PC1 EAQ COMMUNICATION MASTERY
Which response would the nurse provide to a client with colon cancer prescribed neomycin preoperatively who asks why this is necessary?
"It kills intestinal bacterial to decrease the risk for infections."
Which initial action would the nurse take to provide a therapeutic environment for a client who is withdraw and reclusive? A. Foster a trusting relationship. B. Administer medications on time. C. Involve the client in a group with peers. D. Remove the client from the family home.
A. Foster a trusting relationship.
Which information would be placed in the medical record before implementing the use of restraints?
A prescription from the health care provider
Which response would the nurse provide to a client who develops a seizure disorder as a result of a traumatic fall and states "I have not had a seizure in 2 years. When can i stop taking my antiseizure medications?" A. "A gradual reduction in seizure medication may be considered." B. "You will require medication for the rest of your life." C. "The medication probably will be discontinued at this visit." D. "A minimum of 10 years without seizures is necessary before discontinuation of medications is considered."
A. "A gradual reduction in seizure medication may be considered."
Which is the BEST action for the nurse to take when a 6 year old child begins to suck his thumb after surgery? A. Accepting the thumb sucking B. Distracting the child by playing checkers C. Reporting this behavior to the health care provider D. Telling the child that thumb sucking causes buck teeth
A. Accepting the thumb sucking
Which type of impairment does the nurse expect the client who has expressive aphasia to exhibit? A. Speaking or writing B. Following instructions C. Understanding speech or writing D. Recognizing words for familiar objects
A. Speaking or writing
Which information would the nurse include in the discharge teaching of the postpartum client? A. The prenatal Kegel tightening exercises should be continued. B. A bowl movement may not occur for up to a week after the birth. C. The episiotomy sutures will be removed at the first postpartum visit D. A postpartum checkup should be scheduled as soon as menses returns
A. The prenatal Kegel tightening exercises should be continued.
Which information would the nurse give a pregnant client about having a chorionic villus sampling (CVS)? A. The test can lead to spontaneous abortion. B. The results are not as accurate. C. The information is provided is inadequate. D. It must be done with the use of laparoscopic surgery.
A. The test can lead to spontaneous abortion. - Not to performed before 9 weeks gestation and should be performed between 10 to 12 weeks
The nurse provides discharge instructions to the parent of a child who has undergone tonsillectomy. Which statement indicates that the parents needs further teaching? A. "I wont let her use a straw to drink." B. "Cherry milkshake will ease the pain." C. "I shouldnt let her gargle for at least 10 days." D. "She'll be able to play with friends in 1 week."
B. "Cherry milkshake will ease the pain."
A client with endometriosis reports having hot flashes. Which of the clients medications would the nurse identify as the cause of this side effect? A. Estrogen B. Leuprolide C. Diclofenac D. Ergonovine
B Leuprolide -Estrogen affects the release of pituitary gonadotropins and inhibits ovulations; it is contraindicated because the goal of treatment is to suppress the action of estrogen on the endometrial tissue. -Diclofenac: Used for primary dysmenorrhea; it is a nonsteroidal anti-inflammatory medication that inhibits prostaglandin synthesis. -Ergonovine: To induce contraction of the postpartum uterus
Which speech patter is disturbed client displaying when they start to repeat phrases that others have just said? A. Alogia B. Echolalia C. Neologism D. Symbolic speech
B. Echolalia -Alogia: Limited speech -Neologism: When new words are coined or old words take on private symbolic meanings -Symbolic speech: Uses of symbols to replace direct communication
Which blood pressure would the nurse recognize as normal in toddlers? A. 85/54 mmHg B. 95/65 mmHg C. 105/65 mm Hg D. 110/65 mmHg
B. 95/65 mmHg -Normal in infants 85/54 mmHg -Optimal BP for children above the age of 6 years is 105/65 mm Hg. -Between the ages of 10 & 13 normal BP is 110/65 mmHg
Which element, if missing from a newly admitted client's medication administration record (MAR), makes the record incomplete? A. Height B. Allergies C. Vital signs D. Body weight
B. Allergies
Which information would the nurse include when explaining the cause of transient ischemic attacks (TIAs) to a client? A. Genetic valvular heart disease B. Atherosclerotic plaques within arteries C. Developmental defects in arterial walls D. Emboli ascending from the lower extremities
B. Atherosclerotic plaques within arteries -Atherosclerotic plaques within arteries progressively narrow the lumens of the carotid arteries, causing TIAs.
Which program would the nurse suggest for the 70 year old client who needs to undergo heart surgery but cannot afford it? A. Medicaid B. Medicare C. Managed care organization D. Preferred car organization
B. Medicare
Medication is prescribed for a child with attention-deficit/hyperactivity disorder (ADHD). Which information would the school nurse emphasize when discussing this childs treatment with the parents? A. Tutoring their child in the subjects that are troublesome B. Monitoring the effects of the medication on their childs behavior C.Explaining to their child that the behavior can be controlled if desired D. Avoiding imposing too many rules because these will frustrate the child
B. Monitoring the effects of the medication on their childs behavior
Which information will the nurse share about alopecia charcteristics to a client who is to receive chemotherapy after surgery for cancer? A. Usually rare B. Not permanent C. Frequently prolonged D. Usually preventable
B. Not permanent
Morning sickness generally disappears by the end of which month? A. fifth month B. third month C. Fourth month D. Second month
B. Third month
Which instruction would the nurse include when teaching the client about sublingual nitroglycerin? A. "Once the tablet is dissolved, spit out the saliva." B. "Take tablets 3 minutes apart up to a maximum of five tablets." C. "Common side effects include headache and low BP." D. "Once opened, the tablets should be refrigerated to prevent deterioration."
