Final 1.0

A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight. Which drug should the nurse advocate?

Aripiprazole

A 25-yr-old male patient calls the clinic complaining of diarrhea for 24 hours. Which action should the nurse take first?

Ask the patient to describe the character of the stools and any associated symptoms.

The nurse is providing postpartum care to a patient 24 hours after a vaginal delivery. Which action does the nurse perform prior to assessing the patient's uterus?

Ask the patient to void.

A multiparous patient reports severe uterine cramps the first day after a vaginal delivery. The nurse is aware the patient is breastfeeding and associates the patient's pain primarily with which occurrence?

An increase in oxytocin release related to the newborn suckling

A patient develops mania after discontinuing lithium. New prescriptions are written to resume lithium twice daily and begin olanzapine. This is the expected reaction to the addition of olanzapine to the medication regimen?

Bring hyperactivity under rapid control.

A patient approaches the nurse and impatiently blurts out, "You've got to help me! Something terrible is happening. My heart is pounding." The nurse responds, "It's almost time for visiting hours. Let's get your hair combed." Which approach has the nurse used?

Bringing up an irrelevant topic

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8° F (38.2° C). Which action should the nurse take next?

Have the patient use the incentive spirometer.

A patient has the nursing diagnosis anxiety as evidenced by an inability to control compulsive cleaning. Which phrase referring to the likely trigger correctly completes the etiological portion of the diagnosis?

Having persistent thoughts about bacteria, germs, and dirt

Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a patient who has acute pancreatitis?

Amylase

Which client statement most supports a diagnosis of agoraphobia?

"Being afraid to go out seems ridiculous, but I can't go out the door."

A patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is appropriate?

"Do you use any over-the-counter drugs?"

A patient prescribed lithium telephones the nurse at the clinic to say, "I've had severe diarrhea 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" What instructions should the nurse provide?

"Have someone bring you to the clinic immediately."

Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome (IBS)?

"How long have you had abdominal pain?"

A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response.

"I am having difficulty understanding what you are saying."

A patient experiencing moderate anxiety says, "I feel undone." An appropriate response for the nurse would be:

"I'm not sure I understand. Give me an example."

A patient being treated for major depressive disorder has taken 300 mg amitriptyline daily for a year. The patient calls the case manager at the clinic and says, "I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares." How should the nurse advise the patient?

"Take one dose of the antidepressant, and then come to the clinic to see the health care provider."

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's most appropriate response.

"Taking the medication every day helps prevent relapses and recurrences."

A patient is interested in a pain relief option that she can control during labor. The nurse explains to the patient what pain relief options are available that would meet her needs, and they mutually decide on nitrous oxide. Which of the following does the nurse describe to the patient about the use of nitrous oxide in labor? Select all that apply.

"The gas takes effect in about 50 seconds after the first breath, and the patient will feel calm." "There is no effect on the labor progress from active labor to delivery, and therefore you do not need to worry about longer labors with the medication."

A patient diagnosed with schizophrenia has auditory hallucinations. The patient anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question.

"What is the voice telling you to do?"

A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response.

"You are laughing. Tell me what's happening."

A nurse wants to reinforce positive self-esteem for a patient diagnosed with major depressive disorder. Today, the patient is wearing a new shirt and has neat, clean hair. Which remark is most appropriate?

"You are wearing a new shirt."

A new patient in an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening." Which response by the nurse will help the patient view the drinking more honestly?

"You describe drinking steadily throughout the day and evening. Am I correct?"

A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example of which defense mechanism?

Compensation

A nurse encourages an anxious patient to talk about feelings and concerns. What is the rationale for this intervention?

Concerns stated aloud become less overwhelming and help decrease feelings of isolation

After change-of-shift report, which patient should the nurse assess first?

A 60-yr-old patient with nausea and vomiting who has dry mucosa and lethargy

A patient is admitted in a comatose state after ingesting five capsules of lorazepam. A friend of the patient says, "Often my friend drinks, along with taking more of the drug than is prescribed." What is the effect of the use of alcohol with this drug?

