Fundamentals Exam 4 Study Guide

On admission to the inpatient psychiatric unit, a client's facial expression indicates severe panic. He repeatedly states, "I know the police are going to shoot me. They found out that I'm the child of the devil." What should the nurse say to initiate a therapeutic relationship with this client? "You certainly look stressed. Can you tell me about the upsetting events that have occurred in your life recently?" "Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?" "You're having very frightening thoughts. I'll help you find ways to cope with this scary thinking." "Hello, ___. I'm going to be caring for you while I'm on duty. You look very frightened, but I'm sure you'll feel better by tomorrow."

"Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?"

While receiving disulfiram (alcohol withdrawl meds) therapy, the client becomes nauseated and vomits severely. Which question should the nurse ask first? "How long have you been taking disulfiram?" "Do you feel like you have the flu?" "How much alcohol did you drink today?" "Have you eaten any foods cooked in wine?"

"How much alcohol did you drink today?"

A client is scheduled to have an elective mandibular osteotomy to correct a mandibular fracture sustained in an accident 6 months earlier. Which statement by the client indicates to the nurse maladaptive coping? "I will be glad to have my jaw fixed because my wife thinks I do not look like myself." "I am somewhat afraid to have the surgery but feel OK about it." "My wife will help me, but I do not think I will need that much help." "I am ready to get this over with."

"I will be glad to have my jaw fixed because my wife thinks I do not look like myself."

The parents of a child who requires skeletal traction are unable to visit their child for more than 1 hour a day because there are five other children at home and both parents work outside of the home. The nurse recognizes expressions of guilt in both parents. To help alleviate this guilt, the nurse should make which statement? "I am sure you feel guilty about not being able to visit often." "It is important that you visit even for 1 hour." "Not all parents can stay all the time." "Perhaps you could take turns visiting for a bit longer."

"It is important that you visit even for 1 hour."

Which of the following statements indicates that a new graduate nurse understands central venous pressure (CVP) measurement when used on a client? "The test will accurately measure rate and rhythm of breathing patterns." "The test determines approximate blood pressure." "A high CVP leads to superior vena cava syndrome." "It will assess pressure and volume changes in the right atrium."

"It will assess pressure and volume changes in the right atrium." The best rationale for CVP measurement is to assess pressure and volume in the right atrium.

A 17-year-old is admitted to a psychiatric day treatment program due to severe lower back pain since her mother's death 3 years ago. Medical examinations have not discovered a physical cause for her pain. She cares for her four younger siblings after school and on weekends because of her father's long work hours. Which predischarge statement indicates that treatment for her condition has been successful? "I understand now why my father spends so much time away from home." "My back pain is worse on weekends with more responsibility and homework." "I do not want to talk about my family. It is my back that is hurting." "I just need more rest and relaxation and then my back will feel fine."

"My back pain is worse on weekends with more responsibility and homework."

As a representative of the treatment team, a nurse is reviewing results of diagnostic studies with the family of an adolescent with anorexia nervosa. What explanation should the nurse give the family about the client's abnormal blood urea nitrogen (BUN) value? "The BUN is decreased because your daughter has developed hypothyroidism." "The BUN is elevated because your daughter has hypoglycemia." "The BUN is decreased because your daughter is hypertensive." "The BUN is elevated because your daughter is dehydrated."

"The BUN is elevated because your daughter is dehydrated."

Which client statement indicates that the client has coped effectively with a relationship problem? "My wife will be happy to know that I can spend less time at work now." "My wife and I are talking about our likes and dislikes in activities." "I can understand how my wife and I see things differently." "We are really listening to each other about our different view on issues."

"We are really listening to each other about our different view on issues."

Three days after surgery, a client continues to take hydrocodone 7.5 mg and acetaminophen 500 mg for postoperative pain. What should the nurse ask the client before administering the pain medication? "When did you last have a bowel movement?" "Have you emptied your bladder?" "How long has it been since your last dose?" "Is your pain better than before you had surgery?"

"When did you last have a bowel movement?"

Blood serum normal osmolality is 2__ - 2__ mOsm/kg

280-295

A true crisis state, involving a period of severe disorganization, is difficult to endure emotionally and physically. The nurse recognizes that a client will only be able to tolerate being in crisis for how long? 1 to 2 weeks 4 to 6 weeks 12 to 14 weeks 24 to 26 weeks

4 to 6 weeks

A client with osteoarthritis purchased a copper bracelet to wear and tells the nurse that there is less pain now. Which response by the nurse is most appropriate? Tell the client that copper is best applied as copper lined gloves. Warn the client not to spend any more money on quackery such as bracelets. Instruct the client to remove the bracelet because the copper in it can interfere with salicylate metabolism. Acknowledge that the client feels better, but encourage the client to continue with the prescribed therapy.

