review questions for NSG 209 exam 2

Jack is a new client on the psychiatric unit with a diagnosis of Antisocial Personality Disorder. Which of the following characteristics would you expect to assess in Jack? 1. Lack of guilt for wrongdoing 2. Insight into his own behavior 3. Ability to learn from past experiences 4. Compliance with authority

1. Lack of guilt for wrongdoing

The nurse caring for a client with Schizoid Personality Disorder would expect to assess: 1. Odd beliefs, magical thinking, suspicious 2. Few interactions with others, chooses solitary activities, emotionally flat 3. Impulsive, aggressive behaviors 4. Suspicious, guarded, bears grudges

2. Few interactions with others, chooses solitary activities, emotionally flat

Kim is a client on the unit diagnosed with Borderline Personality Disorder. Her assigned nurse, Suzie, has told her that she needs to wait until after lunch to be able to take her shower. Kim then goes to another floor nurse, Bob, and asks him if she can take her shower now. Kim tells Bob that he's "the best nurse on the unit" and is "much smarter" than her assigned nurse. Bob recognizes Kim's behavior as: 1. Avoidance 2. Staff splitting 3. Countertransference 4. Regression

2. Staff splitting

Alice is a patient on the psychiatric inpatient unit and is diagnosed with Dependent Personality Disorder. Which characteristics would you expect to assess with Alice? 1. Over conscientious and inflexible 2. Impulsivity 3. Difficulty with making every day decisions and caring for oneself 4. Anger, irritability

3. Difficulty with making every day decisions and caring for oneself

A hospitalized 88-year-old client who has been receiving antibiotics for 10 days tells you he is having frequent watery stools. Which action will you take first? 1.Notify the physician about the watery stools 2.Obtain stool specimens for culture 3.Instruct the client about correct hand washing 4.Place the client on contact precautions

4.Place the client on contact precautions

As a client approaches the medication station, the nurse notices him walking with a shuffling gait. He complains of not being able to stop drooling. She prepares to administer one of the following PRN medications: (select all that apply) A. benzotropine B. diphenhydramine C. trihexphenidyl D. acetaminophen

A,B,C

An experienced LPN/LVN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are within the scope of practice for this LPN/LVN? (Select all that apply) A.Auscultating breath sounds B.Administering metered-dose inhaler (MDI) medications C.Completing in-depth admission assessment D.Checking oxygen saturation using pulse oximetry E.Developing the nursing care plan F.Evaluating the patient's technique for using MDIs

A,B,D

An obstetric emergency may happen at any time during labor, delivery or post partum. Which of the following are important roles of the primary nurse? SELECT ALL THAT APPLY: a. Identify the problem quickly b. Call a "Code C" overhead c. Coordinate immediate interventions with the team d. Know client risk factors

A,C,D

The nurse is caring for a postoperative child who just received an external ventricular drain, the nurse knows to monitor for (select all that apply): A)Color and consistency of the CSF B)Distended abdomen C)Change in leve lof consciousness D)Complaint of headache E)Vision changes

A,C,D,E

Which of the following are characteristics of mannitol? (select all that apply) a. works in the proximal tube b. pulls fluid out of the renal tubes c. increases glomerular filtration d. increases K+ reabsorption e. contains high glucose content

A,C,E

You are working with an experienced UAP and an LPN on the telemetry unit. A client who had an acute MI 3 days ago has a nursing diagnosis of activity intolerance related to fatigue and chest pain. Which nursing activity included in the care plan is best delegated to the LPN? A.Administering nitroglycerin (Nitrostat) if chest discomfort occurs during client actives B.Monitoring pulse, blood pressure, and oxygen saturation before and after client ambulation C.Teaching the client energy conservation techniques to decrease myocardial oxygen demand D.Explaining the rationale for alternating rest periods with exercise to the client and family

A.Administering nitroglycerin (Nitrostat) if chest discomfort occurs during client actives

The patient with COPD has a nursing diagnosis of ineffective breathing pattern. When working with an UAP and a LPN/LVN, which is an appropriate action, related to the diagnosis, to delegate to the experienced LPN? A.Observing how well the patient performs pursed-lip breathing B.Planning a nursing care regimen that gradually increases activity tolerance C.Assisting the patient with basic activities of daily living (ADLs) D.Consulting with the physician about reconditioning exercise

A.Observing how well the patient performs pursed-lip breathing

Which tasks are appropriate to delegate to an LPN who is functioning under the supervision of an RN? (select all that apply) A.Assessing the sexual implications for a client with oculogenital-type Chlamydia trachomatis infection B.Administering sulfacetamidesodium 10% (Sulf-10 Ophthalmic) to a child with conjunctivitis C.Assessing nutritional factors for a client with age-related macular degeneration D.Performing a routine check of a client's visual acuity using the Snellen eye chart

B and D

The nurse is performing an exam on a 4 year old girl who arrives in the office complaining of headache, stiff neck, and chills. The nurse suspects what neurological disorder? A)Hydrocephalus B)Meningitis C)Reye syndrome D)Craniosynostosis

