Physiological integrity
which is the most common cause of opthalmia neonatorum in infants born to adolescent mothers? - chlamydia - gonorrhea - human papilloma virus - herpes simplex virus
- chlamydia
nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina. the nurse advises the client to anticipate pain relief will begin within which period of time? - 1-3 mins - 4-5 seconds - 30-45 seconds - 10-15 mins
1-3 mins
the nurse receives an order to prepare a solution for administering a cleansing enema for an adolescent client. which is the volume of solution? 150- 250 mL 250- 350 mL 300- 500 mL 500- 750 mL
500-750 mL
which is the minimum hr of a 14 yo?
60
which condition can be identified in a client using phalens test? - atrophy - bone tumor - rotator cuff injury - carpal tunnel syndrome
carpal tunnel syndrome
a 2 yo toddler has hearing loss caused by recurrent otitis media. which treatment would the nurse anticipate that the practitioner will recommend? - ear drops - myringotomy - mastoidectomy - steroid therapy
myringotomy
which gland secretes melatonin? - pineal gland - thyroid gland - adrenal gland - parathyroid gland
pineal
which is a secondary cause of adrenal insuffiency? - hemorrhage - tuberculosis - pituitary tumors - metastatic cancer
pituitary tumors
which hormone is formed from cholesterol? - insulin - cortisol - prolactin - growth hormone
cortisol
what would the presence of ketones in the urine of a client indicate? - cystitis - heart failure - urinary calculi - fat metabolism
fat metabolism
the nurse is teaching crutch-walking to an adolescent. which action indicates the need for further teaching? - takes short equal steps - looks forward to maintain balance - looks down when placing the crutches - assumes an erect posture when walking
looks down when placing the crutches
a healthcare provider prescribes furosemide for a client w hypervolemia. the nurse recalls that furosemide exerts its effects in which part of the renal system? - distal tubule - collecting duct - glomerulus of the nephron - loop of henle
loop of henle
a client with hemiparesis voices a reluctance to use a cane. Which rationale would the nurse use to explain the cane's purpose to the client? - maintain balance to improve stability - relieve pressure on weight-bearing joints - prevent further injury to weakened muscles - aid in controlling involuntary muscle movements
maintain balance to improve stability
which otc meds are used to treat vulvovaginal candiasis? select all that apply. one, some, or all responses may be correct. - tinidazole - miconazole - clotrimazole - azithromycin - metronidazole
miconazole clotrimazole
when making rounds the nurse observes a pt experiencing a seizure. which action would the nurse take? - hyperextend the clients neck - move obstacles away from the client - restrain the clients body movements - attempt to place an airway in the clients mouth
move obstacles away from the client
for which purpose is a goniometer used? - to assess range of motion - to reduce phantom limb sensation - to prevent hip flexion - to immobilize a joint during fracture
to assess range of motion
which nutrients would the nurse teach the parents of a child w celiac disease to avoid? - saturated oils and fats - milk and hard cheeses - corn and rice products - wheat and oat products
wheat and oat products - wheats oats rye and barley= major sources of gluten
when teaching a pt about digoxin, which symptom will the nurse include as a reason to withhold the digoxin? - fatigue - yellow vision - persistent hiccups - increased urinary output
yellow vision or blurred vision
the nurse is eval the results of treatment w erythropoietin which assessment findings indicates an improvement in the underlying condition being treated? - 2+ pedal pulses - decreased pallor - decreased jaundice - 2+ deep tendon reflexes
decreased pallor
the nurse understands which condition as being contraindicated for St. Johns wort herbal therapy? - anxiety - seizures - dementia - cardiac disease
dementia
which disorder is caused by the deficiency of antidiuretic horomone? - acromegaly - diabetes insipidus - cushing syndrome - syndrome of inappropriate antidiuretic hormone
diabetes insipidus
which characteristic is common in clients with sjogren syndrome (SS)? - dry eyes - muscle cramping - uti - elevated bp
dry eyes
which diagnostic study is used to detect deep vein thrombosis in the client's lower extremities? - thermography - plethysmography - duplex venus doppler - somatosensory evoked potential
duplex venus doppler
which hormone is released from the posterior pituitary gland oxytocin - prolactin - growth hormone - luteinizing hormone
- oxytocin
how much sleep should a preschooler get? - 8 hrs - 10 hrs - 12 hrs - 14 hrs
12 hours daily
which muscle-strength rating would the nurse record for a client who can complete range of motion w some resistance? - 1 - 2 - 3 - 4
4
which term would the nurse use in a report to describe the absence of menstrual periods in a 35 yo nonpregnant client - rhinnorhea - menopause - amenorrhea - dyspareunia
amenorrhea