C. "Common side effects include headache and low BP."
Which statement describes scoliosis? A. The concave lumbar curvature is exaggerated B. There are pathological changes in the vertebrae C. There is a rotary deformity of the lateral curvature of the spine D. The curvature of the thoracic spine has an increased convex angulation
C. There is a rotary deformity of the lateral curvature of the spine
A client is admitted at 40 weeks gestation with her cervix dilated 5 cm and 100% effaced, the presenting part at station 0, and fetal heart tones heard just above the umbilicus. Which fetal presentation is indicated by these assessment findings? A. Face B. Brow C. Breech D. Shoulder
C. Breech
A prenatal clients vaginal mucosa is noted to have a purplish discoloration. Which sign would be documented in the clients clinical record? A. Hegar B. Goodell C. Chadwick D. Braxton-Hicks
C. Chadwick -Hegar: sign is softening of the lower uterine segment. -Goodell: Sign is softening of the cervix -Braxton hicks: After the fourth month of pregnancy, irregular, painful uterine contractions, can be felt through the abdominal wall.
The nurse is teaching a client how to self administer an intravagina medication. In which directions would the nurse instruct the client to direct the medication? A. To the left B. To the right C. Toward the sacrum D. Toward the umbilic
C. Toward the sacrum
Which characteristic would a nurse explain is usually present in older adults when teaching about aging? A. Inflexible attitudes B. Periods of confusion C. Slower reaction times D. Some senile demetia
C. Slower reaction times
Which strategy would the nurse teach the parents of a child who is being discharged from the hospital after a diagnosis of acute spasmodic laryngitis to help prevent another croup episode? A. Perform postural drainage. B. Discourage before bedtime snacks. C. Use a cool mist vaporizer in the childs room D. Demonstrate to the child how to expel air after inspiration.
C. Use a cool mist vaporizer in the childs room
When auscultating a clients chest, the nurse hears swishing sounds of normal breathing. How would the nurse document this findings? A. Adventitious sounds B. Fine crackling sounds C. Vesicular breath sounds D. Diminished breath sounds
C. Vesicular breath sounds -Adventitious: Abnormal breath sounds -Crackles: Heard at the end of an inspiration are associated with fluid in the alveoli. -Diminshed: Breath sounds are evidence of a reduction in the amount of air entering the alveoli; this usually is caused by obstruction or consolidation
Which activity would the nurse expect to cause the MOST distress when assessing a client with heart failure for activity tolerance?
Climbing a flight of stairs to the bedroom
Which element is the critical factor among health care professionals, state agencies, and federal agencies to determine when and how to evacuate safely during a natural disaster?
Communication
Which education would the nurse provide about the side effects of the Haemophilus influenzae (Hip) Vaccine? A. Lethargy B. Urticaria C. Generalized rash D. Low-grade fever
D. Low grade fever
When teaching a client with type 2 diabetes, which statement by the nurse reflects accurate information about preparing for a serum glucose test? A. "Eat your usual breakfast." B. "Heave clear liquids for breakfast." C. "Take your medication before the test." D. "Do not ingest anything before the test."
D. "Do not ingest anything before the test."
Which response would the school nurse give to a student in high school who asks why a classmate has been absent for so long? A. "Have you asked his girlfriend?" B. "I wonder why you're so curious." C. "Students sometimes miss school for long periods." D. "I know you're concerned, but you'll need to ask your classmate for yourself."
D. "I know you're concerned, but you'll need to ask your classmate for yourself."
Which client statement indicates understanding of content taught about removing his or her three-way indwelling catheter and continuous bladder irrigation (CBI)? A. "I probably will have diluted urine." B. "I probably will be unable to urinate." C. " I probably will produce dark red urine." D. "I probably will experience some burning on urination."
D. "I probably will experience some burning on urination."
A client presents to the health care facility with abdominal pain. Which question would the nurse ask the client to obtain information about concomitant symptoms? A. "Can you describe the pain?" B. "Where exactly do you feel the pain?" C. "Which activities make the pain worse?" D. "What other discomfort do you experience?"
D. "What other discomfort do you experience?"
A client asks the nurse what causes the sudden loss of vision common in persons with multiple sclerosis. Which factor would the nurse include in the explanation? A. Virus-induced iritis B. Intracranial pressure C. Closed-angle glaucoma D. Optic nerve inflammation
D. Optic nerve inflammation
Which therapeutic effect is associated with digoxin prescribed to a client with heart failure? A. Reduces edema B. Increases cardiac conduction C. Increases rate of ventricular contractions D. Slows and strengthens cardiac contractions
D. Slows and strengthens cardiac contractions
Which psychophysiological factors influence communication between the nurse and client?
Emotional status, Growth and development
Which intervention is MOST important to assist a couple to cope with their feelings about the husbands terminal illness?
Helping the couple express to each other their feelings about his terminal illness
Which statement by the adolescent about lifestyle modifications to prevent hyperlipidemia indicates a need for further teaching?
I'll start eating more red meat
An Rh-negative client has a spontaneous abortion at the end of the second trimester and is prescribed Rho(D) immune globulin. The client asks the nurse, "Why do I need this medication?" Which information would the nurse consider before answering the client's question?
It will prevent the woman from producing antibodies.
Which nursing action is legally required?
Reporting incidents of suspected child abuse to the appropriate authorities
The waiting area of a health care facility displays a pink triangle. Which view does this signify?
The health care facility welcomes LGBTQ+ clients
Which explanation would the nurse give about the purpose of the procedure when a client with angina is scheduled to have a cardiac catheterization?
To visualize the disease process in the coronary arteries
The nurse teaches a client about wearing thigh high antiembolism elastic stockings. Which instructions would be correct to include?
