hesi review
A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement?
Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour
A postoperative female client has a prescription for morphine sulfate 10 mg IV q3 hours for pain. One dose of morphine was administered when the client was admitted to the post anesthesia care unit (PACU) and 3 hours later, the client is again complaining of pain. Her current respiratory rate is 8 breaths/minute. What action should the nurse take?
Administer Naxolone IV
A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client's EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, "I feel like an elephant just stepped on my chest" The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform?
Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula.
In a discussion with a group of high school teachers about oppositional defiant disorder (ODD), the nurse says that behavior modification of the parents and teachers toward such children forms the basis of therapy. What is the most appropriate rationale that the nurse gives when asked about this strategy?
Adolescents with ODD learn maladaptive behavior at home and it can be perpetuated at school.
Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement?
Advise the client that assignments are not based on clients requests
Which interventions should a nurse teach the parents of a child with conduct disorder? Select all that apply.
Advise them to avoid rescuing their child. Explain about age-appropriate activities and expectations. Encourage them to seek proper treatment for their own problems.
A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?
Altered consciousness within the first 24 hours after injury.
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)?
An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied
Which client is at the greatest risk for developing delirium?
An adult client who cannot sleep due to constant pain.
A 13-year-old child is constantly involved in breaking tables and chairs at school. On further assessment, the nurse finds that the child has conduct disorder. Which condition is the child most likely to develop in the future if not treated effectively for this condition?
Antisocial personality disorder
After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching, what action should the nurse take?
Apply light pressure over the area.
The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological events in orders of occurrence. (Place the first event on top and the last on the bottom)
Arterial endothelium injury causes inflammation Macrophages consume low density lipoprotein (LDL), creating foam cells Foam cells release growth factors for smooth muscle cells Smooth muscle grows over fatty streaks creating fibrous plaques Vessel narrowing results in ischemia
A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants "no heroic measures" taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement?
Ask the client to discuss "do not resuscitate" with her healthcare provider
An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse implement?
Assign a practical nurse (LPN) to determine if an apical radial deficit is present
Several months after a foot injury, and adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will "finally go away." How should the nurse respond?
Assist the client in developing a goal of managing the pain
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?
Auscultate the client's bowel sounds Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes constipation, so it is most important to Auscultate the client's bowel sounds
Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?
Bagel with jelly and skim milk
A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client?
Baked apples topped with dried raisins
A nurse is assessing an adolescent client with oppositional defiant disorder (ODD). What factors influence the development of this disorder in the adolescent? Select all that apply.
Behavior of parents Temperament of the adolescent Peer group of the adolescent
A nurse is providing community education regarding adolescents with oppositional defiance disorder (ODD). Which point should the nurse include in the educational session?
Behavior problems can develop when parental figures pay attention to a child's maladaptive behaviors
After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse?
Bilateral Wheezing.
After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse?
Capillary refill of 8 seconds
During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first?
Check the client for lacerations or fractures
A nurse is educating a group of parents about conduct disorder. According to the nurse, which children are most at risk for developing conduct disorder? Select all that apply.
Children with low self-esteem Children with poor peer relationships Children neglected by their parents
A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first?
Cleanse the foot with soap and water and apply an antibiotic ointment
The nurse is completing a head to be assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse?
Clear fluid leaking from the nose.
A 16-year-old client is highly disruptive in class and has been in trouble at home. The client's parent recently found the client torturing a cat. When the parent questioned the client about how the client could hurt an animal, the client laughed. Which condition will the client most likely be diagnosed with?
Conduct disorder
A group of nursing students is reviewing information about disruptive behavior disorders. The students demonstrate understanding of the topic when they identify which as an externalizing disorder?
Conduct disorder
Which childhood disorder is characterized by serious violations of social norms, such as destruction of property?
Conduct disorder
Which disorder of childhood is characterized by aggression to people and animals, destruction of property, deceitfulness and theft, and serious violation of rules?
Conduct disorder
Based on the information provided in this client's medical record during labor, which should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)
Continue to monitor the progress of labor.
In clients with conduct disorder, reactivity of the autonomic nervous system is reduced. Which sign related to this physiological abnormality can be seen in clients with conduct disorder?
