NP 5
c. I, II, IV, V, VI
The client with MS tells the nurse about extreme fatigue. Which assessment findings should the nurse identify as contributing to the client's fatigue? Select all that apply. I. Hemoglobin 9.5 g/dL and hematocrit is 31.8% II. Taking baclofen 15 mg 3 times per day III. Working 4 to 8 hours per week in the family business IV. Stopped taking amitriptyline 8 weeks earlier V. Presence of a cardiac murmur at the tricuspid valve. VI. Bilateral leg weakness noted when walking in room a. I, II, III b. I, II, III, IV c. I, II, IV, V, VI d. I, II, III, IV, V
d. "Can you tell me how many months you think rebuilding will take?"
The client's home was destroyed by a major flood. The client is attending a support group and says, "I will rebuild my home as good as new and be back in it in a few months." What should be the nurse's initial response? a. "That's a very ambitious plan to undertake at this time." b. "I'm proud of your resiliency and willingness to start over." c. "Have you given thought to what may happen if it floods again?" d. "Can you tell me how many months you think rebuilding will take?"
c. Ratio
The data on the family's number of children is appropriate for what level of measurement? a. Interval b. Ordinal c. Ratio d. Nominal
d. "Three drinks a day or seven drinks in a week is high-risk drinking for women. You seem concerned that you might have an alcohol dependency."
The female client tells the nurse, "I usually have a few drinks after work, but I always limit it to three. I'm not risking becoming addicted, am I?" What is the nurse's best response? a. "There is no harm in social drinking as long as you know your limits and you are not driving while intoxicated." b. "As long as you don't have any social problems associated with your use of alcohol, you do not need to be concerned." c. "If you are concerned about the frequency and the number of drinks consumed, then you might be developing a dependency." d. "Three drinks a day or seven drinks in a week is high-risk drinking for women. You seem concerned that you might have an alcohol dependency."
d. Identify possible courses of action
The following are basic steps in the controlling process of the department. Which of the following is NOT included? a. Measure actual performance b. Set nursing standards and criteria c. Compare results of performance to standards and objectives d. Identify possible courses of action
a. II, III, V
The home-care nurse is counseling the client who has MS. The client is experiencing weakness, ataxia, intermittent adductor spasms of the hips, and occasional incontinence from loss of bladder sensation. Which self-care measures should the nurse recommend? Select all that apply. I. "Adductor spasms can be relieved by taking a hot bath." II. "If a muscle is in spasm, stretch and hold it, and then relax." III. "Rest first and then walk as able using a walker for support." IV. "When walking, keep feet close together, legs slightly bent." V. "Set an alarm to remind you to void 30 minutes After fluid intake." a. II, III, V b. II, III, IV c. II, III, I d. II, III
c. Spirituality provides a sense of meaning and purpose for many clients.
The hospice care nurse is conducting a spiritual care assessment. Which statement is the scientific rationale for this intervention? a. The client will ask all of his or her spiritual questions and get answers. b. The nurse is able to explain to the client how death will affect the spirit. c. Spirituality provides a sense of meaning and purpose for many clients. d. The nurse is the expert when assisting the client with spiritual matters.
d. acde
The hospitalized client has a history of weekly moderate alcohol use. Which symptoms assessed by the nurse indicate that the client may be experiencing alcohol withdrawal? Select all that apply. a. Agitation b. Hypotension c. Tachycardia d. Hallucinations e. Tongue tremor a. bcde b. abcd c. abcde d. acde
a. "Some people have a warning that the seizure is about to start."
The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, "I don't know what you mean. What are auras?" Which statement by the nurse would be the best response? a. "Some people have a warning that the seizure is about to start." b. "Auras occur when you are physically and psychologically exhausted." c. "You're concerned that you do not have auras before your seizures?" d. "Auras fight for her friend in the bar."
a. Scleral jaundice
The nurse assesses that the client with hemolytic anemia has weakness, fatigue, malaise, and skin and mucous membrane pallor. Which finding should the nurse also associate with hemolytic anemia? a. Scleral jaundice b. A smooth, red tongue c. A craving for ice to chew d. A poor intake of fresh vegetables
b. Spinal shock
The nurse assesses the client, who was injured in a diving accident 2 hours earlier. The client is breathing independently but has no movement or muscle tone from below the area of injury. A CT scan reveals a fracture of the C4 cervical vertebra. The nurse should plan interventions for which problem? a. Complete spinal cord transection b. Spinal shock c. An upper motor neuron injury d. Quadriplegia
b. Explain how to overcome a freezing gait by telling the client to march in place.
