Nurse Labs
A 7-year-old client is brought to the E.R. He's tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and a nonproductive cough. He recently had a cold. From his history, the client may have which of the following? A. Acute asthma B. Bronchial pneumonia C. Chronic obstructive pulmonary disease (COPD) D. Emphysema
A. Acute asthma Based on the client's history and symptoms, acute asthma is the most likely diagnosis. He's unlikely to have bronchial pneumonia without a productive cough and fever and he's too young to have developed COPD or emphysema.
An elderly client with pneumonia may appear with which of the following symptoms first? A. Altered mental status and dehydration B. Fever and chills C. Hemoptysis and dyspnea D. Pleuritic chest pain and cough
A. Altered mental status Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are the common symptoms of pneumonia, but elderly clients may first appear with only an altered mental status and dehydration due to a blunted immune response.
Which of the following is the most common symptom of myocardial infarction (MI)? A. Chest pain B. Dyspnea C. Edema D. Palpitations
A. Chest pain The most common symptom of an MI is chest pain, resulting from deprivation of oxygen to the heart. Dyspnea is the second most common symptom, related to an increase in the metabolic needs of the body during an MI. Edema is a later sign of heart failure, often seen after an MI. Palpitations may result from reduced cardiac output, producing arrhythmias.
After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs? A. Left-sided heart failure B. Pulmonic valve malfunction C. Right-sided heart failure D. Tricupsid valve malfunction
A. Left-sided heart failure The left ventricle is responsible for most of the cardiac output. An anterior wall MI may result in a decrease in left ventricular function. When the left ventricle doesn't function properly, resulting in left-sided heart failure, fluid accumulates in the interstitial and alveolar spaces in the lungs and causes crackles. Pulmonic and tricuspid valve malfunction causes right sided heart failure.
The nurse is caring for a client with schizophrenia. Which of the following outcomes is the least desirable? A. The client spends more time by himself. B. The client doesn't engage in delusional thinking. C. The client doesn't harm himself or others. D. The client demonstrates the ability to meet his own self-care needs.
A. The client spends more time by himself. The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client spend more time by himself wouldn't be a desirable outcome. Rather, a desirable outcome would specify that the client spends more time with other clients and staff on the unit. Delusions are false personal beliefs. Option B: Reducing or eliminating delusional thinking using talking therapy and antipsychotic medications would be a desirable outcome. Option C: Protecting the client and others from harm is a desirable client outcome achieved by close observation, removing any dangerous objects, and administering medications. Option D: Because the client with schizophrenia may have difficulty meeting his or her own self-care needs, fostering the ability to perform self-care independently is a desirable client outcome.
A client with a diagnosis of paranoid schizophrenia comments to the nurse, "How do I know what is really in those pills?" Which of the following is the best response? A. Say, "You know it's your medicine." B. Allow him to open the individual wrappers of the medication. C. Say, "Don't worry about what is in the pills. It's what is ordered." D. Ignore the comment because it's probably a joke.
B. Allow him to open the individual wrappers of the medication. This is correct because allowing a paranoid client to open his medication can help reduce suspiciousness. Option A: This is incorrect because the client doesn't know that it's his medication and he's obviously suspicious. Options C and D: Telling the client not to worry or ignoring the comment isn't supportive and doesn't offer reassurance.
A 19-year-old comes into the emergency department with acute asthma. His respiratory rate is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following actions should be taken first? A. Take a full medication history B. Give a bronchodilator by nebulizer C. Apply a cardiac monitor to the client D. Provide emotional support to the client
B. Give a bronchodilator by nebulizer The client is having an acute asthma attack and needs to increase oxygen delivery to the lung and body. Nebulized bronchodilators open airways and increase the amount of oxygen delivered. First, resolve the acute phase of the attack ad how to prevent attacks in the future. It may not be necessary to place the client on a cardiac monitor because he's only 19-years-old, unless he has a past medical history of cardiac problems.
