Comfort nclex questions/ oxygenation

A client does not want to develop obstructive sleep apnea like an older parent. Which should the nurse recommend to help the client prevent this health​ problem? 1) Weight reduction 2) Continuous positive airway pressure (CPAP) 3) Routine use of modafinil 4)Smoking cessation

​1) Weight redcution Rationale: Weight reduction is recommended for the client at risk for obstructive sleep apnea.

A client fell down some stairs and broke the humerus. Upon​ admission, the client is experiencing limited range of motion and severe pain. Which kind of pain should the nurse recognize this client is​ experiencing? 1) Acute pain 2) Chronic pain 3) visceral pain 4) idiopathic pain

1) Acute pain ​Rationale: This is considered acute pain due to the injury. Any pain that lasts for more than 6 months and progressively worsens is considered chronic pain. Visceral pain is pain arising from an​ organ, while idiopathic pain is a pain with no known cause.

The family of an older adult client tells the nurse that they want their mother to remain as active as possible for as long as possible. Which instruction should the nurse provide the​ family? (Select all that​ apply.) 1) Adequate calcium intake 2) Good nutritional intake 3) regular exercise 4) Adequate rest and sleep 5) daily stretching

1) Adequate calcium intake 2) Good nutritional intake 3) regular exercise

The nurse assessing a client suspects a right pneumothorax. Which finding supports the​ nurse's suspicion? 1) Asymmetry of the chest expansion 2) Right tracheal shift 3) Decreased expansion on the left side of the chest 4) O2 saturation of​ 94%

1) Asymmetry of the chest expansion ​Rationale: A right pneumothorax would cause asymmetry of the chest expansion and decreased expansion on the right side. Tracheal deviation would occur with a tension pneumothorax to the opposite side. An O2 saturation of​ 94% does not suggest a pneumothorax.

A pregnant client is prescribed iron supplements to treat​ iron-deficiency anemia. Which foods should the nurse instruct the client to ingest to help with this health​ problem? 1) Yogurt and milk 2) Apples and bananas 3) Beans and meat 4) Broccoli and potatoes

1) Broccoli and potatoes ​Rationale: The foods that are important for the pregnant client to add for​ iron-deficiency anemia include broccoli and potatoes. Broccoli and potatoes are high in vitamin​ C, which increases iron absorption. Any foods high in vitamin C should be encouraged to be added to the diet of a client taking iron supplements.​ Yogurt, milk,​ beans, meat,​ apples, and bananas are healthy foods that provide other necessary​ macro- and micronutrients necessary to maintain a healthy pregnancy.

The nurse prepares an educational program on the effect of exercise on fatigue for a group of staff nurses. Which medical diagnosis should the nurse identify as responding positively to exercise as an intervention to combat​ fatigue? (Select all that​ apply.) 1) Cancer 2) multiple sclerosis 3) Obstructive sleep apnea 4) chronic fatigue syndrome 5) Fibromyalgia

1) Cancer 2) Multiple Sclerosis 3) Obstructive sleep apnea 5) Fibromyalgia ​ Rationale: Clients with​ cancer, obstructive sleep​ apnea, multiple​ sclerosis, and fibromyalgia respond positively to exercise to combat fatigue. Clients with chronic fatigue syndrome should use caution before beginning exercise.

The nurse is planning care for a client with weight loss related to respiratory alterations. Which intervention should the nurse​ include? (Select all that​ apply.) 1) Consult with a dietitian. 2) Supply nutritional supplements during the day. 3) Choose foods the client enjoys. 4) Encourage the client to eat three full meals every day. 5) Select foods to meet caloric requirements.

1) Consult with a dietitian. 2) Supply nutritional supplements during the day. 3) Choose foods the client enjoys. 5) Select foods to meet caloric requirements. rationale: ​Rationale: Individuals with respiratory alterations often need an increased calorie intake but lack the endurance to consume adequate nutrition. Increased calories are necessary because the client is burning more calories due to the increased work of breathing. A nutritionist is able to assist the individual to select foods and supplements the client enjoys to meet daily caloric and nutritional needs. A nutritionist can guide the individual in developing menus consisting of​ frequent, small, nutritious meals.

The nurse is caring for an older adult client on a​ medical-surgical unit who had abdominal surgery for mass removal one day ago. Which clinical manifestation of pain should the nurse expect to assess in this​ client? 1) Decreased energy 2) loss of appetite 3) cries consolably 4) Changes in sleep pattern 5) Guards abdomen

1) Decreased energy 2) Loss of appetite Rationale: The older adult client will often exhibit decreased energy and a loss of appetite when experiencing pain. Changes in sleep patterns occur in the adolescent client. Guarding the area of pain is seen in the toddler and preschool client. Crying inconsolably occurs in infants experiencing pain.

The nurse teaches the parent of an adolescent client about sleep-rest disorders during puberty. Which risk factor should the nurse emphasize in this​ teaching? 1) Delayed melatonin release 2) Gastroesophageal reflux disease 3) Decreased lung capacity 4) Increased urinary frequency

1) Delayed melatonin release ​Rationale: During​ adolescence, puberty may cause changes in the​ body's internal​ clock, leading to delayed nightly release of melatonin. As a​ result, delayed sleep phase syndrome may occur. Increased urinary​ frequency, preexisting gastroesophageal reflux​ disease, and decreased lung capacity are risk factors associated with the development of sleep-rest disorders during pregnancy.

The nurse is monitoring a client who has been using NSAIDs for treatment of chronic back pain for several months. The nurse should instruct the client to take the medicine with food and a full glass of water to address which common side​ effect? 1) Gastric distress 2) Pruritus 3) Constipation 4) Sedation

1) Gastric distress ​ Rationale: Gastric distress is a common side effect of NSAIDS. It can be potentially prevented by taking the medication with food and a full glass of water.​ Pruritus, sedation, and constipation are all side effects of opioids.

A client is taking morphine for chronic pain. Which instruction should the nurse give the client to minimize adverse effects of this​ medication? 1) Increase fiber in the diet 2) Decrease the amount of fluid intake 3) Eat large frequent meals to increase food intake 4) Decrease the intake of protein

1) Increase fiber in the diet ​Rationale: Morphine can cause​ constipation; therefore, fiber should be increased in the diet to counter this. Decreasing the amount of protein is not necessary. Clients would be encouraged to increase fluid intake to assist with constipation. Large frequent meals would be avoided due to nausea.

The nurse assessing a newborn suspects respiratory distress. Which finding supports the​ suspicion? 1) Intercostal retractions 2) Abdominal breathing 3) Respiratory rate of 44 4) Acrocyanosis at birth

1) Intercostal retractions ​Rationale: Retraction of the intercostals occurs with respiratory distress. A respiratory rate of​ 44, abdominal​ breathing, and acrocyanosis are normal findings for​ neonates/newborns.

Which type of exercise should the nurse implement to maintain the strength of a limb with an immobilized​ joint? 1) Isometric exercise 2) Range-of-motion 3) passive exercise 4) Resistive exercise

1) Isometric exercise ​Rationale: Isometric exercise is used to maintain strength when a joint is immobilized. It is performed by contracting a specific muscle group against another muscle group or immovable object. Resistive exercise is active exercise where the client works against resistance to increase muscle strength.​ Range-of-motion exercises help maintain joint mobility during periods of restricted activity. Passive exercises are performed by a physical therapist or nurse for the client.

The nurse is performing a respiratory assessment on a young adult. Which finding is considered an alteration of​ oxygenation? (Select all that​ apply.) 1) Orthopnea 2) Eupnea 3) Retractions 4) Dyspnea 5) Tachypnea

1) Orthopnea ​3) Retractions 4) Dyspnea 5) Tachypnea Rationale: Alterations of oxygenation are manifested by​ dyspnea, orthopnea,​ tachypnea, and retractions.​ Eupnea, or normal​ breathing, is not a finding that indicates an alteration in oxygenation.

A client recovering from surgery is prescribed an opioid for analgesia. Which medication should the nurse prepare for this​ client? 1) Oxycodone 2) Ibuprofen 3) Gabapentin 4) Temazepam

1) Oxycodone ​Rationale: Oxycodone is an opiate. Temazepam is a​ benzodiazepine, gabapentin is an​ anticonvulsant, and ibuprofen is an NSAID.

The nurse is caring for a​ 5-year-old client experiencing difficulty with sleeping. Which should the nurse discuss with the parents before creating a plan of care for this​ client? 1) Principles of good sleep hygiene 2) The​ child's physiological delay in melatonin release 3) A plan to implement stimulus therapy 4) The plan to initiate cognitive-behavioral therapy

1) Principles of good sleep hygiene Rationale: The nurse should review sleep hygiene with the parents. Sleep hygiene is a critical component for developing healthy sleep habits. Stimulus therapy is used for adults and involves using the bed only for sleep and​ sex, and not for other activities such as watching​ TV, reading, or working. Cognitive-behavioral therapy is used for chronic insomnia. A delay in melatonin release that delays sleep is applicable for adolescent children.

The nurse prepares to assess a client for pain. Which​ structures, as per the​ nurse's recollection, receive pain impulses from the site of​ injury? 1) Spinal cord and brain 2) Muscles and spinal cord 3) brain and muscles 4) Tendons and ligaments

1) Spinal cord and brain Rationale: Nociceptors, or sensory receptors that respond to​ pain, send a signal along the sensory neurons to the spinal​ cord, where the signal is transmitted to the brain for interpretation. The brain then sends a signal back to the site of pain via motor​ neurons, causing the body to respond to the painful stimuli.

During a home​ visit, the family caregiver asks what can be done to help the older client get a good​ night's sleep. Which should the nurse​ suggest? 1) Use flannel sheets to maintain warmth. 2) Play relaxing music at bedtime. 3) Wear​ light-weight clothing. 4) Withhold fluids in the evening to decrease the need to void.

