Hurst Review Practice Questions

The community health nurse is presenting information about birth control measures to a group of young females. The nurse explains that an intrauterine device (IUD) is most appropriate for what individuals? 1. A mother of a toddler who wants another child in three years. 2. The client with a recent exacerbation of sickle cell anemia. 3. A client with stage II breast cancer who has finished chemotherapy. 4. An adolescent who has recently become sexually active. 5. The client with a double mastectomy seven years ago.

1 & 5. CORRECT: An IUD is a surgically placed method of birth control in which a small, t-shaped piece of plastic, or even copper, is inserted into the uterus to decrease the chance of pregnancy. The client must be very healthy, emotionally amenable to a foreign body to prevent pregnancy, and aware that an IUD is not 100% fail-proof. The mother of a toddler who would like to have another child in a few years is an excellent candidate for the use of an IUD. Also, a client who had a double mastectomy over seven years ago is a good candidate, since treatment that long ago means the client would no longer be receiving any type of immunosuppressant therapy. 2. INCORRECT: A client who has had a recent exacerbation of sickle cell anemia is at high risk for several complications, including infection and clots. This is a foreign body in an already compromised client, leading to many potential complications. 3. INCORRECT: The client being actively treated for cancer is also immunosuppressed and would not be a good choice for an IUD. The risk of infection is much too high. 4. INCORRECT: An adolescent who has recently become sexually active presents a challenge. Remember that an adolescent does not have regular menstrual cycles yet, and can experience intermittent bleeding. Many primary healthcare providers argue that the use of an IUD may be safer since the client would not have to remember a pill, a ring, or a patch. But an even greater concern is the fact that an IUD is NOT 100% effective, still presenting the risk of an unwanted pregnancy. Also, an IUD does not protect against sexually transmitted disease (STDs), which is often a concern in those who have become sexually active.

The nurse is discussing television, video games, and internet usage with a group of parents who have 8 to 10 year old children. What should the nurse include? 1. Keep TVs, iPads, and other screens out of kids' bedrooms. 2. Turn off all screens during meals. 3. Allow screen time only after chores and homework are complete. 4. Have a screen free day once a week. 5. Limit screen time to 2 hours daily. 6. Use screen time as a reward for good behavior.

1 2 3 4 5 Correct: It is wise to keep TV, internet and other digital media out of children's rooms. When these devices are in children's bedrooms, it's much more difficult to monitor what's going on. Turn off digital devices during meals. This allows parents to be involved in the lives of their children. Those intimate life details are required for successful parenting. So, parents should observe, listen, ask, and parent. Declare a "screen free day" once a week where nobody watches TV, uses the computer or plays video games. This allows for more family activities like bike rides and hikes. The American Academy of Pediatrics suggests limiting entertainment screen time -- including TV, video games and computer use -- to two hours a day for kids ages 6 - 10 years of age. Incorrect: Screen time should not be used as a reward. Parents should set guidelines on when the child can have screen time; for example, after homework or when chores are complete.

A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to do what? 1. Remove air from the pleural space 2. Create access for irrigating the chest cavity 3. Evacuate secretions from the bronchioles and alveoli 4. Drain blood and fluid from the pleural space

1. Correct: A chest tube placed in the upper chest is to remove air from the pleural space. Remember air rises and fluid settles down low. 2. Incorrect: Chest tubes are placed in the pleural space to get rid of air, blood, fluid, or exudate so that the lung can re-expand. The purpose is not to create an access for irrigating the chest cavity. 3. Incorrect: The chest tube is inserted into the pleural space because the lung has collapsed due to air, blood, fluid, or exudate. The chest tube does not go into the lung so secretions can not be removed from the bronchioles and alveoli by way of the chest tube. 4. Incorrect: You have to know the purpose of the upper chest tube. Fluid drains down, so the lower one is for fluid.

An 82 year old client tells the nurse at the clinic, "I have lived a good, successful life and married my best friend". Which of Erikson's developmental tasks does the nurse recognize that this client has probably accomplished? 1. Ego Integrity versus Despair 2. Generativity versus Stagnation 3. Intimacy versus Isolation 4. Industry versus Inferiority

1. Correct: Ego Integrity versus Despair is the major task of those 65 and over: The developmental task for this age involves the individual reviewing one's life and deriving meaning from both positive and negative events, while achieving a positive sense of self. If the individual considers accomplishments and views self as leading a successful life, a sense of integrity is developed. On the contrary, if life is viewed as unsuccessful without accomplishing life's goals, a sense of despair and hopelessness develops. 2. Incorrect: Generativity versus Stagnation is the major task for 40-64 year olds. To achieve the life goals established for oneself while also considering the welfare of future generations. The primary developmental task during this middle age period is one in which the individual contributes to society as well as helping to guide future generations. A sense of generativity (sense of productivity and accomplishment) often results from such things as raising a family and helping to better the society. In contrast, those individuals not willing to work to better society and those who are egocentric and self-centered often develop a sense of stagnation (dissatisfaction and the lack of productivity). 3. Incorrect: Intimacy versus Isolation is the objective from 20-39 year olds to form an intense, lasting relationship or a commitment to another person. If the individual cannot form the intimate relationships (possibly due to personal needs) a sense of isolation may develop which can lead to feelings of depression. 4. Incorrect: Industry versus Inferiority is the major task for 6-12 year olds in which they attempt to achieve a sense of self confidence by learning, competing, performing successfully, and receiving recognition from significant others, peers, and acquaintances. The child must develop the ability to deal with the demands of learning new social and academic skills, or a sense of inferiority, failure, or incompetence may result.

