SOC 4 Final Exam

8. Nursing interventions directed at health promotion in the older adult are primarily focused on a. disease management. b. controlling symptoms of illness. c. teaching positive health behaviors. d. teaching regarding nutrition to enhance longevity.

c. teaching positive health behaviors.

5. An important nursing action to help a chronically ill older adult is to a. avoid discussing future lifestyle changes. b. ensure the patient that the condition is stable. c. treat the patient as a competent manager of the disease. d. encourage the patient to "fight" the disease as long as possible.

c. treat the patient as a competent manager of the disease.

7. An appropriate care choice for an older adult who lives with an employed daughter but needs help with activities of daily living is a. adult day care. b. long-term care. c. a retirement center. d. an assisted living facility.

a. adult day care.

13. The role(s) of the nurse while working with the bereaved include __________. (Select all that apply.) a. guidance b. resource c. advocacy d. support e. spiritual counseling

a. guidance b. resource c. advocacy d. support Individuals are brought in as requested to meet the spiritual needs of the bereaved. The role of the nurse includes guiding the bereaved as to what needs to be done, serving as a resource for information related to death and dying, being an advocate for the deceased and their family to make requests known related to cultural and spiritual preferences, and supporting the need for privacy and emotional release at the time of death.

601. The home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should tell the client to take which action? 1. Freeze the insulin. 2. Refrigerate the insulin. 3. Store the insulin in a dark, dry place. 4. Keep the insulin at room temperature.

2. Refrigerate the insulin. Insulin in unopened vials should be stored under refrigeration until needed. Vials should not be frozen. When stored unopened under refrigeration, insulin can be used up to the expiration date on the vial. Options 1, 3, and 4 are incorrect.

8. The distraught wife of a terminally ill patient complains to the nurse, "My husband has not been shaved, and he has that miserable gown on instead of his own pajamas. Don't you people care about things like that?" The nurse's best response would be: a. "I delayed his morning care because he was sleeping comfortably. I'll complete his care now that he's awake." b. "We're running late today and I have six other patients to care for. What do you want?" c. "Of course we care! Someone will come to do his care before lunch." d. "I'm sorry you feel we're doing such a poor job. I'm doing my best."

a. "I delayed his morning care because he was sleeping comfortably. I'll complete his care now that he's awake." Listening to criticism without defensiveness and giving a prompt response to requests with an explanation shows the nurse's concern for meeting the needs of the dying person and of the distressed family members.

The nurse understands that moral distress may result in which of the following? Select all that apply: a. Anger at providers b. Disagreements among staff c. Anger at family d. Physical exhaustion e. Poor sleep patterns

a. Anger at providers b. Disagreements among staff c. Anger at family d. Physical exhaustion e. Poor sleep patterns

9. The children caregivers of an older patient whose death is imminent have not left the bedside for the past 36 hours. In the nurse's assessment of the family, what findings indicate the potential for an abnormal grief reaction to occur (select all that apply)? a. Family cannot express their feelings to one another. b. Dying patient is becoming more restless and agitated. c. A family member is going through a difficult divorce. d. Family talks with and reassures the patient at frequent intervals. e. Siblings who were estranged from each other have now reunited.

a. Family cannot express their feelings to one another. c. A family member is going through a difficult divorce.

9. To show willingness to spend time with a dying patient and encourage communication, the nurse should __________. (Select all that apply.) a. address the patient by name at every opportunity b. use direct questions to inquire about the patient's concerns relative to health and end-of-life issues c. complete care with a minimum of conversation to encourage questions from the patient d. provide empathetic touching during care to show concern e. sit down in the room to converse with patient

a. address the patient by name at every opportunity d. provide empathetic touching during care to show concern e. sit down in the room to converse with patient Use of direct questions, which only allow a "yes" or "no" answer from the patient, does not generate communication, nor does limited conversation from the caregiver.

3. The nurse reminds the 70-year-old male patient who has signed an advance directive that copies of the form should be __________. (Select all that apply.) a. given to the person who has been named as his power of attorney for medical decisions b. posted in his home for emergency personnel c. placed in his file in his physician's office d. filed with the hospital of his choice e. given to his spiritual advisor

a. given to the person who has been named as his power of attorney for medical decisions b. posted in his home for emergency personnel c. placed in his file in his physician's office d. filed with the hospital of his choice The spiritual advisor is not usually considered an appropriate recipient for a copy of the advance directive. It should only be given to those who will be directly involved with health choices and require this information.

4. An ethnic older adult may feel a loss of self-worth when the nurse (select all that apply) a. prohibits visits from a faith healer. b. informs the patient about ethnic support services. c. allows a patient to rely on ethnic health beliefs and practices. d. emphasizes that a therapeutic diet does not allow ethnic foods. e. uses a medical interpreter to provide explanations and teaching.

a. prohibits visits from a faith healer. d. emphasizes that a therapeutic diet does not allow ethnic foods.

3. A 67-year-old woman was recently diagnosed with inoperable pancreatic cancer. Before the diagnosis she was very active in her neighborhood association. Her husband is concerned because his wife is staying at home and missing her usual community activities. Which common EOL psychologic manifestation is she most likely demonstrating? a. Peacefulness b. Decreased socialization c. Decreased decision making d. Anxiety about unfinished business

b. Decreased socialization

6. While caring for his dying wife, the husband states that his wife is a devout Roman Catholic but he is a Baptist. Who is considered the most reliable source for spiritual preferences concerning EOL care for the dying wife? a. A priest b. Dying wife c. Hospice staff d. Husband of dying wife

b. Dying wife

1. Examples of primary prevention strategies include a. colonoscopy at age 50. b. avoidance of tobacco products. c. teaching the importance of exercise to a patient with hypertension. d. intake of a diet low in saturated fat in a patient with high cholesterol.

b. avoidance of tobacco products.

12. While working with the bereaved at the time of death, the nurse should __________. (Select all that apply.) a. review the stages of dying with them b. ensure privacy c. observe cultural and spiritual preferences d. legally pronounce the death e. allow the bereaved to express their feelings

b. ensure privacy c. observe cultural and spiritual preferences e. allow the bereaved to express their feelings Reviewing the stages of dying should have been addressed before the death. The physician is the individual who legally pronounces the death. Assuring privacy will allow the bereaved to say final farewells and grieve. Observing cultural and spiritual preferences will prevent the bereaved from being offended.

14. The nurse questions the order for a bulk-forming laxative for the person who is near death because the patient would need a minimum fluid intake of _____ mL to tolerate this type of drug. a. 1000 b. 1500 c. 2000 d. 2500

c. 2000 To prevent a bowel obstruction from bulk-forming laxatives, the patient must have a fluid intake of at least 2000 mL a day.

8. The family attorney informed a patient's adult children and wife that the patient did not have an advance directive after he suffered a serious stroke. Who is responsible for making the decision about EOL measures when the patient cannot communicate his or her specific wishes? a. Notary and attorney b. Physician and family c. Wife and adult children d. Physician and nursing staff

c. Wife and adult children

6. The nurse is aware that hospice care can be made available to terminal patients who: a. have a life expectancy of only 12 months. b. are Medicaid-qualified. c. agree to palliative measures. d. are hospitalized.

c. agree to palliative measures. Hospice is a Medicare-funded program for the provision of palliative care for persons who have 6 months or less life expectancy. The service is extended to qualified persons at home, in a long-term care facility, or in the hospital.

10. The nurse notes that a cardiovascular sign of impending death is: a. Cheyne-Stokes respiration. b. bounding pulse. c. bluish mottling of extremities. d. widening pulse pressure.

c. bluish mottling of extremities. As death approaches, there is vasoconstriction to the extremities to keep blood going to the heart and brain. This causes mottling of the extremities. Bounding pulse and widening pulse pressure are not seen in the dying person. Cheyne-Stokes respirations are changes seen in the respiratory system, not the cardiovascular system.

3. Ageism is characterized by a. denial of negative stereotypes regarding aging. b. positive attitudes toward the elderly based on age. c. negative attitudes toward the elderly based on age. d. negative attitudes toward the elderly based on physical disability.

c. negative attitudes toward the elderly based on age.

10. A nurse has been working full time with terminally ill patients for 3 years. He has been experiencing irritability and mixed emotions when expressing sadness since four of his patients died on the same day. To optimize the quality of his nursing care, he should examine his own a. full-time work schedule. b. past feelings toward death. c. patterns for dealing with grief. d. demands for involvement in patient care.

c. patterns for dealing with grief.

2. A characteristic of a chronic illness is that it (select all that apply) a. has reversible pathologic changes. b. has a consistent, predictable clinical course. c. results in permanent deviation from normal. d. is associated with many stable and unstable phases. e. always starts with an acute illness and then progresses slowly.

c. results in permanent deviation from normal. d. is associated with many stable and unstable phases.

7. A tearful patient tells the nurse that her brother (who is in prison) just received a diagnosis of terminal metastatic lung cancer. She is worried that her brother will die in pain and alone. What is the nurse's best response? a. "It's too bad that they don't have hospice services in prison." b. "I'm sure the prison will let him out if they know he is dying." c. "Maybe if he had not committed a crime, he wouldn't be in this situation." d. "Many prisons offer health care services, including hospice and palliative care."

d. "Many prisons offer health care services, including hospice and palliative care."

7. The dying patient with terminal liver cancer says to the nurse, "I'm going to take a long time to die, aren't I? I'm going to get sicker and weaker every day." The nurse's best response would be: a. "Your type of cancer is usually fatal in 4 to 6 months." b. "I don't want to hear this kind of negative talk. Make use of the time you have." c. "We have many medications that can make you feel better." d. "What concerns you the most about dying?"

d. "What concerns you the most about dying?" Using an open-ended question but being honest about terminal illness creates an interpersonal environment for effective communication.

4. For the past 5 years Tom has repeatedly asked his mother to donate his deceased father's belongings to charity, but his mother has refused. She sits in the bedroom closet, crying and talking to her long-dead husband. What type of grief is Tom's mother experiencing? a. Adaptive grief b. Disruptive grief c. Anticipatory grief d. Prolonged grief disorder

d. Prolonged grief disorder

6. Older adults who become ill are more likely than younger adults to a. complain about the symptoms of their problems. b. refuse to carry out lifestyle changes to promote recovery. c. seek medical attention because of limitations on their lifestyle. d. alter their daily living activities to accommodate new symptoms.

d. alter their daily living activities to accommodate new symptoms.

4. Professional health care providers may neglect to educate patients about end-of-life care because they: a. fear that patients will perceive that they are giving up. b. do not want to influence the patient in any decision. c. want to keep up the patient's morale. d. believe that death is a personal failure on their part.

d. believe that death is a personal failure on their part. Professional health care providers frequently neglect mentioning end-of-life provisions because they believe that death is a personal failure.

16. Because of diminished vision in the person who is dying, caregivers should: a. keep lights bright to increase visual acuity. b. stand slightly away from the bed and identify themselves before speaking. c. keep all lights on in the room, day and night. d. come close to the bed and stand directly in front of the patient.

d. come close to the bed and stand directly in front of the patient. Putting oneself directly in front of the patient, as close as possible, helps the patient with diminished vision identify the speaker.

2. The primary purpose of hospice is to a. allow patients to die at home. b. provide better quality of care than the family can. c. coordinate care for dying patients and their families. d. provide comfort and support for dying patients and their families.

d. provide comfort and support for dying patients and their families.

5. The home health nurse is firm with an 86-year-old man with terminal illness that he needs to file an advance directive to: a. demonstrate understanding of his imminent death. b. comply with most hospital policies. c. clarify treatment protocols. d. spare his family the burden of making end-of-life decisions.

d. spare his family the burden of making end-of-life decisions. The filing of advance directives relieves the family of making those decisions at a more stressful time. It also gives back control over terminal care to the terminally ill person.

15. When the dying patient becomes delirious, the nurse encourages the family to: a. leave the room and wait outside until the delirium clears. b. hold the patient's hand, but say nothing, because hearing stays intact until death. c. remain near the bed and speak to the patient in loud tones to stimulate the patient. d. touch the patient, call the patient by name, and speak in reassuring tones.

d. touch the patient, call the patient by name, and speak in reassuring tones. Touching, calling by name, and speaking in a calm and reassuring manner frequently cause the symptoms of delirium to abate and are beneficial to the delirious patient.

607. The community health nurse visits a client at home. Prednisone, 10 mg orally daily, has been prescribed for the client and the nurse teaches the client about the medication. Which statement, if made by the client, indicates that further teaching is necessary? 1. "I can take aspirin or my antihistamine if I need it." 2. "I need to take the medication every day at the same time." 3. "I need to avoid coffee, tea, cola, and chocolate in my diet." 4. "If I gain more than 5 pounds a week, I will call my health care provider (HCP)."

1. "I can take aspirin or my antihistamine if I need it." Aspirin and other over-the-counter medications should not be taken unless the client consults with the HCP. The client needs to take the medication at the same time every day and should be instructed not to stop the medication. A slight weight gain as a result of an improved appetite is expected, but after the dosage is stabilized, a weight gain of 5 pounds or more weekly should be reported to the HCP. Caffeine-containing foods and fluids need to be avoided because they may contribute to steroid-ulcer development.

892. The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? 1. "I cannot discuss any client situation with you." 2. "If you want to know about Carol, you need to ask her yourself." 3. "Only because you're worried about a friend, I'll tell you that she is improving." 4. " Being her friend, you know she is having a difficult time and deserves her privacy."

1. "I cannot discuss any client situation with you." The nurse is required to maintain confidentiality regarding the client and the client's care. Confidentiality is basic to the therapeutic relationship and is a client's right. The most appropriate response to the neighbor is the statement of that responsibility in a direct, but polite manner. A blunt statement that does not acknowledge why the nurse cannot reveal client information may be taken as disrespectful and uncaring. The remaining options identify statements that do not maintain client confidentiality.

580. The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? 1. "I need to stop my insulin." 2. "I need to increase my fluid intake." 3. "I need to monitor my blood glucose every 3 to 4 hours." 4. "I need to call the health care provider (HCP) because of these symptoms."

1. "I need to stop my insulin." When a client with diabetes mellitus is unable to eat normally because of illness, the client still should take the prescribed insulin or oral medication. The client should consume additional fluids and should notify the HCP. The client should monitor the blood glucose level every 3 to 4 hours. The client should also monitor the urine for ketones.

859. The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instructions? 1. "I should take hot baths because they are relaxing." 2. "I should sit whenever possible to conserve my energy." 3. "I should avoid long periods of rest because it causes joint stiffness." 4. "I should do some exercises, such as walking, when I am not fatigued."

1. "I should take hot baths because they are relaxing." To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.

482. The home care nurse provides instructions regarding basic infection control to the parent of an infant with human immunodeficiency virus (HIV) infection. Which statement, if made by the parent, indicates the need for further instruction? 1. "I will clean up any spills from the diaper with diluted alcohol." 2. "I will wash baby bottles, nipples, and pacifiers in the dishwasher." 3. "I will be sure to prepare foods that are high in calories and high in protein." 4. "I will be sure to wash my hands carefully before and after caring for my infant."

1. "I will clean up any spills from the diaper with diluted alcohol." HIV is transmitted through blood, semen, vaginal secretions, and breast milk. The mother of an infant with HIV should be instructed to use a bleach solution for disinfecting contaminated objects or cleaning up spills from the child's diaper. Alcohol would not be effective in destroying the virus. Options 2, 3, and 4 are accurate instructions related to basic infection control.

3. The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to describe the concept of acculturation. The nurse educator should make which most appropriate response? 1. "It is a process of learning a different culture to adapt to a new or changing environment." 2. "It is a subjective perspective of the person's heritage and a sense of belonging to a group." 3. "It is a group of individuals in a society who are culturally distinct and have a unique identity." 4. "It is a group that shares some of the characteristics of the larger population group of which it is a part."

1. "It is a process of learning a different culture to adapt to a new or changing environment." Acculturation is a process of learning a different culture to adapt to a new or changing environment. Option 2 describes ethnic identity. Option 3 describes an ethnic group. Option 4 describes a subculture.

6. Which client(s) has a high risk of obesity and diabetes mellitus? Select all that apply. 1. A 40-year-old Latino American man 2. A 45-year-old Native American man 3. A 23-year-old Asian American woman 4. A 35-year-old Hispanic American man 5. A 40-year-old African American woman

1. A 40-year-old Latino American man 2. A 45-year-old Native American man 4. A 35-year-old Hispanic American man 5. A 40-year-old African American woman Because of their health and dietary practices, Native Americans, Latino Americans, Hispanic Americans, and African Americans have a high risk of obesity and diabetes mellitus. Asian Americans have a lower risk for obesity and diabetes mellitus.

609. The nurse is monitoring a client receiving levothyroxine sodium (Synthroid) for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply. 1. Insomnia 2. Weight loss 3. Bradycardia 4. Constipation 5. Mild heat intolerance

1. Insomnia 2. Weight loss 5. Mild heat intolerance Insomnia, weight loss, and mild heat intolerance are side effects of levothyroxine sodium. Bradycardia and constipation are not side effects associated with this medication, and rather are associated with hypothyroidism, which is the disorder that this medication is prescribed to treat.

753. A week after kidney transplantation, a client develops a temperature of 101° F, the blood pressure is elevated, and the kidney is tender. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse suspects which complication? 1. Acute kidney rejection 2. Kidney infection 3. Chronic rejection 4. Kidney obstruction

1. Acute kidney rejection Acute rejection most often occurs in the first 2 weeks after transplantation. Clinical manifestations include fever, malaise, elevated white blood cell count, acute hypertension, graft tenderness, and manifestations of deteriorating renal function. Chronic rejection occurs gradually over a period of months to years. Although kidney infection or obstruction can occur, the symptoms presented in the question do not relate specifically to these disorders.

