NCLEX saunders q&a pt. 5

The nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. Which statement most accurately describes Kawasaki disease? 1. It is an acquired cell-mediated immunodeficiency disorder. 2.It is a chronic multisystem autoimmune disease characterized by the inflammation of connective tissue. 3.It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause. 4.It is an inflammatory autoimmune disease that affects the connective tissue of the heart, joints, and subcutaneous tissues.

3. It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause. Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown etiology. Option 1 describes human immunodeficiency virus (HIV) infection. Option 2 describes systemic lupus erythematosus. Option 4 describes rheumatic fever.

A cooling blanket is prescribed for a child with a fever. The nurse prepares to use the cooling blanket and should avoid which action? 1. Keeping the child uncovered to assist in reducing the fever 2. Placing the cooling blanket on the bed and covering it with a sheet 3. Keeping the child dry while on the cooling blanket to prevent the risk of frostbite 4. Checking the skin condition of the child before, during, and after the use of the cooling blanket

1. Keeping the child uncovered to assist in reducing the fever While on a cooling blanket, the child should be covered lightly to maintain privacy and reduce shivering. Options 2, 3, and 4 are important interventions to prevent shivering, frostbite, and skin breakdown.

A health care provider instructs a client with rheumatoid arthritis to take ibuprofen (Motrin IB). The nurse reinforces the instructions, knowing that the normal adult dose for this client is which? 1. 100 mg orally twice a day 2. 200 mg orally twice a day 3. 400 mg orally 3 times a day 4. 1000 mg orally 4 times a day

3. 400 mg orally 3 times a day For acute or chronic rheumatoid arthritis or osteoarthritis, the normal oral adult dose is 400 to 800 mg 3 or 4 times daily.

A child is scheduled for a tonsillectomy. Which should present the highest risk of aspiration during surgery? 1. Difficulty swallowing 2.Bleeding during surgery 3. Exudate in the throat area 4. The presence of loose teeth

4. The presence of loose teeth In the preoperative period, the child should be observed for the presence of loose teeth to decrease the risk of aspiration during surgery. Options 1 and 3 are incorrect. Bleeding during surgery will be controlled via packing and suction as needed.

What is Meniere's disease?

An inner ear disorder that causes episodes of vertigo (spinning). Ménière's disease usually starts in one ear, but later may involve both. Smoking, infections, or a high-salt diet may worsen the disease. Symptoms include a spinning sensation (vertigo), hearing loss, ear ringing (tinnitus), and ear pressure. The vertigo may cause severe nausea and imbalance. Hearing loss may become permanent. Drugs for motion sickness or nausea may help manage symptoms.

A client has a cerebellar lesion. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item? 1. Walker 2.Slider board 3.Raised toilet seat 4.Adaptive eating utensils

1. Walker The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. Adaptive eating utensils may be beneficial when the client has partial paralysis of the hand. A raised toilet seat is useful when the client does not have the mobility or ability to flex the hips. A slider board is used in transferring a client from a bed to stretcher or wheelchair.

A client scheduled for a skin biopsy asks the nurse how painful the procedure is. The nurse should make which response to the client? 1. "There is no pain associated with this procedure." 2. "The local anesthetic may cause a burning or stinging sensation." 3. "A preoperative medication will be given so you will be sleeping and will not feel any pain." 4. "There is some pain, but the health care provider will prescribe an analgesic following the procedure."

2. "The local anesthetic may cause a burning or stinging sensation." Depending on the size and location of the lesion, a biopsy is usually a quick and almost painless procedure. The most common source of pain is the initial local anesthetic, which can produce a burning or stinging sensation. Options 1, 3, and 4 are incorrect.

A client is complaining of low back pain, with radiation down the left posterior thigh. The nurse continues to collect data from the client to see if the pain is worsened or aggravated with which action? 1. Applying heat 2. Bending or lifting 3. Maintaining bed rest 4. Taking Ibuprofen (Motrin IB)

2. Bending or lifting Low back pain with radiation into one leg (sciatica) is consistent with herniated lumbar disk. The nurse continues to collect data from the client to see if the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, coughing, or lifting the leg straight up while supine (straight leg raising test). Options 1, 3, and 4 assist in alleviating pain.

A mother of a child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child has discomfort on the right side and that the acetaminophen (Tylenol) is not very effective. Which is the best suggestion by the nurse? 1. Increase the dose of the acetaminophen. 2. Encourage the child to lie on the left side. 3. Encourage the child to lie on the right side. 4. Increase the frequency of the acetaminophen.

3. Encourage the child to lie on the right side. Splinting of the affected side by lying on that side may decrease discomfort. It is inappropriate to advise the mother to increase the dose or frequency of the acetaminophen. Lying on the left side will not be helpful in alleviating discomfort.

A client has Buck's extension traction applied to the right leg. The nurse should plan which intervention to prevent complications of the device? 1. Giving pin care once a shift 2. Massaging the skin of the right leg with lotion every 8 hours 3. Inspecting the skin on the right leg at least once every 8 hours 4. Releasing the weights on the right leg for range-of-motion exercises daily

3. Inspecting the skin on the right leg at least once every 8 hours Buck's extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or inflammation. Massaging the skin with lotion is not indicated. The nurse never releases the weights of traction unless specifically prescribed by the health care provider. Skin traction does not involve pin care.

The nurse is preparing to administer eardrops to an infant. How should the nurse administer the eardrops? 1. Pull up and back on the ear, and direct the solution onto the eardrum. 2. Pull down and back on the ear, and direct the solution onto the eardrum. 3.Pull down and back on the ear, and direct the solution toward the wall of the canal. 4.Pull up and back on the ear lobe, and direct the solution toward the wall of the canal.

3. Pull down and back on the ear, and direct the solution toward the wall of the canal. When administering eardrops to an infant, the nurse pulls the ear down and straight back. In the adult or a child older than 3 years, the ear is pulled up and back to straighten the auditory canal. The medication is administered by aiming it at the wall of the canal rather than directly onto the eardrum.

The emergency department nurse is caring for a child brought to the emergency department following the ingestion of approximately one half bottle of acetylsalicylic acid (aspirin). Which should the nurse anticipate as the likely initial treatment? 1. Dialysis 2. The administration of vitamin K 3. The administration of activated charcoal 4. The administration of sodium bicarbonate

3. The administration of activated charcoal Initial treatment of salicylate overdose includes administration of activated charcoal to decrease absorption of the aspirin. Intravenous (IV) fluids and inducing emesis may be prescribed to enhance excretion but would not be the initial treatment. Dialysis is used in extreme cases if the child is unresponsive to therapy. Vitamin K is the antidote for warfarin (Coumadin) overdose.

What is glaucoma?

A group of eye conditions that can cause blindness. With all types of glaucoma, the nerve connecting the eye to the brain is damaged, usually due to high eye pressure. The most common type of glaucoma (open-angle glaucoma) often has no symptoms other than slow vision loss. Angle-closure glaucoma, although rare, is a medical emergency and its symptoms include eye pain with nausea and sudden visual disturbance. Treatment includes eye drops, medications, and surgery.

what is atrophy?

Muscle atrophy is when muscles waste away. It's usually caused by a lack of physical activity

What is milieu therapy?

is a therapeutic method in which a safe, structured group setting is used to help people learn healthier ways of thinking, interacting, and behaving in a larger society. Sometimes, MT takes place in an in-patient setting, but it can also be effective in informal outpatient settings like support groups

A client seeking treatment for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client makes which statement? 1. "I can resume a full activity level immediately." 2."I need to stay in a cool environment when possible." 3."I should increase my fluid intake for the next 24 hours." 4."I need to monitor my voiding for adequacy of urine output."

