Nursing concepts 120 final (including pearson)
A client has been admitted with chronic obstructive pulmonary disease. Diagnostic tests have been ordered. Which of the tests will provide the most accurate indicator of the client's acid-base balance? A) Arterial blood gases (ABGs) B) Pulse oximetry C) Sputum studies D) Bronchoscopy
A
A client is brought to the emergency department (ED) after passing out in a local department store. The client has been fasting and has ketones in the urine. Which acid-base imbalance would the nurse expect to assess in this client? A) Metabolic acidosis B) Respiratory alkalosis C) Metabolic alkalosis D) Respiratory acidosis
A
A client is diagnosed with high blood pressure that is not responding to medications. The nurse suspects renal stenosis. When assessing for this condition, which location will the nurse use for auscultation? A) Renal arteries B) Bladder C) Ureters D) Internal urethral sphincter
A
A client presents with delayed wound healing. During the physical assessment, which nutrient deficiency does the nurse anticipate based on the data? A) Protein B) Digestive enzymes C) Insulin D) Carbohydrates
A
A client reports morning headaches that extend into the neck and go away as the day wears on. Based on this initial data, which assessment finding does the nurse anticipate? A) Elevated blood pressure B) Tachycardia C) Otitis media D) Swollen lymph nodes
A
A client tells the nurse about having increasing difficulty seeing the print while reading a newspaper. Which tool should the nurse select to assess this client? A) Rosenbaum eye chart B) Penlight C) Cover-uncover test D) Snellen eye chart
A
A female client, from a male-dominated culture, is being discharged after a lengthy hospitalization. Which action by the nurse prior to providing discharge instructions is appropriate? A) Assess who the decision maker is in the family. B) Ensure that the healthcare provider gives the instructions. C) Make sure instructions are understood by the client. D) Ask the client when the best time for teaching would be.
A
A newly admitted adult client with increased intracranial pressure caused from a head injury has a Glasgow Coma Scale (GCS) score of 6. Which of the following assessment findings is most likely in this client? A) Extension to painful stimuli B) Spontaneous eye opening C) Oriented to time, place, and person D) Withdraws to touch
A
A novice nurse is working in a busy emergency department of a hospital situated in a culturally diverse area of the city. Which should the nurse do when providing culturally competent care? A) Acquire the underlying background knowledge necessary that will provide these clients with the best possible healthcare. B) Treat everyone who comes to the emergency department seeking care as having the same needs. C) Assume that working in this emergency department will be the same as in other care contexts the nurse has encountered. D) Base the standard of care on the needs and attitudes of the dominant cultural group in the area.
A
A nurse is caring for a client with a genetic nerve disorder who has difficulty when attempting to move her tongue. The nurse recognizes that this may indicate a deficit in the functioning of which cranial nerve? A) XII B) XI C) VIII D) VI
A
A nurse is explaining the need to obtain laboratory tests on a client who has an infection and is of a cultural group different from the nurse's. During the interview, the client avoids eye contact and refrains from answering questions for long periods of time. Which does this behavior indicate to the nurse? A) In this client's culture, direct eye contact may show disrespect. B) The nurse should come back at a different time when the client is feeling more communicative. C) The nurse should have another nurse finish the interview who might be more culturally aware of this group's customs. D) Leave the room and come back after having learned more about this particular culture.
A
A nurse is providing care to a client who is scheduled for a colonoscopy. The client requires a bowel prep prior to the diagnostic test. Which approach should the nurse use to facilitate the client's understanding of the procedure? A) Use layman's terms to explain the procedure, then ask the client to describe the procedure in her own words B) Use medical terminology when explaining the procedure to the client to ensure maximum accuracy and clarity C) Focus on intonation when describing the procedure to the client D) Speak slowly and loudly when providing client teaching about the procedure
A
A nurse working in a community health center is counseling an adolescent regarding a suspected eating disorder. The adolescent is of normal weight but admits to periods of overeating, especially when his parents fight. This client's eating habits best demonstrate which risk factor for obesity? A) Cultural and environmental factors B) Heredity C) Low socioeconomic status D) Physical inactivity
A
A patient with an allergy to latex develops contact dermatitis following an examination during which the nurse wore latex gloves. Which best describes the associated pathophysiology? A) An immune response that leads to issues with tissue integrity B) Impaired tissue integrity that leads to an immune response C) Impaired tissue integrity that leads to an infection D) Decreased perfusion that leads to issues with tissue integrity
A
Inadequate fluid intake slows the passage of chyme along the intestines. This slowed passage increases the absorption of fluid from the chyme. How does this decreased intake and increased passage time affect the feces expelled from the body? A) It is drier and harder than normal. B) It is more watery and more soft than normal. C) It is more watery and harder than normal. D) It is drier and more soft than normal.
A
The clinic nurse is caring for an infant during a routine wellness exam. The parents and infant immigrated to the United States 6 months ago. The mother explains that she believes that an herbal remedy is the best way to treat the infant's colic. Which action by the nurse is appropriate? A) Ask the mother what the ingredients are in the remedy. B) Give the mother an alternate remedy for colic. C) Explain how herbal ingredients may be harmful to the infant. D) Tell the mother not to use the remedy because there is no way to know what the ingredients' scientific effect may be.
A
The nurse is caring for a client in the early stage of macular degeneration. What dietary changes should the nurse recommend to slow the progression of the disease? A) High-antioxidant diet B) Low-antioxidant diet C) Low-fat diet D) High-fat diet
A
The nurse is caring for a client with a history of urinary tract infections (UTIs). Which action by the nurse would decrease the risk of the client experiencing future UTIs? A) Instruct the client to avoid delaying urination. B) Tell the client to increase caffeine in the diet. C) Encourage the client to use the pelvic floor muscles to force urine flow. D) Remind the client to wipe from back to front.
A
The nurse is caring for a preadolescent male client who is accompanied by his mother. Which statement by the mother would be consistent with the client experiencing growing pains? A) "My son often complains that his arms and legs feel sore." B) "My son seems to get injured very easily, especially broken bones." C)"My son often doesn't want to walk because his knees hurt." D)"My son occasionally complains of pain in his lower back."
A
The nurse is caring for a terminally ill pediatric client. The parents have decided to remove their child from life support. Which action by the nurse displays the role of client advocate? A) Respecting the parents' decision B) Telling the parents they are making the right decision C) Asking to be assigned to a different client D) Referring the parents to social services
A
The nurse is caring for an adult client who has been diagnosed with high cholesterol. Which is important for the nurse to consider when teaching this adult client? A) Adults are more oriented to learning when the material is useful immediately. B) Adults are more likely to adhere to a regimen than are children. C) Adults usually can find information on their own. D) Adults do not need to be evaluated for understanding as children do.
