Tingnan ang lahat ng mga set ng pag-aaral

Random Cram

Pataasin ang iyong marka sa homework at exams ngayon gamit ang Quizwiz!

1 trust vs. mistrust

(infancy) to 1:Erikson's first stage during the first year of life, infants learn to trust when they are cared for in a consistent warm manner

The client with narcissistic personality disorder often behaves in grandiose and entitled ways, believes that he/she is perfect, and relies on constant reinforcement and admiration from people perceived as ideal. What is the BEST explanation for these clinical characteristics? 1. The client is attempting to maintain self-esteem 2. The client is experiencing delusions of grandeur 3. The client is feeling threatened 4. The client is trying to prevent a panic attack

The nurse is providing care to a client experiencing posttraumatic stress disorder (PTSD) following a terrorist attack at the client's place of worship. What is the PRIORITY nursing action? 1. Acknowledge the client's feelings of anger 2. Assess the client's support system 3. Encourage the client to talk about the trauma 4. Offer the client a PRN sleep medication

8 integrity vs. despair

(late adulthood) late 60s and up:When reflecting his/her life, the older adult may feel a sense of satisfaction or despair.

The nurse is caring for a client with bulimia nervosa. Which is the MOST IMPORTANT time for the nurse to monitor the client's behavior? 1. During 1-2 hours after each meal 2. During every meal 3. During the evening meal 4. During the overnight hours

Which client statement demonstrates mental health well-being when considering stress and anxiety? 1. "I know that relaxation techniques help me deal with my life's stress and anxiety." 2. "I understand stress and anxiety because my family has a history of depression." 3. "You must understand that stress and anxiety affect everyone's life." 4. "You should identify and then avoid those things that cause you stress and anxiety."

Which of the following actions would the nurse include in planning care for a client hospitalized for bipolar disorder, acute manic episode? SELECT ALL THAT APPLY. 1. Assign the client to a private room 2. Choose clothing for the client 3. Have the client be in charge of planning an outing for the unit 4. Have the client join other clients in the dining room for meals 5. Have the client participate in physical exercise with a staff member 6. Include the client in group therapy sessions

1,2,5

The registered nurse is leading a support group for partners of military veterans suffering from postiraumatic stress disorder (PTSD) A participant asks the nurse how to identify the typical symptoms of PTSD. The nurse responds that MOST individuals with PTSD report which symptoms? 1. Auditory hallucinations, feelings of paranoia, isolation from others 2. Increased anxiety, reliving the event, feeling detached from others 3. Rapidly changing emotions, delusions, lethargy 4. Recurring nightmares, uncontrollable anger, daytime sleepiness

The nurse Is preparing discharge instructions for a client with a history of alcohol abuse on the third day after an emergency appendectomy. The nurse suspects delirium tremens based on which assessment data? Select all that apply. 1. Bradypnea 2. Diaphoresis 3. Hallucinations 4. Lethargy 5. Tachycardia

2,3,5

A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. Which of the following is the PRIORITY nursing diagnosis? 1. Impaired social interaction 2. Impaired verbal communication 3. Risk for deficient fluid volume 4. Risk for impaired skin integrity

A client with severe major depressive disorder is lying in bed and has not moved for 3 hours. The client will respond slowly to "yes" and "no" questions otherwise, the client does not respond when spoken to. The clinical manifestations exhibited by the client are known as: 1. Psychogenic dystonia 2. Psychogenic gait 3. Psychomotor retardation 4. Somatization

An elderly client at the end of life is visited by family members. One begins to cry and asks the nurse, "Will you please stay for a few minutes?" The nurse has other clients to care for as well. Which statement by the nurse is the MOST helpful? 1. "I am busy right now but can stay for a few minutes." 2. "I can call the clergy to come sit with you." 3. "I can stay and sit with you if you would like." 4. "I don't think I should interrupt your family time."

The nurse speaks with a client diagnosed with schizophrenia who begins to look away toward the door and grimace. Which statement by the nurse is MOST therapeutic at this time? 1. "It would be helpful if you could look at me while we talk." 2. "We can finish our conversation later; thank you for speaking with me." 3. "What do you see at the door?" 4. "When you don't look at me, I feel like you don't trust me"

A newly admitted client with schizophrenia has been exhibiting severe social withdrawal, odd mannerisms, and regressive behavior. The client is sitting alone in the room when the nurse enters, says "good morning," and proceeds to sit down next to the client. Without responding, the client stands up and starts to leave. Which of the following actions is BEST for the nurse to take? 1. Ask where the client is going 2. Immediately follow the client out the door 3. In a loud voice, direct the client to come back to the room 4. Remain silent and allow the client to leave

Variability

6 - 10 bpm

*A client diagnosed with rheumatoid arthritis (RA) is prescribed 50 mg etanercept subcutaneous weekly. The client reports joint swelling, symmetrical joint pain, and deformities of both hands. Which finding does the nurse report to the health care provider? 1. White cell count 14,000/mm 3 (14 x 10 9/L). 2. C-reactive protein 1.2 mg/dL. 3. Serum hemoglobin 9 mg/dL (90 g/L). 4. Sedimentation rate 22 mm/hr.

Correct: 1 Rationale: WBC of 14,000 may indicate active infection (normal: 4,500 to 10,500), which is a contraindication to etanercept. 2,3,4: Expected findings with moderate to severe RA clients. **Etanercept: DMARDs, MOA: binds to TNF (a mediator of inflammatory response) = decreased inflammation and slowed preogression of RA/spondylitis/psoriasis.**

To maintain client safety, the nurse should have which of the following equipment readily available when inserting an Ewald tube? 1. Suction equipment. 2. Blood pressure cuff. 3. Levine tube. 4. Emesis basin.

Strategy: Think about each answer choice. (1) correct—Ewald tube is a large, orogastric tube designed for rapid lavage; insertion often causes gagging and vomiting, suction equipment must be immediately available to reduce the risk of aspiration (2) not a high priority (3) not a high priority (4) not a high priority

The physician orders sucralfate (Carafate) 1 g PO bid for a client taking digoxin (Lanoxin) 0.25 mg daily. The client asks the nurse if both pills can be taken together at breakfast so that the client doesn't forget to take them. The nurse should advise the client to take which of the following actions? 1. Take the Carafate and Lanoxin before breakfast. 2. Take the Lanoxin 1 hour before breakfast and the Carafate 1 hour after breakfast. 3. Take the Carafate 1 hour before breakfast and the Lanoxin 1 hour after breakfast. 4. Take the Carafate and the Lanoxin after breakfast.

(1) Carafate forms a barrier on the gastrointestinal mucosa, would decrease absorption of other medications, separate by 2 hours (2) Carafate best results on empty stomach (3) correct—Carafate best results on empty stomach, medications should be separated by 2 hours for maximum absorption (4) Carafate best results on empty stomach, medications should be separated by 2 hours for maximum absorption

The nurse observes care given to a client experiencing severe to panic levels of anxiety. The nurse should intervene in which of the following situations? 1. The staff maintains a calm manner when interacting with the client. 2. The staff attends to client's physical needs as necessary. 3. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety. 4. The staff assesses the client's need for medication or seclusion if other interventions have failed to reduce anxiety.

(1) appropriate nursing action for this level of anxiety (2) appropriate nursing action for this level of anxiety (3) correct—at this level of anxiety, client is unable to process thoughts and feelings for problem solving (4) appropriate nursing action for this level of anxiety ...

Which of the following nursing actions is important for safe administration of oxytocin? 1. Assess respirations and urine output. 2. Administer oxytocin parenterally as the primary IV. 3. Have calcium gluconate available as an antidote. 4. Palpate the uterus frequently.

(1) assessment; pertinent to the care of a client receiving magnesium sulfate for pre-eclampsia (2) implementation; oxytocin is always given via an infusion pump and is never allowed to be the primary IV (3) implementation; pertinent to the care of a client receiving magnesium sulfate for pre-eclampsia (4) correct—assessment; oxytocin stimulates the uterus to contract, which necessitates frequent assessment of the uterus; prolonged tetanic contraction can lead to a ruptured uterus

The nurse recognizes which of the following as a positive response to fluoxetine HCl (Prozac)? 1. The nurse notes hand tremors and leg twitching. 2. The client states that he is able to sleep for longer periods of time. 3. The client has an increased energy level and participates in unit activities. 4. The nurse observes that the client is hypervigilant and scans the environment.

(1) can be side effect of the medication (2) not an effect of Prozac, can actually inhibit sleep; is useful with clients who experience increased sleeping and psychomotor retardation and lethargy (3) correct—fluoxetine HC (Prozac) is an "energizing" antidepressant; as client begins to demonstrate a positive response, he has an increased energy level, is able to participate more in milieu (4) can be side effect of medication

The nurse returns to the desk and finds four phone messages to return. Which of the following messages should the nurse return FIRST? 1. A woman in the first trimester of pregnancy complains of heartburn. 2. A man complains of heartburn that radiates to the jaw. 3. A woman complains of hot flashes and difficulty sleeping. 4. A boy complains of knee pain after playing basketball.

(1) caused by reflux of gastric contents into esophagus, treatment is small, frequent meals, don't consume fluids with food, don't wear tight clothing (2) correct—indicates chest pain, needs to seek medical attention immediately (3) caused by menopause, treat with hormone replacement therapy (HRT) (4) should treat with rest and ice

A client is seen in the clinic for treatment of chronic back pain. The client mentions to the clinic nurse that at home he applies an ointment prepared from several different herbs that relieves his lower back pain. He asks the nurse, "Should I continue using it?" Which of the following responses by the nurse would be BEST? 1. "No. It might do you more harm than good." 2. "Yes. Continue using it, but I don't see how it could help your condition." 3. "You may think it works, but I don't believe home remedies work." 4. "Pain can be relieved in several ways. Consult your physician regarding this home remedy."

(1) closed statement (2) closed statement; casts doubt on efficiency of alternative therapy (3) focus should be on client, not on nurse's beliefs (4) correct—herbal medication can interact with other medication ...

An older client undergoes the second exchange of intermittent peritoneal dialysis (IPD). Which of the following requires an intervention by the nurse? 1. The client complains of pain during the inflow of the dialysate. 2. The client complains of constipation. 3. The dialysate outflow is cloudy. 4. There is blood-tinged fluid around the intra-abdominal catheter. An older client undergoes the second exchange of intermittent peritoneal dialysis (IPD). Which of the following requires an intervention by the nurse? 1. The client complains of pain during the inflow of the dialysate. 2. The client complains of constipation. 3. The dialysate outflow is cloudy. 4. There is blood-tinged fluid around the intra-abdominal catheter.

(1) common complaint, moderate pain is frequently experienced as fluid is instilled during first few exchanges (2) common complaint due to inactivity, decreased nutrition, use of medications; high-fiber diet and stool softeners help prevent (3) correct—indicates peritonitis, also will see nausea and vomiting, anorexia, abdominal pain, tenderness, rigidity (4) caused by subcutaneous bleeding, common during first few exchanges ...

(1) correct—Ewald tube is a large, orogastric tube designed for rapid lavage; insertion often causes gagging and vomiting, suction equipment must be immediately available to reduce the risk of aspiration (2) not a high priority (3) not a high priority (4) not a high priority

The nurse cares for clients in the pediatric clinic. The mother of a child calls the nurse to say that after administering Dimetane-DC cough syrup to her child, her child becomes very excitable and restless. Which of the following actions by the nurse is MOST appropriate? 1. Report the child's behavior to the physician to alert the physician to the potential need for a change in medication. 2. Instruct the mother to administer half the ordered amount in all future doses to limit this behavioral response. 3. Instruct the mother to give the child a glass of warm milk to dilute any medication left in the stomach. 4. Chart the child's response to the medication, and alert the staff about the mother's phone call.

(1) correct—although this type of response to antihistamines is not uncommon in young children, it is undesirable and must be reported to the physician so that a change in drug therapy can be initiated (2) is not within the realm of the nurse's scope of practice; physician must order dose changes (3) inappropriate (4) response must be charted, and the child's intolerance to the drug documented and reported to other nurses; this is not enough, physician must be alerted so that preventive action can be taken

A 2-year-old is admitted to the pediatric unit with numerous bruises, a fractured left humerus, and several lacerations with unexplained origin. The nurse identifies which of the following as a priority nursing action? 1. Report the findings to the child protection agency. 2. Share this information only with other health care professionals. 3. Document this information in the chart. 4. Share the information with the pediatric social worker.

(1) correct—any suspicion of child abuse should be reported to the child protection agency (2) does not provide or plan for protection of the child (3) does not provide or plan for protection of the child (4) does not provide or plan for protection of the child

Which of the following statements should the nurse make to a client who is going to self-administer continuous ambulatory peritoneal dialysis (CAPD) at home? 1. "Check your weight daily." 2. "Maintain clean technique at all times during the procedure." 3. "Milk the catheter to encourage extra fluid to be removed from the abdomen." 4. "Eat a well-balanced, low-protein diet."

(1) correct—assessment; daily weight necessary with peritoneum empty to assess fluid volume status, guidelines for weight gain/loss set by physician (2) implementation; strict aseptic technique required to prevent contamination, sterile = aseptic, clean = antiseptic (3) implementation; don't milk catheter, drainage by gravity only (4) implementation; encouraged to eat a high-protein diet because of protein loss with CAPD ...

An extremely agitated client receives haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room. It is MOST important for the nurse to take which of the following actions? 1. Monitor blood pressure every 30 minutes. 2. Remain at the client's side to provide reassurance. 3. Tell the client the name of the medication and its effects. 4. Assess for anticholinergic effects of the medication.

(1) correct—assessment; monitoring vital signs is of utmost importance to ensure client safety and physiological integrity; rapid neuroleptization is a pharmacological intervention used to rapidly diminish severe symptoms that accompany acute psychosis; alpha-adrenergic blockade of peripheral vascular system lowers BP and causes postural hypotension (2) implementation; should be done but is not highest priority (3) implementation; should be done but is not highest priority (4) assessment; circulatory system takes priority

The nurse cares for a client with type 1 diabetes. The client receives nasal oxygen at 4 L/min. The student nurse reports that the client has pulled out the nasogastric tube and is picking at the bed covers. The client's BP is 150/90 and pulse is 90. Which of the following actions by the nurse is MOST appropriate? 1. Obtain a pulse oximetry reading. 2. Apply soft wrist restraints. 3. Reorient the client to person and place. 4. Determine the client's blood glucose level.

(1) correct—assessment; symptoms indicate reduced oxygen levels (2) implementation; must assess first to determine problem; all other interventions must be tried before using restraints (3) implementation; must determine the cause of the behavior before implementing (4) assessment; symptoms indicate decreased oxygen levels

A client comes to the health clinic and tells the nurse that the client has taken acetaminophen (Aspirin-Free Excedrin) daily for 5 months. The nurse is MOST concerned by which of the following lab results? 1. AST (SGOT) 30 units/L, ALT (SGPT) 27 units/L. 2. Hgb 16.2 g/dL, Hct 46%. 3. WBC 7,000/mm3. 4. BUN 9 mg/dL.

(1) correct—can cause liver damage, normal AST (formerly SGOT) 8 to 20 units/L, normal ALT (formerly SGPT) 8 to 20 units/L (2) normal Hgb male 13.5-17.5 g/dL, female 12-16 g/dL, normal Hct male 41 to 53%, female 36 to 46% (3) normal WBC 5,000 to 10,000/mm3 (4) normal BUN 7 to 18 mg/dL

A child returns to the recovery room after a bronchoscopy. The nurse should position the client in which of the following positions? 1. Semi-Fowler's position. 2. Prone with the head turned to the side. 3. Head of the bed elevated 45° with the neck extended. 4. Supine with the head in the midline position.

(1) correct—check vital signs every 15 minutes until stable, assess for respiratory difficulty (stridor and dyspnea resulting from laryngeal edema or laryngospasm) (2) would limit respiratory excursion and assessment of breathing (3) extension of neck could obstruct airway because tongue falls in back of mouth (4) not best position after procedure

The nurse knows which of the following observations is indicative of chronic cocaine use? 1. Nasal septum disruption. 2. Lack of coordination. 3. Constricted pupils. 4. Craving for sweets and carbohydrates.

(1) correct—chronic inhalation creates sores, burns, disruption of mucous membranes, and holes in the nasal septum (2) barbiturate abusers typically suffer from lack of coordination (3) narcotic abusers demonstrate constricted pupils (4) clients who abuse marijuana, hashish, and/or THC experience cravings for sweets and carbohydrates ...

A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are BUN 25 and K+ 4.0 mEq/L. The nurse should restrict which of the following in the client's diet? 1. Protein. 2. Fats. 3. Carbohydrates. 4. Magnesium.

(1) correct—decreased production of urea nitrogen can be achieved by restricting protein; metabolic wastes cannot be excreted by the kidneys (2) decreases the nonprotein nitrogen production; these foods are encouraged (3) decreases the nonprotein nitrogen production; these foods are encouraged (4) should not be restricted ...

The nurse cares for a young adult admitted to the hospital with a severe head injury. The nurse should position the patient in which of the following positions? 1. With the client's neck in a midline position and the head of the bed elevated 30°. 2. Side-lying with the client's head extended and the bed flat. 3. In high Fowler's position with the client's head maintained in a neutral position. 4. In semi-Fowler's position with the client's head turned to the side.

(1) correct—decreases intracranial pressure (2) decreases venous blood return (3) too elevated, would increase intracranial pressure (4) head should be maintained in neutral position

(1) correct—decreases intracranial pressure (2) decreases venous blood return (3) too elevated, would increase intracranial pressure (4) head should be maintained in neutral position ...

The visiting nurse instructs a client how to use esophageal speech following a total laryngectomy. Which of the following actions, if performed by the client, indicates teaching is effective? 1. The client swallows air and then eructates it while forming words with his mouth. 2. The client places a battery-powered device against the side of his neck. 3. The client places a finger over the tracheostomy, forcing air up through the vocal cords. 4. The client covers the stoma in the tracheoesophageal fistula and moves his lips

(1) correct—describes esophageal speech (2) describes electric larynx (3) method of speech for patient with a tracheostomy (4) describes tracheoesophageal fistula (TEF)

The nurse cares for clients in the skilled nursing facility. Which of the following clients requires the nurse's IMMEDIATE attention? 1. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin (Coumadin) expired 2 days ago. 2. A client in pain who was receiving morphine in an acute care institution and was transferred with a prescription for acetaminophen with codeine. 3. A client who has dysuria and foul-smelling, cloudy, dark amber urine. 4. An immunosuppressed client who has not received an influenza immunization.

(1) correct—duration of Coumadin 2 to 5 days, client at risk for a repeat CVA (2) anticoagulant takes priority, client still receiving pain medication (3) painful urination, may indicate infection (4) anticoagulant takes priority

The nurse cares for a 26-year-old woman immediately after delivery of 8-lb, 4-oz baby girl. The patient's history indicates that she was diagnosed with type 1 diabetes at age 12. The nurse expects which of the following changes to occur in the patient? 1. The blood sugar will fall because of a sudden decrease in insulin requirements. 2. The blood sugar will rise because of a rapid decrease in circulating insulin. 3. The blood sugar will gradually rise because of a decreased level of metabolic stress. 4. The blood sugar will gradually fall because of a decrease in food intake.

(1) correct—hormonal interference in glucose metabolism during pregnancy causes insulin requirements to increase then decrease after delivery (2) blood sugar will fall after delivery (3) blood sugar level will fall after delivery (4) fall in blood sugar not primarily caused by decrease in food intake

A patient is returned to the room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential? 1. Potassium chloride for IV administration. 2. Calcium gluconate for IV administration. 3. Tracheostomy setup. 4. Suction equipment.

(1) correct—hypokalemia is not expected after this surgery (2) used to treat tetany resulting from possible damage to parathyroid glands (3) essential equipment to provide for airway (4) needed to maintain a patent airway

Which of the following assessment findings indicates to the nurse the need for more sedation for a client withdrawing from alcohol dependence? 1. Steadily increasing vital signs. 2. Mild tremors and irritability. 3. Decreased respirations and disorientation. 4. Stomach distress and inability to sleep.

(1) correct—indication that the client is approaching delirium tremens, which can be avoided with additional sedation (2) describes normal mild withdrawal symptoms (3) would contraindicate giving more sedation (4) describes expected symptoms of alcohol withdrawal, which will subside as the alcohol is excreted from the body

When administering antipsychotic medications parenterally, the nurse should take which of the following actions? 1. Monitor the client's blood pressure while the client is sitting and standing before and after each dose is given. 2. Caution the client not to drink or operate machinery that requires mental alertness for safety. 3. Have an emergency cart available in case of an adverse reaction. 4. Reassure the client that side effects are only temporary.

(1) correct—primary concern with postural hypotension caused by medication and preventing an injury from a fall; monitoring vital signs will provide data to address this concern (2) not relevant with this classification of medications (3) not relevant with this classification of medications (4) not relevant with this classification of medications

Which nursing intervention is a priority in preventing complications after a cesarean birth? 1. Turn, cough, and deep breathe. 2. Limit fluid intake. 3. Supply a high-carbohydrate diet. 4. Evaluate skin integrity.

(1) correct—represents preventive care for respiratory congestion resulting from anesthesia and shallow respirations due to the abdominal incision (2) fluids should be encouraged (3) will not prevent complications (4) does not address a common complication...

The nurse completes client assignments for the day. The nurse should assign an LPN/LVN to which of the following clients? 1. A client who had a total hip replacement and requires assistance with ambulation. 2. A client with type I diabetes mellitus who has bilateral 4+ pitting edema of the feet. 3. A client with cholelithiasis scheduled for a cholecystectomy and receiving IV morphine. 4. A client 6 hours postoperative after cystoscopy to remove a mass in the bladder.

(1) correct—stable patient with expected outcome (2) requires the assessment skills of the RN (3) requires assessment and teaching (4) requires assessment skills of RN ...

When assisting with a bone marrow aspiration, the nurse should take which of the following actions? 1. Drop additional sterile supplies onto a sterile tray. 2. Unwrap all sterile packs for the procedure in case they are needed. 3. Reach over the tray, and remove contaminated supplies. 4. Place the bottle of sterile liquid on the sterile field so that it does not splash.

(1) correct—sterile articles should be dropped at a reasonable distance from the edge of the sterile area (2) sterile packs should be opened only as needed (3) never reach an unsterile arm over a sterile field (4) outside of a bottle containing sterile liquid is not considered to be sterile ...

Which of the following techniques is correct for the nurse to use when changing a large abdominal dressing on an incision with a Penrose drain? 1. Remove the dressing layers one at a time. 2. Clean the wound with Betadine solution and hydrogen peroxide. 3. Clean the drain area first. 4. If the dressing adheres to the wound, pull gently and firmly.

(1) correct—to avoid dislodging drain, remove the dressing layers one at a time (2) do not clean a wound with both Betadine solution and hydrogen peroxide (3) cleansing of the wound is from the center outward to the edges and from the top to the bottom (4) incorrect; may dislodge drain ...

The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time? 1. Confirm that all staff members understand and comply with the treatment plan. 2. Establish mutually agreed-upon, realistic goals. 3. Ensure that the potent reinforcers (rewards) are important to the client. 4. Establish a fixed interval schedule for reinforcement.

(1) correct—to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program (2) not of primary importance in designing an effective behavior modification program (3) not of primary importance in designing an effective behavior modification program (4) not of primary importance in designing an effective behavior modification program

During preadmission planning for a client scheduled for a renal transplant, the client should be educated by the nurse regarding which of the following? 1. Remind family and friends that there is restricted visiting for at least 72 hours postoperatively. 2. Arrange all live plants received postoperatively in one section of the room. 3. Continue intermittent peritoneal dialysis for 3 months following surgery. 4. Limit consumption of sodium-free liquids for 1 year postoperatively.

(1) correct—transplant clients require protective isolation following surgery (2) can't have live plants in the room at all (3) no need for dialysis following transplant (4) need to force fluids, not restrict them ...

Which of the following assessments does the nurse expect to make regarding the developmental stage of a 40-year-old male? 1. Cognitive skills are starting to decline. 2. A balance is found among work, family, and social life. 3. Bone mass begins to increase at this age. 4. The client starts to measure life accomplishments against goals.

(1) does not occur (2) occurs earlier in development (3) at age 40, bone mass begins to decrease (4) correct—may precipitate a mid-life crisis ...

The nurse plans care for a client on bed rest. To promote evening rest and sleep for this client, it is MOST important for the nurse to take which of the following actions? 1. Provide privacy. 2. Give back rubs at bedtime. 3. Assist with a bath every day. 4. Encourage daytime activities.

(1) excessive privacy can limit sensory input (2) will help client to relax but is not most important (3) should encourage client to do as much of his care as he can to maintain independence (4) correct—provides relief from tension, ensures client naps less during the day, helps client relax ...

The nurse assesses the development of a 3-month-old boy in the well-child clinic. Which of the following behaviors, if observed by the nurse, is UNEXPECTED? 1. The boy holds his head erect when sitting on the examination table. 2. The boy tries to grasp a toy just out of reach. 3. The boy turns his head to try to locate a sound. 4. The boy smiles spontaneously when he sees his mother.

(1) expected at 3 months (2) correct—unexpected until 6 months of age (3) expected at 3 months of age (4) expected at 3 months of age

The nurse supervises the staff caring for four clients receiving blood transfusions. Which of the four clients should the nurse see FIRST? 1. A client complaining of a headache. 2. A client vomiting. 3. A client complaining of itching. 4. A client with neck vein distention.

(1) febrile reaction; symptoms include fever, chills, nausea, headache; treatment is to stop blood and administer aspirin (2) correct—hemolytic reaction; most dangerous type of transfusion reaction, symptoms include nausea, vomiting, pain in lower back, hematuria; treatment is to stop blood, obtain urine specimen, and maintain blood volume and renal perfusion (3) allergic reaction; symptoms include urticaria, pruritus, fever; treatment is to stop blood, give Benadryl, and administer oxygen (4) circulatory overload; treatment is to stop blood, position in an upright position, and administer oxygen

A client diagnosed with bipolar disorder receives haloperidol (Haldol) 2 mg PO tid. The client tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST? 1. "You are seeing things that aren't real." 2. "Why don't we go make some fudge?" 3. "You are experiencing a side effect of Haldol." 4. "I'll contact your physician to change your medication."

(1) hallucinations usually not seen with patients with bipolar disorder; seen with psychotic disorders (2) assumption that patient just wants attention (3) correct—side effects include galactorrhea (excessive or spontaneous flow of milk), lactation, gynecomastia (excessive growth of male mammary glands) (4) indicates a side effect, not effectiveness of medication

The nurse cares for clients on the medical/surgical unit. The nurse identifies which of the following clients is MOST at risk for developing herpes zoster? 1. A 19-year-old with a broken tibia in Buck's traction. 2. A 50-year-old with a diabetic foot ulcer. 3. A 62-year-old heart transplant with suspected rejection. 4. An 84-year-old with chronic obstructive pulmonary disease.

(1) has an acute trauma, is not immunocompromised (2) has a bacterial infection, is not immunocompromised (3) correct—immunocompromised due to immune suppression therapy; clients with compromised immune system at risk for reactivation of the varicella zoster virus (4) has chronic disease, is not immunocompromised ...

A young adult asks the nurse in the AIDS clinic what to do for the multiple small, painless purplish-brown spots on the right leg and ankle. The nurse should instruct the client to take which of the following actions? 1. Clean the spots carefully with soap and warm water twice a week, and cover them with a sterile dressing. 2. Clean the lesions twice a day with a diluted solution of povidone-iodine (Betadine), and leave them open to the air. 3. Shower daily using a mild soap from a pump dispenser, and pat the skin dry. 4. Soak in a warm tub three times a day, and rub the spots with a washcloth.