A synergistic effect occurs.

Which patient should the nurse assess first after receiving change-of-shift report?

A patient with esophageal varices who has a blood pressure of 92/58 mm Hg

Which action by the nurse will be most helpful to a patient who is expected to ambulate, deep breathe, and cough on the first postoperative day?

Administer prescribed analgesic medications before the activities.

In preparation for a cesarean birth, the nurse expects which medical-based preoperative interventions? Select all that apply.

Administration of narrow-spectrum prophylactic antibiotics Assessment for risk of venous thromboembolism (VTE) Prescription for sequential compression devices prior to surgery

A patient presenting with delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient?

Allow the patient to have supervised access to food vending machines.

A patient has peptic ulcer disease that has been associated with Helicobacter pylori. About which medications will the nurse plan to teach the patient?

Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec)

A young adult been admitted to the emergency department with nausea and vomiting. Which action could the RN delegate to unlicensed assistive personnel (UAP)?

Assist the patient with oral care.

The nurse is caring for a 34-year-old woman who is G2P1001 at 39 weeks and 1 day. The patient is an observant Muslim and is in active labor. Which outcome would be the most effective form of applying culturally sensitive communication?

Assuring the patient that her baby is less than 9 lb

A patient admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take?

Check the vital signs.

The nurse will anticipate teaching a patient experiencing frequent heartburn about

Cherry gelatin with fruit

Which patient choice for a snack 3 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective?

Cherry gelatin with fruit

A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling?

Conveying understanding that pressures associated with nursing practice underlie substance abuse

Which breakfast choice indicates a patient's good understanding of information about a diet for celiac disease?

Corn tortilla with scrambled eggs

Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP) when caring for a patient who is using a fentanyl (Duragesic) patch and a heating pad for treatment of chronic back pain?

Count the respiratory rate every 2 hours.

A patient diagnosed with schizophrenia says, "My coworkers are out to get me. I also saw two doctors plotting to overdose me." What term identifies how this patient is perceiving the environment?

Dangerous

A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?

Darting eyes, tilted head, mumbling to self

A patient admitted to an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening." The patient is using which defense mechanism?

Denial

A patient is undergoing diagnostic tests. The patient says, "Nothing is wrong with me except a stubborn chest cold." The spouse reports that the patient smokes, coughs daily, has recently lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using?

Denial

A patient diagnosed with schizophrenia is hospitalized after arguing with coworkers and threatening to harm them. The patient is aloof and suspicious and says, "Two staff members I saw talking were plotting to assault me." Based on data gathered at this point, which nursing diagnoses relate? (Select all that apply.)

Disturbed thought process, risk for other directed violence, disturbed thought process

This nursing diagnosis applies to a patient experiencing mania: imbalanced nutrition: less than body requirements, related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. What is the most appropriate outcome related to patient behavior?

Drinking six servings of a high-calorie, high-protein drink each day

A patient diagnosed with major depressive disorder is taking a tricyclic antidepressant. The patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse should implement what intervention?

Explain how to manage postural hypotension and educate the patient that side effects go away after several weeks.

A student says, "Before taking a test, I feel a heightened sense of awareness and restlessness." What nursing intervention is most helpful for assisting the student?

Explaining that the symptoms are the result of mild anxiety and discussing the helpful aspects

The nurse-manager on a labor and delivery unit is monitoring the reasons for cesarean births at the facility. Which reasons contribute to the high rates of cesarean births? Select all that apply.

Fetuses in breech position unable to deliver vaginally Increased number of elective or maternal request cesareans Incidences of women of older maternal age getting pregnant Presence of nonreassuring fetal tracings during labor

A patient with Crohn's disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider?

Fever

A young woman who has Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient?

Fistulas can form between the bowel and bladder.

The nurse is preparing a postpartum patient for discharge. For which reasons does the nurse instruct the patient to call the primary care provider? Select all that apply.

