Semester 3 FINAL EXAM

An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take? a. Organize a pizza party for each shift. b. Remind the staff of the facility's sick-leave policy. c. Arrange for critical incident stress debriefing. d. Talk individually with staff members.

c. Arrange for critical incident stress debriefing.

A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The client's blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the client's rhythm on the cardiac monitor and observes the reading shown below: Which action should the nurse take first? a. Begin external temporary pacing. b. Assess peripheral pulse strength. c. Ask the client what medications he or she takes. d. Administer 1 mg of atropine.

c. Ask the client what medications he or she takes.

Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next? a. Keep the family in the room and assign a staff member to explain the care given and answer questions. b. Ask the family to wait outside the patient's room with a designated staff member to provide emotional support. c. Ask the family members about whether they would prefer to remain in the patient's room or wait outside the room. d. Tell the family members that patients are comforted by having family members present during resuscitation efforts.

c. Ask the family members about whether they would prefer to remain in the patient's room or wait outside the room.

A mother brings her child to the clinic requesting "genetic testing" to determine whether her child suffers from the same multiple allergies as herself. What action by the nurse is most appropriate? a. Provide a referral to an allergist so the child can be tested. b. Refer the mother to a geneticist for genetic testing on the child. c. Ask the mother about specific symptoms the child may have had. d. Have the mother list her allergies and the symptoms they cause her.

c. Ask the mother about specific symptoms the child may have had.

The nurse is caring for a drowning victim after resuscitation. What focused assessment will the nurse perform to identify complications from drowning? a. Palpation of abdominal cavity b. Inspection of skin color c. Auscultation of lungs d. Palpation of pulse strength

c. Auscultation of lungs

Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day, never coming out for breaks or lunch. Which term best describes this behavior? a. Narcissistic b. Histrionic c. Avoidant d. Paranoid

c. Avoidant

A young man comes into the foyer of the hospital and says that he has a container of anthrax, which he opens and pours on the floor. Which is the priority action for the nurse who first comes upon the scene? a. Don a protective gown, mask, and goggles. b. Escort the man to the decontamination room. c. Begin to evacuate the immediate area. d. Notify the local health department of a biohazard situation.

c. Begin to evacuate the immediate area.

The nurse works with clients who have hearing problems. Which action by a client best indicates goals for an important diagnosis have been met? a. Babysitting the grandchildren several times a week b. Having an adaptive hearing device for the television c. Being active in community events and volunteer work d. Responding agreeably to suggestions for adaptive devices

c. Being active in community events and volunteer work

A nurse determines that parents understood the teaching from the pediatric oncologist if the parents indicate that which test confirms the diagnosis of leukemia in children? a. Complete blood cell count (CBC) b. Lumbar puncture c. Bone marrow biopsy d. Computed tomography (CT) scan

c. Bone marrow biopsy

In counseling an adolescent who is abusing alcohol, the nurse explains that alcohol abuse primarily affects which organ of the body? a. Heart b. Liver c. Brain d. Lungs

c. Brain

Which dinner menu is best suited for a patient with acute mania? a. Spaghetti and meatballs, salad, and a banana b. Beef and vegetable stew, a roll, and chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, and an apple d. Chicken casserole, green beans, and flavored gelatin with whipped cream

c. Broiled chicken breast on a roll, an ear of corn, and an apple

The nurse has taught a client with lupus about skin protection in the clinic. Later, the nurse sees the client at an outdoor music festival. Which observation by the nurse indicates that the client requires further instruction? a. Client is wearing a thin, long-sleeved shirt. b. Client is wearing a hat with a full brim. c. Client is discussing her new perm. d. Client is seen applying sunscreen twice.

c. Client is discussing her new perm.

Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients should the nurse assess first? a. Client with dry, itchy, peeling skin b. Client with a serum calcium of 9.2 mg/dL c. Client with a serum potassium of 2.8 mEq/L d. Client with a weight gain of 0.5 pound (1.1 kg) in 1 day

c. Client with a serum potassium of 2.8 mEq/L

A young adult female patient who is human immunodeficiency virus (HIV)-positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan? a. Driving is allowed when starting this medication. b. Report any bizarre dreams to the health care provider. c. Continue to use contraception while on this medication. d. Take this medication in the morning on an empty stomach.

c. Continue to use contraception while on this medication.

The nurse is assisting with data collection on a patient newly diagnosed with schizophrenia. Which observations should the nurse consider as being positive symptoms of schizophrenia? (Select all that apply.) a. Alogia b. Apathy c. Delusions d. Hallucinations e. Social isolation f. Disorganized behavior

c. Delusions d. Hallucinations f. Disorganized behavior

A nurse manager on an oncology nursing unit notes an increased incidence of infection and serious consequences for clients on the unit. Which action by the nursing manager is most beneficial in this situation? a. Review asepsis policies at a mandatory in-service for staff. b. Spot-check all staff for good handwashing practices. c. Develop standard protocols to identify and treat clients with infection. d. Institute protective precautions for all clients receiving chemotherapy.

c. Develop standard protocols to identify and treat clients with infection.

A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

c. Diaphoresis, weakness, and nausea

When inspecting the IV site of a patient receiving a vesicant chemotherapy agent, the licensed practical nurse (LPN) notes a small area of swelling. What should the LPN do first? a. Check the site every hour. b. Document the finding in the chart. c. Discontinue the infusion and notify the RN. d. No action is needed; this is an expected finding.

c. Discontinue the infusion and notify the RN.

A client has mastoiditis. The nurse assesses most carefully for which manifestations? (Select all that apply.) a. Red and bulging eardrum b. A crackling sound upon yawning c. Enlarged lymph nodes behind the ear d. Low-grade fever and malaise e. Diminished hearing f. Loss of appetite

c. Enlarged lymph nodes behind the ear d. Low-grade fever and malaise e. Diminished hearing f. Loss of appetite

The nurse is planning care for a patient with leukopenia caused by chemotherapy. Which nursing intervention is most important for the nurse to include in this patient's plan of care? a. Protect the patient from injury. b. Observe for bruising or bleeding. c. Ensure that staff members practice good hand washing. d. Assist the patient with activities of daily living (ADLs).

c. Ensure that staff members practice good hand washing.

The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be most appropriate for the nurse to take? a. Instruct the patient to apply ice to the neck. b. Advise the patient that this is probably the flu. c. Explain to the patient that this is an expected finding. d. Request that an antibiotic be prescribed for the patient.

c. Explain to the patient that this is an expected finding.

When a patient diagnosed with a personality disorder uses manipulation to get needs met, the staff applies limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the patient's wishes, so assertiveness will develop. c. External controls are necessary due to failure of internal control. d. Anxiety is reduced when staff assumes responsibility for the patient's behavior.

c. External controls are necessary due to failure of internal control.

A patient who has schizophrenia has a dull facial expression and speaks in a monotone voice, even though a visitor is making an effort to be jovial. What terminology should the nurse use to document this observation? a. Bored b. Depressed c. Flat affect d. Ambivalent attitude

c. Flat affect

The nurse is caring for a client with otitis media and notes purulent drainage in the ear canal during the physical assessment. Which is the nurse's priority intervention? a. Obtain a specimen of the drainage for culture. b. Irrigate the ear canal with sterile normal saline. c. Gently examine the client's ear with an otoscope. d. Place a cotton ball in the ear canal to absorb the drainage.

c. Gently examine the client's ear with an otoscope.

A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate? a. Administer a dose of allopurinol (Aloprim). b. Assess the client's serum potassium level. c. Gently inquire about advance directives. d. Prepare the client for emergency surgery.

c. Gently inquire about advance directives.

While the nurse is visiting the community pool, an adult swimmer is pulled out of the pool, unconscious and cyanotic. What is the priority action of the nurse? a. Begin chest compressions. b. Move from the pool area. c. Give two rescue breaths. d. Check for a carotid pulse.

c. Give two rescue breaths.

A client has a platelet count of 25,000/mm3. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist with oral hygiene using a firm toothbrush. b. Give the client an enema if he or she is constipated. c. Help the client choose soft foods from the menu. d. Shave the male client with an electric razor. e. Use a lift sheet when needed to re-position the client.

c. Help the client choose soft foods from the menu. d. Shave the male client with an electric razor. e. Use a lift sheet when needed to re-position the client.

A person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks" and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient's plan of care? a. Insulting, aggressive behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making

c. Hyperactivity; not eating and sleeping

The admission note indicates a patient diagnosed with major depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply. a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

How does the type V hypersensitivity reaction differ from other reactions? a. It is cell mediated rather than antibody mediated. b. It is an immediate response rather than a delayed response. c. It produces a stimulatory response to normal tissues. d. It results in more severe tissue damage than is caused by other types of reactions.

c. It produces a stimulatory response to normal tissues.

The nurse is assisting with teaching a patient who has been started on fluphenazine (Prolixin). About which side effect should the nurse focus this teaching? a. Weight loss b. Hypoglycemia c. Photosensitivity d. Elevated blood pressure

c. Photosensitivity

A client with Ménière's disease is in the hospital when the client has an attack of this disorder. What action by the nurse takes priority? a. Assess vital signs every 15 minutes. b. Dim or turn off lights in the client's room. c. Place the client in bed with the upper siderails up. d. Provide a cool, wet cloth for the client's face.

c. Place the client in bed with the upper siderails up.

A person was online continuously for over 24 hours, posting rhymes on official government websites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficits and paranoia

c. Poor judgment and hyperactivity

The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Psychomotor agitation

c. Poor personal hygiene

A client with diagnosed osteoarthritis comes to the clinic reporting a low-grade fever, fatigue, and bilateral joint pain. What action by the nurse is most appropriate? a. Assess the client for a systemic infection. b. Discuss increasing the dose of anti-arthritis drugs. c. Prepare the client for a laboratory draw for rheumatoid factor. d. Teach the client joint protection activities.

c. Prepare the client for a laboratory draw for rheumatoid factor.

The nurse determines that a patient with hypovolemic shock is improving. What did the nurse observe to come to this conclusion? (Select all that apply.) a. Heart rate increasing b. Respiratory rate increasing c. Present of peripheral pulses d. Systolic blood pressure increasing e. Urine output 20 mL over the last hour

c. Present of peripheral pulses d. Systolic blood pressure increasing

The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority? a. Methods to prevent perinatal HIV transmission b. Ways to sterilize needles used by injectable drug users c. Prevention of HIV transmission between sexual partners d. Means to prevent transmission through blood transfusions

c. Prevention of HIV transmission between sexual partners

The plan of care for a patient in the manic state of bipolar disorder should include which interventions? Select all that apply. a. Touch the patient to provide reassurance. b. Invite the patient to lead a community meeting. c. Provide a structured environment for the patient. d. Ensure that the patient's nutritional needs are met. e. Design activities that require the patient's concentration.

c. Provide a structured environment for the patient. d. Ensure that the patient's nutritional needs are met.

Which action should the nurse incorporate into a care plan for a 14-year-old child in the emergency department? a. Limit the number of choices to be made by the adolescent. b. Insist that parents remain with the adolescent. c. Provide clear explanations and encourage questions. d. Give rewards for cooperation with procedures.

c. Provide clear explanations and encourage questions.

The nurse prioritizes which intervention in a client with xerostomia secondary to radiation therapy to the neck area? a. Applying lotions and oils to affected areas b. Wearing a hat to decrease heat loss c. Providing oral care after meals and at bedtime d. Monitoring vital signs every 4 hours

c. Providing oral care after meals and at bedtime

A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia

c. Pseudoparkinsonism

A client has severe tinnitus that cannot be treated adequately. What action by the nurse is best? a. Advise the client to take antianxiety medication. b. Educate the client on nerve cutting procedures. c. Refer the client to online or local support groups. d. Teach the client side effects of furosemide (Lasix).

c. Refer the client to online or local support groups.

A child is brought to the emergency department. When he is called to triage, which vital sign should be measured first? a. Temperature b. Heart rate c. Respiratory rate d. Blood pressure

c. Respiratory rate

The most appropriate nursing diagnosis for the child with acute glomerulonephritis is a. Risk for Injury related to malignant process and treatment b. Deficient Fluid Volume related to excessive losses c. Risk for Imbalanced Fluid Volume related to a decrease in plasma filtration d. Excess Fluid Volume related to fluid accumulation in tissues and third spaces

c. Risk for Imbalanced Fluid Volume related to a decrease in plasma filtration

As a nurse prepares to administer medication to a patient diagnosed with a borderline personality disorder, the patient says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response? a. Reinforce this assertive action by the patient. Leave the medication on the table as requested. b. Respond to the patient, "I'm worried that you might not take it. I'll come back later." c. Say to the patient, "I must watch you take the medication. Please take it now." d. Ask the patient, "Why don't you want to take your medication now?"

c. Say to the patient, "I must watch you take the medication. Please take it now."

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this client's concerns? a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client.

c. Schedule periods of exercise and rest during the day.

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this client's concerns? a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client.

c. Schedule periods of exercise and rest during the day.

A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis

c. Short period of asystole

Major depression resulted after a patient's employment was terminated. The patient now says to the nurse, "I'm not worth the time you spend with me. I am the most useless person in the world." Which nursing diagnosis applies? a. Powerlessness b. Defensive coping c. Situational low self-esteem d. Disturbed personal identity

c. Situational low self-esteem

The nurse is assessing a 58-year-old patient. For what yearly screening test for colorectal cancer should the nurse assess the patient? a. Colonoscopy b. Barium enema c. Stool test for blood d. Flexible sigmoidoscopy

c. Stool test for blood

A nurse is working at the scene of a catastrophic natural event. Which person does the nurse attend to first? a. Distraught mother looking for her children b. Person walking about with a bleeding head wound c. Supine person with pale, cool, clammy skin d. Child with a deformed lower leg crying in pain

c. Supine person with pale, cool, clammy skin

The nurse assessing a child with acute poststreptococcal glomerulonephritis should be alert for which finding? a. Increased urine output b. Hypotension c. Tea-colored urine d. Weight gain

c. Tea-colored urine

The nurse is assisting with medication teaching for a patient who is prescribed lithium carbonate (Eskalith) for bipolar disorder. Which instruction by the nurse is most important? a. Instruct the patient to discontinue other antidepressant agents. b. Teach the patient that the lithium will help stabilize mood swings. c. Teach the patient side effects to report, such as nausea or weight gain. d. Explain to the patient and significant other the importance of regular blood tests.

c. Teach the patient side effects to report, such as nausea or weight gain.

A patient diagnosed with major depression received six electroconvulsive therapy sessions and aggressive doses of antidepressant medication. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a. Antidepressant medications alter catecholamine levels, which impairs decision-making abilities. b. Antidepressant medications may cause confusion related to limitation of tyramine in the diet. c. Temporary memory impairments and confusion may occur with electroconvulsive therapy. d. The patient needs time to readjust to a pressured work schedule.

c. Temporary memory impairments and confusion may occur with electroconvulsive therapy.

The emergency department (ED) is expecting a large number of casualties after a bridge collapse. Which is a priority consideration for the ED leadership when activating the disaster plan? a. Responding paramedics and rescue personnel will notify the ED about exactly how many victims to expect. b. Responding paramedics and rescue personnel will triage all victims at the bridge collapse site before bringing them to the ED. c. The ED may receive many unexpected victims with minor injuries from the bridge collapse. d. Victims who have been contaminated with gasoline will be decontaminated by rescue personnel before arriving at the ED.

c. The ED may receive many unexpected victims with minor injuries from the bridge collapse.

The nurse should base a response to a parent's question about the prognosis of acute lymphoblastic leukemia (ALL) on the knowledge that a. Leukemia is a fatal disease, although chemotherapy provides increasingly longer periods of remission. b. Research to find a cure for childhood cancers is very active. c. The majority of children go into remission and remain symptom free when treatment is completed. d. It usually takes several months of chemotherapy to achieve a remission.

c. The majority of children go into remission and remain symptom free when treatment is completed.

The nurse at the outpatient surgery unit obtains the following information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information is most important to report to the health care provider at this time? a. The patient has had blurred vision for 3 years. b. The patient has not eaten anything for 8 hours. c. The patient takes 2 antihypertensive medications. d. The patient gets nauseated with general anesthesia.

c. The patient takes 2 antihypertensive medications.

A nurse reports to the treatment team that a patient diagnosed with an antisocial personality disorder has displayed the behaviors below. This patient is detached and superficial during counseling sessions. Which behavior by the patient most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling

c. Verbal abuse of another patient

A new psychiatric technician says, "Schizophrenia...schizotypal! What's the difference?" The nurse's response should include which information? a. A patient diagnosed with schizophrenia is not usually overtly psychotic. b. In schizotypal personality disorder, the patient remains psychotic much longer. c. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality. d. Schizotypal personality disorder causes more frequent and more prolonged hospitalizations than schizophrenia.

c. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality.

What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will: a. identify when feeling angry. b. use manipulation only to get legitimate needs met. c. acknowledge manipulative behavior when it is called to his or her attention. d. accept fulfillment of his or her requests within an hour rather than immediately.

c. acknowledge manipulative behavior when it is called to his or her attention.

One month ago, a patient diagnosed with borderline personality disorder and a history of self-mutilation began dialectical behavior therapy. Today the patient phones to say, "I feel empty and want to hurt myself." The nurse should: a. arrange for emergency inpatient hospitalization. b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to choose coping strategies for triggering situations. d. advise the patient to take an anti-anxiety medication to decrease the anxiety level.

c. assist the patient to choose coping strategies for triggering situations.

A client in the CCU goes into sudden ventricular fibrillation. The priority action by the nurse would be to immediately administer a. a lidocaine bolus. b. atropine. c. cardiopulmonary resuscitation (CPR). d. intravenous (IV) magnesium.

c. cardiopulmonary resuscitation (CPR).

When counseling patients diagnosed with major depression, an advanced practice nurse will address the negative thought patterns by using: a. psychoanalytic therapy. b. desensitization therapy. c. cognitive behavioral therapy. d. alternative and complementary therapies.

c. cognitive behavioral therapy.

Consider these three anticonvulsant medications: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which medication also belongs to this classification? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (Lamictal) d. aripiprazole (Abilify)

c. lamotrigine (Lamictal)

A nurse teaches a community class about primary prevention for stroke, which includes (Select all that apply) a. adequate control of hypertension. b. keeping tight glycemic control in diabetes. c. maintaining safe cholesterol levels. d. not smoking or smoking cessation. e. reducing heavy alcohol consumption.

c. maintaining safe cholesterol levels. d. not smoking or smoking cessation. e. reducing heavy alcohol consumption.

Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, "Another nurse said you don't do your job right." Collectively, these interactions can be assessed as: a. seductive. b. detached c. manipulative. d. guilt-producing.

c. manipulative.

A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance? a. self- esteem b. psychosocial c. physiological d. self- actualization

c. physiological

For a client experiencing alcohol withdrawal, the action that the nurse would include in the client's plan of care is to a. describe how the alcohol is causing the withdrawal effects. b. leave the client by him/herself so as not to cause agitation. c. promote a safe, calm, and comfortable environment. d. refer the client to an alcohol-abuse counselor.

c. promote a safe, calm, and comfortable environment.

A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: a. maintaining patients' concentration and attention. b. shifting the patients' focus from food to psychotherapy. c. promoting processing of anxiety associated with eating. d. focusing on weight control mechanisms and food preparation.

c. promoting processing of anxiety associated with eating.

The theory that describes substance abuse as a learned behavior is called the a. biologic model. b. family system model. c. psychological model. d. sociocultural model.

c. psychological model

A client had a retinal detachment and has undergone surgical correction. What discharge instruction is most important? a. "Avoid reading, writing, or close work such as sewing." b. "Dim the lights in your house for at least a week." c. "Keep the follow-up appointment with the ophthalmologist." d. "Remove your eye patch every hour for eyedrops."

a. "Avoid reading, writing, or close work such as sewing."

Which recommendation does the nurse provide for the client with Ménière's disease who has periodic spells of vertigo? a. "Avoid wearing high-heeled shoes." b. "Put brightly colored rugs on the floor for visibility." c. "Step on a sturdy chair to get items from high shelves." d. "Wait to drive a car until after you have taken your Benadryl."

a. "Avoid wearing high-heeled shoes."

A client does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best? a. "Because eye pressure was too high, the tissue died." b. "Glaucoma always leads to permanent blindness." c. "The traumatic damage to your eye was too great." d. "The infection occurs so quickly it can't be treated."

a. "Because eye pressure was too high, the tissue died."

A client in the ICU has shock and is getting blood glucose levels drawn and treatment with subcutaneous insulin. The client's spouse is upset seeing this and says "Now s/he's a diabetic, too?" The best response by the nurse is a. "Blood sugar goes up with physical stress and insulin controls it, and clients seem to do better." b. "High blood sugar is a common side effect of all these medications we are giving the client." c. "No, no, s/he is not yet a diabetic. I hope we can prevent it by giving insulin now." d. "Under great physical stress, blood glucose elevates and people can become diabetic."

a. "Blood sugar goes up with physical stress and insulin controls it, and clients seem to do better."

A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by: a. quietly asking the patient, "Why don't you put your clothes on?" b. firmly telling the patient, "Stop dancing and put on your clothing." c. putting a blanket around the patient and walking with the patient to a quiet room. d. letting the patient stay in the group room and moving the other patients to a different area.

c. putting a blanket around the patient and walking with the patient to a quiet room.

A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about: a. restricting sodium intake to 1 gram daily. b. minimizing exposure to bright sunlight. c. reporting increased suicidal thoughts. d. maintaining a tyramine-free diet.

c. reporting increased suicidal thoughts.

A client with AIDS has the nursing diagnosis Fatigue. To conserve energy, the nurse encourages the client to a. bathe before eating breakfast. b. rest after every third major activity. c. sit down while showering. d. use easy-to-clean forks and knives.

c. sit down while showering.

The nurse caring for a client with cancer of the thyroid gland has a tumor classified as T2, N1, M0. The nurse explains that the "T" in this classification schema represents a. number of years the tumor has been present. b. Site of the tumor. c. size of the tumor. d. virulence of malignancy.

c. size of the tumor.

When the AIDS client refuses pain medication because he or she is not in pain presently, the nurse should explain that a. refraining from using the medication makes its effectiveness last longer. b. skipping a dose will decrease diarrhea. c. taking the medication on schedule keeps the blood level constant. d. using the drug will increase the appetite.

c. taking the medication on schedule keeps the blood level constant.

A client with third-degree heart block is admitted to the telemetry unit. The nurse observes wide QRS complexes on the monitor with a heart rate of 35 beats/min. What priority assessment does the nurse perform? a.Pulmonary auscultation b.Pulse strength and amplitude c.Level of consciousness d.Mobility and gait stability

c.Level of consciousness

The physician is about to perform carotid sinus massage on a client with supraventricular tachycardia. What equipment is most important for the nurse to have ready? a.Emesis basin b.Magnesium sulfate c.Resuscitation cart d.Padded tongue blade

c.Resuscitation cart

The triage nurse is assessing a client who has been brought to the emergency department (ED) by emergency medical services (EMS) following a mass casualty incident. Which assessment questions are used to determine the appropriate triage category for the client? (Select all that apply.) a. "Can you wiggle your toes?" b. "Are you having any difficulty breathing?" c. "Are you allergic to any medications?" d. "Does your family know that you are here?" e. "Can you tell me what day it is?" f. "Do you have any abdominal or back pain?"

a. "Can you wiggle your toes?" b. "Are you having any difficulty breathing?" e. "Can you tell me what day it is?" f. "Do you have any abdominal or back pain?"

A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that apply.) a. "Chemo" gloves b. Facemask c. Isolation gown d. N95 respirator e. Shoe covers

a. "Chemo" gloves b. Facemask c. Isolation gown

A nurse teaches a client who has severe allergies to prevent bug bites. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Consult an exterminator to control bugs in and around your home." b. "Do not swat at insects or wasps." c. "Wear sandals whenever you go outside." d. "Keep your prescribed epinephrine auto-injector in a bedside drawer." e. "Use screens in your windows and doors to prevent flying insects from entering."

a. "Consult an exterminator to control bugs in and around your home." b. "Do not swat at insects or wasps." e. "Use screens in your windows and doors to prevent flying insects from entering."

Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective? a. "Converses with few interruptions; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech."

a. "Converses with few interruptions; clothing matches; participates in activities."

What teaching is essential for a client who has received an injection of iodine-131? a. "Do not share a toilet with anyone else or let anyone clean your toilet." b. "You need to save all your urine for the next week." c. "No special precautions are needed because this type of radiation is weak." d. "Avoid all contact with other people until the radiation device is removed."

a. "Do not share a toilet with anyone else or let anyone clean your toilet."

When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate? a. "Do you feel safe in your home?" b. "You should not return to your home." c. "Would you like to see a social worker?" d. "I need to report my concerns to the police."

a. "Do you feel safe in your home?"

A male client comes into the emergency department with a serum creatinine of 2.2 mg/dL and a blood urea nitrogen (BUN) of 24 mL/dL. What question should the nurse ask first when taking this client's history? a. "Have you been taking any aspirin, ibuprofen, or naproxen recently?" b. "Do you have anyone in your family with renal failure?" c. "Have you had a diet that is low in protein recently?" d. "Has a relative had a kidney transplant lately?"

a. "Have you been taking any aspirin, ibuprofen, or naproxen recently?"

A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement? a. "I always wear long sleeves, pants, and a hat when outdoors." b. "I try not to use cosmetics that contain any type of sunblock." c. "Since I tend to sweat a lot, I use a lot of baby powder." d. "Since I can't be exposed to the sun, I have been using a tanning bed."

a. "I always wear long sleeves, pants, and a hat when outdoors."

The nurse is caring for a client on a cardiac monitor. The monitor shows a rapid rhythm with a "saw tooth" configuration. What physical assessment findings does the nurse expect? a.Presence of a split S1 and wheezing b.Anorexia and gastric distress c.Shortness of breath and anxiety d.Hypertension and mental status changes

c.Shortness of breath and anxiety

A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis? a. "I am fat and ugly." b. "What I think about myself is my business." c. "I'm grossly underweight, but that's what I want." d. "I'm a few pounds overweight, but I can live with it."

a. "I am fat and ugly."

A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed? a. "I can go swimming all by myself because I am a certified lifeguard." b. "I cannot leave my toddler alone in the bathtub for even a minute." c. "I will appoint one adult to supervise the pool at all times during a party." d. "I will make sure that there is a phone near my pool in case of an emergency."

a. "I can go swimming all by myself because I am a certified lifeguard."

A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed? a. "I don't need to go to the hospital after using it." b. "I must carry two EpiPens with me at all times." c. "I will write the expiration date on my calendar." d. "This can be injected right through my clothes."

a. "I don't need to go to the hospital after using it."

The nurse is caring for a client admitted for myocardial infarction. The client's monitor shows frequent premature ventricular contractions (PVCs). What dysrhythmia does the nurse remain alert for? a.Sinus tachycardia b.Rapid atrial flutter c.Ventricular tachycardia d.Atrioventricular junctional rhythm

c.Ventricular tachycardia

The nurse is teaching nursing students about personal emergency preparedness. Which statement by a student indicates that further teaching is indicated? a. "I will get a prescription for antibiotics just in case I have to work in an area that has been infected with anthrax." b. "I should keep an extra uniform in my locker in case I get stuck at work." c. "I may be torn between caring for my young daughter and caring for victims at work." d. "I should make plans for my family to evacuate our house in case of tornado or earthquake."

a. "I will get a prescription for antibiotics just in case I have to work in an area that has been infected with anthrax."

The nurse is teaching a community health class about health promotion techniques. Which statement by a student indicates a strategy to help prevent the development of osteoarthritis? a. "I will keep my BMI under 24." b. "I will switch to low-tar cigarettes." c. "I will start jogging twice a week." d. "I will have a family tree done."

a. "I will keep my BMI under 24."

The nurse is caring for a young client who has acquired immune deficiency syndrome (AIDS) and a very low CD4+ cell count. The nurse is teaching the client how to avoid infection at home. Which statement by the client indicates that additional teaching is needed? a. "I will let my sister clean my pet iguana's cage from now on." b. "My brother will change the kitty litter box from now on." c. "It will seem funny but I'll run my toothbrush through the dishwasher." d. "I will not drink juice that has been sitting out for longer than an hour."

a. "I will let my sister clean my pet iguana's cage from now on."

A patient says, "I get in trouble sometimes because I make quick decisions and act on them." Select the nurse's most therapeutic response. a. "Let's consider the advantages of being able to stop and think before acting." b. "It sounds as though you've developed some insight into your situation." c. "I bet you have some interesting stories to share about overreacting." d. "It's good that you're showing readiness for behavioral change."

a. "Let's consider the advantages of being able to stop and think before acting."

A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this client's teaching? a. "Minimize or abstain from caffeine." b. "Lie on your side until the attack subsides." c. "Use your oxygen when you experience PACs." d. "Take amiodarone (Cordarone) daily to prevent PACs."

a. "Minimize or abstain from caffeine."

A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this client's teaching? a. "Minimize or abstain from caffeine." b. "Lie on your side until the attack subsides." c. "Use your oxygen when you experience PACs." d. "Take amiodarone (Cordarone) daily to prevent PACs."

a. "Minimize or abstain from caffeine."

The nurse is caring for a client with Ménière's disease. The client asks the nurse how to prevent another acute episode from occurring. Which is the nurse's best response? a. "Stop or reduce cigarette smoking." b. "Use aspirin rather than acetaminophen (Tylenol) for pain." c. "Reduce the quantity of saturated fats in your diet." d. "Avoid crowds and people with upper respiratory infection."

a. "Stop or reduce cigarette smoking."

A patient who has vague symptoms of fatigue, headaches, and a positive test for human immunodeficiency virus (HIV) antibodies using an enzyme immunoassay (EIA) test. What instructions should the nurse give to this patient? a. "The EIA test will need to be repeated to verify the results." b. "A viral culture will be done to determine the progression of the disease." c. "It will probably be 10 or more years before you develop acquired immunodeficiency syndrome (AIDS)." d. "The Western blot test will be done to determine whether acquired immunodeficiency syndrome (AIDS) has developed."

a. "The EIA test will need to be repeated to verify the results."

A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority? a. "The importance of taking your medication correctly" b. "How to complete an application for employment" c. "How to dress when attending community events" d. "How to give and receive compliments" e. "Ways to quit smoking"

a. "The importance of taking your medication correctly" e. "Ways to quit smoking"

A nurse asks a patient diagnosed with schizophrenia, "What is meant by the old saying 'You can't judge a book by looking at the cover.'?" Which response by the patient indicates concrete thinking? a. "The table of contents tells what a book is about." b. "You can't judge a book by looking at the cover." c. "Things are not always as they first appear." d. "Why are you asking me about books?"

a. "The table of contents tells what a book is about."

An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug? a. "Truvada does not reduce the need for safe sex practices." b. "This drug has been taken off the market due to increases in cancer." c. "Truvada reduces the number of HIV tests you will need." d. "This drug is only used for postexposure prophylaxis."

a. "Truvada does not reduce the need for safe sex practices."

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client's teaching? (Select all that apply.) a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)." e. "Do not lift your left arm above the level of your shoulder for 8 weeks."

a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." e. "Do not lift your left arm above the level of your shoulder for 8 weeks."

The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? a. "You are free to express your feelings; whatever is said here stays here." b. "Let's evaluate what went wrong and develop policies for future incidents." c. "This session is only for nursing and medical staff, not for ancillary personnel." d. "Let's pass around the written policy compliance form for everyone."

a. "You are free to express your feelings; whatever is said here stays here."

The hospital administration has arranged for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? a. "You are free to express your feelings; whatever is said here stays here." b. "Let's determine what we can do better the next time we have this situation." c. "This session is only for nursing and medical staff, not for ancillary personnel." d. "Let's pass around the written policy compliance form for everyone."

a. "You are free to express your feelings; whatever is said here stays here."

A patient hemorrhaging from an incision has a blood pressure of 70/0 mm Hg. What type of fluid replacement should the nurse anticipate will be ordered initially? a. 0.9 % normal saline b. Fresh frozen plasma c. Packed red blood cells d. Lactated Ringer's with 50 mL albumin

a. 0.9 % normal saline

One bed is available on the inpatient eating disorders unit. Which patient should be admitted to this bed? The patient whose weight decreased from: a. 150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9° C; pulse, 38 beats/min; blood pressure 60/40 mm Hg b. 120 to 90 pounds over a 3-month period. Vital signs are temperature, 36° C; pulse, 50 beats/min; blood pressure 70/50 mm Hg c. 110 to 70 pounds over a 4-month period. Vital signs are temperature 36.5° C; pulse, 60 beats/min; blood pressure 80/66 mm Hg d. 90 to 78 pounds over a 5-month period. Vital signs are temperature, 36.7° C; pulse, 62 beats/min; blood pressure 74/48 mm Hg

a. 150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9° C; pulse, 38 beats/min; blood pressure 60/40 mm Hg

The nurse would assess the individual in the most serious stage of shock as a a. 22-year-old man with a falling BP. b. 35-year-old woman with a pulse pressure of 40. c. 50-year-old woman with a MAP of 90. d. 60-year-old man with a pulse rate of 100.

a. 22-year-old man with a falling BP.

A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.) a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag

a. A 35-year-old female with severe chest pain: red tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag

The nurse is caring for a patient with leukopenia. Which item creates the greatest risk for this patient? a. A fresh apple brought in by a friend b. A can of soda from a vending machine c. A get-well card from a family member d. A paperback book purchased at the hospital gift shop

a. A fresh apple brought in by a friend

Following an earthquake, patients are triaged by emergency medical personnel and are transported to the emergency department (ED). Which patient will the nurse need to assess first? a. A patient with a red tag b. A patient with a blue tag c. A patient with a black tag d. A patient with a yellow tag

a. A patient with a red tag

Which sign or symptom is likely to be manifested by an adolescent with a depressive disorder? a. Abuse of alcohol b. Impulsivity and distractibility c. Carelessness and inattention to details d. Refusal to leave the house

a. Abuse of alcohol

A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching? a. Acetaminophen (Tylenol) b. Cyclobenzaprine hydrochloride (Flexeril) c. Hyaluronate (Hyalgan) d. Ibuprofen (Motrin)

a. Acetaminophen (Tylenol)

An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement? a. Administer dexamethasone (Decadron). b. Complete a mini-mental state examination. c. Prepare the client for computed tomography of the brain. d. Request a psychiatric consult.

a. Administer dexamethasone (Decadron).

