Unit 1 - 3rd Semester
What is the route of transmission for Hepatitis A? A) IV drugs, Blood to blood B) Unprotected sex C) Getting a tattoo D) Fecal to oral
D
What side effect of antipsychotic medication therapy is generally irreversible? A) Anticholinergic effects B) Pseudoparkinsonism C) Dystonic reaction D) Tardive dyskinesia
D
When a substance triggers an allergic response causing a rash: a) Herpes virus b) Scabies c) Impetigo d) Contact dermatitis
D
A client had a myringotomy. The nurse provides which discharge teaching? a. Buy dry shampoo to use for a week. b. Drink liquids through a straw. c. Flying is not allowed for 1 month. d. Hot water showers will help the pain.
A
A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity
A
The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and the familys role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family
A
The nurse is caring for a client with an extensive history of alcohol abuse who is experiencing hallucinations. What is the client undergoing? A) Withdrawal B) Relapse C) Mood disorder D) Delusional disorder
A
A client tells the nurse, "I want to stop taking my chlorpromazine because of the way it makes me feel." Which side effect is the nurse likely to note during further assessment of the client's complaint? a) Drowsiness b) Nervousness c) Hand tremors d) Increased urination
A
A nurse is planning care for an asymptomatic child with a positive tuberculin test. What should the nurse include in the plan? Select all that apply. a. Administration of daily isoniazid (INH) b. Instructing family members about administration of INH to all close contacts of the child c. Administration of the Bacillus Calmette-Gurin vaccine d. Reporting the case to the health department e. Administration of INH and rifampin (Rifadin) simultaneously
A, B, D
A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? (Select all that apply.) a. Admit the client to a negative-airflow room. b. Maintain a distance of 3 feet from the client at all times. c. Order specialized masks/respirators for caregiving. d. Other than wearing gloves, no special actions are needed. e. Wash hands with chlorhexidine after providing care.
A, C
An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.) a. Policies related to consistent use of Standard Precautions b. Hepatitis vaccination mandate for workers in high-risk areas c. Implementation of a needleless system for intravenous therapy d. Number of sharps used in client care reduced where possible e. Postexposure prophylaxis provided in a timely manner
A, C, D, E
The process of infection requires which of the following to be present (Select all that apply): a) Mode of transmission b) Encapsulation c) Pathogen d) Portal of entry e) Portal of exit f) Vascular damage g) Reservoir h) Susceptible host
A, C, D, E, G, H
After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. Some medications have been known to cause hepatitis A. b. I may have been exposed when we ate shrimp last weekend. c. I was infected with hepatitis A through a recent blood transfusion. d. My infection with Epstein-Barr virus can co-infect me with hepatitis A.
B
A burn that has large moist vesicles, blanches, and is very painful: a) 1st degree superficial b) 2nd degree partial thickness c) 3rd degree full thickness
B
A child hospitalized for leukemia has developed chicken pox. Which type of isolation is needed? a) Contact only b) Contact & Airborne c) Contact & Droplet d) Standard precautions only
B
A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately? a. Albumin: 5.1 g/dL b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/mm3 d. White blood cell (WBC) count: 12,500/mm3
B
A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, I saw two doctors talking in the hall. They were plotting to kill me. The nurse may correctly assess this behavior as: a. echolalia. b. an idea of reference. c. a delusion of infidelity. d. an auditory hallucination.
B
A nurse assesses a client who has psoriasis. Which action should the nurse take first? a. Don gloves and an isolation gown. b. Shake the clients hand and introduce self. c. Assess for signs and symptoms of infections. d. Ask the client if she might be pregnant.
B
A nurse cares for a client with hepatitis C. The clients brother states, I do not want to contract this infection, so I will not go into his hospital room. How should the nurse respond? a. If you wear a gown and gloves, you will not get this virus. b. Viral hepatitis is not spread through casual contact. c. This virus is only transmitted through a fecal specimen. d. I can give you an update on your brothers status from here.