(1) if lesions are open and draining, they must be cleaned and dressed daily to prevent secondary infection (2) treatment for herpes simplex virus abscess, not Kaposi's sarcoma (3) correct—important to keep the skin clean and prevent secondary skin infection (4) increases risk of secondary skin infection

The nurse cares for a child several hours after the application of a hip spica cast. The patient turns on the call light and complains of pain in the left foot. Which of the following actions should the nurse take FIRST? 1. Elevate the left leg on two pillows. 2. Palpate the cast for warmth and wetness. 3. Administer pain medication as ordered. 4. Check the blanching sign on both feet.

(1) implementation; done to prevent swelling and venous congestion, not helpful to reduce pain due to circulatory impairment (2) assessment; not helpful to reduce pain due to circulatory impairment, should not palpate wet cast, would result in depressions causing pressure (3) implementation; pain important diagnostic symptom, should not be suppressed or masked (4) correct—assessment; pain main symptom of circulatory impairment from cast; pressing nail of great toe indicates circulatory function, compare speed with which color returns with result on the opposite side; sluggish return indicates circulatory impairment, too rapid return indicates venous congestion ...

The nurse monitors the fluid status of an older patient receiving IV fluids following surgery. Which of the following symptoms suggests to the nurse that the patient has fluid volume overload? 1. Temperature 101°F (38.3°C), BP 96/60, pulse 96 and thready. 2. Cool skin, respiratory crackles, pulse 86 and bounding. 3. Complaints of a headache, abdominal pain, and lethargy. 4. Urinary output 700 ml/24 h, CVP of 5, and nystagmus.

(1) indicates dehydration (2) correct—will see bounding pulse, elevated BP, distended neck veins, edema, headache, polyuria, diarrhea, liver enlargement (3) symptoms could be from causes other than volume overload (4) slightly reduced output, CVP would be elevated, normal CVP 3 to 12 mm/H2O, involuntary eye movements not seen

The nurse in the outpatient clinic instructs the mother of a school-aged child diagnosed with asthma how to prevent future asthmatic attacks. The nurse is MOST concerned if the mother states which of the following? 1. "My son plays the tuba in the grade school band." 2. "My son loves to help his dad rake leaves." 3. "My son participates in after-school activities 3 days a week." 4. "My son walks 1 mile to school every day with his friends." The nurse in the outpatient clinic instructs the mother of a school-aged child diagnosed with asthma how to prevent future asthmatic attacks. The nurse is MOST concerned if the mother states which of the following? 1. "My son plays the tuba in the grade school band." 2. "My son loves to help his dad rake leaves." 3. "My son participates in after-school activities 3 days a week." 4. "My son walks 1 mile to school every day with his friends."

(1) involves forced expiration; would not cause problems with asthma (2) correct—main cause of asthma is inhaled allergens (animal dander, mold, pollen, dust), would expose child to pollen and dust from leaves (3) school activities should be encouraged to help development (4) walking is good exercise; running could be a problem if he has exercise-induced asthma

A client who is positive for human immunodeficiency virus (HIV) is to be discharged and will be taking zidovudine (AZT) at home. Which of the following actions by the nurse is BEST? 1. Review the importance of adhering to a 4-hour schedule. 2. Advise the client to buy a timed pill dispenser. 3. Write the schedule of when the medicine should be taken. 4. Encourage self-medication prior to discharge.

(1) less helpful in the overall teaching-learning process (2) less helpful in the overall teaching-learning process (3) correct—planned and written schedule of administration is more effective for adherence to time frames (4) less helpful in the overall teaching-learning process ...

The nurse counsels an elderly client who comes to the outpatient clinic for a routine examination. The history indicates the client takes a laxative tablet twice a day and a laxative suppository once a day. The nurse should suspect which of the following about the client? 1. The client has an anal fixation resulting from recent loss of a spouse. 2. The client is depressed because of alterations in intestinal absorption and excretion. 3. The client is experiencing excessive concern with body function because of physical changes. 4. The client has regressed because of a fear of losing the ability to have bowel movements.

(1) makes judgment without information (2) constipation common finding in elderly; no information about depression (3) correct—physical changes occur in late adulthood causing changes in body image; constipation frequent problem of elderly, but reaction by this client is excessive (4) no information provided about regression ...

After a client has a positive Chlamydia trachomatis culture, the client and partner return for counseling. It is MOST important for the nurse to ask which of the following questions? 1. "Do you have contacts to identify?" 2. "What is your understanding regarding how chlamydia is transmitted?" 3. "Do you have questions about the culture and its validity?" 4. "Do you have allergies to the medications?"

(1) may be part of follow-up (2) correct—means of transmission of chlamydia may or may not have been made clear to both partners; nurse should assess this first; is a sexually transmitted disease (3) most cultures used today have few false positives (4) would be done later in the nursing assessment

The nurse teaches a well-baby class to a group of parents with toddlers. The nurse should encourage the parents to do which of the following? 1. Exercise their children daily. 2. Use a playpen whenever possible. 3. Provide a safe play area for their children. 4. Teach their children noncompetitive activities.

(1) no specific exercise program is necessary; children of this age in good health are naturally active (2) limits a child's interaction with the outside world, should be used judiciously (3) correct—safety is fundamental issue with this age group; they are exploratory in their play (4) unnecessary; children learn by observing and by participating

A 4-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5°C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding indicates an increase in intracranial pressure? 1. Positive Babinski. 2. High-pitched cry. 3. Bulging posterior fontanelle. 4. Pinpoint pupils.

(1) normal for the first year of life (2) correct—high-pitched cry is one of the first signs of an increase in the intracranial pressure in infants (3) fontanelle should be closed by the third month (4) with increased pressure, the pupil may respond to light slowly, rather than with the usual brisk response

After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), the nurse notes a decrease in muscle tone. The nurse determines which of the following nursing diagnoses is priority? 1. Alteration in mobility related to paralysis. 2. Alteration in skin integrity related to decrease in tissue oxygenation. 3. Alteration in skin integrity related to immobility. 4. Alteration in communication related to decrease in thought processes.

(1) not a priority (2) correct—leading cause of skin breakdown is a decrease in tissue perfusion

A client is in cardiogenic shock after a myocardial infarction (MI). Which of the following is a correctly stated nursing diagnosis for the client? 1. Activity intolerance: related to impaired oxygen transport. 2. Altered tissue perfusion related to decreased heart-pumping action. 3. Altered cardiac output related to cardiac ischemia. 4. Potential fluid volume deficit related to decreased intake.

(1) not best (2) correct—correctly stated, appropriate nursing diagnosis (3) altered cardiac output is not a commonly accepted nursing diagnosis (4) not appropriate for this client

(1) not best (2) correct—correctly stated, appropriate nursing diagnosis (3) altered cardiac output is not a commonly accepted nursing diagnosis (4) not appropriate for this client ...

A 48-year-old woman is seen in the outpatient clinic for complaints of irregular menses. The client's history indicates an onset of menses at age 14, para 2 gravida 2, and regular periods every 28 to 30 days. The client is divorced and works full time as a bank teller. The nurse identifies the MOST probable cause of the client's symptom is which of the following? 1. Emotional trauma and stress. 2. Onset of menopause. 3. Presence of uterine fibroids. 4. Possible tubal pregnancy.

(1) not enough information given in question to assume that symptoms are caused by stress (2) correct—ovarian function gradually decreases and then stops, usually 45 to 50 years old (3) benign tumors arising from muscle tissue of uterus, menorrhagia (excessive bleeding) most common symptom along with backache, constipation, dysmenorrhea (4) usually see history of missed periods or spotting with abdominal pain ...

The nurse cares for clients in the pediatric clinic. A mother reports that her infant's smile is "crooked". The nurse should assess which of the following cranial nerves? 1. III. 2. V. 3. VII. 4. XI.

(1) oculomotor; provides innervation for extraocular movement (2) trigeminal; provides sensation to facial muscles (3) correct—facial; provides motor activity to the facial muscles (4) spinal accessory; provides innervation to the trapezius and sternocleidomastoid muscles ...

The nurse cares for a client just returning to the postsurgical unit following abdominal surgery for cancer of the colon. It is MOST appropriate for the nurse to take which of the following actions? 1. Determine the stage of loss and grief. 2. Analyze the quality and quantity of pain. 3. Instruct the client to cough and deep breathe. 4. Ask the client to lift his head off the pillow.

(1) physical needs take priority (2) not most important (3) implementation; should first assess (4) correct—should assess whether there are any remaining effects of neuromuscular blocking agents; may block ability to breathe deeply ...

A client is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse identifies which of the following comments by the client is MOST indicative of this disorder? 1. "I keep having recurring nightmares." 2. "I have a headache, and my stomach has bothered me for a week." 3. "I always check the door locks three times before I leave home." 4. "I don't know who I am, and I don't know where I live."

(1) posttraumatic stress disorder (PTSD) is characterized by anxiety and stress symptoms that occur after an intense traumatic event; characteristic symptoms are hypervigilance, insomnia, and recurring nightmares (2) somatoform disorder (or hypochondria) is concerned with physical and emotional health, accompanied by various bodily complaints for which there is no physical basis (3) reflects the compulsive checking behavior of the anxiety associated with obsessive-compulsive disorder (4) correct—dissociative disorders characterized by either a sudden or a gradual disruption in the integrative functions of identity, memory, or consciousness; disruption may be transient or may become a well-established pattern; development of these disorders is often associated with exposure to a traumatic event

The nurse knows that the client diagnosed with drug-induced Cushing's syndrome should FIRST be instructed about which of the following? 1. Compression fractures from increased calcium excretion. 2. Decreased resistance to stress. 3. The schedule for gradual withdrawal of the drug. 4. Changes in secondary sex characteristics.

(1) problems associated with Cushing's syndrome but are not the first priority (2) problems associated with Cushing's syndrome but are not the first priority (3) correct—if steroids are withdrawn suddenly, the client may die of acute adrenal insufficiency (4) not seen with this medication ...

The nurse leads an in-service education class on legal issues. The nurse identifies which of the following acts constitutes battery? 1. The nurse restrains an agitated, confused patient in the emergency room with a physician's order. 2. The nurse chases a patient who tries to run away while outside for a walk. 3. The nurse holds the arms of a manic patient who struck her while the nurse calls for assistance. 4. The nurse administers an injection to a schizophrenic patient who refuses to take the medication by mouth because he believes it is poison.

(1) restraining a client to prevent injury to self or others is appropriate (2) appropriate behavior (3) restraining a client to prevent injury to self or others is appropriate (4) correct—battery is harmful or offensive touching of another's person; unless court ordered, clients have the right to refuse medication, even if client is psychotic

The nurse administers morphine 6 mg IV push to a patient for postoperative pain. Following administration of the drug, the nurse observes the following: BP 100/68, pulse 68, respirations 8, client sleeping quietly. Which of the following nursing actions is MOST appropriate? 1. Allow the client to sleep undisturbed. 2. Administer oxygen via face mask or nasal prongs. 3. Administer naloxone (Narcan). 4. Place epinephrine 1:1,000 at the bedside.

(1) should be given Narcan for low respiratory rate (2) problem is low respirations; this may be administered after medication (3) correct—IV naloxone (Narcan) should be given to reverse respiratory depression; respiratory rate of 8 is too low and necessitates a nursing action (4) unnecessary

Which of the following is a correct instruction by the nurse to the parent of a 4-year-old client regarding collecting a specimen to be tested for pinworms? 1. Collect the specimen 30 minutes after the child falls asleep at night. 2. Save a portion of the child's first stool of the day and take it to the physician's office immediately. 3. Collect the specimen in the early morning with a piece of Scotch tape touched to the child's anus. 4. Feed the child a high-fat meal, and then save the first stool following the meal.

(1) specimen should be collected early in the morning after the child awakens (2) unnecessary; pinworms are not routinely found in the stool (3) correct—pinworms crawl outside the anus early in the morning to lay their eggs (4) inappropriate for this situation ...

The nurse cares for a client receiving IV antibiotics for 4 days. Which of the following should cause the nurse to be concerned about postinfusion phlebitis? 1. Tenderness at the IV site. 2. Increased swelling at the insertion site. 3. Reddened area or red streaks at the site. 4. Leaking of fluid around the IV catheter.

(1) tenderness at the IV site is common (2) increased swelling at the insertion site may indicate infiltration (3) correct—characterized by inflammation and reddened areas around site and up length of vein (4) not indicative of phlebitis ...

Take every question literally - don't read into it

(ex - pt on Lasix and has dizziness, don't think "it could be a stroke", focus on Lasix and dizziness...so hypotension)

Upon assessment of a client admitted for dehydration, the nurse observes that the client appears restless and reports difficulty breathing. Upon auscultation of the client's lungs, the nurse notes bilateral basilar crackles. Which actions will the nurse take first? 1. Place the client on 2 L of oxygen by nasal cannula and auscultate the lungs. 2. Elevate the head of the bed and stop the IV infusion. 3. Decrease the IV flow rate and administer furosemide as prescribed. 4. Stop the IV infusion and notify the health care provider.

) Providing the client with oxygen via nasal cannula addresses breathing. However, there is another action the nurse will implement first. 2) CORRECT — Elevating the head of the bed will allow for a more open airway. This is the priority action. 3) Decreasing the IV flow rate and administering furosemide addresses circulation. However, there is another action the nurse will implement first. 4) Stopping the IV infusion addresses circulation. However, there is another action the nurse will implement first.

Decorticate posturing

-"flexor posturing" or "mummy" -adduction of arms (arms fold to chest); flexion of elbows and wrists

A client is admitted to the outpatient unit in the cancer center for chemotherapy. The client is lethargic, weak, and pale. During chemotherapy, which of the following nursing interventions is MOST important? 1. Establish emotional support. 2. Position for physical comfort. 3. Maintain droplet precautions. 4. Perform hand washing prior to care.

.(1) appropriate but not a priority (2) appropriate but not a priority (3) unnecessary during chemotherapy (4) correct—chemotherapy can lead to immunosuppression, which predisposes client to infection; hand washing is one of most effective means of decreasing infection transmission ..

A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parent would be that the client 1. acknowledges willing participation in an incestuous relationship. 2. re-establishes a trusting relationship with his/her other parent. 3. verbalizes that he/she is not responsible for the sexual abuse. 4. describes feelings of anxiety when speaking about sexual abuse.

.(1) continues the myth of "badness" and that he/she deserved the abuse and actively consented to it (2) outcome that would be positive but usually is not an initial result of treatment (3) correct—victim needs assistance to challenge "belief of victims," which includes "I am bad and deserve the abuse" (4) expected outcome ..

A 13-year-old male diagnosed with muscular dystrophy (MD) develops nocturia. The client wants to know about external catheters. The nurse should base the response on which of the following statements? 1. The catheter can be removed during the day. 2. External catheters are uncomfortable. 3. The catheter would drain into a bag at the bedside or on the wheelchair. 4. The external condom catheter is easy to apply.

.(1) correct—being free from any drain bags during the day would appeal to a 13-year-old (2) is negative (3) would be embarrassing to a 13-year-old (4) it would be impossible for a teen with muscular weakness to put on an external catheter ..

A nonstress test is scheduled for a client at 34 weeks' gestation who developed hypertension, periorbital edema, and proteinuria. Which of the following nursing actions should be included in the care plan in order to BEST prepare the client for the diagnostic test? 1. Start an intravenous line for an oxytocin infusion. 2. Obtain a signed consent prior to the procedure. 3. Instruct client to push a button when she feels fetal movement. 4. Attach a spiral electrode to the fetal head.

.(1) would be appropriate for an oxytocin (stress) test (2) is incorrect because this is noninvasive (3) correct—nonstress test is a noninvasive test to evaluate the response of the fetal heart rate to the stress of fetal movement; response will be reflected on the fetal monitor (4) prepares for internal fetal monitoring ..

A client is being discharged with sublingual nitroglycerin (Nitrostat). The client should be cautioned by the nurse to 1. take the medication 5 minutes after the pain has started. 2. stop taking the medication if a stinging sensation is absent. 3. take the medication on an empty stomach. 4. avoid abrupt changes in posture.

...(1) should be taken immediately when pain is felt (2) presence or absence of a stinging sensation is not indicative of the effect of the drug (3) should be taken when pain is experienced (4) correct—nitroglycerin can cause hypotension; client should avoid changing positions quickly to decrease the chances of falling

The nurse cares for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions? 1. Take the client to the dining room with 1:1 supervision. 2. Inform the client that he may go to the dining room when he controls his behavior. 3. Hold the meal until the client is able to come out of seclusion. 4. Serve the meal to the client in the seclusion room.

...(1) should remain in the seclusion room (2) should have meal at regular time (3) should have meal at regular time (4) correct—should eat at regular time; remain in the seclusion room for client's safety

An elderly client returns from surgery after a hysterectomy due to cancer, and there is an order for antiembolism stockings. Which of the following should the nurse include when instructing the client about wearing the support stockings? 1. "Wear the stockings when your legs cramp." 2. "Wear the stockings during your hospitalization." 3. "Put the stockings on prior to going to bed." 4. "Put the stockings on after you get out of bed in the morning."

...Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) antiembolism stockings should be worn to prevent any discomfort and to increase the blood flow (2) correct—stockings should be worn the entire time that client is in the hospital; should be removed for baths and replaced after the skin is dry, and before the client gets out of bed (3) stockings should be worn during the day and when client is nonambulatory (4) stockings should be applied before getting out of bed

creatine serum level

0.6-1.2

A 60-year-old client wanders away during halftime at a football game and is found 48 hours later sleeping on a park bench, 100 miles from home. The client is brought to the emergency department by the police. The client can state the name and address but has no recollection of the past 2 days. What is the PRIORITY nursing action? 1. Assess vital signs 2. Contact family members 3. Encourage the client to recall recent events 4. Perform a mental status assessment

A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-minute commute via train. The nurse recognizes that this client MOST LIKELY suffers from which psychological disorder? 1. Agoraphobia 2. Generalized anxiety disorder 3. Social anxiety disorder 4. Zoophobia

A client with borderline personality disorder says to the nurse, "You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you." What is the PRIORITY action for the client's nursing care plan? 1. Assign different staff members to care for the client each day 2. Continue assigning the clients stated preferred nurse to care for the client 3. Frequently reassure the client that all staff members are competent in their jobs 4. Reinforce unit rules and consequences of inappropriate behaviors

A client with moderate Alzheimer disease is started on memantine In evaluating the effectiveness of this medication, the registered nurse should assess the client for which of the following? 1. Improved ability to perform activities of daily living 2. Indications that disease progression has stopped 3. Rapid improvement in cognitive functioning 4. Reversal of the disease

A client with schizophrenia is hospitalized. After 2 weeks of treatment, the frequency of the client's hallucinations seems to be diminishing. When first hospitalized, the client refused to leave the room. Now the client spends time in the dayroom, sitting in a corner watching television, but does not initiate conversation or social interaction with other clients or staff. What is the MOST APPROPRIATE activity for the client? 1. A board game with a staff member 2. Participation in a group songfest 3. Planning a unit picnic 4. Playing Bingo with other clients

A client, who has been hospitalized for 3 days with major depressive disorder, has stayed in the room and not gotten out of bed except for toileting. The nurse enters the room to remind the client that breakfast will be served in the dining room in 20 minutes. The client says, "I'm not hungry and I don't feel like doing anything." What is the BEST response by the nurse? 1. "I will help you get ready; then we can walk to the dining room together." 2. "I'll have breakfast brought to your room." 3. "It's okay. You can join us when you are ready." 4. "You'll feel better when you get up."

The nurse is caring for a client with schizophrenia who has been experiencing visual hallucinations. The client says in a trembling voice, "There's a bad man standing over there in the corner of my room." What is the BEST response by the nurse? 1. "I know you are frightened, but I do not see a man in your room." 2. "I'll make the bad man go away." 3. "Let's go into the dayroom and play checkers." 4. "Your illness is making you hallucinate."

The nurse is educating a client in preparation for discharge from the hospital when the client breaks down crying, saying that the health care provider thinks she is crazy because he diagnosed her with a functional disorder. Which statement would be the BEST reply to this client? 1. "Functional disorder is a general diagnosis for a genuine medical issue that medical science does not yet fully understand." 2. "I am very sorry to hear this, but are you sure that's what he meant?" 3. "The health care provider does not know what he's talking about. I'll give you the information my health care provider used." 4. "Why do you think he said that?"

The nurse is reviewing a client's preoperative questionnaire and notes that the client has indicated spiritual needs or preferences concerning today's surgery. Which action is MOST APPROPRIATE at this time? 1. Ask the client if a spiritual advisor or clergy member is aware of the surgery 2. Ask the client when a spiritual advisor or clergy member is coming to visit 3. Document the response and notify the health care provider and postoperative nurse 4. Tell the client that the hospital chaplain will be notified for a consult

The registered nurse discusses discharge planning with the spouse of an 80-year-old client diagnosed with chronic obstructive lung disease and chronic respiratory failure. The client is bedbound, has a tracheostomy, is on a ventilator, and requires suctioning at least 3 times daily. The spouse says to the nurse, "l've been helping out here, so I'm sure I can manage my spouse's care at home." The nurse's response is based on which understanding? 1. Caregiver strain is a risk for any family member who cares for a loved one at home 2. Client needs to be placed in a skilled nursing facility 3. Clients on ventilators cannot be cared for at home 4. Discharging the client to the home is an unsafe plan

The nurse determines that a client's tracheostomy requires suctioning. Which action does the nurse take first? 1. Elevate the head of the client's bed to 90 degrees. 2. Quickly insert the suction catheter. 3. Preoxygenate the client. 4. Put on clean gloves.

1) A semi-Fowler, not high-Fowler, position is ideal for this client during tracheostomy suctioning. 2) The client requires preparation prior to inserting the suction catheter during this procedure. 3) CORRECT— In order to ensure the client does not experience hypoxia during tracheostomy suctioning, the nurse hyperoxygenates the client before and after each time the airway is entered for suctioning. 4) Sterile gloves are used for tracheostomy suctioning.

The nurse assesses clients for potential spousal abuse. The nurse is most concerned if a client makes which statement? 1. "It's my fault because I push my spouse's buttons." 2. "My spouse and I often disagree on many subjects." 3. "We have talked about divorce multiple times." 4. "I used to be so happy, but now I'm not."

1) CORRECT — Individuals who experience spousal abuse often accept blame, become compliant, and feel helpless. This client statement is concerning to the nurse. 2) This is not typical abuser/victim behavior, as the victim is often compliant. 3) This is not typical abuser/victim behavior, as the victim is often compliant. 4) The nurse should ask the client to elaborate. However, this is not the most alarming statement of those presented.

The nurse provides care for a client diagnosed with acquired immune deficiency syndrome (AIDS). The nurse performs discharge teaching with the client. The nurse determines teaching is effective if the client makes which statements? (Select all that apply.) 1. "I will contact the health care provider if my bed sheets become drenched with perspiration." 2. "It is safe to share toothbrushes with others." 3. "It is safe to not use condoms since we both have HIV." 4. "I will be cured if I take zidovudine as prescribed by my health care provider." 5. "I will not go to the fall festival."

1) CORRECT — The client diagnosed with AIDS is at an increased risk for infection. Wet bed sheets can indicate the development of tuberculosis. 2) A client with AIDS should not share a toothbrush or a razor under any circumstances. 3) Cross-infection with the partner's virus can increase severity of infection. 4) Zidovudine is an anti-retroviral medication that slows disease progression. This medication is not curative. 5) CORRECT — The client diagnosed with AIDS should be instructed to avoid large crowds, as this increases the risk of infection.

When assessing the incision of a client 2 days postoperatively, the nurse notes a shiny pink area with underlying bowel visible. Which action does the nurse implement? 1. Cover the area with sterile gauze soaked in normal saline. 2. Cleanse the wound with hydrogen peroxide and apply a sterile dressing. 3. Pack the opened area with sterile 3/4 inch gauze soaked in normal saline. 4. Apply antibacterial ointment and cover with clear adhesive dressing.

1) CORRECT — The data indicates that the client is experiencing an evisceration. Therefore, the appropriate action from the nurse is to immediately cover the site with a sterile dressing soaked with normal saline and contact the health care provider. 2) It is not appropriate for the nurse to use hydrogen peroxide in this situation. Normal saline is used. 3) This is an inappropriate action by the nurse. 4) This is an inappropriate action by the nurse.

The nurse supervisor is informed that three serious safety events occurred last month between 0730 and 0800. The last serious safety event occurred because the oncoming nursing shift did not know a client was receiving an IV insulin drip. Which is the priority action for the nurse supervisor to take? 1. Implement mandatory bedside reporting. 2. Discuss unsafe nursing practices with the local media. 3. Delay action until hospital risk manager has completed a full investigation. 4. Ask another nurse manager for suggestions.

1) CORRECT — The nurse supervisor needs to take action to ensure proper exchange of information during shift report, as it is essential for staff to have an opportunity for last-minute updates, to clarify information, or to receive information on care events or changes in a client's condition. Bedside report promotes staff accountability, intercepts errors, and allows nurses to better prioritize care. 2) This is not an appropriate action. The nurse supervisor's immediate priority is to proactively address safety concerns within the unit. 3) While the hospital risk manager should be involved, the nurse supervisor is responsible for client outcomes and ensuring proper exchange of information is being distributed during shift report. 4) While this may be an appropriate action by the nurse supervisor, it does not address the immediate safety issue.

The telemetry nurse is notified that the unit is receiving a new admission from the medical surgical unit. Which client currently on the telemetry unit should the nurse suggest be sent to the medical surgical unit? 1. Client with magnesium level 1.6 mg/dL (0.66 mmol/L). 2. Client scheduled for cardiac catheterization the next morning. 3. Client with digoxin level 2.4 ng/mL (3.1 nmol/L). 4. Client who reported chest discomfort during cardiac stress test.

1) CORRECT — This client is stable and can be moved to the medical surgical unit, as the magnesium level is within normal limits (1.3 to 2.3 mg/dL [0.53 to 0.95 mmol/L]). 2) This client is not stable. The client's cardiac rhythm should be monitored until the results of cardiac catheterization are known. 3) This client should remain on the telemetry unit, as the client may experience symptoms of digoxin toxicity. The normal digoxin level is 0.5 to 2.0 ng/mL (0.6 to 2.6 nmol/L). 4) Chest discomfort during a cardiac stress test indicates poor cardiovascular response to increased workload. This client is not stable and should remain on the telemetry unit.

The health care provider prescribes metoclopramide 2 mg/kg IV to be given to a client 30 minutes before the client receives cisplatin. The client asks the nurse why the metoclopramide is being given. Which response will the nurse give to the client? 1. "Metoclopramide prevents or reduces the side effects caused by cisplatin." 2. "Metoclopramide increases the effectiveness of the cisplatin." 3. "Cisplatin prevents or reduces the side effects of the metoclopramide." 4. "Cisplatin increases the effectiveness of metoclopramide."

1) CORRECT— Metoclopramide (Reglan) is prescribed to prevent or reduce the side effects (antiemetic) caused by cisplatin, an anti-neoplastic agent. Therefore, this is an accurate response by the nurse. 2) Metoclopramide does not increase the effectiveness of cisplatin. Therefore, this is not an accurate response by the nurse. 3) This is a false statement about the use of metoclopramide and cisplatin. Therefore, this is not an accurate response by the nurse. 4) This is a false statement about the use of metoclopramide and cisplatin. Therefore, this is not an accurate response by the nurse.

