NCLEX Prep

For a client with a bipolar mood disorder, manic episode, which factor would the nurse consider when planning care?

Client is acutely aware of the environment and reality. RATIONALE: Manic individuals are acutely aware of what is happening and react strongly to the environmental stimuli. These clients are not out of contact with reality; in fact, they are continually reacting to it. These clients' symptoms are an attempt to avoid anxiety and do not cause embarrassment. They are unable to control acting-out behavior. Bingeing and purging is a symptom of bulimia.

The nurse understands that a teratogen would cause neural tube defects in which stage of pregnancy?

Embryonic period RATIONALE: Neural tube defects may occur because of the exposure to a teratogen during the embryonic period (3-8 weeks). Exposure to a teratogen during the fetal period (9-38 weeks) may cuase learning deficits and behavioral abnormalities. Exposure to teratogens during the presomite period and preimplantation period (1-2) weeks may cause a spontaneous abortion.

Which physiological changes are expected during the first trimester of pregnancy? Select all that apply

Fatigue, Morning sickness, breast enlargement RATIONALE: Fatigue, morning sickness, and breast enlargement are observed during the first trimester of pregnancy. Increased libido is observed during the second trimester. Braxton Hicks contractions are observed during the third trimester.

Which signs and symptoms are characteristic of Alzheimer dementia? Select all that apply

Forgetfulness and expressive aphasia RATIONALE: Older clients who have dementia often have short-term memory loss. Clients in whom dementia is developing often have difficulty expressing themselves (expressive aphasia) or understanding the spoken word (respective aphasia). Clients with the diagnosis of schizophrenia or depression are often indecisive and ambivalent. A client who is experiencing a manic episode of BD experiences flight of ideas. Loose associations between thoughts are related to schizophrenia.

Which sexually transmitted infection receives antiviral medications as the treatment of choice?

Genital herpes RATIONALE: Genital herpes is a STI caused by the herpes simplex virus and treated with antiviral medications.

Which STI causes condylomata acuminate?

Human papillomavirus (HPV) RATIONALE: Condylomata acimunate are genital warts that are caused by HPV. Genital warts are not caused by chlamydia, gonorrhea, or herpes simplex.

Which nursing interventions are appropriate while performing an adolescent girl's first pelvic exam? Select all that apply.

Providing a pillow to the adolescent and Allowing the adolescent to handle the speculum RATIONALE: While performing an adolescent girl's first pelvic exam, the nurse would provide a pillow to help the adolescent feel more comfortable and less vulnerable. The nurse would allow the adolescent to handle the speculum to reduce fears associated with the instrument. The nurse would help the adolescent get into a semi-sitting position to allow eye contact. The findings will be discussed with the adolescent after the exam is complete. The adolescent should be allowed to select a supportive person to be present during the examination.

Which medication would the nurse expect to be prescribed first to reduce the symptoms of a female client who has severe cramping, pain, backache, and a migraine and presents with anxiety and mood swings?

Sertraline RATIONALE: A client with severe cramps, backache, and a migraine with anxiety and mood swings likely has premenstrual syndrome (PMS). Selective serotonin reuptake inhibitors (SSRIs) such as sertraline are effective in relieving the symptoms of severe PMS. Busprione is usefully only to relieve anxiety in the client with PMS. Ibuprofen is used to reduce physiological symptoms. Diuretics such as spironolactone are effective in reducing fluid overload.

Which instructions would the nurse provide to adolescent boys regarding the usually procedure to be followed and normal findings observed ruing testicular self-examination? Select all that apply.

A firm, smooth, egg shaped organ can be palpated. Each testicle is examined individually after relaxing the scrotal skin. The thumb and fingers of both hands can be used to apply firm and gentle pressure. A raised swelling that can be palpated on the superior aspect of the testicle is the epididymis. RATIONALE: Testicular self-examination is usually performed after a warm bath when the scrotal skin is relaxed. A firm organ with smooth and egg-shaped contours can be palpated is the testicles. Each testicle is examine individually using thumbs and fingers of both hands while applying firm and gentle pressure. A raised swelling that can be palpated on the superior aspect of the testicle is the epididymis. Testicular cancer can be suspected if a hard mass can be palpated on the anterior or lateral aspect of the testicle.

Which part of the female genitalia is engorged in a female during the excitation phase of sexual intercourse?

Clitoris

Which nursing action has the highest priority for a client with delirium?

Creating a calm and safe environment RATIONALE: The nurse caring for a client with delirium should ensure client safety and ensure a calm and safe environment. The nurse should encourage family members to stay at the bedside along with the silent or move the client to the nurses' station to guarantee safety. The client is at a risk for skin breakdown, which of medium priority. The nurse should ensure the safe environment first, then when it is possible, plan for client-specific behavioral interventions. Reportientation is then followed by contacting the client personally through touching and verbal communication.

