review

A client calls the diabetic hot-line and tells the nurse that she has flu-like symptoms with no fever, but has been vomiting and has had diarrhea since 4:00 am. She is taking NPH insulin. The nursing instruction (based on standard orders) about the amount of insulin she will need is An increased dose of her NPH insulin. A smaller dose of her NPH insulin. No insulin. Her regular dose of NPH insulin.

A smaller dose of her NPH insulin. Although she is unable to eat, the client still needs some insulin for body metabolism processes. If fever is not present, insulin is not increased.

The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply. A. Excess Fluid Volume B. Imbalanced Nutrition; Less than Body Requirements C. Activity Intolerance D. Impaired Gas Exchange E. Pain

A, B, C Question 16 Explanation: Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure.

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. A. Elevate the HOB to 90 degrees B. Loosen constrictive clothing C. Use a fan to reduce diaphoresis D. Assess for bladder distention and bowel impaction E. Administer antihypertensive medication F. Place the client in a supine position with legs elevated

A,B,D,E 18 Explanation: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn't reduce the client's blood pressure, IV antihypertensives should be administered. A fan shouldn't be used because cold drafts may trigger autonomic dysreflexia.

The client with a right side retinal detachment is admitted to the hospital and scheduled for surgery later that day. The most important nursing intervention in the preoperative hours is to position the client So that the area of the detachment is dependent. With the head of his bed flat. On his right side. With the head of his bed elevated

So that the area of the detachment is dependent.

Which is a component in routine urinalysis? Select all that apply. Specific gravity WBC RBC BUN Serum Sodium

Specific gravity WBC RBC

Following an angry outburst the previous evening, on a psychiatric unit a client says , "I'm feeling calmer now. I don't know what got into me. You all must think I'm crazy." The best response to this statement would be "That's all right. We're here to help you." "Why would you think that?" "You think your behavior was crazy?" "How were you feeling last evening?"

"How were you feeling last evening?"

A 20-year old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline personality disorder. When talking with the parents, which information would the nurse expect to be included in the client's history? Select all that apply. A. Impulsiveness B. Lability of mood C. Ritualistic behavior D. psychomotor retardation E. Self-destructive behavior

A. Impulsiveness B. Lability of mood E. Self-destructive behavior

a client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to: A. Providing a calm environment B. Obtaining a diet history C. Administering an analgesic D. Assessing fetal heart tones

A calm environment is needed to prevent seizure activity. Any stimulation can precipitate seizures. Obtaining a diet history should be done later, and administering an analgesic is not indicated because there is no data in the stem to indicate pain. Therefore, answers B and C are incorrect. Assessing the fetal heart tones is important, but this is not the highest priority in this situation as stated in answer D.

During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is: A. Syphilis B. Herpes C. Gonorrhea D. Condylmata

A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. Condylomata lesions are painless warts, so answer D is incorrect. In answer C, gonorrhea does not present as a lesion, but is exhibited by a yellow discharge.

The nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a Corticosteroid drug. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply. A. The inhaler is held upright. B. Head is tilted down while inhaling the medication C. Client waits 5 minutes between puffs. D. Mouth is rinsed with water following administration E. Client lies supine for 15 minutes following administration.

A. The inhaler is held upright. D. Mouth is rinsed with water following administration

When a client with a diagnosis of manic episode returns to the clinic to have lithium blood levels checked, her lithium level is only slightly higher than the previous week but she complains of blurred vision and ataxia. The first intervention is to Withhold the next dose. Suggest she drink more fluid. Instruct her to watch for signs of toxicity. Notify the physician.

A. These are symptoms of toxicity and the nurse must withhold the next dose. The nurse would then notify the physician. The client needs to maintain a normal fluid level to prevent toxicity, but this may not be the cause of her symptoms.

a nurse is caring for a client who just had a transurethral resection of the prostate which of the following should the nurse instruct the client to report to the provider? A. pink-tinged urine B. painful urination C. stress incontinence D. retrograde ejaculation

A. blood clots normal finding, can turn pink up to 6 week B. SIGN OF FEVER, urinary frequency and urgency, painful C. poor sphincter control D. retrograde ejaculation affects fertility results in decreased amount or totally absent ejaculation

A nurse is caring for an older adult client who is confused and continually grabs at the nurses. Which of the following is an nursing action? A. Move the client to his room B. apply restraints to the clients wrists. C. Firmly tell the client not to grab D. Assign an assistive personnel to sit with the client

A. isolating them makes them more angry B. inapp C. important to sett limits by telling the client not to grab people D. unrealisitc

A nurse is caring for a client who is to undergo a cystoscopy. When educating a client on post procedure expectation, which of the following should the nurse state. A. It will be necessary to keep the suture clean B. you will be placed in dorsal recumbent position C. expect to be on bed rest for 24 hours D. pink-tinged urine and burning while printing can be expected

