My HESI FUNDS

A couple demonstrates understanding of the consequences of not treating Chlamydia when they state what? a: "She could become pregnant." b: "She could cause our 1-month-old baby to get an eye infection." c: "He could get an infection in the tube that carries out the urine." d: "It could cause us to develop a rash."

c: "He could get an infection in the tube that carries out the urine." Chlamydia is a major cause of nongonococcal utethritis (NGU) in men.

The nurse is allowing the feeding for a female who has undergone a cholecystectomy to flow slowly at the prescribed rate. The nurse understands this will help prevent? a: bleeding b: urinary incontinence c: cramps d: constipation

c: cramps If the feedings are administered too fast, the client may experience cramps, gas or vomiting.

The nurse is to administer an intramuscular (IM) injection to a six-month-old. What is the most appropriate site to utilize? a: dorsal gluteal b: iliac crest c: vastus lateralis d: ventral gluteal

c: vastus lateralis Infants and small children do not have enough muscle in the gluteal area to use that site. The iliac crest is a site used for subcutaneous injection instead of an intramuscular injection.

Which of the following is a typical physical characteristic of a toddler? Select all that apply a: Head circumference increases about 1 inch between ages 1 and 2. b: Normal height changes include a growth of about 3 inches per year. c: "Pot belly" is noted. c: Weight gain is faster than in infancy.

a: Head circumference increases about 1 inch between ages 1 and 2. b: Normal height changes include a growth of about 3 inches per year. c: "Pot belly" is noted. These are all typical of the physical growth pattern of a toddler. Other physical signs include: closing of the anterior fontanel between 12 and 18 months of age; height and weight increases in phases; and average weight of 22 - 27 pounds by age 2.

Documentation for a female patient indicates an android pelvis. Upon examination of the pelvic area of this patient you would expect to find which of the following? Select all that apply a: angulated pelvis b: transversely rounded or blunt pelvis c: narrow pelvic planes d: normal female pelvis

a: angulated pelvis b: narrow pelvic planes It is heart-shaped or angulated and resembles a male pelvis. This type of pelvis is not favorable for labor and birth. Narrow pelvic planes can cause slow descent and mid-pelvic arrest.

In a client who has burns on the legs, which nursing intervention helps prevent contractures? a: applying knee splints. b: elevating the foot of the bed. c: hyperextending the client's palms. d: performing shoulder range of motion exercises.

a: applying knee splints. Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed cannot prevent contractures because this action does not hold the joints in a position of function.

Which task can the nurse delegate to a nursing assistant? a: irrigating a nasogastric (NG) tube b: assisting a client who had surgery three days ago walk down the hallway c: helping a client who just returned from surgery to the bathroom d: administering an antacid to a client complaining of heartburn

a: assisting a client who had surgery three days ago walk down the hallway. Because the client had surgery three days ago, the nurse can safely delegate the task of helping the client walk down the hallway

You have been assigned to be leader of a task that involves several other nurses and nursing assistants. You feel that connective leadership is the approach to use for this task. This means that you want to achieve results by which of the following? (select all that apply) a: collaboration b: strong control c: cooperation d: a hands-off approach

a: collaboration and c: cooperation Connective leadership draws on the leader's ability to bring others together as a means of effecting change. Leaders achieve results through collaboration, cooperation, coordination, and collegiality.

A person with antisocial personality disorder would exhibit which of the following characteristics? Select all that apply a: disregard for the rights of others b: compulsive overeating c: charming and intellectual appearance d: suspicious of others

a: disregard for the rights of others c: charming and intellectual appearance Others include: lying, cheating, stealing, and promiscuous behaviors; unlawful, aggressive, and reckless behaviors; lack of guilt, remorse, and conscience; and immature and irresponsible. (a sociopath)

The nurse is preparing a teaching plan for a client with a rib fracture. The nurse knows that a rib fracture will cause the most pain a: during inspiration b: while lifting objects c: while sitting d: while lying in bed

a: during inspiration A rib fracture can generate pain when a person breathes in as well as if the client coughs. As a result, the client may have contractions of the abdominal wall known as respiratory splinting. The respiratory splinting can cause shallow breathing and may lead to respiratory complications, such as pneumonia.

You would see which of the following lab results for a person who has Graves' disease? Select all that apply a: elevated basal metabolic rate b: elevated T3 c: decreased T4 d: high titer anti-thyroid antibodies

a: elevated basal metabolic rate b: elevated T3 d: high titer anti-thyroid antibodies.

