Adaptive quizzing Nursing process Asessment

A nurse is assessing the laboratory findings of cerebrospinal fluids of four different clients. Which finding is consistent with meningitis?

Client A

The registered nurse raises a concern about preparedness after the community healthcare provider explains the disaster plan schedule. Which statement made by the provider is the registered nurse concerned about?

"we should improvise the plan structure for handling the risks associated with the disaster

Which drugs can be used as preanesthetic agents? Select all that apply.

-barbituates -benzodiazepines

An adolescent child is in the terminal stage of cancer. The parents ask how they will know when death is imminent. The nurse discusses the physical manifestations with the parents. What are the signs and symptoms of approaching death? Select all that apply. 1

-decreased pulse -weak pulse -difficulty swallowing -loss of bladder control

When receiving hemodialysis, the client may develop hyponatremia. For which clinical findings associated with hyponatremia should the nurse assess the client? Select all that apply.

-diarrhea -seizures

A client with cancer has undergone treatment. The client's primary healthcare provider receives a record of the client's care from the oncologist. Which descriptions are given under the care summary received by the primary healthcare provider? Select all that apply.

-information about treatment institutions and key providers -identification of a key point of contact and coordinate of care

A nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestations should the nurse assess in the client? Select all that apply.

-Ascites -Pruritus -Jaundice

Which physiologic responses should a nurse expect when assessing a client with hyperthyroidism? Select all that apply.

-blurred vision -increased appetite -widened pulse pressure

What would the nurse describe as a similarity between the growth and development of preschoolers and that of toddlers?

both gain 5 to 7 pounds per year

What clinical manifestations does a nurse expect a client with systemic lupus erythematosus (SLE) most likely to exhibit? Select all that apply.

-joint pain -facial rash -percarditis

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse is assessing the vital signs recorded by the student nurse. Which vital sign assessments require reassessment based on the data given by the student nurse? Select all that apply.

-respiratory rate of 14 bpm -blood pressure of 120/80 -o2 sat 95%

A nurse is assessing a 38-year-old female client who has been admitted for a biopsy of a lump in her right breast. Which finding may indicate a malignancy?

A lesion in the upper outer quadrant that is poorly delineated and immobile

A client who works in the leather industry reports bloody discharge and persistent pain after the treatment of sinusitis. The client has a history of smoking. The nurse suspects a tumor of the nasal cavity and suggests the client consult a primary health care provider immediately. Which type of leadership does the nurse exhibit?

Adaptive leadership

A student nurse is learning about the social milestones reached by children at different stages of development. Which statement made by the student nurse demonstrates adequate knowledge on the topic?

an 8 yo child begins to get interested in boy-girl relationships

During a diabetes mellitus campaign, the community nurse is assessing different clients. Which client should be treated first?

b

Which characteristic does the nurse anticipate in an infant born at 32 weeks' gestation?

barely visible areolae and nipples

A client develops hydrocephalus two weeks after cranial surgery for a ruptured cerebral aneurysm. The nurse concludes that the hydrocephalus probably is related to which physiologic response?

blocked absorption of fluid from the arachnoid space

What does a shift to the left indicate in the white blood cell count differential?

immature neutrophils in the blood

A client comes to the clinic reporting weight loss, fatigue, and a low-grade fever. Physical examination reveals a slight enlargement of the cervical lymph nodes. Which question is most appropriate for the nurse to ask initially?

"when did it first become evident to you that you had a fever?"

A nurse is teaching a parent about promoting safety in adolescents. Which statements made by the parent indicate the need of further teaching? Select all that apply.

- "i should limit my child's interaction with adults" -"I should allow my child to play freely with peers"

According to Freud's theory, which stage should the nurse include while educating the parents about a preschooler?

phallic stage

Which nurse could be safely reassigned to assist in the operating room for emergency surgeries being performed on trauma victims?

surgical suite staff development trainer

The parents inform the nurse that their preschooler's teachers often complain about the child's bullying behavior in school. The parents are surprised, because they say the child is well behaved at home. What could be the reason for this inconsistency in the child's behavior?

the child is scared of he parents and displaces anger on others.

A nurse is collecting a health history from a client with thromboangiitis obliterans (Buerger disease). What symptoms are most likely to be associated with this disorder?

burning pain after exposure to cold

The nurse is caring for four different clients in a healthcare facility. Which client should be provided with immediate care?

Client with 85% oxygen saturation

An adolescent girl reports to her primary healthcare provider that she has missed periods. The provider insists on performing a pregnancy test. Which nursing care interventions are most appropriate if the test result is positive? Select all that apply.

-providing emotional support -assisting with parental notification

Which clients should the medical-surgical nurse identify as appropriate for transfer or discharge to make room for admission of victims of a disaster? Select all that apply.

68-year-old client third post-operative day total knee replacement

The nurse is assessing a client who reports breathlessness. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error?

Assess the clients lungs

A client at 40 weeks' gestation is admitted to the birthing unit in early active labor. During her intake assessment, she tells the nurse that her membranes ruptured 26 hours ago. Initial assessments of the fetal heart rate range between 168 and 174 beats/min. What is the priority nursing action?

Assessing maternal vital signs

An infant exhibits purulent conjunctivitis on the fourth day of life and is brought to the emergency department. What is the priority nursing action?

Assessing the infant for signs of pneumonia

Two 3-year-old clients are playing together in a hospital playroom. One is working on a puzzle, and the other is stacking blocks. Which type of play are these children participating in based on this scenario?

Associative play

Which client is at a high risk for a rise in blood pressure based on the given data?

Client C

The laboratory test reports of a client reveal the presence of human leukocyte antigen (HLA-B27). Which diagnosis will the nurse most likely observe written in the client's electronic medical record?

