EAQ 1: Nursing Process

The nurse is caring for a 9 month old infant with gluten-induced enteropathy. Which common term for this disorder would the nurse use when discussing the infant's diagnosis with the parents? - megacolon - celiac's disease - cystic fibrosis - intussusception

celiac's disease

Which finding in older adult clients is associated with aging? - decrease in height - decreased neck rigidity - increased fine motor dexterity - increased range of motion

decrease in height loss of height and deformity and shortening of the trunk are common in older adults because of vertebral compression and degeneration

When evaluating fluid loss for a client with burns, which relationship between a client's burned body surface area and fluid loss would the nurse consider? - equal - unequal - inversely related - directly proportional

directly proportional

A client is having haloperidol for agitation, and the nurse is monitoring the client for side effects. which response identified by the nurse is unrelated to the extrapyramidal tract effect? - akathisia - opisthotonos - oculogyric crisis - hypertensive crisis

hypertensive crisis extrapyramidal tract effects are involuntary movements that you cannot control. a hypertensive crisis is not associated with this. akathisia is characterized by restlessness and twitching or crawling sensations in the muscles, opisthotonos is characterized by hyperextension and arching of the back, and oculogyric crisis is characterized by the uncontrolled upward movement of the eyes; these are all associated with this.

A client with a history of schizophrenia, who responds poorly to medication, is now being treated for acute depression. Which information would the nurse provide in light of the information elicited from the medication list and laboratory results? LAB RESULTS: Hemoglobin: 13.5 g/dl, Hematocrit: 45%, RBCs: 48x10^6/mL, Platelet count: 150,000 mm^3, WBCs: 3,500 mm^3, neutrophils: 100 mm^3 MEDICATIONS: clozapine and fluoxetine - "come in for weekly blood tests to monitor for medication induced agranulocytosis" - "report incidents of unusual bleeding or easy bruising while taking fluoxetine" - "expect to be prescribed only 1 week's supply of fluoxetine at a time" - "consume a high protein diet to offset the risk of anemia while taking clozapine"

"come in for weekly blood tests to monitor for medication induced agranulocytosis" clozapine (antipsychotic) poses a risk for the development of agranulocytosis when paired with fluoxetine (serotonin reuptake inhibitor). the neutrophil and WBC counts are borderline and therefore suggestive of the disorder and weekly monitoring via blood testing is required

Planning to provide self care health information for several clients, which client would the nurse anticipate will be the MOST motivated to learn? - a 55 y/o client who had a mastectomy and is very anxious about her body image - an 18 y/o client who smokes cigarettes and is in denial about the dangers of smoking - a 56 y/o client who had a heart attack last week and is requesting information about exercise - a 47 y/o client who has a long leg cast after sustaining a broken leg and is still experiencing severe pain

a 56 y/o client who had a heart attack last week and is requesting information about exercise a client who is requesting information is indicating a readiness to learn

Which disorder would the nurse classify as neurodevelopmental? - anxiety - bipolar disorder - schizophreniform disorder - attention deficit/hyperactivity disorder

attention deficit/hyperactivity disorder neurodevelopmental disorders are a group of conditions with onset in the developmental period

Which required noninvasive assessment and management skill certification would the nurse need to perform airway maintenance and cardiopulmonary resuscitation? - basic life support - certified emergency nurse - advanced cardiac life support - pediatric advanced life support

basic life support

Why is multiple gestation pregnancy considered a high risk? - postpartum hemorrhage is an expected complication - perinatal mortality is 2-3x more likely in multiple than single births - optimal psychological adjustment after a multiple birth requires 6 months to a year - maternal mortality is higher during the prenatal period in the setting of multiple gestation

perinatal mortality is 2-3x more likely in multiple than single births perinatal morbidity and mortality rates are higher with multiple gestation pregnancies because the greater metabolic demands and the possibility of malpositioning of one or more fetuses increases the risk for complications. postpartum hemorrhage is not an expected outcome. adjustment to multiple gestation birth is individual. maternal mortality is not increased.

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? - planning - evaluation - assessment - implementation

planning

Which area of the client's body would the nurse consider a high risk for developing a pressure injury when caring for an older adult with Alzheimer type dementia who consistently sleeps in a semi-Fowler position in bed? - sacrum - scapulae - ischial spine - greater trochanter

sacrum

Which action is accurate in explaining how neuroleptic medications act in the body to promote medical health for clients diagnosed with schizophrenia? - they inhibit enzymes at the postsynaptic receptor site - they decrease serotonin at the postsynaptic receptor site - they increase dopamine uptake at the postsynaptic receptor site - they block access to dopamine receptors at the postsynaptic receptor site

they block access to dopamine receptors at the postsynaptic receptor site neuroleptics block access to dopamine receptors rather than inhibiting enzymes, at postsynaptic sites. they increase, not decrease, serotonin at postsynaptic sites

A client who has been taking the prescribed dose of zolpidem for 5 days returns to the clinic for a follow up visit. Which statement by the client indicates the medication has been effective? - "i have less pain" - "i have been sleeping better" - "my blood glucose is under control" - "my blood pressure is coming down"

"i have been sleeping better" zolpidem is a sedative hypnotic that produces central nervous system depression in the limbic, thalamic, and hypothalamic areas of the brain

Which age related effects on the immune system occur in the older client? - increased autoantibodies - increased expression of IL-2 receptors - increased delayed hypersensitivity reaction - increased primary and secondary antibody responses

increased autoantibodies the effects of aging on the immune system include increased autoantibodies. expression of IL-2 receptors, delayed hypersensitivity reaction, and primary and secondary antibody responses decrease because of aging

Which guideline would the nurse consider when planning care for a hospitalized older client with Alzheimer disease? - physical contact will increase dependency needs - routines provide stability for clients with neurocognitive disorders - regressive behavior should be interrupted immediately - procedures do not have to be explained to clients with neurocognitive disorders

routines provide stability for clients with neurocognitive disorders routines provide stability for clients with neurocognitive disorders. routines and rituals in activities of daily living provide a framework and structure for clients with Alzheimer disease, adding to their sense of safety and security. touch is a universal message that denotes caring and will not encourage dependency. regressive behavior under stress has a calming effect and should be allowed. care should be explained to all patients

When developing a nursing diagnosis for a client after surgery, the nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to draw the conclusion? - the nurse notes nonverbal signs of discomfort - the nurse observes the client's position in bed - the nurse asks the client to explain the surgery - the nurse asks the client to rate the severity of pain

the nurse asks the client to explain the surgery the nurse must assess the client's knowledge about the surgery to determine if the client is aware of the outcome of surgery

Which characteristic would the nurse associate with collaborative problems experienced by a client? - they are the identification of a disease condition - they include problems treated primarily by nurses - they are identified by the primary health care provider - they are identified by the nurse during the nursing diagnosis stage

they are identified by the nurse during the nursing diagnosis stage the nurse assesses the client to gather information for reaching diagnostic conclusions; collaborative problems are identified by the nurse during this process