the nurse would identify which med as the most common cause of extrapyramidal s/e (EPS)? - clozapine - haloperidol - risperidone - aripiprazole
haloperidol
after numerous diagnostic tests a client w jaundice receives the diagnosis of pancreatic cancer. which rationale explains the cause of the clients jaundice? - necrosis of the parenchyma caused by the neoplasm - excessive serum bilirubin caused by rbc cell destruction - obstruction of the common bile duct by the pancreatic neoplasm - impaired liver function, resulting in incomplete bilirubin metabolism
obstruction of the common bile duct by the pancreatic neoplasm
which term would the nurse document in the clients medical record after observing reduced urinary output? - anuria - dysuria - oliguria - nocturia
oliguria
Which part of the female reproductive system produces testosterone? - uterus - ovary - fallopian tube - ovarian follicle
ovary
which definition of photophobia is accurate? - double vision - foreign body sensation - persistent abnormal intolerance to light - gradual or sudden inability to see clearly
persistent abnormal intolerance to light
the parents of a 2 yo child are watching the nurse admin the denver II developmental screening test to their child. they ask " why did u make our child draw on paper? we dont let our child draw at home?" which is the best response by the nurse? - i should have asked you about drawing first? - these drawing help us determine your childs intelligence - it lets us tests the childs ability to preform tasks required for the hands - i dont understand why drawing is forbidden in your home
these drawing help us determine your childs intelligence
morning sickness generally disappears by the end of which month? - fifth - third - fourth - second
third
which procedure involves inserting a catheter into the pleural space to obtain specimens of pleural fluid or remove a pleural effusion? - thoracentesis - mediastinoscopy - transbronchial biopsy - computed tomography
thoracentesis
which would the nurse state to the mother of a toddler to promote safety? - throw plastic grocery bags away - fill the crib with large stuffed toys - put pacifiers around the neck of a toddler - place the toddler to sleep on their back
throw plastic grocery bags away
which is the causative organism for syphilis? - treponema pallidum - campylobacter jejuni - trichomonas vaginalis - chlamydia trachomatis
treponema pallidum
an adult client w low-functioning down syndrome (trisomy 21) appears in the emergency dept via ambulance after an accident. which assessment method would be best to instrument to use when determining this clients level of pain? - asking the clients parent - using the wong-baker. faces pain rating scale - observe the clients body language - explain and use the 0 to 10 pain scale
using the wong-baker. faces pain rating scale
which function of limbic system is accurate? - influence emotional behavior - regulate autonomic functions - facilitate automatic movements - relay sensory and motor inputs for cerebrum
influence emotional behavior
the nurse is caring from an adolescent admitted to the hospital after taking an acetaminophen overdose. which result is MOST important for the nurse to monitor at this time? - blood gas lvl - liver funct tests - complete blood count - glycosylated hemoglibin
liver funct tests
which part of the kidney senses changes in bp? - calices - glomerulus - macula densa - juxtaglomerular cells
macula densa
which result would the nurse expect to find when reviewing the serum screening tests of a client w acquired immunodeficiency syndrome (AIDS)? - a decrease in CD4 T cells - an increase in thymic hormones - an increase in immunoglobulin E - a decrease in the serum lvl of glucose-6-phosphate dehydrogenase
a decrease in CD4 T cells
which is the most common cause of death among adolescents? - suicide - homicide - accidents - substance abuse
accidents
which action would the nurse confirm before approving a clients transfer to radiology for magnetic resonance imaging (MRI)? - the client received the scheduled preprocedure meds - all metal objects such as jewelry, hair ornaments, and clothing w metal are removed - infusion iv fluids completed per the preprocedure hydration protocol - the client emptied the bladder, donned a gown that which opens in the front, and removed underwear
all metal objects such as jewelry, hair ornaments, and clothing w metal are removed
which terms is used to indicate an absence of menstruation? - gonorrhea - amenorrhea - dysmenorrhea - ectopic pregnancy
amenorrhea
a client has been given a prescription for acetylsalicylic acid. the nurse recalls that this med has which property? - sedative - hypnotic - analgesic - antibiotic
analgesic
Aspirin is prescribed on a regular schedule for a client with rheumatoid arthritis. The nurse understands that the medication is being used primarily for which property? - analgesic - antipyretic - anti-inflammatory - antiplatelet
anti-inflammatory
which condition results in visual distortion? - myopia - hyperopia - presbyopia - astigmatism
astigmatism
