test 6 Allison. hope this is the right test 6. I'm too tired to check.

If nutrients and hydration are provided artificially for a client at the end of life because of the client's diminished muscle control, then what is another therapy that is likely to accompany this therapy? A) Provide oral care regularly. B) Provide mechanical ventilation. C) Gently massage extremities. D) Maintain client safety.

A) A client with diminished muscle control might have decreased food and fluid intake resulting from difficulty swallowing and decreased gastrointestinal activity. In addition to providing nutrients and hydration to this client artificially, other clinical therapies might be to provide regular oral care and to provide hygiene care as needed. Mechanical ventilation is therapy for a respiration etiology, gentle massage is therapy for a circulation etiology, and maintaining client safety is therapy for a sensation etiology.

The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse? A) Blood pressure of 142/92 mmHg B) Pulse of 92 beats per minute C) Respiratory rate of 24 per minute D) Weight gain of 16 oz per week

A) A pregnant client's blood pressure should not be greater than 140/90 mmHg, and if it is elevated, it could be a sign of gestational hypertension or preeclampsia. The pregnant client's heart and respiratory rates will increase slightly as a result of an increased circulatory volume and a decrease in intrathoracic space. Weight gain should average a pound per week in the second and third trimesters.

The nurse is planning care for a client who is experiencing an alteration in mobility. Which would the nurse include as an independent nursing intervention? A) Instructing on the importance of proper nutrition and an active lifestyle B) Administering a prescribed nonsteroidal anti-inflammatory drug (NSAID) C) Identifying necessary modifications to the home environment D) Prescribing a skeletal muscle relaxant

A) An appropriate independent nursing intervention for a client who is experiencing an alteration in mobility is providing instruction on the importance of proper nutrition and an active lifestyle. Administering a prescribed NSAID is an example of a collaborative intervention that the nurse can implement. Identifying necessary modifications for the home environment is a collaborative intervention often implemented by the occupational therapist. Although it is appropriate for the nurse to administer a skeletal muscle relaxant, it is outside the scope of nursing practice to prescribe this medication.

The nurse is providing care for several clients. For which client should the nurse anticipate an order for administering 1000 mg of aspirin? A) A 68-year-old client with rheumatoid arthritis who is experiencing hand pain B) A 5-year-old client who is experiencing ankle pain after a fall from a horse C) A 38-year-old client who is experiencing headache pain after a skiing accident D) A 70-year-old client who is experiencing back pain after laminectomy

A) Aspirin is appropriate for the client with rheumatoid arthritis who is experiencing hand pain, assuming there are no other contraindications. This medication is not appropriate for the other clients, however. Aspirin therapy is not recommended for children because it is associated with an increased risk of Reye syndrome, and it may contribute to bleeding in adult clients who have sustained physical injury.

A client is experiencing sudden-onset severe pain in the left lower quadrant of the abdomen that is rated as a 10 on a pain scale of 0-10. The client is also experiencing nausea, vomiting, and restlessness. Based on this data, the nurse concludes that the client is experiencing which phenomenon? A) Acute pain B) Chronic pain C) End-of-life pain D) Fibromyalgia pain

A) Duration establishes the difference between acute and chronic pain. Acute pain is defined as pain that lasts only through the expected recovery period, which is usually 30 days to 6 months. Acute pain typically has a sudden onset related to injury, surgery, or illness. Chronic pain outlasts the illness and extends beyond the recovery period. End-of-life and fibromyalgia would most likely involve chronic pain.

The nurse provides an in-service to peers regarding situations that can affect the comfort level of the clients on the unit. Which client statement indicates that the client's sense of well-being is negatively impacted? A) "I feel like I have no energy today." B) "I don't feel any physical pain today." C) "I was able to sleep uninterrupted last night." D) "I am so glad that playing cards takes my mind off my worries."

A) Fatigue is a lack of energy and motivation. A fatigued client is unable to focus on healing and lacks the ability to cope in stressful situations. Restful sleep, physical well-being without pain, and appropriate diversion all promote a sense of comfort for the client.

The nurse is caring for the family of a terminally ill client. The family members have been tearful and sad since the diagnosis was given. What is the best nursing diagnosis for this family? A) Grieving B) Hopelessness C) Compromised Family Coping D) Caregiver Role Strain

A) Grieving prior to the actual loss is termed anticipatory grieving. There are no assessment findings that indicate compromised family coping or hopelessness. This reaction is typical of family members, so there is no indication that the family is exhibiting caregiver role strain.

The nurse is caring for a preadolescent male client who is accompanied by his mother. Which statement by the mother would be consistent with the client experiencing growing pains? A) "My son often complains that his arms and legs feel sore." B) "My son seems to get injured very easily, especially broken bones." C) "My son often doesn't want to walk because his knees hurt." D) "My son occasionally complains of pain in his lower back."

A) Long bones of children contain an epiphyseal plate that serves as a location for bone growth. Rapid bone growth in these long bones may produce growing pains as the lengthening bones pull on the muscles. Because this only occurs in the long bones, growing pains are most likely to be felt in the arms and legs. Growing pains would not cause joint pain or lower back pain. Growing pains are also not associated specifically with fractured bones.

The nurse is taking care of a client with terminal lung cancer who is showing signs of imminent death. What change should the nurse most expect the client to exhibit first? A) Decreased blood pressure B) Blurry vision C) Confusion D) Irregular pulse rate

A) Low blood pressure, or hypotension, occurs as a client's body begins to near death. This is often accompanied by cool skin and an irregular pulse rate. Hypotension can lead to blurry vision, as well as confusion and dizziness; however, etiologies other than low blood pressure may also be the source of these symptoms. The nurse should most expect hypotension, potentially presenting with the other signs and symptoms.

The parents of a child with terminal cancer ask the nurse that the child not be told that he will not recover. The nurse anticipates that the child might ask the nurse if he is dying. What would be most appropriate for the nurse to do? A) Suggest a meeting with the healthcare team and the parents. B) If the child asks about death, offer to bring in the child life therapist to help explain the situation. C) Tell the child he is dying if the child asks and offer to stay with him. D) Prepare to ignore the child's question if the child asks it and change the subject.

A) Offering to set up a meeting with the healthcare team to discuss the parents' fears and concerns about telling their child the truth is the best action by the nurse. Telling the child he is dying would be going against the parents' wishes. Avoiding the subject is not an option. Changing the subject or ignoring the child is not appropriate, and the nurse should not simply pass the issue off to a therapist.

The community nurse is caring for a client who is 32 weeks pregnant and diagnosed with preeclampsia. Which statement indicates that the client requires additional teaching? A) "It is normal for my urine may become darker and smaller in amount each day." B) "I should call the doctor if I develop a headache or blurred vision." C) "Pain in the top of my abdomen is a sign my condition is worsening." D) "Lying on my left side as much as possible is good for the baby."

A) Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the condition is worsening. It is not an expected outcome and should be reported to the physician. Headache and blurred vision or other visual disturbances are an indication of worsening preeclampsia, and should be reported to the physician. Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and should be reported to the physician. Left lateral position maximizes uterine and renal blood flow, and therefore is the optimal position for a client with preeclampsia.

A client with permanent paralysis of the trunk, arms, and legs would be said to be experiencing which of the following conditions? A) Tetraplegia B) Paraplegia C) Spinal shock D) Complete spinal cord injury (SCI)

A) Tetraplegia (also called quadriplegia) is paralysis of the upper and lower limbs and trunk. Paraplegia is paralysis of all or part of the trunk, legs, and pelvic organs. Spinal shock is a temporary condition characterized by spinal cord swelling; decreased blood flow and blood pressure; and complete loss of motor function, spinal reflexes, and autonomic function below the level of injury. Complete SCIs involve a total loss of all sensory and motor function below the level of the injury. Depending on its location, a complete SCI could results in either tetraplegia or paraplegia.

A newly admitted adult client with increased intracranial pressure caused from a head injury has a Glasgow Coma Scale (GCS) score of 6. Which of the following assessment findings is most likely in this client? A) Extension to painful stimuli B) Spontaneous eye opening C) Oriented to time, place, and person D) Withdraws to touch

A) The GCS (Glasgow Coma Scale) is a standardized system for assessment of consciousness that analyzes three components: eye opening, verbal response, and motor response. A score of 15 indicates full alertness, and the lowest possible score is 3, which indicates total neurologic unresponsiveness. The client's score is low, so the finding of extension to painful stimuli, a 2 out of a possible 6 for motor response, is most likely for this client. Findings of spontaneous eye opening (a 4 on the scale for eye opening, the maximum score) or orientation to time, place, and person (a 5 for verbal response and also the maximum score for that component) are unlikely. An assessment finding of withdraws to touch would be more typical of an infant or young child, not an adult, and would be a 5 out of 6 for motor response.

Which of the following is a licensure examination developed by the National Council of State Boards of Nursing (NCSBN) for state and territory boards of nursing (BONs) to implement as part of their requirements for licensure? A) National Council Licensure Examination for Registered Nurses (NCLEX-RN) B) National Nurse Aide Assessment Program (NNAAP) C) Medication Aide Certification Examination (MACE) D) Nursing Workforce Diversity (NWD) program

A) The National Council of State Boards of Nursing (NCSBN) has developed two licensure examinations, the National Council Licensure Examination for Registered Nurses (NCLEX-RN) and the National Council Licensure Examination for Practical Nurses (NCLEX-PN), for state and territory BONs to implement as part of their requirements for licensure. The NCSBN also offers two additional examinations: the National Nurse Aide Assessment Program (NNAAP) and the Medication Aide Certification Examination (MACE). The Nursing Workforce Diversity (NWD) program is not a licensure examination.

What part of the body controls reflexes and regulates activities such as vomiting, hiccupping, coughing, and sneezing? A) Brainstem B) Hypothalamus C) Spinal cord D) Thalamus

A) The brainstem is made up of the midbrain, pons, and medulla oblongata. The brainstem controls reflexes and influences all basic life functions including breathing, blood pressure, and heart rate. The brainstem also regulates activities such as vomiting, hiccupping, coughing, and sneezing. The hypothalamus is the autonomic control center, and it is involved in regulating activities such as heart rate, blood pressure, respiratory rate and depth, pain, pleasure, and fear. The spinal cord transmits impulses to and from the brain. The thalamus is the brain's relay center; it takes all incoming nerve impulses and sends those signals to the correct region of the brain.

A competent older adult client has a living will that expresses the client's desire to avoid resuscitation and heroic life support measures. The family members are not supportive of this directive and plan to contest the living will. Which nursing action is the most appropriate? A) Place the document on the chart. B) Contact the Social Services department. C) Explain to the client that the conflict could invalidate the document. D) Notify the hospital attorney.