An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c. Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcut from the PRN medication administration record.

a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record.

Which is the most critical element of pediatric emergency care? a. Airway management b. Prevention of neurologic impairment c. Maintaining adequate circulation d. Supporting the child's family

a. Airway management

A 70-kg adult with chronic renal failure is on a 40-g protein diet. The client has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would give the nurse the most concern? a. Albumin level of 2.5 g/dL b. Phosphorus level of 5 mg/dL c. Sodium level of 135 mmol/L d. Potassium level of 5.5 mmol/L

a. Albumin level of 2.5 g/dL

A client suffered an episode of anaphylaxis and has been stabilized in the intensive care unit. When assessing the client's lungs, the nurse hears the following sounds. What medication does the nurse prepare to administer?(Click the media button to hear the audio clip.) a. Albuterol (Proventil) via nebulizer b. Diphenhydramine (Benadryl) IM c. Epinephrine 1:10,000 5 mg IV push d. Methylprednisolone (Solu-Medrol) IV push

a. Albuterol (Proventil) via nebulizer

What should be the emergency department nurse's next action when a 6-year-old child has a systolic blood pressure of 58 mm Hg? a. Alert the physician about the systolic blood pressure. b. Comfort the child and assess respiratory rate. c. Assess the child's responsiveness to the environment. d. Alert the physician that the child may need intravenous fluids.

a. Alert the physician about the systolic blood pressure.

A nurse works on an oncology unit and delegates personal hygiene to an unlicensed assistive personnel (UAP). What action by the UAP requires intervention from the nurse? a. Allowing a very tired client to skip oral hygiene and sleep b. Assisting clients with washing the perianal area every 12 hours c. Helping the client use a soft-bristled toothbrush for oral care d. Reminding the client to rinse the mouth with water or saline

a. Allowing a very tired client to skip oral hygiene and sleep

A client is hospitalized for chemotherapy. The registered nurse intervenes when observing which action by the nursing assistant? a. Allowing the client to rest instead of making him or her perform oral hygiene b. Helping the client wash the groin and axillary areas every 12 hours c. Cutting food and opening food packages when the client's meal tray arrives d. Reminding the client to use the incentive spirometer every hour while awake

a. Allowing the client to rest instead of making him or her perform oral hygiene

A patient is experiencing delusions of persecution about being poisoned. The patient has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient? a. Allowing the patient supervised access to food vending machines b. Allowing the patient to phone a local restaurant to deliver meals c. Offering to taste each portion on the tray for the patient d. Providing tube feedings or total parenteral nutrition

a. Allowing the patient supervised access to food vending machines

Which action by the nurse is most effective to prevent becoming exposed to the human immune deficiency virus (HIV)? a. Always use Standard Precautions with all clients in the workplace. b. Place clients who are HIV positive in Contact Precautions. c. Wash hands before and after contact with clients who are HIV positive. d. Convert parenteral medications to an oral form for clients who are HIV positive.

a. Always use Standard Precautions with all clients in the workplace.

The nurse is reviewing laboratory results and becomes concerned about one patient being treated for cancer. Which patient does the nurse suspect is in need of nutritional support? a. An 18-year-old with an albumin of 2.5 b. A 60-year-old with a calcium level of 8 mg/dL c. A 43-year-old with a platelet level of 180,000/mm3 d. A 56-year-old with a white cell count of 6000/mm3

a. An 18-year-old with an albumin of 2.5

The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest? a. Anal intercourse b. Masturbation c. Oral sex d. Vaginal intercourse

a. Anal intercourse

The nurse questions which activity for the client with thrombocytopenia? a. Application of warm compresses to bruises b. Cleaning teeth with a soft-bristled brush c. Taking acetaminophen (Tylenol) for pain d. Using stool softeners daily for constipation

a. Application of warm compresses to bruises

A client on interferon therapy is reporting severe skin itching and irritation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply moisturizers to dry skin. b. Apply steroid creams to the skin. c. Bathe the client using mild soap. d. Help the client with a hot water bath. e. Teach the client to avoid sunlight.

a. Apply moisturizers to dry skin. c. Bathe the client using mild soap.

A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply the client's shoes before getting the client out of bed. b. Assist the client with ambulation. c. Shave the client with a safety razor only. d. Use a lift sheet to move the client up in bed. e. Use the Waterpik on a low setting for oral care.

a. Apply the client's shoes before getting the client out of bed. b. Assist the client with ambulation. d. Use a lift sheet to move the client up in bed.

A client's family members are concerned that telling the client about a new finding of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the client. What actions by the nurse are most appropriate? (Select all that apply.) a. Ask the family to describe their concerns more fully. b. Consult with a social worker, chaplain, or ethics committee. c. Explain the client's right to know and ask for their assistance. d. Have the unit manager take over the care of this client and family. e. Tell the family that this secret will not be kept from the client.

a. Ask the family to describe their concerns more fully. b. Consult with a social worker, chaplain, or ethics committee. c. Explain the client's right to know and ask for their assistance.

A client with acquired immune deficiency syndrome (AIDS) is hospitalized with Pneumocystis jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values should the nurse report to the provider as a priority? (Select all that apply.) a. Aspartate transaminase, alanine transaminase: elevated b. CD4+ cell count: 180/mm3 c. Creatinine: 1.0 mg/dL d. Platelet count: 80,000/mm3 e. Serum sodium: 120 mEq/L

a. Aspartate transaminase, alanine transaminase: elevated d. Platelet count: 80,000/mm3 e. Serum sodium: 120 mEq/L

A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first? a. Assess airway, breathing, and level of consciousness. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).

a. Assess airway, breathing, and level of consciousness.

A client receiving chemotherapy has a white blood cell count of 1000/mm3. What actions by the nurse are most appropriate? (Select all that apply.) a. Assess all mucous membranes every 4 to 8 hours. b. Do not allow the client to eat meat or poultry. c. Listen to lung sounds and monitor for cough. d. Monitor the venous access device appearance with vital signs. e. Take and record vital signs every 4 to 8 hours.

a. Assess all mucous membranes every 4 to 8 hours. c. Listen to lung sounds and monitor for cough. d. Monitor the venous access device appearance with vital signs. e. Take and record vital signs every 4 to 8 hours.

A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best? a. Assess medication records for steroid use. b. Facilitate a consultation with physical therapy. c. Measure the range of motion in both hips. d. Notify the health care provider immediately.

a. Assess medication records for steroid use.

A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best? a. Assess the client for support systems. b. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.

a. Assess the client for support systems.

A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started "acting up," especially both hips and knees. What action by the nurse is best? a. Assess the client for the presence of subcutaneous nodules or Baker's cysts. b. Inspect the client's feet and hands for podagra and tophi on fingers and toes. c. Prepare to teach the client about an acetaminophen (Tylenol) regimen. d. Reassure the client that the problems will fade as the weather changes again.

a. Assess the client for the presence of subcutaneous nodules or Baker's cysts.

A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best? a. Assess the client's culture more thoroughly. b. Discuss options for performing duties. c. See if the client will call a community meeting. d. Suggest the client give up the role of elder.

a. Assess the client's culture more thoroughly.

The nurse has completed a seminar teaching a group in the community about ways to reduce cancer risks. The nurse returns a month later to evaluate the effectiveness of the seminar. Which statements made by members of the group indicate retention and application of the material presented by the nurse to reduce the risk of developing cancer? A) "I stopped using tanning booths." B) "I have reduced my intake of fiber." C) "I have increased the amount of lean red meat in my diet." D) "I began drinking two glasses of red wine a day with dinner."

A) "I stopped using tanning booths."

The nurse instructs a group of community members on the difference between benign and malignant neoplasms. Which participant statements indicate that teaching has been effective? Select all that apply. A) "Malignant tumors can grow back." B) "Benign tumors stay in one area." C) "Benign tumors grow slowly." D) "Malignant tumors are easy to remove." E) "Malignant tumors push other tissue out of the way."

A) "Malignant tumors can grow back." B) "Benign tumors stay in one area." C) "Benign tumors grow slowly." D) "Malignant tumors are easy to remove."

The nurse is caring for a patient with leukemia. Which treatment should the nurse expect to be prescribed? A) Chemotherapy B) IV fluid therapy C) Diuretic therapy D) Electrolyte replacement therapy

A) Chemotherapy

The nurse is caring for a thin, older adult patient who is diagnosed with cancer and is receiving aggressive chemotherapy. The patient is experiencing severe side effects from the therapy and has lost 10 pounds in the past week. What should the nurse teach the patient to do? Select all that apply. A) Keep a food diary and record intake. B) Purchase fast foods and prepared foods. C) Eat small frequent meals high in calories. D) Drink liquid supplements to increase intake of nutrients. E) Eat cold foods rather than hot foods, because they are better tolerated.

A) Keep a food diary and record intake. C) Eat small frequent meals high in calories. D) Drink liquid supplements to increase intake of nutrients. E) Eat cold foods rather than hot foods, because they are better tolerated.

The nurse is caring for a patient who is diagnosed with cancer. Which diagnostic tests may be helpful to assist with treatment options? Select all that apply. A) MRI B) Urinalysis C) Stool analysis D) Tumor markers E) Physical assessment

A) MRI B) Urinalysis D) Tumor markers

During a treatment meeting on an oncology unit, the nurse learns that a patient is scheduled for chemotherapy before surgery. What are the purposes for this patient to receive chemotherapy at this specific time? A) Shrink the tumor B) Improve wound healing C) Eradicate all cancer cells D) Allow the immune system to kill cancer cells

A) Shrink the tumor

The nurse is planning care for a patient with osteoarthritis (OA). On what should the nurse focus when preparing teaching material for this patient? Select all that apply. A) Weight management B) Nonsteroidal therapy C) Activity modification D) Joint replacement surgery E) Glucosamine and chondroitin

A) Weight management B) Nonsteroidal therapy C) Activity modification E) Glucosamine and chondroitin

A parent of a child suspected of having systemic lupus erythematosus (SLE) asks why so many blood tests are being done. Which response by the nurse is the most appropriate? A. "Many of these blood tests look for possible organ damage from SLE." B. "SLE is a complicated disorder and is very hard to diagnose." C. "This is a very typical pattern of diagnostic blood tests we usually do." D. "We are also checking for other possible autoimmune diseases."

A. "Many of these blood tests look for possible organ damage from SLE."

A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states "Whew! I was really worried about that result." What action by the nurse is most important? a. Assess the client's sexual activity and patterns. b. Express happiness over the test result. c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months.

a. Assess the client's sexual activity and patterns.

The nurse is caring for a client who had a near-drowning incident in a lake. Which action will the nurse take to monitor for possible complications? a. Assess the client's temperature every 4 hours. b. Check the client's blood glucose level before meals. c. Assess the client's bowel sounds three times daily. d. Check the client's skin for petechiae daily.

a. Assess the client's temperature every 4 hours.

A client hospitalized for a wound infection has a blood urea nitrogen of 45 mg/dL and creatinine of 4.2 mg/dL. What action by the nurse is best? a. Assess the ordered antibiotics for ototoxicity. b. Explain how kidney damage causes hearing loss. c. Use ibuprofen (Motrin) for pain control. d. Teach that hearing loss is temporary.

a. Assess the ordered antibiotics for ototoxicity.

A faculty member is discussing systemic lupus erythematosus (SLE) with a group of nursing students. Which pathophysiological process does the nurse describe as the major problem in this disorder? A. Autoimmune process creates antigen-antibody complexes that damage tissues B. Genetic defect linked strictly to male offspring leading to organ damage C. Limited autoimmune process destroys tissues in specific target organs D. Rapidly progressive disease triggered by hormonal changes such as pregnancy

A. Autoimmune process creates antigen-antibody complexes that damage tissues

A client has frequent hospitalizations for leukemia and is worried about functioning as a parent to four small children. What action by the nurse would be most helpful? a. Assist the client to make "sick day" plans for household responsibilities. b. Determine if there are family members or friends who can help the client. c. Help the client inform friends and family that they will have to help out. d. Refer the client to a social worker in order to investigate respite child care.

a. Assist the client to make "sick day" plans for household responsibilities.

A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking a mood stabilizing medication. What is the priority nursing intervention for the patient as well as the patient's family during this phase of treatment? a. Attending psychoeducation sessions b. Decreasing physical activity c. Increasing food and fluids d. Meeting self-care needs

a. Attending psychoeducation sessions

The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are being met? a. Attends meetings of a book club b. Has a positive outlook on life c. Takes medication as directed d. Uses assistive devices to protect joints

a. Attends meetings of a book club

which statement best describes how a cataract affects a child's vision? A. it prevents a clear image from forming on the retina B. it increases intraocular pressure C. it alters the ability to distinguish among various colors D. it causes double vision

A. it prevents a clear image from forming on the retina

a parent whose child has been diagnosed with a cognitive deficit should be counseled that intellectual impairment A. may be caused by a variety of factors B. is usually caused by parental intellectual impairment C. is rarely due to first trimester events D. is usually due to a genetic defect

A. may be caused by a variety of factors

the nurse is preparing teaching materials for a group of older adults. what information does the nurse include as risk factors for hearing loss? select all that apply A. occupational noise B. heredity C. medications D. smoking history E. recreational noise

A. occupational noise B. heredity C. medications E. recreational noise

what is the goal of therapeutic management for a child diagnosed with ADHD? A. reduce frequency/intensity of characteristic behaviors B. assess the child for other psychosocial disorders c. administer stimulant medications or adjuvant therapy d. correct nutritional imbalances causing this disorder

A. reduce frequency/intensity of characteristic behaviors

what should be the major consideration when selecting toys for a child with an intellectual or developmental disability? A. safety B. ability to provide exercise C. ability to teach useful skills D. age appropriateness

A. safety

what findings should cause the nurse to suspect a diagnosis of spastic cerebral palsy? A. sudden jerking movement caused by stimuli B. clumsy, uncoordinated movements C. writhing, uncontrolled, involuntary movements D. uncontrolled tremors at rest and with activity

A. sudden jerking movement caused by stimuli

the correct position for the postoperative child or adult who has had a cataract removed from the right eye is the _____ position A. supine with head elevated B. right lateral sims C. knee-chest D. prone without pillow

A. supine with head elevated

which manifestation is typical of ADHD? A. talking incessantly B. acting withdrawn in social situations C. fidgeting with hands or feet D. blurting out answers to questions in class

A. talking incessantly C. fidgeting with hands or feet D. blurting out answers to questions in class

A child with acute myeloblastic leukemia is scheduled to have a bone marrow transplant (BMT). The donor is the child's own umbilical cord blood that had been previously harvested and banked. This type of BMT is termed a. Autologous b. Allogeneic c. Syngeneic d. Stem cell

a. Autologous

the nurse is assessing a 3 year old child who has characteristics of autism. which observed behaviors are associated with autism? select all that apply A. the child has a flat affect B. the child flicks the light in the examination room on and off repetitiously C. the child is able to make eye contact D. the child demonstrates imitation and gesturing skills E. the mother reports the child has no interest in playing with other children

A. the child has a flat affect B. the child flicks the light in the examination room on and off repetitiously E. the mother reports the child has no interest in playing with other children

which interventions should the nurse plan when caring for a child with a hearing loss? select all that apply A. use visual aids B. eliminate background noise C. speak loudly D. speak slowly E. have the child's full attention

A. use visual aids B. eliminate background noise D. speak slowly E. have the child's full attention

a middle aged patient is experiencing tinnitus. what does the nurse suggest to help determine the reason for this health problem? A. write down what you are doing when the noises occur B. sleep a few extra hours each night C. encourage the use of earbuds to decrease background noise D. reduce fluid intake after 1800 hours

A. write down what you are doing when the noises occur

A client has a hearing aid. What care instructions does the nurse provide the unlicensed assistive personnel (UAP) in the care of this client? (Select all that apply.) a. Be careful not to drop the hearing aid when handling. b. Soak the hearing aid in hot water for 20 minutes. c. Turn the hearing aid off when the client goes to bed. d. Use a toothpick to clean debris from the device. e. Wash the device with soap and a small amount of warm water.

a. Be careful not to drop the hearing aid when handling. c. Turn the hearing aid off when the client goes to bed. d. Use a toothpick to clean debris from the device. e. Wash the device with soap and a small amount of warm water.

The nurse is preparing to teach a patient about the effects of chemotherapy on other body tissues. What should the nurse explain as the reason why hair, blood, skin, and gastrointestinal (GI) tract cells are more likely to be adversely affected by chemotherapy than other cells? a. Because they are fast growing b. Because they are exposed to air c. Because they are all porous tissues d. Because they are less able to excrete waste products

a. Because they are fast growing

A patient in shock has a falling blood pressure. What should the nurse realize occurs as the sympathetic nervous system responds to falling blood pressure? (Select all that apply.) a. Blood glucose levels increase. b. Sodium and water are retained. c. Less oxygen is delivered to tissues. d. Vasodilation leads to increased fluid loss. e. Epinephrine is released from the adrenal medulla. f. Blood is shunted away from the skin, kidneys, and intestines.

a. Blood glucose levels increase. b. Sodium and water are retained. e. Epinephrine is released from the adrenal medulla. f. Blood is shunted away from the skin, kidneys, and intestines.

A client with advanced cancer is being treated with intravenous mithramycin (Mithracin). Which clinical manifestation indicates that the treatment is effective? a. Bowel sounds are active in all four quadrants. b. The client's serum sodium level is 138 mEq/L. c. The pulse rate is 68 beats/min and bounding. d. Urine output has increased to 30 mL/hr.

a. Bowel sounds are active in all four quadrants.

Which symptom should a nurse recognize as being pertinent to a possible diagnosis of systemic lupus erythematosus (SLE)? a. Butterfly rash of the face b. Protruding abdomen c. Thinning hair d. Bloody diarrhea

a. Butterfly rash of the face

Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 or less than 14% b. Infection with Pneumocystis jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) d. Presence of HIV wasting syndrome e. Taking antiretroviral medications

a. CD4+ cell count less than 200/mm3 or less than 14% b. Infection with Pneumocystis jiroveci d. Presence of HIV wasting syndrome

The nurse understands the most significant laboratory study for the client who is HIV positive is the a. CD4+ cell count. b. enzyme-linked immunosorbent assay (ELISA) test. c. total white blood cell count. d. Western blot test.

a. CD4+ cell count.

A client has a platelet count of 9000/mm3. The nurse finds the client confused and mumbling. What action takes priority? a. Calling the Rapid Response Team b. Delegating taking a set of vital signs c. Instituting bleeding precautions d. Placing the client on bedrest

a. Calling the Rapid Response Team

The nurse is caring for an 85-year-old patient with septic shock. What should the nurse keep in mind when repositioning this patient? a. Change positions slowly. b. Reduce flow rate of oxygen. c. Increase flow rate of IV fluids. d. Place in Trendelenburg position.

a. Change positions slowly.

The nurse is preparing to administer a medication when the client states, "I'm allergic to that." How will the nurse proceed? (Select all that apply.) a. Check the chart for allergies. b. Notify the health care provider. c. Ask what reaction the client gets. d. Continue to give the medication. e. Perform a skin test first. f. Notify the pharmacist. g. Document the allergy on the chart.

a. Check the chart for allergies. b. Notify the health care provider. c. Ask what reaction the client gets f. Notify the pharmacist. g. Document the allergy on the chart.

A nurse works in an allergy clinic. What task performed by the nurse takes priority? a. Checking emergency equipment each morning b. Ensuring informed consent is obtained as needed c. Providing educational materials in several languages d. Teaching clients how to manage their allergies

a. Checking emergency equipment each morning

A student studying leukemias learns the risk factors for developing this disorder. Which risk factors does this include? (Select all that apply.) a. Chemical exposure b. Genetically modified foods c. Ionizing radiation exposure d. Vaccinations e. Viral infections

a. Chemical exposure c. Ionizing radiation exposure e. Viral infections

Which statement about suicide is correct? a. Children younger than 10 years of age do not attempt suicide. b. Suicide risk decreases with age. c. Suicide is usually an isolated event in a school community. d. The prevalence of suicide attempts is higher among males.

a. Children younger than 10 years of age do not attempt suicide.

A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the prevention of perinatal HIV transmission? (Select all that apply.) a. Clean drinking water b. Cultural beliefs about illness c. Lack of antiviral medication d. Social stigma e. Unknown transmission routes

a. Clean drinking water b. Cultural beliefs about illness c. Lack of antiviral medication d. Social stigma

A hospital is receiving large numbers of casualties from a disaster. Which clients does the supervisor identify as appropriate for discharge or transfer to another facility? (Select all that apply.) a. Client who had open reduction and internal fixation of a femur fracture 3 days ago b. Client who had a colostomy 4 days ago and whose daughter is a registered nurse c. Client admitted last night with community-acquired pneumonia d. Infant admitted 2 days ago for fever of unknown origin e. Client in the medical decision unit for evaluation of chest pain

a. Client who had open reduction and internal fixation of a femur fracture 3 days ago b. Client who had a colostomy 4 days ago and whose daughter is a registered nurse

A nurse is caring for four clients with leukemia. After hand-off report, which client should the nurse see first? a. Client who had two bloody diarrhea stools this morning b. Client who has been premedicated for nausea prior to chemotherapy c. Client with a respiratory rate change from 18 to 22 breaths/min d. Client with an unchanged lesion to the lower right lateral malleolus

a. Client who had two bloody diarrhea stools this morning

A primary care clinic sees some clients with sexually transmitted diseases. Which clients would the nurse be required to report to the local authority in every state, according to the Centers for Disease Control and Prevention? (Select all that apply.) a. Client with Chlamydia b. Woman with gonorrhea c. Man with syphilis d. Client with human immune deficiency virus e. Female with pelvic inflammatory disease

a. Client with Chlamydia b. Woman with gonorrhea c. Man with syphilis d. Client with human immune deficiency virus

A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first? a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4° F (39.1° C) b. Client with Bruton's agammaglobulinemia who is waiting for discharge teaching c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia

a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4° F (39.1° C)

A nursing student studying the auditory system learns about the structures of the inner ear. What structures does this include? (Select all that apply.) a. Cochlea b. Epitympanum c. Organ of Corti d. Semicircular canals e. Vestibule

a. Cochlea c. Organ of Corti d. Semicircular canals e. Vestibule

An emergency department nurse is making a general appearance assessment on a preschool child just admitted to the emergency department. Which general assessment findings indicate the child "looks bad"? Select all that apply. a. Color pale b. Capillary refill less than 2 seconds c. Unwilling to separate from parents d. Cold extremities e. Lethargic

a. Color pale d. Cold extremities e. Lethargic

A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the "AIDS guy" and wondering how the client contracted the disease. What action by the nurse is best? a. Confront the staff members about unethical behavior. b. Ignore the behavior; they will stop on their own soon. c. Report the behavior to the unit's nursing management. d. Tell the client that other staff members are talking about him or her.

a. Confront the staff members about unethical behavior.

The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands "HIV+" d. Wearing a mask within 3 feet of the client

a. Consistent use of Standard Precautions

A client with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important? a. Consult with the pharmacy about drug interactions. b. Ensure that the client understands the new medications. c. Give the new drugs without considering the old ones. d. Schedule all medications at standard times.

a. Consult with the pharmacy about drug interactions.

A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The client's partner is listed as the emergency contact, but the client's mother insists that she should be listed instead. What action by the nurse is best? a. Contact the social worker to assist the client with advance directives. b. Ignore the mother; the client does not want her to be involved. c. Let the client know, gently, that nurses cannot be involved in these disputes. d. Tell the client that, legally, the mother is the emergency contact.

a. Contact the social worker to assist the client with advance directives.

The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan (select all that apply)? a. Continue taking antibiotics until all the medication is gone. b. Antibiotics may sometimes be prescribed to prevent infection. c. Unused antibiotics that are more than a year old should be discarded. d. Antibiotics are effective in treating influenza associated with high fevers. e. Hand washing is effective in preventing many viral and bacterial infections.

a. Continue taking antibiotics until all the medication is gone. b. Antibiotics may sometimes be prescribed to prevent infection. e. Hand washing is effective in preventing many viral and bacterial infections.

The nurse is caring for a client diagnosed with human immune deficiency virus. The client's CD4+ cell count is 399/mm3. What action by the nurse is best? a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals.

a. Counsel the client on safer sex practices/abstinence.

The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further? a. Creatinine: 3.9 mg/dL b. Platelet count: 210,000/mm3 c. Red blood cell count: 5.2/mm3 d. White blood cell count: 4400/mm3

a. Creatinine: 3.9 mg/dL

A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output

a. Decrease in cardiac output d. Increase in blood pressure e. Decrease in urine output

A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output

a. Decrease in cardiac output d. Increase in blood pressure e. Decrease in urine output

Which dietary modification is appropriate for a child with chronic renal failure? a. Decreased protein b. Decreased fat c. Increased potassium d. Increased phosphorus

a. Decreased protein

While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. Which action should the nurse take first? a. Deliver rescue breaths. b. Wrap the client in dry blankets. c. Assess for signs of bleeding. d. Check for a carotid pulse.

a. Deliver rescue breaths.

The spouse of an older male patient is concerned because since retiring the patient sits around the house, avoids eating, naps, and refuses to participate in sporting activities. Which disorder should the nurse recognize as being associated with these manifestations? a. Depression b. Bipolar disorder c. Conversion disorder d. Post-traumatic stress disorder (PTSD)

a. Depression

You are the nurse working triage in the emergency department. A school-age child is brought in for treatment, carried by her mother. What is part of a primary assessment that should be performed first on this child? a. Determine level of consciousness. b. Obtain a health history. c. Obtain a full set of vital signs. d. Evaluate for pain.

a. Determine level of consciousness.

The nurse is monitoring a patient with AIDS. Which manifestation should the nurse expect to observe in this patient? a. Diarrhea b. Chest pain c. Hypertension d. Pustular skin lesions

a. Diarrhea

A 42-year-old woman with Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? a. Dim the lights in the patient's room. b. Encourage increased oral fluid intake. c. Change the patient's position every 2 hours. d. Keep the head of the bed elevated 30 degrees.

a. Dim the lights in the patient's room.

A wing of a hospital is on fire. Which actions by the nurse promote safe evacuation of clients? (Select all that apply.) a. Direct ambulatory clients on where to go to be safe. b. Use ambulatory clients to help push clients in wheelchairs. c. Use oxygen tanks for all clients who are on oxygen. d. Manually ventilate clients who are on ventilators. e. Move bedridden clients in their beds if possible.

a. Direct ambulatory clients on where to go to be safe. b. Use ambulatory clients to help push clients in wheelchairs. d. Manually ventilate clients who are on ventilators. e. Move bedridden clients in their beds if possible.

A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select? a. Distraction: "Let's go to the dining room for a snack." b. Humor: "How much are you paying servants these days?" c. Limit setting: "You must stop ordering other patients around." d. Honest feedback: "Your controlling behavior is annoying others."

a. Distraction: "Let's go to the dining room for a snack."

A client had proxymetacaine (Ocu-Caine) instilled in one eye in the emergency department. What discharge instruction is most important? a. Do not touch or rub the eye until it is no longer numb. b. Monitor the eye for any bleeding for the next day. c. Rinse the eye with warm saline solution at home. d. Use all the eyedrops as prescribed until they are gone.

a. Do not touch or rub the eye until it is no longer numb.

The nurse is caring for a client with leukemia who has the priority problem of fatigue. What action by the client best indicates that an important goal for this problem has been met? a. Doing activities of daily living (ADLs) using rest periods b. Helping plan a daily activity schedule c. Requesting a sleeping pill at night d. Telling visitors to leave when fatigued

a. Doing activities of daily living (ADLs) using rest periods

A client presents to the emergency department after prolonged exposure to the cold. The client is shivering, has slurred speech, and is slow to respond to questions. Which treatment will the nurse prepare for this client? a. Dry clothing and warm blankets b. Administration of warmed IV fluids c. Peritoneal lavage with warmed normal saline d. Continuous arteriovenous rewarming

a. Dry clothing and warm blankets

The nurse is working with clients who have connective tissue diseases. Which disorders are correctly paired with their manifestations? (Select all that apply.) a. Dry, scaly skin rash - Systemic lupus erythematosus (SLE) b. Esophageal dysmotility - Systemic sclerosis c. Excess uric acid excretion - Gout d. Footdrop and paresthesias - Osteoarthritis e. Vasculitis causing organ damage - Rheumatoid arthritis

a. Dry, scaly skin rash - Systemic lupus erythematosus (SLE) b. Esophageal dysmotility - Systemic sclerosis e. Vasculitis causing organ damage - Rheumatoid arthritis

A patient with gastrointestinal bleeding has hemoglobin of 8.5 g/dL. While receiving care the patient becomes anxious and irritable and bright red drainage appears through the nasogastric tube. The patient's vital sign measurements are pulse 130 beats/minute, blood pressure 105/55 mm Hg, and respirations 28/minute. What should the nurse recognize as causing the changes in the patient's vital signs? a. Early shock b. Patient anxiety c. Progressive shock d. Parasympathetic response

a. Early shock

The nurse has been discussing actions to prevent AIDS-related wasting syndrome with a patient being treated for AIDS. Which patient statements indicate an understanding of this teaching? (Select all that apply.) a. Eat a low-residue diet. b. Drink liquids before meals. c. Enjoy food odors to stimulate appetite. d. Numb painful oral sores with ice or popsicles. e. Eat three high-calorie, high-protein meals a day, plus snacks. f. Increase consumption of caffeine-containing foods and fluids.

a. Eat a low-residue diet. d. Numb painful oral sores with ice or popsicles. e. Eat three high-calorie, high-protein meals a day, plus snacks.

A client is receiving high-dose chemotherapy for multiple myeloma. Which intervention is most important for the nurse to implement to prevent complications during chemotherapy? a. Ensure that the client's fluid intake is 3000 to 5000 mL/day. b. Monitor telemetry every hour during therapy. c. Apply pressure to all injection sites for 5 minutes. d. Assist the client in all ambulatory activities.

a. Ensure that the client's fluid intake is 3000 to 5000 mL/day.

A patient is diagnosed with a blood disorder after receiving chemotherapy. Which colony-stimulating drugs should the nurse expect might be prescribed to help treat this disorder? (Select all that apply.) a. Filgrastim (Neupogen) b. Pegfilgrastim (Neulasta) c. Hydroxyurea (Hydrea) d. Epoetin alfa (Epogen) e. Exemestane (Casodex) f. Irinotecan (Camptosar)

a. Filgrastim (Neupogen) b. Pegfilgrastim (Neulasta) d. Epoetin alfa (Epogen)

In evaluating dietary teaching for a client with chemotherapy-induced neutropenia, the nurse becomes concerned when the client makes which food choice? a. Fruit salad b. Applesauce c. Steamed broccoli d. Baked potato

a. Fruit salad

A parent of a child with an anxiety disorder states, "I don't know how my child developed this problem." On what information should the nurse base a response? a. Genetic factors, hormonal imbalances, and societal influences all contribute to the development of anxiety disorders in children. b. Like many conditions affecting children, the etiology of anxiety disorders is unknown. c. The majority of anxiety disorders have a clear pattern of genetic inheritance. d. Dysfunctional family patterns are usually identified as the cause of an anxiety disorder.

a. Genetic factors, hormonal imbalances, and societal influences all contribute to the development of anxiety disorders in children.

A marathon runner comes into the clinic and states "I have not urinated very much in the last few days." The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is the priority? a. Give the client a bottle of water immediately. b. Start an intravenous line for fluids. c. Teach the client to drink 2 to 3 liters of water daily. d. Perform an electrocardiogram.

a. Give the client a bottle of water immediately.

A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.) a. Grab bars to reach high items b. Long-handled bath scrub brush c. Soft rocker-recliner chair d. Toothbrush with built-up handle e. Wheelchair cushion for comfort

a. Grab bars to reach high items b. Long-handled bath scrub brush d. Toothbrush with built-up handle

A nurse has delegated applying a warm compress to a client's eye. What actions by the unlicensed assistive personnel (UAP) warrant intervention by the nurse? (Select all that apply.) a. Heating the wet washcloth in the microwave b. Holding the cloth on the client using an Ace wrap c. Turning the cloth so it remains warm on the client d. Using a clean washcloth for the compress e. Washing the hands on entering the client's room

a. Heating the wet washcloth in the microwave b. Holding the cloth on the client using an Ace wrap

The nurse is caring for a client with HIV who has been prescribed didanosine (Videx EC). Which action by the nurse is most appropriate? a. Help the client plan specific meal and dosing times. b. Explain that the client will have frequent complete blood counts (CBCs) drawn. c. Advise the client to take Videx EC with milk or a small meal. d. Tell the client to take Tylenol (acetaminophen) for any abdominal pain.

a. Help the client plan specific meal and dosing times.

The nurse cares for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)? a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin

a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine

After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective? a. Increase in the patient's heart rate b. Increase in strength of peripheral pulses c. Decrease in premature atrial contractions d. Decrease in premature ventricular contractions

a. Increase in the patient's heart rate

The nurse determines that a patient with severely bleeding wounds does not have an adequate airway. What should the nurse do to help this patient? (Select all that apply.) a. Insert an oral airway. b. Insert a nasal airway. c. Apply 100% oxygen via face mask. d. Prepare for endotracheal intubation. e. Attempt the head tilt/chin lift method.

a. Insert an oral airway. b. Insert a nasal airway. d. Prepare for endotracheal intubation. e. Attempt the head tilt/chin lift method.

A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberden's nodules. What assessment technique is correct? a. Inspect the client's distal finger joints. b. Palpate the client's abdomen for tenderness. c. Palpate the client's upper body lymph nodes. d. Perform range of motion on the client's wrists.

a. Inspect the client's distal finger joints.

A school-age child is diagnosed with systemic lupus erythematosus (SLE). The nurse should plan to implement which interventions for this child? (Select all that apply.) a. Instructions to avoid exposure to sunlight b. Teaching about body changes associated with SLE c. Preparation for home schooling d. Restricted activity

a. Instructions to avoid exposure to sunlight b. Teaching about body changes associated with SLE

An assessment of a 7-month-old infant with a hemoglobin level of 6.5 mg/dL is likely to reveal an infant who is a. Lethargic, pale, and irritable b. Thin, energetic, and sleeps little c. Anorexic, vomiting, and has watery stools d. Flushed, fussy, and tired

a. Lethargic, pale, and irritable

Which suggestions are appropriate for the family of a patient diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? Select all that apply. a. Limit credit card access. b. Provide a structured environment. c. Encourage group social interaction. d. Suggest limiting work to half-days. e. Monitor the patient's sleep patterns.

a. Limit credit card access. b. Provide a structured environment. e. Monitor the patient's sleep patterns.

