PrepU Exam 5
The nurse working on a medical surgical floor should determine that which clients are at risk for a fall? Select all that apply. A) A client with macular degeneration B) A client with advanced Alzheimer disease C) A client taking a diuretic D) A client who is hard of hearing E) A client with a blood pressure of 142/90 mm Hg
A) A client with macular degeneration B) A client with advanced Alzheimer disease C) A client taking a diuretic
A client has recently brought her elderly mother home to live with her family. The client states that her mother has moderate Alzheimer's disease and asks about appropriate activities for her mother. The nurse tells the client to A) Ensure that the mother does not have access to car keys or drive an automobile. B) Encourage the mother to take responsibility for cooking and cleaning the house. C) Turn off lights at night so that the mother differentiates night and day. D) Allow the mother to smoke cigarettes outside on the porch without supervision.
A) Ensure that the mother does not have access to car keys or drive an automobile
The nurse is assigned to care for a client age 87 years admitted to the medical unit for congestive heart failure. It is the fourth hospital day, and the response to treatment has been good. The client is no longer short of breath and the lung sounds are clearing. There is still a diet restriction of decreased sodium and fluids are limited to no more than 1000 mL per day. The nurse is preparing the client and family for discharge. The nurse's discharge education, in order to promote the older client's health, will include which instructions? Select all that apply. A) Gradually increase activities as tolerated. B) Do not use the salt shaker at meals. C) Increased stress may interfere with recovery. D) Take several naps during the day.
A) Gradually increase activities as tolerated. B) Do not use the salt shaker at meals. C) Increased stress may interfere with recovery.
A client diagnosed with chronic renal failure is receives continuous peritoneal dialysis (PD). The nurse instructs the client about which diet plan? A) High-protein diet B) Low-protein diet C) Low-sodium diet D) High-calorie diet
A) High-protein diet
A health care provider has diagnosed a client with Wernicke-Korsakoff syndrome based on the client's discrete memory impairment and confabulation. Which assessment finding by the nurse would correspond with the confabulation finding? A) Making up information the client can't remember to fill in gaps in the conversation B) Slowed movement C) Back-and-forth constant rubbing of thumb and forefinger D) Visualizing bugs crawling on the walls
A) Making up information the client can't remember to fill in gaps in the conversation
A client has been prescribed quetiapine for delusional disorder. In teaching the client about this medication, the nurse must be certain to include which information? A) One of the common side effects is dry mouth. B) Quetiapine can cause breast milk production. C) If dizziness is experienced, the client must call the doctor immediately. D) Quetiapine can cause one to crave sugar.
A) One of the common side effects is dry mouth.
A 21-year-old male college student has just been brought to the emergency department by police. He is agitated and talking about how someone is going to find him and appears to experiencing hallucinations, though there is no evidence of substance use. His mother accompanies him and states that he has a history of similar episodes. The care team should screen this client for which disease? A) Schizophrenia B) Panic disorder C) Bipolar disorder D) Mania
A) Schizophrenia
Dilutional hyponatremia occurs in which disorder? A) Syndrome of inappropriate antidiuretic hormone secretion (SIADH) B) Addison disease C) Pheochromocytoma D) Diabetes insipidus (DI)
A) Syndrome of inappropriate antiduretic hormone secretion (SIADH)
The nurse is caring for a client undergoing cognitive behavior therapy for obsessive-compulsive disorder. How does the cognitive model describe the client's thought process? Select all that apply. A) The client overestimates the threats caused by the thoughts. B) The client wants to control own thoughts. C) The client has intolerance for uncertainty. D) The client believes the client has no personal responsibilities. E) The client lacks religious sentiments.
A) The client overestimates the threats caused by the thoughts. B) The client wants to control own thoughts. C) The client has intolerance for uncertainty.
A client is being treated with colchicine for pain in the big right toe. The client begins to complain of severe right flank pain and is diagnosed with kidney stones. Which type of kidney stone does the nurse recognize this client is most likely affected by? A) Uric acid B) Cystine C) Calcium D) Magnesium ammonium phosphate
A) Uric acid
In contrast to anxiety, fear is characterized by: A) a cognitive response to a known threat. B) short-term resolution. C) a real, rather than perceived, threat. D) the creation of an action plan to deal with a perceived threat.
