NURS 124 TH 9-3
Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?
"Because I had a previous reaction to the test, this time I need to get a chest X-ray."
A client asks the nurse how long to use oxymetazoline (Afrin) nasal spray for nasal congestion. What is the nurse's best response
"Consult with your primary care provider."
Which are cognitive client outcomes? Select all that apply.
-The client lists the side effects of digoxin. -The client describes how to perform progressive muscle relaxation. -The client identifies signs and symptoms of hypoglycemia.
Which condition would be the result of air in the pleural space?
Pneumothorax
What is the function of the thymus gland?
Programs T lymphocytes to become regulator or effector T cells.
When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching?
"I will administer the enema while lying on my left side with my right knee flexed."
A nurse is teaching a client with newly diagnosed hypertension who asks if there is any harm in stopping antihypertensive medication. What is the nurse's best response?
"Rebound hypertension can occur."
An adult with diabetes receives 20 units of insulin each morning and evening. How will the nurse teach the client to administer the insulin?
"Use an insulin syringe and give 20 units.
A client has been prescribed clozapine for treatment of schizophrenia. Which would the nurse include in the education plan for this client and family?
"You may experience noticeable weight gain while taking this medication."
What food can the nurse suggest to the client at risk for osteoporosis?
Broccoli
The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?
Total laryngectomy
The primary source of microorganisms for catheter-related infections are the skin and the
catheter hub.
The patient has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as:
within normal limits
A client is prescribed didanosine as part of a highly active antiretroviral therapy (HAART). Which instruction would the nurse emphasize with this client?
Be sure to take this drug about 1/2 hour before or 2 hours after you eat."
A client experiences bronchospasm with asthma. The nurse understands that this is due to:
Histamine
While undergoing a kidney transplant from a non-family member, the client's transplanted kidney has just had the arterial clamps removed. The OR staff notices that the organ is turning purple with no urine output. When explaining to the family why they had to remove the donor kidney, the nurse will anticipate that the surgeon would likely include which statement?
Hyperacute rejection occurs because antibodies against HLA antigens are deposited in vessels, causing necrosis.
Which phase of the nursing process of patient teaching ends when the strategies have been completed and when the patient's responses to the actions have been recorded?
Implementation
A nurse is planning an educational program for families with a mentally ill relative. Which goal is consistent with the current objectives of family education?
Improved family quality of life
When providing client education it is essential for the nurse to incorporate what action so that learning can be optimized?
Include educational strategies that encourage clients to be active participants.
A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do?
Maintain a diet for the client that is high in protein, vitamins, and calories.
Which hormone is secreted by the juxtaglomerular apparatus?
Renin
The nurse is performing discharge teaching for a client who has recovered from sepsis following an open cholecystectomy. What should be the nurse's primary focus?
Signs and symptoms of infection
A neonate develops respiratory distress syndrome. Which would be used?
Surfactant replacements
A client is experiencing a sudden fluid shift as a result of diffusion. What variable most affects the rate of substance movement by diffusion?
The difference in solute concentration on each side of a semipermeable membrane
A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?
You must avoid coughing, sneezing, and blowing your nose."
Which system of measurement uses the minim as the basic unit of liquid measure?
apothecary
During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must:
continue to take antibiotics for the entire 10 days.
The nurse is caring for a client who is receiving neostigmine for the treatment of myasthenia gravis. The nurse is aware that a potential complication of the treatment is cholinergic crisis, which is characterized by which event?
excessive stimulation of the parasympathetic nervous system
The CNS structure containing groups of neurons responsible for vital cardiac, respiratory, and vasomotor functions is the:
medulla oblongata.
A client admitted to the alcohol detoxification program asks the nurse if there is a medication to "stop me from wanting a drink so badly." The nurse should teach the client about:
naltrexone
A nurse is reading an article that describes predictable differences in the effects of drugs in people of particular culture backgrounds due to their genetic makeup. The nurse is reading about:
pharmacogenomics
A new mother asks her nurse about the safety of taking St. John's wort for postpartum depression. What would be the nurse's best response?