A young man has come to the office for a physical examination. The nurse documents his pulse as +3. Which of the following best describes this pulse? a: full and brisk b: palpable, but diminished c: normal d: full and bounding

a: full and brisk a normal or average pulse would be a +2, a full and bounding pulse would be a +4. 0 would indicate no pulse.

A nurse is caring for a teenage girl who has been in a motorcycle accident. The girl has deep abrasions on the right side of her body including on her face. In caring for this teenager, the nurse should know that the girl's primary concern will be: a: her body image b:getting well as quickly as possible c: how she will keep up with schoolwork d: how long she will be in the hospital

a: her body image The patient will want to know if she will have permanent scars, she will be worried about how she looks to her friends when they come to visit, etc. Body image is of great importance to teens and adolescents.

You are speaking to a patient about her upcoming surgery. You nod your head to most of what the patient is saying. This is called acceptance. Acceptance involves which of the following? Select all that apply a: indication that you heard what the other person said b: agreement with what the other person said c: non-judgmental action d: narrow perception

a: indication that you heard what the other person said c: non-judgmental action Accepting is an indication that you have heard what the other person has said. It does not indicate agreement. It is non-judgmental with a broad rather than narrow perception.

Which of the following interventions for anxiety disorders would be likely to enhance the patient's self-esteem? Select all that apply a: making positive statements about the patient b: exploring the patient's previous achievements c: demonstrating relaxation technique with the patient d: avoiding masking the truth

a: making positive statements about the patient b: exploring the patient's previous achievements Making positive statements about the patient and exploring the patient's previous achievements can enhance the patient's self-esteem. Other activities to accomplish this include: monitoring the frequency of self-negating verbalizations; and exploring reasons for self-criticism or guilt.

A client is undergoing an extensive diagnostic workup for suspected muscular dystrophy. The nurse knows that muscular dystrophy has many forms, but that one assessment finding is common to all forms. Which finding belongs in this category? a: muscle weakness. b: cardiac muscle involvement. c: pseydohypertrophy of the calf muscles. d: muscle pain.

a: muscle weakness Muscle weakness is common to all forms of muscular dystrophy. Cardiac muscle involvement and pseudohypertrophy of the calf muscles do not occur in all forms of muscular dystrophy. Muscle pain is rare with any form.

A nurse is assessing the neurological status of a patient. In the course of the assessment the nurse asks the patient to repeat three unrelated words that are spoken to him and after five minutes asks him to repeat these same words. The nurse is testing what type of memory? Select all that apply a: new memory b: remote memory c: long-term memory d: recent memory

a: new memory Asking a patient to repeat three unrelated words 5 minutes apart is testing new memory. Remote or long-term memory is related to something from the past that a nurse would have to check for correctness. Recent memory tests information within days, weeks or months ago.

The RN is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse use to dilute this medication? a: normal saline (0.9%) solution. b: dextrose 5% and half-normal saline (0.45%) solution. c: dextrose 5% solution. d: lactated ringer's solution.

a: normal saline (0.9%) solution Phenytoin (Dilantin) should be administered by injection into a large vein by intermittent intravenous infusion. Normal saline (0.9%) solution is the preferred solution. Dextrose should be avoided because of medication precipitation.

When a client undergoes a tubal ligation, the nurse should teach the client about what possible complication? a: perforation of the bowel b: granulomas c: reconnecting of the tubes d: estrogen imbalance

a: perforation of the bowel In females, sterilization is achieved through tubal ligation where the tubes are cut, ligated or plugged. Complications from this procedure may include perforation of the bowel, the development of an infection and bleeding.

In terms of the etiology of schizophrenia, which of the following statements is accurate? Select all that apply a: schizophrenia typically manifests early in adulthood. b: schizophrenia becomes chronic or recurrent in at least 80% of those who develop it. c: on average, everyone has about a 10% chance of developing schizophrenia. d: it is believed that schizophrenia occurs when multiple inherited gene abnormalities combine with nongenetic factors.

a: schizophrenia typically manifests early in adulthood. b: schizophrenia becomes chronic or recurrent in at least 80% of those who develop it. d: it is believed that schizophrenia occurs when multiple inherited gene abnormalities combine with nongenetic factors. These are accurate statements. Schizophrenia actually may be a group of disorders with common but varying features and multiple, overlapping etiologies. What is known is that brain chemistry, structure, and activity are different in a person with schizophrenia than in a person who does not have the disorder. On average, everyone has about a 0.7% chance of developing schizophrenia.

