EAQ Quiz 2
The nurse is preparing to assess several clients at a pediatric clinic. Which client would require a developmental screening versus developmental surveillance during a scheduled health maintenance visit?
a 9 month old infant
Which result would the nurse expect to find when reviewing the serum screening tests of a client with acquired immunodeficiency syndrome (AIDS)?
a decrease in the CD4T cells - HIV infects helper T- lymphocytes, 300 or fewer CD4T cells per cubic millimeter of blood of CD4 cells accounting for less than 20% of lymphocytes is suggestive of AIDS ; T-cell growth decreased, IgE associated with allergies and parasitic infections, glucose 6 phosphate dehydrogenase is associated with drug induced hemolytic anemia and hemolytic disease of the newborn
Which sign in the newborn infant would reflect and Apgar score of 1 in the category of respiration?
a slow, weak cry - a good cry would receive a score of 2, a grimace is a sign that is evaluated in the category of reflex irritability, not respiration
The spouse of a client with pulmonary tuberculosis (TB) received a tuberculin skin test. The nurse examined the skin test and identified an area of induration greater than 10mm. Which response to this finding would the nurse implement?
additional tests are necessary to determine infection status - test does not indicate whether TB is dormant or active, need chest x-ray or sputum culture , newly infected client will receive preventative therapy with Isoniazid (INH)
Which color tag is used for a client who is expected to die after a disaster with mass casualties?
black
A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, which would the nurse expect to find?
brown or black mole with red, white, or blue areas - have irregular shape and lack uniformity in color ; petechiae are pinpoint red dots that indicate areas of bleeding under the skin ; a red birth mark is a vascular birthmark and often fades with time, a patchy loss of skin pigmentation indicated vitiligo
A client had an annual tuberculin purified protein derivative (PPD) test, and the area of induration was 10mm within 48 hours after planting. Which conclusion would the nurse make about the client's response to this diagnostic?
client has been exposed to tubercle bacillus
Which relationship between a client's burned body surface area and fluid loss would the nurse consider when evaluating fluid loss in a client with burns?
directly proportional- there is greater extravasation of fluid into the tissues as the amount of tissue involved increases. Parkland Baxter formula used to estimate fluid loss based on percentage of body surface area burned
The nurse is assessing a client's nails and finds a slight convex curve at the angle from the skin to nail base of about 160 degrees. Which condition would the nurse suspect?
normal findings
After numerous diagnostic tests, a client with jaundice receives the diagnosis of pancreatic cancer. Which rational explains the cause of the client's jaundice?
obstruction of the common bile duct by the pancreatic neoplasm - the common bile duct passes through the head of the pancreas, the neoplasm often constricts or obstructs the duct causing jaundice
Which criteria would the nurse consider when determining if an infection is a health care associated infection?
occurred in conjunction with treatment for an illness ; health care associated infections are classified as those that are contracted within a health care environment (hospital, long term care facility), or result from a treatment (surgery, medications), they may be endogenous or exogenous
A child has a fractured arm and multiple old injuries. Child maltreatment is suspected. Which parental characteristics supports this suspicion?
offering inconsistent stories about the injuries
The nurse identifies which weight category as reflective of the client's BMI of 25.5kg/m2
overweight - normal BMI 18.5-24.9, overweight 25-29.9, obese over 30
Which hormones are secreted by the posterior pituitary gland?
oxytocin and antidiuretic (vasopressin) hormone - prolactin, corticotropin, and melanocyte-stimulating hormones are secreted by the anterior pituitary gland
Which statement is true regarding antipsychotic medications?
clozapine is a second- generation antipsychotic medication that is more effective than other second- generation antipsychotics; most first and second generation antipsychotics are equally effective, second generation may cause metabolic side effects such as diabetes and dyslipidemia, first generation may cause extrapyramidal side effects
Which term describes the practice of placing clients with the same infection in a semi-private room?
cohorting
When developing the plan of care for a client with rheumatoid arthritis, which client consideration would the nurse include?
comfort - pain is an all encompassing and often demoralizing experience, the nurse would want to keep the client as pain free as possible
Which assessment finding would the nurse observe in a client with bipolar disorder, manic phase?
