NUR 114 Final

A nurse is assessing a client who has a suspected diagnosis of GBS. Which of the following questions should the nurse ask the client?

" Have you had a recent influenza infection?"

A nurse is providing education for a client who has a glaucoma. Which of the following statements should the nurse include in the teaching?

" Without treatment, glaucoma can cause blindness."

A nurse is providing postoperative care teaching to a client who is scheduled for cataract surgery. Which of the following information should the nurse include?

" vision will be greatly improved on the day of surgery."

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?

"I need something for the pain in my eye. I can't stand it."

A nurse is providing teaching to a client who has nephrotic syndrome. The nurse should recognize that which of the following client statements indicates a need for further teaching?

"I should increase my sodium intake"

The nurse is conducting patient teaching about cholesterol levels. When discussing the patients elevated LDL and lowered HDL levels, the patient shows an understanding of the significance of these levels by stating what? A) Increased LDL and decreased HDL increase my risk of coronary artery disease. B) Increased LDL has the potential to decrease my risk of heart disease. C) The decreased HDL level will increase the amount of cholesterol moved away from the artery walls. D) The increased LDL will decrease the amount of cholesterol deposited on the artery walls.

A) Increased LDL and decreased HDL increase my risk of coronary artery disease.

A patients abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the patients laboratory studies, what finding is most closely associated with this diagnosis? A) Increased bilirubin B) Decreased serum cholesterol C) Increased blood urea nitrogen (BUN) D) Decreased serum alkaline phosphatase level

A) Increased bilirubin

Which is believed to be a risk factor specific to the development of delirium? A) Increased severity of physical illness B) Older age C) Baseline cognitive impairment D) Gradual decline in functioning

A) Increased severity of physical illness

A patient with a longstanding diagnosis of type 1 diabetes has a history of poor glycemic control. The nurse recognizes the need to assess the patient for signs and symptoms of peripheral neuropathy. Peripheral neuropathy constitutes a risk for what nursing diagnosis? A) Infection B) Acute pain C) Acute confusion D) Impaired urinary elimination

A) Infection

A nurse is teaching a patient with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the patient to perform what action? A) Instill the medication in the conjunctival sac. B) Maintain a supine position for 10 minutes after administration. C) Keep the eyes closed for 1 to 2 minutes after administration. D) Apply the medication evenly to the sclera

A) Instill the medication in the conjunctival sac.

The nurse asks the client, What is similar about a cow and a horse? and What do a bus and an airplane have in common? These questions would best assess which of the following areas? A) Intellectual function B) Insight C) Judgment D) Memory

A) Intellectual function

Which of the following characteristics describe the obsessional thoughts experienced by clients with OCD? (SATA) A) Intrusive B) Realistic C) Recurrent D) Uncontrollable E) Unwanted F) Voluntary

A) Intrusive C) Recurrent D) Uncontrollable E) Unwanted

The nurse uses cognitiveñbehavioral approaches to assist the client with bulimia toward recovery. Which statement by the nurse would be consistent with this approach? A) Is there any way you can look at that sandwich as fuel for your body? B) You have to eat in moderation for good nutrition. C) You seem to have a really hard time controlling your eating patterns. D) Is this your way of showing your family that you can make decisions?

A) Is there any way you can look at that sandwich as fuel for your body?

Which of the following statements is true of empathy? Select all that apply. A) It is the ability to place oneself into the experience of another for a moment in time. B) It involves interjecting the nurse's personal experiences and interpretations of the C) It is developed by gathering information from the client. D) It results in negative therapeutic outcomes. E) The client must learn to develop empathy for the nurse.

A) It is the ability to place oneself into the experience of another for a moment in time. C) It is developed by gathering information from the client.

The nurse is teaching a client with paranoid personality disorder to validate ideas with another person before taking action on him. Which is the best rationale for this intervention? A) It will assist the client to start basing decisions and actions on reality. B) It will help the client understand the origins of his or her paranoid thinking. C) It will help the client learn to trust other people. D) It will teach the client to differentiate when his or her suspicions are true

A) It will assist the client to start basing decisions and actions on reality.

A patient with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the patient will undergo what intervention? A) Laparoscopic cholecystectomy B) Methyl tertiary butyl ether (MTBE) infusion C) Intracorporeal lithotripsy D) Extracorporeal shock wave therapy (ESWL)

A) Laparoscopic cholecystectomy

A patient with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure? A) Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure. B) Laparoscopic cholecystectomy can be performed in a clinic setting, while an open procedure requires an OR. C) A laparoscopic approach allows for the removal of the entire gallbladder. D) A laparoscopic approach can be performed under conscious sedation.

A) Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure.

The caregiver of a client with Alzheimer's disease reports to the nurse that often the client will suddenly become angry during meals and nothing seems to calm him down. The nurse teaches the caregiver to use distraction techniques. Which response would be best to teach as an example of this technique? A) Let's look at what is on television. B) If you stop yelling, I will get your dessert. C) Don't you want to finish your meal? D) I don't understand what you are saying

A) Let's look at what is on television.

The nurse is caring for a patient who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what? A) Lipids and fibrous tissue B) White blood cells C) Lipoproteins D) High-density cholesterol

A) Lipids and fibrous tissue

The student nurse is preparing a teaching plan for a patient being discharged status post MI. What should the student include in the teaching plan? (Mark all that apply.) A) Need for careful monitoring for cardiac symptoms B) Need for carefully regulated exercise C) Need for dietary modifications D) Need for early resumption of prediagnosis activity E) Need for increased fluid intake

A) Need for careful monitoring for cardiac symptoms B) Need for carefully regulated exercise C) Need for dietary modifications

The student nurse is preparing a teaching plan for a patient being discharged status post MI. What should the student include in the teaching plan? (Mark all that apply.) A) Need for careful monitoring for cardiac symptoms B) Need for carefully regulated exercise C) Need for dietary modifications D) Need for early resumption of prediagnosis activity Need for increased fluid intake

A) Need for careful monitoring for cardiac symptoms B) Need for carefully regulated exercise C) Need for dietary modifications

A nurse is teaching an adult female patient about the risk factors for hypertension. What should the nurse explain as risk factors for primary hypertension? A) Obesity and high intake of sodium and saturated fat B) Diabetes and use of oral contraceptives C) Metabolic syndrome and smoking D) Renal disease and coarctation of the aorta

A) Obesity and high intake of sodium and saturated fat

All of the following are included in the plan of care for a client with schizophrenia. Which nursing intervention should the nurse perform first when caring for this client? A) Observe for signs of fear or agitation B) Maintain reality through frequent contact C) Encourage to participate in the treatment milieu D) Assess community support systems

A) Observe for signs of fear or agitation

The nurse is planning the type of approach that will be most effective in developing a therapeutic relationship with the client. The nurse should use a matter-of-fact approach with clients with which types of personality disorders? Select all that apply. A) Paranoid B) Antisocial C) Schizotypal D) Narcissistic E) Avoidant

A) Paranoid B) Antisocial D) Narcissistic

Which disorder is characterized by pervasive mistrust and suspiciousness of others? A) Paranoid personality disorder B) Schizoid personality disorder C) Histrionic personality disorder D) Dependent personality disorder

A) Paranoid personality disorder

A patient has been prescribed antihypertensives. After assessment and analysis, the nurse has identified a nursing diagnosis of risk for ineffective health maintenance related to nonadherence to therapeutic regimen. When planning this patients care, what desired outcome should the nurse identify? A) Patient takes medication as prescribed and reports any adverse effects. B) Patients BP remains consistently below 140/90 mm Hg. C) Patient denies signs and symptoms of hypertensive urgency. D) Patient is able to describe modifiable risk factors for hypertension.

A) Patient takes medication as prescribed and reports any adverse effects.

The nurse is developing a nursing care plan for a patient who is being treated for hypertension. What is a measurable patient outcome that the nurse should include? A) Patient will reduce Na+ intake to no more than 2.4 g daily. B) Patient will have a stable BUN and serum creatinine levels. C) Patient will abstain from fat intake and reduce calorie intake. D) Patient will maintain a normal body weight.

A) Patient will reduce Na+ intake to no more than 2.4 g daily.

Cardiopulmonary resuscitation has been initiated on a patient who was found unresponsive. When performing chest compressions, the nurse should do which of the following? A) Perform at least 100 chest compressions per minute. B) Pause to allow a colleague to provide a breath every 10 compressions. C) Pause chest compressions to allow for vital signs monitoring every 4 to 5 minutes. D) Perform high-quality chest compressions as rapidly as possible.

A) Perform at least 100 chest compressions per minute.

Which of the following nursing interventions best meets C.J.'s physiological needs during passing kidney stones? A) Perform frequent pain assessments B) Routinely strain urine for stones C) Encourage wife to room-in with C.J. overnight D) Always keep the bed alarm on

A) Perform frequent pain assessments

The nursing supervisor in an extended care facility is managing the environment to best help the clients with dementia. Which should the nurse include in planning the living environment? A) Plan for the same caregivers to provide care to individuals as much as possible. B) Open the windows and doors to allow fresh air to circulate through the environment. C) Provide a buffet-style menu with many food choices. D) Assign peer-led exercise activates on a daily basis.

A) Plan for the same caregivers to provide care to individuals as much as possible.

The physician has placed a central venous pressure (CVP) monitoring line in an acutely ill patient so right ventricular function and venous blood return can be closely monitored. The results show decreased CVP. What does this indicate? A) Possible hypovolemia B) Possible myocardial infarction (MI) C) Left-sided heart failure D) Aortic valve regurgitation

A) Possible hypovolemia

A patient presents to the ED in distress and complaining of crushing chest pain. What is the nurses priority for assessment? A) Prompt initiation of an ECG B) Auscultation of the patients point of maximal impulse (PMI) C) Rapid assessment of the patients peripheral pulses D) Palpation of the patients cardiac apex

A) Prompt initiation of an ECG

Upon admission, a client with a personality disorder identified the following as areas of concern for which the client would like help. According to studies, which will most likely be addressed by the health-care team? A) Psychological distress B) Self-care C) Sexual expression D) Budgeting

A) Psychological distress

A cardiovascular patient with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. What is the nurses best action? A) Rapidly assess the patients cardiopulmonary status. B) Arrange for an ECG. C) Increase the height of the patients bed. D) Manage the patients anxiety.

A) Rapidly assess the patients cardiopulmonary status.

The nurse is performing a health history with a client exhibiting signs of delirium. The nurse asks the client and family members about possible causes of the delirious state. Which would the nurse likely attribute as underlying causes for the client's delirium? Select all that apply. A) Recent alcohol use B) Dehydration C) Use of antihistamines D) Sleep disturbances E) Use of megadose of vitamins F) Exposure to paint or gasoline

A) Recent alcohol use B) Dehydration C) Use of antihistamines D) Sleep disturbances F) Exposure to paint or gasoline

A patient with cardiovascular disease is being treated with amlodipine (Norvasc), a calcium channel blocking agent. The therapeutic effects of calcium channel blockers include which of the following? A) Reducing the hearts workload by decreasing heart rate and myocardial contraction B) Preventing platelet aggregation and subsequent thrombosis C) Reducing myocardial oxygen consumption by blocking adrenergic stimulation to the heart D) Increasing the efficiency of myocardial oxygen consumption, thus decreasing ischemia and relieving pain

A) Reducing the hearts workload by decreasing heart rate and myocardial contraction

A client with schizophrenia reads the advice column in the newspaper daily. When asked why the client is so interested in the advice column, the client replies, ìThis person is my guide and tells me what I must do every day.î The nurse would best describe this type of thinking as which of the following? A) Referential delusion B) Grandiose delusion C) Thought insertion D) Personalization

A) Referential delusion

A patient with primary hypertension comes to the clinic complaining of a gradual onset of blurry vision and decreased visual acuity over the past several weeks. The nurse is aware that these symptoms could be indicative of what? A) Retinal blood vessel damage B) Glaucoma C) Cranial nerve damage D) Hypertensive emergency

A) Retinal blood vessel damage

A patient with primary hypertension complains of dizziness with ambulation. The patient is currently on an alpha-adrenergic blocker and the nurse assesses characteristic signs and symptoms of postural hypotension. When teaching this patient about risks associated with postural hypotension, what should the nurse emphasize? A) Rising slowly from a lying or sitting position B) Increasing fluids to maintain BP C) Stopping medication if dizziness persists D) Taking medication first thing in the morning

A) Rising slowly from a lying or sitting position

The critical care nurse is caring for a patient who has been experiencing bradycardia after cardiovascular surgery. The nurse knows that the heart rate is determined by myocardial cells with the fastest inherent firing rate. Under normal circumstances where are these cells located? A) SA node B) AV node C) Bundle of His D) Purkinje cells

A) SA node

Of the following personality disorders, which are most likely related to lack of caring about others? Select all that apply. A) Schizotypal personality disorder B) Borderline personality disorder C) Antisocial personality disorder D) Narcissistic personality disorder E) Obsessiveñcompulsive personality disorder

A) Schizotypal personality disorder C) Antisocial personality disorder D) Narcissistic personality disorder

A patient with secondary hypertension has come into the clinic for a routine check-up. The nurse is aware that the difference between primary hypertension and secondary hypertension is which of the following? A) Secondary hypertension has a specific cause. B) Secondary hypertension has a more gradual onset than primary hypertension. C) Secondary hypertension does not cause target organ damage. D) Secondary hypertension does not normally respond to antihypertensive drug therapy.

A) Secondary hypertension has a specific cause.

When performing discharge planning for a client who has schizophrenia, the nurse anticipates barriers to adhering to the medication regimen. The nurse assesses which of the following as improving the likelihood that the client will follow the prescribed medication regimen? Select all that apply. A) Short-term memory intact B) History of missing appointments C) Receives monthly disability checks D) Walking is primary mode of transportation E) States location of pharmacy nearest his residence

A) Short-term memory intact C) Receives monthly disability checks E) States location of pharmacy nearest his residence

Which are important in the limit-setting technique to deal with manipulative behavior? Select all that apply. A) Stating the behavioral limit B) Identifying the consequences if the limit is exceeded C) Identifying the expected or desired behavior D) Providing choices E) Allowing flexibility

A) Stating the behavioral limit B) Identifying the consequences if the limit is exceeded C) Identifying the expected or desired behavior

A patient is known to express tangential thinking. The nurse would assess for which of the following when interacting with the patient? A) Stopping abruptly in the middle of expressing himself B) Jumping from one idea to another C) Wandering off the topic and never answering the question D) Excessive and fast talking about an array of ideas

A) Stopping abruptly in the middle of expressing himself

A client with schizophrenia has returned to the clinic because of an increase in symptoms. The client reports he stopped taking his meds because he did not like the side effects. The nurse educates the client about managing uncomfortable side effects. Which of the following is included in the teaching plan? Select all that apply. A) Suck on hard candy as desired B) Spend at least 30 minutes outside in the sun daily C) Use stool softeners as needed D) Decrease the amount of daily fluid intake E) Maintain a balanced calorie-controlled diet

A) Suck on hard candy as desired C) Use stool softeners as needed E) Maintain a balanced calorie-controlled diet

A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. The instructor categorizes this action of the heart as what? A) Systole B) Diastole C) Repolarization D) Ejection fraction

A) Systole

A client with dementia is starting pharmacotherapy to slow the progression of cognitive decline. The client has a history of moderate but steady alcohol use over the past 45 years. Which medication should the nurse question as least suitable for this client? A) Tacrine (Cognex) B) Memantine (Namenda) C) Donepezil (Aricept) D) Rivastigmine (Exelon)

A) Tacrine (Cognex)

Which nursing interventions are most important in a plan of care for a client with histrionic personality disorder? Select all that apply. A) Teach social skills. B) Assist the client to eliminate passive behavior. C) Provide factual feedback about behavior. D) Try to meet the client's needs for attention. E) Acceptance of the behavior.

A) Teach social skills. C) Provide factual feedback about behavior.

The nurse is teaching a client with schizoid personality to function more comfortably with others in the community. Which nursing intervention would be effective to improve the client's social skills? A) Teach the client to make necessary requests in writing or over the phone. B) Accompany the client during initial interactions in the community. C) Suppress the display of any unusual behaviors in public. D) Assist in developing an explanation for bizarre behaviors to offer to others in the

A) Teach the client to make necessary requests in writing or over the phone.

A patient reported to the nurse that on his way to the clinic, a policeman in a patrol car turned on his lights and pulled him over. When asked what he did next, the patient stated, I pulled over, of course. Which of the following was the nurse trying to assess? A) The client's judgment B) The client's insight C) The client's concentration D) The client's self-concept

A) The client's judgment

Which are possible sources of frustrations for nurses caring for persons with dementia? Select all that apply. A) The clients do not retain explanations or instructions, so the nurse must repeat the same things continually. B) The nurse may get little or no positive response or feedback from clients with dementia. C) It can be difficult to remain positive and supportive to clients and family because the outcome is so bleak. D) It can be helpful for the nurse to talk to colleagues or even a counselor about personal feelings of depression and grief as the dementia progresses. E) The clients may seem not to hear or respond to anything the nurse does.

A) The clients do not retain explanations or instructions, so the nurse must repeat the same things continually. B) The nurse may get little or no positive response or feedback from clients with dementia. C) It can be difficult to remain positive and supportive to clients and family because the outcome is so bleak. E) The clients may seem not to hear or respond to anything the nurse does.

The nursing student correctly identifies which of the following statements are true of the etiology of OCD? Select all that apply. A) The cognitive model for OCD etiology focuses on childhood and environmental experiences of growing up. B) The etiology of OCD is not definitively explained at this time. C) OCD is caused by immune dysfunction. D) The primary etiology of OCD is genetics. E) Cognitive models may partially explain why people develop OCD.

A) The cognitive model for OCD etiology focuses on childhood and environmental experiences of growing up. B) The etiology of OCD is not definitively explained at this time. E) Cognitive models may partially explain why people develop OCD.

