NSG411 Exam 3 Practice Questions
Your patient is scheduled for a lumbar puncture to help diagnosis multiple sclerosis. The patient wants clarification about what will be found in the cerebrospinal fluid during the lumbar puncture to confirm the diagnosis of MS. You explain that which of the following will be present in the fluid if MS is present? a. High amounts of IgM b. Oligoclonal bands c. Low amounts of WBC d. Oblong red blood cells and glucose
a. Incorrect - Elevated total levels of immunoglobulin IgG, not IgM, can be seen in a lumbar puncture. b. CORRECT - Oligoclonal bands can be detected and used to diagnose MS if an MRI is not available or inconclusive. c. Incorrect - Clients with MS will have a high level of WBC in the CSF, indicating an inflammatory response within the CNS. d. Incorrect - RBCs and glucose will not be found in the client's CSF with MS.
A nurse is providing teaching about a living will for a client who has end-stage breast cancer. Which of the following pieces of information should the nurse include in the teaching? a. The client has the right to change the living will at any time b. The client should be certain of the decision because the document establishes guidelines for refusing resuscitation c. A durable power of attorney is required with a living will d. The handwritten living will is not a legal document and cannot be included in the client's medical record
a. CORRECT - A living will is one component of advance directives. This legal document expresses the client's wishes regarding healthcare decisions in the event the client becomes incapacitated or unable to make decisions. The client has the right to change or revoke the living will at any time. b. Incorrect - A living will often can address treatments that can prolong life. A living will does not automatically result in a DNR order. The DNR order must be written in the client's chart for each hospitalization. c. Incorrect - A durable power of attorney designates a person to make healthcare decisions for the client. It is not a requirement for a living will. Note that living wills should not have a health care proxy appointed, as the official form for proxies should be completed instead. d. Incorrect - Living wills can be handwritten. The Patient Self Determination Act requires asking all clients admitted to a healthcare facility if they have advance directives and providing information on them if they do not.
The nurse is monitoring the labs of a child admitted for an exacerbation of juvenile pauciarticular arthritis. Which lab result does the nurse expect to be elevated? a. Erythrocyte sedimentation rate (ESR) b. Lymphocyte immunophenotyping T-cell quantification c. Immunoglobulin electrophoresis d. Radioallergosorbent test
a. CORRECT - An elevated ESR indicates increased inflammation in the body, which is a characteristic feature of arthritis. The ESR is a non-specific marker of inflammation and can be used to monitor disease activity. b. Incorrect - This test measures T-cell count and monitors immunosuppressive disorders. c. Incorrect - This test is used to assess the levels of different types of immunoglobulins but is not specific to arthritis monitoring. d. Incorrect - RAST is a blood test used to detect specific IgE antibodies in response to allergens and not typically used to monitor JIA.
A nurse is consoling the partner of a client who just died from liver cancer. The grieving partner states, "I hate them for leaving me." Which of the following statements should the nurse make to facilitate mourning for the partner? (Select all that apply) a. "Would you like me to contact the chaplain to come speak with you?" b. "You will feel better soon. You were expecting this for a while now." c. "Let's talk about your children and how they are going to react." d. "It is quite normal to feel anger toward your loved one at this time." e. "Tell me more about how you are feeling."
a. CORRECT - Asking the grieving individual if they desire spiritual support at this time is an acceptable intervention to facilitate mourning. Be careful not to impose personal religious beliefs on the patient, but offer these services so the individual is aware of resources. b. Incorrect - Avoid giving false reassurance and offering assumptions to facilitate mourning. c. Incorrect - Avoid changing the subject and bringing the focus away from the individual while they are mourning. d. CORRECT - Educate the grieving individual about the grieving process and emotions to expect at this time. e. CORRECT - Encourage open communication of feelings by using therapeutic communication.
A nurse is teaching a patient who has multiple sclerosis about a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? a. "Do not take antihistamines with this medication." b. "Expect to develop diarrhea initially." c. "Stop taking the medication immediately for a headache." d. "Take the medication on an empty stomach."
a. CORRECT - Baclofen can enhance the sedative effects of antihistamines, leading to increased drowsiness. Avoid combining these medications to prevent excessive sedation. b. Incorrect - Diarrhea is not typically associated with baclofen use. c. Incorrect - While headaches can be a side effect of baclofen, it is generally not necessary to stop the medication for a headache. Immediately stopping baclofen can cause seizures, fevers, confusion, or muscle stiffness. d. Incorrect - Baclofen can be taken with or without food. There is no specific requirement to take it on an empty stomach.
A nurse is teaching a client who has human immunodeficiency virus (HIV) about the early manifestations of acquired immune deficiency syndrome (AIDS). Which of the following statements should the nurse include in the teaching? a. "You can expect a persistent fever and swollen glands." b. "You can expect an elevated white blood count." c. "You can expect increased blood pressure and edema." d. "You can expect weight gain."
a. CORRECT - Clients who have AIDS can have a persistent fever, swollen glands, diarrhea, weight loss, and fatigue. Most of these symptoms are non-specific and can mimic flu symptoms. b. Incorrect - Clients with AIDS are more likely to have a decreased WBC count as a result of HIV destroying CD4-T-cells. AIDS is defined by a CD4-T-cell count below 200 cells/mm3. A low WBC count predisposes the client to infection, making them severely immunocompromised. c. Incorrect - Clients with AIDS are more likely to have hypotension. d. Incorrect - Clients with AIDS may experience weight loss due to metabolism alterations.
A nurse is planning care for a client who has acute systemic lupus erythematosus (SLE) and is scheduled to begin treatment for its manifestations. Which of the following types of medications should the nurse plan to administer? a. Corticosteroids b. Antimalarials c. Antidepressants d. Opioids
a. CORRECT - Corticosteroids, like prednisone or methylprednisolone, are the treatment of choice for acute systemic manifestations of SLE because of their rapid anti-inflammatory action. b. Incorrect - Antimalarials, like hydroxychloroquine, are prescribed to reduce the risk of skin manifestations in the treatment of the disease process. c. Incorrect - Although clients with SLE could benefit from antidepressant therapy, these medications will not mitigate clinical manifestations. d. Incorrect - Opioids, like morphine, are not the treatment of choice for SLE.
A nurse is providing support for the parents of a child who has a new diagnosis of a terminal brain tumor. The nurse should expect the parents to experience which of the following stages of grief first? a. Denial b. Bargaining c. Anger d. Depression
a. CORRECT - Evidence-based practice indicates the nurse should first expect the parents to experience denial. Denial is followed by anger, bargaining, depression, and finally acceptance (according to Kubler-Ross model). The initial shock of the news may cause the parents to not process reality. b. Incorrect - Expect the parents to experience this stage eventually, but there is another stage that happens first. c. Incorrect - Same as A. d. Incorrect - Same as A.
A nurse is caring for a preschooler who has a terminal illness. The nurse should expect the preschooler to have which of the following perspectives about death? a. Believes that her own thoughts can cause death b. Has an understanding of the finality of death c. Exhibits curiosity about what happens to the body after death d. Views funeral services as unnecessary
a. CORRECT - Expect preschoolers to believe that their own thoughts or actions can cause death, and they might believe that death is a punishment for wrong-doing. This occurs because preschoolers (3-5 y/o) exhibit magical thinking, and are egocentric (the world revolves around them). b. Incorrect - Expect a preschooler to view death as a temporary occurrence like sleeping. The preschooler might believe the person can "wake up" again. Adolescents tend to understand the finality of death. c. Incorrect - Expect a school-aged child to be curious about what happens to a body following death. School-aged children (6-12 y/o) have a preoccupation with fear involving death, wondering about the body or their own death. d. Incorrect - Expect an adolescent to reject traditions surrounding death such as funeral services as unnecessary or unimportant.