constant singing - ritualistic behavior is indicative of obsessive compulsive disorder, a flat affect and apathetic demeanor are more indicative of a schizophrenic or depressive disorder
A child becomes cyanotic during a generalized tonic- clonic seizure. Which is the most appropriate action by the nurse?
continuing to observe the seizure - the childs status and the progression of the seizure should be monitored, the child will not breathe until the seizure is over and cyanosis should subside at that time
When a client has a superficial tumor involving only 1 vocal cord, which surgery would the nurse anticipate?
cordectomy - surgical procedure performed in clients with laryngeal cancer; removal of a vocal cord
Which health care team member is a first responder when an emergency or mass casualty incident (MCI) occurs?
critical care nurse
The client reports difficulty in breathing. The nurse ausculates lung sounds and assess the respiratory rate. Which is the purpose of the nurse's action?
data collection- the nurse is gathering objective data to support the subjective data
A beta blocker is prescribed for the client with persistent ventricular tachycardia. Which response indicates that the beta blocker is working effectively?
decreased heart rate - beta blockers inhibit the activity of the sympathetic nervous system and of adrenergic hormones, decreasing the heart rate, conduction velocity, and workload of the heart
The nurse is evaluating the results of treatment with erythropoietin. Which assessment findings indicated an improvement in the underlying condition being treated?
decreased pallor - stimulates red blood cell production thereby decreasing the pallor that accompanies anemia
Which treatment would the nurse anticipate for an infant admitted with bronchiolitis caused by respiratory syncytial virus (RSV)
humidified cool air and adequate hydration - focus is on managing symptoms and providing supportive care, there is no effective treatment for bronchiolitis
During which stage of development would the nurse anticipate sibling relationships that fluctuate between open bickering and supportive relationships?
middle school age
Which is the middle layer of the eyeball?
uveal tract - consists of the iris, choroid, and ciliary body
For which client illness would airborne precautions be implemented?
chickenpox - influenza and pneumonia are transmitted by droplet, respiratory syncytial virus transmitted by direct contact
Which toxic effect would the nurse find in a client who has overdosed on isocarboxazid?
circulatory collapse - clinical symptoms of monoamine oxidase inhibitors (MAOIs) generally appear after 12 hours of ingestion
Which joint helps in the gliding movement of the wrist?
Biaxial - pivot joints permit rotation in the radioulnar area, hinge joints allow for flexion and extension, ball and socket joints permit movement in the shoulder and hips
Which medication would the nurse recognize as being contraindicated for use in clients with eating and seizure disorders?
Bupropion - trazadone contraindicated with known allergies, amitriptyline contraindicated with pregnancy and know allergies, lithium citrate contraindicated in clients with renal or cardiovascular disease
Atenolol 150mg by mouth is prescribed for a client with hypertension. Each tablet contains 50mg. How many tablets will the nurse administer?
3
Which ages are the most critical for speech development during the preschool years?
3 and 4 years
At which height is it no longer safe for a toddler to sleep in a crib?
36 inches
The nurse receives an order to prepare a solution for administering a cleansing enema for an adolescent client. Which is the volume of solution that would be prepared?
500-750mL ; 150-250mL of warmed solution for infants, 250-35-mL of warmed solution for toddler, in school-ages children the volume of warmed solution is 300-500mL
Phenytoin suspension 200mg is prescribed for a client with epilepsy. The suspension contains 125mg/5mL. How many mL will the nurse administer?
8mL
Which emergency severity index (ESI) level should be considered a high priority for the nurse caring for clients in the emergency department (ED)?
ESI- 1 ; 1 is client is unstable, 2 client can wait 10 mins for care, 3 can wait up to one hour because they are stable, 4 can be delayed for longer
Which assessment in a traumatized client does the nurse make with the Glasgow Coma Scale?
LOC
A client is receiving Digoxin. The client calls the clinic and complains of yellow vision. Which response would the nurse provide?
The medication may need to be discontinued. Come to the clinic this afternoon - indicates digoxin toxicity
To which part of the respiratory system would the client's radiology report refer when identifying the angle of Louis?
carina - located at the level of the manubriosternal junction
The nurse described a client's abnormal breath sounds and included crackles, rhonchi, wheezes, and pleural friction rubs. Which breath sounds did the nurse hear?