A. no sutures B. placed in lithotomy C. may be short periods D. direct look inside the clients bladder through camera that is inserted through urethra

A client is admitted for an MRI. The nurse should question the client regarding: A. Pregnancy B. titanium hip replacement C Allergies to antibiotics D Inability to move his feet

Although there are no evidence to suggest MRI scans can pose a risk during pregnancy, it is considered precaution to not perform MRI during pregnancy unless absolutely needed. This is particularly the case during the first trimester of pregnancy, as organogenesis takes place during this period. The concerns in pregnancy are the same as for MRI in general, but the fetus may be more sensitive to the effects—particularly to heating and to noise. Clients with a titanium hip replacement can have an MRI. No antibiotics are used with this test and the client should remain still only when instructed, so answers C and D are not specific to this test.

Before a lumbar puncture the nurse must provide the following care. Select all that apply. A. Force fluids. B. Assess the sensation and movement of the lower extremities. C. Explain to the client the need to remain still. D. Keep the patient flat for 12-24 hours E. Have the patient empty his or her bladder

Answer: C, E] Nursing care listed in A, B and D are applicable after lumbar puncture is done.

A nurse is caring for a client who was brought to the emergency department following and accident. Nurse suspect a ruptured bladder. Which would you expect Anuria Hematuria pyuria fever

Anuria- lack or urine is seen in urethral obstruction or renal failure CORRECT hematuria- blood in urine RUPTURED pyuria puss is sign of infection fever- is a sign of infection

A pregnant client arrives in the emergency room. An initial assessment indicates that she is ready to deliver and crowning is occurring. The first nursing action is to Ask the client to push according to your instructions. Instruct the client to take short shallow breaths to improve fetal oxygenation. Apply gentle perineal pressure to prevent rapid expulsion of the head. Notify the physician

Apply gentle perineal pressure to prevent rapid expulsion of the head.

The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting: A. Agnosia B. Apraxia C. Anomia D. Aphasia

Apraxia is the inability to use objects appropriately. Agnosia is loss of sensory comprehension, anomia is the inability to find words, and aphasia is the inability to speak or understand so answers A, C, and D are incorrect.

A client awakens with severe substernal chest pressure and dyspnea. He takes 2 nitroglycerin tablets without relief. In 5 minutes, he takes 2 more without relief. He calls his physician who instructs him to go directly to the hospital. Understanding the rationale for the physician's instructions, the nurse knows that sudden death (outside the hospital) in association with coronary artery disease is most often due to Arrhythmias. Papillary muscle dysfunction. Pump failure accompanied by pulmonary congestion. MI

Arrhythmias.

Following a car accident, a client develops a tension pneumothorax and is admitted to the hospital. The nurse should be prepared to Establish an IV. Assist the physician with chest tube insertion. Draw arterial blood gases for evaluation. Assist the physician to perform chest decompression with a large-bore needle.

Assist the physician to perform chest decompression with a large-bore needle.

The primary physiological alteration in the development of asthma is: A. Bronchiolar inflammation and dyspnea B. Hypersecretion of abnormally viscous mucus C. Infectious processes causing mucosal edema D. Spasm of bronchial smooth muscle

Asthma is the presence of bronchial spasms. This spasm can be brought on by allergies or anxiety. Answer A is incorrect because the primary physiological alteration is not inflammation. Answer B is incorrect because there is the production of abnormally viscous mucus, not a primary alteration. Answer C is incorrect because infection is not primary to asthma.

A 60-year-old male client with CA of the lung has had difficulty breathing due to a buildup of fluid in the left thoracic cavity. The physician has ordered a thoracentesis. For this procedure, the nurse will position the client On his right side with his head elevated 30 degrees. In a supine position with his head elevated 30 degrees. In a sitting position leaning over the bedside table. On his abdomen.

In a sitting position leaning over the bedside table.

As part of a newborn assessment, the nurse knows that signs of hypoglycemia in the infant include Hyperactivity, high-pitched cry, respiratory distress. Twitching, shrill or intermittent cry. Stuporlike behavior, no cry. Weak, soft cry

Infants with signs and symptoms of hypoglycemia usually have a shrill or intermittent cry and may have hypertonicity. Answer (A) refers to an infant born to a drug-addicted mother.

The nurse teaches the mother of a newborn that in order to prevent sudden infant death syndrome (SIDS) the best position to place the baby after nursing is (select all that apply): A. Prone B. Side-lying C. Supine D. Fowler's

B, C Question 27 Explanation: Research demonstrate that the occurrence of SIDS is reduced with these two positions.