The nurse is working with a patient who had an MI and is now active in rehabilitation. The nurse should teach this patient to cease activity if which of the following occurs? A) The patient experiences chest pain, palpitations, or dyspnea. B) The patient experiences a noticeable increase in heart rate during activity. C) The patients oxygen saturation level drops below 96%. D) The patients respiratory rate exceeds 30 breaths/min

A) The patient experiences chest pain, palpitations, or dyspnea.

A patient with glaucoma has presented for a scheduled clinic visit and tells the nurse that she has begun taking an herbal remedy for her condition that was recommended by a work colleague. What instruction should the nurse provide to the patient? A) The patient should discuss this new remedy with her ophthalmologist promptly. B) The patient should monitor her IOP closely for the next several weeks. C) The patient should do further research on the herbal remedy. D) The patient should report any adverse effects to her pharmacist.

A) The patient should discuss this new remedy with her ophthalmologist promptly.

A patient comes to the ophthalmology clinic for an eye examination. The patient tells the nurse that he often sees floaters in his vision. How should the nurse best interpret this subjective assessment finding? A) This is a normal aging process of the eye. B) Glasses will minimize this phenomenon. C) The patient may be exhibiting signs of glaucoma. D) This may be a result of weakened ciliary muscles.

A) This is a normal aging process of the eye.

When assessing a patient's mental health status, which of the following describe the purpose of the psychosocial assessment? Select all that apply. A) To assess the client's current emotional state B) To assess the client's mental capacity C) To assess the client's behavioral function D) To assess the client's plan of care E) To assess the client's physical health status

A) To assess the client's current emotional state B) To assess the client's mental capacity C) To assess the client's behavioral function

The nurse caring for an elderly woman with dementia has asked the woman's children to bring old photo albums when they visit. Which best describes the usefulness of viewing photos when caring for the dementia client? A) Viewing photos is a form of reminiscence therapy for the client. B) Sharing photos will encourage interaction with other clients. C) This can help the children to correctly identify old photographs. D) Talking about the photos will encourage the client to live in the past.

A) Viewing photos is a form of reminiscence therapy for the client.

Which of the following are components of the assessment of thought process and content? Select all that apply. A) What the client is thinking B) Abstract thinking abilities C) How the client is thinking D) Clarity of ideas E) Self-harm or suicide urges

A) What the client is thinking C) How the client is thinking D) Clarity of ideas E) Self-harm or suicide urges

The client spoke of a current event in the national news and described it as it relates to the client. Then the client spoke of a historical event and described it as it relates to the client. Which of the following questions might the nurse ask to determine if the client is experiencing ideas of reference? A) Where were you when this happened? B) Why do you think that? C) Are you sure? D) That is unbelievable!

A) Where were you when this happened?

The nurse is caring for a patient who is scheduled for cardiac surgery. What should the nurse include in preoperative care? A) With the patient, clarify the surgical procedure that will be performed. B) Withhold the patients scheduled medications for at least 12 hours preoperatively. C) Inform the patient that health teaching will begin as soon as possible after surgery. D) Avoid discussing the patients fears as not to exacerbate them.

A) With the patient, clarify the surgical procedure that will be performed.

Which of the following statements would be an empathetic response in a client interaction? A) You must have been embarrassed when your father yelled at you in the grocery store. B) You really should find your own housing and get out of the situation with your father. C) Well, it sounds like your father has difficulty controlling his temper. D) Why do you think your father chose that time and place to yell at you?

A) You must have been embarrassed when your father yelled at you in the grocery store.

A patient says, Its' been so long since I've been with my family. Which statement by the nurse is an example of restating? A) You say you haven't seen your family in a while. B) Tell me when you last saw your family. C) Go on. Tell me more. D) When was the last time you saw your family?

A) You say you haven't seen your family in a while.

The client with OCD has counting and checking rituals that prolong attempts to perform activities of daily living. The nurse knows that interrupting the client's ritual to assist in faster task completion will likely result in A) a burst of increased anxiety. B) gratitude for the nurse's assistance. C) relief from stopping the ritual. D) symptoms of depression or suicidality.

A) a burst of increased anxiety.

A client is being evaluated for dementia. The nurse knows that a client who is able to complete very few tasks is most likely to have A) a greater cognitive deficit. B) A less precise mental status exam. C) more potential for agitation. D) no bearing on mental status.

A) a greater cognitive deficit.

The most important short-term goal for the client who tries to manipulate others would be to A) acknowledge own behavior. B) express feelings verbally. C) stop initiating arguments. D) sustain lasting relationships.

A) acknowledge own behavior.

The advantages of assertive communication are Select all that apply. A) all persons' rights are respected. B) it gains approval from others. C) it protects the speaker from being exploited. D) the speaker can say no to another person's request. E) the speaker can safely express thoughts and feelings. F) the speaker will get their needs met.

A) all persons' rights are respected. C) it protects the speaker from being exploited. D) the speaker can say no to another person's request. E) the speaker can safely express thoughts and feelings.

The nurse asks the patient what he would like to talk about. This is an example of A) broad opening. B) encouraging expression. C) focusing. D) offering self.

A) broad opening.

A client with OCD is admitted to the hospital owing to ritualistic hand washing that occupies several hours each day. The skin on the client's hands is red and cracked, with evidence of minor bleeding. The goal for this client is A) decreasing the time spent washing hands. B) eliminating the hand washing rituals. C) providing milder soap for hand washing. D) providing good skin care.

A) decreasing the time spent washing hands.

The client tells the nurse, That new TV anchor is telling the world about me. This is an example of A) ideas of reference. B) persecutory delusions. C) thought broadcasting. D) thought insertion.

A) ideas of reference.

A client with mania begins dancing around the day room. When she twirled her skirt in front of the male clients, it was obvious she had no underwear on. The nurse distracts her and takes her to her room to put on underwear. The nurse acted as they did to A) minimize the client's embarrassment about her present behavior. B) keep her from dancing with other clients. C) avoid embarrassing the male clients who are watching. D) teach her about proper attire and hygiene.

A) minimize the client's embarrassment about her present behavior.

Sexuality and self-harm behaviors are often difficult areas for nurses to assess. An effective way for nurses to deal with this discomfort includes A) recognizing that these areas may also be uncomfortable for the patient to discuss. B) share feelings of discomfort with the patient. C) defer assessing these areas to a more experienced nurse. D) develop a standard question to ask of all patients during this area of assessment

A) recognizing that these areas may also be uncomfortable for the patient to discuss.

The nurse is caring for a client with cognitive impairment. To determine whether the client is suffering from delirium or dementia, the nurse reviews the symptoms and course of each disorder. Place the letter A beside terms describing delirium and the letter B beside terms describing dementia. Rapid onset: Progressive decline: Long-term memory impairment: Slurred speech: Hallucinations:

A, B, B, A, A

What signs and symptoms are pointing to peptic ulcer disease? Select all that apply. A. 45-year-old female B. Burning sensation located in between the umbilical and sternum C. Complaints of pain immediately after eating D. Some nausea E. All of the above

A. 45-year-old female B. Burning sensation located in between the umbilical and sternum C. Complaints of pain immediately after eating

Mr. DeSousa is a 68-year-old African American man who is 6'3", weighs 400lbs, and smokes 1-2 packs of cigarettes daily. He also states that he likes to drink 4-5 alcoholic beverages every morning to get his day started before he goes to McDonald's to purchase his meals for the day. Which of the following risk factors put him at an increased risk for the development of colon cancer? SATA A. Age B. Race/Ethnicity C. Alcohol use D. Tobacco use E. Consuming a nutritious diet F. Height G. Weight

A. Age B. Race/Ethnicity C. Alcohol use D. Tobacco use F. Height G. Weight

A provider has ordered a blood test for prostate-specific antigen (PSA) because they palpated an enlarged prostate during an exam of a 63 year old man. What is the purpose of this test? A. An elevated PSA can indicate prostate cancer B. An elevate PSA will tell the provider if the patient has metastatic prostate cancer C. A low PSA level can indicate prostate cancer D. A PSA blood test is used to diagnose prostate cancer.

A. An elevated PSA can indicate prostate cancer

Which of the following is the most common first symptom of rectal cancer? A. Bleeding during a bowel movement B. Constipation C. Crampy abdominal pain D. Fatigue

A. Bleeding during a bowel movement

Which of the following are a part of the 5 key practices of a servant leader? (SATA) A. Develops a vision B. Gives away power C. Uses Rewards for task completion D. Listen and learn before speaking and doing E. Makes little to no decisions

A. Develops a vision B. Gives away power D. Listen and learn before speaking and doing

Which of the following are signs of the aura stage? SATA A. Hallucinations B. Dizziness C. Numbness D. Distorted emotions E. Confusion

A. Hallucinations B. Dizziness C. Numbness D. Distorted emotions E. Confusion

A newly licensed nurse overhears a nurse say to a colleague that she does not care for the leadership style being implemented by the unit manager. She says the manager provides little supervision and input in decision making for the unit and does not make an effort to encourage team participation. The style being described may not be ideal for a unit with several newly licensed nurses. Which style is the nurse referring to? A. Laissez-faire B. Democratic C. Servant D. Transactional

A. Laissez-faire

In early stages of Alzheimer's disease, the hippocampus is affected. This part of the brain is responsible for what function(s)? Select all that apply: A. Learning B. Navigation C. Memory D. Language E. Planning

A. Learning B. Navigation C. Memory

What medications should the nurse check to see if the patient has taken before administering a urea breath test? Select all that apply. A. Proton Pump inhibitor. B. Ace inhibitors C. Bismuth Subsalicylate D. Antibiotics E. Antipsychotics

A. Proton Pump inhibitor. B. Ace inhibitors D. Antibiotics

What foods should a person with Crohn's and Ulcerative Colitis avoid? Select all that apply. A. Red meat B. Processed meat C. Hot sauce D. Boiled chicken E. Butter F. Alcohol G. Coffee

A. Red meat B. Processed meat C. Hot sauce E. Butter F. Alcohol G. Coffee

What parts of the body are removed during a full prostatectomy? SATA A. Seminal vesicles B. Bladder C. Prostate D. Surrounding lymph nodes E. Testicles

A. Seminal vesicles C. Prostate D. Surrounding lymph nodes

The nurse is educating a 55 year old male patient about signs and symptoms of BOTH BPH and prostate cancer, which of the following should the nurse include in her teaching? SATA A. Urinary frequency B. Urinary dribbling C. Enlarged prostate on digital exam D. Weight loss E. Hematuria

A. Urinary frequency B. Urinary dribbling C. Enlarged prostate on digital exam E. Hematuria

Which techniques help prevent eye infections from occurring? SATA A. Washing hands before touching eye area B. Making sure eye applicator tip is making contact with eye C. Not using anyone else's makeup or eye drops D. Using contact solution to clean contacts

A. Washing hands before touching eye area C. Not using anyone else's makeup or eye drops D. Using contact solution to clean contacts

A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE) the nurse should include which of the following data? (Select all that apply.)

Ability to perform calculations Recall ability Long-term memory Level of orientation

A nurse is collecting data from an adolescent. Which of the following should the nurse identify as the greatest risk for suicide?

Active psychotic disorder

A nurse is planning care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse include in the plan?

Administer antibiotics.

A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?

Administer the morning dose of lithium

A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

Affective flattening

A client with bipolar disorder begins taking lithium carbonate (lithium) 300 mg four times a day. After 3 days of therapy, the client says, "My hands are shaking." Which is the best response by the nurse? A) "Fine motor tremors are an early effect of lithium therapy that usually subsides in a few weeks." B) "It is nothing to worry about unless it continues for the next month." C) "Tremors can be an early sign of toxicity, but we'll keep monitoring your lithium level to make sure you're OK." D) "You can expect tremors with lithium. You seem very concerned about such a small tremor."

A) "Fine motor tremors are an early effect of lithium therapy that usually subsides in a few weeks."

Which of the following is a concrete message? A) "Help me put this pile of books on M.'s desk." B) "Get this out of here." C) "When is she coming home?" D) "They said it is too early to get in."

A) "Help me put this pile of books on M.'s desk."

The nurse should recognize the greatest risk for the development of blindness in which of the following patients? A) A 58-year-old Caucasian woman with macular degeneration B) A 28-year-old Caucasian man with astigmatism C) A 58-year-old African American woman with hyperopia D) A 28-year-old African American man with myopia

A) A 58-year-old Caucasian woman with macular degeneration

Which patient is most likely suffering from dementia? A) A 90-year-old male who has experienced progressive mental decline that started with forgetfulness B) An 80-year-old female who has been in excellent health until she was admitted through the emergency department with a severe urinary tract infection and is now very anxious and is threatening staff C) A 6-year-old child who has just been administered conscious sedation for a closed reduction of a fractured wrist and says that her parents have three sets of eyes D) A 22-year-old male who was involved in a motorcycle crash without wearing a helmet now unable to remember where he is

A) A 90-year-old male who has experienced progressive mental decline that started with forgetfulness

Which would be an appropriate intervention for a client with OCD who has a ritual of excessive constant cleaning? A) A structured schedule of activities throughout the day B) Intense psychotherapy sessions daily C) Interruption of rituals with distracting activities D) Negative consequences for ritual performance

A) A structured schedule of activities throughout the day

Which statements are true of concrete and abstract messages? Select all that apply. A) Abstract messages include figures of speech that are difficult to interpret. B) Abstract messages are important for accurate information exchange. C) Concrete messages require the listener to interpret what the speaker says. D) Concrete messages are clear, direct, and easy to understand. E) Abstract messages are best used for persons who are anxious.

A) Abstract messages include figures of speech that are difficult to interpret. D) Concrete messages are clear, direct, and easy to understand.

A cardiac patients resistance to left ventricular filling has caused blood to back up into the patients circulatory system. What health problem is likely to result? A) Acute pulmonary edema B) Right-sided HF C) Right ventricular hypertrophy D) Left-sided HF

A) Acute pulmonary edema

A client with dementia is unable to recognize ordinary objects, such as a pen or notebook. Which would this be a symptom of? A) Agnosia B) Amnesia C) Apraxia D) Aphasia

A) Agnosia

The nurse is performing a physical assessment on a patient suspected of having HF. The presence of what sound would signal the possibility of impending HF? A) An S3 heart sound B) Pleural friction rub C) Faint breath sounds D) A heart murmur

A) An S3 heart sound

Which actions would indicate an increased suicidal risk? SATA A) An abrupt improvement in mood B) Calling family members to make amends C) Crying when discussing sadness D) Feeling overwhelmed by simple daily tasks E) Statements such as "I'm such a burden for everyone" F) Statements such as "Everything will be better soon"

A) An abrupt improvement in mood B) Calling family members to make amends F) Statements such as "Everything will be better soon"

The nurse should use clear concrete messages when working with patients displaying which of the following conditions? Select all that apply. A) Anxiety B) Anorexia C) Dementia D) Schizophrenia E) Hypochondriasis

A) Anxiety C) Dementia D) Schizophrenia

A client who has an eating disorder is becoming dependent on the nurse for direction in food choices. Which approach by the nurse would demonstrate the nurse's self- awareness? A) Approach the client with an adult-like objectivity. B) Give the support and direction that the client is seeking. C) Give approval for positive changes seen in the client. D) Take care of the needs that the client is neglecting.

A) Approach the client with an adult-like objectivity.

The nurse observes a client with schizophrenia sitting alone, laughing occasionally, and turning his head as if listening to another person. The nurse assesses this behavior to indicate that the client is experiencing auditory hallucinations and says, A) Are you hearing something? B) It's a beautiful day, isn't it? C) Would you like to go to your room to talk? D) Would you like to take some of your PRN medication?

A) Are you hearing something?

Patient says to the nurse, I wonder what's playing at the movie tonight. The most therapeutic response would be, A) Are you telling me you would like to go to the movies? B) Why don't you look in the newspaper. C) There's nothing worth watching. D) Do you like to go to the movies?

A) Are you telling me you would like to go to the movies?

The nurse working on a cardiac care unit is caring for a patient whose stroke volume has increased. The nurse is aware that afterload influences a patients stroke volume. The nurse recognizes that afterload is increased when there is what? A) Arterial vasoconstriction B) Venous vasoconstriction C) Arterial vasodilation D) Venous vasodilation

A) Arterial vasoconstriction

A client with dependent personality disorder has a goal to increase her problem-solving skills. Which client behavior would indicate progress toward meeting that goal? A) Asking questions B) Being polite C) Controlling emotional outbursts D) Requesting assistance appropriately

A) Asking questions

A college freshman is admitted to the hospital with a diagnosis of schizophrenia. Friends reported that she had been in her room for 2 days in a trance-like state, not eating nor speaking to anyone. Which of the following is the highest priority for this client? A) Assessing fluid intake and output B) Completing an assessment of mental status C) Obtaining more data about her college experiences D) Providing for adequate rest

A) Assessing fluid intake and output

A patient who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. What aspect of the patients health history creates a heightened risk of intracardiac thrombi? A) Atrial fibrillation B) Infective endocarditis C) Recurrent pneumonia D) Recent surgery

A) Atrial fibrillation

Which of the following is the best reason that many psychiatric care units have policies against clients touching one another or staff? A) Because some clients with mental illness have difficulty knowing when touch is or is not appropriate B) Because clients often perceive being touched as a threat and may attempt to protect himself or herself by striking the staff person C) Because it can be threatening to both the client and the nurse D) Because touching always leads to more touching

A) Because some clients with mental illness have difficulty knowing when touch is or is not appropriate

A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU? A) Begin ECG monitoring. B) Obtain information about family history of heart disease. C) Auscultate lung fields. D) Determine if the patient smokes.

A) Begin ECG monitoring.

