Archer Review 6a

The nurse is caring for a client who has developed retinal detachment. Which of the following actions should the nurse take first? A. Instruct the client to restrict activity [46%] B. Establish a vascular access device [13%] C. Review the client's current medications [29%] D. Educate the client about topical eye ointments [11%]

Explanation Choice A is correct. A retinal detachment is an ocular emergency. The client moving may hasten the detachment. It is important to inform the client to restrict their activity, and the nurse should apply an eye patch to the affected eye. Choices B, C, and D are incorrect. A client with a retinal detachment will likely need surgery. Obtaining the client's current medications, establishing vascular access, and educating the client about topical eye ointments that will be prescribed does not prioritize over instructing the client to restrict their head movements. Delaying the instruction of informing the client to restrict their head movements may worsen the detachment. Additional information: A retinal detachment is a serious ocular condition that occurs suddenly and is painless. The client often describes bright flashes of light or floating dark spots in the eye. Aging and ocular injury are common causes of retinal detachment. The client should seek emergent medical treatment as surgery is the remedy. NCLEX Category: Physiological Adaptation Related Content Medical Emergencies Question type: Application

The nurse is providing care for a patient recently transferred from the post-anesthesia care unit [PACU]. The chart indicates that the patient was medicated for pain 1 hour ago, yet the patient reports that he is experiencing extreme pain. He is not due for further medication until another 2 hours. How might the nurse intervene as a patient advocate? A. Contact the physician regarding the need for more effective pain management. [63%] B. Assist the patient to use non-pharmacological pain management strategies. [32%] C. Explain to the patient that giving the pain medication too soon can be dangerous. [2%] D. Provide a quiet environment to help the patient rest and cope with his pain level. [4%]

Explanation Choice A is correct. An essential aspect of advocacy is speaking on behalf of the patient, to help meet the patient's needs, such as when calling the physician to discuss the need for more effective pain management - since it is the patient's fundamental right to be free from pain. Choices B and D are incorrect. These are nursing interventions that can be employed to enhance the prescribed pain medication but do not meet defining characteristics related to advocacy. Choice C is incorrect. While this is factual information, it does not address the need to provide adequate pain management. Bloom's Taxonomy - Analyzing

Among Erickson's Stages of Development, which of the following stages of development would the nurse expect a 2-year-old patient to be in? A. Autonomy vs. Shame and Doubt [67%] B. Industry vs. Inferiority [3%] C. Trust vs. Mistrust [20%] D. Initiative vs. Guilt [9%]

Explanation Choice A is correct. Autonomy vs. Shame and Doubt is the typical stage of development for early childhood, which lasts from ages 2 to 3 years, so this is what the nurse would expect for a 2-year-old patient. In Autonomy vs. Shame and Doubt, children seek to develop a sense of personal control over physical skills and knowledge of independence. When they are successful, for example, with a task like toilet training, they feel independent, and it leads to a sense of autonomy. When they are not successful, they think they are a failure which then results in shame and self-doubt. Choice B is incorrect. Industry vs. Inferiority is the typical stage of development for school-age children, who are 6 to 11-year-olds. In this stage, children need to cope with new social and academic demands. When they are successful with this, they feel competent and achieve more. When they are not successful, they experience failure, and it results in inferiority. Choice C is incorrect. Trust vs. Mistrust is the typical stage of development for infancy, which lasts from birth to 18 months. In this stage, children develop a sense of confidence when caregivers provide reliability, care, and affection. When infants do not have that, they will develop mistrust. Choice D is incorrect. Initiative vs. Guilt is the typical stage of development for preschool children, who are 3 to 5-year-olds. In Initiative vs. guilt, children start to assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval end up feeling guilty. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Pediatric Development

The nurse is caring for a postoperative patient at risk for venous thromboembolism (VTE). Which of the following medications would prevent this complication? A. Enoxaparin [93%] B. Verapamil [3%] C. Tranexamic acid [2%] D. Ropinirole [1%]

Explanation Choice A is correct. Enoxaparin is a low molecular weight-based heparin (LMWH) that is indicated for VTE prophylaxis following surgery. Choices B, C, and D are incorrect. Verapamil is a calcium channel blocker and would not reduce the risk of VTE. Tranexamic acid is an agent that promotes clotting and may hasten the risk of a VTE. Ropinirole is indicated for Parkinson's disease or Restless Leg Syndrome (RLS). Additional information: Enoxaparin is a type of LMWH. This medication may be used prophylactically for a VTE or treat an existing VTE. Nursing considerations for Enoxaparin include - This medication does not require PTT monitoring, unlike heparin. Monitoring for platelet-induced thrombocytopenia is essential while the patient is taking this medication. Recent spinal surgery, an epidural, or peptic ulcer disease all require clarification of the prescription with the prescriber. The medication is given subcutaneously. The patient should be instructed not to rub the injection site

An adolescent who sustained a tibia fracture in a motor vehicle accident has a cast. What should the nurse do to help relieve the itching? A. Apply cool air under the cast with a blow-dryer [85%] B. Use sterile applicators to scratch the itch [3%] C. Apply cool water under the cast [1%] D. Apply hydrocortisone cream under the cast using a sterile applicator [11%]

Explanation Choice A is correct. Itching underneath a cast can be relieved by using a blow-dryer set to the cool setting onto the itchy area. Instructing clients and caregivers on proper cast care will help reduce the risk of further injury or complications. Education regarding cast care and the "do's and don'ts" include: Keep the cast dry. Moisture weakens plaster and dampens padding next to the skin, which can be irritating. Do not submerge it or hold it under running water. A small pinhole in the cast cover can cause the injury to get soaked. Keep dirt, sand, and powder away from the inside of the cast. Do not pull out the padding from a splint or cast. Do not stick objects such as coat hangers inside the splint or cast to scratch itching skin. Do not apply powders or deodorants to itching skin. If itching persists, contact the doctor. Do not break off any rough edges of the cast or trim the cast before asking the doctor. Inspect the skin around the cast. If the skin becomes red or raw around the cast, contact the doctor. Inspect the cast regularly. If it becomes cracked or develops soft spots, contact the doctor's office. Choice B is incorrect. Skin breakdown can occur if anything is placed under the cast. Therefore, the client should be cautioned not to put any object down the cast in an attempt to scratch. Choices C and D are incorrect. The cast should never be allowed to get wet (Choice C). Nothing should be applied under the cast or inserted into the cast to prevent skin breakdown and injury (Choice D). NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control

A 16-year old male arrives at the trauma bay after suffering from a head injury. He is postictal and is being intubated to protect his airway. After obtaining IV access, the doctor orders a diuretic. Based on the history provided, what diuretic will the doctor order? A. Mannitol [79%] B. Hydrochlorothiazide [5%] C. Spironolactone [4%] D. Furosemide [12%]

Explanation Choice A is correct. Mannitol is the preferred diuretic used for reducing the increased intracranial pressure. Mannitol is an osmotic diuretic that does not cross the blood-brain barrier. As a result; osmotic pressure increases in the plasma but not in the brain. A gradient is developed between plasma and brain cells, therefore causing a shift of fluids from the extracellular space into the blood vessels. Choice B is incorrect. Hydrochlorothiazide ( HCTZ) is a thiazide diuretic. HCTZ is used in the treatment of hypertension and peripheral edema. Choice C is incorrect. Spironolactone is used to treat high blood pressure, ascites, edema, and to antagonize high levels of hormones ( aldosterone) in hyper-aldosteronism. Choice D is incorrect. Furosemide is a loop diuretic. It helps decrease edema and fluid retention caused by congestive heart failure/ heart disease, liver disease, and kidney disease. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Subtopic: Acute Intracranial Problems

The nurse should recognize which of the following are physical changes associated with the aging client? Select all that apply. A. Pronounced wrinkles on the face [42%] B. Decreased size of the nose and ears [4%] C. Increased growth of facial hair [15%] D. Neck wrinkles [39%]

Explanation Choice A is correct. Many changes occur in the aging body. With age, the loss of adipose tissue causes sagging skin and wrinkles. This is especially noticeable around the head and face. Wrinkles on the face become more pronounced and tend to take on the general "mood" of the client over the years. For example, laugh lines or wrinkles around the lips, cheeks, and eyes are usually more noticeable. Choice B is incorrect. The nose and ears of the aging client become more extended and broader. Over time, the nose and ears appears to grow in size due to gravity. As individuals age, gravity causes cartilage in the ear and nose to break down and sag which gives these features an elongated appearance. Choice C is correct. Changes in hormone levels, especially the androgen-estrogen ratio, often cause an increase in the growth of facial hair in most older adults. As individuals age, they lose estrogen. When estrogen decreases and testosterone levels are unopposed clients will start to grow more hair where men have it, especially on the face. Choice D is correct. The aging process causes the platysma muscle to shorten, which contributes to neck wrinkles. Neck skin is very similar to facial skin. As a client ages, they lose important dermal plumping factors like collagen, elastin and glysosaminoglycans. These factors are gradually lost over time with the aging process and is also enhanced with environmental stressors like frequent exposure to UV light. Additional Info Aging skin looks thinner, paler, and clear (translucent). Pigmented spots including age spots or "liver spots" may appear in sun-exposed areas. The medical term for these areas is lentigos. Changes in the connective tissue reduce the skin's strength and elasticity.It becomes thinner, loses fat, and no longer looks as plump and smooth as it once did. Your veins and bones can be seen more easily. Scratches, cuts, or bumps can take longer to heal.

The nurse is reviewing tasks for assigned clients. Which action is a priority to implement? A. Visual acuity test for a client reporting blurred vision in one eye. [1%] B. 12-lead electrocardiogram for a client reporting chest pain. [89%] C. Orthostatic vital signs for a client complaining of syncope. [8%] D. Discharge teaching for a client newly diagnosed with hypertension. [1%]

Explanation Choice B is correct. A 12-lead electrocardiogram (ECG) is essential for a client endorsing chest pain. This test will help determine if the client has an acute myocardial infarction by showing ST elevations. In suspected acute myocardial infarction (MI), guidelines recommend obtaining an ECG within 10 minutes of the client's arrival in the emergency room. If the client is experiencing an ST-elevation myocardial infarction (STEMI), a delay in obtaining a diagnosis and/ or therapeutic intervention can lead to poor clinical outcomes ( increased morbidity and mortality). Choices A, C, and D are incorrect. It is important to obtain orthostatic vital signs in a client with syncope. Still, it is not more of a priority than obtaining an electrocardiogram in a client with suspected MI. A visual acuity test using a Snellen chart is not a priority for a client complaining of blurred vision in one eye. This is also true for the client awaiting discharge teaching as this is low-priority. Additional information: The client's complaint of chest pain may likely indicate a circulation problem and thus is the nurse's initial priority. In this case, the client experiencing chest pain is a potential threat to their circulation. When prioritizing client needs, the strategy of "ABCs" airway, breathing, and circulation may be used.