The nurse has asked the nursing assistant to ambulate a client with Parkinson's disease. The nurse observes the nursing assistant pulling on the client's arms to get the client to walk forward. The nurse should: a. Praise the nursing assistant as this is appropriate. b. Explain how to overcome a freezing gait by telling the client to march in place. c. Assist the NA with getting the client back in bed. d. Give the client a muscle relaxant as studies have proved that this is effective in this situation.
b. Drowsy or confused state following a seizure
The nurse in the ED documents that the newly admitted client is "postictal upon transfer." What did the nurse observe? a. Yellowing of the skin due to a liver condition b. Drowsy or confused state following a seizure c. Severe itching of the eyes from an allergic reaction d. Abnormal sensations including tingling of the skin
d. Psycho genie amnesia symptoms include wandering and disorientation.
The nurse in the ED is assessing the client who was injured in a car accident. The nurse considers that the client may have psychogenic amnesia when the client is unable to recall any personal information. Which statement that reflects the nurse's critical thinking about psychogenic amnesia is correct? a. Psycho genie amnesia is a long—lasting condition. b. Psychogenic amnesia is seen more often in men than women. c. Psycho genie amnesia is categorized with memory loss and dementia. d. Psycho genie amnesia symptoms include wandering and disorientation.
a. Purpuric lesions on the face
The nurse is assessing the client diagnosed with meningococcal meningitis. Which assessment data would warrant notifying the HCP? a. Purpuric lesions on the face b. Complaints of light hurting the eyes c. Dull, aching, frontal headache d. Not remembering the day of the week
d. I, II, IV and V
The nurse is assessing the client with a tentative diagnosis of meningitis. Which findings should the nurse associate with meningitis? Select all that apply. I. Nuchal rigidity II. Severe headache III. Pill-rolling tremor IV. Photophobia V. Lethargy a. I, II, III b. I, III, IV, and V c. I and III only d. I, II, IV and V
d. Conjunctival infection
The nurse is assessing the college student who presents with generalized fatigue, dry mouth, tachycardia, and an increased appetite. Which additional finding from the client's history and physical exam should alert the nurse to explore possible marijuana abuse? a. Paranoia b. Flashbacks c. Gastric disturbances d. Conjunctival infection
d. Listen quietly as the client expresses the anger and rage currently being experienced
The nurse is caring for a victim of sexual assault brought to the ED by a roommate. How should the nurse respond when the client begins to angrily insist upon reporting the details of the assault? a. ask the roommate to sit with the client until the examination can be resumed. b. Redirect the client to the physical tasks related to securing any existing evidence. c. Encourage the client to use deep breathing techniques to regain emotional control. d. Listen quietly as the client expresses the anger and rage currently being experienced
d. Respiratory failure
The nurse is caring for the client experiencing Guillain-Barré syndrome (GBS). It is most important for the nurse to monitor the client for which complication? a. Autonomic dysreflexia b. Septic emboli c. Cardiac dysrhythmias d. Respiratory failure
b. Attempted suicide
The nurse is caring for the client with a major depressive disorder. Which nursing problem should be priority? a. Powerlessness b. Attempted suicide c. Anticipatory grieving d. Disturbed sleep pattern
c. Confronting the client's denial that substances have negatively impacted daily life
The nurse is in the working phase of a relationship with the client being treated for substance abuse. Which intervention would be appropriate during this phase of treatment? a. Assessing the client's readiness to change substance-abusing behavior b. Evaluating the effectiveness of the client's newly adapted coping skills c. Confronting the client's denial that substances have negatively impacted daily life d. Determining the extent to which substances have impaired the client's functioning
b. An inpatient mental health unit
The nurse is interviewing the client at a mental health clinic who recently attempted suicide and continues to report active suicidal ideation. Which care setting is most appropriate for this client? a. An acute care hospital unit b. An inpatient mental health unit c. An outpatient mental health clinic d. A community detoxification center
d. Thiamine prevents neuropathy and confusion associated with chronic alcohol use.
