Care of the Adult 2 FINAL EXAM

When collecting data from a patient concerning past diagnostic testing for an ear disorder, the patient reports that a needle was used to draw a blood speciment. Which test would use this step? A. Fluorescent treponemal antibody absorption (FTA-ABS) test B. Rinne test C. Electronystagmography D. Calorie test

Fluorescent treponemal antibody absorption (FTA-ABS) test

The nurse is assessing the sexual health of an elderly woman. Which is the most likely physical symptom that an elderly woman would report? A. Does not feel attractive anymore. B. Is always too tired for sex. C. Has no sexual desire. D. Has decreased vaginal lubrication.

Has decreased vaginal lubrication.

You identify which patient behavior as indicative of mild Alzheimer disease? A. Has difficulty swallowing during meals B. Needs repeated instructions for simple tasks C. Has difficulty learning new things D. Cannot recognize familiar people

Has difficulty learning new things *Having difficulty learning new things is common in the early stages of Alzheimer disease. (1) Difficulty swallowing is a sign in late Alzheimer disease. (2) Needing repeated instructions for simple tasks is characteristic of moderate Alzheimer disease. (4) Inability to recognize familiar people is a sign of late Alzheimer disease.

You are caring for an 18-year-old patient who is diagnosed with anorexia nervosa. What is an appropriate expected outcome for the patient? A. Consume 35% or more of meals B. Develop improved eating behaviors C. Verbalize the importance of eating D. Identify barriers to eating

Consume 35% or more of meals *"Able to eat 35% or more of meals" is a concrete and realistic goal. (2) "Able to develop improved eating behaviors" is too vague and broad. (3) Focusing on the importance of food or the patient's resistance to eating will only lead to power struggles. (4) The primary barrier to eating is the patient.

While working at a long-term care facility, a resident assigned to your care is injured when a sharp object becomes embedded in his right eye. What initial action by the nurse is indicated? A. Contact emergency medical services B. Notify the resident's family C. Attempt to remove the object D. Irrigate the eye with room-temperature saline

Contact emergency medical services

Which component in the eye refracts light rays to be directed to the lens? A. Pupil B. Cornea C. Retina D. Ciliary body

Cornea *The cornea bends or refracts the light rays onto the retina. The pupil acts to regulate the entrance of light in the eye. The ciliary body helps to change the shape of the eye for far and near vision. The retina is the inner coat of the eyeball and is found in the posterior portion of it. The retina contains several layers. The layer with rods and cones acts as the receptor for light images

A nurse is assisting with the care of a client who sustained deep partial-thickness burns over 60% of their body 24 hr ago and requesting pain medication. The nurse should ensure the medication is administered using which of the following routes to administer the medication? A. Subcutaneous B. Oral C. Intravenous D. Transdermal

Intravenous

The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid. The nurse determines that which client complaint may be associated with the use of this medication? A. Itching B. Euphoria C. Drowsiness D. Frequent urination

Itching *Azelaic acid is a topical medication used to treat mild to moderate acne. Adverse effects include burning, itching, stinging, redness of the skin, and hypopigmentation of the skin in clients with a dark complexion. The effects noted in the other options are not specifically associated with this medication

The patient who has had a stapedectomy should be instructed to A. Keep the head elevated when in bed B. Sneeze and cough with the mouth closed C. Apply the ear protector for sleep D. Sleep with the affeected ear up

Keep the head elevated when in bed

A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel and a hyphema has been diagnosed. Which position should the nurse prepare to position the client? A. Flat on bed rest B. On bed rest in a semi-Fowler's position C. In lateral position on the unaffected side D. In the lateral position on the affected side

On bed rest in a semi-Fowler's position

Needs substance to feel good A. Abuse B. Psychological dependence C. Addiction D. Tolerance E. Withdrawal

Psychological dependence

During the physical assessment, the nurse notices bruises and needle marks on the patient's antecubital space. What is the best therapeutic response? A. "What are these marks? Are you injecting IV drugs?" B. "I am going to ask the health care provider to look at your arms." C. "I see you have some bruises. Can you tell me what happened?" D. "Let me clean and bandage your arm to prevent infection."

"I see you have some bruises. Can you tell me what happened?"

The nurse is talking to the patient's mother about enabling. Which statement by the mother indicates that additional intervention in needed for the enabling behavior? A. "I am going to let her take responsibility for her decisions." B. "I'm her mother. I'll always be there for her no matter what." C. "We have been denying the problem for a long time." D. "I will support her recovery by attending Al-Anon."

"I'm her mother. I'll always be there for her no matter what."

The nurse is caring for a patient who is immunocompromised. The patient asks how to prevent infection at home once she is discharged. What would the nurse's best response be? A. "Wash your hands often." B. "Go back to your usual lifestyle." C. "Do not go out to eat more than once per week." D. "Wash your clothes at the laundromat."

"Wash your hands often." When a patient is immunocompromised, avoiding infection is very important. The best way to prevent infection at home is to encourage the patient to wash her hands often. Going back to her usual lifestyle, not eating out more than once per week, and washing clothes at the laundromat will not help prevent infection.

The nurse is interviewing a patient who is seeking assistance at the urology clinic for erectile dysfunction. Which statement is the best way to open the interview? A. "When was the last time you were impotent?" B. "Do you attempt to have intercourse every week?" C. "What medications have you tried previously? D. "What experiences have you had with erectile dysfunction?"

"What experiences have you had with erectile dysfunction?" *Asking open-ended questions will help the patient respond with information that can be used in a plan of care

The nurse is assigned to care for a client at risk for alcohol withdrawal. The client's spouse asks the nurse, "When will the first signs of withdrawal appear?" The nurse should give which reply? A. "In 7 days" B. "In 14 days" C. In 21 days" D. "Within a few hours"

"Within a few hours" *Early signs of alcohol withdrawal develop within a few hours after cessation or reduction or alcohol and peak after 24 to 48 houts

The nurse is caring for a patient with syphilis. Which manifestation indicates that the syphilis has progressed to the secondary stage? A. Foul-smelling penile discharge B. Positive serology C. Purulent skin rash D. Scrotal swelling

Positive serology *A positive serology will appear in the secondary stage of syphilis. Penile discharge is not associated with the secondary stage of syphilis. A generalized skin rash, not purulent, may be seen in the secondary stage of syphilis. Scrotal swelling is not assocated with syphilis

Postmortem brain examinations of Alzheimer disease (AD) patients reveal which type of finding(s) (select all that apply) A. Tangled nerve cells B. Abnormal buildup of proteins C. Hemorrhagic areas D. Occluded cerebral vessels E. Reduced white matter

1. Tangled nerve cells 2. Abnormal buildup of proteins *Tangled nerve cells and abnormal buildup of protein in the brain have been found on postmortem brain examination of people who have AD

What is the normal intraocular pressure of the eye? A. 10 to 20 mm Hg B. 30 to 40 mm Hg C. 32 psi D. 120/80 to 140/90

10 to 20 mm Hg

The nurse understands that the clinical definition of infertility is failure to conceive after frequent, unportiected sex over what period of time? A. 6 months B. 12 months C. 18 months D. 24 months

12 months *A couple who, after 1 year of unprotected sex, has not conveived is considered to be infertile

You are caring for four female patients. Which patient do you identify as most at risk to have an STI? A. 19 year old with urinary tract infection B. 31 year old who is eight weeks pregnant C. 40 year old with breast tenderness D. 53 year old who reports vaginal dryness

19 year old with urinary tract infection *Urinary tract infections share some characteristics with STIs and can be misdiagnosed. (2) Pregnancy does not increase risk of an STI. (3) Breast tenderness is usually related to hormonal changes and not infection. (4) Vaginal dryness can lead to tissue injury during intercourse but is not a risk factor for STIs.

Acceptable urine output for an adult is at least how many milliliters per hour? A. 10 mL B. 20 mL C. 30 mL D. 40 mL

30 mL *The minimum urine output for an adult is 30 mL/hr

You are caring for four patients. Which patient is at highest risk for development of ovarian cancer? A. 32-year old whose father died of colon cancer B. 40 year old who has BRCA2 gene C. 53 year old whose mother had secondary dysmenorrhea D. 60 year old who delivered four children

40 year old who has BRCA2 gene *Women with BRCA2 gene are at higher risk for ovarian cancer. (1) Although family history of cancer is an important health history question, family history of colon cancer does not predispose a woman to ovarian cancer. (3) Secondary dysmenorrhea is not a risk factor. (4) Multiple deliveries are a protective factor.

The nurse should recognize that sounds of ________ decibels or greater have reached a level that may begin to have an impact on hearing. A. 60 B. 70 C. 80 D. 90

70

The patient will need intravenous therapy for at least a week. The nurse would change the IV site every A. 24 hours B. 48-72 hours C. 12 hours D. 72-96

72-96 hours

According to the American Cancer Society (ACS), diagnosis of cancer in the localized stages would result in a 5 year survival rate of ________%. A. 70 B. 80 C. 95 D. 98

95

For which patient would the nurse question an order for isotretinoin (Accutane)? A. A 20-year-old epileptic man with nodular acne and epilepsy B. A 22-year-old pregnant woman with severe acne C. A 46-year-old woman an oral contraceptive pills with cystic acnce D. A 50-year-old hypertensive man with cystic acne

A 22-year-old pregnant woman with severe acne *Accutate is considered a teratogen and can cause fetal malformations. Patients of childbearing age must be on a contraceptive

What is an important teaching point for a patient about self-care for a carbuncle? A. A clean washcloth and towel should be used for bathing each day B. Use a cold compress for comfort and to promote drainage C. Take sedatives as prescribed for relief of discomfort D. Avoid injury of any kind to surround skin

A clean washcloth and towel should be used for bathing each day

The nurse is assigned to care for a client with a detached retina. Which finding should the nurse expect to be documented in the client's record? A. Blurred vision B. Pain in the effected eye C. A yellow discoloration of the sclera D. A sense of a curtain falling across the field of vision

A sense of a curtain falling across the field of vision

When the nurse teaches about "safer sex" practices, it should be stated that proper use of condoms includes using A. Petroleum jelly as a lubricant B. Saliva as a lubricant C. A spermicide containing nonoxynol-9 D. Lambskin condoms

A spermicide containing nonoxynol-9

You are observing a nursing student who must perform a dressing change for a patient. You would intervene if the student A. Gathers all needed supplies prior to entering the patient room B. Identifies the patient using two identifiers C. Performs hand hygiene before donning clean gloves to remove the old dressing D. Prepares supplies, dons sterile gloves, and removes the old dressing

Prepares supplies, dons sterile gloves, and removes the old dressing *The old dressing should be removed with clean gloves. If sterile gloves are used to remove the old dressing, the gloves will have to be removed and discarded, hands rewashed, and new sterile gloves reapplied. The other options are correct actions.

Uses psychoactive drugs in nontherapeutic manner A. Abuse B. Psychological dependence C. Addiction D. Tolerance E. Withdrawal

Abuse

What is the rare type of glaucoma that causes a sudden increase of intraocular pressure and patient experiences severe headache, nausea, vomiting, and halo-effect around lights? A. Primary open angle B. Secondary closed angle C. Acute open angle D. Acute angle closure

Acute angle closure (NARROW GLAUCOMA)

Prolonged erection associated with sickle cell anemia

Priapism

The nurse is caring for a newly admitted patient who is describing his recent symptoms to the nurse. This scenario is an example of which type of source? A. Primary B. Objective C. Secondary D. Complete

Primary

Biologic dressing obtained from a cadaver A. Open technique B. Closed technique C. Escharoctomy D. Allograft E. Xenograft

Allograft

Which medication is mainly used to treat anxiety? A. Paroxetine (Paxil) B. Alprazolam (Xanax) C. Phenelzine (Nardil) D. Amitriptyline (Elavil)

Alprazolam (Xanax)

When assessing for macular degeneration, the nurse should use which assessment tool? A. Snellen eye chart B. Corneal reflex test C. Visual field test D. Amsler grid test

Amsler grid test *The amsler grid test assesses the extent of macular degeneration by noting the patient's perception of missing or wavy line on the grid. The Snellen eye chart is used to assess visual acuity. Visual field assesments may be used to assess peripheral vision

Which drug group for glaucoma has the side effect of darkening the iris color? a. Adrenergic agonists b. Beta blockers c. Cholinergics d. Prostaglandin agonists

Prostaglandin agonists *Two side effects of the prostaglandins agonists are making the lashes grow and darkening the iris color, sometimes changing a blue iris to one that appears browner. No other drugs for glaucoma have these side effects.

___________ have the highest rate of skin cancer. A. Chinese B. Australians C. Mexicans D. Canadians

Australians

Nocturia is a common symptom experienced by males, resulting from A. Use of condoms for contraception B. BPH C. a high fiber diet D. taking an antiestrogen agent

BPH

Research has shown that the negative cancer-causing impact of foods containing nitrates may be blocked by combining with with vitamin A. A B. B C. C D. D

C

Cerumenolytic drugs are sold over the counter and usually contain what chemical? A. Apraclonidine B. Brinzolamide C. Carbamide peroxide D. Carbastat

Carbamide peroxide

A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma? A. Cardiovascular disease B. A history of migraine headaches C. Frequent urinary tract infections D. Frequent upper respiratory infections

Cardiovascular disease

The nurse is assessing a new patient who complains of his chest feeling tight. The patient displays a temperature of 100F and an oxygen saturation of 89% and exportorates frothy mucus. Which finding is an example of subjective data? A. Temperature B. Oxygen saturation C. Frothy mucus D. Chest tightness

Chest tightnes

Aqueous humor is produced by which part of the eye? A. Retina B. Ciliary body C. Optic nerve D. Lacrimal gland

Ciliary body

Processes of perception, memorym and judgment A. Cognition B. Dementia C. Delirium

Cognition

The eye structure that contains the rods is known as the A. Iris B. Cornea C. Retina D. Optic disc

Cornea

A woman complains of eye itching, tearing, halos around lights, and decreased central vision. Which symptom most clearly relates to macular degeneration? A. Eye itching B. Tearing C. Halos around lights D. Decreased central vision

Decreased central vision *A decrease in central vision is most characteristic of macular degeneration. (1) Eye itching, (2) tearing, and (3) halos around lights are not symptoms of macular degeneration.

An acute alteration in cognition A. Cognition B. Dementia C. Delirium

Delirium

Characterized by slow onset A. Cognition B. Dementia C. Delirium

Dementia

Uses confabulation to cover memory gaps A. Cognition B. Dementia C. Delirium

Dementia

The nurse teaches the patient the "ABCD" technique for evaluating melanomas. What does the "D" in this memory prompt represent? A. Darkness B. Drainage C. Dimpling D. Diameter

Diameter *A-Assymetrical *B-Border *C-Color *D-Diameter

Inflammatory response causing fluid shift A. Edema B. Hyperkalemia C. Hypovolemia D. Tissue hypoxia E. Hypermetabolism

Edema

Chronic bacterial infection in skin folds, especially axilla and between toes A. Erythrasma B. Wheal C. Fungal infection D. Keratosis E. Keloid

Erythrasma

Incision into subcutaneous tissue to increase circulation A. Open technique B. Closed technique C. Escharoctomy D. Allograft E. Xenograft

Escharoctomy

A patient is receiving IV fluids through an infusion pump. How often should the nurse check the functioning of the pump? a. Every 15 to 30 minutes b. Every 1 to 2 hours c. Every 2 to 4 hours d. Once during the shift

Every 1 to 2 hours *An IV infusion pump should be checked every 1 to 2 hours to ensure that it is functioning properly.

The nurse is caring for a 41 year old patient. How often should the nurse recommend that this patient undergo testing for glaucoma? A. Yearly B. Every 1 to 3 years C. Every 5 years D. Every 10 years

Every 1 to 3 years

How often should eye cosmetics be discarded? A. Every 2 to 4 months B. Every 3 to 6 months C. Every 6 to 9 months D. Every year

Every 2 to 4 months *Eye cosmetics should be discarded every 2 to 4 months to prevent infection

A nurse is assisting with an educational seminar on stress for other nursing staff. Which of the following information should the nurse recommend for inclusion? A. Excessive stressors cause the client to experience distress B. The body's initial adaptive response to stress is denial C. Absence of stressors results in homeostasis D. Negative, rather than positive, stressors produce a biological response

Excessive stressors cause the client to experience distress *Distress is the result of excessive or damaging stressors (anxiety or anger) *Denial is part of the grief process. The body's initial adaptive reponse to stress is known as the fight-orflight mechanism *Individuals need the presence of some stressors to provide interest and purpose to life *Both positive and negative stressors produce a biological reponse in the body

A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding? A. Pearly gray tympanic membrane (TM) B. Malleus visible behind the TM C. Presence of soft cerumen in the external canal D. Fluid or bubbles seen behind the TM

Fluid or bubbles seen behind the TM *Fluid behind the TM indicates the possibility of otitis media and is not an expected finding

The nurse is caring for a homosexual man with a rectal tear and inflamed rectal tissue. The nurse understands that these findings increase the patient's risk for which disorder? A. An abscess B. Human immunodeficiency virus (HIV) infection C. Hemorrhoids D. Rectal hemorrhage

Human immunodeficiency virus (HIV) infection *Open lesions and inflamed tissue increase the risk of HIV infection

Potassium released from damaged cells A. Edema B. Hyperkalemia C. Hypovolemia D. Tissue hypoxia E. Hypermetabolism

Hyperkalemia

Negative nitrogen balance A. Edema B. Hyperkalemia C. Hypovolemia D. Tissue hypoxia E. Hypermetabolism

Hypermetabolism

When a patient is experiencing a life-threatening emergency, you may be given an order to give drug via which route? a. IV route b. IM route c. Rectal route d. Subcutaneous route

IV route

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness

Illness *The illness stage is when the client experiences manifestations specific to the infection *The prodromal stage consists of nonspecific manifestations of the infection *The incubation period consists of the time when the pathogen first enters the body prior to the appearance of any manifestations of infection

What sudden changes related to cholinergic drugs should be reported to a healthcare provider immediately? A. Nausea and vomiting B. Increased blood pressure and heart rate, and difficulty breathing C. Anxiety D. Iris color changes to brown

Increased blood pressure and heart rate, and difficulty breathing

The nurse is diong a routine assessment of a clients's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred? A. Phlebitis B. Infection C. Infiltration D. Thrombosis

Infiltration *An infiltrated IV is one that has dislodged fromthe vein and is lying in subcutaneous tissue. The pallow, coolness, and swelling are the result of IV fluid being deposited into the subcutaneous tissue. When the pressure in the tissue exceeds the pressure in the tubing, the flow of the IV solution will stop. The other options identify complications that are likely to be accompanied by warmth at the site rather than coolness

A nurse is caring for a client who has sustained burns over 35% of total body surface area. The client's voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the client has which of the following? A. Pulmonary edema B. Bacterial pneumonia C. Inhalation injury D. Carbon monoxide poisoning

Inhalation injury

Which symptoms are most characteristic of depression? A. Lack of interest, loss of libido, and a flight of ideas B. Insomnia, poor hygiene, and grandiose ideas C. Overeating, hyperactivity, and rapid speech D. Insomnia, anorexia, and lack of energy

Insomnia, anorexia, and lack of energy

When communicating with a severely depressed patient, what is the most therapeutic approach? A. Be quiet while assisting with activities of daily living B. Interact and talk with the patient and engage him in activities C. Make an extra effort to be cheerful and positive D. Speak in simple, direct sentences when necessary

Interact and talk with the patient and engage him in activities

A nurse is assisting with instructing a class on therapeutic communication with a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication? A. Personal space B. Posture C. Eye contact D. Intonation

Intonation *Identify intonation as a component of verbal communication. Intonation is the tone of one's voice and can communicate a variety of feelings *Personal space, posture, and eye contacts are components of nonverbal communication

Which drug route would you expect to be the most rapidly absorbed? a. Subcutaneous injection b. Intravenous injection c. Rectal suppository d. Sublingual tablet

Intravenous injection

A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which immediate measure? A. Checking visual acuity B Covering the eye with a pressure patch C. Swabbing the eye with antibiotic ointment D. Irrigating the eye with sterile normal saline

Irrigating the eye with sterile normal saline

The nurse is teaching a group of school children about the relationship between diet and vision. The nurse encourages the ingestion of foods rich in vitamin A. Which food choice should the nurse recommend? A. Kale B. Cauliflower C. Strawberries D. Apples

Kale *Vitamin A protects against night blindness, slow adaptation to darkness, and glare blindness. THe carotenoids are the precursors for vitamin A and are found in green leafy and yellow vegetables

The family of an elderly patient who experiences nighttime confusion reports that he has been wandering from his room into the backyard. Which intervention will best decrease this patient's nighttime confusion? A. Assigning a family member to sit with him until he falls asleep B. Allowing the patient to share a room with another family member C. Leaving a night-light on D. Administering a sedative at the hour of sleep

Leaving a night-light on *Keeping the environment well lit is a strategy for decreasing confusion. Leaving a night-light on will help the patient remain oriented to the environment. Sedative effects may actually increase the likelihood of confusion in an elderly patient. A sitter until the onset of sleep will not help in the event the patient gets up and wanders around.

The nurse is assigned to care for a client hospitalized with Meniere's disease. The nurse expects that which would most likely be prescribed for the client? A. Low-fat diet B. Low-sodium diet C. Low-cholesterol diet D. Low-carbohydrate diet

Low-sodium diet

Betaxolol hydrochloride eyedrops have prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication? A. monitoring temperature B. Monitoring blood pressure C. Checking peripheral pulses D. Checking the blood glucose level

Monitoring blood pressure

When a patient has a systemic reaction to an inflammation, which sign or symptom is the patient likely to exhibit? A. A decreased leukocyte count B. Euphoria C. Muscle aches D. An increased red blood cell count

Muscle aches *Headache, myalgia (muscle aches), fever, diaphoresis, chills, anorexia (loss of appetite), and malaise (weakness) are common signs of an inflammatory response. Euphoria, decreased leukocyte count, and increased red blood cell count are not signs of systemic reaction to inflammation.

The nurse would expect to implement which order for the patient with Meniere disease? A. Cefazolin (Kefzol) 1 g q6h IV B. Furosemide (Lasix) 20 mg three times a day C. Morphine 4 mg IV q4h PRN pain D. Ondansetron (Zofran) 4 mg IV q6h PRN nausea and vomiting

Ondansetron (Zofran) 4 mg IV q6h PRN nausea and vomiting

The LPN/LVN is assisting the RN in planning care for a patient. Which should receive the highest priority? A. Mobility B. Comfort C. Skin status D. Oxygenation

Oxygenation *Oxygenation status should be given priority. Although the patient's comfort, mobility, and skin status are important, they are a lower priority than oxygenation status.

When teaching a patient who is being treated for Chlamydia trachomatis, the nurse should stress that A. Medication must be taken every day for a month B. Partner(s) must be treated concurrently C. Swimming and hot0tubbing are contraindicated while under treatment D. Lesions must be kept clean and dry to prevent secondary infections

Partner(s) must be treated concurrently

Erection curving upward preventing vaginal penetration

Peyronie disease

A 32-year-old mother is undergoing radiation from a sealed-source modality and has been isolated in a private room for 3 days. How should the nurse best prepare for the patient's 8-year-old twins to visit? A. Instruct the children to visit at the bedside one at a time B. Inform family that children cannot visit patients undergoing radiation C. Put chairs in the hall for "long distance" visitation D. Allow visitation for no longer than 3 minutes without any physical contact

Put chairs in the hall for "long distance" visitation *Children and pregnant people should not visit at the bedside, but a visit from a safe distance or by phone helps relieve the boredom of isolation

Though rare, what side effects are possible with cerumenolytics? A. Loss of hearing for 2-3 minutes B. Popping sounds in the ear C. Redness, itching, or rash D. Burning sensation in the ear canal

Redness, itching, or rash

After evaluating the nursing care plan, the nurse finds lack of progress toward the goal. What action should the nurse take? A. Create a more accessible goal B. Revise the nursing interventions C. Change the problem statement/nursing diagnosis D. Use a new evaluation plan

Revise the nursing interventions

A patient is to have an IV insertion site changed. The current line is in the lower right forearm. Which location is contraindicated for the new site? a. Right upper forearm b. Right hand c. Left upper forearm d. Left hand

Right hand *A new IV site should not be placed distal to an old site; the right hand is distal to the right forearm, so it should not be used.

Which kind of hearing loss is the most common? A. Tinnitus B. Conductive C. Sensorineural D. Mixed Types

Sensorineural *Disorders of the hearing nerve (sensorineural loss) are the most commong cause of hearing loss. Conductive hearing loss most often occurs from stiffening of the bones in the middle ear or from scarring of the tympanic membrane. Tinnitus is ringing in the ears

The nurse is caring for a client who is hearing-impaired and should take which approach to facilitate communication A. Speak loudly B. Speak frequently C. Speak in a normal tone D. Speak directly into the impaired ear

Speak in a normal tone

The nurse is caring for a blind patient. Which action is most appropriate when entering the patient's room? A. Touch the patient before speaking to allow her to locate the nurse's position B. Speak to the patient by name when entering the room to avoid startling her C. Speak to the patient only when at bedside to increase orientation D. Walk about in the room, carrying on conversation

Speak to the patient by name when entering the room to avoid startling her *Speaking to the person by name allow the patient to know someone has entered the room and will avoid startling the patient

The nurse is assessing an 84 year old patient. Which finding is consistent with aging? A. Thick cerumen B. Heightened perception of low-frequency sounds C. Outer ear canal pain D. Increased hair on the pinna

Thick cerumen *Thickened, hard cerumen collections in the outer ear can disrupt sounds conduction and impair hearing. Age-related changes may include reduced perception of low-frequency sounds. Pain in the outer ear is not a normal change related to aging, nor is increased hair on the pinna

Needs increasing amounts of substance to achieve desired effect A. Abuse B. Psychological dependence C. Addiction D. Tolerance E. Withdrawal

Tolerance

Arteriosclerosis can cause decreased blood flow to ________, resulting in sensorineural hearing loss. A. Vestibulocochlear nerve B. Tympanic membrane C. Auditory canal D. Bones of the middle ear

Vestibulocochlear nerve *Arteriosclerosis can cause decreased blood flow to the vestibulocochlear nerve (eighth cranial nerve), resulting in sensorineural hearing loss. This often contributes to hearing loss in older adults. Conductive hearing loss is caused by a problem transmitting sound impulses through the auditory canal, the tympanic membrane, or the bones of the middle ear

Smooth, elevated area that is pale or reddened A. Erythrasma B. Wheal C. Fungal infection D. Keratosis E. Keloid

Wheal

Symptomatology related to cessation of drug A. Abuse B. Psychological dependence C. Addiction D. Tolerance E. Withdrawal

Withdrawal

Pelvic relaxation syndrome may lead to A. abdominal pain B. cervical dysplasia C. metrorrhagia D. a cystocele

a cystocele

A patient is receiving total parenteral nutrition (TPN) through a central line. His TPN solution is behind schedule when the nurse comes on duty. The nurse would A. increase the flow rate to "catch up" B. leave the flow rate alone C. notify the primary care provider that the solution is behind schedule D. adjust the flow rate to that which is ordered

adjust the flow rate to that which is ordered

During the first several days of TPN administration, it is especially important to check the patient's ________________.

blood glucose level

A nurse is monitoring the status of an older adult patient who is receiving IV therapy. Indicator of fluid volume overload is suspected when the nurse assesses: a. crackles in the lung fields. b. pulse rate of 64 beats/min, irregular. c. respirations of 16 breaths/min, regular. d. slight edema to the feet.

crackles in the lung fields *Fluid overload is signaled by crackles in the lung fields, increasing pulse rate, and shortness of breath.

What solution can you not give to a child?

hypotonic

What electrolyte imbalance will a burn patient most likely have?

metabolic acidosis

tau protein causes

neurofibrillary tangles

The nurse assisting in the initiation of a blood transfusion is aware that the only appropriate solution to infuse through a parallel infusion set before and after the transfusion is: a. 5% dextrose in water. b. 10% dextrose in water. c. lactated Ringer's solution. d. normal saline.

normal saline. *Normal saline is the only solution used in conjunction with infusion of a blood product.

An older adult resident in a long-term care facility expresses multiple minor complaints at the nurse's station and wanders about aimlessly in the hallway. The nurse examines the patient's chart. Which newly prescribed drug may explain his behavior? A. Tylenol B. Theophylline C. Bisacodyl D. Lisinopril

Theophylline *The drig theophylline may make patients feel anxious and restless. Tylenol, biscodyl, and lisinopril do not typically have this effect

Which side effect of chemotherapy puts the patient at high risk for bleeding? A. Thrombocytopenia B. Elevated potassium C. Neutropenia D. Anemia

Thrombocytopenia *A low platelet count can result in bleeding. (2) Potassium is not part of bleeding and clotting. (3) A low white blood cell count puts the patient at high risk for infection. (4) Low hemoglobin does not increase bleeding risk.

A female patient reports inability, fatigue, mood swings, and feeling out of control several days before menstruation. Which teaching will you provide? A. "Avoid calcium-containing foods." B. "Exercise regularly." C. "Have occasional alcohol." D. "Consider a sodium-rich diet."

"Exercise regularly." *Exercise can help with coping skills. (1) Calcium-containing foods are recommended. (3) Alcohol is not recommended as a coping strategy. (4) High-sodium foods can increase water retention and discomfort.

Which statement indicates that the patient understands teaching about diagnostic examinations for cancer? A. "I will have less scarring if my surgeon uses an incision to biopsy my breast." B. "My CEA level will be low if my pancreatic cancer returns." C. "The doctor will monitor my ovarian cancer remission with the CA-125 test." D. "My colonoscopy results were great, so I won't need another one for 5 years."

"The doctor will monitor my ovarian cancer remission with the CA-125 test." *The CA-125 is one of the tests the physician will monitor to detect the presence of ovarian cancer or recurrence of ovarian cancer after therapy.

The patient is having diarrhea secondary to radiation therapy of the pelvic area. Which statement by the patient indicates a need for additional teaching about the diarrhea? A. "I will cleanse the rectal area and apply petroleum jelly." B. "I will report an increase in the number and frequency of bowel movements." C. "I will avoid eating foods such as bananas and cheese." D. "I may need to have my electrolytes checked if the diarrhea is severe."

"I will avoid eating foods such as bananas and cheese."

Mast cell-stimulated release of histamine A. contact dermatitis B. atopic dermatits C. stasis dermatitis D. seborrheic dermatitis

atopic dermatitis

A patient is admitted with a peripherally inserted central catheter (PICC). As part of standard care for this patient, the nurse should: a. obtain the patient's temperature every 2 hours. b. prepare to infuse fluids at high volumes. c. avoid taking blood pressures on the arm with the PICC line. d. have the catheter withdrawn while the patient is hospitalized.

avoid taking blood pressures on the arm with the PICC line *PICC lines are inserted by physicians or specially trained nurses, and they are used for long-term therapy; blood pressures are not taken in the arm that has the PICC line to avoid interfering with the function or the life of the catheter. Many times this catheter is used in home care.

A high-priority intervention for the patient with serious burns is A. cooling the burn areas every 2 hours with running water B. beginning intravenous fluid administration as soon as possible C. cleansing the burn areas thoroughly as quickly as possible D. administering a tetanus immunization within the first hour of treatment

beginning intravenous fluid administration as soon as possible

When planning an educational program for women concerning the diagnosis of new cancer cases, which body site had the greatest number of new diagnoses for 2015? A. Ovary B. Uterine C. Colon D. Breast

breast

An intrauterine medication to treat dysmenorrhea is A. an intrauterine device B. levonorgestrel-releasing system C. mefenamic acid D. COX-2 inhibitor

levonorgestrel-releasing system

An intrauterine medication to treat dysmenorrhea is: 1. an intrauterine device. 2. levonorgestrel-releasing system. 3. mefenamic acid. 4. COX-2 inhibitor.

levonorgestrel-releasing system.

The most important nursing intervention in the recovery period before discharge from the day surgery unit to ensure success of eye surgery is: a. medicating for pain before it becomes severe. b. answering the call light promptly. c. assisting the patient to walk to the bathroom. d. positioning the patient per orders.

medicating for pain before it becomes severe.

Scaly lesions on scalp, ear canals, and eyebrows A. contact dermatitis B. atopic dermatits C. stasis dermatitis D. seborrheic dermatitis

seborrheic dermatitis

Alopecia resulting from chemotherapy is A. temporary B. irreversible C. treatable D. preventable

temporary

The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fliuid resuscitation? A. vital signs B. urine output C. mental status D. peripheral pulses

urine output *Successful or adequate fluid resuscitation in the adult is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and a clea sensorium. The most reliable indicator for determining the adequacy of fluid rescuscitation is the urine output. For an adult, the hourly urine volume should be 30 mL to 50 mL

The nurse notes that the primary health care provider (PHCP) has documented a diagnosis of presbycusis on the client's chart. Which explanation should the nurse give to the client to explain this condition? A. Tinnitus that occurs with aging B. Nystagmus that occurs with aging C. A conductive hearing loss that occurs with aging D. A sensorineural hearing loss that occurs with aging

A sensorineural hearing loss that occurs with aging

A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? A. "I am a superhero and am immortal." B. "I am no one, and everyone is me." C. "I feel monsters pinching me all over." D. "I know that you are stealing my thoughts."

"I am no one, and everyone is me." *This comment indicates the client is experiencing a loss of identity or depersonalization *(A) This comment indicates the client is experiencing delusions of grandeur *(C) This comment indicates the client is experiencing a tactile hallucination *(D) This comment indicates the client is experiencing thought withdrawal

Which statemtent indicates that a paitent needs additional educatoin about the vaccine for human papillomavirus (HPV)? A. "I know I must have three doses of the vaccine." B. "Girls as young as 9 years of age may be vaccinated." C. "I am relieved that the vaccine protects me from all HPV infections. D. '"I know I should continue having regular Pap smears

"I am relieved that the vaccine protects me from all HPV infections *The vaccine protects again the most prevalent infections, genital warts, and precancerous cervical lesions, but not against all HPV infections. The remaining statements are correct

The caregiver of a patient with dementia tells you, "I just can't do this anumore. I am physically and emotionally exhausted." What is the appropriate intial response? A "Have you considered use of respite care?" B. "I am so sorry that you are experiencing this." C. "Do you have other family members who can help?" D. "Community resources are available that may be helpful."

"I am so sorry that you are experiencing this." *Acknowledging the feelings of the caregiver and the stress they are experiencing is important in supporting them. (1, 3, 4) The other options are all things to explore to help with the burden but validating the caregiver's feelings is most important at this time.

You are caring for an adolescent who has been diagnosed with gonorrhea. When the patient refuses to notify recent sexual partners, what is your appropriate response? A. "Do you not feel responsible for infecting other people?" B. "You do not have to notify anyone that you don't wish to contact." C. "I am still accountable to report this disease through required channels." D. "It is considered a felony offense if you do not disclose b=names of your sexual partners."

"I am still accountable to report this disease through required channels." *Gonorrhea is one of the STIs that is required to be reported to the health department. The health department will follow up to determine others that may have been exposed. (1) Scolding an adolescent is not the most effective communication technique and will not usually obtain the desired outcome. (2) You cannot make the adolescent contact partners, but information should be given regarding the role of the health department. (4) It is not a criminal offense to withhold the names of sexual partners.

A nurse in a long-term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, "I have to get home." Which of the following statements should the nurse make? A. "You have forgotten that this is your home." B. "You cannot go outside without a staff member." C. "Why would you want to leave? Aren't you happy with your care?" D. "I am your nurse. Let's walk together to your room."

"I am your nurse. Let's walk together to your room." *It is inappropriate to introduce oneself with each new interaction and to promote reality in a calm, reassuring manner *Avoid statements that can be interpreted as argumentative or demeaning *Use positive, rather than negative, statements *Using a "why" question can promote a defensive reaction and does not reinforce reality

What is your therapeutic response to a patient who states, "The food service workers put poison in my food, and there is a bomb in the bathroom."? A. "Who do you think is doing all these things? B. "Let's go together and check the bathroom." C. "Tell me how you believe these things are happening." D. "I believe that the hospital is a safe place."

"I believe that the hospital is a safe place." *Stating reality and emphasizing safety and security are the best response. (1, 2) The nurse should not validate or give credence to the delusion. (3) The patient is not able to state why they believe what they do, and asking only provides a forum for the patient to expand on their delusional thoughts.

The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement? A. "My medications won't make me anxious." B. "I'll go to a support group and talk so that I won't hurt anyone." C. "I won't get anxious or hear things if I get enough sleep and eat well." D. "I can call my therapist when I'm hallucinating so I can talk about my feelinds and plans and not hurt anyone."

"I can call my therapist when I'm hallucinating so I can talk about my feelinds and plans and not hurt anyone. *There may be an increased risk for impulsive and/or aggressive behavior if a client is receiving command hallucinations to harm self or others. Talking about the auditory hallucinations can interfere with the subvocal muscluar activity associated with a hallucination. Option D is a specific agreement to seek help and evidences self-responsible commitment and control over his or her own behavior

A nurse is determining a client's understanding of a new prescription of a new prescription for clonidine for the treatment of opioid use disorder. Which of the following statements by the client indicates an understanding of the instruction? A. "Taking this medication will reduce my craving for heroin." B. "While taking this medication, I should keep a pack of sugarless gum." C. "I can expect some diarrhea from taking this medication." D. "Each dose of this medication should be placed under my tongue to dissolve."

"I can expect some diarrhea from taking this medication." *Clonidine commonly causes clients to experience dry mouth, Chewing sugarless gum is an effective method to address this adverse effect *Clonidine is useful during opioid withdrawal. However, it does not reduce cravings *Clonidine reduces, rather than causes, diarrhea and other withdrawal manifestations related to autonomic hyperactivity *Buprenorphine, rather than clonidine, is administered sublingually

You have provided a patient with specific instructions regarding post-operative right radical mastectomy care of the surgical site and surgical complications. Which patient statement indicates a need for further teaching? A. "Blood pressure cannot be taken on the right arm." B. "I can resume intense weight training soon after discharge." C. "No injections must be given in the right arm." D. "When gardening, I need to wear gloves."

"I can resume intense weight training soon after discharge." *Lifting excess weight should be avoided postoperatively. (1, 3, 4) These statements are correct and do not require follow-up.

The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response? A. "I cannot discuss any client situation with you." B. "I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she is doing great!" C. "You may want to know about Carol, so you need to ask her yourself so you can get the story firsthand." D. "I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she really has some problems!"

"I cannot discuss any client situation with you." *The nurse is required to maintain confidentiality regarding clients and their care. Confidentiality is basic to the therapeutic relationship and is a client's right. Option C is correct in a sense, but it is a rather blunt statement. Both options B and D identify statments that do not maintaing client confidentiality

The nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response? A. "No, I won't tell anyone." B. "I cannot promise to keep a secret." C. "If you tell me the secret, I will tell it to your doctor." D. "If you tell me the secret, I will need to document it in your record."

"I cannot promise to keep a secret." *The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship but not in a therapeutic one. The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret

Which patient statement indicates a positive step in the recovery from alcohol use disorder? A. "I do think my job is at the root of my alcohol consumption." B. "I don't have any power over the effects alcohol has on me." C. "I don't ever want to use alcohol again." D. "To stay sober I will increase my exercise and eat healthy foods."

"I don't ever want to use alcohol again." *Recognition of the need to not use alcohol is a positive step in the recovery from alcohol dependence. (1, 2) Blaming the stress of a job for alcohol consumption or stating, "I don't have any power over the effects alcohol has on me" is rationalization. (4) Increasing exercise and eating healthily is a good plan but does not in itself help the patient stay sober.

A patient with schizophrenia comes to the nurse and says, "Here we go, got flacks and sacks and jibbogny tomorrow. Would you like some?" What is the best response? A. "Say that again. I couldn't understand what you are saying." B. "Sure thing, flacks and sacks and jibbogny sound great to me." C. "I don't quite understand, but I do appreciate you including me." D. "You are not making any sense. Try to speak clearly."

"I don't quite understand, but I do appreciate you including me."

An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusice family member indicates that he or she has learned positive coping skills? A. "I will be more careful to make sure that my father's needs are met." B. "Now that my father is moving into my home, I will need to change my ways." C. "I feel better able to care for my father now that I know where to obtain assistance." D. "I am so sorry and embarrassed that the abusive evet occurred. It won't happen again."

"I feel better able to care for my father now that I know where to obtain assistance." *Elder abuse sometimes occurs with family members who are being expected to care for their aging parents. This can cause family members to become overextended, frustrated, or financially depleted. Knowing where in the community to turn for assistance with careing for aging family members can bring much needed relief. Taking advantage of these alternatives is a postive alternative coping strategy, which many families use

A nurse is collecting data for a client who is scheduled for an anterior colporrhaphy. Which of the following client statements should the nurse expect as an indication for this procedure? A. "I have to push the feces out of a pouch in my vagina with my fingers." B. "I have pain and bleeding when I have a bowel movement." C. "I have had frequent urinary tract infections." D. "I am embarrassed by uncontrollable flatus."

"I have had frequent urinary tract infections." *Pouching of feces is an expected finding associated with a rectocele. The surgical procedure for a rectocele is POSTERIOR colporrhaphy *Pain and bleeding with a bowel movement is an expected finding associated with a rectocele *Due to urinary stasis associated with cystocele, this finding is an expected finding of a cystocele. The surgery for a cystocele is an ANTERIOR colporrhaphy *Uncontrollable flatus is an expected finding associated with rectocele

A nurse is reinforcing teaching to a client who has a new prescription of amitriptyline. Which of the following statements by the client indicates an understanding of the teaching? A. "I can expect to experience diarrhea while taking this medication. B. "I may feel drowsy for a few weeks after starting this medication." C. "I cannot eat my favorite pizza with pepperoni while taking this medication." D. "This medication will help me lose the weight that I have gained over the last year."

"I may feel drowsy for a few weeks after starting this medication." *Sedation is an adverse effect of amitriptyline during the first few weeks of therapy *Constipation rather than diarrhea can occur with TCAs, due to anticholinergic effects *Foods (pepperoni) should be avoided if the client is prescribed an MAOI rather than a TCA like amitriptyline *Observe for manifestations of hypomania or mania caused by CNS stimulation with phenelzine

The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching? A. "I need to wear sunscreen when participating in outdoor activities." B. "I need to avoid sun exposure before 10 A.M. and after 4:00 P.M." C. "I need to wear a hat, opaque clothing, and sunglasses when in the sun." D. "I need to examine my body monthly for any lesions that may be suspicious."

"I need to avoid sun exposure before 10 A.M. and after 4:00 P.M." *The client should be instructed to avoid sun exposure between the hours of approximately 10:00 AM and 4:00 PM. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any possible or precancerous lesions

When evaluating patient understanding regarding the use of an incentive spirometer, which statement confirms a need for more teaching? A. "I will inhale as deeply as possible each time I use the spirometer." B. "I need to tilt the incentive spirometer slightly to reduce effort." C. "To monitor progress, I will record the top volume achieved." D. "I need to seal my lips around the mouthpiece."

"I need to tilt the incentive spirometer slightly to reduce effort." *Tilting the incentive spirometer is not a correct use of the device and indicates a need for further teaching. (1) Inhaling deeply with each use of the spirometer is correct. (3) Recording the top volume achieved helps record progress in lung reexpansion. (4) Sealing the lips around the mouthpiece is correct technique for the spirometer.

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife make which statement? A. "I no longer feel that I deserve the beatings my husband inflicts on me." B. "My attendance at the meetings has helped me to see that I provoke my husband's violence." C. "I enjoy attending the meetings because they get me out of the house and away from my husband." D. "I can tolerate my husband's destructive behaviors now that I know they are common for alcoholics."

"I no longer feel that I deserve the beatings my husband inflicts on me." *Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain suggestions about successful behavioral changes. Option A is the healthiest response becuase it exemplifies an understanding that the alcholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. The nonalcoholic partner should not feel responsible when the spouse loses control (option B). Oprion C indicates that the group is being seen as an escape, not a place to work on issues. Option D indicates that the wife remains codependent

The mother of a 4-year-old child reports concerns about how to completely rid her home of lice. Which response indicates that the mother needs further instruction? A. "I should wash all bedding in hot water." B. "I should re-treat my child's hair 1 week after the first application." C. "I should discard my child's stuffed animals." D. "My children should not share hats or hairbrushes."

"I should discard my child's stuffed animals." *For items that cannot be cleaned, such as some stuffed animals, sealing them in plastic bags with the air expelled for 14 days can be effective. Linens should be washed and dried on the hottest cycle. Application of alcohol-based lotion requires reapplication after 1 week. Sharing hats or hairbrushes increases the likelyhood of lice transmission

The nurse has provided discharge instructions to a patient who underwent a vasectomy. Whcih statement indicates the patient understands the nurse's teaching? A. "I can use a heating pad this evening for my discomfort." B. "Taking aspirin every 4 h will help with my pain." C. "I should leave the compression dressing on for the first 24 h." D. "I should ice my scrotum once I get home."

"I should ice my scrotum once I get home." *Instruct the patient to use ice applications and acetaminophen or ibuprofen for scrotal pain and swelling the first 12 to 24 h postoperatively. The patient should wear jockey shorts or a scrotal support for comfort. Heat is not recommended during the first 24 h postoperatively. Aspirin may promote bleeding. The patient will not have a compression dressing

The nurse has provided discharge instructions to a patient who underwent a vasectomy. Which statement indicates the patient understands the nurse's teaching? A. "I can use a heating pad this evening for my discomfort." B. "Taking aspirin every 4 h will help with my pain." C. "I should leave the compression dressing on for the first 24 h." D. "I should ice my scrotum once I get home."

"I should ice my scrotum once I get home." *Instruct the patient to use ice applications and acetaminophen or ibuprofen for scrotal pain and swelling the first 12 to 24 h postoperatively. The patient should wear jockey shorts or a scrotal support for comfort. Heat is not recommended during the first 24 h postoperatively. Aspirin may promote bleeding. The patient will not have a compression dressing

A nurse is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the discussion A. "I can promote my client's sense of control by establishing a schedule." B. "I should encourage clients who have a schizoid personality disorder to increase socialization." C. "I should practice limit-setting to help prevent client manipulation." D. "I should implement assertiveness training with clients who have antisocial personality disorder."

"I should practice limit-setting to help prevent client manipulation." *When caring for a client who has a personality disorder, limit-setting is appropriate to help prevent client manipulation *Rather than establishing a schedule, ask for the client's input and offer realistic choices to promote the client's sense of control *Avoid trying to increase socializtion for a client who has a schizoid personality disorder *Implement assertiveness training for clients who have dependent and histrionic personality disorders

Which statement by Ms. Junic indicates that she understands how to deal with the side effects of chemotherapy? A. "All drugs, including chemotherapy drugs have side effects." B. "I should report side effects; they could be an adverse response to therapy." C. "After I learn to recognize the side effects, I can cope independently." D. "A few side effects are okay as long as they don't interfere with activities of daily living."

"I should report side effects; they could be an adverse response to therapy." *Chemotherapy is given to treat cancer patients and it is used to kill cancer cells, when the medication is given to kill the cancer cells patients get sick ,Fatigue, Hair loss, Easy bruising and bleeding, Infection, Anemia (low red blood cell counts), Nausea and vomiting. are some of the side effects of chemotherapy

A nurse is reinforcing teaching about free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique? A. "I will write down my dreams as soon as I wake up." B. "I might begin to associate my therapist with important people in my life." C. "I can learn to express myself in a nonaggressive manner." D. "I should say the first thing that comes to my mind."

"I should say the first thing that comes to my mind." *Free association is the spontaneous, uncensored verbalization of whatever comes to a client's mind *Dream analaysis and interpretation are therapeutic tools, However, they are not an example of free association *Associating the therapist with significant persons in the client's life is an example of transference rather than free association *Learning to express feelings and solve problems in a nonaggressive manner is an example of assertiveness training, rather than free association

Flueoxetine is prescribed, and the nurse reinforces instructions to the client regarding the administration of the medication. Which statement by the client indicates an understanding about the administration of this medication? A. "I should take the medication with my evening meal." B. "I should take the medication at noon with an antacid." C. "I should take the medication in the morning when I first arise." D. "I should take the medication right before bedtime with a snack."

"I should take the medication in the morning when I first arise." *Fluoxetine is a selective serotonin reuptake inhibitor (SSRI). It is administered in the early morning without consideration to meals. Options A, B, and D are incorrect

The nurse provides discharge teaching about antibiotic therapy. Which statement indicates that the patient requires additional teaching? A. "I should wait 3 days after my symptoms resolve before stopping my antibiotic." B. "I should try to take my medication as evenly spaced apart as possible." C. "If I start feeling worse, I should call my health care provider." D. "I should not share my medication with anyone."

"I should wait 3 days after my symptoms resolve before stopping my antibiotic." *The antibiotic should be taken until it is completely gone in order to ensure the infection has been adequately treated.

A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse about fears of gaining weight. Which of the following responses should the nurse make? A. "Many clients are concerned about their weight. However, the dietitian will ensure that you don't get too many calories in your diet." B. "Instead of worrying about your weight, try to focus on other problems at this time." C. "I understand you have concerns about your weight, but first, let's talk about your recent accomplishments." D. "You are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. We know that is important to you."

"I understand you have concerns about your weight, but first, let's talk about your recent accomplishments." *This statement acknowledges the client's concern and then focuses the conversation on the client's accomplishments, which can promote client self-esteem and self-image *(A) This statement minimizes and generalizes the client's concern and is therefore a nontherapeutic reponse *(B) This statement minimizes the client's concern and is therefore a nontherapeutic response *(C) This statement minimizes the client's concern and is therefore a nontherapeutic reponse

A nurse is talking with the caregiver of a child who has demonstrated recent changes in behavior and mood. When the caregiver of the child asks the nurse for reassurance about their child's condition, which of the following responses should the nurse make? A. "I think your child is getting better. What have you noticed?" B. "I'm sure everything will be okay. It just takes time to heal." C. "I'm not sure what's wrong. Have you asked the doctor about your concerns." D. "I understand you're concerned. Let's discuss what concerns you specifically."

"I understand you're concerned. Let's discuss what concerns you specifically." *This therapeutic response reflects upon, and accepts, the caregovers' feelings, and it allows them to clarify what they are feeling *(A) This nontherapeutic response interjects the nurse's opinion and can cause the caregiver to withhold their thoughts and feelings *(B) This nontherapeutic response interjects the nurse's opinion and provides false reassurance which can cause the caregiver to withhold their thoughts and feelings *(C) This nontherapeutic response avoids addressing the caregiver's concerns directly and indicates disinterest by the nurse for wanting to discuss the concerns with the parents

A nurse is reinforcing discharge teaching to a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching? A. "I will avoid blowing my nose." B. "I should wait until the day after surgery to wash my hair." C. "I will remove the dressing behind my ear in 7 days." D. "My hearing should be back to normal right after my surgery."

"I will avoid blowing my nose." *Clients following ear surgery should be advised to avoid blowing their nose, sneezing, or coughing. This can cause pressure on the client's ear or stitches if in place. This can also cause pain and discomfort to the client following ear surgery *(b)-Avoid showering and washing hair for at least several days up to 1 week following ear surgery. The ear must remain dry during this time. (c)-Middle ear surgery is performed through the tympanic membrane, and the client will have a dry dressing within the ear canal. There is no external excision. (d)-Decreased hearing is expected following middle ear surgery due to presence of a dressing within the ear canal and possible drainage

A nurse is reinforcing discharge teaching for a client who has schizophrenia and a new prescription for iloperidone. Which of the following client statements indicates understanding of the instructions? A. "I will be able to stop taking this medication as soon as I feel better." B. "If I feel drowsy during the day, I will stop taking this medication and call my provider." C. "I will be careful not to gain too much weight while taking this medication." D. "This medication is highly addictive and must be withdrawn slowly."

"I will be careful not to gain too much weight while taking this medication." *Antipsychotic medications (iloperidone) have a high risk of for significant weight gain. *Antipsychotic medications are considered a long-term treatment for schizophrenia. Discontinuing the medication can result in an exacerbation of manifestations *Drowsiness is a common adverse effect of antipsychotic medications. However, it is not appropriate to discontinue the medication *Antipyschotic medications are not considered addictive, and it is not necessary to titrate iloperidone when discontinuing treatment

An office assistant tells the nurse his job requires him to work at his computer for 7 to 8 h each day. Which statement indicates that the nurse's teaching about preventing eyestrain has been successful? A. "I will wear protective googles while working." B. "I will eat more carrots and cooked spinach." C. "I will close my eyes every few hours." D. "I will instill artificial tears each hour while working."

"I will close my eyes every few hours." *To prevent eyestrain, the patient should rest the eye muscles periodically when working at the computer or performing any activity that demands intensive vusual effort. Resting the eye muscles every several hours helps prevent eye fatigue. Protective googles do not help prevent eyestrain. Nutrients such as lutein and zeaxanthin are found in carrots and cooked spinach and are good for the eyes but do not reduce eyestrain. Overuse of artificial tears is not recommended, and proper usuage works to combat dry eyes

A nurse is reviewing testicular self-examination with a client. Which of the following client statements indicates understanding? A. "It is best to examine the testicles before bathing." B. "It is not necessary to report small lumps, unless they are painful." C. "I will examine one testicle at a time." D. "I will use my palms to feel for abnormalities."

"I will examine one testicle at a time." *Examining the testicles after showring or bathing ensures the scrotum is relaxed, and examination is more accurate. *The client should report any lump swelling to the provider as soon as possible. *The client should examine one testicle at a time to ensure that an abnormality is not missed *The client should use the thumb and fingers to examine the testes to better detect small changes because the fingertips are more sensitive

A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? A. "I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood." B. "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up." C. "I will apply pressure approximately 1.2 inches below the insertion site prior to removing the needle." D. "I will choose a vein inthe antecuvital fossa for IV insertion due to its size and easily accessible device."

"I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up." *Use a smooth, steady motion to insert the catheter through the skin at an angle of 10 to 30 degrees with the bevel up. This is the optimal angle for preventing the puncture of the posterior wall of the vein

A nurse is caring for a client who is to begin taking fluoxetine for treatment of panic disorder. Which of the following statements indicates the client understands the use of this medication? A. "I will take the medication at bedtime." B. "I will follow a low-sodium diet whike taking this medication." C. "I will need to discontinue this medication slowly." D. "I will be at risk for weight loss with long-term use of this medication."

"I will need to discontinue this medication slowly." *When discontinuing fluoxetine, the client should taper the medication slowly according to a prescribed tapered dosing schedule to reduce the risk of withdrawal symptoms *The client should take fluoxetine in the morning to minimize sleep disturbances *The client is at risk for hyponatremia while taking fluoxetine *The client is at risk for weight gain, rather than loss, with long-term use of fluoxetine

A nurse is reinforcing teaching with a middle adult client about screening prevention for cancer. Which of the following statements by the client indicates an understanding of the information reviewed? A. "I will need to have a mammogram every 2 years beginning at age 45." B. "I should have a colonoscopy every 15 years beginning at age 60." C. "I will need to have a Pap test every 5 years beginning at age 30." D. "I should have a fecal occult test done every 3 years."

"I will need to have a Pap test every 5 years beginning at age 30." *annual mammograms at age 40+ *colonoscopy at age 50 and then every 10 years thereafter *Pap test every 3 years for ages 21-29 and every 5 years for age 30-65 *fecal occult test every year. stool DNA test every 3 years in place of a fecal occult blood testing can be done

The nurse is caring for a patient in the initial hours after having surgery to manage an enlarged prostate. The patient's postoperative care include continuous bladder irrigation. Which statement indicates the patient understands the nurse's teaching? A. "I will be discharged home in about 6 h." B. "My urine will likely be dark tea color as a result of the blood it contains." C. "I will need to have my bladder irrigated for the first 2 to 3 days." D. "I should report any bladder spasm immediately because it may indicate a serious complication."

"I will need to have my bladder irrigated for the first 2 to 3 days." *The patient will require continuous bladder irrigation or approximately 2 to 3 days. The patient will stay in the hospital for several days. Bloody urine that is red, pink, or watermelon colored is normal during the initial postoperative period. Tea color urine is not associated with this surgical procedure. Bladder spasms are normal and not not necessarily signal complications

A nurse is reinforcing teaching to a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates uderstanding of the information provided? A. "It is common to treat depression with ECT before trying medications." B. "I can have my depression cured if I receive a series of ECT treatments." C. "I should receive ECT once a week for 6 weeks." D. "I will receive a muscle relaxant to protect me from injury during ECT."

"I will receive a muscle relaxant to protect me from injury during ECT." *A muscle relaxant (succinylcholine) is administered to reduce the risk for injury during induced seizure activity *ECT is indicated for clients who have major depressive disorder and who are not respnsive to pharmacological treatment *ECT does not cure depression. However, it can reduce the incidence and severity of relapse *The typical course of ECT treatment is 2 to 3 times a week for a total of 6 to 12 treatments

During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventative strategies? A. "I will leave the IV catheter in place after the client completes the course of IV antibiotics." B. "As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt." C. "If my client needs to use the rest room, it would be safer to disconnect their IV infustion as long as I clean the injection port thoroughly with an antiseptic swab." D. "I will replace any IV catheter when I suspect contamination during insertion."

"I will replace any IV catheter when I suspect contamination during insertion." *Replace IV catheters when suspecting any break in surgical aseptic technique (in emergency insertions)

A charge nurse is discussing TMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the procedure? A. "TMS is indicated for clients who have schizophrenia spectrum disorders." B. "I will provide postanesthesia care following TMS." C. "TMS treatments usually last 5 to 10 minutes." D. "I will schedule the client for TMS treatments 3 to 5 times a week for the first several weeks."

"I will schedule the client for TMS treatments 3 to 5 times a week for the first several weeks." *TMS is commonly prescribed 3 to 5 times a week for the first 4 to 6 weeks *TMS is indicated for the treatment of major depressive disorder that is not responsive to pharmacological treatment. ECT is indicated for the treatment of schizophrenia spectrum disorders *Postanesthesia care is not necessary after TMS because the client does not receive anesthesia and is alert during the procedure *The TMS procedure lasts 30 to 40 min

A patient is scheduled for a hysteroscopy with endometrial ablation. Which statement by the patient indicates additional education about the procedure is needed? A. "I'm glad I won't have to have general anesthesia for this procedure" B. "The interior of my uterus will be visualized for fibroids." C. "I'm hoping to get pregnant within the next 2 years." D. "I should not expect heavy bleeding following the procedure"

"I'm hoping to get pregnant within the next 2 years." *Hysteroscopy is an endoscopic examination of the uterus and may also involve procedures to remove fibroids, adhesions, and septums. The hysteroscope is inserted vaginally, usually under local anesthesia. The patient should be instructed to report heavy bleeding or sharp/severe abdominal pain as this could be caused by an injury to the cervix or uterine wall. When endometrial ablation is done, the woman will have difficulty becoming pregnant because the lining destruction is permanent.

A nurse is caring for a client who has avoidant personality disorder. Which of the following statements should the nurse expect from a client who has this type of personality disorder? A. "I'm scared that you're going to leave me." B. "I'll go to group therapy if you'll let me smoke." C. "I need to feel that everyone admires me." D. "I sometimes feel better if I cut myself."

"I'm scared that you're going to leave me." *Clients who have avoidant personality disorder often have a fear of abandonment. This type of statement is expected *(B) Thie statement indicates manipulation, which is expected from a client who has antisocial personality disorder *(C) This statement indicates a need for admiration, which is expected from a client who has narcissistic personality disorder *(D) This statement indicates a risk for self-injury, which is expected from a client who has borderline personality disorder

The paranoid schizophrenic patient states that his whole family has conspired to have him put in the hospital and that the medical staff are part of the conspiracy. Which is the nurse's most therapeutic response? A. "I promise that I want to help you." B. "You know your family is concerned about you." C. "I'm sorry you feel that way. I'll be around if you want to talk about your feelings." D. "The doctors are trying to help you feel better. The have your best interest in mind."