You will need to apply them in the morning before you lower your legs from the bed to the floor
Which term described the language pattern of a client who created new and meaningless words as they speak? A. Neologism B. Perseveration C. Pressured speech D. Tangential speech
A. Neologism -Perseveration: Repetitive verbalizations or motions. -Pressured speech: Rapid speech with urgent quality. -Tangential Speech: Tendency to digress from the original subject
A client does not take their medication regularly and is depressed. Which inference can the nurse make about the client's motivational level? A. Not motivated B. Intrinsically motivated C. Extrinsically motived with self-determination D. Extrinsically motivated without self-determination
A. Not motivated
Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? A. Planning B. Evaluation C. Assessment D. Implementation
A. Planning
Which therapeutic communication technique would be useful for a client major depressive disorder? SATA. A. Reflecting B. Offering self C. Using silence D. Paraphrasing E. Asking open-ended questions F. Encouraging comparison
A. Reflecting B. Offering self C. Using silence D. Paraphrasing E. Asking open-ended questions F. Encouraging comparison
Which action is NEXT when a nurse determines that an adolescent with newly diagnosed type 1 diabetes has sufficient knowledge of the disorder? A. Setting goals with the client B. Developing a rapport with the client C. Teaching the client how to give insulin injections D. Instructing the client how to monitor blood glucose
A. Setting goals with the client
Which information would the nurse include in a community education session on decreasing the risk of musculoskeletal injuries? SATA. A. Use of seatbelts B. Obey speed limits C. Wearing safety equipment D. Avoiding impaired vehicle use E. Refraining from distracted driving
A. Use of seatbelts B. Obey speed limits C. Wearing safety equipment D. Avoiding impaired vehicle use E. Refraining from distracted driving
Which consistent approach would the nurse use for a client diagnosed with an antisocial personality disorder? A. Warm and firm without being punitive B. Indifferent and detached but nonjudgemental C. Conditionally acquiescent to client demands D. Clearly communicative
A. Warm and firm without being punitive
Which stage of the development would the nurse document for an infant when using Freud's theory of psychosocial development? A. Oral B. Anal C. Phallic D. Latent
A. oral
The school nurse is planning to teach the importance of hand washing to the children in first grade. Which is the MOST effective approach for this age group? A. Showing a vide of the correct hand washing technique B. Demonstrating hand washing and asking for return demonstrations C. Involving them to discussion about the importance of hand washing D. Describing how germs cause illness and how hand washing prevents disease
B. Demonstrating hand washing and asking for return demonstrations
Which condition would the nurse document to describe a client presenting with the loss of the ability to taste after cancer treatment has affected the clients ability to eat food? A. Mucositis B. Dysgeusia C. Dysphagia D. Xerostoma
B. Dysheusia -Mucisitis: Inflammation and irritation of themucosa in the mouth or throat -Dysphagia: Difficult in swallowing or an inability to swallow. -Xerostomia: Dry mouth
The nurse is discussing discharge plans with a client. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." Which interviewing technique did the nurse use? A. Exploring B. Reflecting C. Refocusing D. Acknowledging
A. Exploring
Which therapeutic communication technique is used when the nurse and client have a conversation and the client begins to repeat the conversation to self? A. Focusing B. Clarifying C. Paraphrasing D. Summarizing
A. Focusing
Which strategy would the nurse include in the client's plan of care regarding preventing the development of ureteral colic from renal calculi in the future? A. Instruct the client to drink at least 3L of fluid daily B. Suggest interventions to decrease the serum creatinine level C. Establish a urinary output goal of 2000 mL per 24 hours D. Teach the client to exclude milk products for their diet
A. Instruct the client to drink at least 3L of fluid daily
Which response would the nurse provide the parent of a 15 month old child who expresses feelings of guilt when their child was hospitalized after ingesting toilet bowel cleaner?" A. "Anyone could make a mistake. Don't dwell on it." B. "Let's not worry about the past. Your child is going to get better." C. "It was an accident, but you should consider special locks on your closets." D. "That was careless of you. please make sure that you poison proof your house."
C. "It was an accident, but you should consider special locks on your closets." -Describe the accident as an accident
Whichresponse would the nurse give to the common statement "But you don't understand" when caring for an adolescent? A. "Idont understand what you mean." B. "I do understand; i was a teenager once too." C. "It would be helpful to understand; let's talk." D. "It's you who should try to understand others."
C. "It would be helpful to understand; let's talk."
A student athlete reports muscle pain after a practice session. Which product of muscle metabolism would the nurse explain as being a cause of pain? A. Lactic acid B. Acetoacetic acid C. Hydrochloric acid D> Beta-hydroxybutyric acid
A. Lactic acid -The ache in muscles that have been vigorously worked without adequate oxygen supply is caused in part by the buildup of lactic acid. During rest, the lactic acid is oxidized completely to carbon dioxide and water, providing adenosine triphosphate for further muscular contraction. -Beta-hydroxybutyric acid and acetoacetic acid are not products of muscle contraction; they are ketone bodies resulting from incomplete oxidation of fatty acids. -Hydrochloric acid is not a product of muscle contraction; it is present in the stomach to facilitate the digestive process.
Which statement by an adolescent about sickle cell anemia would cause the nurse to conclude that teaching has been understood? A. "I'll start to have symptoms when I drink less fluid." B. "I'll start to have symptoms when I have fewer platelets." C. "I'll start to have symptoms when i decrease the iron in my diet." D. "I'll start to have symptoms when I have few white blood cells."
A. "I'll start to have symptoms when I drink less fluid." -Dehydration precipitates sickling of red blood cells and is major factor for painful episodes associated with sickle cell anemia.
How would a nurse respond to the spouse of a client with an intracranial hemorrhage who asks the nurse, "Why aren't they administering an anticoagulant?" A. "It is not advisable because the bleeding will increase." B. "If necessary, it will be started to enhance circulation." C. "If necessary, it will be started to prevent pulmonary thrombosis." D. "It is inadivisable because it masks the effect of the hemorrhage."
A. "It is not advisable because the bleeding will increase."
Which is the nurses MOST therapeutic response for the child who is about to have an Intravenous (IV) line inserted and cried out that he is afraid of IVs? A. "Tell me what frightens you." B. "Its just a little prink in the arm." C. "You're a big boy; this will hardly hurt." D. "Come on-there's no reason to be afraid."