"I can resume a full activity level immediately." Discharge instructions for the client hospitalized for hyperthermia include prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting.

The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. How should the nurse plan to position the client? 1. Trochanter roll to prevent abduction while turning 2. Pillow to keep the right leg abducted during turning 3. Pillow to keep the right leg adducted during turning 4. Trochanter roll to prevent external rotation while turning

2. Pillow to keep the right leg abducted during turning Following internal fixation of a hip fracture, the client is turned to the affected side or the unaffected side, as prescribed by the surgeon. Before moving the client, the nurse places a pillow between the client's legs to keep the affected leg in abduction. The client is then repositioned while proper alignment and abduction are maintained. A trochanter roll is useful in preventing external rotation, but it is used once the client has been repositioned. It is not used while repositioning the client.

The nurse notes documentation that a postcraniotomy client is having difficulty with body image. The nurse determines that the client is still working on the postoperative outcome criteria when the client indicates which altered personal appearance? 1. Wears a turban to cover the incision 2.Indicates that facial puffiness will be a permanent problem 3.Verbalizes that periorbital bruising will disappear over time 4.States an intention to purchase a hairpiece until the hair has grown back

2.Indicates that facial puffiness will be a permanent problem After craniotomy, the client may experience difficulty with altered personal appearance. The nurse can help by listening to the client's concerns and by clarifying any misconceptions about facial edema, periorbital bruising, and hair loss, which are temporary. The nurse can encourage the client to participate in self-grooming and use personal articles of clothing. Finally, the nurse can suggest the use of a turban, followed by a hairpiece, to help the client adapt to the temporary change in appearance.

Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication? 1. "I will apply the ointment once a day and leave it open to the air." 2."I will apply the ointment twice a day and leave it open to the air." 3."I will apply the ointment once a day and cover it with a sterile dressing." 4."I will apply the ointment at bedtime and in the morning and cover it with a sterile dressing."

3."I will apply the ointment once a day and cover it with a sterile dressing." Collagenase is used to promote debridement of dermal lesions and severe burns. It is usually applied once daily and covered with a sterile dressing

Following a tonsillectomy, which of the health care provider's prescriptions should the nurse question? 1. Monitor vital signs. 2.Monitor for bleeding. 3.Allow ice cream when awake. 4.Offer clear, cool liquids when awake.

3.Allow ice cream when awake. Clear, cool liquids are encouraged. Milk and milk products are avoided initially because they coat the throat, which causes the child to clear the throat, increasing the risk of bleeding. Options 1 and 2 are important nursing interventions following any type of surgery.

A film-coated form of diflunisal has been prescribed for a client for the treatment of chronic rheumatoid arthritis. The client calls the clinic nurse because of difficulty swallowing the tablets. Which initial instruction should the nurse reinforce to the client? 1. "Crush the tablets and mix them with food." 2. "Open the tablet and mix the contents with food." 3 "Notify the health care provider for a medication change." 4. "Swallow the tablets with large amounts of water or milk."

4. "Swallow the tablets with large amounts of water or milk." Diflunisal may be given with water, milk, or meals. The tablets should not be crushed or broken open. Taking the medication with a large amount of water or milk should be tried before contacting the health care provider.

A client admitted to the hospital gives the nurse a bottle of clomipramine (Anafranil). The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication? 1. Complaints of hunger 2. Complaints of insomnia 3. A pulse rate less than 60 beats per minute 4. Frequent hand washing with hot, soapy water

4. Frequent hand washing with hot, soapy water Clomipramine is commonly used in the treatment of obsessive-compulsive disorder. Hand washing is a common obsessive-compulsive behavior. Weight gain is a common side effect of this medication. Tachycardia and sedation are also side effects. Insomnia may occur but is seldom a side effect.

Surgery has been recommended for the client with otosclerosis. The client tells the nurse that she would prefer not to have surgery and asks the nurse about alternative methods to improve hearing. The nurse should make which appropriate response to the client? 1. "A hearing aid may improve your hearing." 2. "There are no other methods to improve hearing." 3. "You need to have surgery because it has been recommended." 4. "Your health care provider is the best. You need to do what the health care provider suggests."

1. "A hearing aid may improve your hearing." Clients with otosclerosis who do not desire surgery may have their hearing loss relieved by the use of a hearing aid. Options 2, 3, and 4 are inappropriate responses.

The nurse is reviewing the health care provider's prescriptions for an adult client who has been admitted to the hospital following a back injury. Carisoprodol (Soma) is prescribed for the client to relieve the muscle spasms; the health care provider has prescribed 350 mg to be administered 4 times a day. The nurse reviews the medication and determines what about the dosage? 1. This is the normal adult dosage. 2. This is a lower than normal dosage. 3. This is a higher than normal dosage. 4. This dosage requires further clarification.

1. This is the normal adult dosage. The normal adult dosage for carisoprodol is 350 mg orally 3 or 4 times daily.

A client with Parkinson's disease has been prescribed benztropine (Cogentin). The nurse monitors for which gastrointestinal (GI) side effect of this medication? 1. Diarrhea 2.Dry mouth 3.Increased appetite 4.Hyperactive bowel sounds

2. Dry mouth Common GI side effects of benztropine therapy include constipation and dry mouth. Other GI side effects include nausea and ileus. These effects are the result of the anticholinergic properties of the medication

The nurse is providing discharge instructions for a client who has had a fenestration procedure for the treatment of otosclerosis. Which statement by the client indicates an understanding of the instructions? 1. "It is all right to take a shower and wash my hair." 2."I can resume my tennis lessons starting next week." 3. "I will take stool softeners as prescribed by my doctor." 4 ."I should drink liquids through a straw for the next 2 to 3 weeks."

3. "I will take stool softeners as prescribed by my doctor." Following ear surgery, clients need to avoid straining when having a bowel movement. Clients need to be instructed to avoid drinking with a straw for 2 to 3 weeks, avoid air travel, and avoid coughing excessively. Clients need to avoid getting their head wet, washing their hair, and showering for 1 week. Clients need to avoid rapidly moving the head, bouncing, and bending over for 3 weeks.

The nurse is assigned to care for an infant with a diagnosis of tricuspid atresia. The nurse plans care, knowing which is true regarding this diagnosis? 1. A single vessel overrides both ventricles. 2.Frequent episodes of hypercyanotic spells occur. A single vessel overrides both ventricles. 2.Frequent episodes of hypercyanotic spells occur. 3.There is no communication from the right atrium to the right ventricle. 4.There is no communication from the systemic and pulmonary circulations.

3.There is no communication from the right atrium to the right ventricle. In tricuspid atresia, there is no communication from the right atrium to the right ventricle. Option 1 describes truncus arteriosus. Option 4 describes transposition of the great arteries. Frequent episodes of hypercyanotic spells occur in tetralogy of Fallot.

A nursing instructor asks a nursing student about the use of bacillus Calmette-Guerin vaccine (BCG). Which response made by the nursing student is correct? 1. "BCG is administered to children with a positive Mantoux test." 2. "BCG is administered to all children to prevent tuberculosis (TB)." 3. "BCG is administered to children with both a positive Mantoux test and positive chest x-ray." 4. "BCG is administered to asymptomatic human immunodeficiency virus (HIV)-infected children who are at increased risk for developing TB."

4. "BCG is administered to asymptomatic human immunodeficiency virus (HIV)-infected children who are at increased risk for developing TB." The BCG vaccine is used mainly for children with a negative chest x-ray and skin test results who have had repeated exposures to TB and for asymptomatic HIV-infected children who are at increased risk for developing TB.

what is fasciculation?