A) a cognitive response to a known threat.
The nurse at an elementary school is explaining the concept of industry versus inferiority to a group of nursing students. What is part of this stage of Erikson's theory? A) Lack of the ability to think abstractly B) A sense of competence, mastery, and worth C) The principle of conservation D )The conventional stage of development
B) A sense of competence, mastery, and worth
What interventions can the nurse encourage the client with diabetes insipidus to do in order to control thirst and compensate for urine loss? A) Limit the fluid intake at night. B) Consume adequate amounts of fluid. C) Weigh daily. D) Come to the clinic for IV fluid therapy daily.
B) Consume adequate amounts of fluid.
While observing a group of 9-year-old children at school, the nurse is concerned that one of the children is not cognitively developing according the Piaget's stage of concrete-operational thought processes. With which activity is the nurse concerned? A) Arrives to class late from recess and apologizes to the teacher B) Does not understand the phrase "slow as molasses" when used by the teacher C) Believed that not turning in homework on time was acceptable, but has since decided it is not acceptable D) Enjoys math instruction and decides to join the math club
B) Does not understand the phrase "slow as molasses" when used by the teacher
Which statement is true regarding schizophrenia? A) Diagnosis is usually confirmed after middle age. B) It presents with disorganized, positive, and negative symptoms. C) There is no evidence to support a family history. D) Negative symptoms respond well to antipsychotic drug therapy.
B) It presents with disorganized, positive, and negative symptoms.
A client with a diagnosis of schizophrenia has a history of auditory and visual hallucinations. Which intervention is most likely to minimize the client's hallucinations? A) Providing a vivid, bright environment that provides distractions from hallucinations B) Provide frequent contact and communication with the client C) Clustering the client's medications at 0800 hours D) Ensuring that the client does not sleep more than 7 hours in any 24-hour period
B) Provide frequent contact and communication with the client
A client is being seen in the health clinic. The nurse observes a shuffling gait, drooling, and slowness of movement. The client is currently taking an antipsychotic for treatment of schizophrenia. The nurse knows that which side effect is occurring? A) Akathisia B) Pseudoparkinsonism C) Neuroleptic malignant syndrome D) Dystonic movements
B) Pseudoparkinsonism
In which stage of sleep does dreaming occur most frequently? A) Non-rapid eye movement sleep B) Rapid eye movement sleep C) Stage I D) Stages 3 and 4
B) Rapid eye movement sleep
A nurse is caring for a client diagnosed with schizophreniform disorder. The nurse demonstrates understanding of this disorder when identifying that the client is at risk for developing what? A) Major depression B) Schizophrenia C) Substance abuse D) Personality disorder
B) Schizophrenia
A client who was diagnosed with schizophrenia in 1962 was prescribed chlorpromazine. The client has been taking the medication for more than 40 years. What adverse effect will the client most likely experience? A) Central nervous system agitation B) Tardive dyskinesia C) Hypertension D) Urinary frequency
B) Tardive dyskinesia
Which are cognitive client outcomes? Select all that apply. A) The client reports cycling 30 minutes three times each week. B) The client describes how to perform progressive muscle relaxation. C) The client lists the side effects of digoxin. D) The client identifies signs and symptoms of hypoglycemia. E) The client correctly ambulates with a walker.
B) The client describes how to perform progressive muscle relaxation. C) The client lists the side effects of digoxin. D) The client identifies signs and symptoms of hypoglycemia.
Which assessment findings in a client who is suspected of having a delusional disorder would be suggestive of a diagnosis of schizophrenia? A) The client responds to group psychotherapy. B) The client experiences frequent and sustained hallucinations. C) The client does not have insight into his or her delusions. D) The client's beliefs are considered delusional but nonbizarre.
B) The client experiences frequent and sustained hallucinations.