There is insufficient evidence to support the use of St. John's wort, and drug interactions may be extensive."
An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:
10 to 15 g of a simple carbohydrate.
A nurse is teaching a community class about how to decrease the risk of cancer. Which food should the nurse recommend?
Oranges
The nurse is evaluating a child's skills in self-administering insulin (see figure). What should the nurse do?
Remind the child to rotate sites.
The nurse assists and educates clients on the difference between nonspecific and specific immunity. The body possesses several defense systems. Which nonspecific defense mechanism provides a physical barrier and secretes enzymes that kill or reduce the virulence of bacteria?
Skin
The nurse is with a client who has a chronic illness and is reinforcing positive behaviors and teaching about health promotion. For which phase of the trajectory model of chronic illness are these nursing actions appropriate?
Stable
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?
Family members should continue to talk to the client."
A client is scheduled for magnetic resonance imaging (MRI). During the client teaching, what will the nurse discuss?
"Do you experience any claustrophobia?"
A nurse is performing discharge teaching with a client who has an implantable cardioverter defibrillator (ICD) placed. Which client statement indicates effective teaching?
"I'll keep a log of each time my ICD discharges."
A nurse records a client's history and discovers several risk factors for coronary artery disease (CAD). Which cardiac risk factors can the client control?
Diabetes, hypercholesterolemia, and hypertension
What safety actions does the nurse need to take for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)?
Ensure that no client care equipment containing metal enters the room where the MRI is located.
Several of the clients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which statement suggests that the client requires further education
I make sure to limit how much I drink so that I don't have accidents."
During a routine physical examination on an older female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2? (1.7 m) tall." Which statement is the best response by the nurse?
After menopause, the body's bone density declines, resulting in a gradual loss of height."
A nurse is teaching an elderly client about developing good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required?
I need to use laxatives regularly to prevent constipation."
A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in client cast care?
Keep your right leg elevated above heart level."
The nursing instructor is discussing the diagnosis of cancer with their nursing class. The instructor tells her students that scientists have predicted that gene therapy will one day play a large role in the prediction, diagnosis, and treatment of cancer. What cancer is gene therapy currently being investigated in the treatment of?
Melanoma
A patient has been prescribed methocarbamol for fibromyalgia. The nurse has spent an hour educating the patient on the use of methocarbamol for muscle pain. Which statement by the patient indicates that the patient has an understanding of at least one of the significant side effects of methocarbamol?
My urine could be discolored while I take this drug."
The hypothalamus is connected to which endocrine gland?
The hypothalamus is connected to which endocrine gland?
The nursing instructor is teaching her students about the rectal administration of drugs. The instructor gives the students a scenario in which the client is prescribed an antipyretic drug, which is to be administered rectally. What nursing interventions should a student nurse perform after administering the suppository?
Check the client every 30 minutes.
A client has been prescribed the nonselective beta-adrenergic blocker, timolol for the treatment of open angle glaucoma. What instructions should the nurse provide to assure the effectiveness of the medication?
The proper method for instilling eye drops
When describing the term "grief" to a group of students, which of the following would the instructor include?
The response experienced by anyone who has suffered a loss
A client arrives with a very large blister on the heel from "new shoes" and fear having "damaged" the structures (ligaments and tendons) beyond repair and want to know "what caused this blister?" Which nursing response is best in this situation?
This blister is caused by mechanical friction from repeated rubbing on this area. The fluid is in the basement membrane between the epidermis and dermis."
A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following?
Thrombolytic therapy has a time window of only 3 hours.
When teaching a client with bulimia nervosa about possible complications, which condition should the nurse emphasize?
diabetes mellitus
A client with fever and urinary urgency must provide a urine specimen for culture and sensitivity. The nurse should instruct the client to collect the specimen from the
middle stream of urine from the bladder
The nursing instructor is talking with their clinical group about coagulopathies. How should the instructor define coagulopathies?
