NCLEX Stuff

A 15 year old client has been placed in a Milwaukee Brace. Which one of the following statements from the client indicates the need for additional teaching? A) "I will only have to wear this for 6 months" B) "I should inspect my skin daily" C) "The brace will be worn day and night" D) "I can take it off when I shower"

A) "I will only have to wear this for 6 months" The brace must be worn long-term, usually for 1-2 years.

The parents of a 4 year old hospitalized child tell the nurse they will leave for a time and return at 6pm. When the child asks when the parents will come again, the nurse can best respond by saying A) "they will be back right after supper" B) "in about 2 hours, you will see them" C) "after you play awhile, they will be here" D) "when the clock hands are on 6 and 12"

A) "they will be right back after supper" The child interprets time with his own frame of reference, such as, relationship to a specific event.

A 2 year old child has recently been diagnosed with CF. The nurse is teaching the parents about home care for the child. Which of the following information is appropriate for the nurse to include? A) Allow the child to continue with their normal activities B) Schedule frequent rest periods C) Limit exposure to other children D) Restrict activities to inside the house

A) Allow the child to continue with their normal activities Physical activity is important for a 2 year old who is developing autonomy and a valuable adjunct to chest physical therapy and stimulate mucous secretion and develop normal breathing patterns.

While interviewing a client, the nurse notices that the client is shifting positions, wringing her hands, and avoiding eye contact. It is important for the nurse to A) Ask the client what she is feeling B) Assess the client for auditory hallucinations C) Recognize the behavior as a side effect of medication D) Re-focus the discussion on a less anxiety provoking topic

A) Ask the client what she is feeling The initial step in anxiety intervention is observing, identifying, and assessing anxiety.

The nurse is planning care for a 3 month old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to A) Assess for abdominal distention B) Maintain infant in an upright position C) Begin formula feedings when infant is alert D) Pump the shunt to assess for proper function

A) Assess for abdominal distention Cerebrospinal fluid may cause peritonitis or a postoperative ileum as a complication of distal catheter placement.

Therapeutic nurse-client interaction occurs when the nurse A) Assists the client to clarify the meaning of what the client is communicating B) Interprets the client's covert communication C) Praises the client for appropriate behavior D) Advises the client on ways to resolve problems

A) Assists the client to clarify the meaning of what the client is communicating Clarification is a facilitating/therapeutic communication strategy.

A client is receiving digoxin (Lanoxin) 0.25mg daily. The healthcare provider has written a new order to give metoprolol (Lopressor) 25mg BID. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the healthcare provider? A) BP 94/60 B) HR 76 BPM C) Urine output 50ml/hr D) RR 16

A) BP 94/60 Both medications decrease the HR. Metorolol affects BP. Therefore, the HR and BP should be in normal range in order to safely administer both meds.

The nurse is caring for a 4 year old admitted after receiving burns to more than 50% of his body. Which lab data should be reviewed by the nurse as a priority in the first 24 hours? A) BUN B) Hematocrit C) Blood glucose D) WBC

A) BUN Glomerular filtration is decreased in the initial response to severe burns, with fluid shift. Kidney function must be monitored closely, or renal failure may follow in a few days.

A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance and cardiac dysrhythmias. Additional assessment findings that the nurse would expect to observe are A) Brittle hair, lanugo, amenorrhea B) Diarrhea, nausea, vomiting, dental erosion C) Hyperthermia, tachycardia, increased metabolic rate D) Excessive anxiety about symptoms

A) Brittle hair, lanugo, amenorrhea

The nurse is caring for a client 2 hours after a right lower lobectomy. In evaluating the water-seal chest drainage system, it is noted that the fluid level bubbles constantly. On inspecting the chest and tubing, the nurse does not find any air leaks in the system. The next action for the nurse is to A) Call the physician immediately B) Irrigate the tube C) Clamp the tube D) Measure the thoracic drainage

A) Call the physician immediately Continuous bubbling is not a normal finding. The physician must act quickly to prevent lung collapse or mediastinal shift.

The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the client? A) Clean the meatus, begin voiding, then catch urine stream B) Void a little, clean, then collect C) Clean, then urinate into container D) Void continuously and catch some of the urine

A) Clean the meatus, begin voiding, then catch urine stream

A 9 month old infant visits her pediatrician for a routine visit. A developmental assessment was initiated by the nurse. Which skill would cause the nurse to be concerned about the infant's developmental progression? A) She sits briefly alone with assistance B) She creeps and crawls C) She pulls herself to her feet with help D) She stands while holding onto furniture

A) She sits briefly alone with assistance A 9 month old can sit alone for a long period of time. By 6 months, infants can put themselves in a standing position.

The mother of a 2 month old baby calls the nurse 2 days after the first DTaP, IVP, Hepatitis B and HIB immunizations. She reports that the baby is very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated with the findings the infant is displaying? A) DTaP B) Hep B C) Polio D) H. Influenza

A) DTaP Contraindications to giving repeat doses include the occurrence of severe side effects after the previous dose as well as signs of encephalopathy within 7 days of the immunization.

The nurse is assigned to care for a client who had an MI 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time? A) Daily needs and concerns B) The overview cardiac rehab C) Medication and diet guideline D) Activity and rest guidelines

A) Daily needs and concerns

In an acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe? A) Diazepam (Valium) B) Haloperidol (Haldol) C) Sertraline (Zoloft) D) Alprazolam (Xanax)

A) Diazepam (Valuim) It is an anti-anxiety medication and is not designed to reduce psychotic symptoms.

A client is admitted to the ER following an acute asthma attack. Which of the following assessments would be expected by the nurse? A) Diffuse expiratory wheezing B) Loose, productive cough C) No relief from inhalant D) Fever and chills

A) Diffuse expiratory wheezing In asthma, the airways are narrowed-creating difficulty getting air in and causing a wheezing sound.

When the nurse becomes aware of feeling reluctant to interact with a manipulative client, the best action by the nurse is to A) Discuss the feeling of reluctance with an objective peer or supervisor B) Limit contacts with the client to avoid reinforcing the manipulative behavior C) Confront the client regarding the negative effects of his/her behavior on others D) Develop a behavior modification plan that will promote more functional behavior

A) Discuss the feeling of reluctance with an objective peer or supervisor The nurse can gain more objectivity through supervision and must attempt to discover attitudes and feelings in the self that influence the nurse-client relationship.

A client experienced the loss of a 7 month fetus. The nurse planning for discharge should emphasize A) Discussing feelings with support persons B) Focusing on the other healthy children C) Seeking causes for fetal death D) Planning another pregnancy very soon

A) Discussing feelings with support persons

The nurse is teaching a client newly diagnosed with asthma how to use the metered-dose inhaler. The client asks when they will know the canister is empty. The best response is A) Drop the canister in water to observe floating B) Estimate how many doses are usually in the canister C) Count the number of doses as the inhaler is used D) Shake the canister to detect fluid movement

A) Drop the canister in water to observe floating Dropping it in a bowl of water assesses the amount of medication in the inhaler. The client should obtain a refill when the inhaler rises to the surface and begins to tip over.

The nurse is assessing a 55 year old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus transformation in the post-operative period? A) Estrogen replacement therapy B) 10% less than ideal body weight C) Hypersensitivity to heparin D) History of hepatitis

A) Estrogen replacement therapy Estrogen increases the hypercoagualability of the blood and increases the risk for development of thrombophlebitis.

The nurse is teaching parents about diet for a 4 month old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include A) Formula or breast milk B) Broth and tea C) Rice cereal and apple juice D) Gelatin and ginger ale

A) Formula or breast milk

The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is critical for the nurse to include in the plan of care? A) Hourly urine output B) WBC C) Glucose every 4 hours D) Temperature every 2 hours

A) Hourly urine output Clients who had an episode of decrease glomerular perfusion are at risk for pre-renal failure. This is caused by any abnormal decline in kidney perfusion that reduces glomerular perfusion. Pre-renal failure occurs when the effective arterial blood volume falls. EX: drop in circulating blood volume as in a cardiac arrest state or in low cardiac perfusion states such as congestive heart failure associated with cardiomyopathy. Close observation of hourly urine output is necessary for early detection of this condition.

As the nurse interviews the parents of the parents of a child with asthma, it is a priority to ask about A) Household pets B) New furniture C) Lead based paint D) Plants such as cactus

A) Household pets Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting, and household dust.