A patient with HF has met with his primary care provider and begun treatment with an angiotensin- converting enzyme (ACE) inhibitor. When the patient begins treatment, the nurse should prioritize what assessment? A) Blood pressure B) Level of consciousness (LOC) C) Assessment for nausea D) Oxygen saturation

A) Blood pressure

The nurse plans to assess a patient's self-concept in the admission assessment knowing that self-concept influences which of the following? Select all that apply. A) Body image B) Cognitive processing C) Frequently experienced emotions D) Coping strategies E) Responsiveness to medications

A) Body image C) Frequently experienced emotions D) Coping strategies

A 15-year-old female is admitted for treatment of anorexia nervosa. Which is characteristic of anorexia nervosa? A) Body weight less than normal for age, height, and overall physical health B) Amenorrhea for at least two cycles C) Absence of hunger feelings D) Erosion of dental enamel

A) Body weight less than normal for age, height, and overall physical health

A client is fearful and reluctant to talk. Which of the following techniques is most effective when trying to engage the client in interaction? A) Broad opening B) Focusing C) Giving information D) Silence

A) Broad opening

The nurse is caring for a patient admitted with angina who is scheduled for cardiac catheterization. The patient is anxious and asks the reason for this test. What is the best response? A) Cardiac catheterization is usually done to assess how blocked or open a patients coronary arteries are. B) Cardiac catheterization is most commonly done to detect how efficiently a patients heart muscle contracts. C) Cardiac catheterization is usually done to evaluate cardiovascular response to stress. D) Cardiac catheterization is most commonly done to evaluate cardiac electrical activity.

A) Cardiac catheterization is usually done to assess how blocked or open a patients coronary arteries are.

The client stated, I was so upset about my sister ignoring me when I was talking about being ashamed. Which nontherapeutic communication technique would the nurse be using if the nurse would state, How are your stress reduction classes going? A) Changing the subject B) Offering advice C) Challenging D) Disapproving

A) Changing the subject

During the admission assessment, the nurse asks the client, How are you feeling? The client responds, I was able to purchase gas for 7 cents a gallon less than yesterday, which saved me a total of 84 cents. My car has a 12-gallon gas tank. Usually I am able to put in 11.7 gallons. I am very happy to have saved so much money. The nurse recognizes this response as which of the following? A) Circumstantial thinking B) Echolalia C) Flight of ideas D) Neologisms

A) Circumstantial thinking

The nurse asks a patient to list the days of the week in reverse order. The nurse is assessing which of the following? A) Concentration B) Memory C) Orientation D) Abstract thinking

A) Concentration

The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse effects, the nurse should assess for which of the following signs and symptoms? A) Confusion and bradycardia B) Uncontrolled diuresis and tachycardia C) Numbness and tingling in the extremities D) Chest pain and shortness of breath

A) Confusion and bradycardia

"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) Consensual validation B) Encouraging comparison C) Accepting D) General lead

A) Consensual validation

The nurse is creating a care plan for a patient diagnosed with HF. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply. A) Facilitate the presence of friends and family whenever possible. B) Teach the patient about the harmful effects of anxiety on cardiac function. C) Provide supplemental oxygen, as needed. D) Provide validation of the patients expressions of anxiety. E) Administer benzodiazepines two to three times daily.

A) Facilitate the presence of friends and family whenever possible C) Provide supplemental oxygen, as needed. D) Provide validation of the patients expressions of anxiety.

Which of the following are the types of roles that are usually included when assessing roles and relationships? Select all that apply. A) Family B) Hobbies C) Occupation D) Activities E) Race F) Ethnicity

A) Family B) Hobbies C) Occupation D) Activities

The nurse understands that which biologic factors may influence the development of an eating disorder? Select all that apply. A) Family history of eating disorders B) Dysfunction of the hypothalamus C) Norepinephrine imbalances D) First-degree relatives with psychotic disorder E) Decreased serotonin levels

A) Family history of eating disorders B) Dysfunction of the hypothalamus C) Norepinephrine imbalances E) Decreased serotonin levels

When preparing a client with bulimia for discharge, the nurse suggests that the client and family continue with family therapy on an outpatient basis. Which of the following is the rationale for this suggestion? A) Family members often need to learn role independence and autonomy. B) Family members need to learn to monitor for signs of client relapse. C) Family relationships need to be strengthened due to a lifetime of disengagement. D) Family members often feel jealous of the attention the client has been receiving in treatment.

A) Family members often need to learn role independence and autonomy.

A person suffering from schizophrenia has little emotional expression when interacting with others. The nurse would document the client's affect as which of the following? Select all that apply. A) Flat B) Blunt C) Bright D) Inappropriate E) Pleasant

A) Flat B) Blunt

Which term typifies the speech of a person in the acute phase of mania? A) Flight of ideas B) Psychomotor retardation C) Hesitant D) Mutism

A) Flight of ideas

A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? A) Fried chicken B) Mashed potatoes C) Dinner roll D) Tapioca pudding

A) Fried chicken

The nurse is teaching a patient with Guillain-Barr syndrome about the disease. The patient asks how he can ever recover if demyelination of his nerves is occurring. What would be the nurses best response? A) Guillain-Barr spares the Schwann cell, which allows for remyelination in the recovery phase of the disease. B) In Guillain-Barr, Schwann cells replicate themselves before the disease destroys them, so remyelination is possible. C) I know you understand that nerve cells do not remyelinate, so the physician is the best one to answer your question. D) For some reason, in Guillain-Barr, Schwann cells become activated and take over the remyelination process

A) Guillain-Barr spares the Schwann cell, which allows for remyelination in the recovery phase of the disease.

The nurse is performing an initial assessment of a client diagnosed with HF. The nurse also assesses the patients sensorium and LOC. Why is the assessment of the patients sensorium and LOC important in patients with HF? A) HF ultimately affects oxygen transportation to the brain. B) Patients with HF are susceptible to overstimulation of the sympathetic nervous system. C) Decreased LOC causes an exacerbation of the signs and symptoms of HF. D) The most significant adverse effect of medications used for HF treatment is altered LOC.

A) HF ultimately affects oxygen transportation to the brain.

Which of the following questions would best help the nurse to evaluate the effectiveness of antipsychotic medications for a client who has schizophrenia? Select all that apply. A) Have the symptoms you were experiencing disappeared? B) If the symptoms have not disappeared, are you able to carry out your daily life despite the persistence of some psychotic symptoms? C) Are you committed to taking the medication as prescribed? D) Are you satisfied with your quality of life? E) Do you have access to community agencies that will help you to live successfully in this community?

A) Have the symptoms you were experiencing disappeared? B) If the symptoms have not disappeared, are you able to carry out your daily life despite the persistence of some psychotic symptoms? C) Are you committed to taking the medication as prescribed? D) Are you satisfied with your quality of life?

The client with schizophrenia tells the nurse that rats have started to eat his brain. The best response by the nurse would be, A) Have you discussed this with your physician? B) How could that be possible? C) You cannot have rats in your brain. D) You look OK to me.

A) Have you discussed this with your physician?

A client who has suspicion has been placed in a room with a roommate. The night nurse reports that this client has been awake for the past 3 nights. The likely explanation for his wakefulness is which of the following? A) He is fearful of what his roommate might do to him while he sleeps. B) He is a light sleeper and unaccustomed to a roommate. C) He is watching for an opportunity to escape. D) He is worrying about his family problems.

A) He is fearful of what his roommate might do to him while he sleeps.

The nurse is assessing a patient suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem? A) Hematuria B) Precipitous decrease in serum creatinine levels C) Hypotension unresolved by fluid administration D) Glucosuria

A) Hematuria

Which of the following factors predispose C.J. to the development of kidney stones? Select all that apply A) High- sodium intake B) Dehydration C) Immobility D) Male biological gender

A) High- sodium intake B) Dehydration C) Immobility D) Male biological gender

The nurse is teaching a client with bulimia to use self-monitoring techniques. Which client statement would let the nurse know that this has been effective? A) I am learning to recognize events and emotions that trigger my binges and am working on responses other than binging and purging. B) I am beginning to understand how my lack of self-control is hurting me. C) I am keeping a record of everything I eat and how I am feeling every day. D) I am getting more comfortable confronting people when I have conflict with them.

A) I am learning to recognize events and emotions that trigger my binges and am working on responses other than binging and purging.

One evening, a client with schizophrenia leaves his room and begins marching in the hall. When approached by the nurse, the client says, ìGod says I'm supposed to guard the area.î Which of the following responses would be best? A) I understand you hear a voice. You and I are the only ones in the hall, and I don't hear a voice. B) The voices are part of your illness, and they will leave in time. C) This guarding responsibility can make you tired. You rest for now, and I'll guard a while. D) You are just imagining these things. Do not pay any attention to the voices.

A) I understand you hear a voice. You and I are the only ones in the hall, and I don't hear a voice.

The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patients care? SATA A) Improve functional status B) Prevent endocarditis. C) Extend survival. D) Limit physical activity. E) Relieve patient symptoms.

A) Improve functional status C) Extend survival. E) Relieve patient symptoms.

A patient admitted to the medical unit with HF is exhibiting signs and symptoms of pulmonary edema. The nurse is aware that positioning will promote circulation. How should the nurse best position the patient? A) In a high Fowlers position B) On the left side-lying position C) In a flat, supine position D) In the Trendelenburg position

A) In a high Fowlers position

A nurse is teaching a client who has a new prescription for simvastatin. Which of the following instructions should the nurse include?

Avoid grapefruit juice

The nurse coming on shift on the medical unit is taking a report on four patients. What patient does the nurse know is at the greatest risk of developing ESKD? A) A patient with a history of polycystic kidney disease B) A patient with diabetes mellitus and poorly controlled hypertension C) A patient who is morbidly obese with a history of vascular disorders D) A patient with severe chronic obstructive pulmonary disease

B) A patient with diabetes mellitus and poorly controlled hypertension

A patient presents to the ED complaining of increasing shortness of breath. The nurse assessing the patient notes a history of left-sided HF. The patient is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem? A) Right-sided heart failure B) Acute pulmonary edema C) Pneumonia D) Cardiogenic shock

B) Acute pulmonary edema

The nurse is developing interventions to promote socialization in a client with moderate dementia. Which would provide a safe and secure environment for the client? A) A card game with other clients B) An activity with the nurse C) Decorating a bulletin board with the group D) Morning stretch group with music

B) An activity with the nurse

The nurse is doing discharge teaching with a patient who has coronary artery disease. The patient asks why he has to take an aspirin every day if he doesnt have any pain. What would be the nurses best response? A) Taking an aspirin every day is an easy way to help restore the normal function of your heart. B) An aspirin a day can help prevent some of the blockages that can cause chest pain or heart attacks. C) Taking an aspirin every day is a simple way to make your blood penetrate your heart more freely. D) An aspirin a day eventually helps your blood carry more oxygen that it would otherwise.

B) An aspirin a day can help prevent some of the blockages that can cause chest pain or heart attacks.

Transient psychotic symptoms that occur with borderline personality disorder are most likely treated with which type of drug? A) Anticonvulsant mood stabilizers B) Antipsychotics C) Benzodiazepines D) Lithium

B) Antipsychotics

The nurse is providing discharge education to an adult patient who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the patient is able to self-administer these medications safely and effectively? A) Assess the patient for any previous inability to self-manage medications. B) Ask the patient to demonstrate the instillation of her medications. C) Determine whether the patient can accurately describe the appropriate method of administering her D) Assess the patients functional status.

B) Ask the patient to demonstrate the instillation of her medications.

During discharge teaching the nurse realizes that the patient is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene most appropriately in this situation? A) Ask the social worker to investigate alternative housing arrangements. B) Ask the social worker to investigate community support agencies. C) Encourage the patient to explore surgical corrections for the vision problem. D) Arrange for referral to a rehabilitation facility for vision training.

B) Ask the social worker to investigate community support agencies.

A patient has lost most of her vision as a result of macular degeneration. When attempting to meet this patients psychosocial needs, what nursing action is most appropriate? A) Encourage the patient to focus on her use of her other senses. B) Assess and promote the patients coping skills during interactions with the patient. C) Emphasize that her lifestyle will be unchanged once she adapts to her vision loss. D) Promote the patients hope for recovery.

B) Assess and promote the patients coping skills during interactions with the patient.

The nurse uses a variety of therapeutic communication skills when working with patients. Which of the following is a therapeutic goal that can be accomplished through the use of therapeutic communication skills? A) Inform the patient of priority problems B) Assess the patient's perception of a problem C) Assist the patient to control emotions D) Provide the patient with a plan of action

B) Assess the patient's perception of a problem

The nurse is teaching the family of a client who has bulimia about nutritional needs. Which dietary pattern would be most helpful to assist the client in recovering from bulimia? A) Provide the client a diet of mainly vegetables and salads. B) Encourage the entire family to engage in a balanced and regular dietary pattern. C) Encourage autonomy by allowing the client to have total control over food choices. D) Insist that the client complete all meals provided.

B) Encourage the entire family to engage in a balanced and regular dietary pattern.

The nurse is caring for a client with Alzheimer's disease. The nurse observes that the client's pacing and mumbling to himself increase at mealtime and shift change. Which intervention should the nurse implement first? A) Administer an antianxiety drug such as lorazepam (Ativan) at these times. B) Explain the unit routine and the reasons for increased activity to the client. C) Keep unit activity to a minimum. D) Move the client to a quieter area during these times.

B) Explain the unit routine and the reasons for increased activity to the client.

The nurse working with a client with antisocial personality disorder would expect which behaviors? A) Compliance with expectations and rules B) Exploitation of other clients C) Seeking special privileges D) Superficial friendliness toward others E) Utilization of rituals to allay anxiety F) Withdrawal from social activities

B) Exploitation of other clients C) Seeking special privileges D) Superficial friendliness toward others

The parents of a young adult male who has schizophrenia ask how they can recognize when their son is beginning to relapse. The nurse teaches the family to look for which of the following? Select all that apply. A) Excessive sleeping B) Fatigue C) Irritability D) Increased inhibition E) Negativity

B) Fatigue C) Irritability E) Negativity

Which underlying emotion is commonly seen in an avoidant personality disorder? A) Depression B) Fear C) Guilt D) Insecurity

B) Fear

The adult son of a client with dementia asks the nurse how he should respond when his mother repeatedly says she has had a busy day at work. The mother has not worked in over 20 years. Which is the best guidance that the nurse could offer? A) Ask her to explain what she did at work today that kept her busy. B) Go along with her thought of it having been a busy day, but do not refer to her work. C) Reorient her that she is at home and did not go to work. D) Give her 5 to 10 minutes of rest, and she will have no memory of the incident.

B) Go along with her thought of it having been a busy day, but do not refer to her work.

A client with schizophrenia is seen sitting alone and talking out loud. Suddenly, the client stops and turns as if listening to someone. The nurse approaches and sits down beside the client. Which of the following is the best initial response by the nurse? A) You must be pretty bored to be sitting here talking to an invisible person. B) I don't hear or see anyone else; what are you hearing and seeing? C) I can tell you are hearing voices, but they are not real. D) How long have you known the person you are talking to?

B) I don't hear or see anyone else; what are you hearing and seeing?

A patient with HF is placed on a low-sodium diet. Which statement by the patient indicates that the nurses nutritional teaching plan has been effective? A) I will have a ham and cheese sandwich for lunch. B) I will have a baked potato with broiled chicken for dinner. C) I will have a tossed salad with cheese and croutons for lunch. D) I will have chicken noodle soup with crackers and an apple for lunch.

B) I will have a baked potato with broiled chicken for dinner.

A nurse has been teaching a client about bulimia. Which statement by the client indicates that the teaching has been effective? A) I know if I eat pasta, I'll binge. B) I'll eat small meals and snacks regularly. C) I'll take my medication when I feel the urge to binge. D) I'll limit my intake of carbohydrates and fats.

B) I'll eat small meals and snacks regularly.

A client with borderline personality disorder says to the nurse, I feel so comfortable talking with you. You seem to have a special way about you that really helps me. Which would be the most appropriate response by the nurse? A) I'm glad you feel comfortable with me. B) I'm here to help you just as all the staffs are. C) You feel others don't understand you? D) I cannot be your friend. We need to be clear on that.

B) I'm here to help you just as all the staffs are.

Which of the following questions is best to ask when assessing the client's judgment? A) Can you describe your usual daily activities for me? B) If you found yourself downtown without money or a car, how would you get home? C) On a scale of 1 to 10, how stressed would you rate yourself? D) What problem would you like to work on while you're hospitalized?

B) If you found yourself downtown without money or a car, how would you get home?

In preparation for cardiac surgery, a patient was taught about measures to prevent venous thromboembolism. What statement indicates that the patient clearly understood this education? A) Ill try to stay in bed for the first few days to allow myself to heal. B) Ill make sure that I dont cross my legs when Im resting in bed. C) Ill keep pillows under my knees to help my blood circulate better. D) Ill put on those compression stockings if I get pain in my calves.

B) Ill make sure that I dont cross my legs when Im resting in bed.

When working with a client with a personality disorder, the nurse would expect to assess which? SATA A) High levels of self-awareness B) Impaired interpersonal relationships C) Inability to empathize with others D) Minimal insight E) Motivation to change F) Poor reality testing

B) Impaired interpersonal relationships C) Inability to empathize with others D) Minimal insight

Clients with a schizotypal personality disorder are most likely to benefit from which nursing action? A) Cognitive restructuring techniques B) Improving community functioning C) Providing emotional support D) Teaching social skills

B) Improving community functioning

A patient has been diagnosed with glaucoma and the nurse is preparing health education regarding the patients medication regimen. The patient states that she is eager to beat this disease and looks forward to the time that she will no longer require medication. How should the nurse best respond? A) You have a great attitude. This will likely shorten the amount of time that you need medications. B) In fact, glaucoma usually requires lifelong treatment with medications. C) Most people are treated until their intraocular pressure goes below 50 mm Hg. D) You can likely expect a minimum of 6 months of treatment

B) In fact, glaucoma usually requires lifelong treatment with medications.

A patients medication regimen for the treatment of hypertension includes hydrochlorothiazide. Following administration of this medication, the nurse should anticipate what effect? A) Drowsiness or lethargy B) Increased urine output C) Decreased heart rate D) Mild agitation

B) Increased urine output

A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the patients left leg is visibly swollen and reddened. What is the nurses most appropriate action? A) Administer a PRN dose of subcutaneous heparin. B) Inform the physician that the patient has signs and symptoms of VTE. C) Mobilize the patient promptly to dislodge any thrombi in the patients lower leg. D) Massage the patients lower leg to temporarily restore venous return

B) Inform the physician that the patient has signs and symptoms of VTE.