A client with Myasthenia Gravis is undergoing Plasmapheresis. Which of the following should the nurse not tell the client before the procedure? a: the procedure will last between 2 to 5 hours b: you may experience dizziness c: you may have a bruise on the skin d: expect leg cramps

a: the procedure will last between 2 to 5 hours. Plasmapheres is a procedure where antibodies that attack the cells of the body are removed out of the blood. For client's with Myasthenia Gravis, the client has the antiacetylcholine receptor antibody that causes muscle weakness and tiredness. Before the Plasmapheresis procedure is performed, the nurse should educate the client about the procedure, including information on the type of equipment used and how long the procedure will last (between 1 to 3 hours). Also, the nurse will inform the client that a central venous catheter will be inserted for the procedure. Further, dizziness, bruises and leg cramps are symptoms and conditions the nurse is responsible for monitoring during and after the Plasmapheresis procedure.

The nurse interviews a 28-year-old client with a new medical diagnosis of endometriosis. Which os the following questions is MOST appropriate? a: "Are you having hot flashes?" b: "Are you experiencing pain during intercourse?" c: "Is a discharge present?" d: "Where are you having pain?"

b: "Are you experiencing pain during intercourse?" Primary symptoms of endometriosis include dysmenorrhea (painful mensuration), dyspareunia (painful intercourse), and infertility. Hot flashes, a discharge, and rashes are not symptoms of endometriosis.

A 23-year-old female has kidney stones. She is scheduled for an intravenous pyelogram. Which of the following client statements should stand out as a concern to the nurse? a: "I feel nauseated when I am injected with the dye used for the procedure." b: "When I eat crab meat, I get short of breath." c: "I am afraid of needles." d: "I am allergic to Tetanus shots."

b: "when i eat crab meat, I get short of breath." The client's statement should alert the nurse of a potential allergy to iodine (crab has iodine). And, the nurse should report the client's reaction to crab meat to the physician immediately before the client undergoes the procedure. If the client proceeds and has the intravenous pyelogram performed, then the client may have an allergic reaction to the contrast material. The intravenous pyelogram's contrast material contains iodine. This contrast is injected into the client's veins where it is transported through the bloodstream to the kidneys, ureter and bladder. This dye highlights these areas on the x-ray so the physician can see where the kidney stones are located in the client's body.

The nurse is caring for a client traumatized by the sudden death of a brother who was murdered. The nurse understands the client's loss is what? a: perceived b: actual c: anticipatory d: expected

b: actual Actual loss means the loss is validated by other individuals such as with an occurrence of the death of a loved one.

All of the following statements about heart rate are accurate EXCEPT select all that apply a: the faster the heart rate, the less time the heart has for filling, and cardiac output decreases. b: an increase in heart rate decreases oxygen consumption. c: the normal sinus hear rate is 60 - 100 beats/minute. d: sinus bradycardia is a rate more than 100 beats/minute.

b: an increase in heart rate decreases oxygen consumption and d: sinus bradycardia is a rate more than 100 beats/minute. An increase in heart rate increases oxygen consumption. Sinus bradycardia is a rate less than 60 beats/minute. Sinus tachycardia is a rate more than 100 beats/minute.

Nurse Kelly is teaching the parents of a young child how to handle poisoning. If the child ingests poison, what should the parents do first? a: call an ambulance immediately. b: call the poison control center c: punish the child for being bad d: administer ipecac syrup.

b: call the poison control center. Before interviewing in any way, the parents should call the poison control center for specific directions.

For a patient with a B12 deficiency, you might suggest foods rich in this vitamin. This would include all of the following foods EXCEPT: check all answers that apply a: Brewer's yeast b: carrots c: liver d: nuts e: green peppers

b: carrots and e: green peppers. These foods are not rich in vitamin B12. The other choices are foods rich in this vitamin. Other foods to recommend include: citrus fruits, dried beans, and organ meats.