A 25 -year old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority? A. The client will commit to a drug-free lifestyle B. The client will work with the nurse to remain safe C. The client will drink plenty of fluids daily D. The client will make a personal inventory of strength
B. The client will work with the nurse to remain safe. The priority goal in alcohol withdrawal is maintaining the client's safety. Committing to a drug-free lifestyle, drinking plenty of fluids, and identifying personal strengths are important goals, but ensuring the client's safety is the nurse's top priority.
A client receiving fluphenazine decanoate (Prolixin Decanoate) therapy develops pseudoparkinsonism. The physician is likely to prescribe which drug to control this extrapyramidal effect? A. phenytoin (Dilantin) B. amantadine (Symmetrel) C. benztropine (Cogent) D. diphenhydramine (Benadryl)
B. amantadine An antiparkinsonian agent, such as amantadine, may be used to control pseudoparkinsonism; Option A: Phenytoin is used to treat seizure activity. Options C and D: diphenhydramine or benztropine may be used to control other extrapyramidal effects.
A 58-year-old client with a 40-year history of smoking one to two packs of cigarettes a day has a chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based on this information, he most likely has which of the following conditions? A. Adult respiratory distress syndrome (ARDS) B. Asthma C. Chronic obstructive bronchitis D. emphysema
C. Chronic obstructive bronchitis Because of his extensive smoking history and symptoms, the client most likely has chronic obstructive bronchitis. Clients with ARDS have acute symptoms of and typically need large amounts of oxygen. Clients with asthma and emphysema tend not to have a chronic cough or peripheral edema.
The term "blue bloater" refers to which of the following conditions? A. ARDS B. Asthma C. Chronic obstructive bronchitis D. emphysema
C. Chronic obstructive bronchitis Clients with chronic obstructive bronchitis appear bloated; they have large barrel chests and peripheral edema, cyanotic nail beds and, at times, circumoral cyanosis. Clients with ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and large amounts of oxygen. Clients with asthma don't exhibit characteristics of chronic disease, and clients with emphysema appear pink and cachectic (a state of ill health, malnutrition, and wasting).
Which of the following types of asthma involves an acute asthma attack brought on by an upper respiratory infection? A. Emotional B. Extrinsic C. Intrinsic D. Mediated
C. Intrinsic Intrinsic asthma doesn't have an easily identifiable allergen and can be triggered by the common cold. Asthma caused be emotional reasons is considered to be in the extrinsic category. Extrinsic asthma is caused by dust, molds, and pets; easily identifiable allergens. Mediated asthma doesn't exist.
An agitated and incoherent client, age 29, comes to the emergency department with complaints of visual and auditory hallucinations. The history reveals that the client was hospitalized for paranoid schizophrenia from ages 20 to 21. The physician prescribes haloperidol (Haldol), 5 mg I.M. The nurse understands that this drug is used for this client to treat: A. dyskinesia. B. dementia. C. psychosis. D. Tardive dyskinesia.
C. Psychosis By treating psychosis, haloperidol, an antipsychotic drug, decreases agitation. Options A and B: Haloperidol is used to treat dyskinesia in clients with Tourette syndrome and to treat dementia in elderly clients. Option D: Tardive dyskinesia may occur after prolonged haloperidol use; the client should be monitored for this adverse reaction
Which of the following blood tests is most indicative of cardiac damage? A. Lactate dehydrogenase B. Complete blood count (CBC) C. Troponin I D. Creatine kinase (CK)
C. Troponin I Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin I levels aren't detectable in people without cardiac injury. Lactate dehydrogenase (LDH) is present in almost all body tissues and not specific to heart muscle. LDH isoenzymes are useful in diagnosing cardiac injury. CBC is obtained to review blood counts, and a complete chemistry is obtained to review electrolytes. Because CK levels may rise with skeletal muscle injury, CK isoenzymes are required to detect cardiac injury.
Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions? A. Pericarditis B. Hypertension C. MI D. Heart failure
D. Heart Failure These are the classic signs of failure. Pericarditis is exhibited by a feeling of fullness in the chest and auscultation of a pericardial friction rub. Hypertension is usually exhibited by headaches, visual disturbances, and a flushed face. MI causes heart failure but isn't related to these symptoms.