"I'm sorry you feel that way. I'll be around if you want to talk about your feelings." *Arguing with the paranoid patient, or defending self or others, reinforces the paranoia. Passively offering self to the patient to approach you rather than the other way around is helpful to the nurse-patient relationship

The nurse is reviewing strategies for self-care with a patient diagnosed with PMDD. Which statement by the patient indicates a need for further instruction? A. "I sure miss drinking coffee in the morning." B. "I'm trying to lose weight by avoiding all carbohydrates." C. "My usual dinner consists of chicken, salad, and a baked potato." D. "I sure am gassy from eating so many vegetables!"

"I'm trying to lose weight by avoiding all carbohydrates." *Strategies for self-care include stress management exercises; some lifestyle changes; and maintaining a healthy diet rich in complex carbohydrates (peas, beans, whole grains, and starchy vegetables)and fiber (green leafy vegetables), avoiding simple sugars, salty foods, and caffeine (coffee, tea), and prevention of hypoglycemia. Exercise may increase beta-endorphin levels, which results in relief of depression and mood elevation.

Which statement by the patient's family indicates the need for more teaching about the treatment of anorexia nervosa? A. "If she'll just eat more, we can take her home and she'll be okay." B. "She will have to hospitalized if she has dehydration or electrolyte imbalance." C. "Therapy could take between 1-6 years for this disorder." D. "Support groups and family therapy are important aspects of treatment."

"If she'll just eat more, we can take her home and she'll be okay."

You are caring for a patient with a personality disorder. Which statement made by you indicates a need for additional education setting boundaries? A. "I can spend 20 minutes talking with you, and then I have to pass medications." B. "I understand that you are bored, but you have to complete the task." C. "If you promise not to cause trouble, I'll give you the magazine." D. "When someone is speaking in group, it is polite to listen while they speak."

"If you promise not to cause trouble, I'll give you the magazine." *If a privilege is granted and contingent on a future behavior, the patient and nurse are setting up future manipulation and power struggles. (1) The boundary and anticipated actions are very clear in this statement. (2) In this statement, the feelings are acknowledged, but the expectations remain clear. (4) Behavior and circumstances are clearly articulated.

Which statement by a patient indicates a need for additional teaching about the "morning-after pill"? A. "It has to be taken within 72 hours after unprotected sex." B. "It works by preventing ovulation, Implantation, or fertilization." C. "It may cause nausea and vomiting, so I should take an antiemetic." D. "It can be used to terminate a first trimester pregnancy."

"It can be used to terminate a first trimester pregnancy."

Which statement made by a patient indicates an understanding of the information and teaching about genital herpes? A. "It is highly contagious, but it is only transmitted by sexual contact." B. "I am cured once vesicles in the genital area crust over and resolve." C. "Numbness and tingling may occur 24 hours before lesions appear." D. "If lesions are present, it is best to use a condom and spermicide."

"It is highly contagious, but it is only transmitted by sexual contact."

The nurse is providing infection control teaching to a patient. Which patient statement warrants additional patient teaching? A. "It is important that I get my whooping cough vaccination as directed by my health care provider." B. "Getting plenty of sleep each night will help my immune system." C. "I should wash my hands before preparing my food." D. "It is important that I take my antibiotic until my symptoms have completely resolved."

"It is important that I take my antibiotic until my symptoms have completely resolved." *Antibiotics must be completed in entirety. Partial completion of prescribed antimicrobial medication cause a pathogen to become resistant to that particular drug. Vaccinations, adequate rest, and proper hand hygiene are important infection control measures

The family of a patient being treated for a recent diagnosis of schizophrenia voices concerns to the nurse. They report the patient just told them that the pepper flakes on his potatoes were crawling bugs. What reponse by the nurse is most appropriate? A. "At this stage it is most important to humor him and agree that you see them as well." B. "To reduce his stress, just throw out the food." C. "It is important to tell him that you do not see the bugs." D. "The best thing to do in this case is to confront him and let him know that he is mistaken."

"It is important to tell him that you do not see the bugs." *The patient is experiencing an illusion. It is most important to offer support but to attempt to provide reality orientation. Confronting him may cause anger or increased anxiety and should be avoided

The nurse discusses and demonstrates proper hand hygiene to an immunocompromised patient and his wife. Which statement indicates a need for additional teaching? A. "It is okay for my wife to wear artificial nails as long as she washes her hands properly." B. "I should always wash my hands before I eat." C. "Hand gels work as well as handwashing under most circumstances." D. "I should use friction and wash my hands for about 20 seconds if I am using soap and water."

"It is okay for my wife to wear artificial nails as long as she washes her hands properly." *Artificial nails harbor microorganisms regardless of good hand hygiene

A patient with a suspicious skin lesion is scheduled for a punch skin biopsy. What is the most accurate explanation you would give about the procedure? A. "It is shaving a top layer off a lesion that rises above the skin line." B. "It is removing a core from the center of the lesion." C. "It is removing the entire lesion." D. "It is aspirating a tissue sample."

"It is removing a core from the center of the lesion." *A punch biopsy is performed by removing a core from the center of the lesion. (1) A shave biopsy is performed by shaving off a top layer of a lesion that rises above the skin line. (3) An excisional biopsy is performed by excising the entire lesion. (4) Aspiration is done to obtain a fluid sample.

The nurse is teaching a patient with BPH who has a new prescription for finasteride (Proscar). Which information is most important for the nurse to include? A. "It may take several months for this medication to work." B. "This medication has multiple side effects C. "This medication will reduce the size of the prostate." D. "This medication is knows as a 5-Alpha-Reductase-Inhibitor (ARIs)."

"It may take several months for this medication to work." *The patient should be aware that finasteride (Proscar) is a steroid that may take several months to relieve symptoms. Otherwise, the patient may wrongly think that the medication is not working, which could effect compliance. The medication does have multiple side effects, but the nurse should be more specific about emergent and expected effects and direct the patient to consult the physician if questions arise. The nurse should inform the patient that the medication does reduce the size of the prostate and is known as an ARI, but this information is not most important

The nurse advises the patient that tanning salons are not recommended. The patient states, "I have talked to a bunch of people who have been using a tanning salon for years without any problems." What is the best response? A. "They may not be having problems now, but there will be consequences in the future." B. Professional dermatologists are convinced that tanning has adverse long-term effects." C. "It seems like you are interested in doing your own research. Let me get you some additional resources." D. "I can tell that you don't believe me, but I would like you to talk to some patients with skin cancer."

"It seems like you are interested in doing your own research. Let me get you some additional resources."

A nurse is caring for a client who will undergo a neurolytic ablation. The client asks the nurse the reason for this procedure. Which of the following responses should the nurse make? A. "It should provide permanent pain relief." B. "It reduces the adverse effects of your pain medication." C. "It increases your ability to fight infections." D. "It increases cells that stop bleeding."

"It should provide permanent pain relief." *neurolytic ablations causes permanent destruction of the nerves that transmit pain from a specific area and is a last report after other methods have been unsuccessful. *neurolytic ablations should reduce the need for analgesics. However, it does not reduce the adverse effects of pain medication *neurolytic ablation does not treat myelosuppression (which reduces immunity) or increase the ability to fight infections *neurolytic ablation does not treat thrombocytopenia. The procedure can cause complications (disruption of bladder, bowel function), but it does not affect clotting mechanisms

A client is admitted to the in-patient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse should make which therapeutic response? A. "It sounds as though you need to speak to the psychiatrist. B. "Perhaps you'd like to see the ECT room and speak to the staff." C. "Your child has decided to have this treatment. You should be supportive of the decision." D. "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

"It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?" *The nurse needs to encourage the family and client to verbalize their fears and concerns. Option D is the only option that encourages verbalization. Options A, B, and C avoid dealing with the client or family concerns

The nurse is caring for an older male patient. Which patient statement would alert the nurse to a probable presence of benign hyperplasia (BPH)? A. "It takes a long time for me to be able to urinate." B. "I feel a burning sensation when I urinate." C. "I have a throbbing pain in my groin." D. "I have noticed that my urine is very foamy."

"It takes a long time for me to be able to urinate." *Difficulty urinating is the first symptom noticed by a person who has BPH. a burning sensation during urination is most consistent with urinary tract infection (UTI). A throbbing sensation in the groin is a nonspecific complaint that could indicate different underlying issues; the nurse should ask the patient additional questions to determine more data. Bubbly of foamy urine may indicate the presence of protein in the urine

The need for protective isolation and its parameters are being explained to the patient. She wails, "How can I hug my children when I am locked up in this room?" An appropriate response would be A. "They can see you through the intercom." B. "You can communicate through the intercom system or via your cellphone." C. "All people carry microorganisms, and your immune system cannot fight off any infection right now." D. "It won't be long before you can hug them, and we need to keep you safe from infection."

"It won't be long before you can hug them, and we need to keep you safe from infection." *Although all of these statements could apply to this patient, she is most concerned about her family at this point and being able to see them and show affection.

The clinic nurse offers suggestions to a patient who is planning a trip to Mexico that will help prevent a protozoan infection. Which suggestion is mot helpful? A. "Ask the doctor for a prophylactic prescription for an antiviral drug." B. "Broad-spectrum antibiotics will be most helpful if you contract a protozoan infection." C. "Be sure to practice good hand hygiene while on your vacation." D. "It would be best if you drink bottled water while on your trip."

"It would be best if you drink bottled water while on your trip." *Protozoa frequently live in the water and soil and cause infection by ingestion of the parasite. Water in many foreign countries contains protozoa, so drinking bottled water is the best suggestion

The nurse is caring for a patient who is experiencing diabetes-related visual changes. Which statement indicates that the patient accurately understands the nurse's teaching about the cause of vision changes in diabetes? A. "Long-term exposure to high glucose levels can damage the blood vessels in my retina." B. "Frequent injections of regular insulin damage the cornea." C. "High glucose levels cause increase pressure in my eyes that leads to less opacity." D. "Diabetes affects healing and causes frequent eye infections."

"Long-term exposure to high glucose levels can damage the blood vessels in my retina." *Pronlonged periods of hyperglycemia cause damage to the retina from bleeding. Insulin does not result in visual changes in the patient with diabetes. Less opacity and corneal dryness will not promote vision-related complications in the patient with diabetes mellitus

A nurse is talking with a client who is at risk for suicide following their partner's death. Which of the following statements should the nurse make? A. "You will feel much better with time. I promise." B. "Suicide is not the appropriate way to cope with loss." C. "Losing someone close to you must be very upsetting." D. "I know how difficult it is to lose someone close to you."

"Losing someone close to you must be very upsetting." *This statement is an empathetic response that attempts to understand the client's feelings *(A) This statement gives the client false reassurance and is therefore not therapeutic *(B) This statement implies judgment and is therefore not an empathetic or therapeutic reponse *(D) This statement focuses on the nurse's experiences rather than the client's and is therefore not therapeutic

The patient will be discharged within a day or two. Which statement by the patient's family indicates a need for further discussion about the diagnosis of schizophrenia? A. "A stable home environment will help to prevent relapse." B. "He might always hear voices, but the medications will help." C. "Medication will eliminate his blunted affect and social isolation." D. "If he fails to take his medication, it will probably lead to readmission."

"Medication will eliminate his blunted affect and social isolation."

The nurse is caring for a terminally ill cancer patient who is receiving palliative cancer. The patient's wife asks how her husband's pain will be controlled as he nears death. Which is the nurse's best response? A. "Most of the time we can manage the pain with oral morphine and transdermal pain medication." B. "We will probably have to start an IV to administer morphine to control the intense pain he may be experiencing." C. "Dying patients typically do not have any pain, so this will not be an issue." D. "I will have to check with your husband's physician to see how he wants us to handle pain control."

"Most of the time we can manage the pain with oral morphine and transdermal pain medication." Oral and transdermal pain control methods are most often used for the terminally ill patient near death.

A patient who has been prescribed an antineoplastic drug for his newly diagnosed cancer asks the nurse what the most common side effect is for these drugs. What is the nurse's most accurate response? A. "Gastrointestinal upset is the most common side effect." B. "An elevated temperature is a common side effect." C. "Most of these drugs cause some degree of bone-marrow depression." D. "These drugs almost always cause a vitamin B12 deficiency."

"Most of these drugs cause some degree of bone-marrow depression." *All antineoplastic drugs cause bone-marrow depression. The degree of bone-marrow depression depends on the drug and dosage. Gastrointestinal upset is experienced with some neoplastic drugs. An elevated temperature is a sign of infection, and vitamin B12 deficiency is not commonly a side effect.

A 30 year old patient tells you that he located a lump on his testicle that he would like to have the health care provider check if it doesn't go away by his next visit. What is the appropriate response? A. Most testicular lumps are not cancer; you can come back sooner if it does not go away." B. "Most testicular lumps are cancerous, so this should be checked immediately." C. "Most testicular lumps are benign, but we do not want to take a risk, so let's have it checked today." D. "Let's make an appointment on another day; this might go away without intervention."

"Most testicular lumps are benign, but we do not want to take a risk, so let's have it checked today." *Most lumps are caused by infection or some other inflammation but may also be caused by cancer. They should be checked by a health care provider. (1, 4) It is always better to be checked so that if the lump is cancer, it can be treated at as early a stage as possible. (2) Most lumps are benign.

Which statement causes the nunrse to document a schizophrenic patient's delusion of persecution? A. "Did you know that I own this hospital and pay all these people to work for me?" B. "My doctor talked to all the other patients, but not to me. He doesn't want me to get well." C. "The president's speech tonight is going to give me a coded message." D. "I am going to wait in front of the hospital this morning for my limousine to pick me up and take me to my private jet."

"My doctor talked to all the other patients, but not to me. He doesn't want me to get well." *Delusions can be either gradiose or persecutory. An individual who beleives he owns the hospital or is planning to be picked up by a limousine or has a private jet is having delusions of grandeur. Individuals with delusion of persecution believe that they are being persecuted by agencies, by other people, or by supernatural beings. The patient who believes the president's speech is coded is having an idea of reference

An exhausted daughter is the sole caregiver to a patient with moderate Alzheimer disease (AD). She asks the nurse what respite care entails. Which statement indicates that the caregiver understands the nurse's response? A. "My mom would stay in a long-term care facility for a short time while I rest." B. "Home health aides would come to our home and help me with housework." C. "A registered nurse would provide total care for my mom in 3 day interval." D. "I would be connected with a special support group to share stresses and communicate with other caregivers."

"My mom would stay in a long-term care facility for a short time while I rest." *Respite care is placing the patient temporarily in a long-term care facility (usually for no longer than a month) to give the family respite from the responsibility of 24/7 care

The patient is taking olanzapine (Zyprexa) as prescribed. Which patient comment suggests that the medication is successively treating the patient's positive symptoms of schizophrenia? A. "I can leave the hospital whenever I want to." B. "Nurse, I am ready to go home. Would you call my mother?" C. "I can still hear the voices, but they are very distant." D. "The angel stopped talking; now she just sits and waves."

"Nurse, I am ready to go home. Would you call my mother?"

You are teaching a female patient about a new diagnosis of genital herpes. Which patient statement indicates that further teaching is necessary? A. "Once my lesions are healed I am no longer contagious." B. "Primary lesions will resolve in about 2 weeks." C. "This infection can spread to other parts of my body." D. "A cesarean section may be necessary if the infection is active during delivery."

"Once my lesions are healed I am no longer contagious." *Further teaching is needed because viral shedding continues after lesions have healed. (2) The primary lesions should heal in about 2 weeks, but (3) the infection can spread to other parts of the body, and (4) a Cesarean section may be necessary if the infection is active during delivery to avoid spreading the infection to the neonate during delivery.

A patient wishing to decrease her risk for breast cancer asks you what causes this disease. What is the appropriate nursing response? A. "Antiperspirants have been shown to cause breast cancer." B. "Researchers believe that genes and environmental factors cause this disease." C. "Age and weight are the most predictive risks for development of breast cancer." D. "There are no modifiable risk factors that you can control to prevent breast cancer."

"Researchers believe that genes and environmental factors cause this disease." *The cause of breast cancer is not known. However, genetic and environmental risk factors have been identified. (1) Antiperspirants are not a cause of breast cancer. (3) Older age and obesity are risk factors but are not causative factors. (4) Exposure to ionizing radiation, obesity, and alcohol use are all modifiable risk factors.

A 40 year old man requests a prostate examination and a PSA test, stating that he wants to start getting screened early. Which is the appropriate nursing response? A. "Screening for prostate cancer can begin at age 55 years; depending on the results, a screening prevention plan is devised based on risk." B. "You do not need to worry now. Prostate screening begins at age 50 years and then continues annually." C. "Prostate screening is done at the same time as your colon cancer screening and begins by age 50 years." D. "We only check PSA levels now. Prostate examinations have been found to be unreliable."

"Screening for prostate cancer can begin at age 55 years; depending on the results, a screening prevention plan is devised based on risk." *Prostate screening programs are individually designed according to risk stratification. (2, 3) Prostate screening begins at age 55 years and is then scheduled individually. (4) PSA levels are not always checked, and examination is done routinely.

The patient is considering a vasectomy but states to the nurse, "I'm not sure if this is the right option for me. My wife and I don't want any more kids, but we still want to have sex." What is the best response by the nurse? A. "Seminal fluid is still produced and you will still be able to ejaculate, but the semen will not contain sperm." B. "Although you will still be able to experience an orgasm, you will not ejaculate after the procedure." C. "The vasectomy will not affect your wife's ability to get pregnant or for you to experience erections, ejaculation, or orgasm." D. "While you will still be able to get an erection, unfortunately you will no longer experience orgasm."

"Seminal fluid is still produced and you will still be able to ejaculate, but the semen will not contain sperm." *A vasectomy severs or ties the vas deferens, which is the conduit through which the sperm enters the seminal fluid. The patient will be able to maintain an erection, ejaculate, and orgasm normally. A vasectomy is performed to prevent pregnancy.

The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time? A. "I know you feel 'they are out to get you,' but it's not true." B. "I can hear the voice, and she wants you to come to dinner." C. "Sometimes people hear things or voices others can't hear." D. "I talked to the voices you're hearing and they won't hurt you now.

"Sometimes people hear things or voices others can't hear." *It is important for the nurse to reinforce reality with the client. Options A, B, and D do not reinforce reality but reinforce the hallucination that the voices are real

A mother brings her 12 year old daughter in for an annual check-up. You recommend administration of one of the HPV vaccines. The mother replies, "My daughter does not need the vaccine because she is not sexually active." What is the appropriate nursing response? A. "You can bring her back when she becomes sexually active." B. "Studies have shown that the earlier the vaccine is given, the more effective it is. When she does become sexually active, the vaccine will be protecting her." C. "If you wait until your daughter is sexually active, it will be too late. How will you know?" D. "The vaccine must be given before your daughter is sexually active, or it will not work."

"Studies have shown that the earlier the vaccine is given, the more effective it is. When she does become sexually active, the vaccine will be protecting her." *The recommended age for HPV vaccination is 11 to 12 years old. It may be given as early as 9 years old and as late as 26 years old. (1) Giving the vaccine prior to becoming sexually active is most effective. (3) This is not a professionally worded answer. (4). A flippant answer such as this will not achieve results.

Which patient instruction is most critical to a patient being discharged on antibiotic therapy? A. "Wash your hands." B. "Increase fluid intake." C. "Reduce stress." D. "Take all the antibiotics as prescribed."

"Take all the antibiotics as prescribed." *All of these instructions could be given, but when a patient is prescribed antibiotics, it is important to stress that taking all of the medication helps prevent antibiotic resistance and is needed to completely eliminate the infection.

A nurse is assisting with the care of a client who has generalized anxiety disorder and is experiencing severe anxiety. Which of the following statements actions should the nurse make? A. "Tell me about how you are feeling right now." B. "You should focus on the positive things in your life to decrease your anxiety." C. "Why do you believe you are experiencing this anxiety?" D. "Let's discuss the medications your provider is prescribing to decrease your anxiety."

"Tell me about how you are feeling right now." *Asking an open-ended question is therapeutic and assists the client in identifying anxiety *Offering advice is nontherapeutic and can hinder further communication *Asking the client a "why" questions is nontherapeutic and can promote a defensive client response *Postpone reinforcing health teaching until after acute anxiety subsides. Clients experiencing severe anxiety are unable to concentrate or learn

The patient is newly diagnosed with cancer and faces enormous stress. Which response by the nurse would be the most helpful in helping the patient cope? A. "The health care provider will give you all the information you need to know." B. "Tell me what the health care provider told you and maybe I can help to clarify things." C. "Try to read or watch television. Just keep your mind busy." D. "Don't worry about chemotherapy. My aunt had it and she did just fine."

"Tell me what the health care provider told you and maybe I can help to clarify things."

A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "Care during the continuation phase focuses on treating continued manifestations of MDD." B. "The treatment of MDD during the maintenance phase lasts for 6 to 12 weeks." C. "The client is at greatest risk for suicide during the first weeks of an MDD episode." D. "Medication and psychotherapy are most effective during the acute phase of MDD."

"The client is at greatest risk for suicide during the first weeks of an MDD episode." *The client is at greatest risk of suicide during the acute phase of MDD *The focus on the continuation phase is relapse prevention. Treatment of manifestations occurs during the acute phase of MDD *The maintenance phase of treatment for MDD can last for 1 year or more *Medication therapy and psychotherapy are used during the continuation phase to prevent relapse of MDD

After signing a contract that he will no longer smoke in his room, the patient violates the contract. The contract consequences include confiscation of smoking materials and mandatory supervision for future smoke breaks. How should the nurse appropriately address the patient's behavior? A. "Why are you smoking in your room when you know it is not allowed?" B. "The contract states that if you smoke in your room, you must give me your smoking materials. Let me have them, please." C. "Okay, Larry, give me your cigarettes and lighter now." D. "I am going to give you one more chance, Larry. Let's see if you can live up to the contract."

"The contract states that if you smoke in your room, you must give me your smoking materials. Let me have them, please." *Reminding the patient of contract violation and the penalty attached should be done before taking the cigarettes. This approach is fair and puts the blame for the consequence on th offender. Provider the patient with the opportunity to "explain" the actions does not conform to the agreed-on contract. Providing additional opportunities for compliance does not support the contract and may encourage manipulative behavior

What should the nurse tell a patient experiencing hearing loss, they should inquire about a hearing aid? A. "You can wait until your hearing is nearly gone before worrying about it." B. "The earlier your brain is able to adapt to the hearing aid, the easier it will be to use." C. "You might want to get one before you get too old." D. "They don't work very well so I wouldn't spend too much money on it."

"The earlier your brain is able to adapt to the hearing aid, the easier it will be to use." *The sooner a person with a hearing loss obtains and learns to use a hearing aid, the greater the hearing improvement. The brain is better able to integrate thhe hearing aid transmissions when hearing has not been impaired for a very long time.

A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse should tell the client which purpose? A. "The medication will help dilate the eye to prevent an increase in eye pressure." B. "The medication will relax the muscles of the eyes and prevent blurred vision." C. "The medication causes the pupil to constrict and will lower the pressure in the eye." D. "The medication will help block the responses that are sent to the muscles in the eye."

"The medication causes the pupil to constrict and will lower the pressure in the eye."

Which patient statement regarding antipsychotic medication indicates a need for further teaching? A. "The medication helps me think more logically." B. "The medication makes my mouth dry." C. "The medication improves my mood." D. "The medication helps stop the voices."

"The medication improves my mood." *Antipsychotic medications do not function as mood elevators. (1, 4) They should help the patient have less thought disorder and less distortion in sensory perception. (2) A side effect is dry mouth.

Silver sulfadiazine is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? A. "The medication is an antibacterial." B. "The medication will help heal the burn." C. "The medication is likely to cause stinging initially." D. "The medication should applied directly to the wound."

"The medication is likely to cause stinging initially." *Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied.

Before eye surgery, a patient is instructed to take stool softeners. When asked about the rationale for taking the stool softener, an appropriate response would be A. "The medication reduces the possibility of straining at stool postoperatively." B. "The medication prevents constipation caused by anesthetic agents." C. "The medication cleanses the gastrointestinal tract." D. The medication enhances surgical recovery."

"The medication reduces the possibility of straining at stool postoperatively." *Stool softeners help decrease the possibility of straining to pass stool. Straining may cause increased intraocular pressure. Stool softeners are not used for (2) reducing possible constipation from operative drugs, (3) cleansing the gastrointestinal tract, or (4) enhancing recovery.

Donepezil (Aricept) has been prescribed for a patient with Alzheimer disease (AD). Which statement indicates that the patient and spouse understand teaching about the medication? A. "It is best to take the medication at bedtime." B. "The medication will interact with dark leafy greens." C. "Taking the medication with a citrus beverage should improve absorption." D. "The medication should be take with meals."

"The medication should be take with meals." *Donepezil (Aricept) is used in the management of AD. It has been shown to elevate acetylcholine levels in the brain and will slow the progression of the condition. The medications should be taken with meals to reduce gastrointestinal distress

The school health nurse is educating a female student with questions regarding puberty and pubic hair. The student asks "What is the top part where the hair is?" Which response is most helpful? A. "The mons pubis the rounded mound of tissue where pubic hair will be visible." B. "The female genitals have hair on the outer surface, known as the labia majora." C. "You don't have to worry about puberty yet, I'm sure your mom will talk to you." D. "The vulva is the top part of the pubic area and has pubic hair."

"The mons pubis the rounded mound of tissue where pubic hair will be visible." *The mon pubis is rounded mound of fatty tissue that protects the symphysis pubis. It is covered with pubic hair.

The nurse is teaching a group of teenagers about skin care and sun damage. Which statement by a participant indicates the need for further instruction? A. "Although I have a darker complesion, I am still at risk for sun damage." B. "The safest time of day to engage in water sports and avoid sun damage is from 10 A.M. to noon." C. "My sunscreen should ideally have SPF 30 or higher D. "It is important to apply sunscreen about 30 minutes about 30 minutes before sun exposure."

"The safest time of day to engage in water sports and avoid sun damage is from 10 A.M. to noon." *The rays of the sun are most damaging between 10 A.M. and 2 P.M. standard time. Individuals have darker complexions are still at risk for sun damage. The sunscreen should have a minimum of 30 SPF. The application of sunscreen 15 to 30 minutes before sun exposure is needed

A patient is scheduled for a computed tomography (CT) scan. To prepare the patient appropriately, the nurse should provide the patient with which information? A. "The test requires a small surgical incision." B. "The test involves the use of a powerful magnet." C. "The test provides for direct visualization." D. "The test is noninvasive."

"The test is noninvasive." *CT scans are a noninvasive radiologic method of providing diagnostic information. A small surgical incision would be necessary for a biopsy; magnetic resonance imaging involves a powerful magnet; and an endoscopic procedure provides direct visualization of an organ.

A nurse is reinforcing teaching to a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy? A. "Even if my anxiety improves I will need to continue this therapy for 6 weeks." B. "The therapist will focus on my past relationships during our sessions." C. "Psychoanalysis will help me reduce my anxiety by changing my behaviors." D. "This therapy will address my conscious feelings about stressful experiences."

"The therapist will focus on my past relationships during our sessions." *Classical psychoanalysis places a common focus on past relationships to identify the cause of the anxiety disorder *Classical psychoanalysis is a therapeutic process that requires many sessions over months to years *Classical psychoanalysis focus on identifying and resolving the cause of the anxiety rather than changing behavior *Classical psychoanalysis assesses unconscious, rather than conscious, thoughts and feelings

While looking at a card with a geometric grid of identical squares, a patient is asked to focus on a central dot and to describe any distortions of the surrounding boxes. Which patient statement indicates a need for further diagnostic testing? A. "I get dizzy staring at these boxes for so long." B. "I am beginning to see color differences in the squares." C. "I can see all the boxes surrounding the dot." D. "There are wavy lines around the central dot."

"There are wavy lines around the central dot." *Seeing wavy lines on an Amsler grid is an indication that the patient has a macular problem. Further evaluation by an ophthalmologist should be sought quickly. (1) Getting dizzy does not indicate macular degeneration. (2) Color difference is not a function of macular degeneration. (3) Seeing all of the boxes indicates normal vision.

A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. "This medication increases the release of serotonin and norepinephrine." B. "I should tell the client about the likelihood of insomnia while taking this medication." C. "This medication is contraindicated for clients who have an eating disorder." D. "Sexual dysfunction is a common adverse effect of this medication."

"This medication increases the release of serotonin and norepinephrine." *Mirtazapine provides relief from depression by increasing the release of serotonin and norepinephrine *Tell the client about the likelihood of drowsiness rather than insomnia when taking this medication *Buproprion, rather than mirtazapine, is contraindicated in clients who have an eating disorder *Sexual dysfunction is an adverse effect of SSRIs rather than mirtazapine

A nurse is reinforcing teaching with a cliet who has alcohol use disorder and a new presciption for carbamezepine. Which of the following information should the nurse include? A. "This medication will help prevent seizures during alcohol withdrawal." B. "Taking this medication will decrease your cravings for alcohol." C. "This medication maintains your blood pressure at a normal level during alcohol withdrawal." D. "Taking this medication will improve your ability to maintain abstinence from alcohol."

"This medication will help prevent seizures during alcohol withdrawal." *Carbamazepine is used during withdrawal to decrease the risk for seizures *Carbamazepine is used to promote safe withdrawal rather than to decrease cravings for alcohol *Clonidine or propranolol is used during withdrawal to depress the autonomic response and its effect on blood pressure *Carbamazepine is used to promote safe withdrawal rather than abstinence

The nurse is caring for a patient diagnosed with toxic shock syndrome (TSS). Which statement best indicates the patient understands the causative factor of this disorder? A. "This problem likely resulted from an untreated sexually transmitted infection." B. "This problem is linked to my ovarian cyst rupture." C. "This problem could have resulted from using a diaphragm for birth control." D. "Taking steroids is associated with this problem."

"This problem could have resulted from using a diaphragm for birth control." *TSS is a rare and potentially fatal disorder caused by strains of Staphylococcus aureas that produce toxins that cause shock, coagulation defects, and tissue damage if they enter the bloodstream. It is associated with the trapping of bacteria within the reproductive tract for a prolong time. Risk factors include the prolonged use of high-absorbency tampons, cervical caps, or diaphragms

A nurse is caring for a client who is undergoing chemotherapy and reports severe nausea. Which of the following statements should the nurse make? A. "Your nausea will lessen with each course of chemotherapy." B. "Hot food is better tolerated due to the aroma." C. "Try eating several small meals throughout the day." D. "Increase your intake of red meat as tolerated."

"Try eating several small meals throughout the day." *nausea usually occurs to the same extent with each session of chemotherapy *Cold foods are better tolerated than warm or hot foods because odors from heated foods can induce nausea *Several small meals a day are usually better tolerated by the client who has nausea *Red meat is not tolerated well by the client undergoing chemotherapy because the taste of meat is frequently altered and unpalatable

The nurse is caring for a patient with a recent diagnosis of schizophrenia. His wife asks how long it will be until her husband is cured. What reponse by the nurse is most appropriate? A. "Unfortunately, there is no cure, but the condition can be managed." B. "It will take approximately 1 to 2 months of medication therapy to alleviate your husband's symptoms." C. "We cannot consider your husband cured until he has been symptom free for at least 1 year." D. "There is no way to predict his outcome during his initial episode."

"Unfortunately, there is no cure, but the condition can be managed." *Schizophrenia can be managed with therapy and medications. It cannot be permanently cured. Evidence suggests that ealy treatment for schizophrenia improves long-term prognosis. Patients who are treated for first episodes generally respond to the therapeutic effects and require lower doses of antipsychotic medications. After starting a medicaiton, the patient should be monitored for 2 to 4 weeks for therapeutic response

A new nursing assistant expresses fear in caring for patients with HIV/AIDS. Later, the nurse observes this assistant helping a menstruating hepatitis B patient with toileting. She is not waring gloves. Which statement(s) would help the nursing assistant understand infection control precautions in caring for patients with STIs? A. "Use Standard Precautions for all patients, especially when body fluids are involved." B. "Good hand hygiene is adequate when caring for patients with STIs." C. "Hepatitis patients and HIV/AIDS patients deserve equal care and attention." D. "Hepatitis virus is actually more virulent than HIV/AIDS, so you should be more afraid of patients with hepatitis."

"Use Standard Precautions for all patients, especially when body fluids are involved."

Which statement should be included in the teaching plan for a patient with the thrombocytopenia? A. "Take your temperature every 4 hours." B. "Eat a diet that contains cooked foods only." C. "Use a soft-bristled toothbrush and do not floss." D. "Rinse your mouth with antiseptic mouthwash twice daily."

"Use a soft-bristled toothbrush and do not floss." *Irritation of the gums will cause bleeding for the patient with thrombocytopenia. (1) Taking the temperature may be done, but it is not an intervention for thrombocytopenia. (2) This diet is not an appropriate intervention. (4) Antiseptic mouthwash may be appropriate for some patients, but it is not an intervention for thrombocytopenia.

Which instruction should be included when providing health teaching about exposure to the sun? A. "To obtain a slight tan, stay in the sun between 11 A.M. and 3 P.M." B. "Wear light-colored, loose-fitting clothing to protect against the sun." C. "Dark-skinned individuals do not have to be concerned about the length of time they spend in the sun." D. "Use sunscreen even on cloudy days if you expect to be outdoors for extended periods of time."

"Use sunscreen even on cloudy days if you expect to be outdoors for extended periods of time." *Sun exposure and subsequent damage can happen on both sunny and overcast days. Experts agree that there is no such thing as a "good tan." The hours between 11 A.M. and 3 P.M. are those in which the rays of the sun are the strongest and most damaging to the skin. Darker-skinned individuals may also experience burns and damage from overexposure to the sun's rays.

Which statement by the family indicates an understanding of palliative care? A. "We want him to be comfortable, so oral medications are preferred." B. "We should encourage water and other nourishment as much as possible." C. "He'll feel short of breath and we'll hear the 'death rattle'." D. "He'll continue with his cancer treatments if they don't cause side effects."

"We want him to be comfortable, so oral medications are preferred."

A young man who has been diagnosed as sterile says to the nurse, "I am not much of a man or a husband." Which response is most therapeutic? A. "I know you feel awful, but you can always adopt." B. "How do you feel about artificial insemination?" C. "What about this sterility diagnosis concerns you the most?" D. "Sterility isn't the end of the world, is it?"

"What about this sterility diagnosis concerns you the most?" *Use of open-ended questions demonstrates a caring attitude and a willingness to listen. Telling the patient that she "knows how he feels" is incorrect and will be viewed as insincere. The patient feels less masculine as a result of infertility. It is premature and inappropriate to discuss options for alternative means of conception. Telling the patient that the diagnosis is not the end of the world minimizes the patient's concerns

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful reponse by the nurse should be which statement? A. "Why don't you tell your husband about this?" B. "This is not the best time to make that decision." C. "What do you find difficult about this situation?" D. "I agree with you. You should get out of this situation."

"What do you find difficult about this situation?" *The most helpful response is the one that encourages the client to problem solve. Giving advice implied that the nurse knows what is best and can also foster dependency. The nurse should not agree with the client, nor should the nurse request that the client provide explanations

The unrse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement is appropriate to make to this client? A. "You need to stop that behavior now!" B. "You will need to be placed in seclusion!" C. "What is causing you to become agitated?" D. "You will need to be restrained if you do not change your behavior."

"What is causing you to become agitated?" *The best statement is to ask the client what is causing the agitation. This will assist the client with becoming aware of the behavior and will assist the nurse with planning appropriate interventions for the client. Option A is demanding behavior, which could cause increased agitation in the client. Option B and D are threats to the client and are inappropriate

The nurse is making a home visit to an elderly patient with Alzheimer disease. The patient's wife says, "Jim is more confused compared to usual." What is the best response? A. "It's hard to see someone that you love deteriorate." B. "What kind of changes are you seeing?" C. "When was the last time your husband saw a health care provider? D. "With Alzheimer disease, the symptoms do worsen."

"What kind of changes are you seeing?"

The nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, which is the most appropriate question to ask? A. "With whom do you live?" B. "Who is available to help you?" C. "What leads you to seek help now?" D. "What do you usually do to feel better?"

"What leads you to seek help now?" *The nurse's initial task when gathering data from a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. Option C will assist with determining data related to the precipitating event that led to the crisis. Options A and B identify situational supports. Option D identifies personal coping skills

After detoxification from substance abuse, the patient says, "I feel better than I have in years! All I needed was some rest. I am not an alcoholic." Which response is best for the nurse to make? A. "What were you doing that got you admitted to the detoxification center?" B. "Alcoholism has many definitions. What is yours?" C. "Admitting to alcoholism is hard." D. "Alcoholism has ruined your life. How can you say you are not an alcoholic?"

"What were you doing that got you admitted to the detoxification center?" *Confronting denial and encouraging self-diagnosis is the point of the treatment phase after detoxification. Asking for the patient's definition of alchoholism allows for the patient to intellectualize the problem. Stating that alcoholism is "hard" is a sympathetic and unhelpful response. "Alcoholism has ruined your life" is accusatory and counterproductive

A nurse is caring for a client who states, "I'm so stressed at work because of my coworker. I am expected to finish others' work because of their laziness!" When discussing effective communication, which of the following statements by the client to the coworker indicates client understanding? A. "You really should complete on your own work. I don't think it's right to expect me to complete your responsibilities." B. "Why do you expect me to finish your work? You must realize that I have my own responsibilities." C. "It is not fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor." D. "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities."

"When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities." *This response demonstrates assertive communication, which allows the client to state their feelings about the behavior and then promote a change *(A) This statement is an example of disapproving/disagreeing, which can prompt a defensive reaction and is therefore nontherapeutic *(B) This statement uses a "why" question, which implies criticism and can prompt a defesnive reaction and is therefore a defensive reaction and is therefore nontherapeutic *(C) This statement is aggressive and threatening, which can prompt a defensive reaction and is therefore nontherapeutic

During data collection, the patient's son tells the nurse, "Mom can remember her name, but she doesn't seem to know where she is." Based on this information, which question should the nurse ask first? A. "How does she like to be addressed?" B. "When did you first notice this?" C. "What kind of medications does she take?" D. "When did she last see the health care provider?"

"When did you first notice this?"

You are taking a history for a patient who needs emergency surgery and who freely admits to using marijuana, alcohol, cocaine, and hallucinogens. Which is the appropriate nursing question? A. "Does your partner know that you are using drugs?" B. "When was the last time you drank or took a substance?" C. "How frequently are you using thse drugs and alcohol?" D. "Have you ever tried to get treatment for your substance use?"

"When was the last time you drank or took a substance?" *The most important issue in this emergency situation is to determine the last use of substances so that the health care team is aware of drug-drug interactions or the possibility of withdrawal symptoms. (1) This is a not an appropriate question at this time. (3, 4) Direct and nonjudgmental questioning is best for obtaining information. Other questions would also be included to develop short- and long-term interventions for this patient after the emergency situation is resolved.

A patient has been admitted to the unit for a medically managed withdrawal from diazepam. During her third day on the unit, she angrily tells the nurse, "I know how it is. You're all writing lies about me in my chart. None of you care anything about me. You just want to get rid of me." Which response by the nurse is most therapeutic? A. "What do you think we're all saying about you?" B. "Nobody would write lies about you in your chart." C. "I'm not sure what you're referring to." D. "Would you like to talk to me some more about this?"

"Would you like to talk to me some more about this?" *The most therapeutic response would attempt to get the patient to verbalize her concerns. The nurse should not play dumb, encourage the delusion, or ignore the patient's concerns.

The nurse is doing discharge teaching for a manic patient. The patient asks., "Will I have to take lithium forever?" The best answer would be A. "No, only until your symptoms are under control." B. "Yes, you will most likely need to take it for your lifetime." C. "Possible your health care provider will let you discontinue after 4-6 months." D. "No, most patients can usually do without it after about a year."

"Yes, you will most likely need to take it for your lifetime."

A nurse is orienting a new client to a mental health unit. Which of the following statements should the nurse make when explaining the unit's community meetings? A. "You and a group of other clients will meet to discuss your treatment plans." B. "Community meetings have a specific agenda that is established by staff." C. "You and the other clients will meet with staff to discuss common problems." D. "Community meetings are an excellent opportunity to explore your personal mental health issues."

"You and the other clients will meet with staff to discuss common problems." *Community meetings are an opportunity for clients to discuss common problems or issues affecting all members of the unit *Individual treatment plans druing individual therapy rather than a community meeting *Community meetings can be structured so that they are client-led with decisions made by the group as a whiole *Personal mental health issues are discussed during individual therapy rather than a community meeting

After having refused lunch and diner because her "regular" chair was occupied at breakfast, the resident in a long-term care facility asks for a snack. How should the nurse respond? A. "You are hungry now. Is there something else you could have done earlier besides refusing to eat?" B. "Here is your snack. Maybe you won't be so quick to refuse meals the next time you don't get you way." C. "Refusing meals is not the answer. You must eat." D. "Tell me why you left the dining room without eating."

"You are hungry now. Is there something else you could have done earlier besides refusing to eat?" *After acute anxiety passes, the nurse should focus on helpling the resident recognize the behavior that was exhibited and how to deal more effectively with the anxiety. Scolding the patient, attempting to induce guilt, or cauing the patient to dwell on the trigger do not redirect the patient to consider different behaviors

A nurse is preparing a client prior to an initial Papanicolaou (Pap) test. Which of the following statements should the nurse make? A. "You should urinate immediately after the procedure is over." B. "You will not feel any discomfort." C. "You may experience some bleeding after the procedure." D. "You will need to hold your breath during the procedure."

"You may experience some bleeding after the procedure." *The client is instructed to urinate immediately before the procedure *The client can experience discomfort when the provider obtains the cervical sample *The client can experience a small amount of vaginal bleeding due to scraping of the cervix *The client should use relaxation techniques, such as taking deep breaths during the procedure

The manipulative patient approaches the nurse and says, "I know it's too early to give me my pain medication, but you are the only one who seems to care. Could you give me my pain medication now?" Which response is best? A. "The charge nurse is very stringent aout scheduled medications. She would be very angry with me if I gave you the medication now." B. "I know how it is when you are in pain. I'll give you your medication early." C. "You medication is due in 2 h. I will be glad to give it to you on schedule." D. "It makes me feel good to know you are aprpeciative of our care. Here is your medication."

"You medication is due in 2 h. I will be glad to give it to you on schedule." *Setting clear limits is important when managing manipulative patients. Once limits are set, it is important to maintain them. Blaming the charge nurse provides incentive for further manipulative behaviors. The nurse telling the patient that they know what it is like when they are in pain is not accurate or therapeutic. Providing the medication early likely does not follow the prescribed plan

A nurse is reinforcing teaching with a client who is scheduled for a transurethral resection of the prostate (TURP) about postoperative care. Which of the following information should the nurse include? A. "You might have a continuous sensation of needing to void even though you have a catheter." B. "You will be on bed rest for the first 2 days after the procedure." C. "You will be instructed to limit your fluid intake after the procedure." D." Your urine should be clear yellow the evening after the surgery."

"You might have a continuous sensation of needing to void even though you have a catheter." *To reduce the risk of postoperative bleeding, the client will have a catheter with a large balloon that places pressure on the internal sphincter of the bladder. Pressure on the sphincter causes a continuous sensation of needing to void *The client is ambulated early in the postoperative period to reduce the risk of deep-vein thrombosis and other complications that occur due to immobility *The client is encouraged to increase their fluid intake unless contraindicated by another condition. A liberal fluid intake reduces the risks of urinary tract infection and dysuria *The client's urine is expected to be ink the first 24 hr after surgery

The nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic? A. "Right! Why not just 'pack it in?" B. "That seems rather unlikely to me." C. "I don't believe that, and neither do you." D. "You must be feeling all alone at this point."

"You must be feeling all alone at this point." *The client is experiencing loss and is feeling hopeless. The therapeutic response by the nurse is the one that attempts to translate words into feelings. In option A, the nurse uses sarcasm, which gives advice and is nontherapeutic as a nursing response. In option B, the nurse is voicing doubt, which is often used when a client verbalizes delusional ideas. In option C, the nurse is disagreeing with the client, which implies that the nurse has passed judgment on the client's ideas or opinions

A nurse is reinforcing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching? A. "You can resume playing golf in 2 days." B. "You need to tilt your head back when washing your hair." C. "You can get water in your eyes in 1 day." D. "You need to limit your housekeeping activities."

"You need to limit your housekeeping activities." *Instruct the client to limit housekeeping activities following cataract surgery. This activity could cause a rise in IOP or injury to the eye. *(a) Do not instruct the client to resume playing golf for several weeks. This could cause a rise in intraocular pressure (IOP) or possible injury to the eye. (b)-Do not instruct the client to tilt the head back when washing the hair. This cold cause a rise in IOP or possible injury to the eye. (c)-The client should not get water in their eyes for 3-7 days following cataract surgery to reduce the risk for infection and promote healing.

A 48-year old female reporting irregular menses and hot flashes has been told by the health care provider that she has entered the climateric period. When you find the patient crying, what is the appropriate nursing response? A. "Did you want more children?" B. "You seem sad. I am here to listen." C. "Everything will be all right." D. "Aging is not for the faint of heart."

"You seem sad. I am here to listen." *This statement encourages patient to verbalize. (1) This statement expresses the opinion of the caregiver, not the patient. (3) This statement prevents the patient from verbalizing. (4) This statement is the opinion of the caregiver and does not encourage verbalization.

A husband indicates to his wife's nurse in the hospital that he is worried she has been drinking too much lately. What is the best response? A. "Oh my, I'm really sorry to hear that." B. "How is the drinking affecting her?" C. "You seem upset by this; tell me about your concerns." D. "How long do you think this has been happening?"

"You seem upset by this; tell me about your concerns."

The patient is ready to be discharged. The nurse teaches him about his antipsychotic medication and he asks, "What will happen if I stop taking my medication when I go home?" Which is the best reply? A. "You should never stop taking your medication." B. "Someday you may be able to without the medication." C. "If you can get organized and reduce stress, perhaps you can get along without it." D. "If you stop taking your medication, the symptoms will probably return."

"You should never stop taking your medication."

A nurse is caring for a client who has early stage Alzheimer's disease and a new prescription for donepezil. The nurse should include which of the following statements when teaching the client about the medication? A. "You should avoid taking over-the-counter acetaminophen while on donezepil." B. "You should take this medication before going to bed at the end of the day." C. "You will be screened for underlying kidney disease prior to starting donezepil." D. You should stop takine donezepil if you experience nausea or diarrhea."

"You should take this medication before going to bed at the end of the day." *Clients should take donezepil at the end of the day, just before going to bed, with or without food. *Clients taking donepezil should avoid NSAIDs, rather than acetaminophen, due to risk for gastrointestinal bleeding *Clients should be screened for underlying heart and pulmonary disease, rather than kidney disease *Gastrointestinal adverse effects are common with donepezil and can result in a dosage reduction

A nurse is caring for a client who lost their mother to cancer last month. The client states, "I'd still have my mother if the doctor would have made a diagnosis sooner." Which of the following responses should the nurse make? A. "You sound angry. Anger is a normal feeling associated with loss." B. "I think you would feel better if you talked about your feelings with a support group." C. "I understand just how you feel. I felt the same when my mother died." D. "Do other members of your family also feel this way?"

"You sound angry. Anger is a normal feeling associated with loss." *This is a therapeutic reponse for the nurse to make. This reposne acknowledges the client's emotion and privides education on the normal grief response. *(B) This response offers advice, which is a nontherapeutic technique *(C) This response minimizes the client's feelings and takes the focus away from the client, which are nontherapeutic communication techniques *(D) This reponse takes the focus away from the client, which is a nontherapeutic communication technique.

A patient who is in the terminal stages of his illness says to the LPN/LVN, "Get out of here! You do everything so slowly. Leave me alone!" Which of these responses by the nurse is most appropriate? A. "I'm sorry the way I work annoys you so much." B. "I'm leaving until you stop being so angry." C. "You sound very angry today." D. "You cannot talk to me that way."

"You sound very angry today." *Anger is one of the stages of grieving. By saying, "You sound angry today," the nurse acknowledges the patient's feelings without placing the patient on the defensive. This statement will allow the patient to further explore his feelings with the nurse. The statements, "You cannot talk to me that way," and "I'm leaving until you stop being so angry," will cause the patient to be defensive and are not therapeutic communication techniques. Apologizing to the patient about the way the nurse works does not acknowledge the real issue.

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client? A. "Have you talked to your family about this?" B. "Everyone feels this way when they are depressed." C. "You will feel better once your medication begins to work." D. "You sound very upset. Are you thinking of hurting yourself?"

"You sound very upset. Are you thinking of hurting yourself?" *Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The client should be directly asked if a plan for self-harm exists. Option A, B, and C are not therapeutic responses

A client who is diagnosed with pedophilia and has been recently paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters of me all over the neighborhood telling about me with my picture on it." Which of the following is an appropriate response by the nurse? A. "When children are hurt the way you hurt them, people want you isolated." B. "You're lucky it doesn't escalate into something pretty scary after your crime." C. "You understand that people fear for their children, but you're feeling unfairly treated?" D. You seem angry, but you have committed serious crimes against several children, so your neighbors are frightened."

"You understand that people fear for their children, but you're feeling unfairly treated?" *Focusing and verbalizing the implied concern is the therapeutic response because it assists the client to clarify thinking and to reexamine what the client is really saying. Option C is the only option that reflects the use of this therapeutic communcation technique. Option A is insensitive and anxiety-provoking. Option B gives advice and does not facilitate the client's expression of feelings

A nurse is reinforcing teaching with a client who is scheduled for nuclear imaging for suspected cancer. Which of the following statements should the nurse make? A. "The presence of a liver enzyme will be identified." B. "You will be given an injection of a radioactive substance." C. "An endoscope will be inserted through your mouth." D. "The tumor will be aspirated."

"You will be given an injection of a radioactive substance." *Liver function tests involve the identification of altered liver enzyme, which can present in a client who has cancer. The are not nuclear imaging tests *Nuclear imaging involves the administrations of an oral or IV radioactive tracer to identify cancerous tissue *Endoscopy permits visualization inside the body. It is not a form of nuclear imaging *A needle biopsy is performed to aspirate fluid and tissue samples for cancer cells. It is not a form of nuclear imaging

A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication? A. "I wish you would not make me angry. B. "I feel angry when you leave me." C. "It makes me angry when you interrupt me." D. "You'd better listen to me."

"You'd better listen to me." *This statement implies a threat and a lack of respect for another individual. The other 3 statements do not imply a threats, nor do they indicate a lack of respect for another individual.

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response should the nurse make to the client? A. "Have you shared your feelings with your family?" B. "I think we should talk more about your anger with your family?" C. "You're feeling angry that your family continues to hope for you to be 'cured'?" D. "Well, it sounds like you're being pretty pessimistic. After all, years ago people died of pneumonia."

"You're feeling angry that your family continues to hope for you to be 'cured'?" *Reflection is the therapeutic communication technique that redirects the client's feelings back to validate what the client is saying. In option B, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option D, the nurse makes a judgment and in nontherapeutic in the one-on-one relationship. In option A, the nurse is attempting to assess the client's ability to openly discuss feelings with family members. Although this may be appropriate, the timing is somewhat premature and closes off facilitation of the client's feelings

A 62-year old male patient with liver disease asks you why he is receiving a drug intravenously rather than by mouth. What is your best response? a. "Many oral drugs are inactivated as you get older." b. "Your liver disease impairs the transformation of a drug into its active form." c. "Intravenous drugs reduce toxicity to the liver through first-pass metabolism." d. "Individuals with liver disease have a genetic impairment that prevents drug activation."

"Your liver disease impairs the transformation of a drug into its active form." *Many drugs must be activated by enzymes before they can be used in the body. This biotransformation happens in the liver. Liver disease impairs this process

Fluorescein angiography is used as an assessment tool by the health care provider. Teaching for the patient about the procedure includes stating A. "The optic nerve will be visualized to determine any problems." B. "eye muscle testing will occur during the test." C. "the test helps measure visual acuity." D. "dye will be injected intravenously and the blood vessels in the fundus examined."

"dye will be injected intravenously and the blood vessels in the fundus examined."

What suffix (word ending) do beta-blockers have? A. "ine" B. "mide" C. "olol" D. "mic"

"olol"

A nurse us reviewing informaiton about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. "ECT is the recommended initial treatment for bipolar disorder." B. "ECT is contraindicated for clients who have suicidal ideation." C. "ECT is effective for clients who are experiencing severe mania." D. "ECT is prescribed to prevent relapse of bipolar disorder."

. "ECT is effective for clients who are experiencing severe mania." *ECT is appropriate for the treatment of severe mania associated with bipolar disorder *Pharmacological intervention is the recommended initial treatment for bipolar disorder *ECT is effective for clients who have bipolar disorder and suicidal ideation *ECT is prescribed for clients experiencing an acute episode of bipolar disorder rather than for the prevention of relapse

You note a reddened area on a patient's sacral area and check for blanching. What is the best rationale that supports this nursing action? A. Blanching suggests that the redness is probably temporary and will resolve when the pressure to the area is relieved B. Checking for blanching is part of the daily routine for assessing any patient who is at risk for pressure injury C. Evidence of blanching indicates that the patient is at high risk for pressure injury according to the Braden scale D. Occurrence of blanching indicates that the redness is associated with a localized skin infection

. Blanching suggests that the redness is probably temporary and will resolve when the pressure to the area is relieved *The nurse checks for blanching because blanching usually indicates that the redness is temporary and will resolve when pressure on the area is relieved. (2) Checking for blanching and redness may have to occur more frequently than the usual routine basis; in addition, the nurse should know why an action is performed rather than just doing it because it is routine. (3) The Braden scale uses categories of sensory perception, moisture, activity, mobility, nutrition, and friction/shear. (4) Redness could be a sign of infection, but it could also be related to trauma or pressure.

A nurse is caring for a client who states, "I plan to commit suicide." Which of the following findings should the nurse identify as the priority? A. Client's educational and economic background B. Lethality of the method and availability of means C. Quality of the client's social support D. Client's insight into the reasons for the decision

. Lethality of the method and availability of means *The greatest risk to the client is self-harm as a result of carrying out a suicide plan The priority finding is to determine how lethal the method is, how available the method is, and how detailed the plan is

When should a patient conduct breast self-examinations (BSE)? A. The day after the onset of menses B. The day after menses stops C. 1 week after the onset of menses D. 1 week after menses stops

1 week after the onset of menses *The examinations should be performed 1 week after the period has begun, or on a specific date if menses has stopped

Approximately what percentage of the U.S. population is affected with schizophrenia? A. 1% B. 2% C. 3% D. 4%

1% *Schizophrenia is the most common though disorder. It is estimated that 1.1% of the general population is affected with schizophrenia, and in the United States this represents 3.5 million Americans

When assessing a patient for an infection, the nurse suspects infection when the white blood cell count is A. 4500 mm3 B. 6500 mm3 C. 3000 mm3 D. 13,200 mm3

13,200 mm3

After the blood infusion has started, the nurse should let the blood flow at 2 mL/min for the first ___________ minutes.

15 *The initial rate of blood infusion is 2 mL/min for the first 15 minutes. If the patient tolerates this rate, it can be gradually increased.

A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started? A. 5 minutes B. 15 minutes C. 30 minutes D. 45 minutes

15 minutes *The nurse must remain with the client for the first 15 minutes of a transfusion, which is the most likely time that a tranfusion reaction will occur. This enables the nurse to detect a reaction and intervene quickly. THe nurse engages in safe nursing practice by obtaining coverage for the other clients during this time.

How long after exposure does the incubation period for gonorrhea last? A. 2 to 6 days B. 1 week C. 2 weeks D. 4 weeks

2 to 6 days

The National Institute on Deafness and Other Communication Disorders (NIDCD) reports that what percentage of adults aged 20 to 69 years in the United States show signs of noise-induced hearing loss? A. 10% B. 15% C. 24% D. 48%

24%

A patient is planning a weight-reduction program. When assisting the patient to make healthy food choices, the patient should be reminded to keep the total fat intake to no more than _____% of the daily total caloric intake. A. 15 B. 25 C. 30 D. 35

30

Which percentage of the population that is 85 years of age and older and has some stage of Alzheimer's disease (AD)? A. 10% B. 20% C. 33% D. 50%

33% *AD is the most common degenerative disease of the brain. Approximately 5.7 million Americans have AD and there is no known cause or cure. AD typically affects people over 65 years of age, but can also strike younger people. The 85 year old and over age group is currently the fastest growing age group in the United States. It is estimated that 1/3 of this age group have AD

The nurse is aware that of the know fertility causes, approximately what percentage is due to male factors? A. 15% B. 25% C. 33% D. 45%

33% *of the known cases of infertility, 1/3 are due to male factors

The nurse is providing fliod resuscitation for a burn victim according to the Parkland formula. The nurse determines that the patient requires 8000 mL in a 24-h time period. The burn occurred at noon, and the present time is 1400. How many milliliters of fluid should infuse by 2000? A. 2000 mL B. 3000 mL C. 4000 mL D. 7000 mL

4000 mL *According to the Parkland formula, one half of the fluid resuscitation load should be infused within 8 h from the time of the burn. The burn occured at noon, so by 8:00 P.M., 4000 mL should have been infused of the 8000 mL calculated

A patient who requires an immediate transfusion of blood has previously signed a consent form to receive it. The nurse confirms that the consent was signed within the last: a. 8 hours. b. 12 hours. c. 24 hours. d. 48 to 72 hours.

48 to 72 hours. *A consent to receive blood must be signed by the patient, usually no more than 48 to 72 hours before receiving the blood product.

The nurse is assessing an older adult patient's hydration status. The nurse observes that a fold of skin on the upper chest returns to normal position. The nurse should conclude that hydration is adequate if the skin returns to normal position in how many seconds? A. 5 seconds B. 9 seconds C. 10 seconds D. 15 seconds

5 seconds *If the tented skin fold takes more than 3 to 5 seconds to return to normal position, the patient is considered to be dehydrated

After age 75 years of age, about what percentage of the population has some degree of hearing loss? A. 10 B. 25 C. 50 D. 75

50

How long does it take the body to metabolize a single can of beer? A. 20 minutes B. 30 minutes C. 40 minutes D. 60 minutes

60 minutes *The metabolization of any amount of alcohol take approximately 1 h

The student nurse is teaching a community group about risk factors for colorectal cancer. Based on risk factors, which patient has the highest risk for developing colorectal cancer? A. A 50-year-old male who has been exposed to arsenic in the workplace B. A 45-year-old female with a doctorate degree in psychology who smokes occasionally C. A 38-year-old female who had her first child 1 year ago D. A 29-year-old male who has had Crohn's disease since the age of 13

A 29-year-old male who has had Crohn's disease since the age of 13 *Inflammatory diseases of the colon increase the risk of colorectal cancer.