A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the client's spouse about the kidney-specific formulation for the enteral solution compared to standard formulas. What components should be discussed in the teaching plan? (Select all that apply.) a. Lower sodium b. Higher calcium c. Lower potassium d. Higher phosphorus e. Higher calories

a. Lower sodium c. Lower potassium e. Higher calories

A nurse is conducting a community education class on cancer risk. The nurse knows that teaching has been effective when women recognize that they are most at risk of dying of which type of cancer? a. Lung cancer b. Breast cancer c. Uterine cancer d. Ovarian cancer

a. Lung cancer

A child who has symptoms of irritable mood, changes in sleep and appetite patterns, decreased self-esteem, and disengagement from family and friends lasting 3 weeks meets the criteria for which depressive disorder? a. Major depressive disorder b. Dysthymic disorder c. Cyclothymic disorder d. Panic disorder

a. Major depressive disorder

The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for post-renal acute kidney injury (AKI)? (Select all that apply.) a. Man with prostate cancer b. Woman with blood clots in the urinary tract c. Client with ureterolithiasis d. Firefighter with severe burns e. Young woman with lupus

a. Man with prostate cancer b. Woman with blood clots in the urinary tract c. Client with ureterolithiasis

An older adult who takes medications for coronary artery disease has just been diagnosed with asymptomatic chronic human immunodeficiency virus (HIV) infection. Which information will the nurse include in patient teaching? a. Many medications have interactions with antiretroviral drugs. b. Less frequent CD4+ level monitoring is needed in older adults. c. Hospice care is available for patients with terminal HIV infection. d. Progression of HIV infection occurs more rapidly in older patients.

a. Many medications have interactions with antiretroviral drugs.

A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge? a. Medication reconciliation b. Immunization history c. Religious beliefs d. Nutrition preferences

a. Medication reconciliation

A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave

a. Mid-sternal chest pain

A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave

a. Mid-sternal chest pain

Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown? a. Needle stick with a needle and syringe used to draw blood b. Splash into the eyes when emptying a bedpan containing stool c. Contamination of open skin lesions with patient vaginal secretions d. Needle stick injury with a suture needle during a surgical procedure

a. Needle stick with a needle and syringe used to draw blood

The nurse obtains vital signs on a patient with gastrointestinal bleeding who has a large, dark red, foul-smelling stool. Which vital sign changes should the nurse report as indicative of early shock? a. Normal blood pressure, tachycardia, and rapid respirations b. Rise in diastolic blood pressure, bradycardia, and slow respirations c. Decreasing systolic blood pressure, bradycardia, and slow respirations d. Drop in diastolic blood pressure, bradycardia, and shallow respirations

a. Normal blood pressure, tachycardia, and rapid respirations

A client with rheumatoid arthritis had abdominal surgery and has returned to the postoperative nursing unit. The client is unable to use the incentive spirometer correctly, demonstrating limited lung volume and fatiguing easily. What action by the nurse takes priority? a. Notify the physician immediately. b. Have respiratory therapy re-instruct the client. c. Assess for pain and medicate if necessary. d. Let the client rest for a few hours.

a. Notify the physician immediately.

For which patients diagnosed with personality disorders would a family history of similar problems be most likely? Select all that apply. a. Obsessive-compulsive b. Antisocial c. Borderline d. Schizotypal e. Narcissistic

a. Obsessive-compulsive b. Antisocial c. Borderline d. Schizotypal

A patient diagnosed with major depression shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply. a. Offer laxatives if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict intake of processed foods.

a. Offer laxatives if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment.

A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention by the nurse is most beneficial? a. Offer the family choices as appropriate and possible. b. Call the hospital chaplain to stay with the family. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family.

a. Offer the family choices as appropriate and possible.

The nurse working with survivors of a disaster wants to assess them for post-traumatic stress disorder. For which clients does the nurse perform further assessment before administering the Impact of Event Scale-Revised?(Select all that apply.) a. Older adult survivor with minor injuries b. Woman who lost both her children c. Middle-aged victim with multiple medical problems d. Young adult who had serious orthopedic injuries e. Older adolescent who had a traumatic brain injury

a. Older adult survivor with minor injuries e. Older adolescent who had a traumatic brain injury

The nurse is reinforcing teaching on the rising incidence of HIV in adults over the age of 50 with a group of senior community members. Which factors should the nurse include? (Select all that apply.) a. Older adults are less likely to use condoms than younger at-risk adults. b. At-risk individuals over the age of 50 are less likely to be tested for HIV. c. Society continues to age with larger numbers of people entering this age group. d. A decline in the function of the immune system increases the risk of HIV infection. e. Decreased vaginal dryness and friability of tissues increases the risk of HIV in older women. f. Treatments for erectile dysfunction have increased the number of older individuals who are sexually active.

a. Older adults are less likely to use condoms than younger at-risk adults. b. At-risk individuals over the age of 50 are less likely to be tested for HIV. c. Society continues to age with larger numbers of people entering this age group. d. A decline in the function of the immune system increases the risk of HIV infection. f. Treatments for erectile dysfunction have increased the number of older individuals who are sexually active.

To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the duration of the patient's a. P wave. b. Q wave. c. P-R interval. d. QRS complex.

a. P wave.

Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen

a. Partial-thickness burns covering both legs c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes f. Bruising and pain in the right lower abdomen

Which information would be most important to help the nurse determine if the patient needs human immunodeficiency virus (HIV) testing? a. Patient age b. Patient lifestyle c. Patient symptoms d. Patient sexual orientation

a. Patient age

Which patient arriving at the urgent care center will the nurse assess first? a. Patient with acute right eye pain that occurred while using home power tools b. Patient with purulent left eye discharge, pruritus, and conjunctival inflammation c. Patient who is complaining of intense discomfort after an insect crawled into the right ear d. Patient who has Ménière's disease and is complaining of nausea, vomiting, and dizziness

a. Patient with acute right eye pain that occurred while using home power tools

A patient referred to the eating disorders clinic has lost 35 pounds in 3 months. For which physical manifestations of anorexia nervosa should a nurse assess? Select all that apply. a. Peripheral edema b. Parotid swelling c. Constipation d. Hypotension e. Dental caries f. Lanugo

a. Peripheral edema c. Constipation d. Hypotension f. Lanugo

A client with AIDS has been admitted with fever, night sweats, and weight loss of 6 pounds in 2 weeks. The client's purified protein derivative (PPD) test, placed 3 days ago in the clinic, is negative. Which action by the nurse is most appropriate? a. Place the client in Airborne Precautions. b. Facilitate the client's chest x-ray. c. Initiate a 3-day calorie count. d. Start an IV of normal saline.

a. Place the client in Airborne Precautions.

A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse? a. Place the client on a cardiac monitor immediately. b. Teach the client to limit high-potassium foods. c. Continue to monitor the client's intake and output. d. Ask to have the laboratory redraw the blood specimen.

a. Place the client on a cardiac monitor immediately.

The nurse notes that a child's gums bleed easily and he has bruising and petechiae on his extremities. What laboratory values are consistent with these symptoms? a. Platelet count of 19,000/mm3 b. Prothrombin time of 11 to 15 seconds c. Hematocrit of 34 d. Leukocyte count of 14,000/mm3

a. Platelet count of 19,000/mm3

A patient with extreme anxiety is arriving for out-patient chemotherapy. What should the nurse do to help reduce the patient's anxiety during this current treatment? a. Play a CD with nature sounds. b. Select a television station with a sporting event. c. Close the door to the room during the treatment. d. Remind the patient that anxiety is not going to make the treatment effective.

a. Play a CD with nature sounds.

A patient tells the nurse, "I'm ashamed of being bipolar. When I'm manic, my behavior embarrasses everyone. Even if I take my medication, there are no guarantees. I'm a burden to my family." These statements support which nursing diagnoses? Select all that apply. a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

a. Powerlessness c. Chronic low self-esteem

The nurse is caring for a client who is HIV positive. The client has become confused over the course of the shift, and the client's pupils are no longer reacting to light equally. The nurse anticipates an order for which medication? a. Prednisone (Deltazone) b. Trimethoprim/sulfamethoxazole (Bactrim) c. Pentamidine isethionate (Pentam) d. Ketoconazole (Nizoral)

a. Prednisone (Deltazone)

The nurse is aware that suicide risk increases if the child displays which characteristics? Select all that apply. a. Previous suicide attempt b. No previous exposure to violence in the home c. Recent loss d. Effective social network e. History of physical abuse

a. Previous suicide attempt c. Recent loss e. History of physical abuse

A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first? a. Provide a calm location for the family to cope and discuss needs. b. Call the hospital chaplain to stay with the family and pray for the deceased. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family.

a. Provide a calm location for the family to cope and discuss needs.

The nurse explains procedures and treatments while caring for a patient in shock. Why should the nurse provide these explanations to the patient? (Select all that apply.) a. Provide support b. Decrease anxiety c. Enhance learning d. Reduce the signs of shock e. Prevent future shock episodes

a. Provide support b. Decrease anxiety

A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? a. Provide water and healthy snacks for energy throughout the event. b. Schedule 16-hour shifts to allow for greater rest between shifts. c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility.

a. Provide water and healthy snacks for energy throughout the event.

The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and family's role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family

a. Psychoeducational

A patient who is taking atenolol (Tenormin) is experiencing shock. Which symptom of shock should the nurse expected to be absent in this patient? a. Pulse 115 beats per minute b. Respirations 28 per minute c. Blood pressure 88/48 mm Hg d. Capillary refill greater than 3 seconds

a. Pulse 115 beats per minute

Which of the nurse's assessment findings will require collaboration with the client's primary health care provider? (Select all that apply.) a. Purulent drainage from the ear canal b. Hearing loss with nausea and vertigo c. Ringing in the ears after attending a loud rock concert d. Presence of cerumen blocking 50% of the ear canal e. Increasing hearing loss since starting furosemide (Lasix) f. Temperature of 101.7° F following a stapedectomy 3 days ago

a. Purulent drainage from the ear canal b. Hearing loss with nausea and vertigo e. Increasing hearing loss since starting furosemide (Lasix) f. Temperature of 101.7° F following a stapedectomy 3 days ago

An accident has occurred near the hospital, and a victim is brought to the emergency department with severe chest pain, a pulse of 120 beats/min, blood pressure of 100/60 mm Hg, and a respiratory rate of 28 breaths/min. The nurse assesses shortness of breath and diaphoresis. Which color tag does the nurse use when triaging this client? a. Red b. Yellow c. Green d. Black

a. Red

A patient asks what dietary changes can be made to help protect against cancer. The nurse should base his or her response to the patient's question on which of the following? a. Reduced dietary fat intake can lower cancer risk. b. Reduced dietary salt intake reduces malignancy development. c. Increased intake of beef and poultry decrease the risk of malignancy. d. Increased intake of milk products will lower risk of cancer development.

a. Reduced dietary fat intake can lower cancer risk.

Which intervention is appropriate for an individual diagnosed with an antisocial personality disorder who frequently manipulates others? a. Refer requests and questions related to care to the case manager. b. Encourage the patient to discuss feelings of fear and inferiority. c. Provide negative reinforcement for acting-out behavior. d. Ignore, rather than confront, inappropriate behavior.

a. Refer requests and questions related to care to the case manager.

The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first? a. Remove the patient's rings. b. Apply ice packs to both hands. c. Apply calamine lotion to any itching areas. d. Give diphenhydramine (Benadryl) 50 mg PO.

a. Remove the patient's rings.

What is the priority intervention for a nurse beginning to work with a patient diagnosed with a schizotypal personality disorder? a. Respect the patient's need for periods of social isolation. b. Prevent the patient from violating the nurse's rights. c. Teach the patient how to select clothing for outings. d. Engage the patient in community activities.

a. Respect the patient's need for periods of social isolation.

A hospital has "stood down" from a mass casualty disaster. The staff have rested and eaten. Which action by the nursing supervisor takes priority? a. Restocking the emergency department (ED) b. Making rounds on each unit to check staffing c. Determining which staff can go home d. Planning a critical incident stress debriefing

a. Restocking the emergency department (ED)

What is the priority problem for a client experiencing chemotherapy-induced anemia? a. Risk for injury related to fatigue b. Fatigue related to decreased oxygenation c. Body image problems related to skin color changes d. Inadequate nutrition related to anorexia

a. Risk for injury related to fatigue

What is the priority nursing diagnosis for a patient diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Risk for other-directed violence b. Risk for self-directed violence c. Impaired social interaction d. Ineffective denial

a. Risk for other-directed violence

A nurse explains that in autoimmune diseases, the body identifies its own proteins as foreign matter and sets out to destroy itself. Which are examples of autoimmune diseases? (Select all that apply.) a. SLE b. Type 1 diabetes mellitus (DM) c. Rheumatoid arthritis (RA) d. Osteoarthritis e. Pancreatitis

a. SLE b. Type 1 diabetes mellitus (DM) c. Rheumatoid arthritis (RA)

What is the nurse's immediate action when a child comes to the emergency department with sweating, chills, and fang bite marks on the thigh? a. Secure antivenin therapy. b. Apply a tourniquet to the leg. c. Ambulate the child. d. Reassure the child and parent.

a. Secure antivenin therapy.

When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the patient? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose

a. Sedation and muscle stiffness

The nurse is caring for a young woman at the primary health care clinic. Which assessment finding leads the nurse to question the client about risk factors for HIV? a. Six vaginal yeast infections in the last 12 months b. Unable to become pregnant for the last 2 years c. Severe cramping and irregular periods d. Very heavy periods and breakthrough bleeding

a. Six vaginal yeast infections in the last 12 months

The nurse is preparing a seminar on cancer incidence for a group of community members. Which types of cancer are common for both men and women? (Select all that apply.) a. Skin b. Lung c. Breast d. Kidney e. Prostate f. Colorectal

a. Skin b. Lung

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this client's teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium

a. Smoking cessation b. Stress reduction and management d. Adverse effects of medications

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this client's teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium

a. Smoking cessation b. Stress reduction and management d. Adverse effects of medications

An adult diagnosed with major depression was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training b. Relaxation training classes c. Desensitization techniques d. Use of complementary therapy

a. Social skills training

The nurse is monitoring a patient being for septic shock. Which findings indicate that the patient is improving? (Select all that apply.) a. SpO2 94% b. pH is 7.33 c. Pulse 75 beats/minute d. Temperature 101°F (38.3°C) e. Blood pressure 110/90 mm Hg f. Urine output less than 25 mL/hr

a. SpO2 94% c. Pulse 75 beats/minute e. Blood pressure 110/90 mm Hg

What intervention does the nurse implement to provide for client safety during intradermal allergy testing? a. Stay with the client and ensure that emergency equipment is in the room. b. Pretreat the skin area to be tested with a cortisone-based cream. c. Apply oxygen by mask or nasal cannula before injecting the test agent. d. Cover the examination table and pillow with plastic or an ultrafine mesh.

a. Stay with the client and ensure that emergency equipment is in the room.

The emergency department nurse notices that the mother of a young child is making a lot of phone calls and getting advice from her friends about what she should do. This behavior is an indication of a. Stress b. Healthy coping skills c. Attention-getting behaviors d. Low self-esteem

a. Stress

A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurse's interests? a. The Medical Reserve Corps b. The National Guard c. The health department d. A Disaster Medical Assistance Team

a. The Medical Reserve Corps

The nurse is reviewing the process of cellular mutation with a patient newly diagnosed with cancer. What should the nurse explain about cellular mutation? (Select all that apply.) a. The cell becomes malignant. b. The cell can no longer divide. c. DNA mistakes have been made. d. The cell membrane is punctured. e. Proteins are no longer synthesized. f. There has been a genetic change in the cell.

a. The cell becomes malignant. c. DNA mistakes have been made. e. Proteins are no longer synthesized.

The nurse teaches a client with superior vena cava syndrome that improvement is characterized by which clinical manifestation? a. The client's hands are less swollen. b. Breath sounds are clear bilaterally. c. The client's back pain is relieved. d. Pedal edema is present.

a. The client's hands are less swollen.

A client with a history of rheumatoid arthritis will be starting drug therapy with etanercept (Enbrel). What is most important for the nurse to teach the client? a. The correct technique for subcutaneous injections b. How to self-monitor blood glucose levels c. How to set up and prime the IV tubing d. How to calculate the dosage based on symptoms

a. The correct technique for subcutaneous injections

The nurse is explaining the characteristics of a malignant tumor to a patient who is newly diagnosed with cancer. What should the nurse include in this explanation? (Select all that apply.) a. The growth rate is rapid. b. Tissue damage is minimal. c. The cells resemble the tissue of origin. d. The cells may invade surrounding tissues. e. The cells can travel to distant organs and initiate new tumors.

a. The growth rate is rapid. d. The cells may invade surrounding tissues. e. The cells can travel to distant organs and initiate new tumors.

A nursing administrator is evaluating the hospital's response to a recent internal disaster. The administrator assesses that goals for disaster planning have been met when which outcome is assessed? a. The hospital was able to maintain client, staff, and visitor safety during the disaster. b. Supplies were readily available and were transported rapidly where needed. c. The hospital incident command officer successfully utilized ancillary areas for client care. d. All employees followed the chain of command and established policies and procedures.

a. The hospital was able to maintain client, staff, and visitor safety during the disaster.

A nurse provides care for an adolescent patient diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed? a. The nurse interacts with the patient in a protective fashion. b. The nurse's comments to the patient are compassionate and nonjudgmental. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders.

a. The nurse interacts with the patient in a protective fashion.

The nurse is assessing a patient who has recently been treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider? a. The patient has a temperature of 100.6° F. b. The patient complains of "popping" in the ear. c. The patient frequently asks the nurse to repeat information. d. The patient states that the right ear has a feeling of fullness.

a. The patient has a temperature of 100.6° F.

A patient with a right retinal detachment had a pneumatic retinopexy procedure. Which information will be included in the discharge teaching plan? a. The purpose of maintaining the head in a prescribed position b. The use of eye patches to reduce movement of the operative eye c. The need to wear dark glasses to protect the eyes from bright light d. The procedure for dressing changes when the eye dressing is saturated

a. The purpose of maintaining the head in a prescribed position

When an adolescent with a new diagnosis of Ewing sarcoma asks the nurse about treatment, the nurse's response is based on the knowledge that (select all that apply) a. This type of tumor invades the bone. b. Management includes chemotherapy, surgery, and radiation. c. Ewing sarcoma is usually not responsive to either chemotherapy or radiation. d. Affected bones such as ribs and proximal fibula may be removed to excise the tumor. e. Is the most common bone tumor seen in children.

a. This type of tumor invades the bone. b. Management includes chemotherapy, surgery, and radiation. d. Affected bones such as ribs and proximal fibula may be removed to excise the tumor.

The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.) a. Type I - Examples include hay fever and anaphylaxis b. Type II - Mediated by action of immunoglobulin M (IgM) c. Type III - Immune complex deposits in blood vessel walls d. Type IV - Examples are poison ivy and transplant rejection e. Type V - Examples include a positive tuberculosis test and sarcoidosis

a. Type I - Examples include hay fever and anaphylaxis c. Type III - Immune complex deposits in blood vessel walls d. Type IV - Examples are poison ivy and transplant rejection

A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? (Select all that apply.) a. Urine output of 100 mL in 4 hours b. Urine output of 500 mL in 12 hours c. Large amount of sediment in the urine d. Amber, odorless urine e. Blood pressure of 90/60 mm Hg

a. Urine output of 100 mL in 4 hours c. Large amount of sediment in the urine e. Blood pressure of 90/60 mm Hg

The nurse is providing care for a patient with symptoms of tardive dyskinesia from major tranquilizers. What treatment should the nurse anticipate? a. Use of anticholinergic agents b. Use of muscle relaxant agents c. Discontinuance of the tranquilizers d. Addition of rational emotive therapy to the treatment plan

a. Use of anticholinergic agents

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? a. Viral load testing b. Enzyme immunoassay c. Rapid HIV antibody testing d. Immunofluorescence assay

a. Viral load testing

A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan. a. Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return. b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c. Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes. d. Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on reports.

a. Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return.

A patient being treated with paroxetine (Paxil) 50 mg po daily for depression reports to the clinic nurse, "I took a few extra tablets earlier today and now I feel bad." Which assessments are most critical? Select all that apply. a. Vital signs b. Urinary frequency c. Psychomotor retardation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

a. Vital signs d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

The nurse is preparing an oral chemotherapeutic medication for a patient's cancer treatment. What should the nurse do to ensure personal safety when preparing this medication? a. Wear gloves while preparing. b. Wash hands before administering. c. Apply a lead apron when providing. d. Crush the medication before providing.

a. Wear gloves while preparing.

What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms

a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion

The nurse suspects that the client who has entered the emergency department with severe uterine bleeding is in the early stages of shock. The nurse's first priority is to a. administer oxygen per nasal cannula. b. apply super-absorbent perineal pads. c. place the client in Trendelenburg position. d. start an intravenous line.

a. administer oxygen per nasal cannula.

A client is critically ill and in shock. The large, extended family has gathered in the waiting room. Important interventions the nurse can use when working with this family include (Select all that apply) a. allow the family to ask questions and express concerns. b. avoid explaining a lot of equipment so as not to worry the family. c. encourage the family to participate in decision making. d. let the family visit the client as much as possible. e. provide frequent explanations of what is happening with the client.

a. allow the family to ask questions and express concerns. c. encourage the family to participate in decision making. d. let the family visit the client as much as possible. e. provide frequent explanations of what is happening with the client.

An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should: a. assess lung sounds and extremities. b. suggest use of an aerobic exercise program. c. positively reinforce the patient for the weight gain. d. establish a higher goal for weight gain the next week.

a. assess lung sounds and extremities.

Strategies that a nurse could suggest a client use to prevent a relapse into substance abuse include (Select all that apply) a. assessing and building on coping skills. b. changing environmental triggers to abuse substances. c. considering therapy for struggles with daily functioning. d. identifying the personal risks of relapse. e. participating in self-help groups.

a. assessing and building on coping skills. b. changing environmental triggers to abuse substances. c. considering therapy for struggles with daily functioning. d. identifying the personal risks of relapse. e. participating in self-help groups.

The nurse would assess the client with a history of TIAs for a. ataxia and dysarthria. b. bouts of hypertension. c. nausea and vomiting. d. tingling in the extremities.

a. ataxia and dysarthria.

Four new patients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these patients for safety. Which patient will need the most watchful supervision? A patient diagnosed with: a. bipolar I disorder. b. bipolar II disorder. c. dysthymic disorder d. cyclothymic disorder.

a. bipolar I disorder.

A client has been in a motor vehicle accident and sustained significant injuries. The client is in shock and is semi-conscious, but is restless and moaning. The family is concerned the client is in pain and demands the nurse administer ordered morphine. The priority action by the nurse is to a. check the client's oxygen saturation. b. give morphine as ordered, slowly. c. politely decline their request. d. reposition the client.

a. check the client's oxygen saturation.

The nurse caring for a client in shock who is being mechanically hyperventilated explains that the rationale for this intervention is to a. decrease carbon dioxide levels in the blood. b. prevent atelectasis and respiratory failure. c. rest the client to decrease metabolism. d. stimulate endorphin production.

a. decrease carbon dioxide levels in the blood.

The nurse encourages a stroke victim by telling them that following a cerebrovascular accident (CVA) caused by thrombosis, the client's condition may improve after several days as a result of a. decrease of edema in the area. b. formation of collateral blood circulation. c. formation of new nervous pathways. d. reabsorption of the thrombus.

a. decrease of edema in the area.

Primary prevention techniques the nurse can teach a community group in order to prevent shock include (Select all that apply) a. diabetes management. b. heart-healthy living. c. injury prevention. d. safe exercise.

a. diabetes management. b. heart-healthy living. c. injury prevention. d. safe exercise.

Primary prevention activities a nurse can perform related to substance abuse include (Select all that apply) a. education to prevent substance abuse. b. focusing on relapse prevention. c. identification of risk factors for abuse. d. medical detoxification. e. referral to support and self-help groups.

a. education to prevent substance abuse. c. identification of risk factors for abuse.

To prevent possible complications from cardioversion, before administering the shock, the nurse would ensure that the (Select all that apply) a. emergency equipment is nearby and in working order. b. joules are set to 50-100 joules initially on a monophasic machine. c. machine is set to synchronize with the client's QRS complex. d. the Code Blue team has arrived and is prepared.

a. emergency equipment is nearby and in working order. b. joules are set to 50-100 joules initially on a monophasic machine. c. machine is set to synchronize with the client's QRS complex.

A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The patient twirls and shadow boxes. The patient says gaily, "Do you like my scarves? Here; they are my gift to you." How should the nurse document the patient's mood? a. euphoric b. irritable c. suspicious d. confident

a. euphoric

A client in hypovolemic shock has a low pulmonary capillary wedge pressure. This should indicate to the nurse that a. fluid replacement is needed. b. pulmonary edema may be developing. c. resuscitative measures are adequate. d. the client's left ventricle is failing.

a. fluid replacement is needed.

The assessment the nurse documents that supports the finding of apraxia would be the client's inability to a. get dressed independently. b. recognize a pencil. c. see far objects. d. understand the spoken word.

a. get dressed independently.

A client has had two TIAs. Priority nursing actions focus on a. helping the client reduce risk factors for stroke. b. providing emotional support during this stressful time. c. teaching the client's family about rehabilitation. d. working with a speech therapist on speech problems.

a. helping the client reduce risk factors for stroke.

The nurse caring for a client who has an implanted radiation source should reduce self-exposure by incorporating the strategy of a. limiting the time spent close to the client to 30 minutes per 8-hour shift. b. remaining 6 feet away from the client except for essential care. c. wearing a lead-shielded apron whenever entering the client's room. d. wearing a radiation meter or film badge to measure exposure.

a. limiting the time spent close to the client to 30 minutes per 8-hour shift.

A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of fluid. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

a. maintain normal salt and fluids in the diet.

A patient diagnosed with major depression does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Which communication technique will be effective? a. Make observations. b. Ask the patient direct questions. c. Phrase questions to require yes or no answers. d. Frequently reassure the patient to reduce guilt feelings.

a. make observations

An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with: a. meals b. an antacid c. an antiemetic d. a large glass of juice

a. meals

Three months ago a patient diagnosed with binge eating disorder weighed 198 pounds. Lorcaserin (Belviq) was prescribed. Which current assessment finding indicates the need for reevaluation of this treatment approach? The patient: a. now weighs 196 pounds. b. says, "I am using contraceptives." c. says, "I feel full after eating a small meal." d. reports problems with dry mouth and constipation.

a. now weighs 196 pounds.

The priority nursing diagnosis for a patient experiencing an acute attack with Meniere's disease is a. risk for falls related to dizziness. b. impaired verbal communication related to tinnitus. c. self-care deficit (bathing and dressing) related to vertigo. d. imbalanced nutrition: less than body requirements related to nausea.

a. risk for falls related to dizziness.

A patient diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

a. risk for injury

The nurse is contributing to a staff education program about complications associated with urinary catheters. Which type of shock should the nurse recommend be included in the presentation? a. Septic b. Cardiogenic c. Anaphylactic d. Hypovolemic

a. septic

The nurse receives a laboratory report indicating a patient's serum level is 1 mEq/L. The patient's last dose of lithium was 8 hours ago. This result is: a. within therapeutic limits. b. below therapeutic limits. c. above therapeutic limits. d. invalid because of the time lapse since the last dose.

a. within therapeutic limits.

A client experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. What instruction does the nurse include in the client's teaching plan? a."Minimize or abstain from caffeine." b."Lie on your side until the attack subsides." c."Use your oxygen when you experience PACs." d."Take quinidine (Cardioquin) daily to prevent PACs."

a."Minimize or abstain from caffeine."

A client's electrocardiograph (ECG) tracing shows a run of sustained ventricular tachycardia. What is the nurse's first action? a.Assess airway, breathing, and level of consciousness. b.Administer an amiodarone bolus followed by a drip. c.Cardiovert the client with a biphasic defibrillator. d.Begin cardiopulmonary resuscitation (CPR).

a.Assess airway, breathing, and level of consciousness.

A client has a consistently regular heart rate of 128 beats/min. Which related physiologic alterations does the nurse assess for? (Select all that apply.) a.Decrease in cardiac output b.Increase in cardiac output c.Increase in blood pressure d.Decrease in blood pressure e.Increase in urine output

a.Decrease in cardiac output d.Decrease in blood pressure

A client has an epicardial pacemaker. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiograph (ECG) tracing. How does the nurse interpret this event? a.Loss of capture b.Ventricular fibrillation c.Failure to sense d.A normal tracing

a.Loss of capture

A client with tachycardia is experiencing clinical manifestations. Which manifestation requires immediate intervention by the nurse? a.Mid-sternal chest pain b.Increased urine output c.Mild orthostatic hypotension d.P wave touching the T wave

a.Mid-sternal chest pain

A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? a. "Make certain that your bath water is warm." b. "Avoid straining while having a bowel movement." c. "Limit your intake of caffeinated drinks to one a day." d. "Avoid strenuous exercise such as running."

b. "Avoid straining while having a bowel movement."

A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? a. "Make certain that your bath water is warm." b. "Avoid straining while having a bowel movement." c. "Limit your intake of caffeinated drinks to one a day." d. "Avoid strenuous exercise such as running."

b. "Avoid straining while having a bowel movement."

The nurse has instructed a patient recovering from a pulmonary embolism on long-term anticoagulant therapy. Which patient statement indicates that instruction has been effective? 1 A) "I will expect bloody sputum when I brush my teeth." B) "I need to use a soft toothbrush and an electric razor, and avoid injuries." C) "I need to eat a well-balanced diet with green salads." D) "I can expect to be bruised, since this is normal."

B) "I need to use a soft toothbrush and an electric razor, and avoid injuries."

A patient becomes unresponsive without a palpable pulse despite showing bradycardia on the rhythm strip. What action should the nurse take immediately? Select all that apply. A) Auscultate heart sounds B) Begin cardiac compressions C) Adjust cardiac monitor leads D) Prepare for chest tube insertion E) Place epinephrine at the bedside

B) Begin cardiac compressions E) Place epinephrine at the bedside

A person has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, "They're all plotting to destroy me. Isn't that true?" Select the nurse's most therapeutic response. a. "Everyone here is trying to help you. No one wants to harm you." b. "Feeling that people want to destroy you must be very frightening." c. "That is not true. People here are trying to help you if you will let them." d. "Staff members are health care professionals who are qualified to help you."

b. "Feeling that people want to destroy you must be very frightening."

a nurse is giving a parent information about autism. which statement made by the parent indicates understanding of the teaching? A. autism is characterized by periods of remission and exacerbation B. the onset of autism usually occurs before 3 years of age C. children with autism have imitation and gesturing skills D. autism can be treated effectively with medication

B. the onset of autism usually occurs before 3 years of age

which teaching guideline helps prevent eye injuries during sports and play activites? A. discourage the use of goggles with helmets so the child can see better B. wear eye protection when participating in high risk sports C. wear a face mask when playing any sport or playing roughly D. restrict helmet use to those who wear eye glasses or contact lenses

B. wear eye protection when participating in high risk sports

The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the client's blood glucose readings have been elevated. What question by the nurse is most appropriate? a. "Are you compliant with following the diabetic diet?" b. "Have you been taking glucosamine supplements?" c. "How much exercise do you really get each week?" d. "You're still taking your diabetic medication, right?"

b. "Have you been taking glucosamine supplements?"

The nurse is caring for an older adult patient with a history of depression. Which comment by the patient indicates an immediate need for further assessment? a. "I am so old; all my friends have died." b. "I am useless now; there is no reason to be alive." c. "I retire in 6 months, and it will be all downhill from there." d. "I am looking forward to seeing my husband in heaven someday."

b. "I am useless now; there is no reason to be alive."

A patient says, "The other nurses won't give me my medication early, but you know what it's like to be in pain and don't let your patients suffer. Could you get me my pill now? I won't tell anyone." Which response by the nurse would be most therapeutic? a. "I'm not comfortable doing that," and then ignore subsequent requests for early medication. b. "I understand that you have pain, but giving medicine too soon would not be safe." c. "I'll have to check with your doctor about that; I will get back to you after I do." d. "It would be unsafe to give the medicine early; none of us will do that."

b. "I understand that you have pain, but giving medicine too soon would not be safe."

After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. "I should wear a snug-fitting shirt over the ICD." b. "I will avoid sources of strong electromagnetic fields." c. "I should participate in a strenuous exercise program." d. "Now I can discontinue my antidysrhythmic medication."

b. "I will avoid sources of strong electromagnetic fields."

After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. "I should wear a snug-fitting shirt over the ICD." b. "I will avoid sources of strong electromagnetic fields." c. "I should participate in a strenuous exercise program." d. "Now I can discontinue my antidysrhythmic medication."

b. "I will avoid sources of strong electromagnetic fields."

A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best? a. "Avoid sexual intercourse when using injectable drugs." b. "It is important to participate in a needle-exchange program." c. "You should ask those who share equipment to be tested for HIV." d. "I recommend cleaning drug injection equipment before each use."

b. "It is important to participate in a needle-exchange program."

A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate? a. "Are you getting adequate rest and sleep each day?" b. "It is normal to be fatigued even for years afterward." c. "This is not normal and I'll let the provider know." d. "Try adding more vitamins B and C to your diet."

b. "It is normal to be fatigued even for years afterward."

A patient diagnosed with major depression tells the nurse, "Bad things that happen are always my fault." Which response by the nurse will best assist the patient to reframe this overgeneralization? a. "I really doubt that one person can be blamed for all the bad things that happen." b. "Let's look at one bad thing that happened to see if another explanation exists." c. "You are being extremely hard on yourself. Try to have a positive focus." d. "Are you saying that you don't have any good things happen?"

b. "Let's look at one bad thing that happened to see if another explanation exists."