A fasciculation, or muscle twitch, is a spontaneous, involuntary muscle contraction and relaxation, involving fine muscle fibers.

A client who has experienced a stroke (brain attack) has partial hemiplegia of the left leg. The straight-leg cane formerly used by the client is no longer sufficient. Which device would suit the client better if greater support and stability is needed? 1. Quad cane 2. Wheelchair 3. Wooden crutch 4. Lofstrand crutch

quad cane A quad cane may be used by the client requiring greater support and stability than is provided by a straight-leg cane. The quad cane provides a four-point base of support and is indicated for use by clients with partial or complete hemiplegia. Neither crutches nor a wheelchair is indicated for a client such as described in the question.

Coal tar has been prescribed for a client with a diagnosis of psoriasis, and the nurse reinforces instructions to the client about the medication. Which statement by the client indicates a need for further teaching? 1. "The medication can cause phototoxicity." 2. "The medication has an unpleasant odor." 3. "The medication can stain the skin and hair." 4. "The medication can cause systemic effects

4. "The medication can cause systemic effects Coal tar is used to treat psoriasis and other chronic disorders of the skin. It suppresses DNA synthesis, mitotic activity, and cell proliferation. It has an unpleasant odor, can frequently stain the skin and hair, and can cause phototoxicity. Systemic toxicity does not occur.

The nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What should the nurse tell the client about the purpose of the test? 1. Checks for glaucoma 2.Checks for color blindness 3.Examines pupil constriction 4.Examines visual fields or peripheral vision

4.Examines visual fields or peripheral vision The confrontational method of eye testing is used to examine visual fields or peripheral vision. Tonometry is used to check for glaucoma. An Ishihara chart is used to check color vision. A flashlight is used to test pupillary response to light.

Following diagnostic evaluation, it has been determined that the client has Lyme disease, stage 2. The nurse understands that which is most indicative of this stage? 1. Arthralgias 2.Joint enlargement 3.Erythematous rash 4.Neurological deficits

Neurological deficits Stage 2 of Lyme disease develops within 1 to 6 months in most untreated individuals. The most serious problems include cardiac conduction defects and neurological disorders, such as Bell's palsy and paralysis. These problems are not usually permanent. Arthralgias and joint enlargements are noted in stage 3. A rash appears in stage 1.

A child with croup is placed in a cool-mist tent. The mother asks if the child may have her security blanket inside the tent. Which is the most appropriate response by the nurse? 1. "The child may have the security blanket inside the tent." 2. "Objects from home are not allowed to be brought to the hospital." 3. "The blanket is not allowed because it will promote the growth of bacteria." 4. "The blanket is not allowed, but the child may have a toy from the hospital playroom."

1. "The child may have the security blanket inside the tent." Familiar objects provide a sense of security for children in the strange hospital environment. The child is allowed to have a favorite toy or blanket while in the mist tent. Options 2, 3, and 4 are inappropriate statements.

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. The nurse understands that assessment of which cranial nerve should identify a complication specifically associated with this surgery? 1. Cranial nerve I, olfactory 2. Cranial nerve IV, trochlear 3. Cranial nerve III, oculomotor 4. Cranial nerve VII, facial nerve

4. Cranial nerve VII, facial nerve The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. The nurse understands that assessment of which cranial nerve should identify a complication specifically associated with this surgery?

The nurse is collecting data from a client about medications being taken, and the client tells the nurse that he is taking herbal supplements for the treatment of varicose veins. The nurse understands that the client is most likely taking which? 1.Bilberry 2.Ginseng 3.Feverfew 4.Evening primrose

1.Bilberry Bilberry is an herbal supplement that has been used to treat varicose veins. This supplement has also been used to treat cataracts, retinopathy, diabetes mellitus, and peripheral vascular disease. Ginseng has been used to improve memory performance and decrease blood glucose levels in type 2 diabetes mellitus. Feverfew is used to prevent migraine headaches and to treat rheumatoid arthritis. Evening primrose is used to treat eczema and skin irritation.

A mother arrives at the clinic with her child. The mother tells the nurse that the child has had a fever and a cough for the past 2 days, and this morning the child began to wheeze. Viral pneumonia is diagnosed. Which component of the treatment plan should the nurse anticipate? 1. Oral antibiotics 2. Supportive treatment 3. Hospitalization and antibiotics 4. Intravenous (IV) fluid administration

2. Supportive treatment With viral pneumonia, treatment is supportive. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and IV fluids. Antibiotics are not given. Bacterial pneumonia, however, is treated with antibiotic therapy.

Ribavirin (Virazole) is prescribed for the hospitalized child with respiratory syncytial virus (RSV). The nurse prepares to administer this medication via which route? 1. Orally 2. Via face mask 3. Intravenously 4. Intramuscularly

2. Via face mask Ribavirin is an antiviral respiratory medication that may be used in hospitalized children with severe RSV and in high-risk children. Administration is via hood, face mask, or oxygen tent. The medication is most effective if administered within the first 3 days of the infection.

A mother of a child who underwent a myringotomy with insertion of tympanostomy tubes calls the nurse and reports that the child is complaining of discomfort. Which should the nurse instruct the mother to do? 1. Give the child children's aspirin for the discomfort. 2. Be sure that the child is resuming normal activities. 3. Give the child acetaminophen (Tylenol) for the discomfort as per discharge instructions. 4.Speak to the health care provider because the child should not be having any discomfort.

Give the child acetaminophen (Tylenol) for the discomfort as per discharge instructions. Following myringotomy with insertion of tympanostomy tubes, the child may experience some discomfort. Acetaminophen or ibuprofen can be given to relieve the discomfort. Aspirin should not be administered to the child. The child should rest if discomfort is present.

The nurse is collecting physical data of the musculoskeletal system on an assigned client. The nurse should document the presence of which as a normal finding? 1. Presence of fasciculations 2. Atrophy on the client's dominant side 3. Atrophy on the client's nondominant side 4. Hypertrophy on the client's dominant side

Hypertrophy on the client's dominant side Hypertrophy, or increased muscle size on the client's dominant side of up to 1 cm, is considered normal. Atrophy on either side is considered an abnormal finding. Fasciculations are fine muscle twitches that are not normally present. Focus on the subject, assessment of the musculoskeletal system Options 2 and 3 are eliminated first because atrophy is not a normal finding. Knowing that fasciculations are not normal helps you select option 4 over option 1.

An adult client with muscle spasms is taking an oral maintenance dose of baclofen (Lioresal). The nurse reviews the medication record, expecting that which dose would be prescribed? 1. 15 mg 4 times a day 2. 25 mg 4 times a day 3. 30 mg 4 times a day 4. 40 mg 4times a day

1. 15 mg 4 times a day Baclofen is dispensed in 10- and 20-mg tablets for oral use. Dosages are low initially and then gradually increased. Maintenance doses range from 15 to 20 mg administered 3 or 4 times a day.

A 10-year-old child with asthma is treated for acute exacerbation. Which finding would indicate that the condition is worsening? 1. Warm, dry skin 2. Increased wheezing 3. Decreased wheezing 4. A pulse rate of 90 beats per minute

Decreased wheezing Decreased wheezing in a child who is not improving clinically may be interpreted incorrectly as a positive sign, when in fact it may signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing may actually signal that the child's condition is improving. Warm, dry skin indicates an improvement in the condition because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats per minute.

