Week 2: Practice Exam
A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see: 1. tension and irritability. 2. slow pulse. 3. hypotension. 4. constipation.
tension and irritability. Amphetamines are a nervous system stimulant that are subject to abuse because of their ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea, not constipation, is a common adverse effect.
A client has an ordered intravenous infusion that is ordered to infuse at 3000 mL of D5W in a 24-hour period (drop factor of 10). Calculate the drops per minute. Record your answer using a whole number.
21 Volume to be infused times the drop factor, divided by the number of hours, times 60 minutes. 3000 times 10 divided by 24 times 60 equals 30,000 divided by 1440 = 21.
The nurse is caring for a client with an order for an intravenous infusion of dextrose with 5% normal saline at 1500 mL over 8 hrs. The drip administration is set at 10 drops/mL. How fast will the IV infuse (drops/minute)? Record your answer using a whole number.
31 1500 × 10 gtts = 15,000 gtts/8 hr = 1875 gtts/60 min = 31.25 gtts/min=31 gtts/min.
A laboring client with preeclampsia is prescribed magnesium sulfate 2 g/h IV piggyback. The pharmacy sends the IV to the unit labeled magnesium sulfate 20 g/500 ml normal saline. To deliver the correct dose, the nurse should set the pump to deliver how many milliliters per hour? Record your answer using a whole number.
50 Solve as follows: (500 ml/20 g) X 2 g/h = 50 ml/hr.
The nurse collects a urine specimen from a client for a culture and sensitivity analysis. What should the nurse do to preserve the specimen? 1. Send it to the laboratory immediately. 2. Place it on counter for the next specimen pickup. 3. Assign an unlicensed assistive personnel to take it to the laboratory as soon as possible. 4. Store it in the refrigerator until it can be sent to the laboratory.
Send it to the laboratory immediately. A specimen for culture and sensitivity should be sent to the laboratory promptly so that a smear can be taken before organisms start to grow in the specimen.
The physician has prescribed sodium chloride for a hospitalized 51-year-old client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply. 1. Compare ABG findings with previous results. 2. Maintain intake and output records. 3. Document presenting signs and symptoms. 3. Administer I.V. bicarbonate. 4. Suction the client's airway.
Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms. Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. The result is retention of sodium bicarbonate and increased base bicarbonate. Nursing management includes documenting all presenting signs and symptoms to provide accurate baseline data, monitoring laboratory values, comparing ABG findings with previous results (if any), maintaining accurate intake and output records to monitor fluid status, and implementing prescribed medical therapy.
A client with acute mania exhibits euphoria, pressured speech, and flight of ideas. The client has been talking to the nurse nonstop for 5 minutes and lunch has arrived on the unit. What should the nurse do next? 1. Excuse oneself while telling the client to come to the dining room for lunch. 2. Tell the client he needs to stop talking because it is time to eat lunch. 3. Do not interrupt the client, but wait for him to finish talking. 4.Walk away, and approach the client in a few minutes before the food gets cold.
Excuse oneself while telling the client to come to the dining room for lunch. The nurse would request to be excused, showing respect and regard for the client, while telling the client to come to the dining room for lunch. Acutely manic clients need clear, concise comments and directions. Telling the client that he needs to stop talking because it is lunchtime is disrespectful and does not give the client directions for what he needs to do. Using the familiar skill of waiting without interrupting until the person pauses would not be effective with the very talkative, manic client. Walking away and approaching the client after a few minutes before the food gets cold is not helpful because the client would probably continue talking.
The nurse has answered the telephone at the nurses' station, and the individual on the line states that there is bomb in the healthcare facility. What is the nurse's best response? 1. Keep the individual on the line in order to gather more information about the details of the threat. 2. Hang up the telephone immediately, and instruct a colleague to call 911 promptly. 4. Inform the authorities, and begin evacuating clients and closing doors. 5. Hang up the telephone, and use the overhead paging system to call all staff to the nurses' station.
Keep the individual on the line in order to gather more information about the details of the threat If a bomb threat is received, the nurse should keep the caller on the line and talking as long as possible in order to gather information about the location of the bomb and a description of the bomb and the caller. The threat must be reported promptly, but the nurse should not hang up in order to do this.
The nurse should instruct the client to avoid taking which drug while taking metoclopramide hydrochloride? 1. antacids 2. antihypertensives 3. anticoagulants 4. central nervous system depressants
central nervous system depressants Metoclopramide hydrochloride can cause sedation. Alcohol and other central nervous system depressants add to this sedation. A client who is taking this drug should be cautioned to avoid driving or performing other hazardous activities for a few hours after taking the drug. Clients may take antacids, antihypertensives, and anticoagulants while on metoclopramide.
A nursery nurse just received the shift report. Which neonate should the nurse assess first? 1. four-hour-old term neonate with jaundice 2. two-day-old term neonate in an open bassinette 3. six-day-old neonate in an isolette, whose gestational age assessment places him at 36 weeks' gestation 4. twelve-hour-old term neonate who is small for gestational age
four-hour-old term neonate with jaundice The nurse should assess the four-hour-old neonate with jaundice. When jaundice occurs within the first 24 hours of life, it typically indicates a life-threatening disorder, such as sepsis, hemolytic disease of the neonate, Rh incompatibility, or ABO incompatibility. Physiological jaundice, which commonly occurs later, is a benign condition. A 2-day-old term neonate in an open bassinette doesn't require immediate assessment by the nurse. A 6-day-old neonate whose gestational age is 36 weeks is a normal preterm neonate who doesn't require immediate assessment by the nurse. A 12-hour-old term neonate who is small for gestational age doesn't require immediate assessment by the nurse.
A nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality? 1. potassium 2. sodium 3. chloride 4. calcium
sodium Sodium, the major ECF cation, maintains ECF osmolality. Potassium is the major cation in intracellular fluid. Chloride is the major anion in the ECF. Calcium, found primarily in the intravascular fluid compartment of ECF, is the major cation involved in the structure and function of the teeth and bones.