1) Use flannel sheets to maintain warmth.​ Rationale: Interventions to promote warmth and sleep for older adults include the use of flannel sheets to maintain warmth. Physiological changes that may contribute to sleep disorders in older adults are changes in​ circulation, metabolism, and body tissue density. These changes limit the older​ adult's ability to generate heat and maintain a comfortable body temperature. For this​ reason, the nurse would also suggest that the older adult client wear warmer clothing for sleep. Withholding fluids in the evening to decrease the need for the older adult to void may result in dehydration and hypotension. The physiological changes in the older adult result in nocturia.

During an assessment a client explains that discomfort only occurs when using a rowing machine at a local fitness facility. Under which area of the comfort assessment should the nurse document this​ finding? 1) lIfestyle 2) client history 3) current problem 4) Observation

1) lifestyle Rationale: During a comfort assessment questions are used to determine lifestyle behaviors that may be related to the​ discomfort, such as discomfort that occurs during exercise.​ Thus, this information would best fit within the lifestyle assessment​ area, not​ observation, client​ history, or current problem.

Which manifestation should the nurse recognize as a sign of chronic respiratory disease in a​ client? 1) Sudden shortness of breath 2) Clubbing of the nails 3) Crackles noted in bilateral lungs 4) Inspiration to expiration (I&E) ratio of 1:2

2) Clubbing of the nails ​Rationale: Clubbing of the nails can occur with chronic cardiovascular or respiratory disease. An​ I:E ratio​ (duration of inspiration to expiration​ ratio) of​ 1:2 is normal. Sudden shortness of breath and crackles can occur in acute respiratory disorders.

A female client seeks medical attention for​ fatigue, weight​ gain, muscle​ weakness, and joint stiffness. Which etiology is most likely associated with the​ client's clinical​ manifestations? 1) chronic fatigue syndrome 2) Hypothyroidism 3) Iron-deficiency anemia 4) Chronic fatigue

2) Hypothyroidism ​ Rationale: The etiology most likely associated with this​ client's symptoms is hypothyroidism. Hypothyroidism can be confirmed with a laboratory test and treated with a thyroid hormone supplement. Chronic fatigue is mental or physical exhaustion associated with a chronic condition or situation that is not resolved​ quickly, such as a chronic illness or poor lifestyle.​ Iron-deficiency anemia is not associated with weight gain or muscle weakness. Other mental health and physiological disease processes must be ruled out prior to diagnosing a client with chronic fatigue syndrome.

Which statement regarding comfort is true? 1) it can be assessed by vital signs 2) It can be associated with Sleep and rest 3) it is subjective 4) It varies from one individual to another 5) It is objective

2) It can be associated with Sleep and rest 3) it is subjective 4) It varies from one individual to another

A client is being prescribed tests for chronic fatigue syndrome. Which is a basic characteristic required in the diagnosis of this health​ problem? 1) No response to antidepressants 2) Not caused by a primary health condition 3) Lasting more than 1-year minimum 4) Response to certain sedatives

2) Not caused by a primary health condition ​ Rationale: Chronic fatigue syndrome lasts more than 6 months​ minimum, not 1 year. It is not caused by a primary health​ condition, and it is not relieved by stress reduction. Response to medications has nothing to do with the diagnosis.

Which term should the nurse know describes the primary purpose of the​ ribs? 1) deflation 2) protection 3) exhalation 4) inspiration

2) Protection rationale: ​Rationale: The main job of the ribs is protecting the more fragile lungs and heart from injury during daily activity. Each set of ribs assists with​ respiration, but the primary purpose of ribs is to protect the lungs from​ puncture, bruising, and injury.

The nurse is teaching a client about prevention methods for pain. Which item should the nurse include in the teaching​ session? (Select all that​ apply.) 1) Taking medications as prescribed 2) avoiding risky measures 3) exercise daily 4) Eating a balanced breakfast 5) ignoring symptoms

2) avoiding risky measures 3) Exercise daily 4) Eating a balanced breakfast Rationale: Pain prevention methods that the nurse will incorporate in the teaching include the importance of​ exercise, eating a balanced​ diet, and avoiding risky behaviors. Ignoring symptoms is not a prevention strategy. Taking medications as prescribed is a treatment​ method, not a prevention method.

The nurse is planning care for a client who is receiving oxygen. Which intervention should the nurse​ include? 1) Suction upper airways each shift. 2) Increase the oxygen flow if the client requests. 3) Ensure the client is comfortable with the manner of administration. 4) Assess the client for anxiety.

3) Ensure the client is comfortable with the manner of administration. ​Rationale: The nurse ensures that the client is comfortable with the manner in which the oxygen is being administered. There are several​ choices, and the client should be consulted in terms of which method is most comfortable. The nurse should not increase the flow of oxygen at the​ client's request, because the healthcare provider prescribes the flow. Clients who are prescribed oxygen are at risk for​ depression, not anxiety. Suctioning the upper airway should only be done as​ required, if at all.

The nurse completes the health history with a client who is pregnant and works as a computer mainframe programmer. For which nonmodifiable risk factor is this client prone to experiencing​ fatigue? 1) Medications 2) physical inactivity 3) Female gender 4) Stressful job

3) Female gender ​Rationale: Being a woman is a nonmodifiable risk factor for fatigue. A stressful​ job, medications, and physical inactivity are modifiable risk factors for fatigue.

The nurse reviews collected data and suspects that a client is experiencing chronic fatigue. Which finding supports this health​ problem? (Select all that​ apply.) 1) Temporary condition 2) Quick resolution 3) No response to night of sleep 4) No response to sedatives 5) Mental or physical exhaustion

3) No response to night of sleep 5) Mental or physical exhaustion ​ Rationale: Chronic fatigue produces mental or physical​ exhaustion, with no response to a night of sleep. It does not involve sedatives or other medications. It is not a temporary​ condition, nor does it resolve quickly.

The nurse caring for a child with pain understands that a normal sympathetic response to pain is not always present in children. Which clinical manifestation is the most reliable indicator of acute pain in a​ child? 1) Causes change in vital signs 2) have been occurring for 2 months 3) Says the pain varies in intensity and location 4) demonstrates depression 5) describes the pain as persistent

3) Says the pain varies in intensity and location 4) demonstrates depression 5) describes the pain as persistent

The nurse is assessing an​ 8-year-old client. Which anatomical difference should the nurse expect to find compared to an​ adult? (Select all that​ apply.) 1) Atrophy of the tonsils 2) Larynx and glottis lower in the neck 3) Smaller nasopharynx 4) Small mouth with large tongue 5) Soft tracheal cartilage

3) Smaller nasopharynx 4) Small mouth with large tongue 5) Soft tracheal cartilage​ Rationale: Normal findings for the pediatric client from infancy until the age of 12 include a smaller​ nasopharynx, a small mouth with a large​ tongue, and soft tracheal cartilage. The nurse would expect to find enlarged​ tonsils; atrophy does not occur until after 12 years of age. The nurse would expect the larynx and the glottis to be higher in the​ neck, not lower.

Which diagnostic test should the nurse review to determine if a​ client's discomfort is caused by an​ infection? 1) urinalysis 2) liver function studies 3) white blood cell count 4) Hematocrit and hemoglobin

3) White blood cell count ​Rationale: The white blood cell count would be the best study to use to determine if the cause of pain may be due to infection. A urine​ analysis, liver function​ studies, and hematocrit and hemoglobin can provide information about other potential​ issues, but are not the best to determine infection.

The nurse is determining if a client is experiencing acute pain. Which finding should the nurse identify as being consistent with this type of​ pain? 1) The client is​ calm; pupils are constricted. 2) Respiratory rate and blood pressure are normal. 3) pulse rate, respiratory rate and blood pressure are increased. 4) Pulse rate and respiratory rate are​ decreased, and blood pressure is increased.

3) pulse rate, respiratory rate and blood pressure are increased. Rationale: In acute​ pain, the sympathetic nervous system increases the​ client's pulse​ rate, respiratory​ rate, and blood pressure. The client may become​ diaphoretic, and the pupils will dilate. The client may also be restless and anxious.

The nurse taught a class about the role of the pleural membranes. Which statement by a participant indicates that learning​ occurred? 1) ​"The pleural membranes permit gas​ exchange." 2) ​"The pleural membranes contain the​ heart." 3) ​"The pleural membranes help to keep the lungs​ inflated." 4) ​"The pleural membranes warm and moisten​ air."

3) ​"The pleural membranes help to keep the lungs​ inflated." rationale: ​Rationale: The pleural membranes help keep the lungs​ inflated; this statement indicates appropriate understanding of the content. The mediastinum contains the heart. The alveoli permit gas exchange. The bronchi warm and moisten air.

Which sleep-rest disorder should the nurse identify as being the most​ common? 1) hypersomnia 2) Dyssomnia 3) parasomnia 4) Insomnia

4) Insomnia ​ Rationale: Insomnia is the most common sleepdashrest disorder. Insomnia is the inability to fall or stay asleep. Hypersomnia is extreme daytime drowsiness despite getting sufficient sleep. Parasomnias are abnormal actions during sleep. Dyssomnia is also known as restless leg syndrome.

Which method is correct for measuring a​ client's respiratory​ rate? 1) Measure the respiratory rate for 15 seconds and multiply by 4. 2) Measure the respiratory rate for 30 seconds and multiply by 2. 3) Measure the respiratory rate for 6 seconds and multiply by 10. 4) Measure the respiratory rate for 1 minute.

4) Measure the respiratory rate for 1 minute. ​Rationale: The correct method is to count the respiratory rate for one full​ minute, counting one inspiration and one expiration as one breath. While the other methods may yield a​ 1-minute answer, they do not take into account changes in the pattern over a minute.

The nurse uses​ Maslow's hierarchy of needs to help identify a​ client's care issues. What should the nurse recall as being the highest level of this​ hierarchy? 1) Self-esteem 2) Safety and security 3) Love and belonging 4) self-actualization

4) Self-actualization ​ Rationale: According to​ Maslow's hierarchy of​ needs, the highest level of basic human need is​ self-actualization. The other answer choices are levels of the​ hierarchy; however, they are incorrect choices.