There are time when complementary and alternative medicine (CAM) may help a patient. One of the CAM therapies is mind-body therapy. Which of the following would be considered mind-body CAM methods? Select all that apply a: homeopathy b: cognitive-behavioral therapy c: meditation d: clinical hypnosis

b: cognitive-behavioral therapy c: meditation d: clinical hypnosis. Homeopathy is an alternative medical system. Other mind-body methods include: support groups, biofeedback, and visual imagery (among others).

You have a patient who is suspected of having esophageal cancer. You understand that which of the following is most likely to be used to confirm that diagnosis? Select all that apply a: CT scan b: endoscopy c: tracheostomy d: biopsy

b: endoscopy d: biopsy Endoscopy and biopsy confirm the diagnosis of esophageal cancer. CT scans help identify invasive disease and metastases.

A 9-year-old has moderate persistence of asthma. The nurse knows this means what? a: the client has brief exacerbation with symptoms less than twice a week b: the client has daily coughing and wheezing c: the client has coughing and wheezing once a day, three times a week d: the client has coughing and wheezing once a day, once a week

b: the client has daily coughing and wheezing The severity of asthma is classified in steps ranging from step 1 to step 4. A child with daily coughing and wheezing is a step 4, or moderate persistence of asthma.

You are caring for a patient who has just been diagnosed with type 1 diabetes. This patient needs to be educated as to how to be able to cope with this diagnosis. What is the first thing that you should do for this patient? a: show the patient how to inject himself with insulin. b: evaluate what this patient already knows about diabetes and the administration of insulin. c: establish a plan for management of the diabetes with the patient. d: observe the patient as he administers an insulin injection himself.

b: evaluate what this patient already knows about diabetes and the administration of insulin. The first thing that you should do is find out what this patient already knows. Only then can you set a goal and plan for management. Teaching the patient how to administer insulin and observing the patient doing this are important, but not until you have assessed the patient's level of knowledge.

A female client is scheduled for an abdominal ultrasound. The nurse instructs the client to not urinate until the ultrasound is finished. The nurse understands this will help a: decrease discomfort b: improve visualization c: reduce pain d: reduce scaring

b: improve visualization By keeping the bladder full during the procedure, this helps the visualization of the organs because a full bladder helps raise the internal organs located in the pelvic area into the abdominal area so the organs are seen clearer.

All of the following are side effects of streptomycin EXCEPT: a: nausea and vomiting b: increased appetite c: decreased thirst d: muscle numbness

b: increased appetite c: decreased thirst Decreased appetite and increased thirst are side effects

Which of the following IV fluids is as equally concentrated as the body's natural intracellular fluid? a: hypertonic b: isotonic c: none of these d: hypotonic

b: isotonic The concentration of a hypertonic solution is greater than the body's natural intracellular fluid. The concentration of a hypotonic solution is less than the body's natural intracellular fluid.

Which of the following would NOT be an appropriate intervention for a client with a cognitive disorder such as Alzheimer's disease? Select all that apply a: reinforcing retained skills b: keeping the environment as bare as possible c: reminding the client how to perform self-care activities d: avoiding activities that tax the memory

b: keeping the environment as bare as possible. Instead of keeping the environment as bare as possible you would want to furnish it with familiar possessions. Other appropriate interventions include (among many): helping the client to maintain independence; providing the client with consistent routines; and providing the client with exercise.

The nurse is caring for a client under great stress. The client describes feeling nervous and having difficulty focusing on her work. Pulse and respiratory rate are slightly elevated. The nurse recognizes this client is experiencing what level of anxiety? a: mild anxiety b: moderate anxiety c: panic d: severe anxiety

b: moderate anxiety Moderate anxiety produces tension, nervousness, or concern, and focuses perception, making it difficult to concentrate. Vital signs might be slightly elevated. Mild anxiety heightens mental alertness and improves concentration. Severe anxiety takes all of the client's energy, and vital signs are likely to be more acutely elevated. Panic is overpowering, with increased motor activity, agitation, and unpredictability.

Nurse Jones conducts a carotid pulse check of her patient. On what part of the body is this done? a: top of foot b: neck c: ankle d: inner elbow

b: neck You palpate the carotid pulse on the lateral side of the neck.

The nurse is caring for a 2-year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects? a: ototoxicity b: nephrotoxicity c: hepatomegaly d: neurotoxicity.

b: nephrotoxicity Nephrotoxicity is defining as rapid deterioration in the kidney function due to toxic effect of medications and chemicals. Nephrotoxicity is a common side effect of calcium disodium edetate, in addition to lead poisoning in general.