B)Meningitis

Nursing care activities for a client with increased ICP would include: (select all that apply) a. assisting client with isometric exercises b. avoiding activities that interfere with venous drainage of blood from the head c. Use of a NG tube d. teaching client to exhale when being positioned to avoid Valsalva maneuver

B,C,D

Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? A client... (select all that apply) A.With anxiety and chronic pain who frequently uses the call button B.On the second postoperative day who needs pain medication before dressing changes C.With HIV infection who reports headache and abdominal and pleuritic chest pain D.With chronic pain who is to be discharged with a new surgically-implanted catheter E.Who is reporting pain at the site of a peripheral IV line F.With a kidney stone who needs frequent PRN pain medication

B,E,F

You are working as the triage nurse in the ED when the following 4 clients arrive. Which client requires the most rapid action to protect other clients in the ED from infection? A.3-year-old with paroxysmal cough and whose sibling has pertussis B.5-year-old with new pruritic rash and possible chickenpox C.62-year-old with a history of MRSA and an abdominal wound D.74-year-old needing TB testing after being exposed to TB during a recent airplane flight

B.5-year-old with new pruritic rash and possible chickenpox

In the emergency department during initial assessment of a newly-admitted patient with diabetes, the nurse discovers the following findings. Which finding should be reported to the health care provider immediately? A.Hammer toe of the left second metatarsophalangeal joint B.Rapid respiratory rate with deep inspirations C.Numbness and tingling bilaterally in the feet and hands D.Decreased sensitivity and swelling of the abdomen

B.Rapid respiratory rate with deep inspirations

Your 3 y/o client has returned to the PICU after insertion of a ventriculoperitoneal(VP) shunt to correct hydrocephalus. Which assessment finding is most important to communicate to the surgeon? A.The child is crying and says "It hurts!" B.The right pupil is 1 mm larger than the left pupil C.The cardiac monitor shows a HR of 130 beats/min D.The head dressing has a 2 cm area of bloody drainage

B.The right pupil is 1 mm larger than the left pupil

The nurse is assessing a 3 month old boy and during the assessment finds the boy jerking his body with his arms and legs extending at the same time with a cry following this movement. The nurse knows this to be: A)Tonic‐clonic seizures B)Absent seizures C)Infantile spasms D)Focal seizure

C)Infantile spasms

The nurse in interviewing a client on the psychiatric unit. The client tilts his head to the side, stops talking in midsentence, seems to be listening intently and then yells out "No! I won't do that!" the nurse recognizes from these signs that the client may be experiencing which of the following? A. Somatic Delusions B. Catatonic Stupor C. Auditory Hallucinations D. Pseudoparkinsonism

C. Auditory Hallucinations

Which patient is most appropriate for you, the pediatric charge nurse, to assign to an experienced LPN/LVN? A.1- year-old with severe combined immunodeficiency syndrome who is scheduled to receive chemotherapy B.2- year-old with Wiskott-Aldrich syndrome who has orders for a platelet transfusion C.3- year-old with chronic graft-versus-host disease and is incontinent of loose stools D.6- year-old who received chemotherapy last week and is admitted with lethargy and temperature of 101◦F (38.3 ◦C)

C.3- year-old with chronic graft-versus-host disease and is incontinent of loose stools

You are the charge-nurse on a medical-surgical unit and are working with a newly-graduated RN who has been on orientation to the unit for 3 weeks. Which client is best to assign to the new graduate? A.34-year-old who was just admitted to the unit with periorbital cellulitis B.40-year-old who needs discharge instructions after having skin grafts to the thigh C.67-year-old who requires a dressing change after hydrotherapy for a pressure ulcer D.78-year-old needing teaching before a punch biopsy of a facial lesion

C.67-year-old who requires a dressing change after hydrotherapy for a pressure ulcer

Which client has the most immediate need for IV access to deliver immediate analgesia? The client who A.Has sharp chest pain that increases with cough and SOB B.Reports excruciating lower back pain with hematuria C.Is having an acute myocardial infarction with severe chest pain D.Has a severe migraine with an elevated BP

C.Is having an acute myocardial infarction with severe chest pain

A nurse is caring for a client with schizophrenia who is experiencing auditory hallucinations and also exhibits a lack of grooming, limited interactions, and a flat affect. The nurse anticipates an order for which of the following medications? A.chlorpromazine B.fluphenazine C.risperidone D.haloperidol

C.risperidone

Clint, a client on the psychiatric unit, has been diagnosed with schizophrenia. He begins to tell the nurse about how the CIA is looking for him and will kill him if they find him. Which of the following is the most appropriate response of the nurse? A. "That's ridiculous Clint. No one is going to hurt you." B. "The CIA isn't interested in people like you, Clint" C. "Why do you think the CIA wants to kill you?" D. " I know you believe that, Clint, but it's really hard for me to believe."

D. " I know you believe that, Clint, but it's really hard for me to believe."

The health care provider has written all of these orders for a client with a dx of Excess Fluid Volume. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? A.Weigh the client every AM B.Record accurate I&Os C.Restrict fluids to 1500cc/day D.Administer furosemide (Lasix) 40 mg IVP

D.Administer furosemide (Lasix) 40 mg IVP

You are reviewing the complete blood count for a patient who has been admitted for knee arthroscopy. Which value is most important to report to the physician before surgery? A.Hematocrit of 33% B.Hemoglobin of 10.9% g/dL C.Platelet count of 426,000/mm³ D.White blood cell count of 16,000/mm³

D.White blood cell count of 16,000/mm³

The physician has ordered Heparin 25,000 units in 500 ml D5W to run at 1200 units per hour. How many ml per hour do you infuse? a. 24ml/hr b. 24 units/hr c. 12ml/hr d. 12units/hr

a. 24ml/hr

Nipride 50mg in 500 ml of D5W has been ordered to run at 1mcg/kg/min. Your patient weighs 184 lbs. How many ml per hour should this run? Please round to the nearest tenth. a. 50.2 ml/hr b. 51 ml/hr c. 5016 ml/hr d. 50,000 ml/hr

a. 50.2 ml/hr

You are the charge-nurse on a medical-surgical unit and are working with a newly-graduated RN who has been on orientation to the unit for 3 weeks. Which client is best to assign to the new graduate? a. 67-year-old who requires a dressing change after hydrotherapy for a pressure ulcer b. 34-year-old who was just admitted to the unit with periorbital cellulitis c. 40-year-old who needs discharge instructions after having skin grafts to the thigh d. 78-year-old needing teaching before a punch biopsy of a facial lesion

a. 67-year-old who requires a dressing change after hydrotherapy for a pressure ulcer

A client in status epilepticus arrives at the emergency department. The family is interviewed to determine the cause of this problem. Which event may have predisposed the client to this condition? a. Abruptly stopping anticonvulsant therapy b. Airplane travel c. Exposure to sunlight d. Recent upper respiratory infection

a. Abruptly stopping anticonvulsant therapy

A client is admitted in pre-term labor. Which medication will be administered to relax the uterus and stop the contractions. a. MgSO4 b. MSO4 c. Pitocin d. Betamethasone

a. MgSO4

he nurse is caring for a labor patient at who is 6cm dilated complaining of severe persistent back pain. Which of the following labor complications is the nurse suspecting? a. Occiput posterior b. Umbilical cord prolapse c. Shoulder dystocia d. Uterine inversion

a. Occiput posterior

A client is experiencing a seizure that has lasted for several minutes and he has not regained consciousness. The nurse recognizes that this is a life-threatening emergency known as: a. Status epilepticus b. tonic-clonic convulsion c. epilepsy d. secondary epilepsy

a. Status epilepticus

Which structure of the brain contains the appetite regulation center? a. hypothalamus b. thalamus c. medulla d. amygdala

a. hypothalamus

The nurse caring for a client with schizotypal personality disorder would expect to assess a. odd beliefs, magical thinking, suspicious b. impulsive, aggressive behaviors c. guarded, distrustful behaviors d. emotionally flat and irritable

a. odd beliefs, magical thinking, suspicious

Which is an example of a positive symptom of schizophrenia? a. paranoia b. apathy c. catatonia d. anhedonia

a. paranoia

Which medication would the nurse anticipate giving to a patient diagnosed with Tardive Dyskinesia (TD)? a. valbenazine b. trihexphenidyl c. diphenhydramine d. benztropine

a. valbenazine

A client who has had seizures asks the nurse about being able to drive because of the seizures. Which response by the nurse is best? a. A person with a history of seizures can only drive during the daytime hours b. A person with evidence that seizures are under medical control can drive c. A person with evidence that seizures occur no more than once every 12 months can drive d. A person with a history of seizures can drive if he/she carries a medical ID card

b. A person with evidence that seizures are under medical control can drive

A client is admitted to the emergency department with status epilepticus. The nurse knows that which of these drugs is considered the drug of choice for this condition? a. phenobarbital (Luminal) b. diazepam (Valium) c. valproic acid (Depakote) d. phenytoin (Dilantin)

b. diazepam (Valium)

The nurse teaches a client to recognize an aura. The nurse instructs the client to note: a. A postictal state of amnesia b. A hallucination that occurs during a seizure c. A symptom that occurs just before a seizure d. A feeling of relaxation that begins just as the seizure starts to subside

c. A symptom that occurs just before a seizure

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? a. Seizure began at 1300 hours b. The client cried out before the seizure began c. Seizure was 1 minute in duration and included tonic-clonic activitiy d. Sleeping quietly after the seizure

c. Seizure was 1 minute in duration and included tonic-clonic activitiy

The nurse is administering phenobarbital (Luminal) and will monitor the client for which possible adverse effect? a. constipation b. gingival hyperplasia c. drowsiness d. dysrhythmias

c. drowsiness

A client with eclampsia begins to experience a seizure. Which of the following should the nurse do immediately? a. Pad the side rails b. Place a pillow under the left buttock c. Insert a padded tongue blade into the mouth d. Maintain a patent airway

d. Maintain a patent airway

A client is having a tonic-clonic seizure. What should the nurse do first? a. Elevate the head of the bed b. Restrain the client's arms and legs c. Place a tongue blade in the client's mouth d. Take measures to prevent injury

d. Take measures to prevent injury