Which of the following distance zones is acceptable for people who mutually desire personal contact? A) Social B) Intimate C) Personal D) Public

B) Intimate

Which challenges are posed when working with clients with personality disorders? Select all that apply. A) Clients with personality disorders are obviously unable to function more effectively. B) It can take a long time to change their behaviors, attitudes, or coping skills. C) The nurse can easily but mistakenly believe the client simply lacks motivation or the willingness to make changes. D) Clients with personality disorders challenge the ability of therapeutic staff to work as a team. E) Team members may have differing opinions about individual clients.

B) It can take a long time to change their behaviors, attitudes, or coping skills. C) The nurse can easily but mistakenly believe the client simply lacks motivation or the willingness to make changes. D) Clients with personality disorders challenge the ability of therapeutic staff to work as a team. E) Team members may have differing opinions about individual clients.

Which of the following is the most compelling reason for the nurse to discuss matters of sexuality and suicide? A) It is required by the law by the federal government and in most states in the union. B) It is the nurse's professional responsibility to keep safety needs first and foremost. C) This is commonly required documentation for every encounter with every client. D) It allows the nurse to gain valuable experience in these kind of difficult discussions.

B) It is the nurse's professional responsibility to keep safety needs first and foremost.

The client says to the nurse, I have special powers because I am the mother of God. I can heal everyone in the hospital. The nurse's best response would be, A) That sounds interesting. What can you do? B) It would be unusual for anyone to have that kind of power. C) You could not heal everyone. No one has that much power? D) Well, you can certainly try

B) It would be unusual for anyone to have that kind of power.

The nurse is working with a client with schizophrenia, disorganized type. It is time for the client to get up and eat breakfast. Which of the following statements by the nurse would be most effective in helping the client prepare for breakfast? A) I'll expect you in the dining room in 20 minutes. B) It's time to put your dress on now. C) Stay right there and I'll get your clothes for you. D) Why don't you stay here and I'll get your tray for you.

B) It's time to put your dress on now.

During a shift assessment, the nurse is identifying the clients point of maximum impulse (PMI). Where will the nurse best palpate the PMI? A) Left midclavicular line of the chest at the level of the nipple B) Left midclavicular line of the chest at the fifth intercostal space C) Midline between the xiphoid process and the left nipple D) Two to three centimeters to the left of the sternum

B) Left midclavicular line of the chest at the fifth intercostal space

The nurse has completed the psychosocial assessment. Which of the following is the best approach toward analysis of the data to identify nursing diagnoses and develop an appropriate plan of care? A) Focus on each piece of information obtained from the patient. B) Look for patterns reflected in the overall assessment. C) Consider only the abnormal findings in the assessment. D) Present all data obtained in the treatment team meeting.

B) Look for patterns reflected in the overall assessment.

The nurse says to the client, You become very anxious when we start talking about your drinking. Which of the following techniques is the nurse using? A) Confronting behavior B) Making an observation C) Translating into feelings D) Verbalizing the implied

B) Making an observation

Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF? A) Monitor liver function studies B) Monitor for hypotension C) Assess the patients vitamin D intake D) Assess the patient for hyperkalemia

B) Monitor for hypotension

The physical therapist notifies the nurse that a patient with coronary artery disease (CAD) experiences a much greater-than-average increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a patient with CAD may result in what? A) Development of an atrial-septal defect B) Myocardial ischemia C) Formation of a pulmonary embolism D) Release of potassium ions from cardiac cells

B) Myocardial ischemia

Which of the following statements about verbal and nonverbal communication skills is accurate? A) One third of meaning is transmitted nonverbally and two thirds is communicated verbally. B) Nonverbal communication is as important, if not more than, verbal communication. C) Verbal communication is most important because it is what the patient says. D) Verbal communication involves the unconscious mind.

B) Nonverbal communication is as important, if not more than, verbal communication.

The nurse is assessing a client with bulimia nervosa. Which of the following symptoms would the nurse expect to find? Select all that apply. A) Cold intolerance B) Normal weight for height C) Dental erosion D) Hypotension E) Metabolic alkalosis

B) Normal weight for height C) Dental erosion E) Metabolic alkalosis

Which nursing intervention would be most likely to help the client with anorexia to establish healthy eating patterns? A) Leave the client alone to relax during meals. B) Offer liquid protein supplements if the client is unable to complete meal. C) Observe the client for 30 minutes after all meals. D) Weigh the client weekly in the same clothing at the same time of day.

B) Offer liquid protein supplements if the client is unable to complete meal.

When documenting the mental status exam findings in the chart of a client with anorexia, the nurse notes poor judgment and insight. Which client statement would support this impression? A) I know I have a problem. I need help. B) Others are just trying to keep me from looking good. C) I know my weight is a little below normal. D) Those weight charts are for normal people. I am not normal.

B) Others are just trying to keep me from looking good.

The nurse is caring for a 68-year-old patient the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment datum? A) Skin turgor B) Potassium level C) White blood cell count D) Peripheral pulses

B) Potassium level

During an adult patients last two office visits, the nurse obtained BP readings of 122/84 mm Hg and 130/88 mm Hg, respectively. How would this patients BP be categorized? A) Normal B) Prehypertensive C) Stage 1 hypertensive D) Stage 2 hypertensive

B) Prehypertensive

The nurses assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should consequently identify what nursing diagnosis in the patients plan of care? A) Risk for ineffective breathing pattern related to hypotension B) Risk for falls related to orthostatic hypotension C) Risk for ineffective role performance related to hypotension D) Risk for imbalanced fluid balance related to hemodynamic variability

B) Risk for falls related to orthostatic hypotension

A patient is admitted to the unit with acute cholecystitis. The physician has noted that surgery will be scheduled in 4 days. The patient asks why the surgery is being put off for a week when he has a sick gallbladder. What rationale would underlie the nurses response? A) Surgery is delayed until the patient can eat a regular diet without vomiting. B) Surgery is delayed until the acute symptoms subside. C) The patient requires aggressive nutritional support prior to surgery. D) Time is needed to determine whether a laparoscopic procedure can be used.

B) Surgery is delayed until the acute symptoms subside.

The nurse is caring for a patient who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring? A) P wave inversion B) T wave inversion C) Q wave changes with no change in ST or T wave D) P wave enlargement

B) T wave inversion

The nurse is educating an 80-year-old patient diagnosed with HF about his medication regimen. What should the nurse to teach this patient about the use of oral diuretics? A) Avoid drinking fluids for 2 hours after taking the diuretic. B) Take the diuretic in the morning to avoid interfering with sleep. C) Avoid taking the medication within 2 hours consuming dairy products. D) Take the diuretic only on days when experiencing shortness of breath.

B) Take the diuretic in the morning to avoid interfering with sleep.

The nurse reviews current literature and identifies that which of the following are included in current studies of biologic theories regarding the etiology of schizophrenia? Select all that apply. A) That there is a particular pathologic structure associated with the disease. B) That genetics is the cause of schizophrenia. C) Persons with schizophrenia have decreased brain volume and abnormal brain function in the frontal and temporal areas of persons with schizophrenia. D) The brain activity of persons with schizophrenia differs from people who do not have schizophrenia. E) That the etiology of schizophrenia may be related to the body's response to exposure of a virus.

B) That genetics is the cause of schizophrenia. C) Persons with schizophrenia have decreased brain volume and abnormal brain function in the frontal and temporal areas of persons with schizophrenia. D) The brain activity of persons with schizophrenia differs from people who do not have schizophrenia. E) That the etiology of schizophrenia may be related to the body's response to exposure of a virus.

A 16-year-old female with anorexia nervosa is admitted to the unit. Which is the most appropriate short-term outcome? A) The client will accept herself as having value and worth. B) The client will admit she has a fear of gaining weight. C) The client will follow a nutritionally balanced diet for her age. D) The client will identify her problems and potential alternative coping strategies.

B) The client will admit she has a fear of gaining weight.

A nurse working in an assisted living facility is holding an in-service for the nursing assistants. The nurse reviews common behaviors associated with cognitive deterioration associated with dementia. Which would cause the nurse to know that the assistants correctly understood if it were expressed during a posttest? A) The clients should be able to ask us for items they need. B) The clients may not recognize their family when they come to visit. C) The clients who are ambulatory can still carry out activities of daily living independently. D) The clients should know when to come to the dining room for meals.

B) The clients may not recognize their family when they come to visit.

A resident of a long-term care facility has complained to the nurse of chest pain. What aspect of the residents pain would be most suggestive of angina as the cause? A) The pain is worse when the resident inhales deeply. B) The pain occurs immediately following physical exertion. C) The pain is worse when the resident coughs. D) The pain is most severe when the resident moves his upper body.

B) The pain occurs immediately following physical exertion.

When assessing a patient diagnosed with angina pectoris it is most important for the nurse to gather what information? A) The patients activities limitations and level of consciousness after the attacks B) The patients symptoms and the activities that precipitate attacks C) The patients understanding of the pathology of angina D) The patients coping strategies surrounding the attacks

B) The patients symptoms and the activities that precipitate attacks

Which of the following are features of the thinking of a person who has OCD according to the cognitive model? Select all that apply. A) The person with OCD employs a minimalist approach to all aspects of his or her life. B) The person with OCD believes one's thoughts are overly important and has a need to control those thoughts as they overestimate the threat posed by their thoughts. C) The person with OCD is always aware that his or her behavior is related to OCD. D) The person with OCD is concerned with perfectionism and has an intolerance of uncertainty. E) The person with OCD has an inflated personal responsibility

B) The person with OCD believes one's thoughts are overly important and has a need to control those thoughts as they overestimate the threat posed by their thoughts. D) The person with OCD is concerned with perfectionism and has an intolerance of uncertainty. E) The person with OCD has an inflated personal responsibility

The nurse reviews results of the Minnesota Multiphasic Personality Inventory (MMPI) recorded in a patient record. While considering the usefulness of these data, the nurse is mindful that the MMPI has which limitation? A) The patient must be able to read to complete the MMPI. B) The results of the MMPI could be culturally biased. C) The MMPI assesses a narrow scope of functioning. D) The MMPI does not have established validity.

B) The results of the MMPI could be culturally biased.

A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what potential adverse effects? A) Nervousness or paresthesia B) Throbbing headache or dizziness C) Drowsiness or blurred vision D) Tinnitus or diplopia

B) Throbbing headache or dizziness

A 40-year-old male newly diagnosed with hypertension is discussing risk factors with the nurse. The nurse talks about lifestyle changes with the patient and advises that the patient should avoid tobacco use. What is the primary rationale behind that advice to the patient? A) Quitting smoking will cause the patients hypertension to resolve. B) Tobacco use increases the patients concurrent risk of heart disease. C) Tobacco use is associated with a sedentary lifestyle. D) Tobacco use causes ventricular hypertrophy.

B) Tobacco use increases the patients concurrent risk of heart disease.

A new nurse has been working with clients with Alzheimer's disease for almost 6 months. During a staff meeting, the nurse expresses frustration because the same instructions have to be given to clients on a daily basis. The nurse states, ìI feel like all my work doesn't do them any good.î Which should the nurse's supervisor encourage the nurse to do? A) Cease giving instructions because the clients will not remember them anyway. B) Try to stay supportive and meet the clients' needs at the current moment. C) Seek counseling if personal feelings get in the way of client care. D) Consider transferring to a different client care specialty area.

B) Try to stay supportive and meet the clients' needs at the current moment.

The nurse has been teaching the client's family about the client's eating disorder, anorexia nervosa. Which statement would indicate that teaching was effective? A) We will eat our evening meals together with no exceptions. B) We will negotiate resolutions to family conflicts. C) We will spend less time discussing troublesome family members. D) We will give her frequent encouragement for eating well and maintaining her weight.

B) We will negotiate resolutions to family conflicts.

The prevention of VTE is an important part of the nursing care of high-risk patients. When providing patient teaching for these high-risk patients, the nurse should advise lifestyle changes, including which of the following? Select all that apply. A) High-protein diet B) Weight loss C) Regular exercise D) Smoking cessation E) Calcium and vitamin D supplementation

B) Weight loss C) Regular exercise D) Smoking cessation

A nurse can best assess a patient's ability to use abstract thinking by asking the patient which of the following questions? A) What would you do if you found a wallet containing $100 on the sidewalk? B) What do I mean when I say, 'Don't sweat the small stuff?' C) What are you going to do next time you hear voices? D) Can you begin with the number 100 and subtract 7, and then subtract 7 again?

B) What do I mean when I say, 'Don't sweat the small stuff?'

Which of the following are central components of a psychiatric rehabilitation and recovery program? Select all that apply. A) Working with clients to have an improved quality of life according to society's point of view B) Working with clients to manage their own lives C) Working with clients to make effective treatment decisions D) Working with clients to have an improved quality of life according to his or her point of view E) Working with clients to diagnose their problem early

B) Working with clients to manage their own lives C) Working with clients to make effective treatment decisions D) Working with clients to have an improved quality of life according to his or her point of view

The nurse enters the room of a client with schizophrenia the day after he has been admitted to an inpatient setting and says, I would like to spend some time talking with you. The client stares straight ahead and remains silent. The best response by the nurse would be, A) I can see you want to be alone. I'll come back another time. B) You don't need to talk right now. I'll just sit here for a few minutes. C) I've got some other things I can do now. I hope you'll feel like talking later. D) You would feel better if you would tell me what you're thinking.

B) You don't need to talk right now. I'll just sit here for a few minutes.

A patient is sitting alone, slouched, with eyes closed. The nurse approaches. Which statement is most likely to encourage the patient to talk? A) If you are sleepy, would you like me to help you back to your room? B) You look like you are deep in thought. C) Is something wrong? D) Why are you sitting with your eyes closed?

B) You look like you are deep in thought.

During the admission interview, the nurse asks the client what led to his hospitalization. The client responds, They lied about me. They said I murdered my mother. You're the killers. You all killed my mother. She died before I was born. The best initial response by the nurse would be, A) I just saw your mother. She's fine. B) You're having very frightening thoughts. C) We'll put you in a private room until you're in better control. D) If your mother died before you were born, you wouldn't be here.

B) You're having very frightening thoughts.

Client: "I was so upset about my sister ignoring my pain when I broke my leg." Nurse: "When are you going to your next diabetes education program?" This is a nontherapeutic response because the nurse has A) used testing to evaluate the client's insight. B) changed the topic. C) exhibited an egocentric focus. D) advised the client what to do.

B) changed the topic.

"How does T. 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.

B) indicates an external source of the emotion.

Following discharge teaching for a patient who has had a transurethral prostatectomy for BPH, the nurse determines that additional education is needed when the patient says: A. "I will increase fiber and fluids in my diet to prevent constipation." B. "I should call the doctor if I have any incontinence at home." C. "I will avoid heavy lifting or driving until I get approval from my healthcare provider." D. "I should continue to schedule yearly appointments for prostate exams."

B. "I should call the doctor if I have any incontinence at home."

Which statement below is INCORRECT about Alzheimer's disease? A. It's the 5th leading cause of death for adults over 65. B. Alzheimer's disease is more likely to develop in men rather than women. C. Most patients typically start showing signs and symptoms of this disease after the age of 60. D. Hispanics and African Americans are at higher risk for developing Alzheimer's disease.

B. Alzheimer's disease is more likely to develop in men rather than women.

The nurse on the medical-surgical unit is reviewing discharge instructions with a client who has a history of glaucoma. The nurse should anticipate the use of what medications? A. Potassium-sparing diuretics B. Cholinergics C. Antibiotics D. Loop diuretics

B. Cholinergics

The Nurse is helping a patient with Moderate Alzheimer's Disease (middle stage) participate in a task. When Selecting a task for the patient the nurse would want to make sure the task has? A. Multiple steps B. Clear simple directions C. Critical thinking D. Usage of multiple tools

B. Clear simple directions

A nurse is completing discharge teaching to a client with Crohn's disease. Which of the following instructions should the nurse include in the teaching? A. Decrease intake of calorie-dense foods. B. Drink canned protein supplements. C. Increase intake of high fiber foods. D. Take a bulk-forming laxative daily.

B. Drink canned protein supplements.

Which of these results are the most specifically related to peptic ulcer? A. WBC 5.0 B. H. Pylori positive C. RBC 5.2 D. HBG 11

B. H. Pylori positive

A nurse educator is teaching a group of new nurses about complications of BPH and prostate cancer surgical treatments. Which of the following would the educator state is a complication of both prostate cancer and BPH treatment? A. Metastasis B. Incontinence C. Retrograde ejaculation D. Erectile dysfunction

B. Incontinence

During the evening hours you notice your patient with Moderate Alzheimer's Disease (Middle Stage) begins to experience an increase in confusion, agitations, and hallucinations. What intervention below could the nurse implement to help decrease this occurrence? A. Provide the patient with coffee at bedtime B. Provide a relaxing and low noise environment in the evening C. Use stimulating distractions at night D. Limit patient's contact with sunlight during the day

B. Provide a relaxing and low noise environment in the evening

In which of the following situations would an autocratic leadership style be beneficial? A. The nurse manager of a unit asks the team to provide their input on certain decisions being made regarding ways to increase patient satisfaction. B. The nurse is taking care of a post-cesarean section patient and the patient begins to bleed excessively from her surgical site. The nurse immediately tells another nurse to go and take care of her other patients, and she calls the surgeon. She then implements appropriate interventions to tend to the bleeding. C. The charge nurse makes sure to address a newly licensed nurse's needs by seeking ways they can provide further education or instruction for them. D. A nurse assumes the role of being the unit representative for the hospital's governance committee and ensures adjustment to their personal schedule in order to be able to attend important meetings.

B. The nurse is taking care of a post-cesarean section patient and the patient begins to bleed excessively from her surgical site. The nurse immediately tells another nurse to go and take care of her other patients, and she calls the surgeon. She then implements appropriate interventions to tend to the bleeding.