Foul-smelling lochia Hot, red, painful breasts Frequent, painful urination

The patient is a 26-year-old G1P0 at 38 weeks, 2 days of gestation. She is at her provider's office for a visit and complains to the nurse of wrist pain, fatigue, increased discharge, and "feeling heavy." Which complaint could be a sign of impending labor?

Increased discharge

A 49-yr-old man has been admitted with hypotension and dehydration after 3 days of nausea and vomiting. Which prescribed action will the nurse implement first?

Infuse normal saline at 250 mL/hr.

A student nurse caring for a patient diagnosed with major depressive disorder reads in the patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to the vegetative signs? (Select all that apply.)

Insomnia, Sexual dysfunction, self-care deficit, imbalanced nutrition: less than body requirements

The nurse is monitoring a patient closely for signs and symptoms of Stevens-Johnson syndrome. Which medication is likely the trigger for such a syndrome?

Lamotrigine

Which information will the nurse teach a patient with lactose intolerance?

Live-culture yogurt is usually tolerated.

A 30-yr-old male patient with a body mass index (BMI) of 22 kg/m2 is being admitted to the hospital for elective knee surgery. Which assessment finding is important to report to the health care provider?

Liver edge 3 cm below the costal margin

A patient experiences an episode of severe anxiety. Of these medications in the patient's medical record, which is most appropriate to administer as a short-term therapy?

Lorazepam

An adult in the emergency department states, "I feel restless. Everything I look is wavy. Sometimes I'm outside my body looking at myself. I hear colors. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect what triggered these reports?

Lysergic acid diethylamide (LSD) ingestion

A child is placed in a foster home after being removed from parental contact because of both physical and verbal abuse. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help minimize the child's anxious behaviors. What should the nurse recommend? (Select all that apply.)

Maintain simplicity in the environment. Explain and reinforce reality to avoid distortions. Use a calm manner and low voice.

Which nursing action will the nurse include in the plan of care for a 35-yr-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)?

Monitor stools for blood.

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis?

Muscle twitching and finger numbness

A postpartum patient informs the nurse of a frequent urge and burning when attempting to urinate. The nurse reviews the patient's medical record and associates which risk factors related to a possible urinary tract infection (UTI)? Select all that apply.

Neonatal macrosomia Use of a vacuum extractor Poor oral fluid intake Urinary catheter during labor

At a unit meeting, staff members discuss the decor for a special room for patients experiencing mania. What select is the best option?

Neutral walls with pale, simple accessories

Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant?

Observe for depression and suicidal ideation.

A patient who is receiving sustained-release morphine sulfate (MS Contin) every 12 hours for chronic pain experiences level 9 (0 to 10 scale) breakthrough pain and anxiety. Which action by the nurse is appropriate for treating this change in assessment?

Offer immediate-release morphine 30 mg orally.

The nursing is caring for a 31-year-old female patient who is pregnant at 37 weeks and 5 days gestation. The patient is having contractions every 3 minutes and was found to have a platypelloid pelvis upon examination. The fetus has an estimated fetal weight of 7 lbs and is in the LOA position. This patient is laboring on the birth ball, and her mother-in-law is helping her labor. The nurse is concerned about the five Ps and their effect on the patient's labor. Which P is the nurse most likely concerned about based on the patient's history?

Passage

A supervisor assigns a worker a new project. The worker initially agrees but feels resentful. The next day, when asked about the project, the worker says, "I've been working on other things." When asked 4 hours later, the worker says, "Someone else was using the copier, so I couldn't finish it." The worker's behavior demonstrates the use of what mechanism?

Passive aggression

The nurse in labor and delivery notices an increase in the number of women requesting cesarean births. Which are the parameters and criteria used when making the decision to perform a cesarean delivery on maternal request (CDMR)? Select all that apply.

Patient is aware of possible neonatal complications. Procedure is performed after 39 weeks gestation.

A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed?

Patient's breath sounds are clear to auscultation.

A patient diagnosed with schizophrenia is demonstration catatonia. The patient has little spontaneous movement and waxy flexibility. Which patient needs are of priority importance?