pulse oximetry is prescribed for an adolescent. which would the nurse do to ensure the accuracy of the pulse oximeter reading? - attach the probe to a finger or earlobe - wait 30 mins before obtaining a regarding - calibrate the oximeter at least every 8 hours - place the probe on the abdomen or upper leg
attach the probe to a finger or earlobe
which method would the nurse refrain fro using to measure the bp of a 2yo? - using a pediatric stethoscope bell - basing the choice cuff on the brand name - measuring the bp 15 to 20 mins after activity - placing the stethoscope softly on the childs anticubital fossa
basing the choice cuff on the brand name
the home health nurse provides eduction for a client w cancer of the tongue who will begin gastrostomy feedings at home. which client statement indicates effective teaching? - before i start the procedure i will don sterile gloves - before i start the procedure i will obtain my body wt - before i start the procedure i will measure the residual volume - before i start the procedure i will instill 1 oz of carbonated liquid
before i start the procedure i will measure the residual volume
the nurse is caring for a 9 mo infant w a gluten-induced enteropathy. which common term for this disorder would the nurse use when discussing the infants diagnosis w the parents? - megacolon - celiac disease - cystic fibrosis - intussusception
celiac disease
which part of the brain primarily regulates muscle functioning and coordinates movement - cerebrum - cerebellum - epithalamus - hypothalamus
cerebellum
when developing the plan of care for a client w rheumatoid arthritis, which client consideration would the nurse include? - surgery - comfort - education - motivation
comfort
the nurse assesses a clients iv site. which clinical finding leads the nurse to conclude the iv site has infiltrated, rather than caused inflammation - pain - localized swelling - coolness - cessation of flow of fluids
coolness
a 2 yo toddler is to have iv antibiotic therapy. which action will the nurse take to prevent the child from pulling out the iV line? - keep the arms restrained - tell the child not to touch the iv site - cover the iv site with a protective device - have the parent hod the child continuously
cover the iv site with a protective device
which explanation will the nurse give when a client asks about which causes varicose veins? - abnormal configuration of the veins - incompetent valves of superficial veins - decreased pressure win deep veins - atherosclerotic plaque formation in the veins
incompetent valves of superficial veins
an adolescent visits the allergy clinic for testing. which laboratory finding indicates that an allergic response is in progress? - decreased platelet count - increased eosinophil lvl - increased lymphocyte count - increased immunoglobulin count
increased eosinophil lvl
which type of biopsy is required for removal of entire lesions of the skin? - punch biopsy - shave biopsy - incistional biopsy - excisional biopsy
excisional biopsy
The client with Hodgkin's disease adds doxorubicin to current therapy. which advice will the nurse provide about this medication? - cease taking any medication that contains vitamin d - keep the doxorubicin in a dark place protected from light - expect urine to turn red for a few days after taking med take on an empty stomach w large amounts of fluids
expect urine to turn red for a few days after taking med
a client who takes rifampin tells the nurse, "my urine looks orange" which action would the nurse take? - explain that this is expected - check the liver enzymes - ask the dr to order a urinalysis - ask what foods were eaten
explain that this is expected
a child has a resp tract infection w a low-grade fever. when teaching the parents, which intervention would the nurse emphasize? - encouraging high- cal snacks to prevent wt loss - keeping the toddler wrapped in blankets t prevent shivering - giving small amounts of clear liquid freq. to prevent dehydration - using cool-water baths to prevent the child's fever from increasing further
giving small amounts of clear liquid freq. to prevent dehydration
which actions would the nurse take to help a female bipolar client in the manic episode meet personal hygiene needs? - suggest that she wear hospital clothing - guide her to dress appropriately in her own clothing - allow her to apply makeup in whatever manner she chooses - keep makeup away from her bc she will apply it too freely
guide her to dress appropriately in her own clothing
After a discectomy and fusion surgery, the client wants to attempt walking with assistance for the first time. Upon rising to a standing position, the client reports feeling faint and light headed. Which action would the assisting nurse have the client do upon hearing the client's concern? - have the client sit on the edge of the bed so the nurse can hold the client upright. have the client slide to the floor w assistance to avoid injuring the client bc of a fall. - have the client bend forward to increase blood flow to the brain. - have the client lie down immediately so the nurse may obtain the cleints BP.