A
The nurse is conducting a prenatal assessment on a client. Which finding indicates a risk of sensory impairment in the unborn child? A) Lack of immunity to rubella B) History of otitis media C) Immunity to varicella D) Brief case of moderate conjunctivitis
A
The nurse is planning care for a client scheduled for cataract surgery. Which intervention should the nurse include in the plan of care to help provide a safe environment for the client following surgery? A) Ensuring fall hazards are removed from the client's home and additional lighting is provided B) Educating the client about what self-care activities are necessary following surgery C) Making the client's close family aware of the self-care instructions the client has received D) Ensuring the client's employer does not expect the client to return to standard duties until clearance for such activities by the healthcare provider
A
The nurse is planning care for a client who is experiencing an alteration in mobility. Which would the nurse include as an independent nursing intervention? A) Instructing on the importance of proper nutrition and an active lifestyle B) Administering a prescribed nonsteroidal anti-inflammatory drug (NSAID) C) Identifying necessary modifications to the home environment D) Prescribing a skeletal muscle relaxant
A
The nurse is preparing to conduct a physical examination of a client's head and neck area. The client is paralyzed from the neck down. Which action by the nurse is appropriate when conducting the physical assessment of this area? A) Supporting the client during the examination B) Placing the client in an armless regular chair C) Placing the client in Sims position D) Placing the client in supine position
A
The nurse is providing care to a client who is experiencing urinary retention. Which diagnostic tool does the nurse anticipate will be ordered for this client? A) Ultrasonic bladder scan B) Urinalysis C) Intravenous pyelography (IVP) D) Cystoscopy
A
The nurse is providing care to newborns in the nursery. When assessing the newborns' urinary output, which does the nurse anticipate as normal daily urinary output? A) 15-60 mL B) 100-300 mL C) 250-450 mL D) 400-500 mL
A
What is the primary cause of loss of height in individuals with osteoporosis? A) Collapse of vertebral bodies B) Decrease in length of long bones C) Flexion of the knees and hips D) Cervical lordosis
A
What part of the body controls reflexes and regulates activities such as vomiting, hiccupping, coughing, and sneezing? A) Brainstem B) Hypothalamus C) Spinal cord D) Thalamus
A
Where does perception, or the awareness and interpretation of stimuli, take place? A) The brain B) The nerve receptors C) The peripheral nervous system D) The impulses
A
Which assessment finding supports the nurse's conclusion that a client is at risk for cataracts? A) Age 75 years B) Hypertension C) Moderate alcohol use D) Smoker
A
Which diagnostic test should the nurse use to assess hearing in an infant? A) Otoacoustic emissions test B) Weber test C) Rinne test D) Whisper test
A
Which of the following statements best characterizes vitamin use? A) Clients should be careful not to exceed recommended allowances for daily vitamin intake. B) Vitamin D is dangerous if taken in large quantities, but there is no upper limit to Vitamin C intake. C) Generally, two multivitamin pills a day is recommended for all clients regardless of diet. D) Fat-soluble vitamins in general present the least risk of toxicity to clients who take them in excess.
A
Which physiological changes associated with aging increase the risk of hypertension in older adults? A) Increase in systolic blood pressure B) Increase in diastolic blood pressure C) Increase in the pulse pressure D) Decrease in the diastolic blood pressure
A
Which statement about cataract surgery is correct? A) Cataract surgery should be quick but may have to take place in stages. B) Cataract surgery may only be done on an inpatient basis with general anesthesia. C) Cataract surgery is not recommended except in cases of opacification of the remaining posterior capsule. D) Cataract surgery is typically bilateral and can be performed in a single day.
A
The nurse admits a client to the medical unit for a urinary disorder. Which questions are appropriate for the nurse to include when assessing the client's voiding pattern? Select all that apply. A) How many times do you urinate in a 24-hour period? B) Has your pattern of urination changed recently? C) How often do you get out of bed at night to urinate? D) What color is your urine? E) Does your urine have any type of odor?
A, B, C
The nurse is planning care for a client diagnosed with chronic obstructive pulmonary disease (COPD). When planning care for this client, which interventions are appropriate to enhance the clients breathing pattern? Select all that apply. A) Provide adequate rest periods. B) Assist with activities of daily living (ADLs). C) Educate on relaxation techniques. D) Educate on pursed-lip breathing. E) Administer a cough suppressant.
A, B, C, D
The nurse is planning care for an older adult client with a head injury secondary to a motor vehicle crash. Which information should the nurse keep in mind when planning this client's care? Select all that apply. A) Anxiety, illness, and pain can alter the ability to learn. B) Baseline reflexes may be slower or diminished. C) Impulse transmission and reactions to stimuli are slower. D) Neurologic assessment should be completed in a single session. E) Impairment in vision and hearing should be taken into consideration.
A, B, C, E
A nurse working on a medical-surgical unit wants to ensure care is provided within the standard of nursing care. Which actions by the nurse are appropriate? Select all that apply. A) Analyze the position description. B) Review and become familiar with the policy and procedure manual. C) Question the value of collaborating with other disciplines. D) Review applicable state nurse practice act and administrative rules. E) Adhere to national standards of practice and care.
A, B, D, E
During a home visit, the nurse is assessing an older adult client. Which assessment findings support the nursing diagnosis Imbalanced Nutrition: Less than Body Requirements? Select all that apply. A) Client reports a problem with dentures slipping while chewing. B) Client complains of occasional dry mouth and problems with feelings of nausea. C) Client's adult children arrive to eat dinner together several times a week. D) Client is prescribed 15 medications. E) Client's Social Security payments have gone down over the last year.
A, B, D, E
Which clients are at the highest risk of being admitted to the emergency department with severe nausea and vomiting? Select all that apply. A) A 47-year-old with a 3-hour history of chest pressure B) A 61-year-old reporting sudden onset of vertigo C) A 72-year-old with an asthma exacerbation D) A 23-year-old who sustained a head injury in a fall E) A 19-year-old who is 6 weeks pregnant
A, B, D, E
The nurse is determining ways to decrease environmental stimuli for a client with increased intracranial pressure. Which actions should the nurse take to support this client's care need? Select all that apply. A) Limit the client's visitors. B) Teach family to speak softly and minimize touching. C) Elevate the head of the bed. D) Raise pads and bedrails. E) Keep the room dark and quiet.
A, B, E
The nurse is planning care for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which interventions should the nurse select to meet nutritional needs? Select all that apply. A) Encourage a diet high in protein and fats. B) Keep snacks to a minimum. C) Provide frequent small meals with between-meal supplements. D) Encourage carbohydrate-rich foods to provide needed calories for energy. E) Suggest the client eat three meals per day to maintain energy needs.
A, C
The nurse is providing discharge teaching to a client recovering from deep venous thrombosis (DVT). Which instructions are appropriate for the nurse to include in the teaching session? Select all that apply. A) Avoid crossing the legs B) Avoid long car trips C) Avoid prolonged standing or sitting D) Take frequent walks E) Take a daily aspirin dose of 650 mg
A, C, D
The nurse is concerned about being sued for negligence when providing care. Which nursing actions may be grounds for negligence? Select all that apply. A) Client fell getting out of bed because the call light was not used. B) Client name band was checked prior to providing all medications. C) Client's morning medications were administered in the early afternoon. D) Client states not understanding activity restrictions and wound eviscerated. E) Client documentation did not include appearance of infiltrated IV site.
A, C, D, E
The public health nurse is providing community education aimed at promoting nutritional habits that decrease an individual's modifiable risk factors for heart disease. Which topics should the nurse include in this teaching session? Select all that apply. A) Benefits of consuming fruits and vegetables B) Importance of eliminating all fats C) Selecting lean protein sources D) Preparing balanced meals E) Strategies for maintaining recommended daily caloric intake
A, C, D, E
The nurse recognizes that which pathophysiologic changes are occurring when caring for the client with respiratory acidosis? Select all that apply. A) Increased CO2 B) Vasoconstriction C) Decreased O2 D) Decreased intracranial pressure (ICP) E) Increased pulse rate
A, C, E
A nurse is caring for an adult client recently diagnosed with hypothyroidism. After reviewing the nursing admission assessment, on which documented findings should the nurse plan care for this client? Select all that apply. A) Hypothermia B) Hot flashes C) Nausea D) Constipation E) Tachycardia
A, D
The charge nurse is observing a newly licensed nurse conduct an abdominal assessment on a client admitted with an abdominal mass that is affecting bowel elimination. Which actions by the newly licensed nurse would require the charge nurse to intervene? Select all that apply. A) Performing palpation before auscultation B) Performing auscultation before palpation C) Using inspection, auscultation, percussion, and palpation during the abdominal assessment of the client D) Using only inspection, percussion, and palpation during the abdominal assessment of the client E) Using deep palpation during the assessment process
A, D, E
The home care nurse is assessing a client with macular degeneration. What interventions would be appropriate to ensure home safety for this client? Select all that apply. A) Keep the stairs free of clutter. B) Wear socks without shoes when walking in the home. C) Use one electrical outlet for devices. D) Have grab bars installed in the bathroom. E) Remove scatter rugs from the floors in the home.