The nurse assesses a client diagnosed with Ménière disease. The client states, "I take my prescribed medications regularly, but I continue to have episodes of vertigo." Which response by the nurse is most important? 1. "Tell me about your diet." 2. "How are things going at work?" 3. "When was Ménière disease diagnosed?" 4. "What were the results of your last blood test?"

1) CORRECT— This statement allows the nurse to determine if there are dietary factors (food to medication interactions) that may be interfering with the action of the prescribed medication. 2) This response by the nurse does not allow for investigation into why the prescribed medications are not working as anticipated. 3) While it is important to document when the disease process was diagnosed, this information does not allow the nurse to investigate why the prescribed medications are not working as anticipated. 4) This question is too broad and does not allow the nurse to investigate the current situation experienced by the client. **Meniere's disease: a chronic disoreder of the inner ear involving sensorineural hearing loss, sever vertigo and tinnitus. Diet Mgmt: Low sodium (2000 mg/day), avoidance of etoh, nicotine and caffeine.

The nurse provides care for a client diagnosed with diastolic heart failure. The nurse observes the recent onset of the Atrial Fibrillation. Which is the most appropriate action for the nurse to take? 1. Administer digoxin 0.25 mg IV. 2. Instruct the client to take a deep breath and hold it. 3. Assess level of consciousness and orientation. 4. Auscultate posterior chest.

1) The nurse must assess before implementation in this situation. In addition, digoxin is not a first-line drug used to treat atrial fibrillation due to the risk of toxicity. 2) The Valsalva maneuver is not indicated in this situation, as it is used for supraventricular tachydysrhythmias. 3) CORRECT — Level of consciousness (LOC) and orientation are the best indicators regarding the effect of atrial fibrillation on cardiac output. A change in LOC and/or alertness is the earliest indication of poor cardiac output. Therefore, this is the priority action by the nurse. 4) This electrocardiogram strip indicates atrial fibrillation, which may contribute to left-sided heart failure. While it is appropriate to auscultate lung sounds, this is not the priority action in this situation.

The terminally ill client reports to the nurse that a do-not-resuscitate (DNR) prescription has been initiated. The client is concerned that family members do not accept this wish. Which is the best action made by the nurse? 1. Reassure the client that things will work themselves out. 2. Allow the next of kin to make final health care decisions. 3. Schedule a meeting with the client and family. 4. Contact the hospital social worker.

1) The nurse needs to proactively address the client's concerns, not provide reassurance that may not be appropriate. 2) The nurse needs to advocate for the client's wishes. There is no data indicating the client is unable or incapable of making this decision. 3) CORRECT — The client's family members need to acknowledge and understand the client's wishes. Therefore, a meeting with the client and family will open the lines of communication and allow time for questions/explanations. 4) The first action is to open lines of communication with the client and family. If a meeting to open the lines of communication is not effective, a social worker consult might be appropriate.

The nurse discusses the client's plan of care with the student nurse. The student nurse states, "I know the client is from another country, but the client could at least look at me when I'm talking. That is so rude." Which response by the nurse is best? 1. "I am sorry the client made you feel that way." 2. "The client doesn't look at me when I speak either." 3. "Eye contact may be a sign of arrogance in the client's country." 4. "I will ask the family if anything is bothering the client."

1) The nurse should clarify the client's cultural norms, as eye contact interpretation is not universal. 2) The nurse should clarify the client's cultural norms, as eye contact interpretation is not universal. 3) CORRECT — The nurse recognizes that eye contact interpretation is not universal. In north America, maintaining eye contact during conversation communicates respect and willingness to listen. In some cultures, however, maintaining eye contact is considered intrusive, threatening, or shows arrogance. 4) The nurse should clarify the client's cultural norms, as eye contact interpretation is not universal.

The nurse evaluates client care assignments made by the student nurse. The nurse will intervene if the LPN/LVN is scheduled to care for which client? 1. Client who received methylprednisolone for lumbar radiculopathy. 2. Client who received racemic epinephrine for croup. 3. Client who received ketorolac for pleurisy. 4. Client who received tamsulosin for benign prostatic hyperplasia.

1) This is a stable client. Therefore, this assignment is within the LPN/LVN's scope of practice. 2) CORRECT — The nurse should care for this client, as the client will require frequent airway/breathing assessment. 3) This is a stable client. Therefore, this assignment is within the LPN/LVN's scope of practice. 4) This is a stable client. Therefore, this assignment is within the LPN/LVN's scope of practice.

The nurse completes documentation for a client and realizes the entry has been placed in the wrong client's medical record. Which action by the nurse is most appropriate? 1. Complete an incident report and place a copy in the client's medical record. 2. Draw a single line through each line of the incorrect entry and write a new note explaining what occurred. 3. Use correction fluid to delete the wrong entry and write in the space that the note was obliterated due to client confidentiality. 4. Copy the note into the correct client's record and indicate that it was erroneously put in the wrong client's record.

1) This is not an appropriate action by the nurse. An incident report is not placed in the client's medical record. 2) CORRECT— This is an appropriate action when correcting documentation in the client's medical record. 3) This is not an appropriate action by the nurse. Correction fluid is not used when a correction is needed to document in the medical record. 4) This is not an appropriate action by the nurse when care is documented in the wrong client's medical record.

The nurse provides care for a hospitalized older adult client who has a body mass index (BMI) of 16.1. Which is the priority action by the nurse? 1. Document the client's BMI. 2. Decrease caloric intake to 1200 calories per day. 3. Confer with a dietician. 4. Plan a return visit in 1 week.

1) While it is appropriate for the nurse to document the client's BMI in the medical record, this is not the priority action. 2) Individuals who have a BMI lower than 18.5 are at increased risk for problems associated with poor nutritional status. The client's daily caloric intake should be increased, not decreased. 3) CORRECT — The nurse should refer the client to a dietician for further evaluation, as a low BMI is associated with higher mortality rate among hospitalized clients. 4) This client requires prompt evaluation. Delaying treatment for one week negates the potential seriousness of client's current condition. **Normal BMI: 18.5 to 24.9**

The nurse provides care for an adolescent client reporting arm pain after a fall. The nurse notes bruising in multiple stages of healing. The nurse accesses the client's medical record and notes the client was treated twice last month for reported back pain after two separate falls. The client was treated two months ago for a perforated eardrum. Which action by the nurse is the priority? 1. Assess the client's anxiety level. 2. Use light touch to show support. 3. Contact social services. 4. Assess the client's pain level.

1) While the nurse should assess the client's anxiety level, a professional assessment of the client's situation takes priority over psychosocial nursing actions. 2) The use of touch may not be appropriate for this client, as it may make the client feel uneasy or threatened. 3) CORRECT — The adolescent client's history suggests that there may be abuse. The law mandates that the nurse report known or suspected child abuse by collaborating with social services and law enforcement. Therefore, this is the priority action. 4) The nurse should assess pain level. However, the professional assessment of the client takes priority over psychosocial issues, such as pain.

The nurse identifies which of the following is MOST likely to help the family of an emotionally disturbed client manage behaviors at home after discharge from inpatient treatment? 1. Refer the family to Alliance for the Mentally Ill meetings for educational programs and support groups. 2. Provide the family with pamphlets that describe the desired action and side effects of medications the client is taking. 3. Tell the family that it is not their fault that the client behaves inappropriately. 4. Involve the family in the assessment of the client when he/she is first admitted to the hospital.

1) correct—this group provides ongoing support and educational information; people who attend have common needs and goals focused on managing the clients' behavior at home (2) would be helpful but will not have the ongoing impact of the support group (3) would be helpful but will not have the ongoing impact of the support group (4) would be helpful but will not have the ongoing impact of the support group

The emergency department registered nurse is triaging a client for the risk of suicide. The client had thoughts of self-injury yesterday but is not sure today. Which of the following would be considered a known risk factor for suicide in this client? Select all that apply. 1. Constantly hearing voices saying client is worthless 2. Deliberately took an overdose 1 year ago 3. Has a gun at home 4. Married with 3 children 5. Participation in religious activities 6. Unemployed and unable to find a job

1,2,3,6

The nurse performs an initial assessment on a client with suspected post-traumatic stress disorder Which assessments would support this diagnosis? SELECT ALL THAT APPLY. 1. Difficulty concentrating 2. Feeling detached from others 3. Feeling lethargic and apathetic 4. Flashbacks of the traumatic event 5. Persistent angry, fearful mood

1,2,4,5

Which clinical manifestations would the nurse identify with severe anorexia nervosa? SELECT ALL THAT APPLY. 1. Amenorrhea 2. Fluid and electrolyte imbalances 3. Heat intolerance 4. Presence of lanugo 5. Refusal to exercise 6. Weight loss of 25% below normal weight

1,2,4,6

The nurse is presenting an in-service educational session on child abuse and neglect to a class of certified home health aides In identifying the characteristics of the typical perpetrator of child abuse, the nurse will include which statements? SELECT ALL THAT APPLY. 1. Abusers often have a history of substance abuse 2. Abusers often have a history of growing up in an environment of domestic violence 3. Child abusers always present as being agitated or out of control 4. Men are much more likely to abuse children than are women 5. MOST child abusers have a diagnosis of a mental illness 6. Teenage parents are particularly vulnerable to abusing their children

1,2,6

A client hospitalized for anorexia nervosa has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which nursing actions are appropriate for promoting weight gain in this client? SELECT ALL THAT APPLY. 1. Determine minimum goals for daily caloric intake and weekly weight gain 2. Do not allow client to make food choices 3. Restrict privileges if weight loss occurs 4. Reweigh client on request 5. Set limits on physical activities 6. Sit with client during meals and discuss nutritional value of served foods

1,3,5

The nurse assesses a client who is suspected of using illicit substances. Which assessment findings would indicate heroin withdrawal? SELECT ALL THAT APPLY. 1. Bone and muscle pains 2. Bradycardia 3. Dilated pupils 4. Drowsiness 5. Rhinorrhea

1,3,5

The charge nurse in a long-term memory care facility is making assignments for the Alzheimer unit. Which tasks may be delegated to experienced unlicensed assistive personnel? SELECT ALL THAT APPLY. 1. Assisting clients with bathing and hair care 2. Evaluating safety hazards in clients' rooms 3. Monitoring clients for behavioral changes 4. Placing bed alarms at night for clients at risk for wandering 5. Reporting swallowing difficulties of a client during mealtime

1,4,5

A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT). The CBT includes which INTERVENTIONs and strategies? Select all that apply. 1. Desensitization to a specific stimulus or situation 2. Discussing the interpersonal difficulties that have led to the client's psychological problems 3. Helping the client develop insight into the psychological causes of the disorder 4. Relaxation techniques 5. Self-observation and monitoring 6. Teaching new coping skills and techniques to reframe thinking

1,4,5,6

A client with major depressive disorder has been hospitalized for 3 days The night nurse reports that the client has been unable to go to sleep until late at night. The client gets up, paces the hallway, wrings her hands, and appears teary. Which INTERVENTIONs should be included in the client's nursing care plan? SELECT ALL THAT APPLY. 1. Arrange for the client to receive 20 minutes of natural sunlight each day 2. Encourage the client to take naps during the day to make up for lost sleep 3. Have the client engage in strenuous physical exercise just before bedtime 4. Serve the client a glass of warm milk in the evening 5. Spend time with the client in a quiet environment just before bedtime 6. Tell the client to take a warm bath before going to bed

1,4,5,6

side effect of halodol

1. gynecomastia: male grows breast tissue 2. galactorrhea: excessive or spontaneous flow or milk 3.

A client is receiving nasogastric tube feedings as nutritional rehabilitation for anorexia nervosa. After a weigh-in, the client learns of gaining 2 lb (0.9 kg) and says to the nurse, "See what your force feeding has done to me? I'm fatter and uglier than ever." What is the BEST action by the nurse? 1. Have the client keep a journal and write about feelings 2. Initiate one-on-one supervision of the client during feedings 3. Remind the client that gaining weight means being able to go home 4. Say that the client is not fat and ugly

A client with Alzheimer disease is admitted to the hospital for a urinary tract infection. The daughter says to the nurse, "I really want to take my mother home and continue care there. However, lately, my mother has become agitated and restless at night. I'm awake MOST of the night, feel exhausted, and do not know what to do." What is the BEST response by the nurse? 1. "Do not let your mother take naps in the afternoon." 2. "Our social worker can discuss long-term care options with you." 3. "We can ask the health care provider for medication that will help your mother sleep." 4. "Your mother can be cared for in a nursing home."

A client with a 20-year history of schizophrenia is hospitalized. The client appears visibly upset, approaches the nurse, and says in a shaky voice, "I can't find my headband. I can't find my headband. The oil is going to leak out of the crack in my head." What is the BEST response by the nurse? 1. "How long has the oil been leaking from your head?" 2. "Let's go back to your room and look for your headband together." 3. "There is no oil coming out of your head." 4. "You are going to miss breakfast if you do not go into the dining room."

A client with obsessive-compulsive disorder (OCD) has been cleaning a bathroom for MOST of the morning. When the roommate demands that the client leave the bathroom so that the roommate can shower, the client becomes angry and says, "You can't make me leave, everything is still dirty." What is the BEST nursing action? 1. Engage other staff members to remove the client from the bathroom 2. Give a reminder that the client has been cleaning the bathroom for 1½ hours and it is time to take a break 3. Tell the client that the bathroom is very clean and that this behavior is unreasonable 4. Tell the roommate to use the shower in another room

A client with schizophrenia has been hospitalized for a week and placed on an antipsychotic medication. The client tells the nurse of hearing multiple voices all day long arguing about whether the client is a good or bad person. The client says, "Everyone tells me that the voices are not real, but they are driving me crazy." What is the BEST action by the nurse? 1. Give the client a book to read 2. Provide earphones and a DVD player and have the client sing along with the music 3. Tell the client that the voices will go away when the medication starts to work 4. Tell the client to ignore the voices

A client with schizophrenia says to the nurse, "The world turns as the world turns on a ball at the beach. But all the world's a stagecoach and I took the bus home." The nurse recognizes this statement as an example of which of the following? 1. Concrete thinking 2. Loose associations 3. Tangentiality 4. Word salad

A client with social anxiety disorder is receiving treatment at the local community mental health center. Which situation MOST LIKELY caused the client to seek therapy? 1. The client and spouse are soon moving into a new neighborhood 2. The client's boss has asked the client to represent the company at an upcoming convention 3. The client's primary health care provider (HCP) of 30 years is retiring and the client will be seeing a new HCP 4. The client's son is getting married in a few months

A college student finds a roommate mumbling and huddling in the corner of the room. The student brings the roommate to the emergency department, where the roommate is tentatively diagnosed with schizophrenia. The treatment plan includes hospitalization on the acute psychiatric unit and initiation of anti-psychotropic medication therapy. The client refuses to be admitted. Which of the following statements about hospital admission is true for this client? 1. If the client refuses to cooperate with the treatment plan, the client can be involuntarily committed. 2. If the treatment team determines the client poses danger to self or others, the client can be involuntarily committed. 3. The client can be involuntarily committed for observation and treatment if the roommate can provide consent. 4. The diagnosis of schizophrenia alone justifies the need for involuntary commitment.

A student nurse has been assigned to provide care to a client with suicidal ideation who is receiving treatment in an outpatient setting. The student nurse develops a nursing care plan and reviews it with the registered nurse (RN) before meeting with the client Which of the following nursing actions in the care plan requires an INTERVENTION by the RN? 1. Assist the client in identifying the warning signs of a crisis 2. Encourage the client to sign a contract promising not to commit suicide 3. Have the client make a list of people to contact for help and distraction 4. Help the client develop ways of coping with suicidal thoughts

After a daily weigh-in, a client with anorexia nervosa realizes a 2-lb weight gain. The client says to the nurse in a distressed voice, "This is terrible. I'm so fat." What is the BEST response by the nurse? 1. "But you look so thin." 2. "I don't see you that way; you are making progress toward a healthy weight." 3. "If you continue to gain weight at this rate, you will be able to go home soon." 4. "You are not fat; it's all in your imagination."

An adolescent client is brought to the emergency department by the parents after being found in the bathroom making cuts on an arm with a razor blade. There are a few minor cuts in various stages of healing on the client's forearms. Which of the following is the MOST APPROPRIATE statement to make to this client's parents? 1. "Everything is going to be all right." 2. "The cuts on your child's arm are superficial; there is no immediate danger." 3. "You did the right thing by bringing your child here to get help." 4. "You must be very upset after seeing this."

For several months, a client has been unjustifiably accusing the spouse of having affairs. The client comes home from work several times a day to check up on the spouse. Two days ago, the client came home and found the cable TV technician installing new equipment The client became enraged, accused the spouse of sleeping with the technician, and physically attacked the technician. The police were called, and the client was admitted for psychiatric evaluation. Prior to this admission, the client had been self-sufficient in meeting basic needs and worked and attended church regularly. The nurse recognizes that the admitting history is MOST indicative of which of the following? 1. Delusional disorder, erotomanic type 2. Delusional disorder, jealous type 3. Schizophrenia with delusions of a persecutory nature 4. Schizophrenia with paranoid features

The home health aide reports to the nurse care manager that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, "With my spouse dead, there's no reason for me to go on." What is the BEST PRIORITY response by the nurse? 1. "Do you have any friends in the building?" 2. "Have you had any thoughts of hurting yourself?" 3. "Tell me more about how you're feeling." 4. "You're not thinking of killing yourself, are you?"

The nurse assigned to care for the client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors? 1. Pears abandonment, agreeable, needs constant reassurance 2. Likes to be the center of attention, exaggerated emotional expression, little tolerance for frustration 3. Seems uncomfortable around people, lack of close friends, indifferent to praise or criticism 4. Tries to intimidate others; manipulative; lacks empathy

The nurse is caring for a client with paranoid personality disorder. When the nurse directs the client to go to the dining room for dinner, the client says, "And eat that poisonous food? You better not make me go anywhere near that room" Which statement BEST explains the client's behavior? 1. The client has a problem with authority figures 2. The client has an intense need to control the environment 3. The client is hearing voices 4. The client is trying to control anger

The nurse is caring for a hospitalized elderly client who is admitted with pneumonia. Which assessment finding is MOST consistent with the diagnosis of delirium? 1. Client is alert but disoriented to time 2. Client is inattentive and hallucinating 3. Client reports decreased enjoyment in previously pleasurable activities 4. Family reports a gradual progressive inability to remember recent events

The nurse is caring for a new mother whose infant has been diagnosed with Down syndrome. The client says to the nurse, "I'm so worried. My husband is so devastated that he won't even look at the baby." What is the BEST response by the nurse? 1. "Both of you will benefit from supportive counseling." 2. "How are you feeling about your baby?" 3. "I will have the doctor speak to your husband." 4. "Why do you think your husband feels this way?"

The nurse is planning care for an 11-year-old admitted for surgical treatment of a fractured femur. The child also has attention-deficit hyperactivity disorder, predominantly inattentive type. What is the PRIORITY nursing action? 1. Encourage the child to keep up with school work 2. Give the child a written schedule of daily activities 3. Limit the number of visitors 4. Provide verbal explanations of what to expect during hospitalization

The nurse on the mental health unit received report on 4 clients. Which client should the nurse see FIRST? 1. Client diagnosed with major depressive disorder who has consumed no food from the past 3 meal trays 2. Client diagnosed with post-traumatic stress disorder who reports an anxiety level of 8/10 and is pacing in the room 3. Client newly admitted with bipolar mania who reports sleeping only 4 hours last night 4. Client newly admitted with obsessive-compulsive disorder who has spent the last hour counting socks

The nurse on the mental health unit recognizes the use of which defense mechanism when a client leaves a stressful family meeting and immediately begins to verbally abuse a roommate? 1. Compensation 2. Displacement 3. Projection 4. Reaction formation

The school nurse is called to the classroom to assist with a 7-year-old with attention-deficit hyperactivity disorder who is throwing books and hitting the other children. What is the BEST INITIAL action for the nurse to take? 1. Administer a PRN dose of methylphenidate 2. Ask the child to blow up a balloon 3. Give the child a "time out" in a quiet place 4. Reinforce the consequences of disruptive behaviors

The nurse is developing a plan of care for a 16-year-old client with bulimia nervosa. Which INTERVENTIONs would be included in the plan of care? SELECT ALL THAT APPLY. 1. Allow client to remain on current laxatives 2. Assess client for electrolyte imbalances 3. Be alert to hidden or discarded food wrappers 4. Do not allow client to keep a food diary during hospitalization 5. Monitor client for 1-2 hours after each meal in a central area

2,3,5

A client has been admitted to the acute inpatient psychiatric unit with a diagnosis of major depressive disorder (unipolar depression). The nurse understands that this diagnosis was made because the client has been exhibiting at least 1 of which of the 2 KEY clinical findings daily for at least 2 weeks? 1. Daily sleep disturbance or significant weight loss 2. Decreased ability to think or low energy 3. Depressed mood or loss of interest or pleasure 4. Thoughts of worthlessness or recurrent thoughts of death

A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running. The spouse says to the nurse, "If I hadn't come home early from work, my spouse would be dead I can't believe this is happening." What is the BEST response by the nurse? 1. "Do you have any relatives or close friends who can help you through this?" 2. "Has your spouse seemed depressed lately?" 3. "This has been very overwhelming for you. What are you feeling right now?" 4. "Well, you did find your spouse. You need to focus on helping your spouse get better"

A client who is diagnosed with breast cancer asks the nurse, "Am I going to die?" Which statement by the nurse promotes a therapeutic relationship? 1. "Cancer is no longer a death sentence you may live for many years." 2. "l will ask the chaplain to talk to you sometime today." 3. "People with cancer experience fear of dying; tell me about your concerns." 4. "Tell me about your life and hopes for the future."

A client with a diagnosis of antisocial personality disorder was given a 2-hour pass to leave the hospital. The client returned to the unit 15 minutes past curfew and did not sign in. The next day, this behavior is brought up in a group meeting. The client says, "It's all the nurse's fault. The nurse was right there and did not remind me to sign in." What is the BEST response by the nurse? 1. "I'm sorry. I should have reminded you to sign in" 2. "It is not my fault that you forgot to sign in." 3. "It is your responsibility to sign in when you return from a pass." 4. "You were late coming back from your pass. Is that why you did not sign in?"

A client with a history of obsessive-compulsive personality disorder (OCPD) is seeking treatment for a gastrointestinal disorder and is scheduled for a colonoscopy at 10:00 AM. Due to a computer glitch, the procedure is postponed to 3:00 PM. Which response would be characteristic of an individual with OCPD? 1. "How dare they change my appointment? I insist that the procedure be done at 10:00 AM." 2. "That's fine. I can come in whenever it is convenient for everyone." 3. "This is unacceptable. I had my whole day planned out." 4. "Why are they doing this to me?"

A female client who was the victim of acquaintance rape 2 months ago is receiving therapy for posttraumatic stress disorder (PTSD). She says to the nurse, "It's all my fault. I should have known not to accept a drink from someone I just met in a bar." What is the BEST response by the nurse? 1. "It may take time to overcome those thoughts and feelings." 2. "Those kinds of thoughts are self-destructive. You should stop thinking about it." 3. "You could not have anticipated the rape. You did not deserve or ask for it." 4. "You have to stop blaming yourself so you can move on with your life."

After a client with Alzheimer disease is found wandering in the middle of the street at 3:00 AM and returned by police, the community health nurse teaches family members about measures to keep the client safe at home. What is the MOST IMPORTANT strategy for the nurse to include in the instruction? 1. Ensure that the client is never left alone 2. Notify neighbors of the client's tendency to wander 3. Place a chain lock on the door above or below the client's eye level 4. Place a safe return bracelet on the clients non-dominant hand

An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation; confusion, and disorientation to time and place. What is the MOST IMPORTANT nursing action? 1. Encouraging frequent fluid intake 2. Keeping the bed elevated with the side rails raised 3. Providing one-on-one supervision 4. Turning lights off in client's room to reduce stimulation

The client had surgery for possible cancer The positive biopsy result is back in the medical record: but the client has not been told that the biopsy showed malignancy. The client asks the nurse, "Am I going to die?" What is the BEST way for the nurse to INITIALLY handle the situation? 1. "Everyone will die one day, but good treatment is available for MOST cancers today." 2. "I can understand your anxiety about the situation. Let me call your health care provider (HCP)." 3. "Share with me your thoughts and feelings about the situation." 4. "The biopsy result came back as malignant, but that doesn't mean the cancer is not treatable."

The mental health nurse engaged in dialogue with a client would recognize transference when the client makes which statement? 1. "I can pretend to have feelings; how would you know the difference?" 2. "My roommate doesn't seem to like me very much." 3. "Sharing my thoughts with you will be difficult; you remind me of my sister." 4. "The people who work here do not seem genuine."

The nurse is caring for a client who entered the psychiatric emergency department in a state of acute psychosis after ingesting illicit substances. The parents ask the nurse if the client will develop schizophrenia. What is the MOST APPROPRIATE response by the nurse? 1. "I know it must be terrible to see your son like this, but he will be fine." 2. "MOST people have permanent side effects after an episode like this." 3. "Your son will have to remain here for observation until we know more." 4. "Your son would be fine right now if he had not taken these drugs."

The nurse is managing the care of a client diagnosed with chronic anxiety. Which behavior demonstrates to the nurse that the client possesses resilience? 1. Avoids anxiety-producing situations 2. Is able to identify anxiety-inducing triggers 3. Practices stress reduction techniques daily 4. Relies on anxiolytic medication to manage symptoms

The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom? 1. "I need for you to get rid of these bugs that are crawling under my skin." 2. "Hear that? She told me to kill my father." 3. "That song is a message sent to me in secret code." 4. "Those Martians are trying to poison me with the tap water."

The nurse plans care for a client diagnosed with anorexia nervosa who is being admitted after failure of outpatient treatment. Which client outcome will the nurse PRIORITIZE ? 1. Acknowledges poor interpersonal skills 2. Identifies new coping mechanisms 3. Increases caloric intake to gain weight 4. Verbalizes sources of conflict and anger

The registered nurse is counseling the parent of a child recently diagnosed with attention-deficit hyperactivity disorder (ADHD), combined type. Which statement by the parent requires an INTERVENTION? 1. "I should offer a choice between 2 things for my child's clothes or meals." 2. "I will need to advocate for an individualized educational plan for my child." 3. "My child will outgrow this disorder around age 20." 4. "When talking with my child, I should not be multi-tasking."

The spouse brings a client to the emergency department due to erratic behavior and expressions of despair. The emergency department is extremely busy with many clients. When the triage nurse asks if the client feels suicidal now, the client shrugs the shoulders. What INITIAL action should the triage nurse take? 1. Ask the client to make a verbal contract to not harm self 2. Document that the client is not currently suicidal 3. Place the client in an inside hallway with one-on-one observation 4. Return the client to the waiting room with the spouse

Which client BEST demonstrates recovery associated with a mental illness? 1. One who demonstrates self-direction and responsibility regarding physical and psychosocial needs 2. One who is receiving holistic care that addresses both physical and psychosocial needs 3. One who lives, works, and is involved with family and friends to the HIGHEST level of ability 4. One who, while diagnosed with a mental illness, is able to demonstrate hope for the future

Which statement by a client with a diagnosis of dependent personality disorder would the nurse recognize as progress toward a positive therapeutic outcome? 1. "I really appreciate all the time you have spent trying to help me." 2. "I think I really messed up at work today." 3. "My mother could not drive me here today, so I took the bus." 4. "When my parents go away on vacation, I'm planning to stay with my cousin."