A client diagnosed with bronchitis asks the nurse about the function of the bronchi. Which should the nurse include in the​ response? 1) Contain the​ heart, trachea,​ esophagus, and the great vessels 2) Help to keep the lungs inflated 3) Capture and help sweep the debris toward the mouth for removal when coughing 4) Warm and moisten air as it moves through the respiratory tract to the alveoli

4) Warm and moisten air as it moves through the respiratory tract to the alveoli rationale: ​Rationale: The function of the bronchi is to warm and moisten the air as it moves through the respiratory tract to the alveoli in the lungs. The mediastinum contains the​ heart, trachea,​ esophagus, a portion of the right and left main​ bronchi, and the great vessels. Cilia within the trachea capture debris and help to sweep the debris toward the mouth for removal when coughing. Surface​ tension, created by fluid and negative​ pressure, keeps the lungs inflated.

The nurse plans to assess a client for pain. Which​ self-reporting tool should the nurse consider using for this​ assessment? 1) Glasgow coma scale 2) Cage assessment 3) Braden Scale 4) Visual analog scale

D) Visual Analog Scale ​ Rationale: The visual analog scale is a​ self-reporting tool that is used to diagnose pain. The Braden scale is used to assess skin status. The Glasgow coma scale is used to assess level of responsiveness and measures​ verbal, motor, and​ eye-opening responses. The Cage assessment is used to evaluate the use of alcohol.

The nurse caring for a child with pain understands that a normal sympathetic response to pain is not always present in children. Which clinical manifestation is the most reliable indicator of acute pain in a​ child? 1) hypotension 2) excessive sleepiness 3) Bradycardia 4) Compensatory posturing

​ Rationale: Compared to​ adults, children normally have a higher pulse and respiratory rate and lower blood pressure. This needs to be taken into consideration when assessing the sympathetic response to pain in children. Because a normal sympathetic response to pain is not always present in​ children, changes in vital signs may not be a good indicator of pain.​ Therefore, behavioral indicators such as​ crying, grimacing, compensatory​ posturing, and shielding the affected area are important indicators of acute pain in children. In​ infants, sleeplessness, not excessive​ sleepiness, may be a response to pain. Next Question

The nurse is caring for a client who is in pain because of a back spasm. Which independent nursing intervention should the nurse use for this​ client? (Select all that​ apply.) 1) Applying heat or cold asa appropriate 2) Positioning the client to promote comfort 3)Administering analgesics as ordered 4) Ordering physical therapy for the client 5) Providing distractions

​1) Applying heat or cold asa appropriate 2) Positioning the client to promote comfort 5) Providing distractions Rationale:Independent nursing interventions for a client in discomfort include applying heat or cold as​ appropriate, providing​ distractions, and positioning the client to promote comfort. Administering analgesics and ordering physical therapy are collaborative interventions.

The nurse encourages the parents of a child with fatigue to keep a journal about the​ child's behavior. Which items should the parents include in that​ diary? (Select all that​ apply.) 1) Breakfast and other meals 2) Morning wake time 3) Evening sleep time 4) Favorite toys 5) Temper tantrums

​1) Breakfast and other meals 2) Morning wake time 3) Evening sleep time Rationale: The​ child's diary should include the time the child falls asleep and wakes​ up, as well as breakfast and other meals. Temper tantrums and favorite toys are not relevant to record.

The nurse taught a client about ways to prevent alterations in mobility. Which client behavior indicates that the teaching has been​ effective? (Select all that​ apply.) 1) Client walks every day for 30 minutes 2) Client smokes a half pack of cigarettes per day 3) Client drinks milk with every meal 4) Client applies ice to inflamed joints twice a day 5) Client consumes fresh fruits and vegetables every day

​1) Client walks every day for 30 minutes 3) Client drinks milk with every meal 5) Client consumes fresh fruits and vegetables every day Rationale: The best way to avoid an alteration in mobility is to prevent the development of musculoskeletal disorders. Prevention strategies include good​ nutrition, adequate calcium​ intake, and regular exercise. Drinking​ milk, walking, and consuming fresh produce indicate actions to prevent the development of musculoskeletal disorders. Smoking is not a healthy activity. Applying ice to inflamed joints indicates an alteration in mobility already exists.

A client having a routine physical​ states, "I​ don't understand why I am so tired--I only work​ 8-hour days sitting at my desk and rest when I get home. What can I do to increase my energy​ level?" Which intervention should the nurse select to address the​ client's feeling of​ fatigue? 1) Collaborate with the healthcare provider to implement a graded exercise program. 2) Request a referral to a neurologist 3) Refer the client to an alternative healthcare provider 4) Request a sleep study from the healthcare provider

​1) Collaborate with the healthcare provider to implement a graded exercise program. Rationale: The client with a sedentary position and lifestyle may benefit from a graded exercise program. This type of exercise program gradually builds up stamina for​ exercise, which will contribute to the feeling of increased energy. It is not necessary to request a referral to a neurologist. A sleep study is prescribed for clients to rule out a sleep disorder and is not necessary at this point in time. A nurse does not make referrals to alternative healthcare providers.

The nurse is caring for a pregnant client who appears to be experiencing discomfort related to the pregnancy. What content should the nurse include in the teaching plan to enhance comfort for this​ client? (Select all that​ apply.) 1) Eating a balanced diet 2) Getting enough rest 3) Drinking enough water 4) Taking over the counter pain medication 5) Refraining from daily exercise

​1) Eating a balanced diet 2) Getting enough rest 3) Drinking enough water Rationale: The pregnant client who is experiencing discomfort related to pregnancy should be taught the importance of adequate​ nutrition, hydration, and sleep and rest. The pregnant client should not be encouraged to take​ over-the-counter pain medication unless directed by the healthcare provider. The nurse would provide tips on daily​ activity, but the pregnant client would not need to refrain from daily exercise.

The nurse admits a client suspected of having nerve problems. Which diagnostic test should the nurse expect the​ client's healthcare provider to​ order? (Select all that​ apply.) 1) Electromyography 2) ​Dual-photon absorptiometry 3) Peripheral bone density 4) ​Dual-energy x-ray absorptiometry 5) Nerve conduction studies

​1) Electromyography 5) Nerve conduction studies Rationale: Electrical studies are used to determine electrical activity of the muscles or identify nerve compression and include electromyography and nerve conduction studies. Diagnostic tests that produce an image include peripheral bone​ density, dual-photon​ absorptiometry, and​ dual-energy x-ray absorptiometry.

The nurse reviews the universal aspects of comfort with a group of staff members. Which statement should the nurse​ include? (Select all that​ apply.) 1) Emotional needs include love and belonging from family and friends. 2) Emotional needs are higher priority than are physiological needs. 3) Physiological needs include​ oxygen, shelter,​ food, water, and sleep. 4)When physiological needs are​ met, other needs can be achieved. 5) Giving and receiving respect are aspects of​ self-esteem needs.

​1) Emotional needs include love and belonging from family and friends. 3) Physiological needs include​ oxygen, shelter,​ food, water, and sleep. 4)When physiological needs are​ met, other needs can be achieved. 5) Giving and receiving respect are aspects of​ self-esteem needs. Rationale: Physiological needs include​ oxygen, shelter,​ food, water, and sleep. When physiological needs are​ met, other needs can be achieved. Emotional needs include love and belonging from family and friends. Giving and receiving respect are aspects of​ self-esteem needs.

The nurse is teaching a group of staff members about parasomnias. Which example should the nurse use when explaining this​ disorder? (Select all that​ apply.) 1) Enuresis 2) Night terrors 3) Narcolepsy 4) Sleep talking 5) Bruxism

​1) Enuresis 2) Night terrors 4) Sleep talking 5) Bruxism Rationale: Parasomnias include bruxism​ (grinding teeth), sleep​ talking, night​ terrors, and enuresis​ (bed wetting). Narcolepsy is a form of hypersomnia.

The nurse is assessing a client with rheumatoid arthritis. Which assessment data should the nurse expect in the client with chronic​ pain? (Select all that​ apply.) 1) Heart rate of 80 beats per minute 2) Dilated pupils 3) BP 120/80 mmHg 4) Respiratory Rate of 20 5) Temperature of 97 F

​1) Heart rate of 80 beats per minute 3) BP 120/80 mmHg 4) Respiratory Rate of 20 Rationale: Clients with chronic pain often have normal heart and respiratory rates and normal blood pressure. Temperature remains normal in the presence of chronic pain. Dilated pupils often occur with acute​ pain, not chronic pain.

A client is scheduled for a polysomnography​ (PSG) test. Which data should the nurse expect to be collected during this​ test? (Select all that​ apply.) 1) Leg movement 2) eye movement 3) Heart rate 4) urinary output 5) Oxygen saturation

​1) Leg movement 2) eye movement 3) Heart rate 5) Oxygen saturation Rationale: Polysomnography​ (PSG), or a sleep​ study, is the primary diagnostic test for sleep disorders. Client data collected during a PSG includes oxygen​ saturation, heart​ rate, respirations, eye​ movements, leg​ movements, and electroencephalogram​ (EEG) monitoring. Urinary output is not monitored during a PSG.

The family of a client with mobility difficulties asks the​ nurse, "What​ age-related changes to the musculoskeletal system should we expect our father might​ experience?" Which change should the nurse include in the​ response? (Select all that​ apply.) 1) Ligament tears 2) Flexed position of hips 3) Muscle fiber atrophy 4) Decreased joint fluid 5) Increased bone density

​1) Ligament tears 2) Flexed position of hips 3) Muscle fiber atrophy 4) Decreased joint fluid Rationale: Changes in the musculoskeletal system that occur with aging include tears in​ ligaments, atrophy of muscle​ fibers, decreased joint​ fluid, and a flexed position of the hips. Bone density decreases with aging.