Acknowledge that the client feels better, but encourage the client to continue with the prescribed therapy.

A chronically ill school-age child is most vulnerable to which stressor? Mutilation anxiety Anticipatory grief Anxiety over school absences Fear of hospital procedures

Anxiety over school absences

A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? Sit quietly with the client until the episode is over. Ignore the behavior. Attempt to divert the client's attention. Tell the client that this behavior is unacceptable.

Attempt to divert the client's attention.

A client who recently immigrated from Korea to the U.S. or Canada is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after the client's admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action is most appropriate at this time? Documenting that the client is resting quietly and denies pain Calling a family member to obtain information about the client Giving the client the ordered as-needed pain medication Checking vital signs and assessing for nonverbal indications of pain

Checking vital signs and assessing for nonverbal indications of pain

An adult has been admitted to the emergency department diagnosed with food poisoning following an outdoor picnic. What should the nurse do? Select all that apply. Tell the family to discard contaminated food. Collect specimens for lab examination. Assess vital signs. Initiate support for the respiratory system. Monitor fluid and electrolyte status. Provide anti-emetics, as prescribed.

Collect specimens for lab examination. Assess vital signs. Initiate support for the respiratory system. Monitor fluid and electrolyte status. Provide anti-emetics, as prescribed.

The nurse is developing an education plan for clients with hypertension. The nurse should emphasize which long-term goal? Develop a plan to limit stress. Participate in a weight reduction program. Commit to lifelong therapy. Monitor blood pressure regularly.

Commit to lifelong therapy.

A nurse interviews the family of a client hospitalized with severe depression and suicidal ideation. What family assessment information is essential in formulating an effective care plan? Select all that apply. Physical pain Personal responsibilities Employment skills Communication patterns Role expectations Current family stressors

Communication patterns Role expectations Current family stressors

The nurse interviews the family of a client who is hospitalized with severe depression and suicidal ideation. Which family assessment information is essential to formulating an effective plan of care? Select all that apply. Client's experience with physical pain Personal responsibilities Employment skills Communication patterns Role expectations Current family stressors

Communication patterns Role expectations Current family stressors

The physician has prescribed sodium chloride for a hospitalized 51-year-old client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply. Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms. Administer IV bicarbonate. Suction the client's airway.

Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms.

The nurse is preparing to administer IM morphine sulfate to a client who is in pain. On checking the health care provider's (HCP's) prescription, the nurse notes that the prescription states, "morphine sulfate 60 mg IM every 4 hours as needed for pain." The usual dose of morphine is 10 to 15 mg. What is the most appropriate action for the nurse to take? Administer the medication as prescribed. Administer 15 mg of the drug. Contact the HCP to verify the prescription. Ask another nurse to review the prescription.

Contact the HCP to verify the prescription

The nurse is preparing to administer IM morphine sulfate to a client who is in pain. On checking the health care provider's (HCP's) prescription, the nurse notes that the prescription states, "morphine sulfate 60 mg IM every 4 hours as needed for pain." The usual dose of morphine is 10 to 15 mg. What is the most appropriate action for the nurse to take? Administer the medication as prescribed. Administer 15 mg of the drug. Contact the HCP to verify the prescription. Ask another nurse to review the prescription.

Contact the HCP to verify the prescription.

The mother of a child with moderate diarrhea asks how to manage her child's illness. What should the nurse suggest? Begin clear liquids for 24 hours. Feed the child bananas, rice, applesauce, and toast. Offer foods that are low in fat. Continue the child's regular diet.

Continue the child's regular diet.

The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following? A. Loss of autonomy caused by health problems B. Physical appearance, family, friends, and school C. Self-esteem issues, changing family structure D. Search for identity with peer groups and separation from family

D. Search for identity with peer groups and separation from family

A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia? Try to persuade the client to take the medication as ordered by the doctor. Emphasize the rationale for taking the medication now as ordered. Ask the client's spouse wife to hold the client's hands while the nurse puts the pill under the tongue. Document the client's choice and re-assess pain in 1 hour.

Document the client's choice and re-assess pain in 1 hour.

A postpartum client has a temperature of 99.8° F (37.7.° C) during the first 24 hours after birth. Which nursing intervention is appropriate? Check for signs of puerperal infection. Check the client's breasts for red, swollen areas. Encourage more fluid intake. Assess lochia for foul odor.

Encourage more fluid intake.

A child is admitted with a diagnosis of possible appendicitis. The child is in acute pain. Which nursing intervention would be appropriate prior to surgery to decrease pain? Select all that apply. Offer an ice pack. Apply a heating pad. Encourage the child to assume a position of comfort. Limit the child's activity. Request a prescription for a cathartic.