A, D, E
Which risk factors exhibited by the client presenting in the emergency department (ED) would place the client at risk for metabolic acidosis? Select all that apply. A) Abdominal fistulas B) Chronic obstructive pulmonary disease C) Pneumonia D) Acute renal failure E) Hypovolemic shock
A, D, E
A nurse faculty member is speaking to prospective students of the Bachelor of Science in Nursing (BSN) program at their educational institution. Which of the following reasons should the nurse faculty member cite as a major incentive for students to select a BSN program over an Associate of Science in Nursing (ASN) program? Select all that apply. A) Greater autonomy in the practice setting B) Receipt of a fuller liberal arts education C) Easier transition to graduate school D) Ability to work in critical care areas E) Better opportunity for career advancement
A, E
An older adult client is using prescription eyedrops to treat her glaucoma. When providing client teaching about this medication, which of the following should the nurse mention as potential side effects? Select all that apply. A) Blurred vision B) Intermittent loss of eyesight C) Headaches D) Clouding of the eyes E) Change in eye color
A, E
The nurse is caring for an older adult client who is taking calcium for the treatment of osteoporosis. Which statements will the nurse include when educating the client about this medication? Select all that apply. A) "The most common adverse effect is hypercalcemia caused by taking too much of the supplement." B) "Oral calcium supplements are best taken on an empty stomach." C) "Adults 50 years of age and over should obtain at least 500 to 750 mg per day of elemental calcium." D) "If you have a condition called ventricular fibrillation, this medication might help." E) "Report symptoms of weakness, increased urination, and thirst."
A, E
A charge nurse notices that a client has a black eye that was not present when admitted to the facility. Which action by the charge nurse is appropriate in this situation? A) Ask a staff nurse to question the client about the situation. B) Discuss the situation with the client in a private setting. C) Ask the other staff members if abuse is involved. D) Ignore the situation until the client shows a willingness to talk.
B
A client has a blood pressure of 142/92 mmHg. Which classification is appropriate for the nurse to use when documenting this data? A) Normal B) Hypertension stage I C) Prehypertension D) Hypertension stage II
B
A client has an excoriated skin area with purulent drainage. Which diagnostic test does the nurse anticipate being ordered? A) Skin biopsy B) Culture C) Wood's lamp D) Patch test
B
A client has been diagnosed with cataracts of both eyes. The client's vision and activities of daily living have become severely impaired. What collaborative intervention does the nurse anticipate for this client? A) Corrective lenses for the cataracts B) Two surgical procedures, separated by a few weeks, to remove the cataracts C) Two surgical procedures to remove both cataracts at the same time D) Eyedrops to treat the cataracts
B
A client is experiencing visual overstimulation. What can the nurse do immediately to reduce this client's visual sensory overload? A) Suggest the client wear sunglasses that block UVA rays only. B) Reduce the amount of light in the room by lowering shades and turning off overhead lights. C) Provide the client with large-print reading materials. D) Encourage the patient to employ relaxation techniques to reduce anxiety and stress.
B
A client is undergoing surgery to manage glaucoma. When providing postoperative teaching to this client, the nurse should emphasize that the client is now at increased risk for which form of cataracts? A) Congenital B) Secondary C) Radiation D) Traumatic
B
A client presents in the emergency department exhibiting signs indicative of the onset of a bowel obstruction. Which bowel sounds should the nurse anticipate when auscultating the client's abdomen? A) Gurgling or clicking sounds B) High-pitched tinkling, rushing, or growling sounds C) Absence of sounds D) Continuous medium-pitched hum
B
A client with hyperthyroidism is scheduled for surgery in a few days. Which collaborative intervention would address cardiovascular symptoms that may prevent the client from undergoing the procedure? A) Nothing, because there is little effect on the quality of life in older adults. B) Administration of antithyroid medications with propranolol C) The ingestion of radioactive iodine, I-131 D) A combination treatment with levothyroxine (Synthroid) and amiodarone (Cordarone)
B
A nurse is conducting a health history on an older adult client. Which assessment finding indicates the client is at risk for osteoporosis? A) Having a body mass index (BMI) that indicates obesity B) Using glucocorticoids for 10 years because of a chronic lung disorder C) Eating three to five servings of shrimp and liver per week D) Drinking three glasses of skim milk daily
B
A nurse is preparing to discharge a client who experienced a myocardial infarction. The client will have to make many lifestyle changes, and the nurse is providing instruction on how to implement a heart-healthy lifestyle. Which is the best description of the client education the nurse is presenting to this client? A) Dependent function of nursing that needs a healthcare provider's order to implement B) Important independent nursing function C) Activity nurses begin to learn after training on the job D) Way to establish the client's dependence on the nurse
B
A nurse would like to implement an evidence-based practice change that will influence client care on the medical-surgical unit. The nurse works with the nurse manager and other members of the leadership team to write a new policy and produce educational materials for the unit's staff and clients. In carrying out these actions, the nurse is practicing which standard of professional performance? A) Leadership B) Collaboration C) Evaluation D) Collegiality
B
A preadolescent client who fell from a balance beam in physical education class injured her ankle. Given this information, which action by the nurse is appropriate? A) Referring the client to physical therapy B) Placing an ice pack on the client's ankle C) Planning for a corticosteroid injection D) Ordering an x-ray of the ankle
B
After being diagnosed with cataracts, a client believes the right eye has a cataract but not the left eye, as there are no vision changes with the left eye. Which response by the nurse is accurate? A) "Only your doctor can tell if you have a cataract in your left eye." B) "Cataracts develop at different rates, so one eye may be more affected than the other" C) "The changes being confined to one eye indicate a less severe cataract." D) "Surgery is still necessary for both eyes."
B
After completing an assessment, the nurse determines a client is at risk for safety issues. Which data supports the nurse's conclusion? A) Lives with adult married daughter and family B) Occasional dizziness with walking C) Follows a vegetarian diet D) Receives an annual ophthalmologic examination
B
An adult client is diagnosed with a degenerative bone disease that is impairing mobility. Based on this information alone, which of the following actions should be the nurse's first priority? A) Implementing a low-level exercise program for the client B) Assessing the client's pain management C) Teaching the client relaxation techniques D) Referring the client to a dietitian
B
An adult client who resides in a long-term care facility is diagnosed with osteoporosis. The client has a history of falls and dementia. Which nursing intervention will best aid in meeting an outcome goal of injury prevention for this client? A) Using furniture as obstacles to keep the client in the bed B) Keeping the bed in the lowest position C) Keeping a nightlight on in the hallway D) The use of wrist restraints
B
An older adult client comes into the clinic for a pneumonia vaccine. During the client interview, the client reports occasionally having difficulty remembering some words, but denies any other concerns. The client is alert and oriented to time, person, and place, and most responses are appropriate. How should the nurse describe this client's cognitive changes? A) Memory impairment that may be related to cerebral ischemia B) Normal signs of aging C) Indicators of depression in the elderly D) Early symptoms of dementia
B
An older adult client receiving medication for hypertension had a recent fall at home. Which intervention should the nurse include in this client's plan of care? A) Monitor serum sodium levels B) Assess postural blood pressures C) Monitor serum creatinine levels D) Monitor blood pressure every 2 hours
B
An older adult client with severe burns over more than half of the body has an indwelling catheter. When evaluating the client's intake and output, which of the following should be taken into consideration? A) The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment. B) The amount of urine will be reduced in the first 24 to 48 hours and will then increase. C) The amount of urine will be reduced during the first 8 hours of the burn injury and will then increase as diuresis begins. D) The amount of urine output will be greatest in the first 24 hours after the burn injury.
B
By providing volunteer client care to an inadequately insured population, the nurse is demonstrating which value of client advocacy? A) The client has the right to make choices and decisions. B) The nurse has the responsibility to ensure the client has access to healthcare services. C) The client has the right to expect a nurse-client relationship based on shared respect. D) The nurse has the responsibility to make choices and decisions.
