HESI (mixed RN questions)

While reviewing the diagnostic test reports of a client with a kidney tumor, the nurse finds that the tumor has spread to the renal vein and lymph nodes. Which stage of kidney tumor is indicated by this finding? Multiple choice question Stage I Stage II Stage III Stage IV

Stage III A stage III kidney tumor extends to the renal vein and lymph nodes. A stage I kidney tumor is situated within the capsule of the kidney. A stage II kidney tumor is located beyond the capsule but within Gerota's fascia. A stage IV kidney tumor invades the adjacent organs beyond Gerota's fascia or metastasizes to distant tissues.

what causes a plantar wart?

HPV

The leader nurse is calculating the average daily census (ADC) in a 40-bed medical surgical unit, which accrued 679 client days in the month of July. What is the ADC on this unit? Record your answer using a whole number.

The formula is client days for a given time period divided by the number of days in the time-period. There are 31 days in July, so 679/31 = 21.9. Therefore, the ADC is 21.9, rounded to 22.

Which structure helps to bend light rays and allow them to fall onto the retina? Multiple choice question Lens Zonule Cornea Aqueous humor

The lens is a biconvex structure located behind the iris. Its primary function is to bend light rays, allowing them to fall onto the retina. The zonule is a series of microscopic wire-like threads that holds the lens in place. The cornea is responsible for the majority of the light refraction necessary for clear vision. The aqueous humor provides nutrition to ocular tissues and maintains intraocular pressure.

whats Varicella-zoster virus

an acute, painful inflammation of the nerve ganglia, with a skin eruption often forming a girdle around the middle of the body. It is caused by the same virus as chickenpox.

A nurse evaluates that a client understands appropriately how to take the antacids prescribed by the primary health care provider when the client makes which statement? Multiple choice question "I will take this antacid at the onset of pain." "I will take this antacid 30 minutes after meals." "I will take this antacid every 4 hours around the clock." "I will take this antacid each time I have something to eat."

"I will take this antacid 30 minutes after meals." Antacids are most effective when taken after digestion has started but before the stomach begins to empty. Antacids should be taken before the onset of pain; pain indicates that gastric irritation has begun, and the aim of treatment is to protect the gastrointestinal mucosa. Antacids taken every 4 hours around the clock interfere with the absorption of nutrients. Antacids taken with food interfere with the absorption of nutrients.

A mother brings her 9-month-old infant to the clinic. The nurse is familiar with the mother's culture and knows that belly binding to prevent extrusion of the umbilicus is a common practice. The nurse accepts the mother's cultural beliefs but is concerned for the infant's safety. What variation of belly binding does the nurse discourage? Multiple choice question Coin in the umbilicus Tight diaper over the umbilicus Binder that encircles the umbilicus Adhesive tape across the umbilicus

A coin may be dislodged, allowing the infant to put it in his or her the mouth, resulting in a safety issue. A diaper fastened tightly around the waist, a binder, or adhesive tape over the umbilicus will not endanger the infant. Cultural beliefs that do not place the infant at risk should not be discouraged.

A nurse is caring for a client who was admitted to the hospital with the diagnosis of tertiary syphilis. Which system of the body should the nurse assess most closely in this stage of the disease? Multiple choice question Reproductive Cardiovascular Lower respiratory Lower gastrointestinal

Cardiovascular Tertiary syphilis is the last stage, affecting several body systems: skin, cardiovascular, and neurological - Aortic valvular disease and aortic aneurysms can occur. Although lesions occur on the genitalia during primary and secondary syphilis, the reproductive system is not the major body system affected in tertiary syphilis. Structures of the lower respiratory tract and gastrointestinal are not the major structures involved in tertiary syphilis.

After abdominal surgery, a 5-year-old child is experiencing pain, and an opioid analgesic is prescribed. What should the nurse consider about children in pain and their response to opioid analgesics when an opioid analgesic is prescribed? Multiple choice question Addiction to opioids is more of a risk for children than adults. Analgesics are not needed as frequently because pain is not as strongly felt by children as it is by adults. Even though children do not like taking medicines, analgesics will make them more comfortable. Children do not need analgesics because they are easily distracted and will quickly return to play or sleep.

Even though children do not like taking medicines, analgesics will make them more comfortable

Which bacterial skin infections are caused by group A β-hemolytic streptococci? Multiple selection question Furuncle Cellulitis Impetigo Folliculitis Erysipelas

Impetigo n Erysipelas Impetigo is caused by group A β-hemolytic streptococci, staphylococci, or a combination of both. Erysipelas is caused by group A β-hemolytic streptococci. Furuncle is a deep infection with staphylococci. Staphylococcus aureus and streptococci are the usual causative agents of cellulitis. Usually staphylococci are responsible for folliculitis.

A nurse reviews a list of medications that have been prescribed for a client. The nurse is aware that it is unsafe to administer which medication as an intravenous (IV) bolus? Multiple choice question Saline flush Potassium chloride Naloxone Adenosine

Potassium chloride Potassium chloride given as an IV bolus can cause cardiac arrest. It should never be administered intravenously without being diluted and infused slowly through an IV infusion pump. Saline flush, naloxone, and adenosine are appropriate to be given as an IV bolus undiluted.

The nurse is caring for a client in the postanesthesia care unit. The client had a suprapubic prostatectomy for cancer of the prostate and has a continuous bladder irrigation (CBI) in place. Which primary goal is the nurse trying to achieve with the CBI? Multiple choice question Stimulate continuous formation of urine. Facilitate the measurement of urinary output. Prevent the development of clots in the bladder. Provide continuous pressure on the prostatic fossa.

Prevent the development of clots in the bladder. A continuous flushing of the bladder dilutes the bloody urine and empties the bladder, preventing clots. Fluid instilled into the bladder does not affect kidney function. Urinary output can be measured regardless of the amount of fluid instilled. The urinary retention catheter is not designed to exert pressure on the prostatic fossa.

A nurse is reviewing how a hyperglycemic client's blood glucose can be lowered. The nurse recalls that the chemical that buffers the client's excessive acetoacetic acid is what? Multiple choice question Potassium Sodium bicarbonate Carbon dioxide Sodium chloride

Sodium bicarbonate is a base and one of the major buffers in the body. Potassium, a cation, is not a buffer; only a base can buffer an acid. Carbon dioxide is carried in aqueous solution as carbonic acid (H 2CO 3); an acid does not buffer another acid. Sodium chloride is not a buffer; it is a salt.

The client's laboratory report shows localized vasodilation and transudation of fluid. The nurse interprets these findings as erythema and a wheal. Which condition may be present in the client? Multiple choice question Urticaria Angioedema Allergic rhinitis Contact dermatitis

Urticaria Urticaria is a cutaneous reaction to systemic allergens that occurs in atopic people. Histamine causes localized vasodilation (erythema), transudation of fluid (wheal), and flaring. Angioedema is a localized cutaneous lesion similar to urticaria. Dilation and engorgement of the capillaries resulting from the release of histamine cause diffuse swelling. Allergic rhinitis is the most common type I hypersensitivity reaction. Symptoms include nasal discharge, sneezing, lacrimation, and pruritus. Contact dermatitis manifests as erythematous and edematous skin lesions covered in papules, vesicles, and bullae.

A client receiving the medication buspirone is admitted to the hospital with the diagnosis of possible hepatitis. The nurse identifies that the client's sclerae look yellow. What will be the nurse's initial action? Multiple choice question Withhold the medication. Give the buspirone with milk. Reduce the dosage of the medication. Ensure that the medication can be given parenterally.

Withhold the medication. The medication should be stopped immediately, because jaundice indicates possible liver damage, which prolongs elimination of the drug and may result in toxic accumulation. Milk does not change the effect of the drug. The drug must be stopped, not reduced. The drug is available only in an oral form; in addition, the route of administration will not influence the occurrence of toxic accumulation.

After the nurse has completed an oral examination of a healthy 2-year-old child, the parent asks when the child should first be taken to the dentist. What is the best response by the nurse? Multiple choice question Before starting school Within the next few months When the first deciduous teeth are lost The next time a family member visits the dentist

Within the next few months The child should be taken to the dentist between 2 and 3 years of age, when most of the 20 deciduous teeth have erupted. Before the child starts school and when the first deciduous teeth are lost are both too late. The suggestion that the child come to the dentist the next time a family member visits the dentist is too indefinite.

Which clinical indicators is the nurse most likely to identify when taking the admission history of a client with right ventricular failure? Multiple selection question Edema Vertigo Polyuria Ascites Palpitations

edema, ascites Heart failure is the failure of the heart to pump adequately to meet the needs of the body, resulting in a backward buildup of pressure in the venous system. Clinical manifestations include edema, ascites, hepatomegaly, tachycardia, and fatigue. Dyspnea occurs in left-sided heart failure because of pulmonary congestion and inadequate delivery of oxygen to all body cells. Vertigo generally is not related to right ventricular failure. Because a diminished cardiac output decreases blood flow to the kidneys, there will be a decreased, not increased, urine output (polyuria). Palpitations may indicate dysrhythmias or anxiety.

A nurse is teaching dietary management to the parents of a toddler who is undergoing chelation therapy to treat lead poisoning. What will be included in the discussion of the dietary plan? Multiple choice question Maintaining a low-salt diet Ensuring adequate fluid intake Avoiding refined sugar and flour Offering high-calorie, low-protein foods

ensuring adequate fluids Adequate hydration is needed because the lead complexes released during chelation therapy are excreted by the kidneys. There is no basis for restricting salt in the diet of a child with lead poisoning. There is no basis for restricting intake of refined sugar and flour except for improving the nutrition of every child, not just those with lead poisoning. There is no reason to increase caloric intake unless the child is underweight; it is unnecessary to restrict protein. che·la·tion ther·a·py a therapy for mercury or lead poisoning that binds the toxins in the bloodstream by circulating a chelating solution. a form of complementary therapy involving the intravenous infusion of substances intended to remove calcium from hardened arteries. - adequate urinary output is required when giving this and adequate hydration

A client is admitted to the emergency department with head trauma resulting from an accident. The client opens both eyes to painful stimuli, makes incomprehensible sounds, and flexes to pain. Using the Glasgow Coma Scale, which score will the nurse document in the client's medical record? Multiple choice question 8 9 12 15

8 The score is 8. The Glasgow Coma Scale[1][2] is a three-part neurologic assessment measuring eye opening, response to auditory stimuli, and motor response; the lower the score, the deeper the coma. A score of 8 or less indicates coma. Nine and 12 are too high a rating for the behaviors exhibited by the client. A rating of 15 indicates that the client is opening the eyes spontaneously, obeying commands, and fully oriented.

nurse advises the parent of a three-year-old child to encourage scribbling and drawing in the child. Which skills does the nurse plan to enhance in the child by this intervention? Multiple selection question Reading Fine muscle Gross motor Advanced memory Eye-hand coordination

According to Kellogg, scribbling and drawing helps children to learn to read, develop fine muscle skills, and develop eye-hand coordination. Scribbling and drawing may not help develop gross motor and advanced memory skills.

Which is a developmental milestone related to feeding that the nurse anticipates for a 15-month-old client? Multiple choice question Using a straw to drink Drinking well from a cup Chewing food with mouth closed Spilling small amounts of food when using a spoon

Drinking well from a cup The nurse would anticipate that a 15-month-old toddler can drink well from a cup. The use of a straw to drink liquids and chewing food with the mouth closed is an expectation for the 24-month-old toddler. Spilling small amounts of food when using a spoon is an expectation for a 36-month-old toddler.

A client complains to the nurse manager about a coworker. The nurse manager listens to both the patient's and the coworker's side of the story. Which critical thinking quality is shown in this situation? Multiple choice question Fairness Discipline Risk-taking Responsibility

Fairness Fairness is the critical thinking attitude shown by the nurse in this situation. When there is a complaint about a coworker, the nurse should listen to both sides and make a fair decision. Discipline is applicable when the nurse uses known scientific and practice-based criteria for successful time management. Risk-taking is applicable when the healthcare provider orders the nurse to do a task and the nurse recommends alternative approaches of nursing care. Responsibility is applicable when a nursing skill is performed by following standard care practices.

A primigravida asks the nurse, "I've got this blotchy skin on my face, my nipples are darker, and there's this dark line down the middle of my stomach. What causes that?" The nurse explains that the gland that causes these expected changes during pregnancy is the what? Multiple choice question Adrenal gland Thyroid gland Anterior pituitary gland Posterior pituitary gland

Hypersecretion of melanocyte-stimulating hormone (MSH) from the anterior pituitary gland causes darkened pigmentations during pregnancy. MSH is not secreted by the adrenal glands, thyroid gland, or posterior pituitary gland.

Who is most accountable for an initial assessment and the ongoing evaluation of client care? Multiple choice question Client Registered nurse Licensed practical nurse Unlicensed nursing personnel

Registered nurses are accountable for initial assessment and the ongoing evaluation of client care. The client is not responsible for assessment and evaluation. The licensed practical nurse has a responsibility to assess and report client care. Unlicensed nursing personnel perform tasks as delegated by the registered nurse.

A nurse expects that when an individual successfully completes the grieving process after the death of a significant other, the individual will be able to do what? Multiple choice question Accept the inevitability of death. Go on with life while forgetting the past. Remember the significant other realistically. Focus mainly on the good qualities of the person who died.

Remember the significant other realistically. Successful resolution means being able to remember the good as well as the bad qualities of the deceased and accepting them as part of the deceased's being human. Resolution involves working through feelings, not just accepting what occurred. Resolution does not mean forgetting; rather it means realistically remembering the past. Focusing mainly on the good qualities of the person who died is an unhealthy response that may become pathologic as a result of the unresolved feelings about the person's other qualities.

While working with a delegatee, the registered nurse says to the delegate, "It's easy; you can do the procedure tomorrow after watching me do it today. Just follow the steps I have demonstrated." What is the behavior of the registered nurse in this situation? Multiple choice question Telling Selling Delegating Participating

Selling Telling the delegatee that the procedure is easy and he or she can do it by following the demonstrated steps utilizes persuasion. According to Hersey's model, persuading statements of a delegator indicates selling behavior. According to Hersey's model, directing statements indicate telling behavior. According to Hersey's model, monitoring statements indicate delegating behavior. According to Hersey's model, problem-solving statements indicate participating behavior.

What is the role of shark cartilage in the management of human immunodeficiency (HIV) and acquired immunodeficiency syndrome (AIDS)? Multiple choice question Shark cartilage enhances immunity Shark cartilage reduces oral thrush Shark cartilage is a complementary therapy Shark cartilage is a nutritional supplement

Shark cartilage is considered as an alternative or complementary therapy to prescribed medications for clients with HIV and AIDS. Lymphocyte transfusions and bone marrow transplants are used to improve immunity in clients with HIV and AIDS. Lemon juice and lemongrass may provide relief from oral thrush in some clients with HIV and AIDS. A high-calorie, high-protein diet is advised to clients with HIV and AIDS to improve their nutritional status.

During a well-child visit the parents tell a nurse, "Our 3-year-old doesn't listen to us when we speak and ignores us!" An auditory screening reveals that the child has a mild hearing loss. What should the nurse explain to the parents about this degree of hearing loss? Multiple choice question A severe hearing deficit may develop. It will not interfere with progress in school. An immediate follow-up visit is not necessary. Speech therapy in addition to hearing aids may be required.

Speech therapy in addition to hearing aids may be required. A mild degree of hearing loss causes the child to miss approximately 25% to 40% of conversations; it may result in speech deficits and interfere with the child's educational progress if it is not corrected. Hearing aids usually help improve function. There is no evidence that this child's hearing loss is progressive. The significance of the hearing loss requires further analysis and intervention.