A patient with Alzheimer's disease has had difficulties eating and is not getting enough nutrients in his diet. The patient's daughter asks if there is anything that can be done to improve his nutritional intake. What suggestion should the nurse give? A. Help the patient choose his own eating utensils. B. Use less salt when cooking and serving food. C. Provide stand by assistance when the patient eats to offer support. D. Limit calories to have better control over behavior

B. Use less salt when cooking and serving food.

What is the best way to prevent glaucoma and cataracts from occurring later in life? A. Not opening eyes when swimming underwater B. Wearing sunglasses with UV protection anytime you are in the sun C. Focusing on something else for a moment when looking at your computer for a prolonged period of time D. Blinking a lot to increase lubrication and reduce eye inflammation

B. Wearing sunglasses with UV protection anytime you are in the sun

Which of the following are things you should do when a child is having an active seizure in your presence: SATA A. Hold them down B. cushion/support their head C. turn them laterally if vomiting D. time the seizure E. Call 911 immediately F. Make the area safe

B. cushion/support their head C. turn them laterally if vomiting D. time the seizure F. Make the area safe

What are the risk factors, the patient has for developing a duodenal ulcer? Select all that apply A. Frequent coffee consumption. B. smoking cigarettes C. Daily NSAID use. D. Spicy food consumption.

B. smoking cigarettes C. Daily NSAID use.

A nurse is reviewing the Lab values of a client who has chronic glomerulonephritis. Which of the following is an expected finding for this client?

BUN 100mg/dL

A nurse is reviewing the laboratory results of an adolescent who has chronic glomerulonephritis. Which of the following findings should the nurse expect?

BUN 50 mg/dl

Low cholesterol food choice:

Beans

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this conduction?

Breathlessness

A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While providing his health history, the patient reveals that he smokes about two packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the priority health education for this patient? A) The lack of exercise, which is the main cause of PAD. B) The likelihood that heavy alcohol intake is a significant risk factor for PAD. C) Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD. D) Alcohol suppresses the immune system, creates high glucose levels, and may cause PAD.

C) Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD.

A patient who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurses most appropriate action? A) Document the patients low urine output and monitor closely for the next several hours. B) Contact the dietitian and suggest the need for increased oral fluid intake. C) Contact the patients physician and suggest assessment of fluid balance and renal function. D) Increase the infusion rate of the patients IV fluid to prompt an increase in renal function.

C) Contact the patients physician and suggest assessment of fluid balance and renal function.

A patient in a hypertensive emergency is admitted to the ICU. The nurse anticipates that the patient will be treated with IV vasodilators, and that the primary goal of treatment is what? A) Lower the BP to reduce onset of neurologic symptoms, such as headache and vision changes. B) Decrease the BP to a normal level based on the patients age. C) Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment. D) Reduce the BP to 120/75 mm Hg as quickly as possible

C) Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment.

The nurse is assessing a client with an eating disorder. Which personality characteristic would the nurse expect to detect when interacting with the client? A) Careless B) Outspoken C) Defiance D) Eager to please

C) Defiance

A client is admitted to the psychiatric unit and states, I am president of the largest corporation in the world. Everyone comes to me for advice. The client is exhibiting which of the following? A) Flight of ideas B) Thought broadcasting C) Delusion D) Loose associations

C) Delusion

Which distinguishes delirium from dementia? A) Delirium has an acute onset and is progressive in course. B) Delirium has a gradual onset and can be resolved. C) Dementia has a gradual onset and is progressive in course. D) Dementia has an acute onset and can be resolved.

C) Dementia has a gradual onset and is progressive in course.

The nurse is encouraging a group of clients with dementia to join in upper body range of motion exercises using light dumbbells. Which technique will most likely result in the greatest amount of participation? A) Show an instructional video just prior to the activity. B) Describe the exercise immediately before performing it. C) Demonstrate the exercises while clients simultaneously perform them. D) Perform the same routine daily to avoid the need for repeated instruction.

C) Demonstrate the exercises while clients simultaneously perform them.

When interviewing any client with a personality disorder, the nurse would assess for which? A) Ability to charm and manipulate people B) Desire for interpersonal relationships C) Disruption in some aspects of their life D) Increased need for approval from others

C) Disruption in some aspects of their life

A newly diagnosed patient with hypertension is prescribed Diuril, a thiazide diuretic. What patient education should the nurse provide to this patient? A) Eat a banana every day because Diuril causes moderate hyperkalemia. B) Take over-the-counter potassium pills because Diuril causes your kidneys to lose potassium. C) Diuril can cause low blood pressure and dizziness, especially when you get up suddenly. D) Diuril increases sodium levels in your blood, so cut down on your salt.

C) Diuril can cause low blood pressure and dizziness, especially when you get up suddenly.

A nurse suspects that a patient is abusing alcohol while taking prescribed medications. The nurse plans to educate the patient on the dangers of mixing medicine with alcohol. Which of the following would be the most effective way for the nurse to approach this subject with the patient? A) Firmly inform the patient of the dangers of mixing medications with alcohol. B) Recommend a higher level of care, so the patient can be more closely supervised. C) Emphasize the importance of truthful information using a nonjudgmental approach D) Recognize the patient's right to self-determination and avoid addressing the subject.

C) Emphasize the importance of truthful information using a nonjudgmental approach

Which of the following is a psychosocial explanation for the development of personality disorders? A) Highly self-directed people reflect uncooperativeness and intolerance. B) Cooperative people become increasingly helpless over time. C) Failure to complete a developmental task jeopardizes future personality development. D) Self-transcendence contributes to self-consciousness and materialism.

C) Failure to complete a developmental task jeopardizes future personality development.

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

C) General lead

A patient asks the nurse what she should do about her cheating husband. The nurse replies, You should divorce him. You deserve better than that. The nurse used which communication technique? A) Giving information B) Verbalizing the implied C) Giving advice D) Agreeing

C) Giving advice

A patient newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a patient with prolonged, uncontrolled hypertension is at risk for developing what health problem? A) Renal failure B) Right ventricular hypertrophy C) Glaucoma D) Anemia

C) Glaucoma

What would the nurse expect to assess in a client with narcissistic personality disorder? A) Genuine concern for others B) Mistrust of others C) Grandiose and superior self-concept D) Dependence on others for decision making

C) Grandiose and superior self-concept

Which would most likely be a type of behavior that would be manifested by a client who has histrionic personality disorder? A) Insisting that others follow the rules of the unit B) Wondering why others are being friendly to her C) Having a tantrum if not getting enough attention D) Getting others to make decisions for her

C) Having a tantrum if not getting enough attention

Which of the following interventions would be appropriate for a client with anorexia nervosa? A) Allowing the client to eat whenever she feels hungry B) Insisting that the client sit in the dining room until all food is eaten C) Having the client in view of staff for 90 minutes after each meal D) Permitting the client to eat any food she chooses, as long as she is eating

C) Having the client in view of staff for 90 minutes after each meal

The nurse is assessing for negative symptoms of schizophrenia in a newly admitted client. The nurse would note which behavior as indicative of a negative symptom? A) Difficulty staying on subject when responding to assessment questions B) Belief of owning a transportation device allowing for travel to the center of the Earth C) Hesitant to answer the nurse's questions during the assessment interview D) Mimicking the postural changes made by the nurse during the assessment interview

C) Hesitant to answer the nurse's questions during the assessment interview

Which nursing statement is most effective in communicating a positive expectation of the client? A) I'll give you 90 minutes to eat. B) I will allow you space to eat in peace. C) I will sit here quietly with you while you eat. D) There are people who would truly appreciate this food.

C) I will sit here quietly with you while you eat.

A patient remarks, You know, it's the same thing every time. The nurse should respond by stating, A) I understand. B) I'm sure everyone is doing their best. C) I'm not sure what you mean. Please explain. D) It's the same thing every time?

C) I'm not sure what you mean. Please explain.

The grown daughter of a woman with Alzheimer's disease reports to the nurse that she is trying to keep her mother's condition from worsening by asking her questions whenever they are together. Which will be accomplished by this intervention? A) Decrease environmental misinterpretation B) Improve memory retention C) Increase frustration D) Slow the progress of the disease

C) Increase frustration

The nurse is caring for an adult patient who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina? A) Ineffective breathing pattern related to decreased cardiac output B) Anxiety related to fear of death C) Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD) D) Impaired skin integrity related to CAD

C) Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)

The nurse is assessing a patient who was admitted to the critical care unit 3 hours ago following cardiac surgery. The nurses most recent assessment reveals that the patients left pedal pulses are not palpable and that the right pedal pulses are rated at +2. What is the nurses best response? A) Document this expected assessment finding during the initial postoperative period. B) Reposition the patient with his left leg in a dependent position. C) Inform the patients physician of this assessment finding. D) Administer an ordered dose of subcutaneous heparin.

C) Inform the patients physician of this assessment finding.

Throughout the assessment, the client displays disorganized thinking, jumping from one idea to another with no clear relationship between the thoughts. The nurse would assess the client as having which of the following? A) Tangential thinking B) Ideas of reference C) Loose associations D) Word salad

C) Loose associations

When working with a client with a narcissistic personality disorder, the nurse would use which approach? A) Cheerful B) Friendly C) Matter-of-fact D) Supportive

C) Matter-of-fact

The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do to assess her fluid balance in the home setting? A) Monitor her blood pressure daily B) Assess her radial pulses daily C) Monitor her weight daily D) Monitor her bowel movements

C) Monitor her weight daily

A client with moderate Alzheimer's disease is living with her grown daughter. Which statement by the daughter would indicate the need for intervention by the nurse? A) It's distressing when my mother forgets my name. B) I wish my sister would come to visit more often. C) Mother won't let anyone else do anything for her. D) Taking care of my mother is a big responsibility.

C) Mother won't let anyone else do anything for her.

A patient has had a myocardial infarction and has been diagnosed as having damage to the layer of the heart responsible for the pumping action. You are aware that the damage occurred where? A) Endocardium B) Pericardium C) Myocardium D) Visceral pericardium

C) Myocardium

Which of the following factors influencing assessment is under the nurse's control? A) Client participation and feedback B) Client's health status C) Nurse's attitude and approach D) Client's ability to understand

C) Nurse's attitude and approach

The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. What risk factors would the nurse list that can be controlled or modified? A) Gender, obesity, family history, and smoking B) Inactivity, stress, gender, and smoking C) Obesity, inactivity, diet, and smoking D) Stress, family history, and obesity

C) Obesity, inactivity, diet, and smoking

When administering a patients eye drops, the nurse recognizes the need to prevent absorption by the nasolacrimal duct. How can the nurse best achieve this goal? A) Ensure that the patient is well hydrated at all times. B) Encourage self-administration of eye drops. C) Occlude the puncta after applying the medication. D) Position the patient supine before administering eye drops.

C) Occlude the puncta after applying the medication.

Several medications are prescribed for a client who has anorexia. Which medication may be prescribed to help treat the client's distorted body image? A) Amitriptyline (Elavil) B) Cyproheptadine (Periactin) C) Olanzapine (Zyprexa) D) Fluoxetine (Prozac)

C) Olanzapine (Zyprexa)

A patient with Guillain-Barr syndrome has experienced a sharp decline in vital capacity. What is the nurses most appropriate action? A) Administer bronchodilators as ordered. B) Remind the patient of the importance of deep breathing and coughing exercises. C) Prepare to assist with intubation. D) Administer supplementary oxygen by nasal cannula.

C) Prepare to assist with intubation.

The nurse notes that a patient has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms and signs are suggestive of what health problem? A) Pericarditis B) Cardiomyopathy C) Pulmonary edema D) Right ventricular hypertrophy

C) Pulmonary edema

The nurse is assessing a client with early signs of dementia. What is the nurse trying to determine when the nurse asks the client what he ate for breakfast that morning? A) Orientation B) Food preferences C) Recent memory D) Remote memory

C) Recent memory

A nurse is teaching a client with borderline personality disorder to reshape thinking patters. Which is an example of a cognitive restructuring technique that would be helpful for this client? A) When negative thoughts begin, tell yourself stop. B) Learn to look at situations realistically rather than assuming the worst. C) Recognize negative thoughts and replace them with positive ones. D) Express needs using I statements.

C) Recognize negative thoughts and replace them with positive ones.

When establishing a relationship with a client who has borderline personality disorder, which is most important for the nurse to do? A) Aggressively confront the client about boundary violations. B) Limit interactions to 10 minutes at a time. C) Respect the client's boundaries at all times. D) Tell the client the relationship will last as long as the client wishes.

C) Respect the client's boundaries at all times.

Which is the primary objective of nursing interventions in the care of a client with anorexia nervosa? A) Changing her irrational thinking about her body B) Establishing a target weight to be achieved by discharge C) Restoring nutritional status to normal D) Gaining insight into the effects of anorexia on her physical health

C) Restoring nutritional status to normal

Which term describes the extent to which a person considers himself to be an integral part of the universe? A) Cooperativeness B) Self-directedness C) Self-transcendence D) Character

C) Self-transcendence

A client states, I am dead. I have come back from the dead. An appropriate response by the nurse is, A) What is it like to feel dead? B) No you did not die. People don't come back from the dead. C) Show me what you did in art therapy this morning. D) I'll get your medicine and you'll feel better.

C) Show me what you did in art therapy this morning.

A patient has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize which of the following topics? A) Management of fluid balance in the home setting B) The need for blood glucose monitoring for the next week C) Signs and symptoms of intra-abdominal complications D) Appropriate use of prescribed pancreatic enzymes

C) Signs and symptoms of intra-abdominal complications

The critical care nurse is caring for a patient just admitted in a hypertensive emergency. The nurse should anticipate the administration of what medication? A) Warfarin (Coumadin) B) Furosemide (Lasix) C) Sodium nitroprusside (Nitropress) D) Ramipril (Altace)

C) Sodium nitroprusside (Nitropress)

A client diagnosed with schizophrenia is laughing and talking while sitting alone. Which of the following is the best response by the nurse? A) State, Can you share your joke with me? B) To sit with the client quietly until the client is ready to talk C) State, Tell me what's happening. D) State, You look lonely here. Let's join the others in the day room.

C) State, Tell me what's happening.

A student nurse is having a first experience in an inpatient psychiatric unit and is frightened by the behaviors of the clients with schizophrenia. The student should take which of the following actions to deal with fear? A) Express fear to the psychiatrist during rounds B) Pretend to not be afraid C) Stay in an open area while talking with the clients D) Insist that the instructor accompanies the student at all times.

C) Stay in an open area while talking with the clients

The nurse is caring for a patient who has developed obvious signs of pulmonary edema. What is the priority nursing action? A) Lay the patient flat. B) Notify the family of the patients critical state. C) Stay with the patient. D) Update the physician.

C) Stay with the patient.

A student nurse is taking care of an elderly patient with hypertension during a clinical experience. The instructor asks the student about the relationships between BP and age. What would be the best answer by the student? A) Because of reduced smooth muscle tone in blood vessels, blood pressure tends to go down with age, not up. B) Decreases in the strength of arteries and the presence of venous insufficiency cause hypertension in the elderly. C) Structural and functional changes in the cardiovascular system that occur with age contribute to increases in blood pressure. D) The neurologic system of older adults is less efficient at monitoring and regulating blood pressure.

C) Structural and functional changes in the cardiovascular system that occur with age contribute to increases in blood pressure.

The daughter of a woman with dementia asks the nurse if her mother will ever be able to live independently again. Which would be the most appropriate response by the nurse? A) You sound like you aren't ready for her to be dependent on caregivers. B) Her confusion is a temporary complication of her physical illness and should subside when the illness gets better. C) Symptoms of dementia gradually get worse. Unfortunately she will not be independent again D) With early treatment, mild dementia can be reversed. It may be possible

C) Symptoms of dementia gradually get worse. Unfortunately she will not be independent again

The nurse is assisting the client with anorexia to express feelings more openly. Which response by the nurse would be most likely to encourage expression of feelings? A) Are you sad? B) You look anxious. C) Tell me what you are feeling right now. D) Tell me when you feel bad.

C) Tell me what you are feeling right now.

Which of the following attitudes would be best for the nurse when the client who has schizophrenia acts as though the nurse is not trustworthy or that his or her integrity is being questioned? A) That the client is correct and the nurse is not trustworthy B) That the client wants to insult the nurse C) That the client's behavior is a part of the illness D) That the nurse's actions have failed

C) That the client's behavior is a part of the illness

A physician has explained to a patient that he has developed diabetic neuropathy in his right foot. Later that day, the patient asks the nurse what causes diabetic neuropathy. What would be the nurses best response? A) Research has shown that diabetic neuropathy is caused by fluctuations in blood sugar that have gone on for years. B) The cause is not known for sure but it is thought to have something to do with ketoacidosis. C) The cause is not known for sure but it is thought to involve elevated blood glucose levels over a period of years. D) Research has shown that diabetic neuropathy is caused by a combination of elevated glucose levels and elevated ketone levels.

C) The cause is not known for sure but it is thought to involve elevated blood glucose levels over a period of years.

A client with dementia gets angry and begins to yell at the nurse during mealtime. The nurse leaves the client's side for 5 to 10 minutes and then returns. Which of the following best explains the nurse's behavior? A) The nurse was unsure of how to calm the client. B) The nurse was frustrated and needed to take a ìtime-out.î C) The nurse gave the client a chance to calm down before resuming the meal. D) The nurse stepped away to verify the safety of other clients.

C) The nurse gave the client a chance to calm down before resuming the meal.

A patient with low vision has called the clinic and asked the nurse for help with acquiring some low- vision aids. What else can the nurse offer to help this patient manage his low vision? A) The patient uses OTC NSAIDs. B) The patient has a history of stroke. C) The patient has diabetes. D) The patient has Asian ancestry.

C) The patient has diabetes.

Family members bring a patient to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data? A) The symptoms indicate angina and should be treated as such. B) The symptoms indicate a pulmonary etiology rather than a cardiac etiology. C) The symptoms indicate an acute coronary episode and should be treated as such. D) Treatment should be determined pending the results of an exercise stress test.

C) The symptoms indicate an acute coronary episode and should be treated as such.

The nurse is caring for a patient admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this patient. The nurse should recognize what implication of this assessment finding? A) This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours. B) Because the patient has a history of unstable angina, this is a poor indicator of myocardial injury. C) This is an accurate indicator of myocardial injury. D) This result indicates muscle injury, but does not specify the source.