A client's caregivers state that they childproofed their home for their 2-year-old. During a home visit, the nurse discovers some situations that show the caregivers don't fully understand the developmental abilities of their toddler. Which situation displays misunderstanding by the caregivers? 1. safety latches on kitchen cabinets 2. toy chest in front of a second-story, locked window 3. pot handles turned toward the back of the stove 4. hot water heater temperature set at 120° F (48.9° C) or below
toy chest in front of a second-story, locked window A toy chest in front of a second-story locked window displays misunderstanding because toddlers are able to climb on low furniture and open windows that may not always be locked, especially in the summer. In such situations, the client could fall out of the window. Keeping child safety latches on kitchen cabinets, turning pot handles toward the back of the stove, and setting the hot water heater at a nonscalding temperature are all safeguards against toddler injury. These safeguards demonstrate full understanding of a toddler's developmental abilities.
The client asks the nurse, "How can I tell whether my baby is spitting up or vomiting?" The nurse explains that, in contrast to regurgitated material, vomited material is characterized by: 1. one-time occurrence during feeding. 2. a curdled appearance. 3. a brownish color. 4. usually occurring prior to a feeding.
a curdled appearance. Vomited material has been digested and looks like curdled milk with a sour odor. Vomiting usually occurs between feedings and empties the stomach of its contents. It also tends to be forceful or projectile. In contrast, regurgitation is undigested material; it does not have a sour odor, and occurs during or immediately after feeding.Vomiting is unrelated to a feeding. Also, vomiting continues until the stomach is empty, while regurgitation is usually only about 5 to 10 mLs.Vomited material is typically white and curdled in appearance. A brownish color suggests old blood.Vomiting usually occurs between feedings, whereas regurgitation occurs during or immediately after feeding.
The nurse is caring for a client on the psychiatric unit. The client states, "The voices are bothering me. They are yelling and telling me stuff. They are really bad." Which responses by the nurse would be most appropriate? 1. "Do you hear these voices very often?" 2. "Do you have a plan for getting away from the voices?" 3. "I do not hear any voices. What are you hearing?" 4. "Try to ignore them and play cards with the others."
"I do not hear any voices. What are you hearing?" A hallucination is a false sensory perception. It involves all five senses and bodily sensations. Initially, the nurse needs to assess what kind of voices are being heard. That is, are they friendly, commanding, or controlling voices? Acknowledging that the client is experiencing the voices but telling the client that the nurse does not may help the client realize that the voices are not real. Then the nurse can focus on the client's feelings or redirect the client to reality by initiating a simple task with the client such as coloring. When the voices are less severe, the nurse can do a more thorough assessment of the client's hallucinations and begin to assist the client in learning to deal with the voices.
A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan? 1. avoiding using deodorant soap on the irradiated areas 2. applying talcum powder to the irradiated areas daily after bathing 3. wearing a lead apron during direct contact with the client 4. removing thoracic skin markings after each radiation treatment
avoiding using deodorant soap on the irradiated areas Because external radiation commonly causes skin irritation, the nurse should wash the irradiated area with water and a mild soap only and leave the area open to air. No deodorants or powders should be applied. A lead apron is unnecessary because no radiation source is present in the client's body or room. Skin in the area to be irradiated is marked to position the radiation beam as precisely as possible; skin markings must not be removed.
A 3-month-old infant is admitted to the hospital to rule out nonaccidental trauma. X-ray findings indicate a fractured right humerus, fractured ribs, and a fractured left scapula. In this situation, a nurse is responsible for: 1. ensuring that the suspected child abuse is reported to local authorities. 2. contacting the infant's next of kin to begin discharge planning. 3. reporting the suspicions to the hospital's chief of pediatric services. 4. contacting the local children's protective service office with an anonymous tip.
ensuring that the suspected child abuse is reported to local authorities. Nurses must report suspicions of child abuse to local authorities. The contact procedure may vary among hospitals, but the nurse is responsible for making the report. Reporting suspected abuse to the hospital's chief of pediatric services isn't appropriate. Contacting the infant's next of kin to begin discharge planning is inappropriate because the infant may not be discharged to the next of kin. Providing an anonymous tip isn't appropriate behavior for a professional nurse. The hospital record is important to the legal process, and the nurse must handle it professionally.
Which statement made by the parent of a school-age child who has had a craniotomy for a brain tumor would warrant further exploration by the nurse? 1. "After this, I will never let her out of my sight again." 2. "I hope that she'll be able to go back to school soon." 3. "I wonder how long it will be before she can ride her bike." 4. "Her best friend is eager to see her; I hope she won't be upset."
"After this, I will never let her out of my sight again." Parents of a child who has undergone neurosurgery can easily become overprotective. Yet, the parents must foster independence in the convalescing child. It is important for the child to resume age-appropriate activities, and parents play an important role in encouraging this. Statements about going back to school would be expected. Parents want the child to return to normal activities after a serious illness or injury as a sign that the child is doing well.
A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) who is being discharged after treatment for an acute exacerbation. Which statement by the client indicates proper understanding of the discharge instructions? 1. "I should take my bronchodilator at bedtime to prevent insomnia." 2. "I should do my most difficult activities when I first get up in the morning." 3. "I should try to eat several small meals during the day." 4. "I should plan to do most of my exercises after I eat."
"I should try to eat several small meals during the day." The respiratory workload is increased in individuals with COPD. Because digestion also is energy consuming, clients with COPD may feel full after only a small meal. They may tolerate smaller, more frequent, high-calorie meals better than larger meals. Bronchodilators will increase insomnia. Activities should be regulated throughout the day. Eating followed by activity based on intra-abdominal pressure will increase shortness of breath.
The parent of a school-age client with diabetes tells the nurse that she does not want the school to know about her daughter's condition. Which is the nurse's best response? 1. "Our office will not discuss your daughter's diabetes with the school without your written permission." 2. "What is it that concerns you about having the school know about your daughter's condition?" 3. "It would be fine not to tell your daughter's friends, but the teacher must know." 4. "In order to keep your daughter safe, it is necessary for all adults in the school to know her condition."
"What is it that concerns you about having the school know about your daughter's condition?" The nurse's first response should be to obtain more information about the mother's concerns. The nurse can then facilitate a dialogue that will help the mother weigh her concerns against the potential risks to the child's safety. It is true that the nurse would not discuss a client's medical condition with a school without permission, but this statement does facilitate discussion. It is also true that the child may have a diabetic reaction anywhere at school, and it is advisable that her teacher, classmates, and other adults know about her diabetes in order to help her; however, it is ultimately the client and her parents who will make the decision about informing the school. Dictating to the mother does not explain any rationale for the necessity of sharing the information.
