Quiz 2 module 05

A nurse is assessing an 11-month-old infant. Which of the following manifestations is associated with a CNS infection?

Bulging fontanelle

A nurse is preparing a presentation at a senior center about age-related musculoskeletal change. Which of the following changes should the nurse plan to include?

Decreased muscle mass

A nurse is planning care for a client who has viral hepatitis. Which of the following actions should the nurse include in the plan of care?

Provide a high carbohydrate diet.

A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

Begin phototherapy

A nurse is teaching a group of clients about osteoarthritis. Which of the following recommendations should the nurse include in the teaching?

Maintain a recommended body weight.

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

Provide client supervision.

A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize when the client

Makes up stories when he is unable to remember actual events

A nurse is providing dietary teaching to the parents of a newborn who is being breastfed. The nurse should instruct that the transition to whole milk can occur to which of the following ages?

12 months

A nurse is preparing a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device help clients learn to control physical responses to stress?

Biofeedback

A nurse is providing nutritional teaching to a client who has osteoporosis. Which of the following food should the nurse recommend as being the highest calcium?

3 oz canned salmon

A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the rule of nines, the nurse should estimate that the client has burned what percentage of body surface area? Round to the answer to the nearest tenth.

49.5

A nurse is assessing clients in a health clinic for risk factors for contracting hepatitis. Which of the following clients is at risk for developing hepatitis C?

A client who has multiple tattoos.

A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

A dry, red rash across the bridge of the nose and on the cheeks.

A nurse is performing an integumentary assessment for a client. which of the following findings should the nurse identify as a possible squamous cell carcinoma?

A firm nodule with a hard crust.

A community health nurse is preparing a presentation about complementary and alternative therapies. Which of the following therapies should the nurse describe as a means of manipulating a series of channels to re-establish the flow of vital energy within the body?

Acupuncture-ATI

A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching?

Baby powder will help prevent a diaper rash.

A nurse is caring for a client for an 8-hour postoperative following a total knee replacement Which of following actions should the nurse take?

Apply cool compresses to the affected limb every 6 hr.

A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

Assess the cranial nerves

A nurse is caring for a child who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

Auscultate bowel sounds

A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?

Avoid foods high in fat

A nurse is teaching a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following client food choices reflect the client's understanding of these dietary instructions?

Beans

A nurse Midwife is examining a client who is primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?

Cervical dilation

Nurse is caring for a client who is breastfeeding and states that her nipples are sore. Which of the following interventions should the nurse suggest?

Change the newborn's position on the nipples with each feeding.

A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be including in the plan of care?

Cluster the newborn's care activities.

A nurse is caring for a client whose Papanicolaou (Pap) test cytology results are abnormal. Which of the following procedures should the nurse anticipate for this client?

Colposcopy

A nurse is caring for a client who has a fractured tibia because of a fall. The client x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures?

Comminuted

A nurse at a pediatrician's office is contacted by a parent whose child just ingested half a bottle of vitamins with added fluorosis sulfate. Which of the following instruction should the nurse provide to the parent?

Contact the poison control center.

A nurse receives report about a client who is in labor and is having contractions 4 minutes apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?

Contractions that last for 60 seconds each with a 3 min rest between contractions

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Decreased level of consciousness

A nurse is caring for a client who has infective endocarditis. Which of the following manifestation is the priority for the nurse to monitor for?

Dyspnea

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

Encourage the client to empty her bladder every 2 hr.

A nurse is caring for a client who is menopausal and ask the nurse about the use of herbal therapies to reduce her discomfort. Which of the following statements should the nurse make?

Many herbal products have not undergone long-term testing for safety and efficacy

A nurse is presenting information to the public about preventive measures to reduce the risk for contradicting West Nile virus. Which of the following instructions should the nurse include?

Encourage the use of mosquito repellant

A nurse is talking with young adult clients who has a family history of osteoporosis. Which health promotion activity should the nurse recommend as a possible preventive measure?

Engage in weight-bearing exercise regularly

A nurse is teaching a group of male adolescents about testicular self-examination. Which of the following information should the nurse include?

Examine the testicles after a bath or shower.

A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?

Explain to the client what is about to happen.

A nurse is caring for a client who is two days postoperative following creation of an ileal conduit. Which of the following is an unexpected finding associated with this procedure?

Feces in the drainage appliance

A nurse is planning care for a client who has diverticulitis. Which of the following menu selections should the nurse include in the plan?

Grilled chicken breast with white rice.

A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1 + station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?

Have the client pant during the next few contractions.

A nurse is an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report.

Having a decreased ability to perceive colors.

A nurse is caring for a newborn whose mother is positive for the Hepatitis B surface antigen. Which of the following should the infant receive?

Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth.

A nurse is teaching a client who is perimenopausal and has recurrent lower back pain. Which of the following client statements indicates an understanding of the teaching?

I should keep my weight within 10 percent of my ideal weight.

A nurse is reinforcing teaching about food choices with the mother of an 8-month-old infant. Which of the following statements by the mother indicates a need for further teaching?

I will give my child strained carrots and mashed egg yolks.

A nurse is providing teaching to a client who has stomatitis. Which of the following statements by the client indicates a need for further teaching?

I will season foods with dried spices before cooking

A nurse is providing discharge teaching to a client who has gastroesophageal reflux disease. Which of the following statements by the client indicates an understanding of the teaching?

I will sleep with the head of my bed elevated.

A nurse is caring for a client who reports throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

Increase fluid intake.

A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make?

It is caused by the lack of production of aldosterone by the adrenal gland.

A nurse in a burn treatments center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

Large incision will be made in the eschar to improve circulation.

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

Location of the burn

A nurse is caring for a client who is 1-day postoperative following spinal fusion. which of the following actions should the nurse take?

Log roll the client every 2 hr.

A nurse is teaching a group of clients who are in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching?

Moderate exercise improves circulation.

A nurse is caring for a client who is receiving peritoneal dialysis. the nurse should monitor the client for which of the following manifestations of peritonitis?

Nausea and vomiting.

A nurse is caring for a client whose throat culture is positive for a group A streptococcus 24 hr after rapid strep test (RST) was negative. Which of the following actions is the nurse's priority?

Notify the client to return to the clinic for initiation of antibiotic therapy.

A nurse is teaching a client about causes of biliary cirrhosis. Which of the following information should the nurse include in the teaching?

Obstruction of the bile duct

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Obtain a pair of slipper socks for the client.

A nurse is educating new parents about risk factors for sudden infant death syndrome (SIDS). Which of the following statements should indicate to the nurse the need for additional teaching?

Our baby will sleep in our bed because I am breastfeeding

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions require intervention by the charge nurse?

Palpates the abdomen prior to performing auscultation.

A nurse is providing anticipatory guidance about child development to the parents of a preschooler. Which of the following developmental tasks should the nurse include as being expected of a preschooler?

Participate in imaginary play

A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

Place a pillow under the client's head.

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Place the client in a high Fowler's position.

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

Place the client on his side.

A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform?

Pulse rate

A nurse is caring for a client who is 1-day postoperative following a left radical mastectomy. Which of the following behaviors should the nurse to the possibility that the client is having difficulty adjusting to the loss of her breasts?

Refusing to look at dressing or surgical incision.

A nurse is providing post-operative teaching with a client who had a surgical correction of hallux valgus. Which of the following information should the nurse include in the teaching?

Rest frequently with your foot elevated.

A nurse is caring for a client who has traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

Restlessness

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). which of the following assessment by the nurse supports this suspicion?

Restlessness

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?

Scatter rugs are present in the kitchen.

A nurse is providing anticipatory guidance about Child Development to the parents of a toddler. Which of the following development tasks should the nurse include as expected over toddler?

Separates easily form primary care giver for short periods of time.

A nurse is providing care for a client who is 2 days postoperative following abdominal surgery and is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray?

Skim milk

A nurse is providing teaching to the parent of a toddler about appropriate snacks. Which of the following foods should the nurse include?

Sliced bananas

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing intervention is the highest priority?

Suction saliva from the client's mouth

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?

Talk with the client during wound care.

A nurse is providing discharge teaching to a client who has implantable cardioverter/ defibrillator (ICD). Which of the following information should the nurse include?

The client should hold his cell phone the side opposite the ICD

A nurse is assessing a 10-month-old infant. Which of the following findings should the nurse report to the provider?

The infant does not sit steadily without support.

A nurse is reviewing the PT, aPTT and INR laboratory values for a client who is experiencing an acute episode disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?

The laboratory values are prolonged.

A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene?

The mother plans to use a cotton tripped swab to clean the nares.

A nurse is assessing a 15-month-old toddler. Which of the following findings should the nurse report to the provider?

The toddler cannot stand upright without support.

A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and lightheaded. After applying oxygen via nonrebreather face mask at 10 L/min which of the following actions should the nurse take?

Tilt the client onto her right side with her legs elevated to at least 30' Massage the client's fundus to promote contractions.

A nurse is providing teaching about dietary recommendations to a client who has iron deficiency anemia. Which of the following dietary recommendations should the nurse include as a food that enhances iron absorption when consumed with nonheme iron?

Tomato juice

A nurse is preparing to administer a vaccine to a 4-year-old child. Which of the following vaccines should the nurse administer?

Varicella (VAR)

A nurse is teaching an older adult client who has osteoporosis about beginning a program of regular physical activity. Which of the following recommendations should the nurse make?

Walk briskly

A nurse is assisting an older adult client who is sedentary plan a new exercise regimen. Which of the following activities should the nurse recommend?

Walking

A nurse is talking with a client who is beginning a program of moderate exercise. The client asked the nurse why warm up exercises are necessary. Which of the following responses should the nurse make?

Warm-up exercises reduce the risk of injury

A nurse is preparing to teach a parent how to care for a child who has impetigo contagiosa. Which of the following information should the nurse plan to include in the teaching?

Wash clothing in hot water

A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply)

Wash the perineal area using squeeze bottle of warm water after voiding. Blot the perineal area dry after cleansing. Perform hand hygiene before and after voiding. Clean perineal area from front to back.

A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse use to promote this discussion?

What brought you to the hospital?

A nurse is performing discharge teaching with a client about the care of a newly created ileal conduit. The nurse should instruct the client to empty the appliance

When the bag is 2/3 full

The nurse is providing discharge teaching for a client who has chronic pancreatitis. which of the following statements should the nurse make?

You should increase your daily intake of protein.

A nurse is providing teaching to the parents of a newborn. Which of the following information should the nurse include?

Your baby should receive a hepatitis B vaccine prior to discharge.

A nurse is caring for a client who had a vaginal delivery 2 hour ago. Which of the following actions should the nurse anticipate in the care of this client? ( Select all that apply)

a. Determine whether the fundus is midline. b. Massage a firm fundus. c. Document fundal height. d. Observe the lochia during palpation of fundus.