The nurse is conducting a health interview to determine a​ client's mobility status. Which lifestyle behavior is most appropriate for the nurse to​ assess? (Select all that​ apply.) 1) Long-distance running 2) Living alone 3) taking no medications 4) Primarily working on a computer 5) Smoking habits

​1) Long-distance running 4) Primarily working on a computer 5) Smoking habits Rationale: A​ client's lifestyle affects mobility status. Smoking is a negative behavior that adversely affects many aspects of an​ individual's health. Physical activity such as​ long-distance running can affect the​ joints, ligaments, and cartilage. Computer work is a sedentary activity that could potentiate the development of musculoskeletal disorders. Living alone and not taking any medication would not adversely affect an​ individual's musculoskeletal or mobility status.

Which factor increases an​ individual's risk for experiencing obstructive sleep​ apnea? (Select all that​ apply.) 1) Obesity 2) Female gender 3) Narrow airway 4) smoking 5) Large next circumference

​1) Obesity 3) Narrow airway 4) smoking 5) Large next circumference Rationale: Risk factors associated with the development of obstructive sleep apnea include male​ gender, large neck​ circumference, obesity,​ smoking, and a narrow airway.

A nurse is caring for a client who is hospitalized because of a fractured femur. The client tells the nurse that it is difficult to get any sleep while in the hospital. What action should the nurse take to minimize environmental stimuli in the hospital​ environment? (Select all that​ apply.) 1) Performing only essential activities in the​ client's room during sleeping hours 2) Minimizing noise from staff interactions 3) Placing the client in a​ single-bed room when possible 4) Keeping the​ client's door closed 5) Adjusting window coverings to block outside lights during the day and night

​1) Performing only essential activities in the​ client's room during sleeping hours 2) Minimizing noise from staff interactions 3) Placing the client in a​ single-bed room when possible 4) Keeping the​ client's door closed Rationale: To reduce environmental stimuli in the hospital​ environment, the nurse should do all the stated​ actions, except adjust window coverings to block outside lights during the day and night. The window coverings should be adjusted only at​ night; during the​ day, the window coverings should be left open to let in natural light.

Which assistive device should the nurse expect to be ordered for an older client who is unsteady when​ ambulating? 1) Walker 2) lofstrand crutches 3) Cane 4) axillary crutches

​1) Walker Rationale: For​ older, unsteady​ adults, the best assistive device for ambulation is a walker. A walker provides maximum stability for the client. Crutches can be unsteady for older adults to​ use, and a cane is used only when a minimum amount of support is required.

A client reports pain as being an 8 on a scale from 1 to 10. Which finding should the nurse expect when assessing this​ client? (Select all that​ apply.) 1) Posturing 2) Abnormal gait 3) Verbal complaint 4) guarding 5) facial grimaces 6) fever

​1) Posturing 2) Abnormal gait 3) Verbal complaint 4) guarding 5) facial grimaces Rationale: Observations associated with discomfort include​ guarding, posturing, abnormal​ gait, facial​ grimaces, and verbal complaints. Fever is not usually associated with discomfort​ (although it could be a source of​ discomfort).

A client with a​ life-threatening illness has been treated with repeated doses of opioids over a period of several weeks. Which symptom obtained in the assessment should indicate to the nurse that the client is experiencing side effects related to medication​ administration? (Select all that​ apply.) 1) Pruritus 2)Sedation 3) Constipation 4) Vomiting 5) Sweating

​1) Pruritus 2)Sedation 3) Constipation 4) Vomiting Rationale: Opioid side effects include​ constipation, sedation,​ pruritus, and vomiting. Sweating can occur with opioid withdrawal but is not a side effect related to opioid administration.

A pregnant client presents with back pain. Which condition is most likely the cause of this​ pain? (Select all that​ apply.) 1) Strain from the growing uterus and fetus 2) Stretched abdominal muscles 3) Instability of the pelvis 4) improper liftin 5) Bulging discs

​1) Strain from the growing uterus and fetus 2) Stretched abdominal muscles 3) Instability of the pelvis Rationale: Sixty-two percent of women report back pain during pregnancy. This pain is generally caused by strain on the back from the growing uterus and​ fetus, which causes postural​ changes; abdominal weakness from stretched abdominal​ muscles; and hormonal​ changes, which loosen the ligaments in the joints of the pelvis. Bulging discs and improper lifting do not normally cause back pain in pregnancy.

The nurse plans care for an adolescent female client experiencing fatigue caused by anemia. Which independent intervention should the nurse select for this​ client? (Select all that​ apply.) 1) Suggest the use of a pedometer. 2) Identify foods rich in​ nutrients, including iron. 3) Encourage the client to take a yoga class. 4) Point out methods of good sleep hygiene habits. 5) Administer medications for​ iron-deficiency anemia.

​1) Suggest the use of a pedometer. 2) Identify foods rich in​ nutrients, including iron. 3) Encourage the client to take a yoga class. 4) Point out methods of good sleep hygiene habits. Rationale: Independent interventions include identifying foods rich in​ nutrients, encouraging the client to take a yoga​ class, suggesting the use of a​ pedometer, and pointing out methods of good sleep hygiene habits. Administering medications for​ iron-deficiency anemia is a collaborative intervention.

The nurse is caring for a client with an alteration in oxygenation. Which independent action should the nurse​ perform? (Select all that​ apply.) 1) Teaching about smoking cessation 2) Prescribe oxygen therapy 3) Order a diet high in iron 4) Place the client in high fowler position 5) Suction the upper airway

​1) Teaching about smoking cessation 4) Place the client in high fowler position 5) Suction the upper airway Rationale: Independent interventions are those the nurse can implement without an order or prescription. Teaching about smoking​ cessation, placing a client in high Fowler​ position, and suctioning the upper airway are all interventions the nurse can perform independently. Ordering a diet high in iron and prescribing oxygen therapy are outside the scope of nursing practice.

A nurse is caring for an older adult client with cognitive impairment. Which concept should the nurse keep in mind when assessing this client for​ pain? 1) This client is less likely to express pain verbally. 2) Pain assessment is impossible in this client. 3) This client is more likely to express pain verbally. 4) Pain assessment in this client is similar to that of a client without cognitive impairment.

​1) This client is less likely to express pain verbally. Rationale: An older adult client with cognitive impairment is less likely to express pain verbally. The nurse must be aware of behavioral changes in this client to indicate pain or discomfort. The other statements are incorrect.

The client asks the nurse about biofield therapies to help with chronic pain. Which information should the nurse include about the use of biofield​ therapies? (Select all that​ apply.) 1) This complementary alternative therapy has no side effects or interaction with other treatments. 2) They balance the energy fields in the body that are disrupted by physiologic imbalances. 3) Evidence supports the use of these therapies to help people deal with painful experiences. 4) Biofield therapies have been around for quite a long​ time, but they really have no value other than people thinking that they work. 5) There is a large repository of evidence that indicates the clinical efficacy of biofield therapy in effectively reducing pain.

​1) This complementary alternative therapy has no side effects or interaction with other treatments. 2) They balance the energy fields in the body that are disrupted by physiologic imbalances. 3) Evidence supports the use of these therapies to help people deal with painful experiences. Rationale: Evidence supports the use of these therapies to help people deal with painful​ experiences; they have no side​ effects, nor do they interact with other​ treatments; and they balance the energy fields in the body that are disrupted by physiologic imbalances.​ However, evidence does not yet support clinical efficacy.The statement that they really have no value is a subjective opinion and should not be included in the information provided to the client.

The nurse is providing home care instructions to a client with chronic pain. Which item should the nurse include in the teaching​ session? (Select all that​ apply.) 1) Using assistive devices 2) Eating a balanced diet 3) Having resuscitation equipment ready for​ use, if necessary 4) Administering pain medications by the intramuscular​ (IM) route 5) Maintaining adequate hydration

​1) Using assistive devices 2) Eating a balanced diet 5) Maintaining adequate hydration Rationale: Appropriate home care instructions for the nurse to provide a client with chronic pain include maintaining adequate​ hydration, eating a balanced​ diet, and using assistive devices. The nurse would not provide instruction on administering intramuscular pain medications or having resuscitative equipment ready for use for a client being discharged home.

A client is diagnosed with several fractures of the axial skeleton. Which bone fracture should the nurse anticipate providing care for in this​ client? (Select all that​ apply.) 1) Vertebra 2) Femur 3) Ribs 4) Arm 5) Lower leg

​1) Vertebra 3) Ribs Rationale: The axial skeleton is made up of the​ ribs, sternum, vertebral​ column, and skull. The appendicular skeleton is made up of the pectoral​ girdles, upper​ limbs, pelvic​ girdle, and lower limbs.

The nurse is performing a focused health history for a client diagnosed with a herniated disc. Which information is most appropriate for the nurse to include in this​ history? 1) Work and recreational activities 2) Ethnicity 3) Diet recall 4) Drug use

​1) Work and recreational activities Rationale: Frequent twisting and lifting are significant risk factors for herniated​ disc, so work and recreational activities should be assessed. Substance​ abuse, diet and​ nutrition, and genetic risk factors common to specific ethnicities can be important components of a health history but are not particularly pertinent to herniated discs.

A client with eroding cartilage of the left knee asks the nurse why bruising is absent because bruising was present when they injured their knee a few months ago. Which response by the nurse is​ accurate? 1) ​"Cartilage does not contain blood​ vessels." 2) ​"Cartilage is eroded because blood vessels are​ harmed." 3) ​"The cartilage has eroded all blood​ vessels." 4) ​"This injury damaged the blood​ vessels."

​1) ​"Cartilage does not contain blood​ vessels." Rationale: Ligaments and tendons contain blood​ vessels, but cartilage does not. Because of​ this, bruising will be absent with cartilage erosion. The previous injury caused a bruise because either ligaments or tendons were injured. Cartilage erosion does not damage blood vessels. Cartilage does not erode blood vessels. Cartilage does not erode because blood vessels are harmed.

The parents report that their​ 6-year-old child is sleepy during the day and wakes up frequently throughout the night. Which question should the nurse ask the​ parents? 1) ​"Does your child​ sleepwalk?" 2) ​"Does your child​ snore?" 3) ​"Does your child lose control of muscle tone when​ awake?" 4) ​"Does your child complain of headaches in the​ morning?"