A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? 1. I like to soak my feet in the hot tub every day." 2. I walk only to the mailbox in my bare feet." 3. "I stopped smoking and use only chewing tobacco." 4. I have my spouse look at the soles of my feet each day."
"I have my spouse look at the soles of my feet each day." A client with peripheral vascular disease should examine their feet daily for redness, dryness, or cuts. If a client isn't able to do this examination on their own, then a caregiver or family member should help. A client with peripheral vascular disease should avoid hot tubs because decreased sensation in the feet may make them unable to tell if the water is too hot. The client should always wear shoes or slippers on their feet when out of bed to help minimize trauma to the feet. Any type of nicotine, whether it's from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities.
The nurse discusses safety and accident prevention with the parent of a 9-month-old. The nurse understands that the teaching has been effective when the parent makes which statement? 1. I make sure that I keep my cleaning supplies locked up." 2. Sometimes she plays in the bathroom when I'm cleaning in there." 3. "I've enrolled her in an infant water safety classes." 4. "I've found that those child-protective cabinet locks don't work very well."
"I make sure that I keep my cleaning supplies locked up." A major goal of safety and accident prevention focuses on having all cleaning supplies and medications locked up as infants become mobile. The child should not play in the bathroom even if the parent is present because the child will think that it is okay to play with these items when the parent is not present. Water safety classes are not recommended for children under the age of 1 year. The child-protective cabinet locks should work unless they were installed incorrectly or are defective.
An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, (2.3 mmol/L) and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting 1. 2 to 5 g of a simple carbohydrate. 2. 15 g of a simple carbohydrate. 3. 18 to 20 g of a simple carbohydrate. 4. 25 to 30 g of a simple carbohydrate.
15 g of a simple carbohydrate. To reverse hypoglycemia, the American Diabetes Association (Canadian Diabetes Association) guidelines recommend ingesting 15 g of a simple carbohydrate, such as 15 g of glucose tablets, 3 teaspoons (15 mL) or 3 packets of table sugar dissolved in water, 3/4 cup (175 mL) of juice or regular soft drink, 6 LifeSavers (1 = 2.5 g carbohydrate), or a 1 tablespoon (5 mL) of honey. Then the client should check their blood glucose after 15 minutes. If necessary, this treatment may be repeated in 15 minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the blood glucose level sufficiently. Ingesting more than 15 g may raise it above normal, causing hyperglycemia.
The nurse is caring for an adult client who had a gastric resection on November 4. At 1700 the following day, the client requests pain medication. The client's health care provider has prescribed meperidine, 75 to 100 mg every 3 to 4 hours. The nurse reviews the client's progress notes (view the chart). What should the nurse do next? 1. Report the bowel sounds to the health care provider before administering pain medication. 2. Administer the pain medication as requested. 3. Help the client ambulate before administering the pain medication. 4.Tell the client to listen to music until the client can have the pain medication at 1800.
Administer the pain medication as requested. The nurse should administer the pain medication as requested. The client can have pain medication every 3 to 4 hours as prescribed.The few bowel sounds are normal during the first 2 to 3 days after abdominal surgery, and the nurse does not need to report them to the health care provider.It is not necessary to ask the client to use diversional strategies while waiting to receive pain medication.
A preschool-age child presents to the emergency department. His father tearfully reports that his son was on his shoulders in the driveway playing when he began to fall. When the child began to fall, the father grabbed him by the leg, swinging him toward the grass to avoid landing on the pavement. As the father swung his son, the child hit his head on the driveway and twisted his right leg. After a complete examination, it is determined that the child has a skull fracture and a spiral fracture of the femur. Which action should the nurse take? 1. Restrict the father's visitation. 2. Notify the police immediately. 3. Refer the father for parenting classes. 4. Record the father's story in the medical record.
Record the father's story in the medical record. The father's story is consistent with the injuries incurred by the child; therefore, the nurse should document the cause of injury. There is no need to restrict the father's visitation because the injuries sustained by the child are consistent with the explanation given. The police only need to be notified if there is suspicion of child abuse. The injuries incurred by this child appear to be accidental. There is no need to refer the father for parenting classes. The father appears to be upset about the accident and will not likely repeat such reckless behavior. However, the nurse should educate the father regarding child safety.
After instruction of a primigravid client at 8 weeks' gestation about measures to overcome early morning nausea and vomiting, which client statement indicates the need for additional teaching? 1. "I will eat dry crackers or toast before arising in the morning." 2. "I will drink adequate fluids separate from my meals or snacks." 3. "I will eat two large meals daily with frequent protein snacks." 4. "I will snack on a small amount of carbohydrates throughout the day."
"I will eat two large meals daily with frequent protein snacks." The client needs further instructions when she says she should eat two meals a day with frequent protein snacks to decrease nausea and vomiting. The client should eat more frequent, smaller meals, with frequent carbohydrate snacks to decrease nausea and vomiting. Eating dry crackers or toast before arising, consuming fluids separately from meals, and avoiding greasy or spicy foods may also help to decrease nausea and vomiting.
A community nurse arrives at the home of a client. The client is in soiled clothes due to the inability to make it to the bathroom in time. The nurse overhears the unregulated care provider (UCP) scolding the client for the soiled clothes. What is the most appropriate response by the nurse to the UCP? 1. "Your behavior in this situation is considered verbal abuse." 2. "You need to have more training in therapeutic communication." 3. "I'm sure you didn't mean to hurt the client's feelings, but you did." 4. "Why weren't you there to help the client get to the bathroom?"
"Your behavior in this situation is considered verbal abuse." Reprimanding a client for something that is beyond the client's control is considered abusive. The other options do not help the UCP understand the abusive behavior.
A nurse is preparing a client for an intravenous pyelography. Which action is the priority? 1. Assess allergies to iodine. 2. Determine last bowel movement. 3. Record vital signs. 4. Note urine output.