A) The client is competent. The wishes of the client must take priority. The document should first be placed on the chart and the provider notified. If there are concerns about the authenticity of the document, the Social Services department or the unit supervisor will need to be contacted. There is no need to notify the hospital attorney at this time. A lack of support by the family, or a plan to contest, does not invalidate the document legally.

A nurse is caring for a client with cardiomyopathy who is experiencing activity intolerance. Which intervention is inappropriate for this nursing diagnosis? A) Spacing out nursing activities so client fatigue is lessened B) Assisting with client activities of daily living (ADLs) as necessary C) Using passive and active range-of-motion (ROM) exercises as tolerated D) Consulting with a physical therapist on an activity plan

A) The client who is experiencing activity intolerance should have nursing interventions implemented that encourage and preserve client energy. Assisting the client with ADLs, utilizing ROM exercises, and consulting with physical therapy are all interventions that support this nursing diagnosis. The nurse should cluster nursing activities, not space them out, in order to conserve client energy. This allows the client to rest between periods of nursing care.

The nurse assesses a young adult client who was involved in a swimming accident that resulted in tetraplegia. The client makes eye contact with the nurse and states, "I'm going to beat this and walk out of here." Based on this statement, which nursing diagnosis is most appropriate for this client? A) Risk for Post-Trauma Syndrome B) Impaired Physical Mobility C) Self-Care Deficit D) Noncompliance

A) The client's statement is unrealistic and evidence of Risk for Post-Trauma Syndrome. Although the diagnoses of Impaired Physical Mobility and Self-Care Deficit are appropriate for a client with tetraplegia, this statement is not evidence of those nursing diagnoses. There is no indication of Noncompliance.

Which is believed to be the cause of preeclampsia? A) Placental dysfunction B) Liver disease C) Anxiety D) Low sodium intake

A) The exact cause of preeclampsia is unknown. However, it has been identified as a disorder of placental dysfunction leading to a syndrome of endothelial dysfunction with associated vasospasm. The other answers are incorrect.

During a routine prenatal visit, a client who is 24 weeks pregnant has a blood pressure of 143/91. The client's blood pressure at her previous visit was 121/82. A urine dipstick test reveals a trace amount of protein. The nurse identifies which nursing diagnosis as appropriate for the client at this time? A) Risk for Imbalanced Fluid Volume B) Chronic Pain C) Risk for Delayed Development D) Constipation

A) The rise in blood pressure and protein in the urine could indicate that preeclampsia is developing. Because preeclampsia is often accompanied by fluid retention, the client would be at risk for imbalanced fluid volume. The other nursing diagnoses are not appropriate for the client at this time.

The nurse is caring for a pediatric client with a surgical wound. The wound is red with purulent drainage and is causing discomfort for the client. Which diagnostic test will determine if the discomfort of the wound is caused by an infection? A) White blood cell count B) Hematocrit measurement C) Urine analysis D) X-rays of the site

A) There are a few tests that can help the medical team determine the source of the client's discomfort. In this case, a white blood cell count will determine if the discomfort is being caused by an infection. An x-ray is useful for determining the existence of physical injuries, not the presence of infection. Urine analysis may indicate illness or malnutrition, whereas hematocrit measurement may identify iron deficiency anemia.

An 18-month-old toddler scheduled for routine vaccinations begins to cry when placed on the examination table. The parent attempts to comfort the toddler, but nothing is effective. Which action by the nurse is the most appropriate? A) Allow the toddler to sit on the parent's lap and begin the assessment. B) Allow the toddler to stand on the floor until the crying stops. C) Ask another nurse in the office to hold the toddler because the parent is not able to control the toddler's behavior. D) Instruct the parent to hold the toddler down tightly to complete the examination.

A) Toddlers are most comfortable when sitting with the parents. Vaccinations can be administered in this way if the parent is taught proper therapeutic holding techniques to keep everyone safe for the procedure. Allowing the toddler to stand on the floor or holding the toddler down tightly are inappropriate. A nurse can assist if the parent is unable to hold the child during the vaccinations to prevent injury from movement.

An older adult client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. What would the nurse expect to be prescribed for this client? A) Beta blocker B) Digoxin C) Nitrate medications D) Fluids

A) Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and antiarrhythmics. Digoxin should be avoided because it increases the force of contractions. Nitrates should be avoided because they increase blood pressure. The client should be on a sodium and fluid restriction

A 72-year-old client diagnosed with hypertrophic cardiomyopathy (HCM) is speaking to the healthcare team about treatment options. Which treatment option would likely not be recommended for this client, even though it is commonly used to treat younger clients with this condition? A) Defibrillator implantation B) Beta-blocker administration C) Calcium channel blocker administration D) Physical activity restrictions

A) Treatment guidelines for older clients with HCM are not well established, although they may include the use of beta blockers and/or calcium channel blockers. The client will also likely have restrictions on physical activity. However, the low morbidity and mortality rates among older clients do not support the use of the defibrillator devices frequently implanted in younger clients.

The nurse is planning care for an older adult client with a head injury secondary to a motor vehicle crash. Which information should the nurse keep in mind when planning this client's care? Select all that apply. A) Anxiety, illness, and pain can alter the ability to learn. B) Baseline reflexes may be slower or diminished. C) Impulse transmission and reactions to stimuli are slower. D) Neurologic assessment should be completed in a single session. E) Impairment in vision and hearing should be taken into consideration.

A, B, C, E) For an older client, full neurologic assessment can be lengthy. Conduct the assessment in several sessions if indicated, and cease the tests if the client is noticeably fatigued. In the older client, anxiety, illness, and pain can alter the ability to learn. Reflexes may be slower or diminished in an older client. Responses to stimuli are slower because of reduced impulse transmission. Many older adults have some impairment of hearing and vision, which should be taken into consideration when planning care.

The nurse is designing a teaching plan for community members on ways to prevent chronic pain. Which information should the nurse include in this teaching plan? Select all that apply. A) Eating a healthy diet B) Obtaining adequate sleep C) Avoiding illicit drug use D) Limiting smoking to only before bedtime E) Avoiding repetitive movements

A, B, C, E) Lifestyle habits that predispose individuals to chronic health alterations increase an individual's risk for experiencing discomfort. Eating a healthy diet and obtaining adequate sleep can prevent the development of chronic diseases that lead to symptoms of discomfort. Using illicit drugs and smoking can cause emotional and physical withdrawal symptoms when the drug is no longer used. It is wise to not engage in smoking or illicit drug use to prevent the onset of discomfort. Repetitive movements can increase the risk for injury and fatigue, leading to discomfort.

The nurse is caring for a client diagnosed with dilated cardiomyopathy. Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply. A) Fatigue B) Lower extremity edema C) Syncope D) Dyspnea E) Angina

A, B, D) Clinical manifestations of dilated cardiomyopathy include dyspnea, orthopnea, weakness, fatigue, peripheral edema, and ascites. Syncope and angina are commonly associated with hypertrophic cardiomyopathy and other forms of cardiomyopathy, but not with dilated cardiomyopathy.

A nurse working on a medical-surgical unit wants to ensure care is provided within the standard of nursing care. Which actions by the nurse are appropriate? Select all that apply. A) Analyze the position description. B) Review and become familiar with the policy and procedure manual. C) Question the value of collaborating with other disciplines. D) Review applicable state nurse practice act and administrative rules. E) Adhere to national standards of practice and care.

A, B, D, E Explanation: A) Nurses are expected to demonstrate competence within multiple areas of their professional role, including collaboration with the entire care team. The nurse's specific job description will contribute to defining the standard of care. Employers can limit but not expand the scope of practice, and the nurse will be held to functioning within the scope of employment. Agency policies and procedures serve in defining the standard of care. The applicable state nurse practice act and administrative rules form the basis of the standard of care to which each nurse is held. A primary source for defining the standard of care is the prevailing national nursing standards. Nurses who follow national standards of practice and standards of care will provide their clients with the best care possible and be far less likely to commit any unintentional act that may rise to the level of malpractice.

The nurse is providing postpartum care for a client who gave birth by cesarean section several hours ago. The client had preeclampsia during the last 3 weeks of pregnancy. Which interventions are appropriate for this client within the first 48 hours after birth? Select all that apply. A) Assessment of deep tendon reflexes B) Assessment of intake and output C) Oxygen 2 liters nasal cannula as prescribed D) Seizure precautions E) Vital sign assessment

A, B, D, E) Even though the client with preeclampsia usually improves rapidly after giving birth, seizures can still occur during the first 48 hours postpartum. Nursing management during the postpartal period also includes deep tendon reflexes, intake and output assessment, and vital signs. Oxygen is not usually indicated after delivery.

The nurse is determining ways to decrease environmental stimuli for a client with increased intracranial pressure. Which actions should the nurse take to support this client's care need? Select all that apply. A) Limit the client's visitors. B) Teach family to speak softly and minimize touching. C) Elevate the head of the bed. D) Raise pads and bedrails. E) Keep the room dark and quiet.

A, B, E) A dark, quiet room is important to reduce stimuli. Family members should be encouraged to talk to the client in a soft voice with minimal touching. Visitors should be limited. Elevating the head of the bed is important to reducing intracranial pressure but has no effect on stimulation. Raising pads and bedrails is important because of the possibility of seizures but does not relate to stimulation.

The wife of a patient with end-stage chronic obstructive pulmonary disease (COPD) tells the nurse that she wishes her husband were eligible for hospice care but she thinks that hospice is only available for cancer patients. She is also concerned that, even if he were eligible for hospice care, they couldn't afford it, they'd have medical personnel constantly underfoot, and her husband would have to switch healthcare providers. Which responses by the nurse are appropriate? Select all that apply. A) Inform her that a diagnosis of cancer is not required for hospice care. B) Inform her that hospice care is very expensive. C) Tell her that hospice care is intended to ease the burden of primary caregivers, not add to it by being in the way. D) Tell her that, even though her husband has end-stage COPD, he is not eligible for hospice care. E) Inform her that all hospice programs are provided 24/7 in long-term care facilities.

A, C) In addition to clients who are diagnosed with cancer, a variety of clients qualify for hospice care. To be eligible for hospice care, clients need to be diagnosed by a physician as having 6 months or less to live. Hospice care supports the involvement of family in clients' care and is available to help ease the burden of primary caregivers. In many cases, hospice is provided by the individual's health insurance or Medicare policy. Hospice care can take place in the client's home or in hospice centers, hospitals, nursing homes, and other long-term care facilities.

