Nursing Process Mastery Level 5

which client may have concerns related to sexuality when hospitalized with a chronic illness?

an 18 year old

which reaction is an example of a type 1 hypersensitivity reaction?

anaphylaxis

which term describes the practice of placing clients with the same infection in a semi-private room?

cohorting

which would the nurse identify as a group of hospitalized toddler's most important need?

contact with their parents

the nurse assesses a client's IV site. which clinical finding leads the nurse to conclude that the IV has infiltrated, rather than caused inflammation?

coolness

which hormone is formed from cholesterol?

cortisol

the nurse is evaluating the results of treatment with erythropoietin. which assessment finding indicates an improvement in the underlying condition being treated?

decreased pallor

when caring for a client with symptomatic bradycardia caused by heart block, the nurse will anticipate the need to teach the client about which treatment option?

demand pacemakers

place the five stages of grieving identified and described by Elisabeth Kubler-Ross in order of progression from first to last.

denial, anger, bargaining, depression, and acceptance

which component of the human personality, according to freud, allows an individual to judge reality accurately?

ego

when a client who has had a thoracotomy develops respiratory acidosis, which action would the nurse take?

encourage deep breathing

a client who had an above-the-knee amputation has a pressure dressing on the end of the residual limb. the client asks "why do I have this tight dressing on my leg?" which response would the nurse provide?

it decreases the swelling of the area

which information would the nurse include in a teaching session about osteochondroma?

it occurs most often in those 10 to 25 years old

which explanation would the nurse provide the outpatient radiology staff regarding storage of radium in lead containers?

lead functions as a barrier

which type of play do 2 year olds engage in?

parallel

the nurse suggests taking a two year old child to the playroom. the child responds by shaking the head vigorously from side to side, screaming, "no! won't!" however, the child is trying to climb out of the crib at the same time. in light of these behaviors, which is the most likely conclusion by the nurse?

the child is trying to assert independence

a client has been receiving digoxin. the client calls the clinic and complains of "yellow vision." which response would the nurse provide?

the medication may need to be discontinued. come to the clinic this afternoon.

when teaching a client about digoxin, which symptom will the nurse include as a reason to withhold the digoxin?

yellow vision

to which client would the nurse provide education regarding the pubertal growth spurt?

a 12 year old school-age female client

the nurse is planning to provide self-care health information to several clients. which client would the nurse anticipate will be most motivated to learn?

a 56 year old client who had a heart attack last week and is requesting information about exercise

which education would the nurse provide the parent of a preschool-age child about how preschoolers view death?

a form of sleep

according to erikson's psychosocial stages of development, which stage must a three year old accomplish?

autonomy v shame

a beta blocker is prescribed for the client with persistent ventricular tachycardia. which response indicates that the beta blocker is working effectively?

decreased HR

which manifestation indicates tertiary syphilis?

gummas

the nurse educator of a college health course is discussing tattoos with the class. which type of hepatitis associated w/ tattoos would the nurse include in the teaching plan?

hepatitis C

which treatment would the nurse anticipate for an infant admitted with bronchiolitis caused by RSV?

humidified cool air and adequate hydration

which surgery will a client undergo if the pituitary gland must be removed?

hypophysectomy

the nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement?

i'll start to have symptoms when I drink less fluid

the weight of a three month old infant with tetralogy of fallot has decline from the 25th percentile to the 5th. which mechanism would the nurse suspect is the reason for this inadequate weight gain?

inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse

a client who is receiving radiation therapy for bone cancer lives alone and works full time. which client action would the nurse encourage?

include rest periods during the day while receiving radiation

an adolescent visits the allergy clinic for testing. which laboratory finding indicates that an allergic response is in progress?

increased eosinophil level

which is involved in the postprocedure nursing care of a child after left-side cardiac catheterization?

monitoring the insertion site for bleeding

a client sustains a back injury after falling 20 feet. In which position would the nurse place the client?

supine position while not allowing the spine to flex

after a four year old child undergoes craniotomy, the nurse performs a neurological assessment that includes level of consciousness, pupillary activity, and reflex activity. which would the nurse include in this assessment?

motor function

the nurse teaches a new mother how to position her newborn during feedings. which is the best way to evaluate if the teaching is effective?

observe the mother feeding the infant

which client is at increased risk for postpartum hemorrhage?