A. "Tell me what frightens you."
Which statement by a new mother observing her preterm infant in the neonatal intensive care nursery indicates that she has not yet begun the bonding process? A. "its such a tiny baby." B. "Do you think he'll make it?" C."Why does he need to be in an incubator?" D. "My baby looks so much like my husband?"
A. "its such a tiny baby." - Failing to acknowledge the infant as a person
Within which period of time would a nurse advise the client to anticipate pain relief will begin when nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina? A. 1 to 3 minutes B. 4 to 5 seconds C. 20 to 25 seconds D. 10 to 15 minutes
A. 1 to 3 minutes
Which information would the nurse include in explaining glaucoma to a client? A. An increase in the pressure within the eyeball B. An opacity of the crystalline lends or its capsule C. A curvature of the cornea that becomes unequal D. A separation of the neural retina from the pigmented retina
A. An increase in the pressure within the eyeball
Which action would the nurse take after contacting the primary health care provider of a post surgical client complaining of nausea, fatigue, and a headache during the fourth hour of the infusion of total parenteral nutrition (TPN) instituted via a central venous infusion who has an hourly urine output that is twice the amount of the previous hours? A. Check the serum glucose level B. Obtain an oxygen saturation level C. Administer a prescribed analgesic D. Elevate the head of the bed
A. Check the serum glucose level -Rapid administration can cause glucose overload, leading to osmotic diuresis and dehydration.
Which therapeutic response would the nurse provide to the parents of an adolescent treated for allergies who privately tell the nurse that they suspect that their child is a hypochondriac? A. Discussing development behaviors of adolescents B. Explaining potentially serious complications of allergies C. Discussing some of the underlying causes of hypochondriasis D. Explaining that the parents may be transferrin their fears to their adolescent.
A. Discussing development behaviors of adolescents - Adolescents are very aware of their changing bodies and become especially concerned with any alternation resulting from illness or injury.
Which information would the nurse focus on when teaching a high school students about scoliosis treatment options? A. Effect on body image B. Least invasive treatment C. Continuation with schooling D> Maintenance of contact with peers
A. Effect on body image
Which characteristics is MOST essential for the nurse to have in caring for clients with mental health disorder? A. Empathy B. Sympathy C.Organization D. Authoritarianism
A. Empathy -Empathy: Understand and sharing the emotions of another encourages the expression of feelings. -Sympathy: Feeling sorry for someone -Authoritarian: Approach will emphasize the clients weak ego and lack of self-esteem
Which action would the nurse take in a client who takes Rifampin who tells the nurse, "My urine looks orange?" A. Explain that this is expected B.Check the liver enzymes C. Ask the provider to order a urinalysis D. Ask what foots were eaten
A. Explain that this is expected
Which instructions about phenytoin will the nurse provide during discharge teaching to a client with epilepsy who is prescribed phenytoin for seizure control? A."Antiseizure medications will probably be continued for life." B. "Phenytoin prevents any further occurrence of seizures." C. "This medication needs to be taken during period of emotional stress." D. "Your antiseizure medication usually can be stopped after a year's absence of seizures."
A."Antiseizure medications will probably be continued for life." -Seizure disorders are usually are associated with marked changes in the electrical activity of the cerebral cortex, requiring prolonged or lifelong therapy. - Seizure may occur despite medication therapy; the dosage may be adjusted. -A therapeutic blood level must be maintained through consistent administration of the medication irrespective of emotional stress. -Absence of seizures will probably result from medication effectiveness rather than from correction of the pathophysiological condition.
Which finding would the nurse document after observing dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked? A. "Has intact plantar reflexes" B. "Exhibits a positive Babinski sign." C. "Demonstrates normal sensory function." D. "Able to perform active range of motion."
B. "Exhibits a positive Babinski sign."
Which explanation will the nurse give when a client asks about what causes varicose veins? A. "Abnormal configurations of the veins." B. "Incompetent valves of superficial veins." C."Decreased pressure within the deep veins." D. "Atherosclerotic plaque formation in the veins."
B. "Incompetent valves of superficial veins." -Abnormal configurations: Of the veins are considered a result of, rather than a cause of, varicose veins. -Pressure within the deep veins is increased, not decreased. -Plaque formation is considered an arterial, rather than a venous, problem and is associated with atherosclerosis.
Which response would a nurse give to a client who ask "Why can t i take the insulin in pills instead of taking shots?" During a teaching session about insulin injections? A. "Insulin cannot be manufactured in pill form." B. "Insulin is destroyed by gastric juices, rendering it ineffective." C. "Your healthcare provider decided the route of administration." D. "your health care provider will prescribe pills when you are ready."
B. "Insulin is destroyed by gastric juices, rendering it ineffective."
After surgery, an adolescent has a patient-controlled analgesia (PCA) pump that is set to allow morphine delivery every 6 minutes. Which statement indicates to the that the family understand instructions about the PCA pump? A. "I'll make sure that she pushes the PCA button every 6 minutes." B. "She needs to push the PCA button whenever she needs pain medication." C. "I'll have to wake her up on a regular basis so she can push the PCA button." D. "I'll press the PCA button every 6 minutes so she gets enough pain medication while she's sleeping."
B. "She needs to push the PCA button whenever she needs pain medication."
The nurse explains. to the parents of a 6 year old child with a pinworm infestation how pinworms are transmitted. Which statement indicates that the teaching has been understood? A. "We need to keep the cat off the bed." B. "She needs to wash her hands before eating anything." C. "She needs to cover her mouth whenever she coughs." "We need to tell the school so that the cafeteria can be cleaned."
B. "She needs to wash her hands before eating anything."
Which response by the nurse is therapeutic when a make client with ascites is to have a paracentesis and has signed the consent but, while the nurse caring for him, he says he has changed his mind and no longer wants the procedure? A. "Why did you sign the consent?" B. "Tell me why you want to refuse the procedure?" C. "you are obviously afraid about something concerning the procedure?" A. "Although the procedure is very important, I understand why you changed your mine?"