Adventitious - include all of these sounds, vesicular are relatively soft, low-pitched, gently, rustling sounds ; bronchial sounds are louder and higher pitched and resemble air blowing through a hollow pipe ; bronchovesicular sounds have a medium pitch and intensity and are heard over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae
The day after undergoing abdominal appendectomy, a school- aged child is prepared for ambulation. Which nursing action would be most effective before the start of ambulation?
administering the prescribed pain medication
Which does the A of the mnemonic ABCDE of primary nursing survey stand for?
airway - airway/cervical spine, breathing, circulation, disability, exposure
Which action would the nurse confirm before approving a client's transfer to radiology for magnetic resonance imaging (MRI)?
all metal objects, such as jewelry, hair ornaments, and clothing containing metal were removed
Which action would the nurse take for a client with an obsessive- compulsive disorder who continually walks up and down the hall, touching every other chair and becomes upset if interrupted?
allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed
Aspirin is prescribed on a regular schedule for a client with rheumatoid arthritis. The nurse understands that the medication is being used primarily for which property?
anti-inflammatory - reduces joint inflammation
Which is the most important action the nurse would take in preparation for a lumbar puncture for a child with tentative diagnosis of bacterial meningitis?
asking the parents what they were told about the test - informed consent is required, procedure should be explained by the health care practitioner and the nurse would confirm the parent's comprehension and have them sign the consent form
The nurse assesses the integumentary system of four clients. Which client has the least chance of a false- positive result while undergoing assessment of capillary refill time?
client with epilepsy - a client with epilepsy does not have any circulatory inadequacy
A client who is at 20 weeks' gestation visits the prenatal clinic for the first time. Assessment reveals temp of 98.8, pulse of 80 bpm, BP of 128/80, weight of 142 (prepregnancy weight was 132), fetal heart rate of 140 bpm, and fasting blood glucose level of 92mg/dL. Which would the nurse do after making these assessments?
document the results because they are expected at 20 weeks gestation
The nurse understands that which second generation antidepressant can worsen uncontrolled angle- closure glaucoma?
duloxetine - trazadone contraindicated with known allergy, bupropion contraindicated for seizures, mirtazapine contraindicated with known allergy and monoamine oxidase inhibitors
Which effect of povidone-iodine would the nurse consider when using it on the client's skin before obtaining a specimen for a blood culture?
eliminates surface bacteria that will contaminate culture results
Which step would the nurse take when preparing to administer Rho(D) immune globulin to a postpartum client?
ensure that the client is Rh negative and the neonate is Rh positive - given to Rh negative mothers not previously sensitized who have Rh positive neonate, it prevents Rh incompatibility in the next pregnancy , administered IM
For the client taking clopidogrel, the nurse will monitor for which adverse effect?
epistaxis - it is a platelet aggregation inhibitor therefore bleeding can occur as an adverse effect, the high vascularity of the nose, combined with its susceptibility to trauma (sneezing, now blowing) makes it a frequent site of hemorrhage
While performing a physical assessmnet, the nurse notices a minute, nonpalpable change in the skin color of a client. Which would be the type of skin lesion involved?
macule - a flat, nonpalpable change in skin color that is less than 1cm ; wheal is localized edema caused by a mosquito bite ; papuled are palpable, circumscribed solid elevations in the skin that are smaller than 1cm ; vesicles are small, circumscribed skin elevations that are filled with serous fluid
Which clinical finding would the nurse associate with hypokalemia?
muscle weakness - serum hypokalemia diminishes the magnitude of the neuronal and muscle cell resting potential, edema is associated with electrolyte imbalances, including sodium excess hypernatremia, muscle spams and twitching are often seen in the setting of hypocalcemia, Kussmaul respiration is a breathing pattern characterized by deep and labored breaths in response to metabolic acidosis especially diabetic ketoacidosis
The nurse understands which group of the pediatric population is at higher risk of developing respiratory complications upon administration of general anesthesia?
neonates - physical characteristics of the larynx and small airway diameter, the structure of the respiratory system, and the high metabolic rate of neonates place them at higher risk
Which term would the nurse use to document a 1cm elevated solid lesion noted on a client's skin?