Which sexually transmitted infection (STI) is caused by Treponema pallidum? Multiple choice question Syphilis Gonorrhea Genital warts Vulvovaginitis

Syphilis Syphilis is an STI caused by Treponema pallidum. Neisseria gonorrhoeae causes gonorrhea. Haemophilus ducreyi and Klebsiella granulomatis cause genital warts. Herpes simplex virus, Trichomonas vaginalis, and Candida albicans may cause vulvovaginitis.

While performing patterned, paced breathing during the transition phase of labor, a client experiences tingling and numbness of the fingertips. What should the nurse do? Multiple choice question Tell the client to breathe into a paper bag. Place an oxygen mask over the client's face. Call the primary healthcare provider to report the client's response. Instruct the client to begin taking slow deep breaths.

Tell the client to breathe into a paper bag. A paper bag enables the client to rebreathe carbon dioxide, which helps correct the respiratory alkalosis resulting from hyperventilation. The client's oxygen level is increased; the client needs to increase the carbon dioxide level and decrease the oxygen level. The client should rebreathe her own exhalations first; if alkalosis persists, more intensive treatment may be needed. Carbon dioxide is too dilute in room atmosphere; deep breaths will not resolve the alkalosis.

The nurse is caring for a client who meets the criteria for the emergency severity index level 2 (ESI-2). How soon should the client be seen by the physician? Multiple choice question Immediately Within 1 hour Within 2 hours Within 10 minutes

The client at ESI-2 should be cared for within 10 minutes. Clients at ESI-1 should be cared for immediately. Stable clients at ESI-2 or ESI-3 can be given care after 1 and 2 hours, respectively.

A nurse is administering hydroxyzine to a client. The nurse will monitor the client for which common side effects of this drug? Multiple choice question Ataxia and confusion Drowsiness and dry mouth Vertigo and impaired vision Slurred speech and headache

Drowsiness and dry mouth Hydroxyzine suppresses activity in key regions of the subcortical area of the central nervous system; it also has antihistaminic and anticholinergic effects. Ataxia and confusion, vertigo and impaired vision, and slurred speech and headache are not associated with hydroxyzine.

What are the general manifestations associated with clients who have urinary system disorders? Multiple selection question Facial edema Excessive thirst Stress incontinence Nausea and vomiting Elevated blood pressure

Excessive thirst Nausea and vomiting Elevated blood pressure The general manifestations associated with urinary system disorders include excessive thirst, nausea and vomiting, and elevated blood pressure. The specific manifestations associated with urinary system disorders include facial edema and stress incontinence.

A nurse is planning care for a toddler who has ingested aspirin. What assessment warrants close monitoring because an increase can result in further complications? Multiple choice question Blood pressure Abdominal girth Body temperature Serum glucose level

Hyperpyrexia (increased temperature) is a manifestation of acute aspirin poisoning; this leads to increased oxygen consumption and heat loss. Blood pressure is not directly affected by aspirin ingestion. Ascites does not occur as a result of aspirin ingestion; it may occur if liver failure develops. Aspirin ingestion does not affect the serum glucose level.

The nurse and client have entered the working phase of a therapeutic relationship. What can the nurse expect the client to do during this phase? Multiple selection question Initiate topics of discussion. Focus the conversation on the nurse. Repress emotionally charged material. Accept limits on unacceptable behavior. Express emotions related to transference.

Initiate topics of discussion. Accept limits on unacceptable behavior. Express emotions related to transference. This phase is focused on developing the client's problem-solving skills while addressing the areas in the client's life that are causing problems. The nurse helps clients identify these topics for discussion. Focusing the conversation on the nurse occurs during the orientation phase, before trust is established. Repressing emotionally charged material occurs during the orientation phase, before trust is established. Resistant behaviors usually are overcome by the working phase. During the working phase of a therapeutic relationship trust is established on the basis of mutual respect. Once trust is established the client will feel comfortable enough to express feelings; feelings of transference and countertransference usually awaken during the working phase of a therapeutic relationship.

What is the expected average weight for a 6-month-old child? Multiple choice question 680 g (1.5 lb) 7.26 kg (16 lb) 11.34 kg (25 lb) 9.75 kg (21.5 lb)

The average weight of a 6-month-old child is 7.26 kg (16 lb). The average weight gain in an infant is 680 g (1.5 lb) per month until age 5 months, when the birth weight has at least doubled. The average weight of a 6-month-old child is not as high as 11.34 kg (25 lb). The average weight of a 1-year-old child is 9.75 kg (21.5 lb).

What instructions about the use of nitroglycerin should the nurse provide to a client with angina? Multiple choice question "Identify when pain occurs, and place two tablets under the tongue." "Place one tablet under the tongue, and swallow another when pain is intense." "Before physical activity, place one tablet under the tongue, and repeat the dose in 5 minutes if pain occurs." "Place one tablet under the tongue when pain occurs, and use an additional tablet after the attack to prevent recurrence."

"Before physical activity, place one tablet under the tongue, and repeat the dose in 5 minutes if pain occurs." Anginal pain, which can be anticipated during certain activities, may be prevented by dilating the coronary arteries immediately before engaging in the activity. Generally one tablet is administered at a time; doubling the dosage may produce severe hypotension and headache. The sublingual form of nitroglycerin is absorbed directly through the mucous membranes and should not be swallowed. When the pain is relieved, rest generally will prevent its recurrence by reducing oxygen consumption of the myocardium.

What is the most important information the nurse can share with a client who is just diagnosed with hypertension? Multiple choice question "Continue with long-term follow-up care." "Monitor yourself for signs of hypertension." "Perform occasional blood pressure measurements." "Adjust your antihypertensive dose based on daily blood pressure results."

"Continue with long-term follow-up care." Hypertension can affect other body tissues, such as the kidneys and eyes; follow-up care and adherence to the therapeutic regimen (e.g., medications, diet, and exercise) are imperative. Hypertension often is asymptomatic, not symptomatic, and the client is already diagnosed with hypertension. The client should maintain routine (e.g., daily, weekly) records of blood pressure results as advised. The medication regimen should be followed exactly as prescribed; doses are adjusted by the healthcare provider.

A nurse is reviewing discharge plans with a client who is hospitalized with hepatitis A. The nurse concludes that the client understands preventive measures to reduce the risk of spreading the disease when the client makes what statement? Multiple choice question "I should wash my hands frequently." "I should launder my clothes separately." "I should put used tissues in the garbage." "I should wear a mask when leaving the house."

"I should wash my hands frequently." Hepatitis A microorganisms are transmitted via the anal-oral route; handwashing, particularly after toileting, is the most important precaution. The response "Launder my clothes separately" will not deter the spread of the virus; handwashing is necessary. Putting used tissue in the garbage is important, but handwashing is the most important precaution. Hepatitis A microorganisms exit through the rectum, not the respiratory tract.

The nurse determines that a young female client who is being treated for a sexually transmitted infection (STI) understands instructions regarding future sexual contacts. Which client statement confirms the nurse's conclusion? Multiple choice question "If I have sex, nothing I do will really prevent me from getting another STI." "If I get another STI, I can take any antibiotic, because I'm not allergic to any of them." "I won't have unprotected sex again, and I'll tell my partners to be tested for STIs." "I have to ask my partners if they have an STI, and if they say no I'll know that I can have sex."

"I won't have unprotected sex again, and I'll tell my partners to be tested for STIs."

A client who is receiving haloperidol, 5 mg three times a day, complains of twitching of the fingers. What is the best response by the nurse? Multiple choice question "This is a temporary situation until your body adjusts to the medication." "You need the medication that we're giving you. You'll get used to the side effects soon." "Let's wait a few days and see whether the side effects of the drug you're taking go away." "I'll ask the primary healthcare provider to prescribe a medication that'll help overcome this. It's a side effect of the drug you're taking."

"I'll ask the primary healthcare provider to prescribe a medication that'll help overcome this. It's a side effect of the drug you're taking." The finger twitching is a side effect of the medication that can be treated. Offering to ask the primary healthcare provider for a medication to alleviate it validates the client's concern and reassures the client that help is available to address the situation. This is not a temporary side effect. However, it is a reversible condition that can be treated with benztropine or diphenhydramine. Twitching is not a sign that requires patience for adjustment but rather one that must be treated. Failure to address side effects increases the risk of the client not following the medication regimen. Early treatment to reverse the twitching is important.

A client has a colostomy as a result of surgery for cancer of the colon. Which nurse's statement will most effectively minimize the client's stress the first time self-irrigation is done? Multiple choice question "If you are still a little nervous because this is the first time, I'll be happy to do it for you, and you can do it next time." "You have to learn how to do this yourself before discharge. The best place to start is to assemble all the equipment needed for the irrigation." "I'll draw the curtain and assemble all the equipment. Would you like me to stay, or do you prefer to try it yourself and call me if you need help?" "You have a gown on, so I won't draw the curtain unless you want me to. Do you feel comfortable doing the irrigation, or do you want me to do it instead?"

"I'll draw the curtain and assemble all the equipment. Would you like me to stay, or do you prefer to try it yourself and call me if you need help?" Drawing the curtain protects the client's privacy, and the client can make decisions about care; independence is encouraged, and nursing assistance is offered. Raising the issue of nervousness may increase anxiety and promote dependence. Although learning self-care begins in the hospital, teaching will continue in the client's home or extended care facility. While the client is in the hospital, the nurse should assemble the equipment. Having the client ask for the curtain drawn places the client in the position of asking for privacy. The client should be encouraged to attempt self-care rather than be offered an opportunity to continue to be dependent.

An adolescent with the diagnosis of antisocial personality disorder is admitted to the hospital after ingesting 20 tablets of an anxiolytic. When obtaining the client's history, the nurse learns that there was an arrest for drug use and that the client is out on bail. During visiting hours the nurse discovers the client and visitors smoking marijuana in the hall. When confronted, the client responds, "I'm celebrating. Didn't you hear? I went to trial today and just got put on probation." What is the best response by the nurse? Multiple choice question "You were lucky you just got probation, so don't get right back into trouble." "I understand your relief about the trial, but smoking pot is against the rules." "It's important that you and your friends join the other visitors in the dayroom." "If you can't follow the rules against drug use on the unit, your visiting privileges will be canceled."

"If you can't follow the rules against drug use on the unit, your visiting privileges will be canceled." This client needs firm, realistic limits set on behavior. The statement "If you can't follow the rules against drug use on the unit, your visiting privileges will be canceled" permits the client to make the choice and clearly states the consequences of behavior. Clients with this diagnosis do not learn from past errors. The response "I understand your relief about the trial, but smoking pot is against the rules" states the limits but does not inform the client of the consequences if the limits are broken. Clients with the diagnosis of antisocial personality disorder do not care about rules. The client and visitors will probably refuse to socialize with other clients and visitors.

A nurse is trying to bring about a change in the wellness behavior of an obese client. The nurse provides a chart depicting a proper diet and enumerates the benefits of good eating habits. What response might the nurse expect from the client if the client is in the preparation stage? Multiple choice question "I'm perfectly happy and confident about my body and my health." "I can't quit eating junk food twice a week, even with this diet plan." "Please tell me how to stay successful with this diet with my hectic career." "Please help me come up with a realistic strategy for sticking to this diet plan."

"Please help me come up with a realistic strategy for sticking to this diet plan A client in the preparation stage of health behavior change believes that the benefits of behavior change should be taken into consideration. The client may require help in planning to bring about the desired change in health behavior. A client in the precontemplation stage will not show any interest in the information provided by the nurse and might even become defensive. A client in the action stage might find old habits a hindrance when trying to engage in new behaviors. A client who has reached the maintenance stage might require the nurse's assistance in integrating changes into the lifestyle.

A client with a disturbed state of mind is under observation. Which statement made by the nurse indicates that the client is suffering from dementia? . Multiple selection question "The client is very depressed." "The client is not able to make decisions." "The client always tells about his/her failures." "The client is not able to perform purposeful work." "The client has a completely disturbed sleep/wake cycle."

"The client is not able to make decisions." "The client is not able to perform purposeful work." A client with dementia may not able to make decisions because it affects thinking ability. The client with dementia may suffer from apraxia in which the client is not able to perform purposeful work. In depression, the client will remain depressed but in dementia, the mood is affected superficially. A client with depression may tell about his/her failures, but in dementia, the client may or may not be able to recollect details of life. In dementia, the sleep/wake cycle of the client is a bit fragmented but in depression, it is completely disturbed.

The registered nurse is teaching a nursing student about the duties of various health care professionals during disaster management. Which statement by the nursing student indicates a need for further teaching? Multiple selection question "Emergency planning is implemented by the hospital incident commander." "The community relations officer serves as a liaison between hospital administration and media." "The medical command physician assumes overall leadership for all activities of disaster management." "If physician resources are short, the experienced nurse may assume the position of triage officer." "The public relations officer should be able to draw the media's attention to the clinical areas for better media coverage."

"The medical command physician assumes overall leadership for all activities of disaster management." "The public relations officer should be able to draw the media's attention to the clinical areas for better media coverage." While managing a disaster, the role of medical command physician is to decide the resource needs for clients; the hospital incident commander assumes overall leadership. The public relations officer or community relations officer should draw the media away from clinical areas, not toward them, to prevent contamination and disturbance. The hospital incident commander is in charge of implementing the emergency plan. The public relations officer or community relations officer should serve as a liaison between the hospital administration and media. When there are limited resources of physicians, an experienced nurse can act as triage officer.

A nursing student is learning about the nursing process, which consists of four components. Which scenarios would be considered output components? Multiple selection question "While assessing a client, the nurse finds a history of mental illness." "While assessing an obese client, the nurse finds a history of asthma." "The nurse notices that the client's wounds have healed after performing regular wound debridement." "The nurse notices that the client has developed an infection at the surgical site after the dressing has been changed." "The nurse finds that the client's blood pressure has increased even though medication is administered on a timely basis."

"The nurse notices that the client's wounds have healed after performing regular wound debridement." "The nurse notices that the client has developed an infection at the surgical site after the dressing has been changed." "The nurse finds that the client's blood pressure has increased even though medication is administered on a timely basis." The output component determines whether the client's health status has improved, declined, or is stable as a result of nursing care. Noticing that the client's wounds have healed after performing regular wound debridement is an example of output. Noticing the development of an infection at a client's surgical site after the dressing has been changed and noticing that the blood pressure level of a client has increased even after medication is administered on a timely basis are also examples of output. When the nurse discovers that a client has a history of mental illness, this finding an example of input. When the nurse discovers that an obese client has a history of asthma, this finding is an example of 'input' component.

The nurse is assessing an 8-year-old child who suffers from encopresis. Which advice given by the nurse provides effective treatment for the child? Multiple selection question "You should drink lots of fluid." "You should include milk in your diet." "You should delay the urge to defecate." "You should include cereals in your diet." "You should eat fresh fruit for breakfast."

"You should drink lots of fluid." "You should include cereals in your diet." "You should eat fresh fruit for breakfast." Encopresis is the voluntary or involuntary passage of feces of varying consistency in inappropriate settings. The child with encopresis usually has constipation. Therefore cereals should be included in the child's diet, because they contain high amounts of fiber, which helps in the formation and passage of regular stools. Sufficient water is necessary to prevent constipation or pain during defecation. Therefore, the nurse instructs the child to drink sufficient fluids. Fruits are also rich fiber sources and ease the process of defecation. Milk increases the risk of uncontrolled defecation. Therefore, the nurse instructs the child to avoid milk. Delaying defecation results in water absorption from the stool, which may cause constipation and increased pain during defecation.