A client with vascular headaches is taking ergotamine (Ergomar). Which client complaint should the nurse monitor? 1. Constipation 2. Hypotension 3. Dependent edema 4. Cool, numb fingers and toes

4. Cool, numb fingers and toes Ergotamine produces vasoconstriction, which suppresses vascular headaches when given at a therapeutic dose range. The nurse monitors for hypertension; cool, numb fingers and toes; muscle pain; and nausea and vomiting. Options 1, 2, and 3 are not associated with this medication.

A woman is admitted to an inpatient psychiatric unit with the diagnosis of anorexia nervosa. A behavior therapy approach is used as part of her treatment plan. Which is the purpose of the behavior therapy approach? 1. Provide a supportive environment. 2. Examine conflicts and past issues. 3. Emphasize social interaction with clients who withdraw. 4. Help the client identify and examine dysfunctional thoughts and beliefs.

4. Help the client identify and examine dysfunctional thoughts and beliefs. Behavior therapy is used to help clients identify and examine dysfunctional thoughts and the values and beliefs that maintain these thoughts. Options 1, 2, and 3 are incorrect.

The nurse is reinforcing instructions to an adolescent with type 1 diabetes mellitus regarding insulin administration and rotation sites. Which statement made by the adolescent would indicate an understanding of the instructions? 1. "I need to use a different site for each insulin injection." 2."I should use only my stomach and my thighs for injections." 3."I need to use the same site for 1 month before rotating to another site." 4."I need to use one major site for the morning injection and another major site for the evening injection for 2 to 3 weeks before changing major sites."

4."I need to use one major site for the morning injection and another major site for the evening injection for 2 to 3 weeks before changing major sites." To help decrease variations in absorption from day to day, the child should use one location within a major site for the morning injection. The child should then rotate to another site for the evening injection, and a third site for the bedtime injection. The child should follow this pattern for a period of 2 to 3 weeks before changing major sites.

A child is brought to the emergency department for treatment of an acute asthma attack. The nurse prepares to administer which medication first? 1. A β2 agonist 2.Oral corticosteroids 3.A leukotriene modifier 4.A nonsteroidal anti-inflammatory

1. A β2 agonist In treating an acute asthma attack, a short-acting β2 agonist such as albuterol (Proventil HFA) will be given to produce bronchodilation. Options 2, 3, and 4 are long-term control (preventive) medications.

A nursing student is planning care for a client with paraplegia who is at risk for injury because of spasticity of his leg muscles. The nurse intervenes if the student plans to include which intervention to minimize the risk of injury to the client? 1. Use of padded restraints to immobilize the limb 2. Performing range of motion to the affected limbs 3. Removing potentially harmful objects near the spastic limbs 4. Use of as-needed (PRN) prescriptions for muscle relaxants such as baclofen (Lioresal)

1. Use of padded restraints to immobilize the limb Range-of-motion exercises are beneficial in stretching muscles, which may diminish spasticity. Removing potentially harmful objects is an important safety measure. Use of muscle relaxants also is indicated if the spasms cause discomfort to the client or pose a risk to the client's safety. Use of limb restraints will not alleviate spasticity and could harm the client.

Which precautions should the nurse specifically take during the administration of ribavirin (Virazole) to a child with respiratory syncytial virus (RSV)? 1. Wearing goggles 2. Wearing a gown 3. Wearing a gown and a mask 4. Hand washing before administration

1. Wearing goggles Some caregivers experience headaches, burning nasal passages and eyes, and crystallization of soft contact lenses as a result of administration of ribavirin. Specific to this medication is the use of goggles. A gown is not necessary. A mask may be worn. Hand washing is to be performed before and after any child contact.

The nurse is completing a medication reconciliation form for a client. Which is a primary purpose of this process? 1. to make sure the pharmacy knows what medications the client was taking at home 2. To make sure the client is well informed about why each medication needs to be taken 3. To make sure medical insurance companies have a complete list of the client's medications 4. To compare a client's medication prescriptions to all of the medications the client is taking at home

1. to make sure the pharmacy knows what medications the client was taking at home Medication reconciliation is a process of comparing a client's medication prescriptions to all of the medications the client is taking. It helps avoid medication errors related to omissions, duplications, dosing errors, and drug interactions and is done at every transition of care when new medications are prescribed or rewritten. This process does not directly affect the pharmacy or insurance company. It is not related to teaching clients about their medications, although nurses still must inform clients about what medications they are taking and why they need to take them

A client with rheumatoid arthritis is taking acetylsalicylic acid (aspirin) on a daily basis. Which medication dose should the nurse expect the client to be taking? 1. 1 g daily 2. 4 g daily 3. 325 mg daily 4. 1000 mg daily

2. 4 g daily Aspirin may be used to treat the client with rheumatoid arthritis. It may also be used to reduce the risk of recurrent transient ischemic attack (TIA) or stroke ( brain attack) or reduce the risk of myocardial infarction (MI) in clients with unstable angina or a history of a previous MI. The normal dose for clients being treated with aspirin to decrease thrombosis and MI is 300 to 325 mg/day. Clients being treated to prevent TIAs are usually prescribed 1.3 g/day in 2 to 4 divided doses. Clients with rheumatoid arthritis are treated with 3.6 to 5.4 g/day in divided doses.

The nurse is reinforcing instructions to a client who is to have a gallium scan about the procedure. The nurse should include which item as part of the instructions? 1. The client must stand erect during the filming. 2. The procedure takes about 15 minutes to perform. 3. The gallium will be injected intravenously 2 to 3 hours before the procedure. 4. The client should remain on bed rest for the remainder of the day after the scan.

3. The gallium will be injected intravenously 2 to 3 hours before the procedure. A gallium scan is similar to a bone scan, but with an injection of gallium isotope instead of technetium-99m (99mTc). Gallium is injected 2 to 3 hours before the procedure, which takes 30 to 60 minutes to perform. The client must lie still during the procedure. There is no special aftercare.

The nurse is trying to communicate with a stroke (brain attack) client with aphasia. Which action by the nurse would be least helpful to the client? 1. Speaking to the client at a slower rate 2.Allowing plenty of time for the client to respond 3.Completing the sentences that the client cannot finish 4.Looking directly at the client during attempts at speech

3.Completing the sentences that the client cannot finish Clients with aphasia after stroke often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse should avoid shouting (because the client is not deaf), appearing impatient for a response, and completing responses for the client.

The nurse is reinforcing instructions to the mother of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the mother? 1. "The immunization schedule will need to be altered." 2. "The child should not receive any hepatitis vaccines." 3. "The child will receive all of the immunizations except for the polio series." 4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."

4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination." It is essential that children with cystic fibrosis be adequately protected from communicable diseases by immunization. It is recommended that in addition to the basic series of immunizations, children with cystic fibrosis also should receive yearly influenza vaccines.

The nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Based on this information, which determination does the nurse make regarding consent? 1. An informed consent does not need to be obtained. 2. The health care provider will obtain the informed consent. 3. An informed consent should be obtained from the family. 4. An informed consent needs to be obtained from the client.

4. An informed consent needs to be obtained from the client. Clients who are involuntarily admitted do not lose their right to informed consent. The informed consent needs to be obtained from the client.

The nurse is caring for a client diagnosed with Paget's disease. The nurse plans care, knowing that this condition usually affects which bones? 1. Shoulder and humerus 2. Bones of the hands and feet 3. Anterior rib cage and sternum 4. Axial skeleton including the vertebrae

4. Axial skeleton including the vertebrae Paget's disease usually affects the axial skeleton, especially the vertebrae and skull. Besides the vertebrae and skull, the pelvis, femur, and tibia are other common sites of the disease. Skull involvement and deformed facial bones frequently occur.