The nurse is caring for a client in a coronary care unit 2 days following a MI. The client has many questions about his condition. The nurse should focus teaching about A) Immediate needs and concerns B) Post discharge rehabilitation C) Medication therapy at home D) Activity and rest schedule

A) Immediate needs and concerns

Parents of a 4 year-old boy have just been informed that their son has a congenital neurologic demyelinating disorder that is terminal. The nurse anticipates their reaction to be in which phase of the crisis process? A) Impact phase B) Crisis phase C) Pre-crisis phase D) Resolution phase

A) Impact phase

An 80 year old client was admitted with a diagnosis of possible cerebral vascular accident. Blood pressure has ranged from 180/110 to 160/100. Over the past several hours, the nurse noted increasing lethargy. Which of the following assessments should the nurse report immediately to the physician? A) Slurred speech B) Incontinence C) Muscle weakness D) Rapid pulse

A) Slurred speech Changes in speech patterns and level of conscious can be indicators of continued intercranial bleeding. Treatment options may change based on further diagnostic test.

The mother of a 2-month old baby calls the nurse at a well-baby clinic 2 days after the first DTaP immunization. She reports that the baby feels very warm, has cried inconsolably for as long as 3 hours, and has several shaking spells. The response of the nurse should be to A) Instruct the mother to call 911 for an ambulance to transport the infant B) Suggest that these are expected reactions and to begin every 4 hour antipyretics C) Tell the mother to take the infant immediately to the nearest ER D) Give instructions to bring the infant to the clinic now

A) Instruct the mother to call 911 for an ambulance to transport the infant The infant is having a severe reaction to the immunization and there is a risk of a grand mal seizure to occur from potential encephalopathy. The immunization may be contraindicated for life of the infant.

A young adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the most therapeutic approach by the nurse? A) Listen quietly without comment B) Ask for further information on the spies C) Confront client on a delusion D) Contact the government agency

A) Listen quietly without comment

While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse to teach them to A) Maintain good oral hygiene and dental care B) Omit medication if the child is seizure free C) Administer acetaminophen to promote sleep D) Serve a diet that is high in iron

A) Maintain good oral hygiene and dental care

A high school nurse is advising a class of unwed pregnant students that the most important action they can perform to deliver a healthy child is A) Maintaining good nutrition B) Staying in school C) Keeping in contact with the child's father D) Getting adequate sleep

A) Maintaining good nutrition

A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action A) May result in charges of unlawful seclusion and restraint B) Leaves the nurse vulnerable for charges of assault and battery C) Was appropriate in view of the client's history of violence D) Was necessary to maintain the therapeutic milieu of the unit

A) May result in charges of unlawful seclusion and restraint Seclusion should only be used when there is an immediate threat of violence or threatening behavior.

A client being treated for hypertension returns to the clinic for a follow up. He says, "I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." The most appropriate nursing diagnosis would be A) Noncompliance related to medication side effects B) Knowledge deficit related to misunderstanding of disease state C) Defensive coping related to chronic illness D) Altered health maintenance related to occupation

A) Noncompliance related to medication side effects

Which nursing intervention will be most effective in helping a withdrawn client to develop relationship skills? A) Offer the client frequent opportunities to interact with you B) Remind the client frequently to interact with other clients C) Assist the client to analyze the meaning of her behavior D) Identify for her other clients who have similar problems

A) Offer the client frequent opportunities to interact with you

An 8 year old client is admitted to the child mental health unit for evaluation. Following his mother's departure, the client cries and refuses his dinner. The best approach by the nurse is to A) Offer to play with him B) Remind him that he is expected to eat his meals C) Tell him that he will be denied privileges for uncooperative behavior D) Tell him that his mother will be upset with him if he doesn't cooperate

A) Offer to play with him

A client has been admitted to the Coronary Care Unit with a MI. Which of the following nursing diagnosis should have been priority? A) Pain related to ischemia B) Risk for altered elimination: constipation C) Risk for complication: dysrhythmias D) Anxiety

A) Pain related to ischemia Relief of pain will decrease myocardial oxygen demands, reduce blood pressure and HR and relieve anxiety. Pain also stimulates the sympathetic nervous system and increases preload, further increasing myocardial demands.

The nurse is planning discharge for a 90 year old client with musculoskeletal weakness. Which of the following interventions would be most effective in preventing falls? A) Place nightlights in the bedroom B) Wear eyeglasses at all times C) Install grab bars in the bathroom D) Teach muscle strengthening exercises

A) Place nightlights in bedroom Because more falls occur in the bedroom than any other location.

A client is admitted to the rehab unit following a CVA and mild dysphasia. The most appropriate intervention for this client is A) Position client in upright position while eating B) Place client on a clear liquid diet C) Tilt head back to facilitate swallowing reflex D) Offer finger foods such as crackers or pretzels

A) Position client in upright position while eating An upright position facilitates proper chewing and swallowing.

Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy? A) Positive inotropes B) Vasodilators C) Diuretics D) Antidysrythmics

A) Positive inotropes

An 80 year old client on dialysis (Lanoxin) reports nausea, vomiting, abdominal cramps, and halo vision. Which of the following laboratory results should the nurse analyze first? A) Potassium levels B) Blood pH C) Magnesium levels D) Blood urea nitrogen

A) Potassium levels Common cause of digitalis toxicity is a low potassium level. Clients must be taught that it is important to have adequate potassium intake while taking diuretics.

A client has been diagnosed as being preeclamptic. The physician orders magnesium sulfate. MgSO4 is used in the management of preeclampsia for: A) Prevention of seizures B) Prevention of uterine contractions C) Sedation D) Fetal lung protection

A) Prevention of seizures It is an anticonvulsant drug and inhibits hyperactive labor and does not affect lung maturity.

A client has returned to the unit from the recovery room after a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is A) Respiratory obstruction B) Hypercalcemia C) Fistula formation D) Myxedema

A) Respiratory obstruction

The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which of the following should be included in the teaching materials? A) Solid food are introduced one at a time beginning with cereal B) Finely ground meat should be started early to provide iron C) Egg white is added early to increase protein intake D) Solid foods should be mixed with formula in a bottle

A) Solid foods are introduced one at a time beginning with cereal Added one at a time between 4-6 months. Add each week when tolerated. Iron fortified cereal is recommended as first food.

Handshaking is the preferred form of touch or contact used with clients in a psychiatric setting. The rationale behind this limited touch practice is that A) Some clients misconstrue hugs as an invitation to sexual advances B) Handshaking keeps the gesture on a professional level C) Refusal to touch a client denotes lack of concern D) Inappropriate touch often results in charges of assault and battery

A) Some clients misconstrue hugs as an invitation to sexual advances

A spouse is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that A) Such fantasies can gratify unconscious wishes or prepare for anticipated future events B) Detaching or dissociating in this way postpones painful feelings C) This conversion or transferring of a mental conflict to a physical symptom can lead to marital conflict D) Isolating her feelings in this way reduces conflict

A) Such fantasies can gratify unconscious wishes or prepare for anticipated future events

A client recovering from a thyroidectomy. While monitoring the client's initial post operative condition, which of the following should the nurse report immediately? A) Tetany and paresthesia B) Mild stridor and hoarseness C) Irritability and insomnia D) Headache and nausea

A) Tetany and paresthesia

The nurse is caring for a 10 year old child who has just been diagnosed with diabetes insipidus. The parents ask about the treatment prescribed, vasopressin. A priority in teaching the child and family is A) The child should carry a nasal spray for emergency use B) The family must observe the child for dehydration C) Parents should administer the daily intramuscular injections D) The client needs to take daily injections in the short-term

A) The child should carry a nasal spray for emergency use Diabetes insipidus results from reduced secretion of the antidiuretic hormone, vasopressin. The child will need to administer daily injections of vasopressin, and should have the nasal spray form of the medication readily available and need a medical alert tag worn.

A mother telephones the clinic and tells the nurse she is concerned because her breastfed 1 month old has soft, yellow stools after each feeding. The nurse's best response would be based on the knowledge that A) This type of stool is normal for breast fed infants B) The stool should have turned to light brown by now C) Formula supplements will add bulk to the stools D) Water should be offered several times each day

A) This type of stool is normal for breast fed infants In breast-fed infants, stools are frequent and yellow to golden and vary from soft to thick liquid in consistency. No change in feedings is indicated.

Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3 year old child who suffered partial and full thickness burns to 25% of her body? A) Urine output B) Edema C) Hypertension D) Bulging fontanelle

A) Urine output

The nurse is assisting a 4th day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing? A) Vitamin C B) Vitamin B1 C) Vitamin D D) Vitamin A

A) Vitamin C Ascorbic acid is essential in promoting wound healing and collagen formation. B) is for normal GI functioning, oxidizes carbs, and essential for nervous tissue. C) regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. D) necessary for the formation and maintenance of skin and mucous membranes, and normal growth and development of bones and teeth.