Which of the following situations is an example of behavioral therapy? Select all that apply a: organized group activities b: operant conditioning c: group meetings d: desensitization

b: operant conditioning and d: desensitization These are both forms of behavioral therapy. Operant condition is the use of rewards to reinforce positive behavior. Desensitization is used to treat phobias.

You have been asked to educate a group of young women about breast cancer and breast self-examination. In the course of your talk which of the following statements would you make? Select all that apply a: if you are premenopausal, lumps in the breast are normal because of hormonal changes. b: part of self-examination is to stand before a mirror to inspect both breasts. c: it is not necessary to palpate armpit area. d: discharge from the nipple is a reason for concern.

b: part of self-examination is to stand before a mirror to inspect both breasts. d: discharge from the nipple is a reason for concern. A woman should inspect both breasts before a mirror as well as palpate the breasts with three or four fingers and include in this the area of the armpit and between the breast and armpit. Discharge from the nipple and lumps are a reason for concern.

A client has undergone an ileostomy. Which of the following postoperative care approaches is the nurse's top priority? a: check the client's dressing for surgical stitching. b: place the client in the physician ordered position. c: check the type of tube placed. d: assess the type of indwelling urinary catheter.

b: place the client in the physician ordered position. In order to provide client safety after a surgical procedure, the nurse should place the client in the position ordered by the physician. Also, during postoperative care, the nurse will check the stoma for drainage. Instead of checking the type of tube placed for feeding, the nurse should assess the patency of the tube and assess for any drainage of the tube. Further, the nurse should assess the indwelling urinary catheter for drainage, patency and amount of output.

You want to make sure that your patient will not suffer from pressure ulcers because he is not able to position himself effectively. You would do which of the following as part of an early intervention? Select all that apply a: discourage protein in the patient's diet. b: take steps to reduce shearing and friction. c: clean skin as soon as it becomes wet. d: use the sheet to lift or reposition the patient in bed.

b: take steps to reduce shearing and friction. c: clean skin as soon as it becomes wet. d: use the sheet to lift or reposition the patient in bed. The patient should receive adequate protein, calories, vitamins, and minerals in his diet.

A daughter of an elderly client who has schizophrenia calls the office and talks to the nurse about how her mother was acting the past couple of days. Which of the following statements would indicate the client is showing early signs have relapse for schizophrenia? a: "My mother told me that she can't stop thinking about washing her hands." b: "My mother said yesterday, 'I feel great today. I could clean the house.' Then, this morning she didn't want to get out of bed." c: "My mom is very mean. She is normally nice and has kind words. Yesterday, she told me 'I don't need you here everyday taking care of me. Why don't you go to your house for a change? I need privacy sometimes you know." d: "My mother said to me last night, 'Who are you? Do I know you?' That scared me because she couldn't remember who I was. This morning she knew me and didn't remember saying what she said last night."

c: "My mom is very mean. She is normally nice and has kind words. Yesterday, she told me 'I don't need you here everyday taking care of me. Why don't you go to your house for a change? I need privacy sometimes you know." By the client wanting to isolate herself (i.e. why don't you go to your house), having mood swings and acting differently than normal (i.e. the mother is mean when she is normally nice and refusing the daughter's care), these are early indictors for a relapse of schizophrenia. Clients with schizophrenia have delusions, hallucinations or confusion. By treating these clients when early signs are present, a relapse of schizophrenia can be managed or prevented.

The nurse should begin screening for lead poisoning when a child reaches which age? a: 6 months b: 12 months c: 18 months d: 24 months

c: 18 months The nurse should start screening a child for lead poisoning at age 18 months and perform repeat screening at ages 24, 30 and 36 months. High-risk infants, such as premature infants and formula-fed infants not receiving iron supplementation, should be screened for iron deficiency anemia at age 6 months. Regular dental visits should begin at age 24 months.

You are caring for an infant born to a diabetic mother. The infant is receiving IV medication to manage blood glucose levels. Which of the following blood glucose levels would cause you concern? Select all that apply a: 45 mg/dL b: 50 mg/dL c: 35 mg/dL d: 75 mg/dL

c: 35 mg/dL and d: 75 mg/dL. An infant of a diabetic mother who is receiving IV therapy to maintain acceptable glucose levels should maintain a blood glucose level between 45 mg/dL and 65 mg/dL. A blood glucose level of 35 mg/dL is an indication of newborn hypoglycemia. A blood glucose level of 75mg/dL is an indication of newborn hyperglycemia.