one who gives birth to an infant weight 9 lb 8 oz

which hormone is released from the posterior pituitary gland?

oxytocin

why is multiple-gestation pregnancy considered a high risk?

perinatal mortality is 2-3 times more likely in multiple than single births

which step of the nursing process is directly affected if the nurse doesn't make a diagnosis?

planning

which hormone has both inhibiting and releasing action?

prolactin

one week after beginning antithyroid medication for the treatment of hyperthyroidism, a client reports diarrhea, abdominal pain, and a fever. the client is admitted with a diagnosis of thyrotoxic crisis. which intervention is appropriate to implement for this client?

reduce body temp & HR

a primary HCP prescribes PTU for a client with hyperthyroidism. two months after being started on the medication, the client calls the nurse and complains of feeling tired and looking pale. which action would the nurse take for this client?

schedule the client for an appointment

which type of group is AA?

self-help group

an 8 year old girl who is hospitalized for IV antibiotic therapy tells the nurse that she is bored. the nurse has a discussion with the father about appropriate activities. which activity suggested by the father would indicate a need for further teaching?

she'll enjoy having a rubber baseball and plastic hat

which clinical manifestations indicate a client who sustained head and chest injuries from a MVA, responded to medical treatments, and is ready for transfer to a critical care unit?

stabilized VS and complaints of pain

which stage of HIV would a client with a CD4+ T cell count 325 cells/mm be classified?

stage 2

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

2 to 6 weeks

which disorder would the nurse classify as neurodevelopmental?

ADHD

which STI causes condylomata acuminate?

HPV

which nursing intervention is appropriate when a client is first admitted w/ HHNS?

administering fluid replacement

the diagnostic reports of a client who underwent a hypophysectomy indicate an ICP of 20 mm Hg. which action made by the client is responsible for the reported ICP?

bending over at the waist

which STI is most commonly reported?

chlamydia

which disorder is caused by the deficiency of antidiuretic hormone?

diabetes insipidus

in the playroom of a pediatric unit, the nurse sees several toddlers seated at a table trying to copy the same picture from a book. they are not talking to each other or sharing their crayons. which would the nurse conclude about this behavioral interaction?

it is a typical expression of toddlers' social development

which is the causative organism for syphilis?

treponema pallidum

which statement is accurate when teaching the client with diabetes about foot care?

wear synthetic fiber socks when exercising

which is the correct order of steps of the nursing diagnostic process?

1. assess the client's health status 2. validate the data with other sources 3. interpret the meaning of the data 4. cluster data 5. look for defining characteristics 6. identify the client's needs 7. formulate nursing diagnoses

when a previously healthy 23 year old reports new-onset palpitations, which of these beverages would the nurse suggest that the client avoid?

16 oz cold energy drink

how many hours of sleep would the nurse recommend for the eleven year old client?

9

which antibody forms first, after exposure to an antigen?

IGM

which client statement leads the nurse to conclude that the client has been experiencing menorrhagia?

I have severe bleeding during my menstrual periods

which reason would the nurse document as nonadherence for the client not adhering to the prescribed antibiotic therapy?

I left my pills in the bedroom and I forgot to take the with breakfast.

which critical thinking skill demonstrates maturity in the nurse?

ability to reflect on own judgments

which preexisting condition necessitates a cesarean birth?

active genital herpes

The spouse of a client with pulmonary TB received a tuberculin skin test. The nurse examined the skin test and identified an area of induration greater than 10 mm. Which response to this finding would the nurse implement?

additional tests are necessary to determine infection status

which would the nurse do while communicating with a group of adolescents?

ask adolescents open-ended questions, be aware of clues about an adolescent's emotional state

an adolescent client presents to the clinic with complaints of amenorrhea for 2 months. which would the nurse do next?

ask the adolescent to take a pregnancy test

the nurse provides education to a client about colostomy care. to be effective when providing the teaching, the nurse would start with which step?

assess barriers to learning colostomy care

a client with T1DM receives Humulin R in the morning. Shortly before lunch the nurse identifies that the client is diaphoretic & trembling. which intervention is appropriate?

assess the client's blood glucose level

an adolescent girl is concerned about her body image after amputation of a leg for bone cancer. after the nurse has obtained the girl's consent, which action is most therapeutic?