B
Several nurses are discussing the Joint Commission's 2016 National Patient Safety Goals during a staff meeting. Which element of performance should the nurses implement to meet the goal of identifying clients correctly? A) Labeling all medications with the client's name B) Consistently using two methods to identify the client C) Asking the client's name before conducting assessments D) Marking the intended surgical site on the client
B
The nurse assists with the examination of a newborn in the newborn nursery. Prior to placing the child on the exam table, she spreads a cotton pad over the surface. By doing so, the nurse is protecting against heat loss by which method? A) Convection B) Conduction C) Evaporation D) Radiation
B
The nurse in the clinic is assessing an adult client who has signs and symptoms of heart failure. Which of the following lifestyle habits would be useful for the nurse to assess before developing the client teaching plan? A) The client's occupation B) The client's diet C) The client's usual sleep schedule D) The client's marital status
B
The nurse is admitting a client to an inpatient psychiatric unit. The client is speaking wildly and is obviously very agitated. Which action by the nurse would be appropriate to calm the client? A) Placing the client in a private room, away from others B) Speaking to the client in a soft, calm tone C) Administering a prn medication to sedate the client D) Using short sentences when talking to the client
B
The nurse is assessing a postmenopausal client. Which question should the nurse ask to assess for signs of osteoporosis? A) "Have you experienced any palpitations?" B) "Are you having any low back pain?" C) "Are you having problems with swelling in your feet?" D) "Is constipation a problem for you?"
B
The nurse is assessing an older adult client and observes that the client is having several cognitive problems, including memory and attention deficits and fluctuating levels of orientation. The nurse confirms with the family that the client's symptoms developed over a several-year period. The client's symptoms are commonly observed with which condition? A) Depression B) Dementia C) Intellectual disability D) Delirium
B
The nurse is assessing an older adult client during a routine health maintenance visit. To assess the client's range of motion of the knees, which action by the nurse is appropriate? A) Seat the client and extend each knee until the client alerts the nurse of severe pain. B) Seat the client and extend each knee until the client alerts the nurse of any pain whatsoever. C) Place the client prone and gently lift the entire right leg, followed by the entire left leg. D) Have the client stand and extend each knee as far as it will go.
B
The nurse is caring for a 72-year-old client who has presented to the emergency department for the third time in 8 months with acute asthma exacerbations. The client states that he has trouble holding his inhaler, and sometimes he forgets to take his medication. He is also worried because he thinks his new drugs are adversely interacting with medications for his other conditions. What nursing diagnosis is appropriate for this client? A) Deficient Knowledge B) Ineffective Health Management C) Risk for Aspiration D) Ineffective Coping
B
The nurse is caring for a client from a different culture who had a myocardial infarction and is receiving atorvastatin (Lipitor). The nurse assesses the client's diet to be very high in fat. Which is the best plan by the nurse to improve the client's diet and reduce the risk that the client may need additional medications? A) Ask the client if he would rather have another nurse who is from the same culture speak to him about his dietary needs. B) With the client's permission, discuss the dietary requirements with whoever prepares meals for the family. C) Consult a dietitian to teach the client about low-fat diets. D) Give the client information specific to his culture related to low-fat diets.
B
The nurse is caring for a client who has been using timolol (Timoptic) to manage glaucoma. Which assessment finding supports an adverse effect associated with systemic absorption of the drug? A) Eye pain B) Heart rate of 57 C) Urinary frequency D) Blurred vision
B
The nurse is caring for a client who has not been adhering to treatment with anti-hypertension medication. Which approach to addressing this issue should the nurse use? A) Indifference B) Nonjudgmental C) Demanding D) Confrontational
B
The nurse is caring for a group of clients on a medical-surgical unit. Which client does the nurse anticipate to be at the greatest risk for alterations in urinary elimination? A) The client with hypertension who takes a diuretic to manage blood pressure B) An 80-year-old male client reporting frequent urination at night C) A 25-year-old female client with low self-esteem D) A client who had bladder cancer and now has a newly created ileal conduit
B
The nurse is caring for an 8-year-old client with cerebral palsy and limited walking ability. The parents are very protective and perform most activities for the child. Which intervention is essential in promoting bone growth and reducing the risk of osteoporosis? A) Provide client teaching related to using restraints to prevent falls. B) Provide client teaching related to assistive devices to encourage walking. C) Refer the client to a dietitian to increase calcium and vitamin D intake. D) Refer the client to an occupational therapist to increase limb movement.
B
The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation. What should the nurse consider when planning for this client's potential health problem? A) Encouraging ambulation every 30 minutes B) Instructing on deep breathing C) Administering medications appropriate to increase heart rate D) Positioning to increase blood return
B
The nurse is planning care for a client with glaucoma who is experiencing anxiety as a result of the diagnosis. Which intervention should the nurse select to address this need? A) Assure the client there is nothing to be afraid of. B) Support the client's use of coping mechanisms. C) Turn off the lights when leaving the client's room. D) Refer the client to a counseling psychologist.
B
The nurse is preparing an education session for nurses who work in an endocrinology clinic caring for older adult clients. Which statement about the thyroid should the nurse include in her teaching? A) Thyroid hormone is often increased for older adult clients. B) Symptoms of hypothyroidism in this group of clients are often confused with symptoms of aging. C) Hypothyroidism is a congenital disease that manifests in older adult clients. D) Hypothyroidism presents with pitting edema for this group of clients.
B
The nurse is preparing to assess a client who is experiencing difficulty breathing. Before palpating the client's abdomen, which nursing action is appropriate? A) Administering 10 L of oxygen to the client B) Having the client remain upright C) Placing the client in a modified Sims position D) Asking the client to bend over a table
B
The nurse is preparing to conduct a cardiac assessment for a pediatric client. Which location will the nurse use when auscultating the apical pulse? A) At the fifth intercostal space B) At the left nipple C) At the right nipple D) At the eighth intercostal space
B
The nurse is providing care to a client who returns to the medical-surgical unit after herniated disc surgery. The client's vitals are as follows: HR 100, RR 22, BP 130/86 mmHg, T 98.8°F, and pain rating of 7 on a scale of 0 to 10. Which nursing diagnosis is the highest priority for this client based on these assessment data? A) Impaired Physical Mobility B) Acute Pain C) Activity Intolerance D) Chronic Pain
B
The nurse is providing teaching to a client related to maintaining healthy vision. Which of the following should the nurse identify as a modifiable risk factor for macular degeneration? A) Caucasian ancestry B) Smoking 1 pack of cigarettes per day C) 62 years of age D) Family history of AMD
B
The nurse is providing teaching to a client who was prescribed an ophthalmic beta blocker for glaucoma. The client is having difficulty understanding how to self-administer the medication. Which instruction by the nurse is best? A) "Occlude your lacrimal duct." B) "Close your eyes." C) "Guard against systemic absorption." D) "Use punctal occlusion."
B
The nurse is reviewing information about four clients who are coming in to the office today due to concerns about bowel elimination. Which of these clients is most likely to have a daily stool softener added to their treatment regimen? A) A 3-month-old client who is exclusively breastfed B) A 43-year-old client who takes opioid medication for chronic pain C) A 92-year-old client who experiences frequent leakage of feces from the anus D) A 28-year-old client who is anemic and has blood in the stool
B
The nurse is selecting sensory aids for a client with deficits in hearing and sight. Which aid would address both sensory deficits? A) Adequate room lighting with night lights B) Flashing alarm clock with large numbers C) Amplified telephone D) Large-print reading material
B
The nurse teaches a client about lifestyle modifications to help manage hypertension. Which client statement indicates teaching has been effective? A) "I won't be able to run in marathons anymore." B) "I know I need to give up my cigarettes and alcohol." C) "I need to get started on my medications right away." D) 'My father had hypertension, did nothing, and lived to be 90 years old."
B
The pathophysiologic stimulus that initiates asthma is A) bronchoconstriction. B) inflammation in the airways. C) airway edema. D) mucus secretion.
B
What impact might corticosteroids have on tissue integrity? A) It may increase sensitivity to sunlight, leading to sunburns. B) It may cause thinning of the skin, making skin more easily injured. C) It may make skin appear shiny and lose its hair distribution. D) It may cause the skin to become overly dry.