Reiter's syndrome

The nurse cares for a client who develops pyrexia three days after surgery. The nurse should monitor the client for which signs and symptoms commonly associated with pyrexia? (Select all that apply.)

Tachypnea Increased pulse rate

Nitrofuratoin used during the fifth week of pregnancy places the neonate at risk for which condition?

cleft lip

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this pulse can be characterized as what?

full

During an exacerbation of multiple sclerosis a client reports urinary urgency and frequency. What is the most appropriate initial nursing action?

palpate the suprapubic area of the abdomen

A nurse is caring for a client who had an open reduction internal fixation of a fractured hip. Which nursing assessment of the affected leg is most important after this surgery?

toes for mobility

Which assessment question will provide the best information regarding a client's risk for waking in the night and interrupted sleep related to lifestyle choices?

"Do you smoke cigarettes, cigars, or a pipe?"

A 10-year-old child sustains partial-thickness burns of the entire right arm and hand, upper anterior left arm, and anterior chest. The nurse calculates the percent of total body surface area (TBSA) burned with the use of the modified "rule of nines." What percentage of the child's body is burned?

24.5%

A nurse is reviewing the laboratory hormonal profile of four clients. Which client should be evaluated for ovarian cancer?

Client B

A nurse is caring for a client with the clinical manifestation of hypotension associated with a diagnosis of Addison disease. Which hormone is impaired in its production as a result of this disease?

Mineralocorticoids

Because of multiple physical injuries and emotional concerns, a hospitalized client is at high risk to develop a stress ulcer (Curling). Which of these is evidence of a stress ulcer?

Sudden massive hemorrhage

What intrauterine medication exposure may lead to the child being born with a cleft lip?

The mother was on nitrofurantoin therapy.

A nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Why is this necessary?

There is damage above the sixth thoracic vertebra

What is the similarity between evidence-based practice (EBP) and quality improvement (QI)?

both receive funding from internal sources

A nurse in the clinic is assessing a teenager with a tentative diagnosis of primary syphilis. What is an early sign of this infection?

genital lesion

Which health problem is most likely to precipitate acute hypoglycemia in a client?

liver disease

The nurse concludes that a client is experiencing hypovolemic shock. Which physical characteristic supports this conclusion?

oliguria

Lithium therapy is initiated for a client diagnosed with manic episodes. Laboratory testing shows that the client's lithium level is 1.2 mEq/L (1.2 mmol/L). Why would the healthcare provider reduce the client's lithium dosage?

to maintain serum drug level

A multigravida client has a spontaneous vaginal birth. Five minutes later the placenta is expelled. Where does a nurse expect to locate the uterine fundus at this time?

Halfway between the symphysis pubis and the umbilicus

A nurse reviews the history of a client who is hospitalized with a diagnosis of urinary calculi and identifies that which factor may have contributed to the development of the calculi?

History of hyperparathyroidism

A client is prescribed apomorphine. Which concern would be a priority while addressing patient needs?

Operating heavy machinery or driving

During a cardiovascular assessment, a nurse auscultates a client's heart and hears these sounds. How does the nurse document these sounds on the client's assessment report?

Third heart sound (S3)

A client is admitted to the emergency department with allergic rhinitis and asthma. The laboratory report shows histamines and prostaglandins. Which type of hypersensitivity reaction may have occurred?

Type I

A client is admitted to the hospital for acute pain in the hip, and a total hip replacement surgery is scheduled. The client was diagnosed recently with early dementia. The client appears oriented and alert and responds appropriately when interviewed. When the nurse is providing preoperative teaching, the client says, "I don't want to have that surgery." The client's spouse voices a desire to proceed with the surgery to provide relief for the client. How should the nurse respond?

ask the client if a power of attorney for health care has been established

The nurse is assessing the client with subdural hematoma after a fall. The client was admitted for observation with a normal neurologic assessment on admission. Upon entering the room the nurse finds the client exhibiting seizure activity. Which is the first action the nurse should take?

assess the client's airway

A nurse is caring for two clients newly diagnosed with diabetes. One client has type 1 diabetes, and the other client has type 2 diabetes. When determining the main difference between type 1 and type 2 diabetes, the nurse recognizes what clinical presentation about type 1?

complications are not present at the time of diagnosis

During the implementation of evidence-based practice, a nurse researcher using MEDLINE databases collects published scientific studies and uses PICOT questions when conducting the search for evidence. What would be the next step performed by the nurse researcher?

critically appraise the evidence

A nurse is performing an admission health history and physical assessment of a client. The client's face is pictured below. Which information is most important to obtain?

heart rate and rhythm

The nurse assesses a male client with a preliminary diagnosis of cancer of the urinary bladder. Which clinical manifestation will indicate to the nurse the cancer is in the early stage?

hematuria

After a spontaneous pneumothorax, the client becomes extremely drowsy, and the pulse and respirations increase. What do these client responses indicate to the nurse?

hypercapnia

A nurse is caring for a client admitted to the hospital with a diagnosis of Addison disease. The nurse should assess the client for what signs related to this disorder?

hypoglycemi and hypotension

How should a nurse expect a client's anxiety to be manifested physiologically?

increased blood glucose level

A child is admitted to the hospital with a tentative diagnosis of meningitis, and a lumbar puncture is performed to confirm the diagnosis. What finding from the spinal fluid report should lead the nurse to conclude that bacterial meningitis is present?

increased protein

The nurse is caring for a client diagnosed with Cushing syndrome. What symptoms does the nurse expect the client to exhibit?

lability of mood

A client is suffering from the contagious skin infection depicted in the image. Which drug does the nurse expect to be in the client's prescription?

lindane

A school-aged child scores between 55 and 68 on a standardized intelligent quotient (IQ) assessment test. What degree of intellectual impairment should the nurse consider this to represent?

mild

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears coarse rhonchi. Which type of lung sounds will the nurse hear?

moist rumbling sounds that clear after coughing

What is a nursing priority to prevent complications in clients with respiratory acidosis?

monitoring breathing status

After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation to the operative site. For which most critical reaction to the radiation should the nurse assess the client?

mucosal edema

A nurse is caring for a preschooler on the pediatric unit. What does the nurse identify as the child's greatest fear at this age?

mutilation

A newborn's Apgar score at 5 minutes is 5. Which condition correlates with this low Apgar score?

neonatla morbidity

What changes in family status are required for developmental changes in an adolescent to occur? Select all that apply.