The presence of mucus and pus in the stools suggests which condition? A) Small-bowel disease B) Ulcerative colitis C) Disorders of the colon D) Intestinal malabsorption
B) Ulcerative colitis
The nurse instructs a client to perform continuous ambulatory peritoneal dialysis correctly at home. Which educational information should the nurse provide to the client? A) Wear a mask while handling any dialysate solutions. B) Use an aseptic technique during the procedure. C) Clean the catheter insertion site daily with soap. D) Keep the catheter stabilized to the abdomen, below the belt line.
B) Use an aseptic technique during the procedure.
The nurse is providing care for a 13-year-old child diagnosed with iron-deficiency anemia. The client's current hemoglobin level is 11 g/dL (110 g/L). Which intervention will the nurse anticipate including in the client's care? A) providing a high dose of intravenous immunoglobulin weekly B) giving ferrous sulfate with orange juice between meals C) increasing the daily intake of fresh fruits and vegetables D) packed red blood cell transfusions
B) giving ferrous sulfate with orange juice between meals
A nurse is performing a preoperative assessment. Which client statement should alert the nurse to the presence of risk factors for postoperative complications? A) "I had an operation 2 years ago and I don't want to have another one." B) "I haven't been able to eat anything solid for the past 2 days." C) "I've cut my smoking down from two packs to one pack per day." D) "I've never had surgery before."
C) "I've cut my smoking down from two packs to one pack per day."
A nurse suspects that a child, age 4, is being neglected. Which question should the nurse ask the parents to best assess the child's nutritional status? A) "Do you think your child eats enough?" B) "Has your child always been so thin?" C) "What did your child eat for breakfast?" D) "Is your child a picky eater?"
C) "What did your child eat for breakfast?"
A woman comes to the clinic for her first prenatal checkup. The woman has a body mass index (BMI) of 22. The nurse would anticipate that this client should gain approximately how much weight during her pregnancy? A) 15 to 25 lbs (7 to 11 kg) B) 11 to 20 lbs (5 to 9 kg) C) 25 to 35 lbs (11 to 16 kg) D) 28 to 40 lbs (13 to 18 kg)
C) 25 to 25 lbs (11 to 16 kg)
A client being treated for myasthenia gravis is receiving neostigmine. When the client's pulse drops to 50 after the administration, which medication should be administered to treat the bradycardia? A) Bethanechol B) Pseudoephedrine C) Atropine D) Propranolol
C) Atropine
The nurse is encouraging the client with recurrent urinary tract infections to increase his fluid intake to 8 large glasses of fluids daily. The client states he frequently drinks water and all of the following. Which of the following would the nurse discourage for this client? A) Ginger ale at dinner time B) Fruit juice midmorning C) Coffee in the morning D) Milk at lunch
C) Coffee in the morning
A male client who is admitted with the diagnosis of urinary calculi complains of excruciating pain. The pain is suspected to be caused by increased pressure in the renal pelvis. Which measure would be most appropriate to provide pain relief? A) Encourage deep-breathing exercises. B) Restrict the client's sodium intake. C) Encourage frequent ambulation. D) Encourage the client to void every 2 to 3 hours.
C) Encourage frequent ambulation.
The nurse is planning the care of a 5-year-old child with developmental disabilities whose weight is at the 12th percentile for her age. The care team and the child's parents have agreed that interventions are necessary. Which intervention should be added to the plan of care? A) Encourage the family to provide a low-fat, high-carbohydrate diet. B) Facilitate the insertion of a peripherally inserted central catheter for parenteral nutrition. C) Encourage the parents to maintain a detailed log of the child's food and fluid intake. D) Allow the child to choose which foods to eat and which food to reject.
C) Encourage the parents to maintain a detailed log of the child's food and fluid intake.