The nurse is preparing to administer thiamine (vitamin B,) to the client receiving treatment for alcohol dependence. Which statement best describes the rationale for the use of thiamine? a. Thiamine improves the absorption of other essential vitamins and folic acid. b. Thiamine helps to reverse the malnutrition often associated with alcohol abuse. c. Thiamine reduces the risk of seizures occurring during withdrawal from alcohol. d. Thiamine prevents neuropathy and confusion associated with chronic alcohol use.
c. Supplement the diet with vitamin B12
The nurse is teaching the client who is a strict vegetarian how to decrease the risk of developing megaloblastic anemia. Which information should the nurse provide? a. Undergo an annual Schilling test. b. Increase intake of foods high in iron. c. Supplement the diet with vitamin B12 d. Have a hemoglobin level drawn monthly.
a. Remove all hairpins before coming in for the EEG test.
The nurse is teaching the client who is scheduled For an outpatient EEG. Which instruction should the nurse include? a. Remove all hairpins before coming in for the EEG test. b. Avoid eating or drinking at least 6 hours prior to the test. c. Some hair will be removed with a razor to place electrodes. d. Have blood drawn for a glucose level 2 hours before the test.
c. Perception of the patient to the crisis along with the presence of support system and coping mechanism
The nurse should be aware that which of the following is the priority assessment for crisis? a. Defense mechanism of the person b. Financial stability c. Perception of the patient to the crisis along with the presence of support system and coping mechanism d. None of the above
d. abcf
The nurse working at the site of a severe flood sees Janang, standing in knee-deep water, staring at empty lot. Janang told the nurse, "Masamang panaginip lang lahat ng ito. Bukas magigising akong nandyan pa ang bahay ko." Which of the following crisis intervention strategies are most needed at this time? Select that apply. a. Ask the client about any physical injuries she may have. b. Determine if any of her family are injured or missing. c. Allow the client to talk about her fears, anger, and other feelings d. Tell her that groups are being formed at the shelter for flood survivors e. Refer her to the shelter for dry clothes and food f. Assess her for risk of suicide and other signs of decompensation a. abcd b. bdef c. adef d. abcf
a. Hallucinations
The primary medical treatment for schizophrenia is psychopharmacology. The firs-generation antipsychotics target which manifestation of schizophrenia? a. Hallucinations b. Avolition c. Alogia d. Alopecia
d. Autonomy
The principle states that a person has unconditional worth and has the capacity to determine his own destiny. a. Bioethics b. Justice c. Fidelity d. Autonomy
d. Bioethics
The principles that -govern right and proper conducts of a person regarding life, biology and the health professions is referred to as: a. Morality b. Religion c. Values d. Bioethics
c. To help the public understand professional conduct, expected of nurses
The purpose of having nurses' code of ethics is: a. Delineate the scope and areas of nursing practice b. Identify nursing action recommended for specific healthcare situations c. To help the public understand professional conduct, expected of nurses
a. "The body produces about two teaspoons of fluid every minute on its own."
The spouse of a client dying from lung cancer states, " I don't understand this death rattle. She has not had anything to drink in days. Where is the fluid coming from? Which is the hospice care nurse's best response? a. "The body produces about two teaspoons of fluid every minute on its own." b. "Are you sure someone is not putting ice chips in her mouth?" c. "There is no reason for this, but it does happen from time to time." d. "I can administer a patch to her skin to dry up the secretions if you wish."
b. "Sounds like you're feeling discouraged in your marriage."