What is the function of a client's cranial nerve VI? Multiple choice question Movement of the eye with levator muscle Movement of the eye with lateral rectus muscles Movement of the eye with medial rectus muscles Movement of the eye with superior oblique muscles

Activates the classic The classic complement pathway is activated by the IgG and IgM antibodies. IgE antibodies cause a degranulation of mast cells. IgA antibodies are found largely in mucous membrane secretions and play an important role in preventing upper and lower respiratory tract infections. complement pathway

A client is admitted to the hospital with severe back and abdominal pain, nausea and occasional vomiting, and an oral temperature of 101° F (38.3° C). The client reports drinking six to eight beers a day. A diagnosis of acute pancreatitis is made. Based on the data presented, what symptom is the primary nursing concern for this client? Multiple choice question Acute pain Inadequate nutrition Electrolyte imbalance Disturbed self-concept

Acute pain Pain with pancreatitis usually is severe and is the major symptom; it occurs because of the autodigestive process in the pancreas and peritoneal irritation. Although clients with this medical diagnosis often are malnourished, addressing the client's pain takes priority. There are not enough data for electrolyte imbalance; additional data, such as for skin turgor, serum electrolytes, and intake and output, are needed to identify whether the client has a fluid and electrolyte imbalance. There are no data to support the presence of a disturbed self-concept.

Which nursing action is the priority when administering chelation therapy for a preschool-age client? Multiple choice question Assessing vital signs Monitoring urine output Conducting a behavioral assessment Providing education to reduce lead exposure

Adequate urinary output must be ensured with administration of calcium EDTA, the medication used for chelation therapy. Clients receiving the drug intramuscularly must be able to maintain adequate oral intake of fluids. Monitoring vital signs, conducting a behavioral assessment, and providing education to reduce lead exposure are not priority nursing actions when administering chelation therapy.

When caring for a newly admitted depressed client, a nurse arranges for a staff member to remain with the client continuously. What information supports the nurse's decision to institute this precaution? Multiple selection question Refusal to eat any food Inability to concentrate Agitated pacing in the hall History of suicide attempts Statements that life is not worth living Some depressed clients demonstrate agitation rather than psychomotor retardation. Agitated clients are more likely to act impulsively, increasing the risk for self-harm. Clients who have attempted suicide in the past are at risk for attempting suicide in the future. Suicidal ideation may progress to suicide threats, gestures, or attempts. Although depressed clients may not have the energy to eat, this is not an initial priority. An inability to concentrate is a common complaint of depressed clients, but it has not been linked to an increased risk for suicide.

Agitated pacing in the hall History of suicide attempts Statements that life is not worth living Some depressed clients demonstrate agitation rather than psychomotor retardation. Agitated clients are more likely to act impulsively, increasing the risk for self-harm. Clients who have attempted suicide in the past are at risk for attempting suicide in the future. Suicidal ideation may progress to suicide threats, gestures, or attempts. Although depressed clients may not have the energy to eat, this is not an initial priority. An inability to concentrate is a common complaint of depressed clients, but it has not been linked to an increased risk for suicide.

A client receiving a blood transfusion that was just initiated reports urticaria and difficulty breathing. The heart rate has increased, the blood pressure is falling, and the client is becoming extremely apprehensive. Which type of shock does the nurse suspect the client is experiencing? Multiple choice question Septic shock Cardiogenic shock Neurogenic shock Anaphylactic shock

Anaphylactic shock Anaphylactic shock occurs when the body has a hypersensitivity to an antigen. This may lead to death quickly. Common causes are blood products, insect stings, antibiotics, and shellfish. Septic shock is caused by a systemic infection and release of endotoxins. Cardiogenic shock is when the heart fails to pump and demonstrates symptoms of heart failure, such as pulmonary edema. Neurogenic shock is caused by problems with the nervous system and usually occurs because of damage of the spinal cord.

A client who is formula feeding her infant complains of discomfort from engorged breasts. What should the nurse recommend that the client do? Multiple choice question Use warm, moist towels as compresses. Express milk from each breast manually. Apply cold packs and a snugly fitting bra. Restrict oral fluid intake to less than a quart a day.

Apply cold packs and a snugly fitting bra. Application of cold relieves discomfort, and a snug bra provides support and aids in pressure atrophy of acini cells so that milk production is suppressed. Warm, moist compresses are suitable for the breastfeeding mother experiencing discomfort from engorgement because it promotes comfort and stimulates milk production. Expressing milk manually is suitable for the breastfeeding mother who is experiencing engorgement, not one who is formula feeding, because it promotes comfort and stimulates milk production. Restriction of fluids will not prevent engorgement and may cause dehydration.

A newborn boy is being discharged 4 hours after having had a circumcision. What should the nurse instruct the mother to do? Multiple choice question Apply the diaper loosely for several days Give a crushed baby aspirin if there is irritability Check for bleeding every 2 hours during the first day home Call the practitioner if there is whitish exudate around the glans

Apply the diaper loosely for several days The diaper is applied loosely to prevent pressure on the circumcised area because the glans remains tender for 2 to 3 days. Aspirin may prolong clotting and is contraindicated in children because of its relationship to Reye syndrome. Acetaminophen and comfort measures may be prescribed. The caregiver should check for bleeding every hour for the first 12 hours after the circumcision. Whitish exudate around the glans is expected and does not indicate an infectious process.

A parent tearfully tells a nurse, "They think our toddler is developmentally delayed. We're investigating a preschool program for cognitively impaired children." What is the most appropriate response by the nurse? Multiple choice question Praising the parent for the decision and encouraging the plan Asking for more specific information related to the developmental delays Advising the parent to have the healthcare provider help choose an appropriate program Explaining that this action may be premature and that the developmental delays could disappear

Asking for more specific information related to the developmental delay More information is needed. The term developmental delay suggests that some milestones for age are not being met at the average time; it is not synonymous with cognitive impairment. Praising the parent for the decision and encouraging the plan is inappropriate; more information must be obtained. Although the healthcare provider may help, it is not yet known whether such a program is needed. The nurse does not know, without more information, whether the parents' plan is premature or that the delays will disappear.

A client with a suspected kidney disorder reports flank pain. Which nursing interventions should be conducted while performing flank assessment? Multiple selection question Percussing the tender flank first Forming both hands into a clenched fist Asking the client to assume a sitting position Placing one hand flat on costovertebral angle (CVA) Delivering a firm hand thump over the lower abdomen

Asking the client to assume a sitting position Placing one hand flat on costovertebral angle (CVA) While assessing the flank regions of a client with a suspected kidney disorder, the nurse should ask the client to assume a sitting position. The nurse should place one hand on the costovertebral angle (CVA) during assessment. The nurse should first percuss the nontender flank; percussing the tender flank first may aggravate the client's pain. A clenched fist should be formed with one hand. The nurse should deliver a firm hand thump over the costovertebral angle (CVA).

A nurse is planning to teach facts about hyperglycemia to a client with diabetes. What information should the nurse include in the discussion about what causes diabetic acidosis? Multiple choice question Breakdown of fat stores for energy Ingestion of too many highly acidic foods Excessive secretion of endogenous insulin Increased amounts of cholesterol in the extracellular compartment

Breakdown of fat stores for energy In the absence of insulin, which facilitates the transport of glucose into cells, the body breaks down proteins and fats to supply energy; ketones, a by-product of fat metabolism, accumulate, causing metabolic acidosis (pH below 7.35). The pH of food ingested has no effect on the development of acidosis. The opposite of excessive secretion of endogenous insulin is true. Cholesterol level has no effect on the development of acidosis.

A client with schizophrenia uses the word "worriation" when talking with the nurse. How should the nurse respond? Multiple choice question By correcting the pronunciation of the word By asking for clarification of the word's meaning By ignoring its use while interacting with the client By telling the client to use words that everyone can understand

By asking for clarification of the word's meaning This is an example of a neologism, a self-coined word whose meaning is known only to the client. It is not a mispronunciation. The word's meaning must be explored. The use of a neologism should not be ignored, because the word usually has significance to the individual who is using it. Telling the client to use words everyone else can understand is a demeaning response that may cut off communica

A nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated? Multiple choice question Dialysis Osmosis Diffusion Capillarity

Capillarity When a sterile surface becomes wet, microorganisms from the unsterile surface below the sterile field will be drawn up, contaminating the sterile field. The absorption of fluids by gauze results from the adhesion of water to the gauze threads; the surface tension of water causes contraction of the fiber, pulling fluid up the threads. Dialysis is separation of substances in solution using their differing rates of diffusion through a membrane. Osmosis refers to movement of water through a semipermeable membrane. Diffusion is movement of molecules from a high to a low concentration.

A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first? Multiple choice question Check for a pulse Start cardiac compressions Prepare to defibrillate the client Administer oxygen via an ambu bag

Check for a pulse The treatment of ventricular tachycardia depends on the presence of a pulse. Therefore checking for a pulse is the first priority for the nurse. The nurse must rely on client assessment, not solely on the monitor. Cardiac compressions would not be initiated if there was a pulse. Administering oxygen via an ambu bag would only occur if the client was not breathing. The client is not automatically defibrillated. Cardioversion is recommended for slower ventricular tachycardia.

The nurse is assessing four different clients with common benign conditions of the skin. Which client does the nurse anticipate to have nevi? A rubbery compressible round mass of adipose tissue, and the treatment would be excision. B linical manifestations include non-inflammatory lesions, including open and closed comedones, and the treatment is the mechanical removal of lesions and also using topical benzoyl peroxide. C slightly elevated verrucous skin and dome-shaped papillomatosis = no tmt D sharply demarcated, silvery, scaling plaques on reddish colored skin, and the treatment is corticosteroids.

Client C has clinical manifestations of nevi, which include flat and slightly elevated verrucous skin and dome-shaped papillomatosis. No treatment is necessary except for cosmetic reasons unless the nevi change, grows, or becomes malignant. Client A has lipoma; manifestations include a rubbery compressible round mass of adipose tissue, and the treatment would be excision. Client B has acne vulgaris; clinical manifestations include non-inflammatory lesions, including open and closed comedones, and the treatment is the mechanical removal of lesions and also using topical benzoyl peroxide. Client D has psoriasis; clinical manifestations are sharply demarcated, silvery, scaling plaques on reddish colored skin, and the treatment is corticosteroids. Nevus is a nonspecific medical term for a visible, circumscribed, chronic lesion of the skin or mucosa. The term originates from nævus, which is Latin for "birthmark," however, a nevus can be either congenital (present at birth) or acquired.

A nurse caring for a client with dementia notes that the primary healthcare provider has prescribed an experimental course of treatment. What important factor should the nurse keep in mind regarding the procurement of informed consent? Multiple choice question Clients with mental illness are not allowed to give consent. Clients with mental illness have the right to refuse treatment. Family members of the client need to give consent for all procedures. Primary healthcare providers may perform procedures without consent.

Clients with mental illness have the right to refuse treatment. The nurse should know that a client with a mental illness has the right to refuse treatment until a court rules that he/she is incompetent for making health related decisions for himself/herself. The nurse should also remember that even clients with mental illnesses have to give their consent for medical procedures. Family members may give consent only if they are the healthcare proxies of the client. Primary healthcare providers should not perform procedures without the consent of the client.

The nurse leader noticed that the staff nurse recently promoted to the surgical unit is lacking confidence at work and is worried about a pending review by the nursing director. Which source of power is applicable in this situation? Multiple choice question Reward power Coercive power Referent power Connection powe

Coercive power Coercive power stems from a real or perceived fear of another person. Reward power is perceived as being able to provide rewards or favors. Association with a powerful person grants referent power. Association with people who are powerful or who have links to powerful people gains connection power.

When a person who wishes to be athletic is uncoordinated but also successful in a musical career, what defense mechanism might this be related to? Multiple choice question Sublimation Transference Compensation Rationalization

Compensation Compensation is replacing a weak area or trait with a more desirable one. Sublimation is rechanneling unacceptable desires and drives into those that are socially acceptable. Transference is the unconscious tendency to assign to others in the current environment feelings and attitudes associated with another person. Rationalization is the use of justification to make tolerable certain feelings, behaviors, and motives.

A client is admitted to the hospital with a tentative diagnosis of a brain tumor. Which diagnostic test result will the nurse check for confirmation of this diagnosis? Multiple choice question Myelography Lumbar puncture Electromyography Computed tomography

Computed tomography Computed tomography is the most definitive test for identifying unexpected structures in the brain; it provides a three-dimensional view of cranial contents and defines outlines of masses and other abnormalities. Magnetic resonance imaging (MRI) and positron emission tomography (PET) scans are also beneficial and in some cases are better. Myelography is an x-ray examination of the spinal cord and vertebral canal, not the cranium. A lumbar puncture is contraindicated; removal of cerebrospinal fluid in the presence of an increase in intracranial pressure, which usually accompanies a brain tumor, may cause compression of the brainstem. Electromyography measures electrical currents produced by skeletal muscles, not the cranium.

The nurse is creating a discharge teaching plan for a client who had a subtotal gastrectomy. The nurse should include what instructions about minimizing dumping syndrome? Multiple selection question Drink fluids with meals. Eat small, frequent meals. Lie down for one hour after eating. Chew food five times before swallowing. Select foods that are low in fiber.

Eat small, frequent meals. Lie down for one hour after eating. Small, frequent meals keep the volume within the stomach to a minimum at any one time, limiting dumping syndrome. Lying down delays emptying of the stomach contents, which will limit dumping syndrome. Fluids should be taken between meals to decrease the volume within the stomach at one time. Dumping syndrome occurs after eating because of the rapid movement of food into the jejunum without the usual digestive mixing in the stomach and processing in the duodenum. Chewing a set number of times before swallowing is not pertinent to solving this problem. - High fiber, complex carbohydrates, moderate fats, and high protein in small, frequent meals are recommended to prevent dumping syndrome.

A client is suspected of having myasthenia gravis. What are the most significant initial nursing assessments that should be performed? Multiple choice question Ability to chew and speak distinctly Capacity to smile and close the eyelids Effectiveness of respiratory exchange and ability to swallow Degree of anxiety and concern about the suspected diagnosis

Effectiveness of respiratory exchange and ability to swallow Respiratory failure will require emergency intervention, and inability to swallow may lead to aspiration. Difficulty with chewing and speaking are signs of myasthenia gravis that may occur but are not life threatening. Ocular palsies and an inability to smile are signs of myasthenia gravis that may occur but are not life threatening. Although the client's level of anxiety and concerns about the diagnosis are important, they are not the most significant assessments. Myasthenia gravis is a chronic autoimmune neuromuscular disease that causes weakness in the skeletal muscles, which are responsible for breathing and moving parts of the body, including the arms and legs. The name myasthenia gravis, which is Latin and Greek in origin, means "grave, or serious, muscle weakness."

Twenty-four hours after a penile implant the client's scrotum is edematous and painful. What should the nurse do? Multiple choice question Assist the client with a sitz bath. Apply warm soaks to the scrotum. Elevate the scrotum using a soft support. Prepare for an incision and drainage procedure.

Elevating the scrotum using a soft support increases lymphatic drainage, reducing edema and pain. Assisting the client with a sitz bath and applying warm soaks to the scrotum increase circulation to the area, intensifying edema and pain in this client. Preparing for an incision and drainage procedure is not indicated; scrotal swelling is caused by the trauma of surgery, not infection.