Decreased social inhibitions
A nurse is assessing a 13-year-old client with intermittent explosive disorder (IED). The nurse suspects that the client has other psychiatric disorders. What findings would lead the nurse to conclude this? Select all that apply.
Depression Drug abuse Hyperactivity
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?
Describes life without purpose
A 12-year-old child is brought to the mental health clinic by the child's parents because of a court-ordered evaluation. When assessing the child, which would lead the nurse to suspect that the child has a conduct disorder? Select all that apply.
Destruction of neighbor's car on two separate occasions Arrests for petty larceny several times Evidence of overt lying
The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication?
Determine which side of the body is weak.
A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement?
Digitally check the client for a fecal impaction
A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants immediate intervention by the nurse?
Diminished left lower lobe sounds Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax, which required immediate chest tube insertion to re-inflate the lung.
Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?
Direct the nurse to continue the surgical hand scrub for a 5 minute duration
A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it is most important for the nurse to review the laboratory value for which medication?
Divalproex. Rationale: divalproex is the first line of treatment for bipolar disorder BPD because it has a high therapeutic index, few side effects, and a rapid onset in controlling symptoms and preventing recurrent episodes of mania and depression. The serum value of divalproex should be determined since the client is exhibiting symptoms of mania, which may indicate non-compliance with the medication regimen.
In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths / minute. What action should the nurse implement?
Document the assessment data; Rational: reservoir bag should not deflate completely during inspiration and the client's respiratory rate is within normal limits.
A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet?
Eat approximated the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent.
Which instruction should the nurse provide a pregnant client who is complaining of heartburn?
Eat small meal throughout the day to avoid a full stomach.
After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client's discharge plan?
Encourage a low-carbohydrate and high-protein diet
The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply)
Fluid shifts from intravascular to interstitial area due to decreased serum protein Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen Increased circulating aldosterone levels that increase sodium and water retention
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child?
Foods sweetened with aspartame
A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan?
Further evaluation involving surgery may be needed
A nurse is meeting the parents of an 8-year-old child with oppositional defiant disorder. Which strategies can the nurse offer the parents to promote the use of positive reinforcement? (Select all that apply.)
Give high-fives for following through on a request the first time. Offer the child a toy or a game after a week of good behavior at school. Take the child out for ice cream after a weekend free of arguing or questioning.
The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?
Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing, Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-pratt drain. Collapsed lung after a fall 8h ago with 100 ml blood in the chest tube collection container, *Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills. Rationale: the client with an abdominal- perineal resection is at risk for peritonitis and needs to be immediately assessed for other signs and symptoms for sepsis.
Which would be an appropriate intervention for a child diagnosed with conduct disorder?
Have the child accept responsibility for individual behavior
A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask?
Have you noticed any changes in your fingernails? Rationale: The pattern of reported manifestations is suggestive of hypothyroidism
A 15-year-old client with intermittent explosive disorder (IED) gives no history of childhood abuse, neglect, or maltreatment. What could be the cause of the disorder in this client?
Imbalance in the production of serotonin
An adolescent client demonstrates callous and unemotional behavior in the absence of extreme aggressive behavior and mood disturbances. The client has a diagnosis of conduct disorder. Which treatment would be most effective for this client?
Individualized behavior therapy
The nurse should teach the parents of a 6 year-old recently diagnosed with asthma that the symptom of acute episode of asthma are due to which physiological response?
Inflammation of the mucous membrane & bronchospasm
A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?
Inform her that some antianxiety medications are safe to take while breastfeeding; Rationale: there are several antianxiety medications that are not contraindicated for breastfeeding mothers.
At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?
Inform the anesthesia care provider
Which action should the school nurse take first when conducting a screening for scoliosis?
Inspect for symmetrical shoulder height.
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement?
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
A nurse is teaching parents of a child with a disruptive behavior disorder how to use "time-out." The nurse determines the education was successful when the parents identify which as the first step?
Labeling the behavior
The client with which type of wound is most likely to need immediate intervention by the nurse?
Laceration, Rationale: A laceration is a wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and debris from whatever object caused the cut.
In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor?