B
A nurse is conducting a health education class for a group of school-age children. Which statement made by the nurse is correct about the bodys first line of defense against infection in the innate immune system? a. Nutritional status b. Skin integrity c. Immunization status d. Proper hygiene practices
B
A nurse observes a patient who is diagnosed with schizophrenia. The patient is standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Waxy flexibility c. Depersonalization d. Thought withdrawal
B
A patient diagnosed with schizophrenia has catatonia. The patient has little spontaneous movement and waxy flexibility. Which patient needs are of priority importance? a. Psychosocial b. Physiologic c. Self-actualization d. Safety and security
B
A patient smiles broadly at the nurse and says, "Look at my clean teeth. I brushed them with scouring powder because the label said, 'It frightens and whitens everything." Which term should the nurse include when documenting this encounter? a) Circumstantiality b) Concrete thinking c) Poverty of speech d) Associative looseness
B
After teaching a client who has psoriasis, a nurse assesses the clients understanding. Which statement indicates the client needs additional teaching? a. At the next family reunion, Im going to ask my relatives if they have psoriasis. b. I have to make sure I keep my lesions covered, so I do not spread this to others. c. I expect that these patches will get smaller when I lie out in the sun. d. I should continue to use the cortisone ointment as the patches shrink and dry out.
B
Bile channels in the liver are compressed in patients with hepatitis, resulting in elevated: a) Serum creatinine b) Bilirubin c) BUN d) Hemoglobin
B
The nurse teaches the patient with hepatitis that rest is needed to allow the liver to heal by: a) Producing more white blood cells to fight infections b) Regenerating new cells to replace damaged cells c) Producing more platelets to assist in clotting d) Regenerating new blood vessels to replace damaged ones
B
When providing community education, the nurse emphasizes that which group should receive immunization for Hepatitis B? a) Clients who work with shellfish b) Men who prefer sex with men c) Clients traveling to a developing country d) Clients with elevated liver enzymes
B
Which S/S suggests a patient with impaired skin integrity is developing a systemic infection? a) Lesion on the leg that is swollen and warm to the touch b) Temperature that has risen to 101 degrees c) Blood pressure that has risen from 124/80 to 130/84 d) Request by the patient for severe itching medication
B
You suspect your patient has Hepatitis B virus. What symptoms would this patient have to cause you to believe that? (Select all that apply) a) Cough b) N/V c) Dark urine d) Jaundice e) Fever
B, C, D, E
After teaching a client who has plans to travel to a non-industrialized country, the nurse assesses the clients understanding regarding the prevention of viral hepatitis. Which statement made by the client indicates a need for additional teaching? a. I should drink bottled water during my travels. b. I will not eat off anothers plate or share utensils. c. I should eat plenty of fresh fruits and vegetables. d. I will wash my hands frequently and thoroughly.
C
For which problem should the child with chronic otitis media with effusion be evaluated? a. Brain abscess b. Meningitis c. Hearing loss d. Perforation of the tympanic membrane
C
Keratolytic agents are used: a) As a protectant to seal out wetness b) For promoting removal of necrotic tissue c) For controlling conditions of abnormal scaling of the skin d) To inhibit growth of bacteria
C
Tinea is a superficial skin infection caused by: a) E-coli b) MRSA c) Candidiasis d) Fungus
D
Household members of a client with active TB need to be treated prophylactically, T/F?
True
You were exposed to scabies at work. Your household members should be treated prophylactically. T/F?
True
Olanzepine (Zyprexa), a SGA antipsychotic, has what kind of side effects? Select all that apply. A) Weight gain B) Agitation/Restlessness C) Dry Mouth D) Insomnia E) Sexual dysfunction
A, B, D
What are some side effects characterized by Haloperidol (Haldol)? Select all that apply. A) Drowsiness B) Headache C) N/V D) Blurred vision E) Constipation
A, B, D
A nurse is teaching parents about prevention of diaper dermatitis. Which should the nurse include in the teaching plan? Select all that apply. a. Clean the diaper area gently after every diaper change with a mild soap. b. Use a protective ointment to clean dry intact skin. c. Use a steroid cream after each diaper change. d. Use rubber or plastic pants over the diaper. e. Wash cloth diapers in hot water with a mild soap and double rinse.