​1) ​"Does your child​ sleepwalk?" Rationale: Sleep disturbances in children can be manifested in many​ ways, including​ nocturesis, bruxism, and sleepwalking.​ School-age children are more likely to have sleepwalking and sleep​ terrors, which can cause anxiety for the parents. The​ questions, "Does your child​ snore?" and​ "Does your child complain of headaches in the​ morning?" are questions associated with sleep apnea disorders. Loss of muscle control when awake is cataplexy and is associated with narcolepsy.

A nurse is caring for a client with a sleep disorder. Which question should the nurse ask about the current​ problem? (Select all that​ apply.) 1) ​"How would you describe your​ discomfort?" 2) ​"Which activities make the discomfort better or​ worse?" 3) ​"How long have you had this​ discomfort?" 4) ​"Have you had past experiences that affect the way you view this​ discomfort?" 5) ​"When did your discomfort​ start?"

​1) ​"How would you describe your​ discomfort?" 2) ​"Which activities make the discomfort better or​ worse?" 3) ​"How long have you had this​ discomfort?" 5) ​"When did your discomfort​ start?" Rationale: Asking the client about past experiences related to how the client views the current problem would be a question the nurse would ask about health​ history, not the current problem. All other statements are correct.

An older client reports feeling tired most of the time. Which response indicates that the nurse understands the relationship of fatigue in an older​ client? 1) ​"I would like to review your diet and exercise​ routine." 2) ​"An infection may be the cause of your​ fatigue." 3) ​"I would like to review your TSH​ levels." 4) ​"It is normal to experience fatigue when you are​ older."

​1) ​"I would like to review your diet and exercise​ routine." Rationale: Poor nutritional intake and lack of exercise can contribute to fatigue in the older adult. There is no assessment data available that supports an abnormal TSH level or infection. While it is normal for an older adult to experience​ fatigue, it is important to assess the client for the underlying cause of fatigue before assuming it is due to age.

The nurse reviews concepts that are related to comfort with a group of nursing assistants. Which statement should the nurse include in​ teaching? (Select all that​ apply.) 1) ​"Mobility is related to comfort in that decreased mobility is often caused by​ pain, injury, or​ disease." 2) ​"Ethics is related to comfort in that healthcare providers may be reluctant to prescribe opioids based on​ race." 3) ​"Inflammation is related to comfort in that inflammation causes​ pain." 4) ​"Grief and loss is related to comfort in that loss or expected loss of a loved one creates physical​ discomfort." 5) ​"Tissue integrity is related to comfort in that decreased tissue integrity increases the risk for​ pain."

​1) ​"Mobility is related to comfort in that decreased mobility is often caused by​ pain, injury, or​ disease." 2) ​"Ethics is related to comfort in that healthcare providers may be reluctant to prescribe opioids based on​ race." 3) ​"Inflammation is related to comfort in that inflammation causes​ pain." 5) ​"Tissue integrity is related to comfort in that decreased tissue integrity increases the risk for​ pain." Rationale: Inflammation is related to comfort in that inflammation causes pain. Mobility is related to comfort in that decreased mobility is often caused by​ pain, injury, or disease. Tissue integrity is related to comfort in that decreased tissue integrity increases the risk for pain. Ethics is related to comfort in that healthcare providers may be reluctant to prescribe opioids based on race. Grief and loss is related to​ comfort; however, the loss or expected loss of a loved one creates​ emotional, not​ physical, discomfort.

Which factor influences the expression of pain regardless of​ culture, and is important for the nurse to consider for all​ clients? (Select all that​ apply.) 1) ​Client's skills at reporting pain and discomfort 2)Cues from​ client's family or significant others 3) ​Client's level of trust in the healthcare provider 4)​Client's ability to cope with pain 5)Underlying health of the client

​1) ​Client's skills at reporting pain and discomfort 3) ​Client's level of trust in the healthcare provider Rationale: The​ client's ability to cope with​ pain, skills at reporting pain and​ discomfort, and level of trust in the healthcare provider are important factors to consider for all​ clients, regardless of culture. Underlying health issues and cues from significant others are not vital to understanding how clients express pain.

The nurse completes the assessment of a client with chronic fatigue syndrome. Which nursing diagnosis should the nurse identify as being appropriate for this​ client? (Select all that​ apply.) 1) Fluid​ Volume: Excess 2) Activity Intolerance 3) Sleep Deprivation 4) ​Injury, Risk for 5) ​Coping: Readiness for Enhanced

​2) Activity Intolerance 3) Sleep Deprivation 5) ​Coping: Readiness for Enhanced Rationale: Nursing diagnoses appropriate for a client with chronic fatigue syndrome include​ Coping: Readiness for​ Enhanced; Activity​ Intolerance; and Sleep Deprivation. The other diagnoses are not associated with chronic fatigue syndrome.​ (NANDA-1 ©2014)

A client is transferred from the critical care area to a general medical unit. What action should the nurse take first to help promote​ sleep? 1) Encourage the client to take naps when​ able, to decrease the impact of the sleep disturbance. 2) Assess the​ client's individual circadian rhythm. 3) Contact the healthcare provider to obtain an order for a​ hypnotic/sedative. 4) Ask the family to decrease the number of visits since the client has improved and needs to rest.

​2) Assess the​ client's individual circadian rhythm. Rationale: It would be important at this point to assess the​ client's circadian rhythm to schedule routine​ activities, medications, and so on around the​ client's normal sleep patterns. It would not necessarily be appropriate at this point to obtain an order for a​ hypnotic/sedative or to ask the family to decrease the amount of time spent visiting. Naps should be​ avoided, not​ encouraged, because they can also disrupt sleep patterns.

The nurse is participating in a community health clinic. Which client should the nurse identify as being at risk for compromised​ oxygenation? (Select all that​ apply.) 1) A​ 70-year-old woman who eats a​ well-balanced diet and exercises daily 2) A​ 56-year-old man who has been working at a textile factory 3) A​ 46-year-old woman with a history of anxiety attacks 4) A​ 28-year-old man who smokes with a 10 pack per year history 5) A​ 64-year-old woman with osteoporosis and limited mobility

​2) A​ 56-year-old man who has been working at a textile factory 3) A​ 46-year-old woman with a history of anxiety attacks 4) A​ 28-year-old man who smokes with a 10 pack per year history 5) A​ 64-year-old woman with osteoporosis and limited mobility Rationale: Clients with occupations that cause them to inhale chemicals and dust are at increased risk for developing lung disease. Individuals who live a sedentary lifestyle have diminished alveolar​ expansion, placing them at risk for altered respiratory function.​ Additionally, musculoskeletal impairment such as kyphosis​ (which may result from​ osteoporosis) diminishes lung capacity. Clients who smoke are at risk for pulmonary and cardiac disease. High levels of anxiety can cause bronchospasms and the onset of bronchial asthma. Some clients hyperventilate in response to stress. The​ client's arterial oxygen levels​ rise, and the arterial carbon dioxide levels decline. Intake of a diet high in fat predisposes clients to cardiovascular disease.

The nurse is caring for a client who can bear weight but has a weak limb. Which assistive device is the most appropriate for this​ client? 1) Wheelchair 2) Cane 3) Crutches 4) walker

​2) Cane Rationale: Assistive devices are used to provide balance and support and increase confidence with independent ambulation. They also reduce pressure on an injured​ limb, prevent further​ injury, and promote healing. Canes are used by clients who can bear weight but are unsteady or have a weak limb. When using a​ walker, the arms support the majority of the body weight. For​ crutches, upper body and trunk strength is needed. A wheelchair will not assist with ambulation.

A client is experiencing symptoms of obstructive sleep apnea. Which treatment should the nurse anticipate being used for this​ client's health​ problem? 1) Cognitive-behavioral therapy​ (CBT) 2) Continuous positive airway pressure​ (CPAP) 3) Bright light therapy 4) Adhesive nasal strips

​2) Continuous positive airway pressure​ (CPAP) Rationale: Continuous positive airway pressure​ (CPAP) is most often used in the treatment of clients who experience obstructive sleep apnea.

The nurse is caring for a client who is experiencing discomfort from the nasogastric tube that is necessary for gastric suctioning. What relaxation technique should the nurse teach the client to aid in client​ comfort? (Select all that​ apply.) 1) Laughter 2) Guided imagery 3) Movement techniques 4) Breathing exercise 5) Muscle relaxation

​2) Guided imagery 3) Movement techniques 4) Breathing exercise 5) Muscle relaxation Rationale: Relaxation techniques used to aid in client comfort include movement​ techniques, breathing​ exercises, muscle​ relaxation, and guided imagery. Laughter is​ beneficial; however, it promotes psychosocial​ well-being, not relaxation.

The home care nurse is planning nursing interventions for a client with chronic fatigue syndrome who is unable to get out of bed most of the time. Which intervention should be delayed until the​ client's condition​ improves? 1) Teach effective coping techniques. 2) Help the client to surpass the previous​ day's exercise. 3) Encourage the client to participate in decision making. 4) Include the family in the​ decision-making process.

​2) Help the client to surpass the previous​ day's exercise. Rationale: Considering that the client is unable to get out of bed most of the​ time, helping the client to surpass the previous​ day's exercise is unrealistic. The other interventions are appropriate for this​ client's current health status.

The nurse prepares to complete a physical assessment of a client with fatigue. On which area will the nurse focus during this​ assessment? (Select all that​ apply.) 1) Body Mass Index 2) Hydration 3) Muscle strength 4) Mobility 5) Health Education

​2) Hydration 3) Muscle strength 4) Mobility Rationale: The physical assessment of a client with fatigue includes assessment of​ mobility, hydration, and muscle strength. It does not measure health education or body mass index.

An older adult client with difficulty ambulating and nocturia reports an onset of fatigue since taking a new medication for high blood pressure. Which is a likely contributor to this​ client's fatigue? 1) Lack of mobility 2) Hypertension medication 3) hypotension effect 4) Ongoing nocturia

​2) Hypotension medication Rationale: A likely contributor to the fatigue would be the new hypertension medication. The report of fatigue did not indicate hypotension. Ongoing nocturia and lack of mobility have been a stable​ situation, rather than a recent change.