Select all that apply that is appropriate when there is a benzodiazepine overdose: A. dministration of syrup of ipecac B. Gastric lavage C. Activated charcoal and a saline cathartic D. Hemodialysis E. Administration of Flumazenil

B, C, E Question 30 Explanation: If ingestion is recent, decontamination of the GI system is indicated. The administration of syrup of ipecac is contraindicated because of aspiration risks related to sedation. Gastric lavage is generally the best and most effective means of gastric decontamination. Activated charcoal and a saline cathartic may be administered to remove any remaining drug. Hemodialysis is not useful in the treatment of benzodiazepine overdose. Flumazenil can be used to acutely reverse the sedative effects of benzodiazepines, though this is normally done only in cases of extreme overdose or sedation.

Select all that apply to the use of barbiturates in treating insomnia: A. Barbiturates deprive people of NREM sleep B. Barbiturates deprive people of REM sleep C. When the barbiturates are discontinued, the NREM sleep increases D. When the barbiturates are discontinued, the REM sleep increases E. Nightmares are often an adverse effect when discontinuing barbiturates

B, D, E, Question 29 Explanation: Barbiturates deprive people of REM sleep. When the barbiturate is stopped and REM sleep once again occurs, a rebound phenomenon occurs. During this phenomenon, the persons dream time constitutes a larger percentage of the total sleep pattern, and the dreams are often nightmares.

Drugs are used in attacking cancer cells in chemotherapy. Which chemotherapeutic drugs are classified as antimetabolites? Select all that apply. Cisplatin 5-Fluorouracil Chlorambucil Methotrexate Cytoxan

Methotrexate 5-Fluorouracil

Serum BUN levels are decreased with kidney disease and acute renal failure. True False

Question 104 Explanation: [Answer: B False] BUN measures urea and nitrogen levels in a blood sample and are elevated when kidney function is impaired and alters the excretion of these metabolic end products.

TPN solutions should be changed every week in order to prevent bacterial overgrowth due to hypertonicity of the solution. True False

Question 105 Explanation: [Answer: B False] TPN solutions should be changed every 24 hours in order to prevent bacterial overgrowth due to hypertonicity of the solution.

A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor's order should the nurse question? A.Magnesium sulfate 4gm (25%) IV B. Brethine 10 mcg IV C. Stadol 1 mg IV push every 4 hours as needed prn for pain D. Ancef 2gm IVPB every 6 hours

Brethine is used cautiously because it raises the blood glucose levels. Answers A, C, and D are all medications that are commonly used in the diabetic client, so they are incorrect.

A common test used to determine fetal status in the presence of pre-eclampsia is the Nonstress Test (NST). If this test is "reactive," the nurse knows that it means The test was abnormal, indicating a need for an immediate Oxytocin Challenge Test (OCT). The test was normal, showing no change in FHR with fetal movement. The test was normal, showing an increased fetal heart rate (FHR) with fetal movement. Ultrasound is indicated to determine fetal habitat and placental placement.

C Reactive = good outcome. Increased FHR with movement indicates normal reaction and adequate CNS integration.

A nurse is caring for a client who had a renal tumor. The client will undergo renal biopsy. which of the following client care should the nurse provide. A. instruct the client that there is NPO 8hr following the procedure. B. Assess the client for a history of shellfish or iodine allergies prior to the procedure C. Maintain bed rest for 4-12 hr following the procedure C. Obtain a BUN and creatinine clearance prior to the procedure

C correct A. before the procedure B. not needed C. biopsy involves skin biopsy through needle insertion into lower lobe of the kidney be rest is painted after D. heme studies needed

The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply. A. "If I limit my fluid intake I will not have to empty my ostomy pouch as often." B. "I can place an aspirin tablet in my pouch to decrease odor." C. "I can usually keep my ostomy pouch on for 3 to 7 days before changing it." D. "I must use a skin barrier to protect my skin from urine." E. "I should empty my ostomy pouch of urine when it is full."

C, D Question 19 Explanation: The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The client should be taught to increase fluid intake to about 3,000 ml per day and should not limit intake. Adequate fluid intake helps to flush mucus from the ileal conduit. The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak develops. A skin barrier is essential to protecting the skin from the irritation of the urine. An aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration. The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight from pulling the appliance away from the skin.

A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client. A. Monitor maternal vital signs every 2 hours B. Notify the physician if respirations are less than 18 per minute. C. Monitor renal function and cardiac function closely D. Keep calcium gluconate on hand in case of a magnesium sulfate overdose E. Monitor deep tendon reflexes hourly F. Monitor I and O's hourly G. Notify the physician if urinary output is less than 30 ml per hour.

C, D, E, F, G Question 22 Explanation: When caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal vital signs, especially respirations, every 30-60 minutes and notify the physician if respirations are less than 12, because this would indicate respiratory depression. Calcium gluconate is kept on hand in case of magnesium sulfate overdose, because calcium gluconate is the antidote for magnesium sulfate toxicity. Deep tendon reflexes are assessed hourly. Cardiac and renal function is monitored closely. The urine output should be maintained at 30 ml per hour because the medication is eliminated through the kidneys.