-a refocusing on midlife material and career issues - permitting adolescents to move in and out of the family system

The registered nurse is teaching a nursing student about how to educate clients based on their developmental capacity. Which statements made by the nursing student are applicable for older adults? Select all that apply.

-i should keep the teaching sessions short -i should involve the client in any discussion or activity

A mother comes to the clinic with her 7-month-old child for a routine checkup. Which assessment findings noted by the nurse suggest that the child is exhibiting appropriate fine motor development? Select all that apply.

-the child bangs objects together -the child pulls a string to obtain an object

Which action demonstrates the "analyticity" concept of a critical thinker? Select all that apply.

- The nurse uses evidence-based knowledge for clinical decision-making - the nurse anticipates possible results or a consequence in a given situation.

A client is admitted to the hospital due to electrical burns. Which assessment findings does the nurse anticipate? Select all that apply

- burn odor - leathery skin - cardiac arrest

A nurse is collecting information about a client with type 1 diabetes who is being admitted because of diabetic ketoacidotic coma. Which factors can predispose a client to this condition? Select all that apply.

-excessive emotional stess -running a fever with the flu

A nurse who suspects that a newly admitted infant is the victim of child abuse assesses the parents' interaction with their baby. What parental behaviors might support the diagnosis of child abuse? Select all that apply.

-exhibiting difficulty in showing concern for their child -procrastinating in obtaining treatment for their child's injuries

The school nurse is working with a child with a hearing deficit. The child arrives at school today without hearing aids. When the nurse talks with the child about the reasons for not wearing the aids, the nurse will need to ensure that the child hears what is being said. What actions by the nurse will promote effective communication? Select all that apply.

-facing the child directly when talking to the child -avoiding chewing gum while communicating with the child

After assessing a client's condition, the nurse suspects that the client has diabetes mellitus. Which statement made by the client would be most appropriate in helping the nurse reach this conclusion? Select all that apply.

-i am 55 yo -i quite often feel thirsty -i eat food every 2 hours

A nurse is assessing a client with second-degree burns. The shaded areas in the illustration indicate the parts of the body where the client sustained burns. Calculate the percentage of the body that was burned using the rule of nines. Record your answer using one decimal place. _______%

13.5

During auscultation of the heart, where does the nurse expect the first heart sound (S1) to be the loudest?

Apex of the heart

A client is admitted to the psychiatric unit of the hospital with a diagnosis of conversion disorder. The client is unable to move either leg. Which finding should the nurse consider consistent with this diagnosis?

Appearing composed

The nurse is assessing four clients in the postoperative unit. Which client will be monitored for fluid volume overload as nursing safety priority?

Client A

Which medication will cause the nurse to monitor the client closely for hemolytic anemia?

Methyldopa

The nurse is evaluating the client's cardiac rhythm and measures a PR interval of 0.08 seconds (two small boxes). How should the nurse interpret this finding?

abnormally fast conduciton

A client has a tentative diagnosis of primary biliary cirrhosis. What skin change does the nurse expect to observe when performing a physical assessment?

telangiectasia

Which behavior does the delegator adopt when communicating with the delegatee if the relationship between them is new, the delegatee has limited knowledge, and the delegator does not expect the relationship to be ongoing?

telling

During the assessment, the nurse discovers the client takes megadoses of vitamin A. How should the nurse interpret this finding?

the body stores excess vitamin A, even to toxic amounts

A nursing instructor asks a student to describe the moral developmental theory. Which statement made by the student indicates a need for further teaching?

the fifth stage defines 'right' by the decision of conscience in accordance with self-chosed ethical principles

The nurse in the birthing unit is caring for several postpartum clients. Which factor will increase the risk for hypotonic uterine dystocia?

twin gestation

Which complication should the nurse assess in a client who had a bilateral herniorrhaphy?

urinary retention

A lithotripsy to break up renal calculi is unsuccessful, and a nephrolithotomy is performed. Which postoperative clinical indicator should the nurse report to the primary healthcare provider?

urine output of 20 to 30 mL/hr

The priority nursing intervention when the membranes rupture spontaneously is an assessment of what?

variable decelerations or fetal bradycardia

A nurse is caring for a client with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when abnormal, might identify a client who may benefit from neomycin enemas?

Ammonia level

The nurse is performing a physical assessment of a newly admitted client. Identify the area of the chest on the illustration that produces resonance when percussed.

B

A client reports a cold and severe cough lasting for several minutes accompanied by frequent exhaustion. The nurse observes a "whooping" sound at the end of the cough. Which organism may responsible for this condition in the client?

Bordatella pertussis

A nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. Which clinical indicator associated with unresolved severe peripheral edema should the nurse initially assess?

tissue ischemia

Which of the following signs are indications of hydration status during a sickle cell crisis? Select all that apply.

-turgor of tissue -texture of mucous membranes

The healthcare team is organizing a primary survey of a client. What are the priorities to assess during the breathing component? Select all that apply.