The nurse assess several patients in the outpatient clinic. Which patient has the greatest risk for developing cancer? A. A 23-year-old car repairment who repaints cars B. A 30-year-old overweight certified public accountant in New York who has smoked for 4 years and rarely exercises C. A 45-year-old farmer from Texas who has worked on his family's cotton farm since the age of 12 D. A 60-year-old ski instructor in Colorado

A 45-year-old farmer from Texas who has worked on his family's cotton farm since the age of 12 *The cotton farmer in Texas has the most exposure to carcinogens. Chemicals, pesticides, and sun are the carcinogens that this farmer has been exposed to for at least 33 years

A client with a diagnoses of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate? A. A client with pneumonia B. A client receiving diagnostic tests C. A client who thrives on managing others D. A client who could benifit from the client's assistance at mealtimes

A client receiving diagnostic tests *The client is receiving diagnostic tests is an appropriate roommate. The client withanorexia is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client at risk for infection. The client with anorexia nervosa should not be put in a situation in which he or she can focus on the nutritional needs of others or be managed by others, because this may contribute ti sublimation and suppression of his or her own hunger

A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission? A. A client who has schizophrenia with delusions of grandeur B. A client who has manifestations of depression and attempted suicide a year ago C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod D. A client who has bipolar disorder and paces quickly around the room while talking to themselves

A client who has borderline personality disorder and assaulted a homeless man with a metal rod *A client who is in current danger to self or others is a candidate for a temporary emergency admission

A nurse is assisting with caring for a group of clients. Which of the following clients should a nurse consider recommending for referral to an assertive community treatement (ACT) group? A. A client in an acute mental health facility who has fallen several times while running down the hallway B. A client who lives at home and keeps "forgetting" to come in for a scheduled monthly antipsychotic injection for schizophrenia C. A client in a day treatment program who reports increasing anxiety during group therapy D. A client in a weekly grief support who reports still missing a deceased partner who has been dead for 3 months

A client who lives at home and keeps "forgetting" to come in for a scheduled monthly antipsychotic injection for schizophrenia *An ACT group works with clients who are nonadherent with traditional therapy (the client in a home setting who keep "forgetting" a scheduled injection). *A client in acute care who has been running and falling should be helped by the treatment team on the client's unit *A client who has anxiety might be referred to a counseler or mental health provider *A client who is grieving for a deceased partner who die 3 months ago is currently involved in an appropriate intervention

A nurse is assisting with planning care for several clients who are attending community-based mental health programs. Which of the following clients should the nurse collect data from first? A. A client who received a burn on the arm while using a hot iron at home B. A client who requests a change of antipsychotic medication due to some new adverse effects C. A client who reports hearing a voice saying that life is not worth living anymore D. A client who tells the nurse about experiencing manifestations of severe anxiety before and during a job interview

A client who reports hearing a voice saying that life is not worth living anymore *A client who hears a voice saying this is not worth living anymore is at greatest risk for self-harm, and the nurse should collect data from this client first *(A) This client has needs that should be met, but there is another client whom the nurse should collect data from first *(B) This client has needs that should be met, but there is another client who the nurse should collect data from first *(C) This client has needs that should be met, but there is another client whom the nurse should collect data from first

The nurse is caring for a patient with a stage III pressure ulcer. Which assessment findings are consistent with this stage of ulcer? A. A crater-like lesion B. Skin that does not blanch with fingertip pressure C. Presence of mottled skin D. Excoriation around the lesion

A crater-like lesion *A stage III pressure ulcer presents as a crater-like ulcer and underlying subcutaneous tissue is involved in the destructive process. Skin that does not blanch with pressure or is mottled are findings consistent with a stage 1 pressure ulcer. Excoriation around the lesion is consistent with scratching or another abrasive force

The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding? A. An increased hematocrit level B. An increased hemoglobin level C. A decline of the temperature to normal D. A decrease in oozing from puncture sites and gums

A decrease in oozing from puncture sites and gums *Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or the oozing of blood from puncture sites, wounds, and mucous membranes.

What thought process underscores a patient's anorexia nervosa? A. A desire to be attractive by staying slender B. A desire to be involved with food preparation of food, but not eating it C. A desire to punish self by denial of adequate nutrition D. A desire to gain a sense of control by limiting food intake

A desire to gain a sense of control by limiting food intake *Anorexia nervosa is characterized by the patient's refusal to maintain minimal body weight or eat adequate quantities of food. There is a disturbance in the perception of body shape and size and an extreme fear of becoming fat. The patient strives for perfection and control by controlling calorie intake. The person with anorexia nervosa gains a sense of control by limiting food intake

Which patient is exhibiting manifestations consistent with the primary stage of syphilis? A. A female patient with copious vaginal discharge B. A male patient with a generalized skin rash C. A female patient with a painless nodule on her vagina D. A male patient with a gumma

A female patient with a painless nodule on her vagina *Syphilis has three stages. The chancre, or painless, hear nodule, is visible in the primary stage of syphilis and disappears withing a few weeks. The secondary stage occurs approximately 6 weeks later; symptoms may include a generalized skinrash. In tertiary syphilis, spirochetes access to all body tissues and a gumma (a soft encapsulated tumor) may appear on any organ

The student nurse is studying the nursing process. Which statement best describes the nursing process? A. A plan to describe nursing functions B. An attempt to define nursing practice C. A theory of operative nursing standards D. A goal-directed, orderly series of activities

A goal-directed, orderly series of activities *The nursing process is a series of steps planned and followed in an attempt to achieve a patient goal. It is not a plan to describe nursing functions, an attempt to define nursing practice, or a theory of operative nursing standards.

A patient is admitted to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing this patient's record, the nurse would expect to find which report? A. Below-average intelligence B. A history of consistent employment C. Expression of remorse for his actions D. A history of domestic violence

A history of domestic violence *Persons with antisocial disorder lack empathy and exhibit disregard for, and violation of, the rights of others. A tendency toward domestic violence would not be unusual for a person with antisocial personality disorder. Patients with antisocial personality disorder generally have a higher than average intelligence quotient (IQ). Patients with this diagnosis typically lack guilt or remorse for wrongdoing.

You are taking the history from a patient who may be prescribed a carbonic anhydrase inhibitor for the treatment of glaucoma. What information would indicate this category of drug may not be appropriate for this patient? a. The patient is a diabetic. b. The patient has mydriasis. c. A history of sulfa drug allergy d. The patient has unequal pupil size.

A history of sulfa drug allergy *Never give a carbonic anhydrase inhibitor to a patient who has a "sulfa" allergy because these drugs are a type of sulfonamide

The nurse explains to a male patient undergoing infertility studies that his luteinizing hormone (LH) is low and his follicle-stimulating hormone (FSH) is high. Which statement accurately interprets these laboratory findings? A. A low LH means there is adequate stimulation of testosterone. A high FSH means there is a low or decreased spermatogenesis B. The patient is not making testosterone and has decreased spermatogenesis C. The patient is making testosterone and has high spermatogenesis D. The patient is not making testosterone and has high spermatogenesis

A low LH means there is adequate stimulation of testosterone. A high FSH means there is a low or decreased spermatogenesis *A low LH means there is adequate stimulation of testosterone. A high FSH means there is a low or decreased spermatogenesis

A nurse is working with an established group and identifies various member roles. Which of the following should the nurse identify as an individual role? A. A member who praise input from other members B. A member who follows the direction of other members C. A member who brags about accomplishments D. A member who evaluates the group's performance toward a standard

A member who brags about accomplishments *An individual who brags about accomplishments is acting in an individual role that does not promote the progression of the group toward meeting goals *An individual who praises the input of others is acting in a maintenance role *An individual who is a follower is acting in a maintenance role *An individual who evaluates the group's performance is acting in a task role

Unresolved primary dysmenorrhea may cause the young female to develop which negative perception? A. An exaggerated sense of symptom severity B. A distrust of medications C. A negative attitude toward her own sexuality D. An unhealty tendency toward peer comparison

A negative attitude toward her own sexuality *Unresolved dysmenorrhea in the young woman can cause negative attitudes related to sexuality and self-worth

A nurse is assisting in conducting a class for a group of newly licensed nurses on caring for clients who are at risk for suicide. Which of the following information should the nurse include in the teaching? A. A client's verbal threat to oneself is attention-seeking behavior B. Interventions are ineffective for clients who really want to commit suicide C. Using the term suicide increases the client's risk for a suicide attempt D. A no-suicide contract decreases the client's risk for suicide

A no-suicide contract decreases the client's risk for suicide *A no-suicide contract decreases the client's risk for suicide by promoting and maintaining trust between the nurse and the client. However, it should not replace other suicide prevention strategies *It a a myth that a threat or attempt to kill oneself is attention-seeking behavior, that interventions are ineffective for clients who really want to commit suicide (suicide precautions are shown to be effective in reducing the risk of a death by suicide), and that using the term suicide increases the client's risk for a suicide attempt (discuss suicide openly with the client).

Which patients can be assigned to share the same 2-bed hospital room? A. A patient with acquired immune deficiency syndrome (AIDS) and a patient with bronchiectasis. B. A patient with pneumonia and a patient who has just returned from having a cardiac catheterization. C. A patient with rheumatoid arthritis who is receiving steroids and a patient with emphysema. D. A patient scheduled for a hysterectomy and a patient scheduled for a tubal ligation.

A patient scheduled for a hysterectomy and a patient scheduled for a tubal ligation. *The patient scheduled for a hysterectomy and the patient scheduled for a tubal ligation are appropriate candidates for roommates because they are both surgery patients. It is not acceptable to pair at-risk or immune-suppressed patients with a patient who has a potentially communicable disease. The patient with AIDS is immunocompromised, and the patient with bronchiectasis has an infection. The patient with pneumonia poses an infection risk for a patient with an open wound from a cardiac catheterization; in addition, this patient may be immunocompromised because of the stress of the surgery on the body. The patient with rheumatoid arthritis receiving steroids is immunocompromised and would be an inappropriate roommate for a patient with emphysema.

The nurse is caring for several patients and determines which patient to be most at risk for developing an infection related to a decreased anti-inflammatory response? A. A patient who has been experiencing high levels of stress for the last 3 months B. A patient with a glcosylated Hgb level of 6.7% C. A patient with osteoarthritis who was recently diagnosed D. A patient who is scheduled for laparoscopic cholecystectomy in 2 weeks related to gallstones

A patient who has been experiencing high levels of stress for the last 3 months *The presence of increased levels of cortisol resulting from ongoing stress inhibits the anti-inflammatory response, thus making this patient most susceptible to developing an infection.

Which response to anxiety is cause for concern? A. A nursing student stays up most of the night to study for an upcoming examination. B. A woman takes several deep breaths before going into the grocery store because shopping makes her nervous. C. A pilot has a small alcoholic drink before his scheduled flight. D. A man asks several of his friends for opinions before asking a woman out on a date.

A pilot has a small alcoholic drink before his scheduled flight. *Ingesting alcohol before a flight is likely to impair the pilot's judgment and put the pilot and others at high risk for injury. Staying up all night to study, asking several friends for opinions before asking a woman on a date, and taking deep breaths before doing something that causes anxiety are appropriate responses to anxiety.

You are caring for a pregnant patient who has active genital herpes. When the patient asks about delivering her baby, which nursing response is appropriate? A. "You will receive antiviral medication to put the infection into remission before delivery." B. "A Cesarean section will be scheduled." C. "You can still deliver your baby vaginally because there is no risk to a neonate associated with genital herpes. D. "A nurse will bathe your baby immediately after delivery to reduce the risk of transmission."

"A Cesarean section will be scheduled." *A Cesarean section is usually performed to prevent exposure of the baby to the virus. Even if the mother does not have lesions at the time of delivery, virus is still being shed. (1) antiviral medications may be given to suppress active lesions but does not eliminate the need for a Cesarean section. (3) This statement is false. (4) Bathing the baby does not prevent transmission of the virus.

A few hours after undergoing laser eye surgery, the patient reports a mild headache. What information should be provided to the patient? A. "You should contact the physician." B. "A mild headache is normal." C. "Slight congestion may be the underlying cause of the headache, and gentle nose blowing may help." D. "You should lie down in bed with the head of the bed flat for about 4 h to see if the headache is relieved."

"A mild headache is normal."

A nurse is reinforcing teaching with a client who is scheduled for a shave biopsy for suspected cancer. Which of the following statements indicates understanding of the procedure? A. "A test of my bone marrow will be performed." B. "A lymph node will be removed." C. "A needle will be inserted into the mass." D. "A small skin sample will be obtained."

"A small skin sample will be obtained." *Bone marrow aspiration is a type of needle biopsy *Sentinel biopsy involves excision of a lymph node *Needle biopsy involves aspiration of a tumor for fluid and tissue sampling *A shave biopsy is a sampling of the outer skin layer using a scalpel or razor blade

When the patient complains, "If this viral infection I have right now can't be helped by antibiotics, why am I taking this expensive acyclovir?" How should the nurse respond? A. "Acyclovir is an antiviral drug that kills viruses." B. "Acyclovir is given to many patients with viral infections." C. "Acyclovir is an antiviral drug that prevents your infection from becoming worse." D. "Acyclovir helps strengthen your immune system."

"Acyclovir is an antiviral drug that prevents your infection from becoming worse." *The patient currently has a viral infection; acyclovir is an antiviral drug that will decrease the virulence of the infection if started in the early phase of the infection. The drug may not kill the virus and is not given frequently to patients with virus, Acyclovir will not strengthen the immune system

The nurse is talking with a patient who voices concerns about the incidence of schizophrenia in her family. The patient states that she is worried the condition will be inherited by her teenage daughter. What response by the nurse is most appropriate? A. "Unfortunately, schizophrenia does not run in families." B. "Although some familial factors exist, there is no exact known cause for schizophrenia." C. "Your daughter would show some evidence of the condition by this point in her life, so there is no real reason to worry." D. "As long as your home environment is warm and loving, she will be fine."

"Although some familial factors exist, there is no exact known cause for schizophrenia." *The exact cause of schizophrenia is unknown; however, current research favots the theory that there is a neurologic basis with a genetic component. As with most chronic conditions, an unfavorable social environment contriutes to a poor prognosis. Schizophrenia usually develops in late adolescence or the early twenties

A nurse is reinforcing teaching to a client about a new prescription for clotrimazole topical cream. Which of the following statements should the nurse include? A. "It reduces the discomfort of a herpetic infection but does not cure the infection." B. "This is a cream to treat a bacterial infection." C. "Apply the topical medication for up to 2 weeks after the fungal lesions are gone." D. "Apply the cream to lesions while they are moist."

"Apply the topical medication for up to 2 weeks after the fungal lesions are gone."

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse who is present at the time should respond by stating which of the following? A. "The technician at the time is not going to hurt you but is going to help." B. "Are you fearful and think that others may want to hurt you?" C. "What makes you think that the technician wants to hurt you?" D. "The technician will leave and come back later for your blood."

"Are you fearful and think that others may want to hurt you?" *Option B is the only option that recognizes the client's need. This response helps the client focus on the emotion underlying the delusion but does not argue with it. If the nurse attempts to chage the client's mind, the delusion may, in fact, be even more strongly held. Options A, C, and D do not focus on the client's feelings

The nurse is talking to an elderly patient who states, "Sometimes I wish that I would just fall asleep and never wake up again." What is the most therapeutic response? A. "Oh, don't say things like that, everyone would really miss you." B. "Are you thinking about committing suicide?" C. "Many people would agree that dying during sleep is the best way to go." D. "You seem a little sad today, is there anything I can do to help?"

"Are you thinking about committing suicide?"

Which caregiver statement regarding donepezil (Aricept) indicates a need for further nursing teaching? A. "I should give this drug with food to minimize gastric distress." B. "Aricept is rarely used because it causes liver problems." C. "I must increase fiber and fluid in my loved one's diet." D. "Providing frequent sips of cool liquids is helpful."

"Aricept is rarely used because it causes liver problems." *Liver functions should be monitored while on Aricept, but the caregiver is probably referring to tacrine, which is rarely prescribed because of hepatotoxicity. (1, 3, 4) The other options are correct. Give Aricept with food, increase fiber and fluid in the diet, and provide frequent sips of cool fluid.

An elderly patient asks the nurse why he seems to get more gastrointestinal infections now than he used to. Which response by the nurse is accurate? A. "Absorption of electrolytes from the bowel increases with aging, leading to an imbalance that can cause infection." B. "The mucociliary action in the intestine, which inhibits enzyme production, becomes insufficient as we age." C. "As we age, we don't produce enough gastric acid to inhibit the growth of pathogens in the intestine." D. "Motility of the bowel increases with age, which leads to frequent diarrhea."

"As we age, we don't produce enough gastric acid to inhibit the growth of pathogens in the intestine." *Decreased inhibition of pathogenic growth in the intestine is a result of the decreased secretion of gastric acid that occurs with age. Bowel motility slows with aging, which makes the intestine more susceptible to infection because the contents remain in the bowel longer. Electrolytes and the mucociliary action in the intestine do not have a direct effect on intestinal infections.

The patient with dementia presents to the clinic for a routine examination. The patient's daughter, who is her full-time caregiver, states to the nurse, "I just don't know how much longer I can go on caring for Mom full time. My kids feel neglected, my marriage is suffering, and I feel so run down." What is the best response by the nurse? A. "You must stay strong for your mother. You are all she has." B. "You should discuss the many medications available for treating and reversing dementia." C. "Your mother's dementia will improve once we correct the cause." D. "As your mother's condition continues to deteriorate, we should discuss alternative care resources."

"As your mother's condition continues to deteriorate, we should discuss alternative care resources." *Dementia is a progressive loss of cognitive function that has no cure or medication that reverses it. Delirium generally improves once the cause is corrected. The nurse should acknowledge that the patient will continue to deteriorate and inform the patient's daughter of available resources to lessen the burden of being the sole caregiver to a family member with dementia. Telling the patient's daughter to be strong is neither therapeutic nor helpful.

A male patient was informed that he would need to wear a pair of corrective lenses for astigmatism. When asked about the condition, the patient demonstrates understanding when he states that A. "Astigmatism is hardening of the ciliary muscles." B. "Astigmatism is an irregular curvature of the cornea." C. "Astigmatism enables focusing of light in front of the retina D. "Astigmatism is an increased opacity of the lens."

"Astigmatism is an irregular curvature of the cornea." *Astigmatism is caused by an irregular curvature of the cornea. (1) Hardening of the ciliary muscles is not astigmatism. (3) Astigmatism focuses light in several points. (4) Cataracts are increased opacity of the lens.

A 75-year-old patient questions the nurse about vaccination to prevent shingles. Which response is most appropriate? A. "The incidence of shingles in people your age is not overly common, so vaccination is unnecessary." B. "The vaccination has not yet been approved for use in the older adults." C. "Because of the incidence of shingles in your age group, you should consider taking the vaccination." D. "The vaccination is expensive but will provide lifelong immunity."

"Because of the incidence of shingles in your age group, you should consider taking the vaccination." *The vaccination should be considered by high-risk populations. About 50% of individuals over age 80 years will have the disease. The vaccination has been approved for use. The immunity provided is anticipated to last for 6 years

The 40-year-old female who was diagnosed with a benign growth in her colon is concerned about the growth spreading. Which explanation best allays the patient's anxiety? A. "Benign growths arrest their growth on their own." B. "Benign growths never interfere with normal structures or functions." C. "Benign growths are easily controlled with radiation." D. "Benign growths are surrounded by fibrous tissue that prevents spread."

"Benign growths are surrounded by fibrous tissue that prevents spread." *Benign neoplasms are encapsulated with a fibrous membrane that interferes with their spreading. They do not self-limit their growth and may obstruct passages or impinge on an organ. They are not treated with radiation

A patient with cancer who is receiving chemotherapy asks you why her hair would fall out because of this treatment. What is your best response? A. "The cells of your hair fall out to show that the chemotherapy is working." B. "Chemotherapy can cause hair loss if you are lacking protein in your diet." C. "Chemotherapy affects all fast-growing cells, including normal cells." D. "You must have a low white blood cell count."

"Chemotherapy affects all fast-growing cells, including normal cells. *The most rapidly dividing normal cells are hair cells. Cancer drugs target rapidly dividing cells, which are characteristic of cancer but also include hair cells. (2) Hair loss is not an effective measure of therapeutic benefit. (2) A lack of protein in the diet is not the reason for hair loss. (4) Patients receiving chemotherapy have a low white blood cell count, but this is not the cause of hair loss.

A nurse is reinforcing teaching with a client about stress-reduction techniques. Which of the following client statements indicates understanding of the information? A. "Cognitive reframing will helpe me change my irrational thoughts to something positive." B. "Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate." C. "Biofeedback causes my body to release endorphins so that I feel less stress and anxiety." D. "Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety."

"Cognitive reframing will helpe me change my irrational thoughts to something positive." *Cognitive reframing helps the client look at irrational cognitions (thoughts) in a more realistic light and to restructure those thoughts in a more positive way *Biofeedback, rather than progressive muscle training, uses a mechanical device to promote voluntary control over autonomic functions *Physical exercise, rather than biofeedback, causes a release of endorphins that lower anxiety and reduce stress *Priority restructuring, rather than mindfulness, teaches the client to prioritize differently to reduce the number of stressors

A nurse is assisting with the admission of a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client's caregiver, which of the following statements is the priority to report to the provider? A. "Current medical conditions include diabetes that is controlled by diet." B. "Recent medications include a course of prednisone for acute bronchitis." C. "Current vaccinations include a flu vaccine last month." D. "Current medications include furosemide for congestive heart failure."

"Current medications include furosemide for congestive heart failure." *Diuretics (furosemide) are contraindicated for use with lithium due to the risk of toxicity. This is the greatest risk for the client and is therefore the highest priority to report to the provider

A nurse is reinforcing teaching with a client prior to an initial mammogram. Which of the following information should the nurse provide prior to the procedure? A. "You should not take any aspirin products prior to the mammogram." B. "Do not apply any deodorant the day of the exam." C. "You will need to avoid sexual intercourse the day before the mammogram." D. "You should avoid exercise prior to the exam."

"Do not apply any deodorant the day of the exam." *Taking aspirin products does not alter the accuracy of a mammogram *Applying deodorant or powder can alter the accuracy of a mammogram by causing a shadow to appear *Having sexual intercourse does not alter the accuracy of a mammogram *Exercising does not alter the accuracy of a mammogram

A patient with glaucoma reports a possible infection in the affected eye and asks if the usual dose of latanoprost (Xalatan) drops should be instilled. What is your best response? a. "Do not take this dose until your healthcare provider is notified." b. "Rinse the affected eye with sterile saline and then instill the eye drops." c. "You should not put the eye drops in today but can resume them tomorrow." d. "Missing a dose of this drug will increase intraocular pressure and worsen your vision."

"Do not take this dose until your healthcare provider is notified." *Never instill prostaglandin agonists into an eye that has been scratched or has an infection. Contact the healthcare provider for instructions about continuing glaucoma therapy.

When a patient finds a lump in her breast, which question is essential for the LPN/LVN to ask because it is an early indication of breast cancer? A. "Did you breast-feed your children?" B. "Are you having menstrual irregularity?" C. "Do you notice any dimpling of the breast?" D. "Do you have any pain?"

"Do you notice any dimpling of the breast?" *Nipple discharge or a change in the skin pattern such as "dimpled skin" on the breast may also be a sign of breast cancer. Menstrual irregularity is not associated with breast cancer. Pain is a late sign for the presence of breast cancer. Breastfeeding is associated with a reduced incidence of breast cancer.

A nurse is reinforcing teaching about colon cancer to a group of females 45 to 65 years of age. Which of the following statements should the nurse include? A. "Colonoscopies for individuals with no family history of cancer should begin at age 40." B. "A sigmoidoscopy is recommended every 5 years beginning at age 60." C. "Fecal occult blood tests should be done annually beginning at age 50." D. "An MRI provides a definitive diagnosis of colon cancer."

"Fecal occult blood tests should be done annually beginning at age 50." *A colonoscopy is recommended every 10 years beginning at age 50 for a client with no family history of cancer *A sigmoidoscopy is recommended every 5 years beginning at age 50 *A biopsy performed during an endoscopic procedure confirms this diagnosis

A nurse at a provider's office is talking about routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? A. "So I don't need the colon cancer procedure for another 2 to 3 years." B. "For now, I should continue to have a mammogram each year," C. "Because the doctor just did a Pap smear, I'll come back next year for another one." D. "I had my blood glucose test last year, so I won't need it again for 4 years."

"For now, I should continue to have a mammogram each year," *The female client who is between the ages of 45 and 54 should have a mammogram annually. *The female who has no specific family or personal history of colorectal cancer should begin screening procedures at age 50 *The female client who is between the ages of 30 and 65, with no family or personal history of cervical cancer, should either have a Pap smear and HPV test every 5 years or a Pap test every 3 years *The client who is age 45 should have a blood glucose test at least every 3 years. Unless there is a specific family or personal history of diabetes mellitus, annual blood glucose determinations are not necessary

A frustrated patient with a fungal infection complains, "Why is the infection taking so long to heal?" Which response is most appropriate? A. "Fungal infection are essentially incurable." B. "Fungi form spores, which make them difficult to kill." C. "Fungi can be considered natural flora and are protected by the body." D. "Fungi can alter the patient's DNA and RNA."

"Fungi form spores, which make them difficult to kill." *Fungi are capable of forming spores, which makes them resistant to antifungal agents

The nurse is providing infection control teaching to a group of patients. Which statement demonstrates that the patient understands the nurse's teaching? A. "I should take an antibiotic at the first sign of an infection." B. "Hand hygiene is one of the most effective ways I can prevent the spread of infection." C. "Vaccinations only prevent a disease from becoming severe." D. "If I eat a nutritious diet, it will be difficult for me to get an infection:

"Hand hygiene is one of the most effective ways I can prevent the spread of infection." *Hand hygiene is the most effective single act that can reduce the spread of disease.

When assessing a patient who is complaining of ear pain, the most important question would be A. "Have you been listening to loud music?" B. "Have you had a recent upper respiratory infection?" C. "Are you prone to form a lot of wax in your ears?" D. "What have you taken for your pain?"

"Have you had a recent upper respiratory infection?"

A male patient has inflamed, edematous skin of the elbows and knees accompanied by swelling of the joints of the fingers and toes. On examination, the skin is found to be covered with adherent silvery-white scales. Which question would provide more information about the patient's condition? A. "What do you do for a living?" B. "How much do you smoke?" C. "Have you had an upper respiratory tract infection recently?" D. Have you recently changed your laundry detergent?"

"Have you had an upper respiratory tract infection recently?" *The patient has symptoms of psoriasis, and it is likely that an immunologic event triggers the disorder, as the first lesion commonly appears after an upper respiratory infection. (1, 4) Work-related activities and exposure to substances such as laundry detergents are not particularly associated with psoriasis; however, other skin disorders, such as contact dermatitis, could be relevant. (2) Assessment of tobacco use is appropriate for general health history; however, in this case it is not a directly relevant question.

After having a right total mastectomy, the patient confides that her husband has voiced concern about her "disfigurment." Which response is most appropriate for the nurse to make? The nurse's most therapeutic response would be A. "What a terrible thing to say!" B. "Many husbands feel that way at first." C. "His feelings will change over time." D. "How did you respond to his statement?"

"How did you respond to his statement?" *Using open-ended and matter-of-fact tactful questions will help the patient express feelings. Characterizing the husband's statement as terrible renders an inappropriate judgment without exploring how the patient feels. Informing the patient about others' feelings or offering empty reassurance that her husband will change over time is inappropriate and ineffective

When obtaining a history from a female patient suspected of having a sexually transmitted infection (STI), as a way to determine how much at risk the patient is, which of these questions is most important? A. "How often do you have sex?" B. "Are you married?" C. "How many sexual partners have you had in the past year?" D. "Have you ever had an abortion?"

"How many sexual partners have you had in the past year?" *The risk of STIs is greatest in patients who are engaged in sexual activity with multiple partners. Frequency of sexual relations and having had an abortion in the past are not factors. STIs are not limited to people who are not married.

The nurse is caring for a client who is suspected of being dependent on drugs. Which question should be appropriate for the nurse to ask when collecting data from the client regarding drug abuse? A. "Why did you get started on these drugs?" B. "How much do you use and what effect does it have on you?" C. "How long did you think you could take thse drugs without someone finding out?" D. The nurse does not ask any questions because of fear that the client is in denial and will thrown the nurse out of the room

"How much do you use and what effect does it have on you?" *Whenever the nurse collects data from a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option A is incorrect because it is judgmental, off focus, and reflects the nurse's bias. Option C is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option D is incorrect bercause it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention

A nurse is reinforcing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by te client indicates understanding of the teaching? A. "I can expect my problems with PMDD to be worst with I'm menstruating." B. "I should avoid exercising when I am feeling depressed." C. "I am aware that my PMDD causes me to have rapid mood swings." D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active."

"I am aware that my PMDD causes me to have rapid mood swings." *A clinical finding of PMDD is emotional liability. The client can experience rapid changes in mood *Clinical findings of PMDD are present furing the luteal phase of the menstrual cycle just prior to menses. *Aerobic and other exercise are effective treatments for depressive disorders, including PMDD *PMDD increases the client's risk for weight gain due to overeating. It is not appropriate to increase caloric intake

A nurse is assisting with the care of a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following reponses should the nurse make? A. "Why do you think you feel the need to give money away." B. "I am here to provide care and cannot accept this from you." C. "I can request that your case manager discuss appropriate charity options with you." D. "You should know that giving away your money us inappropriate."

"I am here to provide care and cannot accept this from you." *This statement is matter-of-fact and concise and is a therapeutic reponse to a client who has bipolar disorder *Asking a "why" question is a nontherapeutic form of communication and can promote a defensive client response *(C) This statement does not recognize the possibility of poor judgment, which is associated with nbipolar disorder. *(D) This statement offers disapproval and can be interpreted by the client as aggressive, which can promote a defensive client response

When administering an ordered antimicrobial for an infection, you should check the laboratory results for A. Elevated white blood cells B. Culture and sensitivity C. C-reactive protein D. Kidney and liver function

Culture and sensitivity *Culture and sensitivity are specific to identifying the pathogen. The other test results are important as indicators of infection, but they do not guide decision making for the specific choice of antibiotic medication

What underlying pathophysiology explains the gradual graying of an older adult's hair? A. Reduced hair follicles B. Less sabeaceous gland activity C. Loss of collagen fibers in dermis D. Decreased melanocytes at hair follicle

Decreased melanocytes at hair follicle *Reduction in melanocytes at the hair follicle is the cause of graying hair. A reduction in the number of hair follicles will result in thinning hair. Reduced sebaceous gland activity and collagen will result in drying

Experiences an illusion A. Cognition B. Dementia C. Delirium

Delirium

Results from cerebrovascular accident A. Cognition B. Dementia C. Delirium

Delirium

An 85-year-old man is admitted to the hospital with gastroenteritis and dehydration. He receives a dose of meclizine hydrochloride, an anticholinergic, for vomiting. He begins to hallucinate and talk to his wife, who has been dead for 10 years. Which explanation best describes this behavior? A. Dementia related to advanced age B. Delirium related to dehyrdration C. Demential related to early Alzheimer's disease (AD) D. Delirium related to side effect of anticholinergic

Delirium related to side effect of anticholinergic *Anticholinergic drugs can cause sudden confusion in older adults. There is nothing in the history that suggests that the behavior would be related to AD or any other dementia as dementias progress slowly. Dehydration would increase the effect of the anticholinergic

The nurse is collecting data from a client, and the client's spouse reports that the client is taking donepezil hydrochloride. Which disorder should the nurse suspect that this client may have based on the use of this medication? A. Dementia B. Schizophrenia C. Seizure disorder D. Obsessive-compulsive disorder

Dementia *Donepezil hydrochloide is a cholinergic agent used in the treatment of mild to moderate dementia of the Alzheimer type. It enhances cholinergic function by increasing the concentration of acetylcholine. It slows the progression of Alzheimer's disease. This medication is not used to treat the disorders in OPtion B, C, and D

A 42-year-old patient who had a left radical mastectomy expresses concerns about body image. What goal is appropriate? A. Participates in activities of daily living B. Demonstrates acceptance of change in appearance C. Performs aseptic wound care D. States signs and symptoms of infection

Demonstrates acceptance of change in appearance *Demonstrating acceptance of change in appearance is an appropriate goal related to body image. (1) Participating in activities of daily living is not a goal related to body image. (3) Aseptic wound care is not a goal related to body image. (4) Awareness of the signs and symptoms of infection is not a goal related to body image.

The alcoholic patient says to the nurse: "I am not an alcoholic. I can quit any time I want to." The nurse recognizes that the patient is using which defense mechanism? A. Repression B. Denial C. Rationalization D. Intellectualization

Denial *Denial is ignoring reality in spite of hard evidence. Denial is a mechanism frequently used by substance abusers/ Repression refers to unconsciously blocking an unwanted thought or memory from open expression. Rationalization attempts to justify a behavior or action by making an excuse or an explanation. Intellectualization is the excessive reasoning and logic to counter emotional distress

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

Denial *Denial is the refusal to admit to a painful reality and is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other people, objects, or situations. In regression, the client returns to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying the unacceptable attributes about oneself

A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting." The nurse should identify that the client using which of the following defense mechanisms? A. Reaction formation B. Denial C. Displacement D. Sublimation

Denial *This is an example of denial, which is pretending the truth is the not the reality to manage the anxiety of acknowleding what is real *(A) This is not an example of reactio formation, which is overcompensating or demonstrating the opposite behavior of what is felt *(C) This is not an example of displacement, which is shifting feelings related to an object, person, or situation to another less threatening object, person, or situation *(D) This is not an example of sublimation, which is dealing with unacceptable forms of expression

What are the two main defense mechanisms used by substance users? A. Repression and regression B. Sublimation and splitting C. Denial and rationalization D. Displacement and identification

Denial and rationalization

The nurse is educating a patient who has just been prescribed diazepam (Valium). The nurse cautions the patient that diazepam (Valium) may cause which problem? A. Dependency B. Urinary retention C. Severe dehydration D. Hallucinations

Dependency *Valium can cause a physiologic and a psychological dependence. Valium should not cause urinary retention, severe dehydration, or hallucinations

A nurse in the emergency department is assisting with the care of a client who sustained minor injuries in a motor vehicle crash. The client's spouse was killed in the accident. Which of the following actions should the nurse take first? A. Determine if the client has thoughts of self-harm B. Ask the client how the accident occurred C. Assist the client in setting short-term treatment goals D. Instruct the client on use of coping strategies

Determine if the client has thoughts of self-harm *The greatest risk to the client experiencing a crisis is the risk of harm to himself or others. Therefore, determining if the client has thoughts of self-harm is the action to take first.

A patient is taking lithium. For which symptoms will you monitor? A. Hypertension and headache B. Diarrhea and slurred speech C. Confusion and blurred vision D. Convulsion and polyuria

Diarrhea and slurred speech *Diarrhea and slurred speech are early signs of lithium toxicity. (1) Hypertension and headache are more closely associated with the MAOI antidepressants. Sodium depletion and dehydration may cause toxicity. (3, 4) Confusion, blurred vision, convulsion, and polyuria are late signs of lithium toxicity.

A patient tilts her head to the side while reading a pamphlet. The nurse recognizes that this action may be an attempt to compensate for which problem? A. Tinnutus B. Nystagmus C. Photophobia D. Diplopia

Diplopia *Tilting the head may indicate a visual disturbance such as double vision or that one eye is stronger than the other. Tilting the head to read would not affect tinnitus (ringing in the ears) or nystagmus (involuntary eye movements). Shading the eyes may be noted with photophobia

The nurse is doing a routine assessment of a client's peripheral intravenous (IV) infusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown? A. Using a hospital gown with snaps at the sleeves B. Disconnecting the IV tubing from the catheter in the vein C. Checking the IV flow rate immediately after changing the hospital gown D. Putting the bag and tubing through the sleeve, followed by the client's arm

Disconnecting the IV tubing from the catheter in the vein *The tubing should not be removed from the IV catheter. With each break in the system, there is an increased chance of introducing bacteria into the system, which can lead to an infection. Using gowns with snaps and inserting the IV bag and tubing throught the sleeve of the gown first are appropritate. The flow rate should be checked immediately after changing the hospital gown, because the position of the roller clamp may have been affected furing the change

The nurse is caring for a patient with a goal/outcome statement of Patient will sleep for 5 h uninterrupted each night. Which nursing intervention should the nurse include? A. Medicate with sedative each night B. Offer warm fluids frequently C. Arrange for a large meal at supper D. Discourage daytime napping

Discourage daytime napping

A nurse is contributing to the plan of care for a client during the termination phase of the nurse-client relationship. Which of the following interventions should the nurse include? A. Discussing ways to use new behaviors B. Practicing new problem-solving skills C. Developing goals D. Establishing boundaries

Discussing ways to use new behaviors *Discussing ways for the client to incorporate new healthy behaviors is an appropriate task for the termination phase *Practicing new problem-solving skills is an appropriate task for the working phase *Developing goals is an appropraite task for the orientation phase *Establishing boundaries is an appropriate task for the orientation phase

The nurse is caring for a patient diagnosed with shingles who complains of constant pain along the sciatic nerve. What intervention best helps to provide pain relief? A. Distract the patient with conversation B. Massage the area of pain C. Move the affected leg through range of motion (ROM) D. Change the patient's position frequently

Distract the patient with conversation *Distraction, guided imagery, and deep muscle relaxation may help reduce pain. Massage to the affected area will result in disruption in the vesicles of the disease. This disruption will delay healing and cause further discomfort. ROM and changing of positions are needed for patients with shingles in the event they are not mobile, but these actions will not reduce the discomfort.

A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol? A. Chlordiazepoxide B. Buproprion C. Disulfiram D. Carbamazepine

Disulfiram *Expect to administer disulfiram to help the client maintain abstinence from alcohol *Chlordiazepoxide is indicated for acute alcohol withdrawal rather than to maintain abstinence from alcohol *Buproprion is indicated for nicotine withdrawal rather than to maintain abstinence from alcohol *Carbamazepine is indicated for acute alcohol withdrawal rather than to maintain abstinence from alcohol

A nurse is caring for a client who has a prescription for gabapentin for neuropathic pain. The nurse should monitor the client for which of the following adverse effects of this medication? A. Constipation B. Urinary retention C. Insomnia D. Dizziness

Dizziness *monitor a client who is taking an opioid analgesic for constipation. However, constipation is not an adverse effect of gabapentin *monitor a client who is taking an opioid analgesic for urinary retention. However, urinary retention is not an adverse effect of gabapentin. *Monitor the client for sedation, rather than insomnia *Monitor the client for dizziness. Instruct the client to avoid driving until medication effects are know

A patient with Chlamydia trachomatis is most likely to be treated with which medication? A. Doxycycline B. Acyclovir C. Penicillin G/benzathine D. Hydrocortisone

Doxycycline *Treatment for the patient diagnosed with C. trachomatis includes a 7-day course of antibiotics, such as doxycycline, ofloxacin, levofloxacin, or ciprofloxacin. In patients with compliance issues, a single dose of azithromycin (1 g by mouth) may be administered. Erythromycin is indicated for pregnant women. Acyclovir is an antiviral. Hydrocortisone is an immunosuppressant.

The nurse is teaching a patient about infection prevention. The nurse points out that covering the mouth and nose with a tissue for a sneeze reduces the probability of infection spreading by which route? A. Droplet B. Airborne C. Direct contact D. Indirect contact

Droplet *Infection from the droplet route requires the pathogens be expelled in droplets from the host and inhaled by another host

An infertile couple considering zygote intrafallopian lines transfer (ZIFT) asks how it differs from in vitro fertilization (IVF). Which information about ZIFT is most important for the nurse to include? A. During ZIFT, fallopian tubes are artificially lines with material that nourishes the gamete B. During ZIFT, the fertilized egg is placed in the fallopian tube C. During ZIFT, fallopian tubes are clear with injected air D. During ZIFT, fallopian tubes is implanted with unfertilized ova and sperm

During ZIFT, the fertilized egg is placed in the fallopian tube *The ZIFT refers to the placement of the fertilized ovum into the fallopian tube at the zygote stage of development. During IVF-ET, the woman's eggs are collected from the ovary, fertilized in the laboratory, and transferred into the uterus at the embryo stage of development

A nurse in a clinic is talking with a client scheduled for a sentinel lymph node biopsy. Which of the following information should the nurse include? A. Dye is used during the procedure B. The lymph nodes closest to the tumor are removed during the biopsy C. A small amount of chemotherapy is used to test the lymph node response D. A 2 mm plug of tissue is removed during biopsy

Dye is used during the procedure *The client will receive a dye or colloid as a tracer to help identify lymph nodes during a sentinel lymph node biopsy *They might be removed in a later procedure if biopsy shows positive for cancer *Chemo is not administered during biopsy *punch biopsy involves removing 2-6 mm plug of tissue

A nurse is reinforcing teaching with an adolescent client who has a new prescription for clomipramine for OCD. Which of the following information should the nurse provide? A. Eat a diet high in fiber B. Check temperature daily C. Take medication first think in the morning before eating D. Add extra calories to the diet as between-meal snacks

Eat a diet high in fiber *Eating a diet high in fiber will decrease constipation, an anticholinergic effect associated with TCA use *Checking the client's temperature daily is not necessary while taking a TCA *Taking the medication at bedtime rather than in the morning will prevent daytime sleepiness *Following a well-balanced diet rather than adding extra calories as snacks will help prevent weight gain, a common adverse effect of TCAs

The nurse is educating a patient with a premenstrual dysphoric disorder (PMDD) about potential triggers. Which nutritional change should the nurse suggest to help reduce symptoms? A. Eat whole-grain bread instead of white bread B. Drink 4 ounces of red wine once a week C. Increase red meat intake to boost iron stores D. Use sugar instef of artificial sweeteners

Eat whole-grain bread instead of white bread *Strategies of self-care of PMDD may include stress management exercises, some lifestyle changes, and maintaining a healthy diet rich in complex carbohydrates and fiber (like whole-grain breads and pastas or lentils). Alcohol, red meat, and sugar exacerbate the symptoms of PMDD

The home health nurse is providing dietary recommendations to keep the immune system healthy. The patient demonstrates understanding by increasing intake of which foods? A. Eggs and beans B. Celery and water C. Pasta and bread D. Olive oil and peanuts

Eggs and beans *Protein stores must be kept at an adequate level in order to produce antibodies, thus boosting the immune system. Eggs and beans are a good source of protein

The nurse is caring for a patient with a tentative diagnosis of polycystic ovarian syndrome (PCOS). When reviewing the patient's health history, which finding supports this diagnosis? A. Cold intolerance B. Significant weight loss C. Menstrual periods every 33 days D. Elevated serum glucose levels

Elevated serum glucose levels *PCOS is a congenital condition in which many cysts develop on one of both ovaries and prodcue excess estrogen. High levels of testosterione and luteinizing hormone (LH) and low levels of follicle-stimulating hormone (FSH) occur. A manifestation of PCOS includes problems with gluxose tolerance, which would result in elevated serum glucose levels. Other signs and symptoms include excessive body hair (hirsutism), irregular menstruation, and infertility. Cold intolerance could be indicatie of hypothryoidism, anemia, Raynaud syndrome, or other underlying medical issues

The nurse is caring for a patient after a radical mastectomy. Which instruction will be most important for preventing lymphedema? A. Restricting movement of the affected arm B. Elevating the affected arm, on pillows, above the level of the heart C. Applying moist heat to the affected arm around the clock D. Holding the arm close to the body by using a sling

Elevating the affected arm, on pillows, above the level of the heart *Lymphedema is swelling of the arm that sometimes occurs after breast cancer surgery as a result of the damage to, and resulting congestion of, the lymphatic tract. Elevation of the arm will reduce swelling. Restricting movement of the arm and applying moist heat will increase edema.

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn? A. A dependent position B. Elevation of the knees C. Flat, without elevation D. Elevation above the level of the heart

Elevation above the level of the heart *Circumferential burns of the extremities may compromise circulation. Elevating injured extremities above the level of the heart and performing active exercise help to reduce dependent edema formation

The nurse differentiates vascular dementia from Alzheimer dementia. Which causative factor is responsible for vascular dementia? A. Cerebral atrophy B. Global reduction of cognition C. Hypertension D. Emboli in cerebral vessels

Emboli in cerebral vessels *Vascular dementia occurs from brain tissue becoming hypoxic and necrotic in local areas due to small emoboli. The deficits may be intellectual or loss of sensory function

A newly admitted 86-year old patient has scratch marks in the groin and axilla and on her limbs. There are small, punctate red lesions that the patient says itch "like crazy." Which nursing action is most appropriate? A. Employ skin tear precautions B. Employ standard precautions C. Employ use of emollient D. Employs focused assessment for cause

Employ standard precautions *The patient is most likely suffering from scabies. The nurse should employ standard precations in order to avoid the spread of infection

The family becomes distressed when the dying 85-year-old patient becomes delirious and laughs and talks with old friends who have long since died. Which intervention is most appropriate? A. Medicate the patient with the prescribed sedative B. Encourage a family member to talk to the patient calmly C. Stimulate and reorient the patient D. Suggest the family to leave the patient for a while

Encourage a family member to talk to the patient calmly *Delirious patients can still hear. A familiar voice is comforting.

A nurse is contributing to the plan of care for a client who is scheduled for genetic testing for suspected cancer. Which of the following interventions should then nurse recommend for inclusion in the plan? A. Encourage the client to seek genetic counseling B. Send testing results to the client's insurance agency C. Verify the prescription for a tumor marker assay D. Ensure the client is placed in a recovery position after testing

Encourage the client to seek genetic counseling *It is recommended that clients having genetic counseling receive counseling. It is confidential. Do not send the information unless the client requests it. *A tumor marker assay is a lab test to identify the presence of specific body proteins, body secretions, and tissue. It is not a component of genetic testing *Recovery positioning is not required following testing

A patient has recently been diagnosed with cancer. What is the best initial nursing intervention for this patient? A. Reassure the patient that "everything will work out fine." B. Provide literature about the specifics of the cancer. C. Encourage the patient to verbalize feelings and fears. D. Introduce the patient to a recovering cancer patient.

Encourage the patient to verbalize feelings and fears. *Soon after diagnosis, the patient should be encouraged to verbalize feelings and fears. The patient may be in a state of denial or anger, so introducing another cancer patient or providing literature would not be an initial intervention. Stating that "everything will work out fine" does not address the patient's feelings and instills false hope.

A patient is admitted after abusing an inhalant. Which safety precaution is most important for the nurse to take? A. Check the patient's temperature hourly B. Place the patient on seizure precautions C. Monitor carefully for changes in urine output D. Ensure that respiratory support equipment is present at the bedside

Ensure that respiratory support equipment is present at the bedside *Medical treatment and intervention for both hallucinogens and inhalants include provision of safety for the individual who may be experiencing a bad "trip." Emergency measures may be necessary to provide respiratory support for an individual who has impaired gas exchange as a result of inhalants

A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse contribute to the plan of care? A. Assign the client to a private room B. Document the client's behavior every hour C. Allow the client to keep perfume in their room D. Ensure that the client swallows medication

Ensure that the client swallows medication *Ensure that the client swallows medication to prevent hoarding of medication for an attempt to exceed the prescribed dose *Clients who are suicidal should not be assigned a private room *Client's behavior should be documented every 15 min or according to facility policy *Remove perfume from the client's room

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action should be which intervention? A. Escort the manic client to his or her room B. Orient the client to time, person, and place C. Tell the client that the behavior is not appropriate D. Tell the client that smoking privileges are revoked for 24 hours

Escort the manic client to his or her room *The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Option D may increase the agitation that already exists in this client. Orientation will not halt this behavior. Telling the client that the behavior is not appropriate has already been attempted by the psychiatric nurse's aide

The nurse is aware that interventions for the negative symptoms of schizophrenia are based on which factor? A. Establishment of trust B. Acceptance of medication protocols C. Support in interpersonal social activities D. Promotion of conversation with the patient

Establishment of trust *General nursing interventions for the negative symptoms include establishing trust and teaching the patient and family how to manage the signs and symptoms. An attitude of acceptance is necessary to promote trust

The nurse is caring for a female patient who reports using an estrogen cream as a lubricant for sexual intercourse. The nurse should caution a patient about which potential negative effect? A. Estrogen cream may damage latex condoms B. Estrogen cream may exacerbate hot flashes C. Estrogen cream may decrease elasticity of vaginal tissue D. Estrogen cream may cause contact dermatitis for sexual partners

Estrogen cream may damage latex condoms *Using estrogen cream as a lubricant for sexual intercourse is discouraged as the cream may damange latex condoms and require a backup method of contraception. Estrogen cream will not exacerbate hot flashes. Estrogen cream is used to increase vaginal tissue elasticity. While the partner can absorb estrogen from estrogen cream for sexual intercourse, contact dermatitis is not likely

The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently? A. Every hour B. Every 2 hours C. Every 3 hours D. Every 4 hours

Every hour *Safe nursing practice includes monitoring an IV infusion at least once every hour for an adult client.

The police arrive at the emergency room with a client who has seriously lacerated both wrists. What is the initial nursing action? A. Administer an antianxiety agent B. Examine and treat the wound sites C. Secure and record a detailed history D. Encourage and assist the client with venting their feelings

Examine and treat the wound sites *The initial nursing action is to examine and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions may follow after the client has been treated medically

Which action is most important for the nurse to take before providing care for substance abusers? A. Become familiar with self-help programs B. Examine personal bias relative to substance abuse C. Become knowledgeable about theories of addiction D. Ensure consistency with each patient

Examine personal bias relative to substance abuse *Nurses must first determine their own biases and attitude toward substance abuse and substance abusers before they can relate effectively with the patient. Familiarization with resources and knowledge about theories of addiction are tools of lesser importance

The nurse is assisting with developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care? A. Decrease the amount of salt in the diet B. Decrease fluid intake to control the intraocular pressure C. Avoid reading the newspaper and watching television D. Eye medications may need to be administered for the rest of your life.

Eye medications may need to be administered for the rest of your life.

The nurse is caring for a patient with an inner ear disorder and is aware that the patient is at risk for which of the following? A. Aspiration B. Falls C. Inncontinence D. Impaired gas exchange

Falls *Inner ear disorders can cause problems with balance, Dizziness, vertigo, and ataxia can greatly interfere with an individual's ability to work or to perform usual activities of daily living.

A military veteran is admitted to your unit with a diagnosis of chronic post-traumatic stress disorder (PTSD). After being placed in the treatment room, he begins to pace frantically and make references to "Highway 1." As the nurse approaches him, he retreats to the corner and sits on the floor with his arms and legs pulled tightly to his body. This patient is most likely experiencing which occurrence? A. Flashback B. Hallucination C. Phobic reaction D. Delusion

Flashback *This patient's symptoms are consistent with a flashback secondary to PTSD. Hallucinations and delusions are associated with psychotic disorders such as schizophrenia. Phobic reactions are not associated with the symptoms this patient is exhibiting.

A nurse in a provider's office is reviewing a client's laboratory results, which shows a positive rapid plasma regain (RPR). Which of the following tests will be administered to confirm the diagnosis of syphilis? A. Venereal Disease Research Laboratory (VDRL) B. D-dimer C. Fluorescent treponemal antibody absorbed (FTA-ABS) D. Sickledex

Fluorescent treponemal antibody absorbed (FTA-ABS) *The VDRL is another screening for syphilis *The D-dimer is a test used to measure fibrin and is used to diagnose disseminated intravascular coagulation *The FTA-ABS is used to confirm the diagnosis of syphilis *The Sickledex is used to diagnose sickle cell anemia

What is the nurse's primary responsibility in the daily care of a patient with a central line? A. Use sterile technique during insertion B. Flush the line according to agency policy C. Verify catheter placement with an x-ray examination D. Rotate the insertion site every 72 hours

Flush the line according to agency policy. *Nurses are responsible for the maintenance of central lines, which would include flushing to ensure patency. (1) Sterile technique is used during the insertion; however, central lines are usually inserted by physicians or advanced practice nurses who have undergone specialized training. (3) The catheter placement should be verified with a radiograph; however, this is the responsibility of the person doing the insertion. The nurse should not use the catheter for infusion until after placement has been verified. (4) The site is not usually changed so frequently. One of the advantages of central line placement over peripheral sites is longevity.

A patient with Alzheimer disease (AD) has been prescribed oral donepezil 10 mg. The nurse should give priority to assessing the patient for which sign of an adverse effect of this drug? A. Skin rashes B. Cardiac dysrhythmias C. Decreased blood pressure D. Gastrointestinal (GI) bleeding

Gastrointestinal (GI) bleeding *Patients receiving donepezil should be monitored for active or occult GI bleeding. Although patients should be assessed for all of these, especially when beginning a new medication, dysrhythmias, rashes, and decreased blood pressure are not associated with donepezil use.

The nurse uses which technique to correctly palpate the abdomen? A. Depresses gently with the fingertips and thumb B. Uses a sweeping motion with the back of the hand C. Gently feels with the flat palmar surface of the fingers D. Warms the stethoscope bell before listening to four areas

Gently feels with the flat palmar surface of the fingers

The nurse is preparing to administer otic medications to a 2 year old child. Which step is most correct? A. After the medication is expressed from the dropper, gently force air into the ear canal to promote absorption of the medication B. To reduce loss of medication, encourage the patient to lie down for 15 to 25 minutes after administration C. Gently pull the pinna upward and back during administration D. Gently pull the pinna downward and back during administration

Gently pull the pinna downward and back during administration

Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrolled feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? A. Call the client's family B. Place the client in seclusion immediately C. Inform the client that seclusion has not been prescribed D. Get a written prescription from the primary health care provider (PHCP) and ontain an informed consent

Get a written prescription from the primary health care provider (PHCP) and ontain an informed consent *A client may request to be secluded or restrained. Federal laws require the consent of the client unless an emergency situation exists in which an immediate risk to the client or others can be documented. The use of seclusion and restraint is permitter only with the written prescription of the PHCP, which must be reviewed, and renewed every 24 hours, depending on state law requirements. It must also specify the type of restraint to be used

A nurse is assisting with systematic desensitication for a client who has an extreme fear of elevators. Which of the following actions should the nurse implement with this form of therapy? A. Demonstrate riding in an elevator, and then ask the client to imitate the behavior. B. Advise the client to say "stop" out loud every time they begin to feel an anxiety response related to an elevator C. Gradually expose the client to an elevator while practicing relaxation techniques D Stay with the client in an elevator until the anxiety reponse diminishes

Gradually expose the client to an elevator while practicing relaxation techniques *Systemiatic desensitization is the planned, progressive exposure to anxiety-provoking stimuli. During this exposure, relaxation techniques suppress the anxiety responses *Demonstration followed by client imitation of the behavior is an example of modeling *Instructing a client to say "stop" when anxiety occurs is an example of thought stopping *Exposing the client to a great deal of an undesirable stimulus in an attempt to turn off the anxiety response is an example of flooding

The patient confides in the nurse he would like help in controlling his drinking. The nurse should recommend which of the following types of therapy, shown to be most effective at helping patients quit drinking? A. Group support, such as Alcoholics Anonymous (AA) B. Drug therapy, especially aversive therapy with disulfiram C. Reduction of, but not elimination of, alcohol consumption D. Electroconvulsive therapy (ECT)

Group support, such as Alcoholics Anonymous (AA) *Group support, such as AA, is one of the most effective treatments for alcoholism. ECT is not a treatment for alcoholism. Drugs may be used to manage acute withdrawal but are not consistently successful long-term therapy. Reducing alcohol consumption is not successful for most individuals with alcoholism.

While assisting with a sterile dressing change, the nurse notices that the primary health care provider has contaminated his left hand. Which action should the nurse take? A. Hand the primary health care provider another pair of gloves. B. Report the incident to the infection control nurse. C. Say nothing because the patient will be placed on prophylactic antibiotics. D. Tell the primary health care provider he has contaminated his gloves.

Hand the primary health care provider another pair of gloves. *The nurse should hand the primary health care provider another pair of sterile gloves. The nurse should not let the primary health care provider continue the dressing change without using sterile gloves. Telling the primary health care provider implies that he is negligent, and this presumably would occur within hearing of the patient. It may be appropriate to report the incident to the infection control nurse, but this is not the most appropriate first action. Prophylactic antibiotics do not negate the need for sterile procedure.

The patient has been diagnosed with primary stage syphilis. The nurse would anticipate the patient to display which symptom? A. Sore throat B. Hard sore on mucous membrane of genitalia C. Patchy loss of hair from the scalp D. Skin rash on arms and back

Hard sore on mucous membrane of genitalia *Syphilis has three stages. During the primary stage (after a 3-week incubation period), a chancre (hard, painless sore) appears on the mucous membrane of the mouth or genitals, often unnoticed in women. Sore throat, rash, and hair loss are not symptoms of primary stage syphilis.

A 53-year-old female is diagnosed with generalized anxiety disorder. Which behavior do you anticipate? A. Runs out of the room when she notices a spider in the corner B. Continuously checks to see if doors are shut and locked C. Has difficulty concentrating and excessively worries about her family D. Wakes at night screaming because of recurrent nightmares

Has difficulty concentrating and excessively worries about her family *Difficulty concentrating and excessive worry are part of the diagnostic criteria for general anxiety disorder (GAD). (1) Excessive fear of spiders is an example of phobic disorder. (2) Repetitive checking and rechecking doors is an example of behavior associated with obsessive-compulsive disorder. (4) Recurrent nightmares are associated with post-traumatic stress disorder (PTSD).

You are administering medication to a familiar patient who has been on the unit for several weeks. When you ask, "What is your name?". the patient replies, "I am Jesus Christ, the Son of God." What is the appropriate nursing action? A. Give the medication because you know the patient is confused. B. Document that the patient cannot verify identity and hold the medication C. Hold the medication until the family can bring in a picture identification D. Have a second nurse verify the patient's identity and document accordingly

Have a second nurse verify the patient's identity and document accordingly *Having another health care provider verify the patient's identification is the best option, so that the patient can continue to receive the medication. (1) If you give a medication without validating the patient's identity, there is the possibility of medication error. (2, 3) Holding the medication is not in the best interests of the patient; however, it would be worthwhile for the staff to develop an alternative identification process for confused patients, and pictures could be used. Verification of the patient ID band against the electronic health record and scanning the patient ID are other ways of validating the patient's identity.

While ambulating, a patient with Meniere disease complains of dizziness and vertigo. An immediate nursing action would be to A. Provide oxygen B. Have the patient sit down C. Administer nausea medication D. Notify the health care provider

Have the patient sit down *Although option 3 might also be relevant, safety concerns decree that having the patient sit down to prevent a fall or injury takes priority. The patient may only be dizzy, not nauseated. (1) Meniere disease does not result from oxygen deprivation. (3) Nausea medication may be necessary but will not help immediately. (4) The health care provider does not need to be notified of an expected symptom of the diagnosis.

Rule of 9's for burns

Head - 9% (anterior/posterior 4.5% each) R arm - 9% (anterior/posterior 4.5% each) L arm - 9% (anterior/posterior 4.5% each) Perineum - 1% Front of trunk - 18% (anterior/posterior 9% each) Back of trunk - 18% (anterior/posterior 9% each) R leg - 18% (anterior/posterior 9% each) L leg - 18% (anterior/posterior 9% each)

When a patient is receiving furosemide (Lasix) for a problem with edema, which side effect relative to this drug is important to the patient's health? A. Decreased rate of respirations B. Nausea C. Constipation D. Hearing loss

Hearing loss *Lasix (furosemide) can cause tinnitus and hearing loss. (1) Lasix does not affect respiratory rate. (2) Lasix is not associated with nausea. (3) Diarrhea is associated with Lasix.

A patient is in the early recovery process and is attempting to lead a drug-free life. Which nursing intervention is the most appropriate? A. Remind the patient of the discomfort and pain that occurred during detoxification B. Tell the patient that there is no need to feel guilty or ashamed C. Help the patient to identify relationships that were part of the substance use pattern D. Advise the patient that stopping forever is the only choice for a drug-free life

Help the patient to identify relationships that were part of the substance use pattern *Identifying relationships that were part of the substance use pattern will help the patient avoid going back into the same circumstances. (1) The patient is already acutely aware of the physical experience of withdrawal. (2) Dealing with guilt and shame is part of the recovery process. You should not give the patient absolution for past behaviors. (4) The patient is likely to be intellectually aware of the need for a drug-free life; repeating this is not helpful.