Physiological

Which action will the nurse include in the plan of care for a patient who is being admitted with Clostridium difficile?

Place the patient in a private room on contact isolation.

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?

Place the patient on a pressure-relief mattress.

A person is directing traffic on a busy street while shouting and making obscene gestures at passing cars. The person has not slept or eaten for 3 days. What features of mania are evident?

Poor judgment and hyperactivity

A 36-yr-old female patient is receiving treatment for chronic hepatitis C with pegylated interferon (PEG-Intron, Pegasys), ribavirin (Rebetol), and telaprevir (Incivek). Which finding is important to communicate to the health care provider to suggest a change in therapy?

Positive urine pregnancy test

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient?

Potential complication: venous thromboembolism

The nurse on a postpartum unit observes a patient who delivered 2 days ago. The nurse notices extreme agitation and depressed mood. The patient states, "I think that my baby is deformed inside and we have to fix him." Which risk factor is most strongly related to possible postpartum psychosis (PPP)?

Prolonged labor resulting in cesarean

A patient diagnosed with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented? (Select all that apply.)

Provide a quiet sleep environment, monitor food and fluid intake, offer laxatives if needed

A person who is speaking about a contender for a significant other's affection says in a gushy, syrupy voice, "What a lovely person. That's someone I simply adore." The individual is demonstrating what defense mechanism?

Reaction formation

A patient who is using both a fentanyl (Duragesic) patch and immediate-release morphine for chronic cancer pain develops new-onset confusion, dizziness, and a decrease in respiratory rate. Which action should the nurse take first?

Remove the fentanyl patch.

A patient experiencing mania has not eaten or slept for 3 days. Which nursing diagnosis has priority?

Risk for injury

A patient diagnosed with major depressive disorder repeatedly tells staff members, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis.

Risk for suicide

Which prescribed intervention for a patient with chronic short bowel syndrome will the nurse question?

Senna 1 tablet every day

When a hyperactive patient experiencing acute mania is hospitalized, what initial nursing intervention is a priority?

Setting limits on the patient's behavior as necessary

This is the primary reason that the cause of bipolar disorder has not been determined?

Several factors, including genetics, are implicated.

A nurse prepares the plan of care for a patient experiencing a manic episode. Which nursing diagnoses are most appropriate? (Select all that apply.)

Sleep deprivation, disturbed thought processes

A patient tells the nurse, "I don't go to restaurants because people might laugh at the way I eat, or I could spill food and be laughed at." The nurse assesses this behavior as consistent with which mental health diagnosis?

Social anxiety disorder

Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in 1 year. Before discharge, what will the patient do?

State, "I see the need for ongoing treatment."

A patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator to the nurse that the medication has been effective?

Stools test negative for occult blood.

What is the focus of priority nursing care for the period immediately after a patient has an electroconvulsive therapy (ECT) treatment?

Supporting physiological stability

The labor and delivery unit nurses are adopting methods to reduce the number of women who develop postpartum depression. Research from Dennis and Dowswell (2013) provides evidence-based suggestions regarding beneficial interventions. Which suggestions do the nurses consider? Select all that apply.

Telephone-based peer support Interpersonal psychotherapy Professionally based postpartum home visits

Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dL. Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw?

The patient has a high tolerance to alcohol.

A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours ago. Which assessment finding is most important for the nurse to address immediately?

The patient has no breath sounds in the left anterior chest.

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis?

The patient is alert and oriented.

A 58-yr-old patient has just been admitted to the emergency department with nausea and vomiting. Which information requires the most rapid intervention by the nurse?

The patient is lethargic and difficult to arouse.

The nurse is assessing patients who are postpartum. Which patients does the nurse identify as being at increased risk for respiratory complications? Select all that apply.

The patient who received large amounts of IV fluid due to blood loss The patient with preeclampsia treated with magnesium sulfate The patient who was placed on bedrest for threatened abortion

The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?

The patient's hands flap back and forth when the arms are extended.