-observe for chest wall trauma -assess breath sounds and respiratory effort

The emergency department (ED) nurse is providing care to a burn trauma client. Which is the priority for the nurse to monitor for after removing the client's clothing?

hypothermia

What manifestations does the nurse expect to identify when taking a health history from a client with moderate dementia? Select all that apply.

-sundowning -exaggeration of premorbid traits

A nurse is assessing a 3-year-old child with a tentative diagnosis of lead poisoning. What clinical finding supports this diagnosis?

Clumsiness

The nurse is caring for a client with severe preeclampsia. The nurse compares the client's current vital signs to the vital signs obtained on admission. In addition, the nurse performs a physical assessment. What is the nurse's initial action, in light of these assessments?

Stopping the infusion and notifying the primary healthcare provider

A client is admitted with the diagnosis of borderline personality disorder and possible depression. The client has a history of abusive acting-out behavior. What is most important to assess when caring for this client?

potential for suicide

A nursing student analyzes drug information on a chart. Which statement by the nursing student indicates a need for further teaching?

the temporal relation between the onset of action and elimination half-life of uterine stimulants is proportional

A client has a diagnosis of unruptured tubal pregnancy. Which assessment findings correlate with this diagnosis? Select all that apply.

-unilateral abdominal pain -history of a sexually transmitted infection

After reviewing the urinalysis reports of a client with a renal disorder, the nurse concludes that the client may have a urinary tract infection. Which urinary laboratory findings enabled the nurse to make this conclusion? Select all that apply.

- ph 8.5 -white blood cells 6/hpf

A client reports a severe, sharp, stabbing headache and intense pain in and around the eye that lasts for up to 1 hour. History reveals that the client had similar episodes of headaches previously which lasted for ten weeks. What other symptoms may be manifested by the client? Select all that apply.

-Rhinorrhea -Lacrimation - Pupillary constriction

A client who has been immobile for a prolonged time develops hypercalcemia. Which findings are consistent with this condition? Select all that apply.

-bone pain -depressed deep tendon reflexes

The nurse is admitting a client with a history of bipolar disorder. The nurse determines that the client is in the manic phase. Which signs and symptoms contribute to the nurse's conclusion? Select all that apply.

-irritability -grandiosity -pressured speech

A nurse spends time in individual sessions helping a depressed, suicidal client verbalize feelings. For what themes should the nurse particularly listen? Select all that apply.

-isolation -hopelessness

Which gross motor skills should the nurse assess for during a health maintenance visit for a toddler-age client? Select all that apply.

-walking up and down steps -standing on one foot for several seconds

A client is transferred to the postpartum care unit 1 hour after a spontaneous vaginal delivery. On assessment the nurse finds the fundus at U-1 and firm and the pad saturated with blood. The pad is changed and reassessed 15 minutes later, and again found saturated with blood. The fundus remains at U-1, midline and firm. Place the interventions in order of priority.

1. Assessing the episiotomy 2. weighing pads to measure blood loss 3. taking vital signs 4. assessing the client for a vaginal laceration 5. calling the primary health care provider

A depressed client is admitted to the hospital after being found bleeding from a superficial self-inflicted gunshot wound. The client does not respond to any of the nurse's questions. What should the nurse do to assess the client's current potential for suicide?

Ask the family about any recent suicide attempts or threats by the client

Which nutrient-related problem is common to a newborn infant, a client after a cholecystectomy, and a client receiving warfarin therapy after a myocardial infarction?

blood clotting function of vitamin k

A nurse is caring for an adult client with acromegaly. What clinical manifestation does the nurse expect the client to exhibit?

prominent jaw

After fertilizer plant explosion, the nearest healthcare facility services were flooded with clients. The green-tagged clients who self-transported to the hospital from the site unknowingly carried toxins. Which emergency response plan devised by the emergency department (ED) does the registered nurse consider to be most suitable to reduce the risk of potentially disastrous consequences in the hospital?

providing appropriate decontamination measures at the facility

Which medications will prevent the binding of human immunodeficiency virus (HIV) to a client's cells? Select all that apply

-maraviroc -enfuvirtide

During the initial assessment of a newborn the nurse suspects a congenital heart defect. Which clinical manifestations support this suspicion? Select all that apply.

-nasal falaring -sternal retractions -grunting respirations

A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates a positive outcome? Select all that apply.

-respiratory rate 14 bp 110/70 -o2 sat 96%

A client is admitted with a diagnosis of Cushing syndrome. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply.

-weakness -hypertension -truncal obesity

A client reports fever, cough, muscle aches, night sweats, and chest pain. The laboratory reports of the client indicate the presence of Coccidioides organisms in the respiratory tract. Which drug is beneficial for the client?

Flucanazole

The nurse is assessing four clients with musculoskeletal injuries. Which client is advised to have thermotherapy?

Client C

A registered nurse teaches a nursing student about antipsychotic drugs. Which statements made by the nursing student need a correction? Select all that apply.

-"Antipsychotic drugs only benefits clients with psychotic symptoms" -"Antipsychotic drugs are always used in combination with lithium and valproate"

The nurse is comparing Meso-2,3-dimercaptosuccinic acid (DMSA) and British antilewisite (BAL) as chelating agents to be used as treatment for lead poisoning. Which statements indicate correct knowledge regarding chelating agents? Select all that apply.

-"DMSA is given orally while BAL is given intramuscualrly - "Both DMSA and BAL are given in repeated doses over several days"

After reviewing the laboratory reports of a client with a severe joint injury, the nurse suspects fat embolism syndrome (FES). Which findings support the nurse's suspicion? Select all that apply.

-Fat cells in the urine -PaO2 value of 58 mm Hg -Hematocrit value of 30%

Which drugs are used for the treatment of clients with rheumatoid arthritis that inhibit tumor necrosis factor-A? Select all that apply.