Dietary teaching has been initiated for a client newly diagnosed with acute diverticulitis. The nurse knows that further instruction is necessary when the client makes what statement? 1. "I must include a lot of fluid in my daily routine." 2. "I need to take my antibiotics at the same time daily." 3. "Rest and mild exercise are important for my recovery." 4. "Decreasing fiber in my diet can help prevent recurrences."

Diverticulosis occurs when small, bulging pouches called diverticula develop in the lining of the digestive tract, most often in the lower colon. Sometimes one or more of these pouches become inflamed or infected, causing the condition known as diverticulitis. Diverticulitis can cause severe abdominal pain, fever, nausea, vomiting and a marked change in bowel habits. Mild diverticulitis can be treated with rest, changes in diet and antibiotics; however, severe or recurring diverticulitis may require hospitalization or even surgery. The greatest concern is the potential for an abscess, a bowel blockage or even bowel rupture leading to peritonitis. Because diverticula remain permanently, it's important for a client to understand how to make life-style and dietary changes. When you noticed "acute diverticulitis" in the question, were you concerned about what you may, or may not, have studied in school? Let's assume you do not remember all the specifics about this disorder. Break down the words to provide some basic clues! What does acute mean to you? In most cases, acute indicates a quick onset with the potential for the problem to be resolved over time. Recall that diverticula refers to some type of issue in the gastrointestinal tract and "itis" means inflammation. Therefore, the nurse is teaching this client about dietary management for an issue involving bowel inflammation! Now, what do you know about caring for the gastrointestinal system? In some disease processes such as ulcerative colitis, a diet is designed to decrease the already overactive peristalsis. When there are pouches in which material can become trapped, increasing movement with fiber is important. Think about the food pyramid and consider these facts when reading the options. Note that the nurse is looking for a client statement which indicates the need for further teaching! Look for a client statement that is not accurate. Option 1: Definitely not. Most humans can benefit from lots of water or fluid on a daily basis. Remember that we are made mostly of water and lose quite a bit daily which must be replenished. Also, during an exacerbation of diverticulitis, most clients are placed on a liquid diet for a period of time to allow the bowel to heal. Continuing lots of fluids during the healing process, and then daily, is important for bowel health. This statement indicates the client comprehends the teaching. Try another option. Option 2: Not this one either. No matter what the problem is, antibiotics should always be taken at the same time every day. Taking medications consistently and on time maintains a steady blood level of the drug. And most antibiotics should be taken with a full glass of water, which will also help the client stay hydrated. The client obviously understands all the nurse's instructions. No need to reteach here! Option 3: Try again. There is nothing wrong with this statement by the client. Even if you were a bit stumped by the diagnosis, you are aware that rest and mild exercise are important to most any recuperation! Though it seems surprising, recent research has suggested that gentle daily exercise, such as walking, can greatly improve the gastrointestinal health of those with bowel disorders. In fact, it is a great plan for most anyone to improve health! The client clearly understands the discharge teaching. Option 4: Awesome! Did you note the client mentions decreasing fiber in the diet? While it is true that, during hospitalization, a client may be NPO or placed on a liquid diet, after discharge it's important to keep food moving consistently through the bowel. A high fiber diet helps prevent particles of food from lodging in the diverticula, which decreases the potential for an exacerbation of diverticulitis.

A client suffers from migraine headaches. What assessment finding would the nurse expect to find during a migraine attack? 1. Unilateral, pulsating pain quality. 2. Bilateral, pressing/tightening pain quality. 3. Ipsilateral nasal congestion and rhinorrhea. 4. Headache occurs after recovering from a headache treated with narcotics.

1. Correct: Migraine headaches have a pulsating pain quality, unilateral location, moderate or severe pain intensity, aggravated by or causing avoidance of routine physical activity (walking, climbing stairs). During headache at least one of the following accompanies the headache: nausea and/or vomiting; photophobia and phonophobia. 2. Incorrect: This is seen in tension headaches. Headaches last 30 minutes to 7 days. Pain is mild or moderate in intensity. It is not aggravated by routine physical activity. Nausea/vomiting, photophobia and phonophobia are not common manifestations with tension headaches. These usually start gradually, often in the middle of the day. 3. Incorrect: This is associated with cluster headaches, which are severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes. Symptoms include stabbing pain in one eye with associated rhinorrhea (runny nose) and possible drooping eyelid on the affected side. The headaches tend to occur in "clusters": typically one to three headaches per day (but may be as many as eight) during a cluster period. 4. Incorrect: Overuse of painkillers for headaches, can, ironically, lead to rebound headaches. Culprits include over the counter medications such as aspirin, acetaminophen or ibuprofen, as well as prescription medications. Too much medication can cause the brain to shift into an excited state, triggering more headaches. Also, rebound headaches are a symptom of withdrawal as the level of medicine drops in the bloodstream. Rebound headaches may have associated issues such as difficulty concentrating, irritability and restlessness but does not typically include photophobia or visual disturbances as seen with migraines.

A client with type II diabetes reports normal blood glucose levels at bedtime and high blood glucose levels in the morning for the past week. What instruction would the nurse give the client? 1. Monitor blood sugar around 2am. 2. Decrease bedtime snacking. 3. Decrease intermediate acting insulin. 4. Increase intermediate acting insulin.