Encourage the child to assume a position of comfort. Limit the child's activity. Offer an ice pack

A client is undergoing a bone marrow aspiration and biopsy. What is the best way for the nurse to help the client and two upset family members handle anxiety during the procedure? Allow the client's family to stay as long as possible. Stay with the client without speaking. Encourage the client to take slow, deep breaths to relax. Allow the client time to express feelings.

Encourage the client to take slow, deep breaths to relax.

After a third arrest for abusing a neighbor's cat, a client is admitted to the psychiatric unit for treatment of antisocial personality disorder. This client has a history of conduct disorder. Which action is most appropriate for the nurse assigned to this client? Examining personal feelings toward the client Encouraging the client to use problem-solving techniques Insisting that the client obey all unit rules and attend all unit activities Administering antianxiety medication as ordered

Examining personal feelings toward the client

A nurse is reviewing a client's fluid intake and output record. Fluid intake and urine output should relate in which way? Fluid intake should be double the urine output. Fluid intake should be about equal to the urine output. Fluid intake should be half the urine output. Fluid intake should be inversely proportional to the urine output.

Fluid intake should be about equal to the urine output.

A toddler admitted in respiratory distress keeps pulling at the oxygen mask, trying to remove it. Which interventions are indicated? Select all that apply. Restrain the child. Have the parent read to the child. Administer a sedative. Encourage the parent to hold the child. Tell the child the mask will help him breathe better. Ask the parent to leave the child's bedside.

Have the parent read to the child. Encourage the parent to hold the child.

An 80-year-old woman who identifies herself as a devout Catholic has recently relocated to an assisted-living facility. The woman is pleased with most aspects of her new living situation, but laments the fact that she is no longer close to the church where she was in the habit of attending daily mass each morning. What nursing diagnosis may apply to this problem that the woman has identified? Impaired Religiosity Spiritual Distress Spiritual Pain Hopelessness

Impaired Religiosity

A nurse is assessing a client for lifestyle factors that might affect normal coping. Which factor should the nurse most likely consider? Inadequate diet Divorce Job promotion Adopting a child

Inadequate diet

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? Decreased heart rate Increased restlessness Increased blood pressure Decreased level of consciousness (LOC)

Increased restlessness

A nurse is preparing a teaching plan for a client who was prescribed enalapril maleate for the treatment of hypertension. Which instructions would the nurse include in the teaching plan? Select all that apply. Instruct the client to avoid salt substitutes. Tell the client that light-headedness is a common adverse effect that does not need to be reported. Inform the client of a potential sore throat for the first few days of therapy. Advise the client to report facial swelling or difficulty breathing immediately. Tell the client that blood tests will be necessary every 3 weeks for 2 months and periodically after that. Advise the client not to change the position suddenly to minimize the risk of orthostatic hypotension.

Instruct the client to avoid salt substitutes. Advise the client to report facial swelling or difficulty breathing immediately. Advise the client not to change the position suddenly to minimize the risk of orthostatic hypotension.

A client taking furosemide and digoxin for exacerbation of heart failure reports weakness and heart fluttering. What would be the priority action by the nurse? Tell the client to rest more often to decrease symptoms. Tell the client to stop taking the digoxin and to stop all physical activity. Investigate the symptoms further with the client and suggest contacting the physician. Offer the client clear instructions about avoiding foods that contain caffeine.

Investigate the symptoms further with the client and suggest contacting the physician. Furosemide is a potassium-wasting diuretic. A low potassium level may cause weakness and palpitations. Telling the client to rest does not address the priority. Telling the client to stop the digoxin is out of scope of practice. Addressing the diet does not answer the question.

A 35-year-old has been killed as a result of a terrorist attack. What should the nurse advise the friends and relatives of the victim to do during the early stages of the recovery process? Select all that apply. Keep in contact with other family and friends. Attend memorial or religious services. Use relaxation techniques and physical activities. Speak out publicly about the impact of the loss. Attend community meetings with others who have lost loved ones.

Keep in contact with other family and friends. Attend memorial or religious services. Use relaxation techniques and physical activities. Attend community meetings with others who have lost loved ones.

A nurse is caring for a client recently diagnosed with cancer and experiencing situational anxiety. Which interventions would the nurse include in the care plan? Select all that apply. Maintain a calm, nonthreatening environment. Explain relevant aspects of chemotherapy. Encourage the client to verbalize concerns regarding the diagnosis. Encourage the client to use deep-breathing exercises and other relaxation techniques during periods of increased stress. Provide distractions for the client during periods of stress. Teach the stages of grieving to the client.