The nurse in the surgical ward cares for a client who has just undergone a procedure for a Kock pouch as a treatment for his bladder cancer. The initial nursing interventions for this patient would include: A. Monitor urine output through the pouch; checking the ostomy pouch for leaks; taking note of the size, shape, and color of the stoma. [89%] B. Talking to the client's family and updating them about the client's status. [1%] C. Teaching the client about stoma care and skincare. [8%] D. Irrigating the ureteral catheters as needed. [3%]

Explanation Choice A is correct. Monitoring the urine output, checking for leaks, and taking note of the stoma's characteristics are the initial nursing interventions for a patient status-post urinary diversion procedure. The nurse should monitor the urine output and report if the volume is less than 0.5 ml/kg/hr or no output for more than 15 minutes. Checking for leaks makes sure that the skin under the pouch is not irritated. Noting the characteristics of the stoma gives baseline information regarding the stoma's appearance. Following the procedure, a stoma site is usually hyperemic (red or pink). Any changes in the stoma site's color from reddish/pink to cyanotic/dusky may indicate impairment of arterial blood supply (ischemia). If cyanosis is noted, the nurse must notify the physician immediately. A cyanotic stoma is a medical emergency and, if not addressed, can lead to necrosis. Choice B is incorrect. Updating the client's family regarding the patient's condition is typically the role of the doctor. Choice C is incorrect. Stoma care and skincare should be taught to the client at the time of discharge, not immediately after the surgery. Choice D is incorrect. Irrigation of ureteral catheters should not be done unless there are specific orders from the physician. Unnecessary irrigation increases the risk of ascending urinary tract infections.

When a client with mid-stage Alzheimer's disease becomes agitated, which intervention should the nurse use? A. Placing an arm around the client's shoulders [27%] B. Turning on the television [31%] C. Place the client in a darkened room [18%] D. Encourage the client to join a group activity [24%]

Explanation Choice A is correct. Nursing interventions for Alzheimer's patients with "agitation" include providing a safe environment free of external stimulation and offering calming emotional support. Therapeutic touch is a non-pharmacological intervention that is an appropriate and effective treatment of agitation in patients with dementia. Placing an arm around the shoulders is comforting and provides reassurance to an agitated patient. Several studies have provided good evidence for the beneficial effects of regular therapeutic touch on reducing agitation in demented patients. Choices B, C, and D are incorrect. When a client with Alzheimer's disease becomes agitated or hostile, the nurse should respond in a calm and supportive way. Decreasing external stimuli will help lower the patient's agitation level. Turning on the television (Choice B) and leading the client to a group activity (Choice D) are inappropriate because they increase external stimulation and worsen agitation. Finally, the client should not be left alone in a darkened room (Choice C), as this may cause fear and result in increased agitation. Learning Objective Understand that therapeutic touch is an effective modality in reducing agitation in Alzheimer's clients. Additional Info Alzheimer's patients often exhibit behavioral symptoms. Such symptoms include agitation/restlessness, disruptive vocalization (screaming), pacing, sleeplessness, or aggression. Agitation in Alzheimer's patients can occur from various causes or the disease process itself. Identifying the cause of agitation (pain, drug interactions, infection) is crucial to managing the agitation effectively. Caregivers and health care providers use various interventions to treat these behavioral symptoms. However, these conventional interventions are fraught with safety problems and limited effectiveness. Examples include chemical and physical restraints, which can lead to an increased risk for falls. Therefore, therapeutic touch has been studied and established as an effective intervention in addressing agitation. Therapeutic touch is a very effective non-verbal communication technique that can offer immediate security and reassurance

What is the nurse's priority when a fire occurs in a client's room? A. Rescue the patient [86%] B. Extinguish the fire [3%] C. Sound the alarm [11%] D. Run for help [0%]

Explanation Choice A is correct. Patient safety is always the first priority. Choices B and C are incorrect. Sounding the alarm and extinguishing the fire are important things to do after the patient is safe. Choice D is incorrect. Calling for help, if possible, rather than running for help allows you to remain with the patient and is a more appropriate action. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control - Fire Safety

The nurse assesses a client with damage to cranial nerve III. Which finding would be expected? A. Ptosis [61%] B. Anosmia [8%] C. Uvula deviation [6%] D. Asymmetric facial movement [24%]

Explanation Choice A is correct. Ptosis, or eye drooping, occurs with cranial nerve III (oculomotor) lesions, myasthenia gravis, and Horner syndrome. Dysfunction of cranial nerve III is also associated with dilated pupil, absent light reflex, and impaired extraocular muscle movement. Choices B, C, and D are incorrect. Anosmia, or a decrease or loss in smell, occurs with dysfunction of cranial nerve I (olfactory), frontal lobe lesion, tobacco or cocaine use, allergic rhinitis, and upper respiratory infections. Uvula deviation to one side occurs with dysfunction of cranial nerve X (vagus), brainstem tumors, and neck injury. Unilateral facial movement occurs with dysfunction of cranial nerve VII (facial), central nervous system lesions such as stroke, and peripheral nervous system lesions such as Bell's palsy. Additional Info The twelve cranial nerves include - CN I: Olfactory CN II: Optic CN III: Oculomotor CN IV: Trochlear CN V: Trigeminal CN VI: Abducens CN VII: Facial CN VIII: Vestibulocochlear CN IX: Glossopharyngeal CN X: Vagus CN XI: Accessory CN XII: Hypoglossal

A client was brought to a psychiatric hospital when police found him walking around the neighborhood at night without shoes in the snow. He looks confused and disoriented. Which should be the priority at this point? A. Assess and stabilize the client medically [73%] B. Perform a mental assessment and stabilize the client psychologically [20%] C. Locate the nearest family members to get the client's history [1%] D. Arrange for a transfer to the nearest medical facility [5%]

Explanation Choice A is correct. Since the client walked barefoot in the snow, the possibility of frostbite should be evaluated, among other things. Choices B, C, and D are incorrect. The client's psychological needs, locating family members, or arranging for transfer may be addressed after the client's immediate medical needs have been met.

The client has been prescribed fluoxetine for his depression. The nurse understands that fluoxetine should be given at what time? A. In the morning [69%] B. After lunch [2%] C. Before dinner [1%] D. Before bedtime [27%]

Explanation Choice A is correct. The medication should be given in the morning to avoid insomnia. Taking the drug during the later parts of the day will lead to insomnia. Choice B is incorrect. Taking the medication after lunch will lead to sleeping disturbances due to the effects of the drug. Choice C is incorrect. Taking the medication before dinner will lead to sleeping disturbances due to the effects of the drug. Choice D is incorrect. Taking the medication before dinner will lead to sleeping disturbances due to the effects of the drug.

Select the therapeutic diet that is accurately paired with a medical diagnosis. A. The DASH diet: Heart failure [42%] B. A high fiber diet: Coronary artery disease [23%] C. Mechanical soft diet: Myocardial infarction [8%] D. A weight reduction diet: Heart disease [27%]

Explanation Choice B is correct. A high fiber diet and a low cholesterol diet are indicated for clients affected with coronary artery disease. The goal of the low cholesterol diet is to decrease the client's LDL level by limiting dietary cholesterol intake to less than 200 mg per day, and the goal of a high fiber diet is to lower LDL. Choice A is incorrect. The DASH diet or the "Dietary Approaches to Stopping Hypertension" diet is used for clients affected with hypertension rather than heart failure. The DASH diet consists of foods low in sodium, high in calcium, and high in potassium. Choice C is incorrect. A mechanical soft diet is used for clients with swallowing and dentition problems rather than clients who have had a myocardial infarction. Instead, clients who have had a myocardial infarction have a clear liquid diet for 24 hours post the event and then a diet without caffeine. Choice D is incorrect. A weight reduction diet is not necessarily indicated for clients affected with heart disease because many clients with heart disease may be of normal weight or underweight.

Which of the following statements about carbon monoxide is accurate? A. Carbon monoxide is a gas that is gray in color and deadly. [11%] B. Carbon monoxide is a gas that is clear, odorless, and deadly. [83%] C. Carbon monoxide is a gas that is yellow and odorless. [1%] D. Carbon monoxide is a gas that smells like rotten eggs. [5%]

Explanation Choice B is correct. Carbon monoxide is a gas that is clear, odorless, and deadly. This invisible gas most often builds up in enclosed areas where engines, such as car engines, are running idly. Choice A is incorrect. Carbon monoxide is deadly, but it is not gray. Choice C is incorrect. Carbon monoxide is odorless, but it is not yellow. Choice D is incorrect. Carbon monoxide is odorless, but it does not smell like rotten eggs or sulfur.

The nurse is caring for a patient with suspected congestive heart failure (CHF). Which of the following laboratory tests would the nurse expect the primary health care provider (PHCP) to prescribe to confirm the diagnosis? A. Basic metabolic panel (BMP) [6%] B. B-type natriuretic peptide (BNP) [80%] C. Complete Metabolic Profile (CMP) [7%] D. C-Reactive Protein (CRP) [6%]

Explanation Choice B is correct. Congestive Heart Failure (CHF) may be confirmed by an elevation of the B-type natriuretic peptide (BNP). This peptide is elevated when it is cleaved from the ventricle wall because of increased ventricular filling pressures. Choices A, C, and D are incorrect. CHF is a condition that may lead to consequential fluid retention and decreased cardiac output. BMP, CMP, and CRP are not tests indicated for CHF. C-Reactive Protein may be used to detect atherosclerosis but not utilized in diagnosing heart failure. Additional information: Testing for CHF may consist of an electrocardiogram (ECG), echocardiogram, and laboratory work such as a BNP. When consistent with a diagnosis for CHF, the ECG may show left ventricular abnormalities. The echocardiogram may show ventricular dysfunction with reduced ejection fraction. A diagnosis of CHF is made when the ejection fraction is less than 40%.

The nurse is caring for a child with nocturnal enuresis that was not responsive to non-pharmacological modifications. The nurse anticipates the primary healthcare provider (PHCP) to provide which medication? A. Urecholine [22%] B. Desmopressin [55%] C. Prazosin [9%] D. Finasteride [14%]

Explanation Choice B is correct. Desmopressin is indicated for the treatment of diabetes insipidus and nocturnal enuresis. This medication is a synthetic form of antidiuretic hormone. Choices A, C, and D are incorrect. Urecholine is a cholinergic medication that promotes urinary output and is unhelpful in managing nocturnal enuresis. Prazosin is a medication approved to treat benign prostate hyperplasia (BPH). Finasteride is an antagonist of the peripheral form of testosterone, DHT. Thus, this medication is approved to treat BPH. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Expected actions/outcomes Question type: Knowledge/comprehension Additional Info Nocturnal enuresis usually starts at age five and may continue past age ten. The cause of this is multifactorial and may include genetic predisposition. Behavioral interventions are tried first and include a voiding diary to track the episodes and their frequency, use an enuresis alarm, execute positive reinforcement, and avoid shaming the child. Prescriptive therapies include desmopressin or tricyclic antidepressants such as imipramine.

The nurse is planning a staff development conference about vaccines. Which of the following information should the nurse include? A. MMR vaccine should be administered in the first trimester of pregnancy. [3%] B. Human Papillomavirus vaccine can reduce the risk of cervical cancer. [88%] C. Influenza vaccine may be administered to an infant at 3 months. [6%] D. Herpes zoster vaccine is recommended starting at age 40. [3%]

Explanation Choice B is correct. The Human Papillomavirus (HPV) vaccine is the only vaccine proven to decrease the risk of cervical cancer. Nearly all cases of cervical cancer are linked to HPV and thus, the vaccine is an effective primary prevention method. Choices A, C, and D are incorrect. MMR vaccine is contraindicated during pregnancy. The client should not receive this vaccine or any other live vaccines during the pregnancy period. The seasonal influenza vaccine is an effective prevention method for children 6 months and older. Herpes zoster immunization is recommended starting at age 50. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Vaccine administration Question type: Analysis Additional Info The MMR vaccine should not be administered to clients currently pregnant or four weeks prior to pregnancy. This is a two-series vaccine and is recommended for children starting at 12 to 15 months. The HPV Vaccine is available as a two or three-dose vaccine depending on which age it is started. Initial vaccination is recommended for males and females aged 11 to 12. The vaccine is recommended up to age 26. This vaccine is not recommended during pregnancy. The influenza vaccine comes in a variety of preparations - recombinant influenza vaccine, this vaccine is recommended for those aged 18 or older; inactivated influenza vaccine (IIV), which is recommended for ages six months or greater; live attenuated influenza vaccine (LAIV) that is given intranasally for those aged 2 through 49. The herpes zoster vaccine is recommended for individuals aged 50 or greater. This vaccine protects a client against shingles. This vaccine should be administered regardless of prior infection of varicella or herpes zoster.