1. Correct: Morning hyperglycemia may be the result of dawn's phenomenon or the Somogyi effect. The client must take their blood sugar between two and three o'clock in the morning for several days to determine the cause of morning hyperglycemia. If the client has decreased blood sugar between two and three o'clock in the morning, suspect Somogyi effect. 2. Incorrect: This is an intervention; assessment should come first. The nurse must determine the cause of morning hyperglycemia in order to treat the condition appropriately. 3. Incorrect: This is an intervention; assessment should come first. The nurse must determine the cause of hyperglycemia in order to treat the condition appropriately. An appropriate intervention for a client with Somogyi effect would be to decrease the evening dose of intermediate acting insulin, however, the nurse must first determine that the client is in fact experiencing the Somogyi effect. 4. Incorrect: This is an intervention; assessment should come first. Increasing the intermediate acting insulin would not be appropriate action for a client experiencing Somogyi effect.

A client diagnosed with serotonin syndrome is admitted to the unit. The nurse is familiar with this adverse reaction to the serotonin reuptake inhibitors. Which symptoms can the nurse expect on assessment? 1. Fever and shivering 2. Agitation 3. Decreased body temperature 4. Constipation 5. Increased heart rate

1., 2. & 5. Correct: Serotonin syndrome is a group of symptoms that can result from the use of certain serotonin reuptake inhibitors. These symptoms can range from mild to severe and include high body temperature, agitation, increased reflexes, diaphoresis, tremors, dilated pupils and diarrhea. The client is likely to experience shivering with fever. Increased heart rate and blood pressure are also commonly experienced. More severe symptoms, including muscle rigidity and seizures, can occur. If not treated, serotonin syndrome can be fatal. 3. Incorrect: Increased body temperature is expected as is increased diaphoresis.4. Incorrect: Diarrhea, not constipation, is a symptom of serotonin syndrome.

What signs/symptoms would the nurse expect to assess in a client diagnosed with tabes dorsalis neurosyphilis due to untreated syphilis? 1. Abnormal gait 2. Blindness 3. Hyperreflexia 4. Stiff neck 5. Hearing loss

1., 2. Correct: Symptoms of tabes dorsalis are caused by damage to the nervous system. Problems walking occur such as an abnormal gait or inability to walk at all. Vision changes can occur. Blindness is a complication of tabes dorsalis. 3. Incorrect: Loss of coordination and diminished reflexes occur rather than hyperreflexia. 4. Incorrect: Stiff neck is seen with meningitis, but also with meningovascular neurosyphilis. Meningeal neurosyphilis usually manifests with the clinical features of acute meningitis. 5. Incorrect: Hearing is not affected by neurosyphilis. However, vision changes, including blindness can occur. Neurosyphilis is caused by the bacteria Treponema pallidum, which also causes syphilis. It usually occurs about 10 to 20 years after a person is first infected with syphilis and did not receive treatment. Tabes dorsalis is a complication of untreated syphilis that involves muscle weakness and abnormal sensations. Symptoms of tabes dorsalis are caused by damage to the nervous system. Symptoms may include abnormal sensations often called "lightning pains", abnormal gait problems such as with the legs far apart, loss of coordination and reflexes, joint damage, muscle weakness, vision changes including blindness, bladder control problems, and sexual function problems. Penicillin is the drug of choice to treat neurosyphilis. The client must have follow-up blood tests at 3, 6, 12, 24, and 36 months to make sure the infection is gone. The client will also need follow-up lumbar punctures for CSF fluid analysis every 6 months.

Which immunizations obtained by the age of two would indicate to the pediatric nurse that the child is up-to-date on immunizations? 1. Diptheria-tetanus-pertussis (DTaP). 2. Inactivated polio (IPV). 3. Herpes zoster. 4. Meningococcal 5. Haemophilus influenza type B (Hib).

1., 2., & 5. Correct: By the age of two, the DTaP, IPV, MMR, Hib, varicella, pneumococcal, and rotovirus vaccines should have been received. The nurse should clarify this with the parent. 3. Incorrect: This vaccine is recommended for people 60 years or older whether or not the person has ever had chicken pox and is at risk for developing shingles. Although the vaccine can be given to adults between the ages of 50-59, routine administration is not recommended. 4. Incorrect: The minimum age for administering the meningococcal vaccine is two years of age. The recommended age for administering the meningococcal vaccine is at 11 or 12 years of age, or 13 through 18 years of age if they did not previously receive this vaccine. It is especially important for teens going to college and who are likely to stay in close quarters such as a dorm.

What information should a nurse include when educating a client regarding buccal administration of a medication? 1. This route allows the medication to get into the blood stream faster than the oral route. 2. Stinging may occur after placing the medication in the cheek. 3. If swallowed, the medication may be inactivated by gastric secretions. 4. The buccal dose of medication will need to be increased from the oral dose. 5. Remove the tablet from buccal area after 15 seconds.

1., 2., & 3. Correct: These are correct statements about buccal administration of medication. Buccal administration involves the medication being placed between the gums and cheek, where it dissolves and becomes absorbed into the bloodstream. The cheek area has many capillaries that allow the medication to be absorbed quickly without having to pass through the digestive system. The degree of stinging experienced depends on the medication being administered. Some effects of certain medications can be lessened by digestive processes. 4. Incorrect: When given by the buccal route, the medication does not go through the digestive system. This means that the medication is not metabolized through the liver, and thus a lower dose can be used. 5. Incorrect: Placement should be maintained until the tablet is dissolved in order to get the dosage and effects desired.

What should the nurse include in a discharge plan for a client diagnosed with lymphoma who will be receiving outpatient treatment? 1. Avoid uncooked meats, seafood or eggs and unwashed fruits and vegetables. 2. Take bleeding precautions. 3. Do not take influenza or pneumonia vaccine during treatment. 4. Avoid individuals with infections. 5. Emphasize importance of frequent oral hygiene with an alcohol based mouthwash.