When using transdermal Fentanyl, the nurse and patient should be aware of which sign or symptom of Fentanyl overdose? A) Hyperventilation B) Hyperalertness C) Confusion D) Insomnia
C) Hyperalertness
A client is diagnosed with polycystic kidney disease. Which of the following would the nurse most likely assess? A) Fever B) Periorbital edema C) Hypertension D) Extremity pain
C) Hypertension
During an initial assessment, a client exhibits pressured speech and points to patterns on the wallpaper stating, "This is the writing about the tsunami. Thousands of people died because I read the writing." Which term should the nurse use to document this observation? A) Hallucination B) Religious delusion C) Ideas of reference D) Illusion
C) Ideas of reference
Which of the following is considered a bulk-forming laxative? A) Dulcolax B) Mineral oil C) Metamucil D) Milk of Magnesia
C) Metamucil
In a report, the night nurse tells the incoming nurse that one client with dementia has sundowning syndrome. Which of the following nursing diagnoses would be most appropriate for this client? A) Grieving B) Social isolation C) Sleep deprivation D) Noncompliance
C) Sleep deprivation
An occupational therapist conducts a group therapy program called MindWorks with older adults who have diagnoses of dementia and Alzheimer's disease. The goal of the group is to slow the cognitive decline of clients by engaging them in regular, organized mental activity such as reading maps and solving puzzles. How would the program most likely be characterized? A) Primary prevention B) Prognosis enhancement C) Tertiary prevention D)Secondary prevention
C) Tertiary prevention
Which is a true statement regarding regional enteritis (Crohn's disease)? A) The lesions are in continuous contact with one another. B) It is characterized by pain in the lower left abdominal quadrant. C) The clusters of ulcers take on a cobblestone appearance. D) It has a progressive disease pattern.
C) The clusters of ulcers take on a cobblestone appearance.
The nurse has observed that a client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite? A) Offer nutritional supplements and explain the potential benefits of each. B) Reduce the frequency of meals in order to allow the client to develop an appetite. C) Try to ensure that the client's food is attractive and sufficiently warm. D) Offer larger meals and encourage the client to eat as much as is comfortable.
C) Try to ensure that the client's food is attractive and sufficiently warm.
A postsurgical client has been receiving morphine by patient-controlled analgesic for 2 days. What action by the nurse best addresses potential adverse effects? A) encouraging active range of motion exercises B) applying calf compressors as prescribed C) administering a stool softener as prescribed D) auscultating the client's lung for adventitious sounds
C) administering a stool softener as prescribed
A client has been admitted to the emergency department. The client's family tells the nurse that the client has suddenly become lethargic and is "not making sense." The client has not had anything to eat or drink for the last 8 hours. The nurse further assesses the client using the Confusion Assessment Method (CAM). The client's responses to questions are rambling, and the client is not able to focus clearly to answer the nurse's questions. Based on these findings, the nurse should report that the client has which problem? A) dehydration B) depression C) delirium D) dementia
C) delirium
A nurse is preparing to teach an 8-year-old child recently diagnosed with diabetes how to give an insulin injection. Which is the best technique for the nurse to use? A) role modeling B) video C) demonstration D) coloring book about diabetes
C) demonstration
A nurse is caring for a veteran, who exhibits signs and symptoms of posttraumatic stress disorder (PTSD). Signs and symptoms of posttraumatic stress disorder include: A) feelings of hostility and violent behavior. B) memory loss of a traumatic event and somatic distress. C) hyperalertness and sleep disturbances. D) sudden behavioral changes and anorexia.
C) hyperalertness and sleep disturbances.
While caring for a hospitalized client with schizophrenia, a nurse observes that the client is listening to the radio. The client tells the nurse that the radio commentator is speaking directly to the client. The nurse interprets this finding as: A) illusional thinking. B) autistic thinking. C) referential thinking. D) concrete thinking.
C) referential thinking.
The nurse receives a report that a 75-year-old client is recovering from surgery. During the shift, the nurse notes that the client is forgetful and restless. Several times, the client calls the nurse the name of the client's daughter. The nurse interprets this behavior as what? A) Normal for the first postoperative day B) Normal, given the client's age C) Signs of early Alzheimer's disease D) Signs of delirium
D) Signs of delirium
Rebound hypoglycemia is a complication of parenteral nutrition caused by A) glucose intolerance. B) a cap missing from the port. C) fluid infusing rapidly. D) feedings stopped too abruptly.
D) feedings stopped too abruptly.