A, B, E
Negative Symptoms of Schizophrenia, select all that apply: A) Loss of motivation B) Blunted Affect C) Delusions D) Hallucinations E) Feelings of emptiness F) Anhedonia
A, B, E, F
Olanzepine (Zyprexa), an SGA antipsychotic, has what kind of Adverse/Toxic Effects? Select All That Apply. A) Hypotension B) N/V C) Seizures D) Diaphoresis E) Muscle rigidity
A, C, D, E
What extrapyramidal symptoms most commonly occur with he use of FGA antipsychotics? Select all that apply. A) Tardive dyskinesia B) Metabolic syndrome C) Parkinsonism D) Dystonia E) Akathisia
A, C, D, E
Where do the lesions of atopic dermatitis most commonly occur in the infant? Select all that apply. a. Cheeks b. Buttocks c. Extensor surfaces of arms and legs d. Back e. Trunk
A, C, E
In the Acute Phase of Schizophrenia, what can you NOT expect? A) Delusions B) Hallucinations C) Positive symptoms decrease in severity D) Withdrawal
C
The mother of an infant with multiple anomalies tells the nurse that she had a viral infection in the beginning of her pregnancy. Which viral infection is associated with fetal anomalies? a. Measles b. Roseola c. Rubella d. Herpes simplex virus (HSV)
C
When taking a history on a child with a possible diagnosis of cellulitis, what should be the priority nursing assessment to help establish a diagnosis? a. Any pain the child is experiencing b. Enlarged, mobile, and nontender lymph nodes c. Childs urinalysis results d. Recent infections or signs of infection
D
Which statement is characteristic of AOM? a. The etiology is unknown. b. Permanent hearing loss often results. c. It can be treated by intramuscular (IM) antibiotics. d. It is treated with a broad range of antibiotics.
D
The family members of a patient newly diagnosed with schizophrenia state that they do not understand what has caused the illness. The nurses response should be based on which models? Select all that apply. a. Neurobiological b. Environmental c. Family theory d. Genetic e. Stress
A, D
A nurse is working with a client demonstrating behaviors often associated with the acute phase of schizophrenia. Which assessment findings increase the risk of aggressive and violent client behaviors? Select all that apply. A) Paranoia B) Flat affect C) Poor hygiene D) Delusional thinking E) Command hallucinations
A, D, E
A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective? a. I need to take extra vitamin C while on INH. b. I should take this medicine with milk or juice. c. I will take this medication on an empty stomach. d. My contact lenses will be permanently stained.
C
Clay-colored stools are characteristic of: a) Bile obstruction b) Gastritis c) Pancreatitis d) Crohn's disease
A
Patient has clay stools, what is this an indication of? A) GI bleed B) Bile obstruction C) Not enough fiber intake D) Peptic ulcer
B
The nurse understands that SGA Antipsychotic agents contribute to what disease process in the schizophrenic client? A) HIV B) Obesity C) Depressive symptoms D) Tobacco use
B
The primary clinical manifestation of scabies is a. Edema b. Redness c. Pruritus d. Maceration
C
Which statement made by a parent indicates an understanding about the management of a child with cellulitis? a. I am supposed to continue the antibiotic until the redness and swelling disappear. b. I have been putting ice on my sons arm to relieve the swelling. c. I should call the doctor if the redness disappears. d. I have been putting a warm soak on my sons arm every 4 hours.
D
One of the most important aspects of ongoing care for the patient with cirrhosis is to stress the need to avoid which of the following? (Select all that apply) a) Illicit drugs b) Alcohol c) Smoking d) Tylenol e) All of the above
E
Haloperidol (Haldol), has a lower risk for EPS. True or False?
False
A patient diagnosed with schizophrenia begins to talks about cracklomers in the local shopping mall. The term cracklomers should be documented as: a. neologism. b. concrete thinking. c. thought insertion. d. an idea of reference
A
What is an example of persecution delusion? A) Sam believes the Secret Service is planning to kill him B) Myndi is convinced that Chris Hemsworth is in love with her C) Jennifer thinks everybody is staring and judging the food choices she makes while at the grocery store. Because of this, she only shops late at night when there aren't many people out shopping. D) Harry accused his girlfriend of cheating on him, even though this was not the case. His "proof" was that she came home late twice this week.