The nurse reviews the social history of an adolescent client and understands that which behaviors support a diagnosis of conduct disorder? SELECT ALL THAT APPLY. 1. Blames voices when confronted about misbehavior 2. Fluctuates moods between depression and elation 3. Inserts thumbtacks into the feet of a neighbor's dog 4. Taps a pen on the desk to deliberately annoy peers 5. Vandalizes a painting in a local art museum

3,5

Development of 3 months

3months : hold head erect when sitting, turns his head to locate sounds smiles spontaneously when sees mom 6 months: tries to grasp toys out of reach

A client on a medical unit recently received a diagnosis of end-stage renal disease and was told of the need to go on dialysis. This morning the client was found in the bathroom trying to commit suicide by hanging using hospital gown ties. The client was stabilized and transferred to the psychiatric unit. Which of the following is the HIGHEST PRIORITY nursing action for this client? 1. Assess the client's risk for another suicide attempt 2. Encourage the client to express current feelings about the medical diagnosis 3. Place the client in a private room near the nurses' station 4. Provide continuous one-to-one observation with the client

A client on the locked unit of an inpatient psychiatric hospital says to a nurse on the evening shift, "During the day they let me out to go to the gift shop. You're my favorite nurse I know you'll be a good sport and give me a pass." What is the BEST response by the nurse? 1. "I guess the day shift staff needs to be reminded of the rules." 2. "The gift shop is not even open right now." 3. "Why do you want to go to the gift shop?" 4. "You do not have privileges for leaving the unit. I cannot give you a pass"

A client recently diagnosed with schizophrenia is brought to the mental health clinic by the identical twin sibling for the first follow-up visit after hospitalization. The client's sibling says to the nurse, "I read that schizophrenia runs in families. I guess I'm doomed." Which is the BEST response by the nurse? 1. "At the moment, I would worry more about how your sibling is doing." 2. "The odds are about 50-50 that you will come down with the disease as well." 3. "Would you like to talk to a health care provider about this?" 4. "You are at risk for the disease. However, there are other factors that contribute to the development of schizophrenia."

A client recently diagnosed with schizophrenia is hospitalized. The client appears distraught and says to the nurse, "The voices are bad today. They are so angry with me." Which of the following is the BEST response by the nurse? 1 "Do you need something to help you calm down?" 2. "Don't pay any attention to the voices. Let's go into the dayroom." 3. "The voices are not real. Tell them to go away." 4. "What are the voices saying to you?"

A client states, "I just don't know what to do about this situation with my parents," and the nurse replies, "I'm sure you will do the right thing." Which summary is true regarding the nurse's response? 1. The nurse has encouraged exploration of the client's situation 2. The nurse has shown interest in the client's concerns 3. The response conveys empathy toward the client and promotes self-confidence 4. The response devalues the client's feelings and gives false reassurance

A client who was placed in restraints appears in the hallway an hour later and states, "I'm Houdini... I can get out of anything. There could be trouble now." Which of the following is the BEST response to this client? 1. "How are you feeling now?" 2. "How did you manage to get out of the restraints?" 3. Say nothing but signal to other staff that assistance is needed. 4. "What kind of trouble are you thinking about?"

A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner. The client is now shaking and has shortness of breath and heart palpitations. What is the PRIORITY nursing action? 1. Encourage the client to perform deep breathing exercises 2. Explore possible reasons for the episode 3. Place the client in a private room and tell the client to relax 4. Stay with the client

A nurse on the telemetry unit receives a client admitted from the emergency department with acute alcohol intoxication, confusion, and a diabetic toe ulcer. Which INTERVENTION would be the PRIORITY ? 1. Assess for signs of alcohol withdrawal 2. Assess the need for alcohol rehabilitation referral 3. Let the client sleep off the alcohol intoxication 4. Monitor blood glucose levels during the night

A nurse performs the initial assessments for 4 assigned clients. The nurse identifies which client as being at GREATEST RISK for the development of delirium? 1 32-year-old client with gastroenteritis 2. 55-year-old client with coronary artery disease, 4 days post coronary bypass surgery 3 60-year-old client with type Il diabetes. 2 months post bilateral above-knee amputations 4. 80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis

A young adult with obesity comes to the free clinic for a 2-week post-antibiotic follow-up visit for a superficial abdominal skin abscess. The client has a history of major depressive disorder and was hospitalized twice in the past 6 months for attempted suicide. The client now reports feeling "emotionally upset, alone, and at the end of my rope" due to difficulty finding a job and inability to qualify for medical insurance. The client is currently prescribed fluoxetine but has not been able to follow up with the prescribing health care provider (HOP). What is the PRIORITY nursing diagnosis (ND) at this time? 1. Hopelessness 2. Ineffective coping 3. Risk for infection 4. Risk for suicide

A young client is diagnosed with major depressive disorder. Three weeks prior, the client's fiancÃ© broke off their engagement, claiming the client was "too fat and ugly." During a one-on-one interaction with the nurse, the client says, "My fiancÃ© is really wonderful and is not to blame for calling off the engagement. I look awful and I'm not much good for anything." What is the BEST response by the nurse? 1. "How could your fiancÃ© be wonderful after saying those things to you?' 2. "I think you are better off without your fiancÃ©." 3. "Maybe the breakup was for the BEST." 4. "Tell me how you felt when your fiancÃ© broke up with you."

The daughter of an 80-year-old client recently diagnosed with Alzheimer disease says to the nurse, "I can anticipate getting this disease myself at some point." What is the BEST response by the nurse? 1. "Have you suffered any recent head trauma?" 2. "If you modify your lifestyle, you can reduce your risk of familial Alzheimer disease." 3. "It is good that you recognize this now so you can plan for your future care." 4. "Not necessarily. The strongest known risk factor for Alzheimer disease is age."

The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory report shows a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which assessment finding does the nurse anticipate? 1. Constipation and polyuria 2. Increased thirst and dry mucous membranes 3. Leg weakness and soft, flabby muscles 4. Tremors and brisk deep-tendon reflexes

The parent of an adolescent calls the mental health crisis hotline and says, "I just watched a TV program about bulimia and I think my child may have this disease." What is the MOST LIKELY reason that the parent came to this conclusion? 1. The adolescent has been wearing bulky, oversized clothing. 2. The adolescent has lost 20 lb (9 kg) in 2 months. 3. The adolescent stopped going to the gym. 4. The parent has found numerous candy, cake, and cookie wrappers under the adolescent's bed

The partner of a client with borderline personality disorder calls the clinic and reports coming home from work to find the client with self-inflicted superficial cuts to the arm. The partner tells the nurse, "My partner does something like this every time I have to go away on business. My partner is not serious about doing something really harmful, just trying to stop me from going away." What is the BEST response by the nurse? 1. "Are you still going to take your business trip?" 2. "It sounds like you are having a difficult time coping with your partner's behavior." 3. "Your partner is MOST LIKELY doing it for attention, so it's BEST to just ignore it." 4. "Your partner needs to be seen in the clinic today."

The student nurse is performing an assessment of a 10-year-old diagnosed with attention-deficit hyperactivity disorder (ADHD). In addition to the 3 core symptoms of ADHD (hyperactivity, impulsiveness, and inattention), which of the following would the student nurse expect to find during the assessment? 1. Confusion and a learning disability 2. Delayed physical and emotional development 3. Disorientation and cognitive impairment 4. Low self-esteem and impaired social skills

Which statement made by the nurse during a therapy session demonstrates a need for FURTHER INSTRUCTION regarding effective therapeutic communication techniques? 1. "I don't understand what you mean. Can you give me an example?" 2. "It is doubtful the president is out to get you." 3. "Tell me more about the day your child died." 4. "Why did you get so angry when she ignored you?"

Amniotic Fluid

500 - 1200 mL

Suction pressure should never be > ?

>120

People with obsessive compulsive disorder realize that their behavior is unreasonable, but are powerless to control it

A significant toxic risk associated with clozapine (Clozaril) administration is blood dyscrasia

Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn? A."Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period." B."Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk." C."I can start smoking cigarettes while breastfeeding because it will not affect my breast milk." D."When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings.

A."Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period." Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin, which will suppress ovulation and menses, but is not completely effective as a birth control method. Option B is incorrect because alcohol can immediately enter the breast milk. Nicotine is transferred to the infant in breast milk. Taking a warm shower will stimulate the production of milk, which will be more painful after breastfeedings.

The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan? A.Avoid alcohol because it is excreted in breast milk. B.Eat a high-roughage diet to help prevent constipation. C.Increase caloric intake by approximately 500 cal/day. D.Increase fluid intake to at least 3 quarts each day.

A.Avoid alcohol because it is excreted in breast milk. Rationale: Alcohol should be avoided while breastfeeding because it is excreted in breast milk and may cause a variety of problems, including slower growth and cognitive impairment for the infant. Options B, C, and D should also be included in diet teaching for a breastfeeding mother; however, because these do not involve safety of the infant, they do not have the same degree of importance as option A.

A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client? A.Breastfeed the infant, ensuring that both breasts are completely emptied. B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast. C.Breastfeed on the unaffected breast only until the mastitis subsides. D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.

A.Breastfeed the infant, ensuring that both breasts are completely emptied. Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the inflamed breast tissue. Option B is less painful but does not facilitate complete emptying of the breast tissue. Option C will not relieve the engorgement on the affected side. Option D will not decrease antibiotic effects on the infant.

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line? A.Cephalhematoma, which is caused by forceps trauma B.Subarachnoid hematoma, which requires immediate drainage C.Molding, which is caused by pressure during labor D.Subdural hematoma, which can result in lifelong damage

A.Cephalhematoma, which is caused by forceps trauma Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure on the cranium during vaginal delivery, and is a common variation of the newborn. Options B and D both involve intracranial bleeding and could not be detected by physical assessment alone.

A client at 28 weeks of gestation calls the antepartal clinic and states that she has just experienced a small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? A.Come to the clinic today for an ultrasound. B.Go immediately to the emergency department. C.Lie on your left side for about 1 hour and see if the bleeding stops. D.Take a urine specimen to the laboratory to see if you have a urinary tract infection (UTI).

A.Come to the clinic today for an ultrasound. Rationale:Third-trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incident life threatening or cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound. Bleeding that has a sudden onset and is accompanied by intense uterine pain indicates abruptio placenta, which is life threatening to the mother and fetus. If those symptoms were described, option B would be appropriate. Option C does not address the cause of the symptoms. The client is not describing symptoms of a UTI.

Which findings are of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.) A.Cramping with bright red spotting B.Extreme tenderness of the breast C.Lack of tenderness of the breast D.Increased amounts of discharge E.Increased right-side flank pain

A.Cramping with bright red spotting C.Lack of tenderness of the breast E.Increased right-side flank pain Rationale: Options A and C are signs of a possible miscarriage. Cramping with bright red bleeding is a sign that the client's menstrual cycle is about to begin. A decrease of tenderness in the breast is a sign that hormone levels have declined and that a miscarriage is imminent. Option E could be a sign of an ectopic pregnancy, which could be fatal if not discovered in time before rupture. Options B and D are normal signs during the first trimester of a pregnancy.

Which findings are most critical for the nurse to report to the primary health care provider when caring for the client during the last trimester of her pregnancy? (Select all that apply.) A.Increased heartburn that is not relieved with doses of antacids B.Increase of the fetal heart rate from 126 to 156 beats/min from the last visit C.Shoes and rings that are too tight because of peripheral edema in extremities D.Decrease in ability for the client to sleep for more than 2 hours at a time E.Chronic headache that has been lingering for a week behind the client's eyes

A.Increased heartburn that is not relieved with doses of antacids E.Chronic headache that has been lingering for a week behind the client's eyes Rationale: Options A and E are possible signs of preeclampsia or eclampsia but can also be normal signs of pregnancy. These signs should be reported to the health care provider for further evaluation for the safety of the client and the fetus. Options B, C, and D are all normal signs during the last trimester of pregnancy.

On admission to the prenatal clinic, a client tells the nurse that her last menstrual period began on February 15 and that previously her periods were regular (28-day cycle). Her pregnancy test is positive. What is this client's expected date of birth (EDB)? A.November 22 B.November 8 C.December 22 D.October 22

A.November 22 Rationale: Option A correctly applies the Nägele rule for estimating the due date by counting back 3 months from the first day of the last menstrual period (January, December, November) and adding 7 days (15 + 7 = 22). Options B, C, and D are not calculated correctly.

A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being prepared for discharge. Which nursing intervention should be included in this infant's discharge teaching plan? A.Observe the parents applying a Pavlik harness. B.Provide a referral for an orthopedic surgeon. C.Schedule a physical therapy follow-up home visit. D.Teach the parents to check for hip joint mobility.

A.Observe the parents applying a Pavlik harness. Rationale: It is important that the hips of infants with hip dysplasia are maintained in an abducted position, which can be accomplished by using the Pavlik harness; this keeps the hips and knees flexed, the hips abducted, and the femoral head in the acetabulum. Early treatment often negates the need for surgery, and option B is not indicated until approximately 6 months of age. Option C is not indicated for hip dysplasia. It is best for the pediatrician to monitor hip joint mobility, and teaching the parents to perform this technique is likely to increase their anxiety.

The client comes to the hospital assuming she is in labor. Which assessment findings by the nurse would indicate that the client is in true labor? (Select all that apply.) A.Pain in the lower back that radiates to abdomen B.Contractions decreased in frequency with ambulation C.Progressive cervical dilation and effacement D.Discomfort localized in the abdomen E.Regular and rhythmic painful contractions

A.Pain in the lower back that radiates to abdomen C.Progressive cervical dilation and effacement E.Regular and rhythmic painful contractions Rationale: These are all signs of true labor. Options B and D are signs of false labor.

Client teaching is an important part of the perinatal nurse's role. Which factor has the greatest influence on successful teaching of the pregnant client? A.The client's investment in what is being taught B.The couple's highest levels of education C.The order in which the information is presented D.The extent to which the pregnancy was planned

A.The client's investment in what is being taught Rationale: When teaching any client, readiness to learn is related to how much the client has invested in what is being taught or how important the materials are to the client's particular life. For example, the client with severe morning sickness in the first trimester may not be ready to learn about labor and delivery but is probably very ready to learn about ways to relieve morning sickness. Options B and C are factors that may influence learning but are not as influential as option A. Even if a pregnancy is planned and very desirable, the client must be ready to learn the content presented.

The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct? A.Two weeks before menstruation B.Immediately after menstruation C.Immediately before menstruation D.Three weeks before menstruation

A.Two weeks before menstruation Rationale:Ovulation occurs 14 days before the first day of the menstrual period. Although ovulation can occur in the middle of the cycle or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-day cycle. For many women, the length of the menstrual cycle varies. Options B, C, and D are incorrect.

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation is appropriate? A."Weigh the baby daily, and if she is gaining weight, she is getting enough to eat." B."Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day." C."Offer the baby extra bottled milk after her feeding and see if she still seems hungry." D."If you're concerned, you might consider bottle feeding so that you can monitor intake."

B."Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day." Rationale: The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day), if the infant is adequately hydrated. Although a weight gain of 30 g/day is indicative of adequate nutrition, most home scales do not measure this accurately, and the suggestion will likely make the mother anxious. Option C causes nipple confusion and diminishes the mother's milk production. Option D does not address the client's question.

A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce breast engorgement. Which instruction should the nurse provide? A.Avoid using the breast pump. B.Breastfeed the infant every 2 hours. C.Reduce fluid intake for 24 hours. D.Skip feedings to let the sore breasts rest.

B.Breastfeed the infant every 2 hours. Rationale: The mother should be instructed to attempt feeding her infant every 2 hours while massaging the breasts as the infant is feeding. If the infant does not feed adequately and empty the breast, using a breast pump helps extract the milk and relieve some of the discomfort. Dehydration irritates swollen breast tissue. Skipping feedings may cause further engorgement and discomfort.

A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. Which action should the nurse implement? A.Place a wedge under the client's left side. B.Determine cervical dilation and effacement. C.Administer 10 L of oxygen via facemask. D.Increase the rate of the oxytocin (Pitocin) infusion.

B.Determine cervical dilation and effacement. Rationale: The goal of labor augmentation is to produce firm contractions that occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. FHR accelerations are a normal response to contractions, so the oxytocin (Pitocin) infusion should be increased per protocol to stimulate the frequency and intensity of contractions. Options A and C are indicated for fetal stress. A sterile vaginal examination places the client at risk for infection and should be performed when the client exhibits signs of progressing labor, which is not indicated at this time.

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? A.She eagerly reaches for the infant, undresses the infant, and examines the infant completely. B.Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. C.Her arms and hands receive the infant and she then cuddles the infant to her own body. D.She eagerly reaches for the infant and then holds the infant close to her own body.

B.Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. Rationale:Attachment and bonding theory indicates that most mothers will demonstrate behaviors described in option B during the first visit with the newborn, which may be at delivery or later. After the first visit, the mother may exhibit different touching behaviors such as eagerly reaching for the infant and cuddling the infant close to her

A primigravida, when returning for the results of her multiple marker screening (triple screen), asks the nurse how problems with her baby can be detected by the test. What information will the nurse give to the client to describe best how the test is interpreted? A.If MSAFP (maternal serum alpha-fetoprotein) and estriol levels are high and the human chorionic gonadotropin (hCG) level is low, results are positive for a possible chromosomal defect. B.If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect. C.If MSAFP and estriol levels are within normal limits, there is a guarantee that the baby is free of all structural anomalies. D.If MSAFP, estriol, and hCG are absent in the blood, the results are interpreted as normal findings.

B.If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect. Rationale:Low levels of MSAFP and estriol and elevated levels of hCG found in the maternal blood sample are indications of possible chromosomal defects. High levels of MSAFP and estriol in the blood sample after 15 weeks of gestation can indicate a neural tube defect, such as spina bifida and anencephaly, not chromosomal defects. One of the limitations of the multiple marker screening is that any defects covered by skin will not be evident in the blood sampling. After 15 weeks of gestation, there will be traces of MSAFP, estriol, and hCG in the blood sample.

During a prenatal visit, the nurse discusses the effects of smoking on the fetus with a client. Which statement is most characteristic of an infant whose mother smoked during pregnancy compared with the infant of a nonsmoking mother? A.Lower Apgar score recorded at delivery B.Lower initial weight documented at birth C.Higher oxygen use to stimulate breathing D.Higher prevalence of congenital anomalies

B.Lower initial weight documented at birth Rationale:Smoking is associated with low-birth-weight infants. Therefore, mothers are encouraged not to smoke during pregnancy. Options A, C, and D have not been clearly associated with smoking during pregnancy, but there is a strong correlation between smoking and lower birth weights.

The nurse calls a client who is 4 days postpartum to follow up about her transition with her newborn son at home. The woman tells the nurse, "I don't know what is wrong. I love my son, but I feel so let down. I seem to cry for no reason!" Which adjustment phase should the nurse determine the client is experiencing? A.Taking-in phase B.Postpartum blues C.Attachment difficulty D.Letting-go phase

B.Postpartum blues Rationale: During the postpartum period, when serum hormone levels fall, women are emotionally labile, often crying easily for no apparent reason. This phase is commonly called postpartum blues, which peaks around the fifth postpartum day. The taking-in phase is the period following birth when the mother focuses on her own psychological needs; typically, this period lasts for 24 hours. Crying is not a maladaptive attachment response. It indicates a normal physical and emotional response. The letting-go phase is when the mother sees the child as a separate individual.

The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is completed, it is most important for the nurse to obtain which information? A.Maternal blood pressure B.Maternal temperature C.Fetal heart rate (FHR) D.White blood cell count (WBC)

C. Fetal heart rate (FHR) Rationale: The FHR should be assessed before and after the procedure to detect changes that may indicate the presence of cord compression or prolapse. An amniotomy (artificial rupture of membranes [AROM]) is used to stimulate labor when the condition of the cervix is favorable. The fluid should be assessed for color, odor, and consistency. Option A should be assessed every 15 to 20 minutes during labor but is not specific for AROM. Option B is monitored hourly after the membranes are ruptured to detect the development of amnionitis. Option D should be determined for all clients in labor.

Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement? A.Turn the client to her side. B.Begin oxygen by nasal cannula at 2 L/min. C.Place the client in a slight Trendelenburg position. D.Assess for cervical dilation.

C. Place the client in a slight Trendelenburg position. Rationale:The goal is to relieve pressure on the umbilical cord, and placing the client in a slight Trendelenburg position is most likely to relieve that pressure. The FHR pattern is indicative of a variable fetal heart rate deceleration, which is typically caused by cord compression and can occur with or without contractions. Option A may be helpful but is not as likely to relieve the pressure as the Trendelenburg position. Option B is not helpful with cord compression. Option D is not the priority intervention at this time. After repositioning the client, a vaginal examination is indicated to rule out cord prolapse and assess for cervical change.

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny-looking head." Which response by the nurse is best? A."This is not an unusually shaped head, especially for a first baby." B."It may look odd, but newborn babies are often born with heads like that." C."That is normal. The head will return to a round shape within 7 to 10 days." D."Your pelvis was too small, so the head had to adjust to the birth canal."

C."That is normal. The head will return to a round shape within 7 to 10 days." Rationale: Option C reassures the mother that this is normal in the newborn and provides correct information regarding the return to a normal shape. Although option A is correct, it implies that the client should not worry. Any implied or spoken "don't worry" is usually the wrong answer. Option B is condescending and dismissing; the mother is seeking reassurance and information. Option D is a negative statement and implies that molding is the mother's fault.

The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should the nurse assign? A.3 B.4 C.5 D.8

C.5 Rationale: The Silverman-Anderson index is an assessment scale that scores a newborn's respiratory status as grade 0, 1, or 2 for each component; it includes synchrony of the chest and abdomen, retractions, nasal flaring, and expiratory grunt. No respiratory distress is graded 0, and a total of 10 indicates maximum respiratory distress. This infant is demonstrating respiratory distress with maximal effort, so a grade 2 is assigned for marked nasal flaring, grade 2 for an audible expiratory grunting, plus grade 1 for just visible retractions, which is a total score of 5. Options A, B, and D are not accurate.

Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home? A.Wash the cord frequently with mild soap and water. B.Cover the cord with a sterile dressing. C.Allow the cord to air-dry as much as possible. D.Apply baby lotion after the baby's daily bath

C.Allow the cord to air-dry as much as possible. Rationale:Recent studies have indicated that air drying or plain water application may be equal to or more effective than alcohol in the cord healing process. Options A, B, and D are incorrect because they promote moisture and increase the potential for infection.

A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she had expected. Her partner is also becoming anxious. Which of the following should be the focus of the nurse's response? A.Telling the client and her partner that the labor process is often unpredictable B.Informing the client that this means she will give birth sooner than expected C.Asking the client and her partner if they would like the nurse to stay in the room D.Affirming that the fetal heart rate is remaining within normal limits

C.Asking the client and her partner if they would like the nurse to stay in the room Rationale: Offering to remain with the client and her partner offers support without providing false reassurance. The length of labor is not always predictable, but options A and B do not offer the client the support that is needed at this time. Option D may be reassuring regarding the fetal heart rate but does not provide the client the emotional support she needs at this time during the labor process.

A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement? A.Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking. B.Hold the infant's head firmly against the breast until he latches onto the nipple. C.Encourage the mother to stop feeding for a few minutes and comfort the infant. D.Provide formula for the infant until he becomes calm, and then offer the breast again.

C.Encourage the mother to stop feeding for a few minutes and comfort the infant. Rationale: The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself. After such a time out, breastfeeding is often more successful. Options A and D would cause nipple confusion. Option B would only cause the infant to be more resistant, resulting in the mother and infant becoming more frustrated.

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness? A.Wear a cotton bra with nonbinding support. B.Increase nursing time gradually over several days. C.Ensure that the baby is positioned correctly for latching on. D.Manually express a small amount of milk before nursing.

C.Ensure that the baby is positioned correctly for latching on. Rationale: The most common cause of nipple soreness is incorrect positioning of the infant on the breast for latching on. The baby's body is in alignment with the ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the breast. Option A helps prevent chafing, and nonbinding support aids in prevention of discomfort from the stretching of the Cooper ligament. Option B is important but is not necessary for all women. Option D helps soften an engorged breast and encourages correct infant latching on but is not the best answer.

A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color. Which action should the nurse take? A.Instruct the client to go to the emergency room. B.Recommend vaginal douching. C.Explain this is a normal finding. D.Determine if ovulation has occurred.

C.Explain this is a normal finding. Rationale:The client is describing lochia serosa, a normal change in the lochial flow. Options A, B, and D are not recommended for this normal finding.

The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate? A.Herpes B.Trichomonas C.Gonorrhea D.Syphilis

C.Gonorrhea Rationale: Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal. Ophthalmic ointment is not effective against option A, B, or D.

A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3 months of gestation. Which is the correct description of this client that should be documented in the medical record? A.Gravida 1, para 0 B.Gravida 1, para 1 C.Gravida 2, para 0 D.Gravida 2, para 1

C.Gravida 2, para 0 Rationale: This is the client's second pregnancy or second gravid event, so option C is correct. The spontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks), so she is a para 0. Parity cannot be increased unless delivery occurs at 20 weeks of gestation or beyond. Option A does not take into account the current pregnancy, nor does option B, which also counts the miscarriage as a "para," an incorrect recording. Although option D is correct concerning gravidity, para 1 is incorrect.

The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take? A.Administer oxygen by facemask. B.Notify the health care provider of the client's symptoms. C.Have the client breathe into her cupped hands. D.Check the client's blood pressure and fetal heart rate.

C.Have the client breathe into her cupped hands. Rationale: Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands. Option A is inappropriate because the carbon dioxide level is low, not the oxygen level. Options B and D are not specific for this situation.

A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating and states that because she has had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority? A.Altered nutrition, less than body requirements for lactation B.Alteration in comfort related to nausea and abdominal distention C.Impaired bowel motility related to pain medication and immobility D.Fatigue related to cesarean delivery and physical care demands of infant

C.Impaired bowel motility related to pain medication and immobility Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus. Options A and B are both caused by impaired bowel motility. Option D is not as important as impaired motility.

The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's next fertile period occur? A.January 14 to 15 B.January 22 to 23 C.January 29 to 30 D.February 6 to 7

C.January 29 to 30 Rationale: This client can expect her next period to begin 36 days from the first day of her last menstrual period. Her next period would begin on February 12. Ovulation occurs 14 days before the first day of the menstrual period. The client can expect ovulation to occur January 29 to 30. Options A, B, and D are incorrect.

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the lower extremities? A.Wear support stockings. B.Reduce salt in the diet. C.Move about every hour. D.Avoid constrictive clothing.

C.Move about every hour. Rationale: Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase venous return. Option A would increase venous return from varicose veins in the lower extremities but would be of little help with swelling. Option B might be helpful with generalized edema but is not specific for edematous lower extremities. Option D does not address venous return, and there is no indication in the question that constrictive clothing is a problem.

A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan? A.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. B.Wash off the yellow exudate on the glans once every day to prevent infection. C.Place petroleum ointment around the glans with each diaper change and cleansing. D.Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs.

C.Place petroleum ointment around the glans with each diaper change and cleansing. Rationale: With each diaper change, the glans penis should be washed with warm water to remove any urine or feces, and petroleum ointment should be applied to prevent the diaper from sticking to the healing surface. Prepackaged wipes often contain other products that may irritate the site. The yellow exudate, which covers the glans penis as the area heals and epithelializes, is not an infective process and should not be removed. If bleeding occurs at home, the client should be instructed to apply gentle pressure to the site of the bleeding with sterile gauze squares and call the health care provider.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60 mm Hg. Which action should the nurse take immediately? A.Notify the health care provider or anesthesiologist. B.Continue to assess the blood pressure every 5 minutes. C.Place the client in a lateral position. D.Turn off the continuous epidural.