Maintain a calm, nonthreatening environment. Encourage the client to verbalize concerns regarding the diagnosis. Encourage the client to use deep-breathing exercises and other relaxation techniques during periods of increased stress.

A 9-month-old infant is admitted with diarrhea and dehydration. The nurse plans to assess the child's vital signs frequently. Which other action provides important assessment information? Measuring the infant's weight Obtaining a stool specimen for analysis Obtaining a urine specimen for analysis Inspecting the infant's posterior fontanel

Measuring the infant's weight

A client twists his right ankle while playing basketball and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which client statement suggests that ice application has been effective? "I need something stronger for pain relief." "My ankle looks less swollen now." "My ankle appears redder now." "My ankle feels very warm."

My ankle looks less swollen now

The sudden onset of which sign indicates a potentially serious complication for the client receiving an IV infusion? noisy respirations pupillary constriction halitosis moist skin

Noisy respirations. A serious complication of IV therapy is fluid overload. Noisy respirations can develop as a result of pulmonary congestion. Additional symptoms of fluid overload include dyspnea, crackles, hypertension, bounding pulse, and distended neck veins.

A nurse receives a report that a client has had an overdose of heparin. Which of the following actions by the nurse is most important in managing the overdose? Obtain an order to give protamine sulfate. Inform the client that nosebleeds may occur. Review the client's coagulation studies. Have the client remain on bed rest to prevent injury.

Obtain an order to give protamine sulfate. Protamine sulfate is the reversal agent for heparin. Administering this would be the best way to treat the client.

A parent brings her 3-month-old child into the emergency department. The child is listless with dry mucous membranes, tenting of the skin on the forehead, a depressed fontanel, and a history of vomiting and diarrhea for the last 36 hours. In what order from first to last should the nurse implement the primary care provider's prescriptions? All options must be used. Obtain vital signs and weight. Apply a urine collection bag. Insert an IV and infuse fluids as prescribed. Draw blood for laboratory tests

Obtain vital signs and weight. Apply a urine collection bag. Insert an IV and infuse fluids as prescribed. Draw blood for laboratory tests.

During the early postpartum period, a nurse is evaluating several clients' attachment to their neonates. Which client is the highest priority for the nurse? One with little knowledge of parent-neonate attachment One who lost a job recently One who is an only child One whose parent died recently

One whose parent died recently

Which factor should a nurse anticipate having the most influence on the outcome of a client facing a crisis situation? Age Previous coping skills Self-esteem Self-actualization

Previous coping skills

A client is scheduled for an ileostomy. Which would be most helpful in preparing the client psychologically for the surgery? Include family members in preoperative teaching sessions. Encourage the client to ask questions about managing an ileostomy. Provide a brief, thorough explanation of all preoperative and postoperative procedures. Invite a member of the ostomy association to visit the client.

Provide a brief, thorough explanation of all preoperative and postoperative procedures.

A client has been prescribed diuretic therapy for hypertension. It has been causing frequent urination at night and now the client is refusing to take the morning dose of furosemide. What would be the best response by the nurse? Reinforce the reason for the medication. Respect the decision if the client still refuses the medication, and chart the refusal. Take the blood pressure and then discuss with the client the dangers of an increased blood pressure if the medication is not taken. Tell the client that the extra fluid will be gone and urination will not be as frequent. Reinforce how much the edema has decreased and how effective the medication has been, and encourage the client to take the medication.

Reinforce the reason for the medication. Respect the decision if the client still refuses the medication, and chart the refusal.

A client is in the acute phase of rheumatoid arthritis. In which order of priority from first to last should the nurse establish the goals? All options must be used. 1 Relieve pain. 2 Preserve joint function. 3 Prevent joint deformity. 4 Maintain usual ways of accomplishing tasks

Relieve pain. Preserve joint function. Prevent joint deformity. Maintain usual ways of accomplishing tasks.

A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Respiratory acidosis. Respiratory acidosis would be reported to the physician citing the lab values. Analysis of the blood gases reveals that the client is acidotic with a pH under 7.35. Also noted is the PCO2 above the normal range of 30 to 40 mm Hg. The HCO3− is slightly elevated because the normal level is 22 to 26 mEq/L.

The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory alkalosis. At first, arterial blood gas analysis may reveal respiratory alkalosis as a result of rapid, shallow breathing.

A nurse is caring for a client with a central venous catheter and notices redness and tenderness at the catheter insertion site. Which assessment finding would indicate possible systemic infection? Temperature of 97.3 degrees Fahrenheit (36.3 degrees Celsius) Blood pressure of 122/78 mm Hg Respiratory rate of 32 breaths/minute Heart rate of 55 beats/minute

Respiratory rate of 32 breaths/minute, Signs and symptoms of systemic infection may include central nervous system involvement, such as tachypnea, dizziness, and lethargy.