The nurse is caring for a client with a colostomy. During a teaching session, the nurse recommends that the pouch be emptied A) When it is 1/3rd to 1/2 full B) Prior to meals C) After each fecal elimination D) At the same time each day

A) When it is 1/3rd to 1/2 full

You are the of a health care team that consists of one licensed practical nurse, one nursing assistant, a nursing student, and yourself. To whom is it appropriate to assign complete care for A) Yourself B) The nursing student C) The LPN D) The nursing assistant

A) Yourself While the nurse may delegate a bed bath for a stable patient, this care needs to be preformed by an RN for a new admission.

A depressed client in an assisted living facility tells the nurse that "life isn't worth living anymore." What is the best response to this statement? A) "Come on, it is not that bad." B) "Have you thought about hurting yourself?" C) "Did you tell that to your family?" D) "Think of the many positive things in life."

B) "Have you thought about hurting yourself?"

The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements? A) "The injury is expected to heal quickly because of thin periosteum." B) "In some instances the result is a retarded bone growth." C) "Bone growth is stimulated in the affected leg." D) "This type of injury shows more rapid union than that of younger children."

B) "In some instances the result is a retarded bone growth." An epiphyseal (growth) plate fracture in a 7 year old often results in retarded bone growth. Limbs will be different in length.

The nurse is caring for a 14 month old just diagnosed with CF. The parents state this is the first child in either family with this disease, and ask about the risk to future children. The best response by the nurse is based on the knowledge that there is a A) 1 in 4 chance for each child to carry that trait B) 1 in 4 risk for each child to have the disease C) 1 in 2 chance of avoiding the trait and disease D) 1 in 2 chance that each child will have the disease

B) 1 in 4 risk for each child to have the disease

Which of the following times is a depressed client at highest risk for attempting suicide? A) Immediately after admission, during one-to-one observation B) 7-14 days after initiation of antidepressant medication and psychotherapy when energy increases C) Following an angry outburst with family D) When the client is removed from the security room

B) 7-14 days after initiation of antidepressant medication and psychotherapy when energy increases

A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate A) Non stress test B) Abdominal ultrasound C) Pelvic exam D) X-ray of abdomen

B) Abdominal ultrasound The standard diagnosis of placenta previa, which is suggested in the client's history of painless bleeding, is abdominal ultrasound.

A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate A) Nonstress test B) Abdominal ultrasound C) Pelvic exam D) X-ray of abdomen

B) Abdominal ultrasound The standard for diagnosis of placenta previa, which is suggested in the clients history, is abdominal US.

The nurse is teaching an elderly client how to use MDI's (multi dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. The nurse's best recommendation for the client is A) Nebulized treatments for home care B) Adding a spacer device to the MDI canister C) Asking a family member to assist the client with the MDI D) Request a visiting nurse to follow the client home

B) Adding a spacer device to the MDI canister

A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to A) Maintain the airway B) Administer epi 1:1000 as ordered C) Monitor for hypotension with shock D) Administer dephenhydramine as ordered

B) Administer epi 1:1000 as ordered

A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 L/min. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 L/min. What should the nurse do first? A) Notify the physician B) Administer the prn dose of Albuterol C) Apply oxygen at 2 L per nasal cannula D) Repeat the peak flow reading in 30 minutes

B) Administer the prn dose of Albuterol A peak flow reading of less than 50% of the clients baseline reading is a medical alert of short-acting beta-agonist must be taken immediately.

A client is scheduled for an IVP (intravenous pyelogram). Which of the following data from the client's history indicate a potential hazard for this test? A) Reflex incontinence B) Allergic to shellfish C) Claustrophobia D) Hypertension

B) Allergic to shellfish If the client has an allergy to shellfish, they may have an allergic reaction to the IVP contrast dye injected during the procedure.

The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for herpes simplex virus type 2 infection. The nurse should instruct the client to A) Complete the entire course of the medication for an effective cure B) Begin treatment with acyclovir at the onset of symptoms of recurrence C) Stop treatment if she thinks she may be pregnant to prevent birth defects D) Continue to take prophylactic doses for at least 5 years after the diagnosis

B) Begin treatment with acyclovir at the onset of symptoms of recurrence

The nurse planning care for a 12 year old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include which one of the following as a priority? A) Limit fluids B) Client controlled analgesia C) Cold compress to elbow D) Passive range of motion exercises

B) Client controlled analgesia The priority of care is pain relief.

A 2 year old child is brought to the pediatricians office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which one of the following statements? A) Place the child on clear liquids and gelatin for 24 hours B) Continue with the regular diet and include oral rehydration fluids C) Give bananas, apples, rice, and toast as tolerated D) Place on NPO for 24 hours, then rehydrate with milk and water

B) Continue with the regular diet and include oral rehydration fluids.

A client who is a former actress enters the day room wearing a sheer nightgown, high heels, numerous bracelets, bright red lipstick, and heavily rouged cheeks. Which of the following is the best nursing action in response to the client's attire? A) Gently remind her that she is no longer on stage B) Directly assist client to her room for appropriate apparel C) Quietly point out to her the dress of other clients on the unit D) Tactfully explain to her the clothing appropriate for the hospital

B) Directly assist client to her room for appropriate apparel

The nurse is teaching parents about accidental poisoning in children. Which of the following should be emphasized? A) Start treatment before calling the Poison Control Center B) Empty child's mouth in any case of possible poisoning C) Do not move the child if a toxic substance is inhaled D) Induce vomiting if the poison is hydrocarbon

B) Empty child's mouth in any case of possible poisoning Emptying the mouth of poison interferes with further ingestion and should be done first to limit contact with the substance.

The nurse is performing the admission assessment of a client with an acute episode of asthma. Which of the following assessments would the nurse anticipate finding? A) Prolonged inspiration B) Expiratory wheezes C) Expectorating large amounts of purulent mucous D) Lethargy

B) Expiratory wheezes

A 2 year old child will undergo cardiac catheterization tomorrow to evaluate his ventricular septal defect. Based on his developmental stage, the nurse: A) Uses pictures to explain the procedure to the child and his parents that evening B) Explains the procedure using simple words and sentences before the preoperative sedation C) Asks the parents to explain the procedure to the child after she explains it to them D) Asks the parents to leave the room while the preoperative medication and instructions are given

B) Explains the procedure using simple words and sentences before the preoperative sedation. The toddler is not able to conceptualize the inside of his body and the previous evening too far from the procedure.

The nurse is assessing a 4 year old for possible rheumatic fever. Which of the following would the nurse suspect is related to this diagnosis? A) Diagnosis of chickenpox 6 months ago B) Exposure to strep throat in daycare last month C) Treatment for ear infection 2 months ago D) Episode of fungal skin infection last week

B) Exposure to strep throat in daycare last month A strong relationship between infection with Group A Strep and subsequent rheumatic fever (usually within 2-6 weeks). Therefore, playmates recovering from strep throat would most likely mean that they had strep throat. Sometimes, such an infection has no clinical symptoms.

A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority? A) Maintaining proper body alignment B) Frequent neurovasular assessments of the affected leg C) Inspection of pin sites for evidence of drainage or inflammation D) Applying an over-bed trapeze to assist the client with movement in bed

B) Frequent neurovascular assessments of the affected leg Compartment syndrome is a serious complication of fractures. Prompt recognition of this problem and early intervention may prevent permanent limb damage.

A client with guillain barre is in a non responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? A) Comatose, breathing unlabored B) Glascow Coma Scale 8, respirations regular C) Appears to be sleeping, vital signs stable D) Glascow Coma Scale 13, no ventilator required

B) Glascow Coma Scale 8, respirations regular

The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which of the following dinner menus would be best? A) Fish sticks, french fries, bananas, cookies, milk B) Ground beef patty, lima beans, wheat roll, raisins, milk C) Chicken nuggets, macaroni, peas, cantaloupe, milk D) PBJ sandwich, apple slices, milk

B) Ground beef patty, lima beans, wheat roll, raisins, milk Iron rich foods include red meat, fish, egg yolks, green leafy veggies, legumes, whole grains, dried fruits (raisins).

A client is admitted with infective endocarditis. Which symptom would alert the nurse to a complication of this condition? A) Dyspnea B) Heart murmur C) Macular rash D) Hemorrhage

B) Heart murmur Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. These emboli produce symptoms of cardiac murmur, fever, anorexia, malaise, and neurologic sequelae of emboli. The vegetations may travel to various organs such as spleen, kidney, coronary artery, brain, and lungs and obstruct blood flow.

A client admitted with infective endocarditis. Which finding would alert the nurse to a complication of this condition? A) Dyspnea B) Heart murmur C) Macular rash D) Hemorrhage

B) Heart murmur The heart valve emboli produce findings of cardiac murmur, fever, anorexia, malaise, and neurogenic sequelae of vegetations.