The spouse of the client who is currently in inpatient treatment for substance abuse tells the nurse, "We've done this so many times. I don't think my spouse is ever going to change. Do you think it's time for me to get a divorce?" Which response by the nurse is most helpful? a. "You don't think your spouse is ever going to change?" b. "Sounds like you're feeling discouraged in your marriage." c. "Your spouse will likely continue to use and need treatment again." d. "That's your decision; I can't tell you whether you should get a divorce."
c. "This is a bacterial infection of the tissues that cover the brain and spinal cord."
The wife of the client diagnosed with septic meningitis asks the nurse, "I am so scared. What is meningitis?" Which statement would be the most appropriate response by the nurse? a. "There is bleeding into his brain causing irritation of the meninges." b. "A virus has infected the brain and meninges, causing inflammation." c. "This is a bacterial infection of the tissues that cover the brain and spinal cord." d. "This is an inflammation of the brain parenchyma caused by a mosquito bite."
d. "By using the skills you're learning, the goal for you is to feel better or be back to normal in about 6 weeks."
The young adult after being robbed is attending counseling sessions to address anxiety issues. What is the nurse's best response when the client asks, "When will things get better for me?" a. "These types of crises are self-limiting, and usually things are better in 4 to 6 weeks." b. "Try not to worry; it is best for you to think about the future and not focus on the past." c. "Being assaulted is traumatic; in time the anxiety will lessen, and you'll feel more in control." d. "By using the skills you're learning, the goal for you is to feel better or be back to normal in about 6 weeks."
c. Assist the client towards a peaceful death
When caring for a dying client you will perform which of the following activities? a. Encourage the client to reach optimal health b. Assist client perform activities of daily living c. Assist the client towards a peaceful death d. Motivate client to gain independence
a. Process
When she presents the nursing procedures to be followed, she refers to what type of standards? a. Process b. Outcome c. Structure d. Criteria
d. Ease the client to the floor
Which action should the nurse implement first? a. Push aside any furniture b. Place the client on his side c. Assess the client's v/s d. Ease the client to the floor
a. Participants are asked about their emotional reactions to the incident, what symptoms they may be experiencing and other psychological medications.
Which among the following options correctly describe debriefing? a. Participants are asked about their emotional reactions to the incident, what symptoms they may be experiencing and other psychological medications. b. Is a process by which the person receives education about recognition of stress reactions and management strategies for handling stress. c. Either A or B d. None of the above
D. A sudden onset of muscle weakness and pain
Which assessment finding is most indicative of Guillain-Barré syndrome (GBS)?* A. Pupillary dilation B. Expressive aphasia C. Loss of bowel and bladder control D. A sudden onset of muscle weakness and pain
c. Slightly elevated BP
Which assessment finding should the nurse associate with early alcohol withdrawal? a. Agitation b. Somnolence c. Slightly elevated BP d. Delirium tremens (DTs)
c. Memory deficits
Which is a common cognitive problem associated with Parkinson's disease? a. Emotional lability b. Depression c. Memory deficits d. Paranoia
D. Increased protein in the cerebrospinal fluid
Which laboratory result is consistent with the diagnosis of Guillain-Barré syndrome (GBS)?* A. Positive rheumatoid factor B. Decreased serum albumin C. Decreased erythrocyte sedimentation rate D. Increased protein in the cerebrospinal fluid
a. Recurrent depressive episodes with at least one hypomanic episode.
Which of following described Bipolar type II? a. Recurrent depressive episodes with at least one hypomanic episode. b. Manic episodes with at least one depressive episode c. Alternating cycles between periods of mania, normal mood, depression, normal mood, mania, and so forth. d. None of the above
a. Interview and observation.
Which of the following are qualitative data sources?* a. Interview and observation. b. Primary sources and secondary sources c. Books and journals d. Questionnaires and survey
a. Ziprasidone
Which of the following drug is often used in conjunction with mood stabilizers or anti-depressants to treat bipolar disorder? a. Ziprasidone b. Aripiprazole c. Either A or B d. None of the above
d. Perseveration, hallucination, and bizarre behavior
Which of the following group of symptoms are considered positive symptoms? a. Hallucination, Delusions, and Apathy b. Asociality, Catatonia, and Flat affect c. Inattention, avolition, and apathy d. Perseveration, hallucination, and bizarre behavior
d. "Help me put this pile of books on Jeremy's desk."