nodule - elevated solid lesion greater than 0.5cm in diameter ; papule is an elevated lesion less than 0.5cm in diameter ; a vesicle is a circumscribed superficial collection of serous fluid ; a pustule is an elevated, superficial lesion filled with purulent fluid
Which threats included in the term "NBC" lead to implementation of improved emergency medical services (EMS) and hospital safety programs?
nuclear, biological, chemical
Which member of the interprofessional team in a palliative care setting serves as the client advocate, evaluating the physical, emotional, and spiritual needs of the client?
nurse
Which is an appropriate action for the registered nurse regarding assisted suicide?
nurses' participation in assisted suicide violates the code of ethics
After a cerebrovascular accident (CVA, also known as "brain attack"), a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. The nurse would conclude the CVA affected which lobe of the brain?
parietal - sensory impulses from temp, touch, and pain travel via the spinothalamic pathway to the thalamus and then to the postcentral gyrus of the parietal lobe, the somatosensory area, frontal area is the area of abstract thinking and muscular movements, occipital area of the brain is where nerve impulses translate into sight, the temporal area is the area where nerve impulses translate into sound
Which type of delusion would the nurse chart about a client who says "I've figured out how foreign agents have infiltrated the news media. Now they want to shut me up?"
persecution - thoughts of being pursued by powerful agents because of one's special attributes are fixed false beliefs, control- external forced controlling the client, grandeur- false beliefs of being a famous figure
A client with sickle cell anemia is experiencing a pain episode (vaso-occlusive crisis) and has a patient controlled analgesia (PCA) pump. The current pain rating is 5 on a scale of 1 to 10 at the right elbow. The nurse observes that the pump is "locked out" for another 10 mins. Which action would the nurse implement?
placing the prescribed as needed warm, wet compress on the elbow - vasodilation should help reduce pain from cellular clumping
When obtaining a healthy history from a client recently diagnosed with type 1 diabetes, the nurse expects the client to report which clinical manifestation?
polyuria; associated with excessive thirst (polydipsia), excessive hunger (polyphagia), and frequent urination (polyuria) are caused by the body's inability to metabolize glucose adequately
a client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. What are the priority nursing assessments?
quality of respirations and presence of pulses - assessing breathing and circulation are the priorities in trauma management, basic life functions must be maintained or reestablished ABCs
Which personality disorder would the nurse suspect in a client telling a rambling, lengthy, unclear, and overly detailed story about their dog, who they say is president?
schizotypal - a personality disorder that demonstrates symptoms that are strikingly strange and unusual such as magical thinking, odd beliefs, strange speech patterns, and inappropriate affect; schizoid display lack of interest in social relationships, paranoid is distrust and suspicion of others based on the belief that others want to exploit, harm, or deceive the person, histrionic are excitable and dramatic yet often high functioning, borderline is severe impairments in functioning caused by patterns of marked instability in emotional control or regulation, impulsivity, identity or self image distortions, unstable mood, and unstable interpersonal relationships ; narcissistic is feelings of entitlement, and exaggerated belief in ones own importance and a lack of empathy
Which stage of development classifies boys and girls as differing very little in terms of size?
school- age ; toddler, preschool, and adolescent stages boys are often bigger
Which Glasgow Coma Scale indicates that the client is in a coma?
score of 8 or below indicates coma - consists of three assessments; eye opening, response to auditory stimuli and motor response, rated from 3-15, the lower the score the more indicative of a coma, to achieve the rating of 9 and up the client must be exhibiting some meaningful responses
Which gross motor skill is found in children between 2 to 4 months of age?
the child can bear weight on the forearms when prone ; 8-10 can creep on hands and knees, birth and 1 month has predominant inborn reflexes, 6-8 months can sit alone without support
A client reports left- sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area. the nurse expects to identify which finding?
the left lung is collapsed; therefore there are no breath sounds- no vocal fremitus , or rales with rhonchi because there is no airflow into the left lung
While assessing a client for the dorsalis pedis pulse, the nurse documents the reading as a 1+. Which can be inferred from this finding?
the pulse strength is barely palpable
The nurse is caring for several clients with major thought disorders such as those occurring in clients with schizophrenia. They are all being treated with neuroleptic medications. How do these medications act in the body to promote mental health?
they block access to dopamine receptors at the postsynaptic receptor site - they increase serotonin at postsynaptic sites
Which procedure is shown in the picture?