A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant? Blood urea nitrogen (BUN) level of [29 mg/dl (10.4 mmol/L)] Serum sodium level of [132 mEq/L 132 mmol/L)] Urine specific gravity of 1.025 Serum potassium level of [3 mEq/L (3.0 mmol/L)]

Serum potassium level of [3 mEq/L (3.0 mmol/L)] A serum potassium level of 3 mEq/L is below normal, indicating hypokalemia. Because hypokalemia may cause cardiac arrhythmias and asystole, it's the most significant finding.

A client expresses to the nurse that he cannot get the mental support he needs to prepare himself to undergo treatment for leukemia. Which nursing diagnosis is most appropriate for the client? Spiritual distress Ineffective coping Disturbed body image Anxiety

Spiritual distress

The surgeon prescribes cefazolin 1 g to be given IV at 0730 when the client's surgery is scheduled at 0800. What is the primary reason to start the antibiotic exactly at 0730? Legally the medication has to be given at the prescribed time. The antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made. The postoperative dose of cefazolin needs to be started exactly 8 hours after the preoperative dose of cefazolin. The peak and titer levels are needed for antibiotic therapy.

The antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made.

A client is ready to be discharged following an inguinal hernia repair. Which criteria must the client meet before the nurse can discharge the client? Select all that apply. The client has transportation home via a taxicab. The client is able to tolerate oral fluids. The client has pain no greater than 5 on a scale of 1 to 10. The client can walk to the bathroom unassisted. The client has voided.

The client can walk to the bathroom unassisted. The client has voided. The client is able to tolerate oral fluids.

While collecting data from a client diagnosed with impulse-control disorder (and who displays violent, aggressive, and assaultive behavior), the nurse can expect to find which of the following? Select all that apply. The client functions well in other areas of life. The degree of aggression is disproportionate to the stressor. The client often uses a stressor to justify violent behavior. The client has a history of parental substance abuse or a chaotic, abusive family life. The client shows no remorse about the inability to control behavior.

The client functions well in other areas of life. The degree of aggression is disproportionate to the stressor. The client has a history of parental substance abuse or a chaotic, abusive family life.

A nurse recognizes improvement in a client with the nursing diagnosis of Ineffective role performance related to the need to perform rituals. Which behaviors indicate improvement? Select all that apply. The client refrains from performing rituals during stress. The client verbalizes that he uses "thought stopping" when obsessive thoughts occur. The client verbalizes the relationship between stress and ritualistic behaviors. The client avoids stressful situations. The client rationalizes ritualistic behavior. The client performs ritualistic behaviors in private.

The client refrains from performing rituals during stress. The client verbalizes that he uses "thought stopping" when obsessive thoughts occur. The client verbalizes the relationship between stress and ritualistic behaviors.

A shy 12-year-old girl who must change school systems just before she begins junior high school begins cutting her arms to relieve the stress that she feels about leaving long-standing friends, having to develop new friendships, and meeting high academic standards in her new school. After she has been cutting for a few weeks, her parent discovers the injuries and takes her to a psychiatrist mental health provider who prescribes a therapeutic group at the local mental health center and medication to help decrease her anxiety. Which findings indicate that the girl had made appropriate progress toward recovery? Select all that apply. The girl indicates that she had joined three clubs at school and agreed to be an officer in one of them. The girl says she has developed a friendship with a girl in her class and one in her therapy group. The girl wears short-sleeved and/or sleeveless tops when the weather is warm. The girl's grades are good, and her hours of study are not excessive. The girl begins saying she must study hard so she can get into a good university.

The girl says she has developed a friendship with a girl in her class and one in her therapy group. The girl wears short-sleeved and/or sleeveless tops when the weather is warm. The girl's grades are good, and her hours of study are not excessive.

A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess: Trousseau's sign. Homans' sign. Hegar's sign. Goodell's sign.

Trousseau's sign

Hypertonic solutions useful in treatment of hypovolemia, shock, hyponatremia, hypotonic dehydration, True or False

True

A child with rheumatic fever complains of painful joints. Which nonpharmacologic measures should the nurse use to reduce the child's pain? Perform gentle passive range-of-motion exercises. Massage the painful joints. Use a bed cradle to keep linens from pressing on the child's joints. Encourage the child to change position in bed every 2 hours.

Use a bed cradle to keep linens from pressing on the child's joints.

Which client would benefit from the application of warm moist heat? a client with appendicitis a client with a recently sprained joint a client with a suspected malignancy a client with low back pain

a client with low back pain

A client has been taking furosemide (diuretic for HTN) for 2 days. The nurse should assess the client for: an elevated blood urea nitrogen (BUN) level. an elevated potassium level. a decreased potassium level. an elevated sodium level.

a decreased potassium level.