A medication error occurred and the nurse is preparing to complete an incident report. Which information is required to thoroughly complete this report? Select all that apply. A) Name of client involved in the incident B) Location where incident report is completed C) Date and time of the incident D) Medication involved in the incident E) Number of hours the nurse was at work before the incident occurred

A, C, D) An incident report is an agency record of an accident or incident occurring within the agency. Incident reports generally include the names and identifying information of any clients and healthcare personnel involved in the incident as well as information on witnesses; the location, time, and date of the incident; and if a medication is involved, the medication's name and dosage. The location of the incident, not where the incident report itself is completed, should be entered. The number of hours the nurse worked before the incident occurred is not a part of the report.

The nurse is concerned about being sued for negligence when providing care. Which nursing actions may be grounds for negligence? Select all that apply. A) Client fell getting out of bed because the call light was not used. B) Client name band was checked prior to providing all medications. C) Client's morning medications were administered in the early afternoon. D) Client states not understanding activity restrictions and wound eviscerated. E) Client documentation did not include appearance of infiltrated IV site.

A, C, D, E) Checking the client name band before providing medications is not an action that is negligent. However, providing medications beyond the prescribed time can be viewed as negligent care. One strategy to prevent instances of professional negligence is to ensure client safety. The client fell when getting out of bed because the call light was not used. Because there is no way of knowing if the client knew how to use the call light, the nurse should be concerned with this situation. Clear communication of directions, explanations, and providing effective client education regarding the client's healthcare requirements can help decrease the risk of bad outcomes, so the wound evisceration could be viewed as negligent care. Poor documentation about care, wounds, and intravenous sites could be viewed as negligent care.

A client with a head injury is demonstrating signs of increased intracranial pressure (IICP). Which classifications of medications should the nurse anticipate administering to this client? Select all that apply. A) Loop diuretics B) Antibiotics C) Antiseizure drugs D) Histamine H2 antagonists E) Antipyretics

A, C, D, E) Medications play an important role in the management of IICP. Loop diuretics are commonly used to reduce ICP. Antipyretics such as acetaminophen are used alone or in combination with a hypothermia blanket to treat hyperthermia. Antiseizure drugs are often required to manage seizure activity associated with brain injury and IICP. Gastrointestinal prophylaxis with intravenous histamine H2 antagonists is often used because clients with IICP are at increased risk for developing stress gastritis and ulcers. Antibiotics are not routinely prescribed as treatment for IICP.

The nursing instructor is evaluating the success of training provided to staff nurses on ways to reduce the incidence of pediatric medication errors. Which observations indicate that training has been effective? Select all that apply. A) Staff nurses are double-checking medication calculations. B) Staff nurses are refusing to dilute medications. C) Staff nurses are using liquid preparations. D) Staff nurses are asking the pharmacy to prepare the exact doses. E) Staff nurses are asking each other to validate placement of decimal points.

A, C, E) Children are at a higher risk for medical error than other clients and also may be more vulnerable to harm from errors due to their immature physiology. Reasons for increased medical error among children include miscalculation of doses and amounts and incorrect placement of the decimal point in calculations. Nurses who double-check medication calculations, use liquid preparations, and ask another nurse to validate the placement of the decimal point are demonstrating that the training was effective. The nurses should not be refusing to dilute medications because many preparations require dilution to achieve the small dosages required by infants, and they should not expect the pharmacy to prepare the medications in exact doses.

A nurse educator is planning a class for a group of nursing students regarding risk management. Which information should the educator include in this presentation? Select all that apply. A) Risk management seeks to prevent harm. B) Risk management empowers clients. C) Risk management controls the cost of supplies. D) Risk management examines past mistakes and identifies potential hazards. E) Risk management ensures that nurses are truthful.

A, D) The major goal of a risk management department is to limit a healthcare agency's financial and legal risk associated with the delivery of care, particularly in terms of lawsuits, ideally before incidents occur. This involves preventing harm to clients and hospital personnel by examining past mistakes and identifying potential hazards. The cost of supplies, truthfulness of nurses, and empowerment of clients are not goals of risk management.

A client's stroke volume (SV) is 85mL/beat and the heart rate (HR) is 71 beats per minute (bpm). What is the client's cardiac output (CO) rounded to the nearest liter?

Answer: 6 Liters (L) Explanation: CO = SV × HR 85mL = 0.085 L CO = 0.085 × 71 = 6.035 = 6 L

Which action should the nurse carry out for the laboring client who has been diagnosed with preeclampsia? A) Place the client in the room closest to the nurse's station, even if it is a shared room. B) Place the client in left lateral position when the client feels the urge to push. C) Monitor client's fetus intermittently while client is in first stage of labor. D) Encourage the client to be alone in the room without family in order to maintain a quiet environment.

B) A laboring client with preeclampsia is at risk for the development of eclampsia with subsequent seizures. The nurse should place the client in left lateral position because this position improves circulation to the placenta and fetus; the client should remain in this position when pushing if possible. If possible, the nurse should place the client in a private room to promote a nonstimulating environment. However, the client should always have support with her, not be alone during labor. The nurse will monitor the client's fetus continuously during labor.

The nurse is caring for a client who is experiencing acute chest pain that is rated as a 9 on a 0 to 10 pain scale. Based on this data, which medication does the nurse expect to administer? A) Acetaminophen B) Morphine C) Ibuprofen D) Naproxen

B) Acute pain is often treated with an opioid such as morphine. Morphine is often used to treat chest pain that is associated with a myocardial infarction. Acetaminophen, ibuprofen, and naproxen are more appropriate for other types of pain, not acute chest pain.

The nursing instructor asks a student to explain why the American Board of Managed Care Nursing (ABMCN) is an example of a certification program. How should the student respond? A) It formally recognizes nurses who have achieved a high standard of practice in managed care. B) It provides a process for recognizing the professional competence of individuals who pass the program. C) It investigates and adjudicates cases of professional negligence. D) It lists the state requirements for a nursing professional to achieve licensure.

B) Although a nursing license grants the legal privilege to practice, credentialing is the formal identification of professionals who meet predetermined standards of professional skill or competence. The federal government has used the term certification to define the credentialing process by which a nongovernmental agency or association recognizes the professional competence of an individual who has met certain predetermined qualifications specified by the agency or association. The American Board of Managed Care Nursing is one such organization. Formally recognizing nurses who have achieved a high standard of practice in managed care is an example of credentialing. It is not the ABMCN's role to investigate and adjudicate cases of professional negligence or to simply list requirements for nursing professionals to achieve licensure.

A preadolescent client who fell from a balance beam in physical education class injured her ankle. Given this information, which action by the nurse is appropriate? A) Referring the client to physical therapy B) Placing an ice pack on the client's ankle C) Planning for a corticosteroid injection D) Ordering an x-ray of the ankle

B) An appropriate intervention for a client who experiences an ankle injury is placing ice on the ankle to limit swelling. If physical therapy is needed, the referral would be given after the ankle has had time to heal. A corticosteroid injection would be more appropriate for a client with osteoarthritis, not an acute ankle injury. Ordering an x-ray of the ankle is outside the nurse's scope of practice.

The nurse is evaluating the effectiveness of interventions to address a client's bowel and bladder dysfunction as a result of a spinal cord injury. Which finding would indicate that these interventions have been successful? A) The client had two episodes of impacted stool over the last week. B) The client is improving in ability to perform self-urinary catheterization. C) The client is limiting fluids to reduce need to void. D) The client has an indwelling urinary catheter and is provided with stool softeners every morning.

B) An ideal outcome for the client with bowel and bladder dysfunction as a result of a spinal cord injury would be for the client to attain appropriate bowel and bladder elimination habits. If the client's ability to perform self-urinary catheterization is improving, the interventions can be considered successful. A client with an indwelling urinary catheter who is receiving stool softeners every morning is not progressing toward appropriate bowel and bladder elimination habits. A client who had two episodes of impacted stool over the last week is not progressing in bowel elimination habits. A client who is limiting fluids to reduce the need to void is possibly hindering his health in order to avoid having to perform self-urinary catheterization.

Which of the following clients is at highest risk for autonomic dysreflexia? A) A client with an injury to T9 B) A client with an injury to C7 C) A client with an injury to L2 D) A client with an injury to S1

B) Autonomic dysreflexia is the abrupt onset of excessively high blood pressure as the result of an overactive autonomic nervous system; it usually occurs in clients who have injuries above T5. Of the spinal segments listed here, only C7 is located above T5.

The nurse is caring for a client who is 28 weeks pregnant. The client says she has recently begun to experience frequent lower back pain and asks the nurse what can be done to control this pain. What is the nurse's best response? A) "Back pain is common during pregnancy and can usually be managed by taking nonsteroidal anti-inflammatory drugs (NSAIDs)." B) "Let's talk about some postural adjustments that might help alleviate your pain." C) "Back pain during pregnancy is often related to kidney infection. Have you experienced any recent urinary problems, including pain when voiding?" D) "The physician will likely order an x-ray to investigate potential causes of your pain."

B) Back pain is common during pregnancy due to strain on the back from the growing uterus and fetus; abdominal weakness from stretched abdominal muscles; and hormonal changes that loosen the ligaments in the joints of the pelvis. Kidney infection is not a leading cause of back pain in pregnant women. Pregnancy-related back pain is usually managed conservatively. Postural changes or other adaptations can help increase mobility and decrease discomfort. The recommended pain medication is acetaminophen, because NSAIDs are contraindicated during pregnancy. Although diagnostic imaging may be useful, x-rays should be avoided because they deliver ionizing radiation to the fetus.

The nurse is preparing to assess a 1-year-old client for signs of discomfort. When conducting the assessment, which action by the nurse is the most appropriate? A) Asking the client to rate the pain on a scale of 0-10 during the assessment process B) Asking the parent to hold the client in the lap during the assessment process C) Reading a book to the client during the assessment process D) Recommending that the parent leave the room during the assessment process

B) Children may be fearful of physical assessment. To promote comfort, allow the child to sit on the parent's or guardian's lap during the assessment process, rather than asking the parent to leave the room. A numeric pain scale is not appropriate until the client is older; a faces pain scale would be better. Reading a book during the assessment process is not age appropriate.

A 14-year-old child was recently diagnosed with hypertrophic cardiomyopathy. During a follow-up appointment, the mother asks the nurse, "How will this affect my child's ability to play football in the fall?" How should the nurse respond? A) "This shouldn't affect his ability to play football." B) "Children with cardiomyopathy should not play football." C) "He could participate in flag football but not tackle football." D) "This may actually make him a better, stronger football player."