A nurse is caring for a client who received a diagnosis of systemic scleroderma 5 years ago. The nurse plans to assess the client to document the disease's progression. In addition to skin changes, which of the following findings should the nurse expect? a. Finger contractures b. Thinning of the skin c. Periorbital edema d. Excessive salivation
a. CORRECT - Finger contractures are common in systemic scleroderma. Tightening and hardening of the skin on the fingers causes reduced flexibility and joint movement. b. Incorrect - Scleroderma is a connective tissue disorder that affects the skin and various internal organs. One of the hallmark features is the development of fibrosis (thickening and scarring) of the skin and other organs. c. Incorrect - Periorbital edema is not commonly associated with scleroderma. d. Incorrect - Same as C.
A nurse is assessing a client who has osteoarthritis of the knees and fingers. Which of the following manifestations should the nurse expect to find? (Select all that apply) a. Heberden's nodes b. Swelling of all joints c. Small body frame d. Enlarged joint size e. Limp when walking
a. CORRECT - Heberden's nodes are enlarged nodules on the distal interphalangeal joints (DIP) of the hands and feet in a client with OA. b. Incorrect - Swelling and pain of all (bilateral, symmetrical) joints is seen in rheumatoid arthritis (RA). A local joint inflammation is OA. c. Incorrect - A small body frame is a risk factor for RA. Obesity is a risk factor for OA because increased weight places pressure on weight-bearing joints like the hips and knees. d. CORRECT - In OA, a client can experience enlarged joints from bone hypertrophy. Bone spurs, or osteophytes, form after synovial inflammation and bone-on-bone rubbing. e. CORRECT - A client can limp when walking due to pain from inflammation of the hips and knees.
A nurse is assessing a client who has systemic lupus erythematosus and is taking hydroxychloroquine. The nurse should report which of the following adverse effects to the provider immediately? a. Blurred vision b. Pruritis c. Diarrhea d. Fatigue
a. CORRECT - Hydroxychloroquine is an antimalarial medication commonly used in the treatment of SLE. Possible side effects include ocular issues, such as blurred vision. This may indicate retinal toxicity. b. Incorrect - This may be a side effect but is generally not considered an emergency. c. Incorrect - Diarrhea is typically not an immediate cause for concern unless it is severe or persistent. d. Incorrect - Fatigue is a common symptom of lupus and may not necessarily be attributed to the medication.
A nurse is assigned to care for a client diagnosed with idiopathic thrombocytopenic purpura (ITP). When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern is which of the following? a. Bleeding b. Side effects of immunosuppressants c. Constipation d. Fatigue
a. CORRECT - ITP is characterized by a low platelet count, which increases the risk for bleeding. Platelets have a crucial role in blood clotting, and low platelets can lead to easy bruising, petechiae (small red/purple dots on the skin), and more serious bleeding issues. Monitor for signs of bleeding and take measures to prevent injury and bleeding complications. b. Incorrect - While immunosuppressants may be part of treatment, the priority concern is bleeding and risk for injury. c. Incorrect - Constipation is not directly related to ITP, a disease of bleeding complications. d. Incorrect - Fatigue may be a symptom of ITP with increased bleeding, but the primary concern is bleeding and possible hemorrhagic events.
A nurse working in the emergency department is admitting a client who has a gastric ulcer and gastrointestinal (GI) bleeding. Which of the following factors in the client's medical history should the nurse report to the provider? a. Arthritis treated with ibuprofen every 8 hours as needed b. Previous tobacco smoking with cessation 5 years ago c. Negative H. pylori breath test 1 year prior d. Prescribed bismuth subsalicylate as needed for GI upset
a. CORRECT - Identify that ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs cause GI bleeding and are contraindicated in those with ulcer disease. NSAIDs prohibit prostaglandin secretion, which decreases blood flow in the GI tract and decreases bicarbonate and mucus secretion. This environment promotes gastric acid secretion and should be reported. NSAIDs are typically prescribed to treat chronic pain like arthritis. b. Incorrect - Identify that smoking can cause ulcers due to an acid increase in the GI tract. However, a client who stopped smoking 5 years ago does not have this current risk. c. Incorrect - Identify that up to 75% of all clients with peptic ulcer disease have H. pylori in the GI tract. H. pylori is highly associated with duodenal ulcers. d. Incorrect - Identify that bismuth subsalicylate treats GI upset and prevent H. pylori complications when used as an adjunct.
A nurse is beginning a physical assessment of a client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? (Select all that apply) a. Areas of paresthesia b. Involuntary eye movements c. Alopecia d. Increased salivation e. Ataxia
a. CORRECT - Loss of skin sensations is a symptom of MS because of the demyelination of neurons. The sensory neurons of the brain are impacted by plaques that disrupt communication. b. CORRECT - Nystagmus is a finding seen in MS. MS plaques affect the optic nerves in the eyes, causing visual disturbances. c. Incorrect - Hair loss can be seen in lupus, not MS. d. Incorrect - Increased salivation is not seen in MS. e. CORRECT - Ataxia occurs in MS because of muscle weakness and the subsequent loss of coordination.
A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (Select all that apply) a. The child views death as similar to sleep b. The child is interested in what happens to the body after death c. The child recognizes that death is permanent d. The child believes his thoughts can cause death e. The child thinks death is a punishment
a. CORRECT - Preschool-age children may think of death like sleep, or something the deceased can "wake up" from. b. Incorrect - A school-age child will be interested in post-death services and what happens to the body after death due to an improved ability to comprehend what is happening. c. Incorrect - Preschool-age children have difficulty understanding the concept of time and are therefore not likely to believe that death is permanent. Instead, they perceive death as reversible. d. CORRECT - Preschoolers believe that their thoughts and wishes can make things happen because they are egocentric. This is part of why the death of a family member can be difficult for a child at this age. e. CORRECT - Preschoolers sometimes believe that death is the result of guilt or a punishment for something they did, said, or thought.
A nurse is caring for a school-age child who has juvenile idiopathic arthritis (JIA). Which of the following home care instructions should the nurse include in the teaching? (Select all that apply) a. Provide extra time for completion of ADLs b. Use cold compresses for joint pain c. Take ibuprofen on an empty stomach d. Remain home during periods of exacerbation e. Perform range-of-motion exercises
a. CORRECT - Providing extra time for the completion of ADLs promotes independence in the client and provides a means to maintain mobility. b. Incorrect - Using warm compresses or moist packs can provide comfort and relieve stiffness. c. Incorrect - Ibuprofen should be taken with food to prevent GI distress. d. Incorrect - The client should be encouraged to attend school, even during periods of exacerbation when pain is increased. e. CORRECT - Range of motion will assist in maintaining function of the joints.
A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? a. Facial rash b. Thickened skin c. Chronic back pain d. Iritis
a. CORRECT - SLE causes the characteristic facial "butterfly" rash or malar skin rash that is dry, scaly, red, and raised. It appears on the face across the cheeks and bridge of the nose. b. Incorrect - Thickened skin is more characteristic of scleroderma rather than lupus. c. Incorrect - While joint and muscle pain can occur in lupus, chronic back pain is not a specific finding associated with SLE. Joint pain is a common symptom, and it can affect various joints. d. Incorrect - Inflammation of the iris in the eye is not a typical manifestation of SLE. However, lupus can affect the eyes in other ways, such as causing dry eyes.