A client is experiencing some secretion abnormalities, for which diagnostics are being performed. Which substance is typically reabsorbed and not secreted in urine? A) chloride B) creatinine C) potassium D) glucose
D) glucose
A client who's scheduled for open-heart surgery in 2 days has been having circulation problems in the feet and legs. The physician orders antiembolism stockings. The nurse is teaching the client about this treatment. What is the purpose of antiembolism stockings? A) to decrease arterial blood circulation to the legs and feet B) to maintain warmth in the legs C) to decrease venous blood circulation from the legs and feet D) to reduce or prevent edema of the legs and feet
D) to reduce or prevent edema of the legs and feet
A first episode of depression that occurs after what age can be a precursor to dementia? A) 65 B) 45 C) 55 D) 75
A) 65
The client tells a nurse that "many voices in his head are telling him what he should do." The nurse thinks he may be experiencing: A) a hallucination. B) bipolar disorder. C) catatonic features. D) a delusion.
A) a hallucination.
The bacteria that line the gut of a human help maintain normal gut health and provide essential nutrients. This type of relationship is: A) mutualistic. B) saprophytic. C) commensal. D) parasitic.
A) mutualistic.
The nurse is caring for a 4-year-old girl following an appendectomy. The girl becomes fearful and starts to cry as soon as the nurse walks into the room. When the nurse asks about the crying, the girl says, "Nurses who wear shirts with flowers give shots." The nurse understands that this statement is an example of: A) transduction. B) beginning empathy. C) magical thinking. D) animism.
A) transduction.
During data collection, the client expresses concern over a change in the color of the urine from tea-colored to green since beginning a new medication. Which appropriate question would the nurse ask this client? A) "Are you taking a diuretic?" B) "Are you taking any B-complex vitamins?" C) "Are you taking phenazopyridine?" D) "Are you taking levodopa?"
B) "Are you taking any B-complex vitamins?"
A client in an inpatient setting has a delusion that there are a multitude of undetectable noxious gases in circulation that have the potential to poison the client and others. Which of the nurse's responses is most therapeutic? A) "There are actually no poison gases in the atmosphere that we don't know about." B) "I can assure you that you are actually very safe here." C) "Why do you think that you keep insisting on this belief?" D) "If we detect a poison gas here, I promise that you'll be the first to know."
B) "I can assure you that you are actually very safe here."
When educating the middle-age adult, it is important to discuss which of the following? A) Dysuria B) Calcium replacement C) Hypothyroidism D) Drug abuse
B) Calcium replacement
Which procedure is performed to examine and visualize the lumen of the small bowel? A) peritoneoscopy B) small bowel enteroscopy C) colonoscopy D) panendoscopy
B) small bowel enteroscopy
A nurse cares for a client who is 5 feet 11 inches tall and weighs 225 pounds. What statement describes the client's BMI? A) Overweight B) Class II obesity C) Class I obesity D) Normal weight
C) Class I obesity
The nurse is evaluating stool characteristics of an adult client. Which of the following would describe a normal stool? Select all that apply. A) clay colored B) black C) light brown D) yellow E) dark brown
C) light brown E) dark brown
Which occurs when thinking, feeling, or behaviors occur outside a person's awareness? A) Impulsivity B) Dichotomous thinking C) Affective instability D) Dissociation
D) Dissociation
A client is brought to the emergency department after injuring their right arm in a bicycle accident. The orthopedic surgeon tells the nurse that the client has a greenstick fracture of the arm. What does this mean? A) Bone fragments are separated at the fracture line. B) The fracture results from an underlying bone disorder. C) The fracture line extends through the entire bone substance. D) One side of the bone is broken and the other side is bent.
D) One side of the bone is broken and the other side is bent.