A client with glaucoma asks the nurse if complete vision will return. The nurse should make which response to the client? 1. "Your vision will never return to normal." 2."Your vision will return as soon as the medication begins to work." 3."Your vision loss is temporary and will return in about 3 to 4 weeks." 4."Although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan."

4."Although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan." Vision loss to glaucoma is irreparable. The client needs to be reassured that although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan. Options 1, 2, and 3 are incorrect.

The nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. Which would indicate a basal skull fracture as a result of the injury? 1.Epistaxis 2.Periorbital edema 3.Purulent drainage from the auditory canal 4.Bloody or clear drainage from the auditory canal

4.Bloody or clear drainage from the auditory canal Bloody or clear watery drainage from the auditory canal indicates a cerebrospinal fluid leak following trauma and suggests a basal skull fracture. This warrants immediate attention. Option 3 is indicative of an infectious process. Options 1 and 2 are not specifically associated with a basal skull fracture.

The nurse is caring for a 2-year-old child diagnosed with croup. The nurse collects data on the child, knowing that which is characteristic of this illness? Select all that apply 1. The cough is harsh and metallic. 2. Inspiratory stridor may be present. 3. Symptoms usually worsen at night and are better during the day. 4. Symptoms usually worsen during the day and are relieved during sleep. 5. It is usually preceded by several days of upper respiratory infection symptoms.

1. The cough is harsh and metallic. 2. Inspiratory stridor may be present. 3. Symptoms usually worsen at night and are better during the day. 5. It is usually preceded by several days of upper respiratory infection symptoms. Croup often begins at night and may be preceded by several days of upper respiratory infection symptoms. It is characterized by a sudden onset of a harsh, metallic cough, sore throat, and inspiratory stridor. Symptoms usually worsen at night and are better in the day.

A client with a psychotic disorder is being treated with haloperidol (Haldol). Which data would indicate the presence of a toxic effect of this medication? 1. Nausea 2. Hypotension 3. Blurred vision 4. Excessive salivation

4. Excessive salivation Toxic effects include extrapyramidal symptoms (EPS) noted as marked drowsiness and lethargy, excessive salivation, and a fixed stare. Akathisia, acute dystonias, and tardive dyskinesia are also signs of toxicity. Hypotension, nausea, and blurred vision are occasional side effects.

Milieu therapy is prescribed for a client. The nurse understands that this type of therapy can best be described as which? 1. Client involvement in goal setting 2. A form of behavior modification therapy 3. A cognitive approach to changing behavior 4. A behavioral approach to changing behavior

1. Client involvement in goal setting Milieu therapy provides a safe environment that is adapted to the individual client's needs and provides greater comfort and freedom of expression than has been experienced in the past by the client. All members contribute to the planning and functioning of the setting. Options 2, 3, and 4 are not characteristics of milieu therapy.

Sodium hypochlorite (Dakin's solution) is prescribed for a client with a leg wound containing purulent drainage. The nurse is assisting in developing a plan of care for the client and includes which in the plan? 1. Ensure that the solution is freshly prepared before use. 2.Allow the solution to remain in the wound following irrigation. 3.Soak a sterile dressing with the solution and pack into the wound. 4.Apply the solution to the wound and on normal skin tissue surrounding the wound.

1. Ensure that the solution is freshly prepared before use. Dakin solution is a chloride solution that is used for irrigating and cleaning necrotic or purulent wounds. It can be used for packing necrotic wounds. It cannot be used to pack purulent wounds because the solution is inactivated by copious pus. It should not come into contact with healing or normal tissue, and it should be rinsed off immediately if used for irrigation. Solutions are unstable, and the nurse must ensure that the solution has been prepared fresh before use.

The nurse is assigned to care for a client with a diagnosis of Ménière's disease. Which part of the ear is affected with Ménière's disease? 1. Inner ear 2. Middle ear 3. External ear canal 4. Tympanic membrane

1. Inner ear Ménière's disease is a disorder of the labyrinth of the inner ear. This disorder does not affect the external ear, tympanic membrane, or the middle ear.

The nurse is assisting with care for a client who has sustained a nasal fracture. The nurse monitors for which priority finding specifically related to this injury? 1. Leakage of clear fluid from the nose 2. Inability to breathe through one nare 3. Hematoma formation around the eyes 4. Edema noted around the nose and eyes

1. Leakage of clear fluid from the nose When a nasal fracture is suspected or diagnosed, the nurse should monitor the client for leakage of clear fluid from the nose as the priority. This could be cerebrospinal fluid (CSF) and may be indicative of cerebral injury. Any discharge of fluid from the nose should be tested to determine whether it is CSF. Inability to breathe through one nare is important to address, but is not the priority in this question because the client is still able to breathe through the other nare and through the mouth. Hematoma formation around the eyes and edema around the nose and eyes are common manifestations of nasal fracture.

Neuroleptic malignant syndrome is suspected in a client who is taking chlorpromazine. Which medication should the nurse prepare in anticipation of the prescription to treat this adverse effect related to the use of chlorpromazine? 1. Protamine sulfate 2. Bromocriptine (Parlodel) 3. Phytonadione (vitamin K) 4. Enalapril maleate (Vasotec)

2. Bromocriptine (Parlodel) Bromocriptine is an antiparkinsonian prolactin inhibitor used in the treatment of neuroleptic malignant syndrome. Protamine sulfate is the antidote for heparin overdose. Vitamin K is the antidote for warfarin (Coumadin) overdose. Enalapril maleate is an antihypertensive used in the treatment of hypertension.

A male child who had surgery to correct hypospadias is seen in a health care provider's office for a well-baby checkup. The nurse provides instructions to the mother, knowing that which long-term complication is associated with hypospadias? 1. Infertility 2.Renal anomalies 3. Erectile dysfunction 4. Decreased urinary output

2.Renal anomalies The nurse should ask the child's parents about the child's kidney function because hypospadias may be associated with renal anomalies. The incorrect options are not associated with a long-term effect of hypospadias. Test-Taking Strategy: Focus on the subject, well-baby checkup following a hypospadias repair. Note the words, long-term. Remember that hypospadias may be associated with renal anomalies.

Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication? 1. "I will apply the ointment once a day and leave it open to the air." 2. "I will apply the ointment twice a day and leave it open to the air." 3. "I will apply the ointment once a day and cover it with a sterile dressing." 4. "I will apply the ointment at bedtime and in the morning and cover it with a sterile dressing."

3. "I will apply the ointment once a day and cover it with a sterile dressing." Collagenase is used to promote debridement of dermal lesions and severe burns. It is usually applied once daily and covered with a sterile dressing.

The nurse is providing care for the client following a bone biopsy. Which action by the nurse is unnecessary in the care of this client? 1. Elevating the limb for 24 hours 2. Monitoring vital signs every 4 hours 3. Administering intramuscular opioid analgesics 4. Monitoring the site for swelling, bleeding, hematoma

3. Administering intramuscular opioid analgesics Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, and hematoma formation. The biopsy site is elevated for 24 hours to reduce edema. The vital signs are monitored every 4 hours for 24 hours. The client usually requires mild analgesics; more severe pain usually indicates that complications are arising. Focus on the subject, the action that is unnecessary. This indicates you to select an option that is an incorrect action. One way to approach this question is to look at the method of anesthesia used for this procedure. If you know that this procedure is done under local anesthesia, it makes sense that monitoring vital signs every 4 hours is probably sufficient (option 2). The nurse would routinely monitor for complications (option 4). From the remaining options, site elevation is important to reduce edema, but opioid administration by the intramuscular route seems excessive for a local procedure

A client who has had a right total knee replacement asks the nurse how long the right leg must be kept in the continuous passive motion (CPM) machine. How should the nurse answer this question for the client? 1. Every other hour for 60 minutes 2. For 30 minutes out of every hour 3. As much as tolerated while in bed 4. For 3 hours at a time, followed by 1 hour of rest

3. As much as tolerated while in bed The client who has received a total knee replacement often has the leg put into a CPM machine while in the postanesthesia care unit. The device increases circulation and movement of the knee joint. It should be used as much as the client can tolerate.