A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's best initial intervention is to A) Discuss with the mother sharing parenting responsibilities B) Help the mother to express her feelings and concerns C) Arrange for the parents to attend infant care classes D) Talk with the father and help him accept the wife's decision

B) Help the mother to express her feelings and concerns

The father of an 8 month old asks the nurse if his infant's vocalizations are normal for his age. Which of the following would the nurse expect at this age? A) Cooing B) Imitation of sounds C) Throaty sounds D) Laughter

B) Imitation of sounds EX: da-da

The client's self esteem is most damaged by the nurse's A) Anger B) Indifference C) Disapproval D) Fear

B) Indifference Positive connectedness/caring objectivity characterizes therapeutic relationships and is congruent with indifference.

The nurse is caring for a newborn with tracheoesophageal fistula. Which of the following nursing diagnoses is a priority? A) Risk for dehydration B) Ineffective airway clearance C) Altered nutrition D) Risk for injury

B) Ineffective airway clearance Most common form of TEF is one in which proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula at or near the bifurcation. Open airway and preventing aspiration.

The nurse is assessing an 8 month old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be most likely to exhibit? A) Lethargy B) Irritability C) Negative moro D) Depressed fontanel

B) Irritability Signs of IICP in infants include bulging fontanel, instability, high-pitched cry, and cries when held. VS changes include pulse that is variable (rapid, slow and bounding, or feeble). Respirations are more often slow, deep, and irregular.

A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to A) Stabilize thermoregulation B) Maintain alveolar surface tension C) Begin normal pulmonary blood flow D) Regulate intra cardiac pressure

B) Maintain alveolar surface tension RDS is primarily a disease related to developmental delay in lung maturation. Although many factors lead to the development of the problem, the central factor related to the lack of a normally functioning surfactant system due to immaturity in lung development.

The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used to A) Determine oxygen saturation B) Measure forced expiratory volume C) Monitor atmosphere for presence of allergens D) Provide metered doses for inhaled bronchodilator

B) Measure forced expiratory volume A Peak flow meter is used to measure peak expiratory flow volume. It provides useful information about the presence and/or severity of airway obstruction.

The nurse admitting a 5 month old who vomited 9 times in the past 6 hours should observe for signs of A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis

B) Metabolic alkalosis Vomiting causes loss of acid in the stomach. Prolonged vomiting can result in excess loss.

The nurse is caring for a newborn with a neural tube defect. The best covering for the lesion is A) Telfa dressing with antibiotic ointment B) Moist sterile non adherent dressing C) Dry sterile dressing D) Sterile occlusive pressure dressing

B) Moist sterile non adherent dressing Before surgical closure the sac is prevented from drying by the application of a sterile, moist, non adherent dressing over the defect. Dressings are changed often to keep them moist.

Which of the following statements describes what the nurse must know in order to provide anticipatory guidance to parents of a toddler about readiness for toilet training? A) The child learns voluntary sphincter control through repetition B) Myelination of the spinal cord is completed by this age C) Neuronal impulses are interrupted at the base of the ganglia D) The toddler can understand cause and effect

B) Myelination of the spinal cord is completed by this age Voluntary control of the sphincter muscles can be gradually achieved due to the complete myelination of the spinal cord, sometime between the ages of 18-24 months of age.

While obtaining the history of a 2 week old infant during the well baby exam, the nurse finds that the neonatal screening for phenylketonuria (PKU) was done when the infant was less than 24-hours old. It is a priority for the nurse to A) Schedule the infant for a repeat test in 2 weeks B) Obtain a repeat blood test at this point C) Contact the hospital of birth for the results D) Document that the test results are pending

B) Obtain a repeat blood test at his point A repeat blood specimen should be obtained by the 3rd week of life if the initial specimen was taken from an infant less than 24-hours old.

A couple asks the nurse about risks of several birth control methods. The most appropriate response by the nurse would be A) Norplant is safe and may be removed easily B) Oral contraceptives should not be used by smokers C) Depo-Provera is convenient with few side effects D) The IUD gives protection from pregnancy and infection

B) Oral contraceptives should not be used by smokers

The nurse is providing instructions for a client with asthma. Which of the following should the client monitor on a daily basis? A) RR B) Peak air flow volumes C) Pulse ox D) Skin color

B) Peak air flow volumes

A pregnant woman is hospitalized for treatment of pregnancy induced hypertension in the 3rd trimester. She is receiving mag sulfate IV. The nurse understands that this medication is used mainly to A) Maintain normal BP B) Prevent convulsive seizures C) Decrease the RR D) Increase uterine blood flow

B) Prevent convulsive seizures Mag sulfate is a CNS depressant. While it has many systemic effects, it is used in the client with PIH to prevent seizures.

The nurse manager who is responsible for hiring professional nursing staff is required to comply with the Americans with Disabilities Act. The provisions of the law require the nurse manager to A) Maintain an environment free from hazards B) Provide reasonable accommodations for disabled individuals C) Make all necessary accommodations for disabled individuals D) Consider only physical disabilities in making employment decisions

B) Provide reasonable accommodations for disabled individuals The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant's ability to perform the job and not discriminate on the basis of a disability. Employers must also make "reasonable accommodations".

The nurse is caring for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to groin cast. 36 hours after surgery, the client suddenly becomes confused and short of breath and spikes a temperature of 103 degrees F. The first assessment the nurse should perform is A) Orientation to time, place, and person B) Pulse ox C) Circulation to casted extremity D) BP

B) Pulse ox Restlessness, confusion, irritability and disorientation may be the first stages of fat embolism syndrome followed by a very high temp. The nurse needs to confirm hypoxia first.

A mother brings her child to the clinic complaining. The nurse expects to find which of the following in the clinical history and physical assessment? A) Increased temperature and lethargy B) Rash and restless C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor

B) Rash and restless

A newly admitted elderly client is severely dehydrated. When planning care for this client, which one of the following is an appropriate task for an UAP? A) Obtain a history of fluid loss B) Report output of less than 30ml/hr C) Monitor response to IV fluids D) Check skin turgor every 4 hours

B) Report output of less than 30ml/hr RN is responsible for all care-related decisions, only implementing tasks should be assigned because they don't require independent judgement.

When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the best action the nurse would suggest to the parents is A) Administer syrup of ipecac B) Small amounts of water C) Milk D) Soda

B) Small amounts of water Water will dilute the corrosive substance prior to gastric lavage.

The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk because this medication A) Retards pepsin production B) Stimulates hydrochloric acid formation C) Slows stomach emptying time D) Decreases production of hydrochloric acid

B) Stimulates hydrochloric acid formation

A client is admitted to a psychiatric unit with delusions. The nurse can expect which of the following signs and symptoms? A) Flight of ideas and hyperactivity B) Suspiciousness and resistance to therapy C) Anorexia and hopelessness D) Panic and multiple physical complaints

B) Suspiciousness and resistance to therapy Clinical features of delusional disorder include extreme suspiciousness, jealousy, distrust, belief that others intend to harm.

The nurse is performing a physical assessment on a toddler. Which of the following should be the first action? A) Perform traumatic procedures B) Use minimal physical contact C) Proceed from head to toe D) Explain the exam in detail

B) Use minimal physical contact They need to approach slowly and using minimal contact to gain cooperation. Be flexible in the sequence of the exam, and give only brie simple explanations prior to the action.

The provider orders Lanoxin (Digoxin) 0.125mg PO and furosemide 40mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily? A) Spaghetti B) Watermelon C) Chicken D) Tomatoes

B) Watermelon High in potassium and will replace K lost by the diuretic.

As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? A) "The child has been listless and has lost weight." B) "The urine is dark yellow and small in amounts." C) "Clothes are becoming tighter across her abdomen." D) "We notice muscle weakness and some unsteadiness."

C) "Clothes are becoming tighter across her abdomen" One of the common signs is increase in abdominal girth, needing an additional assessment.

Which of the following statements made by a female client indicate to the nurse that she may have a thought disorder? A) "I'm so angry about this. Wait until my husband hears about this." B) "I'm a little confused. What time is it?" C) "I can't find my 'mesmer' shoes. Have you seen them?" D) "I'm fine. It's my daughter who is the problem."

C) "I can't find my 'mesmer' shoes. Have you seen them?" A neologism is a new word self invented by a person and not readily understood by another that is often associated with a thought disorder.

A client states, "People think I'm no good, you know what I mean?" Which of the following nursing responses would be most therapeutic for this client? A) "Well people often take their own feelings of inadequacy out on others." B) "I think you're good. So you see, there's one person who likes you." C) "I'm not sure what you mean. Tell me a bit more about that." D) "Have you done something to create this impression on people?"

C) "I'm not sure what you mean. Tell me a bit more about that."