Lactate Glucose Hemoglobin *Creatinine
Which would be the most appropriate intervention for an adolescent who is manipulative and exhibiting aggressive behaviors?
Limit setting
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first?
Listen with the bell at the same location
The nurse is developing a teaching program for the community. What population characteristic is most influential when choosing strategies for implementing a teaching plan?
Literacy level
An adolescent was expelled from school for being extremely verbally abusive to students in the classroom. What other behavioral abnormalities does the nurse expect to find in this adolescent? Select all that apply.
Low self-esteem Emotional instablity Frequent temper outbursts
A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention.
Maintain contact transmission precaution
The nurse is caring for a client who had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours?
Measure hourly urinary output. Rationale: a serious early complications of gastric bypass surgery is an anastomoses leak, often resulting in death.
A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling "very tired". Which nursing intervention is most important for the nurse to implement?
Measure vital signs
A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs?
Medicare
The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?
Monitor blood pressure frequently, Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-threatening hypertension. The tumor is malignant in 10% of cases but may be cured completely by surgical removal. Although pheochromocytoma has classically been associated with 3 syndromes—von Hippel-Lindau (VHL) syndrome, multiple endocrine neoplasia type 2 (MEN 2), and neurofibromatosis type 1 (NF1)—there are now 10 genes that have been identified as sites of mutations leading to pheochromocytoma.
The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies)
Murmur Rationale: A murmur is auscultated as a swishing sound that is associated with the blood turbulence created by the heart or valvular defect.
One day following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of "a tingly sensation" in his left foot. The nurse determines the client's left pedal pulses are diminished. Based on these finding, what is the client's greatest risk?
Neurovascular and circulation compromise related to compartment syndrome.
Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms?
Neutrophils Lymphocytes *Eosinophils Monocytes Rationale: Eosinophils are involved in allergic responses and destruction of parasitic worms.
An unlicensed assistive personnel UAP leaves the unit without notifying the staff. In what order should the unit manager implement this intervention to address the UAPs behavior? (Place the action in order from first on top to last on bottom.)
Note date and time of the behavior. Discuss the issue privately with the UAP. Plan for scheduled break times. Evaluate the UAP for signs of improvement.
A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?
Observe the antecubital fossa for inflammation.
An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement?
Obtain a clean catch mid-stream specimen
A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client?
Obtain a list of medications taken for cardiac history
Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse's decision to report this finding to the healthcare provider?
Oliguria signals tubular necrosis related to hypoperfusion
Which intervention is most important for the nurse to include in the plan of care for an older woman with osteoporosis?
Place the client on fall precautions
A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?
Place the implant in a lead container using long-handled forceps
The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement?
Position a firm wedge to support pelvis and thorax at 30 degree tilt.
While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion site. What interventions should the nurse implement?
Promptly remove the arterial catheter from the radial artery.
A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor?
Rapid onset of decreased level of consciousness.
Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)
Reduce risks factors for infection
A nurse is planning to educate a client who is diagnosed with intermittent explosive disorder about self-management strategies for the condition. What topics should the nurse address while teaching this client? Select all that apply.
Relaxation techniques Strategies for anger management Strategies to avoid alcohol and substance use
A female client with breast cancer who completed her first chemotherapy treatment today at an out-patient center is preparing for discharge. Which behavior indicates that the client understands her care needs?
Rented movies and borrowed books to use while passing time at home
Which behaviors should the nurse anticipate in children with mild conduct disorder? Select all that apply.
Repeated lying Minor shoplifting
When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client's discharge teaching plan?
Report any signs of cloudy urine output.
The nurse enters a client's room and observes the client's wrist restraint secured as seen in the picture. What action should the nurse take?
Reposition the restraint tie onto the bedframe.
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?
Respiratory apnea of 30 seconds
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse?
Review with the client the need to avoid foods that are rich in milk and cream
When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement?
Schedule an appointment for an out-patient psychosocial assessment.
A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider?
Serum calcium
A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider?
Serum lithium level of 1.6 mEq/L or mmol/l (SI) Rationale: The therapeutic level of Serum lithium is 0.8 to 1.5 mEq/L or mmol/l (SI). Slurred speech and ataxia are sign of lithium toxicity.