The family members of a client with the diagnosis of cerebrovascular accident (CVA, also known as "brain attack") express concern that the client often becomes uncontrollably tearful during their visits. What should the nurse include in a response? Multiple choice question Emotional lability is associated with brain trauma. Their presence allows the client to express feelings. The client is depressed about the loss of functional abilities. Nonverbal expressions of feelings are more accurate than verbal ones.

Emotional lability is associated with brain trauma. Emotional lability is associated with brain trauma from ischemia or injury. The frontal lobe, hypothalamus, thalamus, and cortical limbic system are involved in expression of emotions. Emotional lability is not limited to interactions with family. Although the client may be depressed, the uncontrollable tearfulness is because of the disease process. Although nonverbal messages are often helpful in determining emotional response, these emotional outbursts may be unrelated to feelings.

A client is to be discharged on a regimen of lithium carbonate. What will the nurse include in the discharge teaching plan? Multiple choice question Advising the client to restrict the intake of gluten Instructing the client to take the medication with milk Reminding the client to have a complete blood count once a month Encouraging the client to have the lithium blood level tested regularly

Encouraging the client to have the lithium blood level tested regularly The blood level must be checked monthly or bimonthly when the client is undergoing maintenance therapy, because there is only a small difference between the therapeutic and toxic ranges. A regular diet should be encouraged if the client does not have gluten enteropathy. There is no need to take lithium carbonate with milk, because it does not cause gastrointestinal problems. Lithium carbonate does not affect the blood cells.

The parents of an 11-year-old child with a terminal illness appear overwhelmed and anxious. What is the best response by the nurse? Multiple choice question Explaining the diagnosis in a variety of ways Encouraging the parents to express their feelings Recommending that the parents talk with other parents Offering assurance that surgery will probably correct the problem

Encouraging the parents to express their feelings The parents need to express and work through their feelings before they can move forward with other coping strategies. Explanation of the diagnosis is not focused on the needs of the parents at this time. Participation in a support group may eventually be suggested; however, this is not the priority at this time. Assuring the parents that surgery will correct the problem is false reassurance; there is no guarantee that the surgery will be successful.

A client is admitted and diagnosed with myasthenia gravis. Pyridostigmine bromide therapy via tablets has been prescribed. The nurse anticipates that the dosage will be changed frequently during the first week of therapy. While the dosage is being adjusted, what action does the nurse perform? Multiple choice question Administer the medication after meals. Administer the medication on an empty stomach. Evaluate the client's psychological responses between medication doses. Evaluate the client's muscle strength every hour after the medication is given.

Evaluate the client's muscle strength every hour after the medication is given. The onset of action of pyridostigmine is 30 to 45 minutes after administration, and the effects last up to 6 hours; the client's response will influence dosage levels. Pyridostigmine usually is administered before meals to promote mastication. Pyridostigmine should be administered with food to prevent gastric irritation. There are no psychological side effects associated with pyridostigmine.

Which color tag should be given to "walking wounded" clients according to the disaster triage tag system? Multiple choice question Red Black Green Yellow

Green Green tagged clients are referred to as "walking wounded" because they may evacuate themselves from the mass casualty scene and go to the hospital in a private vehicle. Clients with life-threatening conditions that need immediate treatment are given red tags. Black-tagged clients are expected to die or may be dead. Clients with major injuries are tagged with yellow. They may require urgent treatment but can wait a short time for care as injuries are not life threatening.

After assessing a dark-skinned client, the nurse concludes that the client has cyanosis. Which assessment color variation helped the nurse reach this conclusion? Multiple choice question Grey color Purple color Dark red color Purple-to-brownish color

Grey color In dark-colored skin, cyanosis can be identified by a grey color, which is mostly seen in the conjunctiva of the eye. A purple skin color is an indication of erythema. In a light-skinned client, a dark red color is an indicator of ecchymosis. A purple-to-brownish color identifies ecchymosis.

A nurse has been working for the past 3 months with a 10-year-old child who has a diagnosis of conduct disorder. What is the best long-term outcome for this child? Multiple choice question Avoiding verbally aggressive behavior for 3 months Verbalizing 10 alternative methods to address anger Being sent to the principal's office less than three times in 5 weeks Having no physically aggressive episodes during the next 3 months

Having no physically aggressive episodes during the next 3 months A child with a conduct disorder is physically aggressive; the physical aggression differentiates it from oppositional defiant disorder. An absence of physical aggression over the span of 3 months demonstrates that treatment is successful. Controlling verbal aggression alone is not appropriate for this child; this outcome more correctly addresses the problems of a child with oppositional defiant disorder. Verbalizing 10 alternative methods of addressing anger is an appropriate short-term, not long-term, outcome for this child. Being sent to the principal's office three times in 5 weeks is a negative outcome for this child.

A nurse initiates preparations for an infratentorial craniotomy in a 9-year-old child. What should the nurse include in the plan? Multiple choice question Encouraging doll play with simulated surgical equipment Having the child draw a picture of a brain and briefly clarifying misconceptions Scheduling role playing with other children who have also undergone brain surgery Offering an explanation of the brain's anatomy and how the surgery is performed

Having the child draw a picture of a brain and briefly clarifying misconceptions Having the child draw a picture will elicit the child's level of understanding; an explanation can then proceed. Therapeutic play is more appropriate for younger children; it is inappropriate for a 9-year-old child. Role play is inappropriate and nontherapeutic at this time. Although the school-aged child appreciates some detail, extensive detail is inappropriate.

The nurse concludes that a client with type 1 diabetes is experiencing hypoglycemia. Which responses support this conclusion? Multiple selection question Vomiting Headache Tachycardia Cool, clammy skin Increased respirations

Headache Tachycardia Cool, clammy skin Headache is a neuroglycopenic response directly related to brain glucose deprivation. Tachycardia occurs with hypoglycemia because of a neurogenic adrenergic response; it is a sympathetic nervous system response precipitated by a low blood glucose level. Cool, clammy skin is a neurogenic cholinergic response; it is a sympathetic nervous system response precipitated by a low serum glucose level. Vomiting occurs with hyperglycemia because of the effects of metabolic acidosis. Increased respirations are a sign of hyperglycemia and are related to metabolic acidosis; this is a compensatory response in an attempt to blow off carbon dioxide and increase the pH level.

A client is admitted to the hospital with ureteral calculus. Which urinary clinical findings will the nurse expect upon assessment? Multiple choice question Foul odor and dark urine Urgency and mild aching pain Frequency with small amounts of urine Hematuria with sharp pain when voiding

Hematuria with sharp pain when voiding Hematuria and pain may result from damage to the ureteral lining as the calculus moves down the urinary tract; the urine may become cloudy or pink tinged. Although severe pain may be present, urgency is not associated with renal calculi; urgency may be associated with an enlarged prostate, cystitis, or other genitourinary problems. The odor of urine is not foul with this condition; the color of urine is not dark with this condition, although it may be cloudy, pink, or red from hematuria. Frequency may occur when the calculus reaches the bladder. Ureterolithiasis or ureteric calculi are stones that form in or travel down to the ureters, which are the slender muscular tubes that connect the kidneys to the urinary bladder.

client who had a myocardial infarction asks the nurse, "What's the chance of my having another heart attack if I watch my diet and stress levels carefully?" What is the most appropriate initial response by the nurse? Multiple choice question Identifying the concerns and helping the client explore feelings Telling the client that it is important to be especially careful with diet and stress Suggesting that the client discuss the feelings of vulnerability with the primary healthcare provider Understanding that the client is frightened and suggesting a talk with the psychiatric nurse

Identifying the concerns and helping the client explore feelings The nurse must first analyze the feelings that are implied in the client's question and reflect these to help the client verbalize and explore them; the focus is on collecting more data. Although telling the client that it is important to be especially careful with diet and stress may be true, it does not respond to the feelings implicit in the client's comment. The suggestion that the client discuss feelings of vulnerability with the primary healthcare provider avoids responsibility of helping the client explore feelings; it cuts off communication. No data presented at this time suggest that a referral to a psychiatric nurse is warranted. This response also cuts off communication when the client has expressed a need; the nurse is avoiding responsibility to assist the client.

A nurse in the pediatric clinic is assessing an adolescent child with strabismus. What is one of the priority goals for the surgical correction of this child's disorder? Multiple choice question Improving appearance Preventing the need for glasses Preventing legal blindness Restoring peripheral vision

Improving appearance Cosmetic improvement is a major goal for children with strabismus because with crossed eyes they may be teased by their peers. The child may still need glasses because surgery does not always correct the defect and there may be other vision problems. Strabismus does not affect vision to the extent of blindness. Peripheral vision is intact with strabismus. Amblyopia, also known as lazy eye, is a vision development disorder in which an eye fails to achieve normal visual acuity, even with prescription eyeglasses or contact lenses. Amblyopia begins during infancy and early childhood. In most cases, only one eye is affected.

A nurse is caring for an adolescent who has anorexia nervosa. The nutritional treatment of anorexia is composed of several guidelines. Which guidelines should the nurse emphasize? Multiple selection question Increasing high-fiber foods Eating just three meals a day Increasing food intake gradually Limiting mealtime to half an hour Providing privileges for goal achievement

Increasing food intake gradually Limiting mealtime to half an hour Providing privileges for goal achievement Food intake should be increased by approximately 200 calories weekly. A gradual increase allows the client to adapt emotionally and physically to the increased volume. Thirty minutes is sufficient time for eating. Extended mealtimes place excessive attention on eating and increase anxiety and conflict. Goals should be set (e.g., gaining 2 lb (0.9 kg) per week and eating 90% of each meal). Behaviors that result in achievement of goals should be rewarded. Goals provide structure, and rewards motivate additional positive behaviors while promoting self-esteem. Consumption of high-fiber foods does not have to be increased. A variety of foods and textures should be eaten. Small, frequent meals should be offered.

A 20-year-old woman comes into the clinic after missing her menstrual period 2 weeks ago and states that she suspects that she is pregnant. As the nurse is reviewing her medications, the client says that she is taking isotretinoin. What should the nurse consider regarding isotretinoin? Multiple choice question It is used to suppress hunger in individuals trying to lose weight, so the client should stop taking the medication. It is often used to treat migraines associated with hormonal changes and should be safe for continued use as needed. It is teratogenic and associated with major fetal malformations, so the client should stop the medication immediately. It is an atypical antipsychotic, and the woman needs to make an immediate appointment with her mental healthcare provider to discuss alternative medications.

It is teratogenic and associated with major fetal malformations, so the client should stop the medication immediately. Isotretinoin is used to treat severe acne that has not responded to other forms of treatment. It is teratogenic, and pregnancy should be avoided by female clients taking the medication. Isotretinoin is not used to treat migraines, is not an antipsychotic, and is not used in a weight-loss program.

While on a hike, a rusty nail pierces the sole of a client's foot and he is brought to the emergency department of a local hospital. Tetanus immune globulin is prescribed because the client does not know when the last tetanus immunization was received. What information will the nurse include when teaching the client about this drug? Multiple choice question It will take about a week to become effective. Immune globulin provides lifelong passive immunity. It provides immediate, passive, short-term immunity. Immune globulins stimulate the production of antibodies.

It provides immediate, passive, short-term immunity. Tetanus immune globulin contains ready-made antibodies and provides immediate, short-term, passive immunity. Passive immunity lasts a short time, not throughout life. Immune globulins confer passive artificial immunity, not long-lasting active immunity. Immune globulins are antibodies; they do not stimulate the production of antibodies.

A client has surgery for the creation of burr holes after sustaining head trauma. Which early clinical manifestation of meningeal irritation does the nurse assess in the client? Multiple choice question Sunset eyes Kernig sign Plantar reflex Homans sign

Kernig sign Kernig sign, which is an inability to completely extend the legs, is the classic sign of meningeal irritation. "Sunset eyes" is associated with hydrocephalus; it occurs when the eyelid falls above the iris, allowing the sclera to show. It occurs only in infants whose cranial bones have not yet fused. Plantar reflex, a spinal cord reflex, is unrelated to meningeal irritation. Homans sign indicates the presence of thrombophlebitis; pain is experienced when the foot is dorsiflexed because of vascular irritability.

A client at 30 weeks' gestation visits the clinic for a routine examination. At her last visit she told the nurse that she wanted to diet to avoid losing her figure after the baby's birth, and as a result the nurse provided nutrition counseling. At this visit the client weighs 10 lb (4.5 kg) less than on her previous visit. The nurse suspects that the client is not compliant with the recommended nutritional guidelines for pregnancy. Which complication should the client be monitored for? Multiple choice question Ketonemia Hyperglycemia Anorexia nervosa Hyperemesis gravidarum

Ketonemia When protein and carbohydrate intake is inadequate, the body catabolizes fat stores for energy, leading to the production of excess fatty acids. Excess fatty acids produce excess ketones in the blood (ketonemia). Hypoglycemia is more likely to occur because carbohydrate intake probably is low. Anorexia nervosa is a pre-pregnancy disorder. The data do not indicate a history of this problem. The data do not indicate that the client has a history of hyperemesis gravidarum, which begins during the first trimester.

nurse is caring for a client with glaucoma. Which rationale associated with the need for treatment of this condition should the nurse include in a teaching program? Total blindness is inevitable. Lost vision cannot be restored. Use of both eyes usually is restricted. Surgery will help the problem only temporarily.

Lost vision cannot be restored. Retinal damage caused by the increased intraocular pressure of glaucoma is progressive and permanent if the disease is not controlled; lost vision cannot be restored. Early treatment may prevent blindness. One eye may be affected, and there is no restriction on the use of either eye. Surgery can open up drainage and permanently reduce pressure.

A primigravida at 38 weeks' gestation presents to the clinic with a blood pressure of 142/94, edema in all extremities, and a weight gain of 5 lb (2.3 kilograms) since the previous checkup 1 week ago. The decision has been made to initiate magnesium sulfate therapy. What are the nursing priorities with this choice of therapy? Multiple selection question Respiratory rate of 14 Blood pressure drop to 126/80 Magnesium sulfate level of 9 mg/dL (3.9 mmol/L) Calcium gluconate available at bedside Oxytocin used to strengthen contractions Client on left side in darkened room with visitor restrictions

Magnesium sulfate level of 9 mg/dL (3.9 mmol/L) Calcium gluconate available at bedside Oxytocin used to strengthen contractions Client on left side in darkened room with visitor restrictions A magnesium sulfate level of 9 mg/dL (3.9 mmol/L) is too high; the therapeutic level is 4 to 8 mg/dL (1.74 to 3.48 mmol/L). Calcium gluconate is an antagonist to magnesium and must be available immediately with this therapy. Magnesium inhibits contractions, so oxytocin often is used to strengthen contractions toward the goal of delivery, a concern in relation to the fetus tolerating labor. Maintaining the client on the left side with minimal stimuli will decrease the chance of a seizure and thus is a nursing concern. A respiratory rate of 14 is within normal limits. Respirations can be diminished and must be maintained above 10/min. A decrease of blood pressure to 126/80 can be attributed to the magnesium, which has the primary purpose of preventing convulsions.

client is hospitalized after four days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, Pco 2 50 mm Hg, bicarbonate 58 mEq/L (58 mmol/L), chloride 55 mEq/L (55 mmol/L), sodium 132 mEq/L (132 mmol/L), and potassium 3.8 mEq/L (3.8 mmol/L). What condition does the nurse determine the results to indicate? Multiple choice question Hypernatremia Hyperchloremia Metabolic alkalosis Respiratory acidosis Eugene off target

Metabolic alkalosis The normal plasma pH value is 7.35 to 7.45; the client is in alkalosis. The normal plasma bicarbonate value is 23 to 25 mEq/L (23 to 25 mmol/L); the client has an excess of base bicarbonate, indicating a metabolic cause for the alkalosis. The normal plasma sodium value is 135 to 145 mEq/L (135 to 145 mmol/L); the client has hyponatremia. The normal plasma chloride value is 95 to 105 mEq/L (95 to 105 mmol/L); the client has hypochloremia because of vomiting of gastric secretions. With respiratory acidosis the pH is decreased to less than 7.35.