Which action is not appropriate for the RN to delegate to the UAP? A. Obtain oxygen saturation via pulse oximeter. [7%] B. Assist the patient with adjustment of nasal cannula tubing. [4%] C. Assess for the patient's reaction to oxygen therapy and any worsening shortness of breath. [76%]

Explanation Choice C is correct. Assessment-related tasks are not within the scope of the unlicensed assistive personnel's (UAP) role. The RN should perform the assessment and evaluation of a patient's response to any intervention. Choice A is incorrect. Obtaining and reporting vital signs, such as oxygen saturation via pulse oximeter, is within the scope of the UAP role. Choice B is incorrect. Adjusting the nasal cannula for proper positioning and patient comfort is within the scope of the UAP role. Choice D is incorrect. Only answers A and B are appropriate delegation. NCSBN Client Need Topic: Leadership/Management, Subtopic: Delegation

The nurse is assessing a 2-year-old client with the following symptoms: excessive drooling, stridor, difficulty swallowing, and difficulty speaking. Based on these assessment findings, which condition does the nurse suspect? A. Croup [5%] B. Epiglottitis [87%] C. Laryngotracheal bronchitis [7%] D. Bronchiolitis [1%]

Explanation Choice B is correct. The cardinal signs of epiglottitis are the "4 Ds" - drooling, dysphonia, dysphagia, and distress. Difficulty swallowing is dysphagia and difficulty speaking is dysphonia. Stridor is a high-pitched wheezing sound caused by disrupted airflow, hence the distress. This child is presenting with all of those cardinal symptoms and is therefore highly suspicious of epiglottitis. Choice A is incorrect. Croup is a respiratory infection presenting with a loud barking cough. It does not cause airway obstruction. Choice C is incorrect. Laryngotracheal bronchitis is another name for croup. The cardinal sign of this disorder is a loud, barking cough. It is sometimes described as a "seal-like" barking cough. It lasts 3-5 days and the child is typically febrile. Choice D is incorrect. Bronchiolitis is inflammation of the bronchioles or lower airway. It is characterized by a runny nose, fever, and cough. Children with bronchiolitis do not present with the signs of airway obstruction described; those are very specific to epiglottitis. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Physiological adaptation, Pediatric - Respiratory

The nurse has just given an intradermal injection of PPD to a client in the clinic when she accidentally sticks herself in the finger with the used needle. What is the initial action of the nurse? A. Fill out an incidence occurrence report. [2%] B. Wash the area with soap and water right away. [95%] C. Ask the client if he has HIV or hepatitis. [2%] D. Put an antibiotic cream and bandage over the site. [0%]

Explanation Choice B is correct. The initial action of the nurse should be to wash the area with soap and water first then try to squeeze the area to make it bleed. Choice A is incorrect. The incident should be documented entirely; however, the nurse should care for the wound first. Choice C is incorrect. The nurse should not directly ask the client. The nurse may refer to the client's chart or ask the client to have his blood drawn for testing. Choice D is incorrect. The first puncture site would not need an antibiotic ointment.

The nurse is assigned to supervise a new unlicensed assistive personnel (UAP) in completing personal hygiene tasks. Following the UAP gathering the needed supplies, performing hand hygiene, and donning clean gloves, you observe the UAP provide a bed bath to an elderly client on complete bed rest. The UAP begins by first washing the client's forehead. What should be the nurse's next action? A. Praise the new UAP because they have correctly washed the client's forehead first. [9%] B. Instruct the UAP that the inner canthus of the eyes should be washed first and use a new washcloth to do so. [85%] C. Instruct the new UAP that the outer canthus of the eyes should be washed first. [4%] D. Have the UAP stop and don sterile gloves for the bed bath. [2%]

Explanation Choice B is correct. You would instruct the new UAP that the inner canthus of the eyes should be washed first, followed by the outer canthus of the eyes. Once the eyes have been cleansed in this manner, the UAP may then move on to the remainder of the face. Choice A is incorrect. As described in Choice B, the forehead is not the correct area to cleanse first; therefore, you would not provide positive feedback to a UAP who initiates a bed bath by cleansing the forehead region. Choice C is incorrect. As described in Choice B, the outer canthus is not the correct area to cleanse first; therefore, you would not provide positive feedback to a UAP who initiates a bed bath by cleansing the outer canthus prior to the inner canthus. Choice D is incorrect. Before performing this bed bath, the UAP correctly performed hand hygiene and donned clean gloves. Sterile gloves are not needed when performing a bed bath and instructing the UAP to don sterile gloves would be incorrect. Learning Objective Recognize the correct manner to perform a bed bath in order to minimize the risk for infection. Additional Info To reduce the risk of infection, always perform hygiene measures while moving from cleanest to less clean or dirty areas. This often requires you to change gloves and perform hand hygiene during care activities. Begin with the inner canthus and move to the outer canthus. Bathing the eye from inner to outer canthus prevents secretions from entering the nasolacrimal duct. When washing a client's eyes, use plain warm water, as soap irritates the eyes. Use different sections of the washcloth or mitt for each eye to avoid transmission of any infection. Any rough patches may need to be soaked prior to removal. Gently, but thoroughly, dry the eyes as pressure can cause internal injury.

You are caring for a 17-year-old patient who has been taking isotretinoin (Accutane) for the past three months. The most critical assessment for this patient is: A. Improvement in the appearance of the skin [21%] B. Dry skin on the face [12%] C. Mood changes [55%] D. Problems remembering to take the medication [12%]

Explanation Choice C is correct. Accutane is a synthetic retinoid that is frequently prescribed for severe acne that does not respond to other topical and oral treatments. This medication is usually given for 4 to 6 months or until significant improvement is noticed. Effects can include dry skin and development in the appearance of the skin. However, there are also severe side effects that can develop. The FDA required that the labeling of Accutane be changed to add that there is a possible connection between Accutane and critical mood changes. Depression, irritability, altered sleep patterns, and suicidal ideation should be reviewed with the patient during every visit. Family members should be aware of the possibility of these problems. They should be instructed to watch for these symptoms and should call the physician immediately if issues are noted. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-Topic: Adverse Effects/Contraindications/Side effects/Interactions, Integumentary

The nurse is working with a child who is undergoing a diagnosis of rheumatic fever. The nurse knows that they should ask about which of the following untreated infections in the patient's history? A. Urinary tract infection [3%] B. Seasonal Flu [6%] C. Streptococcal infection [85%] D. Whooping cough [6%]

Explanation Choice C is correct. An untreated streptococcal infection, specifically Group B streptococcus, may lead to rheumatic fever, a severe condition with cardiac implications. Nurses should advocate for strep throat testing when there's a high clinical suspicion for streptococcal pharyngitis in patients complaining of a sore throat in the clinic. Choice A is incorrect. Urinary tract infections, or bacterial colonization of the urinary tract, are not related to rheumatic fever. Choice B is incorrect. The seasonal flu is not associated with rheumatic fever. Choice D is incorrect. Pertussis ( whooping cough, Bordetella Pertussis) infection may affect the patient's skin, throat, urinary tract, and many other sites. Weight loss, urinary incontinence, syncope, and rib fractures from severe coughing may be seen but not rheumatic fever. NCSBN client need Topic: Maintenance and Health Promotion, Health screening

The nurse is caring for a neonate with a decreased cardiac output. If noted in this patient, which of the following is not a sign of decreased cardiac output? A. Oliguria [20%] B. Difficulty breastfeeding [40%] C. Bradycardia [32%] D. Hypotension [7%]

Explanation Choice C is correct. Bradycardia is not a typical symptom of decreased cardiac output in neonates. Instead, a decreased cardiac output generally results in tachycardia as the heart pumps faster to compensate. Typical signs of decreased cardiac output in an infant include oliguria, difficulty feeding, hypotension, irritability, restlessness, pallor, and decreased distal pulses. Choice A is incorrect. Oliguria is an expected finding in an infant with a decreased cardiac output. As the kidneys are perfused less efficiently in an infant with decreased cardiac output, urination reduces or ceases altogether. Choice B is incorrect. Difficulty breastfeeding may be seen in infants with low cardiac output. Feeding is increasingly difficult for babies with poor circulation. Choice D is incorrect. Hypotension is an expected finding in an infant with low cardiac output. Normal cardiac output is required to keep blood pressure regulated.

While assessing a laboring mother during a contraction, the nurse notes a decrease in fetal heart rate from 150 to 120 bpm. The heart rate slows for about 10 seconds and increases back to 150 bpm as the contraction ends. Which of the following correctly classifies this observation? A. Late deceleration [22%] B. Moderate variability [22%] C. Early deceleration [45%] D. Marked variability [11%]

Explanation Choice C is correct. Early decelerations occur when the fetal heart rate decreases at the same time as a contraction. In this question, the nurse noted a decrease from 150 to 120 bpm with the contraction and then a return to baseline. This occurs due to the pressure of the head of the fetus on the pelvis or soft tissue, and no intervention is required by the nurse after an early deceleration. Choice A is incorrect. Late decelerations are a decrease in the fetal heart rate that occurs after a contraction. They are a non-reassuring sign on a fetal heart rate strip. In this question, the nurse noticed an early deceleration because it occurred with a contraction, not after. Choice B is incorrect. Variability on a fetal heart rate is defined as the fluctuations in the fetal heart rate from baseline. A moderate amount of variability is what is expected and is considered a reassuring sign. This question does not mention the variability of the fetal heart rate; instead, it notes an early deceleration. Choice D is incorrect. Variability on a fetal heart rate is defined as the fluctuations in the fetal heart rate from the baseline. Marked variability is a dramatically increased amount of these fluctuations. This question does not mention the variability of the fetal heart rate; instead, it notes an early deceleration. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Problems with Labor and Delivery

The nurse is caring for a client with bulimia nervosa. The nurse anticipates a prescription for which medication? A. metformin [5%] B. bupropion [34%] C. fluoxetine [46%] D. clozapine [15%]

Explanation Choice C is correct. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) and is the only approved medication for bulimia nervosa. This medication effectively treats this disorder, especially when coupled with psychotherapy. Fluoxetine assists in increasing a client's weight and may mitigate comorbid disorders such as generalized anxiety disorder. Choice A, B, and D are incorrect. Metformin may cause weight loss and is quite advantageous in treating diabetes mellitus. Thus, this would not be an effective treatment for bulimia nervosa. Bupropion is an atypical antidepressant and causes weight loss. Bupropion is contraindicated in the treatment of bulimia because of its weight negative effects. Clozapine is an effective atypical antipsychotic that is not employed to treat bulimia. While some antipsychotics may be utilized for eating disorders, it is not common for an antipsychotic to be utilized for bulimia nervosa. Additional Info Fluoxetine is an SSRI and is approved to treat bulimia nervosa. This medication is effective when treating this eating disorder, especially when coupled with psychotherapy. Major side effects of fluoxetine include weight gain, sexual dysfunction, insomnia, and agitation.