608. A client with hyperthyroidism has been given methimazole (Tapazole). Which nursing considerations are associated with this medication? Select all that apply. 1. Administer methimazole with food. 2. Place the client on a low-calorie, low-protein diet. 3. Assess the client for unexplained bruising or bleeding. 4. Instruct the client to report side/adverse effects such as sore throat, fever, or headaches. 5. Use special radioactive precautions when handling the client's urine for the first 24 hours following initial administration.

1. Administer methimazole with food. 3. Assess the client for unexplained bruising or bleeding. 4. Instruct the client to report side/adverse effects such as sore throat, fever, or headaches. Common side effects of methimazole include nausea, vomiting, and diarrhea. To address these side effects, this medication should be taken with food. Because of the increase in metabolism that occurs in hyperthyroidism, the client should consume a high calorie diet. Antithyroid medications can cause agranulocytosis with leukopenia and thrombocytopenia. Sore throat, fever, headache, or bleeding may indicate agranulocytosis and the health care provider (HCP) should be notified immediately. Methimazole is not radioactive and should not be stopped abruptly, due to the risk of thyroid storm.

860. A client develops an anaphylactic reaction after receiving morphine sulfate. The nurse should plan to institute which actions? Select all that apply. 1. Administer oxygen. 2. Quickly assess the client's respiratory status. 3. Document the event, interventions, and client's response. 4. Leave the client briefly to contact a health care provider. 5. Keep the client supine regardless of the blood pressure readings. 6. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

1. Administer oxygen. 2. Quickly assess the client's respiratory status. 3. Document the event, interventions, and client's response. An anaphylactic reaction requires immediate action, starting with quickly assessing the client's respiratory status. Although the health care provider and the Rapid Response Team must be notified immediately, the nurse must stay with the client. Oxygen is administered and an IV of normal saline is started and infused per HCP prescription. Documentation of the event, actions taken, and client outcomes needs to be done. The head of the bed should be elevated if the client's blood pressure is normal.

602. Glimepiride (Amaryl) is prescribed for a client with diabetes mellitus. The nurse instructs the client to avoid consuming which food while taking this medication? 1. Alcohol 2. Organ meats 3. Whole-grain cereals 4. Carbonated beverages

1. Alcohol When alcohol is combined with glimepiride (Amaryl), a disulfiram-like reaction may occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this medication. The items in options 2, 3, and 4 do not need to be avoided.

767. The nurse is reviewing the laboratory results for a client receiving tacrolimus (Prograf). Which laboratory result would indicate to the nurse that the client is experiencing an adverse effect of the medication? 1. Blood glucose of 200 mg/dL 2. Potassium level of 3.8 mEq/L 3. Platelet count of 300,000 cells/mm3 4. White blood cell count of 6000 cells/mm3

1. Blood glucose of 200 mg/dL A blood glucose level of 200 mg/dL is significantly elevated above the normal range of 70 to 110 mg/dL and suggests an adverse effect. Other adverse effects include neurotoxicity evidenced by headache, tremor, and insomnia; gastrointestinal effects such as diarrhea, nausea, and vomiting; hypertension; and hyperkalemia.

746. The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply. 1. Check the level of the drainage bag. 2. Reposition the client to his or her side. 3. Contact the health care provider (HCP). 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system for kinks. 6. Increase the flow rate of the peritoneal dialysis solution.

1. Check the level of the drainage bag. 2. Reposition the client to his or her side. 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system for kinks. If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing and peritoneal dialysis system are also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the HCP. Increasing the flow rate is an inappropriate action and is not associated with the amount of outflow solution.

917. Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1. Communicate expected behaviors to the client. 2. Ensure that the client knows that they are not in charge of the nursing unit. 3. Assist the client in identifying ways of setting limits on personal behaviors. 4. Follow through about the consequences of behavior in a nonpunitive manner. 5. Enforce rules by informing the client that they will not be allowed to attend therapy groups. 6. Have the client state the consequences for behaving in ways that are viewed as unacceptable.

1. Communicate expected behaviors to the client. 3. Assist the client in identifying ways of setting limits on personal behaviors. 4. Follow through about the consequences of behavior in a nonpunitive manner. 6. Have the client state the consequences for behaving in ways that are viewed as unacceptable. Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a nonpunitive manner; and assisting the client in identifying means of setting limits on personal behaviors. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups is a violation of a client's rights.

888. A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? 1. Contact the client's health care provider (HCP). 2. Call the client's family to arrange for transportation. 3. Attempt to persuade the client to stay "for only a few more days." 4. Tell the client that leaving would likely result in an involuntary commitment.

1. Contact the client's health care provider (HCP). In general, clients seek voluntary admission. Voluntary clients have the right to demand and obtain release. The nurse needs to be familiar with the state and facility policies and procedures. The best nursing action is to contact the HCP, who has the authority to discuss discharge with the client. While arranging for safe transportation is appropriate it is premature in this situation and should be done only with the client's permission. While it is appropriate to discuss why the client feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the client to agree to staying "a few more days" has little value and will not likely be successful. Many states require that the client submit a written release notice to the facility staff members, who reevaluate the client's condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat to the client.

24. The nurse calls the heath care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take? 1. Contact the nursing supervisor. 2. Administer the dose prescribed. 3. Hold the medication until the HCP can be contacted. 4. Administer the recommended dose until the HCP can be located

1. Contact the nursing supervisor. If the HCP writes a prescription that requires clarification, the nurse's responsibility is to contact the HCP. If there is no resolution regarding the prescription because the HCP cannot be located or because the prescription remains as it was written after talking with the HCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until obtaining clarification.

4. The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action? 1. Continue with the instructions, verifying client understanding. 2. Walk around the client so that the nurse constantly faces the client. 3. Give the client a dietary booklet and return later to continue with the instructions. 4. Tell the client about the importance of the instructions for the maintenance of health care.

1. Continue with the instructions, verifying client understanding. Most Chinese Americans maintain a formal distance with others, which is a form of respect. Many Chinese Americans are uncomfortable with face-to-face communications, especially when eye contact is direct. If the client turns away from the nurse during a conversation, the best action is to continue with the conversation. Walking around the client so that the nurse faces the client is in direct conflict with this cultural practice. The client may consider it a rude gesture if the nurse returns later to continue with the explanation. Telling the client about the importance of the instructions for the maintenance of health care may be viewed as degrading.

895. A client being seen in the emergency department immediately after being sexually assaulted appears calm and controlled. The nurse analyzes this behavior as indicating which defense mechanism? 1. Denial 2. Projection 3. Rationalization 4. Intellectualization

1. Denial Denial is refusal to admit to a painful reality and may be a response by a victim of sexual abuse. In this case the client is not acknowledging the trauma of the assault either verbally or nonverbally. Projection is transferring one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is justifying the unacceptable attributes about oneself. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking.

885. A client admitted to a mental health unit for treatment of psychotic behavior spends hours at the locked exit door shouting, "Let me out. There's nothing wrong with me. I don't belong here." What defense mechanism is the client implementing? 1. Denial 2. Projection 3. Regression 4. Rationalization

1. Denial Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other persons, objects, or situations. Regression allows the client to return to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener.

606. The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide (Prandin) and metformin (Glucophage) and asks the nurse to explain these medications. The nurse should provide which instructions to the client? Select all that apply. 1. Diarrhea may occur secondary to the metformin. 2. The repaglinide is not taken if a meal is skipped. 3. The repaglinide is taken 30 minutes before eating. 4. A simple sugar food item is carried and used to treat mild hypoglycemia episodes. 5. Metformin increases hepatic glucose production to prevent hypoglycemia associated with repaglinide. 6. Muscle pain is an expected effect of metformin and may be treated with acetaminophen (Tylenol).

1. Diarrhea may occur secondary to the metformin. 2. The repaglinide is not taken if a meal is skipped. 3. The repaglinide is taken 30 minutes before eating. 4. A simple sugar food item is carried and used to treat mild hypoglycemia episodes. Repaglinide, a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion, should be taken before meals (approximately 30 minutes before meals) and should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide and the client should always be prepared by carrying a simple sugar with her or him at all times. Metformin is an oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin but it might signify a more serious condition that warrants health care provider notification, not the use of acetaminophen.

748. The nurse is reviewing a client's record and notes that the health care provider has documented that the client has a renal function disorder. On review of the laboratory results, the nurse most likely would expect to note which finding? 1. Elevated creatinine level 2. Decreased hemoglobin level 3. Decreased red blood cell count 4. Decreased white blood cell count

1. Elevated creatinine level Measuring the creatinine level is a frequently used laboratory test to determine renal function. The creatinine level increases when at least 50% of renal function is lost. A decreased hemoglobin level and red blood cell count may be noted if bleeding from the urinary tract occurs or if erythropoietic function by the kidney is impaired. An increased white blood cell count is most likely to be noted in renal disease.

599. A client has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder? Select all that apply. 1. Fever 2. Nausea 3. Lethargy 4. Tremors 5. Confusion 6. Bradycardia

1. Fever 2. Nausea 4. Tremors 5. Confusion Thyroid storm is an acute and life-threatening condition that occurs in a client with uncontrollable hyperthyroidism. Symptoms of thyroid storm include elevated temperature (fever), nausea, and tremors. In addition, as the condition progresses, the client becomes confused. The client is restless and anxious and experiences tachycardia.

881. A client who is human immunodeficiency virus seropositive has been taking stavudine (d4T, Zerit). The nurse should monitor which most closely while the client is taking this medication? 1. Gait 2. Appetite 3. Level of consciousness 4. Gastrointestinal function

1. Gait Stavudine is an antiretroviral used to manage human immunodeficiency virus infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy, and the nurse should monitor the client's gait closely and ask the client about paresthesia. Options 2, 3, and 4 are unrelated to this medication.

864. The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is at most risk for developing this type of allergy? 1. Hairdressers 2. The homeless 3. Children in day care centers 4. Individuals living in a group home

1. Hairdressers Individuals most at risk for developing a latex allergy include health care workers, individuals who work in the rubber industry, or those who have had multiple surgeries, have spina bifida, wear gloves frequently, such as food handlers, hairdressers, and auto mechanics, or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts.

769. A client with chronic kidney disease is receiving epoetin alfa (Epogen). Which laboratory result would indicate a therapeutic effect of the medication? 1. Hematocrit of 32% 2. Platelet count of 400,000 cells/mm3 3. Blood urea nitrogen level of 15 mg/dL 4. White blood cell count of 6000 cells/mm3

1. Hematocrit of 32% Epoetin alfa is used to reverse anemia associated with chronic kidney disease. Therapeutic effect is seen when the hematocrit is between 30% and 33%. Options 2, 3, and 4 are not associated with the action of this medication.

605. A client is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide which instructions to the client? Select all that apply. 1. Hypoglycemia may be experienced before dinnertime. 2. The insulin dose should be decreased if illness occurs. 3. The insulin should be administered at room temperature. 4. The insulin vial needs to be shaken vigorously to break up the precipitates. 5. The NPH insulin should be drawn into the syringe first, then the regular insulin.

1. Hypoglycemia may be experienced before dinnertime. 3. The insulin should be administered at room temperature. Humulin NPH is an intermediate-acting insulin. The onset of action is 1.5 hours, it peaks in 4 to 12 hours, and its duration of action is 24 hours. Regular insulin is a short-acting insulin. Depending on the type, the onset of action is 0.5 hour, it peaks in 2 to 5.5 hours, and its duration is 5 to 8 hours. Hypoglycemic reactions most likely occur during peak time. Insulin should be at room temperature when administered. Clients may need their insulin dosages increased during times of illness. Insulin vials should never be shaken vigorously. Regular insulin is always drawn up before NPH.

944. The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? 1. Information regarding shelters 2. Instructions regarding calling the police 3. Instructions regarding self-defense classes 4. Explaining the importance of leaving the violent situation

1. Information regarding shelters Tertiary prevention of family violence includes assisting the victim after the abuse has already occurred. The nurse should provide the client with information regarding where to obtain help, including a specific plan for removing the self from the abuser and information regarding escape, hotlines, and the location of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent person. Explaining the importance of leaving the violent situation is important, but a specific plan is necessary.

770. A client with a urinary tract infection is receiving ciprofloxacin (Cipro) by the intravenous (IV) route. The nurse appropriately administers the medication by performing which action? 1. Infusing slowly over 60 minutes. 2. Infusing in a light-protective bag. 3. Infusing only through a central line. 4. Infusing rapidly as a direct intravenous push medication.

1. Infusing slowly over 60 minutes. Ciprofloxacin (Cipro) is prescribed for treatment of mild, moderate, severe, and complicated infections of the urinary tract, lower respiratory tract, and skin and skin structure. A single dose is administered slowly over 60 minutes to minimize discomfort and vein irritation. Other solutions infusing at the same site need to be temporarily discontinued while the ciprofloxacin is infusing.

939. The nurse has been observing a client closely who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is least helpful to this client at this time? 1. Initiate confinement measures. 2. Acknowledge the client's behavior. 3. Assist the client to an area that is quiet. 4. Maintain a safe distance from the client.

1. Initiate confinement measures. During the escalation period, the client's behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. To initiate confinement measures during this period is inappropriate. Initiation of confinement measures, if needed, is most appropriate during the crisis period.

587. The nurse is caring for a postoperative parathyroidectomy client. Which client complaint would indicate that a life-threatening complication may be developing, requiring notification of the health care provider immediately? 1. Laryngeal stridor 2. Abdominal cramps 3. Difficulty in voiding 4. Mild to moderate incisional pain

1. Laryngeal stridor During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which causes swelling and compression of adjacent tissue. Laryngeal stridor is a harsh, high-pitched sound heard on inspiration and expiration; stridor is caused by compression of the trachea, leading to respiratory distress. Stridor is an acute emergency situation that requires immediate attention to avoid complete obstruction of the airway. Options 2, 3, and 4 do not identify signs of a life-threatening complication.

866. The camp nurse prepares to instruct a group of children about Lyme disease. Which information should the nurse include in the instructions? 1. Lyme disease is caused by a tick carried by deer. 2. Lyme disease is caused by contamination from cat feces. 3. Lyme disease can be caused by the inhalation of spores from bird droppings. 4. Lyme disease can be contagious through skin contact with an infected individual.

1. Lyme disease is caused by a tick carried by deer. Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by the Ixodes scapularis or I. pacificus tick can become infected with the spirochete Borrelia burgdorferi. Toxoplasmosis is caused by the ingestion of cysts from contaminated cat feces. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Lyme disease cannot be transmitted from one person to another.

889. When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? 1. Monitor closely for harm to self or others 2. Assist in completing an application for admission 3. Supply the client with written information about their mental illness 4. Provide an opportunity for the family to discuss why they felt the admission was needed

1. Monitor closely for harm to self or others Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment regardless of the client's willingness to consent to the hospitalization. A written request is a component of a voluntary admission. Providing written information regarding the illness is likely premature initially. The family may have had no role to play in the client's admission.

483. Which home care instructions should the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1. Monitor the child's weight. 2. Frequent hand-washing is important. 3. The child should avoid exposure to other illnesses. 4. The child's immunization schedule will need revision. 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). 6. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention.

1. Monitor the child's weight. 2. Frequent hand-washing is important. 3. The child should avoid exposure to other illnesses. 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). AIDS is a disorder caused by HIV and is characterized by a generalized dysfunction of the immune system. Home care instructions include the following: frequent hand-washing; monitoring for fever, malaise, fatigue, weight loss, vomiting, and diarrhea and notifying the health care provider if these occur; monitoring for signs and symptoms of opportunistic infections; administering antiretroviral medications and other medications as prescribed; avoiding exposure to other illnesses; keeping immunizations up to date; monitoring weight and providing a high-calorie, high-protein diet; washing eating utensils in the dishwasher; and avoiding sharing eating utensils. Gloves are worn for care, especially when in contact with body fluids and changing diapers; diapers are changed frequently and away from food areas, and soiled disposable diapers are folded inward, closed with the tabs, and disposed of in a tightly covered plastic-lined container. Any body fluid spills are cleaned with a bleach solution (10:1 ratio of water to bleach).

740. A client is admitted to the emergency department following a fall from a horse and the health care provider (HCP) prescribes insertion of a Foley catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action? 1. Notify the HCP. 2. Use a small-sized catheter. 3. Administer pain medication before inserting the catheter. 4. Use extra povidone-iodine solution in cleansing the meatus.

1. Notify the HCP. The presence of blood at the urinary meatus may indicate urethral trauma or disruption. The nurse notifies the HCP, knowing that the client should not be catheterized until the cause of the bleeding is determined by diagnostic testing. Therefore options 2, 3, and 4 are incorrect.

943. The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? 1. One-to-one suicide precautions 2. Suicide precautions with 30-minute checks 3. Checking the whereabouts of the client every 15 minutes 4. Asking the client to report suicidal thoughts immediately

1. One-to-one suicide precautions One-to-one suicide precautions are required for a client who has attempted suicide. Options 2 and 3 may be appropriate, but not at the present time, considering the situation. Option 4 also may be an appropriate nursing intervention, but the priority is identified in the correct option. The best intervention is constant supervision so that the nurse may intervene as needed if the client attempts to harm himself or herself.

453. The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings should the nurse expect to observe? Select all that apply. 1. Pallor 2. Edema 3. Anorexia 4. Proteinuria 5. Weight loss 6. Decreased serum lipids

1. Pallor 2. Edema 3. Anorexia 4. Proteinuria Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The child gains weight.

958. A client taking lithium carbonate reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L. This level is indicative of which finding? 1. Toxic 2. Normal 3. Slightly above normal 4. Excessively below normal

1. Toxic Maintenance serum levels of lithium are 0.6 to 1.2 mEq/L. Symptoms of toxicity begin to appear at levels of 1.5 to 2 mEq/L. Lithium toxicity requires immediate medical attention with lavage and possible peritoneal dialysis or hemodialysis.