-Infliximab -etanercept - golimumab

A nurse in the child life center is evaluating a 15-month-old toddler's ability to perform physical tasks. What behavior indicates to the nurse that the child's development is age appropriate? Select all that apply.

-drinking from a cup -walking with a wide-based gait -throwing toys around the room

Which drugs may lead to a prolongation of the QT interval in a client who is on drug therapy for schizophrenia? Select all that apply.

-haloperidol -thioridazine -chlorpromazine

A client with a diagnosis of acquired immunodeficiency syndrome (AIDS) has a protozoal infection and is receiving pentamidine. The nurse should monitor the client for which common side effects? Select all that apply.

-hypoglycemia -decreased blood pressure

Which statements are related to nursing roles and function changes in the health care organization? Select all that apply.

-conflict management technique is beneficial -society needs nurses who can engage in political policy development

The laboratory reports of a client reveal selective hypopituitarism related to growth hormone (GH). What other findings does the nurse anticipate in the client? Select all that apply.

-decreased muscle strength -increased serum cholesterol

What clinical findings should lead a nurse to suspect that a toddler with a rash has rubella? Select all that apply.

-low grade fever -lymphaenopathy

Which nurses should be reassigned to assist with acute care of trauma victims coming through the emergency department? Select all that apply.

-nurse who works in ICU -Nurse who works in PACU

A nurse is obtaining a health history from the parents of a toddler who has recently been diagnosed with acute lymphocytic leukemia. Which early physiologic changes does the nurse expect the parents to report? Select all that apply.

-pale skin -eating less food -purplish spots on the skin

A nurse is assessing a client with cardiogenic shock. Which clinical findings should the nurse expect? Select all that apply.

-pallor -agitation -tachycardia -narrow pulse pressure

Which clinical manifestation is associated with the skin disorder present in the client?

nodular lesion topped with a crust or central area of ulceration

A client develops acute glomerulonephritis after a recent streptococcal infection. The nurse should expect to find which clinical manifestation during the health history and physical examination?

periorbital edema

During a status meeting for a research project, the project leader asks the team members for feedback. What leadership theory is represented by the action of the leader?

style theory

The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply.

-rapid pulse -decreased urinary output

A nurse is caring for a client with Parkinson disease. Which clinical indicators does the nurse expect to find upon assessment? Select all that apply.

-resting tremors -flattened affect -slow voluntary movements

What observation caused the nurse to provide additional teaching to a client with AIDS during a home visit? Select all that apply.

-snacked on apple slices -picked a sandwich after petting the cat -rinsed dishes with cold water before using

A client with the diagnosis of multiple sclerosis (MS) develops hand tremors. When performing a history and physical assessment, which finding should the nurse expect the client to report?

the tremors increase when I perform an activity

A nurse is assessing a wound that is healing by secondary intention. How should the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate?

yellow

A nurse caring for a pregnant client at 28 weeks' gestation and her partner suspects intimate partner violence. Which assessments support this suspicion? Select all that apply.

- the woman has injuries to the breast and abdomen -the partner answers questions that are asked of the woman -the woman has visited the clinic several times in the last month

The nurse is preparing to educate a group of clients about health promotion to prevent head and neck cancer. Which clients are of highest priority for education? Select all that apply.

-a client who chews tobacco -a client who has sex with multiple partners - a client with a history of alcohol abuse for 5 years

Which priority interventions should be followed by the nurse when caring for a client with malignant hyperthermia? Select all that apply.

-administer 100% o2 -intubate withan endotracheal tube - stop all inhilation anesthetic agents

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply.

-flaccid paralysis -lack of reflexes below the injury

A client who has hypofunction of the adrenal gland is prescribed oral hydrocortisone. Which clinical finding indicates the need for dosage adjustment in the client? Select all that apply.

-fluid retention -rapid weight gain

The primary healthcare provider prescribed zoledronic acid to a client with osteoporosis. Before administration, the nurse instructs the client to have a dental examination. What is the rationale for this nursing intervention?

to prevent maxillaty osteonecrosis

Which individual is coping with issues concerning dependence versus independence?

toddler

A nurse is admitting a client with the diagnosis of severe procidentia (prolapse of the uterus). What complication would the nurse anticipate finding during the assessment?

ulcerations

A nurse in the pediatric clinic should be most observant for signs of cerebral palsy in a 6-month-old infant in which instance?

was born during the 32nd week of gestation

An orthopedic surgeon plans to have a school-aged child with cerebral palsy walk with crutches. What should the nurse determine before preparing this child for crutch-walking?

weight bearing ability of the child's four extremities

A client with human immunodeficiency virus reports dyspnea on exertion, increased heart rate, a persistent dry cough, and a persistent low-grade fever. The nurse observes crackles during an auscultation of the breath sounds. Which organism is responsible for this condition in the client?

pneumocystis jiroveci

The nurse is assessing a newborn with exstrophy of the bladder. What other defect is often associated with exstrophy of the bladder and may be of concern to the nurse?

pubic bone malformation

A client at 28 weeks' gestation visits the clinic for a routine examination. Which finding is of greatest concern to the nurse?

puffy fingers

Which characteristic should the nurse predict will make an individual most likely to benefit from group therapy?

recognizing that she or he has a problem

The nurse is assessing a client in active labor for signs that the transition phase is beginning. What change does the nurse expect?

rectal pressure during contractions

A 1-year-old infant is brought to the pediatric clinic for the first time. During the assessment the nurse suspects a developmental delay. What developmental milestone should have been achieved by this age?

responding to peek-a-boo

Assessment of a newborn reveals congenital cataracts, microcephaly, deafness, and cardiac anomalies. Which infection does the nurse suspect that the newborn's mother contracted during her pregnancy?

rubella

A client is scheduled for a computed tomography (CT) scan of the chest with intravenous (IV) contrast. Which assessment is the priority before the test is performed?

serum creatinine levels

A nurse is caring for a client who had a skin graft applied over a full-thickness burn on the chest. Which observation of the donor site during the first 24 hours after surgery should the nurse report to the primary healthcare provider immediately?

small amount of yellowish green oozing

Which clinical indicators does the nurse expect to identify when assessing a client with tic douloureux? Select all that apply.