A child is hospitalized with a diagnosis of lead poisoning. The nurse caring for the child should prepare to assist in administering which medication? 1. Activated charcoal 2. Sodium bicarbonate 3. Syrup of ipecac 4. Dimercaprol (BAL in oil)

4. Dimercaprol (BAL in oil) Dimercaprol is a chelating agent that is administered to remove lead from the circulating blood and from some tissues and organs for excretion in the urine. Sodium bicarbonate may be used in salicylate poisoning. Syrup of ipecac is used in the hospital setting in poisonings to induce vomiting. Activated charcoal is used to decrease absorption in certain poisoning situations. Note that dimercaprol is prepared with peanut oil, and hence should be avoided by clients with known or suspected peanut allergy.

A client has had a bone scan procedure. The nurse determines that the client understands the elements of follow-up care if the client states which postprocedural care? 1. Report any feelings of nausea or flushing. 2. Eat only small meals for the remainder of the day. 3. Ambulate at least three times before the end of the day. 4. Drink plenty of water for a day or two following the procedure.

4. Drink plenty of water for a day or two following the procedure. There are no special restrictions following a bone scan. The client is encouraged to drink large amounts of water for 24 to 48 hours to flush the radioisotope from the system. The minimal amount of radioactivity of the isotope poses no hazards to the client or staff.

A client is seen in the clinic for complaints of skin itchiness that has been persistent over the past several weeks. Following data collection, it has been determined that the client has scabies. Lindane is prescribed, and the nurse is asked to provide instructions to the client regarding the use of the medication. How should the nurse teach the client to apply the cream? 1. Apply a thick layer of cream to the entire body. 2. Apply the cream as prescribed for 2 days in a row. 3. Apply to the entire body and scalp, excluding the face. 4. Leave the cream on for 8 to 12 hours and then remove by washing.

4. Leave the cream on for 8 to 12 hours and then remove by washing. Lindane is applied in a thin layer to the entire body below the head. No more than 30 g (1 oz) should be used. The medication is removed by washing 8 to 12 hours later. Usually, only one application is required.

The nurse is assigned to assist in caring for a client with frostbite of the toes. Which should the nurse anticipate to be prescribed for this condition? 1. Rapid and continual rewarming of the toes when flushing occurs 2. Rapid and continual rewarming of the toes in cold water for 45 minutes 3. Rapid and continual rewarming of the toes in hot water for 15 to 20 minutes 4. Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs

4. Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs Frostbite is ideally treated with rapid and continual rewarming of the tissue in a warm water bath for 15 to 20 minutes or until flushing of the skin occurs. Hot or cold water is not used in the treatment of frostbite.

A tricyclic antidepressant is administered to a client daily. The nurse plans to alleviate the common side effects of the medication and includes which in the plan of care? 1. Offer hard candy or gum periodically. 2. Offer a nutritious snack between meals. 3. Monitor the blood pressure every 2 hours. 4. Review the white blood cell (WBC) count results daily.

1. Offer hard candy or gum periodically. Dry mouth is a common side effect of tricyclic antidepressants. Frequent mouth rinsing with water, sucking on hard candy, and chewing gum will alleviate this common side effect. It is not necessary to monitor the blood pressure every 2 hours. In addition, it is not necessary to check the WBC count daily. Weight gain is a common side effect and frequent snacks will aggravate this problem.

The nurse reinforces instructions to a client regarding the use of tretinoin (Retin-A). Which statement by the client indicates the need for further teaching? 1. "Optimal results will be seen after 6 weeks." 2."I should apply a very thin layer to my skin." 3."I should wash my hands thoroughly after applying the medication." 4."I should cleanse my skin thoroughly before applying the medication."

2."I should apply a very thin layer to my skin." Tretinoin is applied liberally to the skin. The hands are washed thoroughly immediately after applying. Therapeutic results should be seen after 2 to 3 weeks but may not be optimal until after 6 weeks. The skin needs to be cleansed thoroughly before applying the medication.

The nurse is caring for a client hospitalized with an acute attack from Ménière's disease. The client verbalizes concern because the client has experienced a hearing loss as a result of the attack. Which response should the nurse make to the client regarding the hearing loss? 1. "The hearing will return to normal." 2."The attack leaves a hearing loss in the involved ear." 3."It will take several weeks before the hearing returns." 4."The hearing loss will fluctuate for a period of 1 week.

2."The attack leaves a hearing loss in the involved ear." After the acute phase, remission occurs but symptoms will recur, with two or three acute attacks per year. As this pattern of attacks and remissions develops, fewer symptoms occur during the acute phase. A complete remission eventually occurs with some degree of hearing loss, varying from slight to complete. It takes several weeks before all symptoms subside after an attack, leaving a loss of hearing in the involved ear. Options 1, 3, and 4 are incorrect.

The nurse has given instructions to the client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the client states that he or she will perform which activity? 1. Sit in soft, deep chairs. 2. Exercise in the evening to combat fatigue. 3. Rock back and forth to start movement with bradykinesia. 4. Buy clothes with many buttons to maintain finger dexterity.

3. Rock back and forth to start movement with bradykinesia. The client with Parkinson's disease should exercise in the morning, when energy levels are highest. The client should avoid sitting in soft, deep chairs because getting up from them can be difficult. The client can rock back and forth to initiate movement. The client should buy clothes with Velcro fasteners and slide-locking buckles to allow for easier dressing.

The nurse is asked to test the visual acuity of a client using a Snellen chart. The nurse prepares to perform the test, knowing that which identifies the accurate procedure for this visual acuity test? 1. The right eye is tested, followed by the left eye, and then both eyes are tested. 2. Both eyes are tested together, followed by the testing of the right and then the left eye. 3. The client is asked to stand at a distance of 40 feet from the chart and to read the largest line on the chart. 4. The client is asked to stand at a distance of 40 feet from the chart and to read the line that can be read 200 feet away by an individual with unimpaired vision.

1. The right eye is tested, followed by the left eye, and then both eyes are tested. Visual acuity is tested in one eye at a time, and then in both eyes together, with the client comfortably seated. Begin with the right eye while the left eye is covered, and then test the left eye with the right eye covered, followed by testing both eyes together. Visual acuity is measured with or without corrective lenses, with the client standing at a distance of 20 feet from the chart.

The nurse is assisting in preparing to administer acetylcysteine to a client with an overdose of acetaminophen (Tylenol). How should the nurse administer the medication? 1. Administer the medication subcutaneously in the deltoid muscle. 2. Administer the medication by the intramuscular route in the gluteal muscle 3. Administer the medication by the intramuscular route, mixed in 10 mL of normal saline. 4. Mix the medication in a flavored ice drink, and allow the client to drink the medication through a straw.