A patient with terminal colon cancer is refusing all food and fluids. The patient has a living will that states no artificial nutrition is to be provided; however, the family is asking for a gastrostomy tube. What should the nurse do? A) Take the case to the hospital's ethics committee. B) Honor the family's wishes and have them sign a consent form. C) Honor the patient's refusal and help the family come to terms with the situation. D) Talk to the physician so he or she can move forward with the family's wishes.

C) Honor the patient's refusal and help the family come to terms with the situation.

A patient with anemia caused by chemotherapy is prescribed synthetic erythropoietin. When teaching the patient about the therapeutic effect of this treatment, which is appropriate for the nurse to include? A) Increase in platelets B) Decrease in lymph fluid C) Increase in red blood cells D) Decrease in white blood cells

C) Increase in red blood cells

The nurse is planning care for a patient with a pulmonary embolism. Which intervention would assist with the patient's decrease in cardiac output? A) Provide oxygen B) Keep protamine sulfate at the bedside C) Monitor pulmonary arterial pressures D) Assess for bleeding

C) Monitor pulmonary arterial pressures

A patient with atrial fibrillation has a heart rate of 90 beats per minute. Which manifestation should the nurse expect to assess in this patient? A) Headache B) Chest pain C) Palpitations D) Hypotension

C) Palpitations

The nurse is caring for a patient with leukemia who is experiencing neutropenia as a result of chemotherapy. Which action should the nurse include in the plan of care for this patient? A) Restrict fluid intake B) Replace hand hygiene with gloves C) Restrict visitors with communicable illnesses. D) Insert an indwelling urinary catheter to prevent skin breakdown

C) Restrict visitors with communicable illnesses.

contact lenses should be prescribed for a child who is A. confident that she really wants contact lenses B. able to read all the written information and instructions C. able to independently care for the lenses in a responsible manner D. at least 12 years of age

C. able to independently care for the lenses in a responsible manner

the nurse correlates which pathophysiological mechanism to the development of detached retina? A. blood vessels in the eye spasm B. overgrowth of vessels damages vision C. inner layers of the retina separate D. drainage of aqueous humor is blocked

C. inner layers of the retina separate

initial care of the child with a chemical burn to the eye(s) is typically focused on which of the following? A. administration of an analgesic B. administration of medication to constrict the pupils C. irrigation of the affected eye(s) D. application of topical steriods

C. irrigation of the affected eye(s)

the nurse coorelates decreased peripheral vision in both eyes to which eye disorder? A. closed angle glaucoma B. secondary glaucoma C. normal tension glaucoma D. open angle glaucoma

C. normal tension glaucoma

which activity should the nurse implement for the toddler with cerebral palsy? A. making play dates with toddlers B. turn the television on the cartoons C. provide opportunities for play D. give the toddler art supplies

C. provide opportunities for play

what is the priority nursing diagnosis for the child autism spectrum disorders I A. anxiety related to frequent contact with healthcare professionals B. chronic pain related to frequent injections and invasive procedures C. risk for delayed growth and development D. anticipatory grieving related to impending life events

C. risk for delayed growth and development

the nurse monitors for which clinical manifestation in the patient experiencing vertigo A. buzzing sounds in the ears B. mucopurulent drainage from the ears C. spinning sensation at rest D. feeling of fullness in the ears

C. spinning sensation at rest

the nurse coorelates an increased risk for developing meniere's disease based upon which information in the patient's health record? A. allergic to house dust and pet dander B. works as a computer science technician C. treated for a pinched nerve in the lower back D. follows a gluten free diet

C. treated for a pinched nerve in the lower back

the nursing diagnosis "impaired visual sensory perception related to abnormal blood vessel growth behind the retina" is most relevent to the patient with which eye disorder? A. cataracts B. glaucoma C. wet macular degeneration D. dry macular degeneration

C. wet macular degeneration

A client verbalizes a fear of contracting HIV because she has a history of intravenous substance abuse. What instructions does the nurse provide to the client to help minimize this risk? a. "Boil all needles and syringes for at least 20 minutes before using them again and be sure not to share them." b. "Rinse used needles and syringes with water followed by laundry bleach after using them." c. "Rinse used needles and syringes with rubbing alcohol before and after using them." d. "Run all needles and syringes through the dishwasher with an extra rinse cycle before using them again."

b. "Rinse used needles and syringes with water followed by laundry bleach after using them."

The nurse is caring for a newly diagnosed HIV-positive client who will be taking enfuvirtide (Fuzeon). Which precaution is important for the nurse to communicate to this client? a. "Stop taking the medication if you develop a fever." b. "Rotate the sites where you will be giving the injections." c. "Take this medication with a snack or a small meal." d. "Do not drive or operate machinery while taking this drug."

b. "Rotate the sites where you will be giving the injections."

A female client with rheumatoid arthritis has taken Rheumatrex (methotrexate) for the past year to control her symptoms. The client comes to the clinic and tells the nurse that a home pregnancy test was positive. What is the nurse's best response? a. "You need to schedule a prenatal appointment with your obstetrician right away." b. "Stop taking Rheumatrex immediately. I'll tell the physician you are pregnant." c. "Continue taking the Rheumatrex, and increase the dose if you have a flare." d. "See a genetic counselor to determine whether your baby will have rheumatoid arthritis."

b. "Stop taking Rheumatrex immediately. I'll tell the physician you are pregnant."

A patient is diagnosed with a stage I tumor in situ (TIS). Which explanation of TIS by the nurse is the best? a. "The tumor has spread and is generalized throughout the body." b. "The tumor has not invaded any tissues beyond the original site." c. "The tumor has spread to the lymph nodes in the immediate area." d. "The tumor is situated between two tissues, so there is risk for metastasis to both tissues."

b. "The tumor has not invaded any tissues beyond the original site."

Which hallucination necessitates the nurse to implement safety measures? The patient says, a. "I hear angels playing harps." b. "The voices say everyone is trying to kill me." c. "My dead father tells me I am a good person." d. "The voices talk only at night when I'm trying to sleep."

b. "The voices say everyone is trying to kill me."

A patient who has AIDS expresses concern about telling others about the illness. Which response would be appropriate by the nurse? a. "It would be best to tell everyone you know." b. "You should tell those who have a reason to know." c. "Your diagnosis will be discovered anyway by those you know." d. "Secrecy is a poor idea because it will erode your self-esteem."

b. "You should tell those who have a reason to know."

Data collection findings for a patient include shortness of breath with crackles in the lung bases, jugular vein distention, daily weight increased by 3 pounds from yesterday, report of chest pain, blood pressure 86/40 mm Hg, pulse 132 beats/minute, and respirations 30/minute. Which order should the nurse question? a. Electrocardiogram (ECG) STAT b. 500 mL 0.9% NS over 30 minutes c. Oxygen 2 L/min via nasal cannula d. Arterial blood gases (ABGs) STAT and repeat in 1 hour

b. 500 mL 0.9% NS over 30 minutes

A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease

b. A 50-year-old who is post coronary artery bypass graft surgery

A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease

b. A 50-year-old who is post coronary artery bypass graft surgery

A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. Which action should the nurse take first? a. Reposition the client into a prone position. b. Administer warmed intravenous fluids to the client. c. Wrap the client's extremities in warm blankets. d. Initiate extracorporeal rewarming via hemodialysis.

b. Administer warmed intravenous fluids to the client.

Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation? a. Use of oral opioids for pain control b. Administration of corticosteroid eye drops c. Importance of coughing and deep breathing exercises d. Need for bed rest for the first 1 to 2 days after the surgery

b. Administration of corticosteroid eye drops

A client has been prescribed brinzolamide (Azopt). What assessment by the nurse requires consultation with the provider? a. Allergy to eggs b. Allergy to sulfonamides c. Use of contact lenses d. Use of beta blockers

b. Allergy to sulfonamides

Which action should the nurse working in the emergency department implement in order to decrease fear in a 2-year-old child? a. Keep the child physically restrained during nursing care. b. Allow the child to hold a favorite toy or blanket. c. Direct the parents to remain outside the treatment room. d. Let the child decide whether to sit up or lie down for procedures.

b. Allow the child to hold a favorite toy or blanket.

The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that apply.) a. It affects single joints only. b. Antibodies lead to inflammation. c. It consists of an autoimmune process. d. Morning stiffness is rare. e. Permanent damage is inevitable.

b. Antibodies lead to inflammation. c. It consists of an autoimmune process.

Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate to experienced unlicensed assistive personnel (UAP)? a. Instilling antiviral drops for a patient with a corneal ulcer b. Application of a warm compress to a patient's hordeolum c. Instruction about hand washing for a patient with herpes keratitis d. Looking for eye irritation in a patient with possible conjunctivitis

b. Application of a warm compress to a patient's hordeolum

A client who is positive for HIV presents with confusion, fever, headache, blurred vision, nausea, and vomiting. What does the nurse do first? a. Assess the client's deep tendon reflexes. b. Ask the client to place his chin on his chest. c. Start an IV line with normal saline. d. Assess the client's pupil reaction.

b. Ask the client to place his chin on his chest.

A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first? a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.

b. Assess the client for adherence to the drug regimen.

The family of a neutropenic client reports the client "is not acting right." What action by the nurse is the priority? a. Ask the client about pain. b. Assess the client for infection. c. Delegate taking a set of vital signs. d. Look at today's laboratory results.

b. Assess the client for infection.

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. Which action should the nurse take next? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.

b. Assess vital signs and level of consciousness.

A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition? a. Auscultating the lungs b. Assessing mucous membranes c. Listening to bowel sounds d. Performing a neurologic examination

b. Assessing mucous membranes

A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply oral anesthetic gels before meals. b. Assist the client with oral care every 2 hours. c. Offer the client frequent sips of cool drinks. d. Provide the client with alcohol-based mouthwash. e. Remind the client to use only a soft toothbrush.

b. Assist the client with oral care every 2 hours. c. Offer the client frequent sips of cool drinks. e. Remind the client to use only a soft toothbrush.

A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assessing the client's fluid and electrolyte status b. Assisting the client to get out of bed to prevent falls c. Obtaining a bedside commode if the client is weak d. Providing gentle perianal cleansing after stools e. Reporting any perianal abnormalities

b. Assisting the client to get out of bed to prevent falls c. Obtaining a bedside commode if the client is weak d. Providing gentle perianal cleansing after stools e. Reporting any perianal abnormalities

A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first? a. Administer the ordered analgesic. b. Check the patient's oxygen saturation. c. Examine the eye for evidence of trauma. d. Assess each of the cranial nerve functions.

b. Check the patient's oxygen saturation.

The nurse assesses a client post-cataract surgery and finds white, dry, crusty drainage on the client's eyelid and lashes. What does the nurse do next? a. Obtain a specimen of the drainage for culture. b. Clean away the drainage and apply the prescribed drops. c. Contact the physician for an antibiotic order. d. Arrange for the client to be seen by the ophthalmologist today.

b. Clean away the drainage and apply the prescribed drops.

A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.) a. Older adult in the medical decision unit for evaluation of chest pain b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin e. Client on the medical unit for wound care

b. Client who had open reduction and internal fixation of a femur fracture 3 days ago e. Client on the medical unit for wound care

A nurse is seeing clients in the ophthalmology clinic. Which client should the nurse see first? a. Client with intraocular pressure reading of 24 mm Hg b. Client who has had cataract surgery and has worsening vision c. Client whose red reflex is absent on ophthalmologic examination d. Client with a tearing, reddened eye with exudate

b. Client who has had cataract surgery and has worsening vision

The nurse assesses several clients. Which one is most likely to have secondary open-angle glaucoma? a. Client with gradual onset of blurred vision b. Client who has recently had eye surgery c. Client who sees halos around lights d. Client with reactive pupils and clear sclera

b. Client who has recently had eye surgery

A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client who reports jaw pain when eating b. Client with a red, hot, swollen right wrist c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit

b. Client with a red, hot, swollen right wrist

The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? a. Administering steroids for severe serum sickness b. Correctly identifying the client prior to a blood transfusion c. Keeping the client free of the offending agent d. Providing a latex-free environment for the client

b. Correctly identifying the client prior to a blood transfusion

A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Detachment and overconfidence b. Darting eyes, tilted head, mumbling to self c. Euphoric mood, hyperactivity, distractibility d. Foot tapping and repeatedly writing the same phrase

b. Darting eyes, tilted head, mumbling to self

A blind client is admitted to the hospital unit. Orientation to the unit includes which information? (Select all that apply.) a. Introduce the staff to the client. b. Describe the room to the client using one reference point. c. Walk the client to the bathroom and describe it. d. Tell the client to use the call light if he or she wants to go to the bathroom. e. Explain the routine of the unit and how to operate the bed controls. f. Assist in putting the client's belongings away.

b. Describe the room to the client using one reference point. c. Walk the client to the bathroom and describe it. e. Explain the routine of the unit and how to operate the bed controls. f. Assist in putting the client's belongings away.

A patient is experiencing mucositis as a result of radiation therapy. Which interventions should the nurse include in the plan of care? (Select all that apply.) a. Provide oral care once daily. b. Discourage use of alcohol and tobacco. c. Encourage citrus juice for vitamin C supplementation. d. Advise the patient to avoid very cold foods and drinks. e. Heat all liquids before drinking to promote oral blood flow. f. Advise the patient to use a neutral mouthwash, such as diphenhydramine (Benadryl), and water.

b. Discourage use of alcohol and tobacco. d. Advise the patient to avoid very cold foods and drinks. f. Advise the patient to use a neutral mouthwash, such as diphenhydramine (Benadryl), and water.

Patients are being treated in the intensive care unit for anaphylactic, septic, and neurogenic shock. For which type of shock should the nurse plan to provide care? a. Obstructive b. Distributive c. Cardiogenic d. Hypovolemic

b. Distributive

Which nursing diagnosis would most likely apply to both a patient diagnosed with major depression as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

b. Disturbed sleep pattern

A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? Select all that apply. a. Imbalanced nutrition: more than body requirements b. Disturbed thought processes c. Sleep deprivation d. Chronic confusion e. Social isolation

b. Disturbed thought processes c. Sleep deprivation

What is an appropriate nursing action before surgery when caring for a child diagnosed with a Wilms' tumor? a. Limit fluid intake. b. Do not palpate the abdomen. c. Force oral fluids. d. Palpate the abdomen every 4 hours.

b. Do not palpate the abdomen.

A patient with depression is prescribed duloxetine (Cymbalta). What should the nurse instruct the patient about this medication? a. Take with fruit juice. b. Do not take with St. John's wort. c. Stop the medication if experiencing adverse effects. d. Expect blood pressure to drop with this medication.

b. Do not take with St. John's wort.

A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this client's care? a. Edema and pain b. Electrolyte and fluid imbalance c. Cardiac and respiratory status d. Mental health status

b. Electrolyte and fluid imbalance

A patient with lung cancer is experiencing neck edema and shortness of breath. What actions can the nurse take to help relieve this patient's symptoms? (Select all that apply.) a. Restrict fluids. b. Elevate the head of the bed. c. Remove restrictive clothing. d. Insert an indwelling urinary catheter. e. Avoid using the arms for venipuncture.

b. Elevate the head of the bed. c. Remove restrictive clothing. e. Avoid using the arms for venipuncture.

The nurse is caring for a client who had a stroke several years ago. The client has indicators of being malnourished. The nurse would assess the client for which of the following? a. Ability to throw the head back to propel the food b. Embarrassment and frustration over trouble eating c. Inability of the bowel to absorb nutrients d. Positioning the head with a sideways' tilt

b. Embarrassment and frustration over trouble eating

What is an expected physical assessment finding for an adolescent with a diagnosis of Hodgkin disease? a. Protuberant, firm abdomen b. Enlarged, painless, firm cervical lymph nodes c. Soft tissue swelling d. Soft to hard, nontender mass in pelvic area

b. Enlarged, painless, firm cervical lymph nodes

A client is brought to the emergency department after a car crash. The client has a large piece of glass in the left eye. What action by the nurse takes priority? a. Administer a tetanus booster shot. b. Ensure the client has a patent airway. c. Prepare to irrigate the client's eye. d. Turn the client on the unaffected side.

b. Ensure the client has a patent airway.

You are the nurse caring for a child who is diagnosed with septic shock. He begins to develop an dysrhythmia and hemodynamic instability. Endotracheal intubation is necessary. The physician feels that cardiac arrest may soon develop. What drug do you anticipate the physician will order? a. Atropine sulfate b. Epinephrine c. Sodium bicarbonate d. Inotropic agents

b. Epinephrine

A patient in shock is diagnosed with metabolic acidosis. What should the nurse realize as being the mechanism behind the development of this acid-base imbalance? a. Excessive aerobic metabolism b. Excessive anaerobic metabolism c. Decreased anaerobic metabolism d. Release of cortisol and glucagon

b. Excessive anaerobic metabolism

A client's spouse reports that the last time the client received lorazepam (Ativan) before receiving chemotherapy, the client was extremely drowsy and didn't remember the trip home. Which is the nurse's best action? a. Hold the dose of lorazepam for this round of chemotherapy. b. Explain that this is a normal response to the drug. c. Perform a Mini-Mental State Examination. d. Document the response in the client's chart.

b. Explain that this is a normal response to the drug.

An older client has decided to give up driving due to cataracts. What assessment information is most important to collect? a. Family history of visual problems b. Feelings related to loss of driving c. Knowledge about surgical options d. Presence of family support

b. Feelings related to loss of driving

Which behavior verbalized by a school-age child should alert the school nurse to a problem of possible obsessive-compulsive disorder (OCD)? a. States feelings of worthlessness and sadness everyday b. Feels need to ride a bike around the tree in front of the house seven times every day before entering the house c. Recurrent episodes of chest pain, heart palpations, and shortness of breath when entering the computer classroom d. Deterioration of relationships with family members

b. Feels need to ride a bike around the tree in front of the house seven times every day before entering the house

The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.) a. Anorexia b. Felty's syndrome c. Joint deformity d. Low-grade fever e. Weight loss

b. Felty's syndrome c. Joint deformity e. Weight loss

The nurse is teaching a client how to apply eye medication. Which is the correct technique for applying ointment into the eye? a. From the middle out b. From the inner canthus to the outer canthus c. From the outer canthus to the inner canthus d. Against the inner aspect of the eyelid

b. From the inner canthus to the outer canthus

A client is receiving an IV infusion of an antibiotic. The client calls the nurse about feeling uneasy and uncomfortable owing to congestion. Which action by the nurse is most appropriate? a. Elevate the head of the client's bed to 45 degrees. b. Have another nurse call the Rapid Response Team. c. Prepare to administer diphenhydramine (Benadryl). d. Slow the rate of the IV infusion.

b. Have another nurse call the Rapid Response Team.

A patient with gastrointestinal bleeding is awake, alert, and oriented and has vital sign measurements of: blood pressure 130/90 mm Hg, pulse 118 beats/minute, respirations 18/minute, and temperature 98.6°F (37°C). Which finding should the nurse consider as a possible sign of early shock? a. Respirations 18/min b. Heart rate 118 beats/min c. Temperature 98.6°F (37°C) d. Blood pressure 130/90 mm Hg

b. Heart rate 118 beats/min

A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best? a. Explain to the client that SLE is an unpredictable disease. b. Help the client create backup plans to minimize disruption. c. Offer to talk to the family and educate them about SLE. d. Tell the client to remain compliant with treatment plans.

b. Help the client create backup plans to minimize disruption.

A client with cancer has anorexia and mucositis, and is losing weight. The client's family members continually bring favorite foods to the client and are distressed when the client won't eat them. What action by the nurse is best? a. Explain the pathophysiologic reasons behind the client not eating. b. Help the family show other ways to demonstrate love and caring. c. Suggest foods and liquids the client might be willing to try to eat. d. Tell the family the client isn't able to eat now no matter what they bring.

b. Help the family show other ways to demonstrate love and caring.

Which client characteristic places her or him at high risk for latex hypersensitivity? a. Allergy to shellfish b. History of spina bifida c. Total hip replacement d. Taking oral contraceptives

b. History of spina bifida

The nurse is teaching a client with rheumatoid arthritis (RA) about joint protection principles. What information does the nurse include? (Select all that apply.) a. Use smaller joints to rest the larger ones. b. Hold objects with two hands, not one. c. Sit most often in a reclining chair. d. Use assistive-adaptive devices. e. Bend at your knees to lift objects.

b. Hold objects with two hands, not one. d. Use assistive-adaptive devices. e. Bend at your knees to lift objects.

A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.) a. Paramedic - Decides the number, acuity, and resource needs of clients b. Hospital incident commander - Assumes overall leadership for implementing the emergency plan c. Public information officer - Provides advanced life support during transportation to the hospital d. Triage officer - Rapidly evaluates each client to determine priorities for treatment e. Medical command physician - Serves as a liaison between the health care facility and the media

b. Hospital incident commander - Assumes overall leadership for implementing the emergency plan d. Triage officer - Rapidly evaluates each client to determine priorities for treatment

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply? a. Heating pad b. Ice packs c. Splints d. Wax dip

b. Ice packs

A patient who is hemorrhaging has pale mucous membranes, blood pressure 92/52 mm Hg, pulse 160 beats/minute, and respirations 30/minute. The patient is receiving IV fluids at 150 mL/hour, has a blood transfusion infusing, and is being provided oxygen via a mask. What should the nurse recognize as the most likely cause of the patient's respiratory rate? a. Electrolyte imbalances b. Inadequate tissue perfusion c. Rapid rate of fluid replacement d. Reaction to the blood transfusion

b. Inadequate tissue perfusion

Which nursing action facilitates care being provided to a child in an emergency situation? a. Encourage the family to remain in the waiting room. b. Include parents as partners in providing care for the child. c. Always reassure the child and family. d. Give explanations using professional terminology.

b. Include parents as partners in providing care for the child.

The nurse is caring for an older adult client who will be discharged home to live with an adult daughter. The client will be given prescriptions for four new medications for rheumatoid arthritis. How does the nurse ensure that the client will be able to take the medications correctly at home? a. Monitor the client self-administering medications while in the hospital. b. Include the client's daughter when teaching the client about the medications. c. Provide the client with pamphlets and information about all the medications. d. Make a chart showing which medications the client should take at different times.

b. Include the client's daughter when teaching the client about the medications.

A large number of victims arrive at the emergency department after a bus is hit by a train. Which interventions are performed immediately for red-tagged victims? (Select all that apply.) a. Splinting a closed tibial fracture b. Intubating a cyanotic client in respiratory distress c. Initiating IV fluids for a client with a blood pressure of 96/60 mm Hg and a pulse of 144 beats/min d. Attaching an external pacemaker for a client with a heart rate of 44 beats/min e. Performing postmortem care for a client who has just died f. Removing glass that is embedded in a client's arm

b. Intubating a cyanotic client in respiratory distress c. Initiating IV fluids for a client with a blood pressure of 96/60 mm Hg and a pulse of 144 beats/min d. Attaching an external pacemaker for a client with a heart rate of 44 beats/min

A client is admitted for a cardiac catheterization. It is essential for the nurse to ask the client about which allergies? (Select all that apply.) a. Penicillin b. Latex c. Iodine d. Shellfish e. Keflex f. Dilantin g. Bananas

b. Latex c. Iodine d. Shellfish g. Bananas

An HIV-positive client is taking lopinavir/ritonavir (Kaletra) and reports nausea, abdominal pain, and diarrhea. What orders does the nurse anticipate? a. Renal function studies b. Liver enzymes c. Blood glucose monitoring d. Albumin and prealbumin

b. Liver enzymes

What is the most challenging nursing intervention with patients diagnosed with personality disorders who use manipulation? a. Supporting behavioral change b. Maintaining consistent limits c. Monitoring suicide attempts d. Using aversive therapy

b. Maintaining consistent limits

The nurse is working with a client who has AIDS-related dementia and will soon be discharged to the care of family members. What teaching topic is best for the nurse to include in the discharge plan? a. Feed the client when he will not do it by himself. b. Make sure that a clock and a calendar are easily visible. c. Remove locks from bathroom and bedroom doors. d. Do not allow the client to smoke when he is alone.

b. Make sure that a clock and a calendar are easily visible.

Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma? a. Morphine sulfate 4 mg IV b. Mannitol (Osmitrol) 100 mg IV c. Betaxolol (Betoptic) 1 drop in each eye d. Acetazolamide (Diamox) 250 mg orally

b. Mannitol (Osmitrol) 100 mg IV

A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve? a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee b. Mashed potatoes, ground beef patty, corn, green beans, apple pie c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

b. Mashed potatoes, ground beef patty, corn, green beans, apple pie

A client is receiving interleukin-2 (IL-2) for cancer. Which drug is the nurse prepared to administer if needed? a. Lorazepam (Ativan) b. Meperidine (Demerol) c. Furosemide (Lasix) d. Epoetin alfa (Epogen)

b. Meperidine (Demerol)

A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed? a. Benzodiazepine b. Mood stabilizing medication c. Monoamine oxidase inhibitor (MAOI) d. Serotonin norepinephrine reuptake inhibitor (SNRI)

b. Mood stabilizing medication

A pregnant woman with a history of asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient? a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Because she is at an early stage of HIV infection, the infant will not contract HIV. d. It is likely that her newborn will become infected with HIV unless she uses antiretroviral therapy (ART).

b. Most infants born to HIV-positive mothers are not infected with the virus.

The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the client's recent history? a. Pyelonephritis b. Myocardial infarction c. Bladder cancer d. Kidney stones

b. Myocardial infarction

At a unit meeting, the staff discusses decor for a special room for patients with acute mania. Which suggestion is appropriate? a. An extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholstery

b. Neutral walls with pale, simple accessories

A client has Hodgkin's lymphoma, Ann Arbor stage Ib. For what manifestations should the nurse assess the client? (Select all that apply.) a. Headaches b. Night sweats c. Persistent fever d. Urinary frequency e. Weight loss

b. Night sweats c. Persistent fever e. Weight loss

A patient with a history of a myocardial infarction has chest pain. The patient's skin color is grayish, blood pressure is 88/70 mm Hg, pulse is 116 beats/minute and irregular, and respirations are 30/minute. Which action should the nurse take? a. Place the patient supine. b. Notify the charge nurse. c. Check the urine specific gravity. d. Infuse 0.9% normal saline wide open.

b. Notify the charge nurse.

Which nursing intervention has the highest priority as a patient diagnosed with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of refeeding. c. Communicate empathy for the patient's feelings. d. Help the patient balance energy expenditures with caloric intake.

b. Observe for adverse effects of refeeding.

During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? a. Palpate extremities for bilateral pulses. b. Observe the patient's respiratory effort. c. Check the patient's level of consciousness. d. Examine the patient for any external bleeding.

b. Observe the patient's respiratory effort.

The nurse provides teaching on nevirapine (Viramune) for a patient who is HIV positive. Which patient statement indicates that teaching has been effective? a. Monitor for rash. b. Observe urine color. c. Report extremity pain. d. Monitor for flulike symptoms.

b. Observe urine color.

A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication? a. Haloperidol (Haldol) b. Olanzapine (Zyprexa) c. Chlorpromazine (Thorazine) d. Diphenhydramine (Benadryl)

b. Olanzapine (Zyprexa)

After receiving the hand-off report, which client should the oncology nurse see first? a. Client who is afebrile with a heart rate of 108 beats/min b. Older client on chemotherapy with mental status changes c. Client who is neutropenic and in protective isolation d. Client scheduled for radiation therapy today

b. Older client on chemotherapy with mental status changes

A patient with cancer is scheduled for palliative surgery. Which explanation should the nurse use to describe the purpose of this surgery? a. Palliative surgery is done to reconstruct tissues damaged by the cancer. b. Palliative surgery is done to increase the patient's comfort when cure is not possible. c. Palliative surgery is done to remove a cancer completely and increase the chances for cure. d. Palliative surgery is done to remove surrounding lymph nodes, reducing the risk for spread of the primary tumor.

b. Palliative surgery is done to increase the patient's comfort when cure is not possible.

A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data may be unreliable. b. Patient involvement in decision making increases sense of control and promotes compliance with treatment. c. Because of increased risk of physical problems with refeeding, the patient's permission is needed. d. A team approach to planning the diet ensures that physical and emotional needs will be met.

b. Patient involvement in decision making increases sense of control and promotes compliance with treatment.

On arrival in the emergency department, a patient who was in a motor vehicle accident is apprehensive, confused, and hypotensive. The patient has tachycardia, oliguria, and cool clammy skin. What should the nurse do first? a. Cover patient with warm blankets. b. Perform a rapid head-to-toe assessment. c. Obtain patient's medical history from family. d. Reorient the patient to person, place, and time.

b. Perform a rapid head-to-toe assessment.

A client is receiving follow-up care after surviving a tornado. The client reports insomnia and the nurse notes that the client jumped as the nurse entered the room. Which action by the nurse is most appropriate? a. Document findings on the client's chart and inform the physician. b. Perform additional assessments for post-traumatic stress disorder. c. Educate the client on nonpharmaceutical methods to promote sleep. d. Plan to initiate a referral to a psychologist experienced in survivor issues.

b. Perform additional assessments for post-traumatic stress disorder.

How should the nurse instruct the mother who calls the emergency department because her 9-year-old child has just fallen on his face and one of his front teeth fell out? a. Put the tooth back in the child's mouth and call the dentist right away. b. Place the tooth in milk or water and go directly to the emergency department. c. Gently place the tooth in a plastic zippered bag until she makes a dental appointment. d. Clean the tooth and call the dentist for an immediate appointment.

b. Place the tooth in milk or water and go directly to the emergency department.

The student nurse is performing a Weber tuning fork test. What technique is most appropriate? a. Holding the vibrating tuning fork 10 to 12 inches from the client's ear b. Placing the vibrating fork in the middle of the client's head c. Starting by placing the vibrating fork on the mastoid process d. Tapping the vibrating tuning fork against the bridge of the nose

b. Placing the vibrating fork in the middle of the client's head

Which characteristic is common to all types of hypersensitivity reactions? a. Decreased inflammatory responses b. Presence of tissue-damaging reactions c. Enhanced natural killer cell activity d. Inability to recognize extraneous cells

b. Presence of tissue-damaging reactions

A patient experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiological functioning. b. Provide a subdued environment. c. Supervise personal hygiene. d. Observe for mood changes.

b. Provide a subdued environment.

The nurse is caring for a hospitalized client who has AIDS and is severely immune compromised. Which interventions are used to help prevent infection in this client? (Select all that apply.) a. Use sterile gloves and gowns whenever the nursing staff is in contact with the client. b. Provide an incentive spirometer to encourage coughing and deep breathing by the client. c. Keep a blood pressure cuff, thermometer, and stethoscope in the client's room for his or her use only. d. Use N95 respirators (all nursing staff) when in the client's room. e. Request that the family take home the fresh flowers that are at the client's bedside. f. Assist the client with meticulous oral care after meals and at bedtime.

b. Provide an incentive spirometer to encourage coughing and deep breathing by the client. c. Keep a blood pressure cuff, thermometer, and stethoscope in the client's room for his or her use only. e. Request that the family take home the fresh flowers that are at the client's bedside. f. Assist the client with meticulous oral care after meals and at bedtime.

The nurse is caring for a client with otitis media. The client reports that the pain was severe during the night but was gone upon awakening in the morning. Which finding does the nurse expect to observe during the client's physical assessment? a. The tympanic membrane is bluish-gray. b. Purulent fluid is present in the ear canal. c. The pinna and the tragus are reddened and swollen. d. Sounds are lateralized toward the affected ear.

b. Purulent fluid is present in the ear canal.

A patient is scheduled for radiation treatments before having surgery to remove a tumor. What should the nurse cite as the reason for the radiation treatments? a. Reduces the need for chemotherapy b. Reduces the size of the tumor before surgery c. Reduces the need for radiation after the surgery d. Reduces the spread of cancer cells during the surgery

b. Reduces the size of the tumor before surgery

Assessment of a child with a submersion injury focuses on which system? a. Cardiovascular b. Respiratory c. Neurologic d. Gastrointestinal

b. Respiratory

A preschool child in the emergency department has a respiratory rate of 10 breaths per minute. How should the nurse interpret this finding? a. The child is relaxed. b. Respiratory failure is likely. c. This child is in respiratory distress. d. The child's condition is improving.

b. Respiratory failure is likely.

Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa? a. Carefree flexibility b. Rigidity, perfectionism c. open displays of emotion d. high spirits and optimism

b. Rigidity, perfectionism

What is a priority nursing diagnosis for the 4-year-old child newly diagnosed with leukemia? a. Ineffective Breathing Pattern related to mediastinal disease b. Risk for Infection related to immunosuppressed state c. Disturbed Body Image related to alopecia d. Impaired Skin Integrity related to radiation therapy

b. Risk for Infection related to immunosuppressed state

A patient with hypovolemic shock is experiencing oliguria due to hemorrhage. Which should the nurse recognize as the most likely cause of the patient's oliguria? a. End-stage renal failure b. Secretion of aldosterone c. Inadequate oral fluid intake d. Obstructed urinary catheter

b. Secretion of aldosterone

When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention? a. Allow the patient to act out feelings. b. Set limits on patient behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.

b. Set limits on patient behavior as necessary.

A condition in which the normal adult hemoglobin is partly or completely replaced by abnormal hemoglobin is known as a. Aplastic anemia b. Sickle cell anemia c. Thalassemia major d. Iron-deficiency anemia

b. Sickle cell anemia

What condition does the nurse recognize as an early sign of distributive shock? a. Hypotension b. Skin warm and flushed c. Oliguria d. Cold, clammy skin

b. Skin warm and flushed

An 82-year-old patient who is being admitted to the hospital repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take? a. Overenunciate while speaking. b. Speak normally but more slowly. c. Increase the volume when speaking. d. Use more facial expressions when talking.

b. Speak normally but more slowly.

A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity

b. Speech alterations

A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity

b. Speech alterations

The nurse is working at a first aid booth for a spring training game on a hot day. A spectator comes in, reporting that he is not feeling well. Vital signs are temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is the priority action of the nurse? a. Encourage drinking of cool water or sports drinks. b. Sponge the victim with cool water and remove his shirt. c. Administer Tylenol (acetaminophen), 650 mg orally. d. Encourage rest, and reassess in 15 minutes.

b. Sponge the victim with cool water and remove his shirt.

On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and re-assess in 15 minutes.

b. Start an intravenous line and infuse 0.9% saline solution.