B. "Tell me why you want to refuse the procedure?" - its an open ended and attempt to explore why the client is refusing the procedure; it promotes communication
Which response would the nurse make to a client who says, "I feel so guilty. None of this makes any sense. Everyone must really think I'm crazy," after performing a complex ritual? A. "Your behavior is bizarre, but it serves a useful purpose." B. "You're concerned about what other people are thinking about you." C. "I am sure people understand that you can't help this behavior right now." D. "Guilt serves no useful purpose. It just helps you stay stuck where you are."
B. "You're concerned about what other people are thinking about you."
Which explanation, when providing a change-of shift report, would the nurse use to describe a client diagnosed with schizophrenia who is experiencing opposing emotion simultaneously? A. Double bind B. Ambivalence C. Loose association D. Inappropriate affect
B. Abimvalence -Ambivalence:two conflicting emotions, impulses, or desires. -Double bind: Means having two conflicting messages, not emotions, in a single communication. -Loose association: Are not two conflicting emotions but instead the loosening of connections between thoughts. -Inappropriate affect: Incongruous expression of emotions when compared with behavior or content of speech.
A client at the fertility clinic is being treated for hypertension and obesity and has lost 8 lbs (3.6 kg) in the past month, and her blood pressure has decreased to 154/98 mmHg. She stated she is using self control strategies to achieve these improvements. Which would be a therapeutic response by the nurse? A. Explaining to the client that her current program needs revision to improve results. B. Acknowledging the clients achievement while encouraging continuation of her current program C. Emphasizing to the client the importance of exercise in addition to reduced sodium and caloric intake D. Recommending that the client ask her health care practitioner about a prescription for an antihypertensive or a diuretic
B. Acknowledging the clients achievement while encouraging continuation of her current program
Which term describes a client who states that she no longer enjoys any of the activities that she once found fun and pleasurable? A. Anergia B. Anhedonia C. Grandiosity D. Tangentiality
B. Anhedonia -Anergia: Lethargy and decreased level of energy. -Grandiosity: Is a symptom seen during manic episodes in which and individual displays an inflated self-esteem. -Tangentiality: Speaking about subjects unrelated or tangent to the main discussion topic of responding to questions without answering the questions.
Which strategy would the nurse use to help a depressed, withdrawn client exhibits sadness through nonverbal behavior? A. Increased structured physical activity B. Cope with painful feelings by sharing them C. Decide which unit activities the client can perform D. Improve the ability to communicate with significant others
B. Cope with painful feelings by sharing them
Which statement explains why are so many drugs are necessary for a client with stage III Hodgkins disease who is started on a multiple drug regimen of doxorubicin, bleomycin, vinblastine, and dacarbazine? A. Using smaller doses of several drugs reduces the likelihood of serious side effects. B. Each drug destroys the cancer cell at a different time in the cell cycle. C. Several drugs are used to destroy cells that are not susceptible to radiation therapy. D. Because there are stages of hodgkins disease, if one drug is ineffective, another will work..
B. Each drug destroys the cancer cell at a different time in the cell cycle.
The parent of a child with terminal illness appears overwhelmed and anxious. Which is the BEST response by the nurse? A. Explaining the diagnosis in a variety of ways B. Encouraging the parents to express their feelings C. Recommending that the parent talk with other parents D. Offering assurance that surgery will probably correct the problem
B. Encouraging the parents to express their feelings
Which description of the onset of symptoms would the nurse give to the client with a tentative diagnosis of Parkinson disease? A. Suddenly B. Gradually C. Overnight D. Irregularly
B. Gradually The onset is slow and gradual
Which aspect of the therapeutic contract is the MOST important for a newly admitted client? A. Determining the time and place for meetings with the client B. Helping the client define treatment goals and expectations C. Helping the client determine the frequency and duration of meetings D. Explaining the professional responsibilities of the nurse to he client
B. Helping the client define treatment goals and expectations
Which important information would the nurse determine regarding the care provided by a mother diagnosed with acquired immunodeficiency syndrome (AIDS) who has been caring for her baby despite not feeling well? A. If she has ever kissed the baby and how B. If the mother is breast- feeding her baby C. When the baby last received antibiotics D. How long she has been caring for the baby
B. If the mother is breast- feeding her baby -Epidemiological evidence has identified breast milk as a source of human immunodeficiency virus (HIS) transmission
Which communication pattern is defined as confabulation? A. The flow of thoughts is interrupted B. Imagination is used to fill in memory gaps. C. Speech flits from one topic to another. D. Statements are too loose to understand.
B. Imagination is used to fill in memory gaps. Using imagination to fill in memory gaps is the definition of canfabulation
During a home visit, the nurse finds that a healthy older adult person is actively practicing laughing therapy to maintain good health without pressure or insistence from family members. Which inference about the client would the nurse make from these findings? A. Not motivated B. Intrinsically motivated C. Extrinsically motivated with self-determination D. Extrinsically motivated without self-determination
B. Intrinsically motivated -Intrinsically motivated individual participated in activity because it is inherently interesting or enjoyable rather than because of obligations or outside pressure from family members. -Extrinsically motivated individual with or without self-determination may practice laughing therapy on suggestion or pressure created by other individuals
Which action would the nurse take for a client diagnose with major depression who is tearful and refuses to ear dinner after a visit with a friend? A. Allow the client to skip the meal B. Offer an opportunity to discuss the visit C. Reinforce the importance adequate nutrition D. Provide the client with adequate quite thinking time
B. Offer an opportunity to discuss the visit
Which client assessment findings would the nurse document as subjective data? A. Blood pressure 100/82 bpm B. Pain rating of 5 C. Potassium 4.0 mEq D. Pulse oximetry reading of 96%
B. Pain rating of 5
Which type of delusion would the nurse chart about a client who says, "I've figured out how foreign agents have infiltrated the news media. Now they want to shut up"? A. Nihilistic B. Persecution C. Control D. Grandeur
B. Persecution -Thoughts of being pursued by powerful agents because of one's special attributes or power are fixed false beliefs and are referred to as delusions of persecution.