have the client sit on the edge of the bed so the nurse can hold the client upright.
a teenager w a diagnosis of osteosarcoma is to have the affected leg amputated. which should promote psychosocial adjustment and early function immediately after surgey? - allow the client to change the first dressing - help the client adjust to the temp prosthesis - assign the client to a room w another adolescent - have the client meet w a member of a cancer survivor organization
help the client adjust to the temp prosthesis
which type of cast or splint will the nurse expect to see on a child w a fractured femur? - cylinder - hip spica - prefabricated knee - robert jones
hip spica
which surgery will a client undergo if pituitary gland must be removed? - mastectomy - prostatectomy - thyroidectomy - hypophysectomy
hypophysectomy
a client is admitted to the hospital for an adrenalectomy. before the clients replacement steroid therapy is regulated fully, the nurse will monitor the client for which complication? - hypotension - hypokalemia - hypernatremia - hyperglycemia
hypotension
the nurse teaches a teenager who is undergoing chemo abt the needs for special moth care. which statement by the teenager leads the nurse to conclude the instructions have been understood? - ill brush my teeth with baking soda - ill use mouth wash to rinse my mouth - ill swish my mouth out w hydrogen peroxide - ill use a soft bristled toothbrush to clean my teeth
ill use a soft bristled toothbrush to clean my teeth
the wt of a 3 mo infant w tetralogy of fallot has declined from the 25th percentile to the 5th. which mechanism would the nurse suspect is the reason for this inadequate weight gain? - cyanosis resulting in cerebral changes - decreased arterial oxygen levels resulting in plycythemia - pulm htn resulting in recurrent respiratory infections - inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse
inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse
after a 4yo child undergoes a craniotomy, the nurse preforms a neuro assessment that includes the level of consciousness, pupillary response and reflex activity. which could the nurse include in the assessment? - bp - motor function - rectal temp - head circumference
motor function
which statements are correct abt acne? - acne is hormonal - it is caused by stress - family history is a reason for acne - propionibacterium acnes causes acne - acne is commonly found on the face, chest, upper back, and neck
it is caused by stress, family history is a reason for acne, propionibacterium acnes causes acne, acne is commonly found on the face, chest, upper back, and neck
which complication of anaphylactic shock in the adolescent client is MOST important for the nurse to detect early? - urticaria - tachycardia - restlessness - laryngeal edema
laryngeal edema
a child is placed in a bilateral hip sica cast for the treatment of developmental hip dysplasia. which would the parents monitor and report to the practitioner - warm toes - leg numbness - skin desquamation - generalized discomfort
leg numbness
which is the etiological factor of nephrogenic diabetes insipidus (DI)? - meningitis - lithium therapy - graves disease - sulfonamide therapy
lithium therapy
a client hospitalized for uncontrolled htn and chest pain was started on a daily diuretic 2 days ago upon admission, w prescriptions for daily basic metabolic panel. the clients potassium lvl this morning is 2.7. which action will the nurse take next? - send another blood sample to the lab to retest the serum potassium lvl - notify provider that potassium lvl is above normal - notify provider that potassium lvl is below normal - no action is required bc the potassium lvl is win normal limits
notify provider that potassium lvl is below normal (3.6- 5.2)
after teaching a family member how to admin subq enoxaparin sodium, how will the nurse evaluate the effectiveness of the training? - return demonstration on a manikin - verbalization of the sid effects of the med - observing the family member admin the enoxaparin sodium to the client - correctly verbalizing all necessary steps in enoxaparin sodium admin
observing the family member admin the enoxaparin sodium to the client
a client w sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient controlled anesthesia pumps. the current pain is a 5/10 at the right elbow. the pump is "locked out" for another 10 mins, which action should the nurse implement? - urning on the tv for diversion - placing the prescribed as needed warm wet compress on elbow - calling the primary provider for another analgesic prescription - informing the client that she must wait until the pump reactivates to get more meds
placing the prescribed as needed warm wet compress on elbow
when obtaining a health history from a client recently diagnosed w type 1 diabetes, the nurse expects the clinical to report which clinical manifestation? - nervousness - polyuria - nocturia - diaphoresis
polyuria
the nurse is education new parents about circumcision. which structure of the penis would the nurse tell the parents is removed during circumcision? - glans - prepuce - epididymis - vas deferens
prepuce
which hormone has both inhibiting and releasing action? - prolactin - somatostatin - somatotropin - gonadotropin