A client says, "Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist." Select the nurse's best initial action. a. Tell the client, "Facebook is a safe website. You don't need to worry about Homeland Security." b. Tell the client, "You are in a safe place where you will be helped." c. Administer a prn dose of an antipsychotic medication. d. Tell the client, "You don't need to worry about that."

b. Tell the client, "You are in a safe place where you will be helped."

The nurse notes that another nurse colleague has been acting differently lately. The nurse often has red watery eyes and a runny nose. Today, the nurse was unhappy with the patient assignment and screamed, "Someone is going to pay for this!" What should the nurse who has observed this behavior do? a. Nothing; all nurses have stressful days sometimes. b. Tell the clinical manager exactly what was observed. c. Tell the clinical manager that the nurse is abusing drugs. d. Confront the nurse with the behavior and provide information about counseling.

b. Tell the clinical manager exactly what was observed.

A patient who experienced injuries from a motor vehicle crash 6 months ago continues to request prescriptions for an opioid analgesic. When assessing this patient for opioid dependency which finding is the nurse least likely to observe? a. The patient drops out of a Saturday night Bingo group. b. The patient continues to manage to get to work each day. c. The patient tried to quit using the opioid but couldn't stop thinking about it. d. The patient has been to three or four physicians to obtain new prescriptions for the drug.

b. The patient continues to manage to get to work each day.

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side.

b. Turn off oxygen therapy.

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side.

b. Turn off oxygen therapy.

A patient is developing anaphylactic shock. What should the nurse expect to observe in this patient? (Select all that apply.) a. Polyuria b. Urticaria c. Bronchospasm d. Muscle cramps e. Laryngeal edema

b. Urticaria c. Bronchospasm e. Laryngeal edema

A patient is scheduled to undergo a prostate biopsy. The patient asks the nurse what is expected immediately following the procedure. Which response by the nurse is the most appropriate? A) 'Your sexual partners will need to be notified." B) "You will need to avoid strenuous activity for 24 hours." C) "You will not have any restrictions following the biopsy." D) "You will likely experience discomfort for 24-48 hours after the procedure."

D) "You will likely experience discomfort for 24-48 hours after the procedure."

A patient is receiving chemotherapy for the treatment of leukemia. While providing care for this patient, which clinical manifestations would indicate tumor lysis syndrome? A) Thrombocytopenia B) Respiratory distress C) Upper-extremity edema D) Altered levels of consciousness

D) Altered levels of consciousness

A patient's cardiac rhythm has no identifiable P or QRS waves. What action should the nurse take first? A) Apply oxygen B) Assess a radial pulse C) Insert an intravenous line D) Begin chest compressions

D) Begin chest compressions

The nurse notes that a patient with a cardiac dysrhythmia is developing shortness of breath. What is the pathophysiological reason for this manifestation? A) Decreased oxygen in the brain B) Stimulation of the sympathetic nervous system C) Imbalance in myocardial oxygen demand and supply D) Increase in oxygenation because of a drop in cardiac output

D) Increase in oxygenation because of a drop in cardiac output

When analyzing a patient's electrocardiogram, the nurse notes that the P wave is normal. What criteria did the nurse use to make this decision? A) Pointed and skinny in width B) Small and rounded in lead II C) Upright and rounded in lead II D) Length 0.10 seconds and height 2.5 mm

D) Length 0.10 seconds and height 2.5 mm

A patient is being evaluated for a blockage in the cardiac ventricles. On which part of the electrocardiogram should the nurse focus as evidence of this blockage? A) T wave B) U wave C) PR interval D) QRS interval

D) QRS interval

A nurse caring for a patient with a pulmonary embolism expects to find which diagnostic result? A) Patchy infiltrates on chest x-ray B) Metabolic alkalosis on arterial blood gas C) Elevated CO2 level found on end-tidal carbon dioxide monitor D) Tachycardia and nonspecific T-wave changes on EKG

D) Tachycardia and nonspecific T-wave changes on EKG

A patient with atrial fibrillation is being considered for cardioversion. Which diagnostic test should the nurse anticipate being prescribed prior to this procedure being completed? A) Chest x-ray B) CT scan of the chest C) 12-lead electrocardiogram D) Transesophageal echocardiogram (TEE)

D) Transesophageal echocardiogram (TEE)

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)

b. Warfarin (Coumadin)

A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCL (Latuda). The patient is 5'6" and currently weighs 204 lbs. Which topic is most important for the nurse to include in the teaching plan related to this medication? a. How to recognize tardive dyskinesia b. Weight management strategies c. Ways to manage constipation d. Sleep hygiene measures

b. Weight management strategies

what is the priority gal for the child with a chronic illness? A. to maintain the intactness of the family B. to eliminate all stressors C. to achieve complete wellness D. to obtain the highest level of wellness

D. to obtain the highest level of wellness

The nurse is assisting with teaching a patient who is to begin taking a monoamine oxidase inhibitor (MAOI). Which foods should the nurse teach the patient to avoid? (Select all that apply.) a. Fish b. Wine c. Bread d. Pastas e. Aged cheese

b. Wine e. Aged cheese

A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." The nurse documents this report as an example of: a. dysthymia. b. anhedonia. c. euphoria. d. anergia.

b. anhedonia.

When a client in the cardiac care unit (CCU) suddenly develops paroxysmal atrial tachycardia (PAT) of 200 beats/min and clinical manifestations of severe dizziness, the nurse would help decrease the heart rate by a. administering digitalis intravenously. b. asking the client to perform the Valsalva maneuver. c. increasing the client's oxygen. d. lowering the head of the bed.

b. asking the client to perform the Valsalva maneuver.

A client who has left hemiparesis as a result of stroke is getting out of bed to the chair for the first time. The nurse should position the chair a. at a right angle to the client's left side. b. at a right angle to the client's right side. c. facing away from the side of the bed. d. facing the side of the bed but within 1 foot.

b. at a right angle to the client's right side.

A client's ECG reveals a rapid atrial rate of 300 beats/min, and the P waves resemble a picket fence without 1:1 conduction. The nurse would identify this dysrhythmia as a. atrial fibrillation. b. atrial flutter. c. paroxysmal atrial tachycardia. d. sinoatrial block.

b. atrial flutter.

The nurse is counseling an HIV-positive woman who has just given birth to a baby. The nurse should advise the client to a. anticipate the needs of her child immediately and make arrangements for placement in a setting where her child's life will be comfortable. b. avoid breast-feeding her infant if she has access to a safe water supply to decrease the chances of vertical transmission. c. report all of her sexual partners to the infectious disease department in order to break the chain of transmission of the disease. d. seek professional counseling to deal with the guilt associated with the almost certain passing of the disease to her child.

b. avoid breast-feeding her infant if she has access to a safe water supply to decrease the chances of vertical transmission.

Priority interventions for a patient diagnosed with major depression and feelings of worthlessness should include: a. distracting the patient from self-absorption. b. careful unobtrusive observation around the clock. c. allowing the patient to spend long periods alone in meditation. d. opportunities to assume a leadership role in the therapeutic milieu.

b. careful unobtrusive observation around the clock.

To prevent a severe withdrawal reaction from alcohol, the nurse explains that drugs from the benzodiazepine group are given because these agents a. cause less nausea and vomiting. b. cause less respiratory depression. c. inhibit the urge to drink. d. raise the blood pressure.

b. cause less respiratory depression.

A patient experiencing acute mania is dancing atop a pool table in the recreation room. The patient waves a cue in one hand and says, "I'll throw the pool balls if anyone comes near me." To best assure safety, the nurse's first intervention is to: a. tell the patient, "You need to be secluded." b. clear the room of all other patients. c. help the patient down from the table. d. assemble a show of force.

b. clear the room of all other patients

A patient diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to kill me." How does this patient perceive the environment? a. Disorganized b. Dangerous c. Supportive d. Bizarre

b. dangerous

Outcome identification for the treatment plan of a patient experiencing grandiose thinking associated with acute mania will focus on: a. developing an optimistic outlook. b. distorted thought self-control. c. interest in the environment. d. sleep pattern stabilization.

b. distorted thought self-control.

A patient is demonstrating signs of anaphylactic shock. What action should the nurse take first? a. Provide pain relief. b. Ensure a patent airway. c. Provide patient teaching. d. Obtain a detailed patient history.

b. ensure a patent airway

The nurse would be most concerned about premature ventricular contractions (PVCs) that a. are uniform in appearance. b. fall on a T wave. c. occur at a rate of four per minute. d. occur with angina.

b. fall on a T wave.

A client had a stroke. A nurse has arranged a consultation with an occupational therapist in order to enhance the client's ability to a. acquire job skills. b. feed himself. c. swallow. d. use a walker.

b. feed himself.

An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones the nurse to say, "I've had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse will advise the patient to: a. restrict food and fluids for 24 hours and stay in bed. b. have someone bring the patient to the clinic immediately. c. drink a large glass of water with 1 teaspoon of salt added. d. take one dose of an over-the-counter antidiarrheal medication now.

b. have someone bring the patient to the clinic immediately.

A patient is experiencing respiratory distress and mild shock. In which position should the nurse place the patient? a. Prone b. Head elevated c. Trendelenburg position d. Flat with elevated foot of bed

b. head elevated

A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a. hypotensive shock. b. hypertensive crisis. c. cardiac dysrhythmia. d. cardiogenic shock

b. hypertensive crisis.

A nursing diagnosis appropriate to consider for a patient diagnosed with any of the personality disorders is: a. noncompliance. b. impaired social interaction. c. disturbed personal identity. d. diversional activity deficit.

b. impaired social interaction.

A patient waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes." Select the nurse's appropriate intervention. The nurse: a. suggests the patient have a friend do the shopping and bring purchases to the unit. b. invites the patient to sit together and look at new fashion magazines. c. tells the patient computer use is not allowed until self-control improves. d. asks whether the patient has enough money to pay for the purchases.

b. invites the patient to sit together and look at new fashion magazines.

A client with AIDS is experiencing fever with night sweats. A suggestion the nurse could make is to a. drink all liquids in the morning. b. keep liquids at the bedside to drink. c. limit fluid intake after supper. d. take aspirin if awakened in the night.

b. keep liquids at the bedside to drink

The nurse is caring for an elderly client who is receiving vasodilators as part of the treatment of shock. The alteration in care the nurse should plan for this client is to a. ensure a patent Foley catheter. b. keep the head of the bed flat. c. provide oxygen by nasal cannula. d. run IV fluids at a lower rate.

b. keep the head of the bed flat.

After an episode of shock, a patient's laboratory results reveal elevated serum levels of ammonia and bilirubin and decreased plasma proteins and clotting factors. Which organ should the nurse recognize as being damaged from the shock? a. Heart b. Liver c. Kidneys d. Intestines

b. liver

The nurse is caring for a patient in mild shock. Which medication should the nurse question before providing if ordered for a patient experiencing shock? a. Benadryl b. Morphine c. Dopamine d. Solu-Medrol

b. morphine

When a client is admitted to the emergency department with a gunshot wound to the abdomen and is experiencing severe blood loss, the nurse anticipates the initial use of a. dextran. b. normal saline. c. packed red blood cells. d. whole blood.

b. normal saline.

To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse can evaluate the patient for improvement by a. questioning the patient about blurred vision. b. noting any changes in the patient's visual field. c. asking the patient to rate the pain using a 0 to 10 scale. d. assessing the patient's depth perception when climbing stairs.

b. noting any changes in the patient's visual field.

A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should a. obtain a complete set of vital signs. b. obtain a Glasgow Coma Scale score. c. ask about chronic medical conditions. d. attach a cardiac electrocardiogram monitor.

b. obtain a Glasgow Coma Scale score.

Personality traits most likely to be documented regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder are: a. affable, generous. b. perfectionist, inflexible. c.suspicious, holds grudges. d. dramatic speech, impulsive.

b. perfectionist, inflexible.

A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome would be that the patient will: a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. accept tube feeding without objection by day 2.

b. perform self-care activities with coaching by the end of day 3.

The nurse is reviewing the function of DNA and RNA with a group of students. Which structure should the nurse explain as providing the genetic code for a gene? a. Cell b. Protein c. Piece of DNA d. Piece of RNA

b. protein

A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should: a. maintain a stern and authoritarian affect. b. provide care in a matter-of-fact manner. c. encourage the patient to express anger. d. be very rigid and challenging.

b. provide care in a matter-of-fact manner.

The client's ECG shows normal-appearing P waves that occur at regular intervals. Every third impulse from the atria is missing a QRS complex. The nurse would recognize this pattern as the dysrhythmia of a. first-degree AV block. b. second-degree AV block. c. third-degree AV block. d. fourth-degree AV block.

b. second-degree AV block.

As part of ongoing data collection and care of a patient in shock, the nurse notes a slowing heart rate, systolic blood pressure less than 60 mm Hg, a decreasing temperature, decreasing respiration rate, and scant urine output. These signs and symptoms should indicate to the nurse that the patient is in which stage of shock? a. Mild b. Severe c. Moderate d. Compensated

b. severe

The recommendation the nurse should share with a 22-year-old sexually active client who is seeking information on the prevention of cervical cancer is that a Pap smear a. is needed annually by all women over age 18. b. should be done annually until two tests are negative, then once every 2-3 years, in women over 30. c. should be done biannually for clients who have been sexually active for 3 years but not later than age 21. d. should be performed twice a year for all sexually active women over age 18.

b. should be done annually until two tests are negative, then once every 2-3 years, in women over 30.

A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was wrong. You're evil." This outburst can be assessed as: a. denial b. splitting c. defensive d. reaction formation

b. splitting

A patient on chemotherapy after surgery develops thrombocytopenia. Which manifestation should the nurse report immediately to the physician? a. Headache b. Tarry stools c. Pain at the surgical site d. Blood pressure 136/88 mm Hg

b. tarry stools

A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. echolalia b. waxy flexibility c. depersonalization d. thought withdrawal

b. waxy flexibility

A client has a heart rate averaging 56 beats/min with no adverse symptoms. What activity modifications does the nurse suggest to avoid further slowing of the heart rate? a."Make certain that your bath water is warm (100° F)." b."Avoid bearing down or straining while having a bowel movement." c."Avoid strenuous exercise, such as running, during the late afternoon." d."Limit your intake of caffeinated drinks to no more than 2 cups per day."

b."Avoid bearing down or straining while having a bowel movement."

A client with myocardial ischemia is having frequent early, wide ventricular complexes seen on the cardiac monitor. Which medication does the nurse administer? a.Lanoxin (Digoxin) b.Amiodarone (Cordarone) c.Dobutamine (Dobutamine) d.Atropine sulfate (Atropisol)

b.Amiodarone (Cordarone)

The nurse is assessing clients at a community clinic. Which client does the nurse assess most carefully for atrial fibrillation? a.Middle-aged client who takes an aspirin daily b.Client who is dismissed after coronary artery bypass surgery c.Older adult client after a carotid endarterectomy d.Client with chronic obstructive pulmonary disease

b.Client who is dismissed after coronary artery bypass surgery

A client with ventricular tachycardia (VT) is unresponsive and has no pulse. The nurse calls for assistance and a defibrillator. What is the nurse's priority intervention while waiting for the defibrillator to arrive? a.Perform a pericardial thump. b.Initiate cardiopulmonary resuscitation. c.Start an 18-gauge IV in the antecubital. d.Ask the client's family about code status.

b.Initiate cardiopulmonary resuscitation.

The nurse observes a prominent U wave on the client's electrocardiograph (ECG) tracing. What is the most appropriate action for the nurse to take? a.Document the finding as a normal variant. b.Review the client's daily electrolyte results. c.Move the crash cart closer to the client's room. d.Call for an immediate electrocardiogram.

b.Review the client's daily electrolyte results.

A client with unstable ventricular tachycardia is receiving amiodarone by intravenous infusion. The nurse notes that the client's heart rate has decreased from 68 to 50 beats/min. The client is asymptomatic. What is the nurse's priority intervention? a.Stop the infusion and flush the IV. b.Slow the amiodarone infusion rate. c.Administer a precordial thump. d.Place the client in a side-lying position.

b.Slow the amiodarone infusion rate

The nurse is caring for a client with atrial fibrillation. What manifestation most alerts the nurse to the possibility of a serious complication from this condition? a.Sinus tachycardia b.Speech alterations c.Fatigue d.Dyspnea with activity

b.Speech alterations

The nurse is completing a health history for a client and begins to obtain a sexual history. What is the nurse's best opening question? a. "How long have you been sexually active?" b. "Are you in a monogamous relationship with your spouse?" c. "How do you feel about answering questions about your sexual history?" d. "Have you noticed any problems with your ability to have or enjoy sex?"

c. "How do you feel about answering questions about your sexual history?"

A client who has just had a mastectomy is crying. When the nurse asks about her crying, the client responds, "I know I shouldn't cry because this surgery may well save my life." What is the nurse's best response? a. "It is all right to cry. Mourning this loss will help make you stronger." b. "I know this is hard, but your chances of survival are better now." c. "I can arrange for someone who had a mastectomy to come visit if you like." d. "How have you coped with difficult situations in the past?"

c. "I can arrange for someone who had a mastectomy to come visit if you like."

The nurse evaluates that the client has learned an important fact about cocaine use when he says a. "Cocaine is not addictive. I can use it as a recreational drug." b. "Cocaine withdrawal is relatively easy. There is only mild fatigue." c. "I know a young person can have a heart attack from using cocaine." d. "Since cocaine is a depressant, one should not drive under its influence."

c. "I know a young person can have a heart attack from using cocaine."

A client states that he is "allergic" to poison ivy. Which statement by the client indicates a good understanding of this type of sensitivity? a. "Drinking 3 liters of water a day will prevent kidney damage." b. "I will always wear a medical alert bracelet for this allergy." c. "I need to try to avoid coming into contact with poison ivy." d. "I should carry diphenhydramine (Benadryl) with me at all times."

c. "I need to try to avoid coming into contact with poison ivy."

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement? a. "I will take salt tablets when I work outdoors in the summer." b. "I should take acetaminophen (Tylenol) if I start to feel too warm." c. "I should drink sports drinks when working outside in hot weather." d. "I will move to a cool environment if I notice that I am feeling confused."

c. "I should drink sports drinks when working outside in hot weather."

Which statement indicates that the client needs more teaching about mucositis? a. "I will rinse my mouth with water after every meal." b. "I will use a soft-bristled toothbrush to prevent trauma." c. "I should use an alcohol-based mouth rinse to kill bacteria." d. "I cannot use floss because it may irritate my gums."

c. "I should use an alcohol-based mouth rinse to kill bacteria."

A client has thrombocytopenia. What client statement indicates the client understands self-management of this condition? a. "I brush and use dental floss every day." b. "I chew hard candy for my dry mouth." c. "I usually put ice on bumps or bruises." d. "Nonslip socks are best when I walk."

c. "I usually put ice on bumps or bruises."

A client is seen in the ophthalmology clinic with bacterial conjunctivitis. Which statements by the client indicate a good understanding of home management of this condition? (Select all that apply.) a. "As long as I don't wipe my eyes, I can share my towel." b. "Eye irrigations should be done with warm saline or water." c. "I will throw away all my eye makeup when I get home." d. "I won't touch the tip of the eyedrop bottle to my eye." e. "When the infection is gone, I can use my contacts again."

c. "I will throw away all my eye makeup when I get home." d. "I won't touch the tip of the eyedrop bottle to my eye."

What is the best response to a parent who asks the nurse whether her 5-month-old infant can have cow's milk? a. "You need to wait until she is 8 months old and eating solids well." b. "Yes, if you think that she will eat enough meat to get the iron she needs." c. "Infants younger than 12 months need iron-rich formula to get the iron they need." d. "Try it and see how she tolerates it."

c. "Infants younger than 12 months need iron-rich formula to get the iron they need."

What is the nurse's best response to a mother whose child has a diagnosis of acute lymphoblastic leukemia and is expressing guilt about not having responded sooner to her boy's symptoms? a. "You should always call the physician when your child has a change in what is normal for him." b. "It is better to be safe than sorry." c. "It is not uncommon for parents not to notice subtle changes in their children's health." d. "I hope this delay does not affect the treatment plan."

c. "It is not uncommon for parents not to notice subtle changes in their children's health."

A client is being started on scopolamine (Transderm Scop) for vertigo. What does the nurse tell the client regarding this medication? a. "You may drive your car while taking this medication." b. "Concentration on your college courses will not be affected." c. "It is recommended that you limit activities requiring a detailed focus." d. "You should be able to continue your job as a crane operator."

c. "It is recommended that you limit activities requiring a detailed focus."

A patient being treated for depression has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, "I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares." The nurse will advise the patient to: a. "Go to the nearest emergency department immediately." b. "Do not to be alarmed. Take two aspirin and drink plenty of fluids." c. "Take a dose of your antidepressant now and come to the clinic to see the health care provider." d. "Resume taking your antidepressants for 2 more weeks and then discontinue them again."

c. "Take a dose of your antidepressant now and come to the clinic to see the health care provider."

When obtaining a sexual history from a client in a clinic setting, the nurse notes that the client appears very uncomfortable and pauses for long periods before answering the nurse's questions. What is the nurse's best response? a. "I am sorry that my questions are making you very uncomfortable." b. "Don't worry. We'll be done with these questions in no time at all." c. "Take your time. I realize that this is a very private topic to talk about." d. "These questions are making you uncomfortable, so we'll finish next time."

c. "Take your time. I realize that this is a very private topic to talk about."

The student nurse overhears several staff members referring to a client who is receiving chemotherapy as having "chemo brain." The student asks the instructor what that means. Which response by the instructor is best? a. "That is an awful thing to say and the staff should not call a client by that name." b. "It refers to the client's brain as being irreversibly damaged by the chemotherapy." c. "The client has reduced cognitive function that may last for several years." d. "The client has delirium related to the toxic effects of the chemotherapy."

c. "The client has reduced cognitive function that may last for several years."

A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/mL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? a. "The patient meets the criteria for a diagnosis of an acute HIV infection." b. "The patient will be diagnosed with asymptomatic chronic HIV infection." c. "The patient has developed acquired immunodeficiency syndrome (AIDS)." d. "The patient will develop symptomatic chronic HIV infection in less than a year."

c. "The patient has developed acquired immunodeficiency syndrome (AIDS)."

A client with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best? a. "Gabapentin can be used as an antidepressant too." b. "I have no idea why you should be taking this drug." c. "This drug helps treat the pain from nerve irritation." d. "You are at risk for seizures due to fungal infections."

c. "This drug helps treat the pain from nerve irritation."

A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best? a. "Let's ask the provider about increasing your pain pills." b. "Hold ice bags against your hands before quilting." c. "Try a paraffin wax dip 20 minutes before you quilt." d. "You need to stop quilting before it destroys your fingers."

c. "Try a paraffin wax dip 20 minutes before you quilt."

A client is on chemotherapy and has a platelet count of 25,000. Which intervention is most important to teach this client? a. "Eat a low-bacteria diet." b. "Take your temperature daily." c. "Use a soft-bristled toothbrush." d. "Avoid alcohol-based mouthwashes."

c. "Use a soft-bristled toothbrush."

The nurse contributed to a staff education program about transmission precautions to use when caring for a patient who has AIDS. Which statement by a staff member indicates a correct understanding of the teaching? a. "Wear a mask for any patient contact." b. "Wear a waterproof gown at all times." c. "Wear clean gloves for body fluid contact." d. "Wear sterile gloves for any patient contact."

c. "Wear clean gloves for body fluid contact."

A patient referred to the eating disorders clinic has lost 35 pounds during the past 3 months. To assess eating patterns, the nurse should ask the patient: a. "Do you often feel fat?" b. "Who plans the family meals?" c. "What do you eat in a typical day?" d. "What do you think about your present weight?"

c. "What do you eat in a typical day?"

The nurse is caring for a client who has a history of severe rheumatoid arthritis. The client becomes combative and abusive to the staff when she is unable to perform personal care independently. What is the best statement the nurse can make to the client at this time? a. "I will have to restrain your hands if you cannot keep them to yourself." b. "I will ask your doctor for a psychiatrist to talk to you about anger management." c. "You seem frustrated. Would you like to try to dress again in a few minutes?" d. "Would you like me to get an order for medication to help you settle down?"

c. "You seem frustrated. Would you like to try to dress again in a few minutes?"

A patient in shock is found unresponsive. The nurse knows that immediate cardiopulmonary resuscitation is required because brain cells begin to die if deprived of oxygen for how many minutes? a. 1 b. 2 c. 4 d. 8

c. 4

The nurse is receiving report on patients assigned for the next shift. Which patient should the nurse observe first? a. A patient who has a pressure ulcer who is due for a dressing change b. A patient with diabetes who has a blood sugar of 85 and is eating lunch c. A patient with cellulitis who is receiving the first dose of IV antibiotics and who is reporting a feeling of tightness in the throat d. A patient with sickle cell anemia who is receiving a monthly transfusion of a unit of packed red blood cells who is reporting left knee pain

c. A patient with cellulitis who is receiving the first dose of IV antibiotics and who is reporting a feeling of tightness in the throat

A psychiatric clinical nurse specialist uses cognitive-behavioral therapy for a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a. "What are your feelings about not eating foods that you prepare?" b. "You seem to feel much better about yourself when you eat something." c. "It must be difficult to talk about private matters to someone you just met." d. "Being thin doesn't seem to solve your problems. You are thin now but still unhappy."

d. "Being thin doesn't seem to solve your problems. You are thin now but still unhappy."

The nurse is reinforcing teaching on transmission of HIV for a family of a patient diagnosed with HIV. Which explanation by the nurse would be correct? a. "HIV can be spread by casual contact." b. "HIV lives for long periods outside the body." c. "HIV is most commonly transmitted via tears and saliva." d. "HIV enters the body through breaks in the skin or mucous membranes."

d. "HIV enters the body through breaks in the skin or mucous membranes."

The best response for the nurse to make to an adolescent who states, "I am very sad. I wish I was not alive." is a. "Everyone feels sad once in a while." b. "You are just trying to escape your problems." c. "Have you told your parents how you feel?" d. "Have you thought about hurting yourself?"

d. "Have you thought about hurting yourself?"

A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response. a. "Nothing you are saying is clear." b. "Your thoughts are very disconnected." c. "Try to organize your thoughts and then tell me again." d. "I am having difficulty understanding what you are saying."

d. "I am having difficulty understanding what you are saying."

A patient with schizophrenia calls the nurse into the room and says, "Help me! The books are on fire!" Which response by the nurse is best? a. "I'll get some water and put it out." b. "That's crazy; you know the books are not on fire!" c. "You don't have any books; how could they be on fire?" d. "I do not see any fire. Here is your supper; it's time to eat."

d. "I do not see any fire. Here is your supper; it's time to eat."

A patient's spouse filed charges after repeatedly being battered. The patient sarcastically says, "I'm sorry for what I did. I need psychiatric help." Which statement by the patient supports an antisocial personality disorder? a. "I have a quick temper, but I can usually keep it under control." b. "I've done some stupid things in my life, but I've learned a lesson." c. "I'm feeling terrible about the way my behavior has hurt my family." d. "I hit because I am tired of being nagged. My spouse deserves the beating."

d. "I hit because I am tired of being nagged. My spouse deserves the beating."

A nurse is teaching a patient about risk factors for cancer. Which statement by the patient indicates a need for further teaching? a. "I should eat plenty of fruits and vegetables." b. "I should eat a low-fat diet that is high in fiber." c. "I understand that eating a high-fat diet increases my risk of breast cancer." d. "I know that eating pickled and smoked foods can help prevent GI cancers."

d. "I know that eating pickled and smoked foods can help prevent GI cancers."

Which statement by the patient to the home health nurse indicates a need for more teaching about self-administering eardrops? a. "I will leave the ear wick in place while administering the drops." b. "I should lie down before and for 5 minutes after administering the drops." c. "I will hold the tip of the dropper above the ear while administering the drops." d. "I should keep the medication refrigerated until I am ready to administer the drops."

d. "I should keep the medication refrigerated until I am ready to administer the drops."

The nurse is teaching a client who has AIDS how to avoid infection at home. Which statement indicates that additional teaching is needed? a. "I will wash my hands whenever I get home from work." b. "I will make sure to have my own tube of toothpaste at home." c. "I will run my toothbrush through the dishwasher every evening." d. "I will be sure to eat lots of fresh fruits and vegetables every day."

d. "I will be sure to eat lots of fresh fruits and vegetables every day."

What statement indicates that the client understands teaching about neutropenia? a. "I need to use a soft toothbrush." b. "I have to wear a mask at all times." c. "My grandchildren may get an infection from me." d. "I will call my doctor if I have an increase in temperature."

d. "I will call my doctor if I have an increase in temperature."

A 72-year-old patient with age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective? a. "I will need to use bright lights to read for at least the next week." b. "I will use drops to keep my pupils dilated until my appointment." c. "I will not use facial lotions near my eyes during the recovery period." d. "I will cover up with long-sleeved shirts and pants for the next 5 days."

d. "I will cover up with long-sleeved shirts and pants for the next 5 days."

A client has been educated about activities that can increase intraocular pressure. Which statement indicates that the client requires further teaching? a. "I will avoid wearing tight shirt collars and ties." b. "I will take stool softeners daily to prevent straining." c. "I will try not to sneeze, cough, or blow my nose." d. "I will not put my arms above my head."

d. "I will not put my arms above my head."

The nurse is teaching a client with severe allergies how to prevent bug bites. Which statement by the client indicates that additional teaching is needed? a. "I will avoid wearing perfume when I go outside." b. "I will put the picnic food out when we are ready to eat." c. "I will keep my car windows up at all times." d. "I will wear sandals whenever I go outside."

d. "I will wear sandals whenever I go outside."

A patient became severely depressed when the last of the family's six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful? a. "Things will look brighter soon. Everyone feels down once in a while." b. "Our staff members care about you and want to try to help you get better." c. "It is difficult for others to care about you when you repeatedly say the same negative things." d. "I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you."

d. "I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you."

A client has conjunctivitis in both eyes and is being treated with topical antibiotics. Which statement by the client indicates a need for further teaching? a. "I'll avoid sharing washcloths or towels with other family members." b. "I will wash my hands after applying the eye ointment to each eye." c. "I will call the ophthalmologist if the drainage continues after the antibiotics are started." d. "I'll use the same tube of topical ointment for each infected eye."

d. "I'll use the same tube of topical ointment for each infected eye."

Which statement indicates that a client understands why his cataract surgery is being done first on the eye with the poorest vision? a. "Insurance reimbursement dictates the timing of surgeries." b. "The eye with poorer vision is at greater risk for permanent damage." c. "The pressure in the poorer eye could increase, causing permanent damage." d. "If a complication arises in that eye, I will still have some vision in the better eye."

d. "If a complication arises in that eye, I will still have some vision in the better eye."

The nurse has taught a client with cancer ways to prevent infection. What statement by the client indicates that more teaching is needed? a. "I should take my temperature daily and when I don't feel well." b. "I will wash my toothbrush in the dishwasher once a week." c. "I won't let anyone share any of my personal items or dishes." d. "It's alright for me to keep my pets and change the litter box."

d. "It's alright for me to keep my pets and change the litter box."

An HIV-positive client verbalizes concerns about the high cost of antiretroviral medications. What is the nurse's best response? a. "The medications are actually less expensive than they used to be." b. "These medications are the best course of treatment for you." c. "You should be glad the medications will help prolong your life." d. "Let's talk to the social worker about getting financial assistance for you."

d. "Let's talk to the social worker about getting financial assistance for you."

The nurse is teaching a client about home care after cataract surgery. Which statement indicates that the client requires further teaching? a. "I am glad that I don't need an eye patch after the surgery." b. "I will try a cool compress to decrease the swelling around the operated eye." c. "Dark sunglasses will be necessary when I am in the sun." d. "Pain, nausea, and vomiting are normal after this surgery."

d. "Pain, nausea, and vomiting are normal after this surgery."

The nurse is instructing a client about management of discoid lupus erythematosus (DLE). Which statement indicates that the client requires additional teaching? a. "I will be sure to apply sunscreen whenever I am outside." b. "I will apply small amounts of the steroid cream to my face twice a day." c. "I will take Plaquenil (hydroxychloroquine sulfate) with breakfast each morning." d. "Steroids weaken the immune system, so I will wash my hands frequently."

d. "Steroids weaken the immune system, so I will wash my hands frequently."

The family of a patient in shock asks the nurse to explain the condition. How should the nurse respond to this family? a. "It is caused by massive blood loss." b. "It is a profound circulatory collapse." c. "It is the result of overwhelming emotion." d. "There is inadequate oxygen delivered to the tissues."

d. "There is inadequate oxygen delivered to the tissues."

A patient asks, "What is the main purpose of these medications I take for my HIV?" Which response should the nurse make? a. "They encapsulate the virus-infected cells." b. "They mark the virus for natural killer cells to destroy." c. "They attract macrophages to the cells making the virus." d. "They inhibit enzymes to interfere with viral production."

d. "They inhibit enzymes to interfere with viral production."

A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the client's white blood cell count (WBC) is high. What response by the registered nurse is best? a. "If the WBCs are high, there already is an infection present." b. "The client is in a blast crisis and has too many WBCs." c. "There must be a mistake; the WBCs should be very low." d. "Those WBCs are abnormal and don't provide protection."

d. "Those WBCs are abnormal and don't provide protection."

A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question. a. "How long has the voice been directing your behavior?" b. "Does what the voice tell you to do frighten you?" c. "Do you recognize the voice speaking to you?' d. "What is the voice telling you to do?"

d. "What is the voice telling you to do?"

The nurse is caring for a client with Ménière's disease. What does the nurse recommend to the client to reduce the symptoms of vertigo? a. "Take salt and potassium supplements daily." b. "Drink at least eight glasses of water every day." c. "Blow your nose hard when dizziness first begins." d. "When dizziness begins, lie down and keep your head still."

d. "When dizziness begins, lie down and keep your head still."

A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response. a. "Why are you laughing?" b. "Please share the joke with me." c. "I don't think I said anything funny." d. "You're laughing. Tell me what's happening."

d. "You're laughing. Tell me what's happening."