A
What is the route of transmission of Hepatitis C? A) Sharing tattoo needles B) Drinking contaminated water C) Having unprotected sex with someone with HDV D) Wearing gloves when handling blood
A
What should be included in teaching a parent about the management of small red macules and vesicles that become pustules around the childs mouth and cheek? a. Keep the child home from school for 24 hours after initiation of antibiotic treatment. b. Clean the rash vigorously with Betadine three times a day. c. Notify the physician for any itching. d. Keep the child home from school until the lesions are healed.
A
A patient diagnosed with schizophrenia is hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof and suspicious and says, Two staff members I saw talking were plotting to assault me. Based on data gathered at this point, which nursing diagnoses relate? Select all that apply. a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation
A, B
Positive symptoms of Schizophrenia, select all that apply: A) Delusion B) Hallucination C) Loss of motivation D) Feelings of emptiness E) Blunted Affect
A, B
A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive but the patient continues to have apathy, poverty of thought, and social isolation. The nurse expects a change to which medication? a. haloperidol (Haldol) b. olanzapine (Zyprexa) c. chlorpromazine (Thorazine) d. diphenhydramine (Benadryl)
B
Parents of a child with lice infestation should be instructed carefully in the use of antilice products because of which potential side effect? Test Bank - Maternal-Child Nursing (5th Edition by McKinney) 871 a. Nephrotoxicity b. Neurotoxicity c. Ototoxicity d. Bone marrow depression
B
The primary healthcare provider prescribes a neuroleptic drug to a client diagnosed with schizophrenia. On what basis would the primary healthcare provider choose the drug? A)Symptoms B) Side effects C) Therapeutic effects D) Underlying pathology
B
Some adverse/toxic effects of Haloperidol (Haldol) include, Select all that apply: A) Dizziness B) Tachycardia C) Urinary retention D) EPS E) Hypotension
B, C, D
A nurse at the mental health clinic plans a series of psychoeducational groups for persons diagnosed with schizophrenia. Which two topics would take priority? a. How to complete an application for employment b. The importance of correctly taking your medication c. How to dress when attending community events d. How to give and receive compliments e. Ways to quit smoking
B, E
A client diagnosed with schizophrenia is most likely to experience which type of hallucination? A) Visual B) Tactile C) Auditory D) Olfactory
C
A client who exhibits concrete thinking is unable to communicate in what manner? A) Coherently B) Reasonably C) Abstractly D) Positively
C
A patient diagnosed with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene, and motor agitation. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Motor agitation
C
Treatment for herpes simplex virus (types 1 or 2) includes a. Corticosteroids b. Oral griseofulvin c. Oral antiviral agent d. Topical and/or systemic antibiotic
C
What is a grandeur delusion? A) False belief that a famous person is in love with him/her B) Exaggerated belief in the futility of everything C) False belief that one is a very powerful and important person D) False belief that one is being singled out for harm by others
C
What is the route of transmission for Hepatitis B? A) Fecal to oral B) IV drugs C) Direct contact with blood D) Sharing tattoo needles
C
Which child requires a Mantoux test? a. The child who has episodes of nighttime wheezing and coughing b. The child who has a history of allergic rhinitis c. The child whose baby-sitter has received a tuberculosis diagnosis d. The premature infant who is being treated for apnea of infancy
C
A nurse is instructing parents on treatment of pediculosis (head lice). Which should the nurse include in the teaching plan? Select all that apply. a. Bedding should be washed in warm water and dried on a low setting. b. After treating the hair and scalp with a pediculicide, shampoo the hair with regular shampoo. c. Retreat the hair and scalp with a pediculicide in 7 to 10 days. d. Items that cannot be washed should be dry cleaned or sealed in plastic bags for 2 to 3 weeks. e. Combs and brushes should be boiled in water for at least 10 minutes.
C, D, E
A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, Demons are in the basement and they can come through the floor. The nurse can correctly assess this information as an indication of: a. need for psychoeducation b. medication noncompliance c. chronic deterioration d. relapse
D
A client is anxious, and the healthcare provider prescribes alprazolam 5 mg by mouth three times a day. What will the nurse do before administering this prescription? A) Assess the apical pulse B) Take the blood pressure C) Encourage the ventilation of feelings D)Clarify the prescription with the healthcare provider
D
A patient diagnosed with schizophrenia anxiously says, I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror. While listening, the nurse should: a. sit close to the patient. b. place an arm protectively around the patients shoulders. c. place a hand on the patients arm and exert light pressure. d. maintain a normal social interaction distance from the patient.