741. The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent? 1. Palpation of a thrill over the fistula 2. Presence of a radial pulse in the left wrist 3. Absence of a bruit on auscultation of the fistula 4. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand

1. Palpation of a thrill over the fistula The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. The presence of a thrill and bruit indicate patency of the fistula. Although the presence of a radial pulse in the left wrist and capillary refill shorter than 3 seconds in the nail beds of the fingers on the left hand are normal findings, they do not assess fistula patency.

766. Tacrolimus (Prograf) is prescribed for a client. Which disorder, if noted in the client's record, would indicate that the medication needs to be administered with caution? 1. Pancreatitis 2. Ulcerative colitis 3. Diabetes insipidus 4. Coronary artery disease

1. Pancreatitis Tacrolimus (Prograf) is used with caution in immunosuppressed clients and in clients with renal, hepatic, or pancreatic function impairment. Tacrolimus is contraindicated in clients with hypersensitivity to this medication or hypersensitivity to cyclosporine.

578. The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign, if exhibited in the client, would indicate hyperglycemia? 1. Polyuria 2. Diaphoresis 3. Hypertension 4. Increased pulse rate

1. Polyuria Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia. Options 2, 3, and 4 are not signs of hyperglycemia.

616. A client with diabetes mellitus visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide (DiaBeta) daily, but recently the fasting blood glucose level has been 180 to 200 mg/dL. Which medication, if added to the client's regimen, may have contributed to the hyperglycemia? 1. Prednisone 2. Phenelzine (Nardil) 3. Atenolol (Tenormin) 4. Allopurinol (Zyloprim)

1. Prednisone Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements. Option 2, a monoamine oxidase inhibitor, and option 3, a β-blocker, have their own intrinsic hypoglycemic activity. Option 4 decreases urinary excretion of sulfonylurea agents, causing increased levels of the oral agents, which can lead to hypoglycemia.

862. The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? 1. Protecting the client from infection 2. Providing emotional support to decrease fear 3. Encouraging discussion about lifestyle changes 4. Identifying factors that decreased the immune function

1. Protecting the client from infection The client with immunodeficiency has inadequate or absence of immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority.

918. The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, what is the nurse's immediate priority of care? 1. Provide safety for the client and other clients on the unit. 2. Provide the clients on the unit with a sense of comfort and safety. 3. Assist the staff in caring for the client in a controlled environment. 4. Offer the client a less stimulating area to calm down in and gain control.

1. Provide safety for the client and other clients on the unit. Safety of the client and other clients is the priority. The correct option is the only one that addresses the safety needs of the client as well as those of the other clients.

15. The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? 1. Reassess the client. 2. Conduct a staff meeting to describe the fall. 3. Document in the nurse's notes that an incident report was completed. 4. Contact the nursing supervisor to update information regarding the fall.

1. Reassess the client. After a client's fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary.

589. The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which client complaint(s) would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply. 1. Tremors 2. Anorexia 3. Irritability 4. Nervousness 5. Hot, dry skin 6. Muscle cramps

1. Tremors 3. Irritability 4. Nervousness Decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as nervousness, irritability, and tremors. Option 5 is more likely to occur with hyperglycemia. Options 2 and 6 are unrelated to the signs of hypoglycemia. In hypoglycemia, usually the client feels hunger.

871. The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate for the nurse to perform? Select all that apply. 1. Record site, date, and time of the test. 2. Give the client a list of potential allergens if identified. 3. Estimate the size of the wheal and document the finding. 4. Tell the client to return to have the site inspected only if there is a reaction. 5. Have the client wait in the waiting room for at least 1 to 2 hours after injection.

1. Record site, date, and time of the test. 2. Give the client a list of potential allergens if identified. Skin testing involves administration of an allergen to the surface of the skin or into the dermis. Site, date, and time of the test must be recorded, and the client must return at a specific date and time for a follow-up site evaluation, even if no reaction is suspected; a list of potential allergens is identified. For the follow-up evaluation, the size of the site has to be measured and not estimated. After injection, clients only need to be monitored for about 30 minutes to assess for any adverse effects.

1. The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior? 1. Reflecting a cultural value 2. An acceptance of the treatment 3. Client agreement to the required procedures 4. Client understanding of the preoperative procedures

1. Reflecting a cultural value Nodding or smiling by a Japanese American client may reflect only the cultural value of interpersonal harmony. This nonverbal behavior may not be an indication of acceptance of the treatment, agreement with the speaker, or understanding of the procedure.

894. The nurse in the mental health unit recognizes which as being therapeutic communication techniques? Select all that apply. 1. Restating 2. Listening 3. Asking the client, "Why?" 4. Maintaining neutral responses 5. Providing acknowledgment and feedback 6. Giving advice and approval or disapproval

1. Restating 2. Listening 4. Maintaining neutral responses 5. Providing acknowledgment and feedback Therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking why is often interpreted as being accusatory by the client and should also be avoided. Providing advice or giving approval or disapproval are barriers to communication.

446. The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to implement which measure? 1. Restrict fluids as prescribed. 2. Care for the arteriovenous fistula. 3. Encourage foods high in potassium. 4. Administer analgesics as prescribed.

1. Restrict fluids as prescribed. Hemolytic-uremic syndrome is thought to be associated with bacterial toxins, chemicals, and viruses that result in acute kidney injury in children. Clinical manifestations of the disease include acquired hemolytic anemia, thrombocytopenia, renal injury, and central nervous system symptoms. A child with hemolytic-uremic syndrome undergoing peritoneal dialysis because of anuria would be on fluid restriction. Pain is not associated with hemolytic-uremic syndrome, and potassium would be restricted, not encouraged, if the child is anuric. Peritoneal dialysis does not require an arteriovenous fistula (only hemodialysis)..

914. The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? 1. Setting limits on the client's behavior 2. Asking the client to leave the group session 3. Asking another nurse to escort the client out of the group session 4. Telling the client that they will not be able to attend any future group sessions

1. Setting limits on the client's behavior Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client's behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the client's behavior further. Barring the client from group sessions is also an inappropriate action because it violates the client's right to receive treatment and is a threatening action.

940. Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1. The adolescent gives away a DVD and a cherished autographed picture of a performer. 2. The adolescent runs out of the therapy group, swearing at the group leader, and runs to her room. 3. The adolescent becomes angry while speaking on the telephone and slams down the receiver. 4. The adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking.

1. The adolescent gives away a DVD and a cherished autographed picture of a performer. A depressed suicidal client often gives away that which is of value as a way of saying goodbye and wanting to be remembered. Options 2, 3, and 4 deal with anger and acting-out behaviors that are often typical of any adolescent.

20. Which identifies accurate nursing documentation notations? Select all that apply. 1. The client slept through the night. 2. Abdominal wound dressing is dry and intact without drainage. 3. The client seemed angry when awakened for vital sign measurement. 4. The client appears to become anxious when it is time for respiratory treatments. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

1. The client slept through the night. 2. Abdominal wound dressing is dry and intact without drainage. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable because it can be misunderstood. The use of vague terms, such as seemed or appears is not acceptable because these words suggest that the nurse is stating an opinion.

865. Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. 1. Use nonlatex gloves. 2. Use medications from glass ampules. 3. Place the client in a private room only. 4. Keep a latex-safe supply cart available in the client's area. 5. Avoid the use of medication vials that have rubber stoppers. 6. Use a blood pressure cuff from an electronic device only to measure the blood pressure.

1. Use nonlatex gloves. 2. Use medications from glass ampules. 4. Keep a latex-safe supply cart available in the client's area. 5. Avoid the use of medication vials that have rubber stoppers. If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex gloves and latex-safe supplies, and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication vials with rubber stoppers that require puncture with a needle. It is not necessary to place the client in a private room.

884. A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? 1. Using open-ended questions and silence 2. Sharing personal preference regarding food choices 3. Documenting reasons why the client does not want to eat 4. Offering opinions about the necessity of adequate nutrition

1. Using open-ended questions and silence Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing personal food preferences is not a client-centered intervention. The remaining options are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior.

596. The nurse is caring for a client with pheochromocytoma who is scheduled for adrenalectomy. In the preoperative period, what should the nurse monitor as the priority? 1. Vital signs 2. Intake and output 3. Blood urea nitrogen results 4. Urine for glucose and ketones

1. Vital signs Pheochromocytoma is a catecholamine-producing tumor. Hypertension is the hallmark of pheochromocytoma. Severe hypertension can precipitate a stroke or sudden blindness. Although all the options are accurate nursing interventions for the client with pheochromocytoma, the priority nursing action is to monitor the vital signs, particularly the blood pressure.

600. The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching? 1. Withdraws the NPH insulin first 2. Withdraws the regular insulin first 3. Injects air into NPH insulin vial first 4. Injects an amount of air equal to the desired dose of insulin into each vial

1. Withdraws the NPH insulin first When preparing a mixture of short-acting insulin such as regular insulin with another insulin preparation, the short-acting insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of short-acting insulin with insulin of another type. Options 2, 3, and 4 identify correct actions for preparing NPH and short-acting insulin.

604. The health care provider (HCP) prescribes exenatide (Byetta) for a client with type 1 diabetes mellitus who takes insulin. The nurse should plan to take which most appropriate intervention? 1. Withhold the medication and call the HCP, questioning the prescription for the client. 2. Administer the medication within 60 minutes before the morning and evening meal. 3. Monitor the client for gastrointestinal side effects after administering the medication. 4. Withdraw the insulin from the prefilled pen into an insulin syringe to prepare for administration.

1. Withhold the medication and call the HCP, questioning the prescription for the client. Exenatide (Byetta) is an incretin mimetic used for type 2 diabetes mellitus only. It is not recommended for clients taking insulin. Hence, the nurse should withhold the medication and question the HCP regarding this prescription. Although options 2 and 3 are correct statements about the medication, in this situation the medication should not be administered. The medication is packaged in prefilled pens ready for injection without the need for drawing it up into another syringe.

891. The nurse is providing care to a client admitted to the hospital with a diagnosis of acute anxiety disorder. The client says to the nurse, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" What is the most appropriate nursing response? 1. "No, I won't tell anyone." 2. "I cannot promise to keep a secret." 3. "It depends on what the secret is about." 4. "If you tell me the secret, I may need to document it."

2. "I cannot promise to keep a secret." The nurse should never promise to keep a secret. Secrets are never appropriate in a therapeutic relationship. The nurse needs to be honest and tell the client that a promise cannot be made to keep the secret. The remaining options are inappropriate responses since they either promise to keep the secret or provide the criteria for when a secret may be appropriately kept.

947. A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client would indicate to the nurse the possible diagnosis of posttraumatic stress disorder? Select all that apply. 1. "I'm afraid of spiders." 2. "I keep reliving the robbery." 3. "I see his face everywhere I go." 4. "I don't want anything to eat now." 5. "I might have died over a few dollars in my pocket." 6. "I have to wash my hands over and over again many times."

2. "I keep reliving the robbery." 3. "I see his face everywhere I go." 5. "I might have died over a few dollars in my pocket." Reliving an event, experiencing emotional numbness (facing possible death), and having flashbacks of the event (seeing the same face everywhere) are all common occurrences with posttraumatic stress disorder. The statement. "I'm afraid of spiders," is more relative to having a phobia. The statement "I have to wash my hands over and over again many times" describes ritual compulsive behaviors to decrease anxiety for someone with obsessive compulsive disorder. Stating "I don't want anything to eat now" is vague and could relate to numerous conditions.

594. The nurse is providing discharge instructions to a client who has Cushing's syndrome. Which client statement indicates that instructions related to dietary management are understood? 1. "I will need to limit the amount of protein in my diet." 2. "I should eat foods that have a lot of potassium in them." 3. "I am fortunate that I can eat all the salty foods I enjoy." 4. "I am fortunate that I do not need to follow any special diet."

2. "I should eat foods that have a lot of potassium in them." A diet low in carbohydrates and sodium but ample in protein and potassium is encouraged for a client with Cushing's syndrome. Such a diet promotes weight loss, reduction of edema and hypertension, control of hypokalemia, and rebuilding of wasted tissue.

867. A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? 1. Maintain bed rest as much as possible. 2. Administer corticosteroids as prescribed for inflammation. 3. Advise the client to remain supine for 1 to 2 hours after meals. 4. Keep the room temperature warm during the day and cool at night.

2. Administer corticosteroids as prescribed for inflammation. Scleroderma is a chronic connective tissue disease similar to systemic lupus erythematosus. Corticosteroids may be prescribed to treat inflammation. Topical agents may provide some relief from joint pain. Activity is encouraged as tolerated and the room temperature needs to be constant. Clients need to sit up for 1 to 2 hours after meals if esophageal involvement is present.

491. A child with rubeola (measles) is being admitted to the hospital. In preparing for the admission of the child, the nurse should plan to place the child on which precautions? 1. Enteric 2. Airborne 3. Protective 4. Neutropenic

2. Airborne Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Airborne droplet precautions are required, and persons in contact with the child should wear masks. The child is placed in a private room if hospitalized, and the hospital room door remains closed. Gowns and gloves are unnecessary, but standard precautions are used. Articles that are contaminated should be bagged and labeled. Special enteric precautions and protective (neutropenic) isolation are not indicated in rubeola.

861. A client with pemphigus is being seen in the clinic regularly. The nurse plans care based on which description of this condition? 1. The presence of tiny red vesicles 2. An autoimmune disease that causes blistering in the epidermis 3. The presence of skin vesicles found along the nerve caused by a virus 4. The presence of red, raised papules and large plaques covered by silvery scales

2. An autoimmune disease that causes blistering in the epidermis Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 3 describes herpes zoster, and option 4 describes psoriasis.

2. When communicating with a client who speaks a different language, which best practice should the nurse implement? 1. Speak loudly and slowly. 2. Arrange for an interpreter to translate. 3. Speak to the client and family together. 4. Stand close to the client and speak loudly.

2. Arrange for an interpreter to translate. Arranging for an interpreter would be the best practice when communicating with a client who speaks a different language. Options 1 and 4 are inappropriate and are ineffective ways to communicate. Option 3 is inappropriate because it violates privacy and does not ensure correct translation.

863. A client calls the nurse in the emergency department and states that he was just stung by a bumble bee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which nursing action should the nurse take? 1. Advise the client to soak the site in hydrogen peroxide. 2. Ask the client if he ever sustained a bee sting in the past. 3. Tell the client to call an ambulance for transport to the emergency department. 4. Tell the client not to worry about the sting unless difficulty with breathing occurs.

2. Ask the client if he ever sustained a bee sting in the past. In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the client if he ever experienced a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry."

948. A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, how should the nurse administer the dose? 1. On an empty stomach 2. At the same time each evening 3. Evenly spaced around the clock 4. As needed when the client complains of depression

2. At the same time each evening Sertraline (Zoloft) is classified as an antidepressant. Sertraline (Zoloft) generally is administered once every 24 hours. It may be administered in the morning or evening, but evening administration may be preferable because drowsiness is a side effect. The medication may be administered without food or with food if gastrointestinal distress occurs. Sertraline (Zoloft) is not prescribed for use as needed.

921. The nurse is caring for a client who is experiencing disturbed thought processes as a result of paranoia. In formulating nursing interventions with the members of the health care team, what best instruction should the nurse provide to the staff? 1. Increase socialization of the client with peers. 2. Avoid laughing or whispering in front of the client. 3. Begin to educate the client about social supports in the community. 4. Have the client sign a release of information to appropriate parties for assessment purposes.

2. Avoid laughing or whispering in front of the client. Disturbed thought process related to paranoia is the client's problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client who is paranoid.

893. The nurse calls security and has physical restraints applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. 1. Libel 2. Battery 3. Assault 4. Slander 5. False imprisonment

2. Battery 3. Assault 5. False imprisonment False imprisonment is an act with the intent to confine a person to a specific area. The nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the client has been admitted voluntarily and if no agency or legal policies exist for detaining the client. Assault and battery are related to the act of restraining the client in a situation that did not meet criteria for such an intervention. Libel and slander are not applicable here since the nurse did not write or verbally make untrue statements about the client.

444. The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects to note which finding that is associated with this diagnosis? 1. Hypotension 2. Brown-colored urine 3. Low urinary specific gravity 4. Low blood urea nitrogen level

2. Brown-colored urine Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria, resulting in dark, smoky, cola-colored or brown-colored urine, is a classic symptom of glomerulonephritis. Hypertension is also common. Blood urea nitrogen levels may be elevated. A moderately elevated to high urinary specific gravity is associated with glomerulonephritis.

575. A client with diabetes mellitus demonstrates acute anxiety when first admitted to the hospital for the treatment of hyperglycemia. What is the most appropriate intervention to decrease the client's anxiety? 1. Administer a sedative. 2. Convey empathy, trust, and respect toward the client. 3. Ignore the signs and symptoms of anxiety so that they will soon disappear. 4. Make sure that the client knows all the correct medical terms to understand what is happening.

2. Convey empathy, trust, and respect toward the client. The appropriate intervention is to address the client's feelings related to the anxiety. Administering a sedative is not the most appropriate intervention. The nurse should not ignore the client's anxious feelings. A client will not relate to medical terms, particularly when anxiety exists.

450. The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention? 1. Cover the bladder with petroleum jelly gauze. 2. Cover the bladder with a nonadhering plastic wrap. 3. Apply sterile distilled water dressings over the bladder mucosa. 4. Keep the bladder tissue dry by covering it with dry sterile gauze.

2. Cover the bladder with a nonadhering plastic wrap. In bladder exstrophy, the bladder is exposed and external to the body. In this disorder, one must take care to protect the exposed bladder tissue from drying, while allowing the drainage of urine. This is accomplished best by covering the bladder with a nonadhering plastic wrap. The use of petroleum jelly gauze should be avoided because this type of dressing can dry out, adhere to the mucosa, and damage the delicate tissue when removed. Dry sterile dressings and dressings soaked in solutions (that can dry out) also damage the mucosa when removed.

737. A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious and the nurse suspects air embolism. What is the priority nursing action? 1. Monitor vital signs every 15 minutes for the next hour. 2. Discontinue dialysis and notify the health care provider (HCP). 3. Continue dialysis at a slower rate after checking the lines for air. 4. Bolus the client with 500 mL of normal saline to break up the air embolus.

2. Discontinue dialysis and notify the health care provider (HCP). If the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, notify the HCP, and administer oxygen as needed. Options 1, 3, and 4 are incorrect.

941. The police arrive at the emergency department with a client who has lacerated both wrists. What is the initial nursing action? 1. Administer an antianxiety agent. 2. Examine and treat the wound sites. 3. Secure and record a detailed history. 4. Encourage and assist the client to ventilate feelings.

2. Examine and treat the wound sites. The initial nursing action is to assess and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions, such as options 1, 3, and 4, may follow after the client has been treated medically.

956. The nurse is performing a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine (Prozac). What information would be important for the nurse to obtain during this client visit regarding the side/adverse effects of the medication? 1. Cardiovascular symptoms 2. Gastrointestinal dysfunctions 3. Problems with mouth dryness 4. Problems with excessive sweating

2. Gastrointestinal dysfunctions The most common side/adverse effects related to this medication include central nervous system and gastrointestinal system dysfunction. Fluoxetine (Prozac) affects the gastrointestinal system by causing nausea and vomiting, cramping, and diarrhea. Cardiovascular symptoms, dry mouth, and excessive sweating are not side/adverse effects associated with this medication.

445. The nurse performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome? 1. Hypertension 2. Generalized edema 3. Increased urinary output 4. Frank, bright red blood in the urine

2. Generalized edema Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, hyperlipemia, and edema. Other manifestations include weight gain; periorbital and facial edema that is most prominent in the morning; leg, ankle, labial, or scrotal edema; decreased urine output and urine that is dark and frothy; abdominal swelling; and blood pressure that is normal or slightly decreased.

612. The nurse performs an admission assessment on a client who visits a health care clinic for the first time. The client tells the nurse that propylthiouracil (PTU) is taken daily. The nurse continues to collect data from the client, suspecting that the client has a history of which condition? 1. Myxedema 2. Graves' disease 3. Addison's disease 4. Cushing's syndrome

2. Graves' disease Propylthiouracil (PTU) inhibits thyroid hormone synthesis and is used to treat hyperthyroidism, or Graves' disease. Myxedema indicates hypothyroidism. Cushing's syndrome and Addison's disease are disorders related to adrenal function.

752. The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication? 1. Infection 2. Hyperglycemia 3. Hypophosphatemia 4. Disequilibrium syndrome

2. Hyperglycemia An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis.

912. When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? 1. Suppressing feelings of anxiety 2. Identifying anxiety-producing situations 3. Continued contact with a crisis counselor 4. Eliminating all anxiety from daily situations

2. Identifying anxiety-producing situations Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.

953. The nurse is teaching a client who is being started on imipramine (Tofranil) about the medication. The nurse should inform the client to expect maximum desired effects at what time period following initiation of the medication? 1. In 2 months 2. In 2 to 3 weeks 3. During the first week 4. During the sixth week of administration

2. In 2 to 3 weeks The maximum therapeutic effects of imipramine (Tofranil) may not occur for 2 to 3 weeks after antidepressant therapy has been initiated. Options 1, 3, and 4 are incorrect.

579. The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places highest priority on which client problem? 1. Lack of knowledge 2. Inadequate fluid volume 3. Compromised family coping 4. Inadequate consumption of nutrients

2. Inadequate fluid volume An increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options 1, 3, and 4 are not related specifically to the subject of the question.

951. The nurse is describing the medication side and adverse effects to a client who is taking oxazepam (Serax). What information should the nurse incorporate in the discussion? 1. Consume a low-fiber diet. 2. Increase fluids and bulk in the diet. 3. Rest if the heart begins to beat rapidly. 4. Take antidiarrheal agents if diarrhea occurs.

2. Increase fluids and bulk in the diet. Oxazepam (Serax) causes constipation, and the client is instructed to increase fluid intake and bulk (high fiber) in the diet. If the heart begins to beat fast, the health care provider (HCP) is notified because this could indicate overdose. In addition, diarrhea could indicate an incomplete intestinal obstruction and, if this occurs, the HCP is notified.

399. A mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 1 mg/dL. The nurse reviews this result and makes which interpretation? 1. It is positive. 2. It is negative. 3. It is inconclusive. 4. It requires rescreening at age 6 weeks.

2. It is negative. Phenylketonuria is a genetic (autosomal recessive) disorder that results in central nervous system damage from toxic levels of phenylalanine (an essential amino acid) in the blood. It is characterized by blood phenylalanine levels greater than 20 mg/dL (normal level is 1.2 to 3.4 mg/dL in newborns and 0.8 to 1.8 mg/dL thereafter). A result of 1 mg/dL is a negative test result.

613. The nurse is instructing a client regarding intranasal desmopressin (DDAVP). The nurse should tell the client that which occurrence is a side effect of the medication? 1. Headache 2. Vulval pain 3. Runny nose 4. Flushed skin

3. Runny nose Desmopressin administered by the intranasal route can cause a runny or stuffy nose. Options 1, 2, and 4 are side effects if the medication is administered by the intravenous route.

758. The nurse is providing discharge instructions to a client receiving sulfamethoxazole. Which instruction should be included in the list? 1. Restrict fluid intake. 2. Maintain a high fluid intake. 3. If the urine turns dark brown, call the health care provider (HCP) immediately. 4. Decrease the dosage when symptoms are improving to prevent an allergic response

2. Maintain a high fluid intake. Each dose of sulfamethoxazole should be administered with a full glass of water, and the client should maintain a high fluid intake. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Some forms of sulfamethoxazole cause urine to turn dark brown or red. This does not indicate the need to notify the HCP.

583. A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action would the nurse prepare to carry out initially? 1. Warm the client. 2. Maintain a patent airway. 3. Administer thyroid hormone. 4. Administer fluid replacement

2. Maintain a patent airway. The initial nursing action would be to maintain a patent airway. Oxygen would be administered, followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones by the intravenous route.

890. The nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task that is most appropriate for this phase? 1. Planning short-term goals 2. Making appropriate referrals 3. Developing realistic solutions 4. Identifying expected outcomes

2. Making appropriate referrals Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. The remaining options identify tasks appropriate for the working phase of the relationship.

875. Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions should the nurse include when administering this medication? Select all that apply. 1. Restrict fluid intake. 2. Monitor liver function studies. 3. Instruct the client to avoid alcohol. 4. Administer the medication with an antacid. 5. Instruct the client to avoid exposure to the sun. 6. Administer the medication on an empty stomach.

2. Monitor liver function studies. 3. Instruct the client to avoid alcohol. 5. Instruct the client to avoid exposure to the sun. Ketoconazole is an antifungal medication. There is no reason for the client to restrict fluid intake; in fact, this could be harmful to the client. The medication is hepatotoxic, and the nurse monitors liver function. It is administered with food (not on an empty stomach) and antacids are avoided for 2 hours after taking the medication to ensure absorption. The client is also instructed to avoid alcohol. In addition, the client is instructed to avoid exposure to the sun because the medication increases photosensitivity.

933. The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors? 1. Signs of depression 2. Normal reactions to a devastating event 3. Evidence that the client is a high suicide risk 4. Indicative of the need for hospital admission

2. Normal reactions to a devastating event During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate a normal reaction. Options 1, 3, and 4 are incorrect interpretations.

595. The nurse is caring for a client who is 2 days postoperative following an abdominal hysterectomy. The client has a history of diabetes mellitus and has been receiving regular insulin according to capillary blood glucose testing four times a day. A carbohydrate-controlled diet has been prescribed but the client has been complaining of nausea and is not eating. On entering the client's room, the nurse finds the client to be confused and diaphoretic. Which action is most appropriate at this time? 1. Call a code to obtain needed assistance immediately. 2. Obtain a capillary blood glucose level and perform a focused assessment. 3. Ask the unlicensed assistive personnel (UAP) to stay with the client while obtaining 15 to 30 g of a carbohydrate snack for the client to eat. 4. Stay with the client and ask the UAP to call the health care provider (HCP) for a prescription for intravenous 50% dextrose.

2. Obtain a capillary blood glucose level and perform a focused assessment. Diaphoresis and confusion are signs of moderate hypoglycemia. A likely cause of the client's change in condition could be related to the administration of insulin without the client eating enough food. However, an assessment is necessary to confirm the presence of hypoglycemia. The nurse would obtain a capillary blood glucose level to confirm the hypoglycemia and perform a focused assessment to determine the extent and cause of the client's condition. Once hypoglycemia is confirmed, the nurse stays with the client and asks the unlicensed assistive personnel (UAP) to obtain the appropriate carbohydrate snack. A code is called if the client is not breathing or if the heart is not beating.

874. The nurse caring for a client who is taking an aminoglycoside should monitor the client for which adverse effects of the medication? Select all that apply. 1. Seizures 2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias 5. Hepatotoxicity

2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias Aminoglycosides are administered to inhibit the growth of bacteria. Adverse effects of this medication include confusion, ototoxicity, renal toxicity, gastrointestinal irritation, palpitations (dysrhythmias), blood pressure changes, and hypersensitivity reactions. Therefore, the remaining options are incorrect.

736. A client with acute kidney injury has a serum potassium level of 6.0 mEq/L. The nurse should plan which action as a priority? 1. Check the sodium level. 2. Place the client on a cardiac monitor. 3. Encourage increased vegetables in the diet. 4. Allow an extra 500 mL of fluid intake to dilute the electrolyte concentration.

2. Place the client on a cardiac monitor. The client with hyperkalemia is at risk of developing cardiac dysrhythmias and cardiac arrest. Because of this, the client should be placed on a cardiac monitor. Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly. Vegetables are a natural source of potassium in the diet, and their use would not be increased. The nurse also may assess the sodium level because sodium is another electrolyte commonly measured with the potassium level. However, this is not a priority action of the nurse.

586. The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? 1. Diarrhea 2. Polyuria 3. Polyphagia 4. Weight gain

2. Polyuria Hypercalcemia is the hallmark of hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis and thus polyuria. This diuresis leads to dehydration (weight loss rather than weight gain). Options 1, 3, and 4 are not associated with hyperparathyroidism. Some gastrointestinal symptoms include anorexia, nausea, vomiting, and constipation.

5. The nurse identifies low-risk therapies to a client and should include which therapy(s) in the discussion? Select all that apply. 1. Herbs 2. Prayer 3. Touch 4. Massage 5. Relaxation 6. Acupuncture

2. Prayer 3. Touch 4. Massage 5. Relaxation Low-risk therapies are therapies that have no adverse effects and, when implementing care, can be used by the nurse who has training and experience in their use. Low-risk therapies include meditation, relaxation techniques, imagery, music therapy, massage, touch, laughter and humor, and spiritual measures, such as prayer. The other options are not considered low-risk therapies.

957. A client who has been taking buspirone (Buspar) for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred? 1. Paranoid thought process 2. Rapid heartbeat or anxiety 3. Alcohol withdrawal symptoms 4. Thought broadcasting or delusions

2. Rapid heartbeat or anxiety Buspirone (Buspar) is not recommended for the treatment of paranoid thought disorders, drug or alcohol withdrawal, or schizophrenia. Buspirone (Buspar) most often is indicated for the treatment of anxiety.

960. A hospitalized client has begun taking bupropion (Wellbutrin) as an antidepressant agent. The nurse understands that which is an adverse effect, indicating that the client is taking an excessive amount of medication? 1. Constipation 2. Seizure activity 3. Increased weight 4. Dizziness when getting upright

2. Seizure activity Seizure activity can occur in clients taking bupropion (Wellbutrin) dosages greater than 450 mg daily. Weight gain is an occasional side effect, whereas constipation is a common side effect of this medication. This medication does not cause significant orthostatic blood pressure changes.

574. The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply. 1. Polyuria 2. Shakiness 3. Palpitations 4. Blurred vision 5. Lightheadedness 6. Fruity breath odor

2. Shakiness 3. Palpitations 5. Lightheadedness Shakiness, palpitations, and lightheadedness are signs of hypoglycemia and would indicate the need for food or glucose. Polyuria, blurred vision, and a fruity breath odor are signs of hyperglycemia.

739. A client is admitted to the emergency department following a motor vehicle accident. The client was wearing a lap seat belt when the accident occurred and now the client has hematuria and lower abdominal pain. To assess further whether the pain is caused by bladder trauma, the nurse should ask the client if the pain is referred to which area? 1. Hip 2. Shoulder 3. Umbilicus 4. Costovertebral angle

2. Shoulder Bladder trauma or injury is characterized by lower abdominal pain that may radiate to one of the shoulders due to phrenic nerve irritation. Bladder injury pain does not radiate to the umbilicus, costovertebral angle, or hip.

22. Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the UAP violated? 1. Libel 2. Slander 3. Assault 4. Negligence

2. Slander Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group.

913. A client is unwilling to go out of the house for fear of "making a fool of myself in public." Because of this fear, the client remains homebound. Based on these data, which mental health disorder is the client experiencing? 1. Agoraphobia 2. Social phobia 3. Claustrophobia 4. Hypochondriasis

2. Social phobia Social phobia is a fear of situations in which one might be embarrassed or criticized, such as the fear of speaking, performing, or eating in public. The person fears making a fool of oneself. Agoraphobia is a fear of open spaces and the fear of being trapped in a situation from which there may not be an escape. Claustrophobia is a fear of closed places. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health.

955. The nurse notes that a client with schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing which medication complication? 1. Parkinsonism 2. Tardive dyskinesia 3. Hypertensive crisis 4. Neuroleptic malignant syndrome

2. Tardive dyskinesia Tardive dyskinesia is a reaction that can occur from antipsychotic medication. It is characterized by uncontrollable involuntary movements of the body and extremities, particularly the tongue. Parkinsonism is characterized by tremors, masklike faces, rigidity, and a shuffling gait. Hypertensive crisis can occur from the use of monoamine oxidase inhibitors and is characterized by hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, and vomiting. Neuroleptic malignant syndrome is a potentially fatal syndrome that may occur at any time during therapy with neuroleptic (antipsychotic) medications. It is characterized by dyspnea or tachypnea, tachycardia or irregular pulse rate, fever, blood pressure changes, increased sweating, loss of bladder control, and skeletal muscle rigidity.

489. A parent brings her 4-month-old infant to a well-baby clinic for immunizations. The child is up to date with the immunization schedule. The nurse should prepare to administer which immunizations to this infant? 1. Varicella, hepatitis B vaccine (HepB) 2. Diphtheria, tetanus, acellular pertussis (DTaP); measles, mumps, rubella (MMR); inactivated poliovirus vaccine (IPV) 3. MMR, Haemophilus influenzae type b (Hib), DTaP 4. DTaP, Hib, IPV, pneumococcal vaccine (PCV), rotavirus (RV)

4. DTaP, Hib, IPV, pneumococcal vaccine (PCV), rotavirus (RV)

868. A female client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which nursing actions are most appropriate? Select all that apply. 1. Tell the client that testing is not necessary unless arthralgia develops. 2. Tell the client to avoid any woody, grassy areas that may contain ticks. 3. Instruct the client to immediately start to take the antibodies that are prescribed. 4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. 5. Tell the client if this happens again to never remove the tick but vigorously scrub the area with an antiseptic.

2. Tell the client to avoid any woody, grassy areas that may contain ticks. 3. Instruct the client to immediately start to take the antibodies that are prescribed. 4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. A blood test is available to detect Lyme disease; however, the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner. Immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years. Areas that ticks inhabit need to be avoided. Ticks should be removed with tweezers and then the area is washed with an antiseptic. Options 1 and 5 are incorrect.

581. The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? 1. Lower the head of the bed. 2. Test the drainage for glucose. 3. Obtain a culture of the drainage. 4. Continue to observe the drainage.

2. Test the drainage for glucose. After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid leak. If this occurs, the drainage should be collected and tested for the presence of cerebrospinal fluid. The head of the bed should not be lowered to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication.

492. The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply. 1. The child has symptoms of a cold. 2. The child had a previous anaphylactic reaction to the vaccine. 3. Mother reports that the child is having intermittent episodes of diarrhea. 4. Mother reports that the child has not had an appetite and has been fussy. 5. The child has a disorder that caused a severely deficient immune system. 6. Mother reports that the child has recently been exposed to an infectious disease.

2. The child had a previous anaphylactic reaction to the vaccine. 5. The child has a disorder that caused a severely deficient immune system. The general contraindications for receiving live virus vaccines include a previous anaphylactic reaction to a vaccine or a component of a vaccine. In addition, live virus vaccines generally are not administered to individuals with a severely deficient immune system, individuals with a severe sensitivity to gelatin, or pregnant women. A vaccine is administered with caution to an individual with a moderate or severe acute illness, with or without fever. Options 1, 3, 4, and 6 are not contraindications to receiving a vaccine.

934. The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis could be caused by which event? 1. Witnessing a murder 2. The death of a loved one 3. A fire that destroyed the client's home 4. A recent rape episode experienced by the client

2. The death of a loved one A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss of or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis of disaster; it is unplanned or accidental.

477. The clinic nurse is instructing the parent of a child with human immunodeficiency virus (HIV) infection regarding immunizations. The nurse should provide which instruction to the parent? 1. The hepatitis B vaccine will not be given to the child. 2. The inactivated influenza vaccine will be given yearly. 3. The varicella vaccine will be given before 6 months of age. 4. A Western blot test needs to be performed and the results evaluated before immunizations.