Which statement, if made by a nurse to the parents of a child with leukemia, indicates an understanding of teaching related to home care associated with the disease? a. "Your son's blood pressure must be taken daily while he is on chemotherapy." b. "Limit your son's fluid intake just in case he has central nervous system involvement." c. "Your son must receive all of his immunizations in a timely manner." d. "Your son's temperature should be taken frequently."

d. "Your son's temperature should be taken frequently."

A client is afraid of a recent possible HIV exposure. The nurse should explain that the period of time it takes before HIV antibodies can be detected by laboratory tests is generally a. 1 to 3 days. b. 7 to 10 days. c. 1 to 3 weeks. d. 4 to 12 weeks.

d. 4 to 12 weeks.

The nurse is preparing to read the Mantoux tuberculin skin test placed on the forearm of a patient with HIV. Which finding should the nurse report as a positive test for this patient? a. 2 mm b. 3 mm c. 4 mm d. 5 mm

d. 5 mm

Hematopoietic stem cell transplantation (HSCT) is the standard treatment for a child in his or her first remission with what cancer? a. ALL b. Non-Hodgkin lymphoma c. Wilms' tumor d. Acute myeloblastic leukemia (AML)

d. Acute myeloblastic leukemia (AML)

While at a public park, a nurse encounters a person immediately after a bee sting. The person's lips are swollen, and wheezes are audible. Which action should the nurse take first? a. Elevate the site and notify the person's next of kin. b. Remove the stinger with tweezers and encourage rest. c. Administer diphenhydramine (Benadryl) and apply ice. d. Administer an EpiPen from the first aid kit and call 911.

d. Administer an EpiPen from the first aid kit and call 911.

A patient who is withdrawing from alcohol is restless and reports seeing snakes on the ceiling. Vital signs are blood pressure 180/100 mm Hg, pulse 92 beats/min, and respirations 22 breaths/min. What should the nurse do first? a. Teach the patient a relaxation technique. b. Administer a dose of lorazepam (Ativan). c. Search the patient's room for hidden alcohol. d. Administer an antihypertensive agent as ordered.

d. Administer an antihypertensive agent as ordered.

A patient involved in a motor vehicle accident has pale mucous membranes, diaphoresis, confusion, blood pressure 88/48 mm Hg, irregular heart rhythm, and metabolic acidosis. Which finding should the nurse recognize as the likely cause of acidosis? a. Hyperventilation b. Aerobic metabolism c. Inadequate ventilation d. Anaerobic metabolism

d. Anaerobic metabolism

The nurse discovers that a patient recovering from surgery is hemorrhaging from the incisional site. What action should the nurse take? a. Offer oral fluids. b. Warm the patient. c. Relieve the patient's apprehension. d. Apply pressure to the bleeding site.

d. Apply pressure to the bleeding site.

A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate? a. Clozapine (Clozaril) b. Ziprasidone (Geodon) c. Olanzapine (Zyprexa) d. Aripiprazole (Abilify)

d. Aripiprazole (Abilify)

The hospital is overwhelmed when caring for victims after an earthquake that occurred 48 hours ago. Which responsibility of the nursing supervisor is most important at this time? a. Assuming leadership for implementation of the hospital emergency plan b. Releasing updates of client conditions to the media c. Converting the physical therapy clinic into a treatment area for the injured d. Arranging relief and coordinating breaks so nursing staff can rest and eat

d. Arranging relief and coordinating breaks so nursing staff can rest and eat

A patient diagnosed with schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness

d. Associative looseness

Which assessment alerts the nurse to the possible presence of a cataract in a client? a. Loss of central vision b. Loss of peripheral vision c. Dull aching in the eye and brow areas d. Blurred vision and reduced color perception

d. Blurred vision and reduced color perception

A patient's cardiac monitor shows sinus rhythm, rate 64. The P-R interval is 0.18 seconds at 1:00 AM, 0.22 seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take next? a. Place the transcutaneous pacemaker pads on the patient. b. Administer atropine sulfate 1 mg IV per agency dysrhythmia protocol. c. Document the patient's rhythm and assess the patient's response to the rhythm. d. Call the health care provider before giving the next dose of metoprolol (Lopressor).

d. Call the health care provider before giving the next dose of metoprolol (Lopressor).

The nurse educator is preparing a seminar on cancer for a group of nursing students. Which definition should the nurse educator use to accurately describe cancer? a. Cancer is a name for cells that produce toxins that destroy body organs. b. Cancer is a term used to describe all new abnormal growths in the body. c. Cancer is a name given to a disease caused primarily from toxins in the environment. d. Cancer is a name for a large group of diseases characterized by cells that multiply rapidly and invade normal tissue.

d. Cancer is a name for a large group of diseases characterized by cells that multiply rapidly and invade normal tissue.

A patient with lung cancer is receiving chemotherapy. Why should the nurse closely monitor the patient's white blood cell (WBC) count? a. Chemotherapy drugs cause polycythemia and can precipitate thrombosis. b. Chemotherapy drugs attack WBCs and shorten their life span, which increases risk for infection. c. Chemotherapy drugs cause proliferation of blood cells, which can lead to sluggish circulation. d. Chemotherapy drugs depress the bone marrow, which can lead to infection and an increase in WBC count.

d. Chemotherapy drugs depress the bone marrow, which can lead to infection and an increase in WBC count.

A nurse is teaching a community group about noise-induced hearing loss. Which client who does not use ear protection should the nurse refer to an audiologist as the priority? a. Client with an hour car commute on the freeway each day b. Client who rides a motorcycle to work 20 minutes each way c. Client who sat in the back row at a rock concert recently d. Client who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day

d. Client who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day

The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client taking celecoxib (Celebrex) and ranitidine (Zantac) b. Client taking etanercept (Enbrel) with a red injection site c. Client with a blood glucose of 190 mg/dL who is taking steroids d. Client with a fever and cough who is taking tofacitinib (Xeljanz)

d. Client with a fever and cough who is taking tofacitinib (Xeljanz)

After receiving change-of-shift report, which client does the nurse assess first? a. Client with leukemia who needs an antiemetic before chemotherapy b. Client with breast cancer scheduled for external beam radiation c. Client with xerostomia associated with laryngeal cancer d. Client with neutropenia who has just been admitted with a possible infection

d. Client with neutropenia who has just been admitted with a possible infection

A patient with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the patient's behavior? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patient's speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.

d. Consider the need to check the lithium level. The patient may not be swallowing medications.

A nurse is caring for a client who has had rheumatoid arthritis (RA) for 5 years. Which laboratory value requires the most immediate intervention by the nurse? a. White blood cell count (WBC), 3800/mm3 b. Hemoglobin (Hg), 10.6 g/dL c. Blood urea nitrogen (BUN), 16 mg/dL d. Creatinine, 3.2 mg/dL

d. Creatinine, 3.2 mg/dL

Which behavior demonstrated by an adolescent should alert the school nurse to a problem of substance abuse? a. States feelings of worthlessness b. Increased desire for social conformity c. Does not feel need for peer approval d. Deterioration of relationships with family members

d. Deterioration of relationships with family members

An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.

d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.

Which is the priority action for the emergency department charge nurse in the event of a mass casualty situation? a. Directing medical-surgical and case management nurses to assist emergency department (ED) staff with critically injured victims b. Calling additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in c. Informing the incident commander at the mass casualty scene about how many victims may be handled by the ED d. Directing medical-surgical and critical care nurses to assist with clients who are already in the ED while the ED staff prepares to receive the mass casualty victims

d. Directing medical-surgical and critical care nurses to assist with clients who are already in the ED while the ED staff prepares to receive the mass casualty victims

A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi's sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly

d. Disposing of soiled dressings properly

The nurse is contributing to a teaching plan. What should the nurse emphasize as being the most effective method known to control the spread of HIV infection? a. Premarital serological screening b. Prophylactic exposure treatment c. HIV screening for pregnant women d. Education about preventive behaviors

d. Education about preventive behaviors

A patient recovering from vascular leg surgery is found standing in a large pool of blood flowing from the surgical site. After assisted into bed, the patient is pale with a palpable pulse. What action should the nurse take? a. Notify the charge nurse. b. Start an infusion of 0.9% NaCl. c. Apply oxygen at 2 L/min via nasal cannula. d. Elevate legs and apply pressure over the bleeding site.

d. Elevate legs and apply pressure over the bleeding site.

What is an appropriate nursing intervention for a 6-month-old infant in the emergency department? a. Distract the infant with noise or bright lights. b. Avoid warming the infant. c. Remove any pacifiers from the baby. d. Encourage the parent to hold the infant.

d. Encourage the parent to hold the infant.

A patient develops fatigue related to radiation therapy. Which intervention is the most appropriate for this patient? a. Discuss the patient's views concerning blood transfusion. b. Encourage moderate exercise between radiation treatments. c. Encourage larger portions of foods rich with calories and protein. d. Encourage the patient to prioritize activities around frequent rest periods.

d. Encourage the patient to prioritize activities around frequent rest periods.

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed.

d. Ensure that everyone is clear of contact with the client and the bed.

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed.

d. Ensure that everyone is clear of contact with the client and the bed.

A client is in the preoperative holding area prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best? a. Assess that the client has been NPO as directed. b. Communicate this information with dietary staff. c. Document the information in the client's chart. d. Ensure the information is relayed to the surgical team.

d. Ensure the information is relayed to the surgical team.

A patient is admitted for care because of heat stroke. Why should the nurse include interventions to prevent the onset of shock? a. The heat causes excessive dilation of veins and arteries. b. Inability to tolerate oral fluids could lead to more water lost. c. Parasympathetic stimulation causes blood to pool in the extremities. d. Excessive water lost through sweating can lead to hypovolemic shock.

d. Excessive water lost through sweating can lead to hypovolemic shock.

A newly diagnosed patient is prescribed lithium. Which information from the patient's history indicates that monitoring of serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Heart failure

d. Heart failure

A client is taking timolol (Timoptic) eyedrops. The nurse assesses the client's pulse at 48 beats/min. What action by the nurse is the priority? a. Ask the client about excessive salivation. b. Assess the client for shortness of breath. c. Give the drops using punctal occlusion. d. Hold the eyedrops and notify the provider.

d. Hold the eyedrops and notify the provider.

A 3-year-old is brought to the emergency department by ambulance after her body was found submerged in the family pool. The child has altered mental status and shallow respirations. She did not require resuscitative interventions. Which condition should the nurse monitor first in this child? a. Neurologic status b. Hypothermia c. Hypoglycemia d. Hypoxia

d. Hypoxia

The nurse is monitoring hourly urine output from an indwelling catheter for a patient experiencing hypovolemic shock. What should the nurse do if the patient's urine output drops to 15 mL for one hour of monitoring? a. Document the finding. b. Flush the urinary catheter c. Clamp the catheter for 30 minutes. d. Immediately report the drop in urine output.

d. Immediately report the drop in urine output.

On a hot, humid day, several clients present to the emergency department with symptoms of heat exposure. Which client will be treated first? A client who: a. Has normal mental status and flu-like symptoms b. Is diaphoretic with nausea and vomiting c. Is hypotensive and tachycardic d. Is anxious and confused

d. Is anxious and confused

The nurse is participating in the planning of care for a patient who has HIV. Which therapeutic action should the nurse recognize as the treatment goal for HIV? a. Stimulating the immune system b. Treating opportunistic infections c. Killing the virus with medication d. Keeping the virus from replicating

d. Keeping the virus from replicating

A child with a history of fever of unknown origin, excessive bruising, lymphadenopathy, anemia, and fatigue is exhibiting symptoms most suggestive of a. Ewing sarcoma b. Wilms' tumor c. Neuroblastoma d. Leukemia

d. Leukemia

A client is suspected to have rheumatoid arthritis. Which manifestations does the nurse assess this client carefully for? a. Crepitus when the client moves the shoulders b. Numbness and tingling in the client's fingers c. Client has cool feet, with weak pedal pulses d. Low-grade fever, fatigue, anorexia with weight loss

d. Low-grade fever, fatigue, anorexia with weight loss

The nurse is caring for a patient who has AIDS. Which outcome should receive priority? a. Remain socially active. b. Report high self-esteem. c. Remain free of infection. d. Maintain baseline weight.

d. Maintain baseline weight.

A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath

d. Multiple fractured ribs and shortness of breath

A 24-year-old woman is admitted to the hospital for a complete medical examination. Her current complaints are indicative of SLE. Which symptom would indicate this diagnosis? a. Recent weight gain of 10 lb b. Difficulty breathing in the morning c. Frequent episodes of diarrhea d. Musculoskeletal pain in the hands

d. Musculoskeletal pain in the hands

A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse's best analysis and action. a. Agranulocytosis; institute reverse isolation. b. Tardive dyskinesia; withhold the next dose of medication. c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet. d. Neuroleptic malignant syndrome; notify health care provider stat.

d. Neuroleptic malignant syndrome; notify health care provider stat.

A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like "pins and needles" and that the neck is very painful since returning from surgery. What action by the nurse is best? a. Assist the client to change positions. b. Document the findings in the client's chart. c. Encourage range of motion of the neck. d. Notify the provider immediately.

d. Notify the provider immediately.

A client with macular degeneration would like to watch television. Where does the nurse place the television for best visualization of the screen? a. As close to the client's face as possible b. As far away as possible, with low lights c. Directly in front of the client d. On either side of the client

d. On either side of the client

A patient diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia

d. Paranoia

A patient who has AIDS has been instructed on foods to eat to reduce the risk of infection. Which foods should the patient select that indicates correct understanding of this teaching? (Select all that apply.) a. Rare meat b. Raw seafood c. Soft egg yolks d. Pasteurized milk e. Well-cooked meat

d. Pasteurized milk e. Well-cooked meat

Disturbed body image is a nursing diagnosis established for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat congruence with height, frame, age, and sex b. Calorie intake is within required parameters of treatment plan c. Weight reaches established normal range for the patient d. Patient expresses satisfaction with body appearance

d. Patient expresses satisfaction with body appearance

A patient with schizophrenia has not bathed recently and a family member states that the patient has not been out of the house for 10 days. The patient tells the nurse, "They are trying to hurt me; don't let them hurt me." Which symptom is this patient demonstrating? a. Paranoid delusions b. Grandiose delusions c. Auditory hallucinations d. Persecutory hallucinations

d. Persecutory hallucinations

The nurse notes that a patient with AIDS is prescribed trimethoprim-sulfamethoxazole (Bactrim). For which opportunistic infection should the nurse realize that is this medication indicated? a. Tuberculosis b. Cytomegalovirus retinitis c. Mycobacterium avium complex d. Pneumocystis jiroveci pneumonia

d. Pneumocystis jiroveci pneumonia

A patient who is a war veteran states, "It should have been me that died. I'll never forgive myself for leaving my buddy when he needed me." The nurse recognizes this statement is most associated with which diagnosis? a. Bipolar depression b. Generalized anxiety c. Obsessive-compulsive disorder d. Post-traumatic stress disorder (PTSD)

d. Post-traumatic stress disorder (PTSD)

A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which of the following actions should the nurse take next? a. Immediately notify the health care provider. b. Document the rhythm and continue to monitor the patient. c. Perform synchronized cardioversion per agency dysrhythmia protocol. d. Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.

d. Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.

After collecting data, the nurse suspects that a patient is experiencing cardiogenic shock. Which finding supports this nurse's suspicion? a. Oliguria b. Tachypnea c. Bronchospasm d. Pulmonary edema

d. Pulmonary edema

When analyzing the rhythm of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n) a. isoelectric ST segment. b. P-R interval of 0.18 second. c. Q-T interval of 0.38 second. d. QRS interval of 0.14 second.

d. QRS interval of 0.14 second.

A nurse is assessing a female client who is taking progestins. What assessment finding requires the nurse to notify the provider immediately? a. Irregular menses b. Edema in the lower extremities c. Ongoing breast tenderness d. Red, warm, swollen calf

d. Red, warm, swollen calf

What is the goal of therapeutic management for a child diagnosed with ADHD? a. Administer stimulant medications. b. Assess the child for other psychosocial disorders. c. Correct nutritional imbalances. d. Reduce the frequency and intensity of unsocialized behaviors.

d. Reduce the frequency and intensity of unsocialized behaviors.

The long-term treatment plan for an adolescent with an eating disorder focuses on a. Managing the effects of malnutrition b. Establishing sufficient caloric intake c. Improving family dynamics d. Restructuring perception of body image

d. Restructuring perception of body image

The nurse has been exposed to HIV through splashing of urine from a client who is HIV positive with a low viral load. The urine came into contact with the nurse's face. Which drug regimen does the nurse prepare to initiate? a. Retrovir (zidovudine) for 14 days b. Retrovir (zidovudine) for 28 days c. Retrovir (zidovudine) and Epivir (lamivudine) for14 days d. Retrovir (zidovudine) and Epivir (lamivudine) for 28 days

d. Retrovir (zidovudine) and Epivir (lamivudine) for 28 days

A client with chemotherapy-induced bone marrow suppression has received filgrastim (Neupogen). Which laboratory finding indicates that this therapy is effective for the client? a. Hematocrit is 28%. b. Hematocrit is 38%. c. Segmented neutrophil count is 2500/mm3. d. Segmented neutrophil count is 3500/mm3.

d. Segmented neutrophil count is 3500/mm3.

A nurse assesses a client's electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this client's ECG strip? a. Ventricular tachycardia b. Ventricular fibrillation c. Sinus rhythm with premature atrial contractions (PACs) d. Sinus rhythm with premature ventricular contractions (PVCs)

d. Sinus rhythm with premature ventricular contractions (PVCs)

A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurse's priority action? a. Calculate the mean arterial pressure (MAP). b. Ask for insertion of a pulmonary artery catheter. c. Take the client's pulse. d. Slow down the normal saline infusion.

d. Slow down the normal saline infusion.

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal pulse is absent and the leg is swollen. Which action will the nurse take next? a. Send blood to the lab for a complete blood count. b. Assess further for a cause of the decreased circulation. c. Finish the airway, breathing, circulation, disability survey. d. Start normal saline fluid infusion with a large-bore IV line.

d. Start normal saline fluid infusion with a large-bore IV line.

A nurse is irrigating a client's ear when the client becomes nauseated. What action by the nurse is most appropriate for client comfort? a. Have the client tilt the head back. b. Re-position the client on the other side. c. Slow the rate of the irrigation. d. Stop the irrigation immediately.

d. Stop the irrigation immediately.

Which assessment finding for a patient diagnosed with an eating disorder meets criteria for hospitalization? a. Urine output 40 mL/hr b. Pulse rate 58 beats/min c. Serum potassium 3.4 mEq/L d. Systolic blood pressure 62 mm Hg

d. Systolic blood pressure 62 mm Hg

A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority? a. Helping clients adjust to their appearance b. Reassuring clients that this change is temporary c. Referring clients to a reputable wig shop d. Teaching measures to prevent scalp injury

d. Teaching measures to prevent scalp injury

The father of a child in the emergency department is yelling at the physician and nurses. Which action is contraindicated in this situation? a. Provide a nondefensive response. b. Encourage the father to talk about his feelings. c. Speak in simple, short sentences. d. Tell the father he must wait in the waiting room.

d. Tell the father he must wait in the waiting room.

The nurse is caring for a client with external otitis. Which assessment finding indicates to the nurse that the client's infection has worsened? a. The client now reports tinnitus and vertigo at night. b. The client now has a positive Rinne test, with AC > BC. c. The tympanic membrane is pearly gray with white patches. d. The auricular lymph nodes have increased in size over the last 24 hours.

d. The auricular lymph nodes have increased in size over the last 24 hours.

In which situation is the administration of milk or water indicated after ingestion? a. The child is suspected of ingesting lead paint chips. b. The child ingested approximately 15 tablets of baby aspirin. c. The child ingested an over-the-counter product containing acetaminophen. d. The child ingested an acid or alkali.

d. The child ingested an acid or alkali.

Which finding in an emergency department patient who reports being struck in the right eye with a fist is a priority for the nurse to communicate to the health care provider? a. The patient complains of a right-sided headache. b. The sclera on the right eye has broken blood vessels. c. The area around the right eye is bruised and tender to the touch. d. The patient complains of "a curtain" over part of the visual field.

d. The patient complains of "a curtain" over part of the visual field.

The nurse is caring for an HIV-positive client. What assessment finding assists the nurse in confirming progression of the client's diagnosis to AIDS? a. Generalized lymphadenopathy b. HIV-positive status for 8 years c. Low-grade fever for the last 10 days d. Thick white patches on the client's tongue

d. Thick white patches on the client's tongue

A client is going on a cruise but has had motion sickness in the past. What suggestion does the nurse make to this client? a. Avoid alcohol on the cruise ship. b. Change positions slowly on the ship. c. Change your travel plans. d. Try scopolamine (Transderm Scop).

d. Try scopolamine (Transderm Scop).

An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate? a. Initiate Contact Precautions. b. Place the client on Airborne Precautions. c. Place the client on Droplet Precautions. d. Use Standard Precautions consistently.

d. Use Standard Precautions consistently.

The intravenous line of a patient receiving a vesicant chemotherapy agent has disconnected and is lying on the floor. The medication is dripping all over the floor. Which action should the nurse take first? a. Reconnect the IV tubing immediately. b. Wipe it up as quickly as possible with disposable cloths. c. No special precautions are needed for vesicant drug cleanups. d. Use gloves and a protective gown to clean the spill according to agency policy.

d. Use gloves and a protective gown to clean the spill according to agency policy.

Which nursing action is most appropriate to assist a preschool-age child in coping with the emergency department experience? a. Explain procedures and give the child at least 1 hour to prepare. b. Remind the child that she is a big girl. c. Avoid the use of bandages. d. Use positive terms and avoid terms such as "shot" and "cut."

d. Use positive terms and avoid terms such as "shot" and "cut."

The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use? a. Count the number of large squares in the R-R interval and divide by 300. b. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. c. Calculate the number of small squares between one QRS complex and the next and divide into 1500. d. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

d. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.

d. Ventricular and atrial depolarizations are initiated from different sites.

The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjögren's syndrome? a. Abdominal assessment b. Oxygen saturation c. Renal function studies d. Visual acuity

d. Visual acuity

A nursing student is instructed to remove a client's ear packing and instill eardrops. What action by the student requires intervention by the registered nurse? a. Assessing the eardrum with an otoscope b. Inserting a cotton ball in the ear after the drops c. Warming the eardrops in water for 5 minutes d. Washing the hands and removing the packing

d. Washing the hands and removing the packing

A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client's oral chemotherapy medications. What action by the nurse is most appropriate? a. Crush the medications if the client cannot swallow them. b. Give one medication at a time with a full glass of water. c. No special precautions are needed for these medications. d. Wear personal protective equipment when handling the medications.

d. Wear personal protective equipment when handling the medications.

The nurse is reviewing the use of a condom to prevent the transmission of HIV with a young adult patient seeking testing for HIV. Which patient statement indicates an understanding of how to use a condom? a. Use a non-latex condom. b. Apply adequate oil-based lubricant. c. Apply condom before penile erection occurs. d. Withdraw from partner while the penis is erect.

d. Withdraw from partner while the penis is erect.

A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.

d. arrange for one-on-one supervision.

Withdrawn patients diagnosed with schizophrenia: a. are usually violent toward caregivers. b. universally fear sexual involvement with therapists. c. exhibit a high degree of hostility as evidenced by rejecting behavior. d. avoid relationships because they become anxious with emotional closeness.

d. avoid relationships because they become anxious with emotional closeness.

A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) b. clonidine (Catapres) c. risperidone (Risperdal) d. carbamazepine (Tegretol)

d. carbamazepine (Tegretol)

The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention "monitor for complications of refeeding." Which system should a nurse closely monitor for dysfunction? a. renal b. endocrine c. integumentary d. cardiovascular

d. cardiovascular

A nurse provided medication education for a patient diagnosed with major depression who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient: a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. can identify foods with high selenium content that should be avoided. d. confers with a pharmacist when selecting over-the-counter medications.

d. confers with a pharmacist when selecting over-the-counter medications.

The nurse provides comfort measures to maintain normal body temperature and reduce pain and anxiety for a patient who is experiencing shock. What is the purpose of the nurse performing these actions? a. Increases fluid volume b. Decreases fluid volume c. Increases oxygen demand d. Decreases oxygen demand

d. decreases oxygen demand

A nurse determines desired outcomes for a patient diagnosed with schizotypal personality disorder. Select the best outcome. The patient will: a. adhere willingly to unit norms. b. report decreased incidence of self-mutilative thoughts. c. demonstrate fewer attempts at splitting or manipulating staff. d. demonstrate ability to introduce self to a stranger in a social situation.

d. demonstrate ability to introduce self to a stranger in a social situation.

The nurse is developing a plan for psychoeducational sessions for several adults diagnosed with schizophrenia. Which goal is best for this group? Members will: a. gain insight into unconscious factors that contribute to their illness. b. explore situations that trigger hostility and anger. c. learn to manage delusional thinking. d. demonstrate improved social skills.

d. demonstrate improved social skills.

A patient has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines that the P-R interval is 0.24 seconds. The most appropriate intervention by the nurse would be to a. notify the health care provider immediately. b. give atropine per agency dysrhythmia protocol. c. prepare the patient for temporary pacemaker insertion. d. document the finding and continue to monitor the patient.

d. document the finding and continue to monitor the patient.

A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse will: a. bring up the issue at the community meeting. b. calmly tell the patient, "You must bathe daily." c. avoid forcing the issue in order to minimize stress. d. firmly and neutrally assist the patient with showering.

d. firmly and neutrally assist the patient with showering.

Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will: a. weigh self accurately using balanced scales. b. limit exercise to less than 2 hours daily. c. select clothing that fits properly. d. gain 1 to 2 pounds.

d. gain 1 to 2 pounds.

When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include: a. preoccupation with minute details; perfectionist. b. charm, drama, seductiveness; seeking admiration. c. difficulty being alone; indecisive, submissiveness. d. grandiosity, self-importance, and a sense of entitlement.

d. grandiosity, self-importance, and a sense of entitlement.

A nursing diagnosis for a patient diagnosed with bulimia nervosa is Ineffective coping related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will: a. appropriately express angry feelings. b. verbalize two positive things about self. c. verbalize the importance of eating a balanced diet. d. identify two alternative methods of coping with loneliness.

d. identify two alternative methods of coping with loneliness.

When a client with AIDS experiences pain while swallowing, the nurse could suggest a. avoiding the use of straws while drinking. b. drinking acidic juices such as orange juice. c. eating very cold foods. d. increasing the intake of well-cooked eggs and noodle dishes.

d. increasing the intake of well-cooked eggs and noodle dishes.

A health care provider recently convicted of Medicare fraud says to a nurse, "Sure I overbilled. Everyone takes advantage of the government. There are too many rules to follow and I should get the money." These statements show: a. shame b. suspiciousness c. superficial remorse d. lack of guilt feelings

d. lack of guilt feelings

A patient diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should: a. sit close to the patient. b. place an arm protectively around the patient's shoulders. c. place a hand on the patient's arm and exert light pressure. d. maintain a normal social interaction distance from the patient.

d. maintain a normal social interaction distance from the patient

A patient diagnosed with major depression refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient? a. tomato juice b. orange juice c. hot tea d. milk

d. milk

Nursing care for a client in hypovolemic shock caused by trauma should include a. giving narcotics for pain relief. b. maintaining a cool environment. c. placing the client in Trendelenburg position. d. providing nasogastric suctioning.

d. providing nasogastric suctioning.

If a client admitted to the hospital for treatment of atrial fibrillation complains of dyspnea and chest pain, the nurse would suspect a. heart block. b. myocardial infarction. c. pulmonary edema. d. pulmonary emboli.

d. pulmonary emboli.

The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, P-R interval not measurable, ventricular rate 162, R-R interval regular, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as a. atrial flutter. b. sinus tachycardia. c. ventricular fibrillation. d. ventricular tachycardia.

d. ventricular tachycardia.

When analyzing a client's electrocardiograph (ECG) tracing, the nurse observes that not all QRS complexes are preceded by a P wave. What is the nurse's interpretation of this observation? a.The client has hyperkalemia causing irregular QRS complexes. b.Ventricular tachycardia is overriding the normal atrial rhythm. c.The client's chest leads are not making sufficient contact with the skin. d.Ventricular and atrial depolarizations are initiated from different sites.

d.Ventricular and atrial depolarizations are initiated from different sites.

The nurse has administered adenosine (Adenocard). What is the expected therapeutic response? a.Increased intraocular pressure b.A brief tonic-clonic seizure c.A short period of asystole d.Hypertensive crisis

c.A short period of asystole

A patient who had surgery 3 days ago has a temperature of 98°F (36.6°C), blood pressure 82/72 mm Hg, pulse 120 beats/minute, and respirations 30/minute. Which type of shock should the nurse suspect is occurring in this patient? a. Septic b. Neurogenic c. Cardiogenic d. Hypovolemic

a. septic

A patient is in normal sinus rhythm with prolonged PR intervals. What treatment should the nurse expect to be prescribed for this patient? A) Continue to monitor B) Anticipate defibrillating C) Prepare for cardioversion D) Prepare for pacemaker insertion

A) Continue to monitor

the nurse is working in an OB/GYN office and commonly obtains patient histories and performs initial assessments. which woman is likely to be referred for genetic counseling after her first visit? A. a woman whose male partner is 50 years of age B. a woman who carries a y linked disorder C. a pregnant woman who has a history of smoking D. an anxious woman with a normal serum screening result

A. a woman whose male partner is 50 years of age

The nurse is preparing a school-age child for a CT scan to assess cerebral function. which statement should the nurse include when preparing the child? A. "unfortunately no one can remain in the room with you during the test" B. "the scan will not hurt" c. "you will be able to move once the equipment is in place" D. "pain medication will be given"

B. "the scan will not hurt"

A patient being treated for cancer has a tumor designation of Stage IV, T4, N3, M1. What does this staging indicate to the nurse? A) The tumor is small in size. B) There is one single tumor to treat. C) The tumor will respond to chemotherapy. D) The tumor has metastasized with lymph node involvement.

D) The tumor has metastasized with lymph node involvement.

The nurse is caring for a patient who is undergoing diagnostic tests to rule out lung cancer. The patient asks the nurse why a computed tomography (CT) scan was ordered. What is the best response by the nurse? A) "The doctor prefers this test." B) "Why are you concerned about this test?" C) "It is more specific in diagnosing your condition." D) "To rule out the possibility that your problems are caused by pneumonia."

C) "It is more specific in diagnosing your condition."

a patient is scheduled for a cochlear implant. which patient statement indicates that teaching about this surgery has been effective? A. "this surgery will rebuild my damaged tympanic membrane" B. "I will be able to hear perfectly after this surgery" C. "this surgery will drain fluid from my middle ear D. " this implant will enhance my ability to understand speech"

D. " this implant will enhance my ability to understand speech"

A nurse is teaching a client about ear hygiene and health. What client statement indicates a need for further teaching? a. "A soft cotton swab is alright to clean my ears with." b. "I make sure my ears are dry after I go swimming." c. "I use good earplugs when I practice with the band." d. "Keeping my diabetes under control helps my ears."

a. "A soft cotton swab is alright to clean my ears with."

The nurse working at a first aid booth during a summer marathon sees several runners. Which runner should be seen first? A runner who: a. Has fallen several times b. Is fatigued c. Thinks he has the flu d. Has tachypnea

a. Has fallen several times

A newly hospitalized patient experiencing psychosis says, "Red chair out town board." Which term should the nurse use to document this finding? a. Word salad b. Neologism c. Anhedonia d. Echolalia

a. Word salad

The exact cause of bipolar disorder has not been determined; however, for most patients: a. several factors, including genetics, are implicated. b. brain structures were altered by stress early in life. c. excess sensitivity in dopamine receptors may trigger episodes. d. inadequate norepinephrine reuptake disturbs circadian rhythms.

a. several factors, including genetics, are implicated.

A patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first? a. Heart rate b. Breath sounds c. Body temperature d. Level of consciousness

b. Breath sounds

An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient: a. to eat a small meal after purging. b. not to skip meals or restrict food. c. to increase oral intake after 4 PM daily. d. the value of reading journal entries aloud to others.

b. not to skip meals or restrict food.

A patient with osteoporosis asks why the health problem developed. What nursing response would be appropriate for this patient? A) Osteoclasts break down bone with acids and enzymes. B) Osteoclastic activity is greater than osteoblastic activity. C) Osteoblastic activity is greater than osteoclastic activity. D) Osteoblasts synthesize and add minerals to the bony matrix.

B) Osteoclastic activity is greater than osteoblastic activity.

The nurse is providing care to several patients on a medical-surgical unit. Which patient is at highest risk for a nonthrombotic pulmonary embolism? A) The patient who is receiving intravenous pain medication B) The patient who is postoperative from a femur fracture repair C) The patient with a primary lung tumor D) The patient who uses intravenous illicit drugs

B) The patient who is postoperative from a femur fracture repair

A teenage girl is diagnosed with systemic lupus erythematosus (SLE). Which health promotion guidance is important for the nurse to provide? A. "Acetaminophen (Tylenol) is best for daily pain." B. "Consider adding vitamin D to your daily routine." C. "Plan to choose a career that is sedentary." D. "You should consider elective sterilization."

B. "Consider adding vitamin D to your daily routine."

a nurse should plan to implement which interventions for a child admitted with inorganic failure to thrive? select all that apply A. use of 28 calorie per ounce concentrated formulas B. observation of parent-child interactions C assignment of different nurses to care for the child from day to day D. administration of daily multivitamin supplements E. role-modeling appropriate adult-child interactions

B. observation of parent-child interactions D. administration of daily multivitamin supplements E. role-modeling appropriate adult-child interactions

the nurse monitors for which clinical manifestation in the patient presenting to the emergency department after being hit in the eye by a bat during a softball game? A. loss of peripheral vision B. pain and edema C. crusty exudate D. loss of central vision

B. pain and edema

the nurse coorelates which clinical manifestation to the patient being evaluated for menieres disease? A. nasal drainage B. positive romhberg test C. facial pain D. decreased deep tendon reflexes

B. positive romhberg test

A patient asks why cardiac leads are being placed on the chest. What should the nurse respond to this patient? A) "It shows where the heart vessels are blocked." B) "It is used to evaluate the effectiveness of dietary changes." 3 C) "It provides a graphic picture of the heart's electrical activity." D) "It determines which medications are needed to improve heart function."

C) "It provides a graphic picture of the heart's electrical activity."