D
A patient diagnosed with schizophrenia has auditory hallucinations. The patient anxiously tells the nurse, The voice is telling me to do things. Select the nurses priority assessment question. a. How long has the voice been directing your behavior? b. Do the messages from the voice frighten you? c. Do you recognize the voice speaking to you? d. What is the voice telling you to do?
D
A patient diagnosed with schizophrenia says, High heat. Last time here. Did you get a coat? What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness
D
A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 10:30 AM. By noon, the patient is diaphoretic, drooling, and has difficulty swallowing. By 4:00 PM, vital signs are body temperature, 102.8 F; pulse, 110 beats per minute; respirations, 26 breaths per minute; and blood pressure, 150/90 mm Hg. Select the nurses best analysis and action. a. Agranulocytosis. Institute reverse isolation. b. Tardive dyskinesia. Withhold the next dose of medication. c. Cholestatic jaundice. Begin a high-protein, low fat diet. d. Neuroleptic malignant syndrome. Immediately notify the health care provider.
D
The pediatric nurse understands that cellulitis is most often caused by a. Herpes zoster b. Candida albicans c. Human papillomavirus d. Streptococcus or Staphylococcus organisms
D
What is an expected finding in a client displaying associative looseness? A) Speaking in rhyme B) Made up words C) Mimicking movements of another D) Illogical thinking
D
Which patient diagnosed with schizophrenia would be expected to have the lowest level of overall functioning? a. 39 years old; paranoid ideation since age 35 years b. 32 years old; isolated episodes of catatonia since age 24 years; stable for 3 years c. 19 years old; diagnosed with schizophreniform disorder 6 months ago d. 40 years old; frequent relapses since age 18; often does not take medication as prescribed
D
Which sign/symptom indicates that a client being treated with haloperidol may be experiencing an adverse effect of this medication? a) Nausea b) Hypotension c) Blurred vision d) Excessive drooling
D
When a child is diagnosed with lice, all household members need to be treated prophylactically. T/F?
False
Hepatitis C is spread most commonly by: a) Illicit IV drug needle sharing b) Sharing bath towels c) Sharing a bed d) Single-couple sexual relations
A
Which intervention is appropriate for a hospitalized child who has crops of lesions on the trunk that appear as a macular rash and vesicles? a. Place the child in strict isolation; airborne and contact precautions. b. Continue to practice Standard Precautions. c. Pregnant women should avoid contact with the child. d. Screen visitors for immunity to measles.
A
You were exposed to psoriasis at work. Household members should be treated prophylactically. T/F?
False
A client has been hospitalized with tuberculosis (TB). The clients spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a. Ask the spouse to explain the fear of visiting in further detail. b. Inform the spouse the precautions are meant to keep other clients safe. c. Show the spouse how to follow the isolation precautions to avoid illness. d. Tell the spouse that he or she has already been exposed, so its safe to visit.
A
A client with active TB demonstrates less-than-expected interest in learning about the prescribed medication therapy. Which technique would the nurse ultimately need to employ in order to encourage participation? a) Directly observed therapy b) More medication instructions c) Involvement of the family in teaching d) Reinforcement by the health care provider
A
A 9 y/o patient had a 15 mm indurated area following a PPD skin test. This results from (Select all that may apply): a) A previous BCG vaccination b) An active case of TB c) A previous exposure to TB d) An allergic response to the ingredients in the PPD
A, B, C
A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurses best plan. a. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return. b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c. Visit twice daily; sit beside the patient with a hand on the patients arm; leave if the patient does not respond within 10 minutes. d. Visit every other day; remind the patient of the nurses identity; encourage the patient to talk while the nurse works on reports.
A
A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action should the nurse take? a. Place the client in a single room. b. Administer an antihistamine. c. Assess the clients airway. d. Apply gloves to minimize friction.