1., 2., & 4. Correct: The client with lymphoma is susceptible to infection and should eat foods low in bacteria. The client should avoid uncooked meats, seafood or eggs and unwashed fruits and vegetables as the bacteria count will be higher than desired. Instruct client and family about bleeding precautions and management of active bleeding due to thrombocytopenia. They should be advised to avoid activities that place them at risk for injury or bleeding (including excessive straining). This client is at risk for infection due to low white count, so the client should avoid individuals who are ill. 3. Incorrect: Encourage clients to maintain current immunizations for influenza and pneumonia. They are more susceptible to infection. Cancer and cancer treatment can weaken the immune system, which puts them at higher risk of serious problems if they get the flu or pneumonia. Only live vaccines (MMR, varicella, oral polio) are contraindicated in clients receiving chemotherapy. 5. Incorrect: This client is at risk for bleeding and infection due to low platelet and white cell counts. The client needs frequent oral care with a soft toothbrush and alcohol free mouthwash. Alcohol-based mouthwashes can dry out the gum and increase bleeding.

What should the nurse tell the parents of a newborn about a Guthrie test? 1. The purpose of this test is to determine the presence of phenylalanine in the blood. 2. A positive test indicates a metabolic disorder. 3. To conduct this test, a sample of blood is taken from the baby's heel. 4. An increase in protein intake can interfere with the test. 5. This test will be done when your baby is 6 weeks old.

1., 2., 3. Correct: These are true statements. A positive test indicates decreased metabolism of phenylalanine, leading to phenylketonuria. The normal level of phenylalanine in newborns is 0.5to 1 mg/dl. The Guthrie test detects levels greater than 4 mg/dl. Only fresh heel blood, not cord blood, can be used for the test. The main objective for diagnosing and treating this disorder is to prevent cognitive impairment. 4. Incorrect: A lack of protein intake can interfere with the test. The screening test is most reliable when the blood sample is obtained after the baby has ingested a source of protein. 5. Incorrect: Screening protocol involves testing the infant as close to discharge as possible but no later than 7 days after birth. If the infant is less than 24 hours old when the specimen is collected, a repeat test should be done before the infant is 2 weeks of age.

Which vaccines would a nurse participating at a health fair encourage a 65 year-old adult to receive? 1. Influenza 2. Herpes Zoster 3. Diphtheria 4. Pertussis 5. Pneumococcal vaccine 6. Measles, mumps, and rubella (MMR)

1., 2., 3., 4., & 5. Correct: Influenza is often quite serious for people 65 and older due to weaker immune defenses. CDC recommends a single dose of herpes zoster vaccine for people 60 years of age or older to prevent shingles.Tetanus, diptheria and pertussis (Tdap) vaccine is given to older adults to protect against whooping cough (pertussis), tetanus and diptheria. Adults should get one dose of the tetanus and diptheria (Td) vaccine every 10 years. For adults who did not get Tdap as a preteen or teen, they should get one dose of Tdap in place of a Td dose to boost protection against whooping cough. However, adults who need protection against whooping cough can get Tdap at anytime, regardless of when they last got Td. Pneumococcal vaccines protect against infections in the lungs and blood stream and are recommended for all adults over 65 years old and for adults younger than 65 who have certain chronic health conditions. 6. Incorrect. A booster for measles, mumps, and rubella is not indicated for this age group.

child is brought into the emergency department (ED) after accidently ingesting 3 grams of acetylsalicylic acid. Initial assessment reveals lethargy, excessive sweating, hyperventilation, and hyperthermia. What interventions should the nurse initiate? 1. Provide tepid water sponge bath. 2. Start an IV for fluid resuscitation. 3. Insert a nasogastric tube. 4. Pad side rails. 5. Obtain blood gases. 6. Administer ipecac syrup orally.

1., 2., 3., 4., & 5. Correct: This client has hyperthermia. Methods to decrease temperature include external cool down, such as with a tepid water sponge bath. Dehydration occurs early in aspirin poisoning due to vomiting and hyperventilation. IV fluid is needed to offset the dehydration. Gastric lavage and activated charcoal are needed to deactivate the aspirin. The child is at risk for seizures so pad the side rails for safety. Care is based on blood gas results. Metabolic acidosis is the imbalance of the most concern. 6. Incorrect: Although ipecac syrup was used commonly in the past to make a client vomit, it is rarely recommended today. It would not be suggested in aspirin poisoning due to the chance that the client might develop altered mental status or convulsions.

The nurse is caring for a client diagnosed with herpes varicella zoster. What pharmacologic agent should the nurse anticipate the primary healthcare provider will prescribe? 1. Metronidazole 2. Acyclovir 3. Ceftriaxone 4. Ampicillin

2. Correct: Herpes varicella zoster is a virus that causes chickenpox in children and shingles in adults. An antiviral such as acyclovir, is indicated.1. Incorrect: Herpes varicella zoster is a virus; an antiviral is indicated, not a nitromodazole antimicrobial, such as metronidazole. Metronidazole may have additional classifications such as: amebecide, antibiotic, antibacterial, etc.3. Incorrect: Herpes varicella zoster is a virus; an antiviral is indicated, not an antibiotic such as ceftriaxone.4. Incorrect: Herpes varicella zoster is a virus; an antiviral is indicated, not an antibiotic such as ampicillin.