A patient with severe hip pain is diagnosed with osteoarthritis (OA). What information should the nurse provide to the patient about this disease process? A) "OA causes an overgrowth of cartilage in the joints." B) "OA causes joint fluid to become bluish-white in color." C) "OA causes a decrease in joint fluid that affects the cartilage." D) "OA causes a build of fluid in the joints, hindering movement."

C) "OA causes a decrease in joint fluid that affects the cartilage."

A patient being treated with chemotherapy for cancer complains of fatigue, pallor, progressive weakness, exertional dyspnea, headache, and tachycardia. Which diagnosis should the nurse use as the priority when planning this patient's care? A) Powerlessness B) Ineffective Coping C) Activity Intolerance D) Imbalanced Nutrition, Less than Body Requirements

C) Activity Intolerance

the nurse monitors for which manifestation in the patient diagnosed with a cataract? A. redness of the sclera of the right eye B. itching of the right eye C. tearing of the right eye D. cloudy vision in the right eye

D. cloudy vision in the right eye

the parents of a child with ADHD ask the nurse for advice about discipline. the nurses response should be based on knowledge that discipline A. is not needed unless the child becomes problematic B. is too difficult to implement with this child C. is best achieved with punishment for misbehavior D. should be consistent and is essential for the child

D. should be consistent and is essential for the child

A 20-year-old has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54, and the student denies any health problems. What action by the nurse is most appropriate? a. Allow the student to participate on the soccer team. b. Refer the student to a cardiologist for further diagnostic testing. c. Tell the student to stop playing immediately if any dyspnea occurs. d. Obtain more detailed information about the student's family health history.

a. Allow the student to participate on the soccer team.

A patient is diagnosed with a malignant tumor of the bone. Which term should the nurse consider when documenting this patient's health problem? a. Sarcoma b. Osteoma c. Adenoma d. Carcinoma

a. Sarcoma

A patient diagnosed with schizophrenia begins to talks about "macnabs" hiding in the warehouse at work. The term "macnabs" should be documented as: a. a neologism. b. concrete thinking c. thought insertion d. an idea of reference

a. a neologism.

Physical assessment of a patient diagnosed with bulimia often reveals: a. prominent parotid glands. b. peripheral edema. c.thin, brittle hair. d. 25% underweight.

a. prominent parotid glands.

The nurse is working with a client who has severe rheumatoid arthritis in her hands. The client states that she is frustrated at mealtime because it is difficult for her to manage cups and silverware. What is the nurse's best response? a. "I'll have the nursing assistants set up your meal trays while you are in the hospital." b. "Let's see if the occupational therapist can provide you with some utensils that are easier for you to use." c. "I'll arrange for a home nursing assistant to help you with your meals after you are discharged from the hospital." d. "Let's see if the physical therapist can suggest some muscle strengthening exercises for you."

b. "Let's see if the occupational therapist can provide you with some utensils that are easier for you to use."

A client is undergoing radiation therapy and asks the nurse about skin care for the exposed area. Which statement by the nurse is most accurate? a. "No products work well to reduce the skin reactions you get from radiation." b. "No one product works best, so you can choose what you would like to use." c. "The only medication that works well for skin reactions is very expensive." d. "No good studies on skin care with radiation have been conducted to date."

b. "No one product works best, so you can choose what you would like to use."

The nurse is working with a client who will be taking 20 mg of prednisone daily for rheumatoid arthritis. Which precautions does the nurse give the client about taking this medication? a. "Take this medication at bedtime because it will make you sleepy." b. "Take calcium and vitamin D supplements daily." c. "Eat a high-fiber diet with lots of lean meats." d. "Wash your face twice a day with an antibacterial soap."

b. "Take calcium and vitamin D supplements daily."

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's appropriate response. a. "You will be able to stop the medication in about 1 month." b. "Taking the medication every day helps reduce the risk of a relapse." c. "Usually patients take medication for approximately 6 months after discharge." d. "It's unusual that the health care provider hasn't already stopped your medication."

b. "Taking the medication every day helps reduce the risk of a relapse."

A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eye drops cause eye burning and visual blurriness for a short time after administration. The best response to the patient's statement is a. "Those symptoms may indicate a need for an increased dosage of the eye drops." b. "The drops are uncomfortable, but it is important to use them to retain your vision." c. "These are normal side effects of the drug, which should be less noticeable with time." d. "Notify your health care provider so that different eye drops can be prescribed for you."

b. "The drops are uncomfortable, but it is important to use them to retain your vision."

The nurse is teaching a postmenopausal client about the risk of acquiring HIV infection. The client states, "I'm an old woman! I cannot possibly get HIV." What is the nurse's best response? a. "Your vaginal walls become thicker after menopause, which increases your risk." b. "Women in your age-group are the fastest growing population of AIDS clients today." c. "Hormonal fluctuations after menopause make it harder to fight off infection." d. "You might be right. How often do you engage in sexual activities?"

b. "Women in your age-group are the fastest growing population of AIDS clients today."

A client is undergoing radiation therapy and says, "I will be so glad when this is over and I don't have to worry about my skin." What response by the nurse is most appropriate? a. "Unfortunately, your skin will be permanently damaged from the radiation." b. "You need to protect your skin from the sun for at least a year afterward." c. "You can get a prescription for special lotions that reduce the effects of radiation." d. "You're having skin problems? That is unusual; let me take a look at your skin."

b. "You need to protect your skin from the sun for at least a year afterward."

A patient demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially? a. Confer with the health care provider to consider use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all staff and patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

b. Hold a staff meeting to discuss consistency and limit-setting approaches.

A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as: a. echolalia. b. an idea of reference. c. a delusion of infidelity. d. an auditory hallucination.

b. an idea of reference.

Distributive shock is primarily due to a. a fluid shift from the vascular space. b. an increase in the size of the vascular space. c. inadequate circulating blood volume. d. inadequate pumping action of the heart.

b. an increase in the size of the vascular space.

A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). What is the rationale for the addition of olanzapine to the medication regimen? It will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. be used for long-term control of hyperactivity.

b. bring hyperactivity under rapid control.

A patient diagnosed with depression repeatedly tells staff, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. a. powerlessness b. risk for suicide c. stress overload d. spiritual distress

b. risk for suicide

A client is using an ophthalmic beta-blocking agent for the treatment of glaucoma. Which instruction does the nurse give to the client to prevent orthostatic hypotension? a. "Change positions quickly after administering the drops." b. "Take your pulse at least four times daily." c. "Apply pressure to the inside corner of your eye when administering the drops." d. "Lay down for 10 minutes after administering the drops."

c. "Apply pressure to the inside corner of your eye when administering the drops."

A patient with HIV asks the nurse if thinking about dying frequently is common with HIV. What is an appropriate response by the nurse? a. "HIV is a serious disease that results in death." b. "Thinking about death will not change the prognosis." c. "HIV is now considered a chronic disease with treatment." d. "HIV has a very high mortality rate, so it is realistic to plan for death."

c. "HIV is now considered a chronic disease with treatment."

The client's chart indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause? a. "Do you feel like something is in your ear?" b. "Do you have frequent ear infections?" c. "Have you been exposed to loud noises?" d. "Have you been told your ear bones don't move?"

c. "Have you been exposed to loud noises?"

The nurse is caring for a pregnant client who is taking Humira (adalimumab) to control symptoms of rheumatoid arthritis. The client mentions the pain and inconvenience of the subcutaneous injections and asks, "While I'm pregnant, can I take this drug by mouth instead?" What is the nurse's best response? a. "I will ask the physician to write a prescription for you today." b. "Humira takes much longer to work when it is given orally." c. "Humira can be given only by subcutaneous injection." d. "You can switch from Humira to oral leflunomide (Arava)."

c. "Humira can be given only by subcutaneous injection."

A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I am bad. I have got to get away from them." Select the nurse's most helpful reply. a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I'll stay with you. Focus on what we are talking about, not the voices. " d. "Forget the voices and ask some other patients to play cards with you."

c. "I'll stay with you. Focus on what we are talking about, not the voices. "

The nurse asks a young adult client if she is sexually active. The client asks why the nurse needs to know. What is the nurse's best response? a. "I just need to make sure that the information you are providing is reliable." b. "I have to fill in answers to all of the questions on the health history form." c. "If you are sexually active, we should talk about ways to prevent getting HIV." d. "I will have to notify your partner if you have a sexually transmitted disease."

c. "If you are sexually active, we should talk about ways to prevent getting HIV."

A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, "Why are the individuals with black tags not receiving any care?" How should the nurse respond? a. "To do the greatest good for the greatest number of people, it is necessary to sacrifice some." b. "Not everyone will survive a disaster, so it is best to identify those people early and move on." c. "In a disaster, extensive resources are not used for one person at the expense of many others." d. "With black tags, volunteers can identify those who are dying and can give them comfort care."

c. "In a disaster, extensive resources are not used for one person at the expense of many others."

A client is receiving rituximab (Rituxan) and asks how it works. What response by the nurse is best? a. "It causes rapid lysis of the cancer cell membranes." b. "It destroys the enzymes needed to create cancer cells." c. "It prevents the start of cell division in the cancer cells." d. "It sensitizes certain cancer cells to chemotherapy."

c. "It prevents the start of cell division in the cancer cells."

A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important? a. "Be sure you get enough sleep at night." b. "Eat plenty of high-protein, high-iron foods." c. "Notify your provider at once if you get a fever." d. "Weigh yourself every day on the same scale."

c. "Notify your provider at once if you get a fever."

A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, "I can't believe that my wife is gone and I am left to raise my children all by myself." How should the nurse respond? a. "Please accept my sympathies for your loss." b. "I can call the hospital chaplain if you wish." c. "You sound anxious about being a single parent." d. "At least your children still have you in their lives."

c. "You sound anxious about being a single parent."

The nurse is working with a client at a public health clinic. The client says to the nurse, "The doctor said that my CD4+ count is 450. Is that good?" What is the nurse's best response? a. "Your count is high so you can cut back on your medication." b. "Your count is normal because your medications are working well." c. "Your count is a bit low and you are susceptible to infection." d. "Your count is very low and you actually now have AIDS."

c. "Your count is a bit low and you are susceptible to infection."

Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the patient's needs and maintain a therapeutic milieu? a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to provoke interpersonal conflict d. Inability to develop trusting relationships

c. Ability to provoke interpersonal conflict

Which manifestation is atypical of ADHD? a. Talking incessantly b. Blurting out the answers to questions before the questions have been completed c. Acting withdrawn in social situations d. Fidgeting with hands or feet

c. Acting withdrawn in social situations

A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? Select all that apply. a. Flexible mealtimes b. Unscheduled weight checks c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips f. Privileges correlated with emotional expression

c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips

Which nursing diagnosis is more appropriate for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient diagnosed with bulimia nervosa who purges? a. Powerlessness b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements

d. Imbalanced nutrition: less than body requirements

A client is in the preoperative holding area waiting for cataract surgery. The client says "Oh, yeah, I forgot to tell you that I take clopidogrel, or Plavix." What action by the nurse is most important? a. Ask the client when the last dose was. b. Check results of the prothrombin time (PT) and international normalized ratio (INR). c. Document the information in the chart. d. Notify the surgeon immediately.

d. Notify the surgeon immediately.

The most common cause of acute renal failure in children is a. Pyelonephritis b. Tubular destruction c. Urinary tract obstruction d. Severe dehydration

d. Severe dehydration

Which initial assessment made by the triage nurse suggests that a child requires immediate intervention? a. The child has thick yellow rhinorrhea. b. The child has a frequent nonproductive cough. c. The child's oxygen saturation is 95% by pulse oximeter. d. The child is grunting.

d. The child is grunting.

When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F (30.6° C), which assessment indicates that the nurse should discontinue active rewarming? a. The patient begins to shiver. b. The BP decreases to 86/42 mm Hg. c. The patient develops atrial fibrillation. d. The core temperature is 94° F (34.4° C).

d. The core temperature is 94° F (34.4° C).

The nurse is caring for the newborn of a mother who is HIV positive. What treatment should the nurse expect to be prescribed for the infant? a. Bacitracin b. Erythromycin c. Protease inhibitor d. Zidovudine (AZT)

d. Zidovudine (AZT)

A nurse worked with a patient diagnosed with major depression, severe withdrawal, and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at risk for feelings of: a. guilt and despair. b. over-involvement. c. interest and pleasure. d. ineffectiveness and frustration.

d. ineffectiveness and frustration.

The critical care nurse explains to the family of a client who is to receive nimodipine following hemorrhagic stroke that the purpose of this drug is to treat a. dizziness. b. hypertension. c. spasticity. d. vasospasm.

d. vasospasm.

A nurse notes that the PR interval on a client's electrocardiograph (ECG) tracing is 0.14 second. What action does the nurse take? a.Assess serum cardiac enzymes. b.Administer 1 mg epinephrine IV. c.Administer oxygen via nasal cannula. d.Document the finding in the client's chart.

d.Document the finding in the client's chart.

A patient receiving radiation therapy as treatment for colorectal cancer is experiencing nausea and vomiting. What should the nurse encourage the patient to do? A) Use a commercial mouthwash before eating a meal. B) Eat spicy or well-seasoned foods instead of bland foods. C) Delay the intake of a meal until three to four hours after treatment. D) Avoid all food and liquid until nausea and vomiting stop.

C) Delay the intake of a meal until three to four hours after treatment.

The nurse is planning care for a newly admitted patient diagnosed with pulmonary embolism. The nurse anticipates the patient will need anticoagulant therapy. What is true regarding this therapy for the treatment of this condition? A) It is considered second-line treatment. B) Major hemorrhage is common. C) Heparin and warfarin (Coumadin) are usually initiated at the same time. D) Heparin alters the synthesis of vitamin K-dependent clotting factors, preventing further clots

C) Heparin and warfarin (Coumadin) are usually initiated at the same time.

the teaching plan for the parents of a 3 year old child with amblyopia (lazy eye) should include what instruction? A. apply a patch only during waking hours B. apply a patch to the childs eyeglasses C. cover the "good" eye completely with a patch D. apply a patch over the "bad" eye to strengthen it

C. cover the "good" eye completely with a patch

an infant is hospitalized with FFT ( failure to thrive). the nurse should plan care that includes A. placement in foster care or adoption B. child's routine habits and preferences are maintained C. evaluation of and interventions for nutritional support D. parents' expectations are being met

C. evaluation of and interventions for nutritional support

A patient is suspected of having osteoporosis. Which diagnostic test should the nurse expect to be prescribed for this patient? A) MRI B) CT scan C) Bone scan D) DEXA scan

D) DEXA scan

a patient seeking medical attention for "buzzing in the ears" asks why the blood pressure is being measured. what is the nurses' best response? A. "the blood pressure is used to determine what medication you will need" B. "the ear buzzing means your blood vessels are constricted" C. "blood pressure measurement is done on every patient" D. "elevated blood pressure makes the buzzing more noticable"

D. "elevated blood pressure makes the buzzing more noticable"

a parent asks the nurse why a developmental assessment is being conducted for a child during a routine well child visit. the nurse answers based on the knowledge that routine developmental assessments during well child visits are A. frightening to parents and children and should be avoided B. not necessary unless the parents request them C. valuable in measuring intelligence in children D. the best method for early detection of cognitive disorders

D. the best method for early detection of cognitive disorders

A nurse is teaching a community group about preventing hearing loss. What instruction is best? a. Always wear a bicycle helmet. b. Avoid swimming in ponds or lakes. c. Don't go to fireworks displays. d. Use a soft cotton swab to clean ears.

a. Always wear a bicycle helmet.

A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important? a. Assess the client's gait and balance. b. Ask the client about the ease of urine flow. c. Document the report completely. d. Inquire about the client's job risks.

a. Assess the client's gait and balance.

A client who has had a stroke appears to understand words that are spoken but cannot verbally respond. The nurse clarifies that this type of aphasia is a. Broca's. b. global. c. receptive. d. Wernicke's.

a. Broca's.

What is the goal of the initial intervention for a child in cardiopulmonary arrest? a. Establishing a patent airway b. Determining a pulse rate c. Removing clothing d. Reassuring the parents

a. Establishing a patent airway

The primary clinical manifestations of acute renal failure are a. Oliguria and hypertension b. Hematuria and pallor c. Proteinuria and muscle cramps d. Bacteriuria and facial edema

a. Oliguria and hypertension

Which type of incontinence is most common after a difficult vaginal delivery? a. Stress b. Urge c. Reflex d. Overflow

a. Stress

The nurse would assess a heart rate of 55 beats/min as a normal finding in a client who a. is an athlete. b. is obese. c. takes a diuretic. d. weighs less than 90 pounds.

a. is an athlete.

During the preoperative assessment of the patient scheduled for a right cataract extraction and intraocular lens implantation, it is most important for the nurse to assess a. the visual acuity of the patient's left eye. b. how long the patient has had the cataract. c. for a white pupil in the patient's right eye. d. for a history of reactions to general anesthetics.

a. the visual acuity of the patient's left eye

A patient became depressed after the last of the family's six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. The patient will: a. verbalize realistic positive characteristics about self by (date). b. agree to take an antidepressant medication regularly by (date). c. initiate social interaction with another person daily by (date). d. identify two personal behaviors that alienate others by (date).

a. verbalize realistic positive characteristics about self by (date).

A client is experiencing sinus bradycardia with hypotension and dizziness. What medication does the nurse administer? a.Atropine (Atropine) b.Digoxin (Lanoxin) c.Lidocaine (Xylocaine) d.Metoprolol (Lopressor)

a.Atropine (Atropine)

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. Which action should the nurse take next? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.

b. Assess vital signs and level of consciousness.

A client is in shock and is receiving naloxone (Narcan). The client's sibling is an EMT and questions why the client is getting medication for "an overdose." The most appropriate response by the nurse is a. "Because of HIPAA laws, I am not allowed to tell you about his/her care." b. "I don't know but I can have the doctor come and speak with you." c. "In clients with shock it helps the hypotension and cardiac output." d. "The client may have gotten too much morphine in the emergency department."

c. "In clients with shock it helps the hypotension and cardiac output."

What action is not appropriate for a 14-month-old child with iron deficiency anemia? a. Decreasing the infant's daily milk intake to 24 oz or less b. Giving oral iron supplements between meals with orange juice c. Including apricots, dark-green leafy vegetables, and egg yolk in the infant's diet d. Allowing the infant to drink the iron supplement from a small medicine cup

d. Allowing the infant to drink the iron supplement from a small medicine cup

A patient is newly diagnosed with a trauma related disorder. Which medication should the nurse expect to be prescribed for this patient? a. Paroxetine (Paxil) b. Sertraline (Zoloft) c. Buspirone (Buspar) d. Alprazolam (Xanax)

d. Alprazolam (Xanax)

A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? a. Chooses high-protein food b. Has decreased oral discomfort c. Eats 90% of meals and snacks d. Has a weight gain of 2 pounds/1 month

d. Has a weight gain of 2 pounds/1 month

A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "My computer is sending out infected radiation beams." The nurse can correctly assess this information as an indication of: a. the need for psychoeducation. b. medication noncompliance. c. chronic deterioration. d. relapse.

d. relapse.

The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include: a. arrogant, grandiose, and a sense of self-importance. b. attention seeking, melodramatic, and flirtatious. c. impulsive, restless, socially aggressive behavior. d. socially anxious, rambling stories, peculiar ideas.

d. socially anxious, rambling stories, peculiar ideas.

When the nurse in charge of the code is ready to defibrillate a client, the nurse assisting with the defibrillation would a. assess for unresponsiveness. b. continue to perform CPR. c. prepare to administer lidocaine. d. stand away from the bed.

d. stand away from the bed.

The nursing action that would be appropriate in caring for a client who has experienced stroke because of hemorrhage is to a. maintain the head of the bed in a flat position. b. monitor rectal temperature every 4 hours. c. teach isometric exercises. d. teach the client to avoid the Valsalva maneuver.

d. teach the client to avoid the Valsalva maneuver.

When teaching a client who is HIV positive, the nurse should explain that the virus can be transmitted a. as soon as manifestations of illness appear. b. once the diagnosis has been made. c. only to another susceptible host. d. to anyone having contact with blood or semen.

d. to anyone having contact with blood or semen.

When assisting a blind patient in ambulating to the bathroom, the nurse should a. take the patient by the arm and lead the patient slowly to the bathroom. b. have the patient place a hand on the nurse's shoulder and guide the patient. c. stay beside the patient and describe any obstacles on the path to the bathroom. d. walk slightly ahead of the patient and allow the patient to hold the nurse's elbow.

d. walk slightly ahead of the patient and allow the patient to hold the nurse's elbow.

The nurse identifies a client's rhythm to be a sustained supraventricular tachycardia. What medication does the nurse administer? a.Atropine (Atropine) b.Epinephrine (Adrenalin) c.Lidocaine (Xylocaine) d.Diltiazem (Cardizem)

d.Diltiazem (Cardizem)

The nurse is monitoring a patient who has been in a shock state for several days. For which serious complications should the nurse observe in the patient and then report? (Select all that apply.) a. Sepsis b. Malnutrition c. Diabetes mellitus d. Cerebrovascular accident e. Adult respiratory distress syndrome f. Multiple organ dysfunction syndrome

e. Adult respiratory distress syndrome f. Multiple organ dysfunction syndrome

The nurse is teaching a patient scheduled for a colonoscopy on pre- and postprocedure care. Which statement by the patient indicates the need for further teaching? A) "It might be quite painful." B) "The procedure will only take about one hour." C) "The physician might take tissue samples for further analysis." D) "I will likely have medications that will make me drowsy during the test."

A) "It might be quite painful."

A patient with shortness of breath has a heart rhythm of 46 beats per minute. Which medication should the nurse anticipate being prescribed for this patient? A) Atropine sulfate B) Atenolol (Tenormin) C) Diltiazem (Cardizem) D) Adenosine (Adenocard)

A) Atropine sulfate

The nurse is providing discharge instructions to a patient being treated for cancer. For which symptoms should the patient be instructed to call for help at home? Select all that apply. A) Desire to end life B) Difficulty breathing C) New onset of bleeding D) Improved sense of well-being E) Significant increase in vomiting

A) Desire to end life B) Difficulty breathing C) New onset of bleeding E) Significant increase in vomiting

A nurse is planning care for a patient with leukemia. The nurse chooses "Risk for Bleeding" as the nursing diagnosis. Which interventions support this nursing diagnosis? A) Educate patient in use of soft toothbrush for oral care B) Use non-electric razor when providing grooming for patient C) Apply pressure to arterial puncture sites for 5 minutes D) Encourage patient to breathe deeply and huff cough frequently

A) Educate patient in use of soft toothbrush for oral care

A nurse is caring for a patient who is diagnosed with skin cancer. Which nursing interventions will reduce the growth of cancer cells and support normal cell function? Select all that apply. A) Increasing calorie intake B) Encouraging mobility and exercise C) Encouraging increased rest and sleep D) Assessing normal functioning of organ systems E) Reducing oxygen supply to retard growth of cancer cells

A) Increasing calorie intake C) Encouraging increased rest and sleep D) Assessing normal functioning of organ systems

The nurse is caring for an adolescent Asian patient with a strong family history of breast cancer. What should the nurse teach the patient regarding cancer prevention? A) Perform monthly breast self-examination. B) Teach the side effects of cancer treatment. C) Talk to family members who have the disease. D) Discuss cancer fears with the health-care provider.

A) Perform monthly breast self-examination.

A nurse is caring for a patient with leukemia who is neutropenic. Which intervention will the nurse implement to ensure this patient's safety? A) Place patient in reverse isolation B) Place patient in standard precaution isolation C) Administer a prophylactic gram-negative antibiotic D) Administer neutrophil colony-stimulating factor (N-CSF) as ordered

A) Place patient in reverse isolation

The nurse accompanies the health-care provider into the patient's room and listens as the diagnosis of cancer is shared with the patient and family. Once the health-care provider leaves the room, the nurse notes that the patient and family are teary-eyed regarding the diagnosis. What is the nurse's most appropriate intervention at this time? A) Provide emotional support in coping with the diagnosis. B) Help the patient and family remain realistic about prognosis. C) Provide teaching about the treatment options for this form of cancer. D) Arrange for the patient to complete a medical power of attorney form.

A) Provide emotional support in coping with the diagnosis.

a woman tells the nurse at a prenatal interview that she has quit smoking, only has a glass of wine with dinner, and has cut down on coffee to four cups a day. what response by the nurse will be most helpful in promoting lifestyle changes? A. "You have made some great progress toward having a healthy baby. Let's talk about the changes you have made." B. "You need to do a lot better than that. You may still be hurting your baby right now." C. "Those few things won't cause any trouble. Good for you." D. "Here are some pamphlets for you to study. They will help you find more ways to improve."

A. "You have made some great progress toward having a healthy baby. Let's talk about the changes you have made."

A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patient's head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely? a. An acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia

A. An acute dystonic reaction

The teaching plan for a 7-year-old boy with color deficiency should include which instruction? A. Teach him an alternate way to distinguish between the colors of traffic signals. B. buy only one color of clothing to ensure the child's ability to match items himself C. patching the weaker eye will improve focus and his color vision D. botulism toxin drops must be administered every 2 months to improve color vision

A. Teach him an alternate way to distinguish between the colors of traffic signals.

the nurse is preparing information about ear health for a community health fair. the nurse includes which risk factors for the development of otitis media? select all that appply A. current upper respiratory infection B. chronic illness C. exposure to smoking D. genetic predisposition E. flat eustachian tube in children

A. current upper respiratory infection C. exposure to smoking D. genetic predisposition E. flat eustachian tube in children

the nurse monitors for which clinical manifestations in the patient diagnosed with external otitis? select all that apply A. edema of the ear canal B. pain when moving the auricle C. purulent drainage from the ear D. swelling around the external ear E. external ear tender to touch

A. edema of the ear canal B. pain when moving the auricle D. swelling around the external ear E. external ear tender to touch

the nurse is caring for a patient recovering from cataract removal surgery. which action does the nurse take to reduce intraocular pressure (IOP) A. elevating the HOB 30 to 45 degrees B. restricting oral and intravenous fluid administration C. positioning on the operative side D. administering mydriatic eye drops

A. elevating the HOB 30 to 45 degrees

what should the nurse keep in mind when planning to communicate with a child who has autism? A. the child may exhibit parroting and echolalia B. the child is not listening if she is not maintaining eye contact C. the child is shy by has normal verbal communication D. expect the child to use sign language

A. the child may exhibit parroting and echolalia

the nurse monitors for which clinical manifestations in the patient being treated for menieres disease? A. uncontrollable eye movements B. muscle cramps C. drop in blood pressure D. capillary glucose 60 mg/dL

A. uncontrollable eye movements

The nurse is preparing to perform a health assessment on an adult patient who has a family history of cancer. Which questions should the nurse ask the patient to assess for the early warning signs of cancer? Select all that apply. A) "Have you noticed a change in your appetite?" B) "Have you noticed any cuts that have not healed?" C) "Have you had any changes in bowel or bladder habits?" D) "Have you experienced any problems swallowing?" E) "Do you have a cough that is not associated with seasonal allergies?

B) "Have you noticed any cuts that have not healed?" C) "Have you had any changes in bowel or bladder habits?" D) "Have you experienced any problems swallowing?" E) "Do you have a cough that is not associated with seasonal allergies?

The nurse instructs a group of community members about ways to reduce the development of cancer. Which participant statements indicate that teaching has been effective? Select all that apply. A) "I need to cut down on my smoking." B) "I need to get my home tested for radon." C) "I need to keep my children away from smokers." D) 'Sunscreen should be applied before spending time outdoors." E) "I should eat at least two servings of fruits or vegetables each day."

B) "I need to get my home tested for radon." C) "I need to keep my children away from smokers." D) 'Sunscreen should be applied before spending time outdoors."

The nurse is preparing a seminar that discusses the risk and incidence of cancer and culture. What information is considered culturally correct when teaching about the risk of developing cancer? A) Hispanics have an increased risk of cervical, stomach, and liver cancer. B) African-Americans are more likely to develop cancer than any other ethnic group. C) The incidence and mortality rate of all type of cancers are lowest in the Caucasian population. D) African-Americans are less likely to develop cancer than any other ethnic or racial group in the United States.

B) African-Americans are more likely to develop cancer than any other ethnic group.

The nurse is assisting the health-care provider with a bone marrow aspiration and biopsy on a patient who has leukemia. The patient also has thrombocytopenia. Upon completing of the test, which intervention is a priority for the nurse? A) Make certain the patient understands the purpose of the test. B) Hold pressure on the wound for approximately five minutes. C) Label and refrigerate the specimen obtained by the physician. D) Dispose of the equipment used, and clean the area properly.

B) Hold pressure on the wound for approximately five minutes.

A patient is experiencing supraventricular tachycardia. What should be done before determining this patient's treatment? A) Assess for thyroid disease B) Identify the underlying rhythm C) Evaluate serum electrolyte values D) Study lifestyle and behavioral habits

B) Identify the underlying rhythm

which question by the nurse will most likely promote sharing of sensitive information during a genetic counseling interview? A. "How many people in your family are mentally retarded or handicapped?" B. "Are there any family members who have learning or developmental problems?" C. "What kinds of defects or diseases seem to run in the family?" D. "Did you know that you can always have an abortion if the fetus is abnormal?"

B. "Are there any family members who have learning or developmental problems?"

the nurse provides instruction for an adult patient who is prescribed ear drops in the treatment of otitis media. which patient statement indicates the need for additional teaching? A. "I will place a cotton ball in the ear after the drops are administered" B. "I will pull the pinna down and back to administer the drops" C. "I will gently move my head back and forth after administering the drops" D. "I will place the bottle of ear drops in warm water for several minutes before administration"

B. "I will pull the pinna down and back to administer the drops"

the most common type of hearing loss, which results from interference of transmission of sound to the middle ear, is called A. mixed conductive-sensorineural B. conductive C. central auditory imperceptive D. sensorineural

B. conductive

the school nurse is caring for a child with a penetrating eye injury. Emergency treatment includes which of the following? A. taping the affected eye closed B. covering the both eyes until evaluated C. irrigating the eye with normal saline D. applying ice until the physician is seen

B. covering the both eyes until evaluated

a patient comes into the emergency department with clinical manifestations of retinal detachment. what action by the nurse is the priority to minimize this patient's eye movements? A. provide a sedative B. loosely cover both eyes C. apply an eye patch over the affected eye D. elevate the HOB 45 degrees

B. loosely cover both eyes

The nurse is preparing to discharge a patient recovering from a pulmonary embolism. Which topics are appropriate for the nurse to include in the teaching session? A) Resume the use of any over-the-counter medications B) Diet to include green leafy vegetables C) Anticoagulant administration schedule D) Resume normal activity level

C) Anticoagulant administration schedule

A patient is being cardioverted for symptomatic atrial fibrillation. At which point of the cardiac cycle will the electric impulse occur? A) At the end of the P wave B) Before the QRS complex C) At the peak of the R wave D) After the QRS complex but before the T wave

C) At the peak of the R wave

A patient's heart rate is 48 beats per minute. Which structure is most likely generating this heart rate? A) Purkinje fibers B) Sinoatrial node C) Atrioventricular node D) Ventricular pacer cells

C) Atrioventricular node

A nurse is caring for a patient with cancer. The nurse teaches the patient about which potentially undesirable cellular alterations that can occur during the cell cycle? A) Dysphagia B) Adaptation C) Hyperplasia D) Differentiation

C) Hyperplasia

a patient with external otitis rates pain as 8 on a scale of 0-10. what action does the nurse take to address the patients comfort? A. position supine with affected ear up B. position supine with affected ear down C. apply warm, dry heat to the ear D. apply cool compress to the ear

C. apply warm, dry heat to the ear

a patient with severe meniere's disease is considering a labyrinthectomy. what potential complication does the nurse include in the preoperative teaching? A. chronic otitis media B. rupture of tympanic membrane C. complete hearing loss of the affected ear D. long term tinnitus

C. complete hearing loss of the affected ear

The nurse is caring for a patient who had a bone marrow transplant for the treatment of leukemia several weeks ago. The patient requires protective isolation. Which statement by the patient's family indicates understanding of this type of isolation? A) "It will be important to restrict all visitors." B) "We will encourage oral hygiene twice a day." C) "You will have to administer all medications by IM injection." D) "We will encourage meticulous hand washing among all visitors."

D) "We will encourage meticulous hand washing among all visitors."

The nurse is preparing to defibrillate a patient. Which setting should the nurse use for this treatment? A) 50 J B) 100 J C) 150 J D) 200 J

D) 200 J

In explaining the rationale for the patient prescribed diphenhydramine to treat tinnitus, what is the nurses best response? A. "This is a vitamin supplement that will improve blood flow to the ears" B. "this is an antibiotic that will cure the problem" C. " this is an anticonvulsant that will stop the aura of the noises" D. "this is a decongestant to help reduce the symptoms"

D. "this is a decongestant to help reduce the symptoms"

the nurse recognizes which patient is at highest risk for developing macular degeneration? A. 55 year old man with HTN B. 70 year old man with history of smoking for 50 years C. 45 year old woman with bmi of 36 D. 65 year old woman with elevated cholesterol levels

D. 65 year old woman with elevated cholesterol levels

in the immediate postoperative period after typmanoplasty, how does the nurse position the patient? A. flat on the affected side B. HOB elevated 60 degrees C. supine with eyes toward ceiling D. flat with operative ear facing up

D. flat with operative ear facing up

a patient who has a hyphema is at risk for developing which condition? A. diplopia B. strabisums C. astigatism D. glaucoma

D. glaucoma

in administering pilocarpine to a patient, the nurse correlates which mechanism of action to this medication? A. decreases production of aqueous humor B. vasocontricts blood vessels C. suppresses the inflammatory response D. increases outflow of aqueous humor

D. increases outflow of aqueous humor

which medication does the nurse correlate to the treatment of vertigo in the patient diagnosed with menieres disease? A. dimenhydrinate (dramamine) B. promethazine (phenergan) C. diazepam (valium) D. meclizine (antivert)

D. meclizine (antivert)

the nurse correlates decreased peripheral vision in both eyes to which eye disorder? A. closed angle glaucoma B. secondary glaucoma C. normal tension glaucoma D. open angle glaucoma

D. open angle glaucoma

The emergency department nurse manager is explaining concepts of emergency and disaster preparedness to a group of students. Which statement by the nurse manager is most accurate? a. "An internal disaster is something that occurs inside the health care facility." b. "An external disaster occurs when someone not employed here disrupts our operations." c. "A multi-casualty event involves disasters at several different locations." d. "The Joint Commission requires that we participate in a disaster drill once a year."

a. "An internal disaster is something that occurs inside the health care facility."