Which organism infestation is diagnosed with the help of the mineral oil test? Multiple choice question Lice Ticks Mites Fungus

Mites Mites are the causative organism of scabies. Examination using mineral oil is a diagnostic measure for the scabies infection. To check for infestations, scrapings are placed on a slide with mineral oil and viewed microscopically. Lice leave excrement and eggs on skin and hair, live in seams of clothing (if body lice), and in hair as nits. A diagnosis of Lyme disease caused by ticks is often based on clinical manifestations, in particular the erythema migrans lesion, and a history of exposure in an endemic area. If the enzyme immunoassays is positive or inconclusive, a Western blot test is done to confirm the infection. The microscopic examination of skin lesions in 10% to 20% potassium hydroxide is a diagnostic measure to determine the presence of a fungus.

Which technique would the nurse describe as promoting autolysis in the spontaneous separation of necrotic tissue? Multiple choice question Continuous wet gauze Moisture-retentive dressing Topical enzyme preparations -Wet-to-dry damp saline moistened gauze

Moisture-retentive dressing moisture-retentive dressing is used to promote autolysis in the spontaneous separation of necrotic tissue in wound debridement. Continuous wet gauze is used in promoting dilution of viscous exudate and softening the dry scar. Topical enzyme preparation shows proteolytic action on thick, adherent eschar, causing the breakdown of denatured protein and a more rapid separation of necrotic tissue. In wet-to-dry damp saline-moistened gauze, necrotic debris is mechanically removed but with less trauma to healing tissue.

What is the role of unlicensed assistive personnel in intravenous (IV) therapy for a client? Multiple choice question Monitoring clinical manifestations Collecting the data to be used in the assessment of the IV site Administering IV fluids and medications Evaluating the client for clinical manifestations

Monitoring clinical manifestations In IV therapy the role of the registered nurse is to collect the data that can be used in the assessment of the IV site. Monitoring clinical manifestation is performed by the unlicensed assistive professional and report to the RN. Administering IV fluids and medications is done by a registered nurse or LPN. Evaluating the client for clinical manifestations is performed by the registered nurse.

A client has been diagnosed with type 1 diabetes mellitus. When providing instructions on sharps disposal, the nurse should instruct the client to place the syringes in what? Multiple choice question Bubble wrap/packaging wrap A garbage bag in the trash can A cardboard box with a firmly secured lid A plastic liquid detergent bottle with a screw-top lid

Most states (provinces) allow patients to place used needles/pen needles and lancets ( sharps) in a household container such as a laundry detergent bottle, bleach bottle, or other opaque sturdy plastic container with a screw-top lid. Some states (provinces) do have disposal drop-off locations. Bubble wrap, a garbage bag, and cardboard put those who are handling the containers at risk for needle sticks.

Which groups may be activated by state and federal government authorities to assist during a flooding situation that results from a hurricane? Multiple selection question National Guard American Red Cross Medical Reserve Corps Public health departments Local emergency departments

National Guard American Red Cross Medical Reserve Corps Public health departments During catastrophic mass casualty events, such as flooding that can occur with a hurricane, the National Guard, the American Red Cross, the public health department, various military units, a Medical Reserve Corps (MRC), or a Disaster Medical Assistance Team (DMAT) can be activated by state and federal government authorities. While authorities may contact local emergency departments for notification purposes, they do not have the authority to activate a disaster preparedness plan for individual emergency departments.

A nurse is teaching a birthing/prenatal class about breast-feeding. Which hormone stimulates the production of milk during lactation? Inhibin Estrogen Prolactin Progesterone

Prolactin Prolactin is the hormone that initiates and produces milk during lactation. Inhibin prevents the secretions of follicle stimulating hormone and gonadotropin releasing hormone. Estrogen and progesterone are the sex hormones produced by the ovaries.

A client is prescribed sertraline, an antidepressant. What does the nurse include when preparing a teaching plan about the side effects of this drug? Multiple choice question Seizures Agitation Tachycardia Agranulocytosis

Sertraline, a selective serotonin reuptake inhibitor (SSRI), inhibits neuronal uptake of serotonin in the central nervous system, thus potentiating the activity of serotonin. Central nervous system side effects of this drug include agitation, anxiety, confusion, dizziness, drowsiness, and headache. Seizures are a side effect of clozapine, an antipsychotic, not sertraline, which is an antidepressant. Tachycardia is a side effect of tricyclic antidepressants, not sertraline, which is an SSRI antidepressant. A decrease in the production of granulocytes (agranulocytosis) causing a pronounced neutropenia is a side effect of clozapine, not sertraline.

After several interactions with a client, the nurse at the mental health clinic identifies a pattern of withdrawal and nonparticipation in situations requiring communication with others. In which area should the nurse expect the client to have difficulty? Multiple choice question Personal identity Social interaction Sensory perception Verbal communication

Social interaction Characteristics of clients with problems with social interaction include avoidance of others, problematic patterns of interaction, and an inability to establish or maintain stable supportive relationships. Withdrawal from others is not a characteristic of individuals with difficulties involving personal identity. These clients usually exhibit an inability to distinguish between the self and nonself. Withdrawal from others is not a characteristic associated with clients who have alterations in sensory perception. A client with impaired sensory perception demonstrates altered processing of sensory stimuli and an exaggerated or distorted response to stimuli. Withdrawal from others is not a characteristic of clients who have difficulty communicating with others. A client who has problems communicating has a decreased ability to receive, process, or transmit communication.

A client with mild chronic heart failure is to be discharged with prescriptions for daily oral doses of an antidysrhythmic, potassium chloride 40 mEq, docusate sodium 100 mg, and furosemide 40 mg twice a day. The client reports having no family members who can help after discharge. What should the nurse help this client identify? Multiple choice question Support systems that can assist the client at home Potential nursing homes in which the client can recuperate Agencies that can help the client regain activities of daily living Ways that the client can develop relationships with neighbors

Support systems that can assist the client at home The rehabilitative phase requires a balance between activity and rest; supportive individuals are needed to perform more strenuous household tasks and to provide emotional support. A client with mild heart failure does not need inpatient care. A support system should be identified before considering community agencies. More information is needed before encouraging the development of relationships with neighbors.

A leader observes the direct care nurse making more frequent errors and being anxious. Which advice provided by the leader to the direct care nurse would help to manage the stress? Multiple choice question "Yoga can help you with stress management." "Time-management skills are important for stress reduction." "Taking more continuing education courses may help reduce stress." "Communicating your feelings will help with your stress management."

Symptoms such as anxiety and frequent errors in work indicate mental stress. The direct care nurse should develop time-management skills to help manage the stress. Practicing yoga would help to reduce physical stress. Taking more continuing educational courses may increase mental stress. Communicating feelings helps to reduce emotional/spiritual stress.

A client with a new diagnosis of bipolar disorder is prescribed lithium carbonate. In light of the information shown, what teaching should the nurse provide to the client? Lithium can affect WBC production and therefore increases the client's risk for infection. The client's current thyroid function will require frequent assessments while taking lithium. Hyponatremia could lead to lithium toxicity, so the primary healthcare provider must first be notified of the level. Because of the platelet count, neutropenic precautions will be initiated once the client starts lithium therapy. The current hemoglobin and hematocrit levels require regular monitoring once the lithium level is stabilized.

The client's current thyroid function will require frequent assessments while taking lithium. Hyponatremia could lead to lithium toxicity, so the primary healthcare provider must first be notified of the level. Lithium carbonate therapy can negatively affect thyroid function; the client's current TSH is at the high normal level, so frequent checks are appropriate. Low serum sodium levels would result in the kidneys reabsorbing the lithium; this situation would lead to lithium toxicity. The primary healthcare provider must first be notified of the lab result. Lithium is not known to have a negative effect on WBC, platelet, or RBC production.

How many words should the nurse expect the 3-year-old child to acquire each day? Multiple choice question 2 to 3 5 to 6 8 to 10 11 to 13

The nurse would expect the 3-year-old toddler-age child to acquire 5 to 6 new words each day. Two to 3 new words, 8 to 10 new words, and 11 to 13 new words are not expected parameters for language development.

A client with cancer of the bladder is admitted to the hospital for diagnostic tests to determine the extent of the disease. While the nurse is caring for the client, the client asks, "If they remove my bladder, how will I be able to urinate?" Which is the best response by the nurse? Multiple choice question "You can still function normally without a bladder." "I am sure this is very upsetting to you, but it will be over soon." "I know you're upset, but there are alternatives to removing your bladder." "The tests will help to determine whether your bladder has to be removed."

The response "I know you're upset, but there are alternatives to removing your bladder" offers the best combination of factual information and emotional support. The response "You can still function normally without a bladder" disregards the client's feelings; it is inaccurate information, because if the bladder is removed, bladder function will not be normal. Although the response "I am sure this is very upsetting to you, but it will be over soon" identifies the client's feelings, further communication is cut off by the second part of the response. The response "The tests will help to determine whether your bladder has to be removed" is factual but does not answer the question or offer emotional support; it may increase anxiety.

A clinically depressed young mother whose husband has been killed tells the nurse that she sees no purpose in life and feels like ending it all. What is the best response by the nurse? Multiple choice question "How much consideration have you given to the method you'd use to kill yourself?" "Death is hard on everyone, but people make it through every day. You'll see; things will get better." "It can be hard to lose someone you care about so much; it can seem that life isn't worth living right now." "You feel that way now, but you still have your whole life ahead of you. Why don't you try to make a new start?"

The response "It can be hard to lose someone you care about so much; it can seem that life isn't worth living right now" validates the client's experience and opens a channel of communication for further exploration; empathy helps build trust. Asking how much consideration the client has given to the method she would use to kill herself is premature; the nurse should first explore the client's feelings before discussing thoughts and plans. Telling the client that death is hard on everyone but people make it through every day and that things will get better is false reassurance; it invalidates the client's experience. Telling the client that she has her whole life ahead of her and advising her to make a new start is false reassurance; it invalidates the client's experience.

A mother indicates to the nurse in the pediatric clinic that she is concerned that her 20-month-old child's bedtime thumb-sucking will cause the teeth to protrude. How should the nurse respond? Multiple choice question "You should seek counseling; the thumb-sucking could indicate an emotional problem." "Children need to satisfy their sucking needs until about 2 years of age before they stop on their own." "If you switch your child to a pacifier within the next 2 months, you can prevent protrusion of the teeth." "There is no reason to be concerned about the teeth protruding unless your child keeps sucking the thumb after the permanent teeth have come in."

There is no reason to be concerned about the teeth protruding unless your child keeps sucking the thumb after the permanent teeth have come in." Lips and teeth closed around the finger create suction and can move permanent teeth forward, causing malocclusion. Thumb-sucking is not considered to be related to emotional problems during the toddler years. Developmentally, children's sucking needs diminish at about 1 year of age when they are able to drink from a cup and ingest a variety of solid foods; however, thumb-sucking often persists as a means of gratification, especially at bedtime. Using a pacifier to replace thumb-sucking has the same result on the permanent teeth that thumb-sucking does. In addition, a toddler with a well-established thumb-sucking habit will refuse a pacifier as a substitute.

Serum cardiac marker studies are prescribed for a client after a myocardial infarction. Which laboratory test is most important for the nurse to monitor? Multiple choice question Troponin Myoglobin Homocysteine Creatine kinase (CK)

Troponin is the biomarker of choice for a myocardial infarction. Troponin, specifically subtypes cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI), reflects myocardial muscle protein released into circulation soon after injury. Troponin increases as quickly as CK and remains increased for 2 weeks. Although myoglobin is one of the first cardiac markers to increase after a myocardial infarction (MI), it lacks cardiac specificity. Homocysteine is produced when proteins break down, but it is more indicative of cardiovascular disease than a myocardial infarction. CK isoenzyme levels, especially the creatine phosphokinase (MB) subunit, begin to increase in 3 to 6 hours, peak in 12 to 24 hours, and are increased for 48 hours after the occurrence of the infarct. Although reliable in assisting with an early diagnosis of MI, it is not as sensitive or specific as the troponin test.

Which antiepileptic drug is used as the first-line treatment for absence seizures? Multiple choice question Phenytoin Diazepam Valproic acid Acetazolamide

Valproic acid Valproic acid is used as the first-line treatment for absence seizures. Phenytoin is used to treat partial, secondary, and generalized tonic-clonic seizures. Diazepam (lorazepam too so benzos) is used to treat status epilepticus. Acetazolamide is used as an adjunct drug for the treatment of absence seizures.

A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first? Multiple choice question Feel for a pulse Begin chest compressions Leave to call for assistance Perform the abdominal thrust maneuver

chest compressions According to the American Heart Association and Heart and Stroke Foundation of Canada for CPR, the first step is to feel for a pulse after unresponsiveness is established. In this case, it has been established the client has no pulse (cardiopulmonary arrest); therefore chest compressions are initiated. Do not leave the client to call for assistance. The abdominal thrust (Heimlich) maneuver is used to relieve airway obstruction and is not appropriate in this instance.

A healthcare provider determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? . Multiple selection question Double vision Problems with cognition Difficulty swallowing saliva Intention tremors of the hands Drooping of the upper eyelids Nonintention tremors of the extremities

double vision, difficulty swallowing, drooping eyelids Double vision occurs as a result of cranial nerve dysfunction. Facial muscles innervated by the cranial nerves often are affected; difficulty with swallowing (dysphagia) is a common clinical finding. Drooping of the upper eyelids (ptosis) occurs because of cranial nerve III (oculomotor) dysfunction. Myasthenia gravis is a neuromuscular disease with lower motor neuron characteristics, not central nervous system symptoms. Intention tremors of the hands are associated with multiple sclerosis. Nonintention tremors of the extremities are associated with Parkinson disease.

A client with end-stage kidney disease says to the nurse, "I heard that it is inevitable that I will need a kidney transplant. If so, which one of my kidneys will be removed?" Which is the best response by the nurse? Multiple choice question "Neither of your kidneys will be removed unless they are infected." "The kidney that is the most diseased is removed and replaced with a new one." "It is up to the primary healthcare provider as to which kidney is replaced with a new one." "Your right kidney will be removed, because it has a longer renal vein, making transplantation easier."

"Neither of your kidneys will be removed unless they are infected." The recipient's own kidneys are not removed unless a chronic infection is present. The primary healthcare provider will not decide which kidney is replaced, the most diseased kidney will not be removed, and the right kidney will stay because the kidneys are left in place; the new kidney is placed in the right lower quadrant.

A mother tells the clinic nurse that her 6-year-old child has been wetting the bed for the past 3 weeks. Previously there had been no problems. How should the nurse respond? Multiple choice question "Try to eliminate fluids after dinner." "Children sometimes wet the bed when they're angry." "You did the right thing to bring your child in to be examined." "Wake your child every few hours at night to go to the bathroom."

"You did the right thing to bring your child in to be examined." This child, who is older than 5 years, had control of the bladder until 3 weeks ago; the first step in evaluating enuresis is to rule out any physical problems that may be causing it. Suggesting interventions for the problem is inappropriate until the cause of the problem is identified. Stating that children wet the bed when they are angry is inappropriate because it implies that this is a voluntary act. Waking the child every few hours will interfere with the child's rest; advice is inappropriate until the cause of the problem is identified.v en·u·re·sis involuntary urination, especially by children at night.