Which of the following is NOT a component of a normal EKG? a: P wave < 0.11 second. b: QRS complex: Normal = 0.06-0.10 second. c: D wave. d: P-R Interval: Normal = 0.12-0.20.

c: D wave An EKG (electrocardiogram) measures the electrical activity of the heart. Choices A, B and D are stated correctly. There is no such measurement as "D wave". The proper phrase is T wave.

A client had unprotected sex 8 hours ago. The client asks the nurse what she can use to prevent pregnancy. What should the nurse tell the client? a: don't worry about it as long as your partner used the withdrawal method during sex you won't get pregnant. b: there is nothing available to prevent pregnancy after you have had unprotected sex. c: a copper IUD is an option. Let me tell you about it. d: you can use a spermicide within 12 hours of having unprotected sexual intercourse and this will prevent pregnancy.

c: a copper IUD is an option. Let me tell you about it. A copper intrauterine device (IUD) is an alternate emergency method to prevent pregnancy if it is inserted within the uterus 5 days after engaging in unprotected sexual activity. The copper IUD causes the uterus and the fallopian tubes to make a substance that gets rid of the sperm before it is able to fertilize the egg. Also, if the sperm has a chance to fertilize the egg, the substance released due to the copper IUD will keep the egg from moving into the uterus, thus preventing the conception process.

A nurse has several patients in her care. Which of the following patients will be limited in their right to autonomy? a: a patient with end stage renal failure who wants to refuse any further medication b: a patient with breast cancer who refuses a mastectomy c: a patient with an intestinal parasitic infection who refuses treatment d: a patient who has been in a car accident who refuses blood transfusions based upon religious reasons

c: a patient with an intestinal parasitic infection who refuses treatment. When a patient has a communicable disease that can affect others his or her right to autonomy can be limited by the health care providers. This is the case with the parasitic infection that could be transmitted to others.

The client with lead poisoning is being treated with Dimercaprol. Which of the following found in the client's history should the nurse be alerted for? a: an allergy to egg b: an allergy to milk and milk products c: an allergy to peanuts d: an allergy to pollen

c: an allergy to peanuts. Dimercaprol is contraindicated with an allergy to peanut since the medication is prepared in a peanut oil solution.

Neurological impairment takes on many forms. The loss of ability to use language is which of the following? Select all that apply a: ataxia b: diplopia c: aphasia d: dyskinesia

c: aphasia The loss of ability to use language is aphasia. Auditory or receptive aphasia is the loss of ability to understand. Expressive aphasia is the loss of ability to use spoken or written word.

Which of the following factors might increase the incidence of and susceptibility of depression? Select all that apply a: being married b: being male c: being under 40 d: having a substance abuse problem

c: being under 40 and d: having a substance abuse problem. Being single or divorced, having a substance abuse problem, being postpartum, or having inadequate social support are all contributing factors. Depression is twice as common in women as in men, and is more common in those under 40.

You are taking the pulse of a hospitalized patient. You find that the pulse is 55 beats per minute. This is considered which of the following? Select all that apply a: tachycardia b: thready pulse c: bradycardia d: bounding pulse

c: bradycardia Bradycardia is a slow heart rate - below 60 beats per minute. A thready pulse is a weak pulse.

Of the following disorders which one is NOT a disorder of nerve impulse transmission? Select all that apply a: myasthenia gravis b: multiple sclerosis c: cerebral palsy d: Parkinson's disease

c: cerebral palsy Cerebral palsy is a neuromuscular disorder. All of the other choices are disorders of nerve impulse transmission.

The nurse administers heparin to a female client. Which of the following is heparin used to treat? a: gastrointestinal irritation b: leukocytosis c: deep vein thrombus d: loss of bladder control

c: deep vein thrombosis Heparin is prescribed by the physician to a client for the prevention of deep vein thrombosis and pulmonary embolism. This medication is usually prescribed after a client has undergone a hip replacement or knee replacement.