thoracentesis - involves inserting a catheter into the pleural space to obtain specimens of pleural fluid or to remove a pleural effusion
Which rationale supports the nursing intervention to turn the client with paraplegia every 1 to 2 hours?
to prevent development of pressure injuries
Which action would the nurse take when a confused and anxious client voids on the floor in the sitting room of a mental health unit?
toilet the client more frequently with supervision
When checking placement of a feeding tube, the nurse is unable to hear the air injected because of noise breath sounds. Which should the nurse do?
try aspirating stomach contents - gastric returns indicate correct placement of the feeding tube
Which nursing action has the highest priority when preparing to transfer an unconscious client who sustained a head injury from the emergency department to a neurological trauma unit?
validating availability of a bag valve mask during the transfer - in case of respiratory distress, intracranial pressure compresses the brainstem, which contains the medulla, the respiratory center
Which action would the nurse take for a withdrawn client who suddenly screams, bursts into tears, and runs from the room to the far end of the hallway?
walk to the end of the hallway where the client is standing - lets client know that the nurse is available, demonstrates acceptance of the client
Which assessment finding is associated with chronic eczema?
rough, thick skin
Which would the nurse do first if an allergic reaction to a blood transfusion occurs?
shut off the infusion - stop immediately to prevent serious complications
Which action is the priority when the nurse is establishing a therapeutic environment for a client?
ensuring the client's safety
Which would the school nurse's first action be when a child reports a sore throat?
examine the throat- priority to determine the extent of the inflammation, significant swelling can create the potential for airway obstruction
When providing care for a client with quadriplegia, which nursing intervention assists in decreasing the potential occurrence of pressure ulcers?
frequently reposition the client on a scheduled basis
Which method of delivering client care works well in disaster situations?
functional method - each care provider knows the expectations of the assigned role and completes the tasks quickly and efficiently
Which color tag would the nurse use to triage a victim of a train derailment who is able to walk independently to the first aid station?
green
Which site would the nurse use to administer vitamin K to a newborn?
vastus lateralis - because it is well developed and there is little danger of nerve injury
During the administration of an antibiotic, the client becomes restless and flushed, and begins to wheeze. Which action will the nurse take after stopping the antibiotic?
assess the client's respiratory status - reaction may progress to anaphylactic shock which can lead to respiratory distress as a result of laryngeal edema or severe bronchospasm
Pulse oximetry is prescribed for an adolescent. Which would the nurse do to ensure accuracy of the pulse oximeter reading?
attach the probe to a finger or earlobe
Which complications would the nurse monitor in a client who sustained a transection of the spinal cord, but no other injuries?
autonomic hyperreflexia - uninhibited and exaggerated response of the autonomic nervous system to simulation, results in BP greater than 200 mm Hg systolic it is a medical emergency
Clients with which tag are referred to as "walking wounded" clients while managing a disaster?
green, can evacuate themselves - red given to clients who have immediate threats to their life and should be treated immediately, black tags are given to clients who are not expected to live or are dead, yellow tags are given to clients who sustained major injuries and need treatment within 30mins to 2 hours
Which action would the nurse take to help a female, bipolar client in the manic episode meet personal hygiene needs?
guide her to dress appropriately in her own clothing - wearing personal clothing helps keep them more in touch with reality
The nurse would identify which medication as the most common cause of extrapyramidal side effects (EPSs)?
haloperidol and fluphenazine
Which finding would the nurse expect when taking a health history of a 15 month old child with celiac disease?
has bulky, foul, frothy stools ; steatorrhea (fatty, foul smelling, frothy, and bulky stools) occurs with celiac disease because of an intolerance to gluten, toxic substances which can damage the intestinal mucosal cells accumulate and cause diarrhea
A client with supraventricular tachycardia (SVT) has a heart rate of 170 beats/min. After treatment with diltiazem, which assessment indicates to the nurse that the diltiazem is effective?
heart rate of 98 beats/min - purpose is to slow down the heart rate
In which settings would the nurse prepare to administer developmental assessment for pediatric clients?
home, school, hospital, and daycare center
A child is administered a rotavirus vaccine. Which adverse medication effect would the nurse monitor for?