A client diagnosed with major depression has been taking a selective serotonin reuptake inhibitor for the past 6 weeks. When visiting the mental health center, the nurse discusses the medication and response with the client. The nurse's assessment reveals that the client is confused about the date and about the prescribed dosage of the medication. Which question would be most important for the nurse to ask to further assess the situation? 1. Are you having trouble sleeping at night? 2. Do you have periods of muscle jerking? 3. Are you having any sexual dysfunction? 4. Is your mood improving?

2. Correct: Myoclonus, high body temperature, shaking, chills, and mental confusion are some of the symptoms of serotonin syndrome. This client may be having symptoms of this adverse reaction which, if severe, can be fatal. 1. Incorrect: Sleep disturbances are common with depression. Selective serotonin reuptake inhibitors (SSRIs) may cause insomnia; however, there is a more pertinent question needed for assessment of this client. You should be concerned with the more serious or life-threatening issue. 3. Incorrect: Sexual dysfunction may occur with the SSRIs; however, the client is exhibiting significant symptoms of an adverse reaction which would take priority. 4. Incorrect: The response to the SSRI medications is important; however, there is a more significant issue in this case. The possible serotonin syndrome is a serious situation that would be the priority for the nurse to address.

Where should a nurse place the stethoscope when auscultating heart sounds? 1. First intercostal space left of the sternum to hear sounds from the pulmonic valve area. 2. Fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area. 3. Second intercostal space to the right of the sternum to hear sounds from the aortic valve area. 4. Fifth intercostal space left side of sternum to hear sounds from the mitral area. 5. Apex of the heart to hear the loudest 2nd heart sound (S2).

2., & 3. Correct: These are correct locations to listen to heart sounds. 1. Incorrect: Second intercostal space left of the sternum to hear sounds from the pulmonic valve 4. Incorrect: The fifth intercostal space in the midclavicular line is where you will hear sounds in the mitral area. 5. Incorrect: This is where you will hear the loudest 1st heart sound (S1). Listen at the base to hear S2 the loudest.

The nurse is caring for a client who is unresponsive during a postictal state. Which position is correct for this client? 1. Orthopneic 2. Dorsal recumbent 3. Sims' 4. Reverse trendelenburg

3 3. Correct: Sim's is a semi prone position where the client is halfway between lateral and prone positions. Often used for enemas or other examinations of the perianal area. Sim's is used for unconscious client's because it facilitates drainage from the mouth and prevents aspiration. 1. Incorrect: Orthopneic position places the client in a sitting position with arms resting on an overbed table. It allows maximum expansion of the chest. This would not be a safe position for an unresponsive client. 2. Incorrect: Dorsal recumbent is a back lying position where the shoulders are slightly elevated on pillows. it is used after surgeries and anesthetics. 4. Incorrect: Reverse trendelenburg is where the body the body is completely straight but the head is elevated and the feet are down. This position helps with gastroesophageal reflux disease, snoring, and with some surgeries.

A client admitted to the hospital following a fall has a history of Alzheimer's disease with apraxia. The nurse knows the client will need priority assistance with what activity? 1. Ambulating to the bathroom. 2. Understanding instructions. 3. Using utensils at mealtime. 4. Identifying objects in room.

3. Correct: Apraxia is a motor disorder of voluntary movements in which the individual can no longer execute purposeful activity, even though there is adequate mobility, strength, and coordination. This loss of ability to carry out previously learned movements could occur secondary to brain injury or a disease process such as Alzheimer's disease. The client has the ability to pick up utensils but is unable to use them correctly, which may affect the client's nutritional status. 1. Incorrect: Apraxia does not affect the ability to ambulate to the bathroom, although the client may not be able to follow cleanliness procedures once in the bathroom. However, there is another activity is of more concern. 2. Incorrect: The ability to understand is not affected by apraxia, which is a disorder in which the client loses the ability to perform purposeful movement. The client is still able to comprehend instructions at this point. There is another situation in which the client will need assistance. 4. Incorrect: The client is still able to identify objects in the environment; however, the diagnosis of apraxia indicates the client cannot use previously known objects correctly. Because of this situation, there is another area in which assisting the client is of more importance.

A client with a history of eczema has been admitted with cellulitis of the left forearm. Which admission order should the nurse question immediately? 1. Start IV of normal saline at 100 mL per hour. 2. Keep left arm elevated on pillow at all times. 3. Apply ice packs to affected area every shift. 4. Ibuprophen 800 mg po every 6 hours prn pain.

3. Correct: Cellulitis is a bacterial skin infection resulting in warm, redden and edematous tissue, sometimes accompanied by fever and chills. Swelling in the affected area impedes blood flow and increases pain. In order to decrease the edema, warm, moist compresses are used to stimulate circulation and speed reabsorption of the fluid within the tissue. This order should be questioned immediately. 1. Incorrect: An infection serious enough to require hospitalization indicates this client is either septic or may need intravenous antibiotics. Fluids are a primary treatment for sepsis along with bedrest and antibiotics. A basic solution of normal saline at 100/mL per hour would be an appropriate order for this client. 2. Incorrect: The swelling characteristic in cellulitis in painful and diminishes circulation to the area. Elevation on one or two pillows at all times helps to improve blood flow so that healing can take place. In some facilities, clients are provided with a wedge shaped cushion that provides better support of the affected area. This order is appropriate. 4. Incorrect: Ibuprophen provides relief from both pain and inflammation associated with cellulitis. A dose of 800 milligrams by mouth every 6 hours as needed for pain would be appropriate for this client. This is not an order the nurse should question.