C) This is an accurate indicator of myocardial injury.

A client who has schizophrenia is having a conversation with the nurse suddenly stops talking in the middle of a sentence. The client is experiencing which type of thought disruption? A) Thought withdrawal B) Thought insertion C) Thought blocking D) Thought broadcasting

C) Thought blocking

The nurse is sitting with a patient who is crying. After a few minutes the nurse places one hand on the patient's shoulder. Which of the following best describes the purpose of the nurse's touch with this patient? A) To express sympathy to the patient B) To assess the patient's skin temperature and circulation status C) To offer comfort and support for the patient D) To extend an offer of friendship to the patient

C) To offer comfort and support for the patient

An older adult is newly diagnosed with primary hypertension and has just been started on a beta-blocker. The nurses health education should include which of the following? A) Increasing fluids to avoid extracellular volume depletion from the diuretic effect of the beta- blocker B) Maintaining a diet high in dairy to increase protein necessary to prevent organ damage C) Use of strategies to prevent falls stemming from postural hypotension D) Limiting exercise to avoid injury that can be caused by increased intracranial pressure

C) Use of strategies to prevent falls stemming from postural hypotension

A client with schizophrenia is reluctant to take his prescribed oral medication. The most therapeutic response by the nurse to this refusal is, A) I can see that you're uncomfortable now, so we can wait until tomorrow. B) If you refuse these pills, you'll have to get an injection. C) What is it about the medicine that you don't like? D) You know you have to take this medicine for your own good.

C) What is it about the medicine that you don't like?

During the mental status assessment, the client expresses the belief that the CIA is stalking him and plans to kidnap him. The best response by the nurse would be, A) That makes no sense at all. B) You can tell me about that after I finish asking these questions. C) What kinds of things have been happening? D) Why would the CIA be interested in you?

C) What kinds of things have been happening?

The nurse is performing an intake assessment on a patient with a new diagnosis of coronary artery disease. What would be the most important determination to make during this intake assessment? A) Whether the patient and involved family members understand the role of genetics in the etiology of the disease B) Whether the patient and involved family members understand dietary changes and the role of nutrition C) Whether the patient and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately D) Whether the patient and involved family members understand the importance of social support and community agencies

C) Whether the patient and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately

The patient states that he is 14 trillion years old and created the world. The nurse documents this statement as an example of which type of thinking displayed by the patient? A) Delusional thinking B) Ideas of reference C) Word salad D) Hallucination

C) Word salad

A client with antisocial personality disorder is begging to use the phone to call his wife, even though it is against the unit rules. The client begs, It is just this once, and she will be so hurt if I don't call her. Which would be the most appropriate response by the nurse? A) Only to help your wife, you can call this time. B) I will get in trouble with my supervisor if I let you call. C) You may not use the phone to call your wife. D) You cannot call because you need to focus on your recovery while you are here, not your

C) You may not use the phone to call your wife.

The nurse is preparing a client with schizophrenia for discharge. The nurse asks the client, "How are you going to care for yourself at home?" The purpose of the nurse's question is to assess the client's A) self concept. B) judgment. C) insight. D) social support system.

C) insight.

In the space of 5 minutes, the client has been laughing and euphoric, then angry, and then crying for no reason that is apparent to the nurse. This behavior would be best described as A) flight of ideas. B) lack of insight. C) labile mood. D) tangential thinking.

C) labile mood.

During the assessment, the nurse asks the client to describe his problems. The purpose of this question is to obtain information about the client's A) admitting diagnosis. B) communication skills. C) perception of the problem. D) personal needs.

C) perception of the problem.

The nurse is assessing suicide potential in a patient who has expressed hopelessness. In what order does the nurse question the patient about suicidal thoughts? A) How would you carry out this plan? B) Do you have a plan to kill yourself? C) Are you thinking of killing yourself? D) How do you plan to kill yourself?

C, B, D, A

A registered nurse is teaching a group of nursing students about leadership principles. Which statement by a nursing student indicates the need for further teaching? A. Leaders are medical professionals who can intervene with courage. B. Leaders are able to organize a group of colleagues to solve an organizational problem. C. A leader has a formal position and title. D. Leaders have strong qualities, such as communication and problem solving skills.

C. A leader has a formal position and title.

When should a person with diagnosed seizures wear their medical alert bracelet? A. Only at night B. Only during the day C. All the time D. When they want to

C. All the time

Quantum leadership theory involves which view? A. Change as an entity to be planned, managed, and accepted. B. It is important to create revolutionary change through a charismatic and inspirational style of leadership. C. Change as being dynamic, ever present, and continually unfolding. D. Decisions and activities need to be shared among group members.

C. Change as being dynamic, ever present, and continually unfolding.

Which of the following is a common treatment for most cases of colon cancer? A. Chemotherapy before surgical removal of visible cancer B. Colonoscopy to insert a stent into the intestine to hold the obstructed area open C. Surgery to remove the cancerous segment of the intestine D. Surgery to remove the rectum and anus

C. Surgery to remove the cancerous segment of the intestine

A patient with Crohn's Disease is MOST likely to have the disease in what part of the GI tract? A. Rectum B. Duodenum of the small intestine C. Terminal Ileum D. Descending colon

C. Terminal Ileum

The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior?

Confusion

The triage nurse in the ED is performing a rapid assessment of a man with complaints of severe chest pain and shortness of breath. The patient is diaphoretic, pale, and weak. When the patient collapses, what should the nurse do first? A) Check for a carotid pulse. B) Apply supplemental oxygen. C) Give two full breaths. D) Gently shake and shout, Are you OK?

D) Gently shake and shout, Are you OK?

An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that the vessel most commonly used as source for a CABG is what? A) Brachial artery B) Brachial vein C) Femoral artery D) Greater saphenous vein

D) Greater saphenous vein

The daughter of a client with dementia has been the primary caregiver for 5 months. The daughter expresses to the nurse, At times it is so overwhelming! I feel I do not have a life anymore! Which is the most helpful response by the nurse? A) Are you saying you don't want to care for your mother anymore? B) I know it is really hard. It takes a lot of work and you are doing such a good job. C) Your mother really appreciates what you do for her. You are the best one to care for her. D) Here is the number of a caregivers' support group. How do you think you would feel talking with others in the same situation?

D) Here is the number of a caregivers' support group. How do you think you would feel talking with others in the same situation?

A community health nurse is planning an educational campaign addressing hypertension. The nurse should anticipate that the incidence and prevalence of hypertension are likely to be highest among members of what ethnic group? A) Pacific Islanders B) African Americans C) Asian-Americans D) Hispanics

D) Hispanics

The staff educator is teaching ED nurses about hypertensive crisis. The nurse educator should explain that hypertensive urgency differs from hypertensive emergency in what way? A) The BP is always higher in a hypertensive emergency. B) Vigilant hemodynamic monitoring is required during treatment of hypertensive emergencies. C) Hypertensive urgency is treated with rest and benzodiazepines to lower BP. D) Hypertensive emergencies are associated with evidence of target organ damage.

D) Hypertensive emergencies are associated with evidence of target organ damage.

Which statement made by the nurse would be most appropriate to an 89-year-old patient who is confused but has no history of dementia and is hospitalized for an acute urinary tract infection? A) You are likely to become progressively more confused now. B) This should be just a temporary situation. C) Don't worry about it; everyone is confused when they are in the hospital. D) I know things are upsetting and confusing right now, but your confusion should clear as you get better.

D) I know things are upsetting and confusing right now, but your confusion should clear as you get better.

A patient is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the patients statements best demonstrates an adequate understanding? A) I need to call the doctor if I get nauseated. B) I need to call the doctor if I have a light morning discharge. C) I need to call the doctor if I get a scratchy feeling. D) I need to call the doctor if I see flashing lights.

D) I need to call the doctor if I see flashing lights.

A client asks the nurse upon discharge, What should I do if I forget to take my medicine? The nurse should explain to the client which of the following? A) Just double the dose next time it is scheduled. B) Skip that dose and resume your regular with the next dose. C) Don't miss doses, or you will not maintain therapeutic drug levels. D) If you remember within 3 to 4 hours later than it is due, take it then. If you remember more than 4 hours after it was due, do not take that dose.

D) If you remember within 3 to 4 hours later than it is due, take it then. If you remember more than 4 hours after it was due, do not take that dose.

The public health nurse is addressing eye health and vision protection during an educational event. What statement by a participant best demonstrates an understanding of threats to vision? A) Im planning to avoid exposure to direct sunlight on my next vacation. B) Ive never exercised regularly, but Im going to start working out at the gym daily. C) Im planning to talk with my pharmacist to review my current medications. D) Im certainly going to keep a close eye on my blood pressure from now on.

D) Im certainly going to keep a close eye on my blood pressure from now on.

All of the following nursing diagnoses are appropriate for the care of a client with anorexia. Which nursing diagnosis has the highest priority? A) Activity intolerance B) Ineffective coping C) Chronic low self-esteem D) Imbalanced nutrition: less than body requirements

D) Imbalanced nutrition: less than body requirements

A client has been making sexual comments when communicating with the nurse. The nurse wants to spend some time talking to the patient while respecting the patient's right to privacy. Which setting would be the most appropriate setting for the nurse to talk with the client? A) In the patient's room when the patient's roommate is present and 3 feet away B) At the nurse's station when other clients and visitors are less than 4 feet away C) In an interview room in a remote section of the unit with the nurse 1 foot away from the patient D) In a quiet corner of the dayroom at least 4 feet away from others

D) In a quiet corner of the dayroom at least 4 feet away from others

A client with severe back pain and hematuria is found to have hydronephrosis due to renal calculi. The nurse anticipates that which treatment will be done to relieve the obstruction? Select all that apply A) Peritoneal dialysis B) Analysis of the urinary calculi C) IV opioid analgesics D) Insertion of a nephrostomy tube E) Placement of a ureteral stent with ureteroscopy

D) Insertion of a nephrostomy tube E) Placement of a ureteral stent with ureteroscopy

The nurse teaches an antisocial client to take a time-out in his room when challenged by another person instigating an argument. What is the main reason for the time-out? A) It allows time for the instigator to leave the area. B) It allows adequate space between the client and the instigating individual. C) It prevents the client from experiencing negative consequences of behavior. D) It allows an opportunity for the client to regain control of emotions.

D) It allows an opportunity for the client to regain control of emotions.

A client with schizophrenia is attending a follow-up appointment at the community mental health clinic. The client reports to the nurse, I stopped taking the antipsychotic medication because I can't get a hard-on with my girlfriend anymore. Which of the following should the nurse recommend to enhance the client's well-being? A) It sounds like that is a problem for you. Don't you still find her to be sexy enough? B) Sexual dysfunction is a temporary side effect and should get better once your body is used to the medication. C) You should avoid having sex with your girlfriend anyway. Do you really want her to get pregnant? D) It is important for you to take an antipsychotic medication. You may need a different type that will be less likely to affect your sexual functioning. I would like to call your physician about this.

D) It is important for you to take an antipsychotic medication. You may need a different type that will be less likely to affect your sexual functioning. I would like to call your physician about this.

What is the rationale for a person taking lithium to have enough water and salt in their diet? A) Salt and water are necessary to dilute lithium to avoid toxicity. B) Water and salt convert lithium into a usable solute. C) Lithium is metabolized in the liver, necessitating increased water and salt. D) Lithium is a salt that has a greater affinity for receptor sites than sodium chloride

D) Lithium is a salt that has a greater affinity for receptor sites than sodium chloride

The nurse is providing care for a patient with high cholesterol and triglyceride values. In teaching the patient about therapeutic lifestyle changes such as diet and exercise, the nurse realizes that the desired goal for cholesterol levels is which of the following? A) High HDL values and high triglyceride values B) Absence of detectable total cholesterol levels C) Elevated blood lipids, fasting glucose less than 100 D) Low LDL values and high HDL values

D) Low LDL values and high HDL values

A patient in hypertensive urgency is admitted to the hospital. The nurse should be aware of what goal of treatment for a patient in hypertensive urgency? A) Normalizing BP within 2 hours B) Obtaining a BP of less than 110/70 mm Hg within 36 hours C) Obtaining a BP of less than 120/80 mm Hg within 36 hours D) Normalizing BP within 24 to 48 hours

D) Normalizing BP within 24 to 48 hours

An ED nurse is assessing an adult woman for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female patients? Select all that apply. A) Shortness of breath B) Chest pain C) Anxiety D) Numbness E) Weakness

D) Numbness E) Weakness

Which of the following is a realistic outcome for the care of a person with a personality disorder? A) Outcomes that focus on satisfaction with daily life B) Outcomes that focus on the client's perception of others C) Outcomes that focus on increased client insight D) Outcomes that focus on change in behavior

D) Outcomes that focus on change in behavior

While assessing the family dynamics of a client with an eating disorder, which of the following does the nurse most likely discover? A) Multiple siblings B) Lack of interest in the client by other family members C) Supportive and encouraging relationships D) Over controlling parents

D) Over controlling parents

A nursing student appears to cooperate with the group but does not complete agreed upon tasks at the appropriate time repeatedly and then display negativity. The nursing student may be showing signs of which personality disorder or behavior? A) Paranoid B) Borderline C) Narcissistic D) Passive-aggressive behavior

D) Passive-aggressive behavior

A patient presents at the clinic complaining of pain and weakness in her hands. On assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. The nurse knows that these findings are indicative of what? A) Guillain-Barr syndrome B) Myasthenia gravis C) Trigeminal neuralgia D) Peripheral nerve disorder

D) Peripheral nerve disorder

The nurse is caring for patient who tells the nurse that he has an angina attack beginning. What is the nurses most appropriate initial action? A) Have the patient sit down and put his head between his knees. B) Have the patient perform pursed-lip breathing. C) Have the patient stand still and bend over at the waist. D) Place the patient on bed rest in a semi-Fowlers position.

D) Place the patient on bed rest in a semi-Fowlers position.

The nurse performing the health interview of a patient with a new onset of periorbital edema has completed a genogram, noting the health history of the patients siblings, parents, and grandparents. This assessment addresses the patients risk of what kidney disorder? A) Nephritic syndrome B) Acute glomerulonephritis C) Nephrotic syndrome D) Polycystic kidney disease (PKD)

D) Polycystic kidney disease (PKD)

When planning care for a client with passive-aggressive personality disorder, the nurse will need to include interventions for which behavior? A) Avoidance of anxiety-provoking situations B) Compulsive needs for perfection and praise C) Dependence on others for decisions D) Procrastination and intentional inefficiency

D) Procrastination and intentional inefficiency

The nurse observes that a client with bipolar disorder is pacing in the hall, talking loudly and rapidly, and using elaborate hand gestures. The nurse concludes that the client is demonstrating which? A) Aggression B) Anger C) Anxiety D) Psychomotor agitation

D) Psychomotor agitation

A nurse is educating a group of elderly community members about cognitive disorders. Which would the nurse include as a measure most likely to prevent Alzheimer's disease and other dementias? A) Crafts B) Cooking C) Watching television D) Reading

D) Reading

A nurse is assessing a patient who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the patients pain, the nurse should anticipate that it may radiate to what region? A) Left upper chest B) Inguinal region C) Neck or jaw D) Right shoulder

D) Right shoulder

An older adult patient with HF is being discharged home on an ACE inhibitor and a loop diuretic. The patients most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this patients subsequent care, what nursing diagnosis should be identified? A) Risk for ineffective tissue perfusion related to dysrhythmia B) Risk for fluid volume excess related to medication regimen C) Risk for ineffective breathing pattern related to hypoxia D) Risk for falls related to hypotension

D) Risk for falls related to hypotension

The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the SA node and then proceeds in what sequence? A) SA node to bundle of His to AV node to Purkinje fibers B) SA node to AV node to Purkinje fibers to bundle of His C) SA node to bundle of His to Purkinje fibers to AV node D) SA node to AV node to bundle of His to Purkinje fibers

D) SA node to AV node to bundle of His to Purkinje fibers

Which thought process would cause a client with antisocial personality disorder to want to do everything for himself? A) Belief in his own self-worth B) Inability to delay gratification C) Rewards for competitive behavior D) Sense of mistrust of others

D) Sense of mistrust of others

The nurse encourages the client with dementia to meet nutritional needs. Which is the best approach to assist in meeting adequate dietary intake? A) Sit with the client as long as necessary to complete the meal. B) Provide entertainment during meals such as television or music. C) Avoid between-meal snacks to encourage appetite. D) Serve meals in small, bite-size pieces.

D) Serve meals in small, bite-size pieces.

During an initial interview at a clinic, a young female client states that there is nothing wrong with her. Which would indicate to the nurse that this client might have anorexia nervosa? A) Episodes of overeating and excessive weight gain B) Expressions of a positive self-concept C) Flexible thought patterns and spontaneity D) Severe weight loss due to self-imposed dieting

D) Severe weight loss due to self-imposed dieting

The nurse asks the patient, What was it like for you when you first knew you had no place to go? The patient looks down and pauses for quite some time. Which action by the nurse is most therapeutic? A) Change the subject to something the patient will discuss B) Encourage the patient to express any unpleasant feelings C) Apologize for asking such a personal question D) Sit quietly until the patient responds

D) Sit quietly until the patient responds

The nurse is sitting down with a patient to begin a conversation. Which of the following positions should the nurse take to convey acceptance of the patient? A) Leaning forward with arms on the table sitting directly across for the patient B) Turned slightly to the side of the patients with arms folded across the chest C) Leaning back in the chair next to the patient with legs crossed at the knees D) Sitting upright facing the patient with both feet on the floor

D) Sitting upright facing the patient with both feet on the floor

All of the following are nursing diagnoses identified for a client with schizophrenia. The student nurse correctly anticipates which diagnosis will resolve when the client's negative symptoms improve? A) Impaired verbal communication B) Risk for other-directed violence C) Disturbed thought processes D) Social isolation

D) Social isolation

A patient comes to the walk-in clinic complaining of frequent headaches. While assessing the patients vital signs, the nurse notes the BP is 161/101 mm Hg. According to JNC 7, how would this patients BP be defined if a similar reading were obtained at a subsequent office visit? A) High normal B) Normal C) Stage 1 hypertensive D) Stage 2 hypertensive

D) Stage 2 hypertensive

The nurse is caring for a patient who is undergoing an exercise stress test. Prior to reaching the target heart rate, the patient develops chest pain. What is the nurses most appropriate response? A) Administer sublingual nitroglycerin to allow the patient to finish the test. B) Initiate cardiopulmonary resuscitation. C) Administer analgesia and slow the test. D) Stop the test and monitor the patient closely.