A nurse is teaching a female client with a new diagnosis of systemic lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client requires further teaching if she identifies which of the following as an exacerbation factor? a. Exercise b. Pregnancy c. Infection d. Sunlight
a. CORRECT - SLE is a chronic autoimmune disease that develops when the immune system becomes hyperactive and attacks healthy body tissue. This attack results in generalized inflammation. Clients with SLE can follow an exercise regime to improve their immune function and alleviate joint pain and stiffness depending on their activity tolerance. The client needs additional teaching to keep her muscles and joints active. b. Incorrect - Due to hormonal changes, pregnancy can exacerbate SLE (stressor). c. Incorrect - Infections stress the body and can trigger an SLE exacerbation. In addition, many clients with SLE take corticosteroids, placing them at higher risk of infection. d. Incorrect - Sunlight and artificial UV light exposure is the leading cause of SLE exacerbations, especially the characteristic skin lesions and butterfly rash. Clients should use sunscreen with a high sun protection factor (SPF) and cover their skin with appropriate clothing and hats to avoid sunlight.
Which exercise would the nurse suggest as most helpful to maintain mobility in a child with juvenile idiopathic arthritis? a. Swimming b. Jogging every other day c. Using a treadmill d. Playing basketball
a. CORRECT - Swimming is a particularly useful exercise to maintain joint mobility without placing pressure on the joints. The buoyancy of water reduces the impact of joints, making it a low-impact, ideal exercise for children with arthritis. b. Incorrect - Jogging can place strain on the joints, which may not be suitable for children with arthritis, especially if weight-bearing joints are affected. c. Incorrect - While walking on a treadmill can be a low-impact exercise, it may not be as gentle on the joints like swimming. The impact depends on the walking surface and speed. d. Incorrect - Basketball involves a lot of running, jumping, and rapid movements, which may be too high-impact for the child with arthritis. It can exacerbate joint pain and inflammation.
A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching? a. "You can experience morning stiffness when you get out of bed." b. "You can experience abdominal pain." c. "You can experience weight gain." d. "You can experience low blood sugar."
a. CORRECT - The client who has RA can experience joint stiffness upon rising that can persist for more than an hour. b. Incorrect - Pleuritic pain upon inspiration is seen, not abdominal pain. c. Incorrect - Weight loss, not gain, can be seen. d. Incorrect - RA does not cause low blood sugar. Inform the client that hyperglycemia may occur in RA if they are taking corticosteroids, which reduces inflammation during exacerbations.
A nurse is providing discharge teaching to a client who has osteoarthritis. Which of the following instructions should the nurse include? a. "Rest frequently after periods of activity." b. "Perform your exercises only on days that you feel good." c. "Perform your exercises after applying cold packs to your joints." d. "Place a large pillow under your knees when lying down."
a. CORRECT - The joint pain in osteoarthritis is caused by deterioration of the synovial membranes and often worsens after activity. Rest usually helps relieve the pain, so performing activities at a comfortable pace with periods of rest is appropriate. b. Incorrect - Perform exercise consistently on both good and bad days. c. Incorrect - Perform exercise immediately after applying heat to painful joints. d. Incorrect - Do not use a large pillow because this can lead to contractures. A small pillow should be placed under the head or neck when lying down.
A nurse is caring for a client who had a spontaneous miscarriage at 9 weeks gestation. The nurse walks into the client's room and finds her crying uncontrollably. Which of the following statements should the nurse make? a. "It is hard to deal with the loss of a pregnancy. Here is the number of a local support group that you can attend." b. "When a pregnancy ends spontaneously, there is often something wrong with the fetus." c. "You are young and will have other children." d. "The best thing for you to do is to go home and relax."
a. CORRECT - This is therapeutic because the nurse is offering empathy and providing information regarding a support network that can help the client. b. Incorrect - The nurse is not addressing the client's immediate needs but is providing unwanted reassurance instead. It is also unclear why many miscarriages occur, so it is not conclusive to say that the reason is because the fetus is the problem. c. Incorrect - The nurse is minimizing the client's feelings. d. Incorrect - The nurse is giving the client advice and minimizing their immediate needs.
A hospice nurse is conducting a support group for parents of toddlers who have a terminal illness. Which of the following pieces of information should the nurse include in the teaching? a. Toddlers will react to the parents' anxiety and sadness b. Toddlers view death as punishment for bad behavior c. Toddlers view death as permanent and irreversible d. Toddlers have a realistic concept of death
a. CORRECT - Toddlers have little understanding of death. Their reaction is related to changes in routine and the parents' emotions. They may cry more and be irritable. b. Incorrect - Preschoolers might perceive death as punishment for bad behavior. c. Incorrect - A recognition of the permanence of death is often not achieved until age 9 or 10. d. Incorrect - A realistic concept of death is often not achieved until age 9 or 10.
A nurse is caring for a client who has severe multiple sclerosis and asks about completing a living will. Which of the following statements should the nurse make? a. "I will provide you with information you need to complete advance directives." b. "I will contact your provider to inform them of your desire to complete a living will." c. "Your attorney will need to review the document before it can be enacted." d. "Once your living will is complete and on file, the choices you make are final."
a. CORRECT - Under the Patient Self-Determination Act, health care institutions are required to provide educational materials advising clients of their rights to make personal wishes known regarding treatment. b. Incorrect - The nurse does not need to contact the provider unless the client has questions concerning treatment options. The nurse will contact the provider and document once the client has completed a living will. c. Incorrect - Living wills do not require the review of an attorney. d. Incorrect - Inform the client that even if a living will is completed, the decision can always be changed.
A home health nurse is assessing a toddler who is scheduled to begin receiving hospice care for a terminal illness. The child's parents tells the nurse, "This is all my fault, and I wish I could trade places with my child." Which of the following responses should the nurse make? a. "Tell me more about what you are feeling." b. "I understand how you are feeling." c. "Let's talk about hospice care for your child." d. "Try to focus more on the positive things."
a. CORRECT - Use statements that will allow the parent to share feelings and emotions. In the early stages of the grief process, the parent begins to accept the child's illness is terminal and needs to express feelings. The use of an open-ended statement helps the parent feel free to share these feelings with the nurse. b. Incorrect - A sympathetic response infers pity and discourages further exploration of their thoughts and feelings. c. Incorrect - Changing the subject is nontherapeutic and leaves the parent feeling more hopeless. d. Incorrect - This response minimizes their feelings and limits further sharing.
A nurse is planning to administer pain medications to a client following abdominal surgery. Which of the following actions should the nurse take first? a. Use the pain scale to determine the client's pain level b. Discuss the adverse effects of pain medication with the client c. Obtain the client's vital signs d. Check the client's allergies
a. CORRECT - When applying Maslow's Hierarchy of Needs, the nurse should review physiological needs first and then address other needs. To meet these needs, the nurse should ask the client to describe their pain for sufficient pain management. Self-report is the most accurate assessment for a client's pain level. b. Incorrect - Discuss adverse effects of pain medications and to report any problems, but there is another action to be taken first. c. Incorrect - Obtain vital signs before choosing an intervention to relieve pain. Vital signs provide a baseline for the nurse to compare after treating the pain. Respiratory depression and a decreased blood pressure are adverse effects of opioid pain medications. However, another action should be taken first. Vital signs are often not an accurate indicator of their pain level. d. Incorrect - Check for allergies if a medication will be administered. However, another action is first.
A nurse is counseling a client following a recent death in the family. Which of the following situations should the nurse identify as a risk factor for maladaptive grieving? a. The death was a result of violence b. The client expresses anger over the loss c. This is the client's first experience of the loss of a family member d. The client demonstrates reorganization of behavior
a. CORRECT - When death is a result of violence, is traumatic, or is unexpected, the loss can result in maladaptive grieving for those left behind. This type of grief is complicated by the survivors not having an opportunity to prepare for the death or say goodbye. b. Incorrect - Anger is an expected response during the grieving process. It is a phase mourners often experience. c. Incorrect - The loss of family members is a maturational loss that occurs in all families. It is a necessary loss that occurs across the lifespan. d. Incorrect - Behavior reorganization is a healthy, adaptive response to the grieving process in which the mourner accepts the death, takes on new roles, and moves forward in life.