Which of the following is a concrete message? a. "Get this our of here." b. "When is she coming home?" c. "They said it is too early to get in." d. "Help me put this pile of books on Jeremy's desk."
c. Simple random sampling
Which of the following is a method of non-probability sampling? a. Cluster sampling b. Snowball sampling c. Simple random sampling d. stratified random sampling
b. Identify the values of the department
Which of the following is a primary task that they should perform to have an effective control system? a. Make an interpretation about strengths and weaknesses b. Identify the values of the department c. Identify structure, process, outcome standards & criteria d. Measure actual performances
b. Sudden bursts of energy
Which of the following is not a typical clinical manifestation of MS? a. Double vision b. Sudden bursts of energy c. Weakness in the extremities d. Muscle tremors
b. Characteristics used to measure the level of nursing care
Which of the following statements refers to criteria? a. Agreed on level of nursing care b. Characteristics used to measure the level of nursing care c. Step-by-step guidelines d. Statement which guide the group in decision making and problem solving
b. Death of a loved one
Which of the following typify a situational crisis? a. Natural catastrophe b. Death of a loved one c. menarche d. Marriage
b. Theresa with anemia
Which of these clients has a problem with the transport of oxygen from the lungs to the tissues? a. Carol with a tumor in the brain b. Theresa with anemia c. Sonny Boy with a fracture in the femur d. Brigette with diarrhea
b. "Are you also having nightmares when you do sleep?"
Which question would be most helpful in establishing a diagnosis? a. "Do you find yourself falling asleep while working?" b. "Are you also having nightmares when you do sleep?" c. "Your hair seems thin. Are you also pulling at your hair?" d. "Have you ever been diagnosed with obsessive compulsive disorder?"
c. "When I have command hallucinations, I'll call a friend for help."
Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? a. "My medication will help my anxious feelings." b. "I'll go to support group and talk about what I am feeling." c. "When I have command hallucinations, I'll call a friend for help." d. "I need to get enough sleep and eat well to help prevent feeling anxious."
d. Droplet precautions
Which type of precautions should the nurse implement for the client diagnosed with septic meningitis? a. Standard precautions b. Airborne precautions c. Contact precautions d. Droplet precautions
c. Right to obtain information about another patient
You inform the patient about his rights which include the following EXCEPT: a. Right to expect reasonable continuity of care b. Right to consent to or decline to participate in research studies or experiments c. Right to obtain information about another patient d. Right to expect that the records about his care will be treated as confidential
c. Assess for bladder distention
he client with a C6 SCI is admitted to the emergency department complaining of a sever pounding headache and has BP of 180/110. Which intervention should the emergency department nurse implement? a. Keep the client flat in bed b. Dim the lights in the room c. Assess for bladder distention d. Administer a narcotic analgesic.
c. abce
he nurse is caring for the client who is 2 days postadmission to a medical unit and has a long history of heavy alcohol abuse. The nurse should monitor for which acute complications related to alcohol abuse? Select all that apply a. Seizures b. Pancreatitis c. GI bleeding d. Exophthalmos e. Delirium tremens a. edcb b. abcd c. abce d. bcde
c. "Tell me about you and Chiz"
what is the best way for the nurse to ask the client to describe her relationship with Chiz? a. "Chiz, who? b. "Tell me about Chiz" c. "Tell me about you and Chiz" d. "That's a good Chiz-mis"
b. Consensual validation
"Earlier today you said you were concerned that your son was still upset with you. When I stopped by your room about an hour ago, you and your son seemed relaxed and smiling as you spoke to each other. How did things go between the two of you?" This is an example of which therapeutic communication technique? a. Encouraging comparison b. Consensual validation c. Accepting d. General lead
b. Indicates an external source of the emotion
"How does Heart Evangelista make you upset?" is a non-therapeutic communication technique because it a. Gives a literal response b. Indicates an external source of the emotion c. Interprets what the client is saying d. Is just another stereotyped comment
a. Risk for other-directed violence
A 16-year-old who is being seen by the crisis nurse after making several superficial cuts on her wrist states that all her friends are siding with her ex-boyfriend and won't talk to her anymore. She says she knows that the relationship is over, but "If I can't have him, no one else will." Which of the following client problems takes the highest priority? a. Risk for other-directed violence b. Situational low self-esteem c. Risk for suicide d. Risk-prone health behavior
d. At the time scheduled
A new medication regimen is prescribed for a client with Parkinson's disease. At which time should the nurse make certain that the medication is taken? a. At bedtime b. All at one time c. Two hours before mealtime d. At the time scheduled
a. Experimental research design
A nurse researcher wants to study the response of patients who suffer from dysrhythmia to pacemaker. The appropriate research design would be? a. Experimental research design b. Descriptive-correlational c. Comparative descriptive d. Correlational
c. Assess the client's airway.