A client receiving morphine for long-term pain management develops tolerance. Tolerance is defined as: a heightened response to a medication. a diminished response to a drug so that more medication is required to achieve the same effect. an allergic reaction to a medication. an ability to take the same drug for extended periods.

a diminished response to a drug so that more medication is required to achieve the same effect

A client with posttraumatic stress disorder needs to find new housing and wants to wait for a month before setting another appointment to see the nurse. How should the nurse interpret this action? a method of avoidance a detriment to progress the end of treatment a necessary break in treatment

a necessary break in treatment

Which of the following individuals would have the highest percentage of water in their body mass composition? a. Infants b. Teenagers c. Young male adults d. Young female adults

a. Infants

Which solute plays the biggest role in water reabsorption? a. Sodium ions b. Potassium ions c. Bicarbonate ions d. Calcium ions

a. Sodium ions

Amphoteric molecules are molecules that can: a. act as either an acid or a base. b. stimulate water conservation. c. stimulate the reabsorption of sodium. d. stimulate the excretion of hydrogen ions.

a. act as either an acid or a base.

The most important buffer in our plasma is: a. bicarbonate. b. phosphate. c. protein. d. All are equally important.

a. bicarbonate.

The hallmark symptom of hypotonic hydration is: a. hyponatremia. b. oliguria. c. hypoproteinemia. d. all of the above.

a. hyponatremia.

A decrease in the osmolarity of the extracellular fluid would cause water to: a. move into the cells. b. move into the interstitial fluid. c. move into the blood. d. move into the lymph

a. move into the cells.

Hydrogen ions are secreted into the filtrate mainly by the: a. proximal convoluted tubule. b. distal convoluted tubule. c. loop of Henle. d. glomerulus.

a. proximal convoluted tubule.

At about one-half hour before the daily whirlpool bath and dressing change the nurse should: soak the dressing. remove the dressing. administer an analgesic. slit the dressing with blunt scissors.

administer an analgesic

_______________ catheter off needle if blood return shows in back flash chamber of catheter

advance

A client is receiving morphine sulfate by a patient-controlled analgesia (PCA) system after a left lower lobectomy about 4 hours ago. The client reports moderately severe pain in the left thorax that worsens when coughing. The nurse's first course of action is to: reassure the client that the PCA system is working and will relieve pain. encourage the client to rest; no further assessment is needed. assess the pain systematically with the hospital-approved pain scale. encourage the client to take deep breathes and expectorate the mucous that is stimulating the cough.

assess the pain systematically with the hospital-approved pain scale.

Which of the following is not considered part of the interstitial fluid? a. Lymph b. Plasma c. Cerebrospinal fluid d. Synovial fluid

b. Plasma

Which ion is reabsorbed when hydrogen ions are secreted? a. Potassium b. Sodium c. Chloride d. Calcium

b. Sodium

Hypoproteinemia can lead to a condition called: a. hypertension. b. edema. c. hypotonic hydration. d. acidosis.

b. edema.

The most important urine buffer is: a. bicarbonate. b. phosphate. c. protein. d. urea.

b. phosphate.

Hyperventilation leads to: a. respiratory acidosis. b. respiratory alkalosis. c. metabolic acidosis. d. respiratory compensation.

b. respiratory alkalosis.

The driving force of water intake is: a. ADH. b. thirst. c. decline in blood volume. d. decrease in plasma osmolarity.

b. thirst.

The nurse explains to the client that the main reason a back rub is used as therapy to relieve pain is because the massage: blocks pain impulses from the spinal cord to the brain. blocks pain impulses from the brain to the spinal cord. stimulates the release of endorphins. distracts the client's focus on the source of the pain.

blocks pain impulses from the spinal cord to the brain.

A normal arterial pH is: a. 7.0. b. 7.2. c. 7.4. d. 7.8.

c. 7.4.

Aldosterone targets which part of the nephron? a. Glomerulus b. Proximal convoluted tubule c. Distal convoluted tubule d. Loop of Henle

c. Distal convoluted tubule

All the following trigger ADH release except: a. fever. b. burns. c. edema. d. vomiting

c. edema.

The JGA will respond to all of the following except: a. dehydration. b. the sympathetic nervous system. c. hypertension. d. a decrease in NaCl concentration

c. hypertension.

A mother brings her 10-year-old daughter in for a clinical consultation because she has observed the daughter eating chalk and corn starch. You recognize the condition as pica and order blood tests. You suspect that the test will show that she is deficient in: a. protein. b. sodium. c. iron. d. potassium.

c. iron.