A nurse is caring for a client who was newly diagnosed with breast cancer that has metastasized into the spine. The client refuses to discuss treatment options. The nurse should identify that the client is experiencing which of the following Kubler-Ross' grief theory? a. Anger b. Bargaining c. Denial d. Depression
a. Incorrect - During the second stage, the client acknowledges the illness and expresses self-blame or blame toward others, which presents as feelings of anger and anxiety. b. Incorrect - The client may feel vulnerable and helpless during this stage. The client holds out hope for a positive outcome and attempts to strike a bargain with a higher power to allow more time. c. CORRECT - Denial and refusal to accept the loss are self-protection mechanisms that allow the client time to process the diagnosis. The client may refuse to discuss the loss, and may believe a mistake was made and there is no loss. d. Incorrect - The client recognizes that death is inevitable and works through depression to achieve acceptance.
A nurse is assessing a client for HIV. The nurse should identify that which of the following are risk factors associated with this virus? (Select all that apply) a. Perinatal exposure b. Pregnancy c. Monogamous sex partner d. Older adult woman e. Occupational exposure
a. CORRECT - Women who are pregnant should take precautionary measures to prevent HIV exposure, as the newborn can contract the virus during birth. Specific procedures to avoid for pregnant women are AROM/PROM, amniocentesis, fetal scalp monitoring, assisted delivery, or intrauterine pressure catheters. b. Incorrect - Women who are pregnant should always be tested for HIV, but pregnancy itself is not a risk factor associated with HIV. c. Incorrect - Having a monogamous sex partner is not a risk factor. Multiple sexual partners increases HIV risk. d. CORRECT - Being an older adult woman (older than 45 y/o) increases the risk due to vaginal dryness and thinning of the vaginal walls. e. CORRECT - Occupational exposure, such as being a healthcare worker, is a risk factor for HIV. Unintentional injuries, cuts, or splashes of body fluids like blood can occur.
A nurse is discussing pain assessment with a newly licensed nurse. Which of the following information should the nurse include? a. Most clients exaggerate their level of pain b. Pain must have an identifiable source to justify the use of opioids c. Objective data are essential in assessing pain d. Pain is whatever the patient says it is
a. Incorrect - A misconception about pain is that clients exaggerate their pain level. b. Incorrect - Clients can have pain without being able to identify a source. c. Incorrect - Objective data is not always present when patients have pain. A patient's facial expression or body language does not always tell the full picture of the pain they experience. d. CORRECT - Identify that pain is a subjective experience, and the client is the best source of information about it as they are the most reliable diagnostic measure. Self-report is appropriate for patients over 7 y/o.
A nurse is performing a head-to-toe assessment on a patient with multiple sclerosis. The patient reports an "electric shock" sensation that travels down the body whenever they move their head and neck downward. The nurse would document this finding as which of the following? a. Romberg's sign b. Lhermitte's sign c. Uhthoff's sign d. Homan's sign
a. Incorrect - A positive Romberg's sign occurs when the client is unable to remain still with their eyes closed, signaling a balance issue. b. CORRECT - Identify that Lhermitte's sign is a sudden, brief pain or electrical buzzing sensation that clients can experience with MS. c. Incorrect - Uhthoff's phenomenon is the temporary worsening of MS symptoms caused by an increase in body temperature. Avoid submerging in a tub with hot water, entering saunas, or long sun exposures. d. Incorrect - Homan's sign is a dorsiflexion sign test to test for the presence of deep vein thromboses (DVTs).
A nurse is caring for a client who has rheumatoid arthritis (RA). Which of the following laboratory tests are used to diagnose this disease? (Select all that apply) a. Urinalysis b. Erythrocyte sedimentation rate (ESR) c. BUN d. Antinuclear antibody (ANA) titer e. WBC count
a. Incorrect - A urinalysis is not a laboratory test used to diagnose RA. This test can be used to detect kidney failure. b. CORRECT - ESR is used to diagnose RA. This test will be elevated, indicating inflammation in the body. ESR is a non-specific marker for inflammation. c. Incorrect - Same as A. d. CORRECT - There will be a positive ANA titer in RA, which indicates that there is antibody presence targeting the cell nuclei in the body. e. CORRECT - WBC can be elevated during an exacerbation secondary to the inflammatory response, as RA is an autoimmune process.
A nurse is assessing the pain level of a 3-year-old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use? a. Word graphic rating scale b. Color tool c. FACES pain rating scale d. Numeric scale
a. Incorrect - A word graphic rating uses a line with words identifying a scale of no to worst possible pain. 3 y/o children will not understand this scale meant for ages 4-17. b. Incorrect - The color tool uses 4 markers for the child to represent pain. 3 y/o children will have difficulty understanding. c. CORRECT - The FACES scale includes various faces representing various pain levels. A 3 y/o child is able to identify faces that represent different pain levels. d. Incorrect - Using a numeric scale from 0-10 to rate pain requires the child to understand numbers. The tool is helpful for children ages 5 y/o+.
A nurse is reviewing the care plan before assuming the care of a newborn who is prescribed a hepatitis B vaccine, vitamin K, and an antiretroviral regimen. The care plan indicates the mother is HIV-positive and plans to breastfeed. Which of the following should the nurse address with the newborn's interdisciplinary team? a. Hepatitis B vaccine b. Antiretroviral regimen c. Vitamin K d. Breastfeeding
a. Incorrect - All newborns exposed to HIV should receive routine immunizations to prevent future infections. This is an expected element of the care plan. b. Incorrect - Newborns whose mothers are HIV-positive are prescribed ART to prevent neonatal HIV infection. c. Incorrect - Vitamin K is administered routinely to newborns for the prevention of hemorrhagic disease. d. CORRECT - Breastfeeding by mothers who are HIV-positive is not recommended because HIV can be transmitted through breastmilk. HIV is a contraindication to breastfeeding and requires discussion with the team.
A nurse is reviewing the laboratory results for a client who reports bilateral pain and swelling in her finger joints, with stiffness in the morning. The nurse should recognize that an increase in which of the following values can indicate arthritis? a. Reticulocyte count b. Rheumatoid factor c. Direct Coombs' test d. Platelet count
a. Incorrect - An increase in the reticulocyte can indicate chronic loss of blood. b. CORRECT - Rheumatoid factor increases indicate rheumatoid arthritis. c. Incorrect - A direct Coombs' test indicates the presence of antibodies to RBCs, not arthritis. d. Incorrect - An increased platelet count can indicate polycythemia.
A nurse is planning care for a school-aged child who has juvenile idiopathic arthritis (JIA). Which of the following actions should the nurse include in the plan? a. Encourage the child to sleep for 1 hour each afternoon b. Apply cold compresses to the child's affected joints each morning c. Encourage the child to participate in physical activities d. Limit the child's fluid intake of foods that are high in uric acids
a. Incorrect - Discourage the child from sleeping during the daytime. Children who have JIA have interrupted sleep patterns. Therefore, the nurse should encourage 30-60 minutes of quiet play instead of napping to improve nighttime sleep. b. Incorrect - Apply moist heat compresses or provide a long bath each morning to alleviate stiffness and pain. c. CORRECT - Encourage the child to remain physically active to promote mobility and joint function. d. Incorrect - Not necessary to limit specific foods for a child with JIA. Maintain a healthy weight to decrease pressure on the joints, particularly weight-bearing joints like the knees and hips.