intussusception - a life threatening form of bowel obstruction that occurs due to the bowel folding in on itself ; DTaP causes encephalopathy, MMR induce thrombocytopenia, meningococcal conjugate vaccines cause Guillain- Barre syndrome in some children
Which complication of anaphylactic shock in the adolescent client is more important for the nurse to detect early?
laryngeal edema - severe acute upper airway obstruction may be life threatening and requires rapid intervention
Which action would the nurse take for an older client with Alzheimer disease who sleeps very little and becomes more disorientated from sleep deprivation?
leave a dim light on in the client's room at night - may prevent misinterpretation of shadows, which can heighten fear and alter the client's perception of the environment
Which method of contraception may provide adolescents with the longest duration of protection?
levonorgestrel intrauterine system is a T shaped intrauterine system that releases levonorgestrel, must be plaved within 7 days of menses and provides protection up to 5 years
Which outcome would indicate a client who was hospitalized with severe anxiety is ready to be discharged?
maintains anxiety at a manageable level
Which structure is a component of the auditory ossicles?
malleus- along with the incus and stapes constitutes the auditory ossicles
Which medication is unsafe to administer as an IV bolus?
potassium chloride - this can cause cardiac arrest, must be diluted and infused slowly through and IV infusion pump
Which condition contraindicates the use of ginseng herbal therapy?
pregnancy - schizophrenia, bipolar depression, and Alzheimer disease are contraindicated for St. John's Wort
Which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain?
providing oxygen, assessing vital signs, obtaining a 12 lead EKG, drawing blood for cardiac enzymes, auscultating heart sounds, administering nitroglycerin
For which additional defect would the nurse assess an infant with exstrophy of the bladder?
pubic bone malformation - pubic bone and bladder form during the same period of embryonic development
Which colors are often included an organizational disaster plan for use during triage?
red, black, green, yellow, and blue
A client has been prescribed lithium. Which intervention must be implemented while the client is on lithium therapy?
regularly testing the serum medication level - alters sodium transport in nerve and muscle cells and causes a shift toward intraneuronal metabloism of cathecholamines, range between therapeutic and toxic levels is very slim
A client is diagnosed with Parkinson disease and receives a prescription for levodopa therapy. Which mechanism of action would the nurse identify for this medication?
restores the dopamine levels in the brain
Which advice will the nurse give the client to avoid lipodystrophy when self- administering insulin therapy?
rotate injection site ; fibrous scare tissue can result from the trauma of repeated injections at the same site
An older client with Alzheimer type dementia, consistently sleeps in a semi- Fowler position in bed. Which area of the client's body would the nurse consider a high risk for developing a pressure injury?
sacrum
Which type of relationship is most important to the school age child?
same-sex peer relationships
Which action by the nurse would be priority for a male client with a history of schizophrenia who comes to the emergency department accompanied by his spouse?
observing and evaluating his behavior - the client and his needs are the priority and assessment is the first step of the nursing process
A client hospitalized for uncontrolled hypertension and chest pain was started on a daily diuretic 2 days ago upon admission, with prescriptions for a daily basic metabolic panel. The client's potassium level this morning is 2.7. Which action will the nurse take?
Notify the health care provider that the potassium level is above normal - normal range is 3.5 to 5, diuretic can lead to hypokalemia, whereas others spare potassium which can cause hyperkalemia
A client, transferred to the postanesthesia care unit after a transurethral resection of the prostate (TURP), have an intravenous (IV) line and a urinary retention catheter. During the immediate postoperative period, for which potentially critical complication would the nurse monitor?
hemorrhage - common because of venous oozing and bleeding from many small arteries in the area
Which sexually transmitted infection causes condylomata acuminate?
human papillomavirus (HPV) = genital warts
Why is a multiple gestation pregnancy considered a high risk?
perinatal mortality is two to three times more likely in multiple than in single births - due to the greater metabolic demands and the possibility of malpositioning of one of more fetuses increase the risk for complications
Which action would the nurse take for an adolescent with a long history of drug abuse, stealing, and refusal to comply with rules?
serve as a role model for a mature behavior while providing a structured setting - client is unable to control impulses at this time so control must be provided for the client
Tissue plasminogen activator (t-PA) is to be administered to a client in the emergency department. Before beginning the infusion, which assessment is the nurse's priority?
