Test 2 (2nd 8)
The nurse cares for a patient diagnosed with paranoid schizophrenia. Which assessment parameter should be the priority for the nurse to monitor
Ability to make decisions
The school nurse observes an elementary school child arriving in the winter in shorts and a short-sleeved shirt with no coat. The nurse would consider this as which type of abuse?
Neglect
A nurse is gathering data about a patient diagnosed with schizophrenia. Which finding would the nurse identify as a negative symptom?
Flat affect.
A teenaged patient with hemophilia sustains a leg laceration after falling off of his skateboard and is brought to the ED. The laceration is bleeding profusely even with direct pressure to the site. What does the nurse anticipate will be ordered to administer to control bleeding
Fresh frozen plasma
The nurse is caring for a young child whose parents have been charged with physical abuse. Which child reaction is noted as a result of the parental behavior?
Fretful and shrinks away when approached.
The nurse is assessing an infant diagnosed with shaken baby syndrome. Clinical manifestations of shaken baby syndrome effect which bodily system the most?
Nervous system
A patient is prescribed a new medication, haloperidol (Haldol), for chronic schizophrenia. Assessment reveals muscular rigidity, hyperthermia, and an altered level of consciousness. The nurse identifies these findings as suggestive of which condition?
Neuroleptic malignant syndrome
A toddler is brought to the ED with burns on his feet and buttocks. The toddler is screaming in pain. The caregiver states the he/she didn't know the bath water was so hot. What is the initial action completed by the nurse?
Notifying the health care provider.
Isabel Hampton Robb is an American nursing leader dedicated to protecting patients and advancing the profession of nursing. Robb's most important contribution was to advocate for?
Nurse's rights for 8 hour shifts and no more than 6 days a week.
The nurse is caring for a thyroid cancer patient following oral radioactive iodine treatment. Which teaching point is most important?
Flush the toilet twice after every use.
A patient diagnosed with cancer has his tumor staged and graded based on what factors?
How they tend to grow and the cell type.
The Virginia Board of Nursing is composed of 14 members and support staff. Currently serving are RN's, LPN's, and
Citizen members
The nurse is caring for a small child who has been admitted with a diagnosis of shaken baby syndrome. Which condition or concern often occurs with shaken baby syndrome?
Loss of vision and mental retardation
A bowel resection is scheduled for a patient with the diagnosis of colon cancer with metastasis to the liver and bone. Which statement by the nurse best explains the purpose of the surgery?
Tumor removal will promote comfort."
The nurse is reviewing a care plan for a client diagnosed with schizophrenia who has been prescribed an antipsychotic medication. The nurse would expect to find which priority outcome for this patient?
Compliance with therapeutic drug regimen
Lavinia Dock and Mary Adelaide Nutting were both American nursing leaders instrumental in improving the standards for nursing education. What was the most important contribution that the 2 provided the profession of nursing together?
Help to found the National League of Nursing (NLN) and the four volumes History of Nursing.
The nurse is interviewing the caregiver of a 5 yo child who has been admitted with bruises on the abdomen and thighs as well as additional bruises in various stages of healing. Which statement made by the caregiver might alert the health care team to the possibility of child abuse?
His brother just plays too rough with him."
The nurse is reviewing a care plan for an assigned patient diagnosed with paranoid schizophrenia. Which should be a priority diagnosis for this patient?
Risk for other-directed violence
Which situation should the nurse explore for possible emotional abuse of the child by the caregiver?
The caregiver of a 12 year old reports, "I'm sorry we missed Janal's appointment last week, but he was supposed to remind me to come."
The nurse is assisting with a physical exam on a child who has been admitted with a diagnosis of possible child abuse. Which finding might alert the nurse to this possibility that the child may have been abused?
The child has a burn that has not been treated.
Hildegard Peplau (1909-1999) was a pioneer in the development of the theory and practice of mental health and psychiatric nursing. Which was Peplau's primary focus in nursing?
The development of the patient-nurse therapeutic relationship is the foundation of nursing practice.
The patient is diagnosed with a benign brain tumor. Which of the following features of a benign tumor is of most concern to the nurse
Tumor pressure against normal tissues.
The nurse would incorporate which of the following into the plan of care as a primary prevention strategy for reduction of the risk for cancer?
Using skin protection during sun exposure while at the beach
A group of nurses is discussing child maltreatment and one nurse suggests that inadequate parenting skills may lead to child maltreatment. The nurse recognizes that sometimes child maltreatment occurs because the parent:
may have unrealistic expectations of the child.
The nurse is caring for a patient with a DVT in the popliteal vein. Which component of a head-to-toe assessment is crucial?
Lung sounds
A patient is recovering from a craniotomy with tumor debulking. Which comment by the patient indicates to the nurse a correct understanding of what the surgery entails?