encouraging her peers to visit

when the nurse revises the care plan because the goals have not been met, which phase of the nursing process is being applied?

evaluation

which intervention would the nurse implement to relieve the symptoms associated w/ a hypoglycemic reaction?

give 4 oz of fruit juice

which reason would be likely for a client's anger and acting out when the nurse interrupts the hand-washing ritual of a client with OCD?

has overwhelming feelings of anxiety

how would the nurse apply the identify versus role confusion stage in the care delivery of an adolescent?

helps hospitalized adolescents in decision-making about their treatment, provides anticipatory guidance to parents about the changes faces by children

a client is admitted to the hospital for an adrenalectomy. before the client's replacement steroid therapy is regulate fully, the nurse will monitor the client for which complication?

hypotension

which is the cause of milk anemia in toddlers?

increased milk intake

which conditions are risk factors that may place infants at a higher risk for developing jaundice?

infection, prematurity, BF, maternal diabetes

according to erikson's psychosocial stages of development, which developmental conflict affects a 4 year old child?

initative v guilt

a client is admitted to the PACU after a segmental resection of the right lower lobe of the lung. a chest tube drainage system is in place. when caring for this tube, what would the nurse do?

mark the time and fluid level on the side of the drainage chamber

a breast-feeding mother experiences redness and pain in the left breast, a temp of 100.9, chills, and malaise. which condition would the nurse suspect?

mastitis

a two year old toddler has hearing loss caused by recurrent otitis media. which treatment would the nurse anticipate that the practitioner will recommend?

myringotomy

after numerous diagnostic tests, a client with jaundice receives the diagnosis of pancreatic cancer. which rationale explains the causes of the client's jaundice?

obstruction of the common bile duct by the pancreatic neoplasm

which criteria would the nurse consider when determining if an infection is a health-care associated infection?

occurred in conjunction with treatment for an illness

the nurse is caring for a child who has an external fixation device on the leg. which is the nurse's priority goal when providing pin care?

preventing infection

which nursing intervention would the nurse direct toward a child admitted for acute glomerulonephritis?

promoting diuresis

three days after a cast is applied to a client's fractured tibia, the client reports burning pain over the ankle that is not relieved by a change of position. The cast over the ankle feels warm to the touch. which action would the nurse take first?

report the data to the primary health care provider

a client with COPD has a blood pH of 7.25 and a partial pressure of carbon dioxide of 60 mm Hg. which complication would the nurse suspect the client is experiencing?

respiratory acidosis

the nurse determines that an adolescent with newly diagnosed T1DM has sufficient knowledge of the disorder. Which is the next appropriate action?

setting goals with the client

which is a complication that may develop in the child with hypospadias with chordee?

sexual difficulties

after surgery, an adolescent has a patient-controlled analgesia pump that is set to allow morphine delivery every 6 minutes. which statement indicates to the nurse that the family understand instructions about the PCA pump?

she needs to push the PCA button whenever she needs pain medication

the nurse explains to the parents of a six year old child with a pinworm infestation how pinworms are transmitted. which statement indicates that the teaching has been understood?

she needs to wash her hands before eating anything

when teaching a client with diabetes about monitoring for episodes of hypoglycemia, which symptom would the nurse include in the teaching plan?

sweating

which statement explains the benefit of continuous regional analgesia versus conventional methods?

systemic side effects are minimal

the nurse is developing a nursing diagnosis for a client after surgery. the nurse documents the "related" to factor as first-time surgery. which assessment activity enabled the nurse to derive this conclusion?

the nurse notes nonverbal signs of discomfort

a client is admitted to the hospital with Laennec cirrhosis and chronic pancreatitis. bile salts (bile acid factor) are prescribed, and the client asks why they are needed. how would the nurse respond?

they aid in the absorption of fat-soluble vitamins

which statement is true for collaborative problems in a client?

they are identified by the nurse during the nursing diagnosis stage

how do toddlers learn self-protection?

through trial and error strategies

which clinical indicator would the nurse monitor to determine if the client's simvastatin is effective?

triglycerides

which is a risk factor associated with IVF?

tubal pregnancy

The nurse instructs the parents of an adolescent with asthma on how to reduce the allergens in the child's bedroom. The mother tells the nurse what she plans to do to make the room hypoallergenic. Which idea indicates that further teaching is needed?

using flat outdoor carpeting to cover hardwood floors