A
A nurse assesses clients at a community health fair. Which client is at greatest risk for the development of hepatitis B? a. A 20-year-old college student who has had several sexual partners b. A 46-year-old woman who takes acetaminophen daily for headaches c. A 63-year-old businessman who travels frequently across the country d. An 82-year-old woman who recently ate raw shellfish for dinner
A
A nurse works with a patient diagnosed with schizophrenia regarding the importance of medication management. The patient repeatedly says, I dont like taking pills. Which treatment strategy should the nurse discuss with the health care provider? a. Use of a long-acting antipsychotic injections b. Addition of a benzodiazepine, such as lorazepam (Ativan) c. Adjunctive use of an antidepressant, such as amitriptyline (Elavil) d. Inpatient hospitalization because of the high risk for exacerbation of symptoms
A
A patient diagnosed with schizophrenia is acutely disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patients head rotated to one side in a stiff position; the lower jaw is thrust forward, and the patient is drooling. Which problem is most likely? a. Acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia
A
A patient diagnosed with schizophrenia says, "I hear the voices everyday. They always say bad things about me." Which action by the nurse has the highest priority? a) Assess the patient for suicidal thinking and plans b) Review the patient's medication regime and compliance c) Educate the patient about symptoms associated with schizophrenia d) Suggest distractors for the patient to use when auditory hallucinations occur
A
A patient has developed Hepatitis A after eating contaminated oysters. The nurse assesses the patient for which of the following? a) Malaise b) Dark stools c) Weight gain d) Left upper quadrant pain
A
A patient with delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient? a. Allow the patient to have supervised access to food vending machines b. Allow the patient to telephone a local restaurant to deliver meals c. Offer to taste each portion on the tray for the patient d. Begin tube feedings or total parenteral nutrition
A
An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patients head rotated to one side in a stiffly fixed position; the lower jaw is thrust forward, and the patient is drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c. Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcutaneously from the PRN medication administration record.
A
An infants parents ask the nurse about preventing OM. What should be recommended? a. Avoid tobacco smoke. b. Use nasal decongestant. c. Avoid children with OM. d. Bottle feed or breastfeed in supine position.
A
Side effects from topical corticosteroids include: a) Ulceration, especially with occlusive dressings b) Dermatitis with frequent application c) Photosensitivity d) Impaired kidney or liver function
A
The nurse expects the initial plan of care for a 9-month-old child with an acute otitis media infection to include a. symptomatic treatment and observation for 48 to 72 hours after diagnosis b. an oral antibiotic, such as amoxicillin, five times a day for 7 days c. pneumococcal conjugate vaccine d. myringotomy with tympanoplasty tubes
A
The physician has determined that patient with hepatitis has contracted the infection from contaminated food. The nurse understands that this patient is most likely experiencing what type of hepatitis? a) Hep A b) Hep B c) Hep C d) Hep D
A
What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms
A
When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, I stopped taking those pills. They made me feel like a robot. What common side effects should the nurse validate with the patient? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose
A
Which interventions should a nurse implement when caring for a child with hepatitis? Select all that apply. a. Provide a well-balanced low-fat diet. b. Schedule playtime in the playroom with other children. c. Teach parents not to administer any over-the-counter medications. d. Arrange for home schooling because the child will not be able to return to school. e. Instruct parents on the importance of good handwashing.
A, C, E
A patient diagnosed with schizophrenia has catatonia. The patient is stuporous, demonstrates little spontaneous movement, and has waxy flexibility. The patients activities of daily living are severely compromised. An appropriate outcome is that the patient will: a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. voluntarily accept tube feeding by day 2.
B
A patients care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Aloofness, haughtiness, suspicion b. Darting eyes, tilted head, mumbling to self c. Elevated mood, hyperactivity, distractibility d. Performing rituals, avoiding open places
B
A person diagnosed with schizophrenia has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, Theyre all plotting to destroy me. Select the nurses most therapeutic response. a. Everyone here is trying to help you. No one wants to harm you. b. Feeling that people want to destroy you must be very frightening. c. That is not true. People here are trying to help if you will let them. d. Staff members are health care professionals who are qualified to help you.