Assess allergies to iodine. The nurse should assess this client for allergies to iodine because the dye used in an intravenous pyelography is iodine based, and the client could potentially have a life-threatening reaction to the dye. The nurse should obtain vital signs before the client receives the procedure and assess the client's last bowel movement, but these actions are not the priority. Urine output should be monitored and documented.
A parent asks the nurse if a child's iron deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which principle? 1. Little is known about iron deficiency anemia and its relationship to infection in children. 2. Children with iron deficiency anemia are more susceptible to infection than are other children. 3. Children with iron deficiency anemia are less susceptible to infection than are other children. 4. Children with iron deficiency anemia are equally as susceptible to infection as are other children.
Children with iron deficiency anemia are more susceptible to infection than are other children. Children with iron deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis.
A nurse observes a physician providing care to an infectious client without the use of personal protective equipment. What should the nurse do first? 1. Notify the unit manager. 2. Complete an incident report. 3. Discuss the breach of practice with the physician. 4. Ask the nurse educator to in-service the physician.
Discuss the breach of practice with the physician. The nurse should first discuss the breach of infection control procedures with the physician and discuss the practices that should be followed. The other options may be followed subsequently, but discussing with the physician is the first step.
The nurse is assisting a healthcare provider in debriding a necrotic skin wound. The healthcare provider is using a plastic basin to collect the bloody supplies. When cleaning the area on completion of debridement, which nursing action is done after placing the supplies in a hazardous material bag? 1. Wash the basin in hot, soapy water. 2. Dispose of the plastic basin. 3. Spray the basin with a disinfectant agent. 4. Clean the basin with an antiseptic agent.
Dispose of the plastic basin. The plastic basin would be disposed of. Hot water causes the protein materials to stick to the basin. The basin does not need to be disinfected. An antiseptic is used to limit bacteria on the skin. Plastic emesis basins are disposable. The nurse would obtain a new one for the room.
The nurse is teaching a client with stomatitis about managing oral discomfort. Which instruction is most appropriate? 1. Drink hot tea at frequent intervals. 2. Gargle with antiseptic mouthwash. 3. Use an electric toothbrush. 4. Eat a soft, bland diet.
Eat a soft, bland diet. Clients with stomatitis (inflammation of the mouth) have significant discomfort, which impacts their ability to eat and drink. They will be most comfortable eating soft, bland foods, and avoiding temperature extremes in their food and liquids. Gargling with an antiseptic mouthwash will be irritating to the mucosa. Mouth care should include gentle brushing with a soft toothbrush and flossing.
The nurse is caring for a 3-year-old with acute lymphocytic leukemia and notes that the child has a decreased appetite. What is the priority nursing intervention? 1. Provide oral hygiene after eating. 2. Refrain from serving snacks as requested. 3. Have the dietician meet with the child and family to provide foods the child will eat. 4. Encourage the child to eat all of the meal to get adequate nutrition.
Have the dietician meet with the child and family to provide foods the child will eat. The dietician should be involved to help determine foods appropriate for children in different age groups. The child and family should help select preferred foods and identify cultural beliefs and dining habits. Take advantage of a hungry period and serve small snacks. Encourage parents to relax pressures placed on eating by stressing the legitimate nature of loss of appetite. The other responses do not help to stimulate the child's appetite.
A client taking disulfiram during alcohol rehabilitation therapy reports to the nurse that they have a mild cold and plan to use a cough medicine. Which statement made by the client indicates understanding of the nurse's teaching? 1. "I realize that taking cough syrup with this medication might cause me to be depressed." 2. "As long as the physician is aware, its okay." 3. "I may experience vomiting and an upset stomach if I take cough medicine while taking this medicine." 4. "Small doses of cough syrup might make me crave alcohol."
I may experience vomiting and an upset stomach if I take cough medicine while taking this medicine." Disulfiram provokes a violent reaction in the presence of alcohol; the client may not realize that cough medicine may contain an alcohol base. This medication combination won't cause depression. Because the cold is minor, there's no need for the client to talk with his physician.
A school nurse assesses that an 8-year-old child is preoccupied with sexual comments and activities. The nurse is concerned that the child may have been sexually abused at home. What is the nurse's best response to this situation? 1. Notify the local Child Protective Services. 2. Continue to observe the behavior of the child. 3. Discuss the child's behavior with the parents. 4. Advise the child that the inappropriate behavior must stop.
Notify the local Child Protective Services. If a nurse suspects abuse of any nature, it must be reported to the appropriate authorities, such as Child Protective Services. The other options are incorrect because they do not demonstrate the required action of the nurse in this situation.
The family of a client who died unexpectedly arrives to the care area. In which way should the nurse support the family at this time? Select all that apply. 1. Provide emotional support. 2. Serve as an attentive listener. 3. Expect the family to express grief. 4.Arrange for the family to view the body. 5. Direct the family to the funeral home.
Provide emotional support. Serve as an attentive listener. Expect the family to express grief. Arrange for the family to view the body. Postmortem care of a client includes care of the family. When a client dies, the family needs emotional support. The nurse serves as an attentive listener and should expect the family to express grief. Part of this care is preparing the client so the family can view the body. The nurse should not direct the family to the funeral home. The family should not have to wait to view the body; plans can be made for the viewing to occur in the care facility.
Assessment of a pregnant client reveals that she feels very anxious because of a lack of knowledge about giving birth. The client is in her second trimester. Which intervention by the nurse is most appropriate for this client? 1. Provide the client with the information and teach her the skills she'll need to understand and cope during birth. 2. Provide the client with written information about the birthing process. 3. Have a more experienced pregnant woman assist her. 4. Do nothing in hopes that she'll begin coping as the pregnancy progresses.
Provide the client with the information and teach her the skills she'll need to understand and cope during birth. Because the client is in her second trimester, the nurse has ample time to establish a trusting relationship with her and to teach her in a style that fits her needs. Written information would be effective only in conjunction with teaching sessions. Introducing her to another pregnant client may be helpful, but the nurse still needs to teach the client about giving birth. Doing nothing won't address the client's needs.
Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized? 1. The client's skin is intact with non-blanchable redness of a localized area over a bony prominence. 2. The client's skin has partial loss of dermis presenting as a shallow open ulcer with a red pink wound bed. 3. The client's skin is a shiny, dry ulceration with bruising noted. 4. The client's subcutaneous tissue is visible with a blood blistered wound bed.