A nurse in a nursing home is assessing an older adult client who moved in 3 months ago following the death of his partner. The client reports awakening early in the morning and admits feeling very sad. The nurse should identify that the client is experiencing which of the following types of grief? a. Anticipatory grief b. Unresolved grief c. Acute grief d. Disenfranchised grief
a. Incorrect - Anticipatory grief is an expected response occurring prior to an actual loss. Clients might be preoccupied with the impending loss, make extensive funeral arrangements, or exhibit a change in attitude toward the lost individual. b. Incorrect - Unresolved grief is brought about traumatic or unexpected loss, such as the sudden death of a child. Clients feel stuck in the grieving process because they lack closure with the loved one. c. CORRECT - Clients with acute grief will experience both somatic and psychological manifestations of distress, such as the inability to sleep well or profound sadness. The nurse should assess his support system, concurrent stressors, and ability to manage stress. d. Incorrect - Disenfranchised grief is when a client cannot openly acknowledge the loss because of societal or religious norms.
A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? a. Fluctuations in blood pressure b. Loss in cognitive function c. Ineffective cough d. Drooping eye lids
a. Incorrect - Blood pressure fluctuations are seen in ALS. b. CORRECT - Loss of cognitive function, including attention span, concentration, memory, and judgment, is a symptom of MS. If plaques are present in the higher control centers of the brain, then cognitive loss is seen. c. Incorrect - Ineffective cough is seen in ALS. d. Incorrect - Drooping eyelids is seen in myasthenia gravis. Visual disturbances, such as diplopia (double vision), blurry vision, and spotty vision is seen in MS because of possible plaques on the optic nerve.
A nurse is performing discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include? a. "Use a sun-blocking agent with a sun protection factor of at least 15 SPF." b. "Wash your hair with a mild protein shampoo." c. "Apply powder liberally to sensitive skin areas." d. "Avoid using moisturizing lotions on your skin."
a. Incorrect - Clients with SLE are advised to use a sun-blocking agent with a sun protection factor of at least 50 SPF. Sun exposure increases SLE exacerbations. b. CORRECT - Clients with SLE are prone to hair loss (alopecia), so advise the client to use mild shampoo and avoid treatments that can damage the hair and scalp, such as dyes. c. Incorrect - Clients with SLE should not use powder or other drying skin products to avoid irritating existing rashes. d. Incorrect - Encourage clients to apply unscented moisturizing lotion to the skin to help with the dry, scaly, and inflamed rashes.
A nurse in a provider's office is collecting information from an older adult client who reports taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? a. Constipation b. Gastric ulcers c. Respiratory depression d. Liver damage
a. Incorrect - Constipation is an adverse effect of opioid analgesics. b. Incorrect - Gastric ulcers are common in aspirin and other nonselective NSAIDs. c. Incorrect - Same as A. d. CORRECT - Acetaminophen in large doses can be liver toxic. Daily intake should be limited and those with a history of liver impairment are at an increased risk. Educate the client that other medications may have acetaminophen, which increases hepatotoxicity if taking concurrently with acetaminophen itself.
A nurse is teaching a client with systemic lupus erythematosus who has a new prescription for prednisone. The nurse should instruct the client to monitor for which of the following adverse effects of this medication? a. Hypoglycemia b. Tendinitis c. Infection d. Weight loss
a. Incorrect - Corticosteroids may cause hyperglycemia because these medications increase insulin resistance and promote glucose production. b. Incorrect - Corticosteroids do not cause tendinitis. c. CORRECT - Instruct the client to avoid contact with people who are ill and monitor for infection manifestations such as a fever or sore throat. Prednisone can suppress the client's immune response and mask infectious symptoms. d. Incorrect - Monitor for weight gain, not loss, due to fluid retention.
A nurse is discussing palliative care with the family of a client who is terminally ill. Which of the following should the nurse include as the purpose of palliative care? a. Curing the disease b. Producing remission c. Hastening death d. Providing comfort measures
a. Incorrect - Curing the disease is only possible when specific treatment is available. Palliative care is only an option when there is no possibility of a cure or when a client with a terminal disease has refused treatment. b. Incorrect - If a remission is possible with treatment, this should be offered to clients before palliative care. It is not possible for remission in palliative care. c. Incorrect - Palliative care is not intended to prolong or hasten death. Instead, it seeks to provide comfort. d. CORRECT - Palliative care is an approach to care that promotes comfort for clients with terminal diagnoses and is not receiving aggressive therapy. Palliative care focuses on managing manifestations of the disease, not on curing the disease.
A nurse is caring for an older adult client who has a terminal illness. The client tells the nurse, "I just want to live 1 more month so I can see my grandchild get married." Which of the following Kubler-Ross stages of grief is this client experiencing? a. Depression b. Acceptance c. Denial d. Bargaining
a. Incorrect - Depression is the fourth stage of grief, according to Kubler-Ross. In the depression stage, the client deals with the full impact of imminent death and grieves for losses both in the past and future. b. Incorrect - Acceptance is the fifth and last stage of grief. The client comes to grips with eventual death and makes preparations for it. c. Incorrect - Denial of death is the first stage. Clients are unable to admit to themselves that they might die. d. CORRECT - Bargaining is the third stage. Bargaining represents the last effort at overcoming death by earning longer life. Trying to put off death for a last major celebration in the client's life (e.g. the marriage of a grandchild) is a form of bargaining.
A school nurse is providing care to a student who is angry and states, "My parents don't know I'm gay, so I can't visit my girlfriend in the hospital while she receives cancer treatment." Which of the following forms of grief is the client experiencing? a. Chronic grief b. Uncomplicated grief c. Disenfranchised grief d. Delayed grief
a. Incorrect - Grief is the emotional response to significant loss. Each person responds to loss differently. A client who experiences chronic grief has a maladaptive grief response which can impact ADLs, extending years or decades. b. Incorrect - Uncomplicated grief includes expected reactions to loss and death, such as crying and sadness. This student is experiencing a more complicated grief. c. CORRECT - Disenfranchised grief occurs when social expectations restrict an individual's ability to cope with grief in an expected way. This type of grief occurs when the social relationship between the client and their loved one cannot be openly recognized. As a result, the client does not have the social support that may be available otherwise. d. Incorrect - The absence of an expected response is delayed grief. This occurs when the person is unable to accept the reality of the loss.
A nurse is teaching a client who has human immunodeficiency virus (HIV) about how the virus is transmitted. Which of the following statements should the nurse include in the teaching? a. "HIV can be transmitted as soon as a person develops manifestations." b. "HIV can be transmitted to anyone who has had contact with infected blood." c. "HIV is transmitted through the respiratory route via droplets." d. "HIV is transmitted only during the active phase of the virus."
a. Incorrect - HIV can be transmitted before a person develops manifestations. The virus is commonly transmitted when a person is asymptomatic and unaware of having the virus. Typically, the asymptomatic period can be as long as 8-10 years, and still infectious. b. CORRECT - The concentration of the virus is highest in blood (viral load) but has also been found in semen, sputum, saliva, and CSF. Clients with HIV are cautioned to practice safe sex, avoid breastfeeding, avoid donating blood, and abstain from sharing needles. c. Incorrect - HIV has not been found to transmit this way. HIV is transmitted only through intimate sexual contact, parenteral exposure to infected blood or blood products, sharing of contaminated needles, and perinatal transmission (mother to newborn). d. Incorrect - HIV can be transmitted at any time. There are no active/inactive phases in HIV.
A nurse is caring for a client who is dying and unable to make decisions for himself. The client's adult children disagree about his code status. Which of the following sources should the nurse depend on for decisions regarding end-of-life care? a. The client's oldest child b. The attending provider c. The client's healthcare proxy d. The client's spouse
a. Incorrect - If the client does not have advance directives or has not named a health care proxy, the family may be asked to make end-of-life decisions. b. Incorrect - The attending provider may offer suggestions on end-of-life care, but the client or their health care proxy directs treatment. c. CORRECT - If the client cannot speak for himself, the nurse should follow the direction of their health care proxy, as this is the person the client chose to make decisions under these circumstances. d. Incorrect - Same as A.