A patient is prescribed a calcium channel blocker to treat primary hypertension. When teaching the patient about the medication, which of these foods will the healthcare provider advise the patient to avoid? A. Eggs [3%] B. Milk [7%] C. Grapefruit [84%] D. Bananas [7%]

Explanation Choice C is correct. Grapefruit can interfere with other drugs, as well, including statins (atorvastatin, lovastatin, simvastatin), some antibiotics, and some cancer drugs. Grapefruit and its juice contain furanocoumarins, which block the enzymes that are involved in metabolizing many drugs, including calcium channel blockers. Medication blood levels can increase, resulting in toxicity. The levels of calcium channel blockers are increased when grapefruit or grapefruit juice is consumed, potentially causing hypotension. Choices A, B, and D are incorrect. Neither of these answer options adversely affect calcium channel blockers. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies, Calcium Channel Blockers

The nurse is teaching a client about using crutches. The client has a fractured leg and cannot bear any weight on the affected leg. It would be appropriate for the nurse to instruct the client to use which crutch-walking gait? A. Two-point gait [10%] B. Swing-through gait [35%] C. Three-point gait [47%] D. Four-point gait [8%]

Explanation Choice C is correct. The appropriate gait to teach this client is the three-point gait. In the three-point gait, the client bears weight on both crutches and then on the unaffected leg, repeating the sequence. Choices A, B, and D are incorrect. The two-point gait requires at least partial weight bearing on each foot. The client moves a crutch at the same time as the opposing leg, so the crutch movements are similar to arm motion during normal walking. Individuals with paraplegia who wear weight-supporting braces on their legs frequently use the swing-through gait. Four-point gait gives stability to the client but requires weight-bearing on both legs. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times. Additional Info The basic crutch stance is the tripod position, formed when the crutches are placed 6 inches in front of and 6 inches to the side of each foot. This position maintains a client's balance by providing a wider support base.

The nurse unit manager receives a complaint from a client's family regarding the care that the client received from the night shift nurse. What would be the manager's most appropriate initial action? A. Tell the night charge nurse to ensure the night nurse performs her work [2%] B. Talk to the nurse regarding the complaint and discuss the care provided [66%] C. Discuss the situation with the client's family that made the complaint [30%] D. Take note of the complaint and place it in the employee's file [1%]

Explanation Choice C is correct. The nurse manager should talk to the client's family first to let them feel that they are being heard. This also enables the nurse manager to ask questions for further investigation of the complaint to determine whether it is valid or not. Once the manager has determined that the claim was correctly made, the manager would then talk to the nurse regarding the care that she has provided and ask more questions. The incident may go into the nurse's file, but not without investigating the matter first. Choices A, B, and D are incorrect. These are not the first actions that should be done by the nurse manager.

The nurse is assessing a patient diagnosed with stage IV nephroblastoma. Which of the following actions should the nurse not perform in this patient? A. Checking capillary refill [3%] B. Auscultating heart sounds [3%] C. Abdominal palpation [90%] D. Assessing urine color [4%]

Explanation Choice C is correct. The nurse should not perform abdominal palpation in a patient with a nephroblastoma (Wilm's tumor). Vigorously palpating the mass can cause the tumor to rupture and bleed into the peritoneal cavity. In patients with early-stage disease, rupture of the tumor may also cause it to spread to other parts of the body. If necessary, the physician may palpate the tumor cautiously. Nephroblastoma develops from immature kidney cells and grows into the peritoneal cavity. It is the 4th most common cancer in children. Nephroblastoma most commonly presents with an asymptomatic, palpable abdominal mass. Other features include hypertension, abdominal pain, microscopic hematuria, and fever. Occasionally, gross hematuria may be present. Long-standing hypertension in nephroblastoma may lead to cardiomyopathy/congestive heart failure. Choice A is incorrect. There is no contraindication for checking the capillary refill in a patient with nephroblastoma. By checking capillary refill, the nurse will be assessing the client's perfusion status, which is important. Choice B is incorrect. There is no contraindication for auscultating heart sounds in the patient with nephroblastoma. In fact, auscultating an S3 heart sound may provide a clue for underlying fluid overload/heart failure in these patients. Nephroblastomas can cause an increase in renin production (hyperreninemia). Elevated renin produces vasoconstriction and fluid retention that leads to hypertension. Sustained hypertension may lead to cardiomyopathy in these patients. Fluid overload must be avoided in patients with nephroblastoma. Choice D is incorrect. Nephroblastoma arises from the kidney. Therefore, hematuria is a common finding in patients with nephroblastoma. Red urine color may suggest gross hematuria. The nurse should assess for adequate urine production and hematuria and report any alarming findings to the healthcare provider. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Basic care, comfort

When caring for a patient who has impaired hearing, the nurse knows that the best way to approach them is to do which of the following? A. Speak loudly [21%] B. Speak quickly [0%] C. Speak at a normal volume [76%] D. Speak into the impaired ear [3%]

Explanation Choice C is correct. The nurse should speak directly to the client and at an average volume. If this method does not work, the nurse should try to express what is being said differently. Choice A is incorrect. Speaking loudly may startle the patient as the nurse approaches. Choice B is incorrect. Babbling is not the most appropriate way to approach this client. Choice D is incorrect. Speaking into the impaired ear as the nurse approaches may make the patient nervous. This is inappropriate. NCSBN client need Topic: Physiological integrity, physiological adaptation

An LPN is working in a group home for adolescents who are recovering from substance abuse. She is assigned to work with a 16-year-old girl who is trying to quit smoking marijuana. While talking with the girl, she uses motivational interviewing to help her work towards her goals. Which of the following statements by the LPN would be the best? A. "Would it be alright if we talk about your pot use now?" [11%] B. "What good things do you have going for you in your life?" [48%] C. "What changes can you make in your marijuana use this week?" [40%] D. "Who can help you quit marijuana?" [2%]

Explanation Choice C is correct. This is a direct, open-ended question that addresses the patient's substance abuse. Motivational interviewing maintains direct communication with open items, as does this question. By using motivational interviewing, the patient should be empowered and encouraged to make positive changes. The nurse will help to facilitate the patient in seeing the need to change, but the patient will make their own decision to work for that change. Choice A is incorrect. If the LPN asks her patient if it is alright to talk about her substance abuse, it allows the patient to say no. This could prevent the LPN from having a productive conversation with her patient and will not likely be an excellent motivational interviewing conversation. Choice B is incorrect. This is an off-topic question and does not directly address the patient's substance abuse. The LPN should use open-ended questions that directly address the patient's substance abuse to begin motivational interviewing. Choice D is incorrect. This is not an appropriate statement because it does not focus on the patient. Instead, it seeks to involve another person. This will not aid in helping the patient feel empowered to make their positive changes, which is what motivational interviewing seeks to do. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Mental Health - Substance Abuse

The RN is caring for a family who just found out that their newborn baby has tetralogy of Fallot. The parents state, "We can't believe our baby is going to die!" Which of the following statements by the RN is most appropriate? A. "Yes, that is so sad. What can I do to help you?" [2%] B. "Your baby will be fine! This is not so serious." [0%] C. "Tetralogy of Fallot can be surgically repaired. Let's talk more about what you can expect." [98%] D. "Well, at least you get to spend time with your baby now. Some people don't even get that." [0%]

Explanation Choice C is correct. This statement does not support that the baby will die, but provides factual information about the treatment plan for the defect and leads into a more detailed conversation about what the parents can expect. It is clear that they do not fully understand tetralogy of Fallot (TOF) and the treatment options, so education is very important for these parents. Choice A is incorrect. This is not a therapeutic statement, as it is not necessarily true that the baby is going to die. The nurse should not validate this fear, rather the nurse needs to provide further education to help the family understand what to expect. Choice B is incorrect. The nurse should not invalidate the parent's fears. TOF is a very serious heart defect, so telling the parents that the baby will be fine may not be true. It is important to provide factual education to the parents so that they understand their child's cardiac defect. Choice D is incorrect. This statement is neither helpful nor accurate. The nurse should not say this. NCSBN Client Need Topic: Health promotion and maintenance; Subtopic: Pediatrics - Cardiac

The nurse is caring for a client who is severely hypernatremic. Based on the complications from this electrolyte imbalance, the nurse knows that the priority assessment is which of the following? A. Cardiovascular status [23%] B. Genitourinary status [7%] C. Neurological status [68%] D. Gastrointestinal status [2%]

Explanation Choice C is correct. When a client is suffering from severe hypernatremia, monitoring neurological status is the nurse's priority. Neurological complications of hypernatremia range from a restless, agitated client, to a comatose state. Sodium plays a major role in the brain and nervous system, so any imbalances can cause serious neurological symptoms. Choice A is incorrect. Monitoring cardiovascular status is always important, but it is not the priority in a client with severe hypernatremia. Sodium plays a large role in the brain and nervous system, therefore the nurse should be careful to monitor the client's neurological status very closely when there is an imbalance. Choice B is incorrect. Monitoring genitourinary status is important, but it is not the priority in a client with severe hypernatremia. There are no major GU symptoms with hypernatremia, but the nurse knows that very serious neurological complications can occur in the hypernatremic client. Choice D is incorrect. Monitoring gastrointestinal status is important, but it is not the priority in a client with severe hypernatremia. There are no major GI symptoms with hypernatremia, but the nurse knows that very serious neurological complications can occur in the hypernatremic client. NCSBN Client Need Topic: Physiological Adaptation, Subtopic: Fluid and electrolyte imbalances

You are serving as the preceptor for a new graduate nurse. This new nurse is caring for a small group of adult clients under your supervision. Your shift is 8 hours long. The intake and output of clients are calculated and documented at the end of the shift. The new nurse reports a total urinary production of 150 mL from the urinary drainage bag for your 58-year-old male postoperative client at the end of your shift. What should you do? A. Simply record the urinary output according to your facility's policy and procedure. [5%] B. Simply report this urinary output to the oncoming shift as part of your "hand-off" report. [5%] C. Call the doctor to report this urinary oliguria and initiate hourly urinary output measurements. [83%] D. Call the doctor and report this urinary output as part of your daily doctor's update. [6%]

Explanation Choice C is correct. You would call the doctor to report this urinary oliguria and initiate hourly urinary output measurements because 150 mL over 8 hours is less than 19 mL per hour and less than 450 mL for 24 hours. This output is considered oliguria because the expected urinary production for an adult client is about 1,500 mL per day. Additionally, a urinary output of less than 19 mL per hour is a significant finding that can indicate a severe medical problem; therefore, the doctor must be notified immediately. Choice A is incorrect. You would not merely record the urinary output according to your facility's policy and procedure; there is something else that you must do in addition to this recording and documentation. Choice B is incorrect. You would not merely report this urinary output to the oncoming shift as part of your "hand-off" report; there is something else that you must do in addition to this reporting. Choice D is incorrect. You would not call the doctor and report this urinary output as part of your daily doctor's update; there is another reason why you would call the doctor.

The nurse is caring for a patient demonstrating avolition. The nurse would expect to observe the patient have which of the following? A. Loss of balance [9%] B. Full range of affect [6%] C. Diminished expression [18%] D. Lack of motivation [67%]

Explanation Choice D is correct. Avolition is a lack of motivation and is a key feature in schizophrenia as well as some depressive disorders. Choices A, B, and C are incorrect. Loss of balance, full range of affect, and diminished expansion are not findings associated with avolition. Loss of balance would be a problem associated with proprioception. A diminished expression would be consistent with schizophrenia and other psychiatric disorders. This could be termed constricted or flat affect depending on the significance. Additional information: Avolition is a clinical feature of some psychiatric illnesses, and this includes schizophrenia. This negative symptom may significantly impact a patient's socioeconomic status as maintaining employment and social relationships may become difficult. The nurse should maintain the patient's activities of daily living and encourage participation.