B
What is vertigo? A) Involuntary rapid eye movements B) A feeling of rotation or imbalance C) An infection of the vestibular nerve D) Impaired olfaction
B
Which best describes photophobia? A) Fear of light B) Aversion to light C) Reactive to light D) Need for light
B
Which hormone is responsible for epinephrine release and thus chemical thermogenesis? A) Norepinephrine B) Thyroxine C) Progesterone D) Aldosterone
B
Which of the following clients most likely will require assistance with properly taking medications for macular degeneration? A) 72-year-old client, no dementia, no arthritis, hypertension B) 67-year-old client, dementia, arthritis, no hypertension C) 47-year-old client, no comorbidities D) 52-year-old client, gastroesophageal reflux disease (GERD), hypertension
B
Which score would a nurse select from the muscle function grading scale if the client has full strength and range of motion in a given joint? A) 0 B) 5 C) 8 D) 10
B
Within the human body, which type of connective tissue connects bones to other bones to form a joint? A) Tendon B) Ligament C) Cartilage D) Myelin
B
The nurse is caring for a client with hypertension. Which diagnostic tests should the nurse anticipate being ordered to rule out secondary causes? Select all that apply. A) Cerebral angiogram B) Intravenous pyelogram C) Renal ultrasonography D) Cardiac catheterization E) Myelogram
B, C
The nurse is instructing a client on lifestyle changes to promote a healthy cardiovascular system. Which of the following should be included in this teaching session? Select all that apply. A) Limit exercise to 15 minutes a day B) Reduce saturated fats in the diet C) Avoid cigarette smoking D) Wear elastic hose E) Limit fluid intake
B, C
The nurse is preparing to examine a toddler's ear canals with an otoscope. Which actions by the nurse are appropriate? Select all that apply. A) Having the child sit on the examination table B) Having the child play with the equipment C) Having the child sit on the parent's lap D) Telling the child the examination will not hurt E) Asking the child to tilt the head
B, C
A nurse educator is teaching a group of students about professionalism. The educator informs the students that a profession is distinguished from other kinds of occupations by a number of characteristics. Which of the following are among those characteristics? Select all that apply. A) The members of a profession are financially liable for their actions. B) The members of a profession participate in ongoing research. C) The members of a profession must acquire specialized education. D) The members of a profession possess autonomy. E) The members of a profession regularly socialize with one another.
B, C, D
The family of an older adult client is concerned about the changes in the client's behavior. The client used to be a wonderful cook but now cannot even remember how to use a blender. For which causes of impaired cognitive function should the nurse assess the client? Select all that apply. A) Obesity B) Nutritional deficiencies C) Medication reactions D) Stroke E) Snoring
B, C, D
The nurse is caring for a client who is experiencing limited mobility related to a musculoskeletal alteration. Which laboratory tests would be useful to diagnose the client appropriately? Select all that apply. A) Magnetic resonance imaging (MRI) B) Alkaline phosphatase (ALP) C) Human leukocyte antigen-B27 (HLA-B27) D) Rheumatoid factor (RF) E) Electromyography (EMG)
B, C, D
The community health nurse reviews data collected during interviews with community members during a health fair and decides to create a brochure on how to improve iron intake. Which of the following action items might the nurse include that would help vegans and vegetarians increase their iron intake? Select all that apply. A) Take calcium supplements. B) Consume tofu. C) Consume lentils. D) Increase intake of vitamin C. E) Consume Swiss chard.
B, C, D, E
The nurse is preparing educational materials for a client with hypertension. Which of the following elements should the nurse include when preparing this material? Select all that apply. A) Advising the client to avoid all sodium in the diet B) Explaining the effects of sodium on blood pressure C) Teaching the client how to read nutritional labels D) Helping the client to recognize foods that are low in sodium E) Showing the client how to follow the DASH eating plan
B, C, D, E
The nurse is reviewing results of diagnostic testing performed on a client with increased intracranial pressure (ICP) in preparation for an evaluation to be done by the healthcare provider during morning rounds. Which diagnostic test results should the nurse make available to the healthcare provider for review? Select all that apply. A) Bronchoscopy results B) MRI result C) Head CT scan with and without contrast D) Electroencephalogram E) Cerebrospinal fluid differential cell count
B, C, D, E
During a health assessment, a client states, "I only eat carbohydrates and low-fat foods. I don't understand why I am still gaining weight!" Which principles of nutrition should guide the nurse's response? Select all that apply. A) Carbohydrates should only be eaten at breakfast. B) Eating too many carbohydrates leads to excess glucose, which is converted to fat. C) Excess carbohydrates can lead to obesity. D) A carbohydrate-limited diet is the only way to not gain weight. E) Carbohydrates should be high in fiber and low in sugar.
B, C, E
The nurse is caring for an older adult. Which age-related changes should the nurse identify as increasing the risk of dry skin? Select all that apply. A) Reduction in elastin B) Depleted moisture in epidermal cells C) Decreased size of sebaceous glands D) Thinner subcutaneous skin layer E) Poor nutrition
B, C, E
A child with acute asthma has a PaCO2 of 48 mmHg, a pH of 7.31, and a normal HCO3 blood gas value. The nurse interprets these findings as indicative of which condition? A) Metabolic acidosis B) Respiratory alkalosis C) Respiratory acidosis D) Metabolic alkalosis
C
A client diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon inspiration. Based on this data, which nursing diagnosis is the most appropriate? A) Ineffective Airway Clearance B) Impaired Tissue Perfusion C) Ineffective Breathing Pattern D) Activity Intolerance
C
A client who is at risk for developing osteoporosis asks what can be done to decrease the risk of actually developing the disease. Which intervention would be the most beneficial for this client? A) Decreasing the amount of calcium in the client's diet B) Providing the client with assisted range of motion exercising twice daily C) Increasing regular weight-bearing activities D) Protecting the client's bones with strict bedrest
C
A nurse is caring for a group of clients who are recovering in a rehabilitation hospital following total hip replacements. Which client is exhibiting the highest motivation to learn? A) A client who has been there the longest and is a great "coach" for newcomers B) A client who has been struggling with following nursing directives regarding discharge goals C) A client who is excited to learn ambulation techniques D) The client who has just moved in and is already eager for discharge
C
A nurse is conducting a skin assessment of a patient. Upon palpating skin temperature, the nurse notes the skin is warm and red. This is an abnormal sign that may be indicative of A) decreased hydration. B) decreased blood flow to the skin. C) inflammation and elevated body temperature. D) hypothyroidism.
C
A nurse working at a burn center is caring for a client with an electrical burn. According to the American Burn Association, how would this burn be classified? A) Minor B) Moderate C) Major D) Significant
C
A postmenopausal adult client is concerned about the development of osteoporosis and wants to begin preventative activities. Which statement by the nurse is appropriate? A) "You should first determine if you are at risk for the development of osteoporosis." B) "After menopause, the decline is too rapid to begin preventative interventions" C) "Weight-bearing exercise and calcium supplements are helpful in the prevention of osteoporosis." D) "Hormone replacement therapy should be initiated as soon as possible."
C
An adolescent client with scoliosis has a Cobb angle of 32 degrees. Given this information, what treatment will the nurse likely need to prepare the client for? A) This client will not need specific treatment. B) The nurse will prepare the client for physical therapy. C) The nurse will prepare the client for wearing a brace. D) The nurse will prepare the client for undergoing spinal fusion surgery.
C
An adult client and her spouse are seen in an urgent care clinic. The client presents with a temperature of 102°F, complains of nausea, and has experienced vomiting and diarrhea for 12 hours. The nurse notes that the client's mucous membranes are pale and dry and suspects that the client is dehydrated. Which action by the nurse is the most appropriate? A) Ask the spouse for more information. B) Assess for pedal edema. C) Assess skin turgor. D) Repeat the temperature measurement.
C
An older adult client with bilateral cataracts, arthritis, and a hearing deficit is scheduled for cataract surgery. Which is the priority nursing diagnosis for this client? A) Disturbed Body Image B) Decisional Conflict: Cataract removal C) Risk for Ineffective Health Maintenance D) Ineffective Coping
C
Blood pressure is influenced by all except which factor? A) Pumping action of the heart B) Peripheral vascular resistance C) Heart rate D) Blood volume
C
Clients experiencing diarrhea often lose electrolytes. Which of the following best describes the reason for this loss? A) Decreased secretion of intestinal mucus inhibits the absorption of electrolytes from the chyme by the intestine. B) Pathogenic microorganisms that cause diarrhea consume the electrolytes in the chyme, resulting in fewer electrolytes being available for absorption. C) Diarrhea causes rapid passage of chyme through the large intestine, reducing the time available for absorption of electrolytes. D) Intestinal bacteria break down electrolytes during diarrhea and make them unfit for absorption by the intestine.