After stabilizing the client's cervical spine, which action should the nurse take next? a. Carefully remove the driver from the car. b. Assess the client's pupil for reaction. c. Assess the client's airway. d. Attempt to wake the client up by shaking him.
d. Respondents may provide socially acceptable answers
All of the following are advantages of using questionnaires EXCEPT: a. Easy to test data for reliability and validity b. Facilitates data gathering c. Less time consuming than interview and observation d. Respondents may provide socially acceptable answers
b. Prednisone
Another young adult client is diagnosed with bipolar disorder. He has been religiously taking his medications and has managed the disorder effectively. One day, the client suddenly becomes manic. The nurse reviews the client's medication record. Which among the following medications should the nurse expect to have contributed to the development of his manic state? a. Amitriptyline b. Prednisone c. Gabapentin d. Buspirone
c. General lead
Client: "I had an accident" Nurse: "Tell me about your accident" This is an example of which therapeutic communication technique? a. Making observations b. Offering self c. General lead d. Reflection
d. 1 week
How long would it take for a diagnosis of manic episode or mania be made? a. 4 weeks b. 2 weeks c. 3 weeks d. 1 week
a. No reflex activity below the waist
In assessing the client with T12 SCI, which clinical manifestations would the nurse expect to find to support the diagnosis of spinal shock? a. No reflex activity below the waist b. Inability to move upper extremities c. Complaints of a pounding headache d. Hypotension and bradycardia
a. Low hemoglobin and hematocrit
Laboratory tests are prescribed for the client who has a smooth and reddened tongue and ulcers at the corners of the mouth. Which result would the nurse find if the client has iron-deficiency anemia? a. Low hemoglobin and hematocrit b. Elevated red blood cells (RBCs) c. Prolonged prothrombin time (PT) d. Elevated white blood cells (WBCs)
b. Rotation of duty will be done every four weeks for all patient care personnel.
Ms. Valencia develops the standards to be followed. Among the following standards, which is considered as a structure standard? a. The patients verbalized satisfaction of the nursing care received b. Rotation of duty will be done every four weeks for all patient care personnel. c. All patients shall have their weights taken recorded d. Patients shall answer the evaluation form before discharge
a. GABA
Neurochemical studies have consistently demonstrated alterations in the neurotransmitter systems of the brain in people with schizophrenia. Which of the following neurotransmitter is not implicated by several studies to have been associated with schizophrenia? a. GABA b. Dopamine c. Serotonin d. Norepinephrine
d. Slowed nerve impulse transmission
Nurse Carla learns that the pathophysiology of Guillain-Barré syndrome includes segmental demyelination. The nurse should understand that this causes what?* a. Delayed afferent nerve impulses b. Paralysis of affected muscles c. Paresthesia in upper extremities d. Slowed nerve impulse transmission
b. " Ang pag-sasabi ng mga malalaswang bagay at pag hipo sa iba ay hindi pinahihintulutan dito"
Nurse Gemma has observed Jimot who is hyperactive and intrusive sitting very close to Jerlyn, a female patient with his arm around her shoulders. The nurse hears the male client cracking sexually explicit joke. Nurse Gemma approaches Jimot and asks him to walk down the hallway. Which of the following statements by the nurse Gemma should be beneficial to the patient? a. "Ayaw ni Jerlyn na nasa tabi mo siya dahil sa pananalita mo" b. " Ang pag-sasabi ng mga malalaswang bagay at pag hipo sa iba ay hindi pinahihintulutan dito" c. "Kailangan mong maging maingat sa mga sinasabi mo sa ibang tao" d. "Kinakailangan mo ng pumunta sa iyong kwarto"
d. SSRI
Nurse Gemma is aware that Jimot has a history of bipolar I disorder with hospitalization for a significant manic episode. With this knowledge, the nurse would draw special concern regarding which category of psych medications? a. Atypical antipsychotics b. Mood stabilizers/antimanics c. Antianxiety agents (benzodiazepines) d. SSRI
b. Level of anxiety
Nurse Jan is assessing a client who has just experienced a crisis due to typhoon Egay. Nurse Jan should first assess this client for which of the following behaviors? a. Effective problem solving b. Level of anxiety c. Attention Span d. Help-seeking
b. Difficulty swallowing and immobility.