4. Mix the medication in a flavored ice drink, and allow the client to drink the medication through a straw. Because acetylcysteine (Mucomyst) has a pervasive odor of rotten eggs, it must be disguised in a flavored ice drink. It is consumed preferably through a straw to minimize contact with the mouth. It is not administered by the intramuscular or subcutaneous route. Focus on the subject, administration of acetylcysteine (Mucomyst). Knowing that the medication is a solution that is also used for nebulization treatments will help you select the option that indicates an oral route. Note that options 1, 2, and 3 are comparable or alike in that they indicate parenteral administration.

The nurse reinforces cast application instructions to a client who is going to have a plaster cast applied. The nurse determines that the client needs further teaching if the client makes which statement about the casting? 1. The cast will give off heat as it dries. 2. The cast edges may be trimmed with a cast knife. 3. The client may bear weight on the cast in 30 minutes. 4. A stockinette will be placed over the leg area to be casted.

3. The client may bear weight on the cast in 30 minutes. The procedure for casting involves washing and drying the skin and placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or smoothed as needed. A plaster cast gives off heat as it dries. A plaster cast can tolerate weight bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast.

The nurse is teaching the client with myasthenia gravis about prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by which activity? 1.Eating large, well-balanced meals 2. Doing muscle-strengthening exercises 3. Doing all chores early in the day while less fatigued 4. Taking medications on time to maintain therapeutic blood levels

4. Taking medications on time to maintain therapeutic blood levels Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. It is very important to take medications correctly to maintain blood levels that are not too low or too high. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms as are exposure to heat, crowds, erratic sleep habits, and emotional stress. Note the strategic words, most effectively. If you know that common causes of myasthenic and cholinergic crises are undermedication and overmedication, respectively, you should be able to eliminate each of the incorrect options easily. Remember that it is extremely important that these clients take medications on time to maintain therapeutic blood levels.

A client with right-sided weakness needs to learn how to use a cane. How should the nurse teach the client to position the cane? 1. Left hand, and 6 inches lateral to the left foot 2. Right hand, and 6 inches lateral to the right foot 3. Left hand, placing the cane in front of the left foot 4. Right hand, placing the cane in front of the right foot

1. Left hand, and 6 inches lateral to the left foot The client is taught to hold the cane on the opposite side of the weakness. This is done because with normal walking, the opposite arm and leg move together (called reciprocal motion). The cane is placed 6 inches lateral to the fifth toe.

The nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How should the nurse explain compartment syndrome? 1. A bone fragment has injured the nerve supply in the area. 2. Bleeding and swelling cause increased pressure in an area that cannot expand. 3. An injured artery causes impaired arterial perfusion through the compartment. 4. The fascia expands with injury, causing pressure on underlying nerves and muscles.

2. Bleeding and swelling cause increased pressure in an area that cannot expand. Compartment syndrome is caused by bleeding and swelling within a compartment lined by fascia, which does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms.

A client with a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the should nurse avoid which action? 1. Giving the client thin liquids 2.Thickening liquids to the consistency of oatmeal 3.Placing food on the unaffected side of the mouth 4.Allowing plenty of time for chewing and swallowing

1. Giving the client thin liquids Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration.

The family of an unconscious client with increased intracranial pressure is talking at the client's bedside. They are discussing the gravity of the client's condition and wondering if the client will ever recover. How should the nurse interpret the client's situation? 1. It is possible the client can hear the family. 2. The family needs immediate crisis intervention. 3. The client may have wanted a visit from the hospital chaplain. 4.The family could benefit from a conference with the health care provider.

1. It is possible the client can hear the family. Some clients who have awakened from an unconscious state report that they remember hearing specific voices and conversations. Family and staff should assume that the client's sense of hearing is still intact and act accordingly. Research has also demonstrated that positive outcomes are associated with coma stimulation, that is, speaking to and touching the client

The nurse is collecting medication information from a client, and the client states that she is taking garlic as an herbal supplement. The nurse understands that the client is most likely treating which condition? 1. Eczema 2. Insomnia 3. Migraines 4. Hyperlipidemia

hyperlipidemia Garlic is an herbal supplement that is used to treat hyperlipidemia and hypertension. An herbal supplement that may be used to treat eczema is evening primrose. Insomnia has been treated with both valerian root and chamomile. Migraines have been treated with feverfew.

The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? Select all that apply. 1. Pedal pulses 2. Capillary refill 3.Color of the extremity 4.Temperature of the skin 5.Condition of the toenails

1. Pedal pulses 2. Capillary refill 3. Color of the extremity 4. Temperature of the skin Before applying heat or cold therapy, the nurse should collect data related to circulatory status, particularly for the prescribed site. Baseline circulatory status is determined so that the nurse can continuously monitor the client before, during, and after therapy. Circulatory status can be monitored by checking pedal pulses, capillary refill, color of the extremity, and temperature of the skin. Condition of the toenails is not directly related to circulatory status. If circulatory status is impaired, the nurse should notify the health care provider before heat or cold application.

A nursing student is asked to discuss sudden infant death syndrome (SIDS) at the clinical conference being held at the end of the clinical day. The student plans to include which information in the discussion during the conference? 1. SIDS usually occurs during sleep and is more common in girls. 2. SIDS usually occurs during sleep and is more common in premature infants. 3. SIDS usually occurs during sleep and is more common in high-birth-weight infants. 4. SIDS usually occurs during sleep and most frequently occurs between 8 and 10 months of age.

2. SIDS usually occurs during sleep and is more common in premature infants. SIDS usually occurs during sleep. It most frequently occurs between the second and fourth months of life. It is more common in boys, low-birth-weight infants, and premature infants.

The nurse teaches a child with cystic fibrosis how to perform the "huff" maneuver. Which instructions should the nurse tell the child? 1. Take a deep breath and then exhale rapidly, whispering the word huff. 2. Take a shallow breath and then exhale rapidly, whispering the word huff. 3. Take a deep breath, hold it for 15 seconds and then exhale slowly, whispering the word huff. 4. Take a shallow breath, hold it for 10 seconds and then exhale rapidly, whispering the word huff.

1. Take a deep breath and then exhale rapidly, whispering the word huff. The "huff" maneuver (forced expiratory technique) is used to mobilize secretions. This technique reduces the likelihood of bronchial collapse. The child is taught to cough with an open glottis by taking a deep breath, then exhaling rapidly, whispering the word huff.

A client is placed on chloral hydrate (Somnote) for short-term treatment. Which nursing action indicates an understanding of the major side effect of this medication? 1. Monitoring neurological signs every 2 hours 2. Monitoring the blood pressure every 4 hours 3. Instructing the client to call for ambulation assistance 4. Lowering the bed and clearing a path to the bathroom at bedtime

3. Instructing the client to call for ambulation assistance Chloral hydrate (a sedative-hypnotic) causes sedation and impairment of motor coordination; therefore, safety measures need to be implemented. The client is instructed to call for assistance with ambulation. Options 1 and 2 are not specifically associated with the use of this medication. Although option 4 is an appropriate nursing intervention, it is most important to instruct the client to call for assistance with ambulation.

The nurse is reviewing the treatment plan with the parents of a newborn infant with hypospadias. Which statement by the parents indicates their understanding of the plan? 1. "Caution should be used when straddling my infant on a hip." 2."Catheterization will be necessary if my infant does not void." 3."Vital signs should be taken daily to check for bladder infection." 4."Circumcision has been delayed to save tissue for surgical repair.

4."Circumcision has been delayed to save tissue for surgical repair. Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. The incorrect option is unrelated to this disorder.

A client is being discharged from the ambulatory care unit following cataract removal, and the nurse provides instructions regarding home care. Which statement by the client indicates an understanding of the instructions? 1. "I will take aspirin if I have any discomfort." 2."I will sleep on the side that I was operated on." 3. "I will not lift anything if it weighs more than 10 pounds." 4."I will wear my eye shield at night and my glasses during the day."