C
The cells that produce the matrix for bone formation are known as A) osteoclasts. B) sarcomeres. C) osteoblasts. D) epiphyseal plates.
C
The nurse is assessing the nutritional status of an older client. Which finding is most likely to suggest xerostomia? A) The client refuses food because it is difficult to chew with missing teeth. B) The client frequently becomes dehydrated due to failure to remember to drink water. C) The client has a chronically dry mouth despite adequate intake of fluids. D) The client does not enjoy foods due to diminished taste.
C
The nurse is assigned to a postpartum client who had an anesthetic block during labor and delivery. When providing care for this client, which does the nurse anticipate? A) Nocturnal enuresis B) Risk for hyperkalemia C) Residual urine D) Glycosuria
C
The nurse is caring for a breastfeeding client recovering from a cesarean section. The physician diagnoses her with superficial venous thrombosis. Which intervention should the nurse anticipate carrying out first? A) Encourage to ambulate freely B) Aspirin 650 mg every 4 hours C) Apply warm, moist compresses D) Provide methylergonovine (Methergine) IM
C
The nurse is caring for a client who just had abdominal surgery. The client's nonverbal cues indicate pain, but the client denies the need for the pain medication prescribed by the healthcare provider. The nurse recognizes that this client is from a culture that feels it is inappropriate to complain about pain. Which action by the nurse is appropriate? A) Seek out a family member to convince the client to take the medication. B) Consult with the healthcare provider about providing pain medication without the client's knowledge. C) Offer the pain medication to the client again, stating that providing comfort is the nurse's most important responsibility. D) Allow the client to suffer in silence.
C
The nurse is caring for a client who presents to the emergency department after a boating accident in which the client nearly drowned. The nurse understands that which type of heat loss resulted in a diagnosis of hypothermia? A) Evaporation B) Insensible water loss C) Convection D) Insensible heat loss
C
The nurse is caring for a woman who is at 14 weeks gestation with her first child. The woman asks the nurse, "Am I at risk for osteoporosis since my baby takes calcium from my body?" What response by the nurse is correct? A) "You may lose small amounts of bone mass with each pregnancy, but if you only have one child, the bone loss should not be significant enough to cause osteoporosis." B) "When bone mass is lost during pregnancy, it is very difficult to restore, and you may be at increased risk for osteoporosis later in life. You should take a calcium supplement to prevent this." C) "If you eat a diet that is rich in calcium, any bone mass that is lost during pregnancy and breastfeeding will be restored within several months of weaning the child." D) "The baby won't require enough calcium during development to affect your bone mass or cause osteoporosis."
C
The nurse is caring for an older adult client on a medical-surgical unit. The client tells the nurse, "I don't get any sleep at night because I have to get up and use the bathroom every couple of hours!" When providing an explanation for the nocturia, which statement by the nurse is the most appropriate? A)"As you get older, there is a decrease in number of nephrons." B)"As you get older, there is a decrease in the blood supply to your bladder." C)"As you get older, you may have a decreased bladder capacity." D)"As you get older, there is a decrease in cardiac output, causing these symptoms."
C
The nurse is caring for an older adult client who was admitted with pneumonia. The client's vital signs are: P 84, R 22, BP 118/74, T (oral) 98.3°F. The client asks the nurse to explain how she can have an infection without having a fever. How should the nurse respond? A) The cool temperature of the hospital room helps prevent fevers. B) The client was likely misdiagnosed and does not have an infection. C) The body's ability to respond to changes in temperature declines with age. D) The loss of body heat associated with pneumonia reduces the risk of fever.
C
The nurse is completing an assessment on a newly admitted client. What finding would alert the nurse that the client may be experiencing a deep venous thrombosis (DVT)? A) Shortness of breath after activity B) Two-plus palpable pedal pulses C) Swelling in one leg with edema D) Sharp pain in both legs
C
The nurse is conducting a gait and posture assessment for a client who is experiencing mobility issues. Which action by the nurse is appropriate during this assessment? A) Assessing the client's muscle mass and strength B) Measuring the length and circumference of the client's extremities C) Inspecting the client's spine for curvature D) Palpating the client for tenderness and pain
C
The nurse is evaluating instructions provided to a client with glaucoma. Which client statement indicates that teaching has been effective? A) "The eyedrops only need to be used when my eyes hurt." B) "I can stop the eyedrops when the glaucoma has resolved." C) "I must use my eyedrops as prescribed for the rest of my life." D) "I will need to continually increase the dose of my eyedrops."
C
The nurse is planning care for a client with deep venous thrombosis (DVT). Which problem would be a priority for this client? A) Infection B) Fluid volume C) Peripheral perfusion D) Sleep pattern
C
The nurse is preparing discharge instructions for a client with age-related macular degeneration (AMD) and type 1 diabetes mellitus. What should the nurse include in this client's teaching plan? A) Information on assisted-living facilities B) Information on the need to have routine eye examinations every 5 years C) Referral to home care to ensure safety with administering insulin and AMD medications at home D) Information on Stargardt disease
C
The nurse is providing care for a client who is experiencing subjective symptoms of carpal tunnel syndrome. Which test should the nurse anticipate being performed by a provider during the physical assessment of this client? A) Bulge test B) Ballottement test C) Phalen test D) McMurray test
C
The nurse is providing care for several clients on a medical-surgical unit. The nurse anticipates that the client with which condition may require surgery? A) Hepatitis B) Pancreatitis C) Pyloric stenosis D) Malabsorption disorder
C
The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD) after years of experiencing emphysema. Which clinical manifestation does the nurse anticipate when assessing this client? A) Tachycardia B) Cough C) Barrel chest D) Wheezing
C
The nurse is providing teaching to a young adult who is at risk for early-onset osteoporosis. Which intervention should the nurse suggest? A) The client should stop all physical activity. B) The client should reduce the intake of dairy in the diet. C) The client should increase intake of calcium and vitamin D. D) The client should start estrogen replacement therapy.
C
The nurse is reviewing discharge instructions with a client who is newly diagnosed with asthma. Which client statement indicates a need for further teaching? A) "I need to rinse my mouth after every use of my inhaler." B) "I need to take my Singulair at least 1 hour before I eat." C) "When inhaling two different medications, I should use the bronchodilator last." D)"Because I am on theophylline, I will need to have therapeutic blood levels drawn."
C
The nurse needs to assess the body temperature of a client who has just smoked a cigarette and consumed hot coffee. Which temperature assessment method should the nurse use? A) Axillary B) Temporal artery C) Tympanic D) Rectal
C
The nurse observes flakes of greasy white dandruff in a client's hair. The nurse should correctly identify this as which type of secondary lesion? A) Nodule B) Macule C) Scales D) Crusts
C
The nurse presses a finger into swollen skin tissue on a client's feet and ankles and notes that it creates an indentation. The nurse should correctly document a finding of which alteration in skin integrity? A) Poor turgor B) Ascites C) Peripheral edema D) Hypothermia
C
What causes edema in adults with hypothyroidism? A) Excess reabsorption of water and sodium in the kidneys B) Decreased plasma oncotic pressure in the capillaries C) Water retention in mucoprotein deposits in the interstitial spaces D) Increased capillary permeability in the extremities
C
What class of drugs both decreases production of aqueous humor in the eye and increases drainage of aqueous humor from the uveoscleral pathway? A) Beta-adrenergic blockers B) Prostaglandin analogs C) Alpha2-adrenergic agonists D) Cholinergic agonists
C
What does the nurse anticipate finding in a client with impetigo? A) An infection in the hair follicles B) Loss of skin color in blotches or sections C) An itchy rash with clusters of fluid-filled vesicles D) A fungal infection in the skinfolds
C
What is the definition of the basal metabolic rate? A) The amount of energy stored in fat each day B) The speed of triglyceride breakdown C) The cost in kilocalories of being alive D) The speed at which glucose is converted to energy
C
Which client is at the greatest risk for developing hypothyroidism? A) A 21-year-old woman who has a mother with Graves disease B) A 32-year-old man who has an uncle with type 1 diabetes mellitus C) A 57-year-old woman whose aunt had systemic lupus erythematosus D) A 72-year-old man whose father had cardiovascular disease
C
Which nursing intervention related to perfusion can be performed independently? A) Administration of drug regimens B) Insertion of device to measure central venous pressure (CVP) C) Teaching relaxation techniques D) Thoracentesis
C
Which of the following scenarios is consistent with secondary congenital glaucoma? A) A newborn is diagnosed with glaucoma at birth. B) An infant is diagnosed at 6 months with glaucoma. C) A 1-year-old infant develops glaucoma following neurofibromatosis. D) A 5-year-old child is diagnosed with glaucoma.