A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer's at 100 ml/H. which finding is most important for the nurse to report to the healthcare provider?
Serum potassium level of 3.1 mEq/L or mmol/L (SI) Rationale: The normal potassium level in the blood is 3.5-5.0 milliEquivalents per liter (mEq/L).
A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child?
Sitting up and leaning forward
A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective?
Skills of staff and client acuity
A nurse is counseling the parents of a client with conduct disorder. The nurse tells them that they should be vigilant in watching for certain behaviors that their child is prone to exhibit. Which behaviors would the nurse want the parents to watch for? Select all that apply.
Smoking Alcohol and substance abuse Early onset of sexual behavior
An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first?
Start an intravenous (IV) infusion of normal saline; Rationale: the nurse should first start an intravenous infusion of normal saline to replace the fluids and electrolytes because the client has been vomiting, and it is unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting, and abdominal cramping are all suggestive of hyperglycemia, which also contributes to diuresis and fluid electrolyte imbalance.
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement." What instruction should the nurse provide?
Stop using the ointment and encourage complete drying of the feet and wearing clean socks.
A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?
Stroke secondary to hemorrhage
A nurse is caring for a client with conduct disorder. The nurse needs to help the client understand the relationship between aberrant behavior and the consequences when the behavior is problematic. Which nursing intervention is most appropriate to help this client?
Teach the client about limit setting and the need for limits.
A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan?
Teach tracheal suctioning techniques
A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath (Uhthoff's sign). Which pathophysiological mechanism supports this response?
Temporary vasodilation
For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action?
Tented skin turgor.
A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication?
The additive effect of multiple medications has caused the blood pressure to drop too low
A nurse is assessing a 15-year-old adolescent with conduct disorder. Which appearance might the nurse see in the adolescent?
The adolescent has lots of tattoos and body piercings.
A nurse is assessing an adolescent with conduct disorder. Which should the nurse expect to find in this adolescent? Select all that apply.
The adolescent may be unwilling to speak to the nurse. The adolescent may behave disrespectfully to the nurse. The adolescent may make derogatory comments about parents and teachers.
A nurse is counseling the parents of an adolescent client with oppositional defiant disorder (ODD). The parents state, "We've tried everything, what else are we supposed to do?" What is the most likely reason for the parents' voiced loss of hope?
The adolescent may have limited sensitivity to reward and punishment.
A nurse is assessing an adolescent with conduct disorder. The nurse finds that the adolescent has been prescribed risperidone by the primary health care provider. What would be the most likely reason for the health care provider to prescribe this drug to the client?
The adolescent's behavior poses a danger to others.
A nurse is counseling the parents of a 5-year-old child with oppositional defiant disorder (ODD). What type of management does the nurse suggest to help the parents deal with the disorder?
The child can be managed if the parents modify their own behavior.
Which responses to an emotional stressor would indicate that a child is at risk for conduct disorder? Select all that apply.
The child screams loudly. The child breaks things around her or him.
A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?
The client experiences Palpitations and shortness of breath
The nurse is documenting clinical observations after a therapeutic session with an adolescent client with a disruptive behavior disorder. What should the nurse identify is an internalizing behavior?
The client only stares at the nurse when asked how the client is doing today.
The nurse is assessing an adolescent with conduct disorder. The nurse finds that the adolescent is not interested in seeking summer employment. What is the most likely reason for the client's disinterest in getting a job?
The client prefers stealing money over working for it.
After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse's signature on the client's surgical consent form? (Select all that apply)
The client voluntarily grants permission for the procedure to be done, The client is competent to sign the consent without impairment of judgment, The client understands the risks and benefits associated with the procedure
A nurse is developing a plan of care for a client with conduct disorder. Which would be treatment outcomes for this client? Select all that apply.
The client will engage in socially acceptable behavior. The client will learn effective problem-solving skills. The client will not hurt others or damage property.
After teaching a group of nursing students about kleptomania, the instructor determines that the education was successful when the students state what?
The disorder is difficult to detect and treat.
When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation?