Following change of shift report on an orthopedic unit, which client should the nurse see first? A) 16 year old who had an open reduction of a fractured wrist 10 hours ago B) 20 year old in skeletal traction for 2 weeks since a motor cycle accident C) 72 year old recovering from surgery after a hip replacement 2 hours ago D) 75 year old who is on skin traction prior to planned hip pinning surgery

C) 72 year old recovering from surgery after a hip replacement 2 hours ago

Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment? A) An increase in appetite B) A decrease in fluid retention C) A decrease in lethargy D) A reduction in jaundice

C) A decrease in lethargy

In performing a nutritional assessment on a 2 year old, the nurse must know that, in general A) An accurate measurement of intake is not reliable B) The food pyramid is not used in this age group C) A serving size at this age is about 2 tablespoons D) Total intake varies greatly each day

C) A serving size at this age is about 2 tablespoons In children, a general guide to serving size is 1 tablespoon of solid food per year of age.

The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the following actions would be most appropriate? A) Fluid restriction 1000cc per day B) Ambulate in hallway 4x a day C) Administer analgesic therapy as ordered D) Encourage increased caloric intake

C) Administer analgesic therapy as ordered Treatment of sickle cell crisis includes bed rest, hydration, electrolyte replacement, analgesics for pain, blood replacement and antibiotics for existing infection.

A client with a documented pulmonary embolism has the following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 4.5, SaO2 - 87%, HCO3 - 22. Based on this data, what is the first nursing action? A) Review other lab data B) Notify the health care provider C) Administer oxygen D) Calm the client

C) Administer oxygen Low PCO2 from increased RR from the hypoxemia and signs of respiratory alkalosis.

What document should be in guiding the care of this client? A) Client Self Determination Act B) Physician's treatment orders C) Advance Directives D) Clinical Pathway Protocols

C) Advance Directives It specifies client's wishes.

The nurse is planning care for a 14 year old client returning from scoliosis corrective surgery. Which of he following actions should receive priority in the plan? A) Antibiotic therapy for 10 days B) Teach the client isometric exercises for legs C) Assess movement and sensation of extremities D) Assist to stand up at bedside within the first 24 hours

C) Assess movement and sensation of extremities

A child is injured on the school playground and appears to have a fractured leg. The first action the nurse should take is A) Call for emergency transport to the ER B) Immobilize the limb and joints above and below the injury C) Assess the child and the extent of the injury D) Apply cold compress to the injured area

C) Assess the child and the extent of the injury Assessment first.

A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is A) Call for emergency transport to the hospital B) Immobilize the limb and joints above and below the injury C) Assess the child and the extent of the injury D) Apply cold compresses to the injured area

C) Assess the child and the extent of the injury When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis).

A 72 year old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is most important action by the nurse? A) Investigating the client's insurance coverage for home IV antibiotic therapy B) Determining if there are adequate hand washing facilities in the home C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver D) Selecting the appropriate venous access device

C) Assess the client's ability to participate in self care and/or the reliability of a caregiver The cognitive ability of the client as well as the availability and reliability of a caregiver must be assessed to determine if home care is a feasible option.

A 72 year old client with osteomyelitis requires a six week course of intravenous antibiotics. In planning for home care, the most important action by the nurse is A) Investigating the client's insurance coverage for home IV antibiotic therapy B) Determining if there are adequate hand washing facilities in the home C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver D) Selecting the appropriate venous access device

C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver The cognitive ability of the client as well as the availability and reliability of a caregiver must be assessed to determine if home care is a feasible option.

An 8 year old client is admitted to the hospital for surgery. The child's parent reports several allergies. Which of the following should all health care personnel be aware of? A) Shellfish B) Molds C) Balloons D) Perfumed soap

C) Balloons Balloons would be the latex allergy for needing to wear non latex gloves.

In children suspected to have a diagnosis of diabetes, which one of the following complaints would most likely to prompt parents to take their school age child for evaluation? A) Polyphasia B) Dehydration C) Bed wetting D) Weight loss

C) Bed wetting

When assessing a client admitted to the hospital for diabetic acidosis, which of the following clinical manifestations would the nurse expect? A) A blood pH level above 7.5 B) Arterial blood PCO2 above 40 C) Blood pH level below 7.3 D) Arterial blood PCO2 below 10

C) Blood pH level below 7.3 In the absence of insulin, which facilitates the transport of glucose into the cell, the body breaks down fat and proteins to supply energy ketones, a by-product of fat metabolism. These accumulate causing metabolic acidosis (<7.3).

An 8 year old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which one of the following is the best choice? A) Bologna sandwich, pudding, milk B) Frankfurter, baked potato, milk C) Chicken strips, corn on the cob, milk D) Grilled cheese, apple, milk

C) Chicken strips, corn on the cob, milk This menu is lowest in sodium.

A 32 year old female client is being treated for Guillain-Barre syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for further evaluation? A) Complaints of a headache B) Loss of superficial and deep tendon reflexes C) Complaints of SOB D) Facial paralysis

C) Complaints of SOB 40% of all clients have some detectable respiratory weakness and should be prepared for a possible trach and pneumonia is also a common complication of this syndrome.

The nurse is administering an IV vesicant chemotherapeutic agent to a client. Which assessment would require the nurse's immediate action? A) Stomatitis lesion in the mouth B) Severe nausea and vomiting C) Complaints of pain at site of infusion D) A rash on the clients extremities

C) Complaints of pain at site of infusion A vesicant is a chemotherapeutic agent capable of causing blistering of tissues and possible tissue necrosis if there is a extravasation. These agents are irritants which cause pain along the vein wall, with or without inflammation.

The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to one chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most important nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Continue to monitor the client to see if the bubbling increases D) Instruct the client to try to avoid coughing

C) Continue to monitor the client to see if the bubbling increases Bubbling associated with a cough after lung surgery is to be expected as small amounts of air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only action required.

The nurse is assessing a 17 year old female client with bulimia. Which of the following laboratory reports would the nurse anticipate? A) Increased serum glucose B) Decreased albumin C) Decreased potassium D) Increased sodium retention

C) Decreased potassium In bulimia, loss of electrolytes can occur in addition to signs and symptoms of starvation and dehydration.

A client voluntarily admits herself to the hospital due to suicidal ideation. The client has been on the unit for 2 days and is now demanding to be released. The most appropriate action is for the nurse to A) Tell the client that she cannot be released because she is still suicidal B) Inform the client that she can be released only if she signs a no suicide contract C) Discuss with the client the decision to leave and prepare for her discharge D) Instruct her regarding her right to sign out upon receipt of the physician's discharge order

C) Discuss with the client the decision to leave and prepare for her discharge

The nurse is caring for a client who has developed cardiac tamponade. Which of the following assessments would the nurse anticipate finding? A) Widening pulse pressure B) Pleural friction rub C) Distended neck veins D) Bradycardia

C) Distended neck veins

A 25 year old client believes she may be pregnant with her first child. She schedules an obstetric exam with the NP to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nagel's rule is A) March 27 B) February 1 C) February 27 D) January 3

C) February 27 Subtract 3 months from the date from period date then add 7 days to the result.

A 6 year old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has short palpebral fissures, thinned upper lip, and hypoplastic philtrum of the lip. The mother states that the child seems to have problems learning to count and recognizing basic colors. Based on this data, the nurse suspects that the child is most likely showing the effects of A) Congenital abnormalities B) Chronic toxoplasmosis C) Fetal alcohol syndrome D) Lead poisoning

C) Fetal alcohol syndrome Major features are facial and associated features, such as short palpebral fissure, hypo plastic philtrum, thinned upper lip, short, upturned nose. Behavioral problems, cognitive impairment, and psychosocial deficits are also associated with this syndrome.

When teaching suicide prevention to the parents of a 15 year old who recently attempted suicide, the nurse describes the following behavioral cue A) Angry outbursts at significant others B) Fear of being left alone C) Giving away valued personal items D) Experiencing the loss of a boyfriend

C) Giving away valued personal items

Which blood serum finding in a client with diabetic ketoacidosis alerts the nurse that immediate action is required? A) pH below 7.3 B) Potassium of 5.0 C) HCT of 60 D) Pa O2 of 79%

C) HCT of 60 Severe dehydration indication.