The nurse reviews the problem list for a client with a sleep-rest disorder. Which problem should the nurse identify as the priority for this​ client? 1) Stress overload 2) Insomnia 3) Fatigue 4) Ineffective coping

​2) Insomnia Rationale: Insomnia is a priority for the nurse to address for the client with a sleep-rest disorder. Insomnia can be severe enough to affect the​ client's cognitive ability to function and place the client at increased risk for injury. When the insomnia is​ addressed, the fatigue may lessen and the client may be more receptive to addressing the stress overload the individual may be experiencing and learning new coping skills for stress.

The nurse is caring for a client with a chest tube. Which intervention should the nurse​ implement? (Select all that​ apply.) 1)Prescribe pain medications as needed. 2) Monitor for air leaks. 3) Assess for pain. 4) Report hyperresonance with percussion. 5) Ensure oxygen is available.

​2) Monitor for air leaks. 3) Assess for pain. 5) Ensure oxygen is available. Rationale: When caring for a client with a chest​ tube, the nurse would ensure that oxygen is​ available, monitor tubing for air​ leaks, and assess for pain. The nurse would not report hyperresonance with percussion but would report​ tympany, or a hollow sound. It is outside the scope of nursing practice to prescribe pain medications.

A client with altered mobility reports gastric upset. Which medication should the nurse suspect is causing the​ client's symptoms? 1) ​Direct-acting antispasmodic 2) Nonsteroidal​ anti-inflammatory drug​ (NSAID) 3) Bone growth stimulator 4) Skeletal muscle relaxant

​2) Nonsteroidal​ anti-inflammatory drug​ (NSAID) Rationale: Side effects of nonsteroidal​ anti-inflammatory drugs​ (NSAIDs) include gastric upset and bleeding. Central nervous system​ (CNS) effects are commonly caused by skeletal muscle relaxants. Bone growth stimulators may cause renal or liver impairment.​ Direct-acting antispasmodics may cause​ angina, difficulty​ breathing, and muscle weakness.

The nurse is providing care for a child who is experiencing discomfort due to intermittent urinary catheterizations. Which should the nurse encourage the family to do during the procedure to most appropriately enhance comfort for the​ child? 1) Offer the child a treat such as a sticker or a small toy after the procedure. 2) Offer a distraction during the procedure. 3) Hold the child while the procedure is being performed. 4) Explain the procedure each time before it is performed to ensure understanding.

​2) Offer a distraction during the procedure. Rationale: For the child experiencing discomfort during a procedure such as​ this, it would be most appropriate to encourage the parents to distract the child. Holding the child would likely complicate completion of the procedure and would not be the best option. While offering the child a treat or small toy after the procedure may help encourage them to cooperate with the​ procedure, it would not be the most appropriate option to enhance comfort. Explaining procedures can help to decrease​ anxiety, but doing so each time may not necessarily enhance comfort.

A client has crackles and reports increasing shortness of breath. Which action should the nurse take first​? 1) Assess the respiratory rate 2) Place the client in high fowler position 3) Administer a bronchodilator 4) Apply oxygen to the client

​2) Place the client in high fowler position Rationale: Positioning affects​ oxygenation, and the high Fowler position may benefit individuals experiencing alterations in oxygenation by moving fluid to the bases and allowing for increased lung expansion. A bronchodilator is used when bronchoconstriction is a concern for oxygenation. Oxygen may be​ used, but position change will have a more immediate impact. Assessment of the respiratory rate may be​ done, but after the position is changed.

The nurse is developing a plan of care for a client experiencing an alteration in mobility. Which objective is most appropriate for the nurse to​ include? (Select all that​ apply.) 1) Promote healthy relationships 2) Promote education 3) Prevent injury 4) Promote comfort 5) Recommend immunizations

​2) Promote education 3) Prevent injury 4) Promote comfort Rationale: Independent nursing interventions for the client with an alteration in mobility focus on promoting education and comfort as well as preventing injury. Although promoting healthy relationships and recommending immunizations may be important for all​ clients, these nursing interventions are not specifically important to clients with alterations in mobility.

A client is prescribed a nonsteroidal​ anti-inflammatory drug​ (NSAID) for arthritis. Which information should the nurse teach the client about this​ medication? 1) Avoid driving or using machinery while taking this medication. 2) Report any gastrointestinal distress to the healthcare provider. 3) This medication may cause confusion and hallucinations. 4) Take this medication with calcium supplements.

​2) Report any gastrointestinal distress to the healthcare provider. Rationale: NSAIDs can cause gastrointestinal​ distress, which should be reported to the healthcare provider. Calcium supplements do not need to be taken with NSAIDs. Antispasmodics can cause confusion and hallucinations. Driving and machinery use should be restricted when taking an antispasmodic.

A client reports sudden muscle and leg weakness and excessive fatigue despite sleeping 7 hours a night. Which sleep disorder should the nurse suspect this client is​ experiencing? 1) Narcolepsy 2) Restless leg syndrome 3) Sleep loss 4) Insomnia

​2) Restless leg syndrome Rationale: The client sleeping 7 hours a​ night, experiencing sudden muscle weakness is describing symptoms of narcolepsy. Narcolepsy is a condition where the client experiences excessive daytime sleepiness even with adequate nighttime​ sleep, resulting in sleep attacks and cataplexy. Insomnia is characterized by difficulty falling asleep or maintaining sleep or by a short sleep duration even with adequate time spent attempting to fall asleep. Sleep loss refers to a duration of sleep shorter than the recommended 7 to 8 hours per night for adults. Restless leg syndrome​ (RLS) is a neurologic disorder that results in an irresistible urge to move the legs or other body​ parts, often resulting in impaired sleep habits.

The healthcare provider prescribes erythropoietin for a client experiencing chronic fatigue. What should the nurse realize as the purpose for this​ medication? 1)Stimulate white blood cell production 2) Stimulate red blood cell production 3) Increase the affinity of iron to hemoglobin 4) Stimulate the release of stored ferritin

​2) Stimulate red blood cell production Rationale: For a client with chronic​ fatigue, erythropoietin is used to stimulate red blood cell production. Clients with fatigue related to​ iron-deficiency anemia will receive iron supplements​ and/or erythropoietin to stimulate the production of hemoglobin and red blood cells. Erythropoietin does not stimulate white blood cells or the release of stored​ ferritin, nor does it increase the affinity of iron to hemoglobin.

Which oxygen delivery method should the nurse know may be set to deliver an exact FiO2 of​ 45%? 1) Nasal cannula 2) Nonrebreather mask 3)Simple face mask 4) Venturi mask

​4) Venturi mask Rationale: Venturi masks are set with a specific oxygen flow rate and specific jet adapter device. Flow rates of 24-​50% may be set with the Venturi mask. The other oxygen delivery methods cannot deliver a specific flow rate.

The nurse begins an early ambulation routine with a client diagnosed with altered mobility. Which benefit of early ambulation should the nurse explain to the​ client? (Select all that​ apply.) 1) Promote diarrhea 2) Strengthens muscles 3) improve skin turgor 4) Improves self-esteem 5) Reduces risk of thrombophlebitis

​2) Strengthens muscles 4) Improves self-esteem 5) Reduces risk of thrombophlebitis Rationale: Early ambulation decreases the risk of complications of​ inactivity, including​ thrombophlebitis, osteoporosis, muscle​ atrophy, constipation, and urinary incontinence. It also strengthens​ muscles, increases joint​ flexibility, stimulates​ circulation, and improves​ self-esteem. Ambulation does not promote diarrhea or improve skin turgor.

A client recovering from a tonsillectomy to treat sleep apnea is being discharged. Which should the nurse identify as the major concern for this​ client? 1) The treatment may be ineffective. 2) The client is at increased risk for adverse events. 3) The client is unable to utilize a CPAP machine. 4) The client may need further surgery if apnea continues.

​2) The client is at increased risk for adverse events. Rationale: After a​ tonsillectomy, snoring will not occur as an indication of apneic periods. The tonsillectomy may be ineffective and further treatment may be required. The client may use a CPAP machine when fully recovered from surgery.

A client returns to the clinic for​ follow-up care for fatigue related to sleep apnea obstruction. Which information indicates to the nurse that the plan of care has been​ successful? 1) The spouse reports an absence of snoring. 2) The client reports sleeping 7 hours a night. 3) The client reports a decrease in naps during the day. 4) The spouse reports a decrease in apneic episodes.

​2) The client reports sleeping 7 hours a night. Rationale: Sleeping 7 hours a night indicates the plan of care is working. The recommended hours per night of sleep for an adult is 7 to 8 hours. The client should avoid napping during the day. Naps may be an indicator the interventions did not work and they may interfere with the​ client's ability to sleep at night. The​ client's spouse may report a decrease in​ snoring, not necessarily an absence of snoring. The​ client's spouse should report no apneic episodes if the plan of care is working.

The nurse is assessing a client for pain. Which question should the nurse avoid using during this​ assessment? 1) ​"Have you been in pain​ before?" 2) ​"Are you really sure you are in​ pain?" 3) ​"Does anything make the pain​ better?" 4) ​"What is causing the​ pain?"

​2) ​"Are you really sure you are in​ pain?" Rationale: Asking the client if they are really in pain is not therapeutic. Pain is a subjective experience. Appropriate questions for the nurse to ask when assessing pain include asking what is causing the​ pain, what things make the pain​ better, and if the client has experienced this type of pain in the past.

A client having difficulty sleeping asks if there is an herbal supplement that can help. How should the nurse respond to this​ client? 1) ​"Valerian root can be taken daily and you should start sleeping better within a few​ days." 2) ​"Chamomile tea is very soothing and may help you​ sleep." 3) ​"Melatonin is a very useful sleep​ aid." 4) ​"Melatonin is a very useful sleep​ aid."

