of a pulse. Thickening of the toenails on the left foot is not as significant as the pulse; this can occur because of inadequate circulation, aging, or fungal infection.

A client is admitted with dysphasia, dry mouth, drooping eyelids, blurred vision, vomiting, and diarrhea, and within 24 hours develops bilateral cranial nerve impairment and descending weakness. Which bioterrorism agent results in these clinical manifestations? 1. Plague 2. Anthrax 3. Botulism 4. Smallpox

3. Botulism These symptoms are found with botulism. With anthrax and smallpox, a rash will be noted. Symptoms of lymphatic plague include fever and chills, painful lymphadenopathy, gastrointestinal symptoms, and progressive weakness.

To what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis? 1 Narrowed airways 2 Impaired immunity 3 Ineffective coughing 4 Viscosity of secretions

3. Ineffective coughing MG has to do with the muscles Weakened muscles result in ineffective coughing; secretions are retained and provide a medium for bacterial growth. The airways are not narrowed. Immune mechanisms are not impaired directly. Viscosity of secretions depends on fluid intake and humidity.

A healthcare provider notices dermatitis on overlying surfaces of the skin of a client. Which abnormal condition does the nurse anticipate? 1 Comedo 2 Hirsutism 3 Intertrigo 4 Ecchymosis

3. Intertrigo Dermatitis/infection of overlying surfaces of the skin is the clinical finding of intertrigo. -A comedo is an enlarged hair follicle plugged with sebum, bacteria, and skin cells. -Hirsutism is a condition characterized by development of male pattern distribution of hair in females. -Ecchymosis is the development of a large, bruise-like lesion caused by the collection of extravascular blood in the dermis and subcutaneous tissue.

What would the nurse state is true about the sleep pattern of preschoolers? 1 They sleep at least 15 hours during the day. 2 It is uncommon for them to wake up during night. 3 It is difficult for them to relax after they have had long and active days. 4 About 50% of their sleep is under random eye movement (REM) sleep.

3. It is difficult for them to relax after they have had long and active days.

The magnetic resonance image (MRI) of a client who sustained brain trauma reveals injury to the occipital lobe. Which disability might be anticipated in the client? 1 Loss of perception 2 Loss of learning ability 3 Loss of visual capability 4 Loss of auditory sensation

3. Loss of visual capacity OCCIPITAL = EYES

When a client who has had a mastectomy returns from surgery, a dressing and a portable wound drainage system to the axillary area are in place. The nurse notes an excessive amount of serosanguineous drainage on the mastectomy dressing. What is the nurse's next action? 1. Notify the surgeon 2. apply a pressure dressing 3. check the functioning of the draining system 4. use pillows to prop the arm up

3. check the functioning of the draining system If the tubing is patent and negative pressure is present, the wound should be free of exudate. Drainage is expected; it is the nurse's responsibility to maintain the drainage system. Pressure dressings are not used with portable wound drainage systems because the systems are effective in removing interstitial fluid. Although elevating the arm may facilitate drainage, it is not the priority in relation to the data presented

After receiving streptomycin sulfate for 2 weeks as part of the medical regimen for tuberculosis, the client reports feeling dizzy and having some hearing loss. The nurse withholds the drug and promptly reports the problem to the healthcare provider. Which part of the body does the nurse determine is being affected as indicated by the symptom reported by the client? 1. Pyramidal tracts 2. Cerebellar tissue 3. Peripheral motor end-plates 4. Eighth cranial nerve's vestibular branch

4. Eighth cranial nerve's vestibular branch

A nurse is caring for four postpartum clients, each with a different medical condition. Which condition will result in the primary healthcare provider advising the new mother not to breast-feed? 1 Mastitis 2 Inverted nipples 3 Herpes genitalis 4 Human immunodeficiency virus (HIV)

4. HIV Breast-feeding by a mother infected with HIV is contraindicated, because breast milk can transmit the virus to the infant. Breast-feeding by a mother with mastitis is not always contraindicated; during antibiotic treatment the mother can maintain lactation by pumping the breasts and discarding the milk. Once the infection has resolved, breast-feeding may be resumed. Breast-feeding is not contraindicated with inverted nipples, because a breast shield can provide mild suction to help evert the nipples. Breast-feeding is not contraindicated in a client with genital herpes. The newborn may contract the infection during a vaginal birth, not from breast milk.

A combination of drugs, including vincristine and prednisone, is prescribed for a child with leukemia. For which adverse effect of vincristine will the nurse assess the child? 1. Hemolytic anemia 2. irreversible alopecia 3. hyperglycemia 4. Neurologic complications

4. Neurologic complications