The burn client is receiving treatments of topical mafenide acetate (Sulfamylon) to the site of injury. The nurse monitors the client knowing that which indicates the occurrence of a systemic effect? A. Hyperventilation B. Elevated blood pressure C. Local rash at the burn site D. Local pain at the burn site

Hyperventilation *Mafenifide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatement should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication will probably be discontinued for 1 to 2 days. Elevated Blood pressure and local pain at the burn site describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury

The patient with ED is picking up a prescription for sildenafil (Viagra). The nurse should plan to tell the patient about which potential side effects? A. Hypotension, color vision disturbance, and priapism B. Thromboembolus, decreased sperm count, depression C. GI cramping, skin irritation, and bleeding D. Nausea, hypoglycemia, hypertension

Hypotension, color vision disturbance, and priapism

The nurse is orienting a visually impaired patient to a meal plate. Which action is most appropriate? A. Identify the location of the plate B. Hold the patient's hand and direct it to the plate C. Place eating utensil in the patient's hand D. Identify food according to an imaginary clock face

Identify food according to an imaginary clock face *Identifying food location by position on an imaginary clock face is helpful to the visually impaired

The patient is suffering acute delirium related to a systemic infection. During the evening, the patient appears to be very frightened by the IV tubing. The nurse recognizes that the patient might be experiencing which disturbance? A. Hallucination B. Illusion C. Delusion D. Confabulation

Illusion

A nurse is contributing to the plan of care of a client who is experiencing benzodiazepine withdrawal. Which of the following interventions should the nurse identify as the priority? A. Orient the client frequently to time, place, and person B. Offer fluids and nourishing diet as tolerated C. Implement seizure precautions D. Encourage participation in group therapy sessions

Implement seizure precautions *The greatest risk to the client is injury. Implementing seizure precautions is the priority intervention *The other 3 are appropriate interventions but are not the highest priority

The nurse educates a patient about differences between primary infertility and secondary infertility. Which statement accurately describes primary infertility? A. Inability to maintain a pregnancy past the first trimester B. Inability to conceive after 1 year of active unprotected sex C. Inability to deliver a viable infant after two pregnancyies D. Inability to conceive after using a follicle stimulator for 1 year

Inability to conceive after 1 year of active unprotected sex *Primary infertility is defined as the inability to conceive after 1 year of active unprotected sex. Secondary infertility is the inability to conceive after having once conceived, or the inability to maintain a pregnancy long enough to deliver a viable infant

The nurse is planning care for a patient with dementia. Which would be an appropriate intervention to include in this patient's care plan? A. Increase verbal and environmental cues. B. Speak loudly and slowly. C. Involve the patient in new activities. D. Restrain the patient for safety.

Increase verbal and environmental cues. *Increasing verbal and environmental cues (e.g., signs indicating bathroom and room locations) can help in orienting patients with dementia. There is no indication that the patient is hard of hearing. New activities would serve to confuse and perhaps agitate a patient with dementia.

What is the main problem that comes accompanies glaucoma? a. Cloudiness of the lens b. Cloudiness of the cornea c. Increased intraocular pressure d. Increased intracranial pressure

Increased intraocular pressure *Glaucoma is a problem related to increased intraocular pressure that can put so much pressure on ocular blood vessels, photoreceptors, and the optic nerve that blindness results. It does not affect the lens, the cornea, or the intracranial pressure.

The nurse is caring for a suicidal patient who has been treated effectively with antidepressant therapy. The patient verbalizes that he feels better. The nurse is alert that the patient is most at risk for which potential complication? A. Increased risk for self-harm B. Increased emotional fragility C. Increased potential for weight gain D. Increased activity intolerance

Increased risk for self-harm *The risk of suicide is greater now that the patient has increased energy to plan and complete the suicide. Effective antidepressant therapy should not cause an increase in emotional fragility, weight gain, or activity intolerance

The nurse is reviewing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory finding is indicative of the massive cell destruction that occurs with the chemotherapy? A. Anemia B. Decreased platelets C. Increased uric acid levels D. Decreased leukocyte count

Increased uric acid *Hyperuricemia, elevated levels of uric acid is especially common after treatment for leukemias and lymphomas, because the therapy results in massive cell destruction and the release of uric acid, Anemia (low RBC count), low platelet levels, and low WBC counts are associated with the bone marrow abnormalities that are a part of the leukemias and lymphoma disease process

An older adult is admitted for cataract extraction. Which sign or symptom is associated with this condition? A. Increased tearing B. Increasing farsightedness C. Increasing complaints about glare D. Bluish discolorations

Increasing complaints about glare *Increasing complaints about glare are associated with the growth of a cataract. Retinopathy is frequent in patients with diabetes, either from overgrowth of blood vessels or from hypertension that causes increased pressure and rupture of vessels. (1) Cataracts do not cause tearing. (2) Cataracts do not alter the point of focus on the retina. (4) Cataracts do not cause blue discoloration.

The nurse encourages the recovering alcoholic to participate in group therapy. Which benefit is most important for the nurse to mention? A. Development of improved social skills B. Progression toward sobriety C. Provision of a sense of belonging D. Increasing self-discipline

Increasing self-discipline *The learning of the skill of self-discipline is the long-lasting benefit from group therapy. The other options are also benefits, but the major one is self-discipline, a skill a drug abuser must acquire for successfuly rehabilitation

A nurse is providing support to a client who has a new diagnosis of endometriosis. The nurse should inform the client that which of the following conditions is a possible complication of endometriosis? A. Insulin resistance B. Infertility C. Vaginitis D. Pelvic inflammatory disease

Infertility *Insulin resistance is a complication of PCOS *Infertility is a complication of endometriosis because endometrial tissue overgrowth can block the fallopian tubes *Vaginitis is typically caused by an infection *PID is caused by an infection of the pelvic organs

A patient receiving a chemotherapy agent that is a vesicant should be monitored for which adverse effect? A. Infiltration of the intravenous fluid containing the chemotherapy agent into the surrounding skin B. Orthostatic hypotension due to fluid expansion in the vascular system C. Dehydration due to the emetogenic effect of the drug D. The presence of blood in the urine or stool

Infiltration of the intravenous fluid containing the chemotherapy agent into the surrounding skin *Infiltration of a vesicant can cause tissue necrosis. (2) Orthostatic hypotension is a sign of hypovolemia. (3) Dehydration may occur but is not the priority. (4) Blood in the urine or stool is not an expected adverse effect.

A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are stating, "kill your doctor." Which of the following actions should the nurse take first? A. Encourage the client to participate in group therapy on the unit B. Initiate one-to-one observation of the client C. Focus the client on reality D. Notify the provider of the client's statement

Initiate one-to-one observation of the client *A client who is experiencing a command hallucination is at risk for injury to self or others. Safety is the priority, and initiating one-to-one observation is the first action the nurse should take *Encourage the client to participate in group therapy to assist with reality testing and to increase coping skills. However, there is another action to take first *Attempt to focus the client on reality. However, there is another action to take first *Notify the provider of the client's hallucination. However, there is another action to take first

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis? A. Identifying the client's ability to function B. Identifying the client's potential for self-harm C. Inquiring about the client's feelings that may affect coping D. Inquiring about the client's perception of the cause of the neighbor's death

Inquiring about the client's feelings that may affect coping *The client must first deal with feelings and negative responses before the client is able to walk through the meaning of the crisis. Option C pertains directly to the client's feelings. Options A, B, and D do not directly address the client's feelings

A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention should the nurse anticipate to be prescribed? A. Irrigation of the ear B. Instillation of antibiotic eardrops C. Instillation of corticosteroid ointment D. Instillation of mineral oil or diluted alcohol

Instillation of mineral oil or diluted alcohol

The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doiing vigorous push-ups. Which nursing action is appropriate? A. Interrupt the client and weigh her immediately B. Interrupt the client and offer to take her for a walk C. Allow the client to complete her exercise program D. Tell the client that she is not allowed to exercise vigorously

Interrupt the client and offer to take her for a walk *Clients with anorexia nervosa are frequently preoccupied with vigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise as well as place limits on vigorous activities. Options A, C, and D are inappropriate nursing actions

The nurse is caring for a patient admitted with a diagnosis of serotonin syndrome. Which type of medication will most likely be included in the plan of treatment? A. Antihypertensive medications B. Intravenous (IV) therapy C. Antianxiety medications D. Sedatives

Intravenous (IV) therapy *Serotonin syndrome is a potential life-threatening condition that could start 30 minutes to 48 h after taking the medication. Symptoms include change of mental status, increase in pulse and fluctuation in blood pressure, loss of musclar coordination, and hyperthermia. Treatment includes stopping medication, administering IV fluids, and decreasing temperature

Which statement is true regarding giving drugs by the IV route? a. Intravenous drugs must go through first-pass metabolism to be absorbed. b. Intravenous drugs are deposited directly into the blood stream. c. Intravenous drugs have lower rates of adverse events. d. Intravenous drugs are less effective than oral drugs.

Intravenous drugs are deposited directly into the blood stream. *Drugs administered by the intravenous route are deposited directly into the bloodstream and have a higher incidence of chance for adverse events.

The nurse is educating a patient with a new prescription for lithium carbonate. Which information is most important for the nurse to include in the teaching plan? A. It can take up to 2 weeks for Lithium to reach a therapeutic level in the body B. Lithium is often given in conjunction with loop diuretics C. Carefully restrict sodium intake to less than 1 g/day D. Take medication before breakfast for maximum effectiveness

It can take up to 2 weeks for Lithium to reach a therapeutic level in the body *Lithium may take 7 to 14 days to reach therapeutic level in the body. Diuretics should be avoided while on Lithium therapy. Patients should not restrict sodium intake since low sodium levels could cause Lithium toxicity. Medication should be taken with meals to decrease gastric distress

The delusional patient has become agitated and angry. The patient reports that the cook put tacks in his cereal. He is pacing back and forth in the crowded dining room and cursing the cook. How should the nurse respond? A. Keep distance from the patient and ask, "Can we go to the dayroom and talk?" B. Touch the patient's arm and say, "Calm down, I'm sure we can straighten this out." C. Call experienced CNAs to restrain the patient. D. Stand calmly and say, "This behavior is unacceptable. Sit down and eat, Carl."

Keep distance from the patient and ask, "Can we go to the dayroom and talk?" *Allowing the angry patient space is important. Encourage the patient to find a quieter place. Acknowledge the anger and demonstrate willingness to help. The agitated patient should not be touch without permission. Restraints are a last resort and will increase the patient's anger and feelings of persecution

The nurse is reviewing the plan of care for a patient following a tympanoplasty. Which intervention should the nurse implement in the immediate postoperative period? A. Keep the patient flat in bed B. Encourage deep breathing and coughing C. Reposition the patient quickly to reduce nausea and vomiting D. Position the patient's head with the affected ear touching the mattress

Keep the patient flat in bed *Postoperative care involves keeping the patient quiet and flat in bed for at least 12 h. Coughing and sneezing should be avoided, or if unavoidable, should be accomplished with the mouth opern to decrease pressure in the ear. Position changes should be accomplished slowly. The head is turned so that the affected ear is uppermost

Which alternative to restraints will you select for an older adult patient on a medical-surgical unit who is confused and trying to get out of bed? A. Raise four side rails of the bed B. Put the patient's mattress on the floor C. Keep the patient in a wheelchair close to the nurse's station D. Use hand mitts and a soft vest with Velcro fasteners

Keep the patient in a wheelchair close to the nurse's station *Putting the patient close to the nurses' station is the least restrictive option. (1, 4) Raising the side rails and using mitts are considered types of restraints. If the nurse opts to use either of these measures, documentation and a health care provider's order are required. (2) Putting the mattress on the floor is not commonly done in a hospital, but it might be considered in other settings, such as the patient's home or a long-term care facility.

Thick ridge of scar tissue A. Erythrasma B. Wheal C. Fungal infection D. Keratosis E. Keloid

Keloid

Benign, wartlike lesions on trunk, arms, and scalp A. Erythrasma B. Wheal C. Fungal infection D. Keratosis E. Keloid

Keratosis

The patient reports that her physician has prescribed an anti-inflammatory medication to manage an eye condition. Which medication is in this classification? A. Carteolol B. Dipiverfrin (Propine) C. Ketorolac (Acular) D. Brimonidine tartrate (Alphagan)

Ketorolac (Acular)

The nurse recognizes the staging T3, N2, M2 of the patient's cancer. Which interpretation is correct? A. Small tumor with fewer than two lymph nodes involved B. Large tumor that is localized C. Small tumor with adjacent nodes involved D. Large tumor with extensive lymph node involvement

Large tumor with extensive lymph node involvement *The staging means a large tumor (T3) with involvement in regional lymph nodes (N2) and metastasis to distant lymph nodes (M2)

An 80 year old resident prefers to lie in bed on her left side. The nurse anticipates that the risk for skin breakdown is greatest over which area? A. Left buttock B. Left heel C. Left trochanter D. Left ribs

Left trochanter *The areas that are most prone to breal down in the immobile patient are overy bony prominences

Which patient resonse indicates that large doses of vitamin B1 for treatment of Wernicke encephalopathy are working? A. No seizure activity B. Less confusion and improvement of memory C. Decreased urge to drink alcohol D. No tremors, nausea, or vomiting

Less confusion and improvement of memory *Patients with Wernicke encephalopathy are likely to show confusion, memory loss, and ataxia; it is a reversible condition that responds to vitamin B1. (1, 4) Seizure activity, tremors, nausea, and vomiting are signs of alcohol withdrawal. (3) Naltrexone (ReVia) is an example of medication used to help block the craving for alcohol.

A nurse is caring for a client who has a WBC count of 20,000/mm3. The nurse should conclude that the client has which of the following? A. Neutropenia B. Leukocytosis C. Left shift D. Leukopenia

Leukocytosis *Leukocytosis is WBC greater than 10,000/mm3, which can indicate inflammation or infection. *Neutropenia count is WBC less than 2,000/m3 *Left shift is an increase in immature neutrophils (bands or stabs) that occurs with acute infection *Leukopenia is a total WBC count of less than 4,000/mm3, which can indicate overwhelming infection or drug toxicity.

Which intervention is most important for a person who is in a wheelchair for long periods? A. Reposition self every 2 h B. Lift weight on the arms of the chair every 15 minutes C. Massage bony prominences of the buttocks and hips D. Use a donut devide to keep weight off of the buttocks

Lift weight on the arms of the chair every 15 minutes *Lifting or off-loading weight every 15 minutes while in a wheelchair will reduce the threat of pressure ulcer. Tissue anoxia can result in less than 2 h. Movement to shift weight every 15 minutes is most effective. Massage can damage delicate tissues in the at-risk patient. The donut devicere reduces circulation to the area compressed and is contraindicated

Whe are women at a greater risk for contracting sexually transmitted infections (STIs) than men? A. Male secretions are in contact with female mucous membranes for longer periods of time B. Estrogens increase susceptibility of vaginal membranes C. Penile friction to the vaginal wall encourages STIs D. Changing hormonal levels create a vaginal environment conducive to bacterial growth

Male secretions are in contact with female mucous membranes for longer periods of time *Male secretions are in contact with female mucous membranes longer than female secretions are in contact withthe penis. Estrogen provides for vaginal lubrication and therefore reduces friction and tissue tearing

A nurse is assisting with a family therapy session. The younger child tells the nurse about plans to make the older sibling look bad, believing this will earn more freedom and privileges. The nurse should identify this dysfunctional behavior as which of the following? A. Placation B. Manipulation C. Blaming D. Distraction

Manipulation *Manipulation is the dysfunctional behavior of using dishonesty to support an individual agenda *Placation is the dysfunctional behavior of taking responsibility for problems to keel peace among family members *Blaming is the dysfunctional behavior of blaming others to shift focus away from the individual's own inadequacies *Distraction is the dysfunctional of inserting irrelevant information during attempts at problem solving

The nursing student demonstrates knowledge of the proper use of the following when determining that it is safe to administer meperidine (Demerol) and promethazine (Phenergan) together? A. Medication reconciliation form B. Polypharmacy C. EHR D. Medications

Medication reconciliation form

In a hospital, a patient who is having trouble breathing is very upset because the LPN/LVN has to help the patient bathe. The patient says to the nurse, "I don't think you should have to bathe me." The nurse's response is based on which of these understandings about the nurse's role? A. Patients must be encouraged to meet their own needs at all times. B. When a patient indicates that he or she is uncomfortable with getting assistance, then no assistance should be given. C. Hospital patients deserve to have basic needs cared for by someone else regardless of their ability to care for themselves. D. Meeting one's basic needs may require assistance from someone until the individual is able to manage independently.

Meeting one's basic needs may require assistance from someone until the individual is able to manage independently. *The goal of care is to work toward the patient functioning as independently as possible. The LVN/LPN should distinguish which activities to carry out, and which activities the patient must learn to do to gain independence. The nurse should explain that assistance is given in an attempt to help the patient achieve independence. It is inappropriate to care for patients' needs regardless of their ability to care for themselves. It is also inappropriate to withhold assistance simply because the patient is uncomfortable with receiving it.

The patient presents to the clinic for her annual well-woman examination. Which symptom, if reported by the patient, indicates that the woman may be beginning menopause? A. Menstrual irregularities B. Extreme coldness at night C. Stress incontinence D. Acne-like skin changes

Menstrual irregularities *Menopause is defined as the cessation of menses for 12 consecutive months as a result of decreased estrogen production. The perimenopausal period or climacteric is the time around the actual cessation of the menstrual cycle. Signs and symptoms of the climacteric and menopause include hot flashes (a sensation of warmth), hot flushes (a visible redness and moistness of the skin), and night sweats caused by vasomotor instability resulting from low estrogen levels. These symptoms usually decrease as the woman's body adjusts to the lower level of estrogen. Being cold at night, acne, and stress incontinence are not indicative of menopause.

Which term refers to constriction of the pupil of the eye? a. Miosis b. Punctum c. Glaucoma d. Mydriasis

Miosis *Miosis means constriction of the pupil; mydriasis means dilation of the pupil; glaucoma is an eye disease that is caused by increased intraocular pressure; and punctum is the opening in the lower lid that drains tears into systemic circulation

The patient complains to the nurse about a sharp pain in the lower quadrants every month at mid-cycle that lasts for several hours. This description is consistent with which underlying pathophysiological process? A. Round ligament stretching to support the uterus B. Mittelschmerz, a pain associated with ovulation C. Premenstrual uterine enlargement D. Endometrial changes

Mittelschmerz, a pain associated with ovulation *Mittelschmerz is a pain in either lower quadrant associated with ovulation. There is no stretching of the round ligaments during the mid-cycle peroids. Premenstrual ueterine changes do not produce discomfort

A nurse is reinforcing preoperative teaching with a client who was informed of the need for emergency surgery. The client has a respiratory rate 30/min, and says, "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify thay the client is experiencing which of the following levels of anxiety? A. Mild B. Moderate C. Severe D. Panic

Moderate *Moderate anxiety decreases problem solving and may hamper the client's ability to understand information. Vital signs may increase somewhat, and the client is visibly anxious *In mild anxiety, the client's ability to understand information may actually increase *Severe anxiety causes restlessness, decreased perception, and an inability to take direction *During a panic attack, the person is completely distracted, unable to function, and can lose touch with reality

A 62-year-old woman is admitted to an assisted-living facility with symptoms of forgetfulness, anger outbursts, wandering, and paranoia. These would suggest which stage of AD? A. Mild B. Severe C. Moderate D. Moderate to severe

Moderate to severe *This patient's symptoms indicate her AD has progressed beyond the early stage. Later signs of disease progression include increasing confusion and inability to recognize self or others.

A nurse is reviewing the plan of care for a client who has leukemia and has developed thrombocytopenia. Which of the following actions should the nurse take first? A. Instruct the client to take rest periods throughout the day B. Encourage the client to reposition in bed every 2 hr C. Check temperature every 4 hr D. Monitor platelet counts

Monitor platelet counts *The greatest risk to the client who has thrombocytopenia is injury due to bleeding. The priority action to take is to monitor the client's platelet level to ensure it does not reach critical level. Institute bleeding precautions

A nurse is contributing to the plan of care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? A. Assist the client with systematic desensitization therapy B. Reinforce the use of the client appropriate coping mechanisms C. Check the client for comorbid health conditions D. Monitor the client for adverse effects of medications

Monitor the client for adverse effects of medications *Assisting with systematic desensitization therapy is a cognitive and behavioral, rather than a psychobiological intervention *Reinforcing the use of appropriate coping mechanisms is a counseling or health teaching *Checking for comorbid health conditions is health promotion and maintenance, rather than a psychobiological intervention

A nurse is assisting with the care of a client who has bipolar disorder. Which of teh following is the priority nursing action? A. Set consistent limits for expected client behavior B. Administer prescribed medications as scheduled C. Provide the client with step-by-step instructions during hygiene activities D. Monitor the client for escalating behavior

Monitor the client for escalating behavior *The greatest risk to this client is harming self or others due to the potential of a manic episode. Therefore, the priority actions the nurse should take is to monitor the client for escalating behavior *Set consistent limits for expected client behavior, administer prescribed medications as scheduled, and provide the client with step-by-step instructions during hygiene activities. However these do no address the client's priority need for safety and is therefore not the priority action

A nure is assisting with planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse expect to be assigned to perform first? A. Monitor the client's risk for self-harm B. Instill hope for positive outcomes C. Encourage the client to participate in group therapy sessions D. Assist the client to participate in treatment decisions

Monitor the client's risk for self-harm *The greatest risk to a client who has a body dysmorphic is self-harm or suicide. Therefore, the first action to take is to monitor the client's risk for self-harm to ensure that the client is provided with a safe environment *Instill hope for positive outcomes, without providing reassurance, as part of milieu therapy; however there is another action to take first *Encourage the client to participate in group therapy to assist the client in order to address social impairments that result from the disorder; however, there is another action to take first *Encourage the client to participate in treatment decisions as part of milieu therapy; however, there is another action to take first

You are admitting a patient with an infected abdominal wound. Wound cultures are positive for methicillin-resistant Staphylococcus aureus. Appropriate nursing care for this patient includes A. Monitoring temperature and white blood cell count B. Placing the patient on strict intake and output C. Instituting respiratory precautions D. Encouraging ambulation along the hallways

Monitoring temperature and white blood cell count *Temperature and white blood cell count are indicators for response to therapy or worsening of infection. (2) Strict intake and output might be considered if the patient is losing a lot of fluid from the wound or if the patient is NPO or vomiting. (3) Respiratory precautions are not needed. (4) The patient should be on contact precautions and should limit trips outside the room.

A patient reports taking chlorpromazine (Thorazine) for 4 months. Which symptom do you identify as a concern? A. Muscle rigidity B. Tongue protrusion C. Photophobia D. Dry eyes

Muscle rigidity *Muscle rigidity is a symptom of neuroleptic syndrome that is rare but potentially fatal. (2) Tongue protrusion is a sign of tardive dyskinesia, which may not be reversible even if medication is discontinued. (3, 4) Photophobia and dry eyes are anticholinergic symptoms that will respond to trihexyphenidyl (Artane) or benztropine (Cogentin).

The nurse explains that an alternative to disulfiram (Antabuse) is the drug naltrexone (Vivitrol). Which information should the nurse include in the teaching plan? A. Naltrexone (Vivitrol) causes severe headaches if alcohol is consumed while using the drug B. Naltrexone (Vivitrol) can cause a dependence on the medication itself if taken improperly C. Naltrexone (Vivitrol) releases endorphin-like enzymes that mimic intoxification D. Naltrexone (Vivitrol) blocks craving and prevents relapse

Naltrexone (Vivitrol) blocks craving and prevents relapse *Naltrexone (Vivitrol) can be used to block the craving for alcohol and to prevent relapse in the recovery phase

The student nurse is preparing to document a suspicious area over a bony prominence. Which description would be most appropriate? A. Reddened area on left hip B. Reddened, nonblanching area approximately 1 cm x 1 cm C. Suspicious area over left trochanter D. Nonblanching area over left trochanter 0.8 cm x 1.2 cm

Nonblanching area over left trochanter 0.8 cm x 1.2 cm *The area should be described as to location, appearance, and exact measurement

The nurse is caring for a patient who has been admitted to the acute care facility with painful, infected lesions of the skin. Which action would be the priority of the LPN/LVN? A. Observing and carefully recording the patient's skin condition B. Applying a comforting lotion until the primary health care provider writes the medical orders C. Giving the patient a disinfecting tub bath during that shift D. Carefully cleaning the affected area with soap and water

Observing and carefully recording the patient's skin condition *The first priority is for the nurse to observe the area and document the findings. There is no indication of the type of skin lesions present. Cleaning the affected area with soap and water, disinfecting the lesions by giving the patient a tub bath, or applying lotion must be undertaken only after orders are received from the primary health care provider. Initiating these types of interventions would be against the scope of practice.

The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action? A. Engaging in immoral acts B. Always reinforcing self-approval C. Observing rigid rules and regulations D. Having the need to always make the right decision

Observing rigid rules and regulations *Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help the clients manage their anxiety. Options A, B, and D are incorrect

The nurse observes a coworker who is always behind because he checks and rechecks the accuracy of his medication dosages. Even after being assured his dosages are correct, he checks them again. The nurse suspects her coworker suffers from which disorder? A. Perfectionism B. Phobic disorder C. Obsessive-compulsive disorder (OCD) D. General anxiety disorder

Obsessive-compulsive disorder (OCD) *When a person has an OCD, he experiences an obsession, recurrent, or intrusive thoughts that he cannot stop thinking about, and these thoughts create anxiety. Time spent in these thought and rituals can become overwhelming to the point of interfering with normal life

A patient has a hacking cough, a runny nose, and painful swallowing because of a sore throat. He is diagnosed with a streptococcal infection of the throat. The nurse should use gloves for which type of activity? A. Taking a history from the patient B. Obtaining a throat swab for a culture and sensitivity test C. Delivering the throat culture tube to the lab D. Reviewing the culture results with the patient

Obtaining a throat swab for a culture and sensitivity test

A 93 year old resident eats only a few bites at meals and then refuses to eat more. Which intervention might the nurse use to help delay skin breakdown from diminished nutrition? A. Spoon-feed the resident B. Request an order for a feeding tube C. Inform the resident of the need to increase intake D. Offer 4 ounces of fluid every hour

Offer 4 ounces of fluid every hour *Dehydration can cause loss of skin turgor and predisposes the skin to break down. Spoon-feeding and instructing about increased intake may only result in a power struggle with the resident

A resident in a long-term care facility has been in a manic stage for 2 days. He has not slept and cannot focus long enough to eat a meal. How should the nurse best enhance the resident's nutrition? A. Insist he sit down and eat at the table B. Spoon-feed him at the table at regular mealtimes C. Offer him small glasses of high-protein drinks every hour D. Make up a game about who can finish a meal first

Offer him small glasses of high-protein drinks every hour *The patient displays an inability ti concentrate and a decreased need for sleep or nutrients. Offering a small amount of high-energy foods and drinks every hour will support nutrition until the manic behavior is under control. Because of the manic patient's abbreviated focus, eating an entire meal may not be possible. The nurse should not force the patient to sit and eat, demean him by spoon-feeding, or challenge him to process a new activity

An intoxicated client is brought to the emergency department by local police. The client is told that the oprimary health care provider (PHCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen y the PHCP immediately. The nurse assising to care for the client should take which appropriate nursing intervention? A. Watch the behavior escalate before intervening B. Attempt to talk with the client to de-escalate the behavior C. Offer to take the client to an examination room until he or she can be treated D. Inform the client that he or she will be asked to leave if the behavior continues

Offer to take the client to an examination room until he or she can be treated *Safety of the client, other clients, and staff is of prime concern. Options C is in effect an isolation technique that allows for separation from others and provides for a less stimulating environment when the client can maintain dignity. When dealing with an impaired individual, trying to talk may be out of the question. Waiting to intervene could cause the client to become even more agitated and a threat to others. Option D would only further aggravate an already agitated individual

A nurse is communicating with a client who was admitted for treatment of a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication? A. Offering advice B. Reflecting C. Listening attentively D. Giving information

Offering advice *Offering advice to a client is a barrier to therapeutic communication that should be avoided. Advice tends ti interfere with the client's ability to make personal decisions and choices *The technique of reflection directs the focus back to the client in order for the client to examine their feelings *The skill of active listening is an important therapeutic technique to help hear and understand the information and messages the client is trying to convey *Giving information informs the client of needed information to assist in the treatment planning process

The nurse is performing an intake interview on a new resident to the long-term care facility. The nurse detects the odor of acetone from the patient's breath. Which term accurately describes this assessment? A. Inspection B. Observation C. Auscultation D. Olfaction

Olfaction

A nurse is caring for a client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? A. Cataracts B. Open-angle glaucoma C. Macular degeneration D. Angle-closure glaucoma

Open angle glaucoma *A gradual loss of peripheral vision is a manifestation associated with open angle glaucoma *(a)-a client with cataracts experiences a decrease in peripheral and central vision due to opacity of the lens. (c)-A client who has macular degeneration experiences a loss of central vision. (d)-a client who has angle-closure (NARROW) glaucoma experiences sudden nausea, severe pain, and halos around lights=medical emergency

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that their food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat? A. Open-ended questions and silence B. Focusing on self-disclosure regarding food preferences C. Stating the reasons that the client may not want to wat D. Offering opinions about the necessity of adequate nutrition

Open-ended questions and silence *Open-ended questions and silence are strategies used to encourage clients to discuss their problem. Options C and D do not encourage the client to express feelings. The nurse should not offer opinions and should not state the reasons, but should encourage the client to identify the reasons for their behavior. Option B is not a client-centered intervention

The office nurse is preparing information regarding contraception for a young patient, noting that which method of contraceptives is the most popular? A. Oral contraceptives B. Emergency contraception C. Natural family planning D. Diaphragm

Oral contraceptives *Oral contraceptives are the most popular method of reversible hormonal contraception in use. Known as the morning after pill, emergency contraception may be considered after the woman has had unprotected intercourse. natural family planning, also known as fertility awareness, involves identifying signs of ovulation and abstaining from intercourse during periods of infertility. A diaphragm is a latex dome-shamed cup that fits snugly over the cervix

The client with small cell lung cancer is being treated with etoposide and the nurse is assisting with caring for the client during administration with caring for the client during administration. The client gets up to use the bathroom and is dizzy and very weak. The nurse understands these symptoms are likely as a result of which side/adverse effect that is specifically associated with this medication A. Alopecia B. Chest pain C. Pulmonary fibrosis D. Orthostatic hypotension

Orthostatic hypotension

The nurse is aware that the older adult is at risk for drug-induced delirium. Which age-related change contributes to this risk? A. Slower bowel motility B. Reduced fluid intake C. Overall reduced metabolism D. Sedentary lifestyle

Overall reduced metabolism *Slower renal and liver clearance of drugs allows the drugs to accumulate in the system of the older adult

A nurse is assessing a patient who has just returned to the unit after receiving ECT. Which assessment finding is of greatest concern? A. Patient complains of a headache B. Patient does not remember having ECT C. Patient displays a cardiac dysrhythmia D. Patient is disoriented to time

Patient displays a cardiac dysrhythmia

Why is glaucoma called a "thief-in-the-night" disease? A. Patient typically has no symptoms other than a gradual loss of peripheral side vision B. Patient often has night blindness as a first symptom C. Patient has sudden loss of vision D. Patient only experiences symptoms when first waking up in the morning

Patient typically has no symptoms other than a gradual loss of peripheral side vision

A patient with a chronic substance use has a problem of denial or psychological dependence. Which outcome statement is most appropriate? A. Patient will stop denying dependence on substances B. Patient will list three negative effects that substances have on his life C. Patient will decrease substance use in 2 weeks D. Patient will talk to his wife about reasons for substance use

Patient will stop denying dependence on substances

Which technique should the nurse employ to best assess skin turgor? A. Examine mucous membranes of the mouth B. Compare limbs for similar color C. Pinch a skinfold on chest to assess for tenting D. Palpate the ankles for evidence of pitting edema

Pinch a skinfold on chest to assess for tenting

A nurse working on an acute mental health unit is collecting data from a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actios is the nurse's priority? A. Place the client on one-to-one observation B. Assist the client to perform ADLs C. Encourage the client to participate in counseling D. Reinforce teaching to the client about medication adverse effects

Place the client on one-to-one observation *The greatest risk for a client who has MDD and comorbid anxiety is injury due to self-harm. The highest priority intervention is placing the client on one-to-one observation *The client who has MDD can require assistance with ADLs. However, this does not address the greatest risk to the client and is therefore not the priority intervention *Encourage the client who has MDD to participate in counseling. However, this does not address the greatest risk to the client and is therefore not the priority intervention *Reinforce teaching to the client who has MDD about medication adverse effects. However, this does not address the greatest risk to the client and is therefore not the priority intervention

A patient who is near death has the following nursing diagnosis—Impaired gas exchange related to fluid in the lungs. Which intervention is most appropriate? A. Suction the patient as needed. B. Teach the patient how to do pursed-lip breathing. C. Place the patient in the Fowler position. D. Encourage the patient to cough and breathe deeply at least every 3 h.

Place the patient in the Fowler position. *When patients are near death, they often subjectively feel as if they cannot get enough air. Placing the patient in the Fowler position will help prevent aspiration of mucus and fluids produced during the dying process. Suctioning is uncomfortable and will stimulate more mucus and fluid production by irritating the mucosa. Pursed-lip breathing and coughing will not decrease the mucus and fluid production and would be exhausting to the dying patient.

The nurse hears in report that a patient has global amnesia. The nurse will allot extra time for which intervention? A. Talking about family members and their recent visits B. Reminiscing about family holidays and past events C. Reorienting to person, place, and time D. Placing signs and arrows to the bathroom and dining room

Placing signs and arrows to the bathroom and dining room

The nurse is caring for a patient who was admitted with fractures sustained during an MVC (Motor Vehicle Collision). The patient tearfully condfesses that she relives the accident in her dreams and is afrain to sleep. The nurse recognizes that this scenario is consistent with which disorder? A. Post-traumatic stress disorder (PTSD) B. Phobic disorder C. Obsessive-compulsive disorder (OCD) D. Panic level of anxiety disorder

Post-traumatic stress disorder (PTSD) *Individuals with PTSD have endured one or more extreme life-threatening events, and the remembrance of these events now produces feelings of intense horror, with recurrent symptoms of anxiety and nightmares or flashbacks

A nurse is caring for a client who has a suspected fungal skin lesion. Which of the following laboratory findings should the nurse suspect to review to confirm this diagnosis? A. Potassium hydroxide (KOH) B. Diascopy C. Tzanck smear report D. Biopsy

Potassium hydroxide (KOH)

After a transurethral resection of the prostate (TRUP), a priority nursing problem in the immediate post-operative period is A. Altered activity tolerance due to required bedrest B. Pain due to bladder spasms C. Potential for bleeding due to surgery D. Anxiety due to sexual function after surgery

Potential for bleeding due to surgery

A nurse is collecting data from a client who has a new diagnosis of persistent depressive disorder. Which of the following findings should the nurse expect? A. Wide fluctuation in mood B. Report of a minimum of five clinical findings of depression C. Presence of manifestations for at least 2 years D. Inflated sense of self esteem

Presence of manifestations for at least 2 years *Manifestations of persistent depressive disorder last for at least 2 years in adults *Wide fluctuations in mood are associated with bipolar disorder *MDD contains a minimum of five clinical findings of depression *A decreased, rather than inflated, sense of self-esteem is associated with persistent depressive disorder

What is the highest priority when caring for the burn patient? A. Preventing contractures from forming B. Grafting to cover open burn areas C. Preventing infection or controlling it D. Providing psychosocial support to the patient

Preventing infection or controlling it

The nurse is educating a patient who has been given a prescription for tadalafil (Cialis). The nurse warns the patient about which potential complication? A. Priapism B. Obstructed urethra C. Hydronephrosis D. Urethritis

Priapism *Cialis can cause priapism, a persistent erection that can develop into a urologic emergency as penil vessels may become thrombosed. Urethral obstruction is not associated with the use of tadafil (Cialis). Hydronephrosis refers to the dilation of the renal pelvis and is not associated with the use of tadalafil (Cialis). Urethritis refers to infection or inflammation of the urethra and is not associated with the use of tadafil (Cialis)

The nurse evaluating a piggyback IV setup finds an error in the construction of the fluids. Which situation would the nurse correct? a. Secondary bag is hung higher than the primary bag. b. Primary line clamp is closed. c. Slide clamp near the insertion site is open. d. Secondary line clamp is open.

Primary line clamp is closed *When a medication is given via piggyback setup, the secondary bag is hung slightly higher than the primary line and, when the secondary infusion finishes, the primary one takes over again; therefore, all clamps (roller and slide) must be open for the setup to work properly.

How does the body benefit from the normal acidic pH of the vaginal vault? A. Supported vaginal muscle tone B. Vaginal lubrication C. A hostile environment to sperm D. Protection against infection

Protection against infection *The acidic pH of the vagina, provided by lactic acid, is a defense against infection. The low pH is a hostile environment for pathogens. Muscle tone in the vagina is not affected by the pH level. The vagina is not a hostile environment to the sperm

What effect does the nurse desire to achieve by using clear, direct communication with patients with borderline personality disorder? A. Avoid generating an intense reaction from the patient B. Eliminate the possibility of manipulation C. Decrease the probability of the patient reacting emotionally D. Provide a role model for good communication

Provide a role model for good communication *Clear communication can model a communication style that allows a person to verbalize feelings and make thoughts and expectations known

The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's effect is belligerant. Based on these observations, which is the nurse's immediate priority of care? A. Provide safety for the client and other clients on the unit B. Provide the clients on the unit with a sense of comfort and safety C. Assist the staff with caring for the client in a controlled environment D. Offer the client a less-stimulating area to calm down and gain control

Provide safety for the client and other clients on the unit *Safety of the client and other clients is the priority. Option A is the only option that addresses the client and other clients' safety needs. Option B addresses other client's needs. Option C is not client centered. Option D adresses the client's needs

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which situation? A. Poor dietary choices B. Lack of exercise and poor diet C. Inadequate dietary intake and dehydration D. Psychomotor retardation and side effects of medication

Psychomotor retardation and side effects of medication *In this situation, urinary retention is most likely caused by medications. Option D is the only option that addresses both constipation and urinary retention. Constipation may be related to inadequate food intake, lack of exercise, and poor diet

A 38-year-old patient has been admitted to the unit after ingesting a high dose of "bath salts." Which of the following conditions is the patient at the greatest risk for developing? A. Muscle cramping and abdominal pain B. Tachycardia and euphoria C. Diaphoresis and tachypnea D. Psychosis and suicidal ideation

Psychosis and suicidal ideation *"Bath salts" or "plant food," a powder that is inhaled, injected, ingested, or smoked to produce an effect close to that of cocaine or amphetamine. High doses bring a risk of violence, paranoid psychoses, and suicide. Tachycardia, euphoria, diaphoresis, tachypnea, muscle cramping, and abdominal pain are not associated with bath salts; rather, they are associated with opiate withdrawal. Amphetamine withdrawal causes bradycardia and depression.

You are preparing to instill otic drops into the ear canal of an adult. What is the correct technique for giving otic drugs to an adult? a. Pull the external ear down and back. b. Press the pinna against the mastoid bone. c. Pull the pull the external ear up and back. d. Press the upper portion of the ear until the eustachian tube is seen.

Pull the pull the external ear up and back. *When instilling eardrops into an adults' ear, gently pull the external ear up and back.

The nurse observes the CNA who is changing a patient's bed. Which action demonstrates that the CNA requires additional teaching? A. Lifting the patient on the drawsheet to the stretcher B. Pulling the drawsheet out from under the patient C. Rolling the patient to the side to change the drawsheet D. Using the gait belt to lift the patient from the bed to a wheelchair

Pulling the drawsheet out from under the patient *Pulling linens out from under a patient instead of rolling or lifting the patient causes a shearing type of skin tear. Use of a lift sheet, rolling the patient from side to side, and the use of the gait are recommended

The nurse is preparing to administer eardrops to an adult client. The nurse administered eardrops by which technique? A. Pulling the pinna up and back B. Pulling the earlobe down and back C. Tilting the client's head forward and down D. Instructing the client to stand and lean to one side

Pulling the pinna up and back

The wife of an alcoholic tells the nurse, "My husband only drinks on the weekends to relax. He has a very stressful job." The nurse recognizes that the patient's wife is using which defense mechanism? A. Repression B. Denial C. Rationalization D. Identification

Rationalization *Rationalization is a justification for an unreasonanle act to make it appear reasonable. Rationalization is used by many families to allay their own anxiety about the substance abuse of a family member. Repression refers to unconsciously blocking an unwanted thought or memory from open expression. Denial is ignoring reality in spite of hard evidence. Denial is a mechanism frequently used by substance abusers. Identification refers to modeling behaviors after another individual

A patient reports slight stinging after applying her eye drops for glaucoma. What is the nurse's best action? A. Culture the patient's eye for bacteria and send it to the laboratory B. Report the stinging to the healthcare provider and ask for a change in the prescription C. Reassure the patient that it is normal to have slight stinging after applying her eye drops D. Document the comments as the only action

Reassure the patient that it is normal to have slight stinging after applying her eye drops

When approaching a clinical problem, an important characteristic of a critical thinker is to A. rely on one's own family values in considering a problem B. Consider only data given in report C. Recognize one's own biases and limitations D. Read chart documentation and draw a conclusion

Recognize one's own biases and limitations

What patient action will provide maximum effectiveness of treatment when given cerumenolytics? A. A warm, moist cloth placed over the ear B. Heating the drops before giving C. Cooling the drops before giving D. Remaining lying down for 5 minutes for optimum absorption

Remaining lying down for 5 minutes for optimum absorption

Shortly after receiving one dose of naloxone (Narcan) for an overdose of opiates, a patient experiences a change in level of consciousness and a decreased respiratory rate. What should the nurse do first? A. Inform the charge nurse B. Repeat the Narcan C. Notify the health care provider D. Update family members

Repeat the Narcan *Narcan has a short half-life, and opiate action may resume and cause respiratory depression. Narcan may be repeated, or thenurse can request a continuous intravenous infusion of the drug

The nurse is caring for a patient in the moderate Alzheimer stage. In planning care, the nurse should anticipate the need for which intervention? A. Repeat the date and time frequently B. Restrain the patient to protect from falls and wandering C. Vary routine and provide unstructured environment D. Allot extra time for grooming and toileting

Repeat the date and time frequently

The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse should take which appropriate action? A. Document the finding B. Continue to monitor vital signs C. Report the finding to the registered nurse (RN) D. Mark the drainage on the dressing and monitor for any increase in bleeding

Report the finding to the registered nurse (RN)

The mother of a toddler with mumps asks the nurse what she needs to watch for in her child with this disease. The nurse bases the response on the understanding that mumps is which type of communicable disease? 1. Skin rash caused by a virus 2. Skin rash caused by a bacteria 3. Respiratory disease caused by virus involving the lymph nodes 4. Respiratory disease caused by a virus involving the parotid gland

Respiratory disease caused by a virus involving the parotid gland *Mumps is caused by a paramyxovirus that causes swelling from the parotid gland, causing jaw and ear pain. It is transmitted via direct contact or droplets spread from an infected person, saliva from infected saliva, and possibly by contact with urine. Airborne and contact precautions are indicated during the period of communicability

After being stained with crystal violet, how will a gram-positive gonoccus react? A. Fluoresce after counterstain is applied B. Accept the counterstain C. Retain the original stain after the counterstain is applied D. Turn dark after the counterstain is applied

Retain the original stain after the counterstain is applied *Staining procedures differentiate organisms by using dyes that have been found to stain some bacterial in specific ways. An example of this would be a Gram stain, in which bacterial are first stained with crystal violet, then treateed with a strong iodine solution, decolorized with ethanol or ethanol acetone, and then counterstained with contasting dye. Those retaining the initial stain are considered gram positive; those losing the stain but accepting the counterstain are considered gram negative

The nurse is preparing a 55-year-old patient for a mammogram. The patient states, "I'm so happy that I won't need to have any more mammograms after this." Which recommendation by the American Cancer Society does the nurse explain to the patient? A. Screening mammography should continue after the age of 55 every 1 to 2 years for as long as she is in good health. B. Yearly screening mammography is recommended after the age of 55 only if the patient has a family history of breast cancer. C. Once the patient is in menopause, screening mammography is no longer recommended. D. Screening mammography is recommended every year until the age of 65.

Screening mammography should continue after the age of 55 every 1 to 2 years for as long as she is in good health. *Older women may feel that they no longer need regular mammograms and Pap smears, particularly if they are not sexually active. The American Cancer Society (2017) recommends screening mammography continue after the age of 55 every 1 to 2 years for as long as the woman is in good health and is expected to live 10 years or more.

A patient requests information about birth control methods that delay menstruation. Which method does the nurse discuss with the patient? A. NuvaRing B. Skin patch C. "The pill" D. Seasonale

Seasonale *Seasonale and Seasonique are oral contraceptives that delay menstruation so that the woman experiences four menstrual periods a year. "The pill", NuvaRing, and the skin patch are based on a 28-day cycle, so the woman continues to experience monthly menstruation.

The nurse is assigned to care for patients who are admitted for detoxification. Which drug represents the potentially highest risk situation during withdrawal? A. Cocaine B. Heroin C. Methadone D. Secobarbital

Secobarbital *A patient withdrawing from barbiturates requires gradual detoxification to prevent convulsions, delirium, tachycardia, and death. Although withdrawal from heroin, cocaine, or methadone is extremely uncomfortable and exhausting for the patient, it is not life threatening.

A client arrives at teh health care clinic and tells the nurse that they have been doubling their daily dosage of bubpropion hydrochloride to help them get better faster. The nurse understands that the client is now at risk for which problem? A. Insomnia B. Weight gain C. Seizure activity D. Orthostatic hypotension

Seizure activity *Buproprion is an atypical antidepressant and does not cause significant orthostatic blood pressure changes. Seizure activity is common in dosages greater than 450 mg daily. Buproprion frequently causes a drop in body weight. Insomnia is a side effect, but seizure activity causes a greater client risk

A patient displaying mania is investigating the unit and overseeing the activities of other patients; because of these behaviors, she is unable to finish her dinner. The nurse should institute which intervention to ensure proper nourishment for this patient? A. Allow her in the unit kitchen for extra food whenever she wishes. B. Encourage her appetite by ordering out for her favorite foods. C. Serve high-calorie foods she can carry with her. D. Serve her small, attractively arranged portions.

Serve high-calorie foods she can carry with her. *During periods of mania, the patient may be unable to sit long enough to complete a meal. Providing high-calorie finger foods will allow the patient to move around the unit while maintaining adequate nutrition. Attractively arranged portions, providing the patient's favorite foods, and allowing the patient to enter the unit kitchen whenever she likes would not help this patient attain proper nourishment.

The nurse is providing education to a group of teenage girls on the importance of wearing skin protection when outside. The nurse should inform the girls that overexposure to ultraviolet (UV) rays can cause which change in the skin? A. Thinning B. Loss of hair follicles C. Loss of adipose tissue D. Severe wrinkles

Severe wrinkles *Overexposure to the UV rays of the sun can seriously and permanently damage the superficial and deeper layers of the skin. The damage results in severe wrinkling and furrowing, as well as loss of elasticity, and the skin assumes a tissue-paper transparency. In addition to the potential for premature aging and degenerative changes, solar damage can also result in malignant changes. UV overexposure does not cause skin thinning, loss of hair follicles, or loss of adipose tissue.

The nurse is explaining the components of a complete problem statement/nursing diagnosis. In addition to the NANDA stem and etiology, which other component should the diagnosis include? A. A time reference for meeting the need B. A designation of what the patient should do C. Signs and symptoms of the problem assessed D. A specifically worded medical diagnosis

Signs and symptoms of the problem assessed

The CNA approaches the older adult in the long-term care facility and says, "Oh, look! Your pretty dress is icky with food spots! Let's change your clothes, sweetie." The nurse identifies that the CNA is using which type of communication? A. Instruction for personal hygiene B. Encouragement for self-care C. Simplistic "elderspeak" D. Reorientation techniques

Simplistic "elderspeak" *Elderspeak is a way of communicating with older adults, that is, infantile, over-simplistic, over-solicitous, and demeaning. It serves no therapeutic purpose

The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. Which is the appropriate nursing intervention? A. Ask direct questions to encourage talking B. Leave the client alone and intermittently check on them C. Sit beside the client in silence and verbalize occasional open-ended questions D. Take the client into the dayroom with other clients so they can help watch him

Sit beside the client in silence and verbalize occasional open-ended questions *Clients with catatonic stupor may be immobile and mute and may require consistent, repeated approaches. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. The nurse would not leave the client alone. Fortunately, with pharmacotherapy and improved individual management, severe catatonic symtoms rarely occur. Option D relies on other clients to care for this one, which is an appropriate expectation. Asking direct questions of this client is not therapeutic. Option C is the best action because it provides for client supervision and communication as appropriate

The nurse observes a withdrawn schizophrenic. The patient is sitting along and moving her lips as if she is talking, but there is no audible sound. The nurse speaks to the patient by name, but the patient does not seem to hear. What should the nurse do first? A. Hug the patient's shoulders, refer tothe patient by name, and ask if she's praying B. Document the patient's nonresponsiveness and continued detached behavior C. Sit down in the chair next to the patient, touch her arm, and speak softly D. Touch the patient's shoulder and then join another group of patients

Sit down in the chair next to the patient, touch her arm, and speak softly *Sitting with the patient and touching her presents the reality of the nurse's presence. Continued attention will make the patient feel safe. Feelings of safety are needed in the beginning of the nurse-patient relationship. Hugging the patient may invade the patient's personal space. The nurse's assessment will be documented but it is most appropriate to attempt an interaction with the patient

Which behavior is characteristic of a patient with schizoid personality disorder? A. Violation of the rights of others B. Excessive emotional outburst C. Attention-seeking behavior D. Social detachment

Social detachment *Patients with schizoid personality disorder exhibit behaviors such as withdrawal from social relationships and a restricted affect. Attention-seeking behaviors, excessive emotional outbursts, and the violation of the rights of others are not associated with schizoid personality disorders.

The nurse is caring for a patient receiving lithium for bipolar disorder. The nurse knows to monitor dietary intake of which electrolyte? A. Chloride B. Potassium C. Sodium D. Magnesium

Sodium *Sodium depletion or dehydration could cause lithium toxicity; therefore, monitor fluid intake and dietary sodium. Diuretics should be avoided. Lithium dosage is not related to chloride, potassium, or magnesium.

A nurse is caring for a client whp has borderline personality disorder. The client says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client's statement is an example of which of the following defense mechanism? A. Regression B. Splitting C. Undoing D. Identification

Splitting *Splititng occurs when a person is unable to see both positive and negative qualities at the same time. The client who has borderline personality disorder tends to see a person as all bad one time and all good another time *Regression refers to resorting to an earlier way of functioning (having a temper tantrum) *Undoing is a behavior that is intended to undo or reverse unacceptable thoughts or acts (buying a gift for a spouse agfter having an extramarital affair) *In identification, the person imitates the behavior of someone admired or feared

A nurse is caring for a client who is experiencing a panic attack, Which of the following actions should the nurse take? A. Discuss new relaxation techniques B. Show the client how to change the behavior C. Distract the client with a television show D. Stay with the client and remain quiet

Stay with the client and remain quiet *During a panic attack, quietly remain with the client. This promotes safety and reassurance without additional stimuli *During a panic attack the client is unable to concentrate on learning new information. *During a panic attack, avoid further stimuli that can increase the client's level of anxiety

A patient is irritable, pacing, crying, and becoming increasingly agitated. Which is the appropriate nursing intervention? A. Discussing suicude openly B. Administering an ordered antidepressant medication C. Staying with the patient while making the surroundings less stimulating D. Offering small nourishing meals and finger foods to sustain nutrition

Staying with the patient while making the surroundings less stimulating *Making the area less stimulating and staying with the patient can lower anxiety. (1) The patient is not displaying signs of intending to commit suicide. (2) Antidepressant medication is not appropriate in this situation. (4) The patient is exhibiting signs of anxiety, not hyperactivity. Small nourishing meals and finger foods to sustain nutrition are more important for the patient with dementia who will not stay still.

The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter while applying pressure to the site with which item? A. Band-Aid B. Alcohol swab C. Betadine swab D. Sterile 2x2 gauze

Sterile 2x2 gauze *A dry, sterile dressing such as sterile 2x2 gauze is used to apply pressure to the site while the cathter is discontinued and removed. This material is absorbent, sterile, and nonirritating to the site. A Band-Aid may be used to cover the site after hemostasis as occurred. An alcohol swab or Betadine would irritate the opened puncture site and would not stop the blood flow

The patient is receiving a blood transfusion and develops a fever, shortness of breath, and a diffuse rash within 10 minutes after the start of the transfusion. What is the priority action? A. Take vital signs and call the primary care provider B. Place the patient in a supine position and start oxygen C. Stop the blood and change the IV tubing D. Slow the blood and check the vital signs

Stop the blood and change the IV tubing. *First stop the blood and change the IV tubing so that the patient does not receive the blood that is within the tubing. (1, 2, 3) Taking the vital signs, starting oxygen, and calling the primary care provider are appropriate actions. The high Fowler position is better initially for oxygenation; if the patient's vital signs suggest shock, the supine position is used. Slowing the blood is not an adequate measure if a transfusion reaction is in progress.

The nurse is helping a patient get dressed to go to her dialysis treatement. The patient bursts into tears and says, "I can't go! I can't stand another day in that awful place. I will die if I have to go!" Which intervention is best? A. Stop the dressing process and calmly ask the patient to talk about her feelings B. Continue to dress the patient and reassure her that she will feel better after her treatment C. Stop the dressing process and remind the patient that missing a treatment can make her very sick D. Continue dressing the patient and remind her that she must stay on task in order to be on time

Stop the dressing process and calmly ask the patient to talk about her feelings *A calm and supportive attitude will help the patient identify feelings. The nurse should put the dressing process on hold so that the nurse can focus attention on a therapeutic response to the patient's concerns. The nurse shouls then ask an open-ended question to give the patient freedom to express her concerns. Making a threatening statement about consequences of missed treatements only exacerbates the patient's concern. Continuing to dress the patient while offering empty reassurance or changing the subject ignores the problem at hand

A 31-year-old patient with a history of borderline personality disorder is admitted to the psychiatric unit after cutting both wrists with a kitchen knife. Which nursing approach would be most therapeutic for this patient? A. Open and flexible B. Nonintrusive and passive C. Structured and consistent D. Warm and nurturing

Structured and consistent *The nurse should be consistent and keep the environment structured when caring for a patient with borderline personality disorder. Open and flexible, warm and nurturing, and nonintrusive and passive do not provide boundaries for a patient with borderline personality disorder, and boundaries are crucial to the patient's management.

Carbonic anhydrase inhibitor should not be given to patients with what condition? A. Sulfa allergy B. Diabetes C. Glaucoma D. Food allergies

Sulfa allergy

A patient is in the manic phase of bipolar disorder. He is talking very loudly and starting to argue with other patient. Which intervention is the most appropriate to try first? A. Instruct him to go sit down and watch television B. Take him for a walk down a quiet corridor C. Invite him to play cards or board games D. Advise him to lower his voice or lose privileges

Take him for a walk down a quiet corridor

The nurse is caring for a patient with moderate anxiety. Which activity should the nurse encourage to best manage the patient's anxiety? A. Taking a walk B. Learning a new game C. Watching an intense television show D. Reading a pamphlet about the negative effects of anxiety

Taking a walk *To best manage moderate level anxiety, the nurse should help provide outlets for tension. These activities include walking, crying, and working at simple, concrete tasks. Learning something new, watching an intense TV show, or reading information about the negative effects of anxiety are activities that may exacerbate anxiety rather than relieve it

A patient with a diagnosis of schizophrenia is experiencing auditory hallucinations and is admitted for evaluation and treatment. Which would be an appropriate activity for this patient? A. Taking a walk with the nurse B. Playing a game of solitaire C. Working on a large-piece puzzle alone D. Taking a nap

Taking a walk with the nurse *Strategies for helping patients to manage persistent auditory hallucinations include monitoring what triggers the hallucinations, talking with someone, listening to music, watching TV, saying "stop," using earplugs, doing deep breathing or relaxation exercises, and doing a favorite activity. Actively involving the patient will minimize active hallucinations. Solo activities such as solitaire, napping, and working on a puzzle alone provide ample opportunity for active hallucinations.

While sitting at the nurse's station, the nurse observes a patient using a tissue to pick up magazines and change the television channels. The nurse recognizes this as a new behavior for this patient. Which nursing action would be most important? A. Taking the tissues away from the patient B. Recognizing the behavior as attention-seeking C. Talking with the patient about the behavior D. Providing the patient with nonsterile gloves

Talking with the patient about the behavior *The nurse should question the patient regarding any changes in behavior to determine responses to treatment. It would not be therapeutic for the patient to have the tissues taken away, to be provided with nonsterile gloves, or to have the behavior recognized as attention-seeking.

A nurse is caring for a client who has a new diagnosis of benign prostatic hyperplasia (BPH). The nurse should expect a prescription for which of the following medications? A. Oxybutynin B. Diphenhydramine C. Ipratropium D. Tamsulosin

Tamsulosin *Oxybutynin is an anticholinergic medication that is used to treat overactive bladder. Anticholinergic medications are contraindicated for a client who has BPH. Oxybutynin causes urinary retention *Diphenhydramine is an antihistamine and is contraindicated for a client who has BPH *Ipratropium is an anticholinergic medication used to treat asthma and other respiratory conditions. It causes urinary retention *Tamsulosin is an alpha adrenergic receptor antagonist that relaxes the bladder outlet and the prostate gland, which improves urinary flow

You need to apply a dressing to a patient who has fragile skin. Which intervention would you use to protect the patient from skin tears? A. Ask the health care provider to give specific orders for wound care B. Gently clean and apply a sterile transparent dressing C. Tape the dressing with paper tape and prevent tension D. Allow any tape and gauze dressing materials to fall off naturally

Tape the dressing with paper tape and prevent tension *Small amounts of paper tape applied without tension to the skin is a method to prevent skin tears. (1) Choice of dressing material and wound cleansing is often based on hospital protocol and nursing discretion. (2) Transparent dressings were used in the past but are not currently recommended. (4) Colloidal or wafer barriers are allowed to fall off naturally, but tape and gauze dressings should be changed on a regular basis.

A 78-year-old woman is prescribed 1 drop of 0.25% timolol (Timoptic ophthalmic) to her left eye every day for glaucoma. How does the LPN/LVN teach the patient to perform digital nasolacrimal occlusion? A. Teach the patient to gently press her index finger over the inner corner of her eye over her tear duct for 3 minutes after putting in the eye drop B. Teach the patient to press her index finger over the outer portion of her eye (between her eye and her cheek) for 3 minutes after putting in the eye drop C. Teach the patient to press her index finger over the inner part of her eye over her tear duct for 10 to 20 seconds after putting in the eye drop D. Teach the patient to press her index finger over the outer portion of her eye (between her eye and her cheek) for 10 to 20 seconds after putting in the eye drop

Teach the patient to gently press her index finger over the inner corner of her eye over her tear duct for 3 min after putting in the eye drop.