A client is admitted to the emergency department reporting abdominal discomfort and constipation lasting 3 days. Which abdominal assessment data would the nurse report to the primary healthcare provider? 1. Striae. 2. Borborygmi. 3. High-pitched bowel sounds. 4. Tympany noted on percussion.

3. Correct: High-pitched bowel sounds are indicative of an early bowel obstruction and hypoactive bowel sounds develop as obstruction worsens. The additional signs presented are also clues of a possible obstruction. 1. Incorrect: Striae on the abdomen may be a sign of past weight changes such as those seen with weight gain from pregnancy. These do not create abdominal discomfort nor constipation. 2. Incorrect: Borborygmi are normal, loud, rumbling sounds from gas movement through the intestines or from hunger. These are easily audible bowel sounds. These are not typically associated with constipation but may be present with diarrhea. 4. Incorrect: This is a normal finding in the abdomen. Tympany is usually present in most of the abdomen caused by air in the gut (a higher pitch than the lungs). Tympany would be minimal in this case, dependent upon the degree of constipation, which would lead to a dull sound upon percussion.

How does the nurse identify the correct size of crutches for a client? 1. Turn the crutches upside down and measure from the heel to the shoulder. 2. Obtain a set of crutches and adjust the height until the client can stand comfortably while resting the axilla on the crutch pad. 3. Measure the client while standing upright from the axilla to the heel then adjust the crutches so that the elbow flexion is a 30-degree angle. 4. Measure the client from 2 inches below the axilla to 6 inches lateral to the client's heel.

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The nurse is teaching a client about foods containing tyramine which should be avoided while taking a monoamine oxidase inhibitor (MAOI). Which meal selection by the client would indicate understanding of an acceptable food to eat? 1. Smoked turkey and dressing, sweet peas and carrots and milk. 2. Baked chicken over pasta with parmesan sauce, baked potato and tea. 3. Fried catfish, French fries, coleslaw and apple juice. 4. Liver smothered in gravy and onions, rice, squash and water.

3. Correct: These foods are not high in tyramine. Tyramine is an amino acid that helps in the regulation of blood pressure. MAOIs block the enzyme monoamine oxidase which is responsible for breaking down excess tyramine in the body. Eating foods high in tyramine while on MAOIs can result in dangerously high levels of tyramine in the body. This can lead to a serious rise in blood pressure, creating an emergency situation. Tyramine is found in protein-containing foods and the levels increase as these foods age. Food such as strong or aged cheese, cured meats, smoked or process meats, liver (especially aged liver), pickled or fermented foods, sauces, soybeans, dried or overripe fruits, meat tenderizers, brewer's yeast, alcoholic beverages and caffeine- such as in tea, cokes and coffee are considered to be high in tyramine and should be avoided in clients taking MAOIs. 1. Incorrect: The following foods in the options listed above contain moderate to high levels of tyramine and should be avoided while taking MAOIs: smoked turkey, parmesan cheese, tea and liver.2. Incorrect: The following foods in the options listed above contain moderate to high levels of tyramine and should be avoided while taking MAOIs: smoked turkey, parmesan cheese, tea and liver.4. Incorrect: The following foods in the options listed above contain moderate to high levels of tyramine and should be avoided while taking MAOIs: smoked turkey, parmesan cheese, tea and liver.

A client with cervical cancer received an internal cervical radiation implant. What should be the initial nursing action if the radiation implant becomes dislodged and is found lying in the bed? 1. Call the client's primary healthcare provider. 2. Pick up the implant immediately with gloved hands and place it in double biohazard bags. 3. Notify the radiology department. 4. Utilize long-handled forceps to pick up the implant and dispose of it in a lead container.

4 4. Correct: If a client is receiving a radiation implant, a lead container and long-handled forceps should be placed in the client's room and kept for the duration of the therapy. If the implant becomes dislodged, the nurse should pick up the implant with long-handled forceps and place it in the lead container. 1. Incorrect: The placement of the implant into the lead container should be done initially. The primary healthcare provider may be notified but this is not the initial nursing action needed. 2. The implant should be picked up with long forceps for distance and reduction of contact. In addition, a biohazard bag is not sufficient for proper disposal of the radiation implant. 3. The initial action is to use long-handled forceps and dispose of the implant in a lead container. Calling the radiology department is delaying care and exposing individuals to the implant.

Four clients are admitted to the medical-surgical unit. The nurse is aware that what client will need standard precautions only? 1. The client with chicken pox. 2. The client with rubeola. 3. The client with impetigo. 4. The client with pancreatitis.

4 4. Correct: Standard precautions are observed with all clients admitted to the hospital, without the need for additional safeguards. The client with pancreatitis is not contagious and does not present any unique concerns other than the need for gloves and hand washing. 1. Incorrect: Chicken pox, also known as varicella zoster, requires airborne precautions. The virus can be spread through contact with the droplets, either touching or inhaling the droplet, while providing care for this client. 2. Incorrect: Measles, also called rubeola, is spread through droplet contact with the contaminated individual, including inhalation of the droplets. Airborne precautions are necessary when caring for a client diagnosed with rubeola. 3. Incorrect: Impetigo is a severe skin infection characterized by itchy, red, fluid-filled blisters caused by either staphylococcus or streptococcus bacteria. This skin infection is highly contagious, and requires contact precautions to protect staff and visitors.