A client with the diagnosis of C4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report A) Dizziness and tachypnea B) Circumoral fallow and lightheadedness C) Headache and facial flushing D) Pallor and itching of the face and neck

C) Headache and facial flushing

The mother of a 2 year old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The best response of the nurse would be to A) Request the mother remain with the child at all times B) Explain that this behavior will stop within a few days C) Help the mother understand this is a normal response to hospitalization D) Suggest that the mother "sneak out" of the child's room when he is sleeping

C) Help the mother understand this is a normal response to hospitalization

The nurse caring for a 9 year old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which of the following nursing diagnoses is a priority at this time? A) Risk for fluid volume deficit related to morphine overdose B) Decreased GI mobility related to mucosal irritation C) Ineffective breathing patterns related to CNS depression D) Altered nutrition related to inability to control nausea and vomiting

C) Ineffective breathing patterns related to CNS depression

An appropriate goal for a client with anxiety would be to A) Ventilate her feelings to the nurse B) Establish contact with reality C) Learn self-help techniques for reducing anxiety D) Become desensitized to past trauma

C) Learn self-help techniques for reducing anxiety

A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning? A) Use ready-to-feed commercial infant formula B) Boil the tap water for 10 minutes prior to preparing the formula C) Let tap water run for 2 minutes before adding the concentrate D) Buy bottled water labeled "lead free" to mix the formula

C) Let tap water run for 2 minutes before adding the concentrate Use of lead-contaminated water to prepare formula is a major source of poisoning in infants. Drinking water may be contaminated by lead from old lead pipes or lead solder used installing water pipes. Letting tap water run for several minutes will diminish the lead contamination.

The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed RBCs. Which of the following is an appropriate action for the nurse when administering the infusion? A) Storing the RBCs in the medicine refrigerator while starting IV B) Slow the infusion if the client develops fever or chills C) Limit the infusion time of each of the units to a maximum of 4 hours D) Assess vital signs every 15 minutes throughout the entire infusion

C) Limit the infusion time of each of the units to a maximum of 4 hours If the infusion exceeds 4 hours, the blood should be divided into appropriately sized quantities.

The nurse's primary intervention for a client who is experiencing a panic attack is to A) Develop a trusting relationship B) Assist the client to describe his experience in detail C) Maintain safety for the client D) Teach the client to control his or her own behavior

C) Maintain safety for the client

What findings signifies that children have attained the stage of concrete operations (Piaget)? A) Explores the environment with the use of sight and movement B) Thinks in mental images or word pictures C) Makes the moral judgement that "stealing is wrong" D) Reasons that homework is time-consuming yet necessary

C) Makes the moral judgement that "stealing is wrong"

What nursing observation signifies that a client has attained the stage of concrete operations (Piaget)? A) Explores his environment using sight and movement B) Can think in mental images or word pictures C) Makes the moral judgement that "stealing is wrong" D) Reasons that homework is time-consuming but necessary

C) Makes the moral judgement that "stealing is wrong" The stage of concrete operations is depicted by logical thinking and moral judgements.

The history for a newborn suspected of having pyloric stenosis would most likely reveal A) Absence of gastrointestinal peristalsis B) Frequent vomiting of bile-stained fluid C) Mild emesis progressing to projectile vomiting D) Cyanosis and vomiting immediately after feedings

C) Mild emesis progressing to projectile vomiting Mild regurgitation or emesis that progresses to projectile vomiting is a pattern of vomiting associated with pyloric stenosis.

To which of the following nursing home residents could the nurse safely administer tricyclic antidepressants without questioning the physician's order, a client with A) Narrow-angle glaucoma B) Benign prostatic hypertrophy C) Mild hypertension D) Coronary artery disease

C) Mild hypertension

A client has returned to the unit following a renal biopsy. Which of following nursing interventions is appropriate? A) Ambulate the client 4 hours after procedure B) Maintain client on NPO status for 24 hours C) Monitor vital signs D) Change dressing every 8 hours

C) Monitor vital signs The potential complication is internal hemorrhage and there are early indications of bleeding to monitor vitals.

A client is admitted with a right upper lobe infiltrate, and also to rule out tuberculosis. The isolation precautions the nurse would institute include A) Positive pressure ventilation B) Gown and gloves C) Particulate respirator mask D) Barrier precaution

C) Particulate respirator mask Airborne diseases require high-efficiency masks.

A 10 year old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a Hbg of 9 g/dL and a Hct of 28%. The best approach for the nurse to use is to A) Limit milk and milk products B) Encourage bed activities and games C) Plan nursing care around lengthy rest periods D) Promote a diet rich in iron

C) Plan nursing care around lengthy rest periods The initial priority is rest due to inability of RBC to carry oxygen.

A 3 year old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack? A) Cheese crackers B) PBJ sandwich C) Potato chips D) Vanilla cookies

C) Potato chips Gluten is found in grains of wheat and rye and in smaller quantities in barley and oats. Corn, rice, soybeans, and potato are digestible.

The nurse is aware that which of the following psychosocial needs are best described in the adolescent when hospitalized? A) Independence, confidence, narcissism B) Group sports, competition, being right C) Privacy, autonomy, peer interactions D) School performance, reading, journal writing

C) Privacy, autonomy, peer interactions

When caring for a client receiving warfarin sodium (Coumadin), the nurse would monitor the results of the clients A) Bleeding time B) Coagulation time C) Prothrombin time D) Partial thromboplastin time

C) Prothrombin time The pathway in the clotting cascade and affects the Vitamin K dependent clotting factors.

When caring for a client receiving warfarin sodium (Coumadin), the nurse would monitor the results of the client's A) Bleeding time B) Coagulation time C) Prothrombin time D) PTT

C) Prothrombin time This test evaluates the adequacy of the extrinsic system and common pathway in the clotting cascade; Coumadin affects the Vitamin K dependent clotting factors.

A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of the following symptoms noted on the initial nursing assessment is expected? A) Recent weight gain B) Physical growth delay C) Protruding eyes D) Sudden onset of irritability

C) Protruding eyes Exophthalmos or protruding eyeballs is a distinctive characteristic of the disease.

Which of the following interventions best demonstrates the nurse's sensitivity to a 16 year old's appropriate need for autonomy? A) Alertness for feelings regarding body image B) Allows young siblings to visit C) Provides opportunity to discuss concerns without presence of parents D) Explores his feelings of resentment to identify causes

C) Provides opportunity to discuss concerns without presence of parents This intervention provides the teen with the opportunity to have control and encourages decision making.

An important goal in the development of a therapeutic in patient milieu is A) Providing a business like atmosphere where clients can work on individual goals B) Providing a group forum in which clients decide on unit rules, regulations, and policies C) Providing a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions D) Discouraging expressions of anger because they can be disruptive to other clients

C) Providing a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions

Which of the following symptoms contraindicate the use of haloperidol (Haldol) and warrant withholding the dose? A) Drowsiness, lethargy, inactivity B) Dry mouth, nasal congestion, blurred vision C) Rash, blood dycrasias, severe depression D) Hyperglycemia, weight gain, edema

C) Rash, blood dycrasias, severe depression They are side effects of anti-psychotic drugs and a history of severe depression is a contraindication to the use of neuroleptics.

The nurse notes that a 2 year old child recovering from a tonsillectomy has a temperature of 98.2 at 8am. At 10am the child's parent reports that the child "feels very warm" to touch. The first action by the nurse should be to A) Reassure the parent that this is normal B) Offer the child cold oral fluids C) Reassess the child's temperature D) Administer the prescribed acetaminophen

C) Reassess the child's temperature

The nurse notes that a 2 year old child recovering from a tonsillectomy has a temperature of 98.2 degrees F at 8am. At 10am the child's mother reports that the child feels very warm to the touch. The first action by the nurse should be to A) Reassure the mother that this is normal B) Offer the child cold oral fluids C) Reassess the child's temperature D) Administer the prescribed acetaminophen

C) Reassess the child's temperature

The nurse assessing a newborn notices that the breasts are enlarged bilaterally with a white, thin discharge. The initial action of the nurse should be to A) Notify the attending practitioner B) Ask about medications taken in pregnancy C) Record the findings as "normal" D) Obtain fluid to send for culture

C) Record the findings as "normal"

A client with bipolar disorder taking lithium tells the nurse that he has ringing in his ears, blurred vision, and diarrhea. The nurse notices a slight tremor in his left hand and a slurring pattern to his speech. Which of the following actions by the nurse is appropriate? A) Administer a stat dose of lithium as necessary B) Recognize this as an expected response to lithium C) Request an order for a stat blood lithium level D) Give an oral dose of lithium antidote

C) Request an order for a stat blood lithium level These are symptoms of lithium toxicity.

An 18 year old client is admitted to intensive care from the ER following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's priority assessment should be A) Response to stimuli B) Bladder control C) Respiratory function D) Muscle weakness

C) Respiratory control

Which of the following best describes the application of time management strategies in the role of the nurse manager? A) Scheduling staff efficiently to cover client needs B) Assuming a fair share of the client care as a role model C) Setting daily goals to prioritize work D) Delegating tasks to reduce work load

C) Setting daily goals to prioritize work Time management strategies must include setting priorities and meeting goals.