signs of bleeding - contraindicated for administration of thrombolytic agents, administration in the presence of bleeding can cause life threatening hemorrhage
Which variable is an example of an external variable?
socioeconomic factors
A recently hospitalized client with multiple sclerosis voices a concern about generalized weakness and fluctuating physical status. Which nursing intervention is the priority for this client?
space activities throughout the day - will encourage maximum functioning within the limits of strength and fatigue, bed rest and limited activity may lead to muscle atrophy and calcium depletion, stress strengths rather than weaknesses
Which clinical manifestations indicate a client who sustained head and chest injuries from a motor vehicle accident, responded to medical treatments, and is ready for transfer to a critical care unit?
stable vital signs and complaints of pain - major indicator predicting transfer will not jeopardize the client's condition
Which stage of the human immunodeficiency virus (HIV) would a client with a CD4+ T cell count of 325 cells/mm3 be classified?
stage 2 is 200-499 ; stage 1 is greater than 500, stage 3 is less than 200, stage 4 is a client with conformed infection but no infor regarding cell count
Which action would be appropriate to implement when collecting a 24 hour urine test?
start the time of the test after discarding the first voiding
The child is admitted with an acute infection and dehydration. There is a prescription for an IV antibiotic to be piggybacked to a continuous hydration solution. During the administration of the antibiotic the child becomes restless, flushes, and begins to wheeze. Place the nursing actions in order of their priority.
stopping the antibiotic infusion, assessing the respiratory status, maintaining the hydration infusion, notifying the health care provider
Which action will the nurse take to determine a client's pulse pressure?
subtracting the diastolic from the systolic reading ; multiplying heart rate by the stroke volume is cardiac output, calculating the difference between the apical and radial rate is the pulse deficit
Which clinical indicator would the nurse monitor to determine if the client's simvastatin is effective?
triglycerides - therapeutic effects include decreased levels of serum triglycerides, low density lipoprotein (LDL), and cholesterol
An adult client with low- functioning Down Syndrome (trisomy 21) appears in the emergency department via ambulance after an accident. Which assessment method would be the best instrument to use when determining the client's level of pain?
using the Wong- Baker FACES pain rating scale - client can relate to the patients
A client has a colon resection and formation of a colostomy 2 days ago. Which color indicates to the nurse that the stoma is viable?
brick red - indicates adequate vascular perfusion
Which nursing action would be included in the plan of care for a child with acute poststreptococcal glomerulonephritis?
monitoring for seizures - cerebral edema from hypertension or cerebral ischemia may occur, which may result in seizures
When making rounds, the nurse observes a client who experiencing a seizure. Which action would the nurse take?
move obstacles away from the client
Which relationship reflects the relationship of naloxone to morphine sulfate?
protamine sulfate is the antidote for heparin overdose
At which age would the nurse anticipate the appearance of an imaginary friend for a preschool- age client?
3 years old
Which sexually transmitted infection (STI) is most commonly reported?
chlamydia
During an annual physical assessment, a client reports not being able to smell coffee and most foods. Which cranial nerve function would the nurse assess?
1 - the cranial nerve 1 is the olfactory nerve that concerns the sense of smell, the inability to sense odors occurs with the presence of an intracranial lesion, cranial nerve II is optic nerve, Nerve X is the vagus nerve associated with the gag reflex, supplying parasympathetic fibers to body organs, and transmitting sensory impulses from the viscera, Nerve VII is the facial nerve
A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. Which percentage of total body surface area (TBSA) would the nurse calculate?
36% - using the rule of nine, the percentage of total body surface are burned is 9% for each arm (18% total for both arms) and 18% for the anterior trunk
Which manifestation indicates tertiary syphilis?
Gummas - chronic, destructive lesions affecting the skin, bone, liver, and mucous membranes ; chancre appears during primary syphilis, alopecia and condylomata lata occur during secondary syphilis
Which antibody forms first, after exposure to an antigen?
Immunoglobulin M(IgM) - first antibody formed by a newly sensitized B-lymphocyte plasma cell ; IgA has low circulating levels and responsible for preventing infection in the upper and lower respiratory tracts and the GI and genitourinary tracts. IgE variable concentrations and is associated with antibody-mediated hypersensitivity reactions. IgG heavily expressed on second and subsequent exposures to antigens to provide sustained long term immunity against invading microorganisms
Which nursing objective would the nurse add to the plan of care for a child with ADHD who engages in destructive behavior?