The gallbladder is normal; Rationale: a normal healthy gallbladder is not palpable
A nurse is caring for a client with conduct disorder. The nurse tells the client, "It is not appropriate for you to break things in this center every time you get angry. You should inform me when you get angry. If you break anything else in the facility, you will not be allowed to play video games for a week." What is the statement indicative of?
The nurse is trying to teach limit setting.
A nurse is counseling the parents of a child with oppositional defiant disorder (ODD). What does the nurse advise the parents for dealing with the maladaptive behavior of their child?
The parents should ignore the child's behavior.
A nurse is studying the medical records of a client with conduct disorder. The nurse finds that the client was prescribed lithium. What would be the most likely reason for prescribing this drug for this client?
The presence of aggression
A nurse observes a middle school student having an angry outburst in the hallway. The nurse is aware that the student has these outbursts frequently. The nurse suspects that the student has intermittent explosive disorder (IED). What other assessment findings would support this conclusion? Select all that apply.
The student has caused extensive damage to school property. The student has experienced anger episodes over very minor events. The student has had outbursts of anger without any warning.
What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?
The technique is intended to maintain straight spinal alignment.
The nurse uses the technique of time-out for a client with conduct disorder. Which problem demonstrated by the client would have led the nurse to use this intervention?
Threatening the nurse
A nurse is caring for a client with conduct disorder who injures people around the client when angry. Which is the primary goal for intervention in this case?
To ensure safety of others.
For which reason would a nurse ask an adolescent client with conduct disorder to maintain a diary?
To help identify feelings.
When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention?
To reduce abdominal pressure on the diaphragm, Rationale: a semi-sitting position is the best position for matching ventilation and perfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing.
A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline?
Toasted wheat bread and jelly
When providing education to the parents of a client with conduct disorder, which is a valid teaching point?
Use 'I' language and express an emotion when setting limits.
Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client?
Use two forms of contraception while taking this drug.
The nurse is assessing a child diagnosed with conduct disorder. Based on which behavior would this client be described as exhibiting the disorder at moderate intensity?
Verbal bullying
An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change.
What action should the nurse take first? Explore client's readiness to discuss the situation.
The nurse is interviewing the parents of a child with conduct disorder. Which question is appropriate for the nurse to ask?
What type of discipline do you use at home?"
The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? Select all that apply
White blood cell (WBC) count Sputum culture and sensitivity
The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?
Yogurt and/or buttermilk.
A nurse is assessing a client with oppositional defiant disorder (ODD). What questions related to the disorder should the nurse ask the parents while taking the history of the client? Select all that apply.
"Does your child get confused much of the time?" "Does your child have difficulty paying attention?" "Does your child get extremely upset for getting poor grades in school?
A nurse is assessing students in a school to determine those at risk of developing conduct disorder. To help determine each child's risk, which questions should the nurse ask the parents? Select all that apply.
"Have you caught your child drinking alcohol?" "Does your child have friends in school?" "Are there any disturbances in your marital life?"
While interviewing a client with conduct disorder, the nurse asks the client about having friends in school. What is the most likely response of the client?
"I don't want to be friends with the stupid idiots at school."
Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication?
"I have a headache that gets worse when I sit up""I am having pain in my lower back when I move my legs""My throat hurts when I swallow""I feel sick to my stomach and am going to throw up"
A nurse is seeing an adolescent with a diagnosis of conduct disorder for the first time to establish goals for treatment. During the first meeting, the adolescent yells a profanity at the nurse and states, "This is pointless." What is the nurse's best response?
"I want to continue to work with you but I don't accept the language you have chosen."
A nurse is assessing a 2-year-old child in a child and family outpatient mental health clinic. The parents tell the nurse that the child can be combative when the child's wants are not met. The parents describe the child as "defiant." What is the most appropriate response of the nurse to the parents?
"It sounds like very challenging behavior, testing is quite normal at this age."
A nurse is speaking to the parents of a 15-year-old client who has been suspended from school for physically abusing classmates. The client has had many warnings from school staff; however, the client's behavior persists. What other statements by the parents would lead the nurse to suspect this client has conduct disorder? Select all that apply.
"My child is consistently performing poorly academically." "My child does not have any friends."