The nurse is assessing an 8 month old child. The nurse would anticipate that the child would be able to A) Say 2 words B) Pull up to stand C) Sit without support D) Use a spoon

C) Sit without support

While the nurse assesses a 2 month old infant, the mother expresses concern because a flat pink birthmark on the baby's forehead and eyelid has not gone away. The nurse should tell the parents that A) Mongolian spots are a normal finding in dark-skinned children B) Port wine stains are often associated with other malformations C) Telangiectatic nevi are normal and will disappear as the baby grows D) The child is too young for surgical removal at this time

C) Telangiectatic nevi are normal and will disappear as the baby grows Telangiectatic nevi, salmon patch or stork bite are a normal variation and the facial nevi will generally disappear by ages 1-2 years.

The nurse is caring for a client with COPD who suddenly complains of sharp pains in the right side of his chest, is cyanotic and has a tracheal deviation toward the right side. The nurse recognizes that these symptoms are probably due to A) Atelectasis B) Respiratory acidosis C) Tension pneumothorax D) Bronchospasm

C) Tension pneumothorax

A client had 20mg of Lasix (furosemide) PO at 10am. Which would be essential for the nurse to include at the change of shift report? A) The client lost 2 lbs in 24 hours B) The client's potassium level is 4 mEq/L C) The client's urine output was 1500 cc in 5 hours D) The client is to receive another dose of Lasix at 10pm

C) The client's urine output was 1500 cc in 5 hours In a shift report, this is an essential piece of info to include.

A client has 20mg of Lasix (Furosemide) PO at 10am. Which would be essential for the nurse to include at the change of shift report? A) The client that lost 2 lbs B) The client's potassium level is 4 mEq/L C) The client's urine output was 1500cc in 5 hours D) The client is to receive another dose of Lasix at 10pm

C) The client's urine output was 1500cc in 5 hours

A 6 month old infant has been admitted to the ER with febrile seizures. In the teaching of the parents, the nurse states that: A) Sustained temp elevation over 103 is generally related to febrile seizures B) Febrile seizures do not usually reoccur C) There is little risk of neurological deficit and mental retardation as sequelae to febrile seizures D) Febrile seizures are associated with diseases of the CNS

C) There is little risk of neurological deficit and mental retardation as sequelae to febrile seizures

The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? A) Donating blood B) Using public bathrooms C) Unprotected sex D) Touching a person with AIDS

C) Unprotected sex

The nurse is performing a pre-kindergarten physical on a 5 year old. The last series of vaccines will be administered. What is the preferred site for injection by the nurse? A) Vastus intermedius B) Gluteus rainlinus C) Vastus lateralis D) Dorsogluteal

C) Vastus lateralis

The nurse is giving instructions to the parents of a child with CF. The nurse would emphasize that pancreatic enzymes should be taken A) Once each day B) 3x daily after meals C) With each meal or snack D) Each time carbs are eaten

C) With each meal or snack Pancreatic enzymes should be taken with each meal or snack to allow for digestion of all foods that are eaten.

The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from A) a tissue bank B) a pig C) my thigh D) synthetic skin

C) my thigh Autografts are done with tissue transplanted from the client's own skin.

A diagnosis of hep C is confirmed by a male client's physician. The nurse should be knowledgeable of the differences between hep A, B, and C. Which of the following are characteristics of hep C? A) The potential for chronic liver disease is minimal B) The onset of symptoms is abrupt C) The incubation period is 2-26 weeks D) There is an effective vaccine for hep B, but not for hep C

C. The incubation period is 2-26 weeks. Hepatitis C and B may result in chronic liver disease. Hepatitis A has a low potential for chronic liver disease. Hepatitis C and B have insidious onsets. Hepatitis A has an abrupt onset. Incubation periods are C:2-26 weeks, B:6-20 weeks, and A:2-6 weeks. Only Hep B has an effective vaccine.

A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to: A) Pass a nasogastric tube through the left nostril B) Place a 4x4 gauze in the nares to impede the flow C) Gently suction the nasal drainage to protect the airway D) Perform a halo test and glucose level on the drainage

D) Perform a halo test and glucose level on the drainage

A client states to his nurse that "I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells." Which drug might the nurse expect to be discontinued? A) Prednisone B) Timolol maleate (Blocadren) C) Garamycin (Gentamicin) D) Phenytoin (Dilantin)

D) Phenytoin (Dilantin) It has been linked to blood dycrasias such as aplastic anemia which is linked to chloramphenicol (Cholmycetin).

A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my husband will never come near me." The nurse's best response would be A) "You are underestimating your husband's ability to love you" B) "Are you concerned that your husband will reject you?" C) "Are you wondering about the effect on your sexual relations?" D) "Are you worried that the surgery will change you?"

D) "Are you worried that the surgery will change you?"

A client, recovering from alcoholism, asks the nurse, "What can I do when I start recognizing relapse triggers within myself?" How might the nurse best respond? A) "When you have the impulse to stop in a bar, contact a sober friend and talk with him." B) "Go to an AA meeting when you feel the urge to drink." C) "It is important to exercise daily and get involved in activities that will cause you not to think about drug use." D) "Identify your relapse triggers as part of getting better."

D) "Identify your relapse triggers as part of getting better."

The nurse is teaching administration of albuterol inhalation to an asthmatic adult. The priority is A) "Use this medication at bedtime to promote rest." B) "Discontinue the inhalation if you are dizzy." C) "Inhale this medication after other asthma sprays." D) "Notify the physician if you need the drug more often."

D) "Notify the drug if you need more often."

A pregnant client asks the nurse about the scheduled blood test for alpha-fetoprotein (AFP). The nurse's best explanation is A) "It tells us how far along your pregnancy is" B) "The results help determine if the baby is growing normally" C) "Placental exchange of oxygen is measured" D) "Possible neurological defects may be identified"

D) "Possible neurological defects may be indicated" A fetus with neural tube defects loses AFP to the amniotic fluid and hence the maternal blood. High levels indicate the possibility of defects such as spina bifida and meningocele. Further assessments are indicated if a test is positive.

A client with paranoid delusions stares at the nurse for several days. The client suddenly walks up to the nurse and shouts "you think you're so perfect and pure and good." An appropriate response for the nurse is A) "Is that why you've been starring at me?" B) "You seem to be in a really bad mood." C) "Perfect? I don't quite understand." D) "You are angry right now."

D) "You are angry right now."

A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states, "This is not my baby, and I do not want it." The nurse's best response is A) "This is a common occurrence after birth, but you will come to accept the baby." B) "Many women have post party blues and need some time to love the baby." C) "What a beautiful baby! Her eyes are just like yours." D) "You seem upset; tell me what the pregnancy and birth were like for you."

D) "You seem upset; tell me what the pregnancy and birth were like for you."

The client nurse assesses a toddler with a tentative diagnosis of neuroblastoma. Symptoms the nurse observes that suggest this problem include A) Lymphedema and nerve palsy B) Hearing loss and ataxia C) Headaches and vomiting D) Abdominal mass and weakness

D) Abdominal mass and weakness Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline, weakness, pallor, anorexia, weight loss, and irritability.

A client complaining of severe shortness of breath is diagnosed with CHF. The nurse observes a falling pulse ox. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following? A) Call the physician B) Check vitals C) Position in high Fowler's D) Administer O2

D) Administer O2 When dealing with a medical emergency, the rule is airway first, then breathing, then circulation. Starting O2 is PRIORITY!

The nurse is assessing a client with a stage 2 skin ulcer. Which of the following treatments is most effective to promote healing? A) Covering the wound with a dry dressing B) Using hydrogen peroxide soaks C) Leaving the area open to dry D) Applying a transparent film cover

D) Applying a transparent film cover

The mother of a school-aged child in a long leg cast asks the nurse how to relieve itching inside the cast. Which of the following is appropriate for the nurse to suggest as a remedy? A) Scratching the outside of the cast vigorously, applying pressure over the area B) Blowing a hair dryer or heat lamp on the cast over the area that is itching C) Using a long, smooth piece of wood to gently scratch the affected area D) Applying an ice pack over the area of the cast that is affected

D) Applying an ice pack over the area of the cast that is affected

A 64 year old client scheduled for surgery with a general anesthetic refuses to remove her dentures prior to leaving the unit for the OR. The most appropriate intervention by the nurse is A) Explain to the client that the dentures must come out as they may get lost or broken in the operating room B) Ask the client if she is having second thoughts about the procedure C) Notify the surgeon of the clients refusal D) Ask the client if she would prefer removing the dentures in the OR receiving area

D) Ask the client if she would prefer removing the dentures in the OR receiving area Clients anticipating surgery may experience a variety of hears. This choice allows the client control over the situation and fosters the client's sense of self-esteem and self-concept

2 hours after the normal spontaneous vaginal delivery of a woman who is gravida 4 para 4, the nurse notes that the fundus is boggy and displaced slightly above and to the left of the umbilicus. The appropriate initial nursing action is to A) Assess lochia for color and amount B) Monitor pulse and BP C) Call the physician immediately D) Ask the woman to empty her bladder

D) Ask the woman to empty her bladder A full bladder can displace the uterus and prevent contractions. The fundus should be assessed again after fully emptying.