C
Which statements are correct regarding the various layers of the heart? Select all that apply. A) The endocardium covers the entire heart and great vessels. B) The endocardium is the muscular layer of the heart that contracts during each heartbeat. C) The outermost layer of the heart is the epicardium. D) The myocardium consists of myofibril cells. E) The myocardium has four layers.
C, D
The nurse is planning instruction for a client who is newly diagnosed with glaucoma. What should be included in this teaching? Select all that apply. A) Manage eye pain with over-the-counter analgesics. B) Clouding of the affected eye(s) is expected. C) Self-administer prescribed eye medication properly. D) Attend follow-up appointments with the physician. E) Avoid over-the-counter medication unless discussed with the physician.
C, D, E
Which of the clients described below are at increased risk for back problems? Select all that apply. A) A 45-year-old man who has played golf three times a week for the past 20 years B) An 18-year-old woman who has been a distance runner since middle school C) A 62-year-old man who is a heavy truck mechanic and has a body mass index (BMI) of 30 D) A 12-year-old boy who has a history of cerebral palsy and a current BMI of 21 E) A 78-year-old man with a 40 pack-year smoking history who was recently widowed
C, D, E
A nurse is educating a group of adults about the risks for osteoporosis. Which statements will the nurse include when discussing the use of alcohol and cigarettes? Select all that apply. A) "Smoking decreases nerve supply to the bones." B) "Nicotine increases calcium absorption, leading to decreased bone density." C) "Moderate alcohol consumption in postmenopausal women actually may increase bone mineral content." D) "Alcohol has a direct toxic effect on osteoclast activity, suppressing bone formation." E) "Heavy alcohol use may be associated with nutritional deficiencies that contribute to osteoporosis."
C, E
The nurse is planning care for a female adult client who is high-risk for developing osteoporosis. Which interventions will decrease the client's risk of developing this health problem? Select all that apply. A) Increasing the intake of alcoholic beverages B) Isometric exercise for at least 30 minutes three times per week C) Weight-bearing exercises such as walking D) Having a yearly dual-energy x-ray absorptiometry (DEXA) test E) A diet with adequate amounts of calcium and vitamin D
C, E
Which data supports the nurse's concern that a client is at a high risk for a burn injury? Select all that apply. A) Part-time employment at a convenience store B) Diagnosis of hypertension C) Age 71 years D) Uses public transportation for grocery shopping E) Currently smokes one pack of cigarettes per day
C, E
A client asks the nurse if the staff members make many mistakes because there are so many posters and signs about safety on the walls. Which response by the nurse is best? A) "The nurses here are safe. The posters are directed at certain members of the healthcare team who have been making more mistakes than usual" B) "You don't need to worry about posters on the wall. Our primary concern is getting you well." C) "We never make mistakes here. We want the public to know that we have client safety goals here." D) "There is a potential for errors in all healthcare settings. The posters remind the staff and the clients of the need to work together to prevent them."
D
A client is admitted with the diagnosis of fever of unknown origin. Which diagnostic test does the nurse anticipate for this client? A) CT scan of the abdomen B) Bone scan C) Glucose tolerance test D) Complete blood count
D
A client is evaluated after suffering severe burns to the torso and upper extremities. The nurse notes edema at the burned areas. Which of the following best describes the underlying cause of this manifestation? A) Decreased osmotic pressure in the burned tissue B) Reduced microvascular permeability at the site of the burned area C) Increased potassium in the intracellular compartment D) Inability of the damaged capillaries to maintain fluids in the cell walls
D
A client is receiving verteporfin treatment for macular degeneration. The client asks the nurse what the expected outcome of treatment is. Which response by the nurse is most appropriate? A) It will increase the effectiveness of surgery. B) It will reverse the effects on the disease. C) It will promote the development of new blood vessels. D) The progression of the disease will be slowed.
D
A middle-age adult client states to the nurse, "I do not want to have brown spots on my skin like my parents did as they got older." Which instruction by the nurse is appropriate? A) Spend at least 15 minutes each day in the sun. B) Increase the intake of calcium. C) Increase the intake of dietary fat. D) Avoid the sun or use a sunscreen to reduce skin damage.
D
A nurse is caring for a client with glaucoma who is prescribed an ophthalmic beta-adrenergic blocking agent. When teaching the client about the therapeutic action of this medication, which of the following statements should the nurse include? A) "This drug reduces pressure in the eye by relaxing the muscles of the eye." B) "This medication only needs to be taken when eye pain is experienced." C) "Systemic absorption may occur, resulting in hypotension, bradycardia, and shortness of breath." D) "This drug reduces intraocular pressure by decreasing the production of fluid in the eye."
D
A nurse is caring for several pediatric clients who are affected by cataracts. Of these clients, which is the most obvious candidate for surgical removal of the cataract? A) Two-month-old infant who is asymptomatic B) Six-month-old infant with difficulty noticing toys or faces C) Three-month-old infant with diminished reaction to bright light D) One-month-old infant with no reaction to bright light and failure to notice toys or faces
D
A nurse is performing a neurologic assessment on a 9-year-old child who has displayed unexplained changes in behavior. Which assessment finding is consistent with a neurologic deficit? A) Child has a negative Babinski reflex. B) Child recalls names of well-known cartoon characters. C) Child is able to walk backward heel to toe. D) Child is incapable of balancing on one foot.
D
A nurse is teaching a client about a dressing change that should be done three times per day. The client is from a culture that is "present oriented" Based on this data, at which times should the nurse tell the client to perform the dressing changes? A) At whatever times the client selects, as long as they are 8 hours apart B) At 9 a.m., 3 p.m., and 9 p.m. C) At whatever times the client selects, as long as the dressing is changed three times each day D) After breakfast, lunch, and dinner
D
A nursing student is discussing thermoregulation with fellow students. Which statement about thermoregulation does the student recognize as being true? A) "Core temperature varies widely depending on the outside environment." B)"The body's surface temperature remains relatively constant." C)"Chemical thermogenesis occurs with the increase of cortisol." D)"All muscle activity, regardless of location, produces heat."
D
An older adult client tells the nurse that reading is easier when the material is held to the left or right. What should the nurse suspect this client is experiencing? A) Cataract B) Detached retina C) Exudative macular degeneration D) Nonexudative macular degeneration
D
An older adult client with intermediate dry macular degeneration calls the nurse complaining that his vision is suddenly much more distorted and colors do not seem right. Which action by the nurse is priority? A) Talk with the client to assess for other hallucinations that might be occurring. B) Check the client's medications for side effects of vision changes. C) Ensure the client's safety by raising the bedrails. D) Contact the healthcare provider for an immediate ophthalmologic evaluation.
D
During a sexual history, the client states, "I have always felt like a man trapped in a woman's body." The nurse should recognize that the client may identify as what? A) Bisexual B) Heterosexual C) Homosexual D) Transgender
D
During an assessment, the nurse notes that a client who was a victim of an industrial accident has a mildly elevated body temperature. When discussing the client's increased temperature, which will the nurse attribute it to? A) Infection B) Diet C) Exercise D) Stress
D
Health promotion efforts concerning intracranial regulation that focus on the proper use of protective equipment for outdoor activities and vehicle restraint systems are designed to anticipate and prevent alterations to intracranial regulation related to what? A) Prescription drug side effects B) Congenital hydrocephalus C) Stroke D) Trauma
D
Laser surgery and photodynamic therapy are both treatments for what disease of the eye? A) Congenital cataracts B) Age-related cataracts C) Nonexudative macular degeneration D) Exudative macular degeneration
D
The client is admitted to the hospital following a miscarriage, and she is septic. The healthcare provider orders antibiotics, which the client refuses, stating, 'I don't deserve them. I lost my baby because I had sex outside of marriage." Which is the appropriate response by the nurse? A) "I'll notify your healthcare provider about your decision" B) "Do you think you should be punished because you had a miscarriage?" C) "I think you need to do what is best for you." D) "You have a serious infection and really need the medication."