It's highly recommended that clients with asthma, chronic bronchitis, and emphysema have Pneumovax and flu vaccinations for which of the following reasons? A. All clients are recommended to have these vaccines B. These vaccines produce bronchodilation and improve oxygenation C. These vaccines help reduce the tachypnea these clients experience D. Respiratory infections can cause severe hypoxia and possibly death in these clients
D. Respiratory infections can cause severe hypoxia and possibly death in these clients It's highly recommended that clients with respiratory disorders be given vaccines to protect against respiratory infection. Infections can cause these clients to need intubation and mechanical ventilation, and it may be difficult to wean these clients from the ventilator. The vaccines have no effect on bronchodilation or respiratory care.
Which of the following conditions is most closely associated with weight gain, nausea, and a decrease in urine output? A. Angina pectoris B. Cardiomyopathy C. Left-sided heart failure D. Right-sided heart failure
D. Right-sided heart failure Weight gain, nausea, and a decrease in urine output are secondary effects of right-sided heart failure. Cardiomyopathy is usually identified as a symptom of left-sided heart failure. Left-sided heart failure causes primarily pulmonary symptoms rather than systemic ones. Angina pectoris doesn't cause weight gain, nausea, or a decrease in urine output.
How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a client's delusional thoughts and hallucinations eliminated? A. Several minutes B. Several hours C. Several days D. Several weeks
D. Several weeks Although most phenothiazines produce some effects within minutes to hours, their antipsychotic effects may take several weeks to appear.
A male client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is Nurse Alice most likely to administer to reduce the symptoms of alcohol withdrawal? A. naloxone (Narcan) B. haloperidol (Haldol) C. magnesium sulfate D. chlordiazepoxide (Librium)
D. chlordiazepoxide (Librium) Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal. Haloperidol (Haldol) may be given to treat clients with psychosis, severe agitation, or delirium. Naloxone (Narcan) is administered for narcotic overdose. Magnesium sulfate and other anticonvulsant medications are only administered to treat seizures if they occur during withdrawal.
A client with paranoid schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be most appropriate? A. "Your behavior won't be tolerated. Go to your room immediately." B. "You're just doing this to get back at me for making you come to therapy." C. "Your cursing is interrupting the activity. Take time out in your room for 10 minutes." D. "I'm disappointed in you. You can't control yourself even for a few minutes."
A. "Your behavior won't be tolerated. Go to your room immediately." The nurse should set limits on client behavior to ensure a comfortable environment for all clients. The nurse should accept hostile or quarrelsome client outbursts within limits without becoming personally offended. Option B: This is incorrect because it implies that the client's actions reflect feelings toward the staff instead of the client's own misery. Option D: Judgmental remarks may decrease the client's self-esteem.
The nurse is aware that the outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder? A. Accept responsibility for own behaviors B. Be able to verbalize own needs and assert rights C. Set firm and consistent limits with the client D. Allow the child to establish his own limits and boundaries
A. Accept responsibility for own behaviors. Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, disobedient, and blame others for their actions. Accountability for their actions would demonstrate progress for the oppositional child. Options C and D aren't outcome criteria but interventions. Option B is incorrect as the oppositional child usually focuses on his own needs.
A client with schizophrenia who receives fluphenazine (Prolixin) develops pseudoparkinsonism and akinesia. What drug would the nurse administer to minimize extrapyramidal symptoms? A. benztropine (Cogentin) B. dantrolene (Tantrum) C. clonazepam (Klonopin) D. diazepam (Valium)
A. benztropine (Cogentin) Benztropine is an anticholinergic drug administered to reduce extrapyramidal adverse effects in the client taking antipsychotic drugs. It works by restoring the equilibrium between the neurotransmitters acetylcholine and dopamine in the central nervous system (CNS). Option B: Dantrolene, a hydantoin drug that reduces the catabolic processes, is administered to alleviate the symptoms of neuroleptic malignant syndrome, a potentially fatal adverse effect of antipsychotic drugs. Option C: Clonazepam, a benzodiazepine drug that depresses the CNS, is administered to control seizure activity. Option D: Diazepam, a benzodiazepine drug, is administered to reduce anxiety.