-excruciating facial pain -twitching of the mouth

A nurse is performing a physical assessment of a client with gout. Which parts of the client's body should the nurse assess for the presence of tophi (urate deposits)? Select all that apply.

-feet -ears

A nurse is caring for a client who had a gastroscopy. What response indicates a major complication associated with this surgery?

abdominal distention

Blackwater fever occurs in some clients with malaria. Which response should the nurse assess in this client?

dark red urine

A nurse is caring for a client with type 1 diabetes who developed ketoacidosis. Which laboratory value supports the presence of diabetic ketoacidosis?

increased serum lipids

The nurse manager is teaching the nursing team about funds allocated to health departments for personal health services by local, state, and federal governments. Which statement made by a member of the team would indicate effective learning? Select all that apply.

-the funds provide care for newbornds -the funds provide care for clients with tuberculosis -the funds provide care for children with birth defects

A nursing instructor asks a nursing student to explain the developmental changes in toddlers. Which statements made by the nurse indicate the need for further teaching? Select all that apply.

-toddlers have a concave-shaped abdomen -toddlers sleep approximately 12 hours a day

A client was treated with sex hormones during pregnancy. Which teratogenic effects may be seen in the newborn if the client gave birth to a baby girl? Select all that apply.

-vaginal carcinoma -masculinization of the female fetus -reproductive organ defecits

Arrange the order of donning personal protective equipment (PPE) while caring for a client with isolation precautions.

1. Apply the cover gown, pull the sleeves down to the wrists, and tie the gown securely at the neck and waist 2. Apply either a surgical mask or a respirator around the mouth and nose 3. Apply eyewear or goggles snugly around the face and eyes 4.Apply clean gloves within the gown 5. Bring the glove cuffs over the edge of the gown sleeves

Arrange the order of steps involved in a type one allergic reaction in its correct sequence.

1. exposure to the allergen 2. activation of b lympocytes 3. sensitization of igE antibodies 4. Attachement to mast cells 5. release of chemical mediators

In what order should the tasks be performed by the nurse leader when implementing evidence-based practice?

1. search for most relevant evidence 2. appraise the evidence 3. integrate the best evidence with one's clinical expertise 4. evaluate outcomes of the practice design 5. disseminate the outcomes of the decision

The leader nurse is calculating the average daily census (ADC) in a 40-bed medical surgical unit, which accrued 679 client days in the month of July. What is the ADC on this unit? Record your answer using a whole number. ____________

22

A 20-year-old woman is known to be heterozygous for the cystic fibrosis (CF) gene. Her husband's genotype is unknown at present, and the couple is expecting their first child. What should the nurse tell the couple about the probability of their baby having CF?

25% or less

A nursing instructor is teaching student nurses about the adaptive behaviors exhibited by children at different stages of development. Which statement made by a student nurse indicates that the student nurse needs further teaching?

a 5 year old can brush and comb his or her own hair acceptably without help

A client with end-stage renal disease is hospitalized. For which complications should the nurse monitor the client? Select all that apply.

-anemia -dyspnea

A client is admitted with a diagnosis of gastric ulcer. Which location is most commonly indicated by the client as being painful when the nurse assesses for the presence of pain?

B

The nurse is examining the nails of four different clients. Which client does the nurse anticipate having a myocardial infarction?

Client A

During a physical examination in the prenatal clinic the client's vaginal mucosa is noted to have a purplish discoloration. Which sign should the nurse document in the client's clinical record?

chadwick

A client is admitted to the birthing suite with a blood pressure of 150/90 mm Hg, 3+ proteinuria, and edema of the hands and face. A diagnosis of severe preeclampsia is made. What other clinical findings support this diagnosis? Select all that apply.

-headache -abdominal pain -visual disturbances

The nurse should refer a client to the pulmonary clinic for suspected tuberculosis based on which clinical indicators reported during the initial client interview? Select all that apply.

-hemoptysis -night sweats

A lactating woman with hypertension was diagnosed with a migraine. What would be the drug combination of choice if she wishes to continue breast-feeding?

labetalol, sumatriptan

A nurse is caring for a client after cardiac surgery. Which signs will cause the nurse to suspect cardiac tamponade? Select all that apply.

-pulsus paradoxus -mufffled heart sounds -jugular vein distention

A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client?

lethargy

A client is admitted with the diagnosis of tetanus. Which clinical indicators should the nurse assess in the client? Select all that apply.

-restlessness -muscular rigidity -respiratory tract spasms -spastic voluntary muscle contractions

A nursing student is learning about Erikson's theory of psychosocial development. Which statement made by the client indicates 'Initiative versus Guilt' stage?

my child like to fantasize and tries out new charactes every day

The student nurse is learning about proportional changes exhibited by children during infancy. Which statement made by the student nurse indicates effective learning? Select all that apply.

-breastfed infants gain less weight than bottle-fed infants -The head circumference of breastfed infants is not inadequate.

When caring for a client with a head injury that may have involved the medulla, the nurse bases assessments on the knowledge that the medulla controls a variety of functions. Which functions will the nurse assess? Select all that apply.

-breathing -pulse rate

The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply.

-capillary refill -pulse and skin temperature -movement and sensation

Upon assessment, the primary healthcare provider finds that the client is experiencing weight gain as well as elevated lipid and blood glucose levels. Which drugs in the client's prescription list are most likely to cause these metabolic side effects? Select all that apply.