The nurse is caring for a client in the 8th week of pregnancy. The client is spotting, has a rigid abdomen and is on bedrest. What is the most important assessment at this time? 1. Protein in the urine 2. Fetal heart tones 3. Cervical dilation 4. Hemoglobin and hematocrit levels

4 The client may be bleeding, and that is an emergency! Common causes of hemorrhage during the first half of pregnancy include abortion and ectopic pregnancy. Ectopic pregnancy is a significant cause of maternal death from hemorrhage and the classic signs of ectopic pregnancy include positive pregnancy test, abdominal pain and vaginal "spotting". Remember that in the ruptured ectopic pregnancy, bleeding may be concealed and severe pain could be the only symptom.

How would the nurse determine the correct size oropharyngeal airway for a client? 1. Select the same size as the little finger of the victim. 2. Measure from the tip of the lips to the epiglottis. 3. Determine the length from the earlobe to the xiphoid process. 4. Measure from the earlobe to the corner of the mouth.

4. Correct: An airway of proper size will extend from the corner of the client's mouth to the tip of the earlobe on the same side of the client's face. 1. Incorrect: The size of the client's little finger does not determine the size of the oral airway that should be used. This would result in an inappropriate size oropharyngeal airway to be selected. 2. Incorrect: The epiglottis is an internal body part thus making it impossible to correctly measure it. In addition, the measurement would not determine the appropriate size oropharyngeal airway to use. 3. Incorrect: Measuring from the client's earlobe to the client's xiphoid process would make the oral airway too long.

A client is admitted for management of ulcerative colitis. What sign/symptom would be of immediate concern to the nurse? 1. Tenesmus 2. Hyperactive bowel sounds 3. Ten bloody diarrhea stools in 8 hours 4. Abdominal guarding

4. Correct: Guarding is a completely involuntary response of the muscles. In other words, you have no control over it. It's a sign that your body is trying to protect itself from pain. It can be a symptom of a very serious and even life-threatening medical condition. 1. Incorrect: Tenesmus is the urge to move your bowels even if you've just emptied your colon. This is a common symptom of an ulcerative colitis flair and would not be of immediate concern to the nurse. 2. Incorrect: Hyperactive bowel sounds can mean there is an increase in intestinal activity. This may happen with diarrhea or after eating. This client has ulcerative colitis so hyperactive bowel sounds during a flare is expected. 3. Incorrect: The colon is ulcerated and unable to absorb water, so 10-20 bloody diarrhea stools are the most common symptom of ulcerative colitis and would not be of immediate concern to the nurse. Ulcerative colitis is a chronic disease that causes inflammation and ulcers on the inner lining of the large intestine. It is a chronic inflammatory disease of the gastrointestinal tract, called inflammatory bowel disease (IBD). Ulcerative colitis most often begins gradually and can become worse over time. Symptoms can be mild to severe. Most people have periods of remission that can last for weeks or years. The goal of care is to keep people in remission long term. The exact cause of ulcerative colitis is unknown. Researchers believe the following factors may play a role in causing ulcerative colitis: overactive intestinal immune system, genes, and environment. The most common signs and symptoms of ulcerative colitis are diarrhea with blood or pus and abdominal discomfort. Other signs and symptoms include an urgent need to have a bowel movement, feeling tired, nausea or loss of appetite, weight loss, fever, and anemia. Less common symptoms include joint pain or soreness, eye irritation, and certain rashes. So, let's look at the question stem: A client is admitted for management of ulcerative colitis. What sign/symptom would be of immediate concern to the nurse? What is of IMMEDIATE CONCERN to the nurse? Option 1 is false. Did this term throw you? Tenesmus is the urge to move your bowels even if you've just emptied your colon. This client is having a lot of bloody diarrhea stools. When you have diarrhea you often feel this urge to move your bowels again even though you have just done so. So, this is not of concern to the nurse. Option 2 is false. When you have diarrhea, the bowel sounds will be hyperactive because the intestinal activity has increased. When a client is having a flair of their ulcerative colitis hyperactive bowel sounds is expected. Option 3 is false. This option just sounds bad! But 10-20 bloody diarrhea stools are expected in a client who is having a flair from ulcerative colitis. We do need to monitor the client, but this is not the nurse's immediate concern. Option 4 is true. What does abdominal guarding say to you? Guarding usualy involves pain and a hard, rigid abdomen. Think peritonitis! Peritonitis is a complication of ulcerative colitis and requires immediate attention.

A client diagnosed with a duodenal ulcer is prescribed lansoprazole and sucralfate. What should the nurse teach the client about how to take these medications? 1. Take together immediately before meals. 2. Take together immediately after meals. 3. Take the sucralfate first, wait at least 30 minutes, then take the lansoprazole. 4. Take the lansoprazole first, wait at least 30 minutes, then take the sucralfate.

4. Correct: When prescribed any medication along with sucralfate, the client should avoid taking the medication at the same time with sucralfate. Sucralfate can make it harder for the body to absorb lansoprazole because it forms a "coating" or "barrier" on the stomach lining. Therefore, the client should wait at least 30 minutes after taking the lansoprazole before taking sucralfate. 1. Incorrect: Taking sucralfate and lansoprazole at the same time will decrease the effects of lansoprazole because the sucralfate coats the stomach lining and reduces the absorption of the lansoprazole. 2. Incorrect: Taking sucralfate and lansoprazole at the same time will decrease the effects of lansoprazole because the sucralfate coats the stomach lining and reduces the absorption of the lansoprazole.. 3. Incorrect: Sucralfate can make it harder for your body to absorb lansoprazole because of the barrier created on the stomach lining.