A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? A. Notify the nurse manager. B. Tell the nurse to stop discussing the behavior. C. Provide an in-service program about confidentiality. D. Complete an incident report.

Tell the nurse to stop discussing the behavior. *The greatest risk to this client is an invasion of privacy through the sharing of confidential information in a a public place. The first action to take is to tell the newly licensed nurse to stop discuinning the client's hallucinations in a public location *Notify the nurse manager if the clien't right to privacy is violated. However, there is another action to take first *Provide an in-service program for staff about confidentiality, However, there is another action to take first *Complete an incident report about the violation there is another action to take first

A patient who is taking latanoprost for glaucoma was accidentally poked in the eye by a grandchild and thinks the cornea is scratched. What is the nurse's best action? A. Tell the patient to continue the eye drops and apply cool compresses B. Teach the patient to give the eye drops to the unaffected eye so that he or she does not miss the dose C. Tell the patient to hold the eye drops and wait until the pain from the scratch goes away before putting in the drops D. Tell the patient to hold the eye drops and contact the healthcare provider immediately

Tell the patient to hold the eye drops and contact the healthcare provider immediately

Which institute provides an excellent Internet resource for healthcare professionals, patients, and families about various eye disorders, with information and photographs? A. The John Hopkins Wilmer Eye Institute B. The National Eye Institute (NEI) C. The Vanderbilt Eye Institute D. Rand Eye Institute

The National Eye Institute (NEI)

The nurse who has recently moved from Lousiana to Texas is uncertain about the LPN/LVN's role in applying the nursing process. Which source is the most appropritate source for the nurse to consult? A. Hospital policies B. The Texas State Board of Nursing C. Rules and regulations of the Louisiana Nurse Practice Act D. The National Association of Practical Nurse Education and Service

The Texas State Board of Nursing

An older patient questions why he has begun to experience eye dryness as he has gotten older. Which statement provides the most accurate information? A. Aging places the eyes at a greater risk for infection B. The eyes of older individuals may require oil-based drops C. Environmental influences impact the ability of aging eyes to remain moist D. The amount of tears produced is reduced with aging

The amount of tears produced is reduced with aging

A nurse is assisting with collecting an admission history for a client who has acute stress disorder (ASD). Which of the following client behaviors should the nurse expect? A. The client remembers many details about the traumatic incident B. The client expresses heightened elation about what is happening C. The client remembers first noticing manifestations of the disorder 6 weeks after the traumatic incident occurred D. The client expresses a sense of unreality about the traumatic incident

The client expresses a sense of unreality about the traumatic incident *The client who has ASD often expresses dissociative manifestations regarding the even, which includes a sense of unreality *The client who has ASD tends to be unable to remember details about the incident and can block the entire incident from memory *The client who has ASD reacts to what is happening with negative emotions (anger, guilt, depression, and anxiety). Elation is an emotion that can occur in clients who have mania *Manifestations of ASD occur immediately to a few days following the event

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal? A. The client gives away a DVD and a cherished autographed picture of the performer B. The client runs out of the therapy gorup swearing at the group leader and then runs to their room C. The client gets angry with her roommate when the roommate borrows their clothes without asking D. The client becomes angry while speaking on their cell phone and slams the phone down on her bed

The client gives away a DVD and a cherished autographed picture of the performer *A depressed, suicidal client often gives away that which is of value as a way of saying "goodbye" and wanting to be remembered. Options B, C, and D identify acting-out behaviors

A nurse is reviewing the medical record of a client who has a new prescription for buproprion for depression. Which of the following findings is the priority for the nurse to report to the provider? A. The client has a family history of seasonal pattern depression B. The client currently smokes 1.5 packs of cigarettes per day C. The client had a motor vehicle crash last year and sustatined a head injury D. The client has a BMI of 25 and has gained 10 lb over the last year

The client had a motor vehicle crash last year and sustatined a head injury *The greatest risk to the client is development of seizures. Buproprion can lower the seizure threshold and should be avoided by clients who have a history of a head injury. This information is the highest priority to report to the provider

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, which would the nurse expect to note? A. The client presents a harm to self B. The client requested the admission C. The client consented to the admission D. The client provided written application to the facility for admission

The client presents a harm to self *Involuntary admission is made without the client's consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment or physical care. Options B, C, and D describe the process of voluntary admission

A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization? A. The client describes a feeling of floating above the ground B. The client has suspicions of being targeted in order to be killed and robbed C. The client states that the furniture in the room seems to be small and far away D. The client cannot recall anything that happened during the past 2 weeks.

The client states that the furniture in the room seems to be small and far away *Stating that one's surroundings are far away or unreal in some way is an example of derealization *Feeling that one's body is floating above the ground is an example of depersonalization, in which the person seems to observe their own body from a distance *Having the idea of being targeted in order to be killed and robbed is an example of a paranoid delusion *Being unable to recall any events from the past 2 weeks is an example of amnesia

The nurse in a psychitric unit is assigned to care for a client admitted to the unit 2 days ago. During review of the client's record, the nurse notes that the admission was a voluntary one. Based on this type of admission, which would the nurse expect to note? A. The client will be angry and will refuse care B. The client will participate in the treatment plan C. The client will be very resistant to treatment measures D. The client's family will be very resistant to treatment measures

The client will participate in the treatment plan *Generally, voluntary admission is sought by the client's guardian. If the client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program. Option A and C are not likely for a client seeking voluntary admission. Option D is not centered on the individual client

The nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse should determine that this type of crisis could be caused by which event? A. Witnessing a murder B. The death of a loved one C. A fire that destroyed the client's home D. A recent rape episode experienced by the client

The death of a loved one *A situational crisis is associated with a lfie event. External situations that could precipitate a situational crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, and severe illness. Option A, C, and D identify adventitious crises. An adventitious crisis relates to a crisis, disaster, or event that is not a part of everyday life, is unplanned, and is accidental

The health care provider has recommended that a patiient undergo transurethral microwave thermotherapy (TUMT). Which statement correctly explains this procedure? A. The doctor uses a surgical instrument called a resectoscope to twim away excess prostatic tissue B. The doctor uses a probe with an antenna that releases microwave energy to heat and coagulate prostatic tissue C. The doctor uses a cystoscope to guide using radiofrequency needles to coagulate prostate tissue D. The doctor vaporizes and desiccates prostatic tissue

The doctor uses a probe with an antenna that releases microwave energy to heat and coagulate prostatic tissue *The TUMT procedure uses heat to coagulate the prostatic tissue with a probe. A resectoscope trims excess tissue in a transurethral resection of the prostate (TURP). A transurethral needle ablation (TUNA) uses a cystoscope to guide needles directly into the prostrate. A transurethral electrovaporization of the prostate (TUVP) vaporizes and desiccates prostatic tissue

When a patient with burns has a full-thickness wound, which of these tissues are involved? A. The entire dermis and muscles B. The subcutaneous fat only C. The entire dermis and subcutaneous tissue D. The deeper layers of the dermis only

The entire dermis and subcutaneous tissue *A method to evaluate the depth of burns is based on the layers of skin that have been damaged. Full-thickness wounds involve all layers of skin and the destruction of the epidermal appendages. Wounds of this type will require grafting for the wound to heal and for optimal function to be restored. Partial-thickness wounds are those in which the epidermal appendages (sweat and oil glands and hair follicles) are not destroyed; these wounds will heal by themselves if no further injury occurs from either infection or inappropriate treatment for the phases of wound healing. Grafting may or may not be necessary.

A nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse recognizes that these types of delusions are characteristic of which thoughts? A. The false belief that one is a very powerful person B. The false belief that one is a very important person C. The false belief that one's partner is being unfaithful D. The false belief that one is being singled out for harm by others

The false belief that one is being singled out for harm by others *A delusion is a false belief held to be true even when there is evidence to the contrary. A delusion of persecution is the thought that one is being singled out for harm by others. A delusion of grandeur is the false belief that he or she is a very powerful and important person. A delusion of jealousy is the false belief that one's partner is being unfaithful

During an assessment, you note fever, fatigue, general weakness, cold and clammy skin, nausea, vomiting, and diarrhea. You recognize that the body is fighting infection by what means? A. Antigen-antibody reaction B. The inflammatory response C. Chemical release of interferon D. The acquired immune response

The inflammatory response *The inflammatory response produces most of the symptoms listed. (1) The antibody-antigen reaction and (3) the chemical release of interferon do not produce these symptoms. (4) There is not enough information to conclude that the patient is displaying an acquired immune response.

The 26-year-old patient with a malignant neoplasm has experienced a 10-pound weight loss in 3 weeks. To which factor is this patient's rapid weight loss most likely related? A. Disinterest in eating food in general B. Changes in the nutritional content of the patient's diet C. The malignancy's high nutritional demand D. A self-imposed rigid diet regimen

The malignancy's high nutritional demand *Rapid cell growth of the malignancy robs nutrients from normal cells and results in weight loss

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress during discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." Whole helping the mother prepare for her daughter's discharge, the nurse should make which suggestion? A. The mother should restrict the daughter's socializing time with her friends. B. The mother should restrict the amount of chocolate and caffeine products in the home C. The mother should keep her daughter out of school until she can adjust to the school environment D. The mother should consider taking time off of work to help her daughter readjust to the home enviroment

The mother should restrict the amount of chocolate and caffeine products in the home *Clients with anxiety disorder should abstain from or limit their intake of caffeine, chocolate, and alcohol. These products have the potential of increasing anxiety. Options A and C are unreasonable and are an unhealthy approach. It may not be realistic for a family member to take time away from work

A depressed patient is threatening to harm himself. Which nursing action indicates an understanding of the appropriate care of the suicidal patient? A. The nurse asks the patient if he has a plan. B. The nurse calls the family and asks them to visit the patient. C. The nurse administers a sedative. D. The nurse places the patient in seclusion.

The nurse asks the patient if he has a plan. *When a patient is threatening suicide, is it crucial to ask if the patient has a specific plan to determine the patient's risk. Sedative administration, seclusion, and family visits are not the appropriate interventions for a patient threatening suicide.

The nurse is caring for a patient with an order for an "open dressing." Which action indicates that the nurse accurately understands the order? A. The nurse leaves the entire lesion open to air B. The nurse changes wet compresses frequently enough to keep them wet C. The nurse applies medicated ointment directly in the open wound D. The nurse applies dressings to the perimeter of the wound while leaving the center of the wound open to air

The nurse changes wet compresses frequently enough to keep them wet *An open dressing is a wet dressing that kept that way, but the dressed lesion is not covered with an occlusive dressing. The dressing should be changed with each application

The nurse is caring for a patient who has dementia and has been getting up out of bed at night. What action by the nurse is most therapeutic? A. The nurse raises all of the side rails B. The nurse reassigns the patient to a room closer to the nurse's station C. The nure obtains orders from the physician to apply restraints at night D. The nurse places the mattress on the floor

The nurse places the mattress on the floor *The patient poses a significant risk for falls and needs provisions to increase safety. Placing the mattress on the floor decreases the risk of injury from falling from a larger height. Moving the patient closer to the nurse's station does not offer protection or ensure that the patient will be seen or heard. The use of side rails can be considered a restraint and it can present an additional safety hazard. Restraints are to be the last option when caring for patients

When receiving report, the nurse learns that a schizophrenia patient has been displaying waxy flexibility. Which behavior is consistent with this report? A. The patient sits and stares at the wall without speaking B. The patient arranges himself in several seated postures on the couch C. The patient marches stiffly up and down the center of the dayroom D. The patient holds his arm over with his fist clenched for an hour

The patient holds his arm over with his fist clenched for an hour *Waxy flexibility refers to maintaining a limb in one position for a long time. The catatonic patient will exhibit a stuporous demeanor. It is associated with rigidity and unusual posutring

The nurse explains to a male patient undergoing infertility studies that his luteinizing hormone (LH) is low and his follicle-stimulating hormone (FSH) is high. Which statement accurately interprets these laboratory findings? A. The patient is making testosterone and has decreased spermatogenesis B. The patient is not making testosterone and has decreased spermatogenesis C. The patient is making testosterone and has high spermatogenesis D. The patient is not making testosterone and has spermatogenesis

The patient is making testosterone and has decreased spermatogenesis *A low LH means there is adequate stimulation of testosterone. A high FSH means there is a low or decreased spermatogenesis

The nurse assess a man who is scheduled for a prostate-specific antigen (PSA) test. The nurse understands that which situation could delay the test? A. The patient reports he ate shellfish 48 h previously B. The patient reports that he has a history of an enlarged prostate C. The patient reports having a recent urinary tract infection (UTI) D. The patient's temperature is 99.0 F

The patient reports having a recent urinary tract infection (UTI) *The PSA test would be delayed in the event of a recent UTI. Other considerations include teaching about abstaining from sexual activity for 24 to 48 h before the test and collecting the blood sample prior to digital examination.

You note that a 55-year-old, light skinned patient has dry, flaky skin. Which action by the patient should alert you to a problem? A. The patient always puts a moisturizing lotion on their hands after washing them. B. The patient takes daily showers with soap and hot water C. The patient takes a daily multiple vitamin D. The patient spends some time outdoors and uses sunscreen that they reapply evert 1 1/2 to 2 hours

The patient takes daily showers with soap and hot water *Soap and hot water have been shown to strip the skin of protective oils, and studies of cultures of bath soaps have shown that these soaps harbor bacteria. (1) A daily moisturizer may be effective in reducing dry skin. (3, 4) Daily vitamins and sunscreen can be protective for the skin.

The nurse is caring for a schizophrenic patient who has been prescribed large doses of thioridazine. Which manifestaton may signal an overdose of the medication? A. The patient walks with a shuffling gait and drooling B. The patient is lethargic and takes frequent naps C. The patient exhibits disorganized thought processes D. The patient exhibits extreme excitability with periods of mania

The patient walks with a shuffling gait and drooling *Extrapyramidial side effects of pseudo-parkinonism with a shuffling gait, tremors, and excessive salivation are cardinal signs of overdose of neuroleptics

The nurse working on the renal unit is preparing to make the first rounds of the day. Which patient should the nurse visit first? A. The patient with an acute kidney infection. B. The patient scheduled for injection of dye into the blood to outline the kidney structure. C. The patient maintained on hemodialysis. D. The patient who is 1-h post-kidney transplant.

The patient who is 1-h post-kidney transplant. *The patient who is 1-h post-kidney transplant is the least stable patient and should be assessed first. The patient with an acute kidney infection, the patient maintained on hemodialysis, and the patient scheduled for a diagnostic study are lower acuity patients and can be seen after the transplant patient.

The nurse is caring for a patient with the problem statement/nursing diagnosis of Risk for Impaired Skin Integrity Related to Immobility. Which goal/outcome statement best correlates with this diagnosis? A. The patient will sit in a chair at bedside for 15 minutes after each meal B. The nurse will assist the patient to chair every shift C. The nurse will assess skin and record condition every shift D. The patient will change positions frequently

The patient will sit in chair at bedside for 15 minutes after each meal

Which male patient has the condition with the highest priority for attention? A. The patient with a testicular torsion B. The patient with urinary retention secondary to BPH C. The patient with orchitis D. The patient with Klinefelter's syndrome

The patient with a testicular torsion

What is the usual time period of drug therapy for glaucoma? A. 2 to 6 months B. The rest of the patient's life C. 3 weeks D. Until peripheral vision is restored

The rest of the patient's life

Which example shows that the nursing student demonstrates compliance with the Health Insurance Portability and Accountability Act (HIPAA)? A. The student uses the patient's full name only on clinical assignments submitted to the instructor B. The student uses the facility printer to copy laboratory reposts on an assigned patient C. The student shreds any documents that contain identifying patient information before leaving the clinical facility D. The student asks the patient for permission to copy laboratory and diagnostic reports for educational purposes

The student shreds any documents that contain identifying patient information before leaving the clinical facility

A patient who is 3 days postoperative after suprapubic prostatectomy asks, "When can I get rid of this other catheter?" Which data best indicates the nurse can discontinue the suprapubic catheter as ordered? A. Pain is adequately controlled with acetaminophen B. Urine in the urethral catheter bag is clean with a pink tinge C. The patient consumed 80% of his lunch D. The urine residual after voiding is 50 mL

The urine residual after voiding is 50 mL *After a suprapubic prostatectomy, the patient will have a suprapubic catheter in addition to a urethral catheter. After the urethral catheter is removed (sometime after the third day), the suprapubic catheter is clamped, and the patient attempts to void. Residual urine is measured afterward by unclamping the suprapubic catheter. When there is no more than 60 mL of residual urine after voiding, the suprapubic catheter is removed. Adequate pain control and appetite are signs that the patient is progressing well but do not directly affect the suprapubic catheter removal. The urethral catheter will need to be discontinued before the suprapubic catheter is removed

The teaching plan for the discharged patient whp has Meniere disease and is prescribed meclizine would probably include which information about the drug? A. It is a cholinergic medication B. It is a vitamin-drug combination C. There are antihistamine side effects D. It can be taken when you have glaucoma

There are antihistamine side effects

Which drug for glaucoma is a beta blocker? a. Timolol (Timoptic) b. Travoprost (Travatan) c. Apraclonidine (Iopidine) d. Pilocarpine (Adsorbocarpine)

Timolol (Timoptic) *Timolol is a beta blocker, travoprost is a prostaglandins agonist, apraclonidine is an adrenergic agonist; and pilocarpine is a cholinergic drug.

The patient reports to the nurse that the physician has ordered a Wood light examination. The nurse correctly recognizes the physician is concerned that the patient may have which condition? A. Tinea corpus B. Scabies C. Herpes Simplex D. Dermatitis

Tinea corpus *The Wood light is a specially designed ultraviolet (UV) light source. It is helpful in the diagnosis of fungal infections such as tinea corpus

Increased viscosity of blood slowing blood flow to small vessels A. Edema B. Hyperkalemia C. Hypovolemia D. Tissue hypoxia E. Hypermetabolism

Tissue hypoxia

Which statement explains the reason for the inclusion of potential problems in the nursing care plan? A. To alert nursing staff to prevent potential complication B. To remind the family of potential problems C. To broaden the assessment of the caregiver D. To educate the patient of aspects of her health

To alert nursing staff to prevent potential complication

In preparation for cataract surgery, the nurse is to administer cyclopentolate eyedrops. The nurse administers the eyedrops knowing that which is the purpose of this medication? A. To produce miosis of the operative eye B. To dilate the pupil of the operative eye C. To provide lubrication to the operative eye D. To constrict the pupil of the operative eye

To dilate the pupil of the operative eye

The LPN/LVN is to interview a newly admitted patient. What is the most important reason that the nurse should review the patient's records before beginning the interview? A. To check the accuracy of those records B. To determine other people's opinions of the patient's problems C. To learn as much about the disease process as possible D. To enhance observation skills during the nurse's initial patient contact

To enhance observation skills during the nurse's initial patient contact *Reading the current information before entering the patient's room and knowing current information enhances critical thinking and observation skills. The nurse can also check the accuracy of those records and learn as much about the disease process as possible, but these are not the most important reasons. Determining other people's opinions of the patient's problems is not a necessary aspect of the assessment.

The nurse is caring for a patient with a stage III pressure ulcer that is not healing. Which statement accurately describes the goal of electrical stimulation of the pressure ulcer? A. To sterilize the wound B. To increase blood vessel growth C. To cause the ulcer to close by scabbing D. To coagulate the drainage

To increase blood vessel growth *The electrical stimulation will increase blood supply by stimulating vessel growth. The voltage unit will not cleanse the wound, cause scabbing, or acoagulation of drainage

A client taking lithium carbonate reports vomiting, abdominal pain, diarrheam blurred vision, tinnitus, and tremors. The lithium level is checked as a part of the routine follow-up, and the level is 3.0 mEq/L. The nurse knows that this is which level? A. Toxic B. Normal C. Slightly above normal D. Excessively below normal

Toxic *The therapeutic serum level of lithium is 0.8 to 1.2 mEq/L. A level of 3 mEq/L indicates toxicity

A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings? A. Bacteremia B. Fluid overload C. Hypovolemic shock D. Transfusion reaction

Transfusion reaction *The signs and symptoms exhibited by the client are consistent with a transfusion reaction.

While bathing a patient, the nurse assesses a red, unblancable area on the coccyx. Which type of dressing should the nurse apply? A. Transparent film B. Hydrocolloid C. Fluffy absorbent D. Wet-to-dry

Transparent film *A transparent film for a stage I pressure ulcer will protect it from shearing injury and will retain moisture. a hydrocolloid dressing would be appropriate for a larger, more advanced pressure ulcer. There is no discharge in a stage I pressure ulcer, making absorbent and wet-to-dry dressing options inappropriate

Breast cancer that is HER2-positive has shown to be responsive to which adjuvant therapy? A. Medroxyprogesterone acetate (Depro-Provera) B. Trastuzumab (Herceptin) C. Alendronic acid (Fosamax) D. Ethinyl estradiol

Trastuzumab (Herceptin)

A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following condition? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Tuberculosis

Tuberculosis *A cough for 3 weeks and beginning to cough up blood are manifestations of TB *A pink body rash is a manifestation of an allergic reaction *Red circles with white centers is a manifestation of ringwork *A red edematous rash bilaterally on the cheeks is a manifesation of systemic lupus erythematosus

A nurse is caring for a client who has suspected Meniere's disease. Which of the following is an expected finding? A. Presence of a purulent lesion in the external ear canal B. Feeling of pressure in the ear C. Bulging, red bilateral tympanic membranes D. Unilateral hearing loss

Unilateral hearing loss *Unilateral sensorineural hearing loss is an expected finding in Meniere's disease. *(a)-Meniere's disease is an inner ear disorder. A purulent lesion in the external ear canal is not an expected finding. (b)-A feeling of pressure in the ear can occur with otitis media, but is not an expected finding in Meniere's. (c)-Meniere's disease is an inner ear disorder. Bulging, red bilateral tympanic membranes is a finding associated with a middle ear infection

A patient has been taking lithium for 5 days. The nurse notes his gait is a little unsteady with a walker, and he complains of thirst and insomnia. Which finding is most important for the nurse to report? A. Manic behavior B. Unsteady gait C. Thirst D. Insomnia

Unsteady gait *While all findings should be reported, uncoordinated movement is a sign of lithium toxicity and the priority finding. The patient is likely taking lithium to treat manic behavior. Thirst and insomnia are expected side effects of lithium and not indicative of toxicity

The nurse is caring for an older adult patient with a history or anxiety. Which complaint could indicate that the patient may actually be experiencing emotional distress? A. Upset stomach B. Heightened tooth sensitivity C. Unpleasant taste in mouth D. Dizziness

Upset stomach *The older adult population often expresses somatic complaints rather than openly verbalizing emotional distress. You may observe the anxious older adult complaining of an upset stomach. Inability to sleep, fatigue, or increased need to urinate

Which chemical irritant causes the most damage to skin of the immobilized patient? A. Urine B. Topical medication C. Bath soap D. Laundry soap

Urine *Urine and feces are the most common chemical irritants that cause skin breakdown

Male reproductive disorders are commonly treated by a A. Specialist B. Urologist C. Family practice provider D. Nurse practitioner

Urologist

A nurse is talking with a client who reports experiencing increased stress because a new partner is "pressuring me and my kids to go live with him. I love him, but I'm not ready to do that." Which of the following recommendations should the nurse make to promote a change in the client's situation? A. Learn to practice mindfulness B. Use assertiveness techniques C. Exercise regularly D. Rely on the support of a close friend

Use assertiveness techniques *Assertive communication allows the client to assert their feelings and then make a change in the situation *Mindfulness is appropriate to decrease the client's stress. However, it does not promote a change in the client's situation *Regular exercise is appropriate to decrease the client's stress. However, it does not promote a change in the client's sitation *Social supprt is appropraite to decrease the client's stress. However, it does not promote a change in the client's situation

The nurse is providing discharge teaching of a patient. Which instructions should the nurse include to teach reduction of soap in bed linens and sleeping garment? A. Only use high-efficiency detergents B. Use vinegar in the rinse water C. Only wash clothing in hot water D. Send linens to a professional laundry

Use vinegar in the rinse water *The use of vinegar in the rinse water will cut soap that may be irritaing to the skin if left in bed linens or sleeping garments. The type of washing maching that the patient owns determines whether or not high-efficiency detergent is necessary. Not all clothing may be washed in hot water. professional laundry services are not necessary

Parkland Burn Formula

V = Pt Weight (kg) x Body Surface Burned (%) x 4mL *First half (divide total by 2) is to be given the first 8 hours with the other half given over the remaining 16 hours.

The patient presents to the clinic complaining of severe vaginal itching, pain and burning on urination, and a white, cheese-like vaginal discharge. The nurse anticipates the provider will prescribe which treatment? A. Vaginal miconazole for one dose B. Oral metronidazole for 7 days C. Vaginal clotrimazole for 3 days D. Oral fluconazole for 5 days

Vaginal clotrimazole for 3 days *The patient likely has candidiasis, which is treated with one oral dose of fluconazole or 3 to 7 days of vaginal miconazole or clotrimazole. Metronidazole is an antibacterial medication, not an antifungal.

The nurse in the clinic is examining a patient with a vaginal infection. What symptom is indicative of yeast infection? A. Vaginal itching B. Thin, gray discharge C. Vaginal pH above 4.6 D. Fishy odor

Vaginal itching *The most prominent, severe symptom of a yeast infection is itching. When colonization is heavy, discharge may be thick and white with a cottage cheese texture. Bacterial vaginosis may be accompanied by a fishy odor (most noticeable after intercourse), a thin, gray, frothy discharge; and a vaginal pH above 4.6.

You observe that a patient with mild dementia has difficulty buttoning a shirt. Which nursing intervention is appropriate? A. Verbally coach the patient using simple direction B. Leave the patient alone and give extra time and privacy C. Have the nursing assistant help the patient get dressed D. Give the patient a shirt with Velcro fasteners

Verbally coach the patient using simple direction *The patient needs repetitive coaching to perform the task. This may be more time consuming than simply putting the shirt on them but allowing as much independence in tasks as possible increases self-esteem. (2) If the patient is left alone, it is unlikely that they will dress themself. (3) Having the nursing assistant dress the patient is marginally better than doing it yourself, but both you and the nursing assistant should try to coach the patient to do things for themself. (4) Velcro fasteners help if fine motor skills are the issue.

A client with severe acne is seen in the clinic and the primary health care provider (PHCP) prescribes isotretinoin. The nurse reviews the client's medication record and would contract the PHCP if the client is also taking which medication? A. Digoxin B. Phenytoin C. Vitamin A D. Furosemide

Vitamin A *Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxcity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy. There are no contraindications associated with digoxin, phenytoin, or furosemide

The nurse notes that newly admitted patient with Alzheimer disease (AD) has significant anomia. Which intervention is most appropriate for this problem? A. Frequently reorient the patient to his room location B. Remind the patient about the names and uses for particular items C. Assist the patient with all meals D. Wait patiently for the patient to find the word he wants

Wait patiently for the patient to find the word he wants *Anomia is the inability to recall a word. Waiting for the patient to remember the word or be able to substitute another is more supportive than supplying the word for him

The nurse assists with preparing the client for ear irrigation as prescribed by the primary health care provider (PHCP). Which action should the nurse plan to take? A. Warm the irrigating solution to 98 F (36.6 C) B. Position the client with the affected side up after the irrigation C. Direct a slow, steady stream of irrigation solution toward the eardrum D. Assist the client with turning his or her head that the ear to be irrigated is facing upward

Warm the irrigating solution to 98 F (36.6 C)

Which method is best to use for lotion application? A. Avoid shaking lotion to prevent bubble formation B. Apply lotion heavily as the water from lotion evaporates C. Wash off residue before applying fresh lotion. D. Apply a scant film of lotion on eyelids and in the nose

Wash off residue before applying fresh lotion. *The reside from previous applications should be removed before applying fresh lotion. Shaking lotion is not harmful, lotion should not be applied to damp skin, and application should be avoided on sensitive areas around the eyes an in the nose *SIDE NOTE-rationale says lotion should not be applied to damp skin, however, Mrs. Thompson said to apply it to damp skin as it absorbs better. Watch for a test ? on that. For testing purposes go with Mrs. T. **GOOGLE: As the back of the bottle says, you should always apply moisturizer to clean skin—and for maximum results, shortly after cleansing, before your skin is totally dry. Moisturizers are most effective if you use them while your skin is still damp because damp skin absorbs the product more readily.

The nurse is advising a 20 year old college sophmore with acne vulgaris. Which information is most important for the nurse to include in the teaching plan? A. Avoid all chocolate B. Wash your face gently with mild soap C. Scrub your face with a soft brush D. Gently express clogged sebum from your pores

Wash your face gently with mild soap *The patient should keep his face clean and dry by washing with gently mild soap and water. Although evidence exists that caffeine could potentially cause flare-ups, strict diet restrictions are no longer recommended. Scrubbing the face with a brush can cause irritation

The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client? A. Wear gloves only B. Wear a mask and gloves C. Wear a gown and gloves D. Avoid touching the client's clothes

Wear a gown and gloves *The CDC recommends the wearing of gowns and glvoes when in close contact with a person who has MRSA. Masks are not necessary. Transmission via clothing and other inanimate objects is uncommon. MRSA is contagious and is spread to others by direct contact with infected skin or infected articles

The nurse directs the nursing assistant in safety measures to be used while caring for a patient undergoing radiation therapy with a sealed implant. Which would be appropriate to include? A. Use ordinary Standard Precautions; nothing else is required B. Limit total time in patient's room to 60 minutes/8-hour shift C. Wear a radiation detection badge to detect the amount of radiation exposure D. Wear a lead apron to decrease exposure to radiation

Wear a radiation detection badge to detect the amount of radiation exposure

Which instruction must be included in the discharge teaching of a patient who has undergone corneal transplant? A. Increase physical activity B. Wear an eye shield when in close contact with children or pets C. Remove the pressure dressing as needed D. Lie only on the operative side

Wear an eye shield when in close contact with children or pets *The patient should protect the eye with an eye shield when around children or pets to prevent an accidental injury to the eye with disruption of the corneal transplant. (1) Physical activity should be reduced. (3) The pressure dressing should be kept in place. (4) The patient should lie on the opposite side of the surgery.

When developing a teaching plan for a young man who is undergoing fertility studies, which information is most important for the nurse to include? A. Engage in intercourse in the evening when testosterone levels are highest B. Relax in a hot bath or Jacuzzi nightly to relieve stress C. Wear boxer shorts instead of jockey shorts D. Only engage in intercourse during your partner's fertile period

Wear boxer shorts instead of jockey shorts *The heat from close body contact from wearing jockey shorts reduces spermatogenesis. Sexual intercourse will not increase testosterone levels. Heat will reduce sperm count, not increase it

A patient is suspected of having otosclerosis. Which diagnostic test can be anticipated? A. Amsler grid B. Brainstem-evoked response test C. Calorie test D. Weber's test

Weber's test

A nurse in an acute mental health facility is assisting with planning care for a client who has dissociative fugue. Which of the following interventions should the urse recommend? A. Reinforce with the client to recognize how stress brings on a personality change in the client B. Repeatedly present the client with information about past events C. Make decisions for the cliient on grounding techniques D. Work with the client on grounding techniques

Work with the client on grounding techniques *Grounding techniques (stomping the feet, clapping the hands, or touching physical objects) are useful for clients whp have a dissociative disorder and are experiencing manifestations of derealization *The client who has dissociative identity disorder displays multiple personalities, while the client who has dissociative fugue has amnesia regarding their identity and past *Avoid flooding the client with information about past events, which can increase the client's level of anxiety *Encourage the client to make decisions regarding routine daily activities in order to promote improved self-esteem and decrease the client's feelings of powerlessness

Biologic dressing obtained from a pig A. Open technique B. Closed technique C. Escharoctomy D. Allograft E. Xenograft

Xenograft

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which manifestations are specifically associated with withdrawal from opioids? A. Dilated pupils, tachycardia, and diaphoresis B. Yawning, irritability, diaphoresis, cramps, and diarrhea C. Tachycardia, hypertension, sweating, and marked tremors D. Depressed feelings, high drug craving, fatigue, and agitation

Yawning, irritability, diaphoresis, cramps, and diarrhea *Opioids are central nervouse system (CNS) depressants. Withdrawal effects include yawning, insomnia, irritability, rhinorrhea, diaphoresis, cramps, nausea and vomiting, muscle aches, chills, fever, lacrimation, and diarrhea. Withdrawal is treated by methadone tapering or medication detoxification. Option B identifies the clinical manifestations associated with withdrawal from opioids. Option A describes intoxication from hallucinogens. Option C describes withdrawal from alchohol. Option D describes withdrawal from cocaine

Meclizine (Antivert) is a drug that is used for patients with Meniere disease. This drug is used to reduce dizziness and is a(n) A. antihistamine B. corticosteroid C. antihypertensive D. beta blocker

antihistamine

When a patient is showing signs of severe anxiety and it is time for him to bathe and dress, it is best if the nurse A. leave the patient alone B. asks the patient why he is feeling so anxious C. explains the rationale for practicing good hygiene D. gives simple directions

asks the patient why he is feeling so anxious

A patient is experiencing acute delirium with confusion related to medication side effects. What is the best environmental intervention to use with this patient? A. Turn on a favorite program to provide a familiar distraction B. Ask several family members to come and talk about everyday topics C. Put the patient close to the nurses' station with the door open D. Assign a nursing student to observe 1-to-1 in a quiet room

assign a nursing student to observe 1-to-1 in a quiet room

The nurse instills diluted medication in the portion of the controlled volume IV setup, which is called the ___________.

burette *The burette is the tube-like chamber that holds only about 150 mL of fluid with diluted medication.

The nurse teaches a patient that a potential side effect of tamsulosin (Flomax) is postural hypotension and that he should A. take his blood pressure each day B. change positions slowly to prevent dizziness C. call the office if he starts having headaches D. rest for half an hour each afternoon

change positions slowly to prevent dizziness

The LVN/LPN is told by the RN to discontinue an IV line to the patient. The best nursing action is to: a. check the primary care provider's order. b. stop the IV flow by clamping the tubing securely. c. wash hands and don gloves. d. quickly withdraw the cannula and apply pressure.

check the primary care provider's order. *Checking the primary care provider's order will prevent inadvertently discontinuing the IV and having to restart it.

Cell-mediated immunity resulting in inflammatory response A. contact dermatitis B. atopic dermatits C. stasis dermatitis D. seborrheic dermatitis

contact dermatitis

Rash associated with posion ivy A. contact dermatitis B. atopic dermatits C. stasis dermatitis D. seborrheic dermatitis

contact dermatitis

In the collaboration rolse of the LPN/LVN and RN, when developing a prioritized list of prblem statements/nursing diagnoses, the two nurses use ______________________ to determine relationships among the data.

critical thinking

The therapeutic response expected of dorzolamide (Trusopt) is: a. dilation of the pupil. b. constriction of the pupil. c. decreased intraocular pressure. d. decreased production of aqueous humor.

decreased intraocular pressure

An intervention for setting up a dinner tray for a blind person would be to: a. place the person's hands on each side of the plate. b. describe where each type of food is located using the "clock" method. c. allow the person to cut up the meat. d. make certain there are no shadows in the room.

describe where each type of food is located using the "clock" method.

The focus of the planning step of the nursing process is A. implementing nursing interventions B. Collecting data to determine appropriate nursing diagnoses C. determining goals and identifying expected outcomes D. revising interventions according to outcomes

determining goals and identifying expected outcomes

The nurse is collecting data from an older patient with a history of fractures who has just had gallbladder surgery. Along with a focused assessment, the nurse should include: A. determining orientation to person, place, and time. B. auscultating for a heart murmur. C. checking pulse oximetry. D. testing passive and active range of motion

determining orientation to person, place, and time. *Determining orientation to person, place, and time in order to plan safe care for the patient is important since surgery in an older adult may cause electrolyte shifts that lead to more confusion and disorientation, which could cause a fall and another fracture. (2) Auscultating for a heart murmur is not pertinent to postoperative care by the LPN/LVN, as a health care provider would detect this before surgery. (3) Checking peripheral pulses is standard to the care of a postoperative patient and not pertinent to the potential risk for fracture in this patient at this time. (4) Testing active and passive range of motion is not pertinent to postoperative care after gallbladder surgery.

After the piggyback infusion is finished, the nurse would FIRST A. flush the cannula with normal saline B. attach the next piggyback medication tubing C. disconnect the piggyback tubing D. cleanse the port on the prn device with alcohol

disconnect the piggyback tubing

The nurse observes that the insertion site of an IV catheter looks pale and puffy and the area feels cool to the touch. The initial action for the nurse should be to: a. discontinue the infusion and start a new IV site. b. apply warm compresses to the site. c. monitor the patient's temperature every 4 hours. d. call the primary care provider and report these findings.

discontinue the infusion and start a new IV site *Infiltration is the most common complication of IV therapy, and it occurs when fluid or medication leaks out of the vein and into the tissue. The infusion should be discontinued immediately and a new insertion site initiated. Signs are pale, cool skin that is edematous (puffy).

A patient presents to the clinic stating that she is having problems with heavy periods with bleeding between periods, painful bowel movements, and painful sexual intercourse. You expect her to be treated for A. an inflammation of the lower genital tract B. leiomyoma C. endometriosis D. menorrhagia

endometriosis

During a health care provider visit, a 65-year-old man complains of pain in his right eye associated with excessive tearing. You note that the eye is red with lashes rubbing against the cornea. A likely condition would be A. ptosis B. ectopion C. hordeolum D. entropion

entropion *When the eyelid is inverted and the lashes rub on the eyeball, it is called entropion. (1) Ptosis is a drooping of the lower eyelid. (2) Ectropion is when the eyelid folds outward. (3) Hordeolum is a disorder of the eyelid.

The nurse outlines a diet that would be helpful in the prevention of cancer. This diet includes:

fruit *associated with fewer cancer relapses

The patient is prescribed memantine (Namenda). Common side effects to instruct the patient about are: A. insomnia, nervousness, and anxiety B. weight gain, increased thirst, and gastrointestinal upset C. blurred vision, dizziness, and hypotension D. gastrointestinal bleeding, anorexia, and nausea

gastrointestinal bleeding, anorexia, and nausea

Older adults are more prone to conductive hearing loss and tinnitus because of A. hypertrophy of the cerumen glands B. Hardened cerumen C. widening of the auditory canal D. Hair loss in the auditory canal

hardened cerumen *With age, cerumen becomes less moist and may harden, making it difficult to be expelled on its own. The hardened cerumen may cause a conductive hearing loss if not removed. (1, 3) With aging, there is not hypertrophy of the cerumen glands or widening of the auditory canal. (4) Aging may cause hair changes in the auditory canal but not resulting in conductive hearing loss.

An MAO inhibitor such as phenelzine (Nardil) may cause life-threatening A. respiratory distress B. gastrointestinal bleeding C. cardiac arrhythmias D. hypertensive crisis

hypertensive crisis

The patient reports taking pilocarpine hydrochloride (Isopto Carpine), which A. increases outflow of the aqueous humor B. dilates the pupil to reduce optic pressure C. reduces the production of aqueous humor D. blocks accomodation of the eyes

increases outflow of the aqueous humor

The nurse caring for a patient with an intermittent IV device should: a. attach continuous fluid infusion to the device. b. infuse saline or heparin solution to maintain patency. c. discontinue when the IV medication is finished. d. reduce patient activity to prevent dislodgement.

infuse saline or heparin solution to maintain patency. *The intermittent IV device should be flushed periodically with saline or heparin, depending on facility policy, to maintain patency, which allows more freedom of movement for the patient.

When assessing a patient who complains of a mild hearing loss, the nurse should first A. schedule an audiogram B. inspect the ear canal for cerumen C. inquire about past episodes of upper respiratory infection D. irrigate the ear canal for clear vision of the eardrum

inquire about past episodes of upper respiratory infection

To facilitate the administration of an IV antibiotic every 6 hours to a patient who is ambulatory, well hydrated, and on a regular diet, the nurse would insert a(n): a. primary IV line. b. secondary IV line. c. intermittent infusion device. d. central venous line

intermittent infusion device. *Patients who do not require large amounts of fluid but receive intermittent IV medications benefit from an intermittent infusion device.

The greatest number of cancer DEATHS in women will be from cancer of which site? A. lung and bronchus B. breast C. pancreas D. liver

lung and bronchus

The patient who has had significant exposure to asbestos has an increased risk of developing A. lung cancer B. oral cancer C. liver cancer D. renal cancer

lung cancer

Two serious long-term results of smoking nicotine that may occur are A. addiction to nicotine and impaired coordination B. low blood pressure and cardiac arrhythmias C. stained teeth and bad breath D. lung cancer and emphysema

lung cancer and emphysema

A patient's burns have become infected with Pseudomonas. The nurse should anticipate using which topical dressing? A. Povidone-iodine B. Silver nitrate C. Silver sulfadiazine D. Mafenide acetate

mafenide acetate (Sulfamylon)

Which assessment should the nurse perform to prevent a life-threatening complication of CNS stimulant withdrawal? A. observe frequently for respiratory distress B. monitor for cardiac dysrhythmias C. monitor urinary output D. watch for bleeding signs

monitor for cardiac dysrhythmias

Wound covered with ointment, and additional environmental warmth provided A. Open technique B. Closed technique C. Escharoctomy D. Allograft E. Xenograft

open technique

The health care provider tells the nurse that the patient had a positive reaction to a skin patch test. Which manifestation would the nurse expect to observe? A. Patient has mild shortness of breath B. Patient has a generalized rash C. patient has a wheal at the test site D. Patient has localized exudate

patient has a wheal at the test site

When discussing the nursing process, the student nurse correctly states, "The nursing process is designed to provide a means for measuring __________." A. acuity of the patients on a nursing unit B. patient outcomes C. expenses associated with care D. appropriate tasks for delegation

patient outcomes *The nursing process allows for measurement of patient outcomes by evaluating whether established patient goals have been met. The nursing process is not used to measure expenses associated with care, appropriate tasks for delegation, or acuity of patients on a nursing unit.

A patient rings the call bell and states that the IV insertion site is painful. The site is reddened, warm, and swollen. The nurse assesses that the patient is most likely experiencing: a. bloodstream infection. b. catheter embolus. c. infiltration of the line. d. phlebitis.

phlebitis. *Phlebitis is caused by irritation of the vessel by the needle, cannula, medications, or additives to IV solution. Typical signs are erythema, warmth, swelling, and tenderness.

A nurse is reviewing the medical record of a client who has a cystocele. Which of the following findings should the nurse identify as a risk factor for the development of this disorder? A. BMI of 18 B. Nulliparity C. Chronic constipation D. Postmenopausal

postmenopausal *obesity is a risk factor for the development of a cystocele. A BMI of 18 indicates the client is underweight *Multiparity is a risk factor for the development of a cystocele not nulliparity *Constipation is a risk factor for the development of a rectocele *The advancing age and loss of estrogen that correlate with postmenopausal status are risk factors for the development of a cystocele

You are assigned to care for a patient who has just been diagnosed with Meniere disease. Which diagnosis typically applies to the patient with Meniere disease and has the highest priority? A. knowledge deficit related to new diagnosis B. Anxiety related to hospitalization C. Potential for injury related to impaired balance D. Pain related to disease condition

potential for injury related to impaired balance

Motrin, Anaprox, and Advil are examples of drugs used for dysmenorrhea because they inhibt A. the transmission of pain along nerve pathways B. Salt and water retention C. smooth muscle spasm in the uterus D. production of prostaglandins

production of prostaglandins

When assessing a patient for vision problems, subtle signs of decreasing vision are: a. becoming less interested in a hobby such as sewing. b. developing a bruise on the shin from the open door to the dishwasher. c. seeing better when using prescribed glasses. d. wanting a light on in the room when watching television.

seeing better when using prescribed glasses

The patient is taking an antipsychotic medication, fluphenazine (Prolixin). Which side effect, if noted, should the nurse identify as most significant, requiring immediate intervention? A. A fixed upward gaze B. A shuffling gait C. Tapping of the foot D. Irritability

shuffling gait

A patient complains of chills, back pain, and shortness of breath a few minutes after the blood infusion is started. The first thing the nurse should do is: a. slow down the blood infusion. b. stop the blood infusion and start the saline. c. monitor vital signs and call the primary care provider. d. start low flow oxygen as per facility protocol.

stop the blood infusion and start the saline. *If a transfusion reaction occurs, such as chills, back pain, and shortness of breath or itching, the nurse should stop the infusion and start the saline to keep the line open

Two measure that have been found to decrease the discomfort of fibrocystic breast changes are A. taking vitamin C and getting sufficient exercise B. decreasing fat and protein in the diet C. controlled weight loss and wearing a support bra D. taking vitamin E and decreasing caffeine intake

taking vitamin E and decreasing caffeine intake

A nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 degrees F orally. The nurse reports the finding to the RN and anticipates that which of the following actions will take place? A. The transfusion will begin as prescribed B. The blood will be held and the physician will be notified C. The transfusion will begin after the administration of an antihistamine D. The transfusion will begin after the administration of 600 mg of acetaminophen

the blood will be held and the physician will be notified *If the client has a temperature of 100F or more, the unit of blood should be held until the PCP is notified and has the opportunity to give further prescriptions

Beginning usually around age 40, patients often develop an eye condition known as presbyopia. This condition is when: a. there is increased pressure within the eyeball. b. the ciliary muscle has less ability to allow the eye to accommodate, resulting in close vision impairment. c. protrusion of the eyeball prevents close focus. d. close vision improves while distant vision becomes more difficult.

the ciliary muscle has less ability to allow the eye to accommodate, resulting in close vision impairment.

When irrigating the ear canal to remove cerumen, aim the stream of water above or below the impaction to allow __________ to push out the cerumen.

the pressure

The nurse would plan to get another nurse to try to obtain a successful venipuncture if the first nurse was not successful in: a. five attempts. b. three attempts. c. two attempts. d. one attempt.

two attempts *If the nurse cannot initiate a patent IV in two attempts, it is good judgment to ask another nurse to perform the task.

The client with acute myelocytic leukemia is being treated with busulfan. Which laboratory value should the nurse specifically monitor during treatment with this medication? A. clotting time B. uric acid level C. potassium level D. blood glucose level

uric acid level *Bulsulfan can cause an increase in the uric acid level because of massive cell death of malignant cells. Hyperuricemia produce uric acid nephropathy, renal stones, and acute kidney injury.

A patient has come to the clinic after having been notified of exposure to gonorrhea. He states this his exposure occurred 11 days ago. If he is infected, signs and symptoms that would be expected are A. headache, rash, stiff neck, irritability, and joint pain and stiffness B. urinary frequency, and burning with purulent discharge from the urethra C. nausea, diarrhea, fever, and urinary frequency and urgency D. burning sensation of the penis and swollen lymph nodes in the groin

urinary frequency, and burning with purulent discharge from the urethra

Measures that may decrease the discomfort of dysmenorrhea include A. doing aerobic exercises when the discomfort first starts B. avoiding foods such as asparagus and watermelon C. using a heating pad and doing pelvic rock exercises D. avoiding use of tampons and douching

using a heating pad and doing pelvic rock exercises

A patient has just undergone placement of a central venous catheter through the subclavian vein. When the placement is complete, the nurse should: a. hang the prescribed fluid at a rate of 1 mL/min. b. assess the quality of the breath sounds. c. note the length of the tubing. d. wait for the results of the chest radiograph before beginning fluids.

wait for the results of the chest radiograph before beginning fluids. *Correct placement of subclavian catheters must be verified by radiographic studies before any fluid is infused through them.

The order for the patient reads "D5W 1000 mL to follow the container that is hanging presently." There are 75 mL left in the container hanging. The nurse should A. hang the new container before the old one runs dry B. wait until another 25 mL have infused before hanging the new container C. hang the new container when the remaining fluid has infused D. hang the new container when there are 10 mL left in the container

wait until another 25 mL have infused before hanging the new container

When reinforcing teaching about signs and symptoms of ovarian cancer with a community group of women, the nurse emphasizes which sign/symptom as being a typical manifestation of the disease recognized by persons diagnosed with the condition? A. Pelvic cramping B. Sharp abdominal pain C. Abdominal distention or fullness D. Postmenopausal vaginal bleeding

Abdominal distention or fullness *Ovarian cancer is the leading cause of death from gynecological cancers and occurs in women older than 50 years. The most common sign and symptoms of ovarian cancer is abdominal distention or fullness. Less common are vague symtoms of urinary frequency and urgency, and GI symptoms such as a change in bowel habits. Pelvic cramping, sharp abdominal pain, or postmenopausal vaginal bleeding are not the most typical signs and symptoms

Which drug reduces the production of aqueous humor to the greatest degree? a. Acetazolamide (Diamox) b. Pilocarpine (Isopto) c. Dipivefrin (AK-Pro) d. Travosprost (Travatan)

Acetazolamide (Diamox) *Acetazolamide is a carbonic anhydrase inhibitor that can reduce production of aqueous humor by 60% or more. Although drugs from some other classes can reduce the production of aqueous humor, this effect is much less than that of acetazolamide.

A 56-year-old patient is admitted to the hospital with pneumonia and shingles. The nurse is aware that shingles is caused by which occurrence? A. Exposure to individuals with genital herpes B. Compromised immune function C. Activation of varicella-zoster in individuals who have had varicella D. Reactivation of herpes simplex

Activation of varicella-zoster in individuals who have had varicella *Shingles is an activation of the chickenpox virus in an adult. Although related to it, the herpes simplex virus does not cause chickenpox or shingles. Herpes simplex II does not cause chickenpox or shingles. A compromised immune system (such as might occur when a patient has pneumonia or another infection, the immune system is fighting) does predispose an individual to opportunistic viruses, such as herpes zoster and herpes simplex, however.

The nursing team is prioritizing the problem statement/nursing diagnoses of an overnight hospital patient. Which problem statement/nursing diagnosis would be most important for this patient? A. Risk for dehydration related to vomiting B. Activity intolerance related to shortness of breath C. Knowledge deficit related to weight reduction diet D. Altered self-image related to excessive weight

Activity intolerance related to shortness of breath

A patient has skin lesions on the face, trunk, palms, extensor surfaces of joints, soles on the feet, and dorsum of the hands. On inspection, the lesions are found to have irregular borders and blistered, necrotic centers. The health care provider makes the medical diagnosis of SJS. What is the priority problem for the patient? A. Altered body image B. Altered self-care ability C. Potential for infection D. Acute pain

Acute pain *The patient will have acute pain due to the lesions, and the wound care is similar to burn wound care, which is also generally very painful. (1, 2, 3) The other options are also appropriate but less urgent.

Needs substance to prevent symptoms of withdrawal A. Abuse B. Psychological dependence C. Addiction D. Tolerance E. Withdrawal

Addiction

A nurse is reinforcing teaching with a client who has a history of psoriasis about photochemotherapy and ultraviolet light (PUVA) treatments. Which of the following instructions should the nurse include? A. Apply vitamin A cream before each treatment B. Administer a psoralen medication before the treatment C. Use this treatment every evening D. Remove the scales gently following each treatment

Administer a psoralen medication before the treatment

A patient returns from TURP surgery with a 3-way Foley catheter and CBI. Postoperative orders include meperidine 75 mg intramuscularly as needed for pain, belladonna and opium (B&O) suppository every 4 h or as needed, and strict intake and output. The patient complains of painful bladder spasms, and the nurse notes blood-tinged urine on the sheets. Which action should the nurse take first? A. Administer the meperidine. B. Notify the health care provider immediately. C. Cool the CBI solution with ice packs surrounding the bag. D. Administer the B&O suppository.

Administer the B&O suppository. *The B&O suppository will relieve bladder spasms. Meperidine will relieve pain but not spasms. Bladder spasms are expected; notifying the health care provider is not necessary, and doing so stat is inappropriate.

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium carbonate, the client's lithium blood level is 1.2 mEq/L. Which of the following actions should the nurse take? A. Administrer the next dose of lithium carbonate as scheduled B. Prepare for administration of aminophylline C. Notify the provider for a possible increase in the dosage of lithium carbonate D. Request a stat repeat of the client's lithium blood level

Administrer the next dose of lithium carbonate as scheduled *During a manic episode, the lithium blood level should be 0.8 to 1.4 mEq/L. It is appropriate to administer the next dose as scheduled *Aminophylline can be prescribed for treatment of severe toxicity for levels greater than 1.5 mEq/L *A dosage increase would place the client at risk for toxicity and is therefore not and appropriate action *A lithium level of 1.2 mEq/L is an expected finding for a client who is experiencing a manic episode. It is not necessary to request a stat repeat of the lab test

Which class of drugs for glaucoma therapy generally is used short term to prevent or reduce increases in intraocular pressure (IOP) after eye surgery rather than for long-term IOP control? a. Cholinergic drugs b. Adrenergic agonists c. Prostaglandins agonists d. Beta-adrenergic blockers

Adrenergic agonists *The adrenergic agonists generally are used short term for 1 to 4 weeks to prevent or reduce increases in IOP. They are more likely to cause severe, systemic side effects if used long term. The other three drug classes are used long term for IOP control.

The nurse is providing education to a 22-year-old man at his annual physical examination. The nurse should instruct the patient to perform his monthly testicular self-examination at what time? A. After a cold shower B. After emptying the bladder C. After a warm bath D. Before arising in the morning

After a warm bath

A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse should encourage the client to attend which community group? A. Al-Anon B. Fresh Start C. Families Anonymous D. Alcholics Anonymous

Alcholics Anonymous *Alcoholisc Anonymous is a major self-help organization for the treatment of alcoholism. Option A is a group for families of alcholics. Option B is for nicotine addicts. Option C is for parents of children who abuse substances

Which foundational behavior is necessary for effective critical thinking? A. Unshakeable beliefs and values B. An open-minded attitude C. An ability to disregard evidence inconsistent with set goals D. An ability to recognize the perfect solution

An open-minded attitude

A nurse caring for a child who has contact dermatitis and has a new prescription for diphydramine. For which of the following adverse effects should the nurse monitor? A. Elevated blood glucose levels B. Anorexia C. Increased salivation D. Insomnia

Anorexia

A licensed practical nurse (LPN) attends a session about bioterrorism agents including anthrax. Which statement by an attendee demonstrates the need for further teaching about anthrax? A. Anthrax is treated with antibiotic medications B. The most lethal form of anthrax is contacted by inhalation of the spores C. Anthrax can be transmitted by consumption of meat from an infected animal D. Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis

Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis *Anthrax is caused by Bacillus anthracis, and it can be contracted through the digestive system, abrasions in the skin, or inhalation. Antibiotics are administered. Botulism is caused by a neurotoxin that causes severe paralysis and can be fatal.

The nurse explains that a vaccination provides defense against infection in which type of immunity? A. Innate immunity B. The inflammatory response C. Antibody-mediated immunity D. Cell-mediated immunity

Antibody-mediated immunity *Vaccinations produce an antibody-mediated immunity by stimulating the host to develop specific antibodies against specific diseases

During report, the nurse is told that a patient has Cluster B group type of personality disorder. Which type of behavior can the nurse anticipate? A. Paranoia B. Avoidance C. Antisocial behavior D. Obsessive-compulsive disorder

Antisocial behavior *The antisocial personality disorder is included in Cluster B: dramatic and erratic

The nurse explains that anxiety disorders differ from normal anxiety. Which statement accurately describes anxiety disorders? A. Anxiety disorders develop into suicidal tendencies B. Anxiety disorders are seldom controlled C. Anxiety disorders interfere with effective functioning D. Anxiety disorders make maintenance of relationships impossible

Anxiety disorders interfere with effective functioning *Anxiety disorders interrupt normal day-to-day functioning in the workplace and in family settings

A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which immediate action? A. Apply ice to the affected eye B. Irrigate the eye with cool water C. Notify the primary health care provider D. Accompany the client to the emergency department

Apply ice to the affected eye

After a medicated bath, the patient is assisted from the tub. Which statement about lotion application is correct? A. Apply lotion immediately after drying the patient B. Apply lotion in a thick layer to warm skin C. Apply lotion after returning the patient to bed D. Allow the patient to apply the lotion

Apply lotion immediately after drying the patient *Medication is applied to a thin layer as soon as the patient has completed a bath. Applying the lotion in a thick layer, waiting to apply the lotion, or deferring the lotion application to the patient is not appropriate

Which precaution is most important to teach a patient who is prescribed any type of eye drug given as eye drops? a. Apply only the number of drops prescribed. b. Stop the drug immediately if eye redness occurs. c. Wear dark glasses for 1 h after placing the eye drops. d. Apply pressure to the corner of the eye after the drug has been placed.

Apply only the number of drops prescribed. *Not only can eye drops enter the circulatory system and have systemic effects, excessive drops for some types of drugs for glaucoma can reduce intraocular pressure to dangerously low levels. Many patients do not consider any topical drug, including eye drops, to be "real" drug and believe that more drug is better. Patients must be taught to use all eye drugs exactly as prescribed, and not use more drug than is prescribed.

The nurse is changing the dressing on self-inflicted cigarette burns on a patient with borderline personality disorder. When providing the care, which action is most therapeutic? A. Change the dressing while being nurturing and caring to keep patient from feeling abandoned B. Approach the dressing change with matter-of-fact demeanor to decrease secondary gains of sympathy C. Present a stern attitude to underscore the seriousness of the act D. Interact in a professional and distant manner to diminsh the opportunity for manipulation

Approach the dressing change with matter-of-fact demeanor to decrease secondary gains of sympathy *The person with the borderline personality disorder will seek additional secondary gains in terms of attention about the manipulative act of self-mutilation. Nurturing with reinforce the effectiveness of the mutilation to gain attention. Stern and distant demeanors may appear confrontational to the patient and reduce the therapeutic aspects of the intervention

What information will best help the nurse determine whether the patient is experiencing a threat to his mental health? A. Opinion of the health care provider B. Opinion of family members C. Appropriateness of behavior to a situation D. Intelligence testing and educational level

Appropriateness of behavior to a situation *Appropriate behavior is an indicator of mental health. Although significant, the family's opinion, health care provider's opinion, and intelligence level may not consistently correlate with mental health status.

A tonometer reading reflects the amount of pressure exerted by which component of the eye? A. Sclera B. Aqueous humor C. Vitreous humor D. Cornea

Aqueous humor *The tonometer reads the pressure exerted by the aqueous humor in the anterior chamber. The sclera is the part of the eyeball that is opaque white and covers the posterior portion of the eyeball. The vitrerous hymor is the substance found in the posterior chamber of the eye between the lens and the retina. The cornea is a transparent structure in the eye that allows light to hit the lens. It is involved in the bending of light rays

A client receiving a tricyclic antidepressant arrives at the mental health clinic. Which observation indicates that the client is correctly following the medication plan? A. Reports not going to work for the past week B. Complains of not being able to "do anything' anymore C. Arrives at the clinic neat and appropriate in appearance D. Reports sleeping 12 hours per night and 3 to 4 hours during the day

Arrives at the clinic neat and appropriate in appearance *Depressed individuals will sleep for long periods, are not able to go to work, and feel as if they cannot "do anything." Once they have had some therapeutic effect from their medication, they will report resolution of many of these complaints, as well as demonstrate an improvement in their appearance

The nurse is reviewing the chart of an African American patient and reads that the patient presented to the emergency department with pallor. Pallor is a term used to describe which assessment? A. Ashen-gray tone to the skin B. Extremely pale color to the skin C. Inflammation of an area of the skin D. Bruising to the skin

Ashen-gray tone to the skin *Pallor in a dark-skinned person presents as an ashen-gray tone to the skin. In a brown-skinned person, pallor gives the skin a yellow-brown color. An extremely pale color to the skin is pallor in a white-skinned person. Inflammation appears as redness, usually accompanied by increased warmth. Bruising is referred to as ecchymosis.