B
During grade school head checks, you notice tiny white flakes that easily fall off the hair: a) This is head lice. Send the kid home b) This is most likely dandruff c) These are actually nits - lice eggs
B
The HCP closes a simple laceration with sutures. This wound will heal by which process? a) Closed intention b) Primary intention c) Secondary intention d) Tertiary intention
B
What will happen to blood glucose levels in response to infection? a) Levels will fall and may result in hypoglycemia b) Levels will rise and may result in hyperglycemia c) Levels will remain unchanged, but patients with diabetes are less able to fight off infection d) Non-diabetic patients will experience lower blood glucose levels, whereas diabetic patients will have higher blood glucose levels
B
Which symptoms are expected for a patient diagnosed with schizophrenia who has disorganization? a. Extremes of motor activity, from excitement to stupor b. Social withdrawal and ineffective communication c. Severe anxiety with ritualistic behavior d. Highly suspicious, delusional behavior
B
You develop contact dermatitis at work and get sent home. Household members require: a) Prophylactic treatment b) That you use an antipruritic c) That you utilize contact precautions d) Nothing unless they come into contact with you
B
One good thing about getting sick with Hepatitis A is that: a) You get to miss several weeks of school b) You will no longer require a Hepatitis A vaccine c) You will probably lose 15 lbs d) You will have lifelong immunity against Hep A
B & D
A TB skin test results in an 8 mm area of induration. The adult client has no history of immunosuppression: a) The nurse interprets this as active TB b) The nurse interprets this as a history of TB c) The nurse interprets this as a negative response d) The nurse interprets this as a past exposure to TB
C
A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a. Blood urea nitrogen (BUN): 19 mg/dL b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L e. White blood cell (WBC) count: 72,000/mm3
B, C
A nurse prepares to admit a client who has herpes zoster. Which actions should the nurse take? (Select all that apply.) a. Prepare a room for reverse isolation. b. Assess staff for a history of or vaccination for chickenpox. c. Check the admission orders for analgesia. d. Choose a roommate who also is immune suppressed. e. Ensure that gloves are available in the room.
B, C, E
A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this clients psoriatic lesions? (Select all that apply.) a. Have you eaten a large amount of chocolate lately? b. Have you been under a lot of stress lately? c. Have you recently used a public shower? d. Have you been out of the country recently? e. Have you recently had any other health problems? f. Have you changed any medications recently?
B, E, F
A client being discharged home with TB is worried about the possibility of infecting family members and others. Which info should reassure the client that contamination is not likely? a) The family does not need therapy and the client will not be contagious after 6 consecutive weeks of medication b) The family will receive prophylactic therapy and the client will not be contagious after 1 continuous week of medication therapy c) The family will receive prophylactic therapy and the client will not be contagious after 2-3 consecutive weeks of medication
C
A client diagnosed with delirium anxiously states, "Look at the spiders on the wall." Which response by the nurse addresses the client's concerns therapeutically? a) "Would you like me to kill the spiders for you?" b) While there may be spiders on the wall, they are not going to hurt you." c) "I know that you are frightened, but I do not see any spiders on the wall." d) "You are having a hallucination; I'm sure there are no spiders in the room."
C
A client has external otitis. On what comfort measure does the nurse instruct the client? a. Applying ice four times a day b. Instilling vinegar-and-water drops c. Use of a heating pad to the ear d. Using a home humidifier
C
A newly admitted patient diagnosed with schizophrenia says, The voices are bothering me. They yell and tell me Im bad. I have got to get away from them. Select the nurses most helpful reply. a. Do you hear the voices often? b. Do you have a plan for getting away from the voices? c. I will stay with you. Focus on what we are talking about, not the voices. d. Forget the voices. Ask some other patients to sit and talk with you.
C
A patient diagnosed with schizophrenia says, My co-workers are out to get me. I also saw two doctors plotting to overdose me. How does this patient perceive the environment? a. Disorganized b. Unpredictable c. Dangerous d. Bizarre
C
In the hospital, it is important in the room of a patient with active TB to: a) Not vent the air outdoors b) Have no more than 4 air exchanges per hour c) Have at least 6 air exchanges per hour d) Maintain strict contact isolation precautions
C
Lilly is a 3 month old baby has recently been diagnosed with Varicella-Zoster (Chickenpox) infection, which of the following would you teach her parents not to do? a) Frequent bathing in a oatmeal bath b) Use of antihistamines to relieve itching and to prevent secondary bacterial infections c) Giving aspirin to control fever d) Keep away from other children until lesions are dried (crusted over)
C
The medical treatment of hepatic encephalopathy is directed toward: a) Raising hemoglobin b) Decreasing urea c) Reducing ammonia formation d) Increasing prothrombin time
C
The nurse is gathering data on a client with a diagnosis of TB. The nurse should review the results of which diagnostic test to confirm this diagnosis? a) Chest X-ray b) Bronchoscopy c) Sputum culture d) Tuberculin skin test
C
Which patient is at highest risk for developing herpes zoster? a) Patient with many sexual partners b) Patient recently admitted in a nursing home c) Patient who is immunocompromised d) Patient who has scabies
C
Which statement best characterizes hepatitis A? a. Incubation period is 6 weeks to 6 months. b. Principal mode of transmission is through the parenteral route. c. Onset is usually rapid and acute. d. There is a persistent carrier state.