-clozapine -olanzapine

A client with preeclampsia is admitted to the labor and birthing suite. Her blood pressure is 130/90 mm Hg, and she has 2+ protein in her urine along with edema of the hands and face. Which signs or symptoms would the client display if she were developing hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome)? Select all that apply.

-headache -abdominal pain - flulike symptoms

A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify? Select all that apply.

-hirsutism -buffalo hump

Which questions should the nurse ask to elicit psychosocial issues in a client with cancer? Select all that apply.

-how is your family dealing with your condition -how do you rate your distress on a scale of 0 to 10

The nurse is teaching a client about sleeping positions to follow to prevent pressure ulcers. Which statement made by the client indicates effective learning? Select all that apply.

-i should use pressure relieving pads -i should place pillows between two bony surfaces

A client has a hysterectomy, salpingo-oophorectomy, tumor removal, and multiple abdominal biopsies for ovarian cancer. For which clinical manifestations indicating that the client may be experiencing a pulmonary embolus should the nurse assess the client? Select all that apply.

-increased temperature - decreased oxygen saturation level -sudden onset of SOB

The nurse is caring for four clients who have survived burn injuries from a chemical plant explosion. Which client requires immediate surgical intervention based on priority?

Client with visible thrombosed vessels

The primary healthcare provider suspects agranulocytosis in a client with a history of bipolar disorder (BPD). Which drug used to treat BPD is responsible for this condition?

Clozapine

A nurse is providing immediate postoperative care to a client who had a lung resection for a malignancy. The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse?

Constant bubbling in the water seal chamber

What change in blood pressure (BP) should the nurse anticipate after a client has an aldosteronoma surgically removed?

Gradually return to expected levels for an adult

While performing a neck assessment, the nurse finds the client has enlarged lymph nodes. The client also had a history of intravenous drug use and bisexual activity. What would be the possible diagnosis?

HIV infection

A nurse performs Leopold's maneuvers on a pregnant client and documents the following data: soft, firm mass in the fundus; several small parts on the right side; hard, round, movable object in pubic area; and cephalic prominence on right side. Applying these findings, which fetal position does the nurse identify?

Left occipitoanterior (LOA)

The leader nurse noticed that a staff nurse is unable to meet the responsibilities assigned, though the staff nurse is aware of the working requirements. What is the staff nurse experiencing?

Role conflict

Which assessment finding is characteristic of a client with hypoparathyroidism?

Serum phosphorus of 5 mg/dL (1.61 mmol/L); serum magnesium of 0.9 mEq/L (0.9 mmol/L)

A nurse is caring for a client who has been experiencing delusions. According to psychodynamic theory, what are delusions?

a defense against anxiety

Which toys should the nurse identify as most appropriate for a 3-year-old child? Select all that apply.

-pounding toy -play telephone -box filled with plastic figures

What assessment findings indicate that a client is experiencing an allergic reaction to antibiotic therapy? Select all that apply.

-pruritus -wheezing -bronchospasms

After assessing a client, a nurse concludes that the client may be experiencing hyperglycemia. Which clinical findings commonly associated with hyperglycemia support the nurse's conclusion? Select all that apply.

-polyuria -polydypsia -polyphagia

A client is diagnosed with stage 3 of Parkinson disease. Which clinical manifestations are found in the client? Select all that apply.

-postural instability -incrased gait disturbances

A client reports dry mouth, difficulty swallowing, vomiting, and blurred vision. During an assessment, the client reveals that he or she usually eats contaminated food. The nurse observes that the client has drooping eyelids. The client's laboratory reports indicate the presence of an infection. Which findings are expected in the client in the later stage of the disease indicated by these symptoms? Select all that apply.

-paralysis -bilateral cranial nerve impairment

The registered nurse is teaching the student nurse about care provided for clients according to the five level triage system of the Emergency Severity Index (ESI). Which statement made by the student nurse indicates effective learning? Select all that apply.

- clients who are in the ESI 4 category present with stable vital signs - clients with sever respiratory distress fall within the ESI 1 category

A nurse is caring for a client after a thyroidectomy. Which symptoms indicating thyroid storm should the nurse monitor the client for? Select all that apply.

- increased heart rate -increased temperature

A nurse is caring for a client admitted to the hospital for diabetic ketoacidosis. Which clinical findings related to this event should the nurse document in the client's clinical record? Select all that apply.

-acetone breath -decreased arterial carbon dioxide

After assessing a client's reports, the nurse confirms that the client has moderate hypothermia. What should be the nurse's immediate intervention? Select all that apply.

-administering heated o2 - positioning the client in supine position -applying external heat with blankets

The nurse suspects stage I seminoma in a client with Klinefelter syndrome. Which diagnostic tests would be helpful in further evaluating the mass? Select all that apply.

-alpha fetoprotein -lactase dehydrogenase -beta human chorionic gonadotrophin

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. Which data should the nurse use to determine a client's score on this scale? Select all that apply.

-anorexia -hemiplegia -history of diabetes -urinary incontinence

What are the similarities between a preschooler and a toddler? Select all that apply.

-both preschoolers and toddlers have similar dietary requirements. -both preschoolers and toddlers are unable to recall explanations about pain.

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply.

-bradycardia -hypotension -bladder dysfunction

A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply.

-dependent edema -swollen hands and fingers -right upper quadrant discomfort

A 12-year-old child with Down syndrome is admitted to the hospital for intravenous antibiotics for pneumonia. Which clinical findings associated with Down syndrome should the nurse expect when performing a physical assessment? Select all that apply.

-saddle nose -inner epicanthic folds

A client diagnosed with Paget's disease is prescribed zoledronic acid. Which assessments should be performed before initiating therapy? Select all that apply.