At the surgical scrub sink a nurse demonstrates proper surgical hand washing technique by scrubbing. A. For a minimum of 1 min B. from elbows down to the hands C. with her hands held higher than her elbows D. minimal friction

C. higher than elbows so water goes from clean are to dirty

Care of the catheter insertion site must be done by the nurse in TPN. Which of the following should be implemented by the nurse? Select all that apply. Provide good oral hygiene Monitor for signs and symptoms of infection Practice aseptic technique Change the sterile dressings every two days Cleanse the site with antiseptic solution

Care of the catheter insertion site include: • Monitor for signs and symptoms of infection • Practice aseptic technique • Change the sterile dressings every day • Cleanse the site with antiseptic solution

Assessment findings in a migraine attack include which of the following? Select all that apply. Bilateral pain in the head (occurring at the back of the neck extending diffusely to the top of the head) Characterized by the presence of an aura preceding the pain Severe throbbing pain often in the temporal or supraorbital area Nausea and vomiting Abrupt onset lasting for 30-90 minutes Pallor

Characterized by the presence of an aura preceding the pain Severe throbbing pain often in the temporal or supraorbital area Nausea and vomiting Pallor

Following surgery, a client is returned to the unit with a T-tube in place. To ensure optimal functioning, the T-tube would be connected to the drainage bottle at the level of the bed to prevent bile backflow. T-tube would not be clamped. Client would be positioned in a prone position to promote bile drainage. Client would be positioned to prevent backflow of bile into the liver.

Client would be positioned to prevent backflow of bile into the liver When T tubes are closed, it is recommended you flush them once or twice daily with 10 mL sterile saline, using sterile techniques Clamp one hour before and after to help with digestion 300-500 ml drain in first 24 hours

A client is receiving Pyridium (phenazopyridine hydrochloride) for a urinary tract infection. The client should be taught that the medication may: A. Cause diarrhea B. Change the color of her urine C. Cause mental confusion D. Change in taste

Clients taking Pyridium should be taught that the medication will turn the urine orange or red. It is not associated with diarrhea, mental confusion, or changes in taste; therefore, answers A, C, and D are incorrect. Pyridium can also cause a yellowish color to skin and sclera if taken in large doses

Limiting potassium in the diet is essential to be taught to a client with chronic renal failure. True False

Clients with chronic renal failure have difficulty maintaining normal serum potassium levels, thus it is crucial for clients to limit potassium in the diet.

a Nurse is providing education about prostate health to a group of men. which of the following is an appropriate statement for the nurse to make in regard to prostate specific antigen test A. " you should fast 8 hours prior to having a PSA specimen obtained" B. " Yearly PSA screening should begin at age 40 in all men" C. " Normal PSA values decrease as you get older" D. " The PSA test should not be performed for 48 hours following a digital rectal exam"

D. A. not required B. Age 50 C. gets higher D. may lead to falsely high number because its tests for protein in cytoplasm

An elderly client with dementia suffers from insomnia. The nurse anticipates that the physician will not order barbiturates because their use could result in Delirium and paradoxical excitement. Habituation and dependence. Potential liver damage. Central nervous system depression

Delirium and paradoxical excitement.

A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse's response is based on the knowledge that A. There is no need to take thyroid medication because the fetus's thyroid produces a thyroid-stimulating hormone. B. Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy. C. It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism. D. Fetal growth is arrested if thyroid medication is continued during pregnancy.

During pregnancy, the thyroid gland triples in size. This makes it more difficult to regulate thyroid medication. Answer A is incorrect because there could be a need for thyroid medication during pregnancy. Answer C is incorrect because the thyroid function does not slow. Fetal growth is not arrested if thyroid medication is continued, so answer D is incorrect.

A client is diagnosed with acute maxillary sinusitis. Which of the following clinical assessment would the nurse expect to find in this patient? Select all that apply. General malaise Headache Pain in and around the eyes Fever Sore throat Earache Snoring

General malaise Headache Pain in and around the eyes

The nursing behavior of sitting down at the client's bedside to talk with the client will convey a sense of Communication. Empathy. Sympathy. Encouragement

Empathy.

During the third trimester of her pregnancy, the client has mild preeclampsia. She is discharged home with instructions to remain on bed rest. She should also be instructed to call her doctor if she experiences which symptoms? Select all that apply. Epigastric pain Headache Blurred vision Increased urine output Difficulty sleeping severe nausea and vomiting

Epigastric pain Headache Blurred vision Severe nausea and vomiting

If a BP cuff is inflated, deflated, and immediately reinflated, the resulting BP reading is likely to be incorrect with the systolic reading falsely low and diastolic falsely high. True False

False If a BP cuff is inflated, deflated, and immediately reinflated, the resulting BP reading is likely to be incorrect with the systolic reading falsely high and diastolic falsely low.

After an epidural anesthesia administration the nurse must position the woman on her back. True False

False creates hypotension, prevent vena cava syndrome

Insulin should be stored at the refrigerator. True False

False can be out of fridge up to 30 days

A client is diagnosed with retinal detachment. The nurse would expect the client to be noted with which assessment findings? Select all that apply. Tunnel vision Floaters Halos around lights Veil-like curtain coming across field of vision Flashes of light severe eye pain

Floaters flashed of light Veil-like curtain coming across field of glaucoma Halos around lights vision tunnel vision severe pain

An RN's friend, who is also a nurse, is in her first trimester of pregnancy. While working in the hospital, the nurse knows that her friend should avoid A client who has just been diagnosed with lupus erythematosus. A 3-month-old infant with a generalized rash. Any client with an infection. A child with a fever and upper respiratory disorder

German measles or rubella, if contracted in the first trimester of pregnancy, may result in a child with congenital malformations of the heart, eye and ear, as well as mental retardation.

A client, age 60, is admitted to the hospital for a possible low intestinal obstruction. His preoperative work-up indicates vital signs of BP 100/70, P 88, R 18, and temperature of 96.4 degrees F. Listening to bowel sounds, the nurse would expect to find Gurgling bowel sounds. Hyperactive, high-pitched sounds. Absence of bowel sounds. Tympanic, percussion sounds.

Gurgling bowel sounds. PARALYTIC ILEUS Hyperactive, high-pitched sounds. OBSTRUCTION Absence of bowel sounds. PARALYTIC ILEUS Tympanic, percussion sounds. DISTENTION

Before cardiac catheterization, the nurse should perform which of the following? Select all that apply. Have the client void Assess for allergy to iodine/seafoods Apply pressure dressing and a small ice bag or ice over the punctured area Immobilize affected extremity Elevate HOB to 30-45 degrees monitor ECG

Have the client void Assess for allergy to iodine/seafoods

The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should: A.Utilize an infusion pump B. Check the blood glucose level C. Place the client in Trendelenburg position D. Cover the solution with foil

Hyperstat is given IV push for hypertensive crises, but it often causes hyperglycemia. The glucose level will drop rapidly when stopped. Answer A is incorrect because the hyperstat is given by IV push. The client should be placed in dorsal recumbent position, not a Trendelenburg position, as stated in answer C. Answer D is incorrect because the medication does not have to be covered with foil.

The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client's history should be reported to the doctor? A. Diabetes B. Prinzmetal's angina C. Cancer D. Cluster headaches

If the client has a history of Prinzmetal's angina, he should not be prescribed triptan preparations because they cause vasoconstriction and coronary spasms. There is no contraindication for taking triptan drugs in clients with diabetes, cancer, or cluster headaches making answers A, C, and D incorrect.

The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig's sign is charted if the nurse notes: A. Pain on flexion of the hip and knee B. Nuchal rigidity on flexion of the neck C. Pain when the head is turned to the left side D. Dizziness when changing positions

Kernig's sign is positive if pain occurs on flexion of the hip and knee. The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest so answer B is incorrect. Answers C and D might be present but are not related to Kernig's sign.

A 75-year-old client has the diagnosis of organic brain syndrome. In planning the daily schedule, it is important for the nurse to understand that the client Is more likely to be able to remember current experiences than past ones. May have moderate-to-severe memory impairment and short periods of concentration. Can usually be trusted to be responsible for her daily care needs. Will be more comfortable with a rigid daily schedule

May have moderate-to-severe memory impairment and short periods of concentration.

Which of these medication orders for a patient with a pulmonary embolism is more important to clarify with the prescribing physician before administration? A. Warfarin (Coumadin) 1.0 mg by mouth (PO) B. Morphine sulfate 2 to 4 mg IV C. Cephalexin (Keflex) 250 mg PO D. Heparin infusion at 900 units/hr

Medication safety guidelines indicate that use of a trailing zero is not appropriate when writing medication orders because the order can easily be mistaken for a larger dose, such as 10 mg. The order should be clarified before administration. The other orders are appropriate, based on the patient's diagnosis.

A hypothyroid client has orders for all of the following medications. The nurse would evaluate the client most closely following administration of which medication? Meperidine (Demerol). Levothyroxine (Synthroid). Digoxin (Lanoxin). Ibuprofen (Motrin

Meperidine (Demerol). Hypothyroidism reduces the metabolic rate and prolongs the sedative effects of medications. Narcotics, such as meperidine, are especially dangerous and should be given in smaller doses. The client must be closely monitored for signs of oversedation and respiratory depression.

The nurse will know that the client understands how to maintain an acid urinary pH by dietary means when he says he should avoid Cereals and breads. Meat, fish, and poultry. Prunes and figs. Milk

Milk

A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should be questioned by the nurse? A.Meperidine 100 mg IM q 4 hours PRN pain B. Mylanta 30 ccs q 4 hours via NG C. Cimetidine 300 mg PO q.i.d. D. Morphine 8 mg IM q 4 hours PRN pain

Morphine is contraindicated in clients with gallbladder disease and pancreatitis because morphine causes spasms of the Sphincter of Oddi. Meperidine, Mylanta, and Cimetidine are ordered for pancreatitis, making answers A, B, and C incorrect.

The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs? "I will make sure I eat breakfast within 2 hours of taking my insulin." B "I will need to carry candy or some form of sugar with me all the time." "I will eat a snack around three o'clock each afternoon." D "I can save my dessert from supper for a bedtime snack."

NPH insulin peaks in 8-12 hours, so a snack should be offered at that time. NPH insulin onsets in 90-120 minutes, so answer A is incorrect. Answer B is untrue because NPH insulin is time released and does not usually cause sudden hypoglycemia. Answer D is incorrect, but the client should eat a bedtime snack.

The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's disease. Which side effect is most often associated with this drug? A. Urinary incontinence B. Headaches C. Confusion D. Nausea

Nausea and gastrointestinal upset are very common in clients taking acetlcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity, dizziness, unsteadiness, and clumsiness. The client might already be experiencing urinary incontinence or headaches, but they are not necessarily associated; and the client with Alzheimer's disease is already confused. Therefore, answers A, B, and C are incorrect.

Nurse Pietro receives a 11-month old child with a fracture of the left femur on the pediatric unit. Which action is important for the nurse to take first? A. Call for a social worker to meet with the family. B. Check the child's blood pressure, pulse, respiration, and temperature. C. Administer pain medications. D. Speak with the parents about how the fracture occurred.

Question 11 Explanation: In case of injury, especially among children, it is very important that the nurse should first assess possible abuse. Abuse is one of the reporting responsibilities of the nurse.

A client, 34 weeks pregnant, arrives at the emergency room complaining of painless vaginal bleeding. She states that she has had no contractions. Her vital signs are within normal range. The most important initial intervention is to Obtain a blood sample for typing and cross-match. Complete a vaginal examination. Notify the physician. Place the client on strict bedrest.

Place the client on strict bedrest. It is important to immediately place the client on bedrest, as the symptoms suggest placenta previa: a history of painless bleeding late in pregnancy. A vaginal examination should not be performed. The next interventions would be to notify the physician and obtain a blood sample because if the bleeding is excessive, delivery by C-section would be implemented.

A college student failed her psychology final exam and spent the entire evening berating the teacher and the course. This behavior is an example of Reaction-formation. Compensation. Acting out. Projection

Projection

The symptoms of "malingering" are most like those of conversion reaction in that they Are physically incapacitating. Serve to decrease anxiety. Are produced on a conscious level. Provide a "secondary gain.

Provide a "secondary gain.

Jenna is a nurse from the medical-surgical unit of a tertiary hospital. She was asked to float on the orthopedic in which she has no prior experience on working on. Which client should be assigned to her? A. A client with a cast for a fractured femur and who has numbness and discoloration of the toes. B. A client with balanced skeletal traction and needs assistance with morning care. C. A client who had an above-the-knee amputation yesterday and has currently has a temperature of 101.4ºF. D.A client who had a total hip replacement two days ago and needs blood glucose monitoring.

Question 1 Explanation: A nurse from the medical-surgical floor floated to the orthopedic unit should be given clients with stable condition as those have care similar to her training and experience. A client who is in postoperative state is more likely to be on a stable condition.

The nurse is assigned to care for a patient in a continuous mitten restraint. Which of the following should be included in the client's plan of care? Select all that apply. Document restraint checks and patient status every two hours Educate the client's family about restraint use Obtain the physician's order renewal every 72 hours Provide 10 minutes of release and repositioning q 2 hours Release the restraint and reposition the client every four hours

Question 117 Explanation: [Answer: A, B and D] Restrain standards states that documentation must occur at least every two hours. It is important for the family to understand the purpose of restraint. Standard states that restraint orders are to be renewed ever 24 hours when a restraint is used continuously. Release and positioning should be provided for a minimum of 10 minutes at least every two hours.

A 46-year-old male client has had a gastric resection for peptic ulcer disease. The nurse is preparing him for discharge by giving him guidelines to prevent "dumping syndrome." These guidelines would include Eating salty foods with every meal. Drinking fluids with meals. Including simple carbohydrates (sugar, honey) in his meals. Eating foods with relatively high fat content.

Question 124 Explanation: [Answer: D] A high protein, high fat, low carbohydrate diet is maintained to prevent dumping syndrome. A diet low in carbohydrates and sodium will assist in decreasing the rapid shift of extracellular fluids into the bowel. Fluids should not be taken with meals.