C
A child taking oral corticosteroids for asthma is exposed to varicella. The child has not had the varicella vaccine and has never had the disease. What intervention should be taken to prevent varicella from developing? a. No intervention is needed unless varicella develops. b. Administer the varicella vaccine as soon as possible. c. The child should begin a course of oral antibiotics. d. The child should be prescribed acyclovir.
D
A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting Nurses for directly observed therapy
D
A client suspected of having TB is being admitted. The nurse plans to admit the client to which type of room? a) Venting to the outside and UV light b) UV light with 3 air exchanges per hour c) 10 air exchanges per hour and venting to the outside d) Venting to the outside, 6 air exchanges per hour, and UV light
D
A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight and has hypertension. Which drug should the nurse advocate? a. clozapine (Clozaril) b. ziprasidone (Geodon) c. olanzapine (Zyprexa) d. aripiprazole (Abilify)
D
A mom of a 7 y/o with varicella asks, "how long will she have to stay home from school?" a) Until her temperature returns to normal b) Until all the vesicles have completely healed c) Varicella is only contagious before the vesicles develop d) Until all vesicles have completely crusted over
D
A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurses best response. a. Why are you laughing? b. Please share the joke with me. c. I dont think I said anything funny. d. You are laughing. Tell me whats happening.
D
A patient diagnosed with hepatitis may be self-conscious about her appearance because of: a) Skin rash b) Ulcerations c) Redness d) Jaundice
D
A patient diagnosed with schizophrenia has paranoid thinking. The patient angrily tells a nurse, You are mean and nasty. No one trusts you or wants to be around you. Select the most likely analysis. The patient: a. is trying to manipulate the nurse by using negative comments. b. is likely to experience disorganization and catatonia in the near future. c. is jealous of the nurses position of power in the relationship. d. may be identifying another persons shortcomings in order to preserve his or her own self-esteem.
D
A patient diagnosed with schizophrenia says, Everyone has skin lice that jump on you and contaminate your blood. Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia
D
A patient diagnosed with schizophrenia tells the nurse, I eat skiller. Tend to end. Easter. It blows away. Get it? Select the nurses best response. a. Nothing you are saying is clear. b. Your thoughts are very disconnected. c. Try to organize your thoughts, and then tell me again. d. I am having difficulty understanding what you are saying.
D
A persistent, productive cough with bloody sputum (hemoptysis) is a common symptom of: a) emphysema b) cystic fibrosis c) sinusitis d) tuberculosis
D
In screening a patient for melanoma, which finding is most suggestive of a malignant melanoma? a) A painless brown-colored mole, measuring 3 mm in diameter b) A tender, reddened, raised area c) A mole that has not changed in shape or size for 6 months d) An 8 mm brownish-blue discolored area with a ragged border
D
Patients diagnosed with schizophrenia who are suspicious and withdrawn: a. universally fear sexual involvement with therapists. b. are socially disabled by the positive symptoms of schizophrenia. c. exhibit a high degree of hostility as evidenced by rejecting behavior. d. avoid relationships because they become anxious with emotional closeness.
D
The healthcare worker believes he may have been exposed to Hepatitis A. Which intervention is the highest priority to prevent him from developing the disease? a) Requesting a vaccination for Hepatitis A b) Using a needless system in daily work c) Getting the 3 part Hepatitis B vaccine d) Requesting an injection of immunoglobulin
D
The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection? a. Colonization by host bacteria b. Gastrointestinal secretions c. Inflammatory processes d. Skin and mucous membranes
D