-serum creatinine -dental examination

A client reports sustaining an insect bite. The initial symptoms were edema and itching at the site of the bite. Which immunological reaction may have occurred?

anaphylaxis

After assessing the skin of a client, the primary healthcare provider concludes it is allergic contact dermatitis. Which clinical manifestation made by the primary healthcare provider helped reach that conclusion?

appearance of red papules and plaques

A client is scheduled for surgery to repair an irreducible (incarcerated) hernia. What nursing intervention is of primary importance?

assessing the client's bowel movement

A nurse is assessing four clients. Which client would benefit from reality orientation?

client D

The nurse is caring for four clients in an emergency department. Which client should be provided with immediate care based on priority?

client with bronchiolitis

A 20-year-old woman is admitted to the labor and delivery unit after reporting that she is experiencing severe contractions. She is 38 weeks +2 days' gestation. External fetal monitoring has been initiated. During the assessment the nurse notes that the woman is sweating profusely, has dilated pupils and irregular respirations, is hypertensive, and continues to complain of very severe pain with contractions. The external fetal monitor shows fetal tachycardia with excessive fetal activity. What should the nurse suspect?

cocaine abuse

A client is admitted to the hospital for medical treatment of bronchopneumonia. Which test result should the nurse examine to help determine the effectiveness of the client's therapy?

culture and sensitivity tests

The nurse is providing care to a preschool-age client of Chinese descent diagnosed with lead toxicity. Which question is most appropriate for the nurse to include in the assessment process to determine the source of the lead?

do yo use ba-baw-san to treat your child's colic pain

The primary healthcare provider prescribes an adrenergic agonist to a client with increased intraocular pressure. Which question is priority that the nurse should ask the client?

do you take antidepressants

A nurse is caring for a client who just had coronary artery bypass graft surgery. For which complication should the nurse monitor the client in the immediate postoperative period?

dysrhythmias, especially atrial fibrillation

Which of these features would the nurse state are exhibited by a preschooler?

eagerness for formal education

What is the application of Roger's diffusion theory?

engages key leaders in a change to infuse the energy from early adopters

Hydramnios is diagnosed in a primigravida at 35 weeks' gestation. For what condition should the nurse assess the newborn?

esophagela atresia

A woman who is infertile is diagnosed with primary ovarian failure. Which fertility drug regimen may be prescribed to treat infertility?

estrogen and progestins

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? Select all that apply.

oral temperature of 98.2 -apical pulse of 88 bmp -bp 116/78

Listening to a client's heart sounds using a stethoscope, a nurse hears these sounds. What should the nurse document on the client's report?

pericardial friction rubs

A nurse is monitoring for clinical manifestations of infection in a client with a diagnosis of Addison disease. Which body mechanism related to infectious processes does the nurse conclude is impaired as a result of this disease?

stress response

The oxygen saturation value of an African client measured through a pulse oximeter is 93%. What does the nurse infer from this reading?

the client has a normal SPo2

The nurse is assessing clients on the postpartum unit for pain. Which client will have more severe afterbirth pains?

the client who is a grand multipara

A nurse is learning about the maturation of systems in a school-age child. Which statement made by the nurse indicates effective learning?

the heart grows slower in the school-aged child than any other period of life

The nurse is assessing a newborn with exstrophy of the bladder. What other defect is often associated with exstrophy of the bladder and may be of concern to the nurse?

the nurse recommends the client's pharmacy to relabel the medication in large letters

A nurse is assessing clients with gastrointestinal problems. Which client does the nurse suspect to have shigellosis?

Client 2

The primary healthcare provider has prescribed different drugs for four clients with tuberculosis. Which client is at a risk of sunburn?

Client 4

Two siblings who live in a camp for migrant workers have contracted measles. The nurse, trying to determine which individuals had contact with the children, identifies those with immunity and assesses the probability of containing the measles to the camp. What technique has the nurse used in managing this situation?

Epidemiological process

The nurse is assessing the Apgar scores of four different newborns in a pediatric ward. Which child does the nurse anticipate is experiencing severe distress?

Newborn A

How is stage 2 of Kohlberg's theory different from stage 1?

Stage 2 is about recognizing another's point of view

Which data collected during a developmental assessment for a 5-year-old client would indicate the need for further intervention?

has a vocabulary of 1500 words

A nurse assesses that several clients have low oxygen saturation levels. Which client will benefit the most from receiving oxygen via a nasal cannula?

has many visitors while sitting in a chair

Which charge-nurse remark would be expected in a care area that is using team nursing as a care delivery method?

have you discussed this client care issue with your team leader

A nurse in the prenatal clinic is caring for a client with heart disease who is in her second trimester. Which hemodynamic change of pregnancy is likely to affect the client at this time?

heart rate acceleration in the last half of pregnancy

A client is admitted with chest pain unrelieved by nitroglycerin, an elevated temperature, decreased blood pressure, and diaphoresis. A myocardial infarction is diagnosed. Which should the nurse consider as a valid reason for one of this client's physiologic responses?

inflammation in myocardium causes a rise in the systemic body temperature

A client is undergoing treatment for schizophrenia with antipsychotic drugs. During a client assessment, the primary healthcare provider noticed an increase in body temperature and unstable blood pressure. Which adverse effect of the antipsychotic drug caused this condition in the client?

neuroleptic malignant syndrome

What will the nurse do to assess a client's response to ongoing serum albumin therapy for cirrhosis of the liver?

obtain the client's weight at least once every day

The serum lithium blood level of a client with a mood disorder, manic episode, is 2.3 mEq/L (2.3 mmol/L). What does the nurse expect when assessing this client?

vomiting, diarrhea, and decreased coordination