A male client with the diagnosis of antisocial personality disorder takes a female nurse by the shoulders, kisses her, and shouts, "I like you." What is the most appropriate response by the nurse? Multiple choice question "Thank you. I like you, too." "I wish you wouldn't do that." "Don't ever touch me like that again. I don't like it " "Your behavior is inappropriate. Don't do that again."

"Your behavior is inappropriate. Don't do that again."

A client with type 1 diabetes receives regular insulin every morning at 8:00 AM. During what period of time does the nurse recognize the risk of hypoglycemia is greatest? Multiple choice question 8:30 to 9:30 AM 8:00 PM to midnight 1:00 PM to 8:00 PM 10:00 AM to 1:00 PM

10:00 AM to 1:00 PM Regular insulin peaks in 2 to 5 hours; therefore the greatest risk is between 10:00 AM and 1:00 PM. Although the onset of action occurs earlier, during the period from 8:30 to 9:30 AM, the level is not yet at its highest, so the risk of hypoglycemia is not at its greatest. NPH insulin's peak action is 4 to 12 hours; if hypoglycemia occurs, it will happen most likely between midnight and 8 PM.

The victims of a natural disaster are brought to the emergency department and found to be suffering from hypothermia. What is most likely to be the core body temperature of the hypothermic victim in whom shivering is diminished or absent? Multiple choice question 104° F (40°C) 95° F (35°C) 89.6° F (32°C) 82.4° F (28°C)

82.4° F (28°C) Severe hypothermia occurs at core body temperatures equal to or below 86° F (30°C). At a body temperature of 82.4° F (28°C), the client would be severely hypothermic; this state is likely to be characterized by diminished or absent shivering. At a body temperature 104° F (40°C), the client would be hyperthermic. At body temperatures of 95° F (35°C) and 89.6° F (32°C), clients would have mild and moderate hypothermia, respectively. Both mild and moderate hypothermia are likely to be characterized by shivering.

While assessing a client for the dorsalis pedis pulse, a nurse documents the reading as 1+. What can be inferred from this finding? Multiple choice question There is absence of a pulse. The pulse strength is normal. The pulse strength is bounding. The pulse strength is barely palpable.

A pulse strength of 1+ indicates a diminished or barely palpable pulse and requires immediate intervention. Absence of pulse is documented as 0. Normal pulse strength is documented as 2+. If the pulse strength is bounding, then it is documented as 4+.

A client with acute kidney failure becomes lethargic and fatigued. Upon reviewing the client's medical record, which finding does the nurse determine is the most likely cause of this behavior? Multiple choice question Hyperkalemia Hypernatremia A limited fluid intake An increased blood urea nitrogen level

An increased blood urea nitrogen level, indicating uremia, is toxic to the central nervous system and causes fatigue and lethargy. Hyperkalemia is associated with muscle weakness, irritability, nausea, and diarrhea. Hypernatremia is associated with firm tissue turgor, oliguria, and agitation. Dehydration can cause fatigue, dry skin and mucous membranes, and rapid pulse and respiratory rates.

The registered nurse is caring for an elderly client who is admitted with severe asthma. Which task delegated by the nurse is most suitable to be performed by the client attendant? Multiple choice question Assessing the vital signs Monitoring respiratory rate Administering inhalational medications Assisting the client during nebulization

Assisting the client during nebulization The client attendant is the unlicensed assistive personnel whose scope of practice is limited to providing basic care and comfort to the client. Assisting the client during nebulization is considered basic care and comfort and can be safely carried out by the client attendant. Assessing vital signs should be performed by the registered nurse. Monitoring respiratory rate can be delegated to the client attendant if the client condition is stable; however, since this client's condition is not stable, this task should not be delegated. Administering inhalational medications is not performed by unlicensed personnel such as a client attendant.

What in students is being assessed when a school nurse conducts audiometric screenings? Multiple choice question Hearing acuity Sensorineural hearing loss Auditory processing deficits Hearing problems caused by wax

Audiometric screening permits assessment of hearing ability. It does not pinpoint the type of hearing loss. Processing deficits may occur without hearing deficits. Audiometric testing cannot identify hearing problems caused by an accumulation of earwax, although this type of hearing loss is possible. hearing acuity

A client had a rubella infection (German measles) during the fourth month of pregnancy. At the time of the infant's birth, the nurse places the newborn in the isolation nursery. Which type of infection control precautions should the nurse institute? Multiple choice question Enteric Contact Droplet Standard

Because the rubella virus is found in the respiratory tract and urine, isolation is necessary; rubella is spread by droplets from the respiratory tract. "Enteric precautions" is an outdated term; the techniques used with this precaution are incorporated under contact precautions, and the techniques used with contact precautions are incorporated under standard precautions. The use of standard precautions alone is unsafe; additional precautions must be implemented to protect the nurse from droplet-transmitted infection.

During a follow-up visit the client, who is undergoing treatment for mental illness, complains of painful muscle spasms. The nurse suspects that the client may have pseudoparkinsonism. Which drugs does the nurse anticipate to be prescribed by the primary healthcare provider to counter this condition? Multiple selection question Clozapine Benztropine Haloperidol Risperidone Trihexyphenidyl

Benztropine Trihexyphenidyl The client's painful muscle spasms may be the symptom of pseudoparkinsonism. Benztropine and trihexyphenidyl are the anticholinergic drugs used to treat painful muscle spasms caused by antipsychotic drugs. Clozapine, haloperidol, and risperidone are the antipsychotic drugs that may be the cause of this adverse effect.

Electroconvulsive therapy (ECT) is a mode of treatment that is used primarily to treat which mental disorder? Multiple choice question Clinical depression Substance abuse disorders Antisocial personality disorder Psychosis occurring in schizophrenia

Clinical depression ECT is used to treat clinical depression in clients who do not respond well to a trial of psychotropic medications or who are so severely depressed that immediate intervention is needed. ECT is not used as a primary treatment for clients with substance abuse disorders, antisocial personality disorder, or schizophrenic psychosis.

While reviewing the laboratory reports of a client, the nurse finds that the client has low sodium levels. Which hormonal imbalance should the nurse suspect in the client? Epinephrine Glucagon Calcitonin Cortisol

Cortisol Cortisol is the glucocorticoid secreted by the adrenal cortex that maintains sodium and water balance. Therefore, reduced sodium levels in the client indicate a cortisol imbalance. Additionally, depleted sodium levels in a client indicate hyponatremia. Epinephrine is a catecholamine, which helps in maintaining homeostasis. Glucagon increases blood glucose levels and does not play a role in maintaining electrolyte balance. Calcitonin helps in regulating serum calcium levels.

While assessing the reproductive health of an older adult female, a nurse finds that the client has an age-related finding. Which finding in the client supports the nurse's conclusion? Multiple choice question Breast dimpling Painful intercourse Decreased amount of pubic hair Green discharge from the vulva

Decreased amount of pubic hair With aging, as every organ system undergoes certain changes, females also experience changes in their reproductive system. A decrease in the amount of pubic hair is an age-related change. Therefore this finding in the client supports the nurse's conclusion. Dimpling of the breast occurs in cancer. Painful intercourse could be due to insufficient lubrication, infection, or trauma to the pelvic region. Green discharge from the vulva is a manifestation of a Trichomonas vaginalis infection.

Schizophrenia is associated with both positive and negative symptoms. While assessing a client with schizophrenia, the nurse notes that the client is experiencing positive symptoms; what does the nurse observe that leads to this conclusion? Multiple selection question Poverty of speech Agitated behavior Lack of motivation Delusions of grandeur Auditory hallucinations

Delusions of grandeur Auditory hallucinations Agitated behavior Agitated and restless behaviors are positive symptoms of schizophrenia. A delusion is a fixed false belief that is resistant to reasoning; when a person believes that he or she is a famous, historical or fictional omnipotent character this is called a delusion of grandeur; a delusion is a positive symptom associated with schizophrenia. An auditory hallucination is a sensory perception involving the sense of hearing that occurs in the absence of an external stimulus and is a positive symptom associated with schizophrenia. Decreased verbalization, including a sudden stoppage in the flow of speech (blocking) and lack of inflection, is a negative symptom associated with schizophrenia. Lack of motivation (avolition) and apathy are negative symptoms associated with schizophrenia.

While assessing a client during a routine examination, a nurse in the clinic identifies signs and symptoms of hyperthyroidism. Which signs are characteristic of hyperthyroidism? Multiple selection question Diaphoresis Weight loss Constipation Protruding eyes Cold intolerance

Diaphoresis Weight loss Protruding eyes Diaphoresis occurs with hyperthyroidism because of increased metabolism, resulting in hyperthermia. Weight loss occurs with hyperthyroidism because of increased metabolism. Bulging eyes occur with hyperthyroidism and are thought to be related to an autoimmune response of the retroorbital tissue, which causes the eyeballs to enlarge and push forward. Diarrhea occurs because of increased body processes, specifically increased gastrointestinal peristalsis. Heat intolerance occurs because of the increased metabolism associated with hyperthyroidism.

The nurse is caring for a client with a spinal cord injury. The client exhibits signs of autonomic hyperreflexia. What does the nurse recall is the most common cause of this response? Multiple choice question Hemodynamic changes related to tilt table positioning Deteriorating myelin sheath Distended large intestine Crushed spinal cord

Distended large intestine Bowel or bladder distention causes autonomic nerve impulses to ascend via the cord to the point of injury; here the reflex is completed, and autonomic outflow causes piloerection (goose bumps), sweating, and splanchnic vasoconstriction. Splanchnic vasoconstriction causes hypertension and a pounding headache. The client being upright on a tilt table is not involved in the autonomic hyperreflexia[1][2] phenomenon. The myelin sheath deteriorating is not involved in the autonomic hyperreflexia phenomenon. The spinal cord is crushed rather than severed and is not involved in the autonomic hyperreflexia phenomenon.

Which instruction from the nurse to an 80-year-old client with thinning of a subcutaneous layer would be most beneficial? Multiple choice question Dress warmly in cold weather Use soaps with high fat content Change the position of bed once every 5 hours Apply moisturizer immediately after bathing

Dress warmly in cold weather

A client with mental health problems is given a prescription for fluphenazine. The nurse develops a teaching plan about the medication. What will the nurse caution the client to avoid? Multiple choice question Eating cheeses Nighttime driving Staying in the sun Taking drugs containing aspirin

Fluphenazine causes photosensitivity; severe sunburn may occur with exposure to the sun. The client should avoid eating cheese if she is taking a monoamine oxidase inhibitor, not fluphenazine, which is a phenothiazine. There are no known side effects of fluphenazine that affect the ability to drive at night. Aspirin is not contraindicated for clients taking fluphenazine.

A nurse is caring for a client who just had a liver biopsy. After the procedure, the nurse should monitor for which common complication associated with the biopsy? Multiple choice question Hemorrhage Gastroparesis Pulmonary embolism Tension pneumothorax

Hemorrhage In the impaired liver, blood-clotting mechanisms are disrupted, and hemorrhage may occur from the trauma of this invasive procedure. A liver biopsy will not cause the stomach to empty more slowly. Because clotting mechanisms are prolonged, emboli usually are not a complication. A collapsed lung can occur if the needle is not inserted properly; however, this is not a common occurrence.

A client with rheumatoid arthritis is to begin taking ibuprofen 800 mg by mouth three times a day. The nurse provides education about the medication's side effects. The nurse concludes that the teaching was effective when the client makes which statement? Multiple choice question "I need to have my blood work checked periodically." "I need to balance exercise with rest." "I need to change positions slowly." "I need to take the medication between meals."

If the client will be taking the medication long term, periodic diagnostic tests are necessary because ibuprofen is nephrotoxic, is hepatotoxic, and prolongs the bleeding time. Balancing exercise with rest is important for all clients with arthritis; it is not related to ibuprofen. Ibuprofen does not cause postural hypotension. Ibuprofen causes epigastric distress and occult bleeding; it should be taken with meals or milk to reduce these adverse reactions.

A school nurse teaches a 13-year-old child with hay fever that the prescribed phenylephrine nasal spray must be used exactly as directed. What complication may occur if the nasal spray is used more frequently or longer than recommended? Multiple choice question Tinnitus Nasal polyps Bleeding tendencies Increased nasal congestion

Increased nasal congestion Frequent and continued use of phenylephrine can cause rebound congestion of mucous membranes. Tinnitus is not a side effect of phenylephrine nasal spray; however, hypotension, tachycardia, and tingling of the extremities may occur. Nasal polyps may be associated with allergies but are unrelated to phenylephrine nasal spray. Bleeding tendencies are unrelated to the use of phenylephrine nasal spray.

A healthcare provider prescribes phenobarbital sodium for a client who had a tonic-clonic seizure. The nurse assesses the client's knowledge after teaching about the adverse effects of this drug. What responses should the client identify as a reason for calling the healthcare provider? Multiple choice question Loss of appetite or persistent fatigue Anal itching or dizziness when standing up Diarrhea or a rash on the upper part of the body Decreased tolerance to common foods or constipation

Loss of appetite or persistent fatigue Phenobarbital depresses the central nervous system, particularly the motor cortex, producing adverse effects such as lethargy, loss of appetite, depression, and vertigo. Anal itching, diarrhea, rashes, and decreased tolerance to common foods or constipation are not side effects of phenobarbital.

A client's laboratory report reveals decreased serum and salivary cortisol levels and increased serum potassium level from hypofunctioning of the adrenal gland. The client is prescribed fludrocortisone. Which nursing action in the follow-up visit minimizes risk of a potential side effect of medication? Multiple choice question Monitoring the client's blood pressure Monitoring the client's body temperature Instructing the client to take the drug along with food Instructing the client to report occurrence of uncontrolled watery stools

Monitoring the client's blood pressure Fludrocortisone administered to treat adrenal gland hypofunction could cause hypertension as a side effect. Therefore the nurse should monitor the client's blood pressure. A client on prednisone therapy should be monitored for fever by checking body temperature. The dose of prednisone needs to be altered in case of fever. Cortisone causes gastrointestinal irritation as a side effect. Therefore the nurse should instruct the client on cortisone therapy to take the drug along with food. The dose of prednisone needs modification if the client develops infection or illness. Therefore the nurse should instruct the client on prednisone therapy to report any occurrence of diarrhea or watery stools

Which question should the nurse include in the assessment process for the parent of a toddler-age client who is diagnosed with lead toxicity that is not related to a household item? Multiple choice question "Do you teach for a living?" "Do you refinish furniture?" "Do you work in a hospital?" "Do you work with children?"

Occupational exposure to lead can occur when a parent works with refinishing furniture; therefore, this is a question the nurse should include in the assessment process. Teaching, working in a hospital, and working with children are not occupational exposure risks for lead.

A nurse is caring for a client with the diagnosis of schizophrenia, paranoid type. What should the nurse plan for the client's initial care? Multiple choice question Discussing important life events Providing a nonthreatening environment Concentrating on the content of delusions Limiting topics for discussion to recent situations

Providing a nonthreatening environment These clients are hypersensitive to external stimuli and respond with less anxiety to a minimally threatening environment. Discussing prominent life events is too threatening an approach and interferes with the goals of therapy. Focusing on delusional material will reinforce the delusional system. Limiting topics for discussion to recent situations is not therapeutic; it may trigger suspiciousness and hostile outbursts.