C.Place the client in a lateral position. Rationale: The nurse should immediately turn the client to a lateral position or place a pillow or wedge under one hip to deflect the uterus. Other immediate interventions include increasing the rate of the main line IV infusion and administering oxygen by facemask. If the blood pressure remains low after these interventions or decreases further, the anesthesiologist or health care provider should be notified immediately. To continue to monitor blood pressure without taking further action could constitute malpractice. Option D may also be warranted, but such action is based on hospital protocol.

A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline sulfate? A.Drowsiness and paroxysmal bradycardia B.Depressed reflexes and increased respirations C.Tachycardia and a feeling of nervousness D.A flushed warm feeling and dry mouth

C.Tachycardia and a feeling of nervousness Rationale: Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of nervousness. Option A is not a side effect. Options B and D are side effects of magnesium sulfate.

A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide? A.Lie on your left side and call 911 for emergency assistance. B.Take an antacid and call back if the pain has not subsided. C.Take your blood pressure now, and if it is seriously elevated, go to the hospital. D.See your health care provider to obtain a prescription for a histamine blocking agent.

C.Take your blood pressure now, and if it is seriously elevated, go to the hospital. Rationale: Checking the blood pressure for an elevation is the best instruction to give at this time. A blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can be a sign of an impending seizure (eclampsia), a life-threatening complication of gestational hypertension. Additional data are needed to confirm an emergency situation as described in option A. Options B and D ignore the threat to client safety posed by a significant increase in blood pressure.

Assign the most critical care to the RN

Clients who are being discharged should have final assessments done by the RN

*The nurse provides medication instruction to a client who is prescribed 50 mcg/hour dose of transdermal fentanyl every 3 days. Which statement made by the client indicates understanding of the instructions? 1. "I should avoid placing a heating pad over the medication patch." 2. "If I develop a fever, less medication will be absorbed through my skin." 3. "The medication patch should be folded in half and put in the trash." 4. "I will leave the old patch on for a couple of hours after putting on the new one."

Correct: 1 Rationale: ANY heat source, including hot baths & electric blankets, will increase the absorption of the medication thru the skin. Statement indicated correct understanding. 2: A fever increases med absorption thru the skin. 3: Med patch should be folded in half with the adhesive side on the inside and flushed down the toilet. 4: Med will continue to be absorbed from both patches, increasing the risk of adverse effects.

The nurse provides care for a client who underwent a vagotomy with antrectomy to treat a duodenal ulcer. Postoperatively, the client develops dumping syndrome. Which client statement indicates to the nurse that further teaching is necessary? 1. "I should eat bread with each meal." 2. "I should eat smaller meals more frequently." 3. "I should lie down after eating." 4. "I should avoid drinking fluids with my meals."

Correct: 1 Rationale: Carbohydrates increase the risk of dumping syndrome.

The nurse preceptor observes the novice nurse obtain blood through a peripherally inserted central catheter (PICC). Which observation requires an intervention by the nurse preceptor? 1. The nurse discards 1 mL of blood prior to obtaining the blood sample. 2. The nurse uses a 10 mL syringe to flush through the port of the catheter. 3. The nurse applies clean gloves prior to beginning the procedure. 4. The nurse uses the push-pause technique to flush the catheter.

Correct: 1 Rationale: Novice nurse should discard 3-5 mL of blood to prevent contamination of a blood sample with IV fluids/meds. 2: 10 mL syringe is recommended to reduce pressure on the lumen of the PICC line during the flush. 3: Clean gloves are used when drawing blood from PICC line 4: The push-pause technique reduces the risk of clot formation and damage to the PICC line.

The nurse in the emergency department prepares to administer morphine sulfate to a client. Which action does the nurse take first? 1. Verify the client's name and date of birth. 2. Document the amount used on the medication record. 3. Determine if the client has a responsible driver. 4. Ensure the client's call light and belongings are within reach.

Correct: 1 Rationale: Nurse must verify clients' identity before administering meds, at least with 2 identifiers

The nurse admits a client to the postpartum unit and provides instruction about the postpartum process. The nurse determines that teaching is effective if the client makes which statement? 1. "I will call for assistance the first time I want to get out of bed." 2. "I can expect to pass clots the size of golf balls for the first 24 hours." 3. "I will use lanolin on my nipples when I breast feed my baby." 4. "I will allow my baby to suck no more than 5 minutes on each breast."

Correct: 1 Rationale: Only true statement regarding postpartum care.

*The health care provider prescribes an increase in the parenteral nutrition (PN) infusion rate from 50 mL/hour to 100 mL/hour. The PN is infusing through a peripherally inserted central catheter (PICC) device. Which is the priority action for the nurse? 1. Assess hourly urine. 2. Evaluate total serum protein level. 3. Assess vital signs (VS) every 4 hours. 4. Evaluate aspartate aminotransferase (AST) test.

Correct: 1 Rationale: PN is hyperosmolar and will pull fluid into the intravascular space, thereby causing osmotic diuresis. Fluid volume will affect the ABCs. Therefore, monitoring UO is the priority nursing action. 2: PN is high in protein, necessitating the need to monitor the total serum protein level. This will not impact ABC. 3: Changes in fluid volume may impact VS. However, this is too broad. Urine output is a better indicator of intravascular volume. 4: Not appropriate

*The nurse provides care for a client who is diagnosed with depression and anxiety. The client states, "I feel overwhelmed because I'm the only caregiver for my two children." Which response by the nurse is best? 1. "Do you participate in any religious or spiritual activities?" 2. "What can we do to help take your mind off things?" 3. "You do not plan to have any more children, do you?" 4. "Why do you not work outside the home?"

Correct: 1 Rationale: Spirituality and religious beliefs have the potential to exert influence on how people understand the meaning and purpose in their lives. The beliefs can also impact the use of critical judgment and the ability to problem solve. 2: Distraction is not always the best technique. Nurse should assess the client's coping mechanisms 3: a judgmental question 4: "why" questions is confrontational and not therapeutic

The nurse provides care to a client who has a chest tube and pleural drainage system placed for the treatment of a right-sided pneumothorax. The suction control chamber is set at 20 cm and tubing is attached to the wall suction. Which finding will the nurse expect to observe after the insertion of the chest tube? 1. Bubbling in the water-seal chamber. 2. Serosanguinous drainage in the collection chamber. 3. Fluctuation in the suction control chamber during coughing. 4. One cm sterile water in the water-seal chamber.

Correct: 1 Rationale: The water seal chamber bubbles d/t the pneumothorax 2: serosanguinous drainage is not anticipated, shouldn't have any drainage or very scant drainage 3: fluctuation is expected in the water seal chamber when the client forcefully coughs; not expected after the initial insertion 4: nurse expects 2 cm sterile water in the water seal chamber to prevent reentry of air into the pleural space

A client returns to the recovery area after a colonoscopy procedure. Intravenous midazolam was administered during the procedure. The procedure was completed at 1115. The recovery room nurse reviews the sedation chart below. Based on this information, which is the most appropriate action for the nurse to take? Time (preprocedure) O2Sat: 96% BP: 132/84 LOC: Alert/Oriented Pulse/Pain: 84, 0/10 RR: 18 Time (1115) O2Sat: 92% BP: 124/78 LOC: Sleepy/Arousable Pulse/Pain: 76, 0/10 RR: 14 Time (1130) O2Sat: 94% BP: 130/80 LOC: Sleepy/arousable Pulse/Pain: 80, 0/10 RR: 16 Time (1145) O2Sat: 93% BP: 140/86 LOC: Arouses to command Pulse/Pain: 72, 1/10 RR: 15 Time (1215) O2Sat: 92% BP: 160/88 LOC: Arouses to command Pulse/Pain: 66, 1/10, nausea RR: 16 1. Recheck blood pressure in 15 minutes. 2. Administer ondansetron 4 mg IV. 3. Obtain a 12-lead electrocardiogram (ECG). 4. Assist client to get dressed.

Correct: 1 Rationale: VS should be within 20% of pre-procedure values. While midazolam more commonly causes hypotension, the elevated BP is greater than a 20% change in baseline values, indicating that the client is not stable. 2: Expected, nausea may occur p the procedure 3:ECG is done to determine heart rate changes and dysrythmias. 4: Client is not stable

*The nurse provides care for a client who is prescribed assist-control mechanical ventilation with positive end-expiratory pressure (PEEP) of 5 cm H 2O. Which actions will the nurse include in the client's plan of care? (Select all that apply.) 1. Strict handwashing before suctioning. 2. Brushing teeth every 12 hours. 3. Elevating the head of the bed 20 degrees. 4. Administering pantoprazole 40 mg intravenous daily. 5. Changing client position every 2 hours.

Correct: 1,4,5 Rationale: -Hand hygiene will reduce risk of VAP -Pantoprazole, a proton pump inhibitor, will decrease the risk of aspiration of gastric contents. -Repositioning and turning every 2 hours reduces the risk of atelectasis, PNA and skin breakdown 2: Oral care and teeth brushing should be at least every 8 hours. 3: HOB should be at least 30 degrees

*The nurse provides care for an older adult client who is diagnosed with a fractured ulna. The client reports falling frequently. Which client statements require that the nurse collect more information? (Select all that apply.) 1. "I keep my bedroom pitch black at night." 2. "My adult child secured all electrical cords against the baseboards." 3. "The bottoms of my shoes have rubber soles." 4. "My sister gave me her cane before she died." 5. "I have my vision checked every 3 years." 6. "I prefer for my pants to fit loosely around my waist."

Correct: 1,4,5,6 Rationale: These statements requires follow-up by the nurse *Reducing fall risk: -have a night light -secure all electrical cords -rubber soles on bottom of shoes -cane should be in proper height with client -visual examinations every 1-2 years -no loose fitting pants on waist

*A pediatric client is diagnosed with pneumonia and prescribed ampicillin 50 mg/kg oral suspension every 6 hours. The child weighs 18 lb (8.181818 kg). The ampicillin is available in 125 mg/5 mL. How many mL will the nurse administer for each dose? (Record your answer rounding at the end of your calculations to the nearest whole number.)

Correct: 16 mL Solution: Client Dose: 50 x 8.181818 = 409.0909 mg x mL = (5mL/125mg) x (50mg/1kg) x (1kg/2.2lbs) x 18lbs. x mL = 4500/275 x mL = 16.3636364 ~ 16

*The nurse provides care for pregnant and postpartum clients. Which client does the nurse see first? 1. Client at 6 weeks' gestation, reporting that the LPN/LVN could not obtain fetal heart tones with a Doptone. 2. Client at 5 days postpartum, reporting bright red, bloody discharge. 3. Client at 22 weeks' gestation, reporting feeling fetal movement four times in the last hour. 4. Client at 2 days postpartum, reporting urinary incontinence.

Correct: 2 Rationale: Lochia rubra (endometrial sloughing that is bloody with a fleshy odor) should last 1-3 days. Therefore, client is unstable. Nurse should assess the client's lochia amount and color in addition to monitoring VS. 1: Client is stable. Fetal heart tones cannot be heard with Doptone until 8-12 weeks gestation. 3: Reassuring sign of fetal well being; fewer than 3 fetal mov'ts in a 1 hour period would indicate a potential issue 4: Stable; urinary incontinence is common during the postpartum period. Nurse should teach the client to perform Kegel exercises to tighten pubococcygeal muscles and avoid diuretics.

*A client who is diagnosed with end-stage kidney disease is prescribed hemodialysis treatments three times a week. After two weeks of treatment, the client states, "I have a headache when the dialysis finishes. Is this normal?" Which is the most appropriate response by the nurse? 1. "I have seen this a lot in clients. Don't worry too much about it." 2. "Headaches may occur at the beginning of treatment and should improve over time." 3. "Have you experienced any headaches similar to these in the past?" 4. "Why are you so worried about this? It is a common side effect."

Correct: 2 Rationale: Nurse must provide correct info in a therapeutic way. Headache, nausea and fatigue may occur after hemodialysis d/t disequilibrium syndrome. This is caused by rapid removal of electrolytes and solutes from blood. A reduction of blood flow during dialysis decreases the risk of disequilibrium syndrome. 1: This response is about the nurse, not the client; this also negates client's concern 3: It is more imp't for the nurse to address the here and now versus if the client has experienced similar headaches in the past 4: "why" questions are not therapeutic

At a rehabilitation center for clients with spinal cord injuries (SCIs), the nurse conducts an orientation session for a group of unlicensed assistive personnel (UAP). Which statement is most important for the nurse to include? 1. "The clients may appear angry at times." 2. "Obtain the client's permission before touching the client." 3. "Most clients arrive believing they will walk out of here." 4. "Personnel in this environment often need counseling."

Correct: 2 Rationale: This statement provides the UAP c info needed to provide care for a client c SCI. Therefore, this isa priority when delegating tasks to the UAP who provides client care. 1,3,4: MAY be true but does not provide info regarding care for SCI patients.

*The nurse performs triage in the emergency department (ED). An unemancipated adolescent minor requests to be treated. The registration clerk states the adolescent requires guardian consent for treatment. Which action should the nurse take next? 1. Triage the client after guardian consent has been obtained. 2. Ask the unemancipated minor about the medical reason for seeking treatment. 3. Request that the health care provider perform a medical screening exam. 4. Notify the nursing supervisor.

Correct: 2 Rationale: Unemancipated minors an consent to medical tx if they have a specific medical condition (i.e. pregnancy, pregnancy-related conditions, minor tx for custodial child, STI info & tx, substance abuse tx and mental health tx). 1: depending on why the minor is seeking treatment, guardian consent may not be necessary and could breach HIPAA guidelines 3: Every person who presents to the ED and requests tx should receive medical screening exam from HCP. 4: it is not appropriate

*The nurse reviews the medical record of a client who is confused. The client has soft wrist and ankle restraints in place. The nurse determines care is effective if which actions are documented? (Select all that apply.) 1. Restraints secured tightly to the skin. 2. Client placed in room next to the nursing station. 3. Restraints attached to side rails on the client's bed. 4. Informed consent for the restraints obtained from the client's spouse. 5. Client alert and oriented x 3. 6. Client placed in the prone position.

Correct: 2,4 Rationale: An appropriate action that promotes client's safety, consent is obtained by proxy since the client is confused 1: tight application interferes c circulation and potentially can can neurovascular injury. Nurse should be able to insert 2 fingers under the restraint 3: restraints should be attached to the bed frame; client could be injured if restraint is secured to the side rail and it is lowered 5: restraints should be d/c as soon as client becomes alert and oriented 6: prone position while in restraints increases the client's risk of suffocation

During a urinary bladder catheter insertion, with a size 16 French catheter on an older adult male, the nurse feels increased resistance. Which is the most appropriate action for the nurse to take? 1. Withdraw the catheter and apply more lubricant. 2. Instruct the client to take a deep breath and bear down. 3. Stop the insertion and instruct the client to take deep breaths. 4. Withdraw the catheter and notify the health care provider.

Correct: 3 Rationale: Instructing the client to take deep breaths will relax the urethral muscles and facilitate passage thru the prostate gland. 4: the nurse determines if there is something that can resolve the issue prior to contacting the HCP

The nurse in the emergency department (ED) assesses a client diagnosed with tonic-clonic epilepsy. The client's spouse states that the client has been taking phenytoin as prescribed, but has not been feeling well lately. Which client observation most concerns the nurse? 1. Reddish-brown urine, and the client reports constipation. 2. Acne, hirsutism, and gingival hyperplasia. 3. Ataxia, slurred speech, and nystagmus. 4. The left arm is in a sling and the client walks with a limp.

Correct: 3 Rationale: Slurred speech and ataxia both present an airway concern. 1,2,4: Important manifestations but none impact the ABCs

The client approaches the triage desk in the emergency department (ED) and reports exposure to chemicals after a truck overturned. The client has powder and unknown liquid substances on the clothing. The client is diaphoretic and reports difficulty breathing. Which action does the nurse take first? 1. Escort the client to the decontamination room. 2. Notify the health care provider. 3. Put on appropriate protective gear. 4. Deliver high flow oxygen via a mask.

Correct: 3 Rationale: The nurse's first priority is to protect self and put on the appropriate protective gear. 4: Action is appropriate after the nurse puts on protective gear, as the goal is to prevent the spread of contamination.

*The home care nurse instructs a client diagnosed with multiple sclerosis (MS). The client states, "I have poor concentration and difficulty pronouncing words." The nurse notes that the client's speech is slow and slurred. Which client statement indicates to the nurse that further teaching is necessary? 1. "I will sit up straight when I talk and will feel confident." 2. "I will turn off the TV when speaking and look at the person with whom I am talking." 3. "During a conversation, I will carefully build up to my most important points." 4. "If words fail me, I will draw a picture."

Correct: 3 Rationale: Verbal communication often causes fatigue for MS clients. Therefore, client is taught to make important points first prior to the onset of fatigue. 1,2,3: INDICATES appropriate understanding from the client.

A client diagnosed with malnutrition is prescribed continuous enteral feedings through a newly placed gastrostomy tube. Which actions will the nurse include in the client's plan of care? (Select all that apply.) 1. Cover the insertion site with an adhesive bandage. 2. Add 8 hours of feeding to the bag at a time. 3. Rotate the gastrostomy tube 360 degrees once daily. 4. Auscultate for whoosh of air through the gastrostomy tube. 5. Check for slight in-and-out movement of the gastrostomy tube.

Correct: 3,5 Rationale: Gtube should be rotated 360 degrees daily (to reduce risk of skin irritation and breakdown) and a slight in-&-out mov't indicates that the GTube is not embedded in the stomach wall. 1: Gtube insertion site should be covered c a sterile bandage to reduce infection until the stoma is healed. AN adhesive bandage is not used, as this may cause the tube to become dislodged along with increasing risk of infection. 2: Only 4 hours of feeding should be added to the bag to reduce risk of bacterial contamination. 4: Insertion of air is not recommended for GTube placement assessment.

*The nurse reviews the medical record of a client recently diagnosed with Guillain-Barré syndrome. The client has flaccid paralysis of both legs, a history of coronary artery bypass surgery 3 weeks ago, and a 20-year history of hypertension and hypercholesterolemia. The client was also recently diagnosed with type 2 diabetes mellitus (DM). The nurse prepares to apply anti-embolism stockings to both legs. Which priority action does the nurse implement? 1. Assess for bilateral pretibial edema. 2. Palpate both calves for pain. 3. Ask the client the reason for application of anti-embolism stockings. 4. Palpate bilateral pedal pulse strength.

Correct: 4 Rationale: Best indication of PAD and circulation in the extremities is to monitor the client's pedal pulses. In addition, decreased circulation is a contraindication for an anti-embolism stockings. 1: Some edema is expected to an immobile client. Purpose of TED socks may be to reduce edema 2: Venous thromboembolism is a contraindication for anti-embolism stockings. However, client may not have calf pain c VTE in the deeper veins. Pain is also considered psychosocial.

The nurse provides care to a client who is diagnosed with a stroke and is admitted to a rehabilitation center. The client has left-sided pronator drift and decreased dorsiflexion strength of the left extremity. The nurse notes the client bumps into the left wall when ambulating with a walker. The client leans to the left when sitting in a chair or wheelchair. Which is the most appropriate action for the nurse to take? 1. Place the client's favorite watch on the left wrist. 2. Provide a written list for the client to follow during morning care. 3. Instruct the client to choose a dress for the day. 4. Position the client so the right side faces the door of the room.

Correct: 4 Rationale: Client has R side stroke c L side unilateral neglect syndrome. Therefore, the client cannot see out of the left side of both eyes. Safety is a priority when providing care. To enhance safety, the nurse positions the client for best vision so that the client is not scared or upset by approaching people. 1,3: Psychosocial 2: Client recovering from stroke may have short attention span or visual difficulties, making reading with comprehension a difficult task. Nurse should provide verbal instructions c short sentences.

A client is brought to the emergency department (ED) by friends reporting a dry mouth, frequent urination, extreme thirst, and no fluid intake for the last 8 hours. The friends report the client may not have taken insulin during the last couple of days. The nurse reviews prescriptions from the health care provider. Which prescription does the nurse implement first? 1. Administer 20 mEq potassium chloride orally. 2. Begin regular insulin at 0.1 units/kg/hour. 3. Obtain a 12-lead electrocardiogram. 4. Begin infusion of 0.9 % NaCl at 1 L per hour.

Correct: 4 Rationale: During DKA, osmotic diuresis occurs and the client is at significant risk for fluid volume deficit. Since this deficit impacts the ABCs (specifically circulation), this is the priority prescription for the nurse to implement. 1: Mild to moderate hyperkalemia is often seen during the initial phase of DKA. Once an insulin drip is initiated, causing potassium to move into the cells, a KCl prescription may be appropriate. 2: does not address ABC's Restoring volume is the priority for this client 3: This does not address the client's actual problem

*The community health nurse conducts a program for suicide prevention at a high school. The nurse discusses high-risk groups for suicide. The nurse determines that further teaching is necessary if students from the group make which statement? 1. "Adolescents are at risk to commit suicide." 2. "Depressed people are at risk to commit suicide." 3. "History of previous suicide attempts put people at risk." 4. "People grieving a loss for 9 months are at risk."

Correct: 4 Rationale: Grief is a normal human response that occurs in response to loss. The entire grieving process may take up to 3 years. Therefore, this statement indicates the need for further instruction. 1) Males over the age of 50 years and adolescents ages 15 to 19 years are at risk for suicide. This statement indicates correct understanding of the information presented. 2) Indications of depression include low self-esteem, feelings of helplessness/hopelessness, and a sense of doom or failure. Individuals who are depressed are at an increased risk to commit suicide. This statement indicates correct understanding of the information presented. 3) A suicide attempt is the result of the client turning aggression and rage toward self. Anyone with a history of a previous suicide attempt is at risk for another attempt. This statement indicates correct understanding of the information presented.

*The nurse receives a phone call from a client's adult child who states, "I just got here to see my elderly parent, and I think heat stroke has occurred. I think the air conditioning is not working and the house is very hot." The adult child reports that the parent is confused, very thirsty, nauseated, and in pain. Which is the most appropriate statement for the nurse to make? 1. "If perspiration is present, heat stroke has not occurred." 2. "Give your parent cool fluids to drink immediately." 3. "What medications does your parent take daily?" 4. "Remove any excess clothing immediately."

Correct: 4 Rationale: Removing the parent's clothing will begin the cooling process, thereby enhancing circulation. Other measures to reduce temp can be implemented once this step occurs. 1: Provides education to family but does not address the immediate concern 2: Client is at risk for aspiration d/t altered mental status, should be NPO. 3: This is an assessment question but info is not immediately needed.

*The nurse provides care for a young adult client requiring an emergent appendectomy. The health care provider explains to the client the risks and benefits of the procedure. However, the client refuses to sign the informed consent. The client states, "No one is removing any organs from my body because it is against my religious beliefs. I'm leaving!" The client's mother insists the client receive the operation. Which response does the nurse make to the client? 1. "I am going to apply soft wrist and ankle restraints." 2. "Let us contact the hospital chaplain to mitigate the situation." 3. "Intravenous diazepam will help calm your nerves before the procedure." 4. "It is your decision to refuse medical treatment."

Correct: 4 Rationale: The competent client has the right to make personal choice without interference 1: false imprisonment 2: contacting the hospital chaplain violates the client's rights 3: use of diazepam in this situation would be considered a chemical restraint. Psychotropic drugs cannot be used to control behavior

*The nurse works on the medical surgical unit. The nurse-to-client ratio is 1:10. Which action does the nurse take first? 1. Document the situation in writing. 2. Refuse the client assignment. 3. Delegate tasks to the LPN/LVN. 4. Notify the nursing supervisor.

Correct: 4 Rationale: Thisi s the priority action, as the nurse-to-client ratio is proportionately high. This action alerts the nursing supervisor of the situation so nurses can be "floated" from other departments, if available. 1: Notifying the supervisor is the priority. Nurse should provide documentation to the nursing admin, but the documentation does not relieve the nurse of responsibility if clients suffer harm because of inattention. It does show that the nurse attempted to act appropriately. 2: Refusing the client assignment could be regarded as abandonment 3: Nurse maintains responsibility for client outcomes. Problem is nurse-to-client ratio.

*The nurse provides care for the client immediately after arrival in the emergency department (ED). Emergency personnel report that the client was involved in a head-on collision with immediate loss of consciousness. Which is the first action taken by the nurse? 1. Determine Glasgow Coma Scale (GCS) score. 2. Assess bilateral blood pressure. 3. Check bilateral pupillary response to light. 4. Determine oxygen saturation levels.

Correct: 4 Rationale: When prioritizing care for a client, nurse uses the ABC's (airway, breathing, circulation). Oxygen saturation levels allow the nurse to monitor the client's airway (priority). 1: GCS is used to assess ABC and neuro status for clients c head trauma. It is appropriate but too broad and will take longer. 2: Assessing BP is monitoring for circulation. However, airway is priority and increases in arterial CO2 will increase ICP. 3: Nurse assesses neuro status (eg. PERRLA) after ABC.

The nurse reviews the medical record of a client diagnosed with acute kidney injury. It is most important for the nurse to review which lab value? 1. Fasting blood glucose. 2. Serum uric acid. 3. Serum protein. 4. Urine specific gravity.

Correct: 4 Rationale: When providing care for a client diagnosed with acute kidney injury, it is important for the nurse to monitor circulation by reviewing the client's urine specific gravity, which is a good indicator of fluid volume. 1,2,3: Not necessary to review for acute kidney injury

The nurse provides care for the client diagnosed with a hypertensive emergency. The client is prescribed sodium nitroprusside 0.3 mcg/kg/min. The client weighs 176 lb (80 kg). The concentration of the sodium nitroprusside is 50 mg/250 mL. What rate will the nurse set for the per hour amount on the micro infusion pump? (Record your answer rounding at the end of the calculation using one decimal place.)

Correct: 7.2 mL/hr Solution: x mL/hr = (250mL/50mg) x (1mg/1000mcg) x (24mcg/1min) x (60min/1hr) =360000/50000 =7.2

An expectant father tells the nurse he fears that his wife is "losing her mind." He states that she is constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which recommendation should the nurse make to this expectant father? A.Suggest that his wife seek professional counseling to deal with her symptoms. B.Explain that his wife is exhibiting ambivalence about the pregnancy. C. Ask him to report similar abnormal behaviors at the next prenatal visit. D.Reassure him that normal maternal-fetal bonding is occurring.

D) Reassure him that normal maternal-fetal bonding is occurring. Rationale: These behaviors are positive signs of maternal-fetal bonding and do not reflect ambivalence. No intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal bonding during the second trimester. Options A and C are not necessary because the behaviors displayed are normal.

When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A.At 16 weeks of gestation B.At 20 weeks of gestation C.At 24 weeks of gestation D.At 30 weeks of gestation

D.At 30 weeks of gestation Rationale: Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy, when they are beginning to anticipate the onset of labor and the birth of their child. Option D is closest to the time when parents would be ready for such classes. Options A, B, and C are not the best times during a pregnancy for the couple to attend childbirth education classes. At these times they will have other teaching needs. Early pregnancy classes often include topics such as nutrition, physiologic changes, coping with normal discomforts of pregnancy, fetal development, maternal and fetal risk factors, and evolving roles of the mother and her significant others.

The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take? A.Reapply the external transducer. B.Insert the intrauterine pressure catheter. C.Discontinue the oxytocin infusion. D.Continue to monitor labor progress

D.Continue to monitor labor progress Rationale: The fetal heart rate indicates early decelerations, which are not an ominous sign, so the nurse should continue to monitor the labor progress and document the findings in the client's record. There is no reason to reapply the external transducer if the FHR tracings are being captured. Options B and C are not indicated at this time.