The client's skin is intact with non-blanchable redness of a localized area over a bony prominence. Clients who are immobilized and are in stationary positions without regular position changes are more likely to develop pressure ulcers because of pressure on the skin for extended periods. This is the definition of a stage 1 ulcer. The other answers are incorrect because they describe different stages of ulcerations.
A nurse discussing injury prevention with a group of workers at a daycare center is focusing on toddlers. When discussing this age-group, the nurse should stress that 1. accidents are the leading cause of death among toddlers. 2. the risk for homicide is highest among toddlers. 3. toddlers can distinguish right from wrong. 4. toddlers will always chase a ball that rolls into the street.
accidents are the leading cause of death among toddlers. The leading cause of death in toddlers is accidents, so it's important for parents, family members, and childcare providers to understand the importance of accident prevention. Toddlers don't have the highest risk for homicide. Toddlers are just beginning to understand right from wrong, but don't understand the consequences of their actions. Although many children will chase balls or toys into the street, not all children will do so.
What data indicates to the nurse that placental detachment is occurring? 1. an abrupt lengthening of the cord 2. a decrease in the number of contractions 3. relaxation of the uterus 4. decreased vaginal bleeding
an abrupt lengthening of the cord An abrupt lengthening of the cord, an increase (not a decrease) in the number of contractions, and an increase (not a decrease) in vaginal bleeding are all indications that the placenta has detached from the wall of the uterus. Relaxation of the uterus is not an indication for detachment of the placenta.
A client with esophageal cancer decides against placement of a jejunostomy tube. Which ethical principle is a nurse upholding by supporting the client's decision? 1. autonomy 2. fidelity 3. nonmaleficence 4. veracity
autonomy Autonomy refers to an individual's right to make their own decisions. Fidelity is equated with faithfulness. Nonmaleficence is the duty to "do no harm." Veracity refers to telling the truth.
A client at term arrives in the labor unit experiencing contractions every 4 minutes. After a brief assessment, she's admitted and an electric fetal monitor is applied. Which finding should most concern the nurse? 1. total weight gain of 30 lb (13.6 kg) 2. maternal age of 32 years 3. blood pressure of 146/90 mm Hg 4. treatment for syphilis at 15 weeks' gestation
blood pressure of 146/90 mm Hg A blood pressure of 146/90 mm Hg may indicate gestational hypertension. Over time, gestational hypertension reduces blood flow to the placenta and can cause intrauterine growth restriction and other problems that make the fetus less able to tolerate the stress of labor. A weight gain of 30 lb (13.6 kg) is within expected parameters for a healthy pregnancy. A woman older than age 30 doesn't have a greater risk of fetal complications if her general condition is healthy before pregnancy. Syphilis that has been treated doesn't pose an additional risk to the fetus.
A home health nurse sees a client with end-stage chronic obstructive pulmonary disease (COPD). An outcome identified for this client is preventing infection. Which finding indicates that this outcome has been met? 1. decreased oxygen requirements 2. increased sputum production 3. decreased activity tolerance 4. increased white blood cell count
decreased oxygen requirements A client who is free from infection will most likely have decreased oxygen requirements. A client with infection will display increased sputum production, fever, shortness of breath, decreased activity tolerance, and increased oxygen requirements. Elevated white blood cell count may be indicative of infection.
While planning the care for a client with paranoid delusions, which will be the nurse's initial goal for the client? 1. Be free of delusions. 2. Participate in unit activities. 3. Meet self-care needs. 4. Establish trust with staff.
establish trust with staff Establishing a trusting relationship is the priority goal when working with clients with delusions. Only after trust is established can other assessment and goal setting or interventions take place. Being free of delusions, participating in unit activities, and performing tasks independently are important but are not initial priorities.
A physician orders spironolactone, 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? 1. serum potassium level of 3.5 mEq/L 2. loss of 2.2 lb (1 kg) in 24 hours 3. serum sodium level of 135 mEq/L 4. blood pH of 7.25
loss of 2.2 lb (1 kg) in 24 hours Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.
The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance? 1. hypercalcemia 2. metabolic acidosis 3. metabolic alkalosis 4. respiratory acidosis
metabolic alkalosis Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This client would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the client's respiratory status.
A client is having elective surgery under general anesthesia. Who is responsible for obtaining the informed consent? 1. the nurse 2. the surgeon 3. the anesthesiologist 4. the social worker
the surgeon It is the role of the surgeon or the person performing the procedure to obtain the informed consent. This consists of informing the client about the procedure, the risks of treatment, the side effects, other types of treatments available, and the effects without the procedure. Nurses, anesthesiologists, and social workers do not obtain informed consent.
A group has asked the nurse to discuss how lifestyle factors affect heart health. Which statements by members of the group would indicate that the teaching was effective? Select all that apply. 1. "Chewing tobacco rather than smoking it lessens the negative effect on the heart." 2. "Gradually increasing my exercise levels will help enhance circulation through the heart." 3. "If I change my diet and lessen my intake of saturated fats and trans fatty acids, this may decrease my cholesterol levels." 4."As a borderline diabetic, if I lose weight and lessen my intake of simple carbohydrates, this should benefit my heart." 5. "Walking is excellent exercise to strengthen my heart."
"Gradually increasing my exercise levels will help enhance circulation through the heart." "If I change my diet and lessen my intake of saturated fats and trans fatty acids, this may decrease my cholesterol levels." "As a borderline diabetic, if I lose weight and lessen my intake of simple carbohydrates, this should benefit my heart." "Walking is excellent exercise to strengthen my heart." Increasing exercise levels, diet changes, losing weight, and walking are all important elements of heart health. Chewing tobacco is still harmful to the body.
A client is experiencing uncontrollable back pain and a physical therapist suggests a back massage. The clients asks the nurse how massage will help the pain. What is the best response by the nurse? 1. "A massage will relax muscles but does not wrok on ligaments and tendons." 2. Massage is widely practice by all hospitalized clients." 3. Massage is an alternative therapy that uses herbal supplements." 4. "Massage is point stimulation used for orthopedic and neurological conditions
"Massage is point stimulation used for orthopedic and neurological conditions. Massage uses point stimulation of pushing and pulling of the skin to relieve orthopedic and neurological conditions. Massage will realx muscles, ligaments, and tendons. Massage is not widely used by hospitalized clients nor does it include the use herbal supplements.