The nurse is caring for a pregnant client with hypertension. Which client care tasks are most suitable to be delegated to the patient care associate (PCA)? Multiple choice question Recording the vital signs Monitoring the blood pressure Administering intravenous fluids Administering antihypertensive medications

Recording the vital signs A patient care associate (PCA) is an unlicensed assistive personnel whose scope of practice is very limited. A PCA can be delegated the task of recording the vital signs as communicated by the delegator even if the condition of the client is acute or unstable. In stable clients, the PCA may be instructed to monitor the blood pressure, but in this acute condition, only the registered nurse (RN) should monitor the blood pressure. Administration of intravenous fluids or medications is out of scope of practice of the PCA. A PCA is not suitable to be delegated the task of administering any medication to a client.

A client is admitted to the hospital with a diagnosis of a large cancerous tumor of the sigmoid colon, and surgery for a colon resection is scheduled. What clinical finding does the nurse expect when completing this client's nursing admission history and physical? Diarrhea Dehydration Rectal bleeding Ribbon-shaped stool

Rectal bleeding Tumors of the sigmoid colon are associated with rectal bleeding. Diarrhea alternating with constipation frequently occurs. Dehydration usually does not occur unless there is severe vomiting or severe prolonged diarrhea. A change in the shape of stool occurs with tumors in the descending colon and sigmoid colon.

What is the most important intervention to prevent hospital-acquired catheter-associated urinary tract infections (CAUTIs)? Multiple choice question Removing the catheter Keeping the drainage bag off of the floor Washing hands before and after assessing the catheter Cleansing the urinary meatus with soap and water daily

Removing the catheter esearch demonstrates that decreasing the use of indwelling urinary catheters is the most important intervention to prevent hospital-acquired catheter-associated urinary tract infections (CAUTIs). Keeping the drainage bag off the floor, washing hands before and after assessing the catheter, and cleansing the urinary meatus daily with soap and water will help reduce infections; however, these are not the most important interventions to prevent CAUTIs.

A nurse begins planning for the discharge of a client who had a brain attack (cerebrovascular accident, CVA) with residual hemiparesis and hemianopsia. Which information should the nurse include in the discharge teaching plan for this client? Multiple choice question Necessity for bed rest at home Use of oxygen therapy at home Significance of a safe environment Need for decreased protein in the diet

Significance of a safe environment Safety becomes a priority when the client has hemiparesis (paralysis on one side) and hemianopsia (abnormal visual field). Although a balance between activity and rest is important, the client does not have to maintain bed rest. Oxygen generally is not necessary. All the basic nutrients should be included in the diet; there is no reason to reduce protein intake.

Which of these is a part of health belief model? Multiple choice question Behavioral outcomes Behavior-specific knowledge Perception of susceptibility to an illness Individual characteristics and experience

The health belief model is divided into three components. The first component is an individual's perception of susceptibility to an illness. The second component is an individual's perception of seriousness of an illness. The third component is the preventive actions taken by a person. The health promotion model focuses on behavioral outcomes, behavior-specific knowledge and affect, and individual characteristics and experience.

A client at 36 weeks' gestation is admitted to the high-risk unit with the diagnosis of severe preeclampsia, and antiseizure therapy is instituted. A fetal monitor and an electronic blood pressure machine are applied. Which complication of severe preeclampsia requires diligent monitoring of the blood pressure? Multiple choice question Stroke Hemorrhage Precipitous labor Disseminated intravascular coagulation

The likelihood of a stroke increases with a rising blood pressure reading. The degree of hypertension is not associated with hemorrhage. The course of labor is not affected by blood pressure changes except in the presence of abruptio placentae. Fluctuations in blood pressure do not affect the status of clotting factors.

Which example indicates that the nurse is following evidence-based practice? Multiple choice question The nurse documents client care in an electronic health record. The nurse reads current nursing journals and uses the latest scientific methods. The nurse uses flowcharts and diagrams to record the client's progress. The nurse encourages the hospitalized client's family to bring home-cooked food.

The nurse reads current nursing journals and uses the latest scientific methods. Evidence-based practice requires the nurse to read current nursing journals and use the latest scientific methods. It also requires the integration of best current evidence with clinical expertise and client preferences while providing health care. The nurse uses informatics to document client care in an electronic health record. The nurse uses flowcharts and diagrams to record the client's progress and monitor the outcomes of client care. This helps the nurse to improve the quality of care. The nurse provides client-centered care by encouraging the hospitalized client's family to bring home-cooked food.

A client at 36 weeks' gestation is admitted to the high-risk unit with heavy bleeding because of complete placenta previa. Why does the nurse place the client in a lateral Trendelenburg position? Multiple choice question To prevent shock To control bleeding To keep pressure off the cervix To move the placenta off the cervix

To prevent shock The Trendelenburg position shunts blood to the upper body and vital organs. The Trendelenburg position will not help control the bleeding. Pressure on the cervix is thought to have no bearing on bleeding episodes. In late pregnancy the placenta does not change its location in the uterus. Also, the Trendelenburg position cannot move the placenta from the cervix.

Which approach is a comforting approach that communicates concern and support? Multiple choice question Touch Listening Knowing the client Providing a positive presence

Touch Touch is a comforting approach that involves reaching out to clients to communicate concern and support. Listening is a critical component of nursing care and is necessary for meaningful interactions with clients. Knowing the client comprises both the nurse's understanding of a specific client and his or her subsequent selection of interventions. Providing presence is a person-to-person encounter that conveys a closeness and sense of caring.

A nurse is teaching a health class about heart disease to older adult women. The nurse discusses the most common prodromal symptom reported by women with acute coronary heart disease that usually is not experienced by men. Which response indicates a woman in the group understands the teaching? Multiple choice question Unusual fatigue Shortness of breath Crushing pain in the chest Substernal pressure radiating to the neck

Unusual fatigue Studies indicate that women who have myocardial infarctions frequently experience unusual prodromal fatigue; also, during the prodromal period, women more frequently experience upper abdominal fullness instigated by exertion or emotional stress. Substernal pressure that radiates to the neck is experienced more often by men than by women during the acute period of a myocardial infarction. Although women do experience the other symptoms, they do not occur as frequently as fatigue.

A nurse is caring for a client who is receiving a unit of packed red blood cells. Which findings lead the nurse to suspect a transfusion reaction caused by incompatible blood? Multiple selection question Cyanosis Backache Shivering Bradycardia Hypertensio

backache n shivering Mismatched blood cells are attacked by antibodies, and the hemoglobin released from ruptured erythrocytes plugs the kidney tubules; this kidney involvement results in backache. Shivering occurs as part of the inflammatory response associated with a transfusion reaction. Cyanosis is not commonly associated with a transfusion reaction. Tachycardia, not bradycardia, is associated with a transfusion reaction. Hypotension, not hypertension, is associated with a transfusion reaction.

The nurse is caring for a community-dwelling older adult who is suffering from confusion. Which are the best nursing interventions in this situation? Multiple selection question The nurse should provide a protective environment. The nurse should assist with personal hygiene. The nurse should educate the client about correct body mechanics. The nurse should promote activities that reinforce reality. The nurse should teach the client's caregiver proper feeding techniques.

nurse should provide a protective environment. The nurse should assist with personal hygiene. The nurse should promote activities that reinforce reality. When caring for an older adult who is in a confused state, the nurse should provide a protective environment, assist with personal hygiene, and promote activities that reinforce reality. If a client is suffering from arthritis, the nurse should educate him or her about correct body mechanics. If the nurse is caring for a dementia client, then he or she should teach the family caregiver proper feeding techniques.

A sexually active client presents with a sore throat and a generalized rash. The client states that a chancre that had been present healed approximately 3 months ago. The physical assessment and the serologic test findings indicate a diagnosis of syphilis. Which stage should the nurse determine the client is in at this time? Multiple choice question Primary Secondary Latent Tertiary

secondary

The client reports excessive bleeding during the menstruation. Which herbal therapies are unlikely to be prescribed by the primary healthcare provider? Multiple selection question Raspberry Chamomile Lady's mantle Chaste tree fruit Shepherd's purse

Chamomile Chaste tree fruit Chamomile is an antispasmodic agent that helps to reduce breast pain. Chaste tree fruit is used to reduce breast pain by reducing the prolactin levels. Raspberry, lady's mantle, and shepherd's purse are uterotonic drugs used to treat menorrhea.

A client is diagnosed with an eczematous eruption with well-defined and geometric margins on the scalp. Which condition does the nurse anticipate in the client? Drug eruption Atopic dermatitis Contact dermatitis Nonspecific eczematous dermatitis

Contact dermatitis The diagnostic feature of contact dermatitis is the presence of localized eczematous eruptions with well-defined and geometric margins. The diagnostic feature of drug eruption is the presence of bright-red erythematous macules and papules in large areas. In atopic dermatitis, the client has lichenification with scaling and excoriation, which causes extreme itching. In nonspecific eczematous dermatitis, lesions evolve from vesicles to weeping papules and plaques.

What assessment finding should a nurse expect to note in a child with chronic hypoxia? Multiple choice question Clubbing of fingers Decreased red cell count Slow, irregular respirations Subcutaneous hemorrhages

Hypoxia leads to poor peripheral circulation; clubbing occurs as a result of tissue hypertrophy and additional capillary development in the fingers. These children have polycythemia, not a decreased red blood cell count. Respirations generally are rapid to compensate for oxygen deprivation. Subcutaneous hemorrhage is not a physiologic response in children with chronic hypoxia.

A 55-year-old client who has a long history of drug and alcohol abuse mentions taking ginkgo biloba. The nurse knows that ginkgo biloba is taken to treat what condition? Multiple choice question Insomnia Depression Memory impairment Anxiety and nervousness

Memory impairment Ginkgo biloba is an herb used to treat age-related memory impairment and dementia. It has not been shown to be effective in treating insomnia, depression, or anxiety.

A nurse is observing two 18-month-old children playing side by side in a sandbox. Although they watch each other, neither interacts with the other. What type of play does the nurse identify? Multiple choice question Solitary Parallel Associative Cooperative

Parallel Parallel play is typical of the toddler age group, when children play beside but not with each other. Solitary play is a feature of infancy. Associative play is a characteristic of the preschool years, when children interact in loose association. Cooperative play is seen in school-aged children, whose play is organized, such as in sports and board games.

Which behavior indicates that a nurse is functioning as a case manager? Multiple choice question Discusses medication side effects with the pharmacist Prepares a performance appraisal for cross-trained staff Meets with a client's family when preparing discharge instructions Reviews evidence-based practice prior to identifying interventions for a client

Reviews evidence-based practice prior to identifying interventions for a client One standard of practice for case managers is to use evidence-based guidelines. These guidelines explain research performed and outcomes that can be applied to client care. Discussing medication side effects would be an activity performed in client-focused care. Preparing a performance appraisal for cross-trained staff would be performed by a manager of a client-focused care area. Meeting with family when preparing discharge instructions would be performed by a primary nurse.

A geriatric patient with hypertension and diabetes mellitus is taking propranolol (Inderal) and insulin (Humulin N) therapy. Which interventions by health care professionals help prevent patient medication errors according to the Leapfrog Group? Multiple choice question Scheduling regular follow-up visits Prescribing low dosage of medication Using computer physician order entry Closely monitoring the patient for 24 hours

The Leapfrog Group suggests using computer physician order entry (CPOE) to prevent medication errors. CPOE provides immediate information to the primary healthcare providers and nurses about the medications prescribed to the patients and helps prevent drug interactions and adverse effects. Scheduling regular follow-up visits helps prevent the side effects of the medication, but not medical errors. The Leapfrog Group does not suggest the dosage guidelines for geriatrics. Therefore the Leapfrog Group does not prescribe low dosage of medication. Closely monitoring the patient for just 24 hours will not help prevent medication errors, drug interactions, and other adverse effects.

What is a clinical manifestation in a client with hyposecretion of growth hormone? Multiple choice question Lethargy Weight gain Decreased libido Reduced bone density

reduced Bone density Growth hormone deficiency changes tissue growth patterns resulting in increasing bone destructive activity and reduced bone density. A client becomes lethargic and gains weight due to the deficiency of thyroid stimulating hormone. Decreased libido (sexual desire) is seen due to the deficiency of gonadotropins.

Which individual is at risk of developing carpal tunnel syndrome? Multiple choice question Housekeeper Software engineer Healthcare worker Professional athlete

software eng. Carpal tunnel syndrome is a painful condition of the hands and fingers that is caused by repetitive movements that lead to compression of the medial nerve near the wrist. Computer-related jobs involve repetitive movement of the fingers and hand, thereby predisposing the individual to carpal tunnel syndrome. Musculoskeletal injuries can occur in clients whose jobs require manual labor, such as housekeepers and mechanics. Healthcare workers may be at risk of developing back injury due to prolonged standing and excessive lifting. Professional athletes experience acute musculoskeletal injuries, such as joint dislocations and fractures.

A client has a new colostomy. The nurse has provided teaching related to when the client should irrigate the colostomy. Which client statement indicates correct understanding of the teaching? Multiple choice question "After it gets done healing in a few weeks, I will begin irrigating it just before going to bed each day." "It will need to be irrigated each morning before I can eat any food." "I plan to irrigate it in the late morning, the same time I had a bowel movement every day before I had my surgery." "I can wait to start irrigating it until after I have gotten used to this bag and change in lifestyle."

"I plan to irrigate it in the late morning, the same time I had a bowel movement every day before I had my surgery." Although most people defecate after breakfast because ingestion of food on an empty stomach initiates the gastrocolic reflex, not all people defecate at this time. Irrigation should be performed at the time the client routinely defecated before the colostomy, to maintain continuity in lifestyle. Irrigations should be performed at the same time the client routinely defecated before the colostomy, to maintain continuity in lifestyle. Clients can eat before irrigating the colostomy. An irrigation cannot be postponed until the client accepts the altered body image, because this may take weeks or months.

The nurse is assessing a client who reports breathlessness. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error? Multiple choice question Assess the client's lungs. Assess the client for pain. Obtain details of smoking habits. Ask about the onset of breathlessness.

Assess the client's lungs. The nurse should assess the client's lungs to gather objective data that will support subjective data provided by the client. The nurse can obtain objective data for this client by auscultating for lung sounds, assessing the respiratory rate, and measuring the client's chest excursion. The nurse should review the data for accuracy and completeness before grouping the data into clusters. The nurse may also assess the client for pain, which is subjective data. The client may provide details about smoking habits, which is also subjective data. It is important for the nurse to identify what causes breathlessness; however, the client's statement is subjective data. All subjective data must be supported by measurable objective data.

Which skills are essential for the nurse who is setting priorities for client care? Multiple selection question Evaluation Assessment Critical thinking Case management Clinical decision-making

Assessment Critical thinking Clinical decision-making Essential skills for the nurse who is setting priorities for client care include assessment, critical thinking, and clinical decision-making. Evaluation and case management are nursing skills; however, these are not essential for setting priorities

Which laboratory test will be elevated in a client with inflammatory arthritis? Multiple choice question Leukocyte count Hemoglobin and hematocrit Blood urea nitrogen and creatinine Erythrocyte sedimentation rate (ESR)

Erythrocyte sedimentation rate (ESR) The erythrocyte sedimentation rate (ESR) measures the rate at which red blood cells fall through plasma. This rate is most significantly affected by an increased number of acute-phase reactants, which occur with inflammation. An elevated ESR (>20 mm/hr) indicates inflammation or infection somewhere in the body. The ESR is chronically elevated with inflammatory arthritis. Leukocytes will be elevated when a bacterial infection is present. Hemoglobin and hematocrit are not used to determine the presence of inflammation. Blood urea nitrogen and creatinine levels are used to determine renal function.