The nurse is reviewing the medical record for a patient who is postpartum. The nurse notices the patient is rubella-nonimmune. Which information does the nurse present to the patient? Select all that apply.

The risks to the fetuses of any future pregnancies. The patient will need to be immunized before discharge. Pregnancy should be avoided for 4 weeks.

The nurse is aware that there are multiple classifications for cesarean deliveries. Which situations does the nurse classify as an unscheduled cesarean birth? Select all that apply.

There is evidence of a prolapsed cord with membrane rupture. The cervix fails to fully dilate after prolonged labor. There is evidence of a prolapsed cord with membrane rupture. The cervix fails to fully dilate after prolonged labor. Patient has a preexisting cardiac health condition. There is recognition of placenta previa with mild bleeding.

The nurse is speaking with a pregnant patient who is asking what processes start labor. Which responses by the nurse are appropriate? Select all that apply.

There is more pressure on the cervix, which causes the start of contractions by releasing oxytocin. Oxytocin stimulates uterine muscles to contract. The placenta begins to age and deteriorate and this triggers the start of contractions. The fetus releases a stress hormone, cortisol, and this starts contractions.

The nurse is collecting the urine of a postpartum patient who is passing large clots. For which reason does the nurse examine the large collected clots?

To determine the presence of tissue

The nurse is palpating a patient's uterus 12 hours after a vaginal delivery. For which reason does the nurse place one hand just above the symphysis pubis?

To prevent uterine inversion

When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After 1 year of drinking, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur?

Tolerance develops.

Which information about an 80-yr-old male patient at the senior center is of most concern to the nurse?

Unintended weight loss

Prior to discharge from the birthing center, the nurse informs the patient that she will receive vaccines for rubella, hepatitis B, pertussis, and influenza. For which reason does the nurse explain the need for the vaccinations?

Vaccinating the mother will protect the neonate from serious illnesses.

The nurse is counseling a 15-year-old pregnant patient at her first prenatal appointment. Which patient teaching by the nurse is appropriate?

Your response to pregnancy, labor, and delivery will differ from that of an adult because your cognitive development is not yet complete.

The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to

administer IV fluids.

To prepare a patient with ascites for paracentesis, the nurse

asks the patient to empty the bladder.

Four hours after a bowel resection, a 74-yr-old male patient with a nasogastric tube to suction complains of nausea and abdominal distention. The first action by the nurse should be to

check for tube placement and reposition it.

A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should

document stoma assessment findings.

A young adult patient is hospitalized with massive abdominal trauma from a motor vehicle crash. The patient asks the nurse about the purpose of receiving famotidine (Pepcid). The nurse will explain that the medication will

inhibit development of stress ulcers.

At his first postoperative checkup appointment after a gastrojejunostomy (Billroth II), a patient reports that dizziness, weakness, and palpitations occur about 20 minutes after each meal. The nurse will teach the patient to

lie down for about 30 minutes after eating.

The nurse is planning care for a patient with acute severe pancreatitis. The highest priority patient outcome is

maintaining normal respiratory function.

The nurse will plan to teach the patient diagnosed with acute hepatitis B about

measures for improving the appetite.

A patient who requires daily use of a nonsteroidal antiinflammatory drug (NSAID) for the management of severe rheumatoid arthritis has recently developed melena. The nurse will anticipate teaching the patient about

misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa.

An older patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place. The health care provider prescribes 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse

periodically aspirates and tests gastric pH.

A patient who is 8 months postpartum arrives for an OB appointment. The nurse notices that both the patient and the infant appear unkempt. The nurse anticipates a diagnosis of _________________________.

post partum depression

While caring for a patient with a methamphetamine overdose, which tasks are the priorities of care? (Select all that apply.)

prevention of seizures, reduction of fever

The nurse understands that logically ____________________ cesarean births are an influential factor related to the overall incidence of cesarean births

previous

After pregnancy and birth, a mother may notice a condition called diastasis recti abdominis, which is a(n) ____________________ of the rectus muscle.

seperation