A nurse educator is presenting a module on multiple sclerosis. The nurse educator understands that teaching is effective when nursing students recognize which of the following as a risk factor for MS? a. Living in a temperate zone closer to the equator b. Male sex c. Younger age, particularly 15-45 d. Asian descent
a. Incorrect - Increased risk for MS occurs if individuals live in temperate zones farther from the equator. b. Incorrect - Female sex is more predisposed to MS than male sex, most likely from hormonal influences. However, this is not understood. c. CORRECT - MS often presents itself during young adulthood, typically between the ages of 20-40. This is not well understood, but may be due to immunological changes during adolescence and young adulthood. d. Incorrect - MS can occur in every individual regardless of race. However, people of Northern European ancestry are more likely to develop MS than others.
A nurse is assessing a client who has osteoarthritis. The client's medical record indicates the presence of Heberden's nodes. Which of the following findings should the nurse expect? a. Inflamed, fluid-filled sacs over the joints b. Clubbing of the fingernails c. Flexion contracture of the fingers d. Hard lumps over the joints of the fingers
a. Incorrect - Inflamed, fluid-filled sacs over the joints are manifestations of bursitis, inflammation of the bursa located in the joints. b. Incorrect - Clubbing reflects prolonged hypoxia. c. Incorrect - A progressive flexion contracture of the palmar fascia affecting the middle, fourth, or fifth fingers describes Dupuytren's disease. d. CORRECT - Heberden's nodes are hard, bony lumps or nodules in the joints of the fingers. They are located at the distal interphalangeal (DIP) joints.
A nurse is providing teaching about antiretroviral medication therapy to a client who has a new diagnosis of AIDS. Which of the following statements should the nurse include in the teaching? a. "Your provider will prescribe a single antiretroviral medication at a time." b. "You should take antiretroviral medications on a routine schedule." c. "You should increase your intake of raw fruits and vegetables while taking these medications." d. "Your provider will prescribe antiretroviral therapy to kill the HIV."
a. Incorrect - Inform the client that the provider will prescribe multiple antiretroviral medications at a time, which improves the effectiveness of treatment. b. CORRECT - The need to take antiretroviral therapy exactly as prescribed helps with treatment progression. c. Incorrect - Avoid raw fruits and vegetables to reduce the risk of infection due to immunosuppression, as AIDS highly predisposes patients to opportunistic infections. AIDS is classified as having a CD4+ T-cell count of less than 200, which is a problem for fighting infection. d. Incorrect - Antiretroviral therapy does not kill the HIV virus but inhibits viral replication.
A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is concerned about skin lesions on her face and neck. The client asks, "What should I do about these spots?" Which of the following responses should the nurse give? a. "Keep lesions covered with a light sterile dressing when going outdoors." b. "Rub lesions with a washcloth to dry after washing." c. "Apply moisturizer after bathing the lesions with warm water." d. "Apply antibiotic cream twice a day until scabs form."
a. Incorrect - Instruct the client to wear a hat and protective clothing when outside to avoid ultraviolet rays of the sun, which increases exacerbations. Covering SLE lesions with a sterile dressing when outdoors is unnecessary. Most often, these lesions are dry and scaly, not open and draining. b. Incorrect - Instruct the client to gently pat the lesions dry. c. CORRECT - Clean, dry, and moisturize the skin using warm (not hot!) water and unscented lotion. d. Incorrect - Topical corticosteroid creams, not antibiotic creams, are indicated for cutaneous manifestations of SLE to reduce inflammation.
A nurse is reviewing the provider's admission orders for a client who is at 37 weeks of gestation and is HIV positive. Which of the following orders should the nurse clarify with the provider? a. Intermittent auscultation b. Biophysical profile c. Non-stress test (NST) d. Fetal scalp monitoring
a. Incorrect - Intermittent auscultation with a Doppler is a noninvasive and safe method of fetal monitoring for a client who is HIV positive and poses no risk of HIV transmission. b. Incorrect - A biophysical profile is a noninvasive method of evaluating fetal wellbeing, posing no risk of transmission. c. Incorrect - An NST includes external fetal and uterine monitors. It is noninvasive and safe. d. CORRECT - The placement of a fetal scalp electrode is an invasive procedure that requires ruptured membranes. The electrode is inserted into the fetal scalp, which increases fetal exposure to HIV and is contraindicated.
A nurse is caring for an adult client who is grieving the death of a loved one. Which of the following factors increases the client's risk of developing complicated grief? a. The deceased was a close friend b. The client lived far from the deceased c. The death was sudden d. The client has not visited the deceased in a long time
a. Incorrect - Loss of a close friend is only a risk factor for complicated grief if the grieving individual has had multiple recent losses, was strongly dependent on the friend, or influenced by another compounding factor. b. Incorrect - Same as A. c. CORRECT - Complicated grief can occur when the death of a loved one is sudden and unexpected. d. Incorrect - Same as A.
A nurse is teaching about the adverse effects of morphine with a client who has chronic pain. Which of the following statements should the nurse include in the teaching? a. "You might notice that you see better in dim areas." b. "You should increase your fluid intake." c. "You should expect to have excessive urination." d. "You might experience difficulty sleeping."
a. Incorrect - Morphine can cause pupillary constriction, making it difficult to see in a dark or dim room. The room should be kept well-lit to provide optimal visibility. b. CORRECT - Constipation is an adverse effect of morphine. Encourage the client to increase oral fluids to promote bowel motility. c. Incorrect - Urinary retention is an adverse effect. Encourage the client to void at least once every 4 hours. d. Incorrect - Sedation and drowsiness are adverse effects. Encourage the client to stand up slowly when getting out of bed.
A nurse is planning discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include? a. "Avoid the use of NSAIDs." b. "Stop taking the corticosteroids when your symptoms resolve." c. "Exposure to ultraviolet light will help control the skin rashes." d. "Monitor your body temperature and report any elevations promptly."
a. Incorrect - NSAIDs are commonly used to treat inflammation, joint pain and discomfort, and fevers that can accompany SLE. b. Incorrect - Corticosteroids are typically required on a chronic basis in SLE because of its autoimmune nature. If the client stopped taking them, the client would need to taper off. c. Incorrect - SLE can affect any organ of the body, including the skin. Any source of UV light, including sun exposure, can cause exacerbations. d. CORRECT - With SLE, the immune system is hyperactive, forming antibodies that attack multiple organs (heart, skin, kidneys, brain, blood, lungs). SLE is characterized by exacerbations and remissions. Teach the client to monitor body temperature as a fever can suggest an exacerbation or infection.
A nurse at a clinic is talking with a client who has cancer and takes extended-release opioids twice daily. The client reports an increase in localized, achy pain over the last few days. How should the nurse document this increase in pain? a. Phantom limb pain b. Mixed pain c. Breakthrough pain d. Neuropathic pain
a. Incorrect - Phantom limb pain is pain that is perceived to be initiated from a part of the body that is no longer present (amputations). b. Incorrect - Mixed pain is pain that is difficult to define, for conditions such as fibromyalgia. c. CORRECT - Breakthrough pain is an acute exacerbation of pain beyond the level the client typically experiences. Typically, additional relief measures are added to mitigate this increase of pain from their baseline pain. d. Incorrect - Neuropathic pain sensations are described as burning, shooting, or pins and needles.