Which professional standard does the nurse feel is most important for critical thinking? Multiple choice question Logical thinking Evaluation criteria Accurate knowledge Relevant information

Evaluation criteria An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.

A nurse is assessing aclient who is suspected of having memory loss. Which question asked by the nurse will be appropriate to test recent recall memory of the client? Multiple choice question "What is your date of birth?" "How did you reach the clinic?" "How many schools have you attended?" "Can you count backwards from 100 to 1?"

How did you reach the clinic?" To test the recent recall memory of a client, questions regarding the mode of transportation to the clinic can be asked. Questions regarding date of birth can be asked to test the remote memory of a client. Questions about number of schools attended can be asked to test the remote memory of a client. Backward counting of numbers can be asked to assess the attention of a client.

The laboratory report of a client reveals increased levels of atrial natriuretic peptide. Which other finding does the nurse anticipate to find in the client? Multiple choice question Decreased urine output Increased concentration of urine Increased sodium excretion in urine Decreased glomerular filtration rate

Increased sodium excretion in urine Atrial natriuretic peptide is secreted by the myocyte cells in the right atrium. Atrial natriuretic peptide acts on the kidneys and causes an increase in the excretion of sodium by inhibiting aldosterone. Atrial natriuretic peptide increases urine output. Atrial natriuretic peptide causes inhibition of renin and angiotensin II, and therefore the resultant urine produced contains more water and is dilute. Because atrial natriuretic peptide relaxes the afferent arteriole in the nephron, glomerular filtration rate is increased.

Which vaccine is administrated through the intranasal route? Multiple choice question Rotavirus vaccine Influenza (live) vaccine Varicella virus vaccine Human papillomavirus vaccine

Influenza (live) vaccine is administered through the intranasal route. The rotavirus vaccine is administered orally. The varicella virus vaccine is given as a subcutaneous injection. The human papillomavirus vaccine is given as intramuscular injection.

A nurse is caring for a client who is experiencing urinary incontinence. The client has an involuntary loss of small amounts (25 to 35 mL) of urine from an overdistended bladder. How should this be documented in the client's medical record? Multiple choice question Urge incontinence Stress incontinence Overflow incontinence Functional incontinence

Overflow incontinence Overflow incontinence[1][2][3] describes what is happening with this client; overflow incontinence occurs when the pressure in the bladder overcomes sphincter control. Urge incontinence describes a strong need to void that leads to involuntary urination regardless of the amount in the bladder. Stress incontinence occurs when a small amount of urine is expelled because of an increase in intraabdominal pressure that occurs with coughing, lifting, or sneezing. Functional incontinence occurs from other issues rather than the bladder, such as cognitive (dementia) or environmental (no toileting facilities).

A client reports a severe, sharp, stabbing headache and intense pain in and around the eye that lasts for up to 1 hour. History reveals that the client had similar episodes of headaches previously which lasted for ten weeks. What other symptoms may be manifested by the client? . Multiple selection question Vertigo Rhinorrhea Lacrimation Phonophobia Pupillary constriction

Rhinorrhea Lacrimation Pupillary constriction Cluster headaches are short headaches occurring in episodes, with characteristic sharp stabbing pain. Pain occurs in the oculotemporal or oculofrontal regions or deep around the eye. The headaches may be persistent for about 4 to 12 weeks followed by a period of remission of 9 to 12 months. Cluster headaches are associated with other symptoms, including rhinorrhea (a runny nose), tearing of eyes (lacrimation), myosis (pupillary constriction), and ptosis (drooping eyelids). Vertigo is a neurologic change seen in a migraine with aura. Phonophobia is sound sensitivity and is seen in a migraine without aura.

A 4-year-old child who weighs 44 lb (20 kg) is prescribed prednisone. The recommended dosage for children is 2 mg/kg/day given in four divided doses. What will the child receive in each dose? Express your answer as a whole number.

The child's weight is 44 lb; divide by 2.2 to yield 20 kg. A dosage of 2 mg × 20 kg yields a 40-mg daily dose that should be divided by four: 40/4 = 10 mg.

A client who is 28 weeks into her second pregnancy is experiencing increased edema in the lower extremities. The nurse advises rest with the legs elevated and provides dietary instructions. What other advice should the nurse provide? Multiple choice question The preferred diet will include favorite foods. A nutritionist should be involved in planning a diet. The selected foods do not need to have a low salt content. The client should consult the healthcare provider at the prenatal clinic.

The selected foods do not need to have a low salt content. Dependent edema is common during the last trimester; there is no need to lower the salt content of the client's diet. Teaching should be based on optimal nutrition, as well as the caloric content of the diet. Not all preferences can be included; the diet should include a normal sodium and high protein intake and sufficient calories. Immediate planning based on the nurse's knowledge of dietary needs is sufficient. Unless there is reason to believe that a need for medical intervention exists, the nurse may discuss care related to human responses.

A nurse is caring for a client with right-sided heart failure. Which assessment findings are key features of right-sided heart failure? Multiple selection question Collapsed neck veins Distended abdomen Dependent edema Urinating at night Cool extremities

Distended abdomen Dependent edema Urinating at night Right-sided heart failure is associated with increased systemic venous pressures and congestion, as manifested by a distended abdomen, dependent edema, and urinating at night. Distended, not collapsed, neck veins occur in right-sided heart failure. Cool extremities are key features of left-sided heart failure.

What is a common characteristic of Sjögren's syndrome (SS)? Multiple choice question Dry eyes Muscle cramping Urinary tract infection Elevated blood pressure

Dry eyes Sjögren's syndrome (SS) is a group of problems that often appear with other autoimmune disorders. Problems include dry eyes, which are caused by autoimmune destruction of the lacrimal glands. Muscle cramping, urinary tract infection, and elevated blood pressure are not common characteristics of Sjögren's syndrome (SS). In Sjogren's syndrome, the mucous membranes and moisture-secreting glands of your eyes and mouth are usually affected first — resulting in decreased tears and saliva.

A nursing student notes that a nurse is required to integrate best current research with clinical expertise and client preferences and values in order to provide quality healthcare. Which Quality and Safety Education for Nurses (QSEN) competency does this comply with? Multiple choice question Safety Quality improvement Patient-centered care Evidence-based practice

Evidence-based practice The QSEN competency evidence-based practice states that a nurse should integrate best current research with clinical expertise and client's preferences and values in order to provide quality healthcare. Safety involves nursing actions aimed at minimizing the risk of harm to clients and healthcare workers by ensuring system effectiveness and improving individual performance. Quality improvement involves the use of data to monitor outcomes of processes and implementation of methods to improve the healthcare delivery system. Patient-centered care states that the client is the source of control in providing healthcare.

The health care provider prescribes one tube of glucose gel for the client with type 1 diabetes. The nurse recognizes that this is for treatment of which diabetes complication? Multiple choice question Diabetic acidosis Hyperinsulin secretion Insulin-induced hypoglycemia Idiosyncratic reactions to insulin

Insulin-induced hypoglycemia Glucose gel delivers a measured amount of simple sugars to provide glucose to the blood for rapid action. Acidosis occurs when there is an increased serum glucose level; therefore glucose gel is not indicated. Diabetes mellitus involves a decreased insulin production. Glucose gel is not indicated in idiosyncratic reactions to insulin.

A client is admitted to the hospital with a recurrence of chronic arterial insufficiency of the legs. Which clinical manifestations does the nurse expect to identify when performing an admission history and physical? Multiple choice question Edema of the feet and ankles Reddened and painful areas on the calves Pain when exercising and thickening of the toenails Ulcers around the ankles and reports of a dull ache in the legs

Pain when exercising and thickening of the toenails Inadequate oxygenation of tissues of the affected limb causes intermittent claudication and thickened toenails. Edema of the feet and ankles occurs with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, dependent edema may be associated with decreased cardiac output related to heart failure. Reddened and painful areas on the calves are adaptations related to thrombophlebitis, a venous rather than arterial problem. Ulcers around the ankles and reports of a dull ache in the legs occur with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, these adaptations may be associated with decreased cardiac output related to heart failure.

A client is diagnosed with acute mania. The primary healthcare provider plans to prescribe lithium therapy to the client. After assessing the client's condition, the primary healthcare provider changes the therapy. Which client conditions would cause the provider to change course? Multiple selection question Glaucoma Pregnancy Atherosclerosis Renal insufficiency Severe dehydration

Pregnancy Atherosclerosis Renal insufficiency Severe dehydration Lithium therapy has been widely used to treat bipolar disorders and maniac episodes; cardiovascular diseases increase lithium toxicity. Therefore, it is contraindicated in clients with atherosclerosis. Lithium therapy is also contraindicated in clients with kidney related problems such as renal insufficiency. Dehydration causes electrolyte imbalances, which increases the risk of lithium toxicity. Lithium also may harm a fetus and, whenever possible, is not given to women who are pregnant. Clients with narrow-angle glaucoma should not be prescribed benzodiazepines.

What nursing care should be included for a client who is receiving doxorubicin for acute myelogenous leukemia? Multiple choice question Serving hot liquids with each meal Providing frequent oral hygiene and increasing oral fluids Emphasizing that the disease will be cured with this treatment Administering medications intramuscularly and encouraging activity

Providing frequent oral hygiene and increasing oral fluids Stomatitis and hyperuricemia are possible complications of therapy; therefore, oral care and hydration are important. Food and fluids with extremes in temperature should be avoided because of the common occurrence of stomatitis. Emphasizing that the disease will be cured with this treatment may provide false reassurance. Abnormal bleeding is a common problem, and thus injections are contraindicated; rest is important for increased fatigability. Stomatitis is inflammation of the mouth and lips. Doxorubicin, sold under the trade names Adriamycin among others, is a chemotherapy medication used to treat cancer. This includes breast cancer, bladder cancer, Kaposi's sarcoma, lymphoma, and acute lymphocytic leukemia.

A client is prescribed the benzodiazepine alprazolam for the management of panic attacks. The nurse is confident that the medication information discussed has been understood when the client takes which action? Multiple choice question Removes the pepperoni from a pizza Asks for an extra bottle of flavored water to drink with dinner Requests a prescription for oral birth control before being discharged States that chewable antacids may be taken to relieve heartburn

Requests a prescription for oral birth control before being discharged Benzodiazepines increase the risk of congenital anomalies and so should not be taken by pregnant women. Refraining from eating pepperoni is appropriate for people taking monoamine oxidase inhibitors because tyramine needs to be strictly avoided. Appropriate hydration is critical for those taking lithium. Antacids can affect both absorption and metabolism of benzodiazepines and should be avoided.

A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority? Multiple choice question Urinary output Sensation to touch Neurologic status Respiratory exchange

Respiratory exchange Guillain-Barré syndrome is a rare but serious autoimmune disorder in which the immune system attacks healthy nerve cells in your peripheral nervous system. This leads to weakness, numbness, and tingling. It can eventually cause paralysis. The respiratory center in the medulla oblongata can be affected with acute Guillain-Barré syndrome because the ascending paralysis can reach the diaphragm, leading to death from respiratory failure. Although urinary output, sensation to touch, and neurologic status are important, none of them are the priority.

A client with a history of chronic myelogenous leukemia and splenomegaly is admitted to the hospital. What should the nurse expect to identify when completing the admission assessment? Multiple choice question Increased urinary output Tender mass in the left upper abdomen Elevated erythrocytes, platelets, and granulocytes Polydipsia, increased appetite, and urinary frequency

Tender mass in the left upper abdomen Splenomegaly usually accompanies chronic myelogenous leukemia; the spleen usually is gross, palpable, and tender and necessitates removal. The spleen is located high in the abdomen on the left side and usually is not palpable unless it is enlarged. The urinary output is not affected with these conditions. With leukemia and splenomegaly there is increased destruction of blood cells; the erythrocyte count will be low. Polydipsia, increased appetite, and urinary frequency are not associated with leukemia or splenomegaly, but rather diabetes.

Which major gross motor development skills would the nurse expect to see demonstrated during a teaching session with parents of a 12-month old client who is entering the toddler stage of development? Multiple choice question Walking alone Drawing a stick figure person Showing interest in cooperative play Beginning to develop object permanence

Walking alone A major gross motor development the nurse should include in the teaching session with the parents of a 12-month old client is walking alone[1][2]. Drawing a stick figure person is a fine motor skill that is not developed until the preschool stage of development. Showing interest in cooperative play does not occur until late in the preschool stage of development. Object permanence occurs during infancy.

A client is receiving clonidine for hypertension. What side effect of clonidine will the nurse include when providing drug education? Multiple choice question Xerostomia Diarrhea Euphoria Photosensitivity

Xerostomia Xerostomia (dry mouth) is one of the common side effects of this drug. The reaction usually diminishes over the first 2 to 4 weeks of therapy. This drug causes constipation, not diarrhea. This drug may cause depression, anxiety, fatigue, and drowsiness, not euphoria. Photosensitivity is not a side effect of this medication.

A nurse notes gentamycin in the prescription of an older adult with osteomyelitis. Which nursing interventions should be conducted before starting therapy? Multiple selection question Assessing renal function Assessing hydration status Checking the erythrocyte count Checking the blood platelet count Assessing serum thyroxin levels

Assessing renal function Assessing hydration status Because gentamycin can increase the risk of nephrotoxicity, the nurse should assess a client's renal function before starting therapy. Dehydration can further increase the risk of nephrotoxicity; therefore the client's hydration status should also be checked before starting therapy. Gentamycin generally does not impact erythrocyte and blood platelet counts nor does it affect serum thyroxin levels.

Which instructions should the nurse include in the teaching plan for a client who will be taking simvastatin when discharged? . Multiple selection question Increase dietary intake of potassium. Avoid prolonged exposure to the sun. Schedule regular ophthalmic examinations. Take the medication at least half an hour before meals. Contact your healthcare provider if skin becomes gray-bronze.

Avoid prolonged exposure to the sun. Schedule regular ophthalmic examinations. Contact your healthcare provider if skin becomes gray-bronze Simvastatin increases photosensitivity; the client should avoid sun exposure and use sunblock. The client should be monitored for the adverse effects of glaucoma and cataracts. Gray-bronze skin and unexplained muscle pain are signs of rhabdomyolysis. Rhabdomyolysis, a life-threatening response, is the disintegration of muscle associated with myoglobin in the urine. Simvastatin does not affect levels of potassium. The medication is most effective when taken at bedtime because cholesterol synthesis is highest at night..

A client has been prescribed chlorpromazine for the management of positive symptoms of schizophrenia. What is the nurse's response when the client reports difficulty sustaining an erection? Multiple choice question Reassuring the client that this side effect will resolve in a few weeks Consulting with the primary healthcare provider regarding alternative medication therapies Explaining that all conventional antipsychotic medications cause impotence Providing additional medication education to explain the medication's side effects in detail

Consulting with the primary healthcare provider regarding alternative medication therapies Although erectile dysfunction can result from conventional antipsychotic medication therapy, the provider is often able to prescribe an alternative medication that will help manage the symptoms but is less likely to cause the dysfunction. Education regarding side effects is certainly appropriate, but such information will only confirm that the side effect is not likely to subside with time.

Which term refers to a blowing sound created by turbulence caused by narrowing of arteries while assessing for carotid pulse? Multiple choice question Bruit Ectropion Entropion Borborygmi

A bruit is an audible vascular blowing sound associated with turbulent blood flow through a carotid artery. Ectropion is a condition in which the eyelid is turned outwards away from the eyeball. Entropion is a malposition resulting in an inversion of the eyelid margin. Borborygmi are rumbling or gurgling noises made by the movement of fluid and gas in the intestines