A 20-year-old primigravid client tells the nurse that her mother had a friend who died from hemorrhage about 10 years ago during a vaginal birth. Which response would be most helpful? 1. Today's modern technology has resulted in a low maternal mortality rate." 2. Do not concern yourself with things that happened in the past." 3. "In North America, mothers seldom die in birth." 4. What is it that concerns you about pregnancy, labor, or childbirth?"
"What is it that concerns you about pregnancy, labor, or childbirth?" The client is verbalizing concerns about death during birth, thus providing the nurse with an opportunity to gather additional data. Asking the client about these concerns would be most helpful to determine the client's knowledge base and to provide the nurse with the opportunity to answer any questions and clarify any misconceptions. Although the maternal mortality rate is low in the United States and Canada, maternal deaths do occur, even with modern technology. Leading causes of maternal mortality in the United States and Canada include embolism, pregnancy-induced hypertension, hemorrhage, ectopic pregnancy, and infection. Telling the client not to concern herself about what has happened in the past is not useful. It only serves to discount the client's concerns and block further therapeutic communication. Also, postponing or ignoring the client's need for a discussion about complications of pregnancy may further increase the client's anxiety.
A client who is being treated for cancer has expressed interest in exploring complementary and alternative therapies. What is the nurse's best action? 1. All treatments should be encouraged unless there are known and significant contraindications. 2. The care team should help the client choose between alternative treatment and conventional treatment. 3. The care team should arrange any complementary or alternative treatment that the client desires. 4. The nurse and the care team should avoid direct involvement in arranging complementary therapies.
All treatments should be encouraged unless there are known and significant contraindications. Unless there is a known safety risk, complementary and alternative treatments should be facilitated. The nurse should make it clear that the client does not have to choose between conventional treatment and alternatives.
A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to their back. Which intervention takes priorityfor this client? 1. placing the client in a semi-Fowler's position 2. maintaining nothing-by-mouth (NPO) status 3. administering morphine I.V. as ordered 4. providing mouth care
administering morphine I.V. as ordered The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.
A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of 1. right-sided heart failure. 2. acute pulmonary edema. 3. pneumonia. 4. cardiogenic shock.
acute pulmonary edema. Shortness of breath, agitation, and pink-tinged, foamy sputum signal acute pulmonary edema. This condition results when decreased contractility and increased fluid volume and pressure in clients with heart failure drive fluid from the pulmonary capillary beds into the alveoli. In right-sided heart failure, the client would exhibit hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike and sputum that varies in color. Cardiogenic shock is indicated by signs of hypotension and tachycardia.
A client, who had intracavity radiation treatment for cervical cancer 1 month earlier, reports small amounts of vaginal bleeding. This finding most likely represents 1. development of a rectovaginal fistula. 2. an expected effect of the radiation therapy. 3. recurrence of the carcinoma. 4. infection secondary to a change in vaginal flora.
an expected effect of the radiation therapy. After intracavity radiation, some vaginal bleeding occurs for 1 to 3 months. Intermittent, painless vaginal bleeding is a classic symptom of cervical cancer, but given the client's history, bleeding in more likely a result of the radiation. The passage of feces through the vagina, not vaginal bleeding, is a sign of rectovaginal fistula. Vaginal infections are indicated by various types of vaginal discharge, not vaginal bleeding.
When interviewing the parents of a toddler, the nurse should suspect pneumococcal meningitis if there is a history of which illness? 1. bladder infection 2. middle ear infection 3. fractured clavicle 4. septic arthritis
middle ear infection Organisms that cause bacterial meningitis, such as pneumococci or meningococci, are commonly spread in the body by vascular dissemination from a middle ear infection. The meningitis may also be a direct extension from the paranasal and mastoid sinuses. The causative organism is a pneumococcus. A chronically draining ear is also frequently found. Bladder infections commonly are caused by Escherichia coli, unrelated to the development of pneumococcal meningitis. Pneumococcal meningitis is unrelated to a fractured clavicle or to septic arthritis, which is commonly caused by Staphylococcus aureus, group A streptococci, or Haemophilus influenzae.
At a public health fair, a nurse teaches a group of women about breast cancer awareness. What is most important for the nurse to include in teaching about the warning signs of breast cancer? 1. breast discomfort and multiple movable nodules 2. breast changes during menstruation 3. nipple discharge and a breast nodule 4. fever and erythema of the breast
nipple discharge and a breast nodule Nipple discharge, breast nodules, nipple retraction, and lymphadenopathy may be signs of breast cancer and should be reported. Breast pain with multiple movable nodules are indicative of benign fibrocystic breasts. Breast changes during menstruation are normal; for this reason, women should examine their breasts 4 to 7 days after menses ends, when the breasts are least congested. Fever and erythema of the breast may indicate a breast abscess.
A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of: 1. metabolic acidosis. 2. respiratory alkalosis. 3. increased PaCO2. 4. acute CNS disturbances.
respiratory alkalosis. The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation, which does not cause metabolic acidosis. Acute CNS disturbances result from multiple potential causes. Increased carbon dioxide levels are associated with acidosis, not alkalosis.
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to 1. take a hot bath. 2. rest in an air-conditioned room. 3. increase the dose of muscle relaxants. 4. avoid naps during the day.
rest in an air-conditioned room. Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity.
After a laminectomy, the client states, "The doctor said that I can do anything I want to." Which activity that the client intends to do indicates the need for further teaching? 1. drying the dishes 2. sitting outside on firm cushions 3. making the bed walking from side to side 4. sweeping the front porch
sweeping the front porch Sweeping causes a twisting motion, which should be avoided because twisting can cause undue stress on the recently ruptured disc site, muscle spasms, and a potential recurrent disc rupture. Although the client should not bend at the waist, such as when washing dishes at the sink, the client can dry dishes because no bending is necessary. The client can sit in a firm chair that keeps the back anatomically aligned. The client should not twist and pull, so when making the bed, the client should pull the covers up on one side and then walk around to the other side before trying to pull the covers up there.