"I guess the doctor could not remove the entire tumor."
The nurse has telephone messages from 4 patients who requested information and assistance. Which one should the nurse refer to a social worker or community agency first?
"I ran out of money and am cutting my insulin dose in half."
A group of pediatric nurses is discussing the diagnosis of Munchausen syndrome by proxy. Which statement most accurately describes this disorder?
"It is seen when 1 person fabricates or induces illness in another to get attention."
A patient with a 4cm breast mass is scheduled for biopsy with frozen section followed by lumpectomy and possible mastectomy. The patient asks the nurse, "Why can't the doctor tell me specifically whether I will need to have my entire breast removed?" Which is the best response from the nurse?
"The frozen section will determine presence of cancer and type of surgery required."
You have an order for Synthroid 0.118mg. You have on hand Synthroid 118mcg. How many tablets will you give
1 tab
While the nurse is obtaining the health history of a 75 yo. Female patient, which of the following has the greatest implication for the development of cancer?
Advancing age
A patient experiencing extrapyramidal side effects secondary to prescribed antipsychotic therapy. The nurse anticipates which drug class as being used most to relieve these effects?
Antiparkison
Responsibilities of the Virginia Board of Nursing include:
Approval and regulation of Virginia education programs for RN/LPN/CAN, Enforcement of Regulations Governing the Practice of Nursing, Determining eligibility of applicants to take the NCLEX-PN, and Authorization and Renewal of nursing license.
The nurse is providing a patient teaching for a patient undergoing chemotherapy. What dietary modifications should the nurse advise?
Avoid spicy and fatty foods.
An older adult patient is prescribed an antipsychotic medication for the management of psychotic behaviors. The patient's spouse asks, "Why is the dose prescribed lower than the range listed in the teaching materials we received?" Which response by the nurse would be most appropriate?
Changes to liver and kidney function normally experienced with age require smaller doses."
The nurse is caring for a patient with thrombophlebitis. When assessing the patient, what would be most important to assess for?
Chest pain and dyspnea
Which is the primary physical sign of a child who the nurse suspects as being emotionally abused?
Delays in physical development
A nurse is reviewing the HX of a patient with psychosis. Which diagnosis increase a patient's risk for the development of psychotic behaviors?
Depression, Bipolar disorder, Dementia, and Alcoholism
Which is essential in working with caregivers that have been affected by abuse?
Developing a therapeutic relationship
Today, most countries have their own Red Cross organization that also belongs to the International Red Cross. What was the most important contribution of the Red Cross when it was founded by J.H. Dunant in the 19th century?
Established rules for the treatment of wounded people during the wartime.
The caregiver brings a 23-month-old child for a well-child check. The caregiver apologizes, stating: "It's my allergies, not a cold that is causing me to sniffle so much. The caregiver reports that the toddler seems, "slower at doing things than my older children did." The nurse notices that the child sits in the caregiver's lap without fear or hesitation and responds to the caregiver's questions, but fails to look at the caregiver's face when being spoken to. These behaviors are supportive of what additional assessment?
Evidence of cocaine abuse by the caregiver affecting the child.
The patient is receiving a vesicant antineoplastic for the tx of cancer. Which assessment finding would require the nurse to take immediate action?
Extravasation
What is the priority nursing diagnosis for a patient experiencing chemotherapy-induced anemia?
Fatigue related to decreased cellular oxygenation
A patient is scheduled for a nerve-sparing prostatectomy. The emotional spouse confides in the nurse that the patient will not talk about the cancer and/or upcoming surgery. Which nursing diagnosis will the nurse choose as primary diagnosis for this patient
Fear
Assessment of a patient with schizophrenia reveals evidence of perceptual disturbances. The nurse would most likely document which finding?
Hallucinations, Illusions, and Delusions
While collecting a health HX on a patient admitted for colon cancer. Which of the following questions would be a priority to ask this patient?
Have you noticed any blood in your stool?"
The nurse understands that the patient should be vaccinated with the HPV vaccine per the health care provider's orders. What is this vaccine for?
Helps prevent cervical cancer.
The patient is diagnosed with schizophrenia. Which behavior best supports the nurse's belief that the patient demonstrates an understanding of the long-term needs of this mental illness?
Identifying reliable, willing individuals to include as a social support system.
An elderly patient has been diagnosed with metastatic cancer and has a poor prognosis of survival. The family asks the nurse for advice on whether to tell the patient of the diagnosis or to keep it quiet. Which is the best response from the nurse?
In my experience, patients who know are more likely to be involved with their plan of care."
While completing an admission assessment, the patient reports a family history of ovarian cancer among a maternal grandmother, aunt, and sister. The nurse knows that these cancers are most likely associated with what etiology?
Inherited gene mutation.