D) Stop the test and monitor the patient closely.

A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event? A) Psychosocial stress B) Hypersensitivity to an immunization C) Menarche D) Streptococcal infection

D) Streptococcal infection

A patient is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this patients care? A) Antioxidant supplements, vitamin C and E, beta-carotene, and selenium B) Eyeglasses or magnifying lenses C) Corticosteroid eye drops D) Surgical intervention

D) Surgical intervention

Which is the main reason why the periodic team meetings are important when caring for a client with antisocial personality? A) The team needs to consider updating treatment recommendations as the client improves. B) Rotating team members need to be apprised of the care planned for the client. C) Staff frustrations in caring for the client need to be processed. D) Team consistency is important to prevent manipulation by the client.

D) Team consistency is important to prevent manipulation by the client.

The nurse is trying to obtain some information about family relationships from the client. Which of the following statements is best? A) Is it upsetting for you to talk about your family? B) Is your family ready for you to come home? C) So, how is your family? D) Tell me your feelings about your family situation.

D) Tell me your feelings about your family situation.

The student nurse correctly recognizes that which one of the following findings is best supported by genetic studies in the etiology of schizophrenia? A) If a person has schizophrenia, distant relatives are also at risk. B) That there is no relationship at all between schizophrenia and genetics. C) That there is a weak correlation between genetics and schizophrenia. D) That schizophrenia is at least partially inherited.

D) That schizophrenia is at least partially inherited.

A nurse is reviewing the physiological factors that affect a patients cardiovascular health and tissue oxygenation. What is the systemic arteriovenous oxygen difference? A) The average amount of oxygen removed by each organ in the body B) The amount of oxygen removed from the blood by the heart C) The amount of oxygen returning to the lungs via the pulmonary artery D) The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood

D) The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood

The nurse is caring for her first client with obsessiveñcompulsive disorder. During the treatment team meeting, the nurse shares her frustration as to the client's inability to stop washing his hands. The nurse manager offers which one of the following explanations? A) The hand washing represents a way to exert independence from the staff. B) The client is not aware of the excessive hand washing. C) The client does not think anything is abnormal with washing his hands repeatedly. D) The client feels terrible but cannot stop washing his hands to try to get rid of his anxiety.

D) The client feels terrible but cannot stop washing his hands to try to get rid of his anxiety.

A client with schizophrenia is admitted to the inpatient unit. He does not speak when spoken to but has been observed talking to himself on occasion. What would be the priority objective at this time? A) The client will begin talking with other clients B) The client will express his feelings freely C) The client will increase his socialization with others D) The client will increase his reality orientation

D) The client will increase his reality orientation

When the nurse asks the client to restate the following in his or her own words, which sensorium and intellectual process is the nurse attempting to identify? The nurse states, A stitch in time saves nine. A) The client's orientation B) The client's memory C) The client's ability to concentrate D) The client's ability to use abstract thinking

D) The client's ability to use abstract thinking

The nurse is assessing an older adult patient with numerous health problems. What assessment datum indicates an increase in the patients risk for heart failure (HF)? A) The patient takes Lasix (furosemide) 20 mg/day. B) The patients potassium level is 4.7 mEq/L. C) The patient is an African American man. D) The patients age is greater than 65.

D) The patients age is greater than 65.

A patients recently elevated BP has prompted the primary care provider to prescribe furosemide (Lasix). The nurse should closely monitor which of the following? A) The clients oxygen saturation level B) The patients red blood cells, hematocrit, and hemoglobin C) The patients level of consciousness D) The patients potassium level

D) The patients potassium level

A nurse is assessing a patient who has diabetes for the presence of peripheral neuropathy. The nurse should question the patient about what sign or symptom that would suggest the possible development of peripheral neuropathy? A) Persistently cold feet B) Pain that does not respond to analgesia C) Acute pain, unrelieved by rest D) The presence of a tingling sensation

D) The presence of a tingling sensation

The nurse is talking to a client with schizoid personality disorder about finding a job. Which suggestion by the nurse would be most helpful? A) Being a loner really limits your employment opportunities. B) Maybe your friend could see if there is a night position available at the convenience store. C) Perhaps working part-time at a fast-food restaurant would be something you could do. D) There is a job posting at the hospital for a file clerk in medical records.

D) There is a job posting at the hospital for a file clerk in medical records.

A delusion represents a problem in which of the following areas? A) Memory B) Motivation C) Orientation D) Thinking

D) Thinking

A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patients left foot. How should the nurse proceed with assessment? A) Have the primary care provider order a CT. B) Apply a tourniquet for 3 to 5 minutes and then reassess. C) Elevate the extremity and attempt to palpate the pulses. D) Use Doppler ultrasound to identify the pulses.

D) Use Doppler ultrasound to identify the pulses.

The nurse caring for a patient diagnosed with Guillain-Barr syndrome is planning care with regard to the clinical manifestations associated this syndrome. The nurses communication with the patient should reflect the possibility of what sign or symptom of the disease? A) Intermittent hearing loss B) Tinnitus C) Tongue enlargement D) Vocal paralysis

D) Vocal paralysis

The nurse best assesses a patient's memory by asking which of the following questions? A) Do you have any problems with memory? B) What did you have for lunch yesterday? C) Do you know where you are? D) Who is the current president?

D) Who is the current president?

The nurse is working with a client who has hallucinations and delusions. The client tells the nurse she cannot take a shower because she is waiting for her husband to take her home. Which response by the nurse is best in this situation? A) It would be best if you just took your shower now. B) You seem anxious and upset. C) You have plenty of time to shower before it's time to go home. D) Why are you thinking you're going home?

D) Why are you thinking you're going home?

The nurse is caring for an 82-year-old patient. The nurse knows that changes in cardiac structure and function occur in older adults. What is a normal change expected in the aging heart of an older adult? A) Decreased left ventricular ejection time B) Decreased connective tissue in the SA and AV nodes and bundle branches C) Thinning and flaccidity of the cardiac values D) Widening of the aorta

D) Widening of the aorta

Which statement by the nurse would be most appropriate to the family member who is the primary caregiver to a client with dementia? A) Most people seek help when they really need it. B) What is wrong with your family? Can't they see you need help? C) You should be grateful that you still have your family member around. D) Yes, it is important for you to spend some time relaxing and doing what you like to do.

D) Yes, it is important for you to spend some time relaxing and doing what you like to do.

A patient states, I feel fine. It's a good day. The nurse notes the patient looking away, and a decreasing pitch in his voice while speaking. Which of the following is the most therapeutic response by the nurse? A) I'm glad you are feeling good today. B) I'm not sure I believe you. C) Tell me what is good about today. D) You say you feel fine, but you don't really sound fine.

D) You say you feel fine, but you don't really sound fine.

A patient yells, All the nurses here are so mean. None of you really care about us! The most therapeutic response would be, A) I cannot allow you to yell like that. B) We care about you. C) Oh, really? D) You seem very irritated.

D) You seem very irritated.

The client with schizophrenia makes the following statement, ìI just don't know how to count. The sky turned to fire. I have a ball in my head.î The nurse documents this entire statement as an example of A) flight of ideas. B) ideas of reference. C) delusional thinking. D) associative looseness.

D) associative looseness.

Actions for a client with OCD would include (SATA) A) encouraging the client to verbalize feelings. B) helping the client avoid obsessive thinking. C) interrupting rituals with appropriate distractions. D) planning with the client to limit rituals. E) teaching relaxation exercises to the client. F) telling the client to tolerate any anxious feelings.

D) planning with the client to limit rituals. E) teaching relaxation exercises to the client. F) telling the client to tolerate any anxious feelings.

Cognitive restructuring techniques include all of the following, except A) decatastrophizing. B) positive self-talk. C) reframing. D) relaxation.

D) relaxation.

The nurse must be alert to the nonverbal expressions of the client. Because the meaning attached to nonverbal behavior is subjective, it is important for the nurse to A) increase the client's awareness of nonverbal behavior. B) investigate the source of nonverbal behavior. C) validate the client's feelings. D) validate the meaning of the nonverbal behavior.

D) validate the meaning of the nonverbal behavior.

A nurse is assessing a client who has hypercholesterolemia and is receiving simvastatin. Which of the following findings should the nurse recognize as a potential adverse effect?

Muscle weakness

A nurse is revealing BP classifications with a group of nurses at an in service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension?

Obstructive sleep apnea

Ms. Smith tells you "I am afraid I'm going to have to have surgery". What is the nurse's best response? A. Its to early to tell if you'll need surgery. B. Surgery is the best treatment. C. Ah, don't worry you probably want need it. D. Surgery used to be a common treatment but with new medications now it is rarely needed.

D. Surgery used to be a common treatment but with new medications now it is rarely needed.

A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority?

Daily weight

A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?

Decrease anxiety to a tolerable level

A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)

Difficulty relaxing Rule conscious behavior Perfectionist behavior

A nurse is administering timolol eye drops to a client who has glaucoma. Which of the following actions should the nurse take?

Drop prescribed an amount of medication in the conjunctival sac.

What treatment options are available for people diagnosed with Ulcerative Colitis and Crohn's disease? A. Surgery B. Medication C. Counseling/Support Groups D. Dietician consultations E. All of the above

E. All of the above

A nurse in a cardiac care unit is caring for a client with acute right sided HF. which of the following should the nurse expect?

Elevated CVP

A nurse is providing care for a client who had a laparoscopic cholecystectomy. Which of the following is an appropriate nursing action?

Encourage ambulation once fully awake.

A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following actions should the nurse take when caring for the client's JP drain?

Expel the air from the JP bulb after emptying to re-establish suction.

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

Experiencing diarrhea

True or false When a child is having a seizure you should hold them down.

False

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?

Fatty Stools

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a MODIFIABLE risk factor for this disorder? SATA

Hypercholesterolemia Hypertension Obesity Smoking

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates concrete thinking?

I am aware that each problem has only one solution

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates understanding of a relapse prevention plan?

I know which of my hallucinations trigger a relapse

A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching?

I may thicken gravies with cornstarch as i cook

A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make?

I'm glad you called. And i want to send an ambulance to help you

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?

Identify precipitating factors for ritualistic behaviors

A nurse is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?

Initiating suicide precautions

A nurse in an acute care facility is assessing a client who had hip surgery and has Alzheimer's disease. The nurse asks the client how therapy went that morning. Which of the following statements by the client should the nurse document as confabulation?

It was good. The queen of england visited me.

A nurse is teaching about necessary baseline examinations with a female client who is to start taking atorvastatin. Which of the following baseline examinations should the nurse include in the teaching?

Liver function test

A nurse is caring for a female client who reports an increase in bruising. The nurse should Expect which of the following laboratory values?

Platelets 110,000

A patient complains of experiencing angina at night. On further questioning, the nurse finds there are no causes for the angina. What type of angina is this?

Prinzmetals

A nurse is caring for a client who has chronic glomerulonephritis. The nurse should expect to find a decrease in which of the following serum Lab values?

RBC

A nurse is providing discharge instructions for a client following cataract surgery with insertion of an intraocular lens. Which of the following instructions should the nurse include?

Restrict lifting objects greater than 10 pounds.

A nurse is teaching a client who has cholecystitis about required dietary modifications. The nurse should include which of the following foods as appropriate for the clients diet?

Roast turkey

Home health nurse is assessing an older adult client in the home who has decreased vision due to hc of glaucoma. Which of the following findings should the nurse identify as a safety risk?

Scatter rugs are present in the kitchen

A nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted to a long-term care facility following the death of her partner of 40 years. The client states, "I want to go home; my husband is waiting for me to cook dinner." Which of the following responses by the nurse is appropriate?

Tell me what you like to cook for dinner

A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching?

The client should wear dark glasses while outdoors.

How can chronic dry eye contribute to the risk of eye infections? a) By increasing tear production b) By promoting a healthy ocular surface c) By compromising the protective barrier of the eyes d) By reducing eye sensitivity

c) By compromising the protective barrier of the eyes

Which of the following symptoms is often associated with bacterial conjunctivitis? a) Blurred vision b) Watery eyes c) Yellow or green discharge d) Dryness in eyes

c) Yellow or green discharge

Which is a DVT prophylaxis post surgery? A. pillows under legs B. don't cross legs in bed

don't cross legs in bed

A nurse is caring for a client who has bipolar disorder and has been taking lithium for 1 year. Before administering the medication, the nurse should check to see that which of the following tests have been completed?

Thyroid hormone assay

A nurse is caring for a client who has chemotherapy induced peripheral neuropathy. The nurse should expect the client to report having experienced which of the following symptoms?

Tingling feeling in the extremities

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.)

Tongue thrusting and lip smacking Facial grimacing and eye blinking Involuntary pelvic rocking and hip thrusting movements

While auscultating a patients heart sounds, the nurse hears an extra heart sound immediately after the second heart sound (S2). An audible S3 would be considered an expected finding in what patient? A) An older adult B) A 20-year-old patient C) A patient who has undergone valve replacement D) A patient who takes a beta-adrenergic blocker

B) A 20-year-old patient

Which client would have an increased risk for delirium? A) An elderly woman with abdominal pain B) A 3-year-old child with a temperature of 103.2F C) A middle-aged woman newly diagnosed with multiple sclerosis D) A young adult male with gastroenteritis and dehydration

B) A 3-year-old child with a temperature of 103.2F

The nurse is caring for a patient who has a history of heart disease. What factor should the nurse identify as possibly contributing to a decrease in cardiac output? A) A change in position from standing to sitting B) A heart rate of 54 bpm C) A pulse oximetry reading of 94% D) An increase in preload related to ambulation

B) A heart rate of 54 bpm

A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?

A client attempts to climb out of bed and repeating states she must go home

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingual for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make?

A headache is an expected adverse effect of med

A nurse is reinforcing teaching with a client regarding reduction of risk factors for CAD. which of the following indicates understanding SATA

A must stop smoking I need to monitor my weight I am limiting intake of fast foods

The nurse correctly identifies that which of OCDs self-soothing behaviors may involve self-destruction of the body of a person who has OCD? Select all that apply. A) Dermatillomania B) Trichotillomania C) Onychophagia D) Kleptomania E) Oniomania

A) Dermatillomania B) Trichotillomania C) Onychophagia

A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What should this nurse cite as the most common causes of blindness and visual impairment among adults over the age of 40? Select all that apply. A) Diabetic retinopathy B) Trauma C) Macular degeneration D) Cytomegalovirus E) Glaucoma

A) Diabetic retinopathy C) Macular degeneration E) Glaucoma

Which techniques are important for nurses caring for clients with personality disorders to use in order to effectively provide care? Select all that apply. A) Discuss feelings of anger or frustration with colleagues to help them recognize and cope with their own feelings. B) Considering the client to be a personal friend. C) Employ ongoing communication with team members to remain firm and consistent about expectations for clients. D) Solving the problems of the client. E) Understanding that behavior changes in clients with personality disorders can occur quickly.

A) Discuss feelings of anger or frustration with colleagues to help them recognize and cope with their own feelings. C) Employ ongoing communication with team members to remain firm and consistent about expectations for clients.

What are the most common types of side effects from SSRIs? A) Dizziness, drowsiness, and dry mouth B) Convulsions and respiratory difficulties C) Diarrhea and weight gain D) Jaundice and agranulocytosis

A) Dizziness, drowsiness, and dry mouth

Which activities would be appropriate for a client with mania? A) Drawing a picture B) Modeling clay C) Playing bingo D) Playing table tennis E) Stretching exercises F) Stringing beads

A) Drawing a picture B) Modeling clay E) Stretching exercises

The nurse is assessing a patient with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply. A) Dyspnea B) Unusual fatigue C) Hypotension D) Syncope E) Peripheral cyanosis

A) Dyspnea B) Unusual fatigue D) Syncope

A patient with a diagnosis of HF is started on a beta-blocker. What is the nurses priority role during gradual increases in the patients dose? A) Educating the patient that symptom relief may not occur for several weeks B) Stressing that symptom relief may take up to 4 months to occur C) Making adjustments to each days dose based on the blood pressure trends D) Educating the patient about the potential changes in LOC that may result from the drug

A) Educating the patient that symptom relief may not occur for several weeks

The nurse is reviewing a client's record and notes that the PCP has documented that the client has CKD. On review of the lab results, the nurse most likely would expect to note which finding? A) Elevated Creatinine level B) Decreased Hemoglobin level C) Decreased RBC count D) Decreased RBC count

A) Elevated Creatinine level

Which of the following would be most supportive for family and friends of a client with an eating disorder? A) Emotional support, love, and attention B) Focus on food intake, calories, and weight C) Unlimited access to unhealthy foods that the client enjoys D) Positive reinforcement for weight gain

A) Emotional support, love, and attention

The nurse asks the client what that experience was like. Which communication skill is the nurse using? A) Encouraging expression B) Encouraging description of perceptions C) Exploring D) Requesting an explanation

A) Encouraging expression

The nurse would assess for which characteristics in a client with narcissistic personality disorder? A) Entitlement B) Fear of abandonment C) Hypersensitivity D) Suspiciousness

A) Entitlement

When discussing angina pectoris secondary to atherosclerotic disease with a patient, the patient asks why he tends to experience chest pain when he exerts himself. The nurse should describe which of the following phenomena? A) Exercise increases the hearts oxygen demands. B) Exercise causes vasoconstriction of the coronary arteries. C) Exercise shunts blood flow from the heart to the mesenteric area. D) Exercise increases the metabolism of cardiac medications.

A) Exercise increases the hearts oxygen demands.