​2) ​"Chamomile tea is very soothing and may help you​ sleep." Rationale: Chamomile tea has a soothing effect that may induce sleep and decrease​ restlessness, although this effect has not been proven in clinical studies. It is safe for both adults and children except individuals who are allergic to ragweed or daisies. Melatonin is a sleep hormone produced by the pineal gland. Synthetic melatonin may be helpful in regulating sleep patterns. Chloral hydrate is an anxiolytic drug used​ short-term for insomnia. Valerian root is useful as an herbal sleep aid but must be taken for 2 to 3 weeks before it is effective.

The nurse reviews the medication prescription for a client with restless leg disorder. Which category of medication should the nurse expect to be prescribed for this​ client? 1) Anxiolytics 2) ​Anti-Parkinson agents 3) Benzodiazepines 4) Anticonvulsant agents

​2) ​Anti-Parkinson agents Rationale: Anxiolytics,​ benzodiazepines, and anticonvulsant agents are sometimes prescribed for treatment of sleep-rest disorders.​ Anti-Parkinson agents may be prescribed for clients who experience restless leg disorder.

While completing an assessment after administration of morphine for acute​ pain, the nurse notes that the​ client's respiratory rate is 10 and that the client is very lethargic. Which should the nurse do first in response to these assessment​ findings? 1) Continue to monitor for any further decrease in respirations or change in level of consciousness. 2) Immediately obtain a complete set of vital signs to establish a baseline. 3) Administer naloxone as prescribed in incremental doses until symptoms of overdose are resolved. 4) Contact the healthcare provider immediately to advise of client changes.

​3) Administer naloxone as prescribed in incremental doses until symptoms of overdose are resolved. Rationale: Morphine can cause respiratory depression. If this​ occurs, naloxone should be immediately administered as prescribed in incremental doses until the overdose is resolved. A baseline set of vital signs should be obtained as soon as possible but vital signs are not the first priority. Once naloxone is​ begun, the healthcare provider should be contacted. The nurse would not just continue to monitor for further changes as this could result in death.

The nurse is caring for a​ school-age child with appendicitis. Which manifestation of pain should the nurse recognize as being consistent with a child of this​ age? (Select all that​ apply.) 1) May push away painful stimuli 2) May deny pain in front of parents 3) Attempts to be brave 4) Exhibits stalling behaviors 5) Cries Uncontrollably

​3) Attempts to be brave 4) Exhibits stalling behaviors Rationale: Stalling behaviors and attempting to be brave are consistent manifestations in​ school-age children. Crying uncontrollably is consistent with the infant. Denying pain in front of parents is consistent with an adolescent. Pushing away painful stimuli is consistent with a toddler.

A client is prescribed a CPAP machine to treat obstructive sleep apnea. Which teaching will the nurse include as a first step to help the client adjust to wearing the​ mask? 1) Wear the mask with air pressure when asleep. 2) Wear the mask with the air pressure on when awake. 3) Wear the mask without air pressure when asleep. 4) Wear the mask without the air pressure when awake.

​4) Wear the mask without the air pressure when awake. Rationale: It is important for the client to get used to wearing the CPAP mask. For the first step in getting used to wearing the​ mask, the nurse will instruct the client to wear the mask without the air pressure when awake. The second step is to instruct the client to wear the mask with the air pressure on when awake. The third step is to instruct the client to wear the mask with air pressure on when asleep.

The nurse is caring for a client experiencing chronic fatigue. The client​ states, "I​ don't know why I cannot get this under​ control, I feel​ useless." Which can the nurse implement in the plan of care to increase the​ client's self-worth? 1) Facilitate the process of setting​ long-term goals with the client. 2) Establish a rapport with the​ client's family and encourage them to participate in the plan of care. 3) Encourage the client to become involved in the decision making. 4)Assess the​ client's social support network.

​3) Encourage the client to become involved in the decision making. Rationale: For clients with chronic​ conditions, inadequate coping mechanisms may contribute to prolonged feelings of fatigue.​ Therefore, the nurse should encourage the client to be involved in the​ decision-making process to increase their feelings of​ self-worth. Assessing the​ client's social support network and establishing a rapport with the​ client's family and encouraging them to participate in the plan of care are important to address ineffective coping.​ Short- and​ long-term goals are important to establish. The​ short-term goals will provide the client a sense of accomplishment.

The nurse is caring for a client who reports chronic fatigue. Which test aids in determining whether the​ client's fatigue is caused by an underlying biological​ factor? 1) Chemistry panel 2) White blood cell (WBC) count 3) Hematocrit and hemoglobin tests 4) Magnetic resonance imaging (MRI)

​3) Hematocrit and hemoglobin tests Rationale: Hematocrit and hemoglobin lab tests will determine whether the client has​ iron-deficiency anemia, leading to fatigue. While the client may have the additional tests​ performed, the other tests do not help to determine the cause of the​ client's fatigue.

The nurse assesses a client for manifestations associated with a sleep-rest disorder. Which should the nurse include when completing the psychosocial​ assessment? 1) Appearance 2) Muscle Tone 3) Life stressors 4) Reflexes

​3) Life stressors Rationale: Life stressors are included as part of the psychosocial assessment for sleep-rest disorders.​ Reflexes, muscle​ tone, and appearance are components of a physical assessment.

A client​ states, "My healthcare provider says my problem with mobility is with my connective tissues. What are connective​ tissues?" Which structure should the nurse include in the​ response? (Select all that​ apply.) 1) muscle 2) Bones 3) Ligaments 4) Tendons 5) Cartilage

​3) Ligaments 4) Tendons 5) Cartilage Rationale: Tendons,​ cartilage, and ligaments are all connective tissues. Tendons connect bone to muscle to cause movement. Cartilage is flexible connective tissue and is less flexible than muscle but not as stiff as bone. Ligaments connect bones to other bones to form a joint and serve to strengthen and stabilize the joint. Bones provide the framework for the skeletal structure. Muscles contain fibers that move the bones.

The nurse preceptor is monitoring the actions of a new graduate nurse caring for a client with a tracheostomy. Which action by the new graduate requires ​follow-up from the​ preceptor? 1) Assessing for irritation around the stoma 2) Suctioning the​ tracheostomy, then the mouth 3) Suctioning secretions with a clean technique 4) Assessing oxygen saturation

​3) Suctioning secretions with a clean technique Rationale: Sterile​ suctioning, not​ clean, is necessary to remove these secretions from the trachea and bronchi to maintain a patent airway. It is correct to assess oxygen​ saturation, irritation, and suction the tracheostomy first.

The nurse plans care for a client with a sleep disturbance. Which should the nurse identify as an appropriate goal for this​ client? 1) The client will initiate an earlier bedtime. 2) The client will implement relaxing music to induce sleep. 3) The client will initiate relaxation techniques 45 minutes prior to bedtime. 4) The client will wake no more than once during the night.

​3) The client will initiate relaxation techniques 45 minutes prior to bedtime. Rationale: An appropriate goal for the nurse to include in the plan of care for the client with a sleep disturbance is the client initiating relaxation techniques 45 minutes prior to bedtime. This promotes relaxation prior to attempting to sleep. It is not necessary to initiate an earlier​ bedtime; changing a routine may result in worsening the issues associated with the sleep disturbance. The client should be instructed to reduce or remove environmental distractions from the bedroom. The goal for the plan of care is to have the client sleep through the night. Waking in the night may result in inadequate sleep.

The nurse plans outcomes with a client recovering from knee replacement surgery. Which outcome should the nurse identify as appropriate for this​ client? 1) The nurse will administer analgesia when requested. 2) The nurse will utilize a pain scale assessment. 3) The client will report pain of 1 on a scale of 0 4) The client will have impaired physical mobility.

​3) The client will report pain of 1 on a scale of 0 Rationale: The​ client's report of pain is a measurable outcome. The nurse utilizing a pain scale is an assessment and administering analgesia is an intervention. ​Mobility: Physical, Impaired is a nursing​ diagnosis, not an outcome.​ (NANDA-I ©​ 2014)

The nurse is planning care for a client experiencing acute pain. Which should the nurse include in the health history portion of the nursing​ assessment? 1) Monitoring vital signs 2) Assessing facial expressions 3) Using a developmentally appropriate tool 4) Inspecting injuries

​3) Using a developmentally appropriate tool Rationale: The nurse should use a developmentally appropriate pain assessment tool during the health history portion of the nursing assessment. Monitoring vital​ signs, assessing facial​ expressions, and inspecting injuries occur during the physical examination portion of the nursing assessment.

A client is prescribed an oral steroid drug to improve breathing. Which instruction should the nurse provide to the​ client? 1) ​"If you feel side​ effects, cut the dosage in​ half." 2) ​"You will probably be taking this medication​ long-term." 3) ​"Be sure to follow the​ step-wise reduction of the​ medication." 4) ​"Stop the medication when your symptoms​ subside."

​3) ​"Be sure to follow the​ step-wise reduction of the​ medication." Rationale: Exogenous steroid administration can cause suppression of natural corticosteroid production by the adrenal glands. The degree of adrenal suppression that occurs is dependent on the length of medication therapy. Because of​ this, discontinuation of corticosteroid medications requires a​ progressive, step-wise reduction​ (tapering) of the medication. Abrupt discontinuation can cause adrenal​ crisis, which is characterized by manifestations associated with insufficient glucocorticoid​ production, such as profound​ hypotension, tachycardia, and cardiovascular collapse. Because oral steroids have a number of side​ effects, they are usually administered for a short period of time. The client should not be told to decrease the​ dosage, but to call the healthcare provider if side effects occur.

A client who is recovering from a spontaneous arm fracture is prescribed a calcium supplement. Which information is most appropriate for the nurse to explain about the relationship between calcium and bone​ strength? 1) ​"The thyroid gland works to make​ calcium." 2) ​"Calcium helps breakdown of bone​ tissue." 3) ​"The body will break down bone if calcium levels are​ low." 4) ​"Calcium fills in the spaces caused by the​ fracture."