A breastfeeding mother who is experiencing breast engorgement asks the nurse if there is anything she can do to get relief. What is the best intervention for the nurse to implement? 1. applying ice 2. applying a breast binder 3. teaching how to express the breasts 4. administering bromocriptine
teaching how to express the breasts Teaching the client how to express her breasts will facilitate let-down, and provide temporary relief. Ice can promote comfort by decreasing blood flow, numbing, and discouraging further let-down of milk. It is not recommended because it also causes the rebound reaction of more let-down once the ice is removed. Breast binders are not effective in relieving the discomforts of engorgement. Bromocriptine is no longer recommended for lactation suppression.
When providing care on a Native American reservation (First Nations reserve), a nurse has prioritized assessments for type 2 diabetes mellitus and fetal alcohol syndrome. How should the nurse's practice be best understood? 1. The nurse is correct in assessing for health problems that have a higher incidence and prevalence among this population. 2. The nurse is stereotyping Native Americans (First Nations people) as leading unhealthy lifestyles and abusing alcohol. 3. The nurse is performing cultural imposition of the majority of American (Canadian) culture and the accompanying beliefs around diabetes and alcohol use. 4. The nurse should seek specific permission from each client before proceeding with these assessments.
The nurse is correct in assessing for health problems that have a higher incidence and prevalence among this population. Because diabetes and fetal alcohol syndrome are known to have a higher incidence and prevalence among Native Americans (First Nations people), the nurse is justified in reflecting this objective reality during health assessment. This action is rooted in epidemiology, not the inaccurate generalizations of stereotyping. Because the consequences of both problems are significant and objective, the nurse is not guilty of cultural imposition and specific permission for these assessments is not likely necessary.
A primigravid client admitted to the labor area in early labor tells the nurse that her brother was born with cystic fibrosis and she wonders if her baby will also have the disease. The nurse can tell the client that cystic fibrosis is: 1. X-linked recessive and the disease will only occur if the baby is a boy. 2. X-linked dominant and there is no likelihood of the baby having cystic fibrosis. 3. Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease. 4. Autosomal dominant and there is a 50 per cent chance of the baby having the disease.
Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease. Cystic fibrosis and other inborn errors of metabolism are inherited as autosomal recessive traits. Such diseases do not occur unless there are two genes for the disease present. If one of the parents does not have the gene, the child will not have the disease. X-linked recessive genes can result in hemophilia A or color blindness. X-linked recessive genes are present only on the X chromosome and are typically manifested in the male child. X-linked dominant genes, which are located on and transmitted only by the female sex chromosome, can result in hypophosphatemia, an inborn error of metabolism marked by abnormally low serum alkaline phosphatase activity and excretion of phosphoethanolamine in the urine. This disorder is manifested as rickets in infants and children. Autosomal dominant gene disorders can result in muscular dystrophy, Marfan's syndrome, and osteogenesis imperfecta (brittle bone disease). Typically, a dominant gene for the disease trait is present along with a corresponding healthy recessive gene.
A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first? 1. Institute isolation precautions. 2. Begin an I.V. infusion of dextrose 5% in half-normal saline solution at 100 ml/hour. 3. Obtain a nasopharyngeal specimen for reverse-transcription polymerase chain reaction testing. 4. Obtain a sputum specimen for enzyme immunoassay testing.
Institute isolation precautions. SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.
A 2 1/2-year-old child and his 2-month-old sibling are brought to the clinic by their father, who explains that the older child says "no" whenever asked to do something. The nurse should explain that the negativism demonstrated by toddlers is frequently an expression of which characteristic? 1. pursuit of autonomy 2. need to expend excess energy 3. separation anxiety 4. sibling rivalry
pursuit of autonomy According to Erikson, the developmental task of toddlerhood is acquiring a sense of autonomy while overcoming a sense of doubt and shame. Characteristics of negativism and ritualism are typical behaviors in this quest for autonomy. The toddler commonly does the opposite of what others request.Hyperactivity, or the need to expend excess energy, is a typical behavior that may be demonstrated by a toddler; separation anxiety and siblings rivalry may also be demonstrated by the toddler. However, none of these three behaviors is the basis for the toddler's negativism.
A nurse is caring for a 1-day postpartum mother who's very talkative but isn't confident in her decision-making skills. The nurse is aware that this is a normal phase for the mother. What is this phase called? 1. taking-in phase 2. taking-hold phase 3. letting-go phase 4. taking-over phase
taking-in phase The taking-in phase is a normal first phase for a mother when she's feeling overwhelmed by the responsibilities of caring for the neonate while still fatigued from childbirth. Taking-hold is the next phase, when the mother has rested and she can think and learn mothering skills with confidence. During the letting-go or taking-over phase, the mother gives up her previous role. She separates herself from the neonate, giving up the fantasy of birth, and readjusting to the reality of caring for the neonate. Depression may occur during this stage.
What instruction should the nurse include when developing a discharge teaching plan for a client who has been prescribed phenytoin? 1. Take the drug on an empty stomach." 2. You can consume alcoholic beverages in moderation." 3. You can take any phenytoin brand because all brands are the same." 4. "Don't stop taking the drug except with medical supervision."
Don't stop taking the drug except with medical supervision." Abrupt cessation of phenytoin may trigger status epilepticus, so the client should be warned not to stop the drug unless approved by the provider. Taking phenytoin with food minimizes GI distress. Alcoholic beverages can decrease the drug's effectiveness. Changing phenytoin brands may alter the therapeutic effect.
During the emergent (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation? 1. serum creatinine level of 2.5 mg/dL (221 µmol/L) 2. little fluctuation in daily weight 3. hourly urine output of 60 mL 4. serum albumin level of 3.8 g/dL (38 g/L)
serum creatinine level of 2.5 mg/dL (221 µmol/L) Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine. Urine output should be frequently monitored and adequately maintained with intravenous fluid resuscitation that would be increased when a drop in urine output occurs. Urine output should be at least 30 mL/h. Fluid replacement is based on the Parkland or Brooke formula and also the client's response by monitoring urine output, vital signs, and CVP readings. Daily weight is important to monitor for fluid status. Little fluctuation in weight suggests that there is no fluid retention and the intake is equal to output. Exudative loss of albumin occurs in burns, causing a decrease in colloid osmotic pressure. The normal serum albumin is 3.5 to 5 g/dL (35 to 50 g/L).