The patient is prescribed omeprazole. You know that the intended action of this medication is to: A. Enhance intestinal motility [13%] B. Reduce esophageal pressure [27%] C. Eradication of H. pylori growth [18%] D. Increase stomach pH [42%]

Explanation Choice D is correct. Increase stomach pH. The primary action of the proton pump inhibitors (PPIs) is to increase stomach pH or decrease the amount of acid in the stomach. The wall of the stomach produces an enzyme that produces stomach acid. These PPI medications block those enzymes. Although the PPIs are used in combination with antibiotics to limit H. pylori growth, it is the antibiotic that eradicates the bacteria. The nurse should warn the patient against long-term use of PPIs since there is evidence that this may increase the risk for osteoporosis-related fractures, hypomagnesemia, and myocardial infarctions. Choices A, B, and C are incorrect. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-topic: Expected Actions/Outcomes, Gastrointestinal/Nutritional

The nurse provides education on dietary recommendations for a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which statement by the patient would indicate that the teaching was effective? A. "I will reduce my intake of dairy-based foods." [31%] B. "I should avoid nuts and seeds." [26%] C. "I will limit meat products to once per day." [12%] D. "I will snack on dried fruit in between meals." [30%]

Explanation Choice D is correct. Patients with chronic obstructive pulmonary disease (COPD), or any other debilitating disease such as HIV, AIDS, or respiratory failure, should be encouraged to consume nutrient-dense, high-calorie, high-protein foods, including whole milk, peanut butter, beef, chicken, fish, pork, eggs, dried fruit, and avocado. Patients with these diseases should be encouraged to snack between meals to increase caloric intake. Choice A is incorrect. Dairy foods such as whole milk, milk-based products, cream, mayonnaise, and milkshakes are high in calories and are encouraged for patients with COPD and other debilitating diseases. Choice B is incorrect. Patients on a low-residue diet would be instructed to avoid nuts and seeds, however, COPD patients would be encouraged to eat a high-calorie, high-protein diet and unless otherwise contraindicated, nuts and seeds would be a good source of protein for this patient. Choice C is incorrect. Meat products such as beef, chicken, fish, and pork are a good source of calories and protein, therefore they should be encouraged for a patient with COPD.

Select the classification of cultural beliefs/practices that are accurately paired with an example of it. A. Holistic health beliefs: A pathogen causes infection and this leads to health problems. [9%] B. Magical health beliefs: Illness results from disharmony of the body and the mind. [11%] C. Scientific health beliefs: The wearing of an amulet to protect health. [4%] D. Scientific health beliefs: Compliance with the medical regimen is essential to health. [76%]

Explanation Choice D is correct. Scientific health beliefs are grounded in scientific research and evidence-based practice. With research and science, we can know the etiology of diseases and also ways to treat illnesses/disorders. Therefore the clients' compliance and adherence to the medical regimen are essential to health and recovery. Choice A is incorrect. Holistic health beliefs reflect the highly complex interactions of humans and the environment and the whole or integral part of the person. As such, holistic health beliefs create and recreate the harmony and balance of the person within their environment. Choice B is incorrect. Magical health beliefs vary significantly among cultures and religions. The wearing of an amulet and the use of a medicine man are examples of magical health beliefs and practices. Choice C is incorrect. The wearing of an amulet to protect health is an example of a magical health belief.

A school-aged child has developed a phobia for school. The nurse is talking to the child's parents regarding ways that could help with the child's phobia. Which statement by the parents is accurate? A. "We will just wait until his fears wear off; until then, we will just keep him home." [3%] B. "Teachers and counselors at school cannot possibly help him." [0%] C. "We'll try not to talk to him about it too much." [3%] D. "We will discuss some solutions with him together with a counselor." [93%]

Explanation Choice D is correct. Talking to the child allows the child to verbalize and helps the child to air out his feelings and may help to determine causes as well as provide solutions. Choice A is incorrect. Letting the child stay at home does not reduce or solve the child's phobia. It also makes the child feel worthless and dependent. Choice B is incorrect. Enlisting the aid of teachers and counselors at school helps in determining the cause of the child's phobia and helps in developing solutions. Choice C is incorrect. The child needs to verbalize his feelings toward his fears so that the cause and solutions to his worries will be determined.

In preparing for the admission of a toddler who has been diagnosed with febrile seizures, which of the following is the most important nursing action? A. Order a stat admission CBC. [2%] B. Place a urine collection bag and specimen cup at the bedside. [1%] C. Place a cooling mattress on his bed. [10%] D. Pad the side rails of his bed. [87%]

Explanation Choice D is correct. The child has a diagnosis of febrile seizures. Precautions to prevent injury and promote safety should take precedence. Children between 6 months and five years of age are at a higher risk for fever-induced (febrile) seizures. Febrile seizures are not associated with neurological seizure disorders. The priority in nursing care for a patient (of any age) who has experienced a seizure is to implement safety precautions that decrease the likelihood of injury if/when another seizure occurs. Choice A is incorrect. Only a physician can order lab work. Choice B is incorrect. Preparing for routine laboratory studies is not as high of a priority as preventing injury and promoting safety. Choice C is incorrect. A cooling blanket must be ordered by the physician and is usually not used unless other methods for the reduction of fever have not been successful. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control, Seizure Precautions

The nurse in the ICU notes bleeding from the client's transparent dressing over her peripheral intravenous site, gum bleeding, and frank blood in the urine. The client was originally admitted for sepsis. What should be the nurse's immediate next action? A. Assess the client's hemoglobin and hematocrit level. [15%] B. Check the client's oxygen saturation. [14%] C. Apply pressure to the intravenous site. [25%] D. Call the physician. [46%]

Explanation Choice D is correct. The client is manifesting signs of disseminated intravascular coagulation (DIC). This is a critical complication that often happens in the intensive care unit and usually is secondary to other serious etiologies such as sepsis. In this condition, the clotting system is activated significantly and leads to the consumption of platelets and clotting factors. DIC can manifest with either bleeding or clotting complications. Thrombocytopenia (low platelet count), coagulopathy (increased prothrombin time, increased partial thromboplastin time, decreased fibrinogen), and hemolysis are hallmarks of DIC. In the absence of any significant bleeding, transfusing platelets or clotting factors may fuel the thrombotic process in DIC. Therefore, platelets, cryoprecipitate, and fresh frozen plasma are not routinely injected in DIC unless there is significant bleeding. The client is bleeding from multiple sites. The nurse must call the physician first to initiate medical interventions, which may include ordering labs to confirm DIC, transfusing platelets, or infusing clotting factors. Choice A is incorrect. DIC is a consumption coagulopathy and also causes intravascular hemolysis. Intravascular small clots (microthrombi) form due to activation of the coagulation pathway in DIC. Red blood cells may rub against these thrombi leading to hemolysis. Fragmented red blood cells (schistocytes) can be seen in DIC due to this hemolysis. Hemolysis causes a drop in hemoglobin and hematocrit (resulting in anemia). The nurse should undoubtedly check the client's hemoglobin and hematocrit levels; however, the nurse needs to notify the physician right away since the client is showing bleeding signs of DIC. Choice B is incorrect. Assessing the client's oxygen saturation may also be performed later. The client is not in apparent respiratory distress based on the information presented. Hypoxia is not the cause of his bleeding complications. DIC should be suspected in this bleeding, septic patient and the nurse must notify the physician immediately since urgent intervention is needed Choice C is incorrect. The client is bleeding from multiple sites. The application of pressure to the intravenous site alone will not help stop the bleeding from other sites. DIC is a consumption coagulopathy. All the clotting factors and platelets are being used up in the clotting process. Therefore, the bleeding complications of DIC would necessitate platelets and clotting factor infusion.

The nurse is talking to an elderly client who is being discharged with digoxin as a take-home medication. The nurse should initiate further teaching when the client states: A. "I won't take the tablet when my pulse is too slow." [4%] B. "I guess I'll be eating a lot of spinach and bananas from now on." [17%] C. "So, I need to watch out for any nausea and vomiting every now and then." [3%] D. "It's good that I don't have to get my blood examined for potassium from now on." [75%]

Explanation Choice D is correct. This is an inaccurate statement by the client and necessitates the nurse to provide additional clarification. Hypokalemia ( low potassium level) increases the risk of digoxin toxicity, especially cardiac arrhythmias. The client needs to understand that serum potassium levels need to be monitored frequently while on Digoxin. Choice A is incorrect. Digoxin can cause bradycardia. Significantly reduced heart rate below the baseline may indicate supra therapeutic digoxin level. Checking his pulse and not taking the Digoxin when his pulse falls below 50-60 beats per minute is correct about the medication. Choice B is incorrect. Spinach and bananas are foods rich in potassium. Elderly patients are at risk of hypokalemia due to inadequate oral intake. Many patients on Digoxin are also on multiple other medications such as diuretics which increase the risk of hypokalemia. Low potassium level increases the risk of Digoxin toxicity. Consuming high potassium foods would be an effective way to prevent hypokalemia. This statement indicates an accurate understanding. Choice C is incorrect. The patient needs to recognize signs related to digoxin toxicity to access medical help immediately. Gastrointestinal side effects such as nausea and vomiting may be an early sign of digoxin toxicity. Learning Objective Recognize that digoxin toxicity increases in the presence of hypokalemia, and healthcare providers should monitor labs, especially when the clients are on other concomitant medications such as loop diuretics.

Which of the below photos represents an unstageable pressure ulcer? See the exhibit. A. Image A [4%] B. Image B [6%] C. Image C [11%] D. Image D [78%]

Explanation Choice D is correct. This pressure ulcer is considered unstageable because there is full-thickness tissue loss, but the wound bed is covered by eschar. Because of the eschar, real depth and stage cannot be determined. The eschar must be removed to visualize the foundation of the wound before staging. Choice A is incorrect. This is a stage I pressure ulcer. The skin is intact, but the area is red and does not blanch with external pressure. Choice B is incorrect. This is a stage IV pressure ulcer. There is full-thickness skin loss with exposed bone, tendons, or muscles. Choice C is incorrect. This is a stage III pressure ulcer. There is full-thickness loss into the dermis and subcutaneous tissue. There may or may not be slough, visible subcutaneous tissue, or undermining and tunneling. However, the bed of the wound is visible, and there is no exposed bone, tendons, or muscles. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Integumentary

The nurse is conducting a talk about school-age cognitive development to a group of parents. Which statement by the parents would indicate a need for further teaching? A. Collecting marbles and sports cards [7%] B. Arranging dolls according to size [12%] C. Answering simple trivia [6%] D. Deciding which university to go to for college [76%]

Explanation Choice D is correct. This task cannot be performed by the school-aged child yet. Deciding where to go to for college is not developed until adolescence. Choice A is incorrect. The school-aged child can perform inductive reasoning, operate logically, and show real thought. This is an example of concrete operational thinking by the school-aged child. Choice B is incorrect. The school-aged child has the ability to perform inductive reasoning, operate logically, and show real thought. This is an example of concrete operational thinking by the school-aged child. Choice C is incorrect. The school-aged child has the ability to perform inductive reasoning, operate logically, and show real thought. This is an example of concrete operational thinking by the school-agerd child.