A 16-year-old presents at the emergency department. The triage nurse finds that this teenager is legally married and signed the consent form for treatment. What would be the appropriate initial action by the nurse? A) Refuse to see the client until a parent or legal guardian can be contacted B) Withhold treatment until telephone consent can be obtained from the spouse C) Refer the client to a community pediatric hospital emergency room D) Assess and treat in the same manner as any adult client

D) Assess and treat in the same manner as any adult client Minors may become known as "emancipated minor" through marriage, pregnancy, high school graduation, independent living, or service in the military (have the legal capacity of an adult).

A client diagnosed with Hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which of the following as the most important data? A) Recent travel to Central America B) Ingestion of raw shellfish last week C) Multiple sex partners D) Blood transfusion 15 years ago

D) Blood transfusion 15 years ago The client who has transfused before blood screening for Hep C may show symptoms many years later.

The nurse is explaining the proper use of syrup of ipecac to a group of parents. For which of the following accidental poisoning is the treatment appropriate? A) Oven cleaner B) Drain cleaner C) Kerosene D) Chewable vitamins

D) Chewable vitamins Poisoning with vitamins is the only case in which it is safe to induce vomiting with syrup of ipecac.

A client was admitted to the eating disorder unit with bulimia nervosa. When the nurse assesses for a history of complications of this disorder, the following are expected A) Respiratory distress, dyspnea B) Bacterial gastrointestinal infections, over hydration C) Metabolic acidosis, constricted colon D) Dental erosion, parotid gland enlargement

D) Dental erosion, parotid gland enlargement

Diagnostic assessment findings for an infant with possible coarctation of the aorta would include A) A 3rd heart sound B) A diastolic murmur C) Pulse pressure difference between the upper extremities D) Diminished or absent femoral pulses

D) Diminished or absent femoral pulses

The nurse is caring for a 15 month old child with a first episode of otitis media. Which of the following interventions should the nurse include in instructions to the child's parents? A) Explain that the child should complete the full 5 days of antibiotics B) Provide them with handout describing care of myringotomy tubes C) Describe the tymanocentesis to detect persistent infections D) Emphasize the importance of a return visit after completion of antibiotics

D) Emphasize the importance of a return visit after completion of antibiotics The usual treatment for otitis media is oral antibiotics for 10-14 days. The child should be examined again after completion of the full course of antibiotics to assess for persistent infection or middle ear effusion.

A 14 month old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see in the child? A) Hypothermia B) Edema C) Dyspnea D) Epistaxis

D) Epistaxis

A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to A) Promote comfort B) Reduce drying time C) Decrease irritation to the skin D) Improve venous return

D) Improve venous return

The nurse is caring for a 4 year old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately? A) Vomiting of dark emesis B) Complaints of throat pain C) Apical heart rate of 110 D) Increased restlessness

D) Increased restlessness Restlessness and increased RR and HR are early signs of hemorrhage in infants and children.

The nurse is teaching a client with non-insulin dependent DM about the prescribed diet. The nurse should teach the client to A) Maintain previous calorie intake B) Keep a candy bar available at all times C) Reduce carbs intake to 25% of total calories D) Keep a regular schedule of meals and snacks

D) Keep a regular schedule of meals and snacks

The nurse is caring for a 17 month old with acetaminophen poisoning. Which of the following lab reports should the nurse review first? A) Prothrombin time (PT) and partial thromboplastin time (PTT) B) RBC and WBC counts C) Blood urea nitrogen and creatinine clearance D) Liver enzymes (AST and ALT)

D) Liver enzymes (AST and ALT)

The nurse is preparing a client with a DVT for a venous doppler evaluation of the following would be necessary for preparing the client for this test? A) Client should be NPO after midnight B) Client should receive a sedative medication prior to the test C) Discontinue anticoagulant therapy prior to the test D) No special preparation is necessary

D) No special preparation is necessary

An 11-month old infant is admitted with a possible diagnosis of pyloric stenosis. Which of the following best describes the characteristic clinical manifestations of pyloric stenosis? A) Pain, especially when eating B) Poor appetite and sucking reflex C) Increased frequency and quality of stools D) Palpable olive-shaped mass in the epigastrium just right of the umbilical cord

D) Palpable olive-shaped mass in the epigastrium just right of the umbilical cord

A 3 year old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would initially assess for A) Allergies B) Hyperactivity C) Regression D) Pinworms

D) Pinworms Signs of pinworm infection include intense perianal itching, poor sleep patterns, general irritability, restlessness, bed-wetting, distractibility, and short attention span.

A 3 year old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting his bed at night." Based on these complaints, the nurse would initially assess for which problem? A) Allergies B) Scabies C) Regression D) Pinworms

D) Pinworms Signs of pinworm infection include intense perianal itching, poor sleep patterns, general irritability, restlessness, bed-wetting, distractibility.

The nurse manager hears a physician loudly criticizing one of the nurses in the hearing of others. The employee does not respond to the physician's complaints. The nurse manager's first action should be A) Walk up to the physician and quietly ask that this unacceptable behavior stop B) Allow the nurse to handle this situation without interference C) Notify the Nursing Director and Medical Staff Chief of a breech of professional conduct D) Request an immediate private meeting with the physician and staff nurse

D) Request an immediate private meeting with the physician and staff nurse The nurse manager needs to first protect clients and other staff from this display and come to the assistance of the nurse employee.

During the initial home visit, a nurse is discussing the care of a newly diagnosed with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time? A) Leave a book about relaxation techniques B) Write out a daily exercise routine for them to assist the client to do C) List actions to improve the client's daily nutritional intake D) Suggest communication strategies

D) Suggest communication strategies Alzheimer's disease, a progressive chronic illness, greatly challenges caregivers. The nurse can be of greatest assistance in helping the family to use communication strategies to enhance their ability to relate to the client. By use of select verbal and nonverbal communication strategies the family can best support the client's strengths and cope with any aberrant behavior.

A nurse is working with family members of a newly diagnosed client with Alzheimer's disease. Which of the following interventions is most helpful? A) Teaching relaxation techniques B) Implementing a daily exercise routine C) Improving daily nutritional intake D) Suggesting communication strategies

D) Suggesting communication strategies The nurse can be of greatest assistance in helping the family to identify language changes, and select verbal and nonverbal communication strategies to minimize aberrant behavior.

A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse assesses this as A) Dystonia B) Akathisia C) Brady dyskinesia D) Tardive dyskinesia

D) Tardive dyskinesia Signs are lip smacking, grinding of teeth, and "fly catching" tongue movements.

The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that A) Quality of care will improve B) Staff turnover should decrease C) Flexible scheduling will occur D) Team morale will improve

D) Team morale will improve Nurses are more satisfied with autonomy and control. The nurse manager becomes the facilitator of scheduling rather than the decision-maker of the schedule.

As the nurse provides discharge teaching to the parents of a 15 month-old child with Kawasaki disease. The child has received immunoglobulin therapy. Which instruction would be appropriate? A) High doses of aspirin will be continued for some time B) Complete recovery is expected within several days C) Active range of motion exercises should be done frequently D) The measles, mumps and rubella vaccine should be delayed

D) The measles, mumps and rubella vaccine should be delayed Discharge instructions should include that immunoglobulin therapy may interfere with the body's ability to form appropriate amounts of antibodies and live immunizations should be delayed.

Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students. A) Scratching the head more than usual B) Flakes evident on a student's shoulders C) Oval pattern occipital hair loss D) Whitish oval specks sticking to the hair

D) Whitish oval specks sticking to the hair Observing white eggs (nits) firmly attached to the hair shafts. Treatment includes shampoo application, such as lindane for children over 2, and meticulous combing and removal of all nits.

Consensus Formula (Resuscitation Phase- BURNS: Assess LOC)

pt. weight (kg) x % area burned x 2mL= minimum fluid volume/ 24 hours pt. weight (kg) x % area burned x 4mL= maximum fluid volume/ 24 hours The patient should receive 1/2 of the total volume fluid during the 1st 8 hours and the remaining 1/2 in the next 16 hours head: 4.5% chest/back: 18% arms: 4.5% genital area: 1% legs: 9%