Which therapeutic communication technique is a coping strategy to help the nurse and client adjust to stress? A. Sharing hope B.Sharing humor C. Sharing empathy D. Sharing observations
B. Sharing humor
Which instruction would the nurse suggest to an adolescent who suspects their friend is using self-induced vomiting to keep weight down? A. Confront their friend with their suspicions. B. Talk to the school nurse about their concerns. C. Inform the friends mother about their behavior. D. Watch a while longer before doing anything that might ruin the friendship.
B. Talk to the school nurse about their concerns.
An adult client with low function down syndrome (trisomy 21) appears in the emergency department via ambulance after an accident. Which assessment method would be the best instrument to use when determining this clients level of pain? A. Asking the clients parent B. Using the Wong-Bake FACES pain rating scale C. Observing the clients body language D. Explaning and using the 0 to 10 plain scale
B. Using the Wong-Bake FACES pain rating scale
A mother whose son has acute glomerulonephritis (AGN) is fearful that her other children may contract the disorder. Which response would the nurse tell the mother about the origin of AGN? A. "The disorder is difficult to prevent because the cause is unknown." B."It is a result of an autoimmune response after a streptococcal infection." C. "It is transmitted through a sec-linked chromosome that occurs only in males." D. "This disorder is caused by clot formation in the kidney tubules as a response to an infection."
B."It is a result of an autoimmune response after a streptococcal infection." - The beta-hemolytic streptococcal immune complex becomes trapped in the glomerular capillary loop, resulting in acute poststreptococcal glomerulonephritis.
Which response would the nurse provide the parent of a 2 year old child who asks , "Why did you have my child draw on a paper when they don't draw at home?" A. "I should have asked you about drawing first." B."These drawings help us determine your childs intelligence." C. "It lets us test the childs ability to perform tasks requiring the hands." D. "I dont understand why drawing is forbidden in your home."
C. "It lets us test the childs ability to perform tasks requiring the hands."
A 8 year old child has experienced the death of a sister. The child begins to ask many questions about what happens to the body after death. The parent asks whether this abnormal or morbid behavior picked up from playing video games. Which is the BEST response by the nurse? A. "Playing video games cause morbid behaviors." B. "Children handle the event of death more realistically than adults do." C. "School-aged children are inquisitive and ask a lot of questions about death." D. "Giggling attracting attention, and playing are the usual ways of dealing with death."
C. "School-aged children are inquisitive and ask a lot of questions about death."
An 8 year old girl who is hospitalized for intravenous (IV) antibiotic therapy tells the nurse that she is bored. The nurse has a discussion with the parent about appropriate activities. Which activity suggested by the parent would indicate a need for further teaching? A. " I'll bring a radio and CD player." B. "I'll bring homework and school supplies." C. "She'll enjoy having a rubber baseball and plastic bat." D. "She'll enjoy rubber stamps and a pretty box to keep them in."
C. "She'll enjoy having a rubber baseball and plastic bat."
Which response would the nurse make to a client who says, "I'm a terrible, evil person. The voices are telling me that God needs to punish me"? A. "God is loving and won't punish you." B. "Those voices you're hearing are a fantasy." C. "Tell me what you're thinking about yourself." D. "You aren't wicked- both God and I love you."
C. "Tell me what you're thinking about yourself."
A nurse educator instructs a new nurse during orientation about the physiological processes of the endocrine system. Which statement by the new nurse indicates effective learning? A. "The endocrine system comprises glands with narrow ducts." B. "The endocrine system comprises salivary and lacrimal glands." C. "The hormones of the endocrine system exert their action by 'lock and key' mechanism." D. "The hormones secreted by endocrine system exert their action on all tissues they contact."
C. "The hormones of the endocrine system exert their action by 'lock and key' mechanism."
Which response would the nurse use after receiving instructions regarding dressing changes and care of a recently inserted nephrostomy tube when the client states "I hope I can handle all this at home; it's a lot to remember?" A. "I'm sure you can do it." B. "Oh, a family member can do it for you." C. "You seem to be nervous about going home." D. "Perhaps you can stay in the hospital another day."
C. "You seem to be nervous about going home."
Which role is MOST important for the nurse to assume when providing therapeutic crisis intervention? A. Passive listener B. Participant observer C. Active participant D. Friendly advisor
C. Active participant To intervene. in a crisis, the nurse must assume a direct, active role because the client's ability to cope is decreased and help is needed to solve problems
How would the nurse describe heart failure to a client? A. A cardiac condition cause by inadequate circulating blood volume B. A acute state in which the pulmonary circulation pressure decreases C. An inability of the heart to pump in proportion to metabolic needs. D. A chronic state in which the systolic blood pressure drops below 90 mmHg
C. An inability of the heart to pump in proportion to metabolic needs.
Which action would a home care nurse take when an adolescent with terminal cancer states, "I'd really like to get my general education development certificate. Do you think that's possible?" A. Refocusing the conversation on things the adolescent has already accomplished in life B. Trying to help the adolescent understand that this goal is too taxing and slightly unrealistic C. Arranging a conference with the school and encouraging the adolescent to prepare for the test D. Suggesting to the adolescent that this energy should be directed toward expressing feelings about the illness
C. Arranging a conference with the school and encouraging the adolescent to prepare for the test
Which nursing process would the nurse undertake when collecting the medical history of a client? A. Diagnosis B. Evaluation C. Assessment D. Implementation
C. Assessment -The documentation of the clients information is part of an assessment. The nurse will collect all the relevant medical data of the client to help the health care provider understand the clients history a make an accurate diagnosis. -During diagnosis, the collected data is analyzed to find out the clients problems or issues. -Evaluation is the process to see if the expected outcomes of the treatment are achieved or not. Before an evaluation, a plan is made to solve all the clients problems and then to plan is implemented.