You are the case manager for a client who is expected to have laboratory work done today according to their critical pathway. At the end of your shift, you see that the laboratory work was not done correctly. What would you document in the client's medical record? A. A laboratory error [22%] B. An incident [36%] C. An accident [1%] D. A variance [42%]

Explanation Choice D is correct. When you see that the laboratory work was not done according to the critical pathway, you will document this as a variance in the client's medical record. When case management and critical pathways are used, all things that are not done as expected are variances. Choice A is incorrect. Although the laboratory may have erred, the lack of this laboratory work could have resulted from several other things, such as the client's refusal. Choice B is incorrect. Incidents are events that cause harm to the client. There is no indication in this question that the client was harmed, however, the quality of the care may have been jeopardized. Choice C is incorrect. Accidents are events that cause harm to the client. There is no indication in this question that the client was harmed, however, the quality of the care may have been jeopardized.

The nurse is providing discharge instructions to a client with hepatitis A. Which of the following instructions should the nurse include? A. You will need to take daily showers or baths with chlorhexidine. [3%] B. It is important to clean common surfaces with warm soapy water. [27%] C. You will need to have repeat stool testing to determine if you are still infectious. [30%] D. Check with your primary healthcare provider prior to taking any medications. [40%]

Explanation Choice D is correct. While a client is being treated for hepatitis, they should consult with their primary healthcare provider, so they are not taking any medications or substances that are hepatotoxic. Exposing a client with hepatitis to a hepatotoxic medication would significantly complicate their recovery. Choices A, B, and C are incorrect. Having the client shower with chlorhexidine is not an appropriate teaching point for hepatitis A. The pathogen spreads through contaminated food, water, and surfaces. The primary mode of transmission is fecal-oral. Surfaces contaminated with hepatitis should be sanitized with a bleach solution, not warm soapy water. Repeat stool testing is not indicated for hepatitis as diagnosis of hepatitis is made through serum hepatitis-A antibodies. NCLEX Category: Physiological Adaptation Activity Statement: Illness management Question type: Knowledge/comprehension Additional Info Hepatitis A is an infection contracted through the consumption of raw or undercooked food, fecal-oral route, or contaminated water. Most cases are self-limiting with complete clinical recovery within three to six months. Vaccination for hepatitis A is a two-dose series beginning as early as six months for international travel; 12 months for routine vaccination.

You are caring for a client who is using the defense mechanism of denial after hearing a diagnosis of HIV/AIDS. This client is stating that this diagnosis must be a mistake. You should: A. Know that all reasonable clients should know that mistakes like this are rarely made in healthcare. [1%] B. Tell the client that this is not a mistake and that the client must accept this diagnosis as accurate. [6%] C. Recognize the fact that this denial of the diagnosis is not rationale or adaptive for the client. [19%] D. Recognize that the use of this defense mechanism is useful and constructive for the client at this time. [74%]

Explanation Choice D is correct. You should recognize that the use of this defense mechanism of denial is useful and constructive for the client at this time because this denial protects the client from an extreme stressor until the client can cope with it. Choice A is incorrect. It is inaccurate to think that all reasonable clients should know that mistakes like this are rarely made in healthcare for two reasons: mistakes are sometimes made and many sensible clients adapt with an ego defense mechanism such as denial. Choice B is incorrect. The nurse should not tell the client that this is not a mistake and that the client must accept this diagnosis as accurate. Nurses and other healthcare professionals must not strip defense mechanisms away from clients because these ego defense mechanisms are protective for the client. Choice C is incorrect. The nurse should know that denial, although not rational or conscious, is adaptive for the client. Additional Info

The nurse should expect to administer which of the following medications to the infant diagnosed with omphalocele? Select all that apply. A. Ceftriaxone [39%] B. D5W [29%] C. Albumin 25% [19%] D. Sodium bicarbonate [13%]

Explanation Choices A and B are correct. Ceftriaxone is a cephalosporin antibiotic. It is appropriate to use in an infant with omphalocele for prophylactic infection prevention. Infants with omphalocele are at increased risk for infection due to their intestines being exposed to the open air (Choice A). D5W is an isotonic crystalloid solution that would be appropriate for IV maintenance fluid administration in an infant with an omphalocele. These infants will have higher insensible fluid losses due to evaporation from their exposed intestines so that maintenance fluid will be a necessary part of their preoperative treatment (Choice B). Choice C is incorrect. Albumin 25% is a medication used to replace albumin in a patient with hypoproteinemia, or low protein levels. This would not be expected in an infant with omphalocele. Choice D is incorrect. Sodium bicarbonate is a base. It is used to increase the blood pH level when it has dropped below 7.35 and is acidotic, or if the sodium bicarbonate in the body has dropped below 22 and needs to be replaced. This would not be expected in an infant with omphalocele. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies; Pediatrics - Gastrointestinal Additional Info

Loop diuretics are an important classification of medication but have many side effects. Select all of the following side effects that are potential complications of loop diuretics. Select all that apply. A. Hypokalemia [42%] B. Hypernatremia [22%] C. Hypocalcemia [21%] D. Increase in BUN [15%]

Explanation Choices A and C are correct. Loop diuretics, such as furosemide and bumetanide, cause a large amount of urine to be excreted by acting on the loop of Henle. Due to the large volume of urine lost, there is also a significant amount of electrolyte loss. Two of these are potassium and calcium. This causes the side effects of hypokalemia and hypocalcemia. Choice B is incorrect. There would not be an increase in sodium due to loop diuretics, rather a potential loss. Choice D is incorrect. There would not be an increase in BUN due to loop diuretics. An increased BUN is indicative of decreased blood flow to the kidneys indicating renal damage, but as loop diuretics cause vasodilation of the renal vasculature, this would not be a complication you would expect to see. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological and Parenteral Therapies, Renal

Which of the following food choices would be good for a patient experiencing iron deficiency anemia? Select all that apply. A. Quinoa [11%] B. Liver [37%] C. Spinach [35%] D. Baked beans [17%]

Explanation Choices A, B, C, and D are all correct. A is correct. Quinoa is a good source of iron and therefore, an excellent recommendation for a patient with iron deficiency anemia. In one cup of quinoa, there is about 3 mg of iron. B is correct. The liver is a good source of iron and therefore, an excellent recommendation for a patient with iron deficiency anemia. In 3 oz of liver, there is about 15 mg of iron. C is correct. Spinach is a good source of iron and therefore, an excellent recommendation for a patient with iron deficiency anemia. In 100 grams of spinach, there is about 3 mg of iron. D is correct. Beans are a good source of iron and therefore, an excellent recommendation for a patient with iron deficiency anemia. In one cup of baked beans, there is about 5 mg of iron. NCSBN Client Need: Topic: Health promotion and maintenance; Subtopic: Hematology

Which of the following is appropriate for the nurse to include when documenting objective data regarding a client's general appearance and behavior? Select all that apply. A. "Skin diaphoretic." [29%] B. "Clothes disheveled." [20%] C. "Alert and oriented x 3." [20%] D. "Gait steady." [28%] E. "Reports fatigue." [1%]

Explanation Choices A, B, C, and D are correct. Objective data describes actual, measurable, and observable findings that are obtained through observation, physical examination, and laboratory/diagnostic testing. The appearance of the client's skin, clothing, and the client's current level of consciousness are measurable by the nurse's assessment. The client's steady gait is also an objective finding because it is observable by another person other than the client. Choice E is incorrect. Subjective data is information from the client's point of view ("symptoms"), including feelings, perceptions, and concerns obtained through interviews. A client's report of fatigue is an example of subjective data because it is based on the client's own experience and cannot be measured or observed by another person. Additional information: It is important to consider both objective and subjective information when caring for a client, as using both is essential to developing an individualized plan of care. Observations of the client's appearance and behavior provide information about various aspects of the client's health. Observations about the client's speech, facial expressions, ability to relax, eye contact, and behavior provide clues to mood and mental health status. Examples of objective data include: Blood pressure, heart rate, respiratory rate, oxygen saturation Gait and posture Uncoordinated or spontaneous body movements Hygiene and grooming NCLEX Category: Health Promotion and Maintenance Related Content: Techniques of Physical Assessment Question Type: Application

The nurse is teaching a group of students on fluid and electrolytes. It would be correct for the student to identify which intravenous (IV) solutions as hypertonic? Select all that apply. A. 3% saline [25%] B. Dextrose 10% in water (D10W) [32%] C. 5% Dextrose and 0.45% Sodium Chloride (D50.45% NaCl) [21%] D. Lactated Ringers (LR) [20%] E. 0.45% Sodium Chloride (0.45% NaCl) [3%]

Explanation Choices A, B, and C are correct. 3% saline, Dextrose 10% in water (D10W), and 5% Dextrose and 0.45% Sodium Chloride (D50.45% NaCl combined) are all hypertonic solutions. Choices D and E are incorrect. Lactated Ringers (LR) is an isotonic solution. 0.45% Sodium Chloride (0.45% NaCl) is a hypotonic solution. Additional Info Fluid tonicity is an important concept to understand. Isotonic solutions are utilized for fluid resuscitation for hemorrhaging and sepsis, severe vomiting, diarrhea, GI suctioning losses, wound drainage, mild hyponatremia, or blood transfusions (0.9% saline only). Isotonic solutions include 0.9% saline and lactated ringers (LR). Hypotonic solutions are utilized for intracellular dehydration and hypernatremia. Hypotonic solutions include 0.45% Sodium Chloride (0.45% NaCl); 5% Dextrose in Water (D5W). When D5W and 0.45% saline are combined, it is hypertonic Hypertonic solutions are utilized for severe hyponatremia and cerebral edema. They should always be given via an intravenous pump. Hypertonic solutions include 5% Dextrose and Lactated Ringer's (D5LR), 3% saline, and total parenteral nutrition (TPN).

The nurse is planning to utilize reminiscence with an elderly client. Which of the following are not the nurse's roles in this type of intervention? Select all that apply. A. Remind the client when she repeats herself [31%] B. Probe for details of memories shared [31%] C. Focus on happy memories [18%] D. Use props to stimulate discussion [20%]

Explanation Choices A, B, and C are correct. Reminiscence allows an elderly client to share his thoughts and feelings about experiences in his life. It can be a useful assessment tool for nurses to gauge a patient's cognitive functioning. At times, especially if a client is very forgetful, it can be easy to interrupt or direct a patient's thoughts. While asking direct questions is acceptable, clients should be allowed time to think and talk for themselves. Elder clients should be allowed to repeat themselves during a discussion without having attention drawn to their repetition. Reminiscence therapy should enable clients to share both happy and sad memories. The sharing of both should be encouraged. Nurses should avoid pushing for details. The client should be allowed to share his thoughts, informally, and spontaneously. Choice D is incorrect. Themes and props are acceptable to use to stimulate discussion during reminiscence therapy. This is especially helpful in group settings. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Promoting Health in the Older Adult

While working in an outpatient clinic, you take vital signs for a woman who expresses her interest in using herbal therapies to treat her chronic back pain. As a nurse, you know that herbal therapies can be safe when used properly, but should be closely monitored. You review the following teaching points with her to ensure her safe use of any herbal therapies. Select all that apply. A. Tell your health care provider about any herbal therapies you are using. [32%] B. Only take the recommended dose of the herbal therapy to avoid any toxicity. [22%] C. Continue taking your prescribed medications from your healthcare provider; never stop taking a medication without talking to your health care provider. [29%] D. Using herbal remedies is acceptable for any condition as long as they are supervised by a healthcare provider. [16%]

Explanation Choices A, B, and C are correct. The nurse should teach the patient to tell her healthcare provider about any and all herbal therapies she is using. It is important for the patient to understand that these therapies should be treated as seriously as any medication and that her healthcare provider will need to know everything she is taking to prevent any side effects or adverse reactions. Herbal therapies used in doses higher than what is recommended can quickly become toxic and the client should be instructed on this. Discontinuing a prescribed medication, even if adding an herbal therapy, is never recommended and could be dangerous. The client should be educated never to do this. Choice D is incorrect. Herbal remedies are not appropriate for all conditions. For example, in serious medical conditions such as heart disease or stroke, herbal remedies are not appropriate treatments. NCSBN Client Need: Topic: Psychosocial Integrity Subtopic: Cultural Awareness/Cultural Influences on Health

The nurse is assessing a client who has appendicitis. Which of the following would be an expected finding? Select all that apply. A. Leukocytosis [20%] B. Melena [2%] C. Fever [30%] D. Nausea and Vomiting [30%] E. Anorexia [17%]

Explanation Choices A, C, D, and E are correct. Manifestations associated with appendicitis include leukocytosis, fever, nausea and vomiting, and anorexia. Choice B is incorrect. Melena is black tarry stools that occur because of gastrointestinal bleeding. This is not a feature of appendicitis. Additional Info Appendicitis is an emergency that features pain in the right lower quadrant, nausea and vomiting, fever, leukocytosis, and anorexia. Appendicitis may be caused by obstruction, which will lead to inflammation and pressure. Nursing care for appendicitis includes - Maintaining nothing by mouth (NPO) status. Initiating an intravenous (IV) catheter. Administering prescribed antibiotics and IV fluids. Preparing the patient for surgery. The client should be monitored for perforation, which may be manifested by increased pain with coughing.