D
The nurse identifies the nursing diagnosis Imbalanced Nutrition: Less Than Body Requirements as appropriate for a client with osteoporosis. Which client statement indicated to the nurse that this nursing diagnosis was appropriate? A) "I like to remove all of the fat from the meat I eat." B) "I am trying to eat a low-carb diet." C) "I plan to start eating out less." D) "I am allergic to dairy products."
D
The nurse is caring for a new older adult client who speaks a foreign language and who does not speak English. Which action by the nurse is appropriate when conducting the health history portion of the assessment? A) Speaking in a loud tone when addressing the client B) Providing the client with educational materials that are written in English C) Asking the client's adult son to translate during the assessment D) Having a medical translator available during the health history
D
The nurse is caring for a newborn born to a mother with uncontrolled hyperthyroidism during pregnancy. What complication should the nurse monitor the newborn for? A) Late closure of fontanels B) Slow heart rate C) Rapid weight gain D) Breathing problems
D
The nurse is evaluating the following goal: Client will select low-fat foods from a list by the end of the month. The client, who has different beliefs about food, has not been able to achieve this goal. Which action by the nurse is appropriate? A) Extend the time frame and give the client a longer period to achieve the goal. B) Select a different goal. C) Make sure that the client understands the importance of the goal. D) Modify the plan of care to be consistent with the client's beliefs regarding food.
D
The nurse is planning care for a group of clients. Which client should the nurse identify as having the greatest risk for developing deep venous thrombosis (DVT)? A) The client recovering from laparoscopic gallbladder surgery B) The client admitted with new-onset type II diabetes mellitus C) The client admitted with community-acquired pneumonia D) The client recovering from knee replacement surgery
D
The nurse is providing care to a client who is experiencing urinary incontinence. Which independent nursing intervention is the most appropriate for this client? A) Encouraging increased fluid intake B) Providing catheter care C) Instructing on self-catheterization D) Teaching hygiene care
D
The nurse is providing teaching on the recommended hearing tests for older adults. Which information should be included in this teaching? A) Schedule an annual hearing test until the age of 50 and then have a test every 6 months. B) Annual screenings are recommended for adults with diabetes. C) For individuals without comorbidities, hearing exams should be repeated every 1-3 years for ages 55-64, and every 1-2 years for ages 65 and above. D) Have a hearing test every 10 years until age 50 and then every 3 years.
D
The nurse is reviewing the latest arterial blood gas results for a client with metabolic alkalosis. Which result indicates that the metabolic alkalosis is compensated? A) pH 7.32 B) PaCO2 18 mmHg C) HCO3 8 mEq/L D) PaCO2 48 mmHg
D
The nurse places a client in a treatment room of the emergency department for treatment of abdominal pain and vaginal bleeding. The spouse, speaking for the client, asks that only a female provider examine his wife for the pelvic exam. The nurse recognizes that the client is from a culture that prohibits men from examining women. Which is the most culturally appropriate statement by the nurse? A)"Your spouse will be covered with a sheet, so it will not matter whether the examiner is male or female." B) "The male and female providers both respect privacy." C) "The request is unreasonable and cannot be honored." D) "Every attempt will be made to honor your request."
D
The nurse suspects that a client is experiencing hypothyroidism. Which question should the nurse ask during the health history? A)"Is your skin often clammy?" B) "Do you have brown, shiny patches on your legs?" C) "Are you intolerant to heat?" D) "Have you had unexplained weight gain?"
D
The statement "A decrease in level of consciousness may lead to a decrease in respiration" best describes the relationship between intracranial regulation and which of the following? A) Acid-base balance B) Cognition C) Mobility D) Oxygenation
D
The three pathological factors that are associated with the formation of a thrombus are known as what? A) Rastelli syndrome B) Holter triad C) Vena cava syndrome D) Virchow's triad
D
What are the two components of the sensory process? A) Stimulus and receptor B) Kinesthesia and stereognosis C) Visual and auditory D) Reception and perception
D
Which assessment finding is consistent with a diagnosis of open-angle glaucoma? A) A client loses vision intermittently several times over the course of several hours. B) A client has an episode of lost vision when experiencing a panic attack. C) A client loses the ability to see at all during a city-wide blackout. D) A client experiences gradually diminishing vision in both eyes over an extended period.
D
Which change in bone structure contributes to osteoporosis? A) The diaphysis of the bone becomes longer. B) Trabeculae are increased in cancellous bone. C) The outer cortex of the bone becomes thicker. D) The diameter of the bone increases.
D
Which diagnostic technique is used to confirm the location and extent of cataracts? A) Visually inspecting the optic fundus using an ophthalmoscope B) Using tonometry to indirectly measure intraocular pressure C) Revealing a dark area instead of the red reflex through ophthalmoscopy D) Identifying patient history consistent with risk of cataracts and examining the eye to diagnose the cataract
D
Which lobe of the brain stores memory and interprets auditory stimuli? A) Frontal B) Occipital C) Parietal D) Temporal
D
Which nursing action is most appropriate when communicating with a client who has a hearing deficit? A) Drawing out the articulation of words with extra emphasis in order for the client to understand B) Using shorter phrases, which tend to be easier to understand than longer ones C) Varying the volume of voice, which is easier to understand than one consistent volume D) Writing ideas or pantomiming as appropriate in order for the client to understand
D
Which of the following diagrams would the nurse use when describing open-angle glaucoma to a client? A) A diagram showing a completely closed anterior chamber angle B) A diagram showing a completely occluded outflow of aqueous humor C) A diagram showing a blockage of the trabecular meshwork and canal of Schlemm D) A diagram showing congestion of the trabecular meshwork and reduced flow of aqueous humor through the canal of Schlemm
D
Which risk factor for hypertension is modifiable? A) Age B) Ethnicity C) Family history D) Tobacco use
D
A client is experiencing an elevated temperature due to a viral illness. What should the nurse anticipate being included in this client's plan of care? Select all that apply. A) Administer warm intravenous fluids. B) Apply warm blankets. C) Keep limbs close to body. D) Increase fluid intake. E) Administer antipyretic medication.
D, E
A nursing student has been assigned to present a teaching project to the class, using each of Bloom's taxonomy domains. The student has planned several activities to include when presenting the project to the class. Which activities are within the affective domain? Select all that apply. A) Class members must read a paragraph about a new clinical trial, summarize the information, and present it to the rest of the class. B) Class members must list the technical skills they have learned. C) Class members must demonstrate a favorite nursing skill for the class. D) Class members must reflect on how they felt the first time they provided direct client care. E) Class members must identify two attitudinal changes that have occurred in their lives since beginning their nursing education.
D, E
The nurse is caring for a client admitted with minor burns and elevated body temperature after being in a house fire. What should be included in this client's plan of care to address the elevated body temperature? Select all that apply. A) Providing blankets B) Keeping the room temperature warm C) Restricting fluids D) Encouraging fluids E) Lowering room temperature
D, E
The nurse is conducting a physical assessment of a middle-aged female client during an annual exam. What should the nurse assess that is particularly relevant to this age group? Select all that apply. A) Speech and language B) Body development and growth C) Sleeping patterns D) Ability to carry out activities of daily living (ADLs) E) Body mass index (BMI) measurement
D, E
The nurse is conducting education regarding urinary health at an assisted living facility. When planning topics to include in the session, which are appropriate for the nurse to consider? Select all that apply. A) Full urinary control usually occurs at 4 or 5 years of age. B) Due to neuromuscular immaturity in infancy, voluntary urinary control is absent. C) The kidneys reach maximum size between 35 and 40 years of age. D) Renal blood flow decreases because of vascular changes and a decrease in cardiac output. E) Urinary incontinence may occur because of mobility problems or neurological impairments.
D, E