Coagulopathies are bleeding disorders that involve platelets or clotting factors.
To help understand immunostimulant drug therapy, the client has come to the clinic for a class on thrombopoiesis. The nurse explains that the term means the formation of which types of blood cells?
Platelets
The nurse administers the first dose of warfarin to an older adult client. Which important client teaching point(s) should the nurse emphasize regarding this new medication? Select all that apply.
-Limit intake of foods high in vitamin K. -Watch for signs and symptoms of bleeding. -Take extra care to avoid injuries. Explanation:
hen describing the production of interferons, the instructor discusses recombinant DNA technology. What would the instructor include as being produced this way?
Interferon alfacon-1
A client with systemic lupus erythematosus (SLE) complains that his hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these signs and symptoms?
Raynaud's disease
A nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority?
Take ordered medications as scheduled.
Aminoglycoside antibiotics tend to collect in the eighth cranial nerve. The nurse would anticipate that which clinical manifestation may occur from the cranial nerve involvement?
Vertigo
A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?
Weigh yourself daily and report a gain of 2 lb in 1 day.
A 51-year-old male professional is in the habit of consuming 6 to 8 rum and Cokes each evening after work. He assures the nurse practitioner who is performing his regular physical exam that his drinking is under control and does not have negative implications for his work or family life. How could the nurse best respond to the client's statement?
When your body has to regularly break down that much alcohol, your blood and the functional cells in your liver accumulate a lot of potentially damaging toxic by-products."
A nurse is teaching the parent of a 5-month-old infant diagnosed with bronchiolitis. Which statement by the mother indicates that teaching has been effective?
"I know that this disease is serious and can lead to asthma."
The nurse is teaching a young adult male how to perform testicular self-examination (TSE). The nurse determines that the client has understood the instructions when he states which of the following?
"The best time to do it is once a month after I take my warm morning shower."
A nurse is caring for a client who has just been prescribed a loading dose of a drug. The nurse should explain what rationale to the client for administering a loading dose?
"We want to make sure you get the benefits of the drug as quickly as possible."
A 38-year-old client has been diagnosed with major depressive disorder. The client is being placed on an antidepressant and the nurse is providing medication teaching. Which would be appropriate information to provide to the client?
"You may not notice an improvement in your symptoms for 2 to 6 weeks."
A nurse is reviewing discharge instructions with the parents of an adolescent who sustained a head injury to the frontal lobe of the brain. When discussing possible consequences of the injury, which of the following is the most important information to give the parents?
"Your child may exhibit drastic personality changes."
The nurse has educated the client on the pathophysiology of osteoarthritis and degenerative joint disease. This type of teaching best illustrates which learning theory?
Cognitive learning theory
As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client?
Demonstrate how to apply and remove elastic support stockings.
A nurse is preparing a presentation for a health fair about preventing breast cancer. Which of the following would the nurse include?
Maintaining an ideal weight
The nurse is preparing a presentation for a men's community group about health promotion. Which of the following would the nurse include as a current recommendation for screening
Monthly testicular self-examination (TSE)
After a person experiences a closure of the epiphyses, which statement is true?
No further increase in bone length occurs.
Which of the following is a true statement about expected outcomes?
They are documented as measurable goals.
A nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?
baked beans, hamburger, and milk
The nurse is caring for a 3-year-old child with iron deficiency anemia and providing dietary instructions to the parents. Which of the following should be a priority for the nurse to include in the teaching?
recommending lean meats
Characteristics that allow neurons to communicate with other body cells include:
the ability to be stimulated and to convey electrical impulses.
A pediatric nurse is providing a health promotional education program to a group of preschool parents. One parent asks the nurse the following question: "I have started buying bottled water. How will this affect my children?" It is important for the nurse to educate the mothers that:
there is a need to determine if the bottled water has fluoride.