A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become HIV-infected. Which explanation should the nurse provide? A.Most infants of HIV-positive women will continue to test positive for HIV antibodies. B.Infants who have HIV-positive mothers carry the virus and will eventually develop the disease. C.Medication taken during pregnancy to reduce the mother's viral load ensures that the infant is HIV-negative. D.HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present.

D.HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present. Rationale: All newborns of HIV-positive mothers receive passive HIV antibodies from the mother, so the evaluation of an infant for the HIV virus is determined at 18 months of age, when all the maternal antibodies are no longer in the infant's blood. Passive HIV antibodies disappear in the infant within 18 months of age. Option B is inaccurate. Although administration of HIV medication during pregnancy can significantly reduce the risk of vertical transmission, treatment does not ensure that the virus will not become manifest in the infant.

During the transition phase of labor, a client complains of tingling and numbness in her fingers and tells the nurse that she feels like she is going to pass out. What action should the nurse take? A.Encourage her to pant between contractions and blow with contractions. B.Coach her to take a deep cleansing breath and then refocus. C.Instruct her to pant three times and then exhale through pursed lips. D.Have her cup both hands over her nose and mouth while breathing.

D.Have her cup both hands over her nose and mouth while breathing. Rationale: Hyperventilation blows off carbon dioxide, depletes carbonic acid in the blood, and causes transient respiratory alkalosis, so the client should cup both her hands over her mouth and nose so that she can rebreathe carbon dioxide. Options A, B, and C do not help restore carbon dioxide levels as effectively as rebreathing air in the cupped hands or from a paper bag.

The nurse observes that an antepartum client who is on bed rest for preterm labor is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. Which is the best response by the nurse? A.Remove all ice from the client's room. B.Ask the client what foods she might consider eating. C.Remind the client that what she eats affects her baby. D.Notify the health care provider.

D.Notify the health care provider. Rationale: The health care provider should be notified when a client practices pica (craving for and consumption of nonfood substances). The practice of pica may displace more nutritious foods from the diet, and the client should be evaluated for anemia. Option A is overreacting and may be perceived as punishment by the client. Option B allows the dietary department to customize the client's tray but fails to address physiologic problems associated with not consuming nutritious foods in pregnancy. Option C is judgmental and blocks further communication.

One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his lower lip is shaking, and when the nurse assesses for a Moro reflex, the boy's hands shake. Which intervention should the nurse implement first? A.Stimulate the infant to cry. B.Wrap the infant in warm blankets. C.Feed the infant formula. D.Obtain a serum glucose level.

D.Obtain a serum glucose level. Rationale: This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level. Option A is an intervention for a lethargic infant. Option B should be done based on the temperature, but first the glucose level should be obtained. Option C helps raise the blood sugar, but first the nurse should determine the glucose level.

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention should the nurse implement first? A.Assess the husband's feelings about his wife's decision to breastfeed their baby. B.Ask the woman to describe why she was unsuccessful with breastfeeding her last child. C.Encourage the woman to develop a positive attitude about breastfeeding to help ensure success. D.Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

D.Provide assistance to the mother to begin breastfeeding as soon as possible after delivery. Rationale: Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery. Options A and B might provide interesting data, but gathering this information is not as important as providing support and instructions to the new mother. Although option C is also true, this response by the nurse might seem judgmental to a new mother.

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? A.Use thread to tie off the umbilical cord. B.Provide privacy for the woman. C.Reassure the husband and keep him calm. D.Put the newborn to the breast immediately.

D.Put the newborn to the breast immediately. Rationale: Putting the newborn to the breast will help contract the uterus and prevent a postpartum hemorrhage. This intervention has the highest priority. Option A is not necessary; the infant can be transported attached to the placenta. Option B is an important psychosocial need but does not have the priority of option D. Although the husband is an important part of family-centered care, he is not the most important concern at this time.

In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan? A.The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the first week. B.The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the second week. C.The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of the first month. D.The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month

D.The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month Rationale: In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel closes by the end of the second month. These growth and development milestones are frequently included in questions on the licensure examination. Options A, B, and C are incorrect.

Alendornate

For: Osteoporosis S/E: headache, blurred vision, eye pain, abd distention, diarrhea, musculoskeletal pain, vomiting Contraindication: if you can't sit/stand upright for 30 min

HELLP

HELLP Syndrome Abnormal variant of pre-eclampsia Hemolysis Elevated Liver enzymes Low Platelets

Adverse effects of haloperidol (Hadol) administration include drowsiness, insomnia, weakness, headache, and extrapyramidal symptoms, such as akathisia, tardive dyskinesia, and dystonia.

Hypervigilance and deja vu are signs of post traumatic stress disorder (PTSD)

Trust vs. Mistrust

If needs are dependably met, infants develop a sense of basic trust

Pt's at risk

Immobilized Smoker Low vitamin C Low protein

Lochia alba is the vaginal discharge of decreased blood and increased leukocytes that's the final stage of lochia. It occurs 7 to 10 days after childbirth.

In the event of a fire, the acronym most often used is RACE. Remove the patient Activate the system Contain the fire Extinguish the fire

LARA CROFT

L abor - dull ache in back, lower abdomen, pressure in pelvis A bruptio Placenta - bleeding, contractions, fetal distress R upture - ruptured ectopic pregnancy => internal bleeding and intense abdominal pain - rupture of uterus => bleeding, rupture of amniotic sac *SERIOUS EMERGENCY* A bortion - abdominal cramps, bleeding C holestasis - itching, abdominal pain, no risk to mother but can for baby R ectus sheath hematoma - painful tender swelling O varian tumor - occur usually in 2nd trimester, don't pose risk to mother or baby, resolve before/after childbirth naturally F ibroids - benign tumors, no problems during pregnancy T orsion of the uterus - rotation of > 45 degrees around long axis of uterus - severe abdominal pain, tense uterus, fetal distress

The nurse observes the unlicensed assistive personnel (UAP) obtain a capillary glucose sample. Which is the best location for obtaining a blood glucose sample?

Lateral aspect of finger; end of finger is not recommended d/t less blood flow and more nerve fibers.

Wheezes/whistling

Location: Entire lungs - mainly on exhalation Narrow airways Caused by: Asthma & COPD Treatment: Asthma attack (AIM) AIM A = albuterol I = Ipratropium M = methylprednisone

Someone diagnosed with terminal cancer expressing depression

MOST imp't to determine client's perception of the health problem. Open-ended statement. Strategy: need to address the problem and better to ask open-ended questions. It is more imp't to deal with the here and now.

Nitroglycerin sublingual is administered up to three times with intervals of five minutes

Morphine is contraindicated in pancreatitis because it causes spasms of the Sphincter of Oddi. Demerol should be used.

Beneficence is the duty to do no harm and the duty to do good. There's an obligation in patient care to do no harm and an equal obligation to assist the patient

Nonmaleficence is the duty to do no harm.

"PRE" eclampsia

P roteiniuria R ising BP E dema Proteinuria - >300mg/24hrs or protein:creatinine ratio > 0.3 Rising BP - > 140/90 documented on 2 occasions at least 4 hrs apart Edema

Tyramine-rich food, such as aged cheese, chicken liver, avocados, bananas, meat tenderizer, salami, bologna, Chianti wine, and beer may cause severe hypertension in a patient who takes a monoamine oxidase inhibitor.

Projection is the unconscious assigning of a thought, feeling, or action to someone or something else

The school nurse instructs a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates further teaching is necessary? 1. "The poison control center number is stored on all the phones in our house." 2. "I should induce vomiting if my child swallows lighter fluid." 3. "If I carry medication in my purse, it should be in a child-proof container." 4. "Proper storage is the key to poison prevention in the home."

Strategy: "Further teaching is necessary" indicates an incorrect statement. (1) Appropriate action; terminate exposure to the poison and then contact poison control for further instructions (2) correct—vomiting contraindicated when child ingests hydrocarbons because of danger of aspiration (3) 'poison-proofs' the medication (4) store in locked cabinets

A young adult is involved in a motorcycle accident and is brought to the emergency room. The physician diagnoses a closed head injury with suspected subdural hematoma. Although complaining of a severe headache, the client is alert and answers questions appropriately. The nurse should question which of the following orders? 1. "Promethazine (Phenergan) 25 mg IM 3 h." 2. "Morphine sulfate 10 mg IM q3 4h." 3. "Docusate sodium (Colace) 50 mg PO bid." 4. "Ranitidine (Zantac) 50 mg IVPB q12h."

Strategy: "Question which of the following orders" indicates an incorrect order. (1) H1 receptor blocker, used as an antiemetic (2) correct—narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure (3) stool softener, used for an immobilized patient (4) H2 histamine antagonist, reduces acid production in stomach, prevents stress ulcers

Strategy: "Requires an intervention" indicates you are looking for a complication. (1) common complaint, moderate pain is frequently experienced as fluid is instilled during first few exchanges (2) common complaint due to inactivity, decreased nutrition, use of medications; high-fiber diet and stool softeners help prevent (3) correct—indicates peritonitis, also will see nausea and vomiting, anorexia, abdominal pain, tenderness, rigidity (4) caused by subcutaneous bleeding, common during first few exchanges

The nurse in the outpatient clinic instructs a client diagnosed with a sprained right ankle to walk with a cane. What behavior, if demonstrated by the client, indicates to the nurse that teaching is effective? 1. The client advances the cane 18 inches in front of the foot with each step. 2. The client holds the cane in the left hand. 3. The client advances the right leg, then the left leg, and then the cane. 4. The client holds the cane with elbows flexed 60°.

Strategy: "Teaching is effective" indicates a correct behavior. (1) should advance cane 6-10 inches with body weight on both legs (2) correct—should hold cane on strong side, widens base of support, reduces stress on affected side (3) should advance cane, weaker leg, stronger leg (4) should flex no more than 30°

A client is admitted diagnosed with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY? 1. Unequal and dilated pupils. 2. Decerebrate posturing. 3. Grand mal seizures. 4. Decreased level of consciousness.

Strategy: All answers are assessments. Determine how each relates to increased intercranial pressure. (1) indicates brainstem damage (2) late sign of brainstem damage (3) late sign of increased intracranial pressure (4) correct—may be confused and stuporous

A woman at 38 weeks' gestation comes to the emergency room with complaints of vaginal bleeding. Which of the following statements, if made by the client, suggests to the nurse placenta previa as the cause of the bleeding? 1. "I feel fine, but the bleeding scares me." 2. "I've been more nauseated during the past few weeks." 3. "The bleeding started after I carried four bags of groceries." 4. "I've been having severe abdominal cramps."

Strategy: All answers are assessments. Think about what each phrase is describing and how it relates to a placenta previa. (1) correct—placenta previa is characterized by painless vaginal bleeding (2) nausea not a symptom of placenta previa (3) bleeding is not necessarily related to activity (4) pain not characteristic of placenta previa

The physician orders ranitidine hydrochloride (Zantac) 150 mg PO daily for the client. The nurse should advise the client the BEST time to take the medication is which of the following? 1. Prior to breakfast. 2. With dinner. 3. With food. 4. At hour of sleep. After a client has a positive Chlamydia trachomatis culture, the client and partner return for counseling. It is MOST important for the nurse to ask which of the following questions? 1. "Do you have contacts to identify?" 2. "What is your understanding regarding how chlamydia is transmitted?" 3. "Do you have questions about the culture and its validity?" 4. "Do you have allergies to the medications?"

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) absorption is not affected by food (2) absorption is not affected by food (3) absorption is not affected by food (4) correct—best results when taking once a day ...

A client diagnosed with a peptic ulcer has a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the nurse should caution the client about which of the following? 1. Sit up for at least 30 minutes after eating. 2. Avoid fluids between meals. 3. Increase the intake of high-carbohydrate foods. 4. Avoid eating large meals that are high in simple sugars and liquids.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client should recline for 30 minutes after eating (2) fluids should be given between meals (3) intake of carbohydrates should be reduced along with highly spiced foods (4) correct—basic guidelines to teach a postgastrectomy client are measures to prevent dumping syndrome, which include: lying down for 30 minutes after meals, drinking fluids between meals, and reducing intake of carbohydrates

An elderly client returns to the room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include which of the following? 1. High-protein, low-residue diet. 2. Position client on unaffected side. 3. Exercise the client's arms and legs. 4. Encourage the client to cough and deep breathe.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) diet should be high residue to prevent constipation due to inactivity (2) may be positioned on affected side after incision heals (3) foot flexion exercises should be done every hour to prevent complications (4) correct—prevents respiratory complications due to immobility following surgery

The home health care nurse cares for a client diagnosed with type 1 diabetes. The client is maintained on a regimen of NPH and regular insulin and a 1,800-calorie diabetic diet with normal blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past 2 days were 205 and 233 mg/dL. The nurse expects the physician to take which of the following actions? 1. Reduce the client's diet to 1,500 calorie ADA. 2. Order three additional units of NPH insulin at 10 P.M. 3. Order an additional 10 units of regular insulin at 8 P.M. 4. Eliminate the client's bedtime snack.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) diet should not be reduced (2) correct—dawn phenomena, treatment is to adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia (3) peaks in 4 to 6 hours, would not prevent dawn phenomena (4) would adjust snack, not eliminate it

The nurse prepares to perform peritoneal dialysis on an older patient. The patient states that he/she had pain the last time the procedure was done. It is MOST appropriate for the nurse to take which of the following actions? 1. Administer a warm drink to the patient. 2. Administer a warm bath to the patient. 3. Warm the bag of dialysate solution with a heating pad. 4. Warm the bag of dialysate solution in a microwave oven.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not affect pain with fluid infusion (2) does not affect pain with fluid infusion (3) correct—temperature can be regulated, warming reduces pain caused by cold solution (4) contraindicated because of unpredictable warming patterns

An adult client has regular insulin ordered before breakfast. The nurse notes that the client's blood glucose level is 68 mg/dL and the client is nauseated. Which of the following actions should the nurse take? 1. Immediately give the client orange juice to drink. 2. Administer the insulin on time. 3. Withhold the insulin, and notify the physician. 4. Return the breakfast tray to the kitchen.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may cause vomiting (2) correct—take insulin or oral agent as ordered, check blood glucose or urine ketones every 3 to 4 hours, sip 8 to 12 oz liquid per hour, substitute easily digested soft foods, liquids if solids not tolerated (3) blood glucose increases during illness; even though client can't eat, administer insulin (4) does not address the client's problem

The nurse prepares a 5-year-old child for surgery. The nurse notes that the child's parents are divorced and have joint legal custody. The informed consent for surgery has been signed by the mother. Which of the following actions by the nurse is BEST? 1. Notify the physician. 2. Inform surgery. 3. Contact the father to obtain consent. 4. Continue the child's preoperative preparation.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) no reason to notify the physician (2) no reason to call the OR (3) consent from either divorced parent is sufficient (4) correct—parent or legal guardian required to give informed consent prior to surgical procedure

The home care nurse instructs a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan? 1. The client should cover the mouth and nose when coughing or sneezing during the first 2 weeks of treatment. 2. It is necessary for the client to wear a mask at all times to prevent transmission of the disease. 3. The family should support the client to help reduce feeling of low self-esteem and isolation. 4. The client will be required to take prescribed medication for 6 to 9 months.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) on airborne precautions during hospitalization; can send home with family because they are already exposed (2) not required (3) important, but not as important as taking medication (4) correct—necessary to take medication for 6 to 9 months

The nurse observes an LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, indicates an understanding of proper technique? 1. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes. 2. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing. 3. The nurse packs wet gauze into the incision without overlapping it onto the skin. 4. The old dressing is saturated with sterile saline before it is removed.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should clean from the center of wound to the outside using sterile equipment (2) dressings should be soaked before application (3) correct—if wet dressing touches skin, it could cause skin breakdown (4) should be removed dry so that wound debris and necrotic tissue are removed with old dressing

Prochlorperazine maleate (Compazine) 10 mg IM is ordered for a client. The client is also to receive butorphanol (Stadol) 2 mg IM. Before administering these medications, the nurse should take which of the following actions? 1. Obtain respirations and temperature. 2. Dilute with 9 ml of NS. 3. Draw the medications in separate syringes. 4. Verify the route of administration.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should monitor blood pressure and heart rate for orthostatic hypotension; respiration and temperature are not as high a priority (2) inappropriate (3) correct—Compazine should be considered incompatible in a syringe with all other medications (4) unnecessary

The nurse prepares to administer an injection of haloperidol decanoate (Haldol D) to a client. Which of the following actions by the nurse is MOST appropriate? 1. Massage the injection site. 2. Give deep IM in a large muscle mass. 3. Use a 2 inch 25 gauge needle. 4. Administer the medication in divided doses.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should not be done because medication is very irritating to subcutaneous tissue (2) correct—medication is very irritating to subcutaneous tissue (3) should use a 2 inch 21 gauge needle (4) should administer in single dose; patient should lie in recumbent position for one-half hour after administration of IM haloperidol decanoate

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should remain in the seclusion room (2) should have meal at regular time (3) should have meal at regular time (4) correct—should eat at regular time; remain in the seclusion room for client's safety

During a first aid class, the nurse instructs clients on the emergency care of partial thickness burns. The nurse identifies which of the following interventions for partial thickness burns of the chest and arms BEST prevents infection? 1. Wash the burn with an antiseptic soap and water. 2. Remove clothing, and wrap the victim in a clean sheet. 3. Leave the blisters intact and apply an ointment. 4. Take no action until the victim arrives in a burn unit.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) soaps and ointments should not be applied to second-degree burns in an emergency situation (2) correct—after fire is out, remove clothing and cover victim with a clean sheet (3) soaps and ointments should not be applied to second-degree burns in an emergency situation (4) does not prevent infection

A young adult patient constantly seeks attention from the nurses, stomping away from the nurses' station and pouting when requests are refused. Which of the following responses by the nurse is MOST appropriate? 1. Encourage the patient to establish trust with one staff person with whom therapeutic interventions should occur. 2. Give the patient unsolicited attention when the patient is exhibiting acceptable behaviors. 3. Ignore the patient when the patient exhibits attention-seeking behavior. 4. Rotate the staff so that the patient will learn to relate to more than one nurse.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) staff should use a consistent undivided approach (2) correct—reward non-attention-seeking behaviors by giving the patient unsolicited attention (3) remain nonjudgmental, carry out limit-setting (4) staff should use a consistent undivided approach

The nurse's INITIAL priority when managing a physically assaultive client is which of the following? 1. Restrict the client to the room. 2. Place the client under one-to-one supervision. 3. Restore the client's self-control and prevent further loss of control. 4. Clear the immediate area of other clients to prevent harm.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) time out or room restriction might be a useful strategy before the client becomes assaultive; once client is assaultive, he/she may continue this behavior in his/her room without any redirection and support (2) may not stop assaultive behavior (3) correct—most important priority in the nursing management of an assaultive client is to maintain milieu safety by restoring the client's self-control; a quick assessment of situation, psychological intervention, chemical intervention, and possibly physical control are important when managing the physically assaultive client (4) is helpful but may not be realistic if the situation escalates quickly

After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions is MOST appropriate? 1. Irrigate the nasogastric tube with distilled water. 2. Aspirate the gastric contents with a syringe. 3. Administer an antiemetic medicine. 4. Insert a new nasogastric tube.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) tube would be irrigated with normal saline after the position of the tube was evaluated (2) correct—to confirm placement, nurse should aspirate and test the pH of the aspirate; results should be 0 to 4 (3) does not assess status of nasogastric tube (4) does not assess status of nasogastric tube

An older man is seen in the outpatient clinic for treatment of an acute attack of gout. Which of the following nursing interventions is MOST beneficial in decreasing the client's pain during ambulation? 1. Perform passive range-of-motion exercises before walking. 2. Encourage partial weight bearing while ambulating. 3. Immobilize the extremity between activities. 4. Restrict the amount of time and the distance the man walks. An older man is seen in the outpatient clinic for treatment of an acute attack of gout. Which of the following nursing interventions is MOST beneficial in decreasing the client's pain during ambulation? 1. Perform passive range-of-motion exercises before walking. 2. Encourage partial weight bearing while ambulating. 3. Immobilize the extremity between activities. 4. Restrict the amount of time and the distance the man walks.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) would aggravate pain (2) correct—would relieve weight, pressure, and stress on affected leg, may use walker (3) would increase stiffness (4) immobility would aggravate pain and inflammation

A client diagnosed with multiple sclerosis (MS) is at 39 weeks' gestation. The client is admitted to the labor and delivery unit in active labor. The client's vital signs are BP 127/72; pulse 72 bpm; cervix is 4 cm dilated; FHT 124 bpm; moderate contractions are 4 minutes apart. The nurse should anticipate the need for which of the following? 1. Prepare to administer IV Pitocin to the client. 2. A reduction in the amount of pain medication administered. 3. Check the client's blood pressure every 5 minutes. 4. Prepare an isolette for the infant.

Strategy: Answers are a mix of assessments and implementations. Does the assessment make sense? No. Determine the outcome of each intervention. (1) uterine contractions not affected by MS (2) correct—less pain medication is required because of overall decrease in pain perception due to MS (3) no reason to assess this frequently (4) baby's outcome not affected by MS ...

The nurse cares for a postcholecystectomy client who had the T-tube removed this morning. Two hours after removal of the T-tube, the nurse notes that the 4 × 4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which of the following actions? 1. Remove the dressing, and replace it with a more absorbent dressing. 2. Collect a culture and sensitivity specimen of the drainage. 3. Observe the wound for dehiscence. 4. Reinforce the dressing with an 8 × 10 dressing

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? No. Determine the outcome of each implementation. (1) correct—expected that a stab wound will continue to drain until the wound seals; nurse should keep wound clean and dry (2) drainage described is bile, which is expected; no indication of infection (3) doesn't usually occur (4) reinforcing dressing might cause infection; change dressing to keep site clean and dry

The nurse is assigned to work with the parents of a child diagnosed with mental retardation. Which of the following should the nurse include in the care plan for the parents? 1. Interpret the grieving process for the parents. 2. Discuss the reality of institutional placement. 3. Assist the parents in making decisions and long-term plans for the child. 4. Perform a family assessment to assist in the planning of intervention.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) inappropriate before the assessment; action can be taken only when the circumstances are known (2) inappropriate before the assessment; action can be taken only when the circumstances are known (3) inappropriate before the assessment; action can be taken only when the circumstances are known (4) correct—assessment; this will help the nurse to know where the family is in regard to grieving, coping, etc.

A woman has been recently diagnosed with systemic lupus (SLE) and shares with the nurse, "I am thinking about getting pregnant, but I don't know how I will be able to tolerate a pregnancy because I have lupus." Which of the following responses by the nurse is BEST? 1. "Most women find that they feel better when they are pregnant." 2. "How long have you been in remission?" 3. "Women with lupus frequently have slightly longer gestations." 4. "It is best to become pregnant within the first 6 months of diagnosis."

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) maternal morbidity and mortality are increased with SLE (2) correct—should be in remission for at least 5 months prior to conceiving (3) gestation not affected by SLE (4) recommended that a woman wait 2 years following diagnosis before conceiving

The nursing assistant reports to the nurse that a client who is 1 day postoperative after an angioplasty refuses to eat and states, "I just don't feel good." Which of the following actions by the nurse is BEST? 1. Talk with the client about how the client is feeling. 2. Instruct the nursing assistant to sit with the client while the client eats. 3. Contacts the physician to obtain an order for an antacid. 4. Evaluate the most recent vital signs recorded in the chart.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is the assessment appropriate? Yes. (1) correct—assessment required; monitor for closure of vessel, bleeding, hypotension, dysrhythmias (2) assess cause of problem before implementing (3) assess cause of problem before implementing (4) more important to assess what is happening now

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) correct—assessment; symptoms indicate reduced oxygen levels (2) implementation; must assess first to determine problem; all other interventions must be tried before using restraints (3) implementation; must determine the cause of the behavior before implementing (4) assessment; symptoms indicate decreased oxygen levels

The nurse cares for clients in the student health center. A client confides to the nurse that the client's boyfriend informed her that he tested positive for hepatitis B. Which of the following responses by the nurse is BEST? 1. "That must have been a real shock to you." 2. "You should be tested for hepatitis B." 3. "You'll receive the hepatitis B immune globulin (HBIG)." 4. "Have you had unprotected sex with your boyfriend?"

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) nurse is interjecting own feelings (2) will require testing; not best response initially (3) implementation; receive HBIG for postexposure prophylaxis; may also receive HBV vaccine (4) correct—assessment; transmitted through parenteral drug abuse and sexual contact; determine exposure before implement

The nurse cares for a client who has just returned to his room after a scleral buckling procedure was completed to repair a detached retina. Which of the following is the MOST important nursing action? 1. Remove reading material to decrease eyestrain. 2. Ask the client if he is nauseated. 3. Assess color of drainage from the affected eye. 4. Maintain sterility during q3h saline eye irrigations.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Think about what the assessments mean. (1) implementation; would be ineffective (2) correct—assessment; is important to prevent nausea and vomiting, would increase intraocular pressure, could cause damage to area repaired (3) assessment; refers to an eye infection, would be important after initial operative day (4) implementation; eye irrigations are not commonly done following this procedure

A client returns to his room following a myelogram. The nursing care plan should include which of the following? 1. Encourage oral fluid intake. 2. Maintain the prone position for 12 hours. 3. Encourage the client to ambulate after the procedure. 4. Evaluate the client's distal pulses on the affected side.

Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of the implementations. (1) correct—implementation; fluids should be encouraged to facilitate dye excretion and to maintain normal spinal fluid (2) implementation; clients are not placed in the prone position (3) implementation; bed rest is maintained for several hours after the test (4) assessment; an extremity was not used for injection of the dye

Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? Yes. (1) assessment; pertinent to the care of a client receiving magnesium sulfate for pre-eclampsia (2) implementation; oxytocin is always given via an infusion pump and is never allowed to be the primary IV (3) implementation; pertinent to the care of a client receiving magnesium sulfate for pre-eclampsia (4) correct—assessment; oxytocin stimulates the uterus to contract, which necessitates frequent assessment of the uterus; prolonged tetanic contraction can lead to a ruptured uterus

The nurse cares for clients on the neurology unit. What is the MOST appropriate action for the nurse to take after noting that a client suddenly develops a fixed and dilated pupil? 1. Reassess in 5 minutes. 2. Check the client's visual acuity. 3. Lower the head of the client's bed. 4. Contact the physician.

Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment or validation? No. Determine the outcome of the implementations. (1) assessment; situation does not require validation (2) assessment; has symptoms of increased intracranial pressure (ICP) (3) implementation; would increase the ICP (4) correct—implementation; fixed and dilated pupil represents a neurological emergency

Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes. (1) correct—assessment; monitoring vital signs is of utmost importance to ensure client safety and physiological integrity; rapid neuroleptization is a pharmacological intervention used to rapidly diminish severe symptoms that accompany acute psychosis; alpha-adrenergic blockade of peripheral vascular system lowers BP and causes postural hypotension (2) implementation; should be done but is not highest priority (3) implementation; should be done but is not highest priority (4) assessment; circulatory system takes priority ...

The nurse administers terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client's pulse to be 144. Which of the following actions should the nurse take FIRST? 1. Withhold the medication. 2. Decrease the dose by half. 3. Administer the medication. 4. Wait 15 minutes, and then recheck the rate.

Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires validation? No. Determine the outcome of each answer choice. (1) correct—maternal tachycardia is a side effect of Brethine; other maternal side effects include nervousness, tremors, headache, and possible pulmonary edema; fetal side effects include tachycardia and hypoglycemia; Brethine is usually preferred over ritodrine (Yutopar) because it has minimal effects on blood pressure (2) should never change a prescribed dosage of medication (3) should not be given with a high pulse rate (4) assessment; maternal tachycardia is a side effect of Brethine; medication should be withheld

The nurse cares for patient placed in balanced suspension traction with a Thomas splint and Pearson attachment because of a fractured right femur. The nurse notes that the patient's left leg is externally rotated. The nurse should take which of the following actions? 1. Place a trochanter roll on the outer aspect of the thigh. 2. Perform resistive range of motion of the left leg. 3. Adduct and internally rotate the left leg. 4. Instruct the patient to maintain the left leg in a neutral position.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—holds hip in neutral position and leg in normal alignment, entire weight of leg cannot be held by props placed below knee (2) exercise would not prevent future external rotation of the leg (3) adduction (add to midline of body) does not change external rotation, internal rotation is not beneficial, normal alignment is required (4) leg will externally rotate unless propped in proper alignment

The nurse cares for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST? 1. "Take three deep breaths, hold your incision, and then cough." 2. "That was good. Do that again and soon it won't hurt as much." 3. "It won't hurt as much if you hold your incision when you cough." 4. "Take another deep breath, hold it, and then cough deeply."

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—most effective way of deep breathing and coughing, dilates airway and expands lung surface area (2) should splint incision before coughing to reduce discomfort and increase efficiency (3) partial answer, should take three deep breaths before coughing (4) implies coughing routine is adequate, incision needs to be splinted

The newborn infant of an HIV-positive mother is admitted to the nursery. The nurse should include which of the following in the plan of care? 1. Standard precautions. 2. Testing for HIV. 3. Transfer to an acute care nursery facility. 4. Request AZT from the pharmacy.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—provides immediate protective care for the staff members (2) might be employed, safety is the priority (3) might be employed, is not a priority (4) this medication is not used in infancy ...

The clinic nurse performs diet teaching for an older client with acute gout. The nurse should teach the client to limit the intake of which of the following? 1. Red meat and shellfish. 2. Cottage cheese and ice cream. 3. Fruit juices and milk. 4. Fresh fruits and uncooked vegetables.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—should be on low-purine diet, should avoid red and organ meats, shellfish, oily fish with bones (2) calcium-rich foods are not limited with gout (3) no restriction with gout (4) high-roughage foods are not limited with gout ...

In planning anticipatory guidance for parents of a beginning school-aged child, it is MOST important for the nurse to include which of the following? 1. Teach the child to read and write. 2. Teach the child sex education at home. 3. Give the child responsibility around the house. 4. Expect stormy behavior.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may require some assistance from the parents, but children this age learn at their own rate (2) unnecessary at this early age (3) correct—giving children responsibilities allows them to develop feelings of competence and self-esteem through their industry (4) does not occur until about age 11

A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority? 1. Administer oxygen. 2. Turn her to the right side. 3. Provide adequate hydration. 4. Start antibiotics.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not a priority (2) not a priority (3) correct—adequate hydration is a priority for any client with sickle cell crisis (4) not a priority

The nurse instructs a client diagnosed with a lower motor neuron disorder to perform intermittent self-catheterization at home. The nurse should include which of the following instructions? 1. Use a new, sterile catheter each time the client performs a catheterization. 2. Perform the Valsalva maneuver before doing the catheterization. 3. Perform the catheterization procedure every 8 hours. 4. Limit oral fluids to reduce the number of times a catheterization is needed.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should use clean (not sterile) technique, used for clients with lower motor neuron disorders resulting in flaccid bladder (2) correct—client holds breath and bears down as if trying to defecate, or uses Credé maneuver (places hands over bladder and pushes in and down), done to try to empty bladder before catheterization (3) usually done every 2 to 3 hours initially, and then increased to every 4 to 6 hours (4) should encourage fluids

The nurse cares for an elderly client diagnosed with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client? 1. Return the client to usual activities of daily living. 2. Maintain optimal function within the client's limitations. 3. Prepare the client for a peaceful and dignified death. 4. Arrest progression of the disease process in the client.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unrealistic (2) correct—irreversible disease that leads to permanent physical limitations (3) unnecessary; disease usually is not terminal (4) unrealistic; disease is progressive, cannot be arrested

The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse considers the assignments appropriate if the nursing assistant is assigned to care for which of the following clients? 1. A client diagnosed with Alzheimer's requiring assistance with feeding. 2. A client diagnosed with osteoporosis complaining of burning on urination. 3. A client diagnosed with scleroderma receiving a tube feeding. 4. A client diagnosed with cancer who has Cheyne-Stokes respirations.

Strategy: Assign to nursing assistants clients with standard, unchanging procedures. (1) correct—standard, unchanging procedure (2) requires assessment; should assign to an RN (3) stable patient with expected outcome; should assign to an LPN/LVN (4) unstable patient, requires assessment and nursing judgment; should assign to an RN

If a client develops cor pulmonale (right-sided heart failure), the nurse expects to observe which of the following? 1. Increased respiration with exertion. 2. Cough producing large amount of thick, yellow mucus. 3. Peripheral edema and anorexia. 4. Twitching of extremities.

Strategy: Determine how each answer choice relates to cor pulmonale. (1) common assessment finding of the patient with chronic lung disease (2) describes a complication of pneumonia (3) correct—right-sided heart failure is manifested by congestion of the venous system, resulting in peripheral edema; also, there is congestion of the gastric veins, resulting in anorexia and eventual development of ascites (4) is not seen with this client...

A nurse cares for a client diagnosed with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient's nutritional status has improved after 4 days? 1. The patient eats most of the food served to her. 2. The patient has gained 1 pound since admission. 3. The patient's albumin level is 4.0 g/dL. 4. The patient's hemoglobin is 8.5 g/dL.

Strategy: Determine how each answer choice relates to nutritional status. (1) appetite is not the best indicator (2) weight gain may be fluid retention (ascites) (3) correct—albumin levels are best indicators of long-term nutritional status (4) low levels are caused by chemotherapy or cancer, not a good indicator because it takes long time to increase levels

A client at 32 weeks' gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, indicates a possible complication? 1. The client's urine test is positive for glucose and acetone. 2. The client has 1+ pedal edema in both feet at the end of the day. 3. The client complains of an increase in vaginal discharge. 4. The client says that she feels pressure against her diaphragm when the baby moves.

Strategy: Determine how each answer choice relates to pregnancy. (1) correct—abnormal finding, could indicate gestational diabetes (GDM), hazard of placental insufficiency (2) not unusual, caused by pressure of enlarging uterus on veins returning blood from lower extremities (3) common near term with increased vascularity of vagina and perineum, only abnormal if bloody, foul-smelling, or abnormally colored (4) not unusual, due to pressure of enlarging uterus

Strategy: Determine if each answer relates to increased ICP. (1) normal for the first year of life (2) correct—high-pitched cry is one of the first signs of an increase in the intracranial pressure in infants (3) fontanelle should be closed by the third month (4) with increased pressure, the pupil may respond to light slowly, rather than with the usual brisk response

A client is scheduled for a left lower lobectomy. The physician orders diazepam (Valium) 2 mg IM for anxiety. The nurse determines the medication is appropriate if the client displays which of the following symptoms? 1. Agitation and decreased level of consciousness. 2. Lethargy and decreased respiratory rate. 3. Restlessness and increased heart rate. 4. Hostility and increased blood pressure.

Strategy: Determine if the answer choice relates to Valium. (1) more indicative of preoperative complications, should be reported before medications are given (2) more indicative of preoperative complications, should be reported before medications are given (3) correct—observation most indicative for antianxiety drugs is restlessness and increase in heart rate due to circulating catecholamines (fight or flight) (4) hostility may be treated best by ventilating feelings ...

The nurse performs an assessment of an 8-year-old girl diagnosed with scoliosis. Which of the following observations is expected with scoliosis? 1. The girl's thoracic area is asymmetrical. 2. The girl walks with a waddling gait. 3. The girl's lower legs are edematous. 4. The girl has a protruding sternum.

Strategy: Determine the cause of each answer choice and how it relates to Pronestyl. (1) procainamide is given to treat premature ventricular contractions or atrial tachycardia (2) correct—severe hypotension or bradycardia are signs of an adverse reaction to this medication (3) procainamide is given to treat premature ventricular contractions or atrial tachycardia (4) lab value is within normal limits

The home care nurse visits a client with newly diagnosed type 1 diabetes. The physician orders include 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the client perform a blood sugar analysis. The result is 50 mg/dL. The nurse should observe for which of the following? 1. Confusion; cold, clammy skin; and an elevated pulse. 2. Lethargy; hot, dry skin; rapid deep respirations. 3. Alert and cooperative, blood pressure and pulse within normal limits. 4. Shortness of breath, distended neck veins, and a bounding pulse of 96.

Strategy: Determine the cause of each answer choice. (1) correct—symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL (2) symptoms of hyperglycemia, blood sugar above 110 mg/dL (3) normal appearance and vital signs (4) symptoms of fluid overload caused by heart failure, rapid infusion of IV fluids

The nurse cares for clients on a medical/surgical unit and determines that several situations need to be addressed. Which of the following situations should the nurse attend to FIRST? 1. An angry daughter is threatening to sue the hospital because her confused mother fell out of bed during the previous shift. 2. The nursing assistant is 30 minutes overdue from a dinner break in the cafeteria for the third time this week. 3. The physician calls the unit to ask the nurse to obtain a client's latest serum electrolyte results from the lab. 4. The husband of a client reports to the nurse that his wife's nose began bleeding after she returned from radiation therapy.

Strategy: Determine the least stable situation (1) important issue that needs to be addressed after tending to the client who is bleeding (2) patients take priority over personnel issues (3) can be delegated to another staff member (4) correct—should assess client to determine amount and cause of bleeding

An older woman comes to the outpatient clinic because she has not been feeling well for several days. During the admission interview, the nurse learns that the client has a history of heart failure (HF), is on a low-sodium diet, and has been taking chlorothiazide (Diuril) 500 mg PO daily for 6 months. Diagnostic tests indicate sodium 127 mEq/L, potassium 3.8 mEq/L, glucose 110 mg/dL, and normal chest x-ray. It is MOST important for the nurse to assess for which of the following? 1. Sticky mucous membranes; decreased urinary output; and firm, rubbery tissues. 2. Cool, moist skin; fine hand tremors; and mental confusion. 3. Headache, apprehension, and lethargy. 4. Shortness of breath, chest pain, and anxiety.

Strategy: Determine the significance of each answer choice. (1) symptoms of hypernatremia, along with restlessness, weakness, coma, tachycardia, flushed skin, oliguria, fever (2) symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL (3) correct—symptoms of hyponatremia along with muscle twitching, convulsions, diarrhea, fingerprinting of skin (4) symptoms of CHF, chest x-ray clear, no other information provided

The nurse performs triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST? 1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a rusty metal can. 2. A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but not the place and time. 3. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain. 4. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL.

Strategy: Identify the least stable client. (1) no indication of hemorrhage, will require a tetanus shot (2) correct—disoriented, requires immediate assessment to determine underlying cause (3) splint; cover wound with sterile dressing; check temperature, color, sensation; give narcotic (4) hyperglycemic, give IV fluid, regular insulin ...

The nurse in the well-baby clinic observes a group of children. The nurse notes that one child is able to sit unsupported, play "peek-a-boo" with the nurse and is starting to say "mama" and "dada". The nurse determines the infant's behaviors are consistent with which of the following ages? 1. 5 months of age. 2. 6 months of age. 3. 9 months of age. 4. 12 months of age.

Strategy: Picture each infant. (1) unable to sit unsupported until 8 months (2) unable to sit unsupported until 8 months (3) correct—can pull self up and assume a sitting position at 8 months, can say few words (4) would be able to say three to five words in addition to dada and mama

A client takes gemfibrozil (Lopid) 600 mg PO bid. It is MOST important for the nurse to monitor which of the following? 1. Serum creatine. 2. Erythrocyte sedimentation rate (ESR). 3. Aspartate aminotransferase (AST) (or formerly SGOT). 4. Arterial blood gases (ABG).

Strategy: Recall what each lab function is measuring and determine how it relates to gemfibrozil (Lopid). (1) indicates renal function, normal 0.6 to 1.2 mg/dL (2) indicates inflammation, normal 0 to 20 mm/h (3) correct—indicates liver function, normal 8-20 units/L; lipid-lowering agent used with patients with high serum triglyceride levels, side effects include abdominal pain, cholelithiasis; take 30 minutes before breakfast and supper (4) indicates acid/base balance...

A patient is admitted to the surgical unit with a diagnosis with rule out (R/O) intestinal obstruction. The nurse prepares to insert a Salem sump NG tube as ordered. It is BEST for the nurse to place the patient in which of the following positions? 1. Head of bed elevated 30-45°. 2. Head of bed elevated 60-90°. 3. Side-lying with head elevated 15°. 4. Lying flat with head turned to the left side.

Strategy: Remember the positioning strategy. (1) head of bed not elevated enough (2) correct—facilitates swallowing and movement of tube through gastrointestinal tract (3) not the best position (4) not the best position

A client diagnosed with AIDS is seen in the emergency room with complaints of mouth pain, difficulty swallowing, and a white discharge in the back of the throat. The nurse expects the physician to order which of the following? 1. Metronidazole (Flagyl) 7.5 mg/kg q6h. 2. Ketoconazole (Nizoral) 200 mg daily. 3. Trimethoprim-sulfamethoxazole (Bactrim) 800 mg PO q12h. 4. Rifampin (Rifadin) PO 10 mg/kg daily.

Strategy: The topic of the question is unstated. (1) anti-infective, used in treatment of intestinal amebiasis, trichomoniasis, inflammatory bowel disease (2) correct—drug of choice for treatment of candidiasis (3) treatment for PCP; symptoms of dyspnea, tachypnea, persistent dry cough, fever, fatigue (4) treatment for tuberculosis; symptoms of fever, chills, night sweats, weight loss, anorexia

A 4-month-old child is admitted with a tentative diagnosis of meningitis. To confirm the diagnosis, a lumbar puncture (LP) is ordered. While assisting the physician with the procedure, it is MOST important for the nurse to take which of the following actions? 1. Appropriately restrain the child. 2. Instruct the parents about the procedure. 3. Provide support to the child. 4. Elevate the head of the bed.

Strategy: Think "Maslow." (1) correct—primary objective is to prevent trauma to child during the procedure; child must be restrained (2) not as high a priority as preventing injury to the child (3) should be done before and/or after the procedure (4) elevating the head of the bed for a 4-month-old will not expose the spinal column ...

Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of the body? 1. Counseling regarding problems of body image. 2. Maintain airborne precautions. 3. Maintain aseptic technique during procedures. 4. Encourage peers to visit on a regular basis.

Strategy: Think "Maslow." (1) psychosocial, not highest priority (2) physical, use standard precautions (3) correct—safety is a priority for the client who is at high risk for infection (4) psychosocial, important for an adolescent but is not highest priority ...

The nurse in a psychiatric emergency room cares for a client who is a victim of interpersonal violence. The INITIAL priority of the nurse is which of the following? 1. Encourage the client to verbalize feelings. 2. Assess for physical trauma. 3. Provide privacy for the client during the interview. 4. Help the client identify and mobilize resources and support systems.

Strategy: Think "Maslow." (1) psychosocial, priority is physical injury (2) correct—physical, victim may have physical trauma and concealed injuries; assessment is of utmost importance so that the client's physiologic integrity is maintained (3) psychosocial, done concurrently as the nurse is assessing for physical injury (4) psychosocial, priority is physical injury

A client takes perphenazine (Trilafon) by mouth for 2 days and now displays the following: head turned to the side, neck arched at an angle, and stiffness and muscle spasms in neck. The nurse expects to give which of the following as a PRN medication? 1. Promazine (Sparine). 2. Biperiden (Akineton). 3. Thiothixene (Navane). 4. Haloperidol (Haldol).

Strategy: Think about each answer choice. (1) antipsychotic medication, would not relieve the side effects (2) correct—antiparkinsonian agent, used to counteract extrapyramidal side effects the client is experiencing (3) antipsychotic medication, would not relieve the side effects (4) antipsychotic medication, would not relieve the side effects

A psychiatric nurse is assigned to conduct an admission nursing history on a new client. The admission should include which of the following? 1. The nurse's opinion regarding the mental and emotional status of the client. 2. Data addressing the client's emotional state. 3. Data addressing a biopsychosocial approach, including a family system assessment. 4. Specific data detailing the client's mental status.

Strategy: Think about each answer choice. (1) depends on opinions that are not based on a complete assessment (2) limits the degree of information that is obtained from the client (3) correct—complete nursing history includes biopsychosocial data; client's psychosocial and physical status are evaluated along with an assessment of the client's family system and social support network; evaluation of the client's cognitive ability is important during the physiological status assessment (4) is necessary information about mental status but is also an incomplete assessment

Strategy: Think about each answer choice. (1) does not occur (2) occurs earlier in development (3) at age 40, bone mass begins to decrease (4) correct—may precipitate a mid-life crisis

Which of the following is a correctly stated nursing diagnosis for a client with an abruptio placentae? 1. Infection related to obstetrical trauma. 2. Potential for fetal injury related to abruptio placentae. 3. Potential alteration in tissue perfusion related to depletion of fibrinogen. 4. Fluid volume deficit related to bleeding.

Strategy: Think about each answer choice. (1) inaccurate for the situation (2) incorrectly stated (3) incorrectly stated (4) correct—abruptio placentae is premature separation of a normally implanted placenta leading to hemorrhage; fluid volume deficit is a major nursing concern with these clients

A 2-month-old with a temperature of 102°F (39°C) is brought to the emergency department by his mother. The mother tells the nurse that the infant had a DPaT injection 1 week ago, and asks if this fever is related to the immunization. The nurse's response should be based on which of the following? 1. If a fever does occur in a child after a DPaT, it usually occurs within the first 2 hours. 2. An elevated temperature is very rarely seen in a child after a DPaT immunization. 3. If there is a fever after a DPaT, it is usually low-grade and appears within the first 48 hours. 4. The child's high fever is a direct response to the DPaT immunization and should be treated.

Strategy: Think about each answer choice. (1) inaccurate; low-grade fever is expected within 24 to 48 hours (2) inaccurate; low-grade fever is expected within 24 to 48 hours (3) correct—low-grade fever and irritability frequent response to immunization (4) symptoms should be reported to physician, antipyretic usually prescribed

Strategy: Think about each answer choice. (1) not a priority (2) correct—leading cause of skin breakdown is a decrease in tissue perfusion (3) not a priority (4) would be more relevant to right-sided hemiparesis ...

When a nurse is using restraints for an agitated/aggressive patient, which of the following items should NOT influence the nurse's actions during this intervention? 1. The restraints/seclusion policies set forth by the institution. 2. The patient's competence. 3. The patient's voluntary/involuntary status. 4. The patient's nursing care plan.

Strategy: Think about each answer choice. (1) nurse should follow the policies of the institution (2) must get written permission from the patient for restraints; if patient has been judged incompetent, permission is obtained from the legal guardian (3) correct—the need for restraints is based on patient's behavioral status and condition, not the patient's voluntary/involuntary status (4) must first try less restrictive means to control patient before using restraints

The nurse cares for clients in outpatient surgery. The mother of a 4-year-old asks the nurse how to prepare her daughter for eye surgery. Which of the following statements by the nurse is BEST? 1. "Draw a picture of the eye to explain what will happen." 2. "Tell your daughter that the procedure will take 1 hour." 3. "Use dolls or puppets to explain how to get ready for surgery." 4. "Read an age-appropriate illustrated book about eye surgery to your daughter."

Strategy: Think about growth and development. (1) appropriate for school-aged child (2) preschooler can't relate to the concept of 1 hour (3) correct—use puppet or doll to show where procedure is performed; explain procedure in simple terms and what the child will see, hear, taste, smell, and feel (4) appropriate for school-aged child

After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a 5-year-old is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse 3 hours after admission, should be reported to the physician? 1. The client has slight edema of the eyelids. 2. There is clear fluid draining from the client's right ear. 3. There is some bleeding from the child's lacerations. 4. The client withdraws in response to painful stimuli.

Strategy: Think about how each answer choice relates to a head injury. (1) not priority (2) correct—indicates a rupture of meninges and presents a potential complication of meningitis (3) not priority (4) is not a change in assessment

A school-aged child injured his right knee yesterday during a soccer game. He is brought to the outpatient clinic by his mother. The child's right knee is painful, swollen, and bruised. During the interview, the nurse learns that the boy is diagnosed with hemophilia A. The nurse identifies which of the following medications is BEST for this patient? 1. Oxycodone terephthalate (Percodan). 2. Ibuprofen (Motrin). 3. Enteric-coated aspirin. 4. Codeine phosphate (Paveral).

Strategy: Think about the action of each medication. (1) contains aspirin, contraindicated for persons with bleeding disorders (2) increases bleeding time by decreasing platelet aggregation, contraindicated for persons with bleeding disorders (3) increases bleeding time by decreasing platelet aggregation, contraindicated for persons with bleeding disorders (4) correct—analgesic used for moderate to severe pain

The nurse prepares a patient for a cesarean section. The patient says that she had major surgery several years ago and asks if she will receive a similar "shot" before surgery. The nurse's response should be based on an understanding that the preoperative medication given before a cesarean section 1. contains a lower overall dosage of medication than is given before general surgery. 2. contains lower amounts of sedatives and hypnotics than are given before general surgery. 3. contains lower amounts of narcotics than are given before general surgery. 4. contains medications similar in type and dosages to those given before general surgery.

Strategy: Think about the action of the medications. (1) decreased dosage of narcotics are used (2) dosages of sedatives and hypnotics will be similar (3) correct—decreased so that less narcotic crosses the placental barrier, causing respiratory depression in the infant (4) dosages of narcotics are reduced

Which of the following symptoms are MOST likely to be observed by the nurse when a client is withdrawing from heroin? 1. Severe cravings, depression, fatigue, hypersomnia. 2. Depression, disturbed sleep, restlessness, disorientation. 3. Nausea and vomiting, tachycardia, coarse tremors, seizures. 4. Runny nose, yawning, fever, muscle and joint pain, diarrhea.

Strategy: Think about the cause of each symptom and how it relates to narcotic withdrawal. (1) describes cocaine withdrawal (2) describes amphetamine withdrawal (3) describes barbiturate withdrawal (4) correct—narcotic withdrawal is very much like the symptoms of the flu

Which of the following observations BEST indicates to the nurse that a client diagnosed with paraplegia can adequately carry out activities of daily living at home after discharge? 1. The client shaves and brushes his teeth. 2. The client transfers himself into and out of his wheelchair. 3. The client maneuvers the wheelchair without difficulty. 4. The client prepares well-balanced meals. Which of the following observations BEST indicates to the nurse that a client diagnosed with paraplegia can adequately carry out activities of daily living at home after discharge? 1. The client shaves and brushes his teeth. 2. The client transfers himself into and out of his wheelchair. 3. The client maneuvers the wheelchair without difficulty. 4. The client prepares well-balanced meals.

Strategy: Think about the outcome of each answer. (1) paraplegic has full use of his upper body, so this activity presents no problem (2) correct—essential if client is to perform ADLs (3) done with the arms and presents no real problem (4) is a necessary requisite for living alone and performing ADLs but is not directly hindered by paraplegia

Before signing an informed consent form, the patient should know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phases; the risks involved, and the possible complications. The patient should also have a general idea of the time required from surgery to recovery. In addition, he should have an opportunity to ask questions.

The first nursing intervention is a quadriplegic patient who is experiencing autonomic dysreflexia is to elevate his head as high as possible.

Weight is the best indicator of dehydration

When patient is in distress. Administration of medication is rarely the best choice

Delegate sterile skills (e.g., dressing changes) to the RN or LPN

Where non-skilled care is required, delegate the stable patient to the nursing assistant

VIII

acoustic sensory: hearing and equilibrium

metronidazole indication: = flagyl

anti-infective: treat amebiasis, trichomoniasis, inflammatory bowel disease

Biperiden (akineton)

anti-parkinsonian agent--counteract extrapyramidal (head turn to side, neck stiffnes)

isoproterenol

antidysrhythmic-used for heart block, ventricular dysryhmia

Decerebrate posturing

arms and legs extended, toes pointed down, head and neck arched backwards

time to take ranitidine

at our of sleep--absoprtion not affected by food

10 - 11 months

belly to butt

terbuatline

beta agonist--- bronchodilator, side effects tacycardia, nervousness, tremors, headache, pulmonary edema infant: yachycarida hypoglycemia

s/s of abusing narcotic

constricted pupils

s/s of abusing marijuana, hashish, or THC

crave for sweets and CHO

s/s of amphetamine withdrawal

depression, disturbed sleep, restlesness, disorientation

DPat fever!?

expected low grade fever within 24-48 hrs

Impetigo

fluid filled vesicles, honey-crusted crusts, reddened areas around mouth and axillae (usually bacterial). Isolation: isolate 7-10 if not treating and 24 hours if treating, so you can be in contact with people after 24 hours

gemifibrozil (Lopid)

lower Triglyceride and cholestroel monitor liver function: AST, GOT, abdominal pain, cholelithiasis take 30 mins before breakfast and supper

s/s of chroinc cocaine abuse

nasal septum disruption, sores, burns, disruption of mucous membranes and holes in the nasal septum

Esophageal Varices

normal blood flow to liver blocked by clot or scar tissue - so blood flows into smaller blood vessels causing rupture therefore life-threatening bleeding

Dumping syndrome

occurs after gastric cancer or bypass, celiac disease - Reduce sugar and fiber (whole wheat) - increase fat and protein - small frequent meals - lie down after meal to decrease peristalsis - Wait 1 hr after meals to drink

Hepatic encephalopathy

seen in people with cirrhosis - liver coma, crazy movements, high amonia level, don't give protien

regular insulin onset and peak

shorting act onset: 30-60min peak 2-4 hrs

8 month child development

sit unsupported, play peek a boo, start saying mama and dada

6 - 7 months

sits at 6 and waves bye-bye. Can recognize familiar faces and knows if someone is a stranger. Passes things back and forth between hands.

AVA

the umbilical cord has two arteries and one vein

trategy: "MOST probable" indicates discrimination is required to answer the question. (1) not enough information given in question to assume that symptoms are caused by stress (2) correct—ovarian function gradually decreases and then stops, usually 45 to 50 years old (3) benign tumors arising from muscle tissue of uterus, menorrhagia (excessive bleeding) most common symptom along with backache, constipation, dysmenorrhea (4) usually see history of missed periods or spotting with abdominal pain

ketoconazole

treat fungal infection (candida)

perphenazine

treat nausea and vomitting and schizophrenia side effect: parkinson symptoms: head turn to side, neck arched at an angle, stiffness, and muslce spasms in neck

procainamide: indication and side effect

treat pre-ventrcictular contraction and atrial tachycardia side effect: hypotension, bradycardia

Bactrim

treat shigolosis, UTI, PCP (pneumocyticis pneumonia)

12 - 13 months

twelve and up, drinks from a cup. Cries when parents leave, uses furniture to cruise.

atropine

used for bradycardia

Critical Post Op Time Frames to Know

· 1st 24 hrs - most common issues occur -> bleeding · 24-72 we expect inflammation (wbc and temp my go up - it's normal) · 72+ earliest you are going to see an infection

narcotic withdrawal s/s

s/s like flu runny nose, yawning, fever, muslce and joint pain, diarrhea

Bone marrow aspiration and biopsy.

- can cause bleeding (use pressure dressing) - pt will feel stinging and discomfortt - can be done bedside

cocaine withdrawal s/s

severe craving, depression, fatigue, hypersomnia

Fetal Heart Rate

120 - 160 bpm

Contractions

2—5 minutes apart with duration of < 90 seconds and intensity of <100 mmHg.