While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which of the following documents? a. Informed consent form b. Living will document c. Do-not-resuscitate (DNR) directive d. Durable power of attorney document
a. Incorrect - Prior to specific procedures, clients must sign an informed consent form to confirm that the provider has explained the risks and benefits and pertinent information about the procedure. b. Incorrect - A living will contains advance directives that inform medical personnel about the care to provide in case the individual is unable to make decisions. c. Incorrect - A DNR directive is a prescription the provider writes on the client's request to instruct the staff to forego resuscitation efforts for the client. d. CORRECT - A durable power of attorney for health care document, or health care proxy, names a surrogate who can make healthcare decisions for the client if he is unable to do so.
A nurse is teaching a client who has SLE about self-care. Which of the following statements by the client indicates an understanding of the teaching? a. "I should limit my time to 10 minutes in the tanning bed." b. "I will apply powder to any skin rash." c. "I should use mild hair shampoo." d. "I will inspect my skin once a month for rashes."
a. Incorrect - SLE increases photosensitivity, making the skin more sensitive to light and more prone to developing skin rashes when exposed. Clients with SLE should avoid the use of tanning beds, as well as other prolonged sun exposures. b. Incorrect - Apply steroid-based creams to skin rashes to help with inflammation, as powders can irritate the skin. Unscented moisturizers are also recommended. c. CORRECT - A client with SLE should use mild hair shampoo that does not irritate the scalp. Alopecia (hair loss) can be a symptom of lupus because of inflammation that disrupts the hair growth cycle. d. Incorrect - The client should expect the skin daily for rashes. Encourage clients to apply unscented moisturizer daily to preserve the skin.
A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take? a. Encourage the parents to avoid discussing the death with their older children to protect their feelings b. Recommend each parent grieve in private to avoid hindering each other's healing c. Suggest forming a weekly support group for parents who have experienced the death of a child d. Advise the parents to begin counseling if they are still grieving in a few months
a. Incorrect - Siblings also experience feelings of intense grief and need to know it is acceptable for the family to grieve together. b. Incorrect - Although parents tend to grieve differently, it is important they share their grief and communicate their needs. c. CORRECT - Support groups are a positive resource in the process of recovery for patients following the death of a child. d. Incorrect - The grief process varies for each individual. Setting an expected period for grief places the parents at risk for further problems if they feel they have not completed the grieving process in a timely manner.
A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate? a. Swelling of joints of the fingers b. Pallor of toes with cold exposure c. Feet that become reddened with ambulation d. Client report of intense feeling of heat in the fingers
a. Incorrect - Swelling, pain, and joint tenderness are findings in SLE and is not specific to an episode of Raynaud's phenomenon. b. CORRECT - Pallor of the extremities occurs in Raynaud's phenomenon in a client with SLE and has been exposed to cold temperatures or stress. Vasospasms occur in the distal extremities from cold temperatures, reducing blood flow. c. Incorrect - The extremities becoming red, white, and blue when exposed to cold or stress is characteristic of an episode of Raynaud's phenomenon. d. Incorrect - A client report of intense pain in the hands and feet is characteristic of Raynaud's phenomenon.
A nurse is completing discharge teaching with a client who has multiple sclerosis. The nurse should tell the client to prevent increasing symptoms and relapses by avoiding which of the following? (Select all that apply) a. Cold temperatures b. Infection c. Overexertion d. Salt e. Stress
a. Incorrect - Teach the client to avoid extreme heat, which exacerbates symptoms. Uhthoff's phenomenon is the worsening of symptoms in cases of body temperature increases. b. CORRECT - In MS, the immune system attacks the protective covering of nerve fibers (myelin sheath), causing communication problems between the brain and the rest of the body. The additional activation of the immune system during an infection can further contribute to inflammation. c. CORRECT - Overexertion will increase symptoms by elevating body temperature, which can temporarily worsen neurological symptoms. Teach the client to exercise at a tolerable level followed by adequate resting periods. d. Incorrect - Salt does not exacerbate symptoms. e. CORRECT - Stress is associated with increasing levels of inflammation in the body, which is already exacerbated in MS.
A nurse is completing a pain assessment on an infant. Which of the following pain scales should the nurse use? a. FACES b. FLACC c. PAINAD d. CPOT
a. Incorrect - The FACES pain assessment is recommended for children 3 years or older. b. CORRECT - The FLACC pain assessment scale is recommended for infants and young children between 2 months and 7 years of age. c. Incorrect - PAINAD is recommended for patients with advanced dementia. d. Incorrect - CPOT is for patients in critical care units.
A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of this teaching? a. "Clients are required to complete an advance directive prior to discharge." b. "If the client has a health care proxy, he/she is no longer consulted for health care decisions." c. "I will assess the client's understanding of life-sustaining measures." d. "I will ask the next of kin if I should honor the client's advance directive."
a. Incorrect - The Patient Self-Determination Act requires all health care facilities receiving Medicare and Medicaid reimbursement to ask clients if they have advance directives, but it does not require a client to complete them during hospitalization. b. Incorrect - The health care proxy designates someone else to make health care treatment decisions when the client is unable to do so, based on the client's wishes. If the client is alert and oriented, the nurse should consult the client for decisions. c. CORRECT - Assess whether the client has an accurate understanding of life-sustaining measures in order to make informed decisions in advance directives. d. Incorrect - The Patient Self Determination Act requires healthcare facilities receiving Medicare and Medicaid reimbursement to recognize advance directives. These directives allow clients to specify aspects of care they wish to receive if they become unable to communicate these preferences.
A nurse is teaching a client who is at 12 weeks gestation and has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching? a. "Breastfeed your newborn to provide passive immunity." b. "Abstain from sexual intercourse throughout the pregnancy." c. "You will be in isolation after delivery." d. "You should continue to take zidovudine throughout the pregnancy."
a. Incorrect - The client can transmit HIV through breast milk and should bottle-feed her newborn. b. Incorrect - The client can continue to have sexual intercourse during pregnancy, as long as a condom is used. c. Incorrect - The client and her newborn will only require standard precautions after delivery. d. CORRECT - Inform the client that taking prescription antiviral medication every day decreases the risk of transmitting HIV to her newborn. Zidovudine (ZDV) is an effective medication that can prevent HIV transmission to the newborn from the pregnant person.
A patient is receiving Interferon Beta for the treatment of multiple sclerosis. As the nurse, you will stress the importance of which of the following? a. Physical exercise to improve fatigue b. Low fat diet c. Hand hygiene and avoiding infection d. Reporting ideation of suicide
a. Incorrect - The client should be advised to incorporate physical exercise with adequate resting periods to manage symptoms of MS regardless of the medication they are taking. b. Incorrect - Interferon beta does not affect the digestive system. Encourage the client to drink fluids and increase fiber to prevent constipation, which can occur with MS. c. CORRECT - Interferon beta works by modifying the immune response during relapsing episodes of MS, which can result in immunosuppressive effects. Clients are at an increased susceptibility to infections by taking interferon beta, so practicing good hand hygiene reduces the risk. d. Incorrect - Although interferon beta may cause mood changes, the medication rarely causes suicidal ideation.
A nurse is discussing the difference between rheumatoid arthritis (RA) and osteoarthritis (OA) with a newly licensed nurse. Which of the following pieces of information should the nurse include about osteoarthritis? a. "Osteoarthritis is caused by autoimmune processes." b. "Osteoarthritis leads to a decreased erythrocyte sedimentation rate." c. "Osteoarthritis affects other organ systems." d. "Osteoarthritis can impair a joint on a single side of the body."
a. Incorrect - The nurse should identify aging as a risk factor that causes degenerative changes in osteoarthritis. RA is an autoimmune disease in which the body's immune system attacks itself. b. Incorrect - An increased or normal erythrocyte sedimentation rate is observed in OA. c. Incorrect - Osteoarthritis is limited to the joints. RA is a systemic autoimmune disease, involving other body organs. d. CORRECT - Identify unilateral joint involvement as a finding of OA. Overtime, clients may use some joints more than others which causes additional wear-and-tear. A client with RA experiences symmetrical joint impairment because of its systemic nature of attacking all joints.