The nurse is teaching parents of a child diagnosed with varicella. Which of the following information should the nurse include? Select all that apply. A. Your child may return to school once the lesions have crusted. [23%] B. Your child should take the entire course of antibiotics. [17%] C. Acetaminophen may be used for fever. [27%] D. Warm baths with baking soda may help with the itching. [14%] E. Do not use any aspirin or ibuprofen during the illness. [19%]

Explanation Choices A, C, D, and E are correct. Varicella is a highly contagious virus that may be spread by aerosolized droplets, contact with lesions, and contaminated surfaces. A child may return to school once all the lesions have crusted over. Fever is a common manifestation associated with varicella, and acetaminophen may be taken as prescribed to decrease the fever. Symptomatic care for a child with varicella includes warm baths with products such as baking soda or uncooked oatmeal added to relieve itching. Calamine lotion may also be applied to soothe the skin. Ibuprofen and aspirin should not be taken during the course of the illness because they may cause life-threatening skin infections. Choice B is incorrect. Varicella is a viral infection; antibiotics would be unnecessary in treating this infection. Additional Info Varicella is a highly contagious viral infection primarily spread by aerosolized droplets and direct contact with the lesions. Treatment is symptomatic with prescribed acetaminophen and therapeutic baths with warm water and uncooked oatmeal or baking soda. Prescribed antivirals, such as valacyclovir, may shorten the symptoms' duration. The client should be isolated using airborne and contact precautions until the lesions have crusted over.

You are admitting a new patient to your acute psychiatric facility and you determine that they have suicidal ideations. Which of the following questions should you ask this patient? Select all that apply. A. Do you have a plan? [29%] B. Does anyone else know about your plan? [14%] C. What is your plan? [27%] D. Do you have the items to carry out your plan? [29%]

Explanation Choices A, C, and D are correct. A is correct. "Do you have a plan?" is the first question a nurse should ask any suicidal patient. Patients who have a concrete idea are much more likely to actually attempt suicide than patients who do not have a plan. By discovering your patient's plan, you can take active steps to prevent them from carrying out this plan. C is correct. "What is your plan?" should be the second question a nurse asks a suicidal patient after they have answered yes to having a plan to commit suicide. By discovering exactly what your patient's plan is, you can take active steps to prevent them from carrying out this plan. It is essential to be very, very direct with these questions so that you will get straightforward answers and be able to keep the patient safe. D is correct. This question will depend on what the patient tells you their plan is for committing suicide is. For example, if they say to you that they plan to shoot themselves, the appropriate question would be - "do you have a gun?" This is of the utmost importance for the patient's safety. If they do have a gun, or whatever item is needed to carry out their suicide plan, the nurse needs to have it confiscated immediately to keep them safe. Choice B is incorrect. This is not a question of vital importance. If others do or do not know about your client's suicide plan, it will not change any of your interventions. While admitting a suicidal patient, the nursing priority should be safety. Figuring out what the plan is and if they have the items that they need to carry it out is important so that those items can be confiscated and the safety of the client be maintained. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Psychiatric Nursing

Which of the following statements is true regarding fetal circulation? Select all that apply. A. There are high pressures in the fetal lungs causing decreased pulmonary circulation. [15%] B. Blood shunts from left to right in the fetal circulation. [27%] C. The ductus venosus allows freshly oxygenated blood to go to the fetal brain first. [30%] D. There are higher pressures in the right atrium in the fetal circulation. [28%]

Explanation Choices A, C, and D are correct. A is correct. In fetal circulation, the alveoli are filled with fluid. This causes high pressures in the fetal lungs, which shunts blood away from the pulmonary circulation. C is correct. The ductus venosus is a bypass in fetal circulation that shunts blood away from the weak fetal liver and to the brain. This allows the brain to get fresh oxygen first. D is correct. The pressures on the right side of the heart are higher in fetal circulation than on the left side of the heart. Choice B is incorrect. Blood shunts from right to left in the fetal circulation; this is due to increased pulmonary pressures caused by the fluid-filled alveoli. The high pulmonary pressures increase pressure on the right side of the heart, creating a gradient across the foramen ovale shunting blood from right to left. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Newborn

Which of the following medications would be appropriate for the treatment of an allergic reaction to a blood transfusion? Select all that apply. A. Epinephrine [33%] B. Acetaminophen [8%] C. Diphenhydramine [38%] D. Corticosteroids [21%]

Explanation Choices A, C, and D are correct. Allergic reactions occur during blood transfusions as a result of the patient's sensitivity to plasma proteins in the donor's blood. Allergic reactions can range from mild/ moderate (pruritus, urticaria) to severe (anaphylactic shock). Epinephrine, Diphenhydramine, and Corticosteroid drugs are used to treat allergic reactions resulting from a blood transfusion or any other allergen. Diphenhydramine is an antihistamine agent that is useful both as premedication and treatment. Clients may be premedicated with diphenhydramine to prevent allergic reactions. If ordered for prevention, it is usually given 30 minutes before transfusion. If a response occurs even after premedication, the dose can be repeated. It's administered in 25 to 50 mg dosages. Diphenhydramine can be repeated every 30 minutes if the hives, pruritus, or urticaria persist despite initial treatment. The maximum dose limit for diphenhydramine in an hour is about 100 mg. Corticosteroids (e.g. methylprednisolone) are indicated in moderate to severe allergic reactions. They help reduce inflammation and may also prevent delayed phase reactions that follow the initial allergic event. Epinephrine is indicated in the most severe allergic reactions (anaphylaxis) associated with shock or bronchoconstriction. This agent is both an alpha and a beta-agonist. In anaphylactic shock, it helps by causing vasoconstriction (via alpha receptors) and bronchodilation (via beta-2 receptors) Choice B is incorrect. Acetaminophen has not been indicated for the treatment of blood transfusion allergic reactions. It may be ordered as a preventive measure for febrile reactions but has no role in the allergic reaction itself. If requested for prevention, it is usually given 30 minutes before transfusion. NCSBN Client Need Topic: Medication administration, blood and blood products, the potential for complications of treatments, Subtopic: Hematology / Immune

A 3-year-old child presents to the ED with a sore throat, large red, edematous epiglottis, drooling, and moderate subcostal retractions. On exam, heart rate is 188/min, respiratory rate is 72/min, blood pressure is 88/56 mmHg, and temperature is 39 degrees Celsius. The nurse suspects epiglottitis. She should avoid which of the following actions to maintain the child's airway? Select all that apply. A. Taking an oral temperature [35%] B. Obtaining a blood culture [3%] C. Visualizing the posterior pharynx [26%] D. Obtaining a throat culture [35%]

Explanation Choices A, C, and D are correct. Taking an oral temperature could agitate the child and cause spasms of the epiglottis; this leads to complete airway obstruction. Asking the child to open their mouth and say 'ah' so that you may visualize the posterior pharynx can be enough stimulation to cause complete airway obstruction; this should not be performed. Attempting to swab the child's throat to obtain a throat culture would be very dangerous and could lead to complete airway obstruction. Choice B is incorrect. It is okay to obtain a blood culture as this should not lead to spasming of the epiglottis. NCSBN Client Need: Topic: Physiological Adaptation; Subtopic: Alterations in Body Systems

You are assessing a 7-month-old infant. At this age, which of the following reflexes should no longer be present? Select all that apply. A. Rooting [32%] B. Plantar [13%] C. Moro [36%] D. Palmar [18%]

Explanation Choices A, C, and D are correct. The Rooting reflex (Choice A) should disappear by four months of age. It occurs when the infants turn their face toward stimulation (such as stroking their cheek) and make sucking (rooting) motions with the mouth. This reflex helps to ensure successful feeding. The Moro reflex (Choice C) should disappear by two months of age. This reflex is a response to a sudden loss of support. When support is removed, the infant spreads out the arms and cries. The Palmar reflex (Choice D) should disappear by 5-6 months of age. When an object is placed in an infant's hand, and the palm is stroked, the fingers will close reflexively. Choice B is incorrect. The Plantar reflex should not disappear until 10-12 months of age. It is also known as the Babinski reflex. In this reflex, when the sole is stroked upwards, the great toe moves upward (dorsiflexes/extends) while the other toes fan out. The extensor response happens as the corticospinal pathways (brain to spinal cord connections) are not fully myelinated at this age, so the cerebral cortex does not inhibit the reflex. The extensor response disappears and gives way to the flexor response around 10 to 24 months of age. An extensor plantar response is considered normal until two years. An extensor plantar reflex after two years of age is deemed to be abnormal and is a sign of neurological damage (upper neuron lesion). NCSBN Client Need: Topic: Health promotion and maintenance; Subtopic: Growth and Development

Which of the following responses should the nurse avoid when communicating with a client who has just received a poor prognosis? Select all that apply. A. "My mother has the same thing." [29%] B. "I'll sit with you for a while." [7%] C. "I think you should try having surgery." [30%] D. "Don't cry, everything is going to be okay." [31%] E. "Do you have any questions for me right now?" [3%]

Explanation Choices A, C, and D are correct. The nurse should focus on therapeutic communication techniques for a client who has received a poor prognosis. Sharing personal details about the diagnosis does not do anything to comfort the client. It is not appropriate or within the nurse's scope to provide recommendations to influence a client's decision for treatment and procedures. When discussing any diagnosis with a client, the nurse should avoid giving false hope or making promises. Choice B and E are incorrect. Being present and using silence are useful tools in such circumstances; offering to sit with the client is an appropriate response (therefore an incorrect answer to the question). Using broad questions to invite the client to share concerns or questions would be an example of therapeutic communication and would allow the client to express themself openly without added pressure. Additional Information: Therapeutic communication is a basic tool used in developing a caring relationship with clients. In therapeutic communication, the interaction focuses on the client and the client's concerns. Nurses must assist clients as they work through their feelings and explore options related to the situation, outcomes, and treatments. This skill takes practice but can be learned with awareness and close attention. Therapeutic communication means taking the time to listen for messages that may otherwise be unheard. Nurses who practice therapeutic communication techniques typically find it easier to develop good nurse-client relationships. NCLEX Category: Psychosocial Integrity Related Content: Therapeutic Communication Question Type: Application