A child with a high level of school absenteeism has been determined to have school phobia. The school nurse should counsel the child's parent/caregiver to take which action? 1. Allow the child to stay home when the child seems particularly anxious 2. Encourage the parent/caregiver to sit in the classroom with the child 3. Insist on school attendance immediately, starting with a few hours a day 4. Return the child to school when the cause of the school phobia has been identified

Abducens - motor function

Compartment Syndrome S/S

Don't elevate extremity above heart! Paresthesia, abnormal skin sensations, prickling or tingling, decreased cap refill, pallor, pulselessness

XII

Hypoglossal - tongue movement

III

Oculomotor Pupillary reaction - assess PERRLA

Oh Oh Oh to touch and feel a great velvet super hero

Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Acoustic Glossopharyngeal Vagus Spinal Accessory Hypoglossal

Fatty Liver

Risks: diabetes, high cholesterol, alcohol abuse

Trigeminal - Facial sensation

Vagus - gag reflex

2 - 3 months

able to turn head up, and can turn side to side. Makes cooing or gurgling noises and can turn head to sound.

Dawn phenomenon

an abnormal early-morning increase in blood sugar (glucose) usually between 2 a.m. and 8 a.m. · Avoid carbohydrates at bedtime. · Adjust dose of meds or insulin · Switch to a different medication. · Change the time when you take your medication or insulin from dinnertime to bedtime. · Use an insulin pump to administer extra insulin during early-morning hours

verapamil

calcium channel blocker anti-htn

4 G's that increase risk of bleeding

ginseng ginkgo ginger garlic

glossopharyngeal - swallowing and voice

Low BP / High HR =

hypovolemic shock

Restlessness + s.o.b =

hypoxia

Portal HTN

increase in bp within portal venous system (veins)

Parts of the body CKD effects

jijk

hyponatremia s/s

lethargic, headache, convulsion, muscle twitching, diarrhea, fingerprinting, anxiety,

NPH onset and peak

onset: 1-3 hrs intermediate acting peak 8hrs duration: 12-16hrs

Risk factors for arthritis

smoking

8 - 9 months

stands straight at 8, has favorite toy, plays peek-a-boo

Sickle cell - joints

warmth, redness, and range of motion Important: assess client's understanding of PCA pump

ACLS of when to contact management

· A = abuse · C = confidentiality · L = legal · S = safety

Never give potassium (K+) in IVP.

Infants born to an HIV + mother should receive all immunizations on schedule

Fat Emboli

Long bone fractures Typically occur 24-72 hours after trauma. Sx: SOB, Confusion, hypoxemia, tachypnea, a rash, tachycardia, fast breathing Tx: mechanical vent, O2

The LPN can monitor patients with IV therapy, insert urinary catheters, feeding tubes, and apply restraints

Assessment, teaching, medication administration, evaluation, unstable patients cannot be delegated to an unlicensed assistive personnel

Diseases that impair healing

Diabetes Cancer

4 competence vs. inferiority

Elementary school (6 years old until puberty) - Learn the pleasure of applying themselves to tasks, or they will feel inferior.

Crackles (rales) "crazy fluid"

Fine - high pitched Coarse - low pitched Bases of lungs Caused by: PE w/CHF or Pneumonia (infection) Treatment: Diuretics (furosemide) Infection (antibiotics)

Lochia rubra is the vaginal discharge of almost pure blood that occurs during the first few days after childbirth

Lochia serosa is the serous vaginal discharge that occurs 4 to 7 days after childbirth

DVT and PE

Long bone fractures Dyspnea, chest pain, hypoxemia Prevention: anticoags, early ambulation

Pleural Friction Rub "pebbles friction"

Low pitched - like 2 rocks grinding Location: front side - inhalation/exhalation Caused by: Worsening pneumonia (infection) Treatment: TCDB, incentive spirometer, antibiotics

Always check for allergies before administering antibiotics

Neutropenic patients should not receive vaccines, fresh fruits, or flowers

Optic - vision

REEDDA - Episiotomy Healing Eval

R edness E dema E cchymosis D ischarges D rainage A pproximation Expected: - lochia for several weeks - bright red heavy flow first few days - then turn from pink or brown to yellow or white

Sublimation is the channeling of unacceptable impulses into socially acceptable behavior.

Repression is an unconscious defense mechanism whereby unacceptable or painful thoughts, impulses, memories, or feelings are pushed from the consciousness or forgotten.

Osteomyelitis

S/S: fever, malaise, anorexia, night sweats, weight loss Caused by: infection in bone Most commonly Staph Aureus

Rhonchi "Rumble"

Serious Mucous! Location: bronchi Caused by: bronchitis, COPD, pneumonia (infection), CF Treatment: - chest percussion (vibration vest) - fluids (to loosen mucus)

Spinal accessory - Neck motion

A client received six units of regular insulin 3 hours ago. The nurse is MOST concerned if which of the following is observed? 1. Kussmaul respirations and diaphoresis. 2. Anorexia and lethargy. 3. Diaphoresis and trembling. 4. Headache and polyuria.

Strategy: "MOST concerned" indicates a complication. (1) Kussmaul respirations are signs of hyperglycemia (2) not indicative of hypoglycemia (3) correct—regular insulin peaks in 2 to 4 hours; indicates hypoglycemia; give skim milk (4) not indicative of hypoglycemia

The nurse monitors a client's EKG strip and notes coupled premature ventricular contractions greater than 10 per minute. The nurse should expect to administer which of the following? 1. Atropine sulfate (Atropine) IV. 2. Isoproterenol (Isuprel) IV. 3. Verapamil (Calan) IV. 4. Lidocaine hydrochloride (Xylocaine) IV.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) antidysrhythmic, used for bradycardia (2) antidysrhythmic, used for heart block, ventricular dysrhythmias (3) antihypertensive, calcium-channel blocker (4) correct—lidocaine is the drug of choice for frequent premature ventricular contractions (PVC) occurring in excess of 6 to 10 per minute; for coupled PVCs or for a consecutive series of PVCs that may result in ventricular tachycardia

The nurse supervises the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed? 1. The child is placed in a private room. 2. The staff removes a toy from the child's bed and takes it to the nurse's station. 3. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack. 4. The staff uses standard precautions.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—contact precautions required for diapered or incontinent clients (2) do not remove toys from room, possibly contaminated (3) diet should be high in carbohydrates and protein and low in fat (4) contact precautions required in addition to standard precautions

The nurse cares for clients in the antepartal clinic. A client at 34 weeks' gestation comes to the clinic for treatment of a sprained ankle. The nurse should question which of the following orders? 1. ASA (aspirin) 650 mg PO q4h prn for pain. 2. Return to the clinic in 2 weeks. 3. Apply ice to sprain for 20 minutes qh for 24 hours. 4. Teach client three-gait crutch walking.

Strategy: Determine the outcome of each answer choice. Is it desired? (1)correct—aspirin can cause fetal hemorrhage; do not use during pregnancy (2) routine follow-up (3) treat sprain with rest and elevation of affected part; intermittent ice compresses for 24 hours (4) appropriate gait if client unable to bear weight

Strategy: Determine the significance of each answer choice and how it relates to scoliosis. (1) correct—thoracic area becomes noticeably distorted (2) seen with hip dislocation (3) seen with circulatory or inflammatory processes (4) seen with pigeon breast, or pectus carinatum

A mother brings her 2-year-old to the pediatrician's office. Which of the following symptoms suggests to the nurse that the child has strabismus? 1. The child places his head close to the table when drawing. 2. The child rubs his eyes frequently. 3. The child closes one eye to see a poster on the wall. 4. The child is unable to see objects in the periphery of his visual field.

Strategy: Think about each answer choice. (1) suggestive of refractive error, myopia (nearsightedness), able to see objects at close range (2) suggestive of refractive error (3) correct—visual axes are not parallel, so the brain receives two images (4) suggestive of cataracts or problem with peripheral vision

A middle-aged woman, mother of two, has a mastectomy for breast cancer. When she returns to the physician's office a month later for a routine checkup, the nurse asks the client how she has been. Which of the following responses, if made by the client to the nurse, indicates that the client is experiencing a normal reaction to the surgery? 1. "I have been helping my family deal with their feelings about the surgery." 2. "I have been having difficulty coping with the surgery and cry frequently." 3. "I have been unable to leave the house or talk to my friends about the surgery." 4. "I am doing just great since the surgery and have gone back to work at my job."

Strategy: Think about each answer choice. Does it describe an expected response to a crisis situation? (1) will not be able to help others this soon after surgery (2) correct—normal reaction 1 month later (3) excessive, abnormal reaction (4) indicates integration, too early for this stage

TAIIIIGE

Taking All Information Is Important In Giving Expertise Trust vs. mistrust Autonomy vs shame/doubt Initiative vs. guilt Industry vs. inferiority Identity vs role confusion Intimacy vs. isolation Generativity vs. stagnation Ego integrity vs. despair

Usually patients who have the same infection and are in strict isolation can share a room

Veracity is truth and is an essential component of a therapeutic relationship between a health care provider and his patient.

Ascites

accumulation of fluid in the peritoneal cavity >25ml

thioxene

antipsychotic treat schizo

gout diet

avoid red and organ meats, shellfish, oily fish with bones

What drugs can decrease bone mass?

glucocorticoids

4 - 5 months

grasps, switch and roll over tummy to back. Can babble and can mimic sounds.

barbiturate abuse s/s

lack of coordination, cns depressed

5 identity vs. role confusion

(adolescence)12 - 20: the major task is to build a consistent identity, a unified sense of self. Failure of teens to achieve a sense of identity results in role confusion and uncertainty about the future.

A client recently admitted to an inpatient unit for treatment of alcoholism says to the nurse, "I only came here to get away from my nagging spouse. Sometimes I think my spouse is the one who should be here. I can stop drinking any time I want." The nurse recognizes that the client is exhibiting which of the following defense mechanisms? 1. Denial and projection 2. Rationalization and depression 3. Regression and displacement 4. Sublimation and reaction formation

The family member of a client diagnosed with a pneumothorax states, "I think something is wrong with that drainage device. It just got very noisy." The nurse observes that bubbling in the underwater seal is continuous compared to several hours ago. Which action does the nurse take first? 1. Clamp the chest tube at the insertion site. 2. Add sterile water to the underwater seal chamber. 3. Notify the health care provider. 4. Observe the connections of the drainage system.

1) The nurse must assess the system first and then assess the client. Clamping the chest tube at the insertion site is not an independent nursing action, as a health care provider prescription is required. 2) The water level should be at 2 cm. If a leak is present, continuous bubbling will still occur. This is not a priority action. 3) The nurse must perform an assessment prior to this action. If the system is not leaking, the nurse can call the health care provider to get additional prescriptions. 4) CORRECT — A leak in the drainage system can cause continuous bubbling. Therefore, the nurse should assess the equipment. This is the priority action.

The nurse speaks with a client and the spouse who have been undergoing family counseling. The client's spouse states, "You never take any responsibility for the messes you always cause!" Which response by the nurse is best? 1. "Why do you say that?" 2. "Blaming is not effective." 3. "Let's focus only on the positives." 4. "When is the last time you two had a vacation?"

1) The use of "why" questions is often considered confrontational and not therapeutic. 2) CORRECT — Family members often blame others for failures, errors, or negative consequences of an action to keep focus away from themselves. This response by the nurse is both accurate and therapeutic. 3) The nurse needs to correct unhealthy communication patterns. Only focusing on the positives will not correct unhealthy communication patterns. 4) The nurse needs to correct unhealthy communication patterns. Asking the client and spouse when they had a vacation does not correct unhealthy communication patterns.

The nurse is supervising four unlicensed assistive personnel (UAP). The nurse will immediately intervene and provide assistance if which scope of practice violation is observed? 1. The UAP performs a routine blood glucose test on a client. 2. The UAP performs a point of care urine pregnancy test. 3. The UAP assists an older adult client with feeding. 4. The UAP restarts a client's IV fluids.

1) This action is not a scope of practice violation. The UAP can perform standard, unchanging procedures, such as a routine blood glucose test for a stable client. 2) This action is not a scope of practice violation. The UAP can perform standard, unchanging procedures (such as a urine pregnancy test) for stable clients. 3) This action is not a scope of practice violation. The UAP can perform standard, unchanging tasks (such as feeding a stable client). 4) CORRECT — This UAP action requires an intervention by the nurse. Intravenous (IV) line patency should be assessed by the nurse before restarting IV fluids, as assessment is not within the UAP's scope of practice.

The nurse makes client assignments on the medical surgical unit. The nurse assigns an LPN/LVN to a client diagnosed with localized herpes zoster. The LPN/LVN tells the nurse, "I have never had chickenpox." Which response by the nurse is most appropriate? 1. "Use standard precautions when providing care for the client." 2. "You will be fine, because the client is on airborne precautions." 3. "Your client assignment will be changed." 4. "Why are you concerned about providing care for the client?"

1) This is an incorrect statement and is not therapeutic. 2) This response trivializes the LPN/LVN's concern and is not therapeutic. 3) CORRECT— This is a true, therapeutic statement. 4) The use of "why" questions is confrontational and is not therapeutic.

A 12-year-old with moderate intellectual disability and an intelligent quotient of 45 is hospitalized. What will the nurse recommend as the BEST recreational activity for this child? 1. Childs favorite stuffed animal 2. Connect-the-dots puzzle book 3. Putting together a 300-piece jigsaw puzzle 4. Writing in a journal about the hospital stay

A client is newly admitted to the mental health unit with a diagnosis of schizophrenia with persecutory delusions. Which nursing INTERVENTIONs should the nurse include in the client's plan of care with regard to the delusional thinking? SELECT ALL THAT APPLY. 1. Explore the meaning behind the client's delusions 2. Focus on reality and verbally reinforce it 3. Focus on the client's feelings secondary to the delusions 4. Gently confront the client about the false beliefs 5. Present logical explanations to discredit the delusions

The 17-year-old child of a client being treated for alcoholism tells the nurse that the parent's disease and behavior have taken a toll on the whole family the child is especially concerned about a 13-year-old sibling who is having trouble in school. The nurse should provide the child with information about what resource? 1. Adult Children of Alcoholics (ACOA) 2. Alateen 3. Alcoholics Anonymous (AA) 4. National Association for Children of Alcoholics (NACOA)

The clinic nurse speaks with the spouse of a client being treated for alcohol use disorder. Which statements by the spouse indicate codependence? SELECT ALL THAT APPLY. 1. "I am focusing on my new hobby and my friends in the book club." 2. "I left and didn't awaken my spouse, who went back to sleep after turning off the alarm clock." 3. "I try to get up early and keep the children from being too loud in the mornings." 4. "If I didn't get so stressed about my job, my spouse wouldn't drink so much." 5. "When my spouse was sick, I called and rescheduled clients so my spouse could rest."

3,4,5

serum albumin level

3.4-5.4

TB duration of therpay

6-9 months

AST normal serum value

8-20

normal SLT

8-20 unit/ L

normal AST

8-20unit/L

Child has recently become clumsy and uncoordinated.

Adolescent males experience a rapid rate of physical growth, which can cause clumsiness and a lack of coordination.

ACLS of what to avoid w/grapefruit

Anything metabolized by liver not kidney's · A - antianxiety · C - calcium channel blockers · L - lipid lowering · S - seizure meds

APGAR Scoring

Appearance Pulses Grimace Activity Reflex Irritability Done at 1 to 5 minutes with a score of 0 for absent, 1 for decreased, and 2 for strongly positive. Scores 7 and above are generally normal, 4 to 6 fair low, and 3 and below are generally regarded as critically low.

A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding? A.Cyanosis of the hands and feet B.Skin color that is slightly jaundiced C.Tiny white papules on the nose or chin D.Red patches on the cheeks and trunk

B. Skin color that is slightly jaundiced Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of the hands and feet) is a common finding in newborns; it occurs because the capillary system is immature. Milia are small white papules present on the nose and chin that are caused by sebaceous gland blockage and disappear in a few weeks. Small red patches on the cheeks and trunk are called erythema toxicum neonatorum, a common finding in newborns.

When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach concerning the newborn infant born at term gestation? A.Milia are red marks made by forceps and will disappear within 7 to 10 days. B.Meconium is the first stool and is usually yellow gold in color. C.Vernix is a white cheesy substance, predominantly located in the skin folds. D.Pseudostrabismus found in newborns is treated by minor surgery.

C.Vernix is a white cheesy substance, predominantly located in the skin folds. Rationale: Vernix, found in the folds of the skin, is a characteristic of term infants. Milia are not red marks made by forceps but are white pinpoint spots usually found over the nose and chin that represent blockage of the sebaceous glands. Meconium is the first stool, but it is tarry black, not yellow. Pseudostrabismus (crossed eyes) is normal at birth through the third or fourth month and does not require surgery.

Chronic Kidney Failure

Causes: AKI HTN DM Polycystic kidney disease NO NSAIDS Fluid restriction Low: protein, phosphate, na+, k+

The client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which assessment findings for this client? (Select all that apply.) 1. Hypotension. 2. Low back pain. 3. Wet breath sounds. 4. Fever. 5. Urticaria. 6. Severe shortness of breath

Correct: 1,2,4 Rationale: CLIENT c hemolytic transfusion reaction will experience a drop in BP, low back pain and an elevated temp. 3,4: wet breath sounds and SOB/dyspnea is expected for a client c circulatory overload 5: urticaria/hives is expected c an allergic reaction

The nurse instructs a student nurse about the correct way to set up a sterile field. The nurse determines that teaching is effective if which action is observed? 1. The student nurse places the supplies at the edge of the sterile field. 2. The student nurse wears a gown and gloves at all times. 3. The student nurse sets up the sterile field above waist level. 4. The student nurse opens supplies with sterile gloves.

Correct: 3 Rationale: Appropriate action and indicates accurate understanding of the sterile field

When it says check vital signs it means ALL vital signs, if they don't need all vital signs in the moment then answer is wrong.

Ex - child after tonsillectomy restless, agitated, and continuous swallowing...you don't need all vital signs

VII

Facial (Taste, tears, saliva, facial expressions)

Raloxifene

For: Osteoporosis S/E: hot flashes, leg cramps, retinal vein thrombosis, thromboembolism, and stroke

Calcitonin Salmon

For: hypocalcemia S/E: headache, rhinitis, injection site reaction, rash, facial flushing, n/v

Cheyne-Stokes "death rattle"

Increase and decrease in RR - "stop/start" breathing Caused by: apnea => increased CO2 - hyperventilation to blow off CO2 Treatment: Intubation & mech ventilation

Olfactory (smell)

Oxycodone terephthalate=percodan-contains aspirin Strategy: Think about the action of each medication. (1) contains aspirin, contraindicated for persons with bleeding disorders (2) increases bleeding time by decreasing platelet aggregation, contraindicated for persons with bleeding disorders (3) increases bleeding time by decreasing platelet aggregation, contraindicated for persons with bleeding disorders (4) correct—analgesic used for moderate to severe pain

Ischemic Stroke

PRIORITY - finding out when it started

Trochlear, eye movement, motor

(1) correct—describes esophageal speech (2) describes electric larynx (3) method of speech for patient with a tracheostomy (4) describes tracheoesophageal fistula (TEF) ...

A client receives total parenteral nutrition (TPN). To determine the client's tolerance of this treatment, the nurse should assess which of the following? 1. A significant increase in pulse rate. 2. A decrease in diastolic blood pressure. 3. Temperature in excess of 98.6°F (37°C). 4. Urine output of at least 30 ml/h.

(1) if the pulse rate increases, may indicate fluid overload (2) if the diastolic blood pressure decreases, it might indicate shock or lack of blood volume (3) temperature should remain within normal limits (4) correct—if the client is being properly hydrated with hypertonic IV such as TPN, urine output needs to be at least 30 ml/h; other nursing action includes assessment of blood glucose levels ...

The nurse performs discharge teaching for a client diagnosed with Addison's disease. It is MOST important for the nurse to instruct the client about which of the following? 1. Signs and symptoms of infection. 2. Fluid and electrolyte balance. 3. Seizure precautions. 4. Steroid replacement.

(1) not most important (2) not most important (3) not most important (4) correct—steroid replacement is the most important information the client needs to know ...

The nurse cares for clients in the emergency department of an acute care facility. Four clients have been admitted during the previous 10 minutes. Which of the following admissions should the nurse see FIRST? 1. A client complaining of chest pain that is unrelieved by nitroglycerine. 2. A client with full-thickness burns to the face. 3. A client with a fractured hip. 4. A client complaining of epigastric pain.

(1) not the highest priority; airway most important (2) correct—face, neck, chest, or abdominal burns result in severe edema, causing airway restriction (3) airway is most important (4) requires further assessment; airway is a priority

The client exhibits symptoms of myxedema. The nursing assessment should reveal which of the following? 1. Increased pulse rate. 2. Decreased temperature. 3. Fine tremors. 4. Increased radioactive iodine uptake level.

(1) pulse will decrease (2) correct—with myxedema there is a slowing of all body functions (3) associated with hyperthyroidism (4) associated with hyperthyroidism ...

A client at the health clinic asks the nurse if he should get a flu shot. Which of the following factors, if learned by the nurse in the history, would NOT be a reason for the client to receive the flu vaccine? 1. The client is 69 years old. 2. The client had bronchitis twice last year. 3. The client volunteers at a preschool. 4. The client lives with two large dogs.

(1) recommended for people over 65 (2) recommended for people with chronic respiratory or cardiovascular disease (3) recommended for people who come in contact with young children (4) correct—not at risk for getting the flu from a dog ...

An adolescent client is ordered to take tetracycline HCL (Achromycin) 250 mg PO bid. Which of the following instructions should be given to the client by the nurse? 1. "Take the medication on a full stomach or with a glass of milk." 2. "Wear sunscreen and a hat when outdoors." 3. "Continue taking the medication until you feel better." 4. "Avoid the use of soaps or detergents for 2 weeks."

(1) should be taken on an empty stomach (2) correct—photosensitivity occurs with the use of this medication (3) should be taken as directed (4) unnecessary ...

(1) should use clean (not sterile) technique, used for clients with lower motor neuron disorders resulting in flaccid bladder (2) correct—client holds breath and bears down as if trying to defecate, or uses Credé maneuver (places hands over bladder and pushes in and down), done to try to empty bladder before catheterization (3) usually done every 2 to 3 hours initially, and then increased to every 4 to 6 hours (4) should encourage fluids...

(1) suggestive of refractive error, myopia (nearsightedness), able to see objects at close range (2) suggestive of refractive error (3) correct—visual axes are not parallel, so the brain receives two images (4) suggestive of cataracts or problem with peripheral vision

The RN makes nursing assignments for the burn unit. Which of the following indicates the MOST appropriate assignment for a client with a positive cytomegalovirus (CMV) titer? 1. A nurse with an upper respiratory infection. 2. A young nurse who is 8 weeks pregnant. 3. A male nurse who is CMV-negative. 4. An older nurse with 30 years of experience.

(1) those with a cytomegalovirus-positive titer are often immunosuppressed clients who should be protected from other pathogens (2) CMV is fetotoxic; should inform client of risks (3) this nurse is at increased risk for developing the disease (4) correct—most appropriate option due to decreased risk ...

The nurse should explain to a client that glipizide (Glucotrol) is effective for diabetics who 1. can no longer produce any insulin. 2. produce minimal amounts of insulin. 3. are unable to administer their injections. 4. have a sustained decreased blood glucose.

(1) type 1 insulin-dependent diabetic is unable to produce insulin (2) correct—oral hypoglycemic agents are administered to type 2 (non-insulin-dependent) clients who are able to produce minimal amounts of insulin (3) type 1 diabetics who cannot administer their injections need alternate plans to be made for them to receive the injection from a family member (4) Glucotrol is administered for an increase in blood glucose

An elderly patient is admitted to the hospital for treatment of a fractured femur. The patient's spouse tells the nurse that the patient has become very hard of hearing. The nurse might expect the patient to exhibit which of the following characteristics? 1. The patient prefers to be left alone. 2. The patient appears suspicious of strangers. 3. The patient communicates best in writing. 4. The patient's speech is difficult to understand.

(1) unrelated to hearing deficit (2) correct—suspiciousness results from interference with communication (3) writing may be difficult for patient, depends on intellectual capacity (4) diminished hearing late in life does not cause speech difficulties

When caring for a client with a nursing diagnosis of rape trauma syndrome, acute phase, the nurse should consider which of the following the MOST important initial goal for the client? 1. Within 3 to 5 months, the client will state that the memory of the event is less vivid and distressing. 2. The client will indicate a willingness to keep a follow-up appointment with a rape crisis counselor. 3. The client will be able to describe the results of the physical examination that was completed in the emergency room. 4. The client will begin to express her reactions and feelings about the assault before leaving the emergency room.

(1) valid goal that needs to be addressed but after the initial goal has been met (2) valid goal that needs to be addressed but after the initial goal has been met (3) valid goal that needs to be addressed but after the initial goal has been met (4) correct—is nurse's initial priority to encourage client to begin dealing with what happened by verbalizing her feelings and gaining some acceptance and perspective

The parents of a 1-month-old boy bring their son to the clinic for evaluation of a possible developmental dysplasia of the right hip. The nurse should observe for which of the following? 1. Limited adduction of the right leg. 2. Uneven gluteal fold and thigh creases. 3. Increase in length of the right limb. 4. Internal rotation of the right leg.

(1) will see limited abduction (2) correct—folds and creases will be longer and deeper on affected side (3) will be decrease in limb length (4) may or may not see internal rotation

Which of the following nursing interventions is MOST important for a client diagnosed with rheumatoid arthritis? 1. Provide support to flexed joints with pillows and pads. 2. Position the client on the abdomen several times a day. 3. Massage the inflamed joints with creams and oils. 4. Assist the client with heat application and ROM exercises.

(1) would result in contractures due to the strength of flexor muscles (2) should encourage range of motion in all joints, not just hip flexors (3) massaging inflamed joints will add to inflammation and pain (4) correct—reduces swelling, increases circulation, diminishes stiffness while preserving joint mobility ...

7 generativity vs. stagnation

(middle adulthood) 40s to 60s: people discover a sense of contributing to the world, usually though family or work, or they may feel a lack of purpose.

3 initiative vs. guilt

(preschooler)3-5 years old: learn to initiate own activities and feel proud of their accomplishments or feel guilty about efforts to be independent

2 autonomy vs. shame and doubt

(toddlerhood)1-2:Erikson's stage in which a toddler learns to exercise will and to do things independently; failure to do so causes shame and doubt

6 intimicy vs. isolation

(young adulthood) 20s to early 40s: young adults stuggle to form close relationships and to gain the capacity for intimate love or they feel socially isolated

Stridor - medical emergency

*URGENT* Airway obstruction Location: throat - Inhalation Caused by: choking obstruction, epiglottitis, Croup, AFTER THYROID SURGERGY Treatment: diuretics (furosemide), infection (antibiotics)

Hemolytic jaundice

- Results from hemolysis leading to increased production of billirubin - Caused by transfusion reactions, hemolytic anemia, sickle cell crisis

Random Cram

Kaugnay na mga set ng pag-aaral

Mastery Maternal Questions

Maternity-Post-Partum

chapter 9 thinking and language

Chapter 4 history test

ch. 6.3

Chapter 6 - Multiple Choice

Exam 2 His 102 ch21 ch 24

ch. 7 practice quiz

A&P 1 Unit 1

Saunders Fluid & Electrolyte Practice Questions

traductor

Measure Words in Chinese

Preschooler NCLEX Review

Successful Recruitment and Hiring Strategies

Chapter 8

CAPPS 300-085 V2

Lit Test Commonlit

Quiz 3: Stages of Development

Clean Getaway by Nic Stone

CHP 18-The Community and the Corporation