The parents of a 15-year-old adolescent report that their child is behaving abnormally. After obtaining the history of the client, the nurse responds by telling the parents that their child's behavior is normal for his age. What would the parents have told the nurse regarding their child? Select all that apply.
"Our child spends more time playing than studying." "Our child doesn't listen to us, preferring to listen to friends."
After completing a series of parent training sessions with parents of an 8-year-old client with oppositional defiant disorder, the child's mother calls the nurse with concerns. The mother states, "What you taught us isn't working. Can you please talk to my child about his behavior?" Which is the nurse's most effective response?
"Please tell me more about what you are having difficulty with."
Which statement by the nurse demonstrates an understanding of the importance of keeping negative emotions from interfering with care provided to aggressive clients?
"Talking with other staff helps."
A 10 year old who has terminal brain cancer asks the nurse, "What will happen to my body when I die?" How should the nurse respond?
"The heart will stop beating & you will stop breathing."
A nurse is caring for a 10-year-old child with conduct disorder. The child starts throwing stones at the staff. What statement made by the nurse to control the child's behavior is most appropriate?
"You may injure people around you. If you feel angry, you could always come and talk to me or another nurse."
The nurse is teaching the parents of a child with conduct disorder about methods to deal with their child's detention from school for breaking science equipment. What advice should the nurse give the parents to deal with the situation?
"You should be supportive of the school for taking this step regarding your child's inappropriate behavior."
Which statement, made by the parent of a teen diagnosed with conduct disorder, demonstrates effective parenting?
"You will lose your driving privileges for a week if you don't clean your room today."
A nurse is assessing a 9-year-old child diagnosed with conduct disorder. Which advice should the nurse give the child's parents regarding treatment of the disorder?
"You will need to be involved in the therapeutic process for your child."
A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?
*Hypokalemia Ketonuria. Peripheral edema Elevated blood pressure Rational: pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes insipidus, which causes massive polyuria and serum electrolyte imbalances, including hypokalemia, which can lead to lethal arrhythmias.
A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement?
*Negative pressure environment contact precautions droplet precautions protective environment
The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings Select all that apply:
*Restlessness *Clenched Fist *Increased pulse rate *Increased respiratory rate. Increased temperature Peripheral pallor of the skin
The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth)
0.4 rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml
A nurse is assessing a 10-year-old child who is displaying behaviors that are consistent with oppositional defiance disorder. When conducting the assessment, the nurse should also assess for which co-morbidity?
attention deficit hyperactivity disorder
The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.)
75 Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour
Which location should the nurse choose as the best for beginning a screening program for hypothyroidism?
A business and professional women's group.
A school nurse is assessing a group of adolescent students. The nurse is seeking to identify students who may be presenting with risk factors for a disruptive behavior disorder. Based on the assessment, which students should be identified? Select all that apply.
A student who is male A student who has no valued peer connections
A nurse is performing a general assessment of adolescents in a school to identify students with conduct disorder. Which students are likely to be identified with the condition, based on the nurse's assessment? Select all that apply.
A student who repeatedly bullies younger students A student who is constantly involved in activities resulting in damage to school property A student who always uses abusive language while speaking to teachers
A nurse is working with an adolescent client with a diagnosis of conduct disorder. The nurse is helping the client reflect on a situation in which the client became aggressive and asks how the client could have handled it differently. The nurse is employing which intervention?
improving coping skills and self-esteem
The nurse is conducting a health history of a 35-year-old male client with a history of intermittent explosive disorder, diagnosed in adolescence. The nurse should include an assessment of which health issue?
increased blood pressure
A nurse is seeing a female client who has been mandated to counseling sessions after shoplifting numerous times. Which disruptive behavior disorder is the client most likely experiencing?
kleptomania
A school counselor has made a referral to the school health nurse for a 14-year-old client who has been bringing alcohol to school in a water bottle. The client was overheard talking about having multiple sexual partners over the past week. This client can be accurately identified as having which intensity level of conduct disorder?
moderate conduct disorder
Which factor will most influence a nurse's interaction with a child diagnosed with conduct disorder?
personal values regarding child rearing
When providing education to a client with intermittent explosive disorder, the nurse explains that antidepressant medications can be effective in the treatment of the condition because they:
promote balancing of serotonin.