When the health care provider examines the genital area of a 5-year-old child in whom sexual abuse is suspected, which nursing action is the most therapeutic?

Explaining the procedure and remaining with the child during the examination. RATIONALE: Explaining the procedure and remaining with the child during the exam provides reassurance and support for the child. Asking the child to decide whether the mother or nurse will stay is no therapeutic; the child may fear that choosing the nurse will make the mother angry. "Anything wrong down there" is frightening; this suggests that the nurse and provider think that something is wrong. The mother may be able to explain the exam, but communication patterns between the mother and child are probably not ideal.

Which sexually transmitted infection is caused by a virus?

Genital warts RATIONALE: Strains of the HPV cause the STI of genital warts. Bacteria cause syphilis, gonorrhea, and chlamydial infections.

Which symptom of mild anxiety would the nurse expect from the client at 6 weeks' gestation who appears mildly anxious as she waits for her first obstetric appointment?

Increased alertness RATIONALE: Increased alter ness is an expected common behavior that occurs in new or different situations when a person is mildly anxious. Dizziness, breathlessness, and abdominal cramps are all common signs of moderate to severe anxiety.

Which is the medication of choice in a pregnant adolescent diagnosed with syphilis during the first trimester?

Penicillin G RATIONALE: Penicillin G is safe to use during all stages of pregnancy. Doxycycline and tetracycline are contraindicated ruing pregnancy because of their teratogenic effects.. Erythromycin is unlikely to be prescribed for syphilis.

A male client with small overgrowth don't he skin is diagnosed with human papillomarvirus type 16. Which condition is associated with this virus?

Penile carcinoma RATIONALE: Human papillomavirus type 16 is commonly associated with penile carcinoma. Uncircumcised males may be at higher risk for infections such as balanitis and posthitis. Human papillomavirus type 11 and 6 are commonly associated with genital warts.

To prevent the infection and transmission of STIs, the nurse's teaching plan would include an explanation of

Sexual practices that are considered high-risk behaviors

Which STIs are caused by bacteria?

chlamydia, gonorrhea, syphilis RATIONALE: Syphilis is caused by Treponema pallium, a motile spirochete bacterium. Gonorrhea is caused by a bacteria called Neisseria gonorrhoeae. Hepatitis A and herpes simplex are caused by viruses. Trichomoniasis is caused by a protozoan.

Which part of the female genitalia protects inner vulval structures and enhances sexual arousal?

Labia majora RATIONALE: The labia majora are two vertical folds of adipose tissue that protects the inner vulval structures and enhances sexual arousal. The clitoris is a small, cylindrical organ that becomes larger and increases sexual sensation. The mons pubis is a fat pad that covers and protects the symphysis pubis during coitus. The Bartholin glands are located near the vaginal opening; they secrete lubricating fluid during sexual excitement.

For a client with bipolar I disorder, manic episode, which factor would be considered to meet rest and sleep needs?

Is easily stimulated, and this intereferes with sleep RATIONALE: Manic individuals readily respond to environmental cues. Increased stimulation decreases activity. Sleep pattern disturbances characteristically occur because of the psychomotor activity. All individuals require adequate rest and sleep; hyperactive clients may become exhausted because of their high activity level. Expending energy only increases the tendency to remain awake.

Which populations have a higher risk for acquiring sexually transmitted infections (STIs)? Select all that apply.

Transgender person, young adults (age < 25), Men who have sex with men, and Women in correctional facilities

Which time period would the nurse teach the health education class that fertilization of the ovum by the sperm occurs?

When 1 sperm penetrates the wall of the ovum. RATIONALE: Fertilization occurs when 1 sperm penetrates one ovum, producing a viable zygote. Fertilization occurs in the Fallopian tube, not when the ovum is expelled from the ovary or in the uterus. After the sperm penetrates the ovum in a Fallopian tube, the impregnated ovum travels down the tube to the uterus.

The nurse is teaching a male client about measures to maintain sexual health and prevent transmission of sexually transmitted infections. Which statement by the client indicates effective learning?

"I will consult with my primary health care provider when there is a rash or ulcer on my genitalia." RATIONALE: The client should consult a primary health care provider when there is rash or ulcer on genitalia because these are the warning signs of an STI. Having sex with an infected partner with/without using condoms may increase the risk of contracting an STI. A male client should perform a genital self-exam every month after taking a bath, when the scrotal skin is less thick. The HPV vaccine should be taken between 9 and 26 years of age.

To implement primary prevention of STIs, the nurse is counseling an adolescent. Which would be the priority nursing action?

Assess the adolescent's sexual risk behaviors. RATIONALE: The priority step for primary STI prevention is to assess the sexual risk behavior of the adolescent to identify the risk factors and provide appropriate counseling accordingly. With that information in mind, the nurse can then help the adolescent recognize the risk, encourage usage of preventive measures, and provide proper information about STIs.