A male client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from nurse Julia? A. "Why didn't you get someone else to drive you?" B. "Tell me how you feel about the accident." C. "You should know better than to drink and drive." D. "I recommend that you attend an Alcoholics Anonymous meeting."
B. "Tell me how you feel about the accident." An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in his feelings. Asking the client why he drove while intoxicated can make him feel defensive and intimidated. A judgmental approach isn't therapeutic. By giving advice, the nurse suggests that the client isn't capable of making decisions, thus fostering dependency.
A male client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high." Which of the following is the most appropriate response? A. "If you continue to talk like that, I'm going to stop speaking to you." B. "You told me you got fired from your last job for missing too many days after taking drugs all night." C. "Tell me more about how it felt to get high." D. "Don't you know it's illegal to use drugs?"
B. "You told me you got fired from your last job for missing too many days after taking drugs all night." Confronting the client with the consequences of substance abuse helps to break through denial. Making threats (option A) isn't an effective way to promote self-disclosure or establish a rapport with the client. Although the nurse should encourage the client to discuss feelings, the discussion should focus on how the client felt before, not during, an episode of substance abuse (option C). Encouraging elaboration about his experience while getting high may reinforce the abusive behavior. The client undoubtedly is aware that drug use is illegal; a reminder to this effect (option D) is unlikely to alter behavior.
A client with acute asthma showing inspiratory and expiratory wheezes and a decreased expiratory volume should be treated with which of the following classes of medication right away? A. beta-adrenergic blockers B. Bronchodilators C. Inhaled steroids D. Oral steroids
B. Bronchodilator Bronchodilators are the first line of treatment for asthma because bronchoconstriction is the cause of reduced airflow. Beta-adrenergic blockers aren't used to treat asthma and can cause bronchoconstriction. Inhaled or oral steroids may be given to reduce the inflammation but aren't used for emergency relief.
Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6° F (38.7° C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. Nurse Melinda should suspect: A. a postoperative infection B. alcohol withdrawal C. acute sepsis D. pneumonia
B. alcohol withdrawal The client's vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome. Although infection, acute sepsis, and pneumonia may arise as postoperative complications, they wouldn't cause this client's signs and symptoms and typically would occur later in the postoperative course
Which of the following assessment findings would help confirm a diagnosis of asthma in a client suspected of having the disorder? A. Circumoral cyanosis B. Increased forced expiratory volume C. Inspiratory and expiratory wheezing D. Normal breath sounds
C. Inspiratory and expiratory wheezing Inspiratory and expiratory wheezes are typical findings in asthma. Circumoral cyanosis may be present in extreme cases of respiratory distress. The nurse would expect the client to have a decreased forced expiratory volume because asthma is an obstructive pulmonary disease. Breath sounds will be "tight" sounding or markedly decreased; they won't be normal.
Clonidine (Catapres) can be used to treat conditions other than hypertension. Nurse Sally is aware that the following conditions might the drug be administered? A. Phencyclidine (PCP) intoxication B. Alcohol withdrawal C. Opiate withdrawal D. Cocaine withdrawal
C. Opiate withdrawal Clonidine is used as adjunctive therapy in opiate withdrawal. Benzodiazepines, such as chlordiazepoxide (Librium), and neuropleptic agents, such as haloperidol, are used to treat alcohol withdrawal. Benzodiazepines and neuropleptic agents are typically used to treat PCP intoxication. Antidepressants and medications with dopaminergic activity in the brain, such as fluoxotine (Prozac), are used to treat cocaine withdrawal.