The nurse is caring for a 9 month old infant with gluten-induced enteropathy. Which common term for this order would the nurse use when discussing the infants diagnosis with the parents? A. Megacolon B. Celiac disease C. Cystic fibrosis D. Intussusception
C. Celiac disease -Celiac disease: Celiac sprue & gluten-sensitive enteropathy are terms used interchangeably for the same pathophysiologic process -Aganglionic Megacolon: Also referred to as Hirschsprung disease, is characterized by chronic constipation. -Cystic Fibrosis: Inherited disorder characterized by increased viscosity of mucous glands throughout the body. -Intussesception: An intestinal anomaly that causes invagination or telescoping of one portion of the intestine into another. It is an acute problem rather than a chronic disorder.
Which statement will the nurse need to consider when developing the teaching plan for a client with type 2 diabetes prescribed an oral hypoglycemic medication? A. Oral hypoglycemics work by decreasing absorption of carbohydrates B. Oral hypoglycemics work by stimulating the pancreas to produce insulin. C. Clients taking oral hypoglycemics may subconsciously relax dietary rules to gain a sense of control. D. Serious adverse effects are not a problem for oral hypglycemics.
C. Clients taking oral hypoglycemics may subconsciously relax dietary rules to gain a sense of control.
Why would lactulose be prescribed for a client with a history of cirrhosis of the liver? A. The desire to drink alcohol is decreased. B. Diarrhea is controlled and prevented. C. Elevated ammonia levels are lowered. D. Abdominal distension secondary to ascites is decreased
C. Elevated ammonia levels are lowered. -Lactulose is an ammonia detoxicant
A client with a chronic renal failure stops responding to the treatment. On examination, the primary health care provider determines that the client is terminally ill. Which is the correct nursing intervention in this situation? A. Provide information to the family members about getting a second opinion. B. Suggest that the family members continue to try different treatments. C. Encourage the family members to provide palliative care to the client D. Inform the family members that the disease is no longer curable and the client will die shortly
C. Encourage the family members to provide palliative care to the client
A child with iron-deficiency anemia is prescribed oral iron therapy. Anticipatory guidance regarding which side effect would the nurse provide? A. Bloody stool B. Orange urine C. Greenish-black stool D. Staining of the mouth
C. Greenish-black stool
A client with cystic fibrosis asks why the percussion procedure is being performed. Which rationale would the nurse give to the client? A. It relieves bronchial spasms. B. It increases the depth of respirations C. It loosens pulmonary secretions D. It expels carbon dioxide from the lungs
C. It loosens pulmonary secretions
The nurse is planning to teach the four point alternate crutch gait to a 9 year old child with cerbral palsy. How would the nurse explain this choice to the parent? A. The child has minimal step ability in the lower extremities B. It provides for two points of support on the floor at all times C. It provides for equal but partial weight bearing on each limb. D. The child has more power in the upper extremities than in the lower extremities
C. It provides for equal but partial weight bearing on each limb. - The four point alternate crutch gait is simple,slow, stable gait because there are always three points of support on the floor, with equal but partial weight bearing on each limb
Which action by an adolescent after the nurse teaches crutch-walking indicates the need for more teaching? A. Takes short steps of equal length B. Looks forward to maintain balance C. Looks down when placing the crutches D. Assumes an erect posture when walking
C. Looks down when placing the crutches
Which information about the teenagers developmental stage would be considered before starting a counseling program for a 15 year old with type 1 diabetes who has a history of noncompliance with the therapy regimen? A. They usually deny their illness B. They have a need for attention C. The struggle for identity is typical D. Regression is associated with illness
C. The struggle for identity is typical -Attain identity and independence are task of the adolescent and rebellion against established norms may be exhibited.
Which response would the nurse make to a client who has been attending daily treatment facility for 1 month with depressive disorder and is to be discharged in a week? A. "We have a jew sessions left. I'm really pleased at your progress." B. "Your discharge date has been set for next week. That's wonderful news." C. "There are five sessions remaining. We need to start making plans to end our sessions." D. "I understand that your discharge is set for next week. I'm wondering how you feel about that?"
D. "I understand that your discharge is set for next week. I'm wondering how you feel about that?"
Which response would the nurse make to a client with obsessive-compulsive disorder who says, "I know my hands aren't dirty, but I just can't stop washing them?" A. "Let's talk about why you feel that you have to wash your hands." B. "You're getting better; you're beginning to understand your problem." C. "Don't worry about it; these actions are part of your illness, and the feelings will pass." D. "I understand that- maybe we can work together to limit the number of times you wash them."
D. "I understand that- maybe we can work together to limit the number of times you wash them."
Which statement leads the nurse teaching a teenager who is undergoing chemotherapy about the need for special mouth care to conclude that the instructions have been understood? A. "I'll brush my teeth with baking soda." B. "I'll use mouthwash to rinse my mouth." C. "I'll swish my mouth out with hydrogen peroxide." D. "I'll use a soft-bristled toothbrush to clean my teeth."
D. "I'll use a soft-bristled toothbrush to clean my teeth."
The parents of a child with recently diagnosed leukemia ask the nurse why their child has too many white blood cells. Which response by the nurse is BEST? A. "The healthcare provider is the best one to answer that question for you." B. "You seen to be focusing on your childs white blood cells." C. "you dont seem to understand what occurs in this disease." D. "The bone marrow is not controlling you childs white blood cell production as it should."
D. "The bone marrow is not controlling you childs white blood cell production as it should." -An accurate description of the malfunctioning bone marrow is a helpful response to the parents question that reinforces what they were told.
Which response by the nurse is BEST when a client expresses concern regarding the lack of annual flu vaccines because of a supply and demand problem? A. "This is an unfortunate situation, but there was such a limited supply available." B. "There are many others who were unable to obtain flu vaccines this month." C. "The limited supply doesnt really matter because the vaccine is for one particular strain." D. "There are other things you and your family can do to prevent the flu, such as handwashing."