The nurse believes that another nurse is "stealing" narcotic doses from patients and self-injecting the medication. What should the nurse do first? A. Follow the nurse to verify suspicions B. Confront the nurse and ask for an explanation C. Ask the nurse if they are getting pain relief D. Ask a supervisor to give advice about the situation

Ask a supervisor to give advice about the situation

A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take? A. Stop the interview at this point, and resume later when the client is better able to concentrate. B. Ask the client, "Are you seeing something on the ceiling?" C. Tell the client, "You seem to be looking at something on the ceiling. I see something there, too." D. Continue the interview without comment on the client's behavior.

Ask the client, "Are you seeing something on the ceiling?" *Ask the client directly about the halluncation to identify client needs to monitor for a potential risk for injury *Address the client's current needs related to the possible hallucincation rather than stop the interview *Avoid agreeing with the client, which can promote psychotic thinking *Address the client's current needs related to the possible hallucination rather than ignoring the change in behavior

During an intake interview, the nurse observes the patient grimacing and holding his hand over his stomach. The patient previously denied having any pain. What action should the nurse take next? A. Examine the history closely for etiology of pain B. Ask the patient if he is experiencing abdominal pain C. Record that patient seems to be having abdominal discomfort D. Physically examine the patient's abdomen

Ask the patient if he is experiencing abdominal pain

While conducting an admission interview, the nurse questions the patient about pain. The patient responds, "No. I'm pretty wobbly." Which action should the nurse take next? A. Repeat the question about pain B. Ask the patient to clarify his meaning C. Record that the patient denied pain D. Record that the patient stated he was wobbly

Ask the patient to clarify his meaning

Which maneuver serves to lessen the possibility of systemic absorption of an ophthalmic beta-blocker? a. Instill the eye drop in the corner of the eye. b. Perform punctal opening of the affected eye. c. Ask the patient to close their eyes for 2 minutes. d. Ask the patient to take a deep breath while the eye drops are instilled.

Ask the patient to close their eyes for 2 minutes *After giving the drops, ask the patient to close their eyes for 2 minutes. Closing the eyes for 2 minutes reduces the amount of drug absorbed systemically. Another option to reduce systemic absorption of the drug is digital nasolacrimal occlusion (this technique has also been called "punctal occlusion").

A nurse wants to use democratic keadership with a group whose purpose is to learn appropriate conflict resolution techniques. The nurse is correct in implementing this form of group leadership when demonstrating which of the following actions? A. Observes group techniques without interfering interfering with the group process B. Discusses a technique and then directs members to practice of the technique C. Asks for group suggestions of techniques and then supports discussion D. Suggests techniques and asks group members to reflect on their use

Asks for group suggestions of techniques and then supports discussion *Democratic leadership supports group interaction and decision making to solve problems *Laissez-faire leadership allows the group process to progress without any attempt by the leader to control the direction of the group *Autocratic leadership controls the direction of the group

The nurse is aware the patient with brderline personality disorder did not have a family visit this week and adds an intervention to address the patient's perception of abandonment. Which intervention is most appropriate? A. Schedule the patient for pet therapy visit B. Arrange for remote activity during next visiting time C. Assess daily for evidence of self-mutilation D. Assign a young CNA to his care

Assess daily for evidence of self-mutilation *Patients with borderline personality disorder have a deep fear of abandonment and react with intense, emotionally charged acts, such as suicide attempts of self-mutilation

A patient returns from physical therapy, and her IV has a very sluggish flow, but it was functioning well before going to physical therapy. What is the primary nursing action? A. Call the physical therapist and ask if anything happened to the IV during the treatment session B. Discontinue the IV and restart the IV at a new site C. Assess the IV insertion site and tubing and try repositioning the extremity D. Use a heparin flush to clear the line

Assess the IV insertion site and tubing and try repositioning the extremity *Assess the site and try to troubleshoot; repositioning the extremity is one solution. Also, try to aspirate for a small blood clot. (See Table 36-3 for other troubleshooting tips.) (1) PT should have called you if something happened to the patient that created a potential danger. It is unlikely that you will gain any useful information by calling, but you could if you suspect an unusual circumstance. (2) Discontinue and restart, if you have tried to reestablish flow without success. (4) Use of a heparin flush requires a medical order.

What is the priority action when you are caring for a patient with active hallucination? A. Assess the content and themes of hallucinations B. Give an antipyschotic medication C. Take the patient to a secluded area D. Set boundaries and explain rationale

Assess the content and themes of hallucinations *Assess the content and theme of hallucinations to determine if there is a danger to self or others. (2, 3) Based on your assessment, you may decide that medication or isolation is necessary. (4) Setting boundaries does not alleviate the hallucinations; however, you should explain your actions if you medicate or isolate.

A 35-year-old patient scheduled for a unilateral orchiectomy as treatment for testicular cancer is withdrawn and avoids interacting with the nurse. Which action would be most appropriate in this situation? A. Setting a patient outcome that the patient will verbalize his concerns about his diagnosis B. Asking the patient if he is worried about future sexual function C. Telling the patient he probably will not overcome his fears unless he talks about them D. Assessing the patient regarding his concerns related to his diagnosis and treatment

Assess the patient regarding his concerns related to his diagnosis and treatment.

The nurse adds an intervention to the nursing care plan for a patient on neuroleptics. Which intervention is most appropriate? A. Increase fluid intake to compensate for the side effect of diarrhea B. Encourage snacks to prevent weight loss C. Monitor vital signs for hypertension D. Assess urinary output for evidence of urinary retention

Assess urinary output for evidence of urinary retention *Neuroleptics cause urinary retention, weight gain, constipation, and hypotension. Diarrhea is not assiciated with the administration of neuroleptics. Weight gain, and not weight loss, is associated with this type of medication. Hypertension is not associated with this type of medication

The patient with delirium is combative and is putting herself and others at risk. Which nursing intervention should be implemented as an alternative to restraint use? A. Turn the TV up loud to distract the patient. B. Use all four side rails to prevent the patient from getting out of bed. C. Assign a sitter for one-on-one observation. D. Place the patient in a room away from the nurse's station.

Assign a sitter for one-on-one observation. *Nursing interventions that can be used as an alternative to restraints include assigning a sitter for one-on-one observation, reducing noise, and keeping the patient close to the nurse's station. Use of all four side rails should be avoided as it is a strangling hazard and is considered a type of restraint. Three side rails may be used to prevent the patient from rolling out of bed.

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is the nurse's most important intervention to maintain client safety? A. Request that a peer remain with the client at all times B. Remove the client's clothing and place the client in a hospital gown C. Assign a staff member to the client who will remain with him or her at all times D. Admit the client to a seclusion room where all potentially dangerous articles are removed

Assign a staff member to the client who will remain with him or her at all times *Hanging is a serious suicide attempt. The plan of care must reflect action that will promote the client's safety. Constant observation status (one-on-one) with a staff member who is never less than an arm's length away is the safest intervention

The nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse should avoid which intervention in the plan of care? A. Facing the client when providing care B. Ensuring that a security officer is within the immediate area C. Keeping the door to the client's room open when with the client D. Assigning the client to a room at the end of the hall to prevent disturbing the other clients

Assigning the client to a room at the end of the hall to prevent disturbing the other clients *The client should be placed in a room near the nurse's station and not at the end of a long, relatively unprotected corridor. The nurse should not isolate himself or herself with a potentially violent client. The door to the client's room should be kept open, and the nurse should never turn away from the client. A security officer or male aide should be within immediate call in case the possibility of violence is suspected

The nurse is planning care for patients with cognitive disorders. Which task can be assigned to the nursing assistant? A. Determine which patients need assistance with hygienic care B. Evaluate the patient' responses to reality-orientation therapy C. Assist patients to ambulate in the hall or enclosed courtyard D. Observe patients for changes in mental status during the shift

Assist patients to ambulate in the hall or enclosed courtyard

The nurse is caring for a burn patient. Which action best prevents contractures? A. Assist the patient with ambulation as soon as fluid shifts stabilize B. Medicate the patient approximately 30 minutes prior to dressing changes C. Ensure adequate hydration D. Ensure adequate nutritional intake

Assist the patient with ambulation as soon as fluid shifts stabilize *While each of these interventions is important for management of the patient with burns, only ambulation works to prevent contractures. Other interventions adress pain management, adequate hydration, and adequate nutritional intake

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times? A. Immediately before swimming B. 5 minutes before exposure to the sun C. Immediately before exposure to the sun D. At least 30 minutes before exposure to the sun

At least 30 minutes before exposure to the sun *Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating

A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons? A. Nacissistic behavior B. Fear of rejection from staff C. Attempt to reduce anxiety D. Adverse effect of antidepressant medication

Attempt to reduce anxiety *Clients who have OCD demonstrate repetitive behavior in an attempt to suppress persistent thoughts or urges that cause anxiety *Narcissism causes clients to seek admiration from others *Fear of rejection might cause a client to avoid social situations and might be associated with social phobia anxiety disorder *Clients who have OCD might take an antidepressant to help control repetitive behavior

A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe metal illness and requires supervision. The client's partner works all day but is home by late afternoon. Which of the following strategies should the nurse suggest for follow-up care? A. Receiving daily care from a home health aide B. Having a weekly visit from a nurse case worker C. Attending a partial hospitalization program D. Visting a community mental health center on a daily basis

Attending a partial hospitalization program *A partial hospitalization program can provide treatment during the day while allowing the client to spend nights at home, as long as a responsible family member is present *Daily care provided by a home health aide and weekly visits from a case worker will not provide adequate supervision for this client *Daily visits to a community mental health center will not provide consistent supervision for this client

A nurse is caring for a cliet who has a new prescription for disulfiram for treatment of alcohol use disorder. The nurse informs the client this medication can cause nausea and vomiting when alcohol is consumed. Which of the following types of treatment is this method an example? A. Aversion therapy B. Flooding C. Biofeedback D. Dialectical behavior therapy

Aversion therapy *Aversion therapy pairs a maladaptive behavior with unpleasant stimuli to promote a change in behavior. *Flooding is planned exposure to an undesirable stimulus in an attempt to turn off the anxiety response *Biofeedback is a behavioral therapy to control pain, tension, and anxiety *Dialectical behavior therapy is a cognitive-behavioral therapy for clients who have a personality disorder and exhibit self-injurious behavior

The nurse is educating a young woman newly diagnosed with genital herpes. Which information is most important for the nurse to include in the teaching plan? A. Take the entire course of antibiotics B. Increase fluid intake to dilute urine C. Wash hands after applying ointment to lesions D. Avoid all sexual contact until lesions completely resolve

Avoid all sexual contact until lesions completely resolve *To prevent spreading genital herpes, the patient should avoid sex until all the lesions are gone. Genital herpes is a viral condition and symptoms can be managed by antiviral medication. Increasing fluid intake will help dilute urine and can manage pain, but is of lesser importance that preventing the spread of genital herpes. The patient should don glvoes when applying topical ointment

The nurse is educating a patient with acne rosacea that has facial erythema and telangiectases. Which information should then nurse include in the teaching plan? A. Drink 4 ounces of wine daily to promote vasodilation B. Wash your face at least three times daily C. Avoid direct sunlight D. Apply tea bags to the affected areas

Avoid direct sunlight *Avoiding direct sunlight will reduce the symptoms. Factors that cause facial flushing precipitate worsening. Tea, coffee, alcohol (espeically wine), caffeine-containing foods, spicy foods, sunlight, and emotional stress cause flare-ups. Washing the face too frequently can lead to skin irritation and dry skin

A client with Meniere's disease is experiencing severe vertigo. The nurse reinforces instructions to the client to do which to assist with controlling the vertigo? A. Increase sodium in the diet B. Lie still and watch television C. Avoid sudden head movements D. Increase fluid intake to 3000 mL/day

Avoid sudden head movements

A patient has been diagnosed with chlamydia for the seconds time in a 5 month period. Data collection reveals that the patient was not compliant with the plan of treatment with the last infection. Which medication does the nurse anticipate that the provider will prescribe? A. Docycline B. Erythromycin C. Diflucan D. Azithromycin

Azithromycin *Chlamydia is best treated with a single dose of azithromycin for patients having a compliance problem. Doxycycline requres a 7 day course of therapy and may not be best given this patient's history. Erythromycin is indicated to manage the disease in pregnant women. Diflucan is an antifungal medication used in the management of candidiasis

Which drug group for glaucoma can worsen underlying respiratory conditions? a. Cholinergics b. Beta blockers c. Adrenergic agonists d. Prostaglandin agonists

Beta blockers *Beta blockers that are absorbed systemically cause constriction of bronchiolar smooth muscle and can make asthma worse

During a morning assessment, the nurse observes that the patient displays significant edema of both feet and ankles. Which statement best documents these findings? A. Pitting edema present in both feet and ankles B. Edema in both feet and ankles approximately 4 mm deep C. 4 mm pitting edema quickly resolving D. Bilateral pitting edema in feet and ankles, 4 mm deep, resolving in 3 seconds

Bilateral pitting edema in feet and ankles, 4 mm deep, resolving in 3 seconds

The nurse is caring for a patient who was admitted for a lorazepam (Ativan) overdose. Which assessment finding indicates that the patient is experiencing withdrawal? A. Lethargy B. Urine output of 40 mL/h C. Heart rate of 48 beats per minute D. Blood pressure of 140/90

Blood pressure of 140/90 *Elevated blood pressure is consitent with withdrawal from a central nervous system (CNS) depressant like lorazepam (Ativan), a benzodiazepine. If an individual has been abusing drugs that depress the CNS and goes through withdrawal, other symptoms would include an elevation in pulse, nervousness, and heightened anxiety. The patient would likely be agitated rather than lethargic and tachycardic. Urine outpur of 40 mL/h is a normal finding

The nurse is aware that when Korsakoff syndrome is suspected from behavioral cues, the syndrome can be confirmed by which diagnostic test? A. Liver biopsy B. Brain scan C. Magnetic resonance imaging D. Spinal tap

Brain scan *The individual with Korsakoff syndrome has grossly impaired memory and gait disturbance. Confabulation (making up stories) frequently is seen as an attempt to communicate. A brain scan will show brain atrophy; currently, there is no treatment to reverse the condition

The nurse is educating a speaking to a group of junior high girls about reproductive health. Which information is most important to include? A. Breasts may be tender in the middle of the cycle B. Girls ages 12 or older who have not had a period should see a doctor C. Irregular or missed periods are nothing to worry about D. A normal period may last up to 2 weeks

Breasts may be tender in the middle of the cycle *Hormonal changes during the mid-portion of the cycle may increase breast tenderness. The onset of the menstrual cycle completes puberty and usually occurs between ages 9 and 17. During the first year following menarche, the menstrual cycle may be somewhat irregular, but by the second year a regular cycle of approximately 28 days is normalls established. Irregular periods may be a benign finding, but late or absent periods could also be a cause for concern (including a potential sign of pregnacny). Menstrual bleeding occurs about 14 days after oculation and lasts between 2 and 8 days

Intake of cruciferous vegetables is recommended to prevent cancer. Which vegetable belongs to this classification? A. Green beans B. Asparagus C. Parsley D. Cabbage

Cabbage

A nurse is reinforcing teaching with a client on the use of calcipotriene topical medication for the treatment of psoriasis. Which of the following laboratory values should the nurse monitor? A. Potassium B. Calcium C. Sodium D. Chlorine

Calcium

The physician recommends that a patient have diagnostic testing performed to assess for an alteration in vestibular function of the ears. Based on your knowledge, which test do you anticipate will be ordered? A. Weber test B. Evoked-response audiometry testing C. Calorie test D. Rinne test

Calorie test

Critical thinking is important in the nursing process because it A. Can provide a better outcome for the patient B. Simplifies the planning process for the nurse C. Allows the patient to have input on the plan D. Directly communicates the plan to others

Can provide a better outcome for the patient *Critical thinking can help create a better care plan and provide a better outcome for the patient. (2) It does not simplify the planning process for the nurse. (3) The patient should have input on the plan with or without the use of critical thinking. (4) Writing out the plan communicates it to others, not critical thinking.

Why do many people who abuse Cannabis (marijuana) rationalize their use? A. Cannabis sedates them B. Cannabis expands their senses C. Cannabis heightens sexual pleasure D. Cannabis is legal everywhere so it is ok

Cannabis expands their senses *Many young people offer the increased sensitivity to sound, colors, and other environmental elements as a rationale for using the nonaddicting drug

What term would indicate to you that a substance in the environment can cause cancer to develop? A. Biologic B. Carcinogenic C. Emetogenic D. Immunotherapeutic

Carcinogenic *Carcinogenic means cancer causing. (1) Biologic relates to biology. (3) Emetogenic means causing nausea and vomiting. (4) Immunotherapeutic means treatment of disease by enhancing the immune system.

A patient who has been prescribed timolol (Timoptic) for the last month reports that his asthma is worse. What is your best first response? a. Check the patient's breath sounds and pulse rate. b. Hold the dose and notify the prescriber immediately. c. Ask the patient what drugs he takes to control his asthma. d. Reassure the patient that this is an expected response and requires no action.

Check the patient's breath sounds and pulse rate. *Timolol is a nonspecific beta blocker that can have systemic effects. It can cause bronchoconstriction and can make heart failure worse with backing of fluid into the lungs. The first action is to determine whether the patient needs immediate attention for either bronchoconstriction or possible heart failure. This is done by assessing breath sounds with a stethoscope and checking the pulse for rate, strength, and regularity. If a pulse oximeter is available, it should be used to assess the patient's degree of oxygen saturation. The results of this assessment along with the patient's report are then provided to the prescriber. It is likely that the class of drugs used to control this patient's glaucoma will need to be changed.

A patient who had TURP reports increasing bladder spasms. Which is the appropriate initial nursing action? A. Medicate with B&O suppository B. Check the urinary catheter tubing for kinks and obstruction C. Teach relaxation exercises D. Encourage use of patient-controlled analgesia

Check the urinary catheter tubing for kinks and obstruction *Before giving medication, the nurse checks the tubing to ensure that it is not kinked and the catheter is draining well, as obstruction can cause bladder spasm. (1) This is not an initial action. Abdominal distention may be a sign of catheter obstruction as well. (3) Relaxation is not effective to eliminate spasms. (4) The patient who has had a radical procedure may have a patient-controlled analgesia pump to control pain.

The nurse is collecting information from a patient during her annual pelvic examination. The patient reports that she has noted a strong vaginal odor after intercourse. Which condition may be present? A. Gonorrhea B. Bacterial vaginosis C. Chlamydia D. Syphilis

Chlamydia *Chlamydia may cause a strong vaginal odor noted after sexual intercourse. Gonorrhea causes vaginal discharge and a difficult voiding. Bacterial vaginosis is associated with a fishy vaginal odor and discharge. Syphilis causes a chancre sore

How should the nurse speak when communicating with a patient with moderate Alzheimer dementia? A. Slowly B. Clearly C. Loudly D. Softly

Clearly *Clarity is essential when communicating with a patient with Alzheimer dementia. placing self directly in front of the patient and using pictures or symbols is helpful

A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing? A. Uncaps the distal end of the tubing B. Uncaps the spike portion of the tubing C. Opens the roller clamp on the IV tubing D. Closes the roller clamp on the IV tubing

Closes the roller clamp on the IV tubing *The nurse should first clamp the tubing to prevent the solution from running freely through the tubing after it is attached to the IV bag. The nurse should next uncap the proximal (spike) portion of the tubing and attach it ti the IV bag. The IV bag is elevated, and the roller clamp is then opened slowly, and the fluid is allowed to flow through the tubing in a controlled fashion to prevent air from remaining in parts of the tubing

Alcohol based hand sanitizer is frequently adequate, however, when caring for patients with infections, which types of pathogens require strict soap and water hand hygiene. (Select all that apply): A. Clostridium difficile B. Staphylococcus aureus C. Candida albicans D. Pseudomonas aeruginosa E. Klebsiella pneumoniae

Clostridium difficile

A patient with a life-threatening condition is brought to the emergency department. The LPN/LVN is to care for the patient. What is the LPN/LVN's first action? A. Determine nursing diagnoses and set priorities for expected goals. B. Assess the major problems and begin interventions. C. Collect data on the patient and recognize priorities. D. Assess the patient completely and determine what outcomes are realistic.

Collect data on the patient and recognize priorities. *Following the steps of the nursing process is necessary in order to plan and implement effective patient care. Data collection, planning and implementation of nursing interventions, and evaluation of patient goals are the steps followed. Assessing the major problems and beginning interventions is the role of the provider. Determining nursing diagnoses and setting priorities for expected goals is not the initial action. Complete assessment of the patient and determination of realistic outcomes is not an appropriate first action while the patient is in a life-threatening condition.

The patient requires Transmission-Based Precautions because of a draining wound positive for methicillin-resistant Staphylococcus aureus (MRSA). The patient must go to the radiology department for diagnostic-testing. What should the nurse do? A. Call the health care provider and ask if the testing is really needed B. Reschedule the test for after the MRSA is resolved C. Put a mask on the patient just prior to transport D. Communicate with the radiology department regarding the presence of MRSA

Communicate with the radiology department regarding the presence of MRSA

Tamoxifen is prescribed for the client with metastatic breast carcinoma. The nurse understands that which is the primary action of this medication? A. Increase DNA and RNA synthesis B. Promote the biosynthesis of nucleic acids C. Increase estrogen concentration and estrogen response D. Compete with estradiol for binding to estrogen in tissues containing high concentration of receptors

Compete with estradiol for binding to estrogen in tissues containing high concentration of receptors

Which kind of hearing loss most often occurs from stiffening of the bones of the middle ear or from scarring of the tympanic membrane? A. Tinnitus B. Conductive C. Sensorineural D. Mixed Types

Conductive *Conductive hearing loss most often occurs from stiffening of the bones of the middle ear or from scarring of the tympanic membrane. Tinnitus is ringing in the ears. Sensorineural hearing loss is related to nerve damage

You recognize which of the following as symptoms associated with delirium? A. Fading short-term memory, withdrawn behavior, and depression B. Inattention to hygiene, sad countenance, little verbal expression C. Confusion, incoherent speech, sudden onset of symptoms D. Inability to recognize familiar objects, angry outbursts, confusion

Confusion, incoherent speech, sudden onset of symptoms *Patients with delirium have symptoms of confusion and incoherent speech, with the sudden onset of symptoms. (1) Fading short-term memory, withdrawn behavior, and depression are characteristic of Alzheimer disease. (2) Inattention to hygiene, sad countenance, and little verbal expression are common in moderate Alzheimer disease. (4) Inability to recognize familiar objects, angry outbursts, and confusion are particular to moderate to severe Alzheimer disease.

The school nurse is advising a group of high school girls about ways to avoid permanent skin damage from sun exposure. Which information is most important to include in the teaching plan? A. Avoid using cosmetics that have sunscreen added B. Consider a spray tan in the summer C. Limit sunbathing times on a cloudy day D. Wear light, loose clothing while in sun

Consider a spray tan in the summer *A spray-on tan is the safest method to acquire a tan. Cosmetics with added sunscreen are an easy way to remember to protect the face from the sun. Ultraviolet (UV) rays can penetrate clouds and loose clothing

A nurse is caring for a client who has a rectocele. Which of the following findings should the nurse identify as a contributing factor? A. Urinary tract infection B. Urinary incontinence C. Constipation D. Perimenopausal

Constipation *UTI, urinary incontinence, and perimenopausal are contributing factors for a cystocele

A young man with suspected heroin intoxication is admitted to the unit. Which sign is consistent with opiate use? A. Elevated blood pressure (BP) B. Rapid speech C. Dilated pupils D. Constricted pupils

Constricted pupils *Opiate use causes constricted pupils; opiate overdose results in dilated pupils as a result of cerebral anoxia. However, there is no information given to indicate overdose. Opiate use results in slowed speech and decreased BP.

The home health nurse is counseling a family who will be caring for a relative with moderate-stage Alzheimer disease (AD). Which information is most important to include? A. Construct a consistent routine to provide structured environment B. Try to make each day different to enhace attention span C. Use multiple caregivers to decrease unhealthy attachment and prevent caregiver burnout D. Place bright rugs, flower arrangements, and wall decorations around the room to stimulate sensory perception

Construct a consistent routine to provide structured environment *A consistent routine--eating, resting, medication, hygient--are all beneficial to the demented patient. Different caregivers and distracting environmental objects increase confusion

The nurse is caring for an undernourished alcoholic patient. The nurse is helping the patient to select items from the menu. What dietary goal should the nurse try to help the patient achieve? A. Construct a diet that consists of at least 30% protein B. Limit all fat and cholesterol C. Limit sodium intake to less than 1.5 g D. Construct a diet that consists of at least 50% carbohydrates

Construct a diet that consists of at least 50% carbohydrates *The diet for the malnourished alcoholic should be high in protein and consist of at least 50% carbohydrates. There are no specific limitations for fat, cholesterol, or sodium

The patient is taking metoprolol for his high blood pressure. The healthcare provider orders timolol eye drops for the patient's glaucoma. Which of the following actions will the nurse do first? A. Monitor the patient's blood pressure four times a day while the patient is taking the drugs B. Give the eye drops and apply digital nasolacrimal occlusion to prevent systemic absorption C. Increase fluid intake to 2000 to 3000 mL/day to avoid dehydration D. Contact the healthcare provider to clarify the order to avoid a potential adverse drug effect

Contact the healthcare provider to clarify the order to avoid a potential adverse drug effect

The nurse enters a client's room, and the client immediately demands to be released from the hospital. During review of the client's record, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? A. Call the client's family B. Persuade the client to stay a few more days C. Contact the primary health care provider (PHCP) D. Tell the client that discharge is not possible at this time

Contact the primary health care provider (PHCP) *Generally, voluntary admission is sougt by the client or client's guargian. Voluntary clients have the right to demand and ontain release. The best nursing action is to contact the PHCP. Option A violates client confidentiality. Option B is not therapeutic or appropriate. Option D does not apply to a voluntary admission status

A client was admitted to a medical unit with acute blindness. Many tests are performer, and ther eseems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which family of three was killed. The nurse suspects that the client may be experiencing which diagnosis? A. Psychosis B. Repression C. Conversion disorder D. Dissociative disorder

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

The nurse is aware that men with gonorrhea are more likely to seek medical attention because their symptoms are more visible than those of wome. Which clinical manifestations is most consistent with symptoms of gonorrhea in men? A. Copious, purulent penile discharge B. Hematuria when initiating the stream of urine C. Penile ulcers with a foul odor D. Scale scrotal lesions

Copious, purulent penile discharge *Signs and symptoms of gonorrhea in men include penal discharge and scrotal pain. Gonorrhea should not cause hematuria when urinating, penile ulcers with a foul odor, or scaly scrotal lesions.

Pilocarpine hydrochloride is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity? A. Metipranolol B. Atropine sulfate C. Timolol maleate D. Carteolol hydrochloride

Atropine sulfate

When providing care to patients, the nurse must recognize the medications that are considered ototoxic. Which medication has this distinction? A. Amoxicillin B. Gentamicin C. Acetaminophen D. Prednisone

Gentamicin

While reviewing Ms. Nutrim's discharge summary from the hospital, you see that a category I skin tear was identified using the Payne-Martin classification system. Which intervention is most appropriate for this wound? A. Cover with a transparent adhesive dressing B. Remove the moist flap with sterile scissors C. Gently cleanse the skin tear with normal saline D. Apply a pressure dressing to areas of bleeding

Gently cleanse the skin tear with normal saline

You are caring for four patients with major depressive disorder. Which patient do you identify as at highest risk for suicide? A. 23-year-old African American female B. 37-year-old Hispanic male C. 42-year-old Asian American female D. 57-year-old Caucasian male

57-year-old Caucasian male *Statistically, older adult white men are more likely to have suicide completion than any other demographic. (1, 2, 4) All of the other patients may attempt or complete suicide but they are not at the highest risk.

Because of a communication error, the pharmacy says that there is a long delay for a replacement of TPN to be mixed and delivered to the unit for the patient. While awaiting the replacement bag of TPN, the nurse recognizes that a medical order is needed for which type of IV fluid? A. 0.45% Saline B. 5% Dextrose in water C. 10% Dextrose in water D. Lactated Ringer

10% Dextrose in water *If TPN is suddenly discontinued, a patient can experience hypoglycemia. (1) 0.45% saline is a common solution ordered for maintenance replacement of fluids. (2) 5% dextrose is most commonly used as a vehicle for piggyback medications. (4) Lactated Ringer is an isotonic solution that is used for cases of excessive fluid loss, such as trauma or major burns.

The client arrives at the emergency department after a burn injury that occurred in their home basement and an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client? A. Oxygen via nasal cannula at 10 L B. Oxygen via nasal cannula at 15 L C. 100% oxygen via an aerosol mask D. 100% oxygen via a tight-fitting, nonrebreather face mask

100% oxygen via a tight-fitting, nonrebreather face mask *If an inhalation injury is suspected, the administration of 100% oxygen via a tight-fitting, nonrebreather face mask is prescribed until the carboxyhemoglobin level falls below 15%. With inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation is also determined

A nurse accessing the injection port of the IV tubing will "scrub the hub" for: a. 5 seconds. b. 10 seconds. c. 15 seconds. d. 30 seconds

15 seconds *The hub of the injection port on a piggyback setup should be scrubbed for 15 seconds.

The nurse takes into consideration that according to The Joint Commission, the first IV antibiotics order for a community acquired pneumonia must be administered within: a. 1 to 2 hours b. 2 to 4 hours c. 6 to 8 hours d. 24 hours

6 to 8 *The Joint Commission suggests that the first IV antibiotic administered for community acquired pneumonia be administered in the first 6 to 8 hours after admission.

Early symptoms of alcohol withdrawal (anxiety, irritability, and agitation) may manifest as early as A. 1-2 hours after the last drink B. 6-12 hours after the last drink C. 24-48 hours after the last drink D. 2-3 days after the last drink

6-12 hours after the last drink

The nurse is aware that as a safety precaution against over hydration, the tubing drip factor set appropriate for a 6-month-old infant is: a. 60 gtt/mL. b. 20 gtt/mL. c. 15 gtt/mL. d. 10 gtt/mL.

60 gtt/mL. *A microdrip infusion set, which delivers 60 gtt/mL, is used for infants and children.

A nurse is aware that for a patient with a continuous IV infusion running, the IV bag should be changed when only ______ mL of solution remains in the bag. a. 10 mL b. 25 mL c. 50 mL d. 100 mL

50 mL *When the container has only 50 mL of solution left, the next ordered solution is added to the setup and the flow begun to prevent air from entering the line.

A patient who was given intravenous penicillin for a severe infection develops hives, itching, and facial swelling immediately after the infusion. What type of drug reaction is this patient experiencing? a. An adverse reaction b. A paradoxical reaction c. An anaphylactic reaction d. A hypersensitivity reaction

A hypersensitivity reaction *Some drugs (sulfa products, aspirin, and penicillin) can produce allergic (hypersensitivity) reactions that usually occur when an individual has taken the drug and the body has developed antibodies to it.

A pregnant woman is concerned because she has genital herpes. This is a primary infection. The patient is at risk for which delivery? A. A spontaneous abortion B. Delivery of a small, full-term baby C. A post-term delivery D. Delivery of a large, full-term infant

A spontaneous abortion *A primary infection of genital herpes in pregnancy is associated with spontaneous abortion and an increased risk for preterm labor. Post-term delivery and babies who are large or small for gestational age are not associated with a primary genital herpes infection.

A patient is experiencing anticholinergic side effects from the drug to counter side effects of his antipsychotic medication. The nurse should suggest which interventions to relieve dry mouth? A. Chew gum, perform mouth hygiene, and increase fluids B. Encourage fluids, increase fiber in diet, and suck on hard candy C. Decrease the medication dosage and perform mouth hygiene every 2 hours D. Track fluid intake, drink milkshakes, and chew gum

Chew gum, perform mouth hygiene, and increase fluids

A client arrives at the emergency department and has experienced frostbite to the right hand. What should the nurse expect to find when inspecting the client's hand? A. A pink, edematous hand B. Fiery red skin with edema in the nail beds C. Black fingertips surrounded by an erythematous rash D. A white color of the skin which is sensitive to touch

A white color of the skin which is sensitive to touch *The findings related to frostbite include a white or blue skin color and skin that is hard, cold, and insensitive to touch. As thawing occurs, so does flushing of the skin, the development of blisters or blebs, or tissue edema. Gangrene can develop in 9 to 15 days

The family members attending to the needs of a dying patient express distress regarding the patient's noisy breathing. What would be your best action? A. Hold all pain medications B. Administer atropine as ordered C. Place the patient in supine position D. Arrange for hospitalization of the patient

Administer atropine as ordered *Atropine administered by eye drops can dry up secretions and help calm noisy breathing. (1) Pain medication will not reduce noisy breathing but is not contraindicated. (3) Supine position will aggravate the problem. The head of the bed elevated and the patient slightly to one side may be helpful. (4) Hospitalization is not appropriate for an actively dying patient.

The spouse of a patient with alcohol use disorder makes excuses to their children when the patient fails to do things that were promised. What is the priority problem? A. Limited coping ability B. Altered family functioning C. Absence of compliance D. Decreased self-esteem

Altered family functioning *The spouse is trying to maintain the family because the patient is unable to do so because of alcohol abuse. (1) It is likely that none of the family members are coping well; however, the scenario mostly discloses family dysfunction. (3) Nothing in the question mentioned absence of compliance with a treatment plan. (4) The parents may have a decreased sense of self-esteem in this situation, but nothing in the question mentions this.

What safety instructions would be appropriate to give to a patient starting glaucoma treatment with carbachol (Isopto Carbachol)? a. Avoid driving at night due to decreased vision. b. You may develop drowsiness, fatigue, or irritability. c. Do not rub your eye even if it feels as though something is in it. d. Check your blood sugar daily; these drops can cause hypoglycemia.

Avoid driving at night due to decreased vision. *Patients may develop decreased night vision, so patients may need to avoid night driving due to side effects of the cholinergic agonists.

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster? A. A staff member who has never had roseola B. A staff member who has never had mumps C. An unlicensed assistive personnel who has never had chickenpox D. An unlicensed assistive personnel who has never had german measles

An unlicensed assistive personnel who has never had chickenpox *Herpes zoster is caused by a reactivation of the varicella zoster virus, which is the causative virus of chickenpox. Individuals who have not been exposed to the varicella zoster virus are susceptible to chickenpox

A nurse is reinforcing teaching to a client who has tobacco use disorder about the use of nicotine gum. Which of the following information should the nurse reinforce? A. Chew the gum for no more than 10 min B. Rinse out the mouth immediately before chewing the gum C. Avoid eating 15 min prior to chewing the gum D. Use of the gum is limited to 90 days

Avoid eating 15 min prior to chewing the gum *The client should avoid eating or drinking 15 min prior to and while chewing the gum *The client should chew the gum slowly and intermittently over 30 min *The client should avoid drinking 15 min prior to chewing gum *Use of nicotine gum is not recommended for longer than 6 months

A nurse is contributing to the plan of care for a client who has a platelet count of 10,000/mm3. Which of the following interventions should the nurse recommend for inclusion in the plan of care? A. Apply prolonged pressure to puncture site after blood sampling B. Administer epoetin alfas as prescribed C. Place the client in a private room D. Have the client use an oral topical anesthetic before meals

Apply prolonged pressure to puncture site after blood sampling *Implement bleeding precautions for the client who has thrombocytopenia *Epoetin alfa is administered to the client who has anemia *The client who has neutropenia is placed is a private room *A topical oral anesthetic it is used for the client who has mucositis

A nurse is reinforcing teaching with a client on home care after a culture for a bacterial infection and cellulitus. Which of the following information should the nurse include? A. Bathe daily with moisturizing soap B. Apply antibacterial topical medication to the crusted exudate C. Apply warm compresses to the affected area D. Cover affected area with snug-fitting clothing

Apply warm compresses to the affected area

A 25-year old patient presents with severe groin pain, redness, and swelling of the scrotum and fever with chills. You anticipate which of the following orders? A. Acetaminophen 500 mg po now B. Acyclovir 400 mg po now and TID C. Azithromycin 1000 mg po now D. Benzathine penicillin G 2.4 million units IM now

Azithromycin 1000 mg po now *The patient's presenting symptoms indicate epididymitis. In young adults the most common cause of epididymitis is Chlamydia trachomatis. Azithromycin is the treatment of choice. (1) Acetaminophen does not treat the problem; it may be given to control fever if needed. (2) Acyclovir treats viral infections such as herpes. (4) Benzathine penicillin G is given for syphilis.

A patient with psoriasis on PUVA therapy. What factors compose this therapy? A. Radiation and corticosteroids B. X-rays and methotrexate C. Artificial ultraviolet (UV) rays and a coal tar product D. Laser treatment and antimetabolites

Artificial ultraviolet (UV) rays and a coal tar product *PUVA is a combination of artificial UV rays and a psoralen, a coar tar product

The nurse in the clinic is preparing a patient for a routine pelvic examination. What is the most important nursing intervention at this time? A. Administering a disposable (Fleet) enema B. Asking the patient to empty her bladder C. Setting up a suture tray and local anesthetic D. Obtaining a sample of blood

Asking the patient to empty her bladder *Having the patient empty her bladder promotes patient comfort and prevents urine leakage during the gynecologic examination and obtaining of the sample. There is no need to empty the contents of the bowel to perform a Pap smear. Blood samples, sutures, and anesthetic agents are not used for a Pap smear.

Which classic behavior characterizes bulimia? A. Bingeing and purging B. Refusal to eat C. Excessive exercising D. Hiding food to make it appear it was eaten

Bingeing and purging *Patients with bulimia nervosa induce vomiting after consuming large quantities of food. This binge eating occurs in a frenzied state and usually in secrecy; afterward, the patient experiences feelings of shame and self-criticism. Laxatives may be taken to purge the system after the binge. 90% of patients with bulimia are young women

When evaluating the patient's response to chemotherapy, which assessment finding is the greatest immediate concern? A. Constipation and straining B. Bleeding after brushing teeth C. Alopecia or change in hair color D. Fatigue and irritability

Bleeding after brushing teeth

The client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication? A. Glucose level B. Calcium level C. Potassium level D. Prothrombin time

Calcium level *increases calcium, cholesterol, and tryglyceride levels

The LPN/LVN reads on a patient's chart that the patient had a sudden onset of confusion with incoherent speech. The patient is likely to be diagnosed with what cognitive disorder? A. Depression B. Delirium C. Alzheimer disease D. Dementia

Delirium *Delirium (acute confusion) is characterized by a change in overall cognition and level of consciousness over a short time. Dementia is characterized by several cognitive deficits, memory in particular, and tends to be more chronic. The difference between the two conditions is that delirium is an acute condition that requires immediate treatment, and is reversible, whereas dementia is a chronic condition that is irreversible. Alzheimer disease is a type of dementia. Depression is not associated with sudden confusion and incoherent speech.

The nurse is caring for a client with severe depression. Which activity is appropriate for this client? A. A puzzle B. Drawing C. Checkers D. Paint by number

Drawing *Concentration and memory are poor in a client with severe depression. When a client has a diagnosis of severe depression, the nurse needs to provide activities that require little concentration. Activities that have no right or wrong choices or decisions minimize opportunities for the client to put down himself or herself. The nurse can also process the client's feelings by sitting with the client and talking or encouraging the client to write in a journal

To help a patient recover from a throat infection what should he be advised to do: A. Continue his normal workout routine but to get plenty of rest at night B. Drink 8 ounces of liquid every hour while he is awake C. When the sore throat stops, discontinue prescribed medications D. Take an antipyretic with meals or a snack

Drink 8 ounces of liquid every hour while he is awake

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. Which is the appropriate nursing action? A. Call the nursing supervisor B. Call security to block all exit areas C. Tell the client that she cannot return this hospital again if she leaves now D. Restrain the client until the primary health care provider (PHCP) can be reached

Call the nursing supervisor *The nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital. Notifying the nurse supervisor is the correct option. Most health care facilities have documents that the client is asked to sign to relate to the client;s responsibilites when he or she leaves against medical advice (AMA). The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the PHCP before leaving, but if the client refuses to do so, the nurse cannot hold the client against his or her wil. Restraining the client and calling security to block exits constitutes as false imprisonment. Any client has a right to health care (option C) and cannot be told otherwise

For the patient undergoing assessment for a hearing loss, the nurse would explain that electrononystagmography is performed in conjunction with A. caloric testing B. the tuning fork test C. the Rinne test D. an audiogram

Caloric testing.

You are about to give apraclonidine (Iopidine) eye drops to a patient with glaucoma. What assessment should you perform before giving this drug? a. Check the patient's urinary output. b. Check the patient's pulse and blood pressure. c. Check the patient's pupils for responsiveness. d. Check the patient's level of orientation to time, place, and person.

Check the patient's pulse and blood pressure. *Adverse effects of adrenergic agonists include bradycardia or tachycardia and decreased blood pressure. These can result from giving too many drops of the drug causing systemic absorption.

The patient comes to the clinic for a chief complaint of burning with urination and urinary urgency. Based on her complaints, what additional assessment data would be the most appropriate to obtain first: A. Assess her genitalia for signs of inflammation B. Check her chart for a history of kidney problems C. Check her temperature to assess for fever D. Ask her about drug and food allergies

Check her temperature to assess for fever

The patient is experiencing frequent attacks of vertigo. When planning care, which activity should the nurse encourage? A. Increase sodium in the diet B. Consider a smoking cessation program C. Increase daily fluid intake D. Drink a glass of red wine before supper

Consider a smoking cessation program *Cessation of smoking will decrease incidence of vertigo in the person with middle-ear disorders. Tobacco is vasoconstrictive and can affect the blood supply to the inner ear and nerves. When increased fluid pressure in the inner ear is suspected as the cause of dizziness, the provider may order a low-sodium diet and limit fluid intake. Alcohol intake does not combat vertigo

A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first? A. Give the client information about immunization against meningitis B. Tell the client to have a TB skin test every 2 years C. Determine the client's health risks D. Teach the client about exercise recommendations

Determine the client's health risks *The first action that should be taking using the nursing process is assessment. Talk with the client first to determine what risk factors the client might have before initiating the health promotion and disease prevention meaures

A urse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and "not feeling well." The nurse notes warmth, edema, induration, and red streaking on the client's arm close to the IV insertion site. Which of the following actions should the nurse plan to take first? A. Obtain a specimen for culture B. Apply a warm compress C. Administer analgesics D. Discontinue the infusion

Discontinue the infusion *The greatest risk to this client is further injury to the irritated vein. the first action is to stop the infusion and remove the cathter to prevent further harm

How should the home health nurse advise the patient to treat a fever of 100 F? A. Take aspirin as needed B. Take Tylenol every 4 to 6 h C. Bathe in cool water before bed D. Do nothing at all

Do nothing at all *Allowing reasonable levels of fever allows the body's natural defenses to make a hostile environment to the pathogen through heat

The nurse is caring for a patient who returns to the unit after undergoing a transurethral resection of the prostate (TURP). The nurse observes a few small clots and pieces of tissue returning in the indwelling catheter bag. What should the nurse do next? A. Document the finding B. Notify the surgeon immediately C. Adjust the bladder irrigation flow rate D. Apply traction to the catheter

Document the finding *Presence of blood clots tissue in the urinary collection is anticipated and normal, so the nurse should document the finding and continue to monitor the patient. These findings do not warrant immediate notification of the surgeon, adjustment of the irrigation rate, or application of traction to the catheter

The nurse is preparing a 48 year old female patient for her upcoming appointment. She asks how long it has been since her last pap smear, knowing that she should have one how often? A. Every year B. Every 2 years C. Every 3 years D. Every 5 years

Every 3 years *The U.S. Preventative Services Task Force's (2017) most recent draft recommendation includes screening for cervical cancer every 3 years via a Pap test in women between the ages of 21 and 65

The patient was given an SSRI about 60 minutes ago and is now having change of mental status, a rapid pulse, loss of muscular coordination, and hyperthermia. Which action should the nurse take first to address this life-threatening condition? A. Ensure that there is a patent IV access B. Initiate seizure precautions C. Obtain an order for anxiolytic medication D. Prepare the emergency respiratory equipment

Ensure that there is a patent IV access

A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which finding? A. Normal B. Regressive C.. Indicative of the client's ambivalence D. Evidence of the client's altered and distored body image

Evidence of the client's altered and distored body image *Altered or distored body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and present with regressed behavior, the client's coping pattern relates to the basic issue of disorted body image. The client's behavior is not normal

A patient with schizophrenia is receiving clozapine 150 mg twice a day. The nurse knows to be vigilant for which sign of an adverse effect of this drug? A. Elevated blood pressure (BP) B. Weight gain C. Photosensitivity D. Extreme temperature elevations

Extreme temperature elevations *Known as neuroleptic malignant syndrome, this is an adverse reaction to antipsychotics characterized by extreme elevations in body temperature. Elevations in BP are associated with interactions between foods containing tyramine and monoamine oxidase inhibitor. Weight gain and photosensitivity are common side effects of many antipsychotics and do not necessarily represent adverse effects.

The client with ovarian cancer is being treated with vincristine. The nurse monitors the client, knowing that which adverse effect is specific to this medication? A. Diarrhea B. Hair loss C. Chest pain D. Extremity numbness

Extremity numbness *peripheral neuropathy can be manifested as numbness and tingling in the fingers and toes. Depression of the Achilles tendon reflex may be the first clinical sign indicating peripheral neuropathy. Constipation rather than diarrhea may occur occasionally.

Which side effects can you expect to see in a patient receiving a biologic response modifier for cancer treatment? A. Severe alopecia B. Constipation and decreased appetite C. Cough and shortness of breath D. Fever, chills, and flu-like symptoms

Fever, chills, and flu-like symptoms *Flu-like symptoms are common with this category of chemotherapy. (1, 2, 3) Severe alopecia, constipation, decreased appetite, cough, and shortness of breath are not usual side effects of biologic response modifiers.

A student nurse questions the nurse about the frequency of administration of antipsychotics, such as risperidone (Risperdal). Which advantage is true of newer antipsychotics like risperidone (Risperidone)? A. Decreased photosensitivity B. Fewer serious side effects C. Less expensive D. Decreased incidence of headaches

Fewer serious side effects *Risperidone (Risperdal) is a newer generation of "atypical" antipsychotic medications that is known for having fewer serious side effects, such as tardive dyskinesia, but they still have significant effects

The nurse is performing a follow-up teaching session with a client discharged 1 month ago who is taking fluoxetine. Which information should be important for the nurse to gather regarding the adverse effects related to the medication? A. Cardiovascular symptoms B. Gastrointestinal dysfunctions C. Problems with mouth dryness C. Problems with excessive sweating

Gastrointestinal dysfunctions *The most common adverse effects related to fluoxetine include CNS and GI system dysfunction. This medication affects the GI system by causing nausea and vomiting, cramping, and diarrhea. Options A, C, and D are nor adverse effects of this medication

The nurse is concerned about a coworker who she suspects is abusing amphetamines. Which behavior best validates the nurse's concern? A. Frantic, excited speech B. Poor attention to detail C. Poor personal hygiene D. Insatiable hunger

Frantic, excited speech *Excited speech, euphoric behavior, increased alertness, and anorexia are indications of abuse of amphetamines

When caring for the patient diagnosed with glaucoma, it is important that the nurse's instructions include which statement? A. Patients with glaucoma need to have their condition reevaluated every 3 years B. Glaucoma is associated with a diet hign in fat C. Glaucoma may be managed with eye drops D. The vision lost by glaucoma may be corrected with surgery

Glaucoma may be managed with eye drops

The nurse uses the CAGE challendge to alcoholics who persist in denial. What does the "G" in the set of questions frmo CAGE represent? A. Get: "Do you feel like you must get alcohol?" B. Go: "Do you go out to drink?" C. Gone: "Is memory of drinking episodes gone?" D. Guilty: "Do you feel guilty about your drinking?"

Guilty: "Do you feel guilty about your drinking?" *A commonly used screening tool for alcohol abuse is the CAGE assessment. Two of more "Yes" answers have a 90% correlation with an alcohol abuse problem. The "G" stands as a reminder for the question, "DO you feel guilty about your drinking."

A patient taking antipsychotic medications develops a flat affect with drooling, a shuffling gait, and tremors. You would look for a health care provider order in the MAR for which medication? A. Benztropine (Cogentin) B. Haloperidol (Haldol) C. Amantadine (Symmetrel) D. Trihexyphenidyl (Artane)

Haloperidol (Haldol) *The patient is manifesting symptoms of pseudoparkinsonism, which may be caused by haloperidol (Haldol). Treatment of these symptoms involves anticholinergic medications such as (1) benztropine (Cogentin) or antiparkinsonian agents such as (3) amantadine (Symmetrel) or (4) trihexyphenidyl (Artane).

A nurse applies a vibrating tuning fork to the middle of a patient's forehead. What response would indicate normal hearing? A. Hearing the sound in the back of the head B. Feeling a vibration but hearing no sound C. Hearing the sound in the middle of the head D. Feeling a vibration and hearing a soundin the temporal area

Hearing the sound in the middle of the head *This is Weber test, and hearing the sound in the middle of the head is normal. (1) Hearing the sound in the back of the head is abnormal. (2) Hearing no sound is abnormal. (4) Hearing a sound in the temporal area is abnormal.

A patient is being treated for menorrhagia. In a follow-up appointment, which testing would be appropriate for evaluating the treatment's effectiveness? A. Electrolytes B. Ultrasound of the ovaries C. Hemoglobin and hematocrit D. CT scan of the pelvic organs

Hemoglobin and hematocrit

A patient who is recovering from a severe burn is permitted oral feedings. Which diet is most appropriate for this patient? A. Low in protein and high in calories B. Low in protein and low in calories C. High in protein and low in calories D. High in protein and high in calories

High in protein and high in calories *A diet high in protein and calories is necessary for healing. The patient has increased metabolic needs directly proportional to the size of the burn area. Nutritional needs may be increased 50% to 150% above normal, and increased requirements can continue for 9 to 12 months. Caloric needs are calculated to include the patient's weight, age, and percentage of burn over total body surface.

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirum. The nurse should monitor for which symptoms? A. Hypotension, ataxia, vomiting B. Stupor, agitation, muscular rigidity C. Hypotentions, bradycardia, agitation D. Hypertension, disorientation, hallucinations

Hypertension, disorientation, hallucinations *The symptoms associated with alcohol withdrawl delirium typically are anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, agitation, fever, and delusions

A nurse is reinforcing teaching with a client who will start alfuzosin for treatment of benign prostatic hyperplasia. The nurse should instruct the client that which of the following is an adverse effect of this medication? A. Bradycardia B. Edema C. Hypotension D. Tremor

Hypotension *Alfuzosin relaxes muscle tone in veins and cardiac output decreases, which leads to hypotension. Clients taking this medication are advised to rise slowly from a sitting or lying position *Alfuzosin can cause tachycardia *Alfuzosin can cause diarrhea or constipation. Edema is not an adverse effect of this medication *Alfuzosin can cause dizziness. Tremor is not an adverse effect of this medication

Loss of fluid from vascular space A. Edema B. Hyperkalemia C. Hypovolemia D. Tissue hypoxia E. Hypermetabolism

Hypovolemia

The nurse is caring for a patient with pneumonia who complains of shortness of breath. Further assessment reveals an oxygen saturation of 89% on room air, 28 respirations/min with bilateral crackles in lung bases, blood pressure of 160/94, and a pulse rate of 102 beats per minute. Which nursing diagnosis is priority for this patient? A. Activity intolerance B. Impaired gas exchange C. Ineffective cardiopulmonary tissue perfusion D. Self-care deficit: bathing and hygiene

Impaired gas exchange

A nurse is contributing to the plan of care for a client who has anorexia nervosa with binge-eating and purging behavior. Which of the following interventions should the nurse include? A. Allow the client to select preferred meal times B. Establish consequences for purging behavior C. Provide the client with a high-fat diet at the start of treatment D. Implement one-to-one observation during meal times

Implement one-to-one observation during meal times *Closely monitor the client during and after meals to prevent purging *Provide a highly structured milieu, including meal times, for the client requiring acute care for the treatment of anorexia nervosa *Use a positive approach to client care that includes rewards rather than consequences *Limit high-fat and gas-producing foods at the start of treatment

A nurse is reinforcing teaching for a client who has degeneration. Which of the following instructions should the nurse include in the teaching? A. Increase intake of deep yellow and orange vegetables B. Administer eye drops twice daily C. Avoid bending at the waist D. Wear an eye patch at night

Increase intake of deep yellow and orange vegetables *Instruct the client to decrease dietary intake of carotenoids and antioxidants to slow the progression of the macular degeneration. *(b)-a client who has primary open-angle glaucoma should administer eye drops twice daily. (c) a client who is at risk for increased intraocular pressure, such as following cataract surgery, should avoid bending at the waist. (d)-a client who has had surgery, such as cataract surgery, should wear an eye patch at night to protect the eye from injury

The nurse is caring for a patient with who is having difficulty with short-term memory. Which are other signs and symptoms of beginning Alzheimer disease? A. Increased forgetfulness, difficulty learning new things, inability to concentrate B. Unable to speak or ambulate and profound memory loss C. Social withdrawal and decreased ability to perform usual activities of daily living D. Outbursts of anger, hostility, paranoia, and wandering

Increased forgetfulness, difficulty learning new things, inability to concentrate

You read in a patient's record that the health care provider observed "circumcised, superficial vesicles with a collection of serous fluid." You anticipate that the health care provider will make which recommendation for the patient? A. A prescription for a topical application for acne B. Isolation precautions for herpes zoster C. Over-the-counter antihistamine for an insect bite D. Patient education to self-monitor the wart

Isolation precautions for herpes zoster *Superficial vesicles with a collection of serous fluid are a description for chickenpox or shingles. Both are caused by the same contagious organism. (1) Acne lesions are elevated and superficial, filled with purulent drainage. (3) Insect bites are firm, edematous, and irregular. (4) Warts are elevated solid lesions.

When considering complementary and alternative therapy for prostate cancer, which is true? A. Plant extracts should not be taken if receiving hormone therapy B. It is best to train the body to hold urine for an increasingly longer duration C. Research has proven that saw palmetto helps relieve symptoms D. Surgery is the only way to improve symptoms

Plant extracts should not be taken if receiving hormone therapy

The patient with shingles has been on an antiviral medication since the vesicles appeared. The goal of early treatment is to prevent which complication? A. Postherpetic pain B. Outbreak of additional vesicles C. Lesions of the eye D. Transmission to health care workers

Postherpetic pain *Early treatment may avoid postherpetic pain syndrome, but it cannot prevent additional vesicles, eye lesions, or transmission to another person

A nurse is reviewing the laboratory findings of a client who has measles. The nurse should expect to find an increase in which of the following types of WBCs? A. Neutrophils B. Basophils C. Lymphocytes D. Eosinophils

Lymphocytes *Lymphocytes increase with viral infections (measles, mumps, mononucleosis) *Neutrophils increase with an acute bacterial infection. *Basophils increase with leukemia *Eosinophils increase with allergic reactions, leukemia, eczema, and parasitic infections

The nurse is caring for a patient who has a heightened risk for seizures during his alcohol detoxification. Which medication may be included in the patient's care? A. Magnesium sulfate B. Chlordiazepoxide (Valium) C. Promethazine (Phenergan) D. Dicyclomine (Bentyl)

Magnesium sulfate *The person undergoing alcohol withdrawal is at risk for the development of seizures. Magnesium sulfate may be prescribed to prevent their onset. Chlordiazepxide may be administered to reduce anxiety. Promethazine (Phenegan) and dicyclomine (Bentyl) may be used to reduce symptoms such as naisea and vomiting

A patient with flight of ideas and easy distractibility cannot sit through mealtime. Which nursing intervention is appropriate? A. Give three high-calorie meals on a regular schedule B. Offer finger foods such as a meat and cheese sandwich C. Provide a pleasant, odor-free environment D. Encourage family meals and socialization while eating

Offer finger foods such as a meat and cheese sandwich *Offering foods that can be consumed "on the run" will increase the likelihood that the patient will eat something. (1) High-calorie foods are a good idea, but a regular schedule is going to be difficult for this patient at this point. (3) A pleasant, odor-free environment will not hurt, but it is more appropriate for patients who have anorexia related to nausea or for older adult patients. (4) Socialization for this patient is likely to cause distraction and result in decreased intake.

A patient with CNS stimulant use displays agitation and aggression. Which medication is the health care provider most likely to prescribe to address these symptoms? A. Methylphenidate (Ritalin) B. Lorazepam (Ativan) C. Ondansetron (Zofran) D. Naloxone (Narcan)

Methylphenidate (Ritalin)

The nurse is planning care for the patient who is on a protocol of bleomycin. Since bleomycin is an anti-tumor antibiotic, which intervention should the nurse add to the care plan? A. Assess hearing acuity B. Measure urinary output C. Weigh daily to assess fluid retention D. Monitor for cardiac arrhythmias

Monitor for cardiac arrhythmias *Bleomycin is cardiotoxic and can cause cardia arrhythmias; therefore, this would be the highest priority intervention.

The nurse is caring for a patient with acquired immune deficiency syndrom (AIDS) dementia complex. Which factor places this patient at particular risk for injury? A. Manic behavior B. Numbness and muscle weakness C. Suicidal ideation D. Difficulty concentrating

Numbness and muscle weakness *Peripheral neuropathy results in numbness and muscle weakness that may contribute to falls and thermal skin injuries

A patient voices concerns about potential factors for the development of ovarian cancer. What is considered the greatest risk for the development of the disease? A. Never having had children B. Social alcohol use C. Black ancestry D. History of rectal polyps

Never having had children

Which of these attitudes is essential for the LPN/LVN to have when obtaining a history on a patient who has an STI? A. Friendly B. Indifferent C. Nonjudgmental D. Complete acceptance of the patient's behavior

Nonjudgmental *Establishment of a therapeutic relationship between the nurse and the patient is important when collecting sensitive data. This relationship is possible when the nurse displays a nonjudgmental attitude. Indifference, friendliness, and complete acceptance are not the most therapeutic attitudes.

The nurse is caring for a patient with C. difficile infection. Which action is most important for the nurse to take? A. Only use alcohol-based hand cleanser for hand hygiene B. Always wear an impervious mask C. Don proper eye protection D. Notify housekeeping to use appropriate cleaning agents

Notify housekeeping to use appropriate cleaning agents *Notification of housekeeping to use alcohol-free cleaners is necessary in order to eradicate the pathogen. Soap and water must be used after contact with this organism because alcohol-based hand sanitizers do not adequately kill the microorganism. A mask and eye protection are not necessary

When itching is a problem, the patient may be instructed to take which type of bath? A. Oatmeal B. Oil C. Tar D. Calamine

Oatmeal

The nursing studen is creating a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student document which intervention in the plan that is not specific to this disorder? A. Monitor intake and output B. Monitor electrolyte levels C. Observe for excessive exercise D. Monitor for the use of laxatives and diuretics

Observe for excessive exercise *Excessive exercise is a characteristic of anorexia nervosa, not bulimia nervosa. Frequent vomiting, in addition to laxative and diuretic abuse, may lead to dehydration and electrolyte imbalance. Monitoring for both dehydration and electrolyte imbalance is an important nursing action. Option C is the only option that is not associated with care of the client with bulimia

To detect early stage cancer of the prostate, it is suggested that men have which two examinations performed? A. Prostate-specific antigen level and a serum alkaline phosphatase B. A digital rectal examination and a semen analysis C. Semen analysis and a serum alkaline phosphatase D. Prostate-specific antigen level and a digital rectal examination

PSA and a digital rectal examination

When a male patient has nonspecific urethritis, which symptom is he likely to have? A. Painful urination B. Scrotal pain C. Frequent, uncontrolled ejaculations D. Scrotal swelling

Painful urination

The nurse is caring for a patient taking ling-term estrogen replacement for osteoporosis prevention. The nurse recommends that the patient undergo which type of examination annually? A. Pelvic examination B. Bone density study C. Liver scan D. Lower GI study

Pelvic examination *Estrogen therapy increases the incidence of endometrial cancer and breast cancer. An annual pelvic examination is recommended, as well as montly breast self-examinations (BSE)

The long-term care nurse notices that a resident with chronic dementia is uncharacteristically drowsy and lethargic. What is the appropriate nursing intervention? A. Allow the resident to go to sleep B. Include the resident in a social group for stimulation C. Perform a mental status examination and obtain vital signs D. Call the health care provider to report a change in mental status

Perform a mental status examination and obtain vital signs *The patient should be assessed for additional information about mental status, and vital signs should be obtained and then the health care provider called. (1) Allowing the resident to sleep could be dangerous if they are septic or having neurologic or cardiac problems or fluid and electrolyte imbalances that go undetected. (2) Stimulation with group participation is not appropriate, but the resident should be checked for arousability and response to normal stimuli. (4) The health care provider will need to be notified, but you do not have enough information to make the call until you further assess mental status.