For a client with bipolar disorder in the manic phase, which signs and symptoms are expected? Select all that apply.

Irritability, Grandiosity, and Pressured speech RATIONALE: Irritability and emotional lability fluctuating between euphoria and anger are commonly associated with mania. An inflated self-esteem and delusions of grandeur represent mood-congruent psychotic features of mania; clients believe that they possess extraordinary patents that they are famous, or that they know someone famous. They are extremely talkative, and their speech is rapid, with an urgent quality (pressured speech); they rapidly change subjects and have flight of ideas and racing thoughts. Thought blocking occurs most often with schizophrenia; the client loses the train of thinking and is unable to retrieve the previous thought. Psychomotor retardation is related to depression; clients with mania move fast, pace, fidget, and are rarely still.

Explain to the patient with gonorrhea that treatment will include both ceftriazone and azithromycin because

The increasing rates of drug resistance requires using at least 2 drugs

Which length of time would the nurse teach a client regarding the incubation period of syphilis?

2-6 weeks RATIONALE: Although the usually incubation period of syphilis is about 3 weeks, clinical symptoms may appear as early as 9 days or as long as 3 months after exposure. The usually incubation period is 21 days.

Menarche is the central event of puberty in females, indicating the new possibility for fertilization. When does menarche occur in young girls?

24 months after the beginning of the development of breasts. RATIONALE: Menarche in girls occurs 2 years after the appearance of breast buds, which indicates the start of breast development. Ovulation does not occur before menarche but occurs 61-4 months after menarche. Menarche occurs after attainment of 3 months of peak weight velocity and 9 months of peak height velocity.

The nurse teaches a group of nursing students about the physiological changes that occur during pregnancy. Which statement by a student indicates effective teaching?

"Renal blood flow is doubled during the third trimester, which increases the glomerular filtration rate." RATIONALE: Renal blood flow doubles during the last trimester, and the glomerular filtration rate is increased. Medications that are eliminated through the glomerular filtration need an increased dose. Hepatic metabolism is altered and increases for some anti-seizure medications. Medications that undergo enterohepatic recirculating cause an increase in medication reabsorption. Bowel motility and tone decrease during pregnancy, which causes an increase in intestinal transit time. Therefore, the medication absorption increases.

Which signs and symptoms are the "four A's" of Alzheimer disease?

Amnesia, apraxia, agnostic, aphasia RATIONALE: Neurofibrillary tangles in the hippocampus cause recent memory loss (amnesia); temporoparietal deterioration causes cognitive deficiencies in speech (aphasia), purposefully movements (apraxia), and comprehension of visual, auditory, and other sensations (agnostic). Avoidance, aloofness, asocial, and asexual are characteristics of the schizoid personality. Autism, loose association, apathy, and flat affect are characteristics of schizophrenia. Aggressive, amoral, ambivalent, and attractive are characteristics of an antisocial personality.

A 30-year-old woman is scheduled for a total abdominal hysterectomy because of noninvasive endometrial cancer. The nurse anticipates the client may have difficulty adjusting emotionally to thus type of surgery. Which concern would be the cause of this anticipated difficulty?

Change in femininity. RATIONALE: Removal of the uterus may produce changes in how some women view themselves sexually because it is a reproductive organ. The young age of this client may contribute to heightened feelings of loss of femininity and reproductive potential. Although body image changes are possible, they are more likely to occur with surgery that involves obvious external changes. The libido of a premenopausal woman will probably not be altered unless she has concerns about sexuality. An otherwise healthy 30-year-old woman should have an uneventful recovery.

During a home visit to a client, the nurse identifies tremors of the client's hands. When discussing this assessment, the client reports being nervous, having difficulty sleeping, and feeling as if the collars of shirts are getting tight. Which additional assessment would the nurse report immediately to the HCP?

Fluttering in the chest RATIONALE: Many of these problems are associated with hyperthyroidism; palpation may indicate cardiovascular changes requiring prompt intervention. The increased metabolism associated with hyperthyroidism can lead to heart failure. Although an increased appetite becomes a compensatory mechanism for the increased metabolism associated with hyperthyroidism, it is not life threatening. Although unexplained weight loss can result from catabolism associated with hyperthyroidism, it is not life threatening. Although a feeling of warmth caused by the increased metabolism associated with hyperthyroidism is uncomfortable, it is not life threatening.

Which nursing action during a psychosocial assessment of a transgender client may contribute to health disparities?