A 40-year-old primigravid client with AB-positive blood visits the outpatient clinic for an amniocentesis at 16 weeks' gestation. The nurse determines that the most likely reason for the client's amniocentesis is to determine if the fetus has which problem? 1. cri-du-chat syndrome 2. ABO incompatibility 3. erythroblastosis fetalis 4. Down syndrome
Down syndrome Because of the client's age, the amniocentesis is most likely being done to evaluate for Down syndrome (trisomy 21). Women older than 35 years are at higher risk for having a child with Down syndrome. Cri-du-chat syndrome is a genetic disorder involving a short arm on chromosome 5. This disorder is not associated with mothers who are older than 35 years. The client is AB-positive, so the amniocentesis is not being done for ABO incompatibility, in which the mother is type O and the fetus is type A, B, or AB. The amniocentesis is not being done to detect erythroblastosis fetalis because the mother is Rh-positive.
A nurse arriving for duty notes that an unlicensed assistive personnel (UAP) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UAP? 1. Make sure the UAP has practiced sterile technique on at least one other occasion. 2. Reassign the UAP to a client requiring basic tasks that the UAP has mastered. 3. Supervise the UAP during the treatments involving sterile technique. 4. Provide the UAP with a list of resources to guide the implementation of care
Reassign the UAP to a client requiring basic tasks that the UAP has mastered. The nurse is accountable for the delegation of tasks to UAPs. The nurse delegates tasks to UAPs consistent with their level of expertise and education, the job description, agency policy, legislation, and personal need. UAPs should not be assigned to clients who are complex or require skills that involve a higher level of knowledge. Based on the choices offered, if the nurse is confident that the UAP has the appropriate knowledge regarding basic tasks, the tasks can be delegated. The other options are incorrect, as they do not ensure that the UAP has the knowledge and skill to provide the care or carry out the task.
The nurse reads the chart entry for a client who attends group therapy and uses cannabis daily:2/101700The client is congested, with a dry hacking cough. The client could not verbalize treatment goals when asked in the group session. The client laughed when the therapist gave each participant a worksheet to fill out and bring back to the next group, and stated, "I'm not doing that."What health problem is this client experiencing because of extended cannabis use? 1. amotivational syndrome 2. delirium tremens 3. vascular dementia 4. cognitive distortions
amotivational syndrome Long-term use of cannabis is associated with amotivational syndrome. Amotivational syndrome is a psychological health condition that is characterized by losing interest in cognitive and social activities. The client will display a sense of apathy. Delirium tremens is associated with alcohol withdrawal. Vascular dementia is associated with an alteration in a person's thought processes caused by disrupted blood flow to the brain. Cognitive distortions are inaccurate thoughts used to reinforce negative thoughts or feelings, and are common in clients with depression.
During a routine physical examination on a 75-year-old female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2 inches (1.7 m) tall." Which statement is the bestresponse by the nurse? 1. "After age 40, height may show a gradual decrease as a result of spinal compression" 2. "After menopause, the body's bone density declines, resulting in a gradual loss of height." 3. "There may be some slight discrepancy between the measuring tools used." 4. "The posture begins to stoop after middle age."
After menopause, the body's bone density declines, resulting in a gradual loss of height." The nurse should tell the client that after menopause, the loss of estrogen leads to a loss in bone density, resulting in a loss of height. This client's history doesn't indicate spinal compression. Telling the client that measuring tools used to obtain the client's height may have a discrepancy or that the posture begins to stoop after middle age doesn't address the client's question.
The nurse is caring for a client with possible immune deficiency. Which subjective data would be most indicative? 1. "I get up every morning with a stuffy nose and sore throat." 2. "Just as I get over a virus, it seems that I get another." 3. "I have had a sore on my leg that just won't heal." 4. "I sneeze and have watery eyes throughout the spring and summer."
Just as I get over a virus, it seems that I get another." Immune deficiencies make it harder for the body to fight infection. With a low resistance, the client is susceptible to obtaining more circulating viruses. Having morning stuffiness and a sore throat is indicative of sinus congestion. Having a leg sore is indicative of cardiovascular insufficiency or diabetes. Sneezing with watery eyes is indicates seasonal allergies.
A nurse has received a shift report on four clients. Which client should the nurse assess first? 1. an older adult returning to the unit after having a carotid endarterectomy 2. an older adult admitted 3 hours earlier for observation because of possible transient ischemic attack 3. a middle-age adult who had a rhizotomy 2 days earlier 4. a young adult admitted for observation and management of migraine headaches
an older adult returning to the unit after having a carotid endarterectomy The nurse should first assess the client returning from a carotid endarterectomy, who requires close monitoring. The client who had a rhizotomy will require pain assessment after the nurse addresses the client returning from surgery. The clients admitted for observation are stable and are lower priorities than the client returning from a carotid endarterectomy.
A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature? 1. every 5 minutes 2. every 10 minutes 3. every 15 minutes 4. every 20 minutes
every 15 minutes In order to prevent burns, the nurse should assess the client's temperature every 15 minutes when using an external warming device.
The nurse on the oncology unit is caring for a client with a total white blood cell (WBC) count equal to 2000/µL (2.0 ×109/L). Which intervention is most important to include in the plan of care? 1. Monitor temperature every 4 hours 2. avoid rectal thermometers and suppositories 3. perform proper hand hygiene 4. restrict visitors and provide a private room
perform proper hand hygiene The client with a total WBC equal to 2000/µL (2.0 ×109/L) is demonstrating neutropenia and is at increased risk for infection. Proper hand hygiene is the most important intervention to prevent infection for this client. Monitoring the client's temperature is important to detect the infection early. Avoiding rectal thermometers and suppositories prevent the spread of bacteria from rectum into the blood stream, and restricting visitors and providing a private room aid in the prevention of infection, but proper hand hygiene is most important.
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? 1. cholesterol level 2. pupil size and pupillary response 3. bowel sounds 4. echocardiogram
pupil size and pupillary response It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, although it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours, when the primary concerns are cerebral hemorrhage and increased intracranial pressure. An echocardiogram is not needed for the client with a thrombotic stroke without heart problems.