A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.) a. "Avoid acetaminophen in over-the-counter medications." b. "It may take several weeks to become effective on pain." c. "Pregnancy and breast-feeding are not affected by MTX." d. "Stay away from large crowds and people who are ill." e. "You may find that folic acid, a B vitamin, reduces side effects."

a. "Avoid acetaminophen in over-the-counter medications." b. "It may take several weeks to become effective on pain." d. "Stay away from large crowds and people who are ill." e. "You may find that folic acid, a B vitamin, reduces side effects."

A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure? a. "Clean the skin and clip hairs if needed." b. "Add gel to the electrodes prior to applying them." c. "Place the electrodes on the posterior chest." d. "Turn off oxygen prior to monitoring the client."

a. "Clean the skin and clip hairs if needed."

A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure? a. "Clean the skin and clip hairs if needed." b. "Add gel to the electrodes prior to applying them." c. "Place the electrodes on the posterior chest." d. "Turn off oxygen prior to monitoring the client."

a. "Clean the skin and clip hairs if needed."

The nurse is teaching a wilderness survival class. Which statement by a participant indicates that additional teaching is needed? a. "If I get too cold, I can have some brandy to help me get warmed up." b. "My climbing partner should let me know right away if my nose turns white." c. "If my partner can't think straight, we should descend to a lower altitude." d. "It is okay to feel a little short of breath when I am climbing, but not at rest."

a. "If I get too cold, I can have some brandy to help me get warmed up."

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client's teaching? (Select all that apply.) a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)." e. "Do not lift your left arm above the level of your shoulder for 8 weeks."

a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." e. "Do not lift your left arm above the level of your shoulder for 8 weeks."

The nurse is working with a paramedic who just finished assisting at the scene of a school shooting where several students were killed. Which statement by the nurse is most therapeutic? a. "Would you like to talk about what happened?" b. "Surely the department will give you the day off tomorrow." c. "At least the gunman was taken into custody." d. "Let's just sit here for a while quietly."

a. "Would you like to talk about what happened?"

A client has a foreign body in the eye. What action by the nurse takes priority? a. Administering ordered antibiotics b. Assessing the client's visual acuity c. Obtaining consent for enucleation d. Removing the object immediately

a. Administering ordered antibiotics

A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important? a. Assessing the IV site every hour b. Educating the client on side effects c. Monitoring the client for nausea d. Providing warm packs for comfort

a. Assessing the IV site every hour

Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore needs for health teaching.

a. Assist the patient to identify triggers to binge eating.

A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with stage 1 HIV disease are not infectious to others.

a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death.

A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is best? a. Call the client at home the next day to review teaching. b. Give the client information about a cancer support group. c. Provide all the preoperative instructions in writing. d. Reassure the client that surgery will be over soon.

a. Call the client at home the next day to review teaching.

A client had cataract surgery. What instructions should the nurse provide? (Select all that apply.) a. Call the doctor for increased pain. b. Do not bend over from the waist. c. Do not lift more than 10 pounds. d. Sexual intercourse is allowed. e. Use stool softeners to avoid constipation.

a. Call the doctor for increased pain. b. Do not bend over from the waist. c. Do not lift more than 10 pounds. e. Use stool softeners to avoid constipation.

The nurse working with oncology clients understands that which age-related change increases the older client's susceptibility to infection during chemotherapy? a. Decreased immune function b. Diminished nutritional stores c. Existing cognitive deficits d. Poor physical reserves

a. Decreased immune function

A patient who has been treated for breast cancer is undergoing routine laboratory work. Which laboratory finding would cause the nurse to be most concerned about metastasis? a. Elevated serum calcium b. Decreased serum calcium c. Elevated serum potassium d. Decreased serum potassium

a. Elevated serum calcium

A patient with schizophrenia is returning from a CT scan of the brain followed by an electroencephalogram. Which diagnostic test findings should the nurse identify as supporting this patient's diagnosis? (Select all that apply.) a. Enlarged ventricles b. Reduced amount of gray matter c. Areas of nerve de-myelinization d. Aneurysms of the cerebral vessels e. Diminished prefrontal cortex activity

a. Enlarged ventricles b. Reduced amount of gray matter e. Diminished prefrontal cortex activity

A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse prepare to administer? a. Epoetin alfa (Epogen) b. Filgrastim (Neupogen) c. Mesna (Mesnex) d. Oprelvekin (Neumega)

a. Epoetin alfa (Epogen)

Which intervention is most important for the nurse to teach the client who is recovering from an allergic reaction to a bee sting? a. How to use an EpiPen b. Wearing a medical alert bracelet c. Avoiding contact with the allergen d. Keeping diphenhydramine (Benadryl) available

a. How to use an EpiPen

A student nurse caring for a patient diagnosed with depression reads in the patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply. a. Imbalanced nutrition: less than body requirements b. Chronic low self-esteem c. Sexual dysfunction d. Self-care deficit e. Powerlessness f. Insomnia

a. Imbalanced nutrition: less than body requirements c. Sexual dysfunction d. Self-care deficit f. Insomnia

A client has labyrinthitis and is prescribed antibiotics. What instruction by the nurse is most important for this client? a. Immediately report headache or stiff neck. b. Keep all follow-up appointments. c. Take the antibiotics with a full glass of water. d. Take the antibiotic on an empty stomach.

a. Immediately report headache or stiff neck.

A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge? a. Medication reconciliation b. Immunization history c. Religious beliefs d. Nutrition preferences

a. Medication reconciliation

The nurse is preparing to care for a patient who is HIV positive. Which action should the nurse take when following standard precautions for protection from HIV exposure? a. Put on gloves before touching body fluids. b. Recap intramuscular needles after injection. c. Wash own open skin lesion after providing care. d. Remove one finger on a glove during venipuncture.

a. Put on gloves before touching body fluids.

Which documentation for a patient diagnosed with major depression indicates the treatment plan was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. b. Slept 10 hours uninterrupted. Attended craft group; stated "project was a failure, just like me." c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, "I feel tired all the time."

a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.

The nurse assists with admission of a patient to the hospital with pancreatitis and a history of alcohol abuse. Why should the nurse observe the patient for agitation, tremors, and hallucinations? a. These are symptoms of alcohol withdrawal. b. These symptoms indicate possible cirrhosis of the liver. c. The patient may be using alcohol in the hospital setting. d. Patients with a history of alcohol abuse are at risk for mental illness.

a. These are symptoms of alcohol withdrawal.

The nurse is assisting in the care of a patient with early signs and symptoms of shock. Which diagnostic tests should the nurse expect to be prescribed for this patient? (Select all that apply.) a. Urinalysis b. Chest x-ray c. Arterial blood gas d. Complete blood count e. Electroencephalogram (EEG) f. Blood type and crossmatch

a. Urinalysis b. Chest x-ray c. Arterial blood gas d. Complete blood count f. Blood type and crossmatch

When planning a community teaching event, the nurse should recognize that the group in which HIV infection is growing most rapidly is a. adults older than 50 years. b. blacks and Hispanics. c. black teenagers. d. gay white men.

a. adults older than 50 years.

An elderly client was admitted yesterday for dehydration. The client has an IV infusion and a Foley catheter. Today the client appears restless and will not eat. The client's vital signs are T 99.2° F, P 88 beats/min, R 20 breaths/min, BP mm Hg. The nurse should first assess the client further for a. an infection. b. medication usage. c. orientation status. d. stroke/TIA.

a. an infection.

A client with ischemic heart disease has an electrocardiograph (ECG) tracing that shows a PR interval of 0.24 second. What is the nurse's best action? a.Document the finding in the chart. b.Measure blood pressure. c.Notify the health care provider. d.Administer oxygen.

a.Document the finding in the chart.

A client's cardiac status is being observed by telemetry monitoring. The nurse observes a P wave that changes shape in lead II. What conclusion does the nurse make about the P wave? a.It originates from an ectopic focus. b.The P wave was replaced by U waves. c.It is from the sinoatrial (SA) node. d.Multiple P waves are present.

a.It originates from an ectopic focus.

The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide? a. "A high proportion of patients with bipolar disorders are found among creative writers." b. "A higher rate of relatives with bipolar disorder is found among patients with bipolar disorder." c. "Patients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stress." d. "More individuals with bipolar disorder come from high socioeconomic and educational backgrounds."

b. "A higher rate of relatives with bipolar disorder is found among patients with bipolar disorder."

What is most important for the nurse to teach the client with allergic rhinitis and glaucoma? a. "If your heartbeat increases, be sure to contact your health care provider." b. "Avoid allergy drugs containing pseudoephedrine or phenylephrine." c. "Be sure to drink plenty of water with antihistamines." d. "You should use an eye-moistening agent such as Restasis."

b. "Avoid allergy drugs containing pseudoephedrine or phenylephrine."

A patient hospitalized for bipolar disorder is sitting in the corner of the room with the lights off, staring into space. Three hours later, the patient is in the same position. What should the nurse say to the patient? a. "Cheer up! Come on out and join us in a game!" b. "Come with me. I'd like you join our group for a while." c. "You won't make any progress if you stay in your room all the time." d. "What's the matter? Don't you know you should be in your group right now?"

b. "Come with me. I'd like you join our group for a while."

After a hospital's emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to "stand down" from the emergency plan. Which question should the nursing supervisor ask at this time? a. "Are you sure no more victims are coming into the ED?" b. "Do all areas of the hospital have the supplies and personnel they need?" c. "Have all ED staff had the chance to eat and rest recently?" d. "Does the Chief Medical Officer agree this disaster is under control?"

b. "Do all areas of the hospital have the supplies and personnel they need?"

A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate? a. "Avoid getting salt water on the radiation site." b. "Do not expose the radiation area to direct sunlight." c. "Have a wonderful time and enjoy your vacation!" d. "Remember you should not drink alcohol for a year."

b. "Do not expose the radiation area to direct sunlight."

The nurse is teaching a client how to prevent transmitting HIV to his sexual partner. Which statement by the client indicates that additional teaching is needed? a. "I can throw the condoms in the trash after I have used them." b. "I will store my condoms in my wallet so they are always handy." c. "Water-based lubricants are best to prevent condom breakage." d. "The condom needs to stay on until I withdraw my penis."

b. "I will store my condoms in my wallet so they are always handy."

The nurse is teaching a seminar about preventing the spread of HIV. Which statement by a student indicates that additional teaching is required? a. "A woman can still get pregnant if she is HIV positive." b. "I won't get HIV if I only have oral sex with my partner." c. "Showering after intercourse will not prevent HIV transmission." d. "People with HIV are still contagious even if they take HAART drugs."

b. "I won't get HIV if I only have oral sex with my partner."

Which statement indicates that the client understands teaching about the use of aspirin post-cataract surgery? a. "It may increase intraocular pressure after cataract surgery." b. "It changes the ability of the blood to clot and increases the risk of bleeding." c. "It reduces inflammation and might mask any symptoms of infection." d. "It can cause nausea and vomiting and may increase intraocular pressure.

b. "It changes the ability of the blood to clot and increases the risk of bleeding."

The nursing supervisor is working with an HIV-positive nurse who has open weeping blisters on her arms after being exposed to poison ivy. Which instructions should the nursing supervisor provide to the nurse before she starts her shift? a. "You should reassure your clients that you are not contagious." b. "You should work phone triage at the desk today rather than taking clients." c. "You should wear a long-sleeved scrub jacket today while working with clients." d. "You should not care for clients who are immune compromised or in isolation."

b. "You should work phone triage at the desk today rather than taking clients."

A patient diagnosed with major depression says, "No one cares about me anymore. I'm not worth anything." Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient? a. "You look nice this morning." b. "You're wearing a new shirt." c. "I like the shirt you are wearing." d. "You must be feeling better today."

b. "You're wearing a new shirt."

What dose of epinephrine does the nurse prepare for a client in anaphylaxis who is 6 feet 3 inches tall and weighs 250 lb? a. 0.2 mL of a 1:1000 solution b. 0.5 mL of a 1:1000 solution c. 0.3 mL of a 1:10,000 solution d. 0.5 mL of a 1:10,000 solution

b. 0.5 mL of a 1:1000 solution

During treatment for shock, the client receives fluid volume replacement. The nurse determines that renal perfusion is being maintained if the urine output is at least a. 0.25 ml/kg/hour. b. 0.5 ml/kg/hour. c. 1.0 ml/kg/hour. d. 1.5 ml/kg/hour.

b. 0.5 ml/kg/hour.

The nurse is reviewing a patient's diagnostic test report. For which tumor diameter should the nurse evaluate the report to determine if cancer is present? a. 0.5 cm b. 1 cm c. 2 cm d. 5 cm

b. 1 cm

An emergency department nurse is admitting a client with ischemic stroke who is eligible for thrombolytic therapy. The nurse works quickly to provide care, knowing that for this therapy to be effective, it must be administered in a post-stroke time window of a. 30 minutes. b. 3 hours. c. 6 hours. d. 12 hours.

b. 3 hours.

During a psychiatric assessment, the nurse observes a patient's facial expression is without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the patient's affect and mood? a. Affect depressed; mood flat b. Affect flat; mood depressed c. Affect labile; mood euphoric d. Affect and mood are incongruent.

b. Affect flat; mood depressed

A client has angioedema of the lower face. What will the nurse assess next? a. Pulse oximetry b. Airway patency c. Breath sounds d. Chest wall symmetry

b. Airway patency

A nursing administrator is reviewing a hospital's disaster planning. The administrator evaluates the plan that addresses which component as being the best? a. Internal disasters such as fires or power outages b. All possible catastrophes in the community c. The Joint Commission's assessment of possible disasters d. Responses to all types of weather-related emergencies

b. All possible catastrophes in the community

A hospitalized client has Ménière's disease. What menu selections demonstrate good knowledge of the recommended diet for this disorder? (Select all that apply.) a. Chinese stir fry with vegetables b. Broiled chicken breast c. Chocolate espresso cookies d. Deli turkey sandwich and chips e. Green herbal tea with meals

b. Broiled chicken breast e. Green herbal tea with meals

What may cause hypovolemic shock in children? Select all that apply. a. Hyperthermia b. Burns c. Vomiting or diarrhea d. Hemorrhage e. Skin abscess that cultures positive for methicillin-resistant Staphylococcus aureus (MRSA)

b. Burns c. Vomiting or diarrhea d. Hemorrhage

A nurse plans care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? Select all that apply. a. Reclusive behavior b. Callous attitude c. Perfectionism d. Aggression e. Clinginess f. Anxiety

b. Callous attitude d. Aggression

A health care worker is exposed to blood from a patient who has HIV. What action should the worker take after the exposure? a. Apply alcohol to the site. b. Cleanse the site with soap and water. c. Flush the site with hot running water. d. Apply a topical antibiotic to the site.

b. Cleanse the site with soap and water.

Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg? a. Turn the synchronizer switch to the "off" position. b. Give a sedative before cardioversion is implemented. c. Set the defibrillator/cardioverter energy to 360 joules. d. Provide assisted ventilations with a bag-valve-mask device.

b. Give a sedative before cardioversion is implemented.

The nurse is assisting in a teaching plan for the family of a patient with HIV. Which explanation about the transmission of HIV should the nurse include in this plan? a. HIV is spread by casual contact with others. b. HIV spreads by contact with infected blood. c. HIV can be spread by sharing eating utensils. d. HIV is commonly transmitted by tears or saliva.

b. HIV spreads by contact with infected blood.

A child is admitted with acute glomerulonephritis. The nurse expects the urinalysis during this acute phase to show a. Bacteriuria and hematuria b. Hematuria and proteinuria c. Bacteriuria and increased specific gravity d. Proteinuria and decreased specific gravity

b. Hematuria and proteinuria

The student nurse caring for clients who have cancer understands that the general consequences of cancer include which client problems? (Select all that apply.) a. Clotting abnormalities from thrombocythemia b. Increased risk of infection from white blood cell deficits c. Nutritional deficits such as early satiety and cachexia d. Potential for reduced gas exchange e. Various motor and sensory deficits

b. Increased risk of infection from white blood cell deficits c. Nutritional deficits such as early satiety and cachexia d. Potential for reduced gas exchange e. Various motor and sensory deficits

The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the client's family about code status.

b. Initiate cardiopulmonary resuscitation (CPR).

A patient is admitted with suspected septic shock. Which action should the nurse take first? a. Obtain patient temperature. b. Insert an IV access device. c. Determine if the patient has any medication allergies. d. Reassure the patient that everything possible will be done.

b. Insert an IV access device.

A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important? a. Assess the client's bedside glucose reading. b. Instruct the client not to get up without help. c. Monitor the client frequently for tachycardia. d. Record the client's intake, output, and weight.

b. Instruct the client not to get up without help.

A patient insistently states, "I can decipher codes of DNA just by looking at someone." Which problem is evident? a. Visual hallucinations b. Magical thinking c. Idea of reference d. Thought insertion

b. Magical thinking

A patient took trifluoperazine 30 mg po daily for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette's syndrome d. Anticholinergic effects

b. Tardive dyskinesia

The nurse is preparing to provide education related to HIV transmission at a local community health fair. Which statements should the nurse recommend for inclusion in the teaching? (Select all that apply.) a. Use oil-based lubricants. b. Use a new condom for each sex act. c. Use condoms that are not made of latex. d. Fit condom tightly over the tip of the penis. e. Check condom package for expiration date. f. Apply the condom before touching partner with the penis.

b. Use a new condom for each sex act. e. Check condom package for expiration date. f. Apply the condom before touching partner with the penis.

The nurse is providing care to a patient who has had diagnostic testing for HIV. Which test should the nurse review to monitor the response to antiretroviral therapy? a. Western blot b. Viral load testing c. P24 antigen testing d. Enzyme-linked immunosorbent assay

b. Viral load testing

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)

b. Warfarin (Coumadin)

This nursing diagnosis applies to a patient with acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days.Select an appropriate outcome. The patient will: a. ask staff for assistance with feeding within 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at meal time within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.

b. drink six servings of a high-calorie, high-protein drink each day.

A patient has been prescribed fluoxetine (Prozac) to treat depression. What should be included in the nurse's teaching about the drug? (Select all that apply.) a. "You need to take this drug only once a week." b. "Take the prescribed dose in the early evening." c. "A decreased interest in sexual activity may occur with this medication." d. "You should not consume red wine, aged cheese, or other tyramine-rich foods." e. "Do not expect immediate results; it usually takes 6 to 8 weeks for therapeutic effects to be felt." f. "You may experience some nausea, vomiting, and anorexia, but these side effects will subside in time."

c. "A decreased interest in sexual activity may occur with this medication." f. "You may experience some nausea, vomiting, and anorexia, but these side effects will subside in time."

A client with a decreased glomerular filtration rate asks how to prevent further damage to the kidneys. Which is the nurse's best response? a. "The diuretics you are taking will prevent further damage." b. "Kidney damage is inevitable as you age." c. "Avoid taking NSAIDs." d. "You will need to follow a high-protein diet."

c. "Avoid taking NSAIDs."

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" How should the nurse respond? a. "Substance abuse puts clients at risk for many health issues." b. "The hospital requires that I ask you about cocaine use." c. "Clients who use cocaine are at risk for fatal dysrhythmias." d. "We can provide services for cessation of substance abuse."

c. "Clients who use cocaine are at risk for fatal dysrhythmias."

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" How should the nurse respond? a. "Substance abuse puts clients at risk for many health issues." b. "The hospital requires that I ask you about cocaine use." c. "Clients who use cocaine are at risk for fatal dysrhythmias." d. "We can provide services for cessation of substance abuse."

c. "Clients who use cocaine are at risk for fatal dysrhythmias."

A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. "Stop that! No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?"

c. "Do not hit anyone. If you are unable to control yourself, we will help you."

Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective? a. "I think you are the best nurse on the unit." b. "I'm never going to get high on drugs again." c. "I felt empty and wanted to hurt myself, so I called you." d. "I hate my mother. I called her today, and she wasn't home."

c. "I felt empty and wanted to hurt myself, so I called you."

A client scheduled to undergo radiation therapy for breast cancer asks why 6 weeks of daily treatment is necessary. What is the nurse's best response? a. "Your cancer is widespread and requires more than the usual amount of radiation treatment." b. "Giving larger doses of radiation for a shorter period of time does not produce better effects and has worse side effects." c. "Research has shown that more cancer cells are killed if radiation is given in smaller doses over a longer time period." d. "It is less likely that your hair will fall out or that you will become anemic if radiation is given in this manner."

c. "Research has shown that more cancer cells are killed if radiation is given in smaller doses over a longer time period."

Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating b. Bulimia nervosa c. Anorexia nervosa d. Eating disorder not otherwise specified

c. Anorexia nervosa

A client with acute-angle glaucoma has several medications ordered. Which medications does the nurse question? (Select all that apply.) a. Acetazolamide (Diamox) b. Pilocarpine (Pilocar) c. Atropine (Isopto Atropine) d. Latanoprost (Xalatan) e. Timolol (Timoptic) f. Epinephrine

c. Atropine (Isopto Atropine) f. Epinephrine

A client is receiving a chemotherapeutic agent intravenously through a peripheral line. What is the nurse's first action when the client reports burning at the site? a. Check for a blood return. b. Slow the rate of infusion. c. Discontinue the infusion. d. Apply a cold compress.

c. Discontinue the infusion.

Children with non-Hodgkin lymphoma are at risk for complications resulting from tumor lysis syndrome (TLS). The nurse should assess for a. Liver failure b. CNS deficit c. Kidney failure d. Respiratory distress

c. Kidney failure

As a patient admitted to the eating disorders unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet 4 inches tall. Which term should be documented? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor

c. Lanugo

A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability

c. Level of consciousness

A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability

c. Level of consciousness

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? a. Avoid contact sports. b. Get plenty of calcium. c. Lose weight if needed. d. Engage in weight-bearing exercise.

c. Lose weight if needed.

The nurse is working in the emergency department on a hot, humid day, when a hiker is brought in after collapsing. The hiker is confused and tachycardic with a temperature of 105.6° F (40.9° C). Which IV solution and medication will the nurse have ready for the client? a. Normal saline and methylprednisolone (Solu-Medrol) b. Lactated Ringer's solution and morphine sulfate c. Normal saline and lorazepam (Ativan) d. Dextrose 5% and diphenhydramine (Benadryl)

c. Normal saline and lorazepam (Ativan)

A client who is near blind is admitted to the hospital. What action by the nurse is most important? a. Allow the client to feel his or her way around. b. Let the client arrange objects on the bedside table. c. Orient the client to the room using a focal point. d. Speak loudly and slowing when talking to the client.

c. Orient the client to the room using a focal point.

The nurse has been assigned the role of triage nurse after a weather-related disaster. What is the priority action of the nurse? a. Call in additional staff to assist with care of the victims. b. Splint fractures and clean and dress lacerations. c. Perform a rapid assessment of clients to determine priority of care. d. Provide psychological support to staff and family members.

c. Perform a rapid assessment of clients to determine priority of care.

A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first? a. Initiate Droplet Precautions for the client. b. Notify the provider about the CD4+ results. c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care.

c. Place the client under Airborne Precautions.

A client's intraocular pressure (IOP) is 28 mm Hg. What action by the nurse is best? a. Educate the client on corneal transplantation. b. Facilitate scheduling the eye surgery. c. Plan to teach about drugs for glaucoma. d. Refer the client to local Braille classes.

c. Plan to teach about drugs for glaucoma.

Which finding constitutes a negative symptom associated with schizophrenia? a. Hostility b. Bizarre behavior c. Poverty of thought d. Auditory hallucinations

c. Poverty of thought

A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis

c. Short period of asystole

Which condition is a type II hypersensitivity reaction? a. Allergic rhinitis b. Positive purified protein derivative (PPD) test for tuberculosis c. Transfusion reaction to improper blood type d. Serum sickness after receiving immune globulin

c. Transfusion reaction to improper blood type

The outpatient nurse understands that the phase of substance abuse characterized by a 14-year-old child admitting to using marijuana every day with friends after attending school is a. Experimentation b. Early drug use c. True drug addiction d. Severe drug addiction

c. True drug addiction

Despite aggressive treatment, the condition of a patient in shock continues to worsen. Surgical intervention stops the bleeding, and the shock stabilizes. Which finding should the nurse act upon immediately? a. The blood pH is 7.36. b. Bowel sounds are hypoactive. c. Urinary output is 15 mL/hour. d. Pupils are equally reactive to light.

c. Urinary output is 15 mL/hour.

A client has external otitis. On what comfort measure does the nurse instruct the client? a. Applying ice four times a day b. Instilling vinegar-and-water drops c. Use of a heating pad to the ear d. Using a home humidifier

c. Use of a heating pad to the ear

What is most appropriate for a nurse to include when preparing discharge plans for a patient with SLE? a. Need to consume 2 L of fluid daily b. Close monitoring of daily blood glucose level c. Use of daily sunscreens with a sun protection factor (SPF) higher than 15 d. Careful concern for certain food allergies

c. Use of daily sunscreens with a sun protection factor (SPF) higher than 15

The history shows that a newly admitted patient is impulsive. The nurse would expect behavior characterized by: a. adherence to a strict moral code. b. manipulative, controlling strategies. c. acting without thought on urges or desires. d. postponing gratification to an appropriate time.

c. acting without thought on urges or desires.

A patient diagnosed with major depression began taking escitalopram (Lexapro) 5 days ago. The patient now says, "This medicine isn't working." The nurse's best intervention would be to: a. discuss with the health care provider the need to increase the dose. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptoms of improvement.

c. explain the time lag before antidepressants relieve symptoms.

A nurse provides health teaching for a patient diagnosed with binge-purge bulimia. Priority information the nurse should provide relates to: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. how to recognize hypokalemia. d. self-esteem maintenance.

c. how to recognize hypokalemia.

A patient is receiving a dopamine infusion for shock. What should the nurse expect to assess in the patient because of this medication? a. Pain relief b. Decreased heart rate c. Increased blood pressure d. Increased respiratory rate

c. increased blood pressure

A patient diagnosed with major depression began taking a tricyclic antidepressant 1 week ago. Today the patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse will: a. limit the patient's activities to those that can be performed in a sitting position. b. withhold the drug, force oral fluids, and notify the health care provider. c. teach the patient strategies to manage postural hypotension. d. update the patient's mental status examination.

c. teach the patient strategies to manage postural hypotension.

The nurse is caring for a client with a complete heart block (third-degree atrioventricular [AV] block). What is the nurse's priority intervention? a.Perform a cardioversion. b.Assist with carotid massage. c.Begin external pacing. d.Administer adenosine (Adenocard) IV.

c.Begin external pacing.

The nurse is assessing the client's electrocardiography (ECG). What does the P wave on the ECG tracing represent? a.Contraction of the atria b.Contraction of the ventricles c.Depolarization of the atria d.Depolarization of the ventricles

c.Depolarization of the atria

The client's heart rate increases slightly during inspiration and decreases slightly during expiration. What action does the nurse take? a.Evaluate for a respirator disorder. b.Assess the client for chest pain. c.Document the finding in the chart. d.Administer antidysrhythmic drugs.

c.Document the finding in the chart.

The nurse is caring for a client with a temporary pacemaker. The client's bedside monitor shows a spike followed by a QRS complex. What is the nurse's best action? a.Remove the pacemaker; it is not needed. b.Decrease the threshold of the pacemaker. c.Document the finding in the client's chart. d.Set the pacemaker to the synchronous mode.

c.Document the finding in the client's chart.

The nurse is teaching a client who has osteoarthritis ways to slow progression of the disease. Which statement indicates that the client understands the nurse's instruction? a. "I will eat more vegetables and less meat." b. "I will avoid exercising to minimize wear on my joints." c. "I will take calcium with vitamin D every day." d. " will start swimming twice a week."

d. " will start swimming twice a week."

A nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate? a. "You and I will have to sit down and discuss this problem." b. "It bothers me to see you exercising. I am afraid you will lose more weight." c. "Let's discuss the relationship between exercise, weight loss, and the effects on your body." d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

An HIV-infected patient reports being a cat lover and says, "I always get my pets from a known sanitary source." What should the nurse instruct the patient about cats and the risk of infection? a. "Keep cats outdoors most of the time." b. "Obtain only cats that are less than 1 year old." c. "Remove all pets from your home. Avoid all contact with cats." d. "Be sure all the cats have up-to-date immunizations, and avoid their feces."

d. "Be sure all the cats have up-to-date immunizations, and avoid their feces."

A patient with a mental illness says, "I have to go to the bank. The voices are telling me to go there." Which response by the nurse is best? a. "Do you need money?" b. "I will call you a cab later. Right now, it is time for therapy." c. "Why do you think the voices are telling you to go to the bank?" d. "I want to help you focus away from the voices. I am real, they are not."

d. "I want to help you focus away from the voices. I am real, they are not."

An older adult client who has a mature cataract in the right eye states, "Now I have lost the sight in my right eye because I waited too long for treatment." How does the nurse best respond to the client? a. "Yes, this type of blindness could have been prevented by earlier treatment." b. "It is fortunate you came for treatment in time to save the sight of your other eye." c. "Nothing you could have done would have made any difference." d. "Surgery can still save the sight in your eye with removal of the cataract."

d. "Surgery can still save the sight in your eye with removal of the cataract."

The spouse of a patient in neurogenic shock asks what is happening to the patient. How should the nurse response to the spouse? a. "This is because of an allergic reaction." b. "There is a drop in circulating blood volume." c. "The heart has failed to pump blood throughout the body." d. "The blood vessels have dilated and lowered the blood pressure."

d. "The blood vessels have dilated and lowered the blood pressure."

A client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask, gloves, and gown while administering drugs to the client. What is the nurse's best response? a. "These coverings protect you from getting an infection from me." b. "I am preventing the spread of infection from you to me or any other client here." c. "The policy is for any nurse giving these drugs to wear a gown, gloves, and mask." d. "The clothing protects me from accidentally absorbing these drugs."

d. "The clothing protects me from accidentally absorbing these drugs."

The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first? a. A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago b. A patient with new onset atrial fibrillation, rate 88, who has a first dose of warfarin (Coumadin) due c. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating d. A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due

d. A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due

The infant with Down syndrome is closely monitored during the first year of life for what serious condition? a. Thyroid complications b. Orthopedic malformations c. Dental malformation d. Cardiac abnormalities

d. Cardiac abnormalities

A patient receiving doxorubicin (Adriamycin) voids urine that is bright red. Which action by the nurse is appropriate? a. Notify the physician STAT. b. Withhold all red dye from the patient's diet. c. Draw a hemoglobin sample and prepare for possible blood transfusion. d. Check the patient's urine, and tell the patient that this is a common side effect of Adriamycin.

d. Check the patient's urine, and tell the patient that this is a common side effect of Adriamycin.

A patient with progressive shock is diaphoretic and confused. The most recent blood pressure measurement was 82/40 mm Hg and a urinary catheter output was 10 mL for 1 hour. Intravenous (IV) fluids are infusing at 150 mL/hr. Which action should the nurse take related to the urine output? a. Encourage oral fluids. b. Irrigate urinary catheter. c. Increase IV fluid infusion rate. d. Check urinary catheter for kinking.

d. Check urinary catheter for kinking.

After an episode of shock, a patient's laboratory results reveal decreased clotting factors. Based on these laboratory results, the nurse should monitor for which complication of shock? a. Brain attack b. Multisystem organ failure c. Adult respiratory distress syndrome d. Disseminated intravascular coagulation

d. Disseminated intravascular coagulation

A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL. Which nursing diagnosis applies? a. Adult failure to thrive related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

d. Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair over the trunk. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient says, "I won't eat until I look thin." Select the priority initial nursing diagnosis. a. Anxiety related to fear of weight gain b. Disturbed body image related to weight loss c. Ineffective coping related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements related to self-starvation

d. Imbalanced nutrition: less than body requirements related to self-starvation

The nurse is assisting in the planning of care for a patient in shock. Which nursing diagnoses should the nurse recommend be included in the patient's plan of care? a. Hopelessness b. Risk for aspiration c. Excess fluid volume d. Inadequate tissue perfusion

d. Inadequate tissue perfusion

What is the most appropriate nursing action when the nurse notes a reddened area on the forearm of a neutropenic child with leukemia? a. Massage the area. b. Turn the child more frequently. c. Document the finding and continue to observe the area. d. Notify the physician.

d. Notify the physician.

Which diagnostic finding is present when a child has primary nephrotic syndrome? a. Hyperalbuminemia b. Positive ASO titer c. Leukocytosis d. Proteinuria

d. Proteinuria

The nurse is contributing to a teaching plan. What information should the nurse include that identifies the methods in which HIV can be transmitted? (Select all that apply.) a. Urine b. Sweat c. Saliva d. Semen e. Breast milk f. Vaginal secretions

d. Semen e. Breast milk f. Vaginal secretions

A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.

d. Ventricular and atrial depolarizations are initiated from different sites.

A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to: a. an inherited disorder that manifests itself as an incapacity to tolerate stress. b. use of projective identification and splitting to bring anxiety to manageable levels. c. a constitutional inability to regulate affect, predisposing to psychic disorganization. d. fear of abandonment associated with progress toward autonomy and independence.

d. fear of abandonment associated with progress toward autonomy and independence.

A client has a history of experiencing focal neurologic deficits, such as slurred speech and facial weakness, that last for a few hours at a time. The nurse then assesses this client for other possible manifestations of a. embolic stroke. b. encephalopathy. c. intracranial hemorrhage. d. transient ischemic attacks (TIAs).

d. transient ischemic attacks (TIAs).

For which behavior would limit setting be most essential? The patient who: a. clings to the nurse and asks for advice about inconsequential matters. b. is flirtatious and provocative with staff members of the opposite sex. c. is hypervigilant and refuses to attend unit activities. d. urges a suspicious patient to hit anyone who stares.

d. urges a suspicious patient to hit anyone who stares.

A patient diagnosed with depression is receiving imipramine (Tofranil) 200 mg qhs. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. dry mouth b. blurred vison c. nasal congestion d. urinary retention

d. urinary retention