The diagnosis of delirium is supported when the nurse notes which in the client? A) The client spends much of the day sleeping in the dayroom and usually denies being hungry B) The client responds to most assessment questions with "I don't know" and appears apathetic C) The client repeatedly asks where the client is and attempts to drink the water in a flower vase D) The is convinced that the client sees "hundreds" of bugs and is not always oriented to time and place
D) The is convinced that the client sees "hundreds" of bugs and is not always oriented to time and place
A client with a neurologic impairment reports having problems with constipation. Which foods might the nurse recommend? A) ice cream B) meat C) white rice D) vegetables
D) vegetables
A nurse is assessing a client receiving tube feedings and suspects dumping syndrome. What would lead the nurse to suspect this? Select all that apply. A) Diarrhea B) Hypertension C) Tachycardia D) Decreased bowel sounds E) Diaphoresis
A) Diarrhea C) Tachycardia E) Diaphoresis
Which of the following would a nurse classify as a prerenal cause of acute renal failure? A) Septic shock B) Polycystic disease C) Prostatic hypertrophy D) Ureteral stricture
A) Septic shock
A client with dissociative disorder is referred for psychotherapy. What would be the main focus of therapy for this client? A) To reassociate with conciousness B) To combat feelings such as guilt and self-blame C) To have a positive outlook toward life D) To help the client face troublesome thoughts
A) To reassociate with conciousness
The nurse is preparing to administer a large-volume enema to an adult client. How far should the nurse insert the tubing into the rectum? A) 1 in (2.5 cm) B) 3 in (7.5 cm) C) 5 in (12.5 cm) D) 2 in (5.0 cm)
B) 3 in (7.5 cm)
A client receives a dose of furosemide intravenously at 8:00 AM. The nurse would expect this drug to exert is peak effects at which time? A) 8:15 AM B) 8:30 AM C) 8:45 AM D) 9:00 AM
B) 8:30 AM
Abnormalities in which lobe is believed to be associated with schizophrenia? A) Parietal B) Frontal C) Occipital D) Temporal
B) Frontal
A client begins to exhibit hallucinations and delusions along with disorganized speech after forgetting to take antipsychotic medication. The nurse suspects that the client is at which point in the clinical course of the disorder? A) Acute illness B) Relapse C) Stabilization D) Prodromal phase
B) Relapse
A 29-year-old first-time mother has been diagnosed with postpartum psychosis after her partner reported the client was hearing voices and told the partner she "saw someone trying to steal the baby." In the planning of this client's care, which outcome should the nurse prioritize? A) The client will describe the causes of her fatigue. B) The client will demonstrate the ability to differentiate between perceptual disturbances and reality. C) The client will consume at least 1,500 calories each day. D) The client will demonstrate an improved ability to express herself.
B) The client will demonstrate the ability to differentiate between perceptual disturbances and reality.
When examining a client who has abdominal pain, a nurse should assess A) the symptomatic quadrant first. B) the symptomatic quadrant last. C) any quadrant first. D) the symptomatic quadrant either second or third.
B) the symptomatic quadrant last.
The family of a male client documented to be in a vegetative state excitedly reports to the nurse that the client has just opened his eyes for the first time. The best response by the nurse is: A) "That is a miracle." B) "Clients in a vegetative state often open and close their eyes." C) "I will come and assess the client." D) "That is a just a reflexive action."
C) "I will come and assess the client."
The nurse cares for a client with acute kidney injury (AKI). The client is experiencing an increase in the serum concentration of urea and creatinine. The nurse determines the client is experiencing which phase of AKI? A) Diuresis B) Recovery C) Oliguria D) Initiation
C) Oliguria
Why should the nurse avoid palpating both carotid arteries at one time? A) Palpating both arteries at one time may cause transient hypertension. B) The nurse can't assess the pulse accurately unless the arteries are palpated one at a time. C) Palpating both arteries at one time may cause severe bradycardia. D) Palpating both arteries at one time may cause severe tachycardia.
C) Palpating both arteries at one time may cause severe bradycardia.
The nurse is caring for of a 6-month-old infant diagnosed with iron deficiency anemia. The nurse determines further teaching is necessary when the mother states: A) "I know this anemic condition can be resolved with good nutrition." B) "I need to feed my baby cereals with fortified iron." C) "I need to decrease my baby's intake of whole milk to provide the best nutrition." D) "I must stop breast-feeding my baby because of the anemia."
D) "I must stop breast-feeding my baby because of the anemia."