You are instructing an elderly client on home safety during her discharge process. The client is at high risk for falls due to her neurological status. Which of the following will NOT be an appropriate measure to prevent falls? a: teach her to keep all of her personal items within reach. b: encourage her to keep adequate lighting in her bathroom area. c: discuss keeping her bed up high to allow for ease of rising. d: explain to her to avoid clutter in her pathways at home.

c: discuss keeping her bed up high to allow for ease of rising. The bed position should be low to prevent falls and side rails should be up. Other advice would include maintaining a toileting schedule, staying oriented to surroundings and having a family member provide wellness checks on the client frequently

Which of the following defense mechanisms is when an individual deals with an emotional issue through a short-term change in identity? a: rationalization b: reaction formation c: dissociation d: regression

c: dissociation

After a gastrectomy, the nurse should evaluate the client carefully for which of the following complications? a: septicemia. b: gangrene of the bowel. c: dumping syndrome. d: postprandial hyperglycemia.

c: dumping syndrome The most common complication after a gastrectomy is dumping syndrome, which affects 50 percent of the clients. Dumping syndrome is fluid from a bolus of gastric chyme and hypertonic fluid entering the intestine

The nurse understands that good hand hygiene involves washing the hands ___. a: gently without using friction. b: and using non antibacterial soap. c: for at least 15 seconds. a: and ensuring the hands are higher than the elbow.

c: for at least 15 seconds. Hand washing technique includes using antibacterial soap and washing the hands for at least 15 seconds. Further, the nurse should use friction while washing hands as the friction is what helps to remove any microorganisms that can cause infections. Additionally, the nurse should keep the hands lower than the elbow during hand washings to prevent soap and water from moving onto the upper part of the arms and elbow.

A client is seen in the emergency department with a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps. With each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term? a: ataxic b: dystrophic c: helicopod d: steppage

c: helicopod A helicopod gait is an abnormal gait in which the client's feet make a half circle with each step. An ataxic gait is staggering and unsteady. In a dystophic gait, the client waddles with the legs far apart. In a steppage gait, the feet and toes rise high off the floor and the heel comes down heavily with each step.

Your patient is scheduled for amniocentesis to determine if the fetus has a genetic disorder. In monitoring the patient after the amniocentesis, you know that which of the following is least likely to be a complication of the procedure? a: spontaneous abortion b: fetal injury c: hypotension d: infection

c: hypotension The three most common complications of amniocentesis are: spontaneous abortion (1%), fetal injury, and infection. Hypotension is not a likely complication.

Which of the following created rights for the mentally ill patient? a: joint Commission on Accreditation of Healthcare Organizations b: american Nurses Association c: mental Health Systems Act d: american Hospital Association

c: mental Health Systems Act

The CAM tool is used to assess the development of delirium. It consists of nine factors. Which of the following are not factors of this tool? Select all that apply a: onset b: attention c: naming items d: following instructions

c: naming items d: following instructions These are not factors of the Confusion Assessment Method (CAM); they are tests of the MMSE to assess cognition. The nine factors include: onset, attention, thinking, orientation, level of consciousness, memory, perceptional disturbances, psychomotor abnormalities, and sleep-wake cycle.

A client who recently lost her mother tells the nurse, "I won't be stopping by my mother's house after work anymore. Maybe I can make plans with my sister in the evenings." Which of the following stages of grieving identified by Engle is the client exhibiting? a: anticipated loss b: adjustable loss c: resolving the loss d: grievance

c: resolving the loss The resolving loss stage happens when an individual is dealing with the emptiness that is left when someone or something passes away. The individual will also continue to think about past memories, talk about the loved one and may start to engage in relationships that help to provide support during this time of loss.

You have a patient whose blood pressure is consistently high. The doctor has decided that the best way to control the hypertension is through medication. You know that it is important to teach this patient all about the medications that he is taking because a: the patient should know all of the risk factors for hypertension. b: the patient should know what normal blood pressure should be. c: the more patients know about their antihypertensive medications, the more likely they are to take them. d: the patient needs to take his blood pressure daily.

c: the more patients know about their antihypertensive medications, the more likely they are to take them. This is important because the number one cause of stroke in hypertensive clients is noncompliance with medication regimen. The other choices are good to know but are not related to why teaching about the medications is important.