The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which? A. Phlebitis of the vein B. Infiltration of the IV line C. Hypersensitivity to the IV solution D. An allergice reaction to the IV catheter material

Phlebitis of the vein *Phlebitis at an IV site results in discomfort and redness, warmth, and swelling proximal to the IV catheter. The IV catheter should be removed, and a new IV should be inserted at a different site.

The client is hospitalized for the insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. Which is the immediate nursing action? A. Reinsert the implant into the vagina B. Call the primary health care provider (PHCP) C. Pick up the implant with gloved hands and flush it down the toilet D. Pick up the implant with long-handled forceps and place it into a lead container

Pick up the implant with long-handled forceps and place it into a lead container *A lead container and long-handled forceps should be kept in the client's room at all times during internal radiation therapy. Lead is an element that has a high density and high atomic number and is used to shield persons from radiation. If dislodged, the implant must be handled carefully to limit radiation exposure to the client and all persons in the environment. If the implant becomes dislodged, the nurse should pick p the implant with long-handled forceps and place it into the lead container. The radiation safety officer of the institution should be notified.

A 25 year old patient is brought to the emergency department by the police. He is a poor historian but the police tell the nurse that they were called because he was wandering down the middle of the freeway. He appears confused, disheveled, and malnourished. Which problem statement on the care plan would be of highest priority for this patient? A. Altered self-care ability B. Wandering due to disorientation to time and place C. Potential for injury due to impaired decision making D. Altered nutrition

Potential for injury due to impaired decision making

A patient with command hallucinations is readmitted for an acute psychotic episode. What priority problem do you identify? A. Altered sensory perception B. Potential for violence C. Anxiety D. Altered coping ability

Potential for violence *The content of command hallucinations should be immediately assessed because the patient may be getting a command to harm self or others. (1, 3, 4) The other diagnoses are also relevant but less urgent.

A nurse is discussing home care with the partner of a client who is in the late stage of Alzheimer's disease. The partner, who wil be the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following actions should the nurse take? A. Verify that a current power of attorney document is on file B. Instruct the client's partner to offer finger foods to increase oral intake C. Provide information on resources for respite care D. Schedule the client for placement of an enteral feeding tube

Provide information on resources for respite care *Providing information on resources for respite care is a correct action to provide the client's partner with a break from caregiving responsibilities *A power of attorney document does not address the client's care or the concerns of the caregiver *Clients in late-stage Alzheimer's disease are at risk for choking and are unable to eat without assistance. Offering finger foods is not a correct action *Placement of an enteral feeding tube is correct only with a prescription from the provider following a discussion that includes the provider, nurse, client's partner, and possibly social services and additional family members

A 26 year old African American man was hospitalized for a prolonged penile erection unrelated to sexual desire or activity. For which condition do you assess? A. Diabetes mellitus B. Sickle cell disease C. Hemophilia D. Urinary infection

Sickle cell disease *Sickle cell disease can cause clumping of blood cells within the vessel, resulting in a prolonged erection. (1, 3, 4) None of these diseases are known to cause prolonged penile erection.

Patients with glaucoma may have unequal size of what part of the eye? If this situation exists, you should consult with patient's healthcare provider? A. Iris B. Eyelid C. Retina D. Pupil

Pupil

The visually impaired person has entered the outpatient clinic with a guide dog. What action is most appropriate for the nurse to take? A. Quietly greet the dog and pat it B. Direct the patient and the dog to an area where the dog will not be distracted C. Take the harness from the patient, and direct the dog and patient to a seat D. Refrain from interacting with the patient and dog until the dog leads the patient to a seat

Refrain from interacting with the patient and dog until the dog leads the patient to a seat *The dog should not be distracted while it is working. The dog will seat the patient if possible; if not, the nurse can ask how best the patient can be directed

A nurse in a mental health practitioner's office is communicating with a client. The client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating? A. Offering general leads B. Summarizing C. Focusing D. Restating

Restating *Restating allows the nurse to repeat the main idea expressed *Offering general leads allows the nurse to take the direction of the discussion *Summarizing enables the nurse to bring together important points of discussion to enhance understanding *Focusing concentrates the attention on one single poing

If the patient has had a left stapedectomy, which position is indicated? A. Supine with the head of the bed elevated to 90 degrees B. Left side-lying with head of the bed elevated to 90 degrees C. Right side-lying with the head of the bed elevated to 40 degrees D. Right side-lying with the head of the bed elevated to 90 degrees

Right side-lying with the head of the bed elevated to 40 degrees

The patient arrives by EMS after being rescued from a house fire. The patient sustained minor burns on the hands and forearms and demonstrates a dry hacking cough. She is upset and weeping, but vital signs are currently unstable. The health care provider orders admission for 23-hour observation. What is the priority nursing diagnosis? A. Anxiety related to traumatic life-threatening event B. Impaired skin integrity related to burns of hands and forearms C. Risk for ineffective breathing pattern related to smoke inhalation D. Risk for fluid imbalance related to fluid shifting and edema formation

Risk for ineffective breathing pattern related to smoke inhalation

The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is present? A. Oily skin B. Silvery-white scaly lesions C. Patchy hair loss and round, red macules with scales D. The presence of wheal patches scattered about the trunk

Silvery-white scaly lesions *Psoriatic patches are covered with silvery white scales. There is no patchy hair or round, red macules with scales. There is not patchy hair loss or round, red macules with scales. The skin is dry and there is no presence of wheal patches scattered about the trunk

The nurse is caring for a patient with moderate Alzheimer disease (AD) in a long-term care facility who "sundowns." The nurse understands that which action would be most beneficial for this patient? A. Scheduling social interaction in the morning B. Darkening the bedroom to encourage sleep C. Administering sedatives to enhance sleep initiation D. Scheduling an exercise program after supper

Scheduling social interaction in the morning *Sundowning occurs when a patient is completely oriented during the day but becomes disoriented and confused during the evening and night hours. Planning interactive activities when the residen is not confused is beneficial. Exercise programs at night would add to agitation and confusion. Sedatives also frequently cause confusion. Lights should be left on to assist with reorientation should the resident wake up at night

Under what circumstances should you never instill prostaglandin agonists in a patient's eye? A. Headaches and sinus congestion B. Scratches or infection C. Dark coloring under the eye D. Dilated pupil

Scratches or infection

The nurse explains that depression is thought to be the result of a deficit of which neurotransmitter? A. Norepinephrine B. Serotonin C. Acetylcholine D. Dopamine

Serotonin *Serotonin is a neurotransmitter of the central nervous center. It is important in sleep, pain perception, and emotional states. Lack of serotonin can lead to depression. Norepinephrine and acetylcholine are neurotransmitters of the autonomic nervous system. Norepinephrine plays and important role in the fight-or-flight reaction (constriction of the blood vessels, dilation of the pupils, increased heart rate, increased awareness, and vigilance). Acetylcholine causes decreased heart rate and force of contraction and plays a role in the sleep-wake cycle. Dopamine is located mostly in the brainstem. It is thought to play a rile in controlling complex movements, motivation, and cognition

The nurse is reviewing the documentation of a patient's skin assessment. Which piece of data causes the most immediate concern? A. Presense of patches of senile purpura B. Skin stays tented after several seconds C. Some seborrheic keratoses on the face D. Formation of a keloid over a surgical site

Skin stays tented after several seconds

During the change-of-shift report, the nurse notes the patient has several papular lesions. The oncoming nurse will most likely observe which lesion? A. Firm, raised, deep lesion of the skin B. Small sac containing serous fluid C. Small, solid elevation of the skin D. Small elevation of the skin filled with purulent matter

Small, solid elevation of the skin *A papule is an elevated, solid lesion that is less than 0.5 cm in diameter. Examples of papules include warts (verruca) and elevated moles.

Which nursing action may aggravate the behavior of a patient who has paranoid tendencies? A. Providing written instructions regarding the patient's medication regimen B. Maintaining a structured environment C. Speaking in short, simple sentences D. Speaking in low tones to another patient in the area

Speaking in low tones to another patient in the area *Speaking so that this patient cannot hear may be interpreted negatively by the patient. Short and simple sentences, structured environments, and written instructions are appropriate for the patient with paranoia.

When selecting foods that will promote the ability of the eyes to see in the darkness, which food should be included? A. Spinach B. Pears C. Apples D. Celery

Spinach

In caring for a stage IV pressure ulcer, the nurse assesses creamy yellow drainage with a necrotic odor. Which type of bacteria most likely causes this exudate? A. Proteus B. Bacteroides C. Staphylcoccus D. Pseudomonas

Staphylcoccus *Creamy yellow drainage is usually caused by Staphylococcus infections. Proteus is associated with a beige discharge having a fishy odor. Brown discharge having a fecal odor is seen in Bacteroides. Pseudomonas-containing wounds produce a green-blue discharge with a fruity odor

Which intervention would you implement for a patient with active pulmonary tuberculosis who is socially isolated related to imposed airborne precaution? A. Limit the number of visitors to immediate family. B. Suggest alternative means of contact, such as email and phone calls C. Arrange for a nursing assistant to sit with the patient D. Reinforce the rationale for airborne precautions

Suggest alternative means of contact, such as email and phone calls *Suggesting alternatives ways to maintain socialization addresses the diagnosis. The other options might be used but do not address the problem of social isolation.

A nurse in a provider's office is collecting data from a client who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? A. Superficial thickness B. Superficial partial-thickness C. Deep partial-thickness D. Full thickness

Superficial thickness

A health care provider has ordered a Venereal Disease Research Laboratory (VDRL) test for a patient. Which condition do you recognize the provider is screening for? A. HIV B. HPV C. Syphilis D. Gonorrhea

Syphilis *A VDRL test measures antibodies to syphilis. (1, 2, 4) A VDRL does not test for these infections.

A client tells a nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always threatening me." Which of the following actions should the nurse take? A. Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince them to admit to hiding the knife B. Keep the client's communication confidential, but watch the client and their roommate closely C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others D. Report the incident to the health care team, but do not inform the client of the intention to do so

Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others *The information presented by the client is a serious safety issue that the nurse must report to the health care team. Using ethical principle of veracity, the student tells the client truthfully what must be done regarding the issue

A nurse in a clinic is reviewing the facility's testing process and procedures for human immune deficiency virus (HIV) with a new employee. Which of the following information should the nurse include? A. In the presence of HIV, the enzyme immunoassay (EIA) test is typically reactive within 72 hr after the client is infected B. The Western blot assay is used to confirm diagnosis of HIV C. The polymerase chain reaction (PR) test is used to confirm diagnosis of HIV D. CD4+ cell counts will be elevated in a client who is infected with HIV

The Western blot assay is used to confirm diagnosis of HIV *The EIA test is typically reactive 3 weeks to 3 months after the infection occurs, but it can be delayed for as long as 36 months *Confirming HIV is a 2-step process. If the EIA is positive, a second test (the western blot assay) is done *The PRC test is used to confirm the diagnosis of genital herpes *The EIA test is typically reactive 3 weeks to 3 months after the infection occurs, but it can be delayed for as long as 36 months

In which situation should the nurse document that the patient with AD exhibitied agnosia? A. The patient attempts to comb her hair with a fork B. The patient struggles to express herself verbally C. The patient appears unable to understand written language D. The patient cannot feed herself, despite having adequate motor function

The patient attempts to comb her hair with a fork *Agnosia is the inability to recognize an object and use it as intended. Expressive aphasia is difficulty in expressing oneself. Alexia is the inability to recognize the written language. Apraxia is the inability to do an activity despite having the motor function to accomplish it

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area? A. The pharmacy B. The laboratory C. The blood bank D. The risk-management department

The blood bank *The nurse prepares to return the blood transfusion bag containing any remaining blood to the blood bank. This allows the blood bank to complete any follow-up testing procedures that are needed after a transfusion reaction has been documented

The nurse is caring for a patient with an electrical burn. What should be monitored on this patient? A. The lungs B. The gastric mucosa C. The heart D. The kidneys

The heart *Electrical burns damage tissue deep within the body. The extent of damage is not always visible and the entrance site and exit site may appear small. Cardiac monitoring should be initiated even if the patient does not complain of chest pain. The lungs, kidneys, and gastric mucosa should be monitored with other types of burns.

Once a diagnosis of syphyilis is confirmed, the nurse understands that she must report the illness to which entity? A. The World Health Organization (WHO) B. The Centers for Disease Control and Prevention (CDC) C. The hospital infection control department D. The local public health agency

The local public health agency *STIs are reported to the local public health angency for accumulation by the CDC. The local public health agency will get in touch with the sexual contacts of the patient and attempt to initiate treatment

A patient has been diagnosed with glaucoma. While discussing the condition, the patient asks when she will get her lost signt back. What should the patient be told? A. The lost sight will not be recovered B. The lost sight will gradually return if the prescribed prescription regimen is closely followed C. The lost sight will only partially return D. Sight recovery is individualized, so it is impossible to know at this time

The lost sight will not be recovered

When does premenstrual syndrome (PMS) occur? A. The follicular phase of the ovarian cycle B. The luteal phase of the ovarian cycle C. The dismantling stage of the menstrual cycle D. The proliferative stage of the stage of the menstural cycle

The luteal phase of the ovarian cycle *PMS occur during a luteal stage, which lasts from day 15 to day 28 of a 28 day cycle. The uterus prepares to receive a fertilized ovum during this phase. The follicular phase includes the first 14 days of a 28 day cycle. During the proliferative stage of the menstrual cycle, the follicle grows and the egg matures

A recently licensed nurse is orienting to the Alzheimer disease (AD) care unit. The nurse is caring for a patient who is transitioning from oral rivastigmine (Exelon) to the medication patch. Which action indicates an accurate understanding of the medication? A. The nurse instructs the patient to apply the patch 12 h after the last oral medication dosage B. The nurse instructs the patient to replace the patch every 36 h C. The nurse explains that the sites of application will need to be rotated D. The nurse instructs the patient to avoid placing the patch on the trunk region of the body

The nurse explains that the sites of application will need to be rotated *Rivastigmine (Exelon) is used to manage AD by elevating acetylcholine. The medication is available orally and transdermally. The patch should be applied 24 h after the last oral dosage is given. The sites for application of the drug patches should be rotated

A nurse is caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse's use of interpersonal communication? A. The nurse discusses the client's weight loss during a health care team meeting B. The nurse examines their own personal feelings about clients who have anorexia nervosa C. The nurse asks the client about personal body image perception D. The nurse presents an educational session about anorexia nervosa to a large group of adolescents

The nurse asks the client about personal body image perception *The nurse's one-on-one communication with the client is an example of interpersonal communication *The nurses's discussion of client information with members of the health care team is an example of small-group communication *The nurse's self-assessment of feelings is an example of intrapersonal communication *The nurse's educational presentation to a large group of adolescents is an example of public communication

Which action best aids in successful rehabilitation from substance abuse? A. The patient and family members collaborate to develop treatment goals B. The patient and family members accurately list signs of relapse C. The patient and family members commit to discarding all drugs and paraphernalia D. The patient and family members commit to a 12-step program

The patient and family members collaborate to develop treatment goals *Collaboration is basic for success of rehabilitation. The patient and family must be part of the decision-making process for the formulation of treatment goals. While it is important to be aware of signs of relapse and essential to discard any paraphernalia and a 12-step program could be helpful, it is most important for the patient and family members to be active participants in the treatment plan

The nurse has asked a catatonic patient, "Where is your hat?" Which response should cause the nurse to document episodes of echolalia? A. The patient excitedly says, "Hat, cat, rat, fat, scat, splat!" B. The patient tearfully says, "I had a hat when my mother drove her yellow car." C. The patient repeatedly says, "Your hat, your hat, your hat." D. The patient places his hands on his head and says, "Where is your hat?"

The patient places his hands on his head and says, "Where is your hat?" *Echolalia is the repetition of words spoken to the patient by another person

During examination of the fundus of the eye, the nurse assesses a choked disc. Which statement accurately explains the significant of this finding? A. The disc has an infarct B. There is increased intracranial pressure (ICP) C. There is significant hypertension D. The lens has become opaque

There is increased intracranial pressure (ICP) *Visualization of the optic disc provides information about the pressure within the eye and within the skull. When ICP gets higher, the optic disc appears "swollen" or "choked."

The nurse knows that current signs are important indicators of what is happening at a given moment. In addition, vital signs should be correlated with which patient data? A. Trends of past readings B. Standardized normal readings C. The patient's ideal body weight D. Accuracy of the equipment

Trends of past readings

Which is a nursing goal when working with a patient with substance abuse? A. To ensure that the patient spends minimal amounts of time sleeping B. To encourage enabling behaviors in the patient's family C. To encourage the patient to eat a high-calorie diet D. To provide safe detoxification for the patient

To provide safe detoxification for the patient *When caring for the patient who has substance abuse, it is important to provide a safe and protected environment. Patients who are experiencing withdrawal from a substance may face physiologic and psychological symptoms. These may be frightening and life threatening. Enabling behaviors worsen substance abuse. A high-calorie diet may not be helpful to a patient withdrawing from drugs. The patient should sleep as much as he or she needs.

What is the primary purpose of a whirlpool bath given to the patient with a stage III pressure ulcer? A. To prevent infection B. To stimulate granulation tissue growth C. To imprive circulation in surrounding skin D. To provide moisture to the ulcer

To stimulate granulation tissue growth *The whirlpool acts as a type of debridement. It gets rid of the necrotic debris and stimulates grannulation tissue growth

A child has been diagnosed with an infection with inflammation in the right ear canal. Which drug route would be most appropriate for treating this condition? a. Oral route b. Topical route c. Ophthalmic route d. Intramuscular route

Topical route *Since the external ear can be reached from the outside, infections and inflammation of the pinna and the ear canal are most often managed by topical drug application.

Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed A. Potassium level B. Triglyceride level C. Hemoglobin A1C D. Total cholesterol level

Triglyceride level *Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measures before treatment and periodically thereafter until the effect on triglycerides has been evaluated. there is no indication that isotretinoin affects potassium, hemoglobin A1, C, or total cholesterol levels

The nurse is caring for a patient with Alzheimer disease (AD) who wakes up moaning and frightened in the middle of the night. She begs that her husband's coffin be removed from her room. How should the nurse respond? A. Turn light on and say, "There is no coffin here. This is the dresser." B. Leave the light off and shine a flashlight on the dresser and say, "See! No coffin!" C. Turn the light on, assist patient to the bathroom, and say, "This is your dresser." D. Leave the light off and say, "You are in your room."

Turn the light on, assist patient to the bathroom, and say, "This is your dresser." *Turning the light on helps reorient the patient. Distraction of going to the bathroom ad identifying the dresser assist with reorientation after a frightening illusion. The other options would lead to greater confusion

When planning care for an 80 year old African American woman, which intervention is most important for the nurse to include? A. Bathe the patient twice weekly B. Use liberal amounts of soap and water C. Use quick, brisk motions to dry the patient's skin D. Apply emollient to limbs and back

Use liberal amounts of soap and water *People with dark complexions need to be bathed frequently due to the oiliness of their skin. Liberal amounts of water and soap are beneficial. Twice weekly bathing is insufficient for cleanliness. Friction and application of emollient are not conducive to skin health

The nurse is educating a patient with psoriasis. Which information is most important for the nurse to include in the teaching plan? A. Liberally apply a lubricating cream three times daily B. Use a humidifier at night C. Use an alcohol-based cleanser in the morning D. Take hot baths to reduce skin discomfort

Use a humidifier at night *Skin should be kept as moist and pliable as possible. Humidifiers increase moisture in the environment. Use and application frequency of lubricating lotions and creams should be approved by the dermatologist before recommending. Drying solutions like alcohol and heat can increase discomfrot of psoriasis

A primary cause of male impotence is related to changes in which body system? A. Vascular B. Respiratory C. Urinary D. Neurologic

Vascular

You are admitting a young adult with a tentative diagnosis of bulimia. Which behavior do you anticipate? A. Vomiting after eating large quantities of food B. Obsessing over exercising constantly C. Stating suicidal thoughts to others D. Cutting food on the plate into tiny bites

Vomiting after eating large quantities of food *Bulimia involves vomiting after eating large quantities of food. (2) The patient with anorexia nervosa frequently performs excessive exercise because they believe that they are overweight. (3) Nurses should always be vigilant for suicidal ideations, but from the information given this is not the highest priority at this time. (4) Cutting food into tiny bites is more characteristic of the patient who has anorexia nervosa.

A patient is receiving hormone therapy for treatment of breast cancer. The nurse should inform the patient that she is at high risk for the development of which of these serious effects? A. Menstrual-like bleeding B. Venous thromboembolism C. An increase in facial hair D. Breast tenderness

Venous thromboembolism *Women receiving estrogens or progestins may have irregular menses, fluid retention, and breast tenderness. All patients who take estrogen or progestins are at increased risk for venous thromboembolism (VTE). Androgens and the antiestrogen receptor drugs cause masculinizing effects in women. Chest and facial hair may develop, menstrual periods stop, and breast tissue shrinks. VTE is the most serious side effect of use of hormone therapy.

An elderly patient with mild dementia has demonstrated ability to feed himself, perform toileting independently, and dress himself; however, he frequently says, "You do it for me." What should the nurse do to encourage independence? A. Instruct him to try first, and then come back later to see what he has accomplished B. Verbally coach him through the task and observe his performance C. Point out to him that he needs to be independent for as long as possible D. Ask him why he frequently does not want to do things for himself

Verbally coach him through the task and observe his performance

When caring for a male patient with suspected gonorrheal infection, which action is most important for the nurse to take? A. Report the infection to the local public health agency B. Assess the patient's temperature hourly C. Administer antibiotics before cultures are drawn D. Wait 1 hour after the patient voids to collect a uretral swab

Wait 1 hour after the patient voids to collect a uretral swab *Since the urine will have flushed out the organisms, the nurse should wait at least 1 hour postvoid before collecting the speciment. The infection has not been confirmed, so not report should be made at this time. The patient's temperature should be obtained to be negative even though the drug or the dose may not be sufficient to cure the infectin. If possible, obtain cultures priort to administering antibiotics

Disulfiram is prescribed for a client and the nurse is collecting data on the client and is reinforcing instructions regarding the use of this medication. Which is most important for the nurse to determine before administration of this medication? A. A history of hyperthryoidism B. A history of diabetes insipidus C. When the last full meal was consumed D. When the last alcoholic drink was consumed

When the last alcoholic drink was consumed * Disulfiram is used as an adjacent treatment for selected clients with chronic alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administed. The most important data are to determine when the las alcoholic drink was consumed. The medication is used with caution in clients with diabetes mellitus, hypothryoidism, epilepsy, cerebral damage, nphritis, and hepaptic disease. It is contraindicated in severe heart disease, psychosis, or hypersensitivity related to the medication

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for monitoring by the nurses? A. Glucose level of 99 mg/dL B. Platelet level of 300,000 mm3 C. Magnesium level of 1.5 mEq/L D. White blood cell count of 3000 mm3

White blood cell count of 3000 mm3 *Silver sulfadiazine is used for the treatment of burn injuries. Adverse effects of this medication include rash and itching, blue-green or gray skin discoloration, leukopenia, and instititial nephritis. The nurse should a complete blood count, particularly the white blood cells, frequently fot the client taking this medication. If leukopenia develops, the PHCP is notified and the medication is usually discontinued. The white blood cell count noted is indicative of leukopenia. The other laboratory values are not specific to this medication, and are also within normal limits

The nurse is planning for the initiation of a blood transfusion. The type of tubing the nurse will prepare is a: a. piggyback set. b. primary infusion set. c. controlled volume set. d. Y administration set

Y administration set. *A Y administration set is used to place the blood on one side and normal saline on the other. This is necessary so that the blood can be discontinued but the vein can remain open with the saline in the case of a transfusion reaction or other medically necessary situation.

Pelvic relaxation syndrome may lead to: A. abdominal pain. B. cervical dysplasia. C. metrorrhagia. D. a cystocele.

a cystocele

The main difference between a furuncle and a carbuncle is the A. furuncle is infectious, the carbuncle isn't B. furuncle involves a single hair follicle and the carbuncle involves a group of hair follicles C. carbuncle is an allergic reaction, the furuncle isn't D. carbuncle is caused by ineffective thermoregulation

furuncle involves a single hair follicle and the carbuncle involves a group of hair follicles

The patient who is taking an SSRI medication must be monitored for A. weight loss B. hypernatremia C. kidney dysfunction D. gastrointestinal bleeding

gastrointestinal bleeding

In an elderly woman, vaginal bleeding is a possible sign of A. hormone imbalance B. cervical or uterine cancer C. breast cancer D. vaginal-rectal fistula

cervical or uterine cancer

Appearance of vesicular lesions following inflammatory response A. contact dermatitis B. atopic dermatits C. stasis dermatitis D. seborrheic dermatitis

contact dermatitis

TThe nurse reminds the 40-year-old female patient that the American Cancer Society (ACS) recommendations for early detection of cancer include that she should:

have a mammogram done every year.

While assessing the patient, the nurse asked if the patient has a son or daughter, and the patient replied "yes" and nodded. The nurse is aware that this may be a sign of A. Hearing loss B. dementia C. loss of consciousness D. ototoxicity

hearing loss *Past experience has taught many people with hearing loss that to ask for repetition of questions irritates people and causes them to think the person is stupid. For this reason, many people who cannot hear well commonly smile and say "yes," when such an answer is either incorrect or inappropriate

An 84-year-old patient has has a low- grade fever for 2 days. This morning, the patient complains of burning tingling hip pain that shoots down the leg. The nurse observes a small group of vesicles on the leg. These findings are consistent with which disorder? A. herpes simplex B. herpes zoster C. Syphilis lesions D. Furuncles

herpes zoster *Herpes zoster (shingles) begins with vague symptoms of chills and low-grade fever and possibly some gasrointestinal disturbance. Discomfort along the nerve pathway is common. Small groups of vesicles appear on the skin, usally following the nerve pathways

A nervous male patient asks the nurse why "they have to put their finger up there?" Which response by the nurse is the most helpful? A. "A digitial rectal exam is necessary to evaluate the prostate for signs of cancer." B. "There is no reason to be nervous, every man has to have this exam." C. "If you want me to answer questions, you will have to use the proper terminology." D. "It's like the female exam but for a man."

"A digitial rectal exam is necessary to evaluate the prostate for signs of cancer." *A lubricated, gloved finger is inserted into the rectum to evaluate the consistency and size of the prostate and detect any nodules.

Which statement indicates to the nurse that the 50-year-old male recently diagnosed with early stage cancer of the prostate has begun to accept his diagnosis? A. "Well, I guess this just about cancels any plans for a second honeymoon." B. "I need to call my lawyer in order to update my will." C. "Do you have any current information on prostate cancer?" D. "My children should come home from college to visit."

"Do you have any current information on prostate cancer?" *Well-adjusted patients should seek information on the disease and varied treatments. requests current information on prostate cancer.

A nurse is reinforcing discharge instructions to a client who had a skin biopsy with sutures. The nurse should identify that which of the following client statements indicates understanding? A. "I can expect redness around the site for 5 to 7 days." B. "I will most likely have a fever for the first few days." C. "I should apply an antibiotic ointment to the area." D. "I will make a return appointment in 3 days for removal of my sutures."

"I should apply an antibiotic ointment to the area."

Which statement by the patient indicates that further teaching is needed regarding home instructions post ear surgery? A. "I should take it easy for the next week." B. "I need to keep my ear dry when I shower." C. "I will be able to fly to see my grandson this weekend." D. "I will keep my head elevated."

"I will be able to fly to see my grandson this weekend." *Changes in altitude will change the pressure in the inner ear and be potentially dangerous to healing. (1, 2, 4) Taking it easy for a week, keeping the ear dry, and keeping the head elevated are appropriate postoperative actions.

The patient is reluctant to talk about his sexual history. Which statement by the nurse would be the most appropriate to complete the task of obtaining a sexual history, while considering the psychological comfort of the patient? A. "This will only take a few minutes to complete these questions." B. "Let's take a short break; then we can continue." C. "Don't be embarrassed. I ask everybody these same questions." D. "Let's start with your kidneys. Are you having trouble with urination?"

"Let's start with your kidneys. Are you having trouble with urination?"

A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90 lb. Which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing? A. "Life isn't worth living if I gain weight." B. "Don't pretend like you don't know how fat I am." C. "If I could be skinny, I know I'd be popular." D. "When I look in the mirror, I see myself as obese."

"Life isn't worth living if I gain weight." *This statement reflects the cognitive distortion of catastrophizing because the client's perception of their appearance or situation is much worse than their current condition *(B) This statement reflects the cognitive distortion of personalization rather than catastrophizing *(C) This statement reflects the cognitive distortion of overgeneralization rather than catastrophizing *(D) This statement reflects a perception of distorted body image commonly experienced by the client who has anorexia nervosa. However, it is not an example of catastrophizing

A patient asks the nurse for information about prostate cancer and how it develops. The nurse answers: A. "It is a quick-growing cancer and the nodule is small." B. "Prostate cancer is a very slow-growing cancer." C. "It is a cancer that is related to sexually transmitted viruses." D. "This type of cancer is embryonic and continues to grow slowly after birth."

"Prostate cancer is a very slow-growing cancer."

A nurse is caring for a client who is prescribed lithium therapy. The client tells the nurse of the plan to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make? A. "That is a good choice. Ibuprofen does not interact with lithium." B. "Regular aspirin would be a better choice than ibuprofen." C. "Lithium decreases the effectiveness of ibuprofen." D. "The ibuprofen will make your lithium fall too low."

"Regular aspirin would be a better choice than ibuprofen." *Aspirin is recommended as a mild analgesic rather than ibuprofen due to the risk of lithium toxicity. *Ibuprofen is not recommended for clients taking lithium. It does not decrease the effectiveness of ibuprofen but concurrent use is not recommended due to the risk of toxicity. It increases the risk for a toxic, rather than low, lithium level

A nurse is reinforcing teaching with a client who is scheduled for a transrectal ultrasound (TRUS). Which of the following information should the nurse include? A. "This procedure will determine whether you have prostate cancer." B. "The procedure is contraindicated if you have an allergy to eggs." C. "Sound waves will be used to create a picture of your prostate." D. "You should avoid having a bowel movement for 1 hr prior to the procedure."

"Sound waves will be used to create a picture of your prostate." *A biopsy or EPCA is used to make a diagnosis of prostate cancer *A TRUS is contraindicated if the client has an allergy to latex *A transrectal ultrasound creates an image of the prostate using sound waves *The provider can prescribe an enema prior to the procedure to decrease the interference of feces with obtaining accurate test results

A parent tells you that a 4-year-old child has some clear drainage coming from the right ear. This drainage is sometimes tinged with blood. The parent asks if the ear canal should be irrigated. What is your best response? a. "Use a small amount of sterile saline instilled into the ear to flush out the fluid and blood." b. "You may use over-the-counter ear drops in this ear to clear up this new infection." c. "The ear will need to be irrigated, and then an antibiotic for the ear instilled." d. "The ear should not be irrigated when there is drainage present."

"The ear should not be irrigated when there is drainage present." *Never place a drug into the ear canal or irrigate the ear canal if there is drainage present because it could enter the middle ear and cause an infection. The healthcare provider should be notified.

What is the appropriate nursing response when a patient with alcohol use disorder asks, "What is the purpose of Antabuse?" A. "It blocks the craving for alcohol." B. "The medication causes unpleasant symptoms when you drink." C. "The drug keeps you from having seizures." D. "It controls symptoms of nausea, vomiting, pain, or cramps."

"The medication causes unpleasant symptoms when you drink." Disulfiram (Antabuse) can cause chest pain, nausea and vomiting, hypotension, weakness, blurred vision, and confusion if alcohol is consumed after taking the medication. (1) Antabuse does not block the craving for alcohol. Naltrexone (ReVia) can be used to block the craving for alcohol. (3, 4) Antabuse does not control nausea and vomiting, pain, cramps, or seizures.

Older women who are, or have been, on long-term hormone replacement therapy are at increased risk for (select all that apply) A. metrorrhagia B. Breast cancer C. oligomenorrhea D. endometrial cancer

1. breast cancer 2. endometrial cancer

A nurse is caring for a client who has herpes zoster. Which of the following medications should the nurse expect to administer for treatment? A. Clotrimazole B. Acyclovir C. Gabapentin D. Penicillin

Acyclovir

A nurse caring for a client 24 hr following a liver lobectomy for hepatocellular carcinoma. Which of the following laboratory reports should the nurse monitor? A. Urine specific gravity B. Blood glucose C. Serum amylase D. D-dimer

Blood glucose *Blood glucose should be monitored during the first 24 to 48 hr following a lobectomy due to decreased gluconeogenesis and stress to the liver from surgery

The nurse is caring for a patient who presents to the clinic a small, hard lesion on the eyelid. Which condition is consistent with these findings? A. Blepharitis B. Chalazion C. Hordeolum D. Conjunctivitis

Chalazion *Chalazion is an internal stye caused by infection of the meribomian gland

A client is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately? A. Sore throat or earache B. Chills, itching, or rash C. Unusual sleepiness or fatigue D. Mild discomfort at the catheter site

Chills, itching, or rash *The client is told to report chills, itching, or rash immediately because these could be signs of a possible transfusion reaction.

What should a patient be taught to do if there is a sudden decrease or loss of vision during ophthalmic drug therapy? A. Remain lying down until vision returns B. Rinse with water or saline solution C. Call 911 or go to the nearest emergency room D. Contact the healthcare provider

Contact the healthcare provider

When administering ear drops to an adult, you would A. Draw the pinna upward and toward the front of the head B. Draw the pinna upward and toward the back of the head C. Pull the pinna downward and toward the front of the head D. Pull the pinna downward and toward the back of the head

Draw the pinna upward and toward the back of the head *Pulling the pinna up and backward straightens the ear canal on the adult, allowing the drops to coat the whole canal and reach the eardrum. (1) Pulling the pinna toward the front of the head will block the ear canal. (3) Pulling the pinna down and frontward will not straighten the ear canal. (4) Pulling the pinna down and backward will not straighten the ear canal.

Treatment for labyrinthitis (Vestibular neurontitis)

FALL RISK!!! 1. Benedryl 2. Antivert 3. Phenergen 5. Ativan 6. Valium 7. Steroids 8. Antibiotics

A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts? A. Invasion of privacy B. False imprisonment C. Assault D. Battery

False imprisonment *A civil wrong that violates a client's civil rights is a tort. In this case, it is false imprisonment, which is the confining of a client to a specific area (a seclusion room) if the reason for such confinement is for the convenience of staff.

Fluoresces under Wood light A. Erythrasma B. Wheal C. Fungal infection D. Keratosis E. Keloid

Fungal infection

A person in jail for public intoxication has been without alcohol for 12 h. Which finding indicates that the patient may be withdrawing from alcohol? A. Irritability B. Nausea and vomiting C. Hallucinations D. Seizures

Irritability *Marked irritability is the early signs (6 to 12 h after last drink) of alcohol withdrawal

The nurse is looking at the patient's chart and other documentation to determine when the patient received the last dose of blood pressure medication. Where would be the best place to locate this information? A. Physician's orders B. Medication reconciliation form C. Nurse's narrative notes D. Medication administration record

Medication administration record

A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action? A. Encourage the client to express feelings out loud B. Maintain eye contact with the client C. Move the client away from others D. Tell the client that the behavior is not acceptable

Move the client away from others *The behavior indicates that the client is at greatest risk for harming others. The priority action for the nurse is to move the client away from others.

The community health nurse is providing education to a group of young women on cervical cancer, which is highly responsive to treatment if diagnosed early. The nurse should be sure to include information on which known risk factor for cervical cancer? A. Commencement of sexual activity late in life B. Multiple sexual partners C. Early-onset menses D. Family history

Multiple sexual partners *Having multiple sexual partners appears to increase the risk of developing cervical cancer. Evidence suggests that late onset of sexual activity may reduce risk of some diseases, including cervical cancer. Family history of cervical cancer and early-onset menses are not associated with an increased risk for cervical cancer.

During an assessment of an older adult patient, the nurse observes a red rash on the palms of the hands and the soles of the feet. What should the nurse do next? A. Notify the charge nurse B. Float the patient's heels on a pillow C. Apply a prescribed emolient D. Reposition the patient on the left side

Notify the charge nurse *A red rash on the palms of the hands and the soles of the feet is consistent with the secondary phase of syphilis. The nurse should notify the charge nurse and health care provider to allow for futher workup and treatment as indicated. Floating the patient's heels or repositioning addresses prevention of skin breakdown, and emollients help decrease dry skin

The nurse adds a nursing order to the care plan related to a patient with a problem statement/nursing diagnosis of altered nutrition/Nutrition: Less Than Body Requirements Related to Nausea and Vomiting. Which nursing order should the nurse include in the plan of care? A. Medicate with an antiemetic before each meal B. Offer crackers and iced drink before each meal C. Change diet to clear liquids D. Give nothing by mouth until nausea subsides

Offer crackers and iced drink before each meal

The nurse is assisting with planning the care of a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? A. One-to-one suicide precautions B. Suicide precations, with 30 minute checks C. Checking the whereabouts of the client every 15 minutes D. Asking the client to report suicidal thoughts immediately

One-to-one suicide precautions *One-to-one suicide precautions are required for the client who has attempted suicide. Options B and C are not appropriate, considering the situation. Option D may be an appropriate intervention, but the priority is stated in option A. The best option is constant supervision so that the nurse may intervene as needed if the client attempts to cause harm to him or herself

A patient admitted to the psychiatric unit states he is the "son of God" and insists he "will not be confined by mere mortals." Which is the most likely explanation for this behavior? A. Paranoia B. A stressful event C. Overwhelming anxiety D. A religious conversion

Paranoia *Delusions of grandeur are associated with paranoia. Conversion is generally expressed as sensory and motor deficits. Stressful events, religious conversion, and overwhelming anxiety do not manifest as delusions of grandeur.

The nurse reminds a 68 year old man that a man of any age can reproduce if he is able to perform which function? A. Maintain an erection B. Ejaculate C. Maintain a high sperm count D. Participate in intercourse

Participate in intercourse *If a man can participate in intercourse, he can still reproduce, even with a low sperm count

A female patient comes to the emergency department with severe abdominal pain, a temperature of 101 F, and a foul smelling, purulent vaginal discharge. The nurse recognizes that these findings are consistent with which infection? A. Pelvic inflammatory disease (PID) B. Gonorrhea C. Syphilis D. Vaginosis

Pelvic inflammatory disease (PID) *Fever, abdominal pain, and purulent discharge are cardinal indicators of PID. Gonorrhea most often presents in females with vaginal discharge and burning with urination. The initial state of syphilis presents with chancre (hard, painless sore) on the mucuous membrane of the mouth or genitals. Vaginosis most often presents with symptoms including a grayish-white discharge that has a fishy odor

Which symptom is consistent with an inhalation burn? A. Full-thickness burns to chest B. Hypotension C. Agitation D. Persistent coughing

Persistent coughing *Persistent coughing, particularly if black mucus is coughed up, is an indicator of an inhalation burn

A postoperative patient who also has alcohol use disorder was given chlordiazepoxide for increased blood pressure, increased pulse, tremors, nausea and vomiting, and diaphoresis. What is the rationale for use of this medication? A. Prevention of postoperative clot formation B. Reduction of symptoms of alcohol withdrawal C. Control of blood pressure D. Relief of postoperative nausea and vomiting

Reduction of symptoms of alcohol withdrawal *Chlordiazepoxide (Librium) is given to reduce the neurologic irritability associated with alcohol withdrawal. (1) Librium has nothing to do with clot formation. (3, 4) Librium should reduce symptoms, including elevated blood pressure and nausea and vomiting, that are part of the overall symptom set associated with withdrawal.

In the immediate care provided to a burn victim with second- and third-degree burns of the arms and legs, the LPN/LVN should expect the primary health care provider to order which intervention? A. Replacement of lost fluids and electrolytes B. Ample occlusive dressings to protect the patient's damaged skin C. Antibiotics to ward off infection D. Sedative injection to calm the patient

Replacement of lost fluids and electrolytes *A priority concern in the patient who has experienced severe burns is the prevention of shock. The two most important measures to relieve profound shock are replacement of lost fluids and electrolytes (fluid resuscitation) and enhancement of tissue perfusion. Antibiotic use may be included in the plan of care but is not of greater priority than the prevention of shock. The patient may be medicated for pain and anxiety, but it is not the priority action. Occlusive dressings are not the appropriate option for this patient.

When assisting with the development of a care plan for the patient with cancer, which nursing diagnosis will be be of the highest priority? A. Disturbed body image B. Activity intolerance C. Self-care deficit D. Risk for injury

Risk for injury

Which patient do you anticipate may have a dual diagnosis? The patient with A. Bipolar disorder and anxiety B. Alcohol use disorder and alcohol intoxication C. Schizophrenia and cannabis use disorder D. Major depressive disorder and PTSD

Schizophrenia and cannabis use disorder *Schizophrenia and cannabis use disorder are not related and are separate conditions. (1, 2, 4) The other conditions listed are related to each other and not standalone diagnoses.

The most important part of writing expected outcomes for problem statements/nursing diagnoses is to A. State the outcome so that it is measurable B. Include health promotion and resource management C. Make the outcome short-term D. Base it on objective patient data

State the outcome so that it is measurable

The health care provider writes an order for continuous observation for a patient admitted for an acute adverse response to a hallucinogenic drug. Which characteristic of hallucinogenic drugs makes close observation necessary? A. Rapid physical dependence B. States of altered perception C. Severe respiratory depression D. Both stimulant and depressant effects

States of altered perception *Hallucinogens produce altered perceptual states, making patient behavior unpredictable. Hallucinogenic drugs do not produce rapid physical dependence; they produce psychological dependence. Respiratory depression is an effect of narcotic use. Hallucinogens do not produce both stimulant and depressant effects.

A nurse on an acute mental health unit forms a group to focus on self-management of medications. At each of the meetings, two of the members conspire together to exclude the rest of the group. This is an example of which of the following concepts? A. Triangulation B. Group process C. Subgroup D. Hidden agenda

Subgroup *A subgroup is a small number of people withing a larger group who function separately from that group *Triangulation is when a third party is drawn into a relationship withing two members whose relationship is unstable *Group process is the verbal and nonverbal communication that occurs within the group during group sessions *A hidden agenda is when some group members have a different goal than the states group goals. The hidden agenda is often disruptive to the effective functioning of the group

What is a potential complication of residual negative symptoms that do not respond to medication? A. Apathy results in failure to adhere to medication regimen B. Bizarre behavior such as public nudity results in social stigma C. Tardive dyskinesia is permanent and debilitating D. Auditory hallucination continue, but are less problematic

Tardive dyskinesia is permanent and debilitating

A nurse at a health department is planning strategies related to heart disease. Which of the following activities should the nurse include as part of primary prevention? A. Providing cholesterol screening B. Teaching about a healthy diet C. Providing information about antihypertensive medications D. Developing a list of cardiac rehabilitation programs

Teaching about a healthy diet *Primary prevention encompasses strategies that help prevent illness or injury. This level of prevention includes health information about nutrition, exercise, stress management, and protection from injuries and illness *Cholesterol screening is an example of secondary prevention *Taking medication to lower blood pressure is part of secondary prevention *Cardiac rehabilitation is an example of tertiary prevention

A nurse in a health clinic is caring for a 21-year-old male client who tells the nurse that their last physical exam was in high school. Which of the following health screenings should the nurse expect the provider to perform? A. Testicular examination B. Blood glucose C. Fecal occult blood D. Prostate-specific antigen

Testicular examination *Starting a puberty, the client should have examinations for testicular cancer, along with blood pressure and body mass index and cholesterol measurements. Testicular cancer is most common in males 15 to 34 years of age *Blood glucose testing begins at age 45 *Testing for fecal occult usually begins at age 50 *Testing for prostate-specific antigen usually begins at age 50

The nurse is advising a young college student who wants a tan before spring break. Which method is safest for the student to use? A. Take advantage of morning sun while using sunscreen with an SPF of 30. B. Use a spray-on tanning solution C. Use a sun lamp for a maximum of 20 minutes a day D. Use a tanning salon for no more than 10 minutes per visit

Use a spray-on tanning solution *Spray-on tanning solution is the safest. All other options increase ultraviolet exposure, even with the use of sunscreen

A client has reported that crying spells have been a major problem over the past several weeks, and that the doctor said that depression is probably the reason. The nurse observes that the client is sitting slumped in the chair and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which assessment? A. Weight loss B. Sleep pattern C. Medication compliance D. Onset of the crying spells

Weight loss *All the options are possible issues to addressl however, the weight loss is the first item that needs further data collection because ill-fitting clothing could indicate a problem with nutrition. The client has already told the nurse that the crying spells have been a problem. Medication or sleep patterns are not mentioned or addressed in the question

Which diagnostic test would be used to differentiate benign versus malignant skin lesions? A. Culture and sensitivity test B. Cold light examination C. Diascopy D. Skin biopsy

skin biopsy

The nurse is providing education to a patient recently prescribed a topical medication. Which instruction would be appropriate for the nurse to give the patient? A. "Inject the medication directly into the lesion." B. "Ingest the medication by mouth." C. "Apply the medication directly to the surface of the affected area." D. "Mix the medication into your bath water."

"Apply the medication directly to the surface of the affected area." *Topical treatments involve the application of compounds directly to the skin and are not mixed into a patient's bath water. Oral medications are ingested by mouth. Subcutaneous or intradermal medications are injected into the lesion.

Which patient statement is true about STIs? A. "One nice thing about current medical practice is that there is a cure for every STI." B. "Barrier protection should be used during intercourse with new partners, even if pregnancy is not a concern." C. "Chlamydia is the most common sexually transmitted viral infection." D. "Syphilis has been conquered and it is no longer possible to contract it."

"Barrier protection should be used during intercourse with new partners, even if pregnancy is not a concern."

The depressed patient who has been taking amitriptyline (Elavil) for the past 2 weeks complains of still feeling depressed and wants to abandon the drug. How should the nurse respond? A. "I will ask the physician about a new order for a different drug." B. "You probably should quit taling Elavil if it is not helping you." C. "Sometimes drinking a small glass of wine with meals helps." D. "These drugs take several weeks to become effective."

"These drugs take several weeks to become effective." *Tricyclics may take up to 4 weeks before patients experience symptom relief. The patient has not been taking the medication long enough to request a new order. The nurse should not encourage the patient to discontinue the medication. This medication should not be combined with alcohol

Approximately how many in 1000 babies born in the United States have some form of congenital hearing problem? A. 1 B. 2 C. 100 D. 200

2

When a patient has primary genital herpes, it is likely that the lesions will resolve spontaneously in which time? A. 2 weeks B. 6 months C. 1 month D. 1 year

2 weeks *Vesicles in the genital area ulcerate, crust over, and resolve spontaneously in about 2 weeks.

The nurse is teaching a high school class about hearing loss and the use of ear buds while listening to loud music. The nurse explains that sustained exposure to noise levels above which of the following can cause hearing loss? A. 25 dB B. 50 dB C. 85 dB D. 100 dB

85 dB *Sustained exposure to noise levels of above 85 dB may result in hearing loss. Personal listening devices at high volumes can produce hearing loss with less than 5 minutes of exposure with dB levels of 105 to 110. The higher the sound level, the less time it takes to cause damage

The nurse is assisting with creating a plan of care for the client in a crisis state. When developing the plan, the nurse should consider which about a crisis response? A. A crisis state indicates that the individual is suffering from a mental illness B. A crisis state indicates that the individual is suffering from an emotional illess C. Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis D. A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person

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

Which statement accurately explains the difference between an enabler and a codependent? A. A codependent covers up the substance abuser's behavior B. A codependent rationalizes the substance abuser's behavior C. An enabler uses the substance abuser's behavior to build up his or her own self-esteem D. An enabler is also a substance abuser

A codependent covers up the substance abuser's behavior *The codependent "fixes" things by overcompensating to prevent the abuser from facing reality. Enabling refers to "helping" a person so that the person's consequences from unhealthy behavior are less severe; thus enabling "helps" the unhealthy behavior to continue

A client was just admitted to the hospital to rule out a gastrointestinal bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication should the nurse determine to be the cause of the client's complain? A. Doxycycline B. Atropine sulfate C. Acetylsalicyclic acid D. Diltiazem hydrochloride

Acetylsalicyclic acid

The patient complains of the unsightly swelling of her lip at the site of an infection. The nurse explains that the swelling is part of the inflammatory response and performs which action? A. Stores blood B. Acts as a compression wall C. Provides an antibody reservoir D. Produces leukocytes

Acts as a compression wall *The swelling of the inflammatory response acts as a compression wall to delay the spread of harmful agents to the rest of the body

The nurse is caring for a patient who is receiving vincristine. Which precaution is most important for the nurse to take? A. Prevent the patient from getting chilled B. Administer a stool softener as ordered C. Offer the patient a soft toothbrush D. Feed the patient a snack during the infusion

Administer a stool softener as ordered *Certain anti-neoplastic drugs, such as vinblastine, vincristine, and paclitaxel, cause constipation. Increasing fluids (as allowed), adding fiber to the diet, administering stool softeners and fiber laxatives, exercise, and monitoring vigilantly for the beginning signs of constipation are the usual measures taken. Suppositories or enemas may be necessary

A client is unwilling to get out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The spouse asks the nurse, "What is the name of my wife's disorder?" Which answer should the nurse give to the spouse? A. Agoraphobia B. Hematophobia C. Claustrophobia D. Hypochondriasis

Agoraphobia *Agoraphobia is a fear of being alone in open of public places where escape might be difficult. Agoraphobia includes experiencing fear or a sense of helplessness or embarrassment if a phobic attack occurs. Avoidance of such situtations usually results in the reduction of social and professional interactions. Hematophobia is the fear of blood. Claustrophobia is a fear of closed-in places. Clients with somatic symptom disorder focus their anxiety on physical complaints and are preoccupied with their health

A patient with psychotic depression is receiving haloperidol. Which side effect is associated with this medication? A. Cataracts B. Akathisia C. Polyuria D. Diaphoresis

Akathisia *Akathisia is pathologic restlessness and agitation; it is an extrapyramidal adverse effect of many of the older antipsychotic medications, such as haloperidol and chlorpromazine. Polyuria, cataracts, and diaphoresis are not associated with haloperidol use.

In which circumstance would the use of a burette be advised as a safety device? A. A trauma patient needs several units of packed red blood cells B. The patient needs IV fluids, but no infusion pump is available C. An infant is at risk for IV fluid volume overload D. A confused patient keeps trying to unplug the infusion pump

An infant is at risk for IV fluid volume overload *The burette provides a way to measure the exact amount of IV fluid that could flow into the infant. (1) The burette would not be used in the case of a trauma patient. (2) You could use a burette for a patient who needs IV fluids, but remember that the burette will hold a limited amount of fluid and you will have to refill the burette frequently, so it may cause more work. (4) If a patient unplugs an infusion pump, the pump is likely to continue on a battery. When the battery runs low, an alarm will begin to sound. If the battery depletes, the IV will not infuse. Use of a burette in this case serves no purpose.

Which critical thinking skill is important to apply when formulating a nursing care plan? A. Having the nursing assistant help with assessment B. Reading the history and physical in the chart C. Analyzing the data to determine appropriate nursing diagnoses D. Including the patient in formulating the care plan

Analyzing the data to determine appropriate nursing diagnoses *Analyzing the data from all areas of the assessment is use of critical thinking. (1) Using the nursing assistant is part of delegation. (2) Reading the history and physical in the chart is appropriate but not a use of critical thinking. (4) Including the patient in care planning is appropriate but not a use of critical thinking.

The nurse is caring for a client about a mastectomy. Which finding would indicate that the client is experiencing a complication that may become a chronic problem related to the surgery? A. pain at the incisional site B. Arm edema on the operative side C. Sanguineous drainage in the Jackson Pratt drain D. Complains of decreased sensation near the operative site

Arm edema on the operative side *Clients who undergo mastectomy for breast cancer, especially those with axillary node resection, may develop chronic lymphedema or excessive swelling in the arm and hand. Lymphedema is a complication that may develop immediately after mastectomy, months, or even years after surgery. Slight edema may occur in the immediate postoperative period, but should decrease especially if the client rests with the arm supported on a pillow. Women should avoid injury to the arm on the affected side and not allow venipunctures or blood pressures to be taken in that arm. Pain and numbness near the incision and drainage from the surgical site are expected occurences after mastectomy and are not indicative of a complication

The assessment technique of percussion is used by the nurse to A. Determine whether lung sounds are normal B. Assess for air in the intestine C. Check for abdominal rigidity D. Assess the degree of abdominal pain

Assess for air in the intestine *Percussion assists in determining if there is air in the intestine. (1) Auscultation is used to determine if lung sounds are normal. (3) Palpation is used to determine abdominal rigidity. (4) The patient must verbalize the degree or amount of abdominal pain.

The nurse observes a new nursing assistant using a mask, a gown, foot covers, and gloves for every patient that she is assigned to. What should the nurse do first: A. Check the assignment sheet to see what kinds of patients the assistant is assigned to B. Ask the charge nurse to intervene because the assistant is wasting supplies C. Assess the assistant's understanding of Standard and Transmission-Based Precautions D. Allow her to continue to work because her actions prevent health care associated infections

Assess the assistant's understanding of Standard and Transmission-Based Precautions

The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for during this phase? A. Plan short-term goals B. Identify expected outcomes C. Assist with making appropriate referrals D. Assist with developing realistic solutions

Assist with making appropriate referrals *Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. Options A, B, and D identify the tasks of the working phase of the relationship

When should a female start having routine pelvic exams and Pap smears? A. As soon as she becomes sexually active or at age 20 B. At age 16, if she has family history of cervical cancer C. At age 21 D. Whenever she starts her menstrual periods

At age 21

The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question? A. Betaxolol B. Pilocarpine C. Atropine sulfate D. Pilocarpine hydrochloride

Atropine sulfate

A nurse is caring for a client who has cancer and has a prescription for transcutaneous electrical nerve stimulation (TENS) for pain management. Which of the following actions should the nurse take? A. Remove hair before applying the electrodes from the TENS unit on the skin B. Apply alcohol to the client's skin before attaching the electrodes from the TENS unit C. Attach the electrodes from the TENS unit over painful incisions or skin damage D. Avoid other pain medications when using the TENS unit

Avoid other pain medications when using the TENS unit *The skin should be clean and intact before applying the electrodes, but the skin does not have to be cleansed with alcohol *Apply the electrodes over intact skin that is over or near the site of pain, but not over incisions or areas of damage.

The nurse instructs a sexually active teenager that frequent douching can cause which infection? A. Syphilis B. Bacterial vaginosis C. Pelvic inflammatory disease (PID) D. Purulent vaginitis

Bacterial vaginosis *Bacterial vaginosis is caused when frequent douching changes the pH of the vaginal vault and creates an environment conducive to bacterial invasion. Sexually transmitted infections (STIs) like syphilis are not transferred by douching. PID is a condition that most often results from an untreated infection. Vaginitis is an inflammatory condition that does not result from douching

The patient underwent a mammogram that indicated breast lesions. A definitive diagnosis of breast malignancy is made by which procedure? A. Culture of breast discharge B. Manual palpation of the breast C. Biopsy of breast tissue D. Chest x-ray

Biopsy of breast tissue *A biopsy of breast tissue is the definitive diagnosis for the presence of breast cancer. A chest x-ray, culture of breast discharge, and manual palpation of the breast are not used for a definitive diagnosis.

A nurse is attending a peer group discussion about the indications for ECT. Which of the following indications should the nurse recommend for inclusion in the discussion? A. Borderline personality disorder B. Acute withdrawal related to a substance use disorder C. Bipolar disorder with rapid cycling D. Dysphoric disorder

Bipolar disorder with rapid cycling *ECT is indicated for the treatment of bipolar with rapid cycling *ECT has not been found to be effective for the treatment of personality disorders, substance use disorders, or dysphoric disorder

The nursing student is asked to identify the characteristics of bulimia nervosa. Which characteristic if identified by the student inidicates a need to further research the disorder? A. Dental erosion B. Electrolyte imbalances C. Enlarged parotid glands D. Body weight well below ideal range

Body weight well below ideal range *Clients with bulimia nervosa may not initally appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. During further inspection, the client demonstrates enlargement of the parotid glands with dental erosion and caries if he or she has been inducing vomiting. Electrolyte imbalances are present

A patient being treated for cancer shows symptoms of a secondary fungal infection of the oral mucosa. What is the most likely type of infection? A. Streptococci B. Staphylococcus aureus C. Legionella D. Candida albicans

Candida albicans *Candida albicans commonly causes a yeast infection (thrush) after treatment with antibiotics, because the normal flora has been destroyed, allowing the Candida to flourish. Streptococci and S. aureus are bacterial infections. Legionella is a bacteria that survives in water

The nurse is caring for a patient and during the assessment, observes a full-thickness 2 cm x 1 cm skin tear on the right buttock. How should the nurse stage this pressure ulcer? A. Category I B. Category II C. Category III D. Category IV

Category III *Category III skin tears have complete tissue loss in which the epidermal flap is missing. Category I skin tears do not have tissue loss. Category II skin tears reflect a partial tissue loss. There is no Category IV.