4."I will wear my eye shield at night and my glasses during the day." The client is instructed to wear a metal or plastic shield to protect the eye from accidental injury and is instructed not to rub the eye. Glasses may be worn during the day. Aspirin or medications containing aspirin are not to be administered or taken by the client, and the client is instructed to take acetaminophen (Tylenol) as needed for pain. The client is instructed not to sleep on the same side of the body that underwent surgery. The client is not to lift more than 5 pounds.

A mother of a child with cystic fibrosis asks the clinic nurse about the disease. How should the nurse respond to the mother about the disease? 1. Cystic fibrosis is transmitted as an autosomal dominant trait. 2. Cystic fibrosis is a chronic multisystem disorder affecting the exocrine glands. 3. Cystic fibrosis is a disease that causes the formation of multiple cysts in the lungs. 4. Cystic fibrosis is a disease that causes dilation of the passageways of many organs.

2. Cystic fibrosis is a chronic multisystem disorder affecting the exocrine glands. Cystic fibrosis is a chronic multisystem disorder affecting the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and the pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait.

A client with spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. Which is the best response by the nurse? 1. Ask the family to deliver the care. 2.Leave the client alone until ready to participate. 3.Advise the client that rehabilitation progresses more quickly with cooperation. 4.Acknowledge the client's anger and continue to encourage participation in care.

4.Acknowledge the client's anger and continue to encourage participation in care. Adjusting to paralysis is difficult both physically and psychosocially for the client and family. The nurse recognizes that the client goes through the grieving process in adjusting to the loss and may move back and forth among the stages of grief. The nurse acknowledges the client's feelings while continuing to meet the client's physical needs and encouraging independence.

The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? Select all that apply. 1. Pedal pulses 2. Capillary refill 3. Color of the extremity 4. Temperature of the skin 5 .Condition of the toenails

1. Pedal pulses 2.Capillary refill 3.Color of the extremity 4.Temperature of the skin Before applying heat or cold therapy, the nurse should collect data related to circulatory status, particularly for the prescribed site. Baseline circulatory status is determined so that the nurse can continuously monitor the client before, during, and after therapy. Circulatory status can be monitored by checking pedal pulses, capillary refill, color of the extremity, and temperature of the skin. Condition of the toenails is not directly related to circulatory status. If circulatory status is impaired, the nurse should notify the health care provider before heat or cold application.

Which interventions should the nurse include when preparing a plan of care for a child with hepatitis? Select all that apply. 1. Providing a low-fat, well-balanced diet 2. Teaching the child effective hand-washing techniques 3. Notifying the health care provider if jaundice is present 4. Scheduling play time in the playroom with other children 5. Instructing the parents about the risks associated with taking medications 6. Arranging for indefinite home schooling because the child will not be able to return to school

1. Providing a low-fat, well-balanced diet 2. Teaching the child effective hand-washing techniques 5. Instructing the parents about the risks associated with taking medications Because hepatitis can be viral, standard precautions should be instituted in the hospital. The child should be discouraged from sharing toys, so playtime in the playroom with other children is not part of the plan of care. The child will be allowed to return to school 1 week after the onset of jaundice, so indefinite home schooling would not need to be arranged. Jaundice is an expected finding with hepatitis and would not warrant notification of the health care provider. Provision of a low-fat, well-balanced diet is recommended. Parents are cautioned about administering any medication to the child because normal doses of many medications may become dangerous because of the liver's inability to detoxify and excrete them. Hand washing is the single most effective measure in control of hepatitis in any setting, and effective hand washing can prevent the compromised child from picking up an opportunistic type of infection.

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse should respond knowing that which can occur if the crutches rest underneath the arm? 1. A fall and further injury 2. Injury to the brachial plexus nerves 3. Skin breakdown in the area of the axilla 4. Impaired range of motion while the client ambulates

2. Injury to the brachial plexus nerves Crutches are measured so that the tops are three or four fingerbreadths or 1 to 2 inches from the axilla. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the body. This could result in injury to the nerves of the brachial plexus.

A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse should avoid which to maintain client safety after this procedure? 1. Head of bed flat 2. Overhead trapeze 3. Pillows under the length of the legs 4. Logrolling technique for repositioning

2. Overhead trapeze Following spinal fusion, the head of the bed is generally kept in a flat position. The client is logrolled from side to side as prescribed. Pillows may be placed under the entire length of the legs by surgeon preference to relieve tension on the lower back. The use of an overhead trapeze is contraindicated because its use could promote twisting of the spine after surgery.

A client is being treated for depression with amitriptyline hydrochloride. During the initial phases of treatment, which is the most important nursing intervention? 1. Prescribing the client a tyramine-free diet 2. Checking the client for anticholinergic effects 3. Getting baseline postural blood pressures before administering the medication and each time the medication is administered 4. Monitoring blood levels frequently because there is a narrow range between therapeutic and toxic blood levels of this medication

3. Getting baseline postural blood pressures before administering the medication and each time the medication is administered Amitriptyline hydrochloride is a tricyclic antidepressant often used to treat depression. It causes orthostatic changes and can produce hypotension and tachycardia. This can be frightening to the client and dangerous because it can result in dizziness and client falls. The client must be instructed to move slowly from a lying to a sitting to a standing position to avoid injury if these effects are experienced. The client may also experience sedation, dry mouth, constipation, blurred vision, and other anticholinergic effects, but these are transient and will diminish with time.

Which interventions should the nurse implement for a child older than 2 years of age with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? Select all that apply. 1. Administer regular insulin. 2. Encourage the child to ambulate. 3. Give the child a teaspoon of honey. 4. Provide electrolyte replacement therapy intravenously. 5. Wait 30 minutes and confirm the blood glucose reading. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

3. Give the child a teaspoon of honey. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs. Hypoglycemia is defined as a blood glucose level less than 70 mg/dL. Hypoglycemia occurs as a result of too much insulin, not enough food, or excessive activity. If able, the nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; the rapid-releasing sugar (such as honey) is followed by a complex carbohydrate and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not planned for more than 30 minutes or if activity is planned. If the child becomes unconscious, cake frosting or glucose paste can be squeezed onto the gums, and the blood glucose level is retested. If the child does not improve within 15 minutes, administration of glucagon may be necessary, and the nurse should be prepared for this intervention. In the hospital setting the nurse should be prepared to administer dextrose intravenously. Encouraging the child to ambulate and administering regular insulin will result in a lowered blood glucose level. Providing electrolyte replacement therapy intravenously is an intervention to treat diabetic ketoacidosis. Waiting 30 minutes to confirm the blood glucose level delays necessary intervention.

A client was involuntarily admitted to the psychiatric unit because of episodes of extremely violent behavior. The client is demanding to be discharged from the hospital. The licensed practical nurse (LPN) reports the information to the registered nurse (RN), and the RN does not allow the client to leave. The LPN understands that which represents the legal ramifications associated with the RN's behavior? 1. The RN will be charged with assault. 2.The RN will be charged with slander. 3.The RN will be charged with imprisonment. 4.No charge will be made against the RN because the RN's actions are reasonable.

4.No charge will be made against the RN because the RN's actions are reasonable. False imprisonment is an act with the intent to confine a person to a specific area. The nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the client was voluntarily admitted and if there are no agency or legal policies for detaining the client. On the other hand, if the client has been involuntarily admitted or has agreed to an evaluation before discharge, the nurse's actions are reasonable.