prolactin
which nursing intervention would the nurse direct toward a child admitted for acute glomerulonephritis? - enforcing bed rest - promoting diuresis - encouraging fluids - removing dietary salt
promoting diuresis
which relationship reflects the relationship of naloxone to morphine sulfate? - aspirin to warfarin - amoxicillin to injection - enoxaparin to dalteparin - protamine sulfate to heparin
protamine sulfate to heparin
which action would the nurse take when admin eardrops to a 4yo? - pull the auricle up and out - place the cotton ball into the innermost part of canal - keep the child side lying 10-15 mins - instill prescribed drops while holding dropper 3 cm above ear canal
pull the auricle up and out
a teenager is being discharged w a cast. which would the nurse recommend if the client experiences pruritus around the case edges? - scratch the itchy area gently - put an ice pack on the affected area - sprinkle a layer of powder in the itchy spots - ask your dr for a prescription fro an antihistamine
put an ice pack on the affected area
which estrogen antagonist would the provider prescribe a client for the prevention of osteoporosis in postmenopausal women? - raloxifene - denosumab - alendronate - zoledronic acid
raloxifene
the nurse is caring for a client who is receiving azathioprine, cyclosporine, and prednisone before receiving a kidney transplant. which med action would the nurse identify as the purpose of these meds? - stimulate leukocytes - provide passive immunity - prevent iatrogenic infection - reduce antibody production
reduce antibody production (to decrease risk for rejection)
a client w rheumatoid arthritis ask the nurse why it is necessary to inject hydrocortisone into the knee joint. which reason would the nurse include in a response to this question? - lubricates the joint - reduces inflammation - provides physiotherapy - prevents ankylosis of the joint
reduces inflammation
which surgery is used to treat excessive wrinkling or sagging of facial skin? - rhinoplasty - rhytidectomy - dermabrasion - blepharoplasty
rhytidectomy (facelift)
when hypokalemia is suspected. which diagnostic test will the nurse use to confirm the diagnosis? - complete blood cell count - serum potassium lvl - x-ray film of long bones - blood cultures x3
serum potassium lvl
which is a complication that may develop i the child w hypospadias w chordee? - renal failure - testicular cancer - testicular torsion - sexual difficulties
sexual difficulties
after surgery an adolescent has a pt- controlled analgesia (PCA) pump that is set to allow morphine delivery every 6 minutes. which statement indicates to the nurse that the family understands instruction abt the PCA pump? - ill make sure that she pushes the PCA button every 6 mins - she needs to push the PCA button whenever she needs pain meds - ill have to wake her up on a reg basis so she can push the PCA button - ill press the PCA button every 6 mins so she gets enough pains meds whiles shes sleeping
she needs to push the PCA button whenever she needs pain meds
which action would be appropriate to implement when collecting a 24-hour urine test? - start the time of the test after discarding the first voiding - discard the last voiding in the 24 hr period for the test - insert a urinary retention catheter to promote the collection of urine - strain the urine after each voiding before adding the urine to the container
start the time of the test after discarding the first voiding
which action will the nurse take to determine a clients pulse pressure? - multiply the hr by the stroke volume - subtract the diastolic from the systolic reading - average the systolic and diastolic pressures - calculate the difference btwn apical and radial pulse rates
subtract the diastolic from the systolic reading
a 13 yo is found to have idiopathic scoliosis. bc exercise and avoidance of fatigue are essential components of care, which sport would the nurse suggest as the most therapeutic for this preadolescent - golf - bowling - swimming - badminton
swimming
the parents of a child w recently diagnosed leukemia asks the nurse why their child had too many wbc. which is the nurses best response? - the health care provider is the best one to answer that question for you. - you seem to b focusing on your childs wbc - you dont seem to understand what occurs in this disease - the bone marrow is not controlling your childs wbc production as it should
the bone marrow is not controlling your childs wbc production as it should
a client has an annual tuberculin purified protein derivative (PPD) test, and the area of induration was 10 mm within 48 hours after planting. which conclusion would the nurse make about the clients response to this diagnostic? - the client has contracted clinical tuberculosis - the client has immunity to tuberculosis - the client has been exposed to the tubercle bacillus - the client has developed a resistance to the tubercle bacillus
the client has been exposed to the tubercle bacillus
which treatment is beneficial for a client w a muscle spasm? - thermotherapy - muscle massage - freq position changes - muscle-strengthening exercise regimen
thermotherapy