​3) ​"The body will break down bone if calcium levels are​ low." Rationale: Bone resorption is the process where bone is broken down and minerals are released into the bloodstream. Resorption occurs when the minerals are needed for other body functions. When calcium levels are​ low, the parathyroid hormone is released to cause osteoclast action or activity that breaks down bone tissue. The breakdown increases blood calcium levels. If calcium levels in the blood are​ elevated, calcitonin is​ released, which stops osteoclast activity and increases mineralization of bones. Calcium does not break down bone tissue. The thyroid gland does not make calcium. Calcium does not fill in the spaces caused by the fracture.

A client at 10​ weeks' gestation is experiencing fatigue. What information should the nurse provide to this client about this health​ problem? 1) ​"You are not sleeping well during this stage of the​ pregnancy, which can contribute to the​ fatigue." 2) ​"The fatigue you are feeling will continue throughout the​ pregnancy." 3) ​"The fatigue should lesson in your second​ trimester." 4) ​"The fatigue you are experiencing is due to the rapid growth of the​ fetus."

​3) ​"The fatigue should lesson in your second​ trimester." Rationale: The fatigue in the first trimester is due to the fact that the body uses large amounts of energy to build the placenta. Hormonal changes can also contribute to fatigue. The fatigue should lesson in the second​ trimester, and if it​ persists, it may be a sign of iron deficiency anemia. The fetus experiences rapid growth in the third​ trimester, contributing to physical stress and disrupted​ sleep, which results in fatigue. Sleep disruption in the first trimester is not the primary cause of fatigue.

The nurse is completing an assessment on a client experiencing lower back pain for several weeks. Which question should the nurse ask to obtain more information about the client​ history? ​1)"Do you believe it may be related to another disease or​ condition?" 2) ​"How does the lower back pain affect your daily​ activities?" 3)​"How often does the lower back pain​ occur?" 4) ​"Do you think that your occupation may be contributing to the back​ pain?"

​3)​"How often does the lower back pain​ occur?" Rationale: Asking how often the lower back pain occurs would provide more information for the client history. Asking if it affects daily activities or if they think it is related to another disease or condition would answer questions related to the current problem. Asking if they think their occupation may be contributing to it would support lifestyle.

A client asks the nurse about the purpose of incentive spirometry. Which information should the nurse include in the​ explanation? 1) Prevents lung collapse 2) Decreases oxygen demand 3) Increases lung volume 4) Clears mucus secretions

​4) Clears mucus secretions Rationale: Incentive spirometry is a breathing exercise using an incentive spirometer that helps clients breathe deeply to expand the lungs. This process can help clients clear mucus secretions and increase the amount of oxygen delivered to the bronchi and alveoli. Incentive spirometry does not decrease oxygen demand or increase lung volume. It may prevent collapse of the​ alveoli, but not the lungs.

The nurse is providing care to a client who is approaching the end of life. Which intervention most directly helps to promote psychosocial​ comfort? 1) Removing all tubes and medical monitoring devices 2) Providing adequate pain relief with pharmacologic agents 3) Reviewing advance directives to ensure​ end-of-life care desires 4) Offering to arrange a visit from a spiritual leader or loved ones

​4) Offering to arrange a visit from a spiritual leader or loved ones Rationale: Offering to arrange a visit by a spiritual leader or loved ones can help to enhance psychosocial comfort.​ Pain-relief medications can help to enhance physical comfort. Reviewing advance directives can help to ensure that​ end-of-life decisions are honored. Removing all tubes and medical devices will not necessarily enhance psychosocial comfort.

A client with altered mobility is unable to bear weight on their wrists. Which type of assistive device should the nurse expect to be prescribed for the​ client? 1) lofstrand crutches 2) Cane 3) Axillary crutches 4) Platform crutches

​4) Platform crutches Rationale: Platform crutches are used for clients unable to bear weight on their wrists. When using axillary​ crutches, the body weight is supported by the wrists. Lofstrand crutches use a forearm piece for​ stability, but the weight is still supported by the wrists. A cane is less supportive than​ crutches, and the body weight is still supported on the wrist.

For which client should the nurse consider skipping step 1​ (nonopioid ​+/-​adjuvant) and step 2​ (opiate for mild to moderate​ pain, ​+/dash ​nonopioid, ​+/- ​adjuvant) of the World Health​ Organization's (WHO)​ three-step approach to administering pain​ relief? 1) The​ 45-year-old female client with chronic back pain 2) The​ 10-year-old male client with a sprained wrist 3) The​ 45-year-old male client with gout 4) The​ 30-year-old female client with several​ first-degree burns

​4) The​ 30-year-old female client with several​ first-degree burns Rationale: If a client is experiencing moderate to severe pain​ (pain rated 4-10 on a scale of 1-10), it may be appropriate to skip step 1 and proceed directly to step 2 or step​ 3, depending on the condition of the client. Step 3 includes opiate for moderate to severe​ pain, ​+/- ​nonopioid, ​+/- ​adjuvant). For​ example, a client with severe burns over a large portion of the body will not receive adequate pain control with​ acetaminophen; in this​ case, treatment should start at step 3. Starting a​ client's pain treatment at step 2 or step 3 depends on the​ client's pain report and the judgment of the healthcare provider.

A client asks the nurse how long the chest tube will remain in place. Which response by the nurse is best​? 1) 1 week 2) 2 days 3) 5 days 4) Until the lungs has re-expanded

​4) Until the lungs has re-expanded Rationale: A chest tube​ (also called a chest drain or thoracic​ catheter) is used to treat conditions in which air or fluid enters the pleural​ cavity, causing lung collapse. Inserted under emergency conditions and treated as a surgical​ procedure, a chest tube will typically remain in place for 2-5 days until the​ client's x-rays indicate that all fluid or air from the pleural cavity has been removed.

The nurse has recommended exercise to a client with a complaint of fatigue. The client​ states, "Exercising does not make sense when I am feeling so tired. All I want to do is just relax on the​ couch." Which response by the nurse provides the most accurate​ information? 1) ​"A high-intensity program will help combat your​ fatigue." 2) ​"Exercising will help you sleep throughout the night so you are refreshed in the​ morning." 3) ​"A moderate exercise program is a form of cognitive behavioral​ therapy." 4) ​"A mild to moderate exercise program has proven to be effective in reducing​ fatigue."

​4) ​"A mild to moderate exercise program has proven to be effective in reducing​ fatigue." Rationale: The response by the nurse that provides the most accurate information is​ "A mild to moderate exercise program has proven to be effective in reducing​ fatigue." A sedentary lifestyle can lead to fatigue and other health complications. Clients who report persistent fatigue should be encouraged to begin a healthcare​ provider-approved mild to moderate exercise regimen. Higher intensity exercise does not appear to produce a greater reduction in​ fatigue, so clients should be instructed to avoid intense workouts that may increase feelings of fatigue. An exercise program is not a form of cognitive behavioral therapy and exercise may not necessarily help the client sleep throughout the night.

When reviewing the​ client's current list of​ medications, the nurse notes the client is taking modafinil. Which question about the medication should the nurse​ ask? 1) ​"Are you being treated for muscle weakness associated with​ narcolepsy?" 2) ​"Are you currently being treated for restless leg​ syndrome?" 3) ​"Are you being treated for​ insomnia?" 4) ​"Are you currently being treated for​ narcolepsy?"

​4) ​"Are you currently being treated for​ narcolepsy?" Rationale: Modafinil is a CNS stimulant prescribed for the client experiencing narcolepsy. Insomnia is treated with different classifications of medications that are based on the type of insomnia the client is experiencing. Restless leg syndrome is treated with different classifications of medications. Muscle weakness associated with narcolepsy is treated with a CNS depressant.

During a​ well-child visit, a female high school student complains about their inability to do as much physically as their twin brother. Which response by the nurse is​ accurate? ​1) "Girls need to eat more to have more​ muscle." 2) ​"Muscle growth in girls peaks at age​ 13." 3) ​"Girls have less muscle after the age of​ 16." 4) ​"Boys have more muscle mass than​ girls."

​4) ​"Boys have more muscle mass than​ girls." Rationale: Boys have more muscle mass than girls. Muscle growth in girls peaks between the ages of 16 and 20. Eating more will not increase the amount of muscle. Boys and girls have the same amount of muscle until age 13.

The nurse is instructing a client on various medications that may be prescribed for pain. Which statement indicates that the client requires additional​ teaching? 1) ​"Nonopioids can be an effective treatment for severe​ pain." 2) ​"Over-the-counter nonopioids have serious side​ effects." 3) ​"I should not take​ over-the-counter nonopioids for a long period of​ time." 4) ​"I should not take an opioid with a​ nonopioid."

​4) ​"I should not take an opioid with a​ nonopioid." Rationale: For clients with moderate to severe​ pain, the World Health Organization​ (WHO) recommends that both opioid and nonopioid medications be given. While nonopioids are rarely effective alone for severe​ pain, they may produce a synergistic effect to relieve pain when combined with an opioid.​ Over-the-counter nonopioids are associated with severe side​ effects, especially when taken long term. Nonsteroidal​ anti-inflammatory drugs can produce gastrointestinal toxicity and prolong bleeding​ times, and acetaminophen can produce liver and kidney toxicity.

The healthcare provider is not sure about the cause of fatigue in a client whose symptoms are inconsistent and prescribes tests to narrow down possible causes. For which health problem should the nurse expect tests to be prescribed for this​ client? (Select all that​ apply.) 1) Hypertension ​Rationale: Diagnostic tests are often ordered to find the underlying cause of fatigue. Typical causes of fatigue include​ anemia; changes in​ endocrine, kidney, or liver​ function; and infection. There is no test for hypertension.

​​Rationale: Diagnostic tests are often ordered to find the underlying cause of fatigue. Typical causes of fatigue include​ anemia; changes in​ endocrine, kidney, or liver​ function; and infection. There is no test for hypertension. Rationale: Diagnostic tests are often ordered to find the underlying cause of fatigue. Typical causes of fatigue include​ anemia; changes in​ endocrine, kidney, or liver​ function; and infection. There is no test for hypertension.