Keep the child from inflicting any self- injury
Which medication may lead to bruxism?
Levomilnacipran - serotonin reuptake inhibitors and serotonin/norepinephrine reuptake inhibitors may lead to bruxism
A client informs the nurse that her home pregnancy test was positive and her last menstrual period began on June 18. According to Naegele's rule, which is the estimated date of birth (EDB)?
March 25th - take the first day of the last menstrual period (June 18th), subtract three months, then add 7 days
A client with cancer experiences severe nausea and vomiting from chemotherapy. The client wants to know if it is true that smoking marijuana will help. How will the nurse respond?
There are some tetrahydrocannabinol (THC)- based medications that contain marijuana control chemotherapy- induced nausea and vomiting in some people - THC acts as an antiemetic in some people and can be absorbed through the GI tract or inhaled. THC based medications, dronabinol and nabilone, are available by prescription to control nausea and vomiting resulting from chemotherapy
Which intervention would the nurse include in the plan of care for a client admitted with herpes zoster?
acyclovir, silvadene, gabapentin, wet compresses, contact isolation ; antiviral medications such as acyclovir, silvadene can be applied to open vesicles, gabapentin can be used to treat the nerve pain associated, wet compresses can be applied to vesicles to relieve discomfort, herpes zoster is highly contagious and must be placed on isolation precautions
A client with type 1 diabetes mellitus has a finger stick glucose level of 258 at bedtime. A prescription for a sliding scale regular insulin exists. Which would the nurse do?
administer the insulin as prescribed
The health care provider prescribed a blood transfusion for a client with esophageal varices. Place the following nursing actions in the correct order?
check the patient's vital signs, establish intravenous IV access with IV normal saline, verify the blood product with another nurse against the client's identification (ID) bracelet, monitor the client's vital signs and status according to agency policy
Which structure lies inside and parallel to the sclera?
choroid - highly vascular structure that nourishes the ciliary body, the iris, and the outermost portion of the retina
The nurse understands which condition as being contraindicated for St. John's wort herbal therapy?
dementia - used to treat anxiety, Bupropion therapy is contraindicated for seizures, Valerian is contraindicated for cardiac disease
Which diagnostic test results indicates if a client will develop acquired immunodeficiency syndrome (AIDS) from the human immunodeficiency virus (HIV)?
dependent on the number of CD4+ T cells
Which medication is associated with sedation as a side effect?
doxepin, zaleplon, suvorexant, nefazodone, mirtazapine, clonazepam
Which hospital department plays a primary role in disaster preparedness?
emergency department
A client who is in the advanced stages of illness asks the nurse to contact pastoral services for support. According to the Macmillan model, which is the correct nursing intervention in this situation?
immediately involve pastoral services while caring for the client - the Macmillan nurse usually has the knowledge of advanced practice and possess specialty training, this practice enhances the nurse to gain an in depth knowledge about spiritual, social, and psychological needs and the pathophysiology of clients living with advanced diseases
A child with a history of nephrotic syndrome has a pale, muddle appearance; his appetite is poor; and he has been unusually tired after school. Which would the nurse suspect?
impending renal failure - the anemia associated with renal failure accounts for the pallor and decreased energy; the decreased appetite and decreased energy are related to the accumulation of toxic wastes
The weight of three month old infant with tetralogy of Fallot has declined from the 25th percentile to the 5th. Which mechanism would the nurse suspect is the reason for this inadequate weight gain?
inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse - because of quick fatigue it is difficult for the infant to consume sufficient calories to adequate weight gain
An adolescent visits the allergy clinic for testing. Which laboratory finding indicates that an allergic response is in progress?
increased eosinophil level - they increase to inhibit the inflammatory response to histamine, which is released in allergic reactions, immunoglobulins increase in response to allergic reaction
A 2 year old toddler has hearing loss caused by recurrent otitis media. Which treatment would the nurse anticipate the practitioner will recommend?
myringotomy - a surgical opening into the eardrum to permit drainage of accumulated fluid associated with otitis media