B) Children with cardiomyopathy should not play competitive sports due to the possibility of collapse or increased heart failure. Depending on the child's clinical status, low-impact activities may be appropriate, but this should be discussed with the child's physician.

What best explains the reason that a nurse should be responsible for communicating any changes in the condition of a client at the end of life that would warrant a change in the care plan? A) Nurses typically are responsible for definitively diagnosing patient conditions. B) Nurses are the healthcare providers who tend to have the greatest amount of contact with clients at the end of life. C) Clients typically do not prefer to talk to physicians about problems. D) It is legally mandated that nurses are solely responsible for communicating this information.

B) Collaboration between healthcare providers is essential to providing quality care at the end of life. Nurses interact with clients most frequently, so they are responsible for communicating any changes in the client's condition that would warrant a change in the care plan, but they don't definitively diagnose patient condition, and they are not the only legally mandated people who may communicate changes in a client's condition. Clients often talk to physicians about problems.

A client diagnosed with cardiomyopathy reports having to rest between activities during the day. The client asks the nurse why this is occurring. Which reason should the nurse include in the response to the client? A) Increased stroke volume B) Decreased cardiac output C) An elongated and dilated aorta D) Increased blood pressure

B) Decreased cardiac output is a result of decreased efficiency and contractibility of the myocardium. Rest could be required after each activity that puts physiological stress on the heart. Less blood is pumped from the heart to the rest of the body with a decreased cardiac output, and this has a direct effect on the activity level that can be tolerated. It is unknown if the client has increased stroke volume, an elongated and dilated aorta, or high blood pressure.

A nurse is educating a client with cardiomyopathy about diet choices that are appropriate for the client's condition. Which statement is inappropriate for the nurse to include in the teaching session? A) "It is important to monitor your sodium intake." B) "Increasing your dietary protein helps with cardiac cell repair." C) "Here is a list of high-fat, high-cholesterol foods to avoid." D) "I have notified the dietitian regarding your condition in order to provide you with more information."

B) Diet is an important part of long-term management of heart failure. It also contributes to reducing fluid retention. The nurse should instruct the client with cardiomyopathy to monitor sodium intake and to avoid high-fat, high-cholesterol food. Instructing the client to increase protein is not appropriate and is not shown effective in managing cardiomyopathy. Consulting with the dietitian is appropriate with this client.

A nurse is caring for a pregnant client who is hypertensive. Which additional clinical manifestations leads the nurse to believe that the client is experiencing early preeclampsia? A) Persistent headache B) Excessive protein in the urine C) Right-sided abdominal pain D) Severe epigastric pain

B) Early signs of preeclampsia include high blood pressure and evidence of protein in the urine. Later symptoms include persistent headache and right-sided abdominal pain. Severe epigastric pain is a symptom of HELLP syndrome.

Which of the following statements best describes the therapeutic approach to acute and chronic pain, fatigue, fibromyalgia, and sleep disorders? A) Therapy is primarily psychosocial in nature. B) Therapy involves both pharmacologic and nonpharmacologic approaches. C) Therapy is essentially physiologically focused. D) Therapy mostly involves the client avoiding risk behaviors.

B) For all of these conditions, therapy involves both pharmacologic and nonpharmacologic approaches. Therapy for these conditions is both physiological and psychosocial, addressing all components of client's conditions. Therapy involves treatment of existing conditions, not just risk prevention measures on the client's part.

A pregnant client is diagnosed with HELLP syndrome. Based on this diagnosis, which laboratory findings are consistent with diagnosis of HELLP? A) Decreased liver enzymes B) Hemolysis C) Elevated lipid panel D) Increased platelet count

B) HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) is thought to be related to severe preeclampsia. Elevated lipid panel is not a characteristic of HELLP syndrome.

Within the human body, which type of connective tissue connects bones to other bones to form a joint? A) Tendon B) Ligament C) Cartilage D) Myelin

B) Ligaments, tendons, and cartilage are all connective tissues. Ligaments connect bones to other bones to form a joint. Tendons connect bones to muscles and carry the contractile forces from the muscle to the bone to cause movement. Cartilage is a type of flexible connective tissue found in many locations throughout the body. Myelin is not a type of connective tissue but rather a fatty substance that insulates neuronal axons and promotes faster signal transmission.

The nurse is caring for a client who is scheduled to receive metoprolol (Lopressor). What should the nurse teach the client about this medication? A) Expect a rapid heart rate. B) Change positions slowly. C) Reduce protein intake. D) Increase fluids.

B) Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and to change positions slowly because this medication causes orthostatic hypotension. This medication does not cause a rapid heart rate. Protein restriction is not indicated with this medication. The client should not be instructed to increase fluids.

Which action demonstrates correct reporting of suspected child abuse? A) The nurse includes the entirety of the client's medical record. B) The nurse compiles a report with all pertinent information that is factually true. C) The nurse recommends that the organization report the abuse to state authorities. D) The nurse reports only information the client has authorized for release.

B) Reports should be complete and accurate and should be made according to the policy of the organization for which the nurse works. In addition to reporting the abuse within the organizational framework, the nurse should personally report the abuse to the proper authorities. When abuse is reported, all pertinent information in the client's medical record (not simply the entire record) is required by law to be disclosed to the reporting agency. As such, reporting abuse or suspected abuse represents an exception to client confidentiality rules.

The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation. What should the nurse consider when planning for this client's potential health problem? A) Encouraging ambulation every 30 minutes B) Instructing on deep breathing C) Administering medications appropriate to increase heart rate D) Positioning to increase blood return

B) The client is at risk for inadequate oxygenation. The nurse should consider teaching the client the importance of deep breathing to increase the amount of oxygen in the body tissues. Encouraging ambulation every 30 minutes would negatively impact oxygenation. Periods of rest should occur between activities, and no activity should be too strenuous. The client with oxygenation issues will have tachycardia. The nurse should consider medications that would reduce instead of increase the heart rate. The client should be in the high-Fowler position to improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg, which would negatively impact oxygenation.

A client with preeclampsia begins to demonstrate manifestations of seizure activity. Which intervention by the nurse is most likely to protect the client and fetus from injury? A) Elevate the client's legs B) Place the client on the left side and protect the airway C) Place the client in the supine position D) Elevate the head of the bed

B) The client should be placed on the side to aid in circulation to the placenta. The airway needs to be maintained to ensure oxygenation throughout the seizure. The client's legs should not be elevated. The client should not be placed in the supine position. The head of the bed should not be elevated.

Which score would a nurse select from the muscle function grading scale if the client has full strength and range of motion in a given joint? A) 0 B) 5 C) 8 D) 10

B) The muscle function grading scale ranges from 0 to 5. A score of 0 indicates paralysis, meaning that the client cannot contract the muscles associated with a given joint. In contrast, a score of 5 indicates that the client can move a joint through the full range of motion under full resistance.

The nurse is caring for an adult client who sustained a right distal radial fracture and a left tibia fracture. Which mobility aid does the nurse anticipate being used for this client? A) Lofstrand crutches B) Platform crutches C) Walker D) Axillary crutches

B) This client has fractures in both the leg and wrist. Platform crutches are used for clients who are unable to bear weight on their wrists. A walker, axillary crutches, and Lofstrand crutches all require use of the wrists.

Traumatic brain injury occurs when which of the following causes some degree of impairment to brain structure or function? A) Congenital disorder B) External force C) Infection D) Stress reaction

B) Traumatic brain injury occurs when an external force causes some degree of impairment to brain structure or function. The damage caused by this external force is referred to as the primary injury. Traumatic injury is not congenital and does not follow from infection or psychologic stress.

The nurse is preparing to conduct a cardiac assessment for a pediatric client. Which location will the nurse use when auscultating the apical pulse? A) At the fifth intercostal space B) At the left nipple C) At the right nipple D) At the eighth intercostal space

B) When assessing a pediatric client, it may be more beneficial to auscultate the apical pulse in the area of the left nipple at the fourth intercostal space. The other answer options are not appropriate.

An adult client is diagnosed with a degenerative bone disease that is impairing mobility. Based on this information alone, which of the following actions should be the nurse's first priority? A) Implementing a low-level exercise program for the client B) Assessing the client's pain management C) Teaching the client relaxation techniques D) Referring the client to a dietitian

B) When caring for a client with a degenerative bone disease that is impairing mobility, the nurse should assess pain management prior to implementing an exercise program, teaching relaxation exercises, or referring to a dietitian.

The nurse is instructing a client on lifestyle changes to promote a healthy cardiovascular system. Which of the following should be included in this teaching session? Select all that apply. A) Limit exercise to 15 minutes a day B) Reduce saturated fats in the diet C) Avoid cigarette smoking D) Wear elastic hose E) Limit fluid intake

B, C) Interventions that help promote a healthy cardiovascular system are to avoid cigarette smoking and reduce saturated fats in the diet. Clients should exercise for at least 30 minutes most days of the week to maintain a healthy cardiovascular system. Wearing elastic hose and limiting fluid intake are not known to contribute to a healthy cardiovascular system.

The nurse is caring for a client who is experiencing limited mobility related to a musculoskeletal alteration. Which laboratory tests would be useful to diagnose the client appropriately? Select all that apply. A) Magnetic resonance imaging (MRI) B) Alkaline phosphatase (ALP) C) Human leukocyte antigen-B27 (HLA-B27) D) Rheumatoid factor (RF) E) Electromyography (EMG)

B, C, D) ALP, HLA-B27, and RF are all laboratory tests that are used to diagnose clients with musculoskeletal disorders that can cause alterations in mobility. ALP is produced by bone and other organs. Increased ALP may indicate bone disease, bone fracture, bone tumors, osteomalacia, Paget disease, or rickets. Decreased ALP may indicate Wilson disease. The presence of HLA-B27 indicates an increased risk for ankylosing spondylitis and arthritis. Elevated levels of RF may indicate rheumatoid arthritis, scleroderma, lupus erythematosus, and adult Still disease. MRI and EMG are both diagnostic, not laboratory, tests use to diagnose the cause of alterations in mobility.

A nurse educator is teaching a group of nursing students about the function of the state board of nursing. Which information will the educator include in the teaching session? Select all that apply. A) Creating the NCLEX-RN examination B) Defining professional standards C) Investigating violations of the nurse practice act D) Suspending or revoking licenses E) Finding drug treatment centers for impaired nurses

B, C, D) Boards of nursing oversee nursing licensure by defining professional standards, investigating violations of the nurse practice act, sanctioning those who violate the nurse practice act, and suspending or revoking licenses. The National Council for the State Boards of Nursing creates the NCLEX-RN examinations. The state board of nursing is not responsible for finding treatment programs for drug-impaired nurses.