D. "There are other things you and your family can do to prevent the flu, such as handwashing."
Which response would the nurse use when a client diagnosed with acquired immunodeficiency syndrome (AIDS) states, "I'm not worried because they have a cure for AIDS?" A. "Repeated phlebotomies may be able to rid you of the virus?" B. "You may be cured of AIDS after prolonged pharmacological therapy." C. "Perhaps you should have worn condoms to prevent contracting the virus?" D. "There is no cure for AIDS, but there are medication that can slow down the virus."
D. "There is no cure for AIDS, but there are medication that can slow down the virus."
Which blood pressure is optimal for an adolescent? A. 85/54 mmHg B. 95/65 mm Hg C. 105/65 mm Hg D. 110/65 mm Hg
D. 110/65 mm Hg -Average optimal optimal blood pressure of an infant is 85/54 mm Hg. -Average optimal pressure of a toddle is 95/65 mm Hg. -Average optimal blood pressure seen in children between the ages of 6 and 13 years is 105/65 mm Hg
A 50 year old client has difficulty communicating because of expressive aphasia after a cerebrovascular accident (CVA). When the nurse inquired about the clients feelings, the spouse responded. Which communication strategy would the nurse use to address this behavior? A. Ask the spouse how they know the clients feelings. B. Instruct the spouse to let the client answer. C. When the spouse leaves, return to speak with the client D. Acknowledge the spouse, but look at the client for a response.
D. Acknowledge the spouse, but look at the client for a response.
A client expresses a complete lack of interest in food. How would the nurse document this finding in the clients medical record? A. Apathy B. Aphasia C. Adactyly D. Anorexia
D. Anorexia
An older adults seems to make up stories to fill in for memory lapses. Which behavior is the client displaying? A. Lying B. Denying C. Fantasizing D. Confabulating
D. Confabulating
Which clotting factor would a nurse explain is deficient to the parents of a child newly diagnosed with hemophilia A? A. Factor II B. Factor XII C. Factor IX D. Factor VIII
D. Factor VIII
Which nursing intervention would the nurse take for an older adult with dilirium who begins acting out while in the dayroom? A. Instructing the client to be quiet B. Allowing the client to act out until fatigue sets in C. Immediately guiding the client from the room by gently holding the clients arm D. Giving the client one simple direction at a time in firm, low-pitched voice
D. Giving the client one simple direction at a time in firm, low-pitched voice -Clients with delirium typically respond to simple directions stated one at a time in a firm, low-pitched voice.
An infant is found to have developmental dysplasia of the hip 6 weeks after birth. The parents ask the nurse why their infant must be restrained in a harness at such an early age. How would the nurse respond? A. Infants are easier to manage in a harness than toddlers. B. Mobility will be delayed if correction is postponed until later C. Adduction devices cannot be used as effectively after the toddler age. D. Infants' hip joints are cartilaginous, allowing molding of the acetabulum.
D. Infants' hip joints are cartilaginous, allowing molding of the acetabulum.
Which term or phrase would the nurse chart about thought processes to describe a client diagnosed with schizophrenia who says, "Yes, its March. March is little women. That's literal, you know? A. Echolalia B. Neologisms C. Flight of ideas D. Loose associations
D. Loose associations. -Loose associations: Thoughts that are presented with minimal logical connections and are common in schizophrenia. -Echolalia: Purposeless repetition of words spoken by others or repetition of overheard sounds. -Neologisms: Are new meaningless words coined by the client.
Which statement must the nurse emphasize to the family when preparing a school aged child with persistent asthma for discharge? A. A cold, dry environment is desirable B. Limits should not be places on the childs behavior C. The health problem is gone when symptoms subside D. Medication must be continued even when the child is asymptomatic
D. Medication must be continued even when the child is asymptomatic
A child has a fractured arm and multiple old injuries. Child maltreatment is suspected. Which parental characteristics supports this suspicion? A. Inquiring about the time of discharge B. Displaying signs of guilt about the injuries C. Expressing concern about the childs health D. Offering inconsistent stories about the injuries
D. Offering inconsistent stories about the injuries
Which activity places a client at risk for hyperthermia? A. Snowmobiling B. Skiing in the winter C. Hiking Alaskan mountains D. Performing strenuous activity in high humidity
D. Performing strenuous activity in high humidity - When a client performs strenuous activity in high humidity, it reduces heat loss from the body and results in hyperthermia.
A child who is cognitively impaired and blind does not speak or respond to the nurse. Which would the nurse do when entering the childs room? A. Blink the rooms light before starting care B. Start care and explain actions as care is given C. Nonverbally acknowledge the child before starting to give care. D. Say the childs name and touch the childs arm before starting care
D. Say the childs name and touch the childs arm before starting care
Which complication may develop in the child with hypospadias with chordee? A. Renal failure B. Testicular cancer C. Testicular torsion D. Sexual difficulties
D. Sexual difficulties -Chordee can affect the childs future reproduction capabilities, which are related to the inability to inseminate directly. -Kidney function: Not affected with hypospadias with chordee. -Testicular cancer: is not increased; nor is the rick for testicular torsion.
Which characteristic would the nurse associate with collaborative problems experienced by a client? A. They are the identification of a disease condition. B. They include problems treated primarily by nurses C. They are indentified by the primary health care provider. D. They are indentified by the nurse during the nursing diagnosis stage.
D. They are indentified by the nurse during the nursing diagnosis stage.
The nurse instructs the parent of an adolescent with asthma on how to reduce the allergens in the child's bedroom. The mother tells the nurse what she plans todo make the room hypoallergenic. Which idea indicates that further teaching is needed? A. Removing a stuffed animal collection B. Storing off-season clothing in another room C. Covering the mattress with a plastic slipcover D. Using flat out door carpeting to cover hardwood floors
D. Using flat out door carpeting to cover hardwood floors