Which of the following treatments are options for treating hyperkalemia? Select all that apply. A. Spironolactone [10%] B. Kayexalate [36%] C. Glucose and insulin [29%] D. Dialysis [25%]

Explanation Choices B, C, and D are correct. B is correct. Kayexalate is an enema that causes potassium to be excreted in the feces. This lowers the amount of potassium in circulation and is an appropriate treatment for hyperkalemia. C is correct. Glucose and insulin are a standard and effective treatment for hyperkalemia when administered together. Insulin transports glucose into the cells for cellular metabolism and takes potassium with it. So, by administering glucose and insulin, the insulin ends up taking both the glucose-regulated and extra potassium into the cells. By transporting potassium to the intracellular space, the amount of potassium in the serum is decreased. D is correct. Dialysis is an appropriate treatment for hyperkalemia. If the kidneys are not working, the patient will become hyperkalemic. Dialysis can remove the excess potassium from the blood. Choice A is incorrect. Spironolactone is a potassium-sparing diuretic. Therefore it increases the potassium that is reabsorbed and put back in circulation. This would increase the potassium in the serum, which is the opposite of what we want for hyperkalemia treatment. Spironolactone is an appropriate treatment for hypokalemia. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies, Electrolytes

The nurse is assessing a client with schizophrenia. Which of the following would be an expected finding? Select all that apply. A. Apraxia [16%] B. Anhedonia [24%] C. Avolition [19%] D. Delusions [33%] E. Bradykinesia [7%]

Explanation Choices B, C, and D are correct. Clinical features of schizophrenia include positive and negative symptoms. Anhedonia, avolition, and delusions are all associated with this psychiatric disorder. Choices A and E are incorrect. Apraxia is defined as being unable to complete a purposeful movement. This is a feature associated with several neurological conditions, such as Alzheimer's disease, but is not a feature of schizophrenia. Bradykinesia is a feature associated with Parkinson's disease, which is slow motor movements. Additional Info Schizophreniaa symptoms are divided into positive or negative symptoms. Positive symptoms include things that add something to the client. They include: Hallucinations: Experiences involving the apparent perception of something not present. They can include any of the five senses: touch, taste, smell, sight, or hearing. Auditory hallucinations, when the client hears something that is not present, are common in schizophrenia. Delusions: Fixed, false beliefs that conflict with reality. Types of delusions include persecution, grandeur, and jealousy Thought and speech disorganization Negative symptoms are things that take something away from the client. They include: Apathy: A lack of interest, enthusiasm, or concern. Alogia: Also known as 'poverty of speech,' alogia is difficulty with speaking or the tendency to speak little due to brain impairment. Anhedonia: The inability to feel pleasure. Avolition: A total lack of motivation that makes it hard to get anything done Flattened affect

Which of the following signs are indicative of respiratory distress in the newborn? Select all that apply. A. Respiratory rate of 48 breaths per minute [11%] B. Mild subcostal retractions [26%] C. Nasal flaring [42%] D. Head bobbing [21%]

Explanation Choices C and D are correct. Nasal flaring is a sign of respiratory distress. If the newborn is working hard to breathe, they use extra effort when trying to pull air in through their nose and their nares flare out with inhalation. This is a sign that they are struggling to breathe and indicates respiratory distress (Choice C). Head bobbing is a severe sign of respiratory distress in the newborn. As they work harder and harder to breathe, they start using the muscles in their neck to pull their head forward with each inhalation. This is a sign that they are struggling to breathe and indicates respiratory distress (Choice D). Choice A is incorrect. A respiratory rate of 20 to 60 breaths per minute is standard in the newborn. Choice B is incorrect. Mild subcostal retractions are not considered a normal finding in the newborn, however, they are not enough to indicate respiratory distress. Since newborns breathe using their abdominal muscles, it is common to see some mild subcostal retractions, especially when they cry. Moderate to severe withdrawals would indicate respiratory distress. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Newborn

The nurse has just completed a continuing education lecture regarding the human immunodeficiency virus (HIV). Which of the following statements by the nurse indicate correct understanding? Select all that apply. A. "I will clean contaminated surfaces with soap and hot water." [11%] B. "The goal of treatment is for the client's viral load to increase and CD4 cells to decrease." [14%] C. "Pre-exposure prophylaxis (PREP) is available to those with risk factors for HIV." [36%] D. "Vertical transmission (mother to fetus) may be reduced with the use of antiretrovirals." [35%] E. "It is possible to spread the infection through contaminated water." [4%]

Explanation Choices C and D are correct. PrEP (pre-exposure prophylaxis) is helpful to those at risk for HIV to reduce infections. PrEP is highly effective in protecting a person from getting HIV from sex or injection drug use if taken as prescribed before the risky event. Highly Active Anti-Retroviral Therapy (HAART) (Choice D) is the drug regimen indicated for HIV and AIDS. Maternal adherence to HAART therapy may significantly reduce the risk of transmitting the disease to the fetus. Choices A, B, and E are incorrect. Surfaces contaminated with HIV/AIDS virus should be disinfected with a bleach product, not soap and hot water. The goal of HAART is to increase the client's CD4 & CD8 counts and to decrease the viral load. Finally. HIV/AIDS is spread through contaminated needles, unprotected intercourse, and mother-to-child transmission (pregnancy, labor, delivery, and breastfeeding), not through contaminated water.

The nurse is teaching a group of nursing students infectious diseases that are reportable to the local health department. Which of the following conditions should be reported? Select all that apply. A. Bacterial vaginosis [2%] B. Herpes simplex virus (HSV) [16%] C. Human immunodeficiency virus (HIV) [27%] D. Hepatitis A [16%] E. Syphilis [24%] F. Human Papilloma Virus infection (HPV) [15%]

Explanation Choices C, D, and E are correct. Infectious conditions are reportable to the local health department including Human immunodeficiency virus (Choice C), Hepatitis-A (Choice D) and Syphilis (Choice E). Other reportable conditions include chlamydia, pulmonary tuberculosis, rabies, chickenpox, influenza, and gonorrhea. Healthcare providers have the responsibility to report these to the state/local health departments. Choice A is incorrect. Bacterial vaginosis is a common infection that does not require reporting. Choice B is incorrect. Herpes simplex virus (HSV) is spread by multiple methods and thus is not reportable. Genital herpes need not be reported. Choice F is incorrect. Human Papillomavirus (HPV) is not a reportable disease. Human Papillomavirus (HPV) infection and other HPV-associated clinical conditions are not nationally notifiable or required by the CDC. Some states and jurisdictions require specific HPV associated conditions reported (cervical cancer, cervical pre-cancer) but not infection itself.

Select the stage of development, according to Eric Erickson that is accurately paired with its developmental task. Select all that apply. A. Infant: Egocentricity versus Integration. [1%] B. Toddler: Autonomy versus Mistrust. [11%] C. Adolescent: Identity versus Role Confusion. [33%] D. Elder years: Integrity versus Despair. [28%] E. Preschool Child: Initiative versus Guilt. [27%]

Explanation Choices C, D, and E are correct. The stages of development, according to Eric Erickson, that are accurately paired with their developmental task are: Adolescent: Identity versus Role Confusion (Choice C), Elder years: Integrity versus Despair (Choice D), and Preschool Child: Initiative versus Guilt (Choice E). The other developmental tasks, according to Erik Erikson, are: Infant: Trust versus Mistrust Toddler: Autonomy versus Shame and Doubt School-Aged Child: Industry versus Inferiority Young Adult: Intimacy versus Isolation Middle Years: Generativity versus Stagnation Choices A and B are incorrect. The infant is not challenged with Egocentricity versus Integration; they are challenged with Trust versus Mistrust. The infant stage revolves around building trust. The toddler is not challenged with Autonomy versus Mistrust; they are challenged with Autonomy versus Shame and Doubt. Toddlers are focused on developing a sense of independence and a sense of personal control over physical skills.

The nurse is caring for a client who is receiving the prescribed hydromorphone. Which of the following side effects should the nurse look for in the client? Select all that apply. A. Urinary incontinence [12%] B. Pupil dilation [18%] C. Diarrhea [4%] D. Altered level of consciousness (LOC) [33%] E. Constipation [32%]

Explanation Choices D and E are correct. Hydromorphone is a potent opioid indicated for pain. Side effects include constipation, altered level of consciousness, pupil constriction, and urinary retention. Choices A, B, and C are incorrect. Urinary incontinence, pupil dilation, and diarrhea are not expected while a client is receiving hydromorphone.

Which natural and normal curve along the spine is supported with a special ergonomically designed chair? A. The hyperlordosis curve [9%] B. The scoliosis curve [16%] C. The lumbar curve [68%] D. The sentinel curve [7%]

Explanation Correct Answer is C. The lumbar curve is the natural curve along the spine that is supported with a unique ergonomically designed chair. The lumbar curve is shown in the picture below. Choice A is incorrect. Hyperlordosis is an abnormal over-exaggeration of the standard lumbar curve. Choice B is incorrect. Scoliosis is the abnormal curvature of the spine in any one or more lateral directions, which is not consistent with the normal curvature of the spine. Choice D is incorrect. There is no curve called the sentinel curve in the human body along the spine.

The nurse is calculating intake for a client. The client received 0.9% saline at 70 mL/hr for four hours, two eight-ounce cups of ice, one eight-ounce cup of coffee, and three cups of water. The nurse should calculate the client's total intake as how many mL? Fill in the blank. 1480 mL

Explanation To calculate the client's total intake, the nurse must recall that one cup is eight ounces, equating to approximately 240 mL. The client received 0.9% saline infusion at 70 mL/hr for four hours → 280 mL total Two cups of ice → 240 mL total When determining the total mL for a cup of ice, the nurse should divide the volume by 1/2 since the ice melts One cup of ice is 240 mL, and it would be divided by half to account for the melt = 120 mL 120 mL x 2 (number of cups the client consumed) One cup of coffee → 240 mL Three cups of water → 720 mL When added up, the total intake was 1480 mL Additional Info When calculating intake, the nurse should consider the amount of volume the client consumes intravenously and by mouth. While intake and output (I&O) help determine a client's condition, I&O is a crude way of a client's status. Weight is the best way to determine fluid volume status as one kilogram equates to 2.2 lb which is one liter of fluid.

The client's electrocardiogram (ECG) monitor reflects regular electrical activity through the heart's conduction system. The nurse knows that the electrical impulse travels in which ordered sequence? A- Atrioventricular node B- Bundle branches C- Sinoatrial node D- Bundle of His E- Purkinje fibers

Sinoatrial node Atrioventricular node Bundle of His Bundle branches Purkinje fibers Explanation The correct ordered sequence is: C, A, D, B, then E. The primary pacemaker of the heart is the sinoatrial (SA or sinus) node, located where the superior vena cava enters the right atrium. The SA node initiates typical electrical impulses that are conducted throughout the heart and result in ventricular contraction. In adults, it usually discharges impulses at a regular rate of 60 to 100 times per minute, the "normal" heart rate. The impulse then spreads throughout the atria via the interatrial pathways. These conduction pathways converge and narrow through the atrioventricular (AV) node, slightly delaying transmission of the impulse to the ventricles. This delay allows the atria to contract slightly before ventricular contraction occurs. From the AV node, the signal then progresses down through the intraventricular septum to the ventricular conduction pathways: the bundle of His, the right and left bundle branches, and the Purkinje fibers. These fibers terminate in ventricular muscle, stimulating contraction. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Cardiac Conduction System