Since admission 4 days ago, a client has refused to take a shower, stating, "There are poison crystals hidden in the shower head. They'll kill me if I take a shower." Which nursing action is most appropriate? A. Dismantling the showered and showing the client that there is nothing in it B. Explaining that other clients are complaining about the client's body odor C. Asking a security officer to assist in giving the client a shower D. Accepting these fears and allowing the client to take a sponge bath
D. Accepting these fears and allowing the client to take a sponge bath By acknowledging the client's fears, the nurse can arrange to meet the client's hygiene needs in another way. Option A: Because these fears are real to the client, providing a demonstration of reality wouldn't be effective at this time. Options B and C: These would violate the client's rights by shaming or embarrassing the client.
A client is unable to get out of bed and get dressed unless the nurse prompts every step. This is an example of which behavior? A. Word salad B. Tangential C. Perseveration D. Avolition
D. Avolition Avolition refers to impairment in the ability to initiate goal-directed activity. Option A: Word salad is when a group of words are put together in a random fashion without logical connection. Option B: Tangential is where a person never gets to the point of the communication. Option C: Perseveration is when a person repeats the same word or idea in response to different questions.
A male adult client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 1 qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition? A. Vomiting, diarrhea, and bradycardia B. Dehydration, temperature above 101° F (38.3° C), and pruritus C. Hypertension, diaphoresis, and seizures D. Diaphoresis, tremors, and nervousness
D. Diaphoresis, tremors, and nervousness Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability. Although diarrhea may be an early sign of alcohol withdrawal, tachycardia — not bradycardia — is associated with alcohol withdrawal. Dehydration and an elevated temperature may be expected, but a temperature above 101° F indicates an infection rather than alcohol withdrawal. Pruritus rarely occurs in alcohol withdrawal. If withdrawal symptoms remain untreated, seizures may arise later.
The term "pink puffer" refers to the client with which of the following conditions? A. ARDS B. Asthma C. COPD D. Emphysema
D. Emphysema Because of the large amount of energy it takes to breathe, clients with emphysema are usually cachectic. They're pink and usually breathe through pursed lips, hence the term "puffer". Clients with ARDS are usually acutely short of breath. Clients with asthma don't have any particular characteristics, and clients with chronic obstructive bronchitis are bloated and cyanotic in appearance.
A 66-year-old client has marked dyspnea at rest, is thin, and uses accessory muscles to breathe. He's tachypneic, with a prolonged expiratory phase. He has no cough. He leans forward with his arms braced on his knees to support his chest and shoulders for breathing. This client has symptoms of which of the following respiratory disorders? A. ARDS B. Asthma C. COPD D. Emphysema
D. Emphysema These are classic signs and symptoms of a client with emphysema. Clients with ARDS are acutely short of breath and require emergency care; those with asthma are also acutely short of breath during an attack and appear very frightened. Clients with chronic obstructive bronchitis are bloated and cyanotic in appearance.
Which of the following pathophysiological mechanisms that occurs in the lung parenchyma allows pneumonia to develop? A. Atelectasis B. Bronchiectasis C. Effusion D. Inflammation
D. Inflammation Pneumonia is an inflammatory pulmonary response to the offending organism or agent.
A client with persistent, severe schizophrenia has been treated with phenothiazines for the past 17 years. Now the client's speech is garbled as a result of drug-induced rhythmic tongue protrusion. What is another name for this extrapyramidal symptom? A. Dystonia B. Akathisia C. Pseudoparkinsonism D. Tardive dyskinesia
D. Tardive Dyskinesia An adverse reaction to phenothiazines, tardive dyskinesia refers to choreiform tongue movements that commonly are irreversible and may interfere with speech. Option A: Dystonia refers to involuntary contraction of a muscle group. Option B: Akathisia is restlessness or inability to sit still. Option C: Pseudoparkinsonism describes a group of symptoms that mimic those of Parkinson's disease.
Which of the following symptoms is the most likely origin of pain the client described as knifelike chest pain that increases in intensity with inspiration? A. Cardiac B. Gastrointestinal C. Musculoskeletal D. Pulmonary
D. pulmonary Pulmonary pain is generally described by these symptoms. Musculoskeletal pain only increases with movement. Cardiac and GI pains don't change with respiration.