If a TENS unit is functioning correctly, the client feels nothing during use. True False

Question 125 Explanation: [Answer: B False] If a TENS unit is functioning correctly, the client should feel numbness or tingling during use.

When assessing a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior. Which of the following assessment data is the nurse also likely to find? Select all that apply. A. The client functions well in other areas of his life. B. The degree of aggressiveness is out of proportion to the stressor. C. The violent behavior is most often justified by the stressor. D. The client has a history of parental alcoholism and chaotic, abusive family life. E. The client has no remorse about the inability to control his anger.

Question 13 Explanation: A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior generally functions well in other areas of his life. The degree of aggressiveness is typically out of proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the aggressive behavior.

A nurse enters a room and finds a patient lying face down on the floor and bleeding from a gash in the head. Which action should the nurse perform first? A. Determine the level of consciousness. B. Push the call button for help. C. Turn the client face up to assess. D. Go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician.

Question 13 Explanation: Assessing the level of consciousness should be the first action when dealing with clients that might have fell over.

Moving the client from the bed to a chair, the first appropriate intervention is to Rock the client and pivot. Dangle the client at his bedside. Put nonslip shoes or slippers on client's feet. Position client so that he is comfortable.

Question 143 Explanation: [Answer: B] Before moving the client, dangling at the bedside is important. This procedure stabilizes the client and allows the nurse time to assess whether he develops vertigo from a drop in blood pressure.

When assessing a 22-year old patient who required emergency surgery and multiple transfusion 3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? A.Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes B. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs C Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation D. Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient's status

Question 16 Explanation: The patient's history and symptoms suggest the development of ARDS, which will require intubation and mechanical ventilation. The maximum oxygen delivery with a nasal cannula is an Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia.

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply. A.Head tilt B. Vomiting C. Polydipsia D. Lethargy E. Increased appetite F. Increased pulse

Question 17 Explanation: Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the diagnosis? Select all that apply. A. Weight loss. B. Increased clotting time. C. Hypertension. D. headaches

Question 2 Explanation: Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This causes an increase in hematocrit and viscosity of the blood. Patients can experience headaches, dizziness, and visual disturbances. Cardiovascular effects include increased blood pressure and increased clotting time. Weight loss is not a manifestation of polycythemia vera.

The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations would the nurse include in the client's teaching plan? Select all that apply. A. Hearing loss B. Visual disturbance C. Headache D. Orthopnea E. Gout F. weight loss

Question 4 Explanation: Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with polycythemia vera.

A client is admitted to the hospital with a diagnosis of portal cirrhosis--late stage. He has generalized edema and ascites and has difficulty sleeping. He asks the nurse to get him something to help him sleep. The doctor orders phenobarbital (Luminal) 100 mg HS or PRN. The nursing intervention is to Give the dose as ordered at bedtime. Question the drug that was ordered. Hold the dose until he asks for it during the night. Question the dose that was ordered

Question the drug that was ordered. appropriate and good nursing judgment to question the order because with late stage cirrhosis, the ability to detoxify the medication by the liver is limited. As a result, barbiturates or sedatives are not ordered for these clients.

The nurse has orders to suction a 50-year-old client. One nursing action necessary to prevent hypoxia during the procedure is to Ensure that the catheter is no more than three-quarters the diameter of the nares. Limit suction time to 30 seconds, at intervals of three minutes. Hyperinflate the lungs with 100 percent oxygen prior to and following suctioning. Suction no more than three consecutive times before administering oxygen

Suction no more than three consecutive times before administering oxygen

Central lines are used for which purposes. Select all that apply. Blood transfusion TPN administration Antibiotic therapy Chemotherapy GI feeding IV therapy

TPN administration Antibiotic therapy Chemotherapy IV therapy

A young client on the pediatric unit weighs 10 kilograms and the adult dose of a medication is 10 mg. The closest correct dosage to give the child is None of the above. 1.5 mg. 1.0 mg. 2.5 mg.

The adult dose is multiplied by the child's weight in pounds, so kilograms must first be changed to pounds. Then this number is divided by 150 and the closest number is selected. 10 kg = 22 lbs divided by 150 = 1.48 or 1.5.

Gentamycin is prescribed for a client with urinary tract infection. The nurse will observe for 8th cranial nerve toxicity indicated by Facial tremors. Dilated pupils. Tinnitus. Vertigo

The primary side effect of gentamycin is toxicity affecting the 8th cranial nerve. The symptom is tinnitus. Vertigo would occur with 5th cranial nerve involvement.

The nurse should position the patient to right lateral position with the left leg acutely flexed when administering a high cleansing enema. True False

The sigmoid and descending colon is located on the left side. Therefore, the left lateral position uses gravity to facilitate the flow of solution into the sigmoid and descending colon. Acute flexion of the right leg allows for adequate exposure of the anus.

In glaucoma which diagnostic tests can be used? Select all that apply. Perimetry Diathermy Tonometry Sclera buckling Weber's test Visual acuity

Tonometry reading of 24-32 mmHg suggests glaucoma and may be 50 mmHg or more in acute (closed-angle) glaucoma. Perimetry reveals defects in visual fields. Visual acuity is reduced in glaucoma and gonioscopy examines the angle of anterior chamber.

A gravida 3 para 2 is admitted to the labor unit. Vaginal exam reveals that the client's cervix is 8 cm dilated, with complete effacement. The priority nursing diagnosis at this time is: A. Alteration in coping related to pain B. for injury related to precipitate delivery C. Alteration in elimination related to anesthesia D. Potential for fluid volume deficit related to NPO status

Transition is the time during labor when the client loses concentration due to intense contractions. Potential for injury related to precipitate delivery has nothing to do with the dilation of the cervix, so answer B is incorrect. There is no data to indicate that the client has had anesthesia or fluid volume deficit, making answers C and D incorrect.

he effectiveness of monoamine oxidase inhibitors (MAOI) drug therapy in a client with posttraumatic disorder can be demonstrated by which of the following? Select all that apply. Control flashbacks Treat sleep problems Control phobias Treat intrusive daytime thoughts Decrease alcohol cravings Relieves the client from nightmares when sleeping

Treat sleep problems Treat intrusive daytime thoughts Relieves the client from nightmares when sleeping

Only dry packages should be used in the OR. True False

True

Assisting the physician to establish a CVP line in a client, the nurse instructs the client to exhale against a closed glottis (perform Valsalva's maneuver). The purpose of this procedure is to Decrease intrathoracic pressure. Establish equal pressure in the line. Prevent an air embolism. Assist in catheter insertion

Valsalva's maneuver--the attempt to forcibly exhale with the glottis, nose and mouth closed--produces increased intrathoracic pressure and lessens the chance of an air embolism as the CVP catheter is inserted.

A client with a severe corneal ulcer has an order for Gentamycin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops? A.Allow 5 minutes between the two medications B.The medications may be used together C. The medications should be separated by a cycloplegic drug D. The medications should not be used in the same client

When using eyedrops, allow 5 minutes between the two medications; therefore, answer B is incorrect. These medications can be used by the same client but it is not necessary to use a cycloplegic with these medications, making answers C and D incorrect.

he nurse is preparing a teaching plan for breast feeding for a new mother. Which one of the following factors is least likely to cause the "let-down" or "milk ejection" reflex? Tension or stress. Sexual arousal. Exercise. A drink with alcohol. Question 119 Explanation:

[Answer: A] Tension, worry, pain, or fear are all emotions that can work to inhibit milk letdown; therefore, it is essential to provide as calm an environment as possible for the breast-feeding mother.

Taking a directive role in the client's verbalization of feelings can escalate the client's anger. True False

[Answer: B False] Taking a directive role in the client's verbalization of feelings can deescalate the client's anger.

A client in her 37th week of pregnancy is showing early signs of pre-eclampsia. The nursing care plan will include assessment for further signs of this condition. Indications of progression of pre-eclampsia to a more severe state would be the presence of Severe hypertension, glycosuria, polyuria. Hypertension, weight loss, diuresis. Hyperreflexia, oliguria, epigastric pain. Hypertension, convulsions, polyuria

] Hyperreflexia occurs with increased CNS irritation. Epigastric pain is usually due to edema or bleeding into the liver capsule and oliguria. Other signs include edema and hypertension.

A 30-year-old client has just been admitted to the psychiatric unit with the diagnosis of manic episode. The client manifests an excess of energy, and it is difficult for her to sit still. The most useful activity for this client that the nurse might suggest would be to Empty wastebaskets on the unit. Engage in occupational therapy and group exercises. Play volleyball outside. Deliver linen to the room

d This activity would channel her energy, but not increase the external stimuli as the group activities would do. Competitive activities are nontherapeutic because they are so stimulating.

Helping a violent and aggressive client identify the stressor or the true object of hostility would help reveal unresolved issues so that they may be confronted. True False

false

A nurse is caring for a client who is having chronic renal failure. When providing education on nutrition which of the following statement is appropriate for the nurse to say "you should limit your fluid intake" "you should eat a diet high in potassium" "you should eat a diet in high in phosphorus" "you should eat a diet high in protein"

limit fluid intake, should limit potassium and phosphorus because kidneys are unable to excrete it eat low protein to prevent increase of BUN

The client is suffering from moderate anxiety. The nurse expects to observe which clinical manifestations in the client. Select all that apply. Increased automatisms Alert Selectively attentive Diaphoresis Vertigo Increased rate of speech Distorted perceptions

ncreased automatisms Selectively attentive Diaphoresis Increased rate of speech

Booster immunization of tetanus should be received every 10 years in adulthood. True false

true