A nurse who is preparing a patient for eye surgery takes his intraocular pressure. She finds that the pressure in the right eye is 12 mm Hg and the pressure in the left eye is 17 mm Hg. The nurse would tell the patient that a: the pressure in the right eye is low, but the pressure in the left eye is normal. b: the pressure in both eyes is high. c: the pressure in both eyes is normal d: the pressure in the right eye is normal, but the pressure in the left eye is high.

c: the pressure in both eyes is normal. In this patient's case the pressure is normal in both eyes. Normal intraocular pressure ranges from 8 mm Hg to 21 mm Hg.

Which of the following statements shows a client's understanding of living with a newly implanted pacemaker? a: "I will set off metal detectors when I pass through them so I guess I can't serve on jury duty." b: "I only need to call the doctor if I experience shortness of breath." c: "I guess I need to get rid of my microwave." d: "I should wear a Medic Alert bracelet and carry an identification card."

d: "I should wear a Medic Alert bracelet and carry an identification card." The Medic Alert bracelet and ID card inform the caregivers of the presence of the pacemaker in an emergency.

The nurse is caring for a client with anorexia nervosa. Which of the following is the first priority? a: address perceptions of distorted body image b: address vitamin deficiencies c: address the client's self-concept d: address fluid volume deficit

d: address fluid volume deficit. The first priority when caring for a client with anorexia nervosa is the client's physical needs. These clients will limit how much they eat or drink and this reduction in fluids, especially, leads to dehydration. Also, the client has a loss of essential vitamins in the body. Correcting the fluid imbalance is critical as dehydration can cause kidney damage.

In what ways does Schizophrenia differ culturally? a: the prevalence of schizophrenia is higher in some countries than in others b: the form of expression of schizophrenia varies across cultures c: the stressors that trigger the onset of schizophrenia may be culturally specific, such as fearing that one is the victim of witchcraft d: all of the above statements are true

d: all of the above statements are true. Culture influences affect the way individuals communicate and manifest symptoms of mental illness. The style of coping, their support system and their willingness to seek treatment also affect the way the individual communicates and manifests symptoms of mental illness.

What medication may be used safely in a pregnant woman with cardiovascular disease? a: antibiotics. b: Coumadin. c: a generic anticoagulant. d: cardiac glycosides.

d: cardiac glycosides No diuretics should be used as they may cause uterine contractions

Which group of clients is at an increased risk for developing a wound infection? a: clients who require frequent pain medication b: clients who are 15 lbs overweight c: clients who ambulate after the first postoperative day d: clients who are undernourished

d: clients who are undernourished. Nutrition plays an important role in wound healing. Vitamins and protein are essential for wound healing; therefore, a malnourished client is at an increased risk for developing a wound infection

A nurse has an African-American patient whom he needs to check for cyanosis? Which of the following sites would be the best to check for this? a: tops of the feet b: back of the hand c: ear lobe d: conjunctiva of the eye

d: conjunctiva of the eye When a nurse is checking a dark-skinned patient for cyanosis it is best to check areas where the epidermis is thin and the pigmentation is lighter. The conjunctiva of the eye is one of these areas. Other areas include mucous membranes and nail beds.

A client is in the recovery unit after having an ileostomy. The nurse finds the client has bulging surrounding the stoma. The nurse understands this is an abnormal finding as this may indicate: a: a deviated vermiform b: a fecalith c: generalized inflammation d: herniation

d: herniation Herniation happens when the tissue of an organ pushes through the opening of an organ.During an ileostomy procedure, a stoma is created to help with drainage. Bulging around it is a sign of herniation. The tissue that pushes through the abdominal wall creates the herniation.

Nurse Gloria is teaching the Mr. and Mrs. Diaz about the early signs and symptoms of lead poisoning; which of the following if stated by the couple would indicate the need for further understanding of the case? a: anorexia b: irritability c: anemia d: seizures.

d: seizures Seizures usually are associated with encephalopathy, a late sign of lead poisoning. Typically, lead levels have already exceeded 70 mg/dl. Anorexia, irritability, and anemia are early signs of lead poisoning.

You have a patient who came into the emergency room in great emotional distress saying that she cannot stand to feel the way she does anymore. She says she doesn't sleep well, can't eat, feels hopeless and does not want to go on like this anymore. You know that this patient is in crisis and you also know that after determining that she is not at risk for injury the primary goal in her care is a: to see that she is provided with the proper medication b: to get her into a self-help group c: to encourage her to exercise more d: to get the patient back to a pre-crisis level of functioning

d: to get the patient back to a pre-crisis level of functioning