The main intracellular electrolyte is: a. sodium. b. chloride. c. potassium. d. both sodium and chloride

c. potassium

Electrolyte balance" usually refers to the balance of: a. acids. b. bases. c. salts. d. pH.

c. salts.

When planning pain control for a client with terminal gastric cancer, a nurse should consider that: only low doses of opioids are safe; higher doses may cause respiratory depression. pain medication should be given only when a client requests it. a client who can fall asleep isn't in pain. clients with terminal cancer may develop tolerance to opioids.

clients with terminal cancer may develop tolerance to opioids.

A client who is admitted to an alcohol treatment program says, "I'm going to have a small morning drink to face the day. Usually, I just keep drinking." The nurse understands the client is in which stage of alcoholism? Prealcoholic phase Early alcoholic phase Crucial phase Chronic phase

crucial phase

Parathormone enhances the re-absorption of _________ ions. a. Sodium b. Potassium c. Chloride d. Calcium

d. Calcium

Which electrolyte is never secreted into the filtrate? a. Chloride b. Potassium c. Calcium d. Sodium

d. Sodium

ANP promotes which of the following? a. ADH release b. Aldosterone release c. Vasoconstriction d. Sodium excretion

d. Sodium excretion

The area of the brain that plays a major role in water and electrolyte balance is the: a. cerebral cortex. b. medulla. c. thalamus. d. hypothalamus.

d. hypothalamus.

The only electrolyte that exerts significant osmotic pressure is the: a. chloride ion. b. potassium ion. c. calcium ion. d. sodium ion

d. sodium ion

All of the following statements about electrolytes are true except: a. they conduct an electrical current. b. they include acids, bases, and salts. c. they possess a greater osmotic power than nonelectrolytes. d. they form mainly covalent bonds.

d. they form mainly covalent bonds.

When admitting a neonate whose mother received magnesium sulfate, the nurse should assess the baby for which complication? Select all that apply. increased Moro reflex decreased muscle tone increased respirations decreased respirations increased temperature

decreased muscle tone decreased respirations

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should assess the client for which alteration in fluid and electrolyte balance? increased osmolality of the plasma decreased serum sodium level increased urine output decreased blood pressure

decreased serum sodium level

The nurse is reviewing laboratory reports for a client who is taking allopurinol (medication to treat gout). Which finding indicates that the drug has had a therapeutic effect? decreased urine alkaline phosphatase level increased urine calcium excretion increased serum calcium level decreased serum uric acid level

decreased serum uric acid level

A female client is admitted to the emergency department after being sexually assaulted. The nurse notes that the client is sitting calmly and quietly in the examination room and recognizes this behavior as a protective defense mechanism. What defense mechanism is the client exhibiting? Intellectualization Denial Regression Displacement

denial

The nurse using healing touch affects a client's pain primarily through: directing the flow of energy fields. lightly touching the client skin. massaging the client's muscles. increasing endorphin production.

directing the flow of energy fields.

The father of a soldier who was killed 2 days ago is admitted after a serious suicide attempt. He is medically stable and has signed a no-harm contract. During a talk with the nurse, he says, "Terrorism and war are holding me and the whole world hostage. It is so unfair. I would rather be dead than live alone in constant fear." Which nursing interventions are important in the next few days? Select all that apply. discussing effective ways to express justifiable anger teaching stress management and relaxation techniques identifying community groups for relatives of military personnel recommending an antiwar advocacy group strategizing about ways to increase a personal sense of security

discussing effective ways to express justifiable anger teaching stress management and relaxation techniques identifying community groups for relatives of military personnel strategizing about ways to increase a personal sense of security

A client who comes to the crisis center in a very distressed state tells the nurse, "I just cannot get over being fired last week. I have asked for help. I have talked to friends. I have tried everything to get through this, but nothing is working. Help me!" Which initial crisis intervention strategy should the nurse use? referral for counseling support system assessment emotion management unemployment assistance

emotion management

An infant diagnosed with Hirschsprung's disease is scheduled to receive a temporary colostomy. When initially discussing the diagnosis and treatment with the parents, which action would be most appropriate? assessing the adequacy of their coping skills reassuring them that their child will be fine encouraging them to ask questions giving them printed material on the procedure

encouraging them to ask questions

An elderly client admitted with new-onset confusion, headache, poor skin turgor, bounding pulse, and urinary incontinence has been drinking copious amounts of water. Upon reviewing the lab results, the nurse discovers a sodium level of 122 mEq/L (122 mmol/L). A report to the health care provider (HCP) should include what recommendations? Select all that apply. fluid restriction encourage fluids vital signs every 4 hours instead of every shift bed alarm Foley catheter strict intake and output repeat electrolytes, urine for sodium and specific gravity in the morning 2-g sodium diet

fluid restriction vital signs every 4 hours instead of every shift bed alarm Foley catheter strict intake and output repeat electrolytes, urine for sodium and specific gravity in the morning