The nurse has just admitted a 66-year-old patient for cardiac surgery. The patient tearfully admits to the nurse that she is afraid of dying while undergoing the surgery. What is the nurses best response? A) Explore the factors underlying the patients anxiety. B) Teach the patient guided imagery techniques. C) Obtain an order for a PRN benzodiazepine. D) Describe the procedure in greater detail.

A) Explore the factors underlying the patients anxiety.

Which one of the following goals of therapeutic communication would the nurse strive to attain first? A) Facilitate the client's expression of emotions. B) Establish a therapeutic nurse/client relationship. C) Teach the client and family necessary self-care skills. D) Implement interventions designed to address the client's needs.

A) Facilitate the client's expression of emotions.

A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?

Are you thinking of harming yourself

When checking a client's cap refill. Color return in 10 sec. This indicates:

Arterial insufficiency

a nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, "Yester noon the sun moon went over the rover to see the lawnmower." Which of the following manifestations is the client exhibiting?

Associative looseness

The nurse is assessing a patient who is known to have right-sided HF. What assessment finding is most consistent with this patients diagnosis? A) Pulmonary edema B) Distended neck veins C) Dry cough D) Orthopnea

B) Distended neck veins

Clients with OCD often have exposure/response prevention therapy. Which statement by the client would indicate positive outcomes for this therapy? A) "I am able to avoid obsessive thinking." B) "I can tolerate the anxiety caused by obsessive thinking." C) "I no longer have any anxiety when I have obsessive thoughts." D) "I no longer feel a compulsion to perform rituals."

B) "I can tolerate the anxiety caused by obsessive thinking."

Identify the serum lithium level for maintenance and safety. A) 0.1 to 1 mEq/L B) 0.5 to 1.5 mEq/L C) 10 to 50 mEq/L D) 50 to 100 mEq/L

B) 0.5 to 1.5 mEq/L

The nurse is planning the care of a patient who has been diagnosed with hypertension, but who otherwise enjoys good health. When assessing the response to an antihypertensive drug regimen, what blood pressure would be the goal of treatment? A) 156/96 mm Hg or lower B) 140/90 mm Hg or lower C) Average of 2 BP readings of 150/80 mm Hg D) 120/80 mm Hg or lower

B) 140/90 mm Hg or lower

A nurse has invited a patient to sit down and have a conversation. The patient takes the first seat. The nurse pulls up another chair to sit with the patient. Approximately how far from the patient should the nurse place her chair? A) 1 to 2 feet B) 3 to 4 feet C) 6 to 8 feet D) 8 to 10 feet

B) 3 to 4 feet

Which nursing diagnosis would be most difficult to successfully resolve in a client who had anorexia nervosa? A) Imbalanced nutrition less than body requirements B) Disturbed body image C) Deficient knowledge (nutritious eating patterns) D) Social isolation

B) Disturbed body image

The nurse is providing health education to a patient newly diagnosed with glaucoma. The nurse teaches the patient that this disease has a familial tendency. The nurse should encourage the patients immediate family members to undergo clinical examinations how often? A) At least monthly B) At least once every 2 years C) At least once every 5 years D) At least once every 10 years

B) At least once every 2 years

During the nursing assessment, a client describes constantly hearing voices mumbling in the background. The client denies that the voices are telling him to do anything harmful. The nurse documents that the client is experiencing which of the following? A) Command hallucinations B) Auditory hallucinations C) Olfactory hallucinations D) Gustatory hallucinations

B) Auditory hallucinations

A person with temperament traits of high harm avoidance would most likely suffer from which personality disorder? A) Schizoid B) Avoidant C) Narcissistic D) Antisocial

B) Avoidant

Which eating disorder is characterized by consuming an amount of food much larger than a person would normally eat and of near-normal weight? Afterward, the client may purge the food or exercise excessively, and between binges, the client may eat low- calorie foods or fast. A) Anorexia nervosa B) Bulimia nervosa C) Pica D) Rumination

B) Bulimia nervosa

The nurse on the medicalsurgical unit is reviewing discharge instructions with a patient who has a history of glaucoma. The nurse should anticipate the use of what medications? A) Potassium-sparing diuretics B) Cholinergic C) Antibiotics D) Loop diuretics

B) Cholinergic

What is the primary difference between anorexia nervosa and bulimia nervosa? A) Anorexia has a psychological basis, whereas the cause of bulimia is biologic. B) Clients who are anorexic are proud of their control over eating, and clients with bulimia are ashamed of their behavior. C) Bulimia can be life threatening, whereas anorexia is seldom so. D) There is no real difference between these two types of disorders.

B) Clients who are anorexic are proud of their control over eating, and clients with bulimia are ashamed of their behavior.

A nurse has taken on the care of a patient who had a coronary artery stent placed yesterday. When reviewing the patients daily medication administration record, the nurse should anticipate administering what drug? A) Ibuprofen B) Clopidogrel C) Dipyridamole D) Acetaminophen

B) Clopidogrel

When working with the family of a client with anorexia nervosa, which of the following issues must be addressed? A) Codependence B) Control issues C) Self-discipline D) Sexual identity

B) Control issues

The nurse is reviewing the medication administration record of a patient who takes a variety of medications for the treatment of hypertension. What potential therapeutic benefits of antihypertensives should the nurse identify? Select all that apply. A) Increased venous return B) Decreased peripheral resistance C) Decreased blood volume D) Decreased strength and rate of myocardial contractions E) Decreased blood viscosity

B) Decreased peripheral resistance C) Decreased blood volume D) Decreased strength and rate of myocardial contractions

A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should implement measures to prevent what complication? A) Aoritis B) Deep vein thrombosis C) Thoracic aortic aneurysm D) Raynauds disease

B) Deep vein thrombosis

"Why do you always complain about the night nurse? She is a nice woman and a fine nurse and has five kids to support. You're wrong when you say she is noisy and uncaring." This example reflects which nontherapeutic technique? A) Requesting an explanation B) Defending C) Disagreeing D) Advising

B) Defending

The patient expresses frustration that the doctor does not spend enough time with the patient when making rounds. The nurse replies, The doctors are very busy. What can I help you with? The nurse incorporated which nontherapeutic technique in this response? A) Belittling B) Defending C) Disagreeing D) Introducing an unrelated topic

B) Defending

The client with schizophrenia believes the student nurses are there to spy on the clients. The client is suffering from which of the following symptoms? A) Hallucinations B) Delusions C) Anhedonia D) Ideas of reference

B) Delusions

A female client with borderline personality was formerly cooperative with the treatment regimen. Suddenly, the client believes the staff is working against her and is refusing all interaction and participation in treatment. The nurse feels very frustrated by this client's behavior. What is the best action for the nurse to take regarding personal frustration with this client? A) Discuss the feelings of frustration with the client in a one-to-one interaction. B) Discuss the frustration with a colleague or supervisor in a private setting. C) Set aside the frustration and focus on reassessing the client's needs. D) Research the client's diagnosis further to better understand the client's behaviors.

B) Discuss the frustration with a colleague or supervisor in a private setting.

Which of the following would best assess a client's judgment? A) Counting by serial sevens B) Discussing hypothetical situations C) Interpreting proverbs D) Spelling words backward

B) Discussing hypothetical situations

The nurse is providing care for a patient with a diagnosis of hypertension. The nurse should consequently assess the patient for signs and symptoms of which other health problem? A) Migraines B) Atrial-septal defect C) Atherosclerosis D) Thrombocytopenia

C) Atherosclerosis

The triage nurse in the ED is assessing a patient with chronic HF who has presented with worsening symptoms. In reviewing the patients medical history, what is a potential primary cause of the patients heart failure? A) Endocarditis B) Pleural effusion C) Atherosclerosis D) Atrial-septal defect

C) Atherosclerosis

The nurse understands that before a client with an eating disorder can accept their body image, he or she must first learn effective coping skills. Which statement best describes the relationship between body image and coping skills? A) Coping skills are dependent on a supportive upbringing. B) When body image is positive, the client will develop better coping skills. C) Being able to cope in healthy ways improves the ability to accept a realistic body image. D) Neurotransmitters that are deficient in clients with eating disorders prohibit the

C) Being able to cope in healthy ways improves the ability to accept a realistic body image.

The nurse observes that a client with depression sat at a table with two other clients during lunch. Which is the best feedback the nurse could give the client? A) "Do you feel better after talking with others during lunch?" B) "I'm so happy to see you interacting with other clients." C) "I see you were sitting with others at lunch today." D) "You must feel much better than you were a few days ago."

C) "I see you were sitting with others at lunch today."

When the client says, "I met J. at the dance last week," what is the best way for the nurse to ask the client to describe her relationship with Joe? A) "J. Who?" B) "Tell me about J." C) "Tell me about you and J." D) "J., you mean that blond guy with the dark blue eyes?"

C) "Tell me about you and J."

A nurse is performing blood pressure screenings at a local health fair. While obtaining subjective assessment data from a patient with hypertension, the nurse learns that the patient has a family history of hypertension and she herself has high cholesterol and lipid levels. The patient says she smokes one pack of cigarettes daily and drinks about a pack of beer every day. The nurse notes what nonmodifiable risk factor for hypertension? A) Hyperlipidemia B) Excessive alcohol intake C) A family history of hypertension D) Closer adherence to medical regimen

C) A family history of hypertension

A 56-year-old male student has a blood pressure reading of 146/96 mm Hg. He exclaims, My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it? Which of the following responses by the nursing instructor would be best? A) Yes. Hypertension is prevalent among men; it is fortunate we caught this during your routine examination. B) We will need to reevaluate your blood pressure because your age places you at high risk for hypertension. C) A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made. D) You have no need to worry. Your pressure is probably elevated because you are being tested.

C) A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made.

Which of the following are non therapeutic techniques? Select all that apply. A) Silence B) Voicing doubt C) Agreeing D) Challenging E) Giving approval

C) Agreeing D) Challenging E) Giving approval

You are writing a care plan for a patient who has been diagnosed with angina pectoris. The patient describes herself as being distressed and shocked by her new diagnosis. What nursing diagnosis is most clearly suggested by the womans statement? A) Spiritual distress related to change in health status B) Acute confusion related to prognosis for recovery C) Anxiety related to cardiac symptoms D) Deficient knowledge related to treatment of angina pectoris

C) Anxiety related to cardiac symptoms

A patient has informed the home health nurse that she has recently noticed distortions when she looks at the Amsler grid that she has mounted on her refrigerator. What is the nurses most appropriate action? A) Reassure the patient that this is an age-related change in vision. B) Arrange for the patient to have her visual acuity assessed. C) Arrange for the patient to be assessed for macular degeneration. D) Facilitate tonometry testing.

C) Arrange for the patient to be assessed for macular degeneration.

An older adult patient has been diagnosed with macular degeneration and the nurse is assessing him for changes in visual acuity since his last clinic visit. When assessing the patient for recent changes in visual acuity, the patient states that he sees the lines on an Amsler grid as being distorted. What is the nurses most appropriate response? A) Ask if the patient has been using OTC vasoconstrictors. B) Instruct the patient to repeat the test at different times of the day when at home. C) Arrange for the patient to visit his ophthalmologist. D) Encourage the patient to adhere to his prescribed drug regimen.

C) Arrange for the patient to visit his ophthalmologist.

A patient states, Right before I got here I was doing alright. My job was going well, my wife and I were happy, and we just moved into a new apartment. The nurse responds, You said you and your wife were happy. Tell me more about that. This is an example of which therapeutic technique? A) Encouraging comparison B) General lead C) Restating D) Exploring

D) Exploring

A patient shows no facial expression when engaging in a game with peers during an outing at a park. The nurse uses which of the following terms when documenting the patient's affect? A) Blunt affect B) Restricted affect C) Broad affect D) Flat affect

D) Flat affect

A patient presents to the emergency department (ED) complaining of severe right upper quadrant pain. The patient states that his family doctor told him he had gallstones. The ED nurse should recognize what possible complication of gallstones? A) Acute pancreatitis B) Atrophy of the gallbladder C) Gallbladder cancer D) Gangrene of the gallbladder

D) Gangrene of the gallbladder

Which of the following are examples of a therapeutic communication response? A) "Don't worry; everybody has a bad day occasionally." B) "I don't think your mother will appreciate that behavior." C) "Let's talk about something else." D) "Tell me more about your discharge plans." E) "That sounds like a great idea." F) "What might you do the next time you're feeling angry?"

D) "Tell me more about your discharge plans." F) "What might you do the next time you're feeling angry?"

The nurse is administering eye drops to a patient with glaucoma. After instilling the patients first medication, how long should the nurse wait before instilling the patients second medication into the same eye? A) 30 seconds B) 1 minute C) 3 minutes D) 5 minutes

D) 5 minutes

A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what? A) Slight morning discharge from the eye B) Any appearance of redness of the eye C) A scratchy feeling in the eye D) A new floater in vision

D) A new floater in vision

The nurse has entered a patients room and found the patient unresponsive and not breathing. What is the nurse's next appropriate action? A) Palpate the patients carotid pulse. B) Illuminate the patients call light. C) Begin performing chest compressions. D) Activate the Emergency Response System (ERS).

D) Activate the Emergency Response System (ERS).

A patient in hypertensive emergency is being cared for in the ICU. The patient has become hypovolemic secondary to natriuresis. What is the nurses most appropriate action? A) Add sodium to the patients IV fluid, as ordered. B) Administer a vasoconstrictor, as ordered. C) Promptly cease antihypertensive therapy. D) Administer normal saline IV, as ordered.

D) Administer normal saline IV, as ordered.

The nurse caring for a patient in ICU diagnosed with Guillain-Barr syndrome should prioritize monitoring for what potential complication? A) Impaired skin integrity B) Cognitive deficits C) Hemorrhage D) Autonomic dysfunction

D) Autonomic dysfunction

The nurse is reviewing a newly admitted patients electronic health record, which notes a history of orthopnea. What nursing action is most clearly indicated? A) Teach the patient deep breathing and coughing exercises. B) Administer supplemental oxygen at all times. C) Limit the patients activity level. D) Avoid positioning the patient supine.

D) Avoid positioning the patient supine.

A patient in the cardiac step-down unit has begun bleeding from the percutaneous coronary intervention (PCI) access site in her femoral region. What is the nurses most appropriate action? A) Call for assistance and initiate cardiopulmonary resuscitation. B) Reposition the patients leg in a nondependent position. C) Promptly remove the femoral sheath. D) Call for help and apply pressure to the access site.

D) Call for help and apply pressure to the access site.

A patient presents to the walk-in clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the patient that angina is most often attributable to what cause? A) Decreased cardiac output B) Decreased cardiac contractility C) Infarction of the myocardium D) Coronary arteriosclerosis

D) Coronary arteriosclerosis

The most commonly supported neuroanatomic theory of schizophrenia suggests which etiology? A) Excessive amounts of dopamine and serotonin in the brain B) Ineffective ability of the brain to use dopamine and serotonin C) Insufficient amounts of dopamine in the brain D) Decreased brain tissue in the frontal and temporal regions of the brain

D) Decreased brain tissue in the frontal and temporal regions of the brain

Knowing that relationships with others are significant to mental health, the nurse effectively assesses a patient's family relationships through which of the following? A) Do you feel your family helps you? B) How many people are in your family? C) Whom are you closest to in your family? D) Describe your relationships with your family.

D) Describe your relationships with your family.

A client voluntarily admitted to the inpatient psychiatric unit is currently experiencing mild delirium. The client approaches the nurse and states, ìI'm going to take walk outside. I'll be back in about 10 minutes.î Which is the most appropriate nursing action? A) Further assess the client's motives for wanting to walk. B) Give the client permission to go on a walk on the grounds. C) Tell the client the walk is not allowed and restrict him to the unit. D) Designate a staff member to accompany the client on the walk.

D) Designate a staff member to accompany the client on the walk.

The public health nurse is participating in a health fair and interviews a patient with a history of hypertension, who is currently smoking one pack of cigarettes per day. She denies any of the most common manifestations of CAD. Based on these data, the nurse would expect the focuses of CAD treatment most likely to be which of the following? A) Drug therapy and smoking cessation B) Diet and drug therapy C) Diet therapy only D) Diet therapy and smoking cessation

D) Diet therapy and smoking cessation

A nurse is presenting information to a community group about health. Which information should the nurse provide regarding calorie restriction diets at an early age in children? A) Dieting helps build a positive self-image in children. B) Dieting during childhood restricts essential nutrients needed for normal growth. C) Dieting at an early age teaches healthy eating habits. D) Dieting at an early age may lead to the development of eating disorders.

D) Dieting at an early age may lead to the development of eating disorders.

During the change of shift report in the intensive care unit, the nurse learns that a client has developed signs of delirium over the past 8 hours. Which behavior documented in the nursing notes would be consistent with delirium? A) Unable to identify a water pitcher B) Unable to transfer to sitting position C) Difficulty with verbal expression D) Disoriented to person

D) Disoriented to person

A patient admitted with nephrotic syndrome is being cared for on the medical unit. When writing this patients care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include? A) Constipation related to immobility B) Risk for injury related to altered thought processes C) Hyperthermia related to the inflammatory process D) Excess fluid volume related to generalized edema

D) Excess fluid volume related to generalized edema

A patient with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the patient administers the pilocarpine, the patient states that her vision is blurred. Which nursing action is most appropriate? A) Holding the next dose and notifying the physician B) Treating the patient for an allergic reaction C) Suggesting that the patient put on her glasses D) Explaining that this is an expected adverse effect

D) Explaining that this is an expected adverse effect

A nurse is providing discharge instructions to the patient of a 10yr old child following cardiac cath. Which of the following instructions should the nurse include?

Give acetaminophen for discomfort

A nurse at an ophthalmology clinic is providing teaching to a client who has an open angle glaucoma and a new RX for timolol eye drops. Which of the following instructions should the nurse provide?

This medication should be applied on a regular schedule for the rest of the client's life.

A patient with a HR 48bpm and BP 120/80 is ordered a beta, ACE, diuretic. What is the correct nursing action?

Withhold the beta blocker and administer the others

A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include?

You may have to stop taking this med 5 days before any planned surgeries