The nurse receives a notice that the state board of nursing has become a member of the Nurse Licensure Compact. How would this change in the state board of nursing structure influence the nurse's ability to practice nursing? Select all that apply. A) The nurse can only practice nursing in the residing state. B) The nurse can practice nursing in other states within the compact. C) The nurse is accountable to the state in which the nurse and clients reside. D) The nursing license will become similar to having a driver's license. E) The nurse has to obtain an additional license.

B, C, D) The mutual recognition model of nurse licensure allows a nurse to have a single license that confers the privilege to practice in other states that are part of the Nurse Licensure Compact. The nurse is held accountable for following the laws and rules of the state in which the nurse practices or where the client is located. It is similar to the driver's license model: A single license to drive is issued in the state of primary residency, but this license also allows the privilege to drive in other compact states. Multistate licensure privilege means the authority to practice nursing in another state that has signed an interstate compact. It is not an additional license.

The nurse is reviewing results of diagnostic testing performed on a client with increased intracranial pressure (ICP) in preparation for an evaluation to be done by the healthcare provider during morning rounds. Which diagnostic test results should the nurse make available to the healthcare provider for review? Select all that apply. A) Bronchoscopy results B) MRI result C) Head CT scan with and without contrast D) Electroencephalogram E) Cerebrospinal fluid differential cell count

B, C, D, E) Diagnosis of increased ICP is made on the basis of observation and neurologic assessment; even subtle changes can be clinically significant. Testing can include CT scan with and without contrast, MRI, electroencephalogram, and cerebrospinal fluid evaluation. Bronchoscopy is not performed routinely for a client with increased intracranial pressure.

The nurse observes a healthcare provider discussing an operative procedure with a client and determines that informed consent was achieved. Which information was included in the informed consent process? Select all that apply. A) The provider's disapproval if the surgery is not performed B) The health problem that requires surgery C) The purpose of the surgery D) The expectations of the surgery E) Outcome if surgery is not performed

B, C, D, E) For informed consent to be achieved, the client should receive the following information: the diagnosis or condition that requires treatment, purposes of the treatment, what the client can expect to feel and experience, intended benefits of the treatment, risks, and what could occur if the surgery is not performed or if alternatives to the treatment are chosen. To give informed consent voluntarily, the client must not be coerced in any manner. If the client provides consent due to fear of disapproval by a healthcare provider, such consent is not considered to be voluntary. Coercion of any kind invalidates the consent.

The nurse is caring for a client who sustained a gunshot wound below the level of T12, resulting in ipsilateral motor paralysis, ipsilateral loss of proprioception and vibratory sense, and contralateral loss of pain and temperature sensation. When planning care for this client, which interpretations of this data by the nurse are likely to be correct? Select all that apply. A) The client's American Spinal Injury Association Impairment Scale score is A. B) The spinal cord injury is incomplete. C) These findings are consistent with Brown-Sequard syndrome. D) Hemisection of the spinal cord is likely. E) Some recovery of sensory function is likely.

B, C, D, E) Hemisection of the spinal cord, usually caused by a penetrating trauma (gunshot, knife), causes sensory and motor deficits on opposite sides of the body because the spinal cord injury is incomplete. These findings are consistent with Brown-Sequard syndrome, which has the best prognosis of all the incomplete spinal cord syndromes. An American Spinal Injury Association (ASIA) Impairment Scale (AIS) score of A indicates a complete spinal cord injury where no sensory or motor function is preserved in the sacral segments S4-S5.

The nurse is evaluating the success of a bowel and bladder retraining program with a client who is recovering from a lower motor neuron spinal cord injury. Which observations indicate that this teaching has been successful? Select all that apply. A) One episode of bladder incontinence in 8 hours B) Client performs self-urinary catheterization every 4 hours while awake C) Client transfers to use bedside commode after breakfast to evacuate bowels D) Two episodes of impacted stool in 1 week E) Client maintains a high-fluid, high-fiber diet

B, C, E) Evidence that a bowel and bladder retraining program for a client with a spinal cord injury has been successful includes the client performing self-urinary catheterization every 4 hours while awake, transferring to the bedside commode to evacuate bowels after breakfast, and maintaining a high-fluid and high-fiber diet to prevent constipation. Evidence that this training has not been successful includes an episode of bladder incontinence and the need to have impacted stool removed twice in 1 week.

A client is receiving care in the hospital for life-threatening injuries sustained in a motor vehicle crash and is taken immediately to surgery. There is no family available to provide consent; however, the client's medical record is available and reviewed by the nurse. Which treatments are inappropriate in this situation? Select all that apply. A) Emergency surgery B) Treatment that was previously refused C) Treatment that violates religious beliefs D) Medications to treat the injury E) Experimental medications for a research study

B, C, E) In most states, the law assumes an individual's consent to medical treatment when the person is in imminent danger of loss of life or limb and unable to give informed consent. In other words, the emergency doctrine assumes that the individual would reasonably consent to treatment if able to do so. This doctrine serves as a guiding principle that permits healthcare providers to perform potentially life-saving procedures under circumstances that make it impossible or impractical to obtain consent. Treatment that was previously refused or violates the client's documented religious beliefs is not appropriate. Experimental medications that are being initiated in conjunction with a research study are also not appropriate.

The nurse is concerned about the risk involved when implementing healthcare provider prescriptions for a newly admitted client. Which strategies should the nurse consider to reduce this risk? Select all that apply. A) Question any order written for a postoperative client. B) Question any order a client questions. C) Question any order if the client's condition changes. D) Question any verbal order. E) Question any order that is incomplete.

B, C, E) Nurses can minimize risk by analyzing procedures and medications ordered by the physician. It is the nurse's responsibility to seek clarification of ambiguous or seemingly erroneous orders from the prescribing physician. To protect themselves legally, nurses should question any order a client questions, any order if the client's condition has changed, and any order that is incomplete. Orders written for postoperative clients do not all need to be questioned. Verbal orders should be recorded accurately to avoid miscommunication, but they do not all need to be questioned.

The nurse is caring for a client diagnosed with cardiomyopathy. The client experiences tachycardia. Which medication does the nurse anticipate being prescribed? A) ACE Inhibitor B) Angiotensin II receptor blocker C) Beta blocker D) Cardiac glycoside

C) A client with cardiomyopathy experiencing tachycardia may take a beta blocker to lower the heart rate. ACE inhibitors and angiotensin II receptor blockers are used to decrease blood pressure in a client with cardiomyopathy. Cardiac glycosides are used in congestive heart failure and do not assist in lowering the heart rate in a client with cardiomyopathy.

A client newly diagnosed with diabetes mellitus tells the nurse that the prescribed diet does not provide enough variation of choice. It is against the state's nurse practice act for a nurse to order a diet for the client. Which response by the nurse is most appropriate? A) "I will bring you a different menu." B) "I will ask my manager to talk with the dietitian." C) "Let's look at your diet and see what type of variety we can find." D) "I will notify the dietary department to change your diet."

C) A nurse practice act (NPA) is a series of state statutes that define the scope of practice, standards for education programs, licensure requirements, and grounds for disciplinary actions. The law provides a framework for establishing nursing actions in the care of clients. It is against most states' nurse practice acts for the nurse to order a diet for the client. The nurse is allowed to assist the client to choose appropriate foods as ordered by the physician. The nurse cannot notify the dietary department or enlist the assistance of a manager to change the diet with a healthcare provider prescription. Providing the client with another menu will not help the client choose foods within the prescribed diet.

A student nurse administers a medication to the wrong client while the instructor is with another student. Which statement by the instructor is most appropriate in this situation? A) "You have placed the nursing student program in danger." B) "You may be sued by the hospital for the extra care cost to the client." C) "You are expected to practice like a licensed nurse." D) "You have set a bad example for the other students."

C) A nursing student is held to the standard of conduct of an experienced, licensed professional nurse. Students are required to know the standards and to follow them. Hospitals do not generally sue nurses to recover money for extended care due to an error. It is not likely that the teaching program is in danger, as people do make mistakes and hospitals do rely on nursing schools to help provide care to clients. It is not likely that the other students are apt to follow the example of a student who fails to follow policy.

Which clinical manifestation is associated with a mild concussion? A) Bleeding in the brain B) Difficulty breathing C) Acute headache D) Prolonged unconsciousness

C) Acute headache is a clinical manifestation of a mild concussion or traumatic brain injury. Bleeding in the brain, difficulty breathing, and prolonged unconsciousness are all clinical manifestations of moderate to severe traumatic brain injury.

Which client is most likely to reject attempts at comfort? A) An infant crying B) A school-age child with abdominal pain who is anxious about a procedure C) An adolescent with a sleep disorder who doesn't want his parents to be near him D) An older adult with end-stage renal disease

C) Adolescents may respond to treatment and comfort better if you interact with them as adults rather than as children. Some adolescents may reject any offer of comfort, and an adolescent with a sleep disorder who has displayed antagonism toward his parents' presence is probably irritable from his condition and may immediately reject attempts at comfort, at least at first. An infant crying is verbalizing the need for comfort. A school-age child anxious about a medical procedure craves reassurance. An older adult with a terminal illness likely will welcome comfort measures even if she has accepted that she is going to die.

The school nurse is teaching a group of adolescent athletes about reducing the risk for sustaining traumatic brain injuries (TBI). To provide client-centered education to this population, which information is most appropriate for the school nurse to include in the teaching session? A) "A fall from even a low height can cause traumatic brain injury." B) "A traumatic brain injury can occur to anyone from a wide range of causes." C) "If you are injured in a game or practice, don't play through the pain." D) "Wearing seat belts can protect against injuries in motor vehicle collisions."

C) Adolescents often downplay their injuries or do not report them for fear of looking weak or being unable to participate in sports and other activities. This greatly increases their risk of being injured again and developing second impact syndrome, which can be fatal. Nurses play a vital role in helping prevent both first-time and repeated TBIs by providing appropriate client teaching. Although the other statements are true, they don't specifically address the prevention challenges for TBIs that adolescents present.

An adolescent client with terminal cancer tells the nurse that she does not want any more treatment, even though her parents are planning for her to participate in a study trial that involves aggressive chemotherapy. Which action by the nurse is the most appropriate? A) Tell the client that the decision is her parents' and she has to participate in the study. B) Tell her that, at 16, she can make her own decisions no matter what her parents want. C) Request that the parents and daughter meet together with the healthcare team to discuss options and the implications of various choices. D) Tell her not to worry because her parents want the best for her.

C) Adolescents with a serious medical condition are more capable of making treatment decisions than most teenagers. However, the Patient Self- Determination Act of 1990 limits the legal rights of individuals younger than 18 to make their own healthcare decisions. If the adolescent states a desire to withdraw from or refuse treatment, her parents and healthcare team should discuss the reasons for her decision and help her understand the implications of her decision and any treatment alternatives that may influence her choice. Telling her not to worry does not address the problem.

Which of the following infant clients presenting with traumatic brain injury (TBI) is least likely the victim of child abuse? A) Infant with contusion sustained from fall from high chair B) Infant with contusion, unknown cause C) Infant with diffuse axonal injury following involvement as passenger in a vehicle collision D) Infant with diffuse axonal injury, unknown cause

C) Assaults/child abuse are the leading cause of death for infants and children with TBI. Injury patterns will depend on the cause of injury. For example, an infant who suffers a TBI from shaken baby syndrome will exhibit diffuse axonal injury, whereas a toddler who suffers a fall may have a local contusion with edema from a coup-contrecoup injury. The fall from a high chair could have happened accidentally or have been caused to happen, and either a contusion or a diffuse axonal injury could be the result of abuse. A diffuse axonal injury following involvement in a vehicle collision, however, is most likely the result of the collision.

A client who sustained a cervical neck injury 2 days ago is demonstrating an irregular respiratory pattern with a rate of 8-10 breaths per minute. Based on this data, which is the priority nursing diagnosis? A) Impaired Physical Mobility B) Autonomic Dysreflexia C) Ineffective Breathing Pattern D) Impaired Gas Exchange

C) Because the client sustained the neck injury 2 days prior, the full extent of the injuries cannot yet be determined. The client's rate of respirations should be between 12 and 20 breaths per minute. Because the client is breathing irregularly at a rate of 8-10 breaths per minute, the client may need assisted ventilation or a tracheostomy. The priority nursing diagnosis for this client would be Ineffective Breathing Pattern. A diagnosis of Impaired Gas Exchange could occur because of the Ineffective Breathing Pattern diagnosis, but it would be the second in priority for this client. The diagnoses of Impaired Physical Mobility and Autonomic Dysreflexia could both be addressed at a later time.

An older school-age child is brought to the emergency department after a car accident. The parents witness and stare at the resuscitation scene unfolding before them. The child is not responding to the resuscitative efforts after 30 minutes. Which is the best communication strategy for the nurse to use in this situation? A) Ask the parents whether they would like resuscitative efforts to be continued at this point. B) Ask the parents to stand at the foot of the cart to watch. C) Inform the parents that resuscitative efforts have not been effective and are not beneficial to the child. D) Ask the parents to leave until the child has stabilized.

C) Care must be used in how the parents are asked to withdraw therapies. An effective communication strategy is to inform the parents that an intervention was initiated to give the child the best chance of recovery, but it has not been effective and is not beneficial to the child. When asking to withhold therapy such as cardiopulmonary resuscitation, it is helpful to indicate that the therapy is not effective in reversing overwhelming illness or brain damage. All other interventions mentioned are not effective communication strategies in this situation.

The nurse is caring for a dying child. Which nursing action supports the primary goal for a dying child? A) Keep the child entertained so she does not think about dying. B) Ensure that a good relationship is maintained with the family. C) Administer pain medication as ordered. D) Maintain a busy schedule for child and family members.

C) Children with life-limiting conditions should receive palliative care in much the same way it is provided to adults. The major goal for the dying child is to promote comfort and keep the child pain-free by providing analgesia to promote optimal pain relief. Maintaining a good relationship is important but not a major goal for the child's care. Keeping the child entertained is good, but the client needs to voice her feelings about death and dying. A dying child does not have the energy to maintain a busy schedule.

The nurse is reviewing objective data obtained during the assessment of a pregnant woman in her 34th week of gestation. Which finding would be cause for concern? A) Pulse 103 bpm B) Blood pressure 108/70 C) Hematocrit 24% D) WBC count 10,340/mm3

C) During pregnancy, red blood cell (RBC) production and plasma volume increase, but because plasma volume increases more than RBC volume, the hematocrit decreases slightly. However, this client is experiencing a significant decrease in hematocrit, indicating that she is not producing adequate RBCs. The pulse normally increases by 10-15 bpm during pregnancy, blood pressure decreases slightly, and WBC count increases. Findings within the given ranges are normal during pregnancy and are not cause for concern at this point.

Which statement exemplifies the ultimate accountability of nursing students for their actions? A) "State regulatory bodies have the ultimate responsibility for my actions." B) "The client's perception of the care I give determines the correctness of my actions." C) "I am responsible for my own actions, correct or incorrect." D) "No one may judge my actions as correct or incorrect other than me."

C) Each nurse practice act (NPA) addresses the duties and responsibilities of nursing students in that state. Typically, this includes language that allows nursing students the privilege to practice nursing without a license while engaged in the clinical practicum of an approved nursing education program under the supervision of qualified faculty. Nursing students have the ultimate responsibility (accountability for their actions that includes the obligation to answer for an act done and to repair any injury one may have caused) for their own actions. This responsibility does not rest ultimately with the state and does not depend solely on client perceptions. Responsibility does not mean that no one else but the nursing student may judge the student's actions.

A school nurse is treating a school-age client who has fallen down a flight of stairs. The client is breathing but unconscious. After calling the ambulance, which is the priority action by the nurse? A) Open the airway using the head tilt maneuver. B) Try to rouse the client by gently shaking the shoulders. C) Protect the client's neck and head from any movement. D) Place the client on the side to prevent aspiration.

C) Guidelines for emergency care are avoiding flexing, extending, or rotating the neck; immobilization of the neck; securing the head; maintaining the client in the supine position; and transferring the client from the stretcher to the hospital bed with backboard in place. This client is unconscious, and the nurse must protect the neck from any (or any further) damage. If the client vomits, the nurse should use the log-roll technique to turn the client while keeping the head, neck, and spine in alignment. This client is breathing; however, if a change in respirations were to occur, the airway should be opened using the jaw thrust maneuver. Rousing the client by shaking could cause damage to the spinal cord.

A novice nurse attends a lecture regarding risk management. Which action should the nurse implement to reduce risks in practice? A) Not discussing errors made B) Questioning every order that the physician writes C) Urging the nurse's organization to purchase liability insurance D) Storing unused equipment in the halls of the unit

C) Healthcare organizations can use several strategies to minimize risk. One of the most basic strategies is protecting against financial risk by purchasing insurance or by self-insuring. Risk management also entails analyzing errors to determine causes and changing policy to reduce more errors. Nurses should report all errors in an effort to assist in the campaign to reduce medical errors. Storing unused equipment in the hall serves to eliminate risk of contamination but could increase the risk due to injury. The nurse does not need to question every order that a physician writes; the nurse is responsible only for questioning orders that may injure clients.

The nurse in the emergency department is preparing to administer methylprednisone to a client with a spinal cord injury. What does the nurse recognize as the intended therapeutic effect of the medication? A) To increase blood glucose level B) To improve the client's level of consciousness C) To prevent cord damage from ischemia and edema D) To improve the client's ability to be adequately ventilated

C) High-dose steroid protocol using methylprednisone must be implemented within 8 hours of spinal cord injury to improve neurologic recovery. Clinical research indicates that use of this medication is effective in preventing secondary spinal cord damage from edema and ischemia. Methylprednisone may cause hyperglycemia if the client also has a diagnosis of diabetes. This medication is not provided to improve respirations or improve the level of consciousness.

Which types of sports are most likely to cause concussion and traumatic brain injury? A) Competitive B) Energetic C) High-impact D) Team

C) High-impact and extreme sports such as boxing, football, hockey, and skateboarding carry a higher risk of concussion and TBI. Team sports might be competitive and energetic without being high impact.

A client states to the nurse, "I know I have high blood pressure, but I don't want to take medication." Based on this data, which health problem is the client at risk for developing? A) Gastritis B) Diabetes C) Cardiomyopathy D) Metabolic syndrome

C) Hypertension places the client at risk for development of cardiomyopathy. Hypertension has not been associated with gastritis, diabetes, or metabolic syndrome.

The cells that produce the matrix for bone formation are known as A) osteoclasts. B) sarcomeres. C) osteoblasts. D) epiphyseal plates.

C) Osteoblasts are the cells that produce the matrix for bone formation, whereas osteoclasts are cells that break down bone tissue. Sarcomeres are filaments made of actin or myosin that are found within muscle. Epiphyseal plates are areas of cartilage located between the epiphysis and diaphysis of a child's long bones.

The nurse is providing care for a client who is experiencing subjective symptoms of carpal tunnel syndrome. Which test should the nurse anticipate being performed by a provider during the physical assessment of this client? A) Bulge test B) Ballottement test C) Phalen test D) McMurray test

C) Phalen test is a special assessment to determine whether the client is experiencing carpal tunnel syndrome. With this test, the wrists are held in acute flexion for 60 seconds. Numbness, tingling, or pain may indicate carpal tunnel syndrome. All of the other tests listed here are used to assess the knee.

Which of the following is a pharmacologic therapy for acute pain? A) Antidepressants B) Muscle relaxants C) Opioid analgesics D) Stimulants

C) Pharmacologic pain management for acute pain involves opioid analgesics, nonopioid analgesics, or nonsteroidal anti-inflammatory drugs (NSAIDs). It does not involve antidepressants, stimulants, or muscle relaxants.

The nurse is caring for a client admitted to the hospital with lower extremity edema and shortness of breath. Which electrocardiogram finding indicates the client is at risk for an alteration in perfusion? A) P wave smooth and round B) Absent U wave C) PR interval 0.30 seconds D) ST segment isoelectric

C) The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a delay in conduction from the SA node to the ventricles. A P wave should be smooth and round. The U wave is not normally seen. The ST segment should be isoelectric.

The nurse identifies assessment findings for a client with preeclampsia. Blood pressure is 158/100 mmHg; urinary output 50 mL/hour; crackles in the lungs on auscultation; urine protein 1+; 1+ edema hands, feet, ankles. On the next hourly assessment, which new assessment finding would indicate worsening of the condition? A) Blood pressure 159/100 mmHg B) Urinary output 40 mL/hour C) Urine protein 2+ D) Lungs clear to auscultation

C) The assessment finding most abnormal is the increase in urine protein. This indicates worsening of the condition. Urinary output is still greater than 30 mL/hour, so this is not concerning yet. The blood pressure increase is not significant. Lungs clear to auscultation is an improvement in her condition.

A client admitted with the diagnosis of cardiomyopathy becomes short of breath with ambulation and eating and fatigued with routine care activities. Which nursing diagnosis does the nurse include in the client's plan of care? A) Imbalanced Nutrition: Less than Body Requirements B) Deficient Knowledge C) Activity Intolerance D) Self-Care Deficit

C) The client is short of breath with ambulation and eating and fatigued with routine care activities. The nursing diagnosis of Activity Intolerance is appropriate for the client at this time. Shortness of breath with meals does not indicate that the client has Imbalanced Nutrition. There is not enough information to determine if the client has a knowledge deficit. Fatigue with routine care activities does not necessarily mean that the client has a Self-Care Deficit.

An adolescent is brought into the emergency department (ED) with injuries sustained from a motor vehicle crash. What is a priority while providing nursing care for this client? A) Adequate urine output B) Stable blood pressure C) Continued stabilization of the neck and spinal cord D) Insertion of an intravenous access line

C) The danger of death from a spinal cord injury is greatest when there is damage to or transection of the upper cervical region. All people who have sustained trauma to the spine should be treated as though they have a spinal cord injury by stabilizing the neck and spinal cord. Assessment of urine output can be delayed. Assessing blood pressure is an intervention for all clients brought into the emergency department. An intravenous access line is necessary, but stabilization of the neck and spinal cord is of first priority.

Blood pressure is influenced by all except which factor? A) Pumping action of the heart B) Peripheral vascular resistance C) Heart rate D) Blood volume

C) The factors that determine blood pressure include the pumping action of the heart, peripheral vascular resistance, and blood volume and viscosity. Heart rate by itself does not determine blood pressure.

The nurse is presenting a talk on spinal cord injury for a community health fair. Which statement on the part of the attendees indicates that they understand the risk factors and prevention methods associated with spinal cord injury? A) "There isn't much I can do to prevent a head injury when another vehicle hits my car." B) "As long as my grandson wears a helmet, he will be safe on his motorcycle." C) "I'm going to spend extra time discussing this talk with my college-age son because of his higher risk for spinal cord injury." D) "Due to their elevated risk, I'd like you to present this talk to members of the local Native American population."

C) The highest-risk population for spinal cord injuries is young adult males, including college-age men. Riding motorcycles increases the risk of spinal cord injuries, even when helmets are used. Native Americans are the ethnic group with the lowest risk of spinal cord injury. Using a seat belt is a major preventive action for individuals who are involved in motor vehicle crashes.

What word best describes the pain a client experiences at the end of life? A) Unmanageable B) Unpredictable C) Inevitable D) Acute

C) The most common symptom at the end of life is pain, so end-of-life care must include pain management. Client pain will likely be chronic with acute episodes, and it won't necessarily be unmanageable or unpredictable.

Which nursing intervention related to perfusion can be performed independently? A) Administration of drug regimens B) Insertion of device to measure central venous pressure (CVP) C) Teaching relaxation techniques D) Thoracentesis

C) The nurse can teach relaxation techniques as an independent intervention to provide psychosocial support to the client. The nurse must administer drug regimens only under the order of a physician or nurse practitioner. Although nurses can monitor central venous pressure, they are not responsible for inserting the device to measure CVP. A physician or nurse practitioner usually performs a thoracentesis.

A client with cardiomyopathy receiving diuretic therapy has a urine output of 200 mL in 8 hours. Which action by the nurse is correct? A) Assist the client to ambulate. B) Document a normal urine output. C) Notify the healthcare provider. D) Measure abdominal girth.

C) The nurse should notify the healthcare provider, because a urine output of 200 cc in 8 hours is less than 30 cc per hour. The client could be dehydrated despite having peripheral edema. The nurse should not assist the client out of bed to ambulate at this time. This is not a normal urine output. Daily weights are an objective measurement of fluid volume; abdominal girth is not.

A nurse is planning a teaching exercise on prevention of traumatic brain injury and identifying examples of people with a higher risk of TBI. Which of the following people is not in a higher-risk group for a TBI? A) A 2-year-old child B) A 13-year-old adolescent C) A 44-year-old office worker D) A 77-year-old retiree

C) The office worker is not in a professional occupation involving a high risk of physical impact and so would not be in a higher-risk group for TBI. Because TBI is often the result of an accident, every individual is at risk for TBI. However, some individuals have a higher risk than others. Children, especially children under the age of 4, are at increased risk for TBI due to falls or abuse. Adolescents and young adults are at increased risk for TBI due to interpersonal violence and sports. Older adults are at increased risk for TBI due to falls, which are usually related to sensory perception changes or medication side effects

Which of the following best characterizes the sociocultural context of holistic human experience? A) Balance of physical processes B) Connection to a higher power C) Connection to others D) Equilibrium with external circumstances

C) The sociocultural context of holistic human experience involves connection with others in society. Connection to a higher power is involved in the psychospiritual context. Homeostatic balance is involved in the physical context. Equilibrium with external circumstances is involved in the environmental context.

A client diagnosed with cardiomyopathy asks the nurse to explain the different types of the disease. Which is inappropriate for the nurse to include in the teaching session? A) Dilated cardiomyopathy B) Restrictive cardiomyopathy C) Hypotrophic cardiomyopathy D) Arrythmogenic right ventricular dysplasia

C) The types of cardiomyopathy include dilated, restrictive, hypertrophic, arrythmogenic right ventricular dysplasia, and unclassified.

The nurse is auscultating heart sounds for a pregnant client in the third trimester of pregnancy. The client wants to know why her doctor told her she had an extra heart sound at the last visit. Which response by the nurse is appropriate? A) "You will need to have an echocardiogram to determine the reason for the extra sound." B) "You are likely experiencing heart failure due to the extra fluid that accumulates during this time in pregnancy." C) "You have what is known as a ventricular gallop, and it can be a normal finding during this trimester of pregnancy." D) "You have what is known as atrial gallop, and this is cause for concern."

C) Two other heart sounds may be present in some healthy individuals. The third heart sound (S3) may be heard in children, in young adults, or in pregnant females during the third trimester. It is heard after S2 and is termed a ventricular gallop. When the atrioventricular (AV) valves open, blood flow into the ventricles may cause vibrations. These vibrations create the S3 sound during diastole. There is no need for an echocardiogram. While the S3 sound can be associated with heart failure, this is not the case during pregnancy. S4, also known as an atrial gallop, can also be present in health individuals.

The nurse is conducting a gait and posture assessment for a client who is experiencing mobility issues. Which action by the nurse is appropriate during this assessment? A) Assessing the client's muscle mass and strength B) Measuring the length and circumference of the client's extremities C) Inspecting the client's spine for curvature D) Palpating the client for tenderness and pain

C) When assessing a client's gait and posture, the nurse should be sure to inspect the client's spine for curvature. Assessing muscle mass and strength, measuring the length and circumference of the extremities, and palpating for tenderness and pain are part of the physical assessment performed by the nurse for clients who are experiencing mobility issues.

Which statements are correct regarding the various layers of the heart? Select all that apply. A) The endocardium covers the entire heart and great vessels. B) The endocardium is the muscular layer of the heart that contracts during each heartbeat. C) The outermost layer of the heart is the epicardium. D) The myocardium consists of myofibril cells. E) The myocardium has four layers.

C, D) The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the endocardium. The epicardium covers the entire heart and great vessels, and then folds over to form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium, the middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The endocardium, which is the innermost layer, is a thin membrane composed of three layers. The myocardium is the muscular layer of the heart that contracts during each heartbeat. The outermost layer of the heart is the epicardium.

The nurse identifies the diagnosis of Excess Fluid Volume as appropriate for a client with cardiomyopathy. Which interventions should the nurse emphasize when planning this client's care? Select all that apply. A) Monitor B-type natriuretic peptide (BNP) level. B) Provide oxygen as prescribed. C) Assess respiratory status and lung sounds every 4 hours and as needed. D) Provide information about activity upon discharge. E) Monitor intake and output.

C, E) Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include assessing respiratory status and lung sounds every 4 hours and as needed, and monitoring intake and output. Monitoring BNP level and providing oxygen are interventions appropriate for the diagnosis of Decreased Cardiac Output. Providing information about activity upon discharge would be appropriate for the nursing diagnosis of Activity Intolerance.

An older adult client with terminal lung cancer is not breathing well and has cold and mottled skin. The client has a living will and requests comfort measures only. What should the nurse do to help this client? A) Ask the family what they want to be done for the client. B) Withhold all care until the client dies. C) Contact the provider for orders to control the client's breathing. D) Provide the client with pain medication as ordered.

D) "Comfort measures only" indicates that the client does not want extraordinary measures to sustain life. This does not mean that nursing care ceases but that nursing care to provide client comfort is intensified and maintained through the end stages of the client's life. Clients with a CMO order should receive effective pain and symptom management, spiritual care, food and fluids as the client is able, and hygiene care. Asking the family what they want to be done is inappropriate when a client has written a living will. Contacting the provider to intervene to control respiration is considered adding extraordinary measures and is inappropriate, as is going against the client's written wishes when a living will is present and in force.

A client presents with a mild concussion following a fall. Which nursing diagnosis is least likely to be made for this client? A) Acute Pain B) Acute Confusion C) Nausea D) Risk for Post-Trauma Syndrome

D) A client with a mild concussion following a fall might present with acute pain, acute confusion, and nausea, but a diagnosis of Risk for Post-Trauma Syndrome would be much more likely for a client with a moderate to severe traumatic brain injury.

A 16-year-old client has requested that she be examined and receive counseling without her parents being present. Which response demonstrates a correct response to this request? A) The nurse asks the client's parents if this is okay with them. B) The nurse agrees but still informs the parents immediately of everything they did not witness. C) The nurse strongly urges the client to reconsider this request to receive the best possible care. D) The nurse agrees that the client has the right to make this request but suggests that the parents still be present and involved.

D) Adolescent clients may wish to be examined or receive counseling separate from their parents. The nurse should make every effort to honor this request, though doing so may lead to confrontation with the parents. Understanding state statutes and organizational policy related to adolescent confidentially is essential when situations such as this arise. When providing confidential care to adolescents, the nurse should encourage adolescents to consider involving parents or guardians in their decision making. The nurse should make it clear that this is a suggestion and not a requirement for receiving care. The nurse should not clear this request with the parents, involve the parents anyway, or make it sound as though competent care depends on the adolescent reconsidering her request.

The nurse is caring for a client with hypertrophic cardiomyopathy. Based on this diagnosis, which class of medications does the nurse anticipate being prescribed? A) Digoxin B) Vasodilators C) Nitrates D) Beta blockers

D) Beta blockers may be prescribed to relax the heart, stabilize the rhythm, and slow the heart's pumping action in clients with hypertrophic cardiomyopathy. Digoxin is contraindicated for the client with hypertrophic cardiomyopathy. Vasodilators and nitrates are not used to treat hypertrophic cardiomyopathy.

A nurse is performing a neurologic assessment on a 9-year-old child who has displayed unexplained changes in behavior. Which assessment finding is consistent with a neurologic deficit? A) Child has a negative Babinski reflex. B) Child recalls names of well-known cartoon characters. C) Child is able to walk backward heel to toe. D) Child is incapable of balancing on one foot.

D) Children should be able to walk backward by 2 years of age, balance on one foot for 5 seconds by 4 years of age, heel-toe walk by 5 years of age, and heel-toe walk backward by 6 years of age. A positive Babinski reflex is abnormal after the child ambulates or reaches 2 years of age. Ability to recall names of well-known cartoon characters would show a normal level of recall. Page Ref: 750

The nurse is preparing to assess comfort for several clients. If the nurse, in addition to assessing the client's physical experience of pain, assesses whether the client has a present and reliable personal support network, then the nurse is assessing which context of holistic human experience during this process? A) Transcendence B) Environmental C) Psychospiritual D) Sociocultural

D) Comfort is the experience of having needs for relief and ease met in four contexts: physical, psychospiritual, social, and environmental. Sociocultural comfort is related to family and social relationships, which a personal support network would exemplify. Transcendence is not a context of holistic human experience.

A client presents with an alteration in mobility. Which finding would suggest damage to the muscle? A) Increased PTH levels B) Decreased PTH levels C) Decreased CK levels D) Increased CK levels

D) Creatine kinase (CK) is used to detect muscle damage, muscle inflammation, rhabdomyolysis, polymyositis, and muscular dystrophy. Thus, increased CK levels are suggestive of increased muscle inflammation. Parathyroid hormone (PTH) levels are not linked to muscle inflammation but rather to osteoporosis, kidney disease, parathyroid gland tumors, lack of calcium, and vitamin D disorders.

The nurse is caring for a client who has suffered a massive cerebral hemorrhage and is not expected to survive. The client's mother indicates the client is Catholic. Which intervention is most appropriate? A) If the nurse is not Catholic, then finding a Catholic nurse to continue care for the client is necessary. B) The nurse should contact a priest and ask him what must be done for the client. C) The nurse should assume the client's desires based on the nurse's existing understanding of the Catholic faith. D) The nurse should ask the client or the client's family what they want in terms of religious rituals.

D) Cultural and religious beliefs and traditions are often of paramount importance for end-of-life clients and their families. Nurses should work to facilitate requests to every extent possible. Contacting a priest may be necessary for the client to receive the Anointing of the Sick, but the nurse should follow the client's or family's request in this matter. The nurse doesn't need to find a Catholic nurse to continue care and should not simply assume what the client wants in this regard.

Health promotion efforts concerning intracranial regulation that focus on the proper use of protective equipment for outdoor activities and vehicle restraint systems are designed to anticipate and prevent alterations to intracranial regulation related to what? A) Prescription drug side effects B) Congenital hydrocephalus C) Stroke D) Trauma

D) Health promotion efforts concerning intracranial regulation that focus on the proper use of protective equipment for outdoor activities and vehicle restraint systems are designed to anticipate and prevent trauma as a cause for alterations to intracranial regulation. Congenital hydrocephalus can cause increased intracranial pressure in infants but is genetic and can't be affected by anticipatory guidance. Stroke and prescription drug side effects are medical conditions that can't be prevented with protective equipment or vehicle restraint systems

The nurse is assessing a client who is 20 weeks pregnant. Which health issue should the nurse recognize as increasing this client's risk for the development of preeclampsia? A) Treatment for vitamin D deficiency B) Surgery for ruptured appendix 1-year prior C) Fibrocystic breast disease D) Obesity

D) One risk factor for the development of preeclampsia is obesity. The other choices will not predispose the client to developing preeclampsia.

The nurse is providing teaching to a client diagnosed with cardiomyopathy. What statement made by the client indicates the discharge teaching was effective? A) "I will exercise as much as possible, regardless of feeling weak and short of breath." B) "My pants getting tight around the waist means I'm eating too much and should cut back on food." C) "I will eat foods containing sodium only if drinking water with them." D) "I will see my cardiologist next week to discuss implanting a pacemaker."

D) Pacemakers are needed in some clients with cardiomyopathy to prevent sudden cardiac death. The client should discuss the need for a pacemaker with his cardiologist. The other client statements indicate that discharge teaching was not effective and the client needs additional instruction and follow-up.

A nurse working on an antepartum unit is providing care for a client with preeclampsia. Which laboratory value does the nurse anticipate for this client? A) Increased platelet count B) Decreased liver enzymes C) Decreased blood urea nitrogen (BUN) D) Increased serum creatinine

D) Preeclampsia decreases renal perfusion, causing an increase in both serum creatinine and blood urea nitrogen (BUN). Preeclampsia can also cause a decrease in platelet count and increase in liver enzymes.

Which statement about cerebral edema or ischemia is true? A) It often causes a skull fracture. B) It is an example of a lacerating injury. C) It is an example of a penetrating injury. D) It is often secondary to a traumatic brain injury.

D) Secondary injuries can be caused by intracranial damage or systemic insults to the brain. Some examples of secondary injuries include cerebral ischemia, cerebral edema, increased intracranial pressure (IICP), infection, hypoxia, hypotension, fever, and hyponatremia. Cerebral edema or ischemia might follow skull fracture but would not cause it, and neither is an example of a lacerating or penetrating injury.

A nurse is teaching a group of pregnant clients regarding seizures associated with eclampsia. Which statement associated with eclampsia are accurate? A) "The tonic phase of a grand mal seizure is evidenced by alternate contraction and relaxation of the muscles." B) "The clonic phase of a grand mal seizure is evidenced by muscular contraction and rigidity." C) "Seizures are rare in eclampsia, but they occur sometimes." D) "Seizures do not occur in preeclampsia."

D) Seizures do not occur in preeclampsia; eclampsia is diagnosed once a client has a seizure, so seizures are not rare in eclampsia. The tonic phase of a grand mal seizure is evidenced by muscular contraction and rigidity. The clonic phase of a grand mal seizure is evidenced by alternate contraction and relaxation of the muscles.

The statement "A decrease in level of consciousness may lead to a decrease in respiration" best describes the relationship between intracranial regulation and which of the following? A) Acid-base balance B) Cognition C) Mobility D) Oxygenation

D) The statement "A decrease in level of consciousness may lead to a decrease in respiration" describes the relationship between intracranial regulation and oxygenation. An increase in CO2 leading to vasodilation and increased intracranial pressure is involved in the relationship between intracranial regulation and acid-base balance. Alterations in intracranial regulation can lead to impaired cognitive function, ranging from mild confusion to lack of consciousness. Clients with alterations in intracranial regulation will have different mobility needs based on the underlying pathology.

Which lobe of the brain stores memory and interprets auditory stimuli? A) Frontal B) Occipital C) Parietal D) Temporal

D) The temporal lobe of the brain stores memory and interprets auditory stimuli. The frontal lobe is involved with speech, thought, learning, emotion, and voluntary movement. The occipital lobe, where the visual cortex is located, processes vision. The parietal lobe processes sensory information, including shapes, temperature, pain, and two-point discrimination.

A client is classified as Grade 4 for risk of cerebral vasospasm because of intracerebral clotting and absence of blood in the basal cisterns. Which diagnostic test is most useful to assess intracerebral hemorrhage and grade cerebral vasospasms? A) Cerebrospinal fluid (CSF) analysis B) CT scan C) MRI D) Transcranial Doppler

D) Transcranial Doppler may be indicated for intracerebral hemorrhage and is especially useful with grading cerebral vasospasms that may accompany a subarachnoid hemorrhage. A CT scan is vital to the diagnosis of traumatic brain injury (TBI) because it can detect the presence and location of skull fractures, contusions, hematomas, hemorrhage, and other brain damage. MRI scans are beneficial for providing more detailed brain images, including axonal injury, once the client is stabilized. Any clear fluid that leaks from the client's nose or ears should be assessed for CSF (glucose will be present) because this may be indicative of a basilar skull fracture.

A female client who sustained a spinal cord injury (SCI) several years ago tells the nurse she is interested in becoming pregnant. She asks the nurse for more information about how her SCI might impact a potential pregnancy. Which of the following statements should the nurse include in her response to the client? A) "Women with SCI should avoid pregnancy, because it puts too much stress on their bodies and can exacerbate their injuries." B) "If you become pregnant, your risk for autonomic dysreflexia will likely decrease." C) "The good news is that none of the medications used in the treatment of SCI are known to have detrimental effects on the fetus." D) "Should you have a baby and opt to breastfeed, you may experience an increase in muscle spasticity."

D) Women with SCI are considered to be "high risk" during pregnancy, but that does not mean pregnancy should be avoided. Instead, the woman will need to work closely with a team of healthcare professionals to prevent complications and prepare for pregnancy, labor, and delivery. Pregnant women are at higher risk for autonomic dysreflexia, especially during labor and delivery. Many women are unable to continue taking prescribed medications during pregnancy due to the potential harm they pose to the fetus. New mothers must also consider the effects of their SCI on breastfeeding; muscle spasticity may increase during breastfeeding, and women with limited sensation in their breasts may have reduced milk production.

The nurse is planning care for a client admitted with a high thoracic spinal cord injury. Which interventions would be appropriate for the nursing diagnosis of Ineffective Peripheral Tissue Perfusion? Select all that apply. A) Discuss future care needs when the client is discharged. B) Increase fluids to 3000 mL per day. C) Turn and reposition the client every 2 hours. D) Assess for a full bladder. E) Assess blood pressure every 2-3 minutes.

D, E) Ineffective perfusion can be caused by autonomic dysreflexia, which is an emergency that requires immediate assessment and intervention. The nurse should continue to assess the client's blood pressure every 2-3 minutes in addition to elevating the head of the bed and removing tight clothing to encourage the pooling of blood in the extremities and decrease the blood pressure. Once the client's blood pressure has stabilized or decreased, the nurse can then assess for the stimuli that caused the episode, such as a full bladder. Discussing future care needs when discharged is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion. Turning the client every 2 hours is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion.