Study Mid term

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond by stating which?

"Are you fearful and think that others may want to hurt you?"

The nurse provides skin care instructions to the client who is receiving external radiation therapy. Which statement by the client indicates the need for further teaching? Select all that apply.

"I will limit sun exposure to 1 hour daily." "I will apply moisturizer with a cotton tipped applicator for itching. "

A client who is diagnosed with pedophilia & recently has been paroled as a sex offender says, "I'm in treatment & I have served my time. Now this group has posters all over the neighborhood with my photograph & details of my crime." Which is an appropriate response by the nurse?

"You understand that people fear for their children, but you're feeling unfairly treated?"

Which are appropriate interventions for caring for the client in alcohol withdrawal? Select all that apply.

- Monitor VS - Provide a safe environment - Provide reality orientation as appropriate - Address hallucinations therapeutically

The nurse in the mental health unit reviews the therapeutic & nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply.

- Restating -Listening -Maintaining neutral response - Providing acknowledgment & feedback

The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the following as a priority in the plan of care?

1. Protecting the client from infection Rationale: The client with immune deficiency has inadequate or absent 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.

Which interventions would apply in the care of a client at high risk for an allergic response to a latex allergy. Select all that apply.

1. Use non-latex gloves., 2. Use medications from glass ampules., 4. Do not puncture rubber stoppers with needles. 5. Keep a latex-safe supply cart available in the client's area.

A client with pemphigus is being seen in the clinic regularly. The nurse plans care based on which of the following descriptions of this condition?

2. An autoimmune disease that causes blistering in the epidermis

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed, and the serum calcium level is 12.0 mg/dL.Based on this laboratory value, the nurse should take which action?

B) inform the registered nurse of the laboratory value

The nurse is caring for a postrenal transplantation client with prescription for cyclosporine. If the nurse notes an increase in one of the client's vital signs and the client is complaining of a headache, which vital sign is most likely increased?

Blood pressure

A Cub Scout leader who is a 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?

3. "I should not use insect repellent because it will attract the ticks."

The nurse is assisting in administering immunizations at a health care clinic. The nurse understands that immunization provides which of the following?

4. Acquired immunity from disease Answer: 4Rationale: Acquired immunity can occur by receiving an immunization that causes antibodies to a specific pathogen to form. Natural (innate) immunity is present at birth. No immunization protects the client from all diseases. The nurse is assigne

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 of the following nursing actions is appropriate?

4. Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable.

The client with diagnosed acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101° F (38.3° C). The nurse continues to monitor the client, knowing that this sign would most likely indicate which condition?

A result of another infection caused by the leukopenic effects of the medication.

The nurse reviews the client's serum level and notes that the level is 8.0 mg/dL. The nurse understands which condition causes this serum calcium level?

A) prolonged bed rest

The nurse is assisting with conducting a health-promotion program to community members regarding testicular cancer. The nurse determines that further teaching is needed if a community member states that which is a sign/symptom of testicular cancer? Select all that apply.

Alopecia Elevation in prostate specific antigen (PSA) levels

The nurse who is caring for a client with renal failure notes that the client is dyspneic and crackles are heard when listening to breaths sounds in the lungs.

An Increased blood pressure

The client is diagnosed with stage I of Lyme disease. The nurse should check the client for which characteristic of this stage?

Flu-like symptoms

The nurse prepares to give a bath and change the bed linens on a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which of the following would the nurse incorporate in 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. Wearing a gown and gloves to change the bed linens and gloves only for the bath

Answer: 2 Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items, such as wound drainage, or while 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.

Which of the following individuals is least likely at risk for the development of Kaposi's sarcoma? 1. A kidney transplant client 2. A male with a history of same-sex partners 3. A client receiving antineoplastic medications 4. An individual working in an environmentwhere exposure to asbestos exists

Answer: 4 Rationale: Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder and is a common acquired immunodeficiency syndrome indicator. It is seen frequently in men with a history of same-sex partners. Although the cause of Kaposi's sarcoma is not known, it is considered to be the result of an alteration or failure in the immune system. The renal transplant client and the client receiving antineoplastic medications are at risk for immunosuppression. Exposure to asbestos is not related to the development of Kaposi's sarcoma.

A client is suspected of having systemic lupus erythematous. The nurse monitors the client, knowing that which of the following is one of the initial characteristic sign of systemic lupus erythematous? 1. Weight gain 2. Subnormal temperature 3. Elevated red blood cell count 4. Rash on the face across the bridge of the nose and on the cheeks

Answer: 4 Rationale: Skin lesions or rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of systemic lupus erythematosus (SLE). Fever and weight loss may also occur. Anemia is most likely to occur later in SLE.

The nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse should avoid which intervention in the plan of care?

Assigning the client to a room at the end of the hall to prevent disturbing the other clients

Saquinavir is prescribed for the client who is diagnosed with human immunodeficiency virus (HIV) seropositive. The nurse should reinforce medication instructions about which health care measure to the client?

Avoid sun exposure.

The nurse reviews a clients electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level should be noted with which condition?

B) Traumatic Burn

The client calls the office of the primary health care provider (PHCP) and states to the nurse that they were just stung by a bumblebee while gardening. The client is afraid of a severe reaction because their neighbor experienced such a reaction just 1 week ago. Which should be the appropriate nursing action?

Ask the client if they ever sustained a bee sting in the past.

The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL. Which prescribed medication should the nurse prepare to assist in administering to the client?

C) Calcitonin (Miacalcin)

The client diagnosed with acquired immunodeficiency syndrome (AIDS) has begun therapy with zidovudine. The nurse should monitor which laboratory result during treatment with this medication?

Complete blood count

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. Which should the nurse observe for on the cardiac monitor as a result of this laboratory value?

D) Narrow, peaked T waves

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom is an indication of this electrolyte imbalance?

D) generalized muscle weakness

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing?

D) the client with diabetes mellitus

A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door & is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which? Denial

Denial

The nurse is assisting with developing a plan of care for the client with multiple myeloma. Which nursing intervention should be included to prevent renal failure for this client? Select all that apply.

Encouraging fluids Monitoring serum calcium and uric acid levels

A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which?

Evidence of the client's altered & distorted body image

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which observation is indicative of the signs/symptoms associated with withdrawal from opioids?

Fever, yawning, irritability, diaphoresis, and diarrhea,

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse should monitor for which?

HTN, disorientation, hallucinations

Amikacin is prescribed for a client with a diagnosed bacterial infection. The nurse instructs the client to contact the primary health care provider (PHCP) immediately if which occurs?

Hearing loss

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking nevirapine. The nurse should monitor for which side/adverse effects of the medication? Select all that apply.

Hepatotoxicity Rash

The nurse is reviewing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory finding is indicative of the massive cell destruction that occurs with the chemotherapy?

Increased uric acid level

The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room & notes that the client is doing vigorous push-ups. Which nursing action is appropriate? Interrupt the client & offer to take her for a walk

Interrupt the client & offer to take her for a walk

The nurse is assigned to care for a client diagnosed with systemic lupus erythematosus (SLE). The nurse should plan care considering which factor regarding this diagnosis?

It is an inflammatory disease of collagen contained in connective tissue.

The parents of a 16-year-old child tell the nurse that they are concerned because the child sleeps until noon every weekend. Which is the most appropriate nursing response? 1. "Adolescents love to sleep late in the morning." 2. "The child shouldn't be staying up so late at night." 3. "If the child eats properly, that shouldn't be hap-pening." 4. "The child needs to have a blood test to check for anemia."

It's 1. Rationale: the sleep patterns of the adolescent vary some according to individual needs. however, in general, adolescents love to sleep late in the morning, but they should be encourages to be responsible for waking themselves, particularly in time to get ready for school

The nurse is caring for a client with diabetic ketoacidosis and observes that the client is experiencing abnormally deep, regular, rapid respirations. How should the nurse correctly document this observation in the medical record?

Kussmaul's respirations observed

The camp nurse prepares to instruct a group of children about Lyme disease. Which information should the nurse include in the instructions?

Lyme disease is caused by a tick carried by deer.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?

Metabolic alkalosis

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.

Monitor liver function studies. Instruct the client to avoid alcohol. Instruct the client to avoid exposure to the sun.

An intoxicated client is brought to the emergency department by local police. The client is told that the health care provider (HCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the HCP immediately. The nurse assisting to care for the client should plan for which appropriate nursing intervention?

Offer to take the client to an examination room until he or she can be treated.

The nurse observes that a client is psychotic, pacing, & agitated & is making aggressive gestures. The client's speech pattern is rapid, & the client's affect is belligerent. Based on these observations, the nurse's immediate priority of care is which?

Provide safety for the client & other clients on the unit

The client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse should determine that this has been confirmed by which finding?

Punch biopsy of the cutaneous lesions

The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should monitor the client for which acid-base imbalance?

Respiratory acidosis

The nurse is reviewing the results of serum laboratory studies drawn on a client diagnosed with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine. The nurse determines that the client may have the medication discontinued by the primary health care provider (PHCP) if which significantly elevated result is noted?

Serum amylase

The nurse is assigned to care for the client diagnosed with cytomegalovirus retinitis and acquired immunodeficiency syndrome (AIDS) who is receiving foscarnet. The nurse should monitor the results of which laboratory study while the client is taking this medication?

Serum creatinine level

The client is receiving external radiation to the neck for cancer of the larynx. The nurse monitors the client knowing that which are side/adverse effects of the external radiation? Select all that apply.

Sore throat Red and dry skin over neck

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status.

The client presents a harm to self

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the data obtained, the nurse should identify which as a priority concern?

The client's report of self-destructive thoughts

The nurse is assigned to care for a client at risk for alcohol withdrawal. The nurse monitors the client, knowing that the early signs of withdrawal will usually develop within which time after cessation or reduction of alcohol intake?

Within a few hours

The client who is diagnosed with human immunodeficiency virus (HIV) seropositive has been taking stavudine. The nurse should monitor which parameter closely while the client is taking this medication?

gait

The client brought to the emergency department is experiencing an anaphylactic shock from eating shellfish. The nurse needs to implement which immediate action?

maintaining a patient airway.

The nurse is reviewing the laboratory results of a client who is receiving chemotherapy and notes that the platelet count is 10,000 mm3 (10 × 109/L). On the basis of this laboratory value, the nurse should perform which interventions? Select all that apply.

monitor stools for occult blood instruct the client not to bend over at the waist or lift instruct the client to blow nose very gently without blocking either nostril

The client is admitted to the hospital with a diagnosis of suspected Hodgkin's disease. Which signs and symptoms of the client are associated with Hodgkin's disease? Select all that apply.

weakness, night sweats and enlarged lypth nodes

the nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins.The nurse suspects hyponatremia. Which additional signs/symptoms should the nurse expect to note in this client if hyponatremia is present?

D) postural blood pressure changes

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit? A) the client with Addison's disease B) The client with metabolic acidosis C) the client with intestinal obstruction D) the client receiving nasogastric suction

D) the client receiving nasogastric suction

the nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse expects that this sodium level would be noted in a client with which condition?

D) the client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply

- Communicate expected behaviors to the clien t- Assist the client in developing means of setting limits on personal behavior. - Follow through about the consequences of behavior in a nonpunitive manner .- Be clear with the client regarding the consequences of exceeding limits set regarding behavior.

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?

A. Using open-ended questions and silence Rationale: 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.

When reinforcing teaching about signs and symptoms of ovarian cancer with a community group of women, the nurse emphasizes which sign/symptom as being a typical manifestation of the disease recognized by persons diagnosed with the condition?

Abdominal distention or fullness