Insisting on using the name listed on the client's driver's license. RATIONALE: Insisting on referring to the client in a different way than the client self-identifies erodes client trust and alienates the client, which may make them less willing to seek care, contributing to health disparities. The nurse can ask specific questions about gender and sexuality if these are relevant to the client's health and can help determine how these factors may affect care. Evidence of abuse is to be reported to the appropriate authority in accordance with the law. The client should be assured that the assessment responses are confidential and would not be shared with anyone, even family, friends, or significant others, without the client's permission.

A client was prescribed a medication for pregnancy-induced hypertension and later developed muscle weakness, edema, and nausea. Which medication was administered to the client to treat pregnancy-induced hypertension.

Magnesium sulfate RATIONALE: Magnesium sulfate can be administered for pregnancy-induced hypertension; this medication may cause magnesium toxicity. Signs of the toxicity include muscle weakness, edema, and nausea. Calcium gluconate is coadministered along with magnitude sulfate to counteract this toxicity. Nifedipine, an anti hypertensive agent, formerly listed as a category C medication, and can be safely used to treat pregnancy-induced hypertension. Terbutaline is a beta-adrenergic blocker used to manage preterm labor. Indomethacin is a non-steroidal anti-inflammatory medication used as a tocolytic for the management of preterm labor.

The nurse is obtaining a subjective data assessment from a woman reported as a sexual contact of a man with chlamydia infection. The nurse understands that symptoms of chlamydial infection in women are

Often absent

Which parameter would the nurse assess first when evaluating memory impairment in a client with Alzheimer disease?

Remembrance of recent events RATIONALE: The nurse would assess remembrance of recent events first. A common sign of AD is the loss of memory for recent events. Disorientation of self is not a common early sign of AD; disorientation to time and place is more common. Recollection of past events if less impaired than that of recent events. Impaired ability to name objects is not as common as recent memory loss; impaired ability to name objects occurs later in the disease.

The nurse is assessing a pregnant client during the third trimester. Which clinical finding is expected in the later stages of pregnancy?

Shortness of breath on exertion RATIONALE: Shortness of breath is an expected cardiopulmonary adaption during pregnancy caused by an increased ventricular rate and elevated diaphragm. Tachycardia, dyspnea at rest, and progressive dependent edema are pathological signs of impending cardiac decompensation.

Provide emotional support to a patient with an STI by

Showing concern when listening to the patient who expresses negative feelings.

A client with a bipolar disorder, depressed episode, displays an increase in depression over the past month. Which behavior is expected?

Slowed though processes RATIONALE: As depression increases, thought processes become slower and verbal expression decreases due to lack of emotional energy. Elation is associated with bipolar disorder, manic episode; the affect of a depressed person is usually one of sadness, or it may be blank. Loose associations are related to schizophrenia, not depression. Physical exhaustion can occur during the manic episode of bipolar disorder.

A client abuses alcohol during pregnancy. Which condition would the nurse anticipate to see in the newborn?

Stillbirth RATIONALE: A client who is an alcohol abuser may deliver a stillborn baby. Heart defects occur in the newborn when the mother is exposed to anti microbial during her pregnancy. Newborn growth delays may be caused by anti seizure medication exposure in the mother. Multiple defects may be seen in a child whose mother was exposed to vitamin A derivatives.

A pregnant woman continues to consume alcohol during pregnancy. Which teratogenic effects might the nurse expect to see in the fetus or neonate? Select all that apply.

Stillbirth, Spontaneous abortion, intellectual disabilities RATIONALE: Prolonged fetal exposure to alcohol may cause a stillbirth. A spontaneous abortion may occur if the pregnant woman consumes alcohol in excess amounts. Intellectual disabilities may be seen in the neonate if it is exposed to alcohol in the fetal stage. Ebstein anomaly is caused by lithium exposure during pregnancy. Neural tube defects may be due to exposure to antiseizure medications during pregnancy.

A primary HSV infection differs from recurrent HSV episodes in that (select all that apply)

Symptoms are less severe during recurrent episodes and systematic manifestation, such as fever and myalgia, are more common in primary infection

In assessing patients for STIs, the nurse needs to know that many STIs can be asymptomatic. Which STIs can be asymtomatic?

Syphilis, gonorrhea, genital warts, genital herpes, and chlamydial infections

A medication is administered to a client in her third trimester of pregnancy. Which statement regarding the medication administration is correct?

The dose of medication should be increased for pregnant clients. RATIONALE: During pregnancy, a client's hepatic metabolism and glomerular filtration are increased. As a result, the excretion rate is faster. The dose of a medication should be increased for the medication action to be optimal. It is tire that some medications should not be given to the pregnant client, because of potential teratogenic effects on the fetus. The client should see her health care provider if in doubt. The dose of a medication should be altered for a pregnant client depending on the trimester she is in. How a medication affects the fetus depends on the stage of development of the fetus and the dosage and strength of the medication administered. During the first 3-8 weeks after fertilization, the major organs are developing, and the dose of a medication should be decreased or withdrawn for pregnant clients.