Promoters are substances that A. help prevent cancer cells from invading other cells B. Cause cancer cells to grow faster C. help cancer metastasize to other areas D. enhance the effect of chemotherapy drugs

Cause cancer cells to grow faster

The nurse is preparing an intravenous (IV) solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to take which action? A. Change the IV tubing B. Wipe the tubing with Betadine C. Scrub the tubing with an alcohol swab D. Scrub the tubing before attaching it to the IV bag

Change the IV tubing *The nurse should change the IV tubing. The tubing has become contaminated, and, if used, it could result in a systemic infection in the client. Wiping or scrubbing the tubing is insufficient to prevent systemic infection

The nurse is caring for a menopausal patient who is experiencing hot flashes. The nurse suggests that the patient increase intake of which foods? A. Red meat and leafy greens B. Cherries and black beans C. Carrots and asparagus D. Yogurt and cheese

Cherries and black beans *During menopause, decreasing estrogen levels may cause hot flashes. Cherries, yams, and black beams are foods rich in phytoestrogens, substances found in plants that may act like normally produced estrogen. Red meat and leafy greens are rich in iron, carrots, and asparagus are rich in beta carotene. Yogurt and cheese are rich in calcium. Iron, betacarotene, and calcium are not known to impact estrogen levels

Wound covered with ointment, then covered with layers of gauze saturated with topical medication A. Open technique B. Closed technique C. Escharoctomy D. Allograft E. Xenograft

Closed technique

Significant subjective data in the assessment of a patient with a skin disorder include A. Appearance of skin adjacent to the lesions B. Having difficulty eating meals, especially breakfast C. Localized or generalized edema of the skin D. Complaints of itching sensation in the affected area

Complaints of itching sensation in the affected area

What factors cause elderly patient to be at risk for substance-induced delirium? A. Increased metabolism and reduction in cardiac and liver function B. Decreased metabolism and reduction in cardiac and respiratory function C. Decreased metabolism and reduction in kidney and liver function D. Increased metabolism and reduction in neurologic and immune function

Decreased metabolism and reduction in kidney and liver function

The patient presents to the clinic with genitourinary complaints. Which symptoms, if reported by the male patient, indicates urethritis? A. Difficult, painful, and frequent urination with penile discharge B. Infrequent, inadequate urination with yellow urine and pain in the legs C. Chancres, gummas, and vesicles on the urethra D. Hot, tender scrotum

Difficult, painful, and frequent urination with penile discharge *Urethritis is a condition involving inflammation of the urethra. Related symptoms include painful voiding and discharge. It is often seen with STIs in men. Hot, tender scrotum; chancres, gummas, and vesicles on the urethra; and infrequent, inadequate urination with yellow urine and pain in the legs are not signs of urethritis.

A client experiencing a severe major depressive episode is unable to adderss activities of daily living. Which is the appropriate nursing intervention? A. Feed, bathe, and dress the client as needed until the client can perform these activities independently B. Offer the client choices and consequences to the failure to comply with the expectation of maintaining activities of daily living C. Structure the client's day so that adequate time can be devoted to the client's assuming responsibility for the activities of daily living D. Have the client's peers confront the client about how their noncompliance with addressing activities of daily living affects the milieu

Feed, bathe, and dress the client as needed until the client can perform these activities independently *The client with depression may not have the energy or interest to complete activities of daily living. Often, severely depressed clients are unable to perform evem the simplest activities of daily living. The nurse assumes this role and completes these tasks with the client. Options B and C are incorrect because the client lacks the energy and motivation to perform these tasks independently. Option D will increase the client's feelings of poor self-esteem and unworthiness

When discussing prostate cancer with a patient who has a strong family history of the disorder and BPH, the nurse tells him that which medication is used to help prevent prostate cancer? A. Finasteride B. Doxazosin C. Terazosin D. Tamsulosin

Finasteride

Memory lapses seen in early stages of Alzheimer's disease (AD) are related to pathophysiology of which condition? A. Frontal lobe atrophy B. Overproduction of neurotransmitters C. Pituitary disorders D. Inadequate clearance of metabolic toxins

Frontal lobe atrophy *Loss of neurons in the frontal and temporal lobes results in atrophy and the many signs of AD, memory deficits being one of the earliest

A patient is prescribed an ophthalmic beta blocker for his glaucoma. Which of the following adverse effects is possible if the drug is absorbed into the blood system? A. Heart rate less than 60 B. Increased tearing C. Increased blood pressure D. Redness of eyes

Heart rate less than 60

The nurse recognizes that smoking is a "promoter" that, although not a carcinogen itself, allows cancer to occur faster in the patients. Which factor is also a promoter of cancer? A. Obesity B. Occupational hazards C. Cocaine abuse D. Heavy alcohol intake

Heavy alcohol intake *Alcohol and smoking are "promoters" that facilitate the occurrence of cancer.

A unilateral orchiectomy is performed on a patient who has a testicular tumor. The patient says to the LPN/LVN, "How will this affect me as a man?" The nurse's response is based on which understanding? A. His other testis will carry on normal testicular function. B. He will be unable to sustain an erection without some mechanical assistance. C. He will not ejaculate sperm. D. He will need to have small supplements of testosterone.

His other testis will carry on normal testicular function.

The nurse reviewing the patient's chart identifies which risk factor for ovarian cancer? A. Tubal sterilization B. Three term pregnancies C. Use of oral contraceptives D. History of pelvic irradiation

History of pelvic irradiation *Risk factors for the development of ovarian cancer include having a sister or mother with the disease or inheriting the BRCA1 or BRCA2 gene. Exposure to asbestos, talc powder, pelvic irradiation, or mumps has also been linked to the development of ovarian cancer. Women on hormone therapy should be informed concerning the risks for ovarian cancer. Factors that may prevent ovarian cancer include one or more term pregnancies, breast-feeding, tubal sterilization, and possibly the use of OCs.

A nursing assistant says to the LPN/LVN, "I can't believe that Mrs. Feld, who is so sick and so near death, still enjoys a good laugh." Which of these ideas should the nurse use as the basis for discussing Mrs. Feld's behavior? A. It is inappropriate for the assistant to encourage humor at this time. B. Humor is a healthful part of everyone's life. C. Use of humor at this time shows an inability to face reality. D. The patient's behavior indicates that she may be suicidal.

Humor is a healthful part of everyone's life. *Humor is a healthy way to deal with stress, even during a terminal illness, as long as it is welcomed by the patient. This behavior does not indicate that she is suicidal or show an inability to face reality. As long as the patient enjoys humor, the assistant should encourage it.

A nurse is assisting with providing care for a client who has benzodiazepine toxicity. Which of the following actions is the nurse's priority? A. Administer flumazenil B. Idenitify the client's level of orientation C. Ensure the administration of IV fluids D. Prepare the client for gastric lavage

Idenitify the client's level of orientation *When taking the nursing process approach to client care, the intial step is data collection. Identifying the client's level of orientation is the priority action *Administer flumazenil will reverse the effects of benzodiaxepine, ensure the administration of IV fluids to maintain blood pressure, and gastric lavage will remove excessive medication from the client's GI system; however, another action is the priority

The nurse uses a visual aid to demonstrate how which antibody attaches to the antigen to clear the pathogen from the body? A. IgA B. IgD C. IgG D. IgM

IgM *Immunoglobulin M (IgM) is the antibody that recognizes the foreign protein and attaches itself to it in order to clear the pathogen from the body

The nurse is caring for a middle-aged woman who is not sexually active. The patice questions the nurse about the recommended frequency of Pap smears. Which response is best? A. Annual screening is recommended B. Screening is not needed for women who are not sexually active C. Screening in the woman who is not sexually active may be spaced every 5 to 7 years D. In the woman with negative screenings, the Pap test may be repeated every 3 years

In the woman with negative screenings, the Pap test may be repeated every 3 years *Women with three consecutive negative screening at age 30 should have repeated testing every 3 years until age 65, when testing of asymptomatic women is no longer necessary. American Congress of Obstetricians and Gynecologist (ACOG) recommends that cervical cancer screesning should begin at age 21 and be repeated every 2 years between ages 21 and 29 in asymptomatic women. Women with three consecutive negative screenings at age 30 should have repeated testing every 3 years until age 65 when testing of asymptomatic women is no longer necessary. Women with cervical pathology or cancer should be screened annually for 20 years after treatment

You emphasize safety precautions to an 80 year old female patient with Meniere disease. An appropriate nursing approach would be to A. Use the patient's first name when addressing her B. Include family members in instructions C. Address decision making with the patient D. Set a specific schedule for providing instructions

Include family members in instructions *Including family members when giving safety instructions will help reinforce needed interventions and help keep the patient safe from falls. (1) Using the patient's name will not increase safety. (3) Decision making is not the focus. (4) There is no need to schedule instructions for a specific time.

A patient taking an SSRI suddenly develops a rapid pulse, fluctuating blood pressure, fever, loss of muscle coordination, and mental status changes. You prepare for which intervention? A. Infuse IV fluids and administer an antipyretic B. Obtain an electrocardiogram and start oxygen through a nasal cannula C. Administer an antidote and encourage oral fluids D. Monitor the patient closely and continue the medication

Infuse IV fluids and administer an antipyretic *The patient is manifesting symptoms of serotonin syndrome. This is a potentially life-threatening condition that could start 30 minutes to 48 hours after taking the medication. Treatment includes stopping medication, administering IV fluids, and decreasing temperature. (2) The health care provider may order an electrocardiogram (ECG) to rule out other problems and giving oxygen for change of mental status is acceptable if pulmonary problems are suspected or oxygenation as measured by pulse oximetry is decreased. (3) There is no single antidote for this condition, and oral fluids are inappropriate for patients who are unstable. (4) Close monitoring is necessary, but the medication should be discontinued.

On the first postoperative day, a patient with TURP complains of abdominal pain. The nurse finds that the bladder is greatly distended. What should the nurse do next? A. Inform the charge nurse B. Irrigate the indwelling catheter with 20 to 30 mL of normal saline C. Increase the continuous bladder irrigation flow rate D. Turn the patient to the right side

Irrigate the indwelling catheter with 20 to 30 mL of normal saline *The patient most likely has a clot that is occluding the catheter and causing pressure on the bladder. Additional irrigation wil dislodge the clot that is occluding the catheter. Increasing continuous bladder irrigation flow rate would add fluid to the bladder and increase pain. It is within the primary care nurse's role to perform the intervention without notifying the charge nurse. Turning the patient to the right side does not offer benefit

A nurse is caring for a client who has angina and asks about obtaining a prescription for sildenafil to treat erectile dysfunction. Which of the following medications should the nurse recognize as contraindicated with sildenafil? A. Aspirin B. Isosorbide C. Clopidogrel D. Atorvastatin

Isosorbide *Isosorbide is an organic nitrate that manages pain from angina. Concurrent use of it is contraindicated because fatal hypotension can occur. The client should avoid taking a nitrate medication for 24 hr after taking isosorbide *Aspirin is contraindicated in clients who have a bleeding disorder, but there are no contraindication for concurrent use of sildenafil *Clopidogrel is contradindicated in clients who are actively bleeding, but there is no contraindication for concurrent use of clopidogrel and sildenafil *Atorvastatin is contraindicated in clients who have hepatic disease, but there is no contraindication for concurrent use of atorvastatin and sildenafil

A premenopausal woman who has a hysterectomy may have difficulty adjusting to this loss for what reason? A. She will be less active and less healthy than others her age. B. It means she will not be able to have any more children. C. She will be less sexually motivated. D. She may be disfigured.

It means she will not be able to have any more children. *The removal of the uterus represents the loss of fertility. She will not necessarily be less sexually motivated, healthy, or active; she will not be disfigured.

The nurse is assisting the patient with middle-stage Alzheimer's disease (AD) with dressing. Which action is most appropriate? A. Select clothes and dress the patient B. Layout clothing and coach the patient to dress self C. Ask the patient what he wants to wear D. Open the closet and tell the patient to choose a shirt

Layout clothing and coach the patient to dress self *Coaching the patient to dress himself helps preserve dignity and function. Selecting clothes and dressing the patient does not allow the patient to actively particpate in any way. Asking the patient what he wants to wear and telling him to choose a short could increase confusion and indecision

When teaching a high school boys' health class, which information about latex condoms is most important for the nurse to include? A. Use petroleum jelly as a lubricant B. Leave room at the condom tip for a reservoir for semen C. Discard condoms after three uses D. Apply the condom immediately before ejaculation

Leave room at the condom tip for a reservoir for semen *Leaving room at the tip of a condom guards against spillage of semen. Petroleum jelly deteriorates latex condoms. Only water-based lubricants should be used. Condoms should be applied only one time. A condom should be applied with erection; sperm is secreted in pre-ejaculate

The nurse is caring for an x-ray technician who wears a badge that is monitored frequently to measure the amount of radiation he has absorbed. The nurse advises the technician that he has the highest risk for developing which type of cancer? A. Bladder cancer B. Leukemia C. Melanoma D. Lung cancer

Leukemia *The blood cancer leukemia is associated with radiation exposure. Bladder, melanoma, and lung cancer are associated with other carcinogens

The nurse explains to the patient who is using Prilosec (a proton pump inhibitor) that the drug reduces the amount of which natural protector in the stomach lining? A. Lactic acid B. Lysozyme C. Cilia D. Fatty acids

Lysozyme *Lysozyme is found in the lining of the stomach and in the stomach acids

The nurse is caring for a patient addicted to heroin who is being treated for withdrawal symptoms. Which medication can the nurse anticipate will be prescribed to manage this condition? A. Naloxone hydrochloride B. Disulfiram C. Lorazepam D. Methadone

Methadone *Methadone maintenance programs are successful in helping patients who have a heroin addiction. Disulfiram is used as aversive therapy for alcoholism. Lorazepam is used for treatment of alcohol withdrawal. Naloxone hydrochloride is used to reverse narcotic and opiate overdose.

The elderly patient is unable to pass urine. He is diagnosed with PBH and the health care provider has ordered the insertion of a Foley catheter. Which task would be appropriate to assign to the nursing assistant? A. Insert the Foley catheter using sterile technique B. Provide perineal and Foley care after insertion C. Observe the meatus for skin skin breakdown during hygienic care D. Evaluate the patient's response to the Foley insertion

Observe the meatus for skin skin breakdown during hygienic care

A nurse is caring for a client who is receiving chemotherapy and has mucositis. Which of the following actions should the nurse take? A. Use a glycerin-soaked swab to clean the client's teeth B. Encourage increased intake of citrus fruit juices C. Obtain a culture of the lesions D. Provide an alcohol-based mouthwash for oral hygiene

Obtain a culture of the lesions *Glycerin-based swabs should be avoided when providing oral hygiene to a client who has mucositis *Acidic foods should be discouraged for a client who has oral mucositis *Obtain a culture of the oral lesions to identify pathogens and determine appropriate treatment *Nonalcoholic mouthwashes are recommended for a client who has mucositis

The nurse is educating the 45-year-old female patient about the American Cancer Society (ACS) recommendations for early detection of cancer. Which information should she include when teaching? A. Obtain a Pap smear every year B. Get an annual fecal occult blood examination C. Plan a sigmoidoscopy every 5 years D. Obtain a mammogram every year

Obtain a mammogram every year *The ACS recommends that 45-year old women have an annual mammogram and a Pap smear every 2 to 3 years. Yearly fecal occult studies and sigmoidoscopy are recommended beginning at age 50

A nurse is assisting with a staff education program on substance use in older adults. Which of the following information should the nurse to include in the presentation? A. Older adults require higher doses of a substance to achieve a desired effect B. Older adults commonly use rationalization to cope with a substance use disorder C. Older adults are at an increased risk for substance use following retirement D. Older adults develop substance use to mask manifestations of dementia

Older adults are at an increased risk for substance use following retirement *Requirement and other life change stressors increase the risk for substance use in older adults, especially if there is a prior history of substance use *Requiring higher doses of a substance to achieve a desired effect is a result of the length and severity of substance use rather than age *Denial, rather than rationalization, is a defense mechanism commonly used by substance users of all ages *Substance use in the older adult can result in manifestations of dementia

The nurse is caring for an adolescent girl with primary dysmenorrhea. The girl's mother reports that her daughter has been absent from school at least 1 day during her last four periods. She anticipates that the health care provider will likely prescribe which treatment? A. Aromatherapy B. Dietary modification C. Effleurage D. Oral contraceptive Seasonale

Oral contraceptive Seasonale *Seasonale is a popular oral contraceptive that provides delayed menstruation Since this patient is accruing multiple short-term school absences over a periods of months, Seasonale would provide longer periods of pain-free amenorrhea by allowing only four menstrual periods per year. Aromatherapy, dietary modification, and effleurage may also help relieve discomfort when present but extend pain-free intervals

What physical assessment findings would you observe when an IV becomes infiltrated? a. Pallor and pain b. Pallor, warmth c. Pain, warmth, and burning d. Pain, swelling, and redness

Pain, swelling, and redness *Infiltration produces pain, swelling of the area, and redness. Pain with warmth and burning are signs of infection.

A nurse is a provider's office is reviewing the medical record of a client who has fibrocystic breast condition. Which of the following findings should the nurse expect? A. Palpable rubberlike lump in the upper outer quadrant B. BRCA1 gene mutation C. Elevated CA-125 D. Peau d'orange dimpling of the breast

Palpable rubberlike lump in the upper outer quadrant *Clients who have fibrocystic breast condition typically have breast pain and rubbery palpable lumps in the upper outer quadrant of the breasts *BRCA1 gene mutation is a risk factor for breast cancer *An elevated CA-125 is finding associated with ovarian cancer *Peau d'orange dimpling of the breast is a finding associated with breast cancer

The nurse is bathing a patient with poison ivy. Which action is most appropriate? A. Bathe the patient with warm water B. Maintain a room temperature of 78° to 80° F to prevent chills C. Cover vesicles with gauze dressings D. Pat skin dry

Pat skin dry *Patting the skin dry will decrease irriation and will not break vesicles. Heat (both water and room temperatures) will exacerbate. Vesicles should not be covered with dressings

The nurse is preparing to care for a patient with psoriasis. The nurse should anticipate which skin assessment? A. Fluid-filled blisters B. An area of local swelling and redness C. Patches covered with silvery scales D. Zigzag lesions that are slightly raised

Patches covered with silvery scales *Psoriasis is a noncontagious, chronic, and recurring skin disorder that typically appears as inflamed, edematous skin lesions covered with adherent silvery-white scales. These scales are the result of an abnormally rapid rate of proliferation of skin cells. Zigzag lesions, fluid-filled blisters, or an area of local swelling and redness are not anticipated assessment data in a patient with psoriasis.

The nurse is caring for several patients on a surgical floor. Which patient needs to be placed in contact isolation? A. Patient has psoriasis with adherent silvery-white scales B. Patient has stasis dermatitis with petechiae and hyperpigmentation C. Patient has herpes zoster with small groups of vesicles along nerve pathways D. Patient has actinic keratoses with small, scaly, grayish papules

Patient has herpes zoster with small groups of vesicles along nerve pathways

The nurse is educating a patient about testicular self-examination. Which information is most important for the nurse to include? A. Report any lumps larger than a pea to the health care provider B. Perform weekly self-examinations on the same day of the week C. Perform self-examinations after bathing when scrotal skin is relaxed D. Pinch skin for at least 5 seconds

Perform self-examinations after bathing when scrotal skin is relaxed *Testicular self-examinations are best done after a warm bath or shower when the scrotal skin is relaxed. The patient should report lumps of any size to the health care provider, perform monthly self-examinations, and roll each testicle between the thumb and fingers

The nurse explains that exposure to a pathogen stimulates the macrophages to migrate to the area of infection to ingest and destroy the pathogen. This statement describes which process? A. Pathogen neutralization B. Immune response C. Antibody action D. Phagocytosis

Phagocytosis *Phagocytosis is the process of the ingestion of a pathogen by macrophages

A nurse is reinforcing teaching with the guardian of a child who has contact dermatitis. Which of the following information should the nurse include? A. Use fabric softener dryer sheets when drying the child's clothing B. Apply a warm, dry compress to the rash area C. Place the child in a bath with colloidal oatmeal D. Leave the child's hands uncovered during the night

Place the child in a bath with colloidal oatmeal

The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? A. Positive patch test B. Positive culture results C. Abnormal biopsy results D. Wood's light examination indicative of infection

Positive culture results *With the classic presentation of herpes zoster, the clinical examination is diagnositc. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergens. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under UV light to identify superficial infections of the skin (fungal infections)

A postoperative prostatectomy patient is discouraged that he is still dribbling and wearing a protective pad 1 month after surgery. Which action should the nurse suggest? A. Eat a low-residue diet to reduce urinary retention B. Drink grapefruite juice to tighten the urinary sphincter C. Acquire an indwelling catheter to prevent leakage D. Practice Kegel exercises several times a day

Practice Kegel exercises several times a day *Kegel exercises increase the strength of the perineal floor muscle and will reduce dribbling. Changes in dietary intake, grapefruit juice consumption, or insertion of an indwelling catheter will not provide the restorative care that the patient needs to correct the problem

The nurse is constructing a teaching plan about fatigue management for a patient who is taking radiation treatments. Which information should the nurse include? A. Prioritize activities and alternate rest with periods of activity B. Plan to spend at least 4 to 5 h of the day in bed C. Discontinue pain medications that may cause drowsiness D. Avoid snacking in between meals

Prioritize activities and alternate rest with periods of activity *Prioritizing activities is essential to balance energy with expenditure. These patients should not spend long periods of daytime in bed, and they should increase fluids and plan between-meal snacks to keep energy up

Which diagnostic test would most likely be performed on an elderly patient who has a PSA result of 7.2? A. Another blood sample for PSA B. CT scan of the pelvis C. Voiding urethrogram D. Prostate needle biopsy

Prostate needle biopsy

While you are performing an initial assessment, a patient with extensive burn injuries suddenly develops increasing hoarseness and stridor. Pulse oximetry is 86%. What is the priority nursing action? A. Encourage the patient to take deep breaths B. Provide humidified oxygen C. Administer respiratory treatments D. Suction respiratory secretions

Provide humidified oxygen *Stridor is an ominous sign that indicates a potential obstruction of the airway and respiratory distress. Giving oxygen is the priority action. The patient may need to be intubated. (1) Encouraging the patient to take deep breaths is not incorrect, but it will not resolve the problem. (3) Respiratory treatments are unlikely to help if the patient has progressed to stridor. (4) Suctioning is not helpful and may worsen the situation.

A long-term care facility resident with generalized anxiety disorder (GAD) enters the dining room and discovers that a visitor is sitting in her regular seat. The resident becomes agitated and insists that she cannot eat unless she sits in her chair. Which response is most appropriate? A. Instruct the visitor to move B. Reassure the resident that she can sit in her regular spot at supper C. Remind the resident that she will be hungry if she does not eat D. Insist that the resident eat

Reassure the resident that she can sit in her regular spot at supper *A calm approach and reassurance will help the anxious patient to mimic the nurse's behavior. Asking the visitor to move, telling the resident that she will go hungry, or insisting that the resident eat are not therapeutic and whll not help in reducing the patient's anxiety

The nurse is educating a pregnant patient who is human immunodeficiency virus (HIV) positive. Which information is most important for the nurse to include in the teaching plan? A. Breast-feeding is always best B. Talk with your doctor about a vaginal delivery C. Engage in oral, rather than vaginal, sex D. Remain on the medication protocol

Remain on the medication protocol *Remiaing on medication is essential. Certain prescribed drug combinations may significantly reduce the transmission to the fetus. Patients with HIV should avoid breast-feeding and vaginal birth. HIV can be spread by oral sex

Which nursing action is appropriate immediately after a patient receives electroconvulsive therapy (ECT)? A. Remaining with the patient until she becomes oriented B. Administering oxygen at 6 L/min C. Restraining the patient for 24 h D. Discharging the patient home with instructions to rest for the following 24 h

Remaining with the patient until she becomes oriented *Patients are often disoriented after ECT; maintaining safety is a primary goal at this time. Oxygen is not standard treatment after ECT. Restraints are unnecessary and inappropriate. The patient should not be discharged until she is oriented and safety is ensured.

Which statement best describes a "shave biopsy" of a skin lesion? A. A removal of the central core of a lesion B. Excision of an entire lesion with a 1/4-inch border around it C. Removal of the top of a lesion that stands above the skin line D. Excision of a lesion down to the dermis

Removal of the top of a lesion that stands above the skin line *The shave biopsy removes the top level of the lesion, which stands above the skin line. Removal of a core from the center of the lesion is referred to as a punch biopsy. Excision of the entire lesion is an excisional biopsy

You are supervising a new graduate nurse (GN) who is examining a new patient with skin lesions. You would intervene if the GN A. gently handles the patient's extremities to prevent skin tears B. Observes the condition of the skin and measures the size of the lesions C. Removes the scales and crusts from the lesions to clean the skin D. Assesses for and documents any home remedies that the patient has tried

Removes the scales and crusts from the lesions to clean the skin *Remind the GN to check the patient's record for treatments or cleaning related to crusts and scales. The health care provider must first examine the patient and order the treatments. (1) Handling the patient gently may prevent skin tears. (2, 4) The GN observes the condition of the skin and assesses for any home remedies tried.

While bathing a patient, the nurse discovers a grayish-black, nodular growth that resembles a blackberry in the middle of the patient's back. What action should the nurse take? A. Report the findings to the patient's health care provider B. Teach the patient how to assess for changes in the growth C. Document the finding of an actinic keratosis on the back D. Inform the patient that he has a growth that is a melanoma

Report the findings to the patient's health care provider *These findings are consistent with a nodular malignant melanoma. This lesion should be evaluated by the physician and removed immediately once the diagnosis is confirmed. Teaching the patient to assess for changes is a lesser priority action. Actinic keratoses are not consistent with these findings but instead appear on fair-skinned people as small, scaly, reed, or grayish papules. Biopsy is required before any diagnosis can be confirmed, at which time the physician should disclose the results

A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat effect. The nurse should expect a prescription from the provider for which of the following medications? A. Chlorpromazine B. Thithixene C. Risperidone D. Haloperidol

Risperidone *Second-generation antipsychotics (risperidone) are effective in treating negative symptoms of schizophrenia (lack of grooming and flat effect) *First-generation antipsychotics (Chlorpromazine, Thithixene, and Haloperidol) are used mainly to control positive, rather than negative, symptoms of schizophrenia

A patient is being treated with IV antibiotics for bacterial infection. The nurse suspects a health care-associated infection (HAI) when the patient begins to develop what? A. Severe diarrhea B. Skin rash C. Hematuria D. Thrush

Severe diarrhea *Patients frequently receiving antibiotic treatment are at risk for Clostridium difficile infection (CDI), a HAI which causes severe colitis and diarrhea. Clostridium difficile colonizes the gut when the normal flora has been disrupted due to antibiotic therapy. A skin rash may indicate an adverse reaction to the antibiotic. Development of thrush could indicate the presence of C. albicans. The presence of hematuria would not be indicative of a HAI.

The nursing student is assisting the nurse to apply restraints to a patient. Whch action by the student indicates that she understands the procedure? A. She checks the circulation and then applies the restraints B. She ties the knot so that it is not readily visible to the patient, family, or staff C. She states that she will check on the patient every 2-4 hours D. She documents the care that was given while the patient was in restraints

She documents the care that was given while the patient was in restraints

The nurse is caring for a patient with a skin tear. Which dressing is most appropriate to apply to the area? A. Silicone-coated net dressing B. Hydrocolloid C. Moist sterile gauze D. Paste

Silicone-coated net dressing *If bleeding has stopped, silicone-coated net dressings are preferred; petroleum-based protective ointments are also used to provide protection for a skin tear and keep the wound bed moist to promote healing. A moist sterile gauze is used for a deeper or infected wound. Hydrocolloid is used for deeper pressure ulcers. Paste is used to fill in a deep wound.

The community health nurse is providing education to a group of young women on contraceptives. The nurse should be sure to include information on which known risk factor for complications related to oral contraceptives? A. Irregular menstruation cycle B. Smoking C. Use of NSAIDS D. Obesity

Smoking *Smoking increases the risk of complications related to OC therapy, especially in women older than 35 years. Use of NSAIDS, irregular menstrual cycle, and obesity are not associated with an increased risk of complications related to oral contraceptives.

A skin biopsy has been scheduled to rule out the presence of a malignancy. Which instruction is most important for the nurse to include in patient teaching? A. General anesthesia will be used during the procedure B. Change the bandage the day after the procedure and then weekly for 2 weeks C. Sutures placed at the site of the biopsy will be removed in approximately 10 days D. Do not eat or drink anything after midnight the night before the procedure

Sutures placed at the site of the biopsy will be removed in approximately 10 days *A skin biopsy can be used to rule out a malignancy or to diagnose the causative organism in a lesion. Sutures will be removed in 10 to 14 days after the procedure. The procedure will be performed under local anesthesia, the bandage should be changed daily, and no preprocedure preparation is required

An intoxicated patient is admitted to a treatment center for detoxification. The nurse understands that his withdrawal will be supported with which method? A. Psychotherapy support B. Large doses opioids to ensure sedation for 72 h C. Symptomatic relief until the substance clears his symptoms D. Titrated amounts of alcohol until severe withdrawal resolves

Symptomatic relief until the substance clears his symptoms *The alcoholic in withdrawal is supported with symptomatic relief for nausea and vomiting, cramps, and possible seizure

The nurse is educating a patient with generalized anxiety disorder (GAD) who has a new prescription for buspirone (BuSpar). Which information is most important for the nurse to include in the teaching plan? A. Use this medication as needed to manage your anxiety B. Taper this medication before discontinuing C. Allow 3 weeks before expecting any relief of symptoms D. This medication poses a great risk of tolerance and dependence

Taper this medication before discontinuing *Patients should not stop taking BuSpar abruptly, but should taper this medication according to health care provider instructions. BuSpar is always given as a sheduled drug (never on an as-needed basis). The patient should allow 7 to 10 days for symptoms to subside. No evidence exists tht BuSpar causes tolerance of physical dependence

A 23 year old patient reports sudden acute scrotal pain. Initial examination reveals absence of the cremasteric reflex. Doppler ultrasound reveals a diminished blood flow. Which condition do you anticipate? A. Variocele B. Testicular torsion C. Hydrocele D. Priapism

Testicular torsion *The patient's symptoms are signs of testicular torsion. (1) Varicocele is enlarged scrotal veins. (3) Hydrocele is the accumulation of fluid. (4) Priapism is a prolonged erection.

After a fall on a bicycle, a 15 year old boy is brought to the emergency department complaining of nausea and sudden and acute scrotal pain. There is an absence of the cremasteric reflex. Which problem does the nurse expect? A. Hydrocele B. Varicocele C. Prostatitis D. Testicular torsion

Testicular torsion *Torsion of the testicle often occurs after trauma and manifests in acute scrotal pain, absense of the cremasteric reflex, and nausea/vomiting. A hydrocele (fluid accumulation in the scrotum) is usually painless and causes scrotal enlargement. A variocele is a painful swelling that results when tributary vessels of the spermatic vein dilate and clump. Prostatitis, or inflammation of the prostate, occurs from an infectious agent or other causes. Symptoms include recurrent urinary infection, pelvic pain, and sexual dysfunction and are often mistaken for benign prostatic hyperplasia (BPH)

The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expecting sputum with black flecks. The client suddenly becomes restless and his color is becoming dusky. Based on this data, which interpretation should the nurse make? A. The client is hypotensive B. Pain is present from the burn injury C. The burn has probably caused laryngeal edema, which has occluded the airway D. The client is afraid and is having a panic attack as a result of the unfamiliar surroundings

The burn has probably caused laryngeal edema, which has occluded the airway *The client exhibits several warning signs of an inhalation injury: a history of a flame burn to the face, hoarseness, cough, carbonaceous sputum, singed facial hair, facial edema, and color change. Additionally, one of the cardinal signs of hypoxia is restlessness

The nurse is educating a sexually active female patient about infection prevention. Which change during the premenstrual period increases the patient's risk of infection? A. Cervical secretions become more alkaline B. The cervical mucous plug becomes more permeable C. Higher estrogen levels increase vaginal lubrication D. Lower antibody levels increase risk for infection

The cervical mucous plug becomes more permeable *The mucous plug in the cervix or women provides protection to the upper genital tract. The hormonal changes make it become more permeable around the menstrual period. This change can result in an increased risk for infections in the upper genital tract, such as pelvic inflammatory disease (PID). Oral contraceptive alter cervical secretions and result in a more alkaline environment. Vaginal lubrication does not increase risk of infection, and antibody levels do not lower during the premenstrual period

A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions by the client indicates transference behavior? A. The client asks the nurse if they can go out to dinner together B. The client accuses the nurse of being controlling just like an ex-partner C. The client reminds the nurse of a friend who died from substance toxicity D. The client becomes angry with the nurse and threatens to engage in self harm

The client accuses the nurse of being controlling just like an ex-partner *When a client views the nurse as having characteristics of another person who has been significant to their personal life and died from substance use (an ex-partner), this indicates trasnferance *(A) This indicates the need to discuss boundaries but does not indicate transferance *(C) This indicates countertransference rather than transferance *(D) This indicates the need for safety intervention but does not indicate transferance

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse should identify which as a priority concern? A. The client's report of not eating or sleeping B. The presence of bruises on the client's body C. The client's report of self-destructive thoughts D. The family member is disapproving of the treatment

The client's report of self-destructive thoughts *The client's thoughts are extremely important when verbalized. Self-destructive thoughts are the highest priority. Options A, B, and D will all affect the treatment of the client but are not of greatest importance at this time

A patient has history of methicillin-resistant Staphylococcus aureus (MRSA) but is being discharged home after antibiotic therapy. The infectious disease specialist has documented that the patient's MRSA is colonized. What information is provided to the patient? A. The patient with colonized MRSA will require lifelong antibiotic therapy. B. The MRSA infection is completely cured when it is colonized. C. Colonized infections only live in stool samples. D. The colonized patient can still spread MRSA infection to others.

The colonized patient can still spread MRSA infection to others. *Individuals who have become colonized with a specific pathogen, such as methicillin-resistant Staphylococcus aureus (MRSA), can be asymptomatic carriers and unknowingly spread the infection to others because they are not aware that they have been exposed and are now colonized with an organism that is known to be multidrug resistant. Colonized infections are not considered cured but they do not require lifelong antibiotic therapy. Colonized infections do not live in the intestines.

The patient with Alzheimer's disease (AD) has been on donepezil (Aricept) for several weeks. In which situation would the nurse suspect an overdose? A. The patient hungrily eats meals and often searches for snacks between meals B. The nurse assesses a radial pulse rate of 92 beats per minute C. The patient's blood pressure is elevated after periods of exertion D. The patient fails to grasp a glass tightly enough to prevent dropping it

The patient fails to grasp a glass tightly enough to prevent dropping it *Inability to grasp the glass indicates muscle weakness, a cardinal indicator of overdose of Aricept. Other overdose signs are hypotension, nausea, and vomitingm and bradycardia. Appetite changes are not consistent with the use of this medication

The nurse is reviewing the health history of a 26 year old patient who denies corrective lenses. Which scenario indicates that the patient follows preventative eye examination recommendations? A. The patient has had annual eye examinations since age 18 B. The patient's last eye examination occurred at age 10 C. The patient had a baseline eye examination at age 25 D. The patient has never had an eye examination

The patient had a baseline eye examination at age 25 *Starting at age 25, adults should have an eye examination every 5 to 10 years until age 40, every 2 to 4 years from 40 to 54, and every 1 to 3 years from 55 to 64. After age 65, eyes should be examined by an eye specialist every 1 to 2 years

The nurse is completing the medication reconciliation form for a patient. Which information is most important for the nurse to include? A. The patient reports taking Ginkgo biloba daily for the last 6 months B. The patient reports having high hematocrit levels during his last hospital stay C. The patient reports he has been diabetic for 10 years D. The patient reports having a recent infection

The patient reports taking Ginkgo biloba daily for the last 6 months

In counseling a man with erectile dysfunction about a prescription for sildenafil (Viagra), when should the nurse suggest a different treatment? A. The patient is over 50 years of age B. The patient takes nitroglycerin for angina C. The patient is more than 50 pounds overweight D. The patient is a long-term diabetic

The patient takes nitroglycerin for angina *Viagra is contraindicated if the patient is also taking nitrates because the combination can cause significant hypotension. Age, weight, and diabetes are not contraindications for the use of Viagra

Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? A. The return of distal pulses B. Decreasing edema formation C. Brisk bleeding from the injury site D. The formation of granulation tissue

The return of distal pulses *Escharotomies are performed to alleviate the compartment sydrome that can occur when edema forms under nondistensible eschar in a circumferential burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. The formation of granulation tissue is not the intent of an escharotomy, escharotomy will not affect the formation of edema

A nurse is reviewing the medical record of a client who had surgery to stage ovarian cancer. The nurse reviews the following diagnostic notation on the pathology report: T2-N3-MX. Which of the following findings should the nurse identify as a supporting diagnosis? A. The tumor is moderate in size B. No lymph nodes contain cancer cells C. The tumor is receptive to current medication therapy D. The cancer has metastasized to other areas in the body

The tumor is moderate in size *T2 describes the size and extent of the ovarian tumor. A T1 is smallest. T4 is largest *N3 indicates that three adjacent lymph nodes show evidence of it spreading *TNM diagnostic notation of the staging system is not used to indicate the response of a tumor to a medication therapy regimen used for treatment *The MX indicates there is no evidence (M0) of distant metastasis to other areas of the body

The nurse is caring for an elderly patient who is prescribed triazolam (Halcion) for insomnia. Benzodiazepines must be used cautiously in the elderly because A. They have a long half-life and are not excreted readily B. They are toxic to the aging endocrine system C. Tolerance causes use of increasing doses D. They may be used along with alcohol

They have a long half-life and are not excreted readily

The nurse is caring for a patient who is undergoing detoxification from alcohol. Which supplement can the nurse expect to be included in the prescribed medications? A. Potassium chloride B. Thiamine C. Roboflavin D. Folic acid

Thiamine *The treatment for the alcoholic undergoing detoxification includes the administration of large doses of thiamine (vitamin B1). Thiamine acts as a nerve insulator in the body and is absent in the diets of most chronic alcoholics

A nurse is reviewing the health care record of a client who is asking about conjugated equine estrogens. The nurse should inform the client this medication is contraindicated in which of the following condition? A. Astrophic vaginitis B. Dysfunctional uterine bleeding C. Osteoporosis D. Thrombophlebitis

Thrombophlebitis *Estrogen increases the risk of thrombolytic events, Estrogen use is a contraindication for a client who has a history of thrombophlebitis *Atrophic vaginitis and dysfunctional uterine bleeding occurs when there is estrogen deficiency *Females are at risk for osteoporosis after the onset of menopause. Estrogen is used to slow the progression of osteoporosis.

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which action? A. Move the client next to the nurse's station B. Use a night light and turn off the television C. Keep the television and a soft light on during the night D. Play soft music during the night and maintain a well-lit room

Use a night light and turn off the television *It is important to provide a consistent daily routine and a low-stimulation environment when the client is agitated and confused. Noise levels including a radio and television may add to the confusion and disorientation. Moving the client next to the nurse's stations is not the intial intervention

You are observing a nursing assistant who is providing skin care to an older adult patient. Which action by the nursing assistant indicates a need for further training? A. Using soap and hot water every day to clean the patient's body B. Alerting you about a wet dressing C. Reporting redness and blanching over the sacral area D. Applying lotion while the skin is still damp

Using soap and hot water every day to clean the patient's body *Soap and hot water can be very drying and are unlikely to be necessary every day. (2, 3, 4) The other options are correct actions on the part of the nursing assistant.

The home health nurse is educating the family of a child with head lice. Which instructions are most important for the nurse to include? A. Lice cannot be transmitted to pets B. Insects must be moving across the scalp to confirm diagnosis of head lice C. Wash and dry all linens on the hottest setting D. Apply a dime-sized amount of alcohol-based lotion to hair

Wash and dry all linens on the hottest setting *Washing in hot water with ordinary detergent and drying on the hottest cycle will kill lice. Lice can be transmitted to pets. Diagnosis of head lice occurs based on physical examination of lice or nits (eggs). Benzyle alcohol lotion 5% treatment amount varies based on the length of the hair and requires a seconds treatment in 7 days

A 68 year old male has come to the clinic stating that it is getting more difficult for him to urinate. Uroflowmetry has been ordered. How would you explain the test to the patient? A. The lab technician will draw a blood sample from your arm B. The healthcare provider will palate your prostate gland using a lubricated, gloved finger inserted into your rectum. C. Contrast will be infused IV and the pathway of urine will be examined by x-ray to identify obstructions D. You will be asked to urinate in a device that will measure the volume of urine expelled from the bladder per second

You will be asked to urinate in a device that will measure the volume of urine expelled from the bladder per second *Urination into a device in a toilet or urinal will measure the amount and rate of flow of urine. (1) This test is not a lab test. (2) A rectal prostate exam may be done to detect prostate enlargement as a cause of the patient's urinary problems but it is not Uroflowmetry. (3) Urography may be performed to further determine the cause of the problem.

In planning care for the depressed patient, the nurse is aware that the risk for self-harm actually increases when the A. Patient is discharged and has to care for himself B. antidepressant medications begin to take effect C. family promises, but fails, to visit him in the hospital D. patient is first admitted and does not trust the staff

antidepressant medications begin to take effect

The nurse's most important evaluation criterion for interventions to prevent complications of glaucoma surgery is: a. checking the degree of eye pain. b. checking security of the eye dressing. c. assessing the amount of nausea. d. checking the amount of redness of the operative eye.

checking security of the eye dressing.

The nurse anticipates that the malnourished postoperative 70-year-old patient will receive an intravenous (IV) infusion of 5% dextrose in 0.45% saline, because it is: a. isotonic. b. hypotonic. c. hypertonic. d. total parenteral nutrition

hypertonic *5% Dextrose in 0.45% saline is a hypertonic or high molecular solution and is a frequent choice for postoperative maintenance fluid.

An increased number of white blood cells (WBCs) is most likely to be associate with A. dehydration B. improper diet C. Iron deficiency D. infection

infection

The patient is diagnosed with hyperopia, a disorder in which the lens A. is too far from the retina and the light rays converge in front of the retina B. is too close to the retina and light rays converge behind the retina C. bends light rays so they focus directly on the retina D. is too far away from the retina, causing light rays to converge behind the retina

is too close to the retina and light rays converge behind the retina

A medication likely to be prescribed to combat a fungal infection is A. acetaminophen (Tylenol) B. trimethoprim-sulfamethoxazole (Septra) C. ketoconazole (Nizoral) D. penicillin V (Pen-Vee K)

ketoconazole (Nizoral)

A patient receiving TPN fluid therapy experiences an air embolus in the central line. The nurse should immediately turn the patient onto the: a. right side and raise the head of the bed. b. right side and lower the head of the bed. c. left side and raise the head of the bed. d. left side and lower the head of the bed.

left side and lower the head of the bed *To anatomically minimize the risk of the air embolus reaching the lungs, the nurse should turn the patient onto the left side and lower the head of the bed. The primary care provider is notified immediately.

In females, testing for Chlamydia is done by A. low vaginal swab for culture and identification B. blood test for VDRL C. Pap smear D. vaginal swab for gram stain

low vaginal swab for culture and identification

a client taking buspirone (buspar) for 1 month returns to the clinic for a follow-up visit. which of the following would indicate medication effectiveness? A. no rapid heartbeats or anxiety B. no paranoid thought process C. no thought broadcasting or delusions D. no reports of alcohol withdrawal symptoms

no rapid heartbeats or anxiety *Buspirone hydrochloride is not recommended for the treatment of drug or alcohol withdrawal, paranoid thought disorders, or schizophrenia (thought broadcasting or delusions). Buspirone hydrochloride is most often indicated for the treatment of anxiety and aggression

The evening nurse reviews the nursing documentation in the client chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area. What should the nurse expect to find when checking the client's sacral area? A. intact skin B. the presence of tunneling C. a deep, crater-like appearance D. partial-thickness skin loss of the epidermis

partial-thickness skin loss of the epidermis *With a stage 2 pressure injury, the skin is not intact. There is a partial-thickness skin loss of the epidermis or dermis. The other is superficial and it may look like an abrasian, blister, or shallow crater. The skin is intact with a stage 1 pressure injury. A deep, crater-like appearance occurs during stage 3 and tunneling develops during stage 4

The nurse is caring for a patient with a history of substance abuse. What is the most important intervention in the treatment of the substance-dependent patient? A. careful detoxification procedures B. sympathetic care by all health professionals C. medical diagnosis of dependence on the substance D. regular participation in a 12-step program

regular participation in a 12-step program

The patient complains that the IV site is stinging. It is not reddened or warm to the touch. He has been up and about and the flow rate has increased from where it was set. You should FIRST A. stop the infusion B. take the vital signs C. reset the drip rate D. change the IV site

reset the drip rate

When a patient has herpes zoster (shingles), the LPN/LVN should expect the patient to report which symptom? A. A rash on the arms B. Pustules on the legs C. Severe pain D. Respiratory involvement

severe pain

When a patient receiving IV medication exhibits light headedness, tightness in the chest, flushed face, and irregular pulse, the nurse suspects: a. speed shock. b. drug allergy. c. fluid overload. d. air embolus.

speed shock *Light headedness, tightness in the chest, flushed face, and irregular pulse are all signs of speed shock. Speed shock is when a foreign substance is infused into the body rapidly. The infusion should be stopped, the primary care provider notified, and the patient monitored.

Erythema and pruritus with scaling associated with phlebitis A. contact dermatitis B. atopic dermatits C. stasis dermatitis D. seborrheic dermatitis

stasis dermatitis

Lesions may become ulcerated A. contact dermatitis B. atopic dermatits C. stasis dermatitis D. seborrheic dermatitis

stasis dermatitis

When providing care for a patient undergoing internal radiation, you would A. wear a lead apron when at the bedside B. quickly and efficiently provide hands on care C. stay out of the patient's room as much as possible D. ask a family member to feel the patient

stay out of the patient's room as much as possible

Your patient is to receive intravenous therapy for several weeks. A PICC line is placed. Where would the nurse expect it to be inserted? A. the antecubital space B. the plantar aspect of the lower arm C. the basilic or cephalic vein of the upper arm D. above the wrist and below the elbow

the basilic or cephalic vein of the upper arm

The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item? A. vital signs B. skin color C. Oxygen saturation D. Latest hematocrit level

vital signs *A change in the vital signs may indicate that a transfusion reaction is occurring. The nurse assesses the client's vital signs before the procedure to obtain a baseline every 15 minutes for the first half hour after beginning the transfusion and every half hour thereafter. Skin color, oxygen saturation, and most recent hematocrit may be checked but are not the most important

Following a visit from his family, the 55-year-old male patient with terminal cancer tearfully says, "I am so afraid" and begins to cry. Which response is most supportive? A. "Would you like to have your pain medication now?" B. "Let's talk about the things that make you afraid." C. "Would you like for me to call the hospital chaplain?" D. "I will leave to give you some privacy."

"Let's talk about the things that make you afraid." *Verbalizing fears to a caring nurse is comforting. Offering medications, chaplains, and privacy is not helpful or supportive as a first nursing response in this situation

When caring for an older woman who developed a 5-cm pressure ulcer on her sacrum because of being immobilized and incontinent, an appropriate expected outcome for the problem of altered skin integrity would be A. "Patient will be able to ambulate to the bathroom with minimal assistance." B. "Turning and repositioning schedules will be provided for the staff." C. "Patient will demonstrate a decrease in size of the ulcer within 1 week." D. "Family will be able to provide protein-rich foods during the hospital stay."

"Patient will demonstrate a decrease in size of the ulcer within 1 week." *Patient will demonstrate a decrease in size of the ulcer within 1 week is an appropriate expected outcome. (1) The ability to ambulate to the bathroom will help prevent further ulceration but will not directly decrease the impaired skin integrity. (2) A turning and repositioning schedule for the staff should be on the chart, but it is not an appropriate expected outcome. (4) It is desirable for the family to bring in protein-rich food for the patient to help the ulcer heal, but that is not an expected outcome.

A patient who has undergone transurethral resection of the prostate (TURP) surgery asks why he needs to have the continuous bladder irrigation (CBI) because it seems to increase his pain. Which explanation would be the best? A. "Normal urine production is maintained until healing can occur." B. "The bladder irrigation is necessary to stop the bleeding in the bladder." C. "The irrigation is needed to keep the catheter from becoming occluded by blood clots." D. "Antibiotics are being instilled into the bladder to prevent infection."

"The irrigation is needed to keep the catheter from becoming occluded by blood clots."

The nurse is interviewing a patient who is seeking assistance at the urology clinic for erectile dysfunction. Which statement is the best way to open the interview? A. "When was the last time you were impotent?" B. "Do you attempt to have intercourse every week?" C. "What medications have you tried previously?" D. "What experience have you had with erectile dysfunction?"

"What experience have you had with erectile dysfunction?" *Asking open-ended questions will help the patient respond with information that can be used in a plan of care

While assessing an obese resident in a long-term care facility, the nurse finds a red, moist rash under the patient's breasts, in the axilla, and in the inguinal fold. Based on this assessment, the nurse reports to the charge nurse that the resident probably has which type of infection? A. A fungal infection B. A bacterial infection C. An allergic reaction D. Contact dermatitis

A fungal infection *Fungal infections thrive in warm, moist environment and most frequently affect the skin

A patient is to have a culture and sensitivity test. Which education should the nurse provide to the patient regarding a culture and sensitivity test? A. The skin is inspected using a special light. B. A sample of exudate is taken from the lesion. C. Pressure will be applied to the lesion to determine the patient's sensitivity level. D. A sample of tissue is removed from the skin.

A sample of exudate is taken from the lesion. *When a bacterial, viral, or fungal infection of the skin is suspected, the dermatologist may wish to know the causative organism and the drug most appropriate for treating the specific infection. A sampling of exudate (drainage) is taken from the lesion and sent to the laboratory for culturing. Once the organism has been cultured, colonies can be tested for sensitivity to certain antiinfective agents. These tests take the guesswork out of treating infectious skin disease and very quickly determine which drug will be most effective in treating it. A biopsy requires removal of a sample of tissue.

A nurse is discussing routine follow-up needs with a client who has a new prescription for valproate. The nurse should inform the client of the need for routine monitoring of which of the following laboratory tests? A. AST/ALT and LDH B. Creatinine and BUN C. WBC and granulocyte counts D. Blood sodium and potassium

AST/ALT and LDH *Routine monitoring of liver function tests is necessary due to the risk for hepatotoxicity *Baseline levels can be drawn. However, routine monitoring of creatinine and BUN, WBC and granulocyte counts, blood sodium and potassium is not necessary

The client is receiving an eyedrop and an eye ointment to the right eye. Which action should the nurse take? A. Administer the eyedrop first, followed by the eye ointment B. Administer the eye ointment first, followed by the eyedrop C. Administer the eyedrop, wait 10 minutes, and administer the eye ointment D. Administer the eye ointment, wait 10 minutes, and administer the eyedrop

Administer the eyedrop first, followed by the eye ointment

Which statement accurately describes BRCA1 and BRCA2? A. BRCA1 and BRCA2 are genes involved with the inherited form of breast cancer B. BRCA1 and BRCA2 are enzymes that are markers for breast cancer C. BRCA1 and BRACA2 are particular proteins attached to the red blood cells indicating presence of breast cancer D. BRCA1 and BRCA 2 are laboratory test performed on a breast biopsy to detect breast cancer

BRCA1 and BRCA2 are genes involved with the inherited form of breast cancer *It should be noted that not all people who have BRCA gene get cancer, and people without it may get cancer

The patient is being treated for a skin infection. The nurse sees an order for metronidazole (Flagyl). What should the nurse do first? A. Give the medication as ordered and observe for side effects B. Review the nursing implications for the drug C. Ask another nurse if this drug is appropriate for the patient D. Check laboratory results to verify presence of an anaerobic infection

Check laboratory results to verify presence of an anaerobic infection

The patient presents to the clinic for an examination. Which symptom, if reported by the patient, indicates that the woman may be experiencing a rectocele? A. Pelvic fullness B. Stress incontinence C. Constipation D. Dyspareunia

Constipation *A rectocele may result in constipation, soiling, or painful defecation. In a cystocele, urinary frequency or incontinence is most common. A uterine prolapse may result in dyspareunia. The woman often complains of general symptoms that include a sense of fullness in the pelvis and backache.

A community mental health nurse is assisting with the plannin of care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse recommend the RN implement as a method of tertiary prevention? A. Educate clients on health promotion techniques to reduce the risk of depression B. Perform screenings for depression at community health problems C. Establish rehabilitation programs to decrease theeffecets of depression D. Provide support groups for clients at risk for depression

Establish rehabilitation programs to decrease theeffecets of depression *Rehabilitation programs are an example of tertiary prevention. Tertiary prevention deals with prevention of further problems in clients already diagnosed with mental illness *(A) This intervention is an example of primary prevention *(B) This interventio is an example of secondary prevention *(D) This intervention is an example of primary prevention

While inserting an indwelling urinary catheter, you notice raised, rough, cauliflower-like growths on the vulva and vaginal walls. Which causative agent do you anticipate? A. Herpes simplex virus B. Human papillomavirus C. Treponema pallidum D. Neisseria gonorrhoeae

Human papillomavirus *These lesions are characteristic of HPV. (1) Herpes simplex virus lesions are moist. (3) Syphilis lesions are chancres. (4) Gonorrhea presents with a thick, yellow discharge.

The nurse is caring for a patient with general sepsis. Which finding should first alert the nurse to a potential complication that warrants immediate attention? A. Increased lethargy B. Sudden coughing C. Elevated blood pressure D. Cloudy urine

Increased lethargy *Increasing lethargy is an indicator of impeding septic shock.

The nurse is caring for a client who is receiving an intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. During an inspection of the site, the nurse notes redness and swelling. The nurse should take which appropriate action? A. Notify the registered nurse immediately B. Administer pain medication to reduce the discomfort C. Apply ice and maintain the infusion rate, as prescribed D. Elevate the extremity of the IV site, and slow the infusion

Notify the registered nurse immediately *When antineoplastic medications are adminstered via IV, great care must be taken to prevent extravasation, the condition in which the medication escapes into the tissues surrounding the injection site, because pain, tissue damage, and necrosis can result. The nurse monitors for signs of extravasation, such as redness or swelling at the insertion site. If extravasation occurs, the RN needs to be notified at once and the infusion will be stopped. The nurse will contact the PHCP. Depending on the specific medication, actios are taken to counteract the negative effects. The medication amey be aspirated out, ice or warmth applied, and the area infiltrated with a neutralizing agent specific to the medication

The patient has bulimia nervosa. Which task would be appropriate to assign to the nursing assistant? A. Observe for marks on the knuckles during AM hygiene B. Listen outside the bathroom door for sounds of induced vomiting C. Check the patient's belonging for secret caches of snacks and good D. Escort the patient to group therapy or to occupational therapy

Observe for marks on the knuckles during AM hygiene

The nurse is providing instructions to a client who will be self-administering eyedrops. To minimize the systemic effects that eyedrops can produce, the client is instructed to perform which action? A. Eat before instilling the drops B. Swallow several times after instilling the drops C. Blink vigorously to encourage tearing after instilling the drops D. Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops

Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops

The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase, an antineoplastic agent. The nurse consults with the registered nurse regarding the administration of the medication of which is documented in the client's history? A. Pancreatitis B. Diabetes Mellitus C. Myocardial infarction D. Chronic obstructive pulmonary disease

Pancreatitis *impairs pancreatic functions and pancreatic function tests should be performed before therapy begins and when a week or more has elaspsed between doses

A patient has been diagnosed as having dementia. Which symptom should the LPN/LVN expect? A. Patient tends to have flight of ideas. B. Patient tends to be oriented to time, place, and person. C. Patient's speech tends to be slurred. D. Patient tends to confabulate.

Patient tends to confabulate. *Dementia is characterized by several cognitive deficits, memory in particular, and tends to be chronic. Confabulation is used to fill conversational gaps. Flight of ideas, slurred speech, and orientation to time, place, and person are not dementia symptoms.

The health care provider has ordered that the patient be restrained for 24 hours because he is a danger to himself or others. Which task is appropriate to assign to the nursing assistant? A. Selecting the type of restraint B. Checking the circulation in the area distal to the restraint C. Performing 1:1 observation D. Obtaining consent from the patient's family to use restraints

Performing 1:1 observation

A nurse is reinforcing teaching with a client who has a new prescription for alprazolam for generalized anxiety disorder. Which of the following information should the nurse reinforce? A. Three to six weeks of treatment is required to achieve therapeutic benefit B. Combining alcohol with alprazolam will produce a paradoxical reponse C. Alprazolam has a lower risk for dependence than other antianxiety medications D. Report confusion as a potential indication of toxicity

Report confusion as a potential indication of toxicity *Confusion is a potential indication of alprazolam toxicity that the client should report to the provider *Buspirone, rather than alprazalom, requires 3-6 weeeks to achieve therapeutic benefit *Combining alcohol with alprazalam can produce CNS and respiratory depression rather than a paradoxical response *Alprazolam is preferably used for short-term treatment because of the increased risk of dependence

A patient undergoes chemotherapy and loses her hair. Which of these findings is most indicative that the patient has satisfactorily adjusted to her alopecia? A. The patient washes her remaining hair daily. B. The patient verbalizes steps in the grief process. C. The patient visits a patient who has had hair loss. D. The patient purchases scarves in varying colors.

The patient purchases scarves in varying colors. *The patient purchasing scarves in varying colors would be indicative that the patient is coming to terms about her hair loss. Buying a wig, washing her remaining hair, and visiting another person with hair loss are also positive actions following alopecia. Verbalizing steps in the grief process does not indicate acceptance of alopecia.

A nurse evaluates the visual acuity of a patient using the Snellen chart. Which statement is true regarding the use of the Snellen chart? A. The chart is placed 40 feet away from the patient B. The patient reads the letters using one eye at a time C. The numerator (top number) indicates the smallest line that the patient could read D. The denominator (bottom number) refers to the patient's distance from the chart

The patient reads the letters using one eye at a time *Visual acuity is tested by having the patient read the lines on the Snellen chart with one eye while the other eye is completely covered. Then the opposite eye is tested in the same manner. (1) The patient is normally 20 feet away from the chart. (3) The top number indicates how far away the patient is. (4) The bottom number refers to the distance at which people with normal vision can read the line of the chart.

The nurse has been assigned four patients. Which patient should the nurse visit first? A. The patient with chronic poor circulation to the extremities B. The patient with chest pain and a history of angina C. The patient with insulin-dependent diabetes and a normal blood sugar D. The patient with hypertension being maintained on oral medication

The patient with chest pain and a history of angina *The patient with chest pain and a history of angina needs further evaluation now. The patient with insulin-dependent diabetes has a normal blood glucose level and does not need to be seen first. The patient with hypertension being maintained on oral medication is stable because of his medication regimen. The patient with chronic poor circulation to the extremities is in no distress.

A patient is taking an ophthalmic drug that causes mydriasis. Which of the following effects are associated with mydriasis? A. The patient's pupil remains constricted even in dark rooms B. The patient's pupil remains dilated even in bright lights C. The patient's pupil dilated even in dark rooms D. The patient's pupil remains constricted in bright lights

The patient's pupil remains dilated even in bright lights

A nurse is adding a secondary piggyback to the patient's existing IV. To use the gravity system, the nurse should hang A. The piggyback bag higher than the maintenance IV bag B. The maintenance IV bag at the same height as the piggyback bag C. The piggyback bag and the maintenance IV bag using Y tubing D. The maintenance IV bag after the piggyback bag is completed

The piggyback bag higher than the maintenance IV bag *If the piggyback bag is higher than the maintenance bag, the fluid from the piggyback will flow in first. As soon as the piggyback is empty, fluid from the maintenance bag will begin. Recall that the fluid level in the piggyback bag must be higher throughout the entire infusion. (2) If the maintenance bag and the piggyback bag are at the same height, the fluid from the maintenance bag can flow up into the piggyback (if there is no backflow valve within the tubing). The bag that has the greater volume will flow first. As the volume of the greater bag depletes, the less the bag will begin to flow. Eventually both would infuse, but the two bags of fluid would be competing for flow. (3) Y-tubing is generally reserved for blood product infusion. It would be an inappropriate waste of a more expensive tubing (which has a special filter). (4) You can manually hang or restart the maintenance IV after the piggyback is completed. In fact, if fluid overload is an issue and you do not have an infusion pump, you may choose to do this; however, this completely eliminates the advantage of having a piggyback setup.

The patient is taking lorazepam (Ativan) for anxiety. The nurse advises him not to drink alcohol while taking this drug for which reason? A. There is an increase in blood pressure caused by frequent use B. There is an additive effect on the nervous system C. There is a decrease in therapeutic response caused by frequent use D. There is increased risk for insