Theory-NCLEX question
10) The nurse plans a class about Alzheimer disease for a caregiver support group. What should the nurse include when teaching this class of caregivers? Select all that apply. A) Glutamatergic inhibitors are the most common class of drugs for treating Alzheimer disease. B) Alzheimer disease accounts for about 70% of all dementias. C) Chronic inflammation of the brain may be a cause of the disease. D) Depression and aggressive behavior are common with the disease. E) Memory difficulties are an early symptom of the disease.
B, C, D, E Explanation: A) Memory difficulties are an early symptom of Alzheimer disease. It is suspected that chronic inflammation and excess free radicals may cause neuron damage, which contributes to the disease. Depression and aggressive behavior are common symptoms of the disease
3) A client with a history of relapsing-remitting multiple sclerosis is expecting her first child. What would be indicated for this client? A) Suggest reproductive counseling, as multiple sclerosis can be genetic. B) Instruct to expect a period of remission after delivery of the baby. C) Instruct to expect an exacerbation of symptoms while pregnant. D) Discuss pain control during labor, as contractions will be severe
A. A definite genetic factor has not been established; however, studies suggest that genetic factors make some individuals more susceptible to the disorder than others. Reproductive counseling would be recommended for this client. Pregnancy often brings about remission of multiple sclerosis, but with a slightly increased relapse rate postpartum. The strength of uterine contractions in a client with multiple sclerosis is not severe, and because clients often have lessened sensation, labor may be almost painless
5) A client admitted with an exacerbation of multiple sclerosis is demonstrating frustration with eating because hand and arm spasms prevent the proper use of utensils. What should the nurse do to assist this client? A) Consult with Occupational Therapy regarding assistive devices for meals. B) Counsel the client to select finger foods for meals. C) Plan time to feed the client. D) Consult with Physical Therapy regarding hand and arm exercises
A. Since the ability to feed oneself is essential to positive self-concept and self-esteem, the nurse should consult with Occupational Therapy for devices that the client can use to maintain independence at meal times. The nurse should not counsel the client to select finger foods for meals, or feed the client. This would not support the client's self-concept and self-esteem needs. Physical Therapy might be consulted for hand splints, but hand and arm exercises might not be beneficial for this client
5) The nurse is planning care for a client with osteoarthritis of the hip. Which intervention would be appropriate for this client? A) Provide moist heat packs to affected joint 3 times each day. B) Instruct on the importance of strict bed rest. C) Provide NSAIDs when pain is severe. D) Provide opioid pain medication as prescribed
A
5) A nurse is concerned about potential substance abuse by a coworker. Which of the coworker's behaviors would place the clients on the unit at risk for injury? A) The nurse in question frequently volunteers to give medications to clients. B) The nurse in question prefers not to be the "medication nurse" on the shift. C) The nurse in question declines to take scheduled breaks. D) The nurse in question frequently requests the largest client care assignment for the shift.
A Explanation: A) Frequently volunteering to give medications or having excessive medication wasting could be a sign that a nurse is using or diverting drugs. The nurse who is unable or unwilling to manage a large client care assignment or who requests to administer medications could be a substance abuser. Taking frequent or lengthy breaks might signal substance abuse.
12) A home health nurse visits a client with Stage 2 Alzheimer disease who lives at home with a spouse. What should the nurse suggest to meet the needs of the client's spouse? A) Encouraging the caregiver to take rest periods and avoid fatigue B) Providing the client a list of daily activities to complete C) Making arrangements for the client to visit the local senior citizen center in the afternoon D) Finding placement in a long-term care facility
A Explanation: A) Stage 2 clients are generally more confused, can demonstrate repetitive behavior, are less able to make simple decisions and to adapt to environmental changes, and are often unable to carry out activities of daily living.
2) An adult child who has brought the client in to be evaluated has been told the client has Alzheimer disease. The adult child asks the nurse if all the children of the client are going to get the disease. What should the nurse explain as a risk factor for this disease? Select all that apply. A) Genetic predisposition B) Age C) History of hypertension D) Race E) Environmental exposure
Answer: A, B, E
2) While teaching a wellness class on the warning signs of stroke, a participant asks the nurse, "What's the most important thing for me to remember?" What is an appropriate response by the nurse? A) "Be alert for sudden weakness or numbness." B) "Know your family history." C) "Keep a list of your medications." D) "Call 911 if you notice a gradual onset of paralysis or confusion."
A) Warning signs of stroke include sudden weakness, numbness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance-the key word is sudden. Family history and past medical history can be indicators for risk, but they are not warning signs of stroke. Gradual onset of symptoms is not indicative of a stroke.
11) During an outpatient clinic follow-up appointment, a 46-year-old client with multiple sclerosis (MS) has lab tests completed. The results show elevated levels of aspartate aminotransferase (AST), serum glutamic-oxaloacetic transaminase (SGOT), alanine aminotransferase (ALT), serum glutamic-pyruvic transaminase (SGPT), and alkaline phosphatase (ALP). What is the priority concern for the nurse?? Select all that apply. A) Adverse response to Avonex B) Adverse response to Aubagio C) Flare-up due to demyelination D) Adverse response to bisacodyl E) Damage from viral infection
A, B AST, SGOT, ALT, SGPT and ALP are liver enzymes that are monitored to detect adverse response to the medications Avonex and Aubagio. Flare-ups due to demyelination do not cause liver enzymes to increase. Bisacodyl is a stool softener used for constipation in MS and does not cause liver enzymes to elevate. Incomplete evidence links viral infection to the risk of MS. There is no reason to attribute elevated liver enzymes to viral exposure
8) A client has been diagnosed as having Stage 1 Alzheimer disease. What would be the goal for the client and the family at this time? Select all that apply. A) Resolving grief over the diagnosis B) Deciding on the desired treatment and selecting a healthcare proxy; sharing the treatment decision with the healthcare proxy C) Beginning cognitive-enhancing medication, such as Aricept D) Setting up a protective physical environment-such as removing throw rugs
A, B, C, D Explanation: A) Grieving over the diagnosis and loss of functioning and mental abilities will be an ongoing process for the client and the family members and is therefore a goal. While the client is still cognizant, it is important that the client and family discuss the desired treatment and designate a healthcare proxy to carry out the client's wishes regarding the treatment. Clients with early Alzheimer disease should start the cholinesterase inhibitor medication as soon as possible to extend the early stage of the disease. During this time period, the home environment should be modified to balance safety with client autonomy.
4) A client with alcoholism is receiving court-ordered care in a residential treatment facility. After alcohol is discovered in the client's room, she denies that it belongs to her. Which statement(s) by the nurse will support the treatment plan made in collaboration with the physician and the addiction therapist? Select all that apply. A) "You will lose your day pass privileges for this Sunday." B) "We have a video of you accepting the alcohol from your brother." C) "What do you think about sharing this at AA tonight?" D) "You won't be allowed to go to dinner tonight." E) "You have violated our behavior contract
A, B, C, E Explanation: A) Used with care and a calm attitude, confrontation interferes with the client's ability to use denial or rationalization. Losing privileges is a consequence of violating the behavior contract. Participation in AA will provide peer feedback. Withholding food is inappropriate, particularly for a client with potential nutritional deficits
4) The nurse is completing a health history with a 16-year-old client and determines the client would benefit from teaching about substance abuse. Which client statement(s) caused the nurse to come to this conclusion? Select all that apply. A) "I drink alcohol with my friends on the weekends." B) "I smoke cigarettes on a daily basis." C) "I use my seat belt every time I ride in a car." D) "I became sexually active at the age of 13." E) "I get all A's and B's in school.
A, B, D Explanation: A) Early sexual activity, smoking cigarettes, and drinking alcohol are all risk factors for teenage substance abuse. Getting good grades and wearing a seat belt are not risk factors for substance abuse
11) The interdisciplinary treatment team proposes interventions to improve and maintain physical function for a 65-year-old client with Parkinson disease. Which interventions are supported by research? Select all that apply. A) Low-intensity treadmill training B) Walking barefoot indoors C) Use of resistance bands D) Active and passive range of motion E) High-intensity treadmill training
A, C, D, E Explanation: A) Research studies have shown improvements on the 6-minute walk test of individuals with Parkinson disease after participation in low-intensity and high-intensity treadmill training, strength training, and range of motion. Use of shoes with non-slip soles is advised.
4) A client with relapsing-remitting multiple sclerosis tells the nurse that even though the primary symptoms of exacerbation are leg spasms and blurred vision, the hardest part is trying to get through the day because of being so tired. Which diagnosis should the nurse identify as a priority for this client? A) Fatigue B) Disturbed Sensory Perception C) Impaired Physical Mobility D) Self-Care Deficit
A. The client states that the worst part of the disease exacerbation is being tired even though leg spasms and blurred vision are present. The nurse should identify the diagnosis of Fatigue as being a priority for this client. The diagnoses of Impaired Physical Mobility because of the leg spasms and Disturbed Sensory Perception because of the blurred vision are additional nursing diagnoses applicable for this client, but they are not the priority based on the client's statement. The client may or may not have a Self-Care Deficit.
6) A client with multiple sclerosis is observed transferring from the bed to a motorized wheelchair and applying splints to the lower extremities before entering the bathroom to perform morning self-care. What could the nurse conclude regarding this observation? A) The client uses assistive devices to optimize autonomy. B) The client needs instruction to conduct morning care before applying splints to lower extremities. C) The client is dependent upon assistive devices. D) The client is reliant upon assistive devices for independent
A. The nurse observed the client independently transfer from the bed to a motorized wheelchair, apply splints, and enter the bathroom to perform morning self-care. This is evidence that the client uses assistive devices to optimize autonomy. The statement "Client is reliant upon assistive devices for independence" indicates that the client is not autonomous. The statement "Client is dependent upon assistive devices" also indicates the client is not autonomous. The statement "Client needs instruction to conduct morning care before applying splints to lower extremities" does not take into consideration the client's preference, which might be to apply the splints before doing self-care
4) The nurse is planning care for a client with osteoarthritis. Which diagnosis would have the highest priority? A) Fatigue B) Chronic Pain C) Ineffective Coping D) Disturbed Body Image
B
6) The nurse is evaluating care provided to a client with osteoarthritis. Which client statement indicates to the nurse that interventions for osteoarthritis have been successful? A) "I had to take early retirement and now stay at home all day and rest my legs." B) "I am sleeping throughout the night and have not missed any work because of knee pain." C) "I am moving from my two-story house into the first floor of my daughter's home so I won't have to walk steps anymore." D) "I changed my work hours so now I work part time and have a nursing assistant who helps me bathe twice a week at home."
B
9) A 48-year-old client seeking treatment for severe knee pain has worked in a factory for 30 years in a position requiring repetitive lifting and carrying of 20-40-pound boxes. The nurse anticipates which recommendation from the multidisciplinary team? A) Joint replacement surgery B) Pharmacologic therapy C) Refer for Disability application. D) Intermittent use of a cane
B
3) The nurse has completed her assessment of a client with a history of alcoholism who is hospitalized with anorexia, dysphagia, odynophagia, and chest pressure after eating. Which nursing diagnosis is a priority for this client? A) Ineffective Coping B) Imbalanced Nutrition: Less Than Body Requirements C) Disturbed Sensory Perception D) Disturbed Thought Processes
B Explanation: A) An alcoholic client with anorexia is at risk for Imbalanced Nutrition, Less Than Body Requirements. Ineffective Coping is a potential diagnosis used in substance abuse. Disturbed Thought Processes and Disturbed Sensory Perceptions are diagnoses used for delusions, hallucinations, and illusions that may occur during delirium tremens
2) A 4-year-old client with myoclonic seizures has been on a ketogenic diet for the last 6 months to reduce seizure activity and is complaining of left-sided abdominal pain. Which complication of the ketogenic diet should the nurse suspect the client is experiencing? A) Bowel obstruction B) Renal calculi C) Urinary tract infection D) Appendicitis
B Explanation: A) Renal calculi are seen in 5% of children on a ketogenic diet. Appendicitis does not occur as a result of the ketogenic diet. Ketogenic diet does not cause a bowel obstruction. Urinary tract infections are not a result of a ketogenic diet. B) Renal calculi are seen in 5% of children on a ketogenic diet. Appendicitis does not occur as a result of the ketogenic diet. Ketogenic diet does not cause a bowel obstruction. Urinary tract infections are not a result of a ketogenic diet.
2) After completing an assessment, the nurse is concerned that a pregnant client is at risk for having a child with autism. Which characteristics should the nurse recognize as increasing the risk for having a child with autism? Select all that apply. A) Employed as a computer operator B) Smokes 1 ppd of cigarettes C) Drinks 2 glasses of wine on the weekends D) Age 40 E) Rides a stationary bicycle four times a week for 30 minutes
B, C, D Explanation: A) Determining risk for autism is difficult; however, some factors appear to be linked. A maternal age of 40 or older increases the risk that a child will be born with autism. Maternal smoking or the use of alcohol during pregnancy also increases rates of autism.
10) A 32-year-old client recently diagnosed with multiple sclerosis is a full-time aerobics exercise instructor at a local fitness center. Which statements contain the correct information to give the client when answering her specific questions about lifestyle? Select all that apply. A) "Hyperbaric oxygen treatment is recommended prior to vigorous physical exercise." B) "You will tolerate exercise better in an air-conditioned room." C) "Acupuncture may benefit some of your symptoms." D) "Drinking cold water is recommended during exercise." E) "You will be able to maintain your exercise teaching schedule."
B, C, D Symptoms of MS are exacerbated by increased body temperature. Exercising in a cold room and drinking cold beverages keep body temperature down. Acupuncture has low risk and may be beneficial for some symptoms. Hyperbaric oxygen therapy carries more risk than benefit. It is unlikely that a newly diagnosed client with MS will be able to tolerate a full-time exercise instructor role.
10) A nurse is caring for a toddler client whose parent suspects the child may have attention-deficit/hyperactivity disorder (ADHD). Which statements should the nurse recognize as true regarding the diagnostic criteria for ADHD? Select all that apply. A) Children must have 3 or more symptoms that have persisted for 3 or more months with negative impacts. B) Children must have 6 or more symptoms that have persisted for 6 or more months with negative impacts. C) Children with learning disabilities are often misdiagnosed as having ADHD. D) Diagnostic criteria for ADHD are nonspecific and vary with every child. E) Children must have a physical examination prior to the diagnosis of ADHD to rule out other diseases.
B, C, E Explanation: A) In order to be diagnosed with ADHD, the child age 17 and younger must have 6 or more symptoms that have persisted for 6 or more months with negative impacts. Children with learning disabilities are often misdiagnosed as having ADHD. The diagnostic criteria for ADHD are specific and standard with every child. Children must have a physical examination prior to the diagnosis of ADHD to rule out other diseases
10) A client is being evaluated for Parkinson disease (PD). Which findings on the Unified Parkinson Disease Rating Scale (UPDRS) would suggest a positive finding for PD? Select all that apply. A) Diarrhea B) Dystonia C) Retropulsion D) Hyperphonia E) Festination
B, C, E Explanation: A) The Unified Parkinson Disease Rating Scale (UPDRS) rates the client in 42 different areas of function. Positive findings for PD are retropulsion (the tendency to fall backward), festination (rapid walking as if trying to run) and dystonia (twisting and repetitive movements). Diarrhea and hyperphonia (loud voice) are not symptoms of PD. Constipation and hypophonia (soft voice) are symptoms of PD
10) A nurse working in a psychiatric hospital is performing a suicide assessment on a client diagnosed with major depressive disorder (MDD). What is true regarding the suicide assessment? Select all that apply. A) Assess all clients for suicide risk by using indirect questioning. B) Ask if the client has any thought of suicide. C) Asking about suicide will "plant the idea" in the client's mind. D) Assess the lethality of the suicide plan, if one exists. E) If the client has suicidal thoughts, assess whether or not the client would act on them.
B, D, E Explanation: A) When performing a suicide assessment, the nurse should always use direct, not indirect, questioning. The nurse should ask if the client has any thought of suicide and assess the lethality of the suicide plan, if one exists, and whether or not the client will act on these thoughts. Asking about suicide will not "plant the idea" in the client's mind.
7) A client with osteoarthritis tells the nurse about difficulty walking to the bathroom first thing in the morning. Which nursing action would assist this client? A) Suggest a family member provide the client with a bedpan. B) Discuss the option of residing in an assisted-living facility. C) Consult with Physical Therapy for an assistive walking device such as a walker or cane. D) Suggest using a bedside commode at home.
C
10) A nurse working in the Emergency Department is aware that there are various cultural and ethnic risk factors for stroke. The nurse understands that which of the following is an example of this? A) African-Americans have an increased incidence of intracerebral hemorrhage. B) Hispanics have almost twice the number of first-ever strokes compared with whites. C) African-Americans are more likely to die following a stroke than whites. D) The prevalence of hypertension among Hispanics is the highest in the world.
C Explanation: A) African-Americans are more likely to die following a stroke than whites. Also, African-Americans have the highest prevalence of hypertension in the world and almost twice the number of first-ever strokes compared with whites. Hispanics have an increased incidence of intracerebral hemorrhage
11) A community health nurse is educating pregnant clients about the prenatal causes and risk factors associated with the development of attention-deficit/hyperactivity disorder (ADHD). Which statement will the nurse include? A) "ADHD has not been linked to prenatal exposure or disease." B) "ADHD has been linked to a specific gene, and genetic testing may help to diagnose this." C) "ADHD has been linked to prenatal exposure to cigarette smoke." D) "ADHD has been linked to childhood exposure to folate."
C Explanation: A) Although ADHD has not been linked to a specific gene, the disorder has been linked to prenatal exposure or disease. Prenatal exposure to cigarette smoke increases the risk for the child to develop ADHD. ADHD has been linked to childhood exposure to lead, not folate
9) A client with a suspected TIA presents to the Emergency Department with aphasia. Which is the pathophysiology causing aphasia? A) Middle cerebral artery involvement B) Posterior cerebral artery involvement C) Ischemia of the left hemisphere D) Ischemia of the right hemisphere
C Explanation: A) Aphasia occurs due to ischemia of the left hemisphere. The other choices may be involved in a TIA, but are not the causative pathology of aphasia.
15) A nurse is caring for a client with Alzheimer disease (AD) who just recently lost the ability to live independently but can still perform activities of daily living (ADLs). Which stage of the disease is this client in? A) Stage 3 B) Stage 4 C) Stage 5 D) Stage 6
C Explanation: A) This client is in Stage 5 (moderate AD) because the client has lost the ability to live independently. In this stage, the client may be unable to choose appropriate clothing or prepare food and is at increased risk of someone taking advantage of him or her because of loss of cognition and lack of safety awareness. A client in Stage 3 (mild cognitive impairment) is able to maintain living independently, but the client's memory lapses are apparent to others. In Stage 6 (moderately severe AD), individuals become unable to perform even basic activities of daily living (ADLs).
5) The nurse is evaluating outcome goals written by a student for an alcoholic client being discharged from a detoxification program. Which outcome or outcomes now are appropriate for this client? Select all that apply. A) Follow a 2000-calorie high-carbohydrate diet. B) Sponsor a participant in Alcoholics Anonymous (AA) meetings. C) Obtain at least 6-8 hours of sleep per night. D) Acknowledge the blame that family members must take for codependent behavior. E) Enroll in the Employee Assistance Program (EAP) through his employer
C, E Explanation: A) Outcome measures for a client discharging from alcohol detoxification are to obtain at least 6-8 hours of sleep a night and to enroll in the Employee Assistance Program if offered through the client's employer. The calorie requirement should be individualized and may not be 2000 calories. New or returning members to AA should be sponsored and are not ready to sponsor another person. This client should accept responsibility for his behavior in the family unit instead of assigning blame for codependent behavior
8) After an assessment of a new client, a nursing student expresses a belief that drug addiction is not a real illness, as these clients "did it to themselves." What should the staff nurse respond to this student's comment? A) "Sometimes a client doesn't show much effort." B) "We are legally obligated to provide care." C) "It is important to remain nonjudgmental when caring for any client, even a drug addict." D) "You are right. I don't know why we bother."
C. Nurses must provide a nonjudgmental attitude with their clients in order to promote trust and respect. Even if a client is not currently making much effort toward management of addiction disorders, the development of a trusting relationship with the nurse helps to set the stage for movement toward recovery in the future. Although it is true that nurses are legally obligated to provide care, this response is not client-focused and is therefore inappropriate.
Exemplar 13.4 Multiple Sclerosis 1) A client diagnosed with multiple sclerosis has an acute onset of visual changes, fatigue, and leg weakness. The client says that the last time this happened, recovery occurred in a few weeks. Which classification of multiple sclerosis is the client experiencing? A) Progressive-relapsing B) Secondary-progressive C) Relapsing-remitting D) Primary-progressive
C. There are four classifications of multiple sclerosis. The client has an exacerbation of symptoms and has a history of full recovery. This is classified as relapsing-remitting and is the most common type. Primary-progressive is a steady worsening of the disease with occasional minor recovery. Secondary-progressive begins as relapsing-remitting but the disease becomes worse between exacerbations. Progressive-relapsing is rare, with the disease progressing from the onset with periods of exacerbation.
2) A young adult client complains of blurred vision and muscle spasms that come and go over the past several months. On what information from the client's history should the nurse focus to help identify this help problem? A) Family history of Parkinson disease B) Family history of epilepsy C) Is an immigrant from Germany D) Has been depressed
C.Multiple sclerosis is primarily a disease of people of northern European ancestry. The onset of multiple sclerosis is usually between the ages of 20 and 50, with the peak at age 30. Family history of epilepsy, Parkinson disease, and depression are important items of the client's history but do not support a diagnosis of MS.
9) The nurse is presenting a talk for the monthly Nursing Case Study education group at her facility. Which client would be a good choice for a case study on multiple sclerosis (MS)? A) Brazilian with chronic parasitic infestation B) Italian with colonized methicillin resistant staphylococcus aureus (MRSA) C) Northern Canadian who has smoked for 25 years D) African-American man in his 20s with a vitamin D deficiency
C.The client with the greatest risk lives the farthest from the equator and smokes. Smokers are at increased risk of MS. Brazilians and Italians live close to the equator, which lowers the risk of MS. Chronic parasitic infestation lowers the immune response, which lowers the risk of MS. African-Americans and men are at lower risk of developing MS. It is theorized that vitamin D deficiency may increase risk of MS because it is seen less in locales near the equator
4) The parents of a child with autism spectrum disorder observe that the child has difficulty making friends and are concerned about social expectations for their child. What is the priority nursing diagnosis based on the concerns of the family for their child? A) Ineffective Coping B) Deficient Diversional Activity C) Social Isolation D) Impaired Social Interaction
D
5) The parent of a child with autism spectrum disorder asks why family therapy has been prescribed. Which statement is the best response by the nurse to the parent? A) "Family therapy will help you learn how to assess the child's potential." B) "Family therapy will provide the child with an opportunity to learn problem-solving skills." C) "Family therapy will help you interact with your child." D) "Family therapy will help you learn how to cope with your situation."
D
8) A client with chronic hip pain is diagnosed with osteoarthritis. What should the nurse instruct this client about home safety? A) Walk up and down the steps at home as much as possible. B) Rest in a recliner. C) Place scatter rugs in high-traffic areas. D) Install grab bars in the bathroom near the commode and in the shower.
D
Exemplar 22.1 Alcohol Abuse 1) A formerly homeless client has been treated for alcoholism. The client's physical examination reveals the client has a BMI of 18. Which medications does the nurse expect the physician to prescribe to manage the client's nutritional status? A) Sertraline (Zoloft) B) Methadone C) Narcan D) Multivitamin with folic acid
D Explanation: A) A client with alcohol dependence may suffer from numerous nutritional deficiencies, including deficiencies in thiamine, folic acid, vitamin A, magnesium, and zinc. A multivitamin may be prescribed to help with these deficiencies. Narcan is used to manage an opiate overdose. Methadone is prescribed to manage heroin cravings. Sertraline (Zoloft) is used to reduce anxiety and stabilize mood.
8) The nurse is instructing the spouse of a client with a stroke on how to do passive range of motion to the affected limbs. What should the nurse explain regarding the purpose of these exercises? A) Improve muscle strength. B) Maintain cardiopulmonary function. C) Improve endurance. D) Maintain joint flexibility.
D Passive range-of-motion exercises help to maintain joint flexibility. Active range-of-motion exercises improve muscle strength, improve endurance, and can help maintain cardiopulmonary functioning. The nurse should instruct the spouse that the exercises will help with joint flexibility.
14) A student nurse is reviewing the pathophysiology and etiology of Alzheimer disease (AD). What is true regarding the pathophysiology and etiology of this disease? Select all that apply. A) Damage to the limbic system results in speech decline and slowed movements. B) Familial Alzheimer disease (FAD) is also called delayed-onset Alzheimer disease. C) Sporadic Alzheimer disease usually manifests before age 65. D) Sporadic Alzheimer disease is more common than familial Alzheimer disease. E) In Alzheimer disease, neuronal cells die in a characteristic order.
D, E
4) The nurse is planning care for a client with Stage 1 Alzheimer disease. Which one of the following nursing diagnoses would the nurse base care for this client and family? A) Impaired Memory and Caregiver Role Strain B) Hopelessness and Functional Family Processes C) Knowledge Deficit and Ineffective Coping D) Pseudohostility and Ineffective Coping
a
2) A middle-aged female client tells the nurse that she is noticing a slight tremor of her left hand when at rest. The client is concerned that she has Parkinson disease, as her mother had the illness and passed away because of respiratory failure. What should the nurse respond to this client? A) "Having a first-degree relative with the illness can increase your chance of developing it as well." B) "You should not worry, as it has a higher prevalence in males." C) "It is unlikely that you have the same illness as your mother." D) "You probably do not have it, as your mother was probably exposed to a toxin that caused the disease."
a
3) A client with Parkinson disease tells the nurse that it is 1950 and he is late for work. What action should the nurse take at this time? A) Orient the client, provide a calendar, and place a clock in the room. B) Ask the client what life is like in 1950. C) Medicate for confusion. D) Apply restraints so the client will not attempt to get out of bed to go to work.
a
3) An older client receiving pain medication for abdominal discomfort reports no relief of pain and continues to describe multiple somatic complaints. What action should the nurse take at this time? A) Further assessment and consider treatment for depression B) Obtaining an order for different pain medication C) Contacting the family to talk to the client D) Review of the client's lab values
a
4) The nurse is caring for a family with four children whose third child has been diagnosed with ADHD. After completing an assessment, which statement made by the mother leads the nurse to a diagnosis of compromised family coping? A) "I don't know how to tell the rest of the family or how we will manage the other children." B) "We need to alert the teachers at school so they will know how to give the medication." C) "Will he have to be put in an institution?" D) "I'm not sure if we should let my child act in the school play."
a
6) The nurse is caring for a 6-year-old child who was recently diagnosed with attention-deficit/hyperactivity disorder (ADHD). Which statement by the child's mother indicates to the nurse that teaching goals have not been achieved? A) "I will let him do his homework while he is watching his favorite television show." B) "I will give him his ADHD medication with his meals." C) "I will take my child to the physician every 3 months for a weight and height check." D) "I will stick to the same routine each day after school.
a
6) The nurse is caring for a child newly diagnosed with autism spectrum disorder. What should the nurse recognize is the overall outcome for a child diagnosed with this disorder? A) To function more effectively in social and emotional interactions B) To stay on task C) To acknowledge the effects of one's own behavior on others D) To acknowledge personal strengths
a
7) A client who is attending a Narcotics Anonymous (NA) program asks the nurse what the most important initial goal of attending the meetings is. Which answer is the best response by the nurse? A) To admit to having a problem B) To learn problem-solving skills C) To take a moral inventory of self D) To make amends to people they have hurt
a
7) A client with multiple sclerosis is prescribed diazepam (Valium). What assessment finding indicates that the medication is effective for the client? A) Muscle spasticity is reduced. B) Blood glucose level is within normal limits. C) The client states that muscles are weak. D) Ophthalmologic examination shows no evidence of cataracts.
a
8) The nurse observes a client being treated for depression sitting with the head down and avoiding conversation with peers. What would be the nurse's priority intervention for this client? A) Ask open-ended questions about the client's feelings. B) Ask the client close-ended questions. C) Encourage a peer to sit with the client and the nurse. D) Tell the client that lack of involvement leads to more depression
a
Exemplar 13.6 Parkinson Disease 1) A client complains of a right-hand tremor, increasing weakness, and muscles feeling tight. The nurse notes the client has poor voice volume and facial muscles do not move easily. What do these assessment findings suggest to the nurse? A) Parkinson disease B) Spinal cord injury C) Cerebral vascular accident D) Multiple sclerosis
a
2) A college student attends a seminar on alcohol abuse. Which statement would alert the nurse that the student needs more education? A) "The children of alcoholics are less likely to become alcoholics." B) "Native Americans are more likely to become alcoholics." C) "Married college graduates are less likely to become alcoholics." D) "Childless people are more likely to become alcoholics than parents."
a A genetic predisposition to alcoholism is established for Native Americans and the children of alcoholics. Married people, college graduates, and parents are less likely to become alcoholics.
Exemplar 22.4 Substance Abuse 1) The nurse is caring for a client who has been diagnosed with a cocaine addiction. For which additional disorder should the nurse assess this client? A) Anxiety B) Diabetes C) Weight gain D) Kidney stones
a Anxiety and depressive disorders frequently occur with substance abuse. More than 90% of individuals who commit suicide have a depressive or substance abuse disorder. Weight gain, diabetes, and kidney stones are not linked to substance abuse
Exemplar 25.2 Autism Spectrum Disorder 1) A pediatric nurse is performing an assessment on a toddler who is suspected of being autistic. When assessing the child's health history, which question to the parents by the nurse would not provide the best information about this disorder? A) "Does your child have manic or depressed episodes?" B) "Tell me about your child's social interactions." C) "Does your child perform ritualistic behaviors when performing activities?" D) "Is your child able to name objects?"
a Manic or depressed episodes are characteristics of bipolar disorder, not autism. Autism is characterized by a triad of impairments: social isolation, communication impairment, and strange repetitive behaviors
5) The nurse is planning care for a client admitted with a stroke. Which intervention would support the client's sensorimotor needs? A) Encourage use of non-affected arm to feed self, bathe, and dress. B) Speak in normal conversational pattern and tones. C) Provide complete care. D) Talk loudly and distinctly
a To address the client's alteration in sensory and motor statuses, the nurse should encourage the client to use the non-affected arm to feed self, bathe, and dress. The nurse should not provide all care for the client. The nurse should not talk loudly to the client but should articulate slower and face the client when speaking. Speaking in normal conversational patterns and tones may not be adequate when communicating with the client.
6) The nurse makes a visit to the home of an adolescent recently discharged from the hospital for a seizure disorder. Which observations indicate that outcomes for care have been achieved? Select all that apply. A) The client is not driving. B) The client has not had a seizure for 1 month. C) The client is participating in the school basketball team. D) The client has bruises on both arms from seizure activity. E) The client has several episodes of constipation each week.
a, b, c
4) The nurse identifies the diagnosis Risk for Trauma as appropriate for a client with a seizure disorder. Which nursing interventions should be done if the client has a seizure? Select all that apply. A) Turn the client to a lateral position, if possible. B) Stay with the client. C) Insert a tongue blade into the client's mouth. D) Call for help. E) Restrain the client
a, b, d
3) An older client is diagnosed with a left cerebral hemorrhage. To meet the needs of the client and family, the nurse will provide teaching in which areas? Select all that apply. A) Time adjustment to complete activities B) How to use a sign board C) Nutrition support D) Transfer techniques E) Information about impulse control
a, b, d The left cerebral hemisphere is responsible for the language center, calculation skills, and thinking/reasoning abilities. Reading and speaking could be compromised if there is left-sided brain damage. The client also might display over-cautious behavior and might be slow to respond or complete activities. Transfer techniques would apply regardless of the side involved. Impulse control problems can arise with right-sided involvement. Nutritional support may or may not be an issue with this client
7) A client with depression is receiving electroconvulsive therapy. Which intervention(s) should the nurse plan when caring for this client? Select all that apply. A) Maintain nothing-by-mouth status until fully awake. B) Administer intravenous fluids for 8 hours post procedure. C) Place in the lateral recumbent position. D) Provide oral fluids immediately after the procedure. E) Place in the supine position with the head flat
a, c
7) The parents of a 4-year-old child with autism spectrum disorder ask what can be done to treat the disorder. The nurse explains that a team of professionals will be assisting their child in various therapies. Which health care professionals should the nurse tell the parents will take part in this child's care? Select all that apply. A) Social services B) Laboratory C) Speech therapy D) Play therapy E) Public health agency
a, c, d
10) Lab results are back on a client who has limiting joint pain. Synovial fluid analysis shows no uric acid crystals, bacteria, or blood. The client asks what conditions are possible cause(s) of this pain. What is the nurse's response? Select all that apply. A) Osteoarthritis B) Rheumatoid arthritis C) Septic arthritis D) Gout E) Trauma
a,b There are no specific joint fluid tests for osteoarthritis, making this a possible diagnosis. There is no report of any tests for rheumatoid arthritis, making this a possible diagnosis. Gout is caused by the collection of uric acid crystals in the joint. The absence of uric acid crystals in the synovial fluid (joint fluid) makes gout unlikely. Septic arthritis is caused by infection. The absence of bacteria makes sepsis unlikely. The absence of blood makes trauma unlikely
13) A nurse is caring for a client with Alzheimer disease (AD) who has receptive aphasia. Which area of the brain is likely damaged from AD? A) Temporal lobe B) Limbic system C) Frontal lobe D) Occipital lobe
a. Damage to the client's temporal lobe causes receptive aphasia. Damage to the limbic system manifests as loss of memory, fluctuating emotions, depression, and difficulty learning new things.
Exemplar 16.13 Stroke 1) While completing a health history with an older client, the nurse learns that the client experienced a transient ischemic attack several months ago. What does this information suggest to the nurse? A) The client is at risk for an ischemic thrombotic stroke. B) The client will have minimal symptoms should a stroke occur. C) The client will not experience a stroke in the future. D) The client is at high risk for a hemorrhagic stroke. Answer: A
a. Transient ischemic attacks are often warning signs of an ischemic thrombotic stroke. One or many transient ischemic attacks may precede a stroke, with the time between the attack and the stroke ranging from hours to months. A hemorrhagic stroke is caused by the rupture of a cerebral blood vessel and is not related to a transient ischemic attack. There is no way to predict the symptoms the client will experience after a stroke.
2) A client with osteoarthritis of the knees tells the nurse that no one else in the family has this disorder. What assessment finding might have increased this client's risk for developing this disorder? A) Body mass index 36.5 B) History of esophageal reflux disease C) Client plays tennis 3 times each week D) Blood pressure 136/78 mmHg
a. Obesity also increases the risk of developing OA, because the added weight increases stress on weight-bearing joints, causing the joints to wear down more quickly. The client has a body mass index of 36.5, which is considered obese. Moderate recreational exercise has been shown to decrease the chance of developing osteoarthritis and the progression of manifestations when osteoarthritis is present. Esophageal reflux is not associated with the disorder. Blood pressure is not a known risk factor for the development of osteoarthritis.
3) The nurse provides teaching about phenytoin (Dilantin) to the mother of a school-age child with a seizure disorder. Which statement made by the mother indicates that teaching has been effective? A) "I will give his medicine on an empty stomach so he will absorb it better." B) "I will check his gums and increase visits to the dentist." C) "I will use a carbonated beverage to dilute his medication." D) "I will let him chew his tablet.
b
3) While planning the care of a child with autism spectrum disorder, the nurse encourages the mother to share the child's behavior with the teachers at the child's school. What should the nurse encourage the mother to discuss with the teachers? A) "The teacher should know that your child may experience depression that results from feelings of inadequacy." B) "The teacher should know that your child may experience an episode of self-mutilation." C) "The teacher should know that your child will have a tendency to be hypoactive." D) "The teacher should know that your child will be very flexible and will have the ability to contribute to his or her learning."
b
4) A client with Parkinson disease ambulates with a shuffling gait and leans slightly forward. When seated, the client conducts a conversation, reads, and is able to self-feed without assistance. Which diagnosis is a priority for this client? A) Ineffective Coping B) Impaired Physical Mobility C) Imbalanced Nutrition: More than Body Requirements D) Anxiety
b
6) A client is admitted for the fourth time in 4 years for alcohol detoxification. Which aspect(s) of the pathophysiology of alcoholism will impact the plan of care? A) Aging can impact the ability of the body to handle detoxification from alcohol and drugs. B) The withdrawal may be greater this time. C) The dependency might have been greater this time. D) Increased difficulty with alcohol detoxification is likely the result of an addiction to another substance at the same time
b
7) The nurse is collecting data from a client regarding alcohol use history. What question will provide the greatest amount of information? A) Are you a heavy drinker? B) How many alcoholic beverages do you drink each day? C) Is alcohol use a concern for you? D) Drinking doesn't cause any problems for you, does it?
b
8) The community health nurse is working with a group of women from another country who smoke. The nurse is encouraging them to stop smoking before and during pregnancy. The nurse knows that her teaching has been effective when the women state that the reason to stop smoking is to lessen the chance that their children could develop which health problem? A) Benzodiazepine withdrawal B) Attention-deficit/hyperactivity disorder (ADHD) C) Unhappy memories D) A personality disorder
b
8) The nurse instructs a client with Parkinson disease about carbidopa-levodopa (Sinemet). Which client statement indicates that teaching has been effective? A) "I will take the medication with my meals." B) "I will sit up for several minutes to gain my balance before going from lying down to standing up." C) "This medication will not affect my blood pressure medications." D) "This medication will cure my Parkinson disease in time."
b
Exemplar 25.1 Attention-Deficit/Hyperactivity Disorder 1) The school nurse is talking to a child with attention-deficit/hyperactivity disorder (ADHD) who wants to play soccer. Which action is the most appropriate for the school nurse to take? A) Recommend that the child become active in an individual sport, rather than a team sport. B) Encourage the child to play soccer. C) Discourage the child from playing a team sport like soccer. D) Ask the child's mother to get permission from the
b
Exemplar 28.1 Depression 1) An older client with cardiac disease describes a decline in the amount of sleep and difficulty falling asleep at night. What should the nurse consider is occurring with this client? A) Normal signs of cardiac disease B) Signs of anxiety and depression C) Normal signs of aging D) Normal signs of respiratory disease
b
2) A client was widowed 3 years ago and has nothing to do except visit with acquaintances at the neighborhood bar. Of which health problem is this client demonstrating manifestations? A) Bipolar disorder B) Depression C) Sadness D) Extended grief
b Explanation: A) Risk factors for the development of depression include a history of the loss of a close family member and substance abuse. Bipolar disorder is characterized by periods of mania with periods of depression. The client is not describing or demonstrating these periods. The client may or may not be experiencing extended grief. There is not enough information to determine if the client is demonstrating sadness
5) The spouse of a client being treated for depression believes the client is not responding to prescribed medication. What should the nurse respond to the spouse? Select all that apply. A) "Stop the medication immediately." B) "A trial-and-error period is the best way to determine which medication is the most effective." C) "A trial of 4 to 6 weeks is usually done to see how people respond to the medication." D) "Stay on the medication for 6 months to see if there is a response." E) "Learn to live with the depression."
b, c
11) A client with osteoarthritis of the knees and hips returns for a 3-month follow-up with her provider. The nurse calculates that the client's BMI is now 22. She reports starting a water aerobics and step aerobics program three times per week. She is using hot packs for edema for 20 minutes and cold packs for pain for 40 minutes daily. After evaluating the client's actions, the nurse plans which follow-up interventions? Select all that apply. A) Reinforce the correct use of hot packs. B) Educate on low-impact exercise modes. C) Explain the risk of injury using cold packs. D) Counsel on continued weight loss. E) Congratulate on starting water aerobics.
b, c, e
5) The nurse is preparing an educational program for the family of a client with dementia who is ready for discharge. On what should the nurse focus to reduce the risk for injury? Select all that apply. A) Have all objects in the room be the same color. B) Check shoes for fit and support. C) Be aware that client in the early stages usually have few problems with unfamiliar places. D) Keep all familiar objects in the home. E) Remove throw rugs and electrical cords.
b, e
6) A client being treated for depression reports the desire to get out of bed, shower, eat, and contact friends and family for socialization. What should the nurse realize this client is demonstrating? A) Risk factors for self-harm B) Improvement in depression C) Denial of the diagnosis of depression D) The need for assistance with activities of daily living
b. The client reports the desire to get out of bed and is showering, eating, and contacting friends and family members. These are all indications that the client's depression is improving. This is not an indication of risk for harm, denial of the diagnosis, or the need for assistance with activities of daily living.
3. A male college student is incoherent after taking "downers with beer." For which health problem should the nurse observe in this client? A) Hallucinations B) Respiratory depression C) Seizure activity D) Signs of withdrawal
b. Downers are central nervous system depressants. Barbiturates and alcohol are a lethal combination. The client who has ingested both items is at risk for varying degrees of sedation, up to coma and death. Seizure activity, signs of withdrawal, and signs of hallucinations do not pose as great a risk for this client as respiratory depression
An older client with bilateral osteoarthritis of the knees tells the nurse that she knows she needs to lose weight but exercise will just make her knees ache more. What instruction should the nurse provide to this client? A) Discuss knee replacement surgery with the physician. B) Exercise the muscles so that they will protect the joints. C) Eat a reduced-calorie diet for several months before attempting exercise. D) Stretch the muscles, because that is the only form of exercise that improves osteoarthritis.
b. Exercise is an important aspect of nursing care for clients with osteoarthritis. Exercise can increase flexibility, improve blood flow, help the client lose weight, and improve mood. This is what the nurse should instruct the client. The nurse should not counsel the client to follow a reduced-calorie eating plan for several months before attempting exercise. The client may or may not want to have knee replacement surgery. Stretching is just one type of exercise that will help a client with osteoarthritis. The other components, strengthening and aerobic exercise, can be obtained through walking, swimming, and isometric, isotonic, and resistive exercises
9) The nurse completes teaching for a 22-year-old client diagnosed with Parkinson disease (PD). Which client statement indicates teaching has been effective? A) "I could have prevented PD with diet and exercise." B) "I probably have a genetic mutation that caused PD." C) "My brain has too much of a chemical called dopamine." D) "Most people get PD when they are my age."
b. Early-onset Parkinson disease is likely due to a genetic mutation. Increasing age is a risk factor for PD; age 22 is uncommon. In PD there is a deficit of available dopamine. Although a healthy diet avoiding pesticides is recommended, it is not a proven causative agent
10) A nurse is caring for a client who displays addiction behavior toward the use of alcohol. The client reveals to the nurse that the client has been jailed twice for driving under the influence. The nurse understands that this type of behavioral therapy is which of the following? A) Positive reinforcement B) Negative reinforcement C) Positive punishment D) Negative punishment
c
5) The nurse, planning care for a client with Parkinson disease, identifies which intervention as supporting mobility while providing the spouse with an activity that is beneficial for the client? A) Suggest the spouse use a blender to make foods easier for the client to swallow. B) Review the medication administration schedule with the spouse. C) Instruct the spouse to ambulate the client at least four times a day. D) Instruct the spouse on proper turning and repositioning techniques
c
6) A family member of a woman addicted to alcohol and opioids says, "I don't understand the reason for Naltrexone treatment for my daughter. Won't she just get high off of that?" What is the best explanation for this family member? A) "Naltrexone will cause your daughter to become violently ill if she drinks alcohol or abuses drugs." B) "Naltrexone is less potent than the street drugs your daughter is currently taking and therefore safer." C) "Naltrexone diminishes the cravings your daughter will feel for alcohol and opioids." D) "Naltrexone will prevent your daughter from getting drunk when she drinks."
c
6) The nurse is evaluating the care of a client with Parkinson disease. Which finding indicates an improvement in nutritional status? A) The client was observed providing morning self-care and dressing. B) The client coughs frequently when drinking fluids. C) The client was able to feed self and had no weight change in 1 week. D) The client had a 4-pound weight loss in 1 week.
c
6) The nurse is planning care for a client who is experiencing Stage 1 Alzheimer disease. What will promote a therapeutic environment for a client with acute confusion? A) Background noise like music will keep this client calm. B) Dim the lights during waking hours. C) Schedule meals at the same time each day. D) Pain medications will enhance the therapeutic environment
c
7) A 78-year-old client is experiencing a tonic-clonic (grand mal) seizure exceeding 10 minutes in length. Which medication should the nurse prepare to administer to this client? A) Intramuscular injection of diazepam B) 5% dextrose solution IV C) Intravenous diazepam slowly over several minutes D) Intravenous bolus of 10% dextrose
c
7) A spouse expresses frustration when trying to communicate with a client with Parkinson disease. What can the nurse do to facilitate communication between the client and spouse? A) Recommend that the client and spouse learn sign language. B) Suggest the spouse obtain a hearing aid. C) Consult with Speech Therapy for exercises to aid with speech and language. D) Suggest communicating by writing.
c
7) The nurse includes information regarding long-term care placement in the discharge materials for the family of a client newly diagnosed with Alzheimer disease. Why is this information important to provide to the family at this time? A) It often takes 6 to12 months for an individual with Alzheimer disease to establish a successful transfer to a facility, and this will allow adequate time. B) It's better to address the issue of placement now instead of later. C) Early introduction to long-term options will allow the client and family time to make a more informed decision. D) Long-term care placement is inevitable with this diagnosis.
c
8) The nurse is caring for a child with autism who is being admitted to the hospital with dehydration. What should the nurse do when the child arrives to the care area? A) Take the child on a tour of the pediatric unit. B) Take the child to the playroom for arts and crafts. C) Quietly orient the child to a single-bed hospital room. D) Orient the child to a four-bed unit.
c
8) The nurse is planning care for a client with multiple sclerosis. Which intervention would address the nursing diagnosis of Fatigue? A) Encourage increased activity. B) Schedule physical therapy three times a day. C) Plan activities with sufficient rest periods. D) Group activities together so care will not be interrupted
c
9) A client with Alzheimer disease is scheduled to attend occupational therapy three times a week. What is the purpose of the client attending this type of therapy? A) Improve language deficits B) Improve muscle tone C) Perform activities of daily living D) Improve access to community organizations
c Individuals who are starting to experience language deficits may be able to slow this decline by working with a speech therapist. Physical therapy can help individuals improve their muscle tone, maintain coordination, and maintain their range of motion. Occupational therapy helps the client maintain the ability to perform many activities of daily living. Access to community organizations is facilitated through the use of social workers
Exemplar 13.5 Osteoarthritis 1) A client tells the nurse about being diagnosed with osteoarthritis but does not know what that means. What should the nurse explain to the client about osteoarthritis? A) Most commonly seen in thin, small-built female clients B) A result of synovial inflammation C) Erosion of joint articular cartilage with new bone formation in the joint space D) A metabolic bone disease
c Osteoarthritis is characterized by progressive erosion of the cartilage within joints, which is then replaced by new bone in the joint spaces. Metabolic bone diseases include osteoporosis, osteomalacia, and Paget disease. Obesity is associated with osteoarthritis. Thin body size is associated with osteoporosis. Osteoarthritis is a non-inflammatory joint disease. Rheumatoid arthritis is a joint disease that involves synovial inflammation
11) The nurse is reviewing content provided to a caregiver of an individual with Alzheimer disease. Which statement indicates that teaching has been effective? A) "There are effective drugs, but they cannot be used over a long period." B) "There aren't any drugs that are effective in treating this disease." C) "The earlier the drugs are started, the greater the effect they will have on the disease." D) "There are drugs that can control symptoms for many years."
c The earlier the medications are started, the greater the effect they will have on the symptoms of Alzheimer disease. Current medications will only decrease symptoms for a short period of time. Drugs will not control symptoms for many years. The drugs for treatment of Alzheimer disease are no more dangerous than other drugs used for a long period of time.
12) A nurse working in the Emergency Department is caring for a client who has overdosed on cocaine. The nurse receives an order from the client's physician to administer an antipsychotic for treatment of the client's condition. Which symptom(s) would this medication help to manage? Select all that apply. A) Alkaline urine B) Decreased deep tendon reflexes C) Hyperpyrexia D) Respiratory distress E) CNS depression
c, d
17 Copyright © 2015 Pearson Education, Inc. 3) The school nurse is administering methylphenidate (Ritalin) to an adolescent male who has been diagnosed with attention-deficit/hyperactivity disorder (ADHD). Even though the drug helps the adolescent with focus and grades, he will not go to the nurse's office at noon for his medication. What should the school nurse suspect is the reason for this adolescent's behavior? A) The adolescent may fear that this drug may be a "gateway drug" that may lead to abusing other substances. B) An additional dose of methylphenidate (Ritalin) is not needed while at school. C) Alternative coping mechanisms to increase focus during classes have been developed. D) The adolescent may be embarrassed about having to take medicine at school and fear a social
d
2) The nurse is interviewing the mother of a child who is being evaluated for attention-deficit/hyperactivity disorder (ADHD). Which factor within the child's health history should the nurse recognize could be associated with the development of ADHD? A) The measles, mumps, and rubella (MMR) vaccine B) The immune response of the child C) Young parental age at conception D) Smoking during pregnancy
d
3) A client diagnosed with Alzheimer disease has a catastrophic reaction during an activity involving simultaneous music playing and a craft project. The client starts shouting, "No! No! No!" and runs from the room. What should the nurse do? A) Administer a PRN anti-anxiety medication and restrict the client's activity participation. B) Intervene one-on-one with the client until the client is calm, and then redirect the client to another activity such as Bingo. C) Discontinue the activity program because it is upsetting the client. D) Follow the client, reassure the client one-on-one, and then redirect the client to a quiet activity
d
4) A client being treated for depression reports feeling better and has started to make plans. What is a priority nursing concern? A) Social Isolation B) Hopelessness C) Situational Low Self-Esteem D) Risk for Self-Directed Violence
d
5) A nurse is caring for a 10-year-old client who is scheduled to have a tonsillectomy the next day. The nurse has planned a preoperative teaching session for the child, who has a history of attention-deficit/hyperactivity disorder (ADHD). Which teaching technique should the nurse use for this client? A) Play a television show in the background. B) Ask other children who have had this procedure to talk to the child. C) Allow the child to lead the session to gain a sense of control. D) Give instructions verbally and use a picture pamphlet, repeating points more than once
d
5) The nurse is planning discharge teaching for a child with epilepsy prescribed phenytoin (Dilantin). Which information is important for the nurse to include in these instructions? A) Brush teeth less frequently. B) Take the medication with milk. C) Increase fluid intake. D) Increase vitamin D intake.
d
8) The nurse is caring for a 1-year-old who starts to have a tonic-clonic (grand mal) seizure while in a crib in the hospital. The child's jaws are clamped shut. What is the most appropriate nursing action? A) Place a tongue blade between the child's jaws. B) Restrain the child to prevent injury. C) Prepare the suction equipment. D) Stay with the child to observe for complications.
d
Exemplar 11.2 Seizure Disorders 1) The nurse observes a school-age child have an absence seizure. How would the nurse describe this seizure in the client's medical record? A) "Pulled arms in toward the body and flexed hands over the chest. This lasted 2 minutes." B) "Became unconscious, and all four extremities were jerking uncontrollably for 2 minutes." C) "Repeatedly moved from the chair to the bed while touching the arms for a length of 2 minutes." D) "Sat very still and was unresponsive with a blank stare for 2 minutes."
d
Exemplar 23.1 Alzheimer Disease 1) The spouse of a client with Alzheimer disease does not understand why the client developed the disorder because no one else in the family has the health problem. What would be the nurse's best response to the spouse? A) "Alzheimer disease develops because of smoking and alcohol intake." B) "Someone in your family must not have been correctly diagnosed with the disorder." C) "Alzheimer disease does not have the same course in every individual." D) "There are genetic and environmental factors in the development of Alzheimer disease."
d
2) A nursing instructor is teaching a class about the role of dopamine in substance abuse. Which student statement indicates that the role of dopamine is understood? A) "The dopamine D(1) and dopamine D(2) receptors are responsible for co-occurring disorders." B) "Dopamine increases opioid transmission, and this reinforces the cycle of substance abuse." C) "Dopamine causes changes in brain neurotransmission that enhance the cycle of substance abuse." D) "The dopamine D(3) receptor is involved in drug-seeking behaviors."
d Although most studies have focused on the role of dopamine D(1) and dopamine D(2) receptors in sustaining the addictive danger of drugs, recent studies also have shown that the dopamine D(3) receptor is involved in drug-seeking behavior. Ethanol, not dopamine, increases opioid transmission and reinforces the cycle of substance abuse. Dopamine does not cause changes in brain neurotransmission that enhance the cycle of substance abuse. D(1) and D(2) receptors are not responsible for co-occurring disorders.
4) A client, diagnosed with Impaired Swallowing, complains of frequent heartburn. What should the nurse do? A) Teach the client the "chin tuck" technique when swallowing. B) Assist the client to a 90° sitting position, or as high as tolerated, during meals. C) Check the client's mouth for pocketing of food. D) Assist the client in maintaining a sitting position for 30 minutes after the meal.
d Keeping the client upright for a time after the meal will help prevent food from being regurgitated back into the esophagus. The position of the client during the meals as well as teaching the "chin tuck" technique will assist with the swallowing mechanism but will not help with regurgitation. Pocketing food does not cause regurgitation.
6) A client recovering from a stroke is being discharged on warfarin sodium (Coumadin). During discharge teaching, which statement by the client would reflect an understanding of the effects of this medication? A) "It will be okay for me to eat anything, as long as it is low-fat." B) "I will stop taking this medicine if I notice any bruising." C) "I'll check my blood pressure frequently while taking this medication." D) "I will not eat spinach while I'm taking this medicine."
d Warfarin sodium suppresses the synthesis of vitamin K coagulation factors. Green, leafy vegetables contain vitamin K and will therefore interfere with the therapeutic effects of the drug. Bruising is a common side effect, and the drug should not be stopped unless prescribed by the physician. Low-fat foods do not interfere with warfarin sodium therapy. Anticoagulants do not affect the blood pressure
7) A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the recombinant tissue plasminogen activator alteplase. What should the nurse explain to the client's family about the use of this medication? A) Used to treat thrombotic and hemorrhagic strokes B) Not associated with serious complications C) Indicated if the stroke symptoms have occurred within the last 6 hours D) Administered to dissolve the clot that is occluding the cerebral circulation and reestablish circulation to the involved part of the brain
d. Thrombolytic therapy using recombinant tissue plasminogen activator is used to dissolve the clot formed with a thrombotic stroke. Dissolving the clot reestablishes cerebral circulation. The treatment can be used if the symptoms have occurred within the last 3 hours. Bleeding is a complication associated with the treatment, which may result in cerebral hemorrhage causing extensive brain damage and disability. The treatment is only used with thrombotic strokes