2. The inactivated influenza vaccine will be given yearly. Immunizations against common childhood illnesses are recommended for all children exposed to or infected with HIV. The inactivated influenza vaccine that is given intramuscularly will be administered (influenza vaccine should be given yearly). The hepatitis B vaccine is administered according to the recommended immunization schedule. Varicella-zoster virus vaccine should not be given because it is a live virus vaccine; varicella-zoster immunoglobulin may be prescribed after chickenpox exposure. Option 4 is unnecessary and is inaccurate.

611. The nurse provides medication instructions to a client who is taking levothyroxine (Synthroid) and should tell the client to notify the health care provider (HCP) if which problem occurs? 1. Fatigue 2. Tremors 3. Cold intolerance 4. Excessively dry skin

2. Tremors Excessive doses of levothyroxine (Synthroid) can produce signs and symptoms of hyperthyroidism. These include tachycardia, chest pain, tremors, nervousness, insomnia, hyperthermia, extreme heat intolerance, and sweating. The client should be instructed to notify the HCP if these occur. Options 1, 3, and 4 are signs of hypothyroidism.

761. Bethanechol chloride (Urecholine) is prescribed for a client with urinary retention. Which disorder would be a contraindication to the administration of this medication? 1. Gastric atony 2. Urinary strictures 3. Neurogenic atony 4. Gastroesophageal reflux

2. Urinary strictures Bethanechol chloride (Urecholine) can be hazardous to clients with urinary tract obstruction or weakness of the bladder wall. The medication has the ability to contract the bladder and thereby increase pressure within the urinary tract. Elevation of pressure within the urinary tract could rupture the bladder in clients with these conditions.

910. A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1. Move the client next to the nurse's station. 2. Use an indirect light source and turn off the television. 3. Keep the television and a soft light on during the night. 4. Play soft music during the night, and maintain a well-lit room.

2. Use an indirect light source and turn off the television. Provision of a consistent daily routine and a low stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station may become necessary but is not the initial action.

858. The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? 1. Wearing gloves 2. Wearing a gown and gloves 3. Wearing a gown, gloves, and a mask 4. Wear a gown and gloves to change the bed linens and gloves only for the bath

2. Wearing a gown and gloves Gowns and gloves are required if the nurse anticipates contact with soiled items such as those with wound drainage, or is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

922. The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? 1. Chess 2. Writing 3. Ping pong 4. Basketball

2. Writing Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. The remaining options have a competitive element to them and should be avoided because they can stimulate aggression and increase psychomotor activity.

898. Which statement demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected? 1. "Autonomy is the fundamental right of each and every client." 2. "A client's rights are guaranteed by both state and federal laws." 3. "Being respectful and concerned will ensure that I'm attentive to my clients' rights." 4. "Regardless of the client's condition, all nurses have the duty to respect client rights."

3. "Being respectful and concerned will ensure that I'm attentive to my clients' rights." The nurse needs to respect and have concern for the client; this is vital to protecting the client's rights. While it is true the autonomy is a basic client right, there are other rights that must also be both respected and facilitated. State and federal laws do protect a client's rights, but it is sensitivity to those rights that will ensure that the nurse secures these rights for the client. It is a fact that safeguarding a client's rights is a nursing responsibility, but stating that fact does not show understanding or respect for the concept.

745. The nurse is collecting data from a client who has a history of benign prostatic hyperplasia. To determine whether the client currently is experiencing this condition, the nurse should ask the client about the presence of which early symptom? 1. Nocturia 2. Urinary retention 3. Urge incontinence 4. Decreased force in the stream of urine

4. Decreased force in the stream of urine Decreased force in the stream of urine is an early symptom of benign prostatic hyperplasia. The stream later becomes weak and dribbling. The client then may develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur.

768. The nurse receives a call from a client concerned about eliminating brown-colored urine after taking nitrofurantoin (Furadantin) for a urinary tract infection. The nurse should make which appropriate response? 1. "Discontinue taking the medication and make an appointment for a urine culture." 2. "Decrease your medication to half the dose because your urine is too concentrated." 3. "Continue taking the medication because the urine is discolored from the medication." 4. "Take magnesium hydroxide (Maalox) with your medication to lighten the urine color."

3. "Continue taking the medication because the urine is discolored from the medication." Nitrofurantoin (Furadantin) imparts a harmless brown color to the urine and the medication should not be discontinued until the prescribed dose is completed. Magnesium hydroxide (Maalox) will not affect urine color. In addition, antacids should be avoided because they interfere with medication effectiveness.

909. A client says to the nurse, "The federal guards were sent to kill me." What is the best nursing response to the client's concern? 1. "I don't believe this is true." 2. "The guards are not out to kill you." 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the guards were sent to hurt you?"

3. "Do you feel afraid that people are trying to hurt you?" It is most therapeutic for the nurse to empathize with the client's experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.

480. A 6-year-old child with human immunodeficiency virus (HIV) has been admitted to the hospital for pain management. The child asks the nurse if the pain will ever go away. The nurse should make which best response to the child? 1. "The pain will go away if you lie still and let the medicine work." 2. "Try not to think about it. The more you think it hurts, the more it will hurt." 3. "I know it must hurt, but if you tell me when it does, I will try and make it hurt a little less." 4. "Every time it hurts, press on the call button and I will give you something to make the pain go all away."

3. "I know it must hurt, but if you tell me when it does, I will try and make it hurt a little less." The multiple complications associated with HIV are accompanied by a high level of pain. Aggressive pain management is essential for the child to have an acceptable quality of life. The nurse must acknowledge the child's pain and let the child know that everything will be done to decrease the pain. Telling the child that movement or lack thereof would eliminate the pain is inaccurate. Allowing a child to think that he or she can control the pain simply by thinking or not thinking about it oversimplifies the pain cycle associated with HIV. Giving false hope by telling the child that the pain will be taken "all away" is neither truthful nor realistic.

869. The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the scouts about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further instructions? 1. "I need to bring a hat to wear during the trip." 2. "I should wear long-sleeved tops and long pants." 3. "I should not use insect repellents because it will attract the ticks." 4. "I need to wear closed shoes and socks that can be pulled up over my pants."

3. "I should not use insect repellents because it will attract the ticks." In the prevention of Lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, heavily wooded areas or areas with thick underbrush should be avoided. Socks can be pulled up and over the pant legs to prevent ticks from entering under clothing.

945. A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. What is the most appropriate nursing response? 1. "You need to try to be realistic. The rape did not just occur." 2. "It will take some time to get over these feelings about your rape." 3. "Tell me more about the incident that causes you to feel like the rape just occurred." 4. "What do you think that you can do to alleviate some of your fears about being raped again?"

3. "Tell me more about the incident that causes you to feel like the rape just occurred." The correct option allows the client to express her ideas and feelings more fully and portrays a nonhurried, nonjudgmental, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are normal and that they may express their concerns freely in a safe, caring environment. Option 1 immediately blocks communication. Option 2 places the client's feelings on hold. Option 4 places the problem-solving totally on the client.

585. A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an inadequate understanding of the peak action of NPH insulin and exercise? 1. "The best time for me to exercise is after I eat." 2. "The best time for me to exercise is after breakfast." 3. "The best time for me to exercise is mid- to late afternoon." 4. "The best time for me to exercise is after my morning snack."

3. "The best time for me to exercise is mid- to late afternoon." A hypoglycemic reaction may occur in response to increased exercise. Clients should avoid exercise during the peak time of insulin. NPH insulin peaks at 4 to 12 hours; therefore, afternoon exercise takes place during the peak of the medication. Options 1, 2, and 4 do not address peak action times

935. The nurse is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, what is the most appropriate question? 1. "With whom do you live?" 2. "Who is available to help you?" 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?"

3. "What leads you to seek help now?" The nurse's initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. The correct option would assist in determining data related to the precipitating event that led to the crisis. Options 1 and 2 assess situational supports. Option 4 assesses personal coping skills.

759. Trimethoprim-sulfamethoxazole (TMP-SMZ; Bactrim) is prescribed for a client. The nurse should instruct the client to report which symptom if it develops during the course of this medication therapy? 1. Nausea 2. Diarrhea 3. Headache 4. Sore throat

4. Sore throat Clients taking trimethoprim (TMP)-sulfamethoxazole (SMZ) should be informed about early signs/symptoms of blood disorders that can occur from this medication. These include sore throat, fever, and pallor, and the client should be instructed to notify the health care provider (HCP) if these occur. The other options do not require HCP notification

937. The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 1. "You need to stop that behavior now." 2. "You will need to be placed in seclusion." 3. "You seem restless; tell me what is happening." 4. "You will need to be restrained if you do not change your behavior."

3. "You seem restless; tell me what is happening." The best statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and may assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behavior that could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate.

886. A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? 1. "Have you shared your feelings with your family?" 2. "I think we should talk more about your anger with your family." 3. "You're feeling angry that your family continues to hope for you to be cured?" 4. "You are probably very depressed, which is understandable with such a diagnosis."

3. "You're feeling angry that your family continues to hope for you to be cured?" Restating is a therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. While it is appropriate for the nurse to attempt to assess the client's ability to discuss feelings openly with family members, it does not help the client discuss the feelings causing the anger. The nurse's attempt to focus on the central issue of anger is premature. The nurse would never make a judgment regarding the reason for the client's feeling; this is nontherapeutic in the one-to-one relationship.

883. When the community health nurse visits a client at home, the client states, "I haven't slept at all the last couple of nights." Which response by the nurse illustrates a therapeutic communication response to this client? 1. "I see." 2. "Really?" 3. "You're having difficulty sleeping?" 4. "Sometimes, I have trouble sleeping too."

3. "You're having difficulty sleeping?" The correct option uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client's major theme, which assists the nurse to obtain a more specific perception of the problem from the client. The remaining options are not therapeutic responses since none encourage the client to expand on the problem. Offering personal experiences moves the focus away from the client and onto the nurse.

486. A child is scheduled to receive inactivated polio vaccine (IPV), and the nurse preparing to administer the vaccine reviews the child's record. The nurse questions the administration of IPV if which is documented in the child's record? 1. Recent recovery from a cold 2. A history of frequent respiratory infections 3. A history of an anaphylactic reaction to neomycin 4. A local reaction at the site of injection of a previous IPV

3. A history of an anaphylactic reaction to neomycin Inactivated poliovirus vaccine (IPV) contains neomycin. A history of an anaphylactic reaction to neomycin is considered a contraindication to IPV. The presence of a minor illness such as the common cold is not a contraindication. In addition, a history of frequent respiratory infections is not a contraindication to receiving a vaccine. A local reaction to an immunization is not a contraindication to receiving a vaccine.

615. Prednisone is prescribed for a client with diabetes mellitus who is taking Humulin NPH insulin daily. Which prescription change does the nurse anticipate during therapy with the prednisone? 1. An additional dose of prednisone daily 2. A decreased amount of daily Humulin NPH insulin 3. An increased amount of daily Humulin NPH insulin 4. The addition of an oral hypoglycemic medication daily

3. An increased amount of daily Humulin NPH insulin Glucocorticoids can elevate blood glucose levels. Clients with diabetes mellitus may need their dosages of insulin or oral hypoglycemic medications increased during glucocorticoid therapy. Therefore, options 1, 2, and 4 are incorrect.

946. A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action? 1. Requesting that a peer remain with the client at all times 2. Removing the client's clothing and placing the client in a hospital gown 3. Assigning a staff member to the client who will remain with the client at all times 4. Admitting the client to a seclusion room where all potentially dangerous articles are removed

3. Assigning a staff member to the client who will remain with the client at all times Hanging is a serious suicide attempt. The plan of care must reflect action that ensures the client's safety. Constant observation status (one-to-one) with a staff member is the best choice. Placing the client in a hospital gown and requesting that a peer remain with the client would not ensure a safe environment. Seclusion should not be the initial intervention, and the least restrictive measure should be used.

452. The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note? 1. Hematuria 2. Proteinuria 3. Bacteriuria 4. Glucosuria

3. Bacteriuria Epispadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. The urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic facilitates entry of bacteria into the urine. Options 1, 2, and 4 are not characteristically noted in this condition.

878. The nurse is caring for a postrenal transplantation client taking cyclosporine (Sandimmune). The nurse notes an increase in one of the client's vital signs and the client is complaining of a headache. What vital sign is most likely increased? 1. Pulse 2. Respirations 3. Blood pressure 4. Pulse oximetry

3. Blood pressure Hypertension can occur in a client taking cyclosporine (Sandimmune) and, because this client is also complaining of a headache, the blood pressure is the vital sign to be monitored most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism. Options 1, 2, and 4 are unrelated to the use of this medication.

762. The nurse, who is administering bethanechol chloride (Urecholine), is monitoring for cholinergic overdose associated with the medication. The nurse should check the client for which sign of overdose? 1. Dry skin 2. Dry mouth 3. Bradycardia 4. Signs of dehydration

3. Bradycardia Cholinergic overdose of bethanechol chloride produces manifestations of excessive muscarinic stimulation such as salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension. Treatment includes supportive measures and the administration of atropine sulfate subcutaneously or intravenously.

25. The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate nursing action? 1. Call the police. 2. Cut up the photograph and throw it away. 3. Call the nursing supervisor and report the incident. 4. Call the laboratory and ask for the individual's name who sent the photograph.

3. Call the nursing supervisor and report the incident. Ensuring a safe workplace is a responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a co-worker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 and 4 are inappropriate initial actions.

17. The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1. Call security. 2. Call the police. 3. Call the nursing supervisor. 4. Lock the co-worker in the medication room until help is obtained.

3. Call the nursing supervisor. Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and so this is not the appropriate action. Option 4 is an inappropriate and unsafe action.

961. A client receiving tricyclic antidepressants arrives at the mental health clinic. Which observation would indicate that the client is following the medication plan correctly? 1. Client reports not going to work for this past week. 2. Client complains of not being able to "do anything" anymore. 3. Client arrives at the clinic neat and appropriate in appearance. 4. Client reports sleeping 12 hours per night and 3 to 4 hours during the day.

3. Client arrives at the clinic neat and appropriate in appearance. Depressed individuals sleep for long periods, are unable to go to work, and feel as if they cannot "do anything." When these clients have had some therapeutic effect from their medication, they report resolution of many of these complaints and exhibit an improvement in their appearance. Options 1, 2, and 4 identify continued depression.

749. A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 100.2° F. Which nursing action is most appropriate? 1. Encourage fluids. 2. Notify the health care provider. 3. Continue to monitor vital signs. 4. Monitor the site of the shunt for infection.

3. Continue to monitor vital signs. The client may have an elevated temperature following dialysis because the dialysis machine warms the blood slightly. Therefore it is not necessary to notify the health care provider. If the temperature is elevated excessively and remains elevated, sepsis would be suspected and a blood sample would be obtained as prescribed for culture and sensitivity determinations. Encouraging fluids is an unsafe action for a client with chronic kidney disease. Since an elevated temperature is expected following dialysis, monitoring the site for infection is unnecessary.

915. A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. Which condition will be the focus of this consult? 1. Psychosis 2. Repression 3. Conversion disorder 4. Dissociative disorder

3. Conversion disorder A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. A conversion disorder is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, interfering with the person's ability to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness.

954. A hospitalized client is started on phenelzine (Nardil) for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply. 1. Figs 2. Yogurt 3. Crackers 4. Aged cheese 5. Tossed salad 6. Oatmeal raisin cookies

3. Crackers 5. Tossed salad Phenelzine is a monoamine oxidase inhibitor (MAOI). The client should avoid ingesting foods that are high in tyramine. Ingestion of these foods could trigger a potentially fatal hypertensive crisis. Foods to avoid include yogurt; aged cheeses; smoked or processed meats; red wines; and fruits such as avocados, raisins, or figs.

573. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings would the nurse expect to note as confirming this diagnosis? Select all that apply. 1. Increase in pH 2. Comatose state 3. Deep, rapid breathing 4. Decreased urine output 5. Elevated blood glucose level 6. Low plasma bicarbonate level

3. Deep, rapid breathing 5. Elevated blood glucose level 6. Low plasma bicarbonate level In DKA, the arterial pH is lower than 7.35, plasma bicarbonate is lower than 15 mEq/L, the blood glucose level is higher than 250 mg/dL, and ketones are present in the blood and urine. The client would be experiencing polyuria, and Kussmaul's respirations (deep and rapid breathing pattern) would be present. A comatose state may occur if DKA is not treated, but coma would not confirm the diagnosis.

614. A daily dose of prednisone is prescribed for a client. The nurse provides instructions to the client regarding administration of the medication and should instruct the client that which time is best to take this medication? 1. At noon 2. At bedtime 3. Early morning 4. Any time, at the same time, each day

3. Early morning Corticosteroids (glucocorticoids) should be administered before 9 AM. Administration at this time helps minimize adrenal insufficiency and mimics the burst of glucocorticoids released naturally by the adrenal glands each morning. Options 1, 2, and 4 are incorrect.

396. The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? 1. Hold the next dose of insulin. 2. Come to the clinic immediately. 3. Encourage the child to drink liquids. 4. Administer an additional dose of regular insulin.

3. Encourage the child to drink liquids. When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child should be encouraged to drink liquids. Bringing the child to the clinic immediately is unnecessary. Insulin doses should not be adjusted or changed.

11. An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that they would like to take an herbal substance to help lower their blood pressure. The nurse should take which action? 1. Tell the client that herbal substances are not safe and should never be used. 2. Teach the client how to take their blood pressure so that it can be monitored closely. 3. Encourage the client to discuss the use of an herbal substance with the health care provider. 4. Tell the client that if they take the herbal substance they will need to have their blood pressure checked frequently.

3. Encourage the client to discuss the use of an herbal substance with the health care provider. Although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be encouraged to avoid herbal substances with similar pharmacological effects because the combination may lead to an excessive reaction or to unknown interaction effects. The nurse should advise the client to discuss the use of the herbal substance with the HCP. Therefore, options 1, 2, and 4 are inappropriate nursing actions.

916. A manic client begins to make sexual advance towards visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? 1. Place the client in seclusion for 30 minutes. 2. Tell the client that the behavior is inappropriate. 3. Escort the client to their room, with the assistance of other staff. 4. Tell the client that their telephone privileges are revoked for 24 hours.

3. Escort the client to their room, with the assistance of other staff. The client is at risk for injury to self and others and should be escorted out of the dayroom. Seclusion is premature in this situation. Telling the client that the behavior is inappropriate has already been attempted by the nurse. Denying privileges may increase the agitation that already exists in this client.

597. The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which symptoms are associated with this diagnosis? Select all that apply. 1. Tremors 2. Weight loss 3. Feeling cold 4. Loss of body hair 5. Persistent lethargy 6. Puffiness of the face

3. Feeling cold 4. Loss of body hair 5. Persistent lethargy 6. Puffiness of the face Feeling cold, hair loss, lethargy, and facial puffiness are signs of hypothyroidism. Tremors and weight loss are signs of hyperthyroidism.

743. The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination? 1. Fever, diarrhea, groin pain, and ecchymosis 2. Nausea, vomiting, scrotal edema, and ecchymosis 3. Fever, nausea, vomiting, and painful scrotal edema 4. Diarrhea, groin pain, testicular torsion, and scrotal edema

3. Fever, nausea, vomiting, and painful scrotal edema Typical signs and symptoms of epididymitis include scrotal pain and edema, which often are accompanied by fever, nausea and vomiting, and chills. Epididymitis most often is caused by infection, although sometimes it can be caused by trauma. Epididymitis needs to be distinguished correctly from testicular torsion.

9. An Asian American client is experiencing a fever. The nurse recognizes that the client is likely to self-treat the disorder, using which method? 1. Prayer 2. Magnetic therapy 3. Foods considered to be yin 4. Foods considered to be yang

3. Foods considered to be yin In the Asian-American culture, health is believed to be a state of physical and spiritual harmony with nature and a balance between positive and negative energy forces (yin and yang). Yin foods are cold and yang foods are hot. Cold foods are eaten when one has a hot illness (fever), and hot foods are eaten when one has a cold illness. Options 1 and 2 are not health practices specifically associated with the Asian American culture or the yin and yang theory.

403. The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? Select all that apply. 1. Administer regular insulin. 2. Encourage the child to ambulate. 3. Give the child a teaspoon of honey. 4. Provide electrolyte replacement therapy intravenously. 5. Wait 30 minutes and confirm the blood glucose reading. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

3. Give the child a teaspoon of honey. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs. Hypoglycemia is defined as a blood glucose level less than 70 mg/dL. Hypoglycemia occurs as a result of too much insulin, not enough food, or excessive activity. If possible, the nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; rapid-releasing glucose is followed by a complex carbohydrate and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not planned for more than 30 minutes or if activity is planned. If the child becomes unconscious, cake frosting or glucose paste is squeezed onto the gums, and the blood glucose level is retested in 15 minutes; if the reading remains low, additional glucose is administered. If the child remains unconscious, administration of glucagon may be necessary, and the nurse should be prepared for this intervention. Encouraging the child to ambulate and administering regular insulin would result in a lowered blood glucose level. Providing electrolyte replacement therapy intravenously is an intervention to treat diabetic ketoacidosis. Waiting 30 minutes to confirm the blood glucose level delays necessary intervention.

765. The nurse is providing dietary instructions to a client who has been prescribed cyclosporine (Sandimmune). Which food item should the nurse instruct the client to exclude from the diet? 1. Red meats 2. Orange juice 3. Grapefruit juice 4. Green leafy vegetables

3. Grapefruit juice A compound present in grapefruit juice inhibits metabolism of cyclosporine. As a result, consumption of grapefruit juice can raise cyclosporine levels by 50% to 100%, thereby greatly increasing the risk of toxicity.

879. Amikacin (Amikin) is prescribed for a client with a bacterial infection. The nurse instructs the client to contact the health care provider (HCP) immediately if which occurs? 1. Nausea 2. Lethargy 3. Hearing loss 4. Muscle aches

3. Hearing loss Amikacin (Amikin) is an aminoglycoside. Side/adverse effects of aminoglycosides include ototoxicity (hearing problems), confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to report hearing loss to the HCP immediately. Lethargy and muscle aches are not associated with the use of this medication. It is not necessary to contact the HCP immediately if nausea occurs. If nausea persists or results in vomiting, the HCP should be notified.

942. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? 1. Suggesting a reduction of medication 2. Allowing increased "in-room" activities 3. Increasing the level of suicide precautions 4. Allowing the client off-unit privileges as needed

3. Increasing the level of suicide precautions A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm himself or herself. Suicide precautions are necessary to keep the client safe. The remaining options are therefore incorrect interpretations.

577. A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level was 950 mg/dL. A continuous intravenous infusion of short-acting insulin is initiated, along with intravenous rehydration with normal saline. The serum glucose level is now 240 mg/dL. The nurse would next prepare to administer which item? 1. Ampule of 50% dextrose 2. NPH insulin subcutaneously 3. Intravenous fluids containing dextrose 4. Phenytoin (Dilantin) for the prevention of seizures

3. Intravenous fluids containing dextrose During management of DKA, when the blood glucose level falls to 250 to 300 mg/dL, the infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL, or until the client recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin (Dilantin) is not a usual treatment measure for DKA.

571. A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? 1. Endotracheal intubation 2. 100 units of NPH insulin 3. Intravenous infusion of normal saline 4. Intravenous infusion of sodium bicarbonate

3. Intravenous infusion of normal saline The primary goal of treatment in hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHNS.

876. The nurse is caring for a client who has been taking a sulfonamide and should monitor for signs/symptoms of which side/adverse effects of the medication? Select all that apply. 1. Ototoxicity 2. Palpitations 3. Nephrotoxicity 4. Bone marrow depression 5. Gastrointestinal (GI) effects 6. Increased white blood cell (WBC) count

3. Nephrotoxicity 4. Bone marrow depression 5. Gastrointestinal (GI) effects Side/adverse effects include nephrotoxicity, bone marrow depression, GI effects, hepatotoxicity, dermatological effects, and some neurological symptoms including headache, dizziness, vertigo, ataxia, depression, and seizures. Options 1, 2, and 6 are unrelated to this medication.

610. The nurse provides instructions to a client who is taking levothyroxine (Synthroid). The nurse should tell the client to take the medication at which time? 1. With food 2. At lunchtime 3. On an empty stomach 4. At bedtime with a snack

3. On an empty stomach Oral doses of levothyroxine (Synthroid) should be taken on an empty stomach to enhance absorption. Dosing should be done in the morning before breakfast.

582. After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse performs an assessment on the client, knowing that which symptom is most indicative of this disorder? 1. Fatigue 2. Diarrhea 3. Polydipsia 4. Weight gain

3. Polydipsia Diabetes insipidus is characterized by hyposecretion of antidiuretic hormone, and the kidney tubules fail to reabsorb water. Polydipsia and polyuria are classic symptoms of diabetes insipidus. The urine is pale, and the specific gravity is low. Anorexia and weight loss occur. Option 1 is a vague symptom. Options 2 and 4 are not specific to this disorder.

870. The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? 1. Swelling in the genital area 2. Swelling in the lower extremities 3. Positive punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions noted on the skin

3. Positive punch biopsy of the cutaneous lesions Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

598. A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? 1. Hypoglycemia 2. Level of hoarseness 3. Respiratory distress 4. Edema at the surgical site

3. Respiratory distress Thyroidectomy is the removal of the thyroid gland, which is located in the anterior neck. It is very important to monitor airway status as any swelling to the surgical site could cause respiratory distress. Although all the options are important for the nurse to monitor, the priority nursing action is to monitor the airway.

877. The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine (Videx). The nurse interprets that the client may have the medication discontinued by the health care provider if which elevated result is noted? 1. Serum protein level 2. Blood glucose level 3. Serum amylase level 4. Serum creatinine level

3. Serum amylase level Didanosine can cause pancreatitis. A serum amylase level that is increased to 1.5 to 2 times normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure.

920. The nurse is caring for a client diagnosed with catatonic stupor who is lying on the bed in a fetal position. What is the most appropriate nursing intervention? 1. Ask direct questions to encourage talking. 2. Leave the client alone so as to minimize external stimuli. 3. Sit beside the client in silence with occasional open-ended questions. 4. Take the client into the dayroom with other clients so that they can help watch him.

3. Sit beside the client in silence with occasional open-ended questions. Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. While overstimulation is not appropriate, there is no therapeutic value in ignoring the client. The client's safety is not the responsibility of other clients.

490. The clinic nurse prepares to administer a measles, mumps, rubella (MMR) vaccine to a 5-year-old child. The nurse should administer this vaccine by which best route and in which best site? 1. Subcutaneously in the gluteal muscle 2. Intramuscularly in the deltoid muscle 3. Subcutaneously in the outer aspect of the upper arm 4. Intramuscularly in the anterolateral aspect of the thigh

3. Subcutaneously in the outer aspect of the upper arm Measles, mumps, rubella (MMR) vaccine is administered subcutaneously in the outer aspect of the upper arm. The gluteal muscle is not recommended for injections. MMR vaccine is not administered by the intramuscular route.

8. Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet? 1. Pork roast, rice, vegetables, mixed fruit, milk 2. Crab salad on a croissant, vegetables with dip, potato salad, milk 3. Sweet and sour chicken with rice and vegetables, mixed fruit, juice 4. Noodles and cream sauce with shrimp and vegetables, salad, mixed fruit, iced tea

3. Sweet and sour chicken with rice and vegetables, mixed fruit, juice Orthodox Judaism believers adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and ritually slaughtered.

592. The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL, temperature of 101° F, pulse of 88 beats/minute, respirations of 22 breaths/minute, and blood pressure of 100/72 mm Hg. Which finding would be of most concern to the nurse? 1. Pulse 2. Respiration 3. Temperature 4. Blood pressure

3. Temperature An elevated temperature may indicate infection. Infection is a leading cause of hyperglycemic hyperosmolar nonketotic syndrome or diabetic ketoacidosis. The other findings noted in the question are within normal limits.

13. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? 1. The client fell out of bed. 2. The client climbed over the side rails. 3. The client was found lying on the floor. 4. The client became restless and tried to get out of bed.

3. The client was found lying on the floor. The incident report should contain the client's name, age, and diagnosis. The report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse.

14. A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1. Obtain a court order for the surgical procedure. 2. Ask the EMS team to sign the informed consent. 3. Transport the victim to the operating room for surgery. 4. Call the police to identify the client and locate the family.

3. Transport the victim to the operating room for surgery. In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the best action.

738. A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition? 1. Pyelonephritis 2. Glomerulonephritis 3. Trauma to the bladder or abdomen 4. Renal cancer in the client's family

3. Trauma to the bladder or abdomen Bladder trauma or injury should be considered or suspected in the client with low abdominal pain and hematuria. Glomerulonephritis and pyelonephritis would be accompanied by fever and are thus not applicable to the client described in this question. Renal cancer would not cause pain that is felt in the low abdomen; rather, the pain would be in the flank area.

603. Sildenafil (Viagra) is prescribed to treat a client with erectile dysfunction. The nurse reviews the client's medical record and should question the prescription if which data is noted in the client's history? 1. Insomnia 2. Neuralgia 3. Use of nitroglycerin 4. Use of multivitamins

3. Use of nitroglycerin Sildenafil (Viagra) enhances the vasodilating effect of nitric oxide in the corpus cavernosum of the penis, thus sustaining an erection. Because of the effect of the medication, it is contraindicated with concurrent use of organic nitrates and nitroglycerin. Sildenafil is not contraindicated with the use of vitamins. Insomnia and neuralgia are side effects of the medication.

23. An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? 1. "Oh, really. I will discuss this situation with your son." 2. "Let's talk about the ways you can manage your time to prevent this from happening." 3. "Do you have any friends that can help you out until you resolve these important issues with your son?" 4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay." The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. Options 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client.

449. The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan? 1. "Caution should be used when straddling the infant on a hip." 2. "Vital signs should be taken daily to check for bladder infection." 3. "Catheterization will be necessary when the infant does not void." 4. "Circumcision has been delayed to save tissue for surgical repair."

4. "Circumcision has been delayed to save tissue for surgical repair." Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. Options 1, 2, and 3 are unrelated to this disorder.

591. The nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement by the student indicates an accurate understanding of this disorder? 1. "Cushing's disease results from an oversecretion of insulin." 2. "Cushing's disease results from an undersecretion of corticotropic hormones." 3. "Cushing's disease results from an undersecretion of mineralocorticoid hormones." 4. "Cushing's disease results from an increased pituitary secretion of adrenocorticotropic hormone."

4. "Cushing's disease results from an increased pituitary secretion of adrenocorticotropic hormone." Cushing's disease is a metabolic disorder characterized by abnormally increased secretion (endogenous) of cortisol, caused by increased amounts of adrenocorticotropic hormone (ACTH) secreted by the pituitary gland. Addison's disease is characterized by the hyposecretion of adrenal cortex hormones (glucocorticoids and mineralocorticoids) from the adrenal gland, resulting in deficiency of the corticosteroid hormones. Options 1, 2, and 3 are inaccurate regarding Cushing's disease.

476. The nurse provides home care instructions to the parent of a child with acquired immunodeficiency syndrome (AIDS). Which statement by the parent indicates the need for further teaching? 1. "I will wash my hands frequently." 2. "I will keep my child's immunizations up to date." 3. "I will avoid direct unprotected contact with my child's body fluids." 4. "I can send my child to day care if he has a fever, as long as it is a low-grade fever."

4. "I can send my child to day care if he has a fever, as long as it is a low-grade fever." AIDS is a disorder caused by HIV and characterized by generalized dysfunction of the immune system. A child with AIDS who is sick or has a fever should be kept home and not brought to a day care center. Options 1, 2, and 3 are correct statements and would be actions a caregiver should take when the child has AIDS.

18. A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? 1. "I will sign as a witness to your signature." 2. "You will need to find a witness on your own." 3. "Whoever is available at the time will sign as a witness for you." 4. "I will call the nursing supervisor to seek assistance regarding your request."

4. "I will call the nursing supervisor to seek assistance regarding your request." Living wills, also known as natural death acts in some states, are required to be in writing and signed by the client. The client's signature must be witnessed by specified individuals or notarized. Laws and guidelines regarding living wills vary from state to state, and it is the responsibility of the nurse to know the laws. Many states prohibit any employee, including the nurse of a facility where the client is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor.

756. A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication? 1. Diuretics 2. Antibiotics 3. Antitussives 4. Decongestants

4. Decongestants In the client with benign prostatic hyperplasia, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants. The client should be questioned about the use of these medications if the client has urinary retention. Retention also can be precipitated by other factors, such as alcoholic beverages, infection, bed rest, and becoming chilled.

576. The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? 1. "I will stop taking my insulin if I'm too sick to eat." 2. "I will decrease my insulin dose during times of illness." 3. "I will adjust my insulin dose according to the level of glucose in my urine." 4. "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL."

4. "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL." During illness, the client should monitor blood glucose levels and should notify the HCP if the level is higher than 250 mg/dL. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the HCP's advice and are usually adjusted on the basis of blood glucose levels, not urinary glucose readings.

448. The nurse provided discharge instructions to the parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicate that further teaching is necessary? 1. "I'll check his temperature." 2. "I'll give him medication so he'll be comfortable." 3. "I'll check his voiding to be sure there's no problem." 4. "I'll let him decide when to return to his play activities."

4. "I'll let him decide when to return to his play activities." Cryptorchidism is a condition in which one or both testes fail to descend through the inguinal canal into the scrotal sac. Surgical correction may be necessary. All vigorous activities should be restricted for 2 weeks after surgery to promote healing and prevent injury. This prevents dislodging of the suture, which is internal. Normally, 2-year-olds want to be active; allowing the child to decide when to return to his play activities may prevent healing and cause injury. The parents should be taught to monitor the temperature, provide analgesics as needed, and monitor the urine output.

479. The mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. The health care provider has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV. The nurse should make which most appropriate response to the mother? 1. "I am so pleased also that everything has turned out fine." 2. "Because symptoms have not developed, it is unlikely that your infant will develop HIV infection." 3. "Everything looks great, but be sure that you return with your infant next month for the scheduled visit." 4. "Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old."

4. "Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old." AIDS is caused by HIV and characterized by generalized dysfunction of the immune system. Most children infected with HIV develop symptoms within the first 9 months of life. The remaining infected children become symptomatic sometime before age 3 years. With their immature immune systems, children have a much shorter incubation period than adults. Options 1, 2, and 3 are incorrect.

593. The nurse is interviewing a client with type 2 diabetes mellitus. Which statement by the client indicates an understanding of the treatment for this disorder? 1. "I take oral insulin instead of shots." 2. "By taking these medications, I am able to eat more." 3. "When I become ill, I need to increase the number of pills I take." 4. "The medications I'm taking help release the insulin I already make."

4. "The medications I'm taking help release the insulin I already make." Clients with type 2 diabetes mellitus have decreased or impaired insulin secretion. Oral hypoglycemic agents are given to these clients to facilitate glucose uptake. Insulin injections may be given during times of stress-induced hyperglycemia. Oral insulin is not available because of the breakdown of the insulin by digestion. Options 1, 2, and 3 are incorrect.

484. The nurse provides home care instructions to the parents of a child hospitalized with pertussis who is in the convalescent stage and is being prepared for discharge. Which statement by a parent indicates a need for further instruction? 1. "We need to encourage our child to drink fluids." 2. "Coughing spells may be triggered by dust or smoke." 3. "Vomiting may occur when our child has coughing episodes." 4. "We need to maintain droplet precautions and a quiet environment for at least 2 weeks."

4. "We need to maintain droplet precautions and a quiet environment for at least 2 weeks." Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase. Options 1, 2, and 3 are accurate components of home care instructions.

919. The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client understands the instructions? 1. "My medications aren't likely to make me anxious." 2. "I'll go to support group and talk so that I don't hurt anyone." 3. "It's not likely that I'll get anxious or hear things if I get enough sleep and eat well." 4. "When I begin to hallucinate, I'll call my therapist and talk about what I should do."

4. "When I begin to hallucinate, I'll call my therapist and talk about what I should do." The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse should ask the client whether he or she has intentions to hurt him- or herself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness, but are not specific interventions for hallucinations, if they occur.

938. A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." What is the nurse's best response? 1. "Have you talked to your family about this?" 2. "Everyone feels this way when they are depressed." 3. "You will feel better once your medication begins to work." 4. "You sound very upset. Are you thinking of hurting yourself?"

4. "You sound very upset. Are you thinking of hurting yourself?" Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The nurse should ask the client directly whether a plan for self-harm exists. Options 1, 2, and 3 do not deal directly with the client's feelings.

882. A client with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication? 1. "You have everything to live for." 2. "Why do you see yourself as a failure?" 3. "Feeling like this is all part of being depressed." 4. "You've been feeling like a failure for a while?"

4. "You've been feeling like a failure for a while?" Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. The remaining options block communication because they minimize the client's experience and do not facilitate exploration of the client's expressed feelings. In addition, use of the word "why" is nontherapeutic.

936. The nurse is developing a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? 1. A crisis state indicates that the client has a mental illness. 2. A crisis state indicates that the client has an emotional illness. 3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis. 4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client. Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one client may not constitute a crisis for another client because each is a unique individual. Being in the crisis state does not mean that the client has a mental or emotional illness.

590. The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? 1. A coagulation time of 5 minutes 2. A urinary output of 50 mL/hour 3. A blood urea nitrogen level of 20 mg/dL 4. A heart rate that is 90 beats/minute and irregular

4. A heart rate that is 90 beats/minute and irregular The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, increased platelet aggregation, and stroke. Death can occur from shock, stroke, kidney failure, dysrhythmias, or dissecting aortic aneurysm. An irregular heart rate indicates the presence of a dysrhythmia. A coagulation time of 5 minutes is normal. A urinary output of 50 mL/hour is an adequate output. A blood urea nitrogen level of 20 mg/dL is a normal finding.

487. A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a history of a severe allergy to which substance? 1. Eggs 2. Penicillin 3. Sulfonamides 4. A previous dose of hepatitis B vaccine or component

4. A previous dose of hepatitis B vaccine or component A contraindication to receiving the hepatitis B vaccine is a previous anaphylactic reaction to a previous dose of hepatitis B vaccine or to a component (aluminum hydroxide or yeast protein) of the vaccine. An allergy to eggs, penicillin, and sulfonamides is unrelated to the contraindication to receiving this vaccine.

760. Phenazopyridine (Pyridium) is prescribed for a client for symptomatic relief of pain resulting from a lower urinary tract infection. The nurse should provide the client with which information regarding this medication? 1. Take the medication at bedtime. 2. Take the medication before meals. 3. Discontinue the medication if a headache occurs. 4. A reddish orange discoloration of the urine may occur.

4. A reddish orange discoloration of the urine may occur. The nurse should instruct the client that a reddish-orange discoloration of urine may occur. The nurse also should instruct the client that this discoloration can stain fabric. The medication should be taken after meals to reduce the possibility of gastrointestinal upset. A headache is an occasional side effect of the medication and does not warrant discontinuation of the medication.

911. A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? a. Encouraging quiet reading and writing for the first few days b. Identification of physical activities that will provide exercise c. No socializing activities, until the client asks to participate in milieu d. A structured program of activities in which the client can participate

4. A structured program of activities in which the client can participate A client with depression often is withdrawn while experiencing difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. The remaining options are either too "restrictive" or offer little or no structure and stimulation.

887. On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse anticipates which client behavior? 1. Fearfulness regarding treatment measures. 2. Anger and aggressiveness directed toward others. 3. An understanding of the pathology and symptoms of the diagnosis. 4. A willingness to participate in the planning of the care and treatment plan.

4. A willingness to participate in the planning of the care and treatment plan. In general, clients seek voluntary admission. If a client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program since they are actively seeking help. The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee a client's understanding of their illness, only of their desire for help.

584. The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? 1. Correct the acidosis. 2. Administer 5% dextrose intravenously. 3. Apply a monitor for an electrocardiogram. 4. Administer short-duration insulin intravenously.

4. Administer short-duration insulin intravenously. Lack (absolute or relative) of insulin is the primary cause of DKA. Treatment consists of insulin administration (short or rapid-acting), intravenous fluid administration (normal saline initially), and potassium replacement, followed by correcting acidosis. Applying an electrocardiogram monitor is not the priority action.

485. An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention should the nurse suggest to the parent? 1. Monitor the infant for a fever. 2. Bring the infant back to the clinic. 3. Apply a hot pack to the injection site. 4. Apply a cold pack to the injection site.

4. Apply a cold pack to the injection site. On occasion, tenderness, redness, or swelling may occur at the site of the DTaP injection. This can be relieved with cold packs for the first 24 hours, followed by warm or cold compresses if the inflammation persists. Bringing the infant back to the clinic is unnecessary. Option 1 may be an appropriate intervention, but is not specific to the subject of the question, a localized reaction at the injection site. Hot packs are not applied and can be harmful by causing burning of the skin.

950. A client is scheduled for discharge and will be taking phenobarbital sodium (Luminal) for an extended period. The nurse would place highest priority on teaching the client which point that directly relates to client safety? 1. Take the medication only with meals. 2. Take the medication at the same time each day. 3. Use a dose container to help prevent missed doses. 4. Avoid drinking alcohol while taking this medication.

4. Avoid drinking alcohol while taking this medication. Phenobarbital is an anticonvulsant and hypnotic agent. The client should avoid taking any other central nervous system depressants such as alcohol while taking this medication. The medication may be given without regard to meals. Taking the medication at the same time each day enhances compliance and maintains more stable blood levels of the medication. Using a dose container or "pillbox" may be helpful for some clients.

872. The home care nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item? 1. Eggs 2. Milk 3. Yogurt 4. Bananas

4. Bananas Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts are at risk for developing a latex allergy. This is thought to be the result of a possible cross-reaction between the food and the latex allergen. Options 1, 2, and 3 are unrelated to latex allergy.

481. The nurse is caring for a 4-year-old child with human immunodeficiency virus (HIV) infection. The nurse should plan care with the understanding that which childhood psychosocial need occurs at this age? 1. Expressing fear, withdrawal, and denial 2. Beginning to understand that something is wrong 3. Unable to grasp the concept of illness and death 4. Beginning to conceptualize the death process as involving physical harm

4. Beginning to conceptualize the death process as involving physical harm A preschool child begins to conceptualize the death process as involving physical harm. A child from birth to 2 years of age is unable to grasp the concept of illness and death. A school-age child begins to understand that something is wrong. An adolescent expresses fear, withdrawal, and denial.

754. A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which assessment finding indicates the need to notify the health care provider (HCP)? 1. Red bloody urine 2. Pain related to bladder spasms 3. Urinary output of 200 mL higher than intake 4. Blood pressure, 100/50 mm Hg; pulse, 130 beats/minute

4. Blood pressure, 100/50 mm Hg; pulse, 130 beats/minute Frank bleeding (arterial or venous) may occur during the first day after surgery. Some hematuria is usual for several days after surgery. A urinary output of 200 mL more than intake is adequate. Bladder spasms are expected to occur following surgery. A rapid pulse with a low blood pressure is a potential sign of excessive blood loss. The HCP should be notified.

402. A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted? 1. The child has no tears. 2. Urine specific gravity is 1.030. 3. Urine output is less than 1 mL/kg/hour. 4. Capillary refill is less than 2 seconds.

4. Capillary refill is less than 2 seconds. Indicators that fluid volume deficit is resolving would be capillary refill less than 2 seconds, specific gravity of 1.002 to 1.025, urine output of at least 1 mL/kg/hour, and adequate tear production. A capillary refill time less than 2 seconds is the only indicator that the child is improving. Urine output of less than 1 mL/kg/hour, a specific gravity of 1.030, and no tears would indicate that the deficit is not resolving.

588. A client is diagnosed with pheochromocytoma. The nurse understands that pheochromocytoma is a condition that has which characteristic? 1. Causes profound hypotension 2. Is manifested by severe hypoglycemia 3. Is not curable and is treated symptomatically 4. Causes the release of excessive amounts of catecholamines

4. Causes the release of excessive amounts of catecholamines Pheochromocytoma is a catecholamine-producing tumor and causes secretion of excessive amounts of epinephrine and norepinephrine. Hypertension is the principal manifestation, and the client has episodes of high blood pressure accompanied by pounding headaches. The excessive release of catecholamine also results in excessive conversion of glycogen into glucose in the liver. Consequently, hyperglycemia and glucosuria occur during attacks. Pheochromocytoma is curable. The primary treatment is surgical removal of one or both of the adrenal glands, depending on whether the tumor is unilateral or bilateral.

397. A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription? 1. Obtains a weight 2. Takes the temperature 3. Takes the blood pressure 4. Checks the amount of urine output

4. Checks the amount of urine output In hypotonic dehydration, electrolyte loss exceeds water loss. The priority assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine output is less than 1 to 2 mL/kg/hour, potassium chloride should not be administered. Although options 1, 2, and 3 are appropriate assessments for a child with dehydration, these assessments are not related specifically to the IV administration of potassium chloride.

19. The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which action to correct the error? 1. Documenting a late entry into the client's record 2. Trying to erase the error for space to write in the correct data 3. Using whiteout to delete the error to write in the correct data 4. Drawing one line through the error, initialing and dating, and then documenting the correct information

4. Drawing one line through the error, initialing and dating, and then documenting the correct information If the nurse makes an error in narrative documentation in the client's record, the nurse should follow agency policies to correct the error. This includes drawing one line through the error, initialing and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation. Erasing data from the client's record and the use of whiteout are prohibited.

742. A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder? 1. Hematuria and pyuria 2. Dysuria and proteinuria 3. Hematuria and urgency 4. Dysuria and penile discharge

4. Dysuria and penile discharge Urethritis in the male client often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge. Because this disorder often coexists with gonorrhea, diagnostic tests are done for both and include culture and rapid assays.

395. A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do? 1. Eat twice the amount normally eaten at lunchtime. 2. Take half the amount of prescribed insulin on practice days. 3. Take the prescribed insulin at noontime rather than in the morning. 4. Eat a small box of raisins or drink a cup of orange juice before soccer practice.

4. Eat a small box of raisins or drink a cup of orange juice before soccer practice. Hypoglycemia is a blood glucose level less than 70 mg/dL and results from too much insulin, not enough food, or excessive activity. An extra snack of 15 to 30 g of carbohydrates eaten before activities such as soccer practice would prevent hypoglycemia. A small box of raisins or a cup of orange juice provides 15 to 30 g of carbohydrates. The child or parents should not be instructed to adjust the amount or time of insulin administration. Meal amounts should not be doubled.

10. The role of the nurse regarding complementary and alternative medicine should include which action? 1. Advising the client about "good" versus "bad" therapies 2. Recommending herbal remedies that the client should use 3. Discouraging the client from using any alternative therapies 4. Educating the client about therapies that he or she is using or is interested in using

4. Educating the client about therapies that he or she is using or is interested in using Complementary (alternative) therapies include a wide variety of treatment modalities that are used in addition to conventional therapy to treat a disease or illness. Educating the client about therapies that he or she uses or is interested in using is the nurse's role. Options 1, 2, and 3 are inappropriate actions for the nurse to take because they provide advice to the client.

764. Following kidney transplantation, cyclosporine (Sandimmune) is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication? 1. Normal hemoglobin level 2. Decreased creatinine level 3. Decreased white blood cell count 4. Elevated blood urea nitrogen level

4. Elevated blood urea nitrogen level Nephrotoxicity can occur from the use of cyclosporine (Sandimmune). Nephrotoxicity is evaluated by monitoring for elevated blood urea nitrogen and serum creatinine levels. Cyclosporine does not depress the bone marrow.

751. A client newly diagnosed with chronic kidney disease has just been started on peritoneal dialysis. During the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse is most appropriate? 1. Stop the dialysis. 2. Slow the infusion. 3. Decrease the amount to be infused. 4. Explain that the pain will subside after the first few exchanges.

4. Explain that the pain will subside after the first few exchanges. Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, the pain usually disappears after 1 to 2 weeks of treatment. The infusion amount should not be decreased, and the infusion should not be slowed or stopped.

959. A client gives the home health nurse a bottle of clomipramine (Anafranil). The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication? 1. Complaints of insomnia 2. Complaints of hunger and fatigue 3. A pulse rate less than 60 beats/minute 4. Frequent hand-washing with hot soapy water

4. Frequent hand-washing with hot soapy water Clomipramine (Anafranil) is a tricyclic antidepressant used to treat obsessive-compulsive disorder. Sedation sometimes occurs. Insomnia seldom is a side effect. Weight gain and tachycardia are side/adverse effects of this medication.

398. An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note? 1. Sweating and tremors 2. Hunger and hypertension 3. Cold, clammy skin and irritability 4. Fruity breath odor and decreasing level of consciousness

4. Fruity breath odor and decreasing level of consciousness Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Signs of hyperglycemia include fruity breath odor and a decreasing level of consciousness. Hunger can be a sign of hypoglycemia or hyperglycemia, but hypertension is not a sign of diabetic ketoacidosis. Hypotension occurs because of a decrease in blood volume related to the dehydrated state that occurs during diabetic ketoacidosis. Cold clammy skin, irritability, sweating, and tremors all are signs of hypoglycemia.

952. The nurse is administering risperidone (Risperdal) to a client who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client? 1. Get adequate sunlight. 2. Continue driving as usual. 3. Avoid foods rich in potassium. 4. Get up slowly when changing positions.

4. Get up slowly when changing positions. Risperidone (Risperdal) can cause orthostatic hypotension. Sunlight should be avoided by the client taking this medication. With any psychotropic medication, caution needs to be taken (such as with driving or other activities requiring alertness) until the individual can determine whether his or her level of alertness is affected. Food interaction is not a concern.

572. An external insulin pump is prescribed for a client with diabetes mellitus and the client asks the nurse about the functioning of the pump. The nurse bases the response on which information about the pump? 1. Is timed to release programmed doses of short-duration or NPH insulin into the bloodstream at specific intervals 2. Continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels 3. Is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream 4. Gives a small continuous dose of short-duration insulin subcutaneously, and the client can self-administer a bolus with an additional dose from the pump before each meal

4. Gives a small continuous dose of short-duration insulin subcutaneously, and the client can self-administer a bolus with an additional dose from the pump before each meal An insulin pump provides a small continuous dose of short-duration (rapid or short-acting) insulin subcutaneously throughout the day and night, and the client can self-administer a bolus with an additional dose from the pump before each meal as needed. Short-duration insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas.

755. The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? 1. Hypertension, tachycardia, and fever 2. Hypotension, bradycardia, and hypothermia 3. Restlessness, irritability, and generalized weakness 4. Headache, deteriorating level of consciousness, and twitching

4. Headache, deteriorating level of consciousness, and twitching Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing increased intracranial pressure and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates.

16. The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which action first? 1. Call the hospital lawyer. 2. Refuse to float to the ICU. 3. Call the nursing supervisor. 4. Identify tasks that can be performed safely in the ICU.

4. Identify tasks that can be performed safely in the ICU. Floating is an acceptable legal practice used by hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Calling the hospital lawyer is a premature action.

897. The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function 2. Exploring the client's potential for self-harm 3. Inquiring about the client's perception or appraisal of why the rescue was unsuccessful 4. Inquiring about and examining the client's feelings for any that may block adaptive coping

4. Inquiring about and examining the client's feelings for any that may block adaptive coping The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. The correct option pertains directly to the client's feelings and is client-focused. The remaining options do not directly focus on or address the client's feelings.

447. A 7-year-old child is seen in a clinic, and the primary health care provider documents a diagnosis of primary nocturnal enuresis. The nurse should provide which information to the parents? 1. Primary nocturnal enuresis does not respond to treatment. 2. Primary nocturnal enuresis is caused by a psychiatric problem. 3. Primary nocturnal enuresis requires surgical intervention to improve the problem. 4. Most children outgrow the bed-wetting problem without therapeutic intervention.

4. Most children outgrow the bed-wetting problem without therapeutic intervention. Primary nocturnal enuresis occurs in a child who has never been dry at night for extended periods. The condition is common in children, and most children eventually outgrow bed-wetting without therapeutic intervention. The child is unable to sense a full bladder and does not awaken to void. The child may have delayed maturation of the central nervous system. The condition is not caused by a psychiatric problem.

400. A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion? 1. Potassium infusion 2. NPH insulin infusion 3. 5% dextrose infusion 4. Normal saline infusion

4. Normal saline infusion Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Rehydration is the initial step in resolving diabetic ketoacidosis. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route. Dextrose solutions are added to the treatment when the blood glucose level decreases to an acceptable level. Intravenously administered potassium may be required, depending on the potassium level, but would not be part of the initial treatment.

451. The nurse understands that which information collected during the assessment of a child recently diagnosed with glomerulonephritis is most often associated with the diagnosis? 1. Child fell off a bike onto the handlebars 2. Nausea and vomiting for the last 24 hours 3. Urticaria and itching for 1 week before diagnosis 4. Streptococcal throat infection 2 weeks before diagnosis

4. Streptococcal throat infection 2 weeks before diagnosis Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Group A β-hemolytic streptococcal infection is a cause of glomerulonephritis. Often, a child becomes ill with streptococcal infection of the upper respiratory tract and then develops symptoms of acute poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks. The assessment data in options 1, 2, and 3 are unrelated to a diagnosis of glomerulonephritis.

488. The home health nurse visits a child with infectious mononucleosis and provides home care instructions to the parents about the care of the child. Which instruction should the nurse give to the parents? 1. Maintain the child on bed rest for 2 weeks. 2. Maintain respiratory precautions for 1 week. 3. Notify the health care provider (HCP) if the child develops a fever. 4. Notify the HCP if the child develops abdominal pain or left shoulder pain.

4. Notify the HCP if the child develops abdominal pain or left shoulder pain. Infectious mononucleosis is caused by Epstein-Barr virus. The parents need to be instructed to notify the HCP if abdominal pain, especially in the left upper quadrant, or left shoulder pain occurs because this may indicate splenic rupture. Children with enlarged spleens also are instructed to avoid contact sports until splenomegaly resolves. Bed rest is unnecessary, and children usually self-limit their activity. Respiratory precautions are not required, although transmission can occur via direct intimate contact or contact with infected blood. Fever is treated with acetaminophen (Tylenol) or ibuprofen (Motrin IB) per health care provider preference.

750. The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the most appropriate nursing action? 1. Monitor the client. 2. Elevate the head of the bed. 3. Medicate the client for nausea. 4. Notify the health care provider (HCP)

4. Notify the health care provider (HCP) Disequilibrium syndrome may be caused by the rapid decreases in the blood urea nitrogen level during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs/symptoms of disequilibrium syndrome and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The HCP must be notified.

21. A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1. Performing a procedure without consent 2. Threatening to give a client a medication 3. Telling the client that he or she cannot leave the hospital 4. Observing care provided to the client without the client's permission

4. Observing care provided to the client without the client's permission Invasion of privacy occurs with unreasonable intrusion into an individual's private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment.

747. A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess the client for which manifestations of this complication? 1. Warmth, redness, and pain in the left hand 2. Aching pain, pallor, and edema of the left arm 3. Edema and reddish discoloration of the left arm 4. Pallor, diminished pulse, and pain in the left hand

4. Pallor, diminished pulse, and pain in the left hand Steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and a diminished pulse distal to the fistula. The client also complains of pain distal to the fistula, caused by tissue ischemia. Warmth and redness probably would characterize a problem with infection. The manifestations described in options 2 and 3 are incorrect.

475. An infant of a mother infected with HIV is seen in the clinic each month and is being monitored for symptoms indicative of human immunodeficiency virus (HIV) infection. The nurse assesses the infant, knowing that which infection is the most common opportunistic infection of children infected with HIV? 1. Meningitis 2. Gastroenteritis 3. Cytomegalovirus infection 4. Pneumocystis jiroveci pneumonia

4. Pneumocystis jiroveci pneumonia AIDS is a disorder caused by HIV and characterized by generalized dysfunction of the immune system. The most common opportunistic infection of children infected with HIV is P. jiroveci pneumonia, which occurs most frequently between the ages of 3 and 6 months, when HIV status may be indeterminate. Cytomegalovirus infection is also characteristic of HIV infection; however, it is not the most common opportunistic infection. Although neurological abnormalities and gastrointestinal disturbances may occur in a child with HIV infection, options 1 and 2 are not specific opportunistic infections noted in the HIV-infected child.

401. The nurse has just administered ibuprofen (Motrin IB) to a child with a temperature of 38.8° C (102° F). The nurse should also take which action? 1. Withhold oral fluids for 8 hours. 2. Sponge the child with cold water. 3. Plan to administer salicylate (aspirin) in 4 hours. 4. Remove excess clothing and blankets from the child.

4. Remove excess clothing and blankets from the child. After administering ibuprofen, excess clothing and blankets should be removed. The child can be sponged with tepid water, but not cold water because the cold water can cause shivering, which increases metabolic requirements above those already caused by the fever. Aspirin is not administered to a child with fever because of the risk of Reye's syndrome. Fluids should be encouraged to prevent dehydration, so oral fluids should not be withheld.

763. Oxybutynin chloride (Ditropan XL) is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication? 1. Pallor 2. Drowsiness 3. Bradycardia 4. Restlessness

4. Restlessness Toxicity (overdosage) of oxybutynin produces central nervous system excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression. Drowsiness is a frequent side effect of the medication but does not indicate overdosage

880. The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome who is receiving foscarnet, an antiviral medication. The nurse should monitor the results of which laboratory study while the client is taking this medication? 1. CD4 cell count 2. Lymphocyte count 3. Serum albumin level 4. Serum creatinine level

4. Serum creatinine level Foscarnet is toxic to the kidneys. The serum creatinine level is monitored before therapy, two or three times per week during induction therapy, and at least weekly during maintenance therapy. Foscarnet also may cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels also are measured with the same frequency.

744. A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder? 1. Soft and swollen prostate gland 2. Reddened, swollen, and boggy prostate gland 3. Tender and edematous prostate gland with ecchymosis 4. Tender, indurated prostate gland that is warm to the touch

4. Tender, indurated prostate gland that is warm to the touch The client with bacterial prostatitis has a swollen and tender prostate gland that is also warm to the touch, firm, and indurated. Systemic symptoms include fever with chills, perineal and low back pain, and signs of urinary tract infection, which often accompany the disorder

896. A client's unresolved feelings related to loss would be most likely observed during which phase of the therapeutic nurse-client relationship? 1. Trusting 2. Working 3. Orientation 4. Termination

4. Termination In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for clients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase. The remaining options are not specifically associated with this issue of unresolved feelings.

873. The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine (Pentam 300). The client develops a temperature of 101° F. The nurse continues to assess the client, knowing that this sign most likely indicates which condition? 1. That the dose of the medication is too low 2. That the client is experiencing toxic effects of the medication 3. That the client has developed inadequacy of thermoregulation 4. That the client has developed another infection caused by leukopenic effects of the medication

4. That the client has developed another infection caused by leukopenic effects of the medication Frequent side/adverse effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of infection. Options 1, 2, and 3 are inaccurate interpretations.

7. The nurse is preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that surgery is necessary. The nurse considers the client's religious preferences in developing the plan of care and should document which information? 1. The client believes the soul lives on after death. 2. Medication administration is not allowed. 3. Surgery is prohibited in this religious group. 4. The administration of blood and blood products is not allowed.

4. The administration of blood and blood products is not allowed. Among Jehovah's Witnesses, surgery is not prohibited, but the administration of blood and blood products is forbidden. This religious group believes the soul cannot live after death. Administration of medication is an acceptable practice except if the medication is derived from blood products.

757. Nitrofurantoin (Macrodantin) is prescribed for a client with a urinary tract infection. The client contacts the nurse and reports a cough, chills, fever, and difficulty breathing. The nurse should make which interpretation about the client's complaints? 1. The client may have contracted the flu. 2. The client is experiencing anaphylaxis. 3. The client is experiencing expected effects of the medication. 4. The client is experiencing a pulmonary reaction requiring cessation of the medication.

4. The client is experiencing a pulmonary reaction requiring cessation of the medication. Nitrofurantoin can induce two kinds of pulmonary reactions: acute and subacute. Acute reactions, which are most common, manifest with dyspnea, chest pain, chills, fever, cough, and alveolar infiltrates. These symptoms resolve 2 to 4 days after discontinuing the medication. Acute pulmonary responses are thought to be hypersensitivity reactions. Subacute reactions are rare and occur during prolonged treatment. Symptoms (e.g., dyspnea, cough, malaise) usually regress over weeks to months following nitrofurantoin withdrawal. However, in some clients, permanent lung damage may occur. The remaining options are incorrect interpretations.

949. A client with schizophrenia has been started on medication therapy with clozapine (Clozaril). The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? 1. Platelet count 2. Blood glucose level 3. Liver function studies 4. White blood cell count

4. White blood cell count A client taking clozapine (Clozaril) may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count. Treatment is interrupted if the white blood cell count decreases to less than 3000 cells/mm3. Agranulocytosis could be fatal if undetected and untreated. The other laboratory studies are not related specifically to the use of this medication.

12. The nurse educator asks a student to list the five categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, would indicate an understanding of the five categories of CAM? 1. Herbology, hydrotherapy, acupuncture, nutrition, and chiropractic care 2. Mind-body medicine, traditional Chinese medicine, homeopathy, naturopathy, and healing touch 3. Biologically based practices, body-based practices, magnetic therapy, massage therapy, and aromatherapy 4. Whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine

4. Whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine The five categories of complementary and alternative medicine (CAM) include whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine. The other options contain therapies within each category of CAM.

478. A health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV) to determine the presence of HIV antigen in the infant. The nurse anticipates that which laboratory study will be prescribed for the infant? 1. Chest x-ray 2. Western blot 3. CD4+ cell count 4. p24 antigen assay

4. p24 antigen assay The detection of HIV in infants is confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain reaction. A Western blot test confirms the presence of HIV antibodies. The CD4+ cell count indicates how well the immune system is working. A chest x-ray evaluates the presence of other manifestations of HIV infection, such as pneumonia.

5. The nurse is sensitive to the fact that a person's perceptions about end-of-life care are dependent on __________. (Select all that apply.) a. age b. gender c. cultural background d. caregivers e. life experiences

a. age b. gender c. cultural background e. life experiences The caregivers are there to be supportive. A person's attitude about end-of-life care is affected by his or her age, gender, cultural background, religious affiliations, and life experiences.

10. The nurse shares the information that the benefits of dehydration for persons near death are __________. (Select all that apply.) a. better gas exchange because of reduction of fluid in the lungs b. decreased need to suction because of reduction of respiratory secretions c. improved bowel elimination because of reduced bulk in the stool d. decreased pain related to release of endorphins e. improved drug distribution via the circulating volume

a. better gas exchange because of reduction of fluid in the lungs b. decreased need to suction because of reduction of respiratory secretions d. decreased pain related to release of endorphins Bowel elimination and drug distribution are both reduced when the patient is dehydrated.

2. The holistic caregiver will bring to end-of-life care the ability to __________. (Select all that apply.) a. communicate and respond to the patient's concerns about death b. embrace the value of palliative care rather than curative care c. help the patient and family face loss and grieve in anticipation of loss d. encourage the patient to focus on wellness and recovery e. collaborate with other professionals for patient support

a. communicate and respond to the patient's concerns about death b. embrace the value of palliative care rather than curative care c. help the patient and family face loss and grieve in anticipation of loss e. collaborate with other professionals for patient support The focus of palliative care is not recovery.

12. The daughter of a dying patient is distressed about oversedation related to her mother's receiving 2 mg of morphine sulfate every hour. The nurse clarifies that this small dose of morphine is helpful in controlling the end-of-life symptom of: a. dyspnea. b. pain. c. hallucinations. d. fatigue.

a. dyspnea. Administering frequent, small doses of morphine sulfate is standard protocol to reduce end-of-life air hunger. One dose is not enough for euthanasia.

1. An 80-year-old female patient is receiving palliative care for heart failure. The primary purpose(s) of her receiving palliative care is (are) to (select all that apply) a. improve her quality of life. b. assess her coping ability with disease. c. have time to teach patient and family about disease. d. focus on reducing the severity of disease symptoms. e. provide care that the family is unwilling or unable to give.

a. improve her quality of life. d. focus on reducing the severity of disease symptoms.

4. The nurse lists the benefits of filing an advance directive, which are that this document __________. (Select all that apply.) a. is legally binding b. remains in effect until the family changes it c. prevents last-minute confusion about the wishes of the patient d. prevents violation of end-of-life choices e. clarifies end-of-life issues for the family

a. is legally binding c. prevents last-minute confusion about the wishes of the patient d. prevents violation of end-of-life choices e. clarifies end-of-life issues for the family The family cannot alter an advance directive made by a patient. It is a legally binding document that clarifies and prevents violation of end-of-life choices of the patient and can only be altered by the patient.

8. To meet the changing needs of the dying person, interservice collaboration is necessary among __________. (Select all that apply.) a. medical professionals b. social workers c. clergy d. transportation services e. dieticians

a. medical professionals b. social workers c. clergy e. dieticians The dying person's needs change as their physical processes decline. Communication and collaboration among specialty services are necessary. Transportation services are not in the basic care collaboration.

11. A resident in the long-term care facility has just expired at 2 AM, and the family is on the way to say their last goodbyes. Before the arrival of the family, the nurse should __________. (Select all that apply.) a. remove equipment (e.g., IV poles and tubing, feeding tubes, oxygen equipment) b. dress the resident in a clean gown and cover him or her with a clean sheet c. remove dentures d. apply a diaper to catch draining body fluids e. provide privacy by drawing the curtain or moving the other resident to an unoccupied room

a. remove equipment (e.g., IV poles and tubing, feeding tubes, oxygen equipment) b. dress the resident in a clean gown and cover him or her with a clean sheet d. apply a diaper to catch draining body fluids e. provide privacy by drawing the curtain or moving the other resident to an unoccupied room Removing the dentures give the face an unnatural appearance. All the other activities are appropriate to prepare the resident and environment after death.

1. The home health nurse encourages the older adult to file an advance directive to indicate: a. the degree of intervention desired for life support. b. who is to manage medical decisions in case of debilitating illness. c. who will manage finances in case of debilitating illness. d. the mortuary to be used in the case of death.

a. the degree of intervention desired for life support. Advance directives indicate the degree of interventions desired for life support in the case of a terminal illness.

6. The charge nurse on an oncology unit encourages the staff to complete a values clarification exercise to identify __________. (Select all that apply.) a. their own values b. values that influence care decisions c. values that must be abandoned or changed d. values that may cause an ethical dilemma e. negative values

a. their own values b. values that influence care decisions d. values that may cause an ethical dilemma A value clarification exercise neither designates any value as negative nor suggests that any value be abandoned. The exercise is to help persons gain insight into their own value system.

7. The nurse considers the provisions of palliative care, which are to __________. (Select all that apply.) a. treat symptoms of pain, dyspnea, and nausea b. promote acceptance of death c. provide CPR d. monitor mechanical ventilation machines e. enable the patient to have a better quality of life

a. treat symptoms of pain, dyspnea, and nausea b. promote acceptance of death e. enable the patient to have a better quality of life Providing mechanical ventilation equipment and performing CPR are not aspects of palliative care.

2. The patient is attempting to make an informed decision about whether to have a life-extending treatment done. The essential piece of information that is significant in the decision is: a. whether the quality of life will improve after the procedure is done. b. the cost of the treatment. c. the amount of time treatment will take. d. whether insurance will cover the cost of treatment.

a. whether the quality of life will improve after the procedure is done. Whether the quality of life will be improved by treatment is the most significant piece of information for making the decision. The consideration about the cost and time involved with the treatment can be addressed after the decision about the treatment has been made.

5. The home health nurse visits a 40-year-old patient with metastatic breast cancer who is receiving palliative care. The patient is experiencing pain at a level of 7 (0-10 point scale). In prioritizing activities for the visit, what should the nurse do first? a. Auscultate for breath sounds. b. Administer PRN pain medication. c. Check pressure points for skin breakdown. d. Ask family about patient's food and fluid intake.

b. Administer PRN pain medication.

1. The nurse is aware that end-of-life planning is often neglected because __________. (Select all that apply.) a. there is a clear procedure to follow b. people are uncomfortable talking about death c. young people do not see the need for end-of-life planning d. end-of-life planning is a relative new concept e. many persons are not really sure what they want to do

b. people are uncomfortable talking about death c. young people do not see the need for end-of-life planning d. end-of-life planning is a relative new concept e. many persons are not really sure what they want to do The options are so numerous that there is not any one clear line of action to follow. End-of-life planning is a relatively new concept that the older generation did not experience in their youth. Persons are reluctant to talk about death issues, especially young persons, who do not see the need.

13. To reduce the threat of aspiration in the unconscious patient who is near death, the nurse should: a. perform deep tracheal suctioning of the patient every hour. b. place the patient in a side-lying position, with the head turned to the side. c. slightly elevate the foot of the bed, with the patient in a supine position. d. give the patient only thickened fluids.

b. place the patient in a side-lying position, with the head turned to the side. Side-lying is a safe position for reducing the threat of aspiration. The supine position is not appropriate for aspiration reduction. Frequent suctioning is stressful to the patient, and fluids are never attempted for an unconscious patient.

3. The totally competent 76-year-old female with terminal cancer is fatigued and tearful about the ineffectiveness of her treatment. She tells the nurse that she wishes she had never started it but now feels obligated to continue. The nurse explains that: a. once treatment has begun, the doctor should decide about any changes. b. she may change her mind about treatment at any time. c. decisions about treatment should be made by the person who is her medical power of attorney. d. cessation of treatment will shorten her life.

b. she may change her mind about treatment at any time. Competent patients can change their minds about treatment options or advance directive options at any time.

9. When the nurse becomes tearful at the death of a patient, the nurse should: a. leave the room so that the family will not witness the unprofessional behavior. b. touch the hand of the daughter and say, "We'll miss your dad." c. become occupied with rearranging a floral bouquet until emotions are under control. d. discontinue the oxygen, turn off the IV, and say, "I'm sorry for your loss."

b. touch the hand of the daughter and say, "We'll miss your dad." Showing that the nurse is experiencing a loss also helps the family deal with their grief. Showing empathetic emotion is not unprofessional. Automatic phrases such as "sorry for your loss" seem insincere.

11. The nurse emphasizes that the objective of pain control for the dying patient is to: a. keep the patient unconscious and relaxed to avoid the perception of pain. b. delay medication until the patient reports that the pain is intense. c. find a control level that reduces pain but allows the patient to interact. d. eradicate pain completely.

c. find a control level that reduces pain but allows the patient to interact. Finding a level of pain control that allows the patient to participate in care and communicate with family is the goal of pain control. Analgesics given before pain becomes intense can keep pain at a moderate level. Completely eradicating pain is usually not realistic.