A nurse is providing teaching to an older adult client who has osteoarthritis of the right hip and lower lumbar vertebrae. Which of the following statements by the client indicates an understanding of the teaching? a. "I should avoid using a heating pad on my back." b. "To relieve the pressure on my hip, I can use a cane while ambulating." c. "I will receive steroid injections in my joints to treat my pain." d. "I will exercise even when I feel pain."
a. Incorrect - The use of heat is a therapeutic treatment in the management of arthritic pain. b. CORRECT - Using a cane as an assistive device enables the client to compensate for weakness in the spine by providing some relief from hip pressure. A cane can provide joint support and safety for self-care activities. c. Incorrect - Acetaminophen is the first medication of choice to treat the older adult client's pain from osteoarthritis. The nurse should instruct the client to take the medication as prescribed and not to wait until the pain is severe. Severe joint injections are used for persistent and disabling pain in the joints. d. Incorrect - The client should not exercise if this causes pain. Goals include balancing rest with activity and avoiding activities that cause pain or discomfort. Consistent activity is not beneficial for a client who has an arthritic joint because it can cause further damage.
A home health nurse is caring for a client who asks about the purpose of a living will. Which of the following statements should the nurse include in the teaching? a. "It establishes who will make health care decisions for the client if they are not able to." b. "It allows the client to express personal wishes regarding health care decisions." c. "It serves as an informed consent form for any procedure prescribed by a provider." d. "It is only valid when a client is lucid and able to make informed decisions independently."
a. Incorrect - This describes a health care proxy document, which frequently accompanies a living will but is not considered part of it. b. CORRECT - A living will allows the client to specify what aspects of care and treatment are to be accepted or refused in the event the client cannot communicate those decisions. c. Incorrect - A living will does not serve the same function as informed consent. Prior to any procedure, consent must be obtained from the client, a family member, or designated proxy. d. Incorrect - A living will is not valid or necessary when a client is able to make decisions independently.
A nurse is caring for a client who experienced a fetal loss. When initiating communication with this client, which of the following statements should the nurse make? a. "I understand how you feel." b. "I am here for you if you would like to talk." c. "It is better that the loss happened now, before you got to know your baby." d. "You are young and can have other children."
a. Incorrect - This is nontherapeutic because the nurse should not presume to know how the client feels after a fetal loss. b. CORRECT - This is a therapeutic statement because it acknowledges the client's loss and invites her to share her thoughts and feelings. c. Incorrect - This is nontherapeutic because it gives common advice. Furthermore, the nurse should never deny the bond that many pregnant individuals feel with the fetus throughout pregnancy. d. Incorrect - This is nontherapeutic because it gives unwanted reassurance that has no basis in fact. The nurse should never assume that any other child could take the place of the lost child.
A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make? a. "You probably want to hold your baby." b. "I'll stay with you just in case you want to talk." c. "I know how you must be feeling." d. "It hurts now, but things will be better soon."
a. Incorrect - This response is nontherapeutic by making an assumption about the client's needs and desires. The nurse should ask if the client wants to hold their baby. Sometimes, the family may not want to hold the baby and their choice should be respected. b. CORRECT - This response is therapeutic by offering self and indicates the nurse's interest in the client and a desire to understand their feelings. c. Incorrect - This response minimizes the client's feelings and makes an assumption about those feelings. d. Incorrect - This response minimizes their feelings and offers false reassurance.
A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my child's wedding." Based on the Kubler-Ross model, which stage of grief is the client experiencing? a. Anger b. Denial c. Bargaining d. Acceptance
a. Incorrect - This statement does not express anger. b. Incorrect - The client is not denying the severity of the diagnosis and prognosis. c. CORRECT - The client is bargaining by attempting to negotiate more time to live to see the child get married. d. Incorrect - Although the client might have accepted their condition, this statement does not convey coming to terms with the situation.
A nurse is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk of complicated grief? a. "I wish I had been more generous to my wife before she died." b. "I told my wife to go to the doctor, but she wouldn't listen to me." c. "I think about my wife all the time when I go on outings with my family." d. "I feel so empty without my wife that it's hard to get up every morning."
a. Incorrect - This statement expresses guilt, which is expected during bereavement. b. Incorrect - This statement expresses anger, which is expected during bereavement. c. Incorrect - This statement expresses a preoccupation with the image of the deceased, which is expected during bereavement. d. CORRECT - Identify that a client who has difficulty carrying on normal activities following the loss of a partner is at risk of complicated grief.
A nurse is teaching a client who takes NSAIDs to treat rheumatoid arthritis. During checkup, the provider prescribes methotrexate. Which of the following statements include the purpose of this medication? a. "Your current medication was not strong enough prior." b. "Once blood levels of methotrexate are within therapeutic range, the NSAID will be stopped." c. "This medication was added to delay the disease progression." d. "Treating with 2 medications will prevent treatment resistance."
a. Incorrect - When a medication is no longer effective, the dosage is increased, or the medication is discontinued. b. Incorrect - Methotrexate does not have a therapeutic range to be effective. However, it is the fastest acting medication in its class. c. CORRECT - Inform the client that the provider prescribed methotrexate to be added along with an NSAID to delay the disease progression and joint damage that can result. Methotrexate suppresses the immune system that causes the autoimmune attacks. d. Incorrect - Rheumatoid arthritis is not a disease in which treatment resistance is a concern.
An adolescent has just been diagnosed with systemic lupus erythematosus (SLE). Following education about the disease, which statement by the adolescent indicates the session was successful? a. "SLE is a rheumatic disease that mostly affects my joints." b. "SLE is an autoimmune disorder that I will always have, with times of flare-ups and times of minimal to no symptoms." c. "If my SLE has been found early enough in the disease process, there is a good chance medications can cure it." d. "SLE only affects my skin. It seldom causes problems in other organs."
a. Incorrect - While joint involvement is common in lupus, it is a systemic disease that can affect various organs and tissues beyond the joints. b. CORRECT - SLE is an autoimmune, chronic disorder with periods of exacerbations and remissions. Managing the disease often involves medications and lifestyle adjustments to control symptoms and prevent flare-ups. c. Incorrect - There is currently no cure for SLE. Early detection and treatment can help prevent complications, but it is a chronic condition. d. Incorrect - Lupus is a systemic disease, meaning it can affect multiple organs and tissues, not just the skin. The lupus can impact the joints, kidneys, heart, lungs, and more.
A nurse is caring for a client who was exposed to human immunodeficiency virus (HIV) 2 days ago. The client asks the nurse what to do. Which of the following responses should the nurse provide? a. "I will administer an HIV vaccine today, and it will need to be repeated in 3 months." b. "I will administer an HIV test today, and after 48 hours, read the results." c. "You will need to have an HIV test every other week for 6 months." d. "You will need to take prophylactic medications for 4 weeks."
a. Incorrect - While vaccines for HIV are in the trial phase of development, a preventive vaccine is not currently available. b. Incorrect - Once a test for TB is administered, the client must return in 48-72 hours for the nurse to read the test. c. Incorrect - Following exposure to HIV, the client should return for testing at 4-6 weeks, 3 months, and 6 months [note: ATI recommends 6 months but now no longer recommended]. d. CORRECT - The client will need to take PEP (post-exposure prophylaxis) medications for 4 weeks to prevent the virus from replicating in the body. PEP is indicated for occupational exposures, sexual assaults, or isolated experiences (condom breaking, needlesticks).