When caring for an older patient who is receiving external beam radiation, which is the key point for the nurse to incorporate into the plan of care?
Inspect skin frequently.
In caring for a patient following lobectomy for lung cancer, which of the following should the nurse include in the plan of care?
Instruct the patient to cough and deep breathe.
Appropriate designation for practical nursing program graduates that are employed but awaiting test results is:
LPN Applicant
A patient with prostate cancer is taking estrogen daily to control tumor growth. He reports that his left calf is swollen and painful. Which of the following would be the nurse's best action?
Measure the calf circumference and compare the measurement with the right calf circumference measurement.
A patient is diagnosed with schizophrenia, catatonic type. Which should be the priority nursing intervention identified on the patient's plan of care
Meeting the basic needs of the patient
Which statement made by a participant at a workshop needs further clarification?
Mostly low-income people commit sexual violence against children."
Which of the following lab findings would be identified by the nurse as the greatest risk for a cancer patient scheduled for implantable port
Platelet count 98,000/mm3
While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing intervention?
Prioritization and administration of nursing care throughout the day
During the Reformation (1500-1600's) nursing changed drastically. Which key event brought about this new era of nursing?
Protestantism changed societal view of women.
The nurse has identified the outcome of improving parenting and coping skills in a caregiver who has shown past poor judgement in caring for the children. Which action promotes a positive image of his or her abilities?
Providing a compliment when a caregiver does something well.
A nurse is reading a journal article about the different types of psychotic disorders. The nurse demonstrates understanding of the article when the nurse identifies which psychotic disorder as being exhibited by a combination of a mood disorder and the primary symptoms of schizophrenia?
Schizoaffective disorder
There are currently 2 major organizations that represent the interests of practical and vocational nurses, the National Association for Practical Nurse Education and Service (NAPNES) and the National Association of Licensed Practical Nurses, INC. (NALPN). Together, these nursing organizations perform which roles?
Set standards of practice for practical and vocational nurses, promote the interests of practical and vocational nurses, and inform the public about practical and vocational nursing.
The nursing instructor is teaching a class on thrombophlebitis. What should the nurse tell the students about the inflammatory response in thrombophlebitis?
The inflammatory response is caused by accumulated waste products in the blocked vessels.
During the early Middle Ages, the theory and practice of health care and nursing continued to change from earlier eras. Emphasis went from scientific principles for health care to providing personal care and comfort. Which circumstance caused the changes in the health care delivery system?
The lack of intellectual growth because of constant war left monks and nuns to care for the sick.
A patient states, "Little green men are implanting destructive asteroids in my brain." The nurse interprets this statement as reflecting which concept?
Thought insertion.
Delegation of tasks by an LPN to a UAP is allowed only when:
assessment of nursing care needs and priorities deemed appropriate with experience, training, and competencies with communication and follow up with UAP.
The nurse is caring for a patient who is scheduled for chemotherapy. Which is the best statement the nurse can make about the patient experiencing chemotherapy induced alopecia?
the hair loss is usually temporary."
The nurse is caring for a patient who received a bone marrow transplant 10 days ago. The nurse would monitor for which of the following clinical manifestations that could indicate a potentially life-threatening situation?
Mild temp. elevation
The nurse working on a bone marrow unit knows that it is a priority to monitor which of the following in a patient who has just undergone a stem cell transplant?
Monitor the patient closely to prevent infection.
The nurse is caring for a patient with the diagnosis of colon cancer with metastasis to the liver. Which statement made by the patient indicates an understanding of the diagnosis?
My cancer has now spread to my liver."
Which type of abuse is reported most quickly to the police?
Sexual Assault
During the years between 1948-1954, the number of schools dedicated to educating practical nurses in the US grew by more than 260 schools. This rapid growth was primarily a result of what phenomenon?
Shortages in the number of registered nurses in the US.
The nurse is invited to present a teaching program to parents of school-aged children. Which topic would be of greatest value for decreasing cancer risks?
Sun safety and use of sunscreen.
A patient is exhibiting lip smacking, facial grimacing, and protruding tongue movements. The nurse would document these extrapyramidal side effects using which term?
Tardive dyskinesia
Chemotherapy has been used for the past 3 months to treat a patient with pancreatic cancer. The CA19-9 levels are rising. Which explanation would the nurse attribute as the most likely cause?
The cancer is growing despite the chemotherapy treatment.
A patient with advanced cancer makes the following comment to the nurse, "Why are you bathing me? I am going to die no matter what." What is the most appropriate response of the nurse?
Would you like to talk about what you are feeling?"
While obtaining a health HX, a patient tells the nurse that her mother, grandmother, and sister died of cancer. The patient wants to know what she can do to keep from getting cancer. What would be the nurse's best response?
"You can't prevent cancer, but you can have your blood analyzed for tumor markers to see what your risk level is."