Which finding is a risk factor for hypovolemic shock? hemorrhage antigen-antibody reaction gram-negative bacteria vasodilation

hemorrhage

Hypotonic Solution - Osmolality ______ than of 250mOsm/L Water moves ___ of blood vessel the cells and interstitial tissue. Used for: Patients with hypertonic dehydration

higher, out

A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which complication? heart failure deep vein thrombosis hypokalemia hypocalcemia

hypokalemia

A client who has been vomiting for 2 days has a nasogastric tube inserted. The nurse notes that over the past 10 hours the tube has drained 2 L of fluid. The nurse should further assess the client for: hypermagnesemia. hypernatremia. hypokalemia. hypocalcemia.

hypokalemia

Isotonic solution has an osmolity of 250 - 375mOsm/L Remain _______ the intravasacular compartments __ fluid shifting occurs Expands only _CF Ideal for pts with ____volemia or hypotension. Examples: 0.9% saline Lactated Ringer's solution

inside, no, hypo

A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the hospital in a daze without any outward display of emotions. The client is being admitted to the stress unit with the diagnosis of acute stress disorder. The client tells the nurse in a matter-of-fact manner that her husband is paraplegic, "but that is better than total paralysis." Which protective mechanism is the client exhibiting? suppression rationalization denial intellectualization

intellectualization

Hypertonic Solutions - Water moves from ICF & interstitial compartments ______ vascular space

into

Since the diagnosis of stomach cancer, the client has been having trouble sleeping and is frequently preoccupied with thoughts about how life will change. The client says, "I wish my life could stay the same." Based on this information, the nurse should understand that the client: is having difficulty coping. has a sleep disorder. is grieving. is anxious.

is grieving

Air embolus - Place client in Trendelenburg position on the ____ side, Administer oxygen

left

Nurse is responsible for administering IVF to the correct client at the right rate and monitoring response. Too rapid an infusion or inappropriate infusions can result in reactions that range from ____ to _____!

mild to fatal

D10W has: __ electrolytes Limit of dextrose concentration may be infused ____________

no, peripherally

The nurse's discharge teaching plan for the client with heart failure should emphasize the importance of: maintaining a high-fiber diet. walking 2 miles (3.2 km) every day. obtaining daily weights at the same time each day. remaining sedentary for most of the day.

obtaining daily weights at the same time each day

A 3-month-old has moderate dehydration. The nurse should assess the client for: oliguria. bulging eyes. sunken posterior fontanel. pale skin color.

oliguria.

The second morning after surgery for a below-the-knee amputation of the left leg, the client says, "This sounds crazy, but I feel my left toes tingling." This statement would indicate to the nurse that he is experiencing a: denial reaction. phantom-limb sensation. hallucination. body image disturbance.

phantom-limb sensation

The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral breast reduction. Which aspect of the plan is the priority? reduction of risk potential physiologic adaptation psychosocial integrity health promotion and maintenance

psychosocial integrity

A client with colon cancer experiences an increase in feelings of anxiety and depression and has suicidal ideation. The nurse realizes that these feelings occur during which stage of the disease? initiation of definitive treatment end of the first course of treatment end stage of the disease recurrence of the disease

recurrence of the disease

The major goal of therapy in crisis intervention is to: withdraw from the stress. resolve the immediate problem. decrease anxiety. provide documentation of events.

resolve the immediate problem.

The nurse is conducting a counseling session with a client experiencing posttraumatic stress disorder (PSTD) using a 2-way video telehealth system from the hospital to the client's home, which is 2 hours away from the nearest mental health facility. What are expected outcomes of using telehealth as a venue to provide health care to this client? Select all that apply. The client will: save travel time from the house to the health care facility. avoid reliving a traumatic event which might be precipitated by visiting a health care facility. experience a shorter recovery time than being treated by being on-site at a health care facility. receive health care for this mental health problem. obtain group support from others with a similar health problem.

save travel time from the house to the health care facility. avoid reliving a traumatic event which might be precipitated by visiting a health care facility. receive health care for this mental health problem.

When reviewing the plan of care for a client with Alzheimer's disease, which intervention would the nurse question? reminiscence group walking pet therapy stress management

stress management

A client is eligible for patient-controlled analgesia (PCA) when: a family member is able to assist with self-dosing. there are advanced directives in place. the client has the ability to self-administer. there is a nurse to assist with self-administration.

the client has the ability to self-administer.

A client with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is: fluid intake and output. urine specific gravity. vital signs. weight.

weight.