Which client statement indicates a good understanding of the nutritional modifications needed to manage hypertension? A) "A glass of red wine each day will lower my blood pressure." B) "If I include less fat in my diet, I'll lower my blood pressure." C) "I should eliminate caffeine from my diet to lower my blood pressure." D) "Limiting my salt intake to 2 grams per day will improve my blood pressure."
D) "Limiting my salt intake to 2 grams per day will improve my blood pressure."
A nurse is teaching an elderly client's family about the causes of mental impairment. The nurse sees that the teaching has been effective when the family says which of the following? A) "Alzheimer's disease (AD) is a reversible neurologic illness." B) "Delirium progressively affects cognitive function and is a chronic process." C) "Dementia is an acute process and develops suddenly." D) "Sundowning is a common problem of dementia."
D) "Sundowning is a common problem of dementia."
Global and focal brain injuries manifest differently. What is almost always a manifestation of a global brain injury? A) Loss of eye movement reflexes B) Respiratory instability C) Change in behavior D) Altered level of consciousness
D) Altered level of consciousness
A client in a long-term care facility cannot control the direction of thought content, has a decreased attention span, and cannot concentrate. Which effect of sensory deprivation might the client be experiencing? A) Physical response B) Emotional response C) Perceptual response D) Cognitive response
D) Cognitive response
A nurse is assessing a hospitalized client who is hearing voices due to psychosis. The client is easily distracted, and this is creating a barrier to completing the assessment. What is the most effective way for the nurse to proceed? A) Wait for psychiatric medication to take effect. B) Ask another nurse to attempt the assessment. C) Use observation only to collect client information. D) Complete the assessment in several short interactions.
D) Complete the assessment in several short interactions
Which of the following would be least appropriate to suggest to a client with a urinary diversion to control odor? A) Avoid foods such as buttermilk or yogurt. B) Add a few drops of diluted white vinegar to the pouch. C) Avoid pouches with carbon filters. D) Eat plenty of cheese and eggs.
D) Eat plenty of cheese and eggs
A nurse is applying principles of cognitive behavioral therapy (CBT) in the treatment of a client with depression. Which intervention is an example of CBT? A) Encouraging the client to review the past and focus on strengths and accomplishments B) Rewarding the client with five tokens for attending group therapy C) Fostering hope by encouraging a focus on abilities rather than problems D) Encouraging the client to identify destructive thoughts and practice mindfulness
D) Encouraging the client to identify destructive thoughts and practice mindfulness
When lecturing about dissociative disorders to a group of nursing students, a nurse states that an essential feature of these disorders involves what? A) Total amnesia of the events that caused the disorder B) Disinhibited social engagement, being overly friendly with strangers C) Overuse of sedatives like alcohol D) Failure to integrate identity, memory, and consciousness
D) Failure to integrate identity, memory, and consciousness
The nurse advises a pregnant client to keep a small high-carbohydrate, low-fat snack at the bedside. The nurse should point out this will assist with which condition? A) Faintness B) Heartburn C) Slowed GI transit time D) Nausea and vomiting
D) Nausea and vomiting
A nurse is caring for a hospitalized 10-year-old child. What would be an appropriate activity for this child to meet the developmental tasks of this age group? A) Writing letters to friends B) Playing with blocks C) Playing with a jack-in-the-box D) Participating in a craft project
D) Participating in a craft project
The nurse is preparing to reposition a confused client from a supine position to a side-lying position. The nurse has asked the client to shift her weight accordingly, but the client has not responded to the nurse's request. How should the nurse respond? A) Enlist the assistance of a colleague. B) Reposition the client without the client's assistance. C) Ask the client if she is feeling confused. D) Rephrase the direction in different terms.
D) Rephrase the direction in different terms.
The nurse is caring for a client with Alzheimer's disease. A family member states, "I am afraid I will go to bed one night, and the next morning my loved one will be missing from wandering off." What is the appropriate nursing response? A) "Consider the Alzheimer's Association 'Safe Return' program." B) "Adjust sleeping schedules so that you can monitor your loved one as they sleep." C) "I know, my parent has Alzheimer's disease and I worry about that too." D) "Clients with Alzheimer's disease often wander."
A) "Consider the Alzheimer's Association 'Safe Return' program."
The nurse is providing an in-service for parents of preschoolers regarding nutrition. Which comments by the parents demonstrate successful learning following the in-service? Select all that apply. A) "I generally give my child choices about foods within each food category, ensuring all food groups are represented." B) "My 4-year-old should be ingesting at least 700 mg of calcium through food daily to promote good bone health." C) "We very rarely feed our child fast food and when we do we try to keep it as healthy as possible with no soda." D) "The only way I can get my child to consume sources of vitamin C is through fruit juices. I guess it's better than not at all." E) "My 4-year-old is above normal in weight but I'm sure it's just baby fat and will be lost with age."
A) "I generally give my child choices about foods within each food category, ensuring all food groups are represented." B) "My 4-year-old should be ingesting at least 700 mg of calcium through food daily to promote good bone health." C) "We very rarely feed our child fast food and when we do we try to keep it as healthy as possible with no soda."
A patient informs the nurse that his father died of prostate cancer, so he wants to know ways in which to reduce his risk factors for developing it. What education can the nurse give to the patient to decrease modifiable risk factors? A) Limit red meat and dairy products high in fat. B) Avoid wearing tight pants and underwear. C) Monitor blood pressure. D) Quit smoking.
A) Limit red meat and dairy products high in fat.
Although no definite genetic links for specific psychiatric disorders have been identified, which disorder is thought to be heritable? A) Schizophrenia B) Obsessive-compulsive disorder C) Dysthymia D) Panic attacks
A) Schizophrenia
The nurse expects psychiatric hospitalization for which of the clients diagnosed with schizoaffective disorder experiencing delusional thoughts? Select all that apply. A) A 39-year-old person who reports minor side effects from the current medication B) A 45-year-old person who was arrested for assaulting a policeman C) A 30-year-old person who also has a diagnosis of depression D) A 25-year-old person who is having a first delusional experience E) A 76-year-old person whose symptoms are acute in nature
B) A 45-year-old person who was arrested for assaulting a policeman C) A 30-year-old person who also has a diagnosis of depression D) A 25-year-old person who is having a first delusional experience E) A 76-year-old person whose symptoms are acute in nature
During an admission assessment with a psychiatric-mental health nurse, a client states that the client hears the voice of God in the client's head and the voice is telling the client that the client is worthless. How should the nurse document this symptom? A) Thought broadcasting B) A hallucination C) A delusion D) Thought insertion
B) A hallucination
Hypoglycemia has a sudden onset with a progression of symptoms. What are the signs and symptoms of hypoglycemia? A) Difficulty problem solving and muscle spasms B) Altered cerebral function and headache C) Altered cerebral function and muscle spasms D) Muscle spasms and headache
B) Altered cerebral function and headache
An older adult client who is a vegetarian has a hemoglobin of 10.2 gm/dL, vitamin B12 of 68 pg/mL (normal: 200-900 pg/mL), and MCV of 110 cubic micrometers. After interpreting the data, what instruction should the nurse give to the client? A) Ingest a diet higher in vitamin B12 sources. B) Supplement the diet with vitamin B12. C) Change the vegetarian diet and begin to eat red meat. D) Continue with the diet but include more sources of iron.
B) Supplement the diet with vitamin B12.
The nurse has been caring for a child who has been receiving growth hormone therapy for several years. When the child returns for evaluation following a sudden growth spurt, what nursing diagnosis should the nurse most likely add to the plan of care? A) deficient knowledge regarding drug therapy B) disturbed body image related to change in height C) risk for imbalanced nutrition: less than body requirements related to metabolic changes D) decreased cardiac output related to increased metabolic needs
C) risk for imbalanced nutrition: less than body requirements related to metabolic changes
To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should A) fill out the menu for the client. B) help the client fill out their menu. C) stay with the client and encourage them to eat. D) give the client privacy during meals.
C) stay with the client and encourage them to eat
What drug, prescribed for Parkinson's disease, has neuroprotective properties? A) Levodopa (Larodopa) B) Amantadine (Symmetrel) C) Bromocriptine (Parlodel) D) Selegiline (Eldepryl)
D) Selegiline (Eldepryl)