Nurse Mira has admitted a patient with PD with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain these assessment data? a. Maskliek facies and shuffling gait. b. Difficulty swallowing and immobility. c. Pill rolling of fingers and flat affect d. Lack of arm swing and bradykinesia
c. II, IV, V
Nurse Oni should conduct a focused assessment with client with multiple sclerosis for risk of which of the following? I. Dehydration II. Falls III. Seizures IV. Skin breakdown V. Fatigue a. II, III, IV, V b. I, II, III, IV c. II, IV, V d. I and II
b. The client experiences spontaneous remissions from time to time.
Nurse Oni should know that the primary reason why she find it difficult to evaluate the effectiveness of the drugs the client has used for 15 years is? a. The client exhibits intolerance to many drugs. b. The client experiences spontaneous remissions from time to time. c. The client requires multiple drugs simultaneously. d. The client endures long periods of exacerbation before the illness responds to a particular drug.
a. Stop all antipsychotic medications; notify the physician
One of the side effects of antipsychotic medication is neuroleptic malignant syndrome. What should be the nursing intervention should this occur? a. Stop all antipsychotic medications; notify the physician b. Administer medications as ordered c. Assess for effectiveness d. None of the above
c. Checking that the cervical collar was correctly placed by EMS
Spinal precautions are ordered for the client. Who sustained a neck injury during an MVA. The client has yet to be cleared that there is no cervical fracture. Which action is the nurse's priority when receiving the client in the ED? a. Assessing the client using the Glasgow Coma Scale (GCS) b. Assessing the level of sensation in the client's extremities c. Checking that the cervical collar was correctly placed by EMS d. Applying antiembolism hose to the client's lower Extremities
c. Safe nursing care and management
Standards of nursing practice serve as guide for: a. Nursing practice in the different fields of nursing b. Proper nursing approaches and techniques c. Safe nursing care and management d. Evaluation of nursing cared rendered
d. You and your child should regularly discuss bad memories to decrease their effect.
The 10—year-old who was sexually abused by a family member experiences flashbacks of a disagreement with that adult and the resulting sexual assault. Which suggestion should the nurse make to the parents in order to help minimize this reaction? a. Have the child avoid arguments with adults until this reaction is unlearned. b. Ask the HCP to prescribe a medication to minimize the child's aggressiveness. c. Adults in your family should learn to recognize and diffuse arguments effectively. d. You and your child should regularly discuss bad memories to decrease their effect.
c. "Plasmapheresis removes circulating antibodies from the blood."
The client diagnosed with Guillain-Barré syndrome is scheduled to receive plasmapheresis treatments. The client's spouse asks the nurse about the purpose of plasmapheresis. Which explanation is correct? a. "Plasmapheresis removes excess fluid from the bloodstream." b. "Plasmapheresis will increase the protein levels in the blood." c. "Plasmapheresis removes circulating antibodies from the blood." d. "Plasmapheresis infuses lipoproteins to restore the myelin sheath."
c. Carbidopa makes more levodopa available to the brain.