What electrolyte imbalance should the nurse monitor for when caring for a client diagnosed with chronic alcoholism? 1. Hypochloremia 2. Hypokalemia 3. Hypophosphatemia 4. Hypomagnesemia 5. Hypocalcemia

The cause of alcoholism is not well-established. There is growing evidence for genetic and biologic predispositions for this disease. First-degree relatives of individuals with alcohol use disorder are four to seven times more likely to develop alcoholism than the general population. Research has implicated a gene (D2 dopamine receptor gene) that, when inherited in a specific form, might increase a person's chance of developing alcoholism. Usually, a variety of factors contribute to the development of a problem with alcohol. Social factors such as the influence of family, peers, and society, and the availability of alcohol, and psychological factors such as elevated levels of stress, inadequate coping mechanisms, and reinforcement of alcohol use from other drinkers can contribute to alcoholism. Also, the factors contributing to initial alcohol use may vary from those maintaining it, once the disease develops. Electrolytes play an important role in cellular metabolism. Electrolyte imbalances caused by alcohol abuse lead to body system dysfunction and interfere with cellular metabolism. Signs of chronic alcohol ingestion include decreases in plasma concentrations of phosphate, magnesium, potassium, and calcium in the first 24 to 36 hours after admission. Option 1 is false. Hypochloremia is not generally seen with alcoholism. Hypochloremia is usually caused by excess use of loop diuretics, nasogastric suction, vomiting or diarrhea due to small bowel abnormalities, and loss of fluids through the skin occurring because of trauma such as burns. Kidney diseases that cause loss of sodium and chloride such as chronic renal failure and post obstructive diuresis also cause hypochloremia and hyponatremia (low sodium). A decreased level of urine chloride can be seen with Cushing syndrome, congestive heart failure, and malabsorption syndrome. Option 2 is true. Plasma potassium concentrations may be normal or only slightly reduced on admission but will decrease over several days because of an inward cellular shift that reveals decreased total-body stores. Potassium deficiency results from inadequate intake and gastrointestinal losses due to diarrhea. Urinary losses also contribute and are multifactorial. Option 3 is true. Acute hypophosphatemia develops in up to 50% of patients over the first 2 to 3 days after hospitalization for problems related to chronic alcohol overuse. Deficits in total-body stores of phosphorus are most often due to inadequate dietary intake of phosphate-rich foods such as meats, poultry, fish, nuts, beans, and dairy products. In addition, use of antacids, chronic diarrhea, vomiting, or all of these may further limit phosphorus intake. Option 4 is true. The development of hypomagnesemia after admission to the hospital is due to the intracellular shift brought about by correction of acidosis and administration of glucose-containing fluids leading to insulin release. Increased catecholamines and respiratory alkalosis accompanying alcohol withdrawal also contribute to the intracellular shift. Option 5 is true. Hypomagnesemia is often accompanied by hypocalcemia, which may be aggravated by a deficiency of vitamin D.

In what order should the nurse address these client events that occur at the same time? Place in order of highest to lowest priority. The water seal chamber is empty in a client's closed chest drainage unit. Client reporting urinary frequency and dysuria. UAP reports a heart rate of 40/min in a client. Client's tracheostomy needs to be suctioned. Client who is on bedrest due to a deep vein thrombus attempting to get out of bed.

The client with the highest need is the client who has a tracheostomy that needs to be suctioned. This client has an airway problem. Maintaining a patent airway is vital to life and is always the first priority. The next client to be seen is the client whose water seal chamber is empty which prevents the CDU from being a closed system. This can create a breathing problem. The purpose of the water seal chamber is to allow air to escape from the pleural space and yet prevent air from re-entering the pleural space. It is a one-way system. The water should be at the prescribed level (2 cm) to maintain this one-way water seal. If air is allowed to re-enter the pleural space, the lung can collapse again (pneumothorax). Once the other client's airway is suctioned, this would be the next priority. The third client to be seen is the client with a heart rate of 40/min which may be affecting cardiac output. This is a circulatory problem. Circulation follows airway and breathing in priority setting. The fourth client to be seen is the client on bedrest for a DVT. If the client gets up and ambulates, the clot can break lose and form an embolus. Although this could potentially be dangerous, it does not take priority over airway or circulatory issues that exist. The fifth client would be the one reporting frequency and dysuria. This client does not have a life-threatening problem. Therefore, this would be the lowest in priority from the events presented.

Following a hemorrhagic stroke, a client had a craniotomy with insertion of a ventriculostomy. Upon arrival in the ICU, the nurse's initial readings indicate an increase in intracranial pressure (ICP). What is the nurse's priority action? 1. Position client on the right side. 2. Call the primary healthcare provider. 3. Lower the head of the bed immediately. 4. Hyperventilate client with a bag valve mask.

hyperventilate client with bag valve mask bc high O2 causes vasoconstriction and can decrease the pressure

Which signs and symptoms will the nurse include when teaching a client about indicators of recurrent nephrotic syndrome? 1. Dysuria 2. Hematuria 3. Foamy urine 4. Periorbital edema 5. Weight loss

Well before you can teach about nephrotic syndrome you have to know something about it, don't you? Yes. So what is it? Nephrotic syndrome is a kidney disorder that causes the body to excrete too much protein in the urine because of big holes that occur in the glomerulus, the filtering portion of the kidneys. Signs and symptoms of nephrotic syndrome include severe edema (anasarca), periorbital edema; foamy urine, which may be caused by excess protein in the urine; and weight gain due to excess fluid retention. So which options match what we know about nephrotic syndrome? Did you say options 3 and 4? Good job! Look at option 1. Dysuria would be a symptom of disorders such as kidney stone or UTI, rather than nephrotic syndrome. Option 2 is hematuria, which would be seen with infection.