The client diagnosed with PD is being discharged on carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which statement is the scientific rationale for combining these medication? a. There will be fewer side effects with this combination than with carbidopa alone. b. Dopamine D requires the presence of both of these medications to work. c. Carbidopa makes more levodopa available to the brain. d. Carbidopa crosses the BBB to treat Parkinson's disease.
d. Completing a thorough vascular assessment of all extremities q2h
The client is at risk for septic emboli after being diagnosed with meningococcal meningitis. Which action by the nurse directly addresses this risk? a. Monitoring vital signs and oxygen saturation levels hourly b. Planning to give meningocoeeal polysaccharide vaccine c. Assessing neurological function with the Glasgow Coma Scale q2h d. Completing a thorough vascular assessment of all extremities q2h
a. Alcoholics anonymous
The client is being admitted with folic acid deficiency anemia. Which would be the most appropriate referral? a. Alcoholics anonymous b. Leukemia society of the PH c. A hematologist d. A social worker
c. "What skills can you utilize if you experience problems again?"
The client is being discharged after hospitalization for a suicide attempt. Which question asked by the nurse assesses the learned prevention and future coping strategies of the client? a. "How did you try to kill yourself?" b. "Why did you think life wasn't worth living?" c. "What skills can you utilize if you experience problems again?" d. "Do you have the phone number of the suicide prevention center?"
b. "I'm ready and able to move on with my life in spite of all that has happened."
The client is being treated after surviving a major hurricane that took the lives of many neighbors. Which statement by the client provides the nurse with the [best evidence that therapy has been successful? a. "Therapy has been a very good thing for me since the hurricane ruined things." b. "I'm ready and able to move on with my life in spite of all that has happened." c. "Nothing can happen to me that is worse than what I've been through already." d. "I've learned a lot about myself since agreeing to attend crisis therapy sessions."
a. Acceptance
The client prepares for eventual death and discusses with the nurse and her family how she would like her funeral to look like and what dress she will use. This client is in the stage of: a. Acceptance b. Resolution c. Denial d. bargaining
c. Do the interview in the same way as for other sexual assaults.
The client presents to the ED reporting that he was sexually assaulted by several men he met at a local bar. Which action should the nurse plan to include when preparing to assess the client? a. Ask the client if he had been drinking alcohol excessively. b. Call the male nurse on duty to assume the care of this client. c. Do the interview in the same way as for other sexual assaults. d. Ask whether the client resisted any of the sexual advancements.
b. Sublimation
The client reports becoming involved with legislation that promotes gun safety after the death of the child by accidental shooting. Which defense mechanism is the client exhibiting? a. Denial b. Sublimation c. Identification d. Intellectualization
d. Distorted grief reaction
The client reports becoming physically ill with frequent crying episodes, intense feelings of worthlessness, and loss of appetite on the anniversary of the death of the client's spouse. The client reports that this has occurred for the last 5 years- What should be the nurse's focus when counseling the client? a. Anticipatory grief b. Uncomplicated grief c. Delayed grief reaction d. Distorted grief reaction
c. "Marijuana has effects similar to alcohol, hallucinogens, and sedatives that are addictive."
The client states, "I don't see any problem with smoking a little weed. It isn't addictive." Which response by the nurse is most accurate? a. "Marijuana is a natural chemical that has many therapeutic uses, but it is still illegal to use." b. "Marijuana is not addictive. The danger is that. it often leads to abuse of more illicit drugs." c. "Marijuana has effects similar to alcohol, hallucinogens, and sedatives that are addictive." d. "There are no withdrawal symptoms, so it is controversial whether marijuana is addictive."
d. Acceptance
The client who is terminally ill called the significant others to the room and said good-bye, then dismissed them and now lies quietly and refuses to eat. The nurse understands the client is in what stage of the grieving process? a. Denial b. Anger c. Bargaining d. Acceptance
c. Turn the client to the side and allow the client to sleep
The client who just had a three minute seizure has no apparent injuries and is oriented to name, place, and time but is lethargic and just wants to sleep. Which intervention should the nurse implement? a. Perform a complete neurological assessment b. Awaken the client every 30 minutes c. Turn the client to the side and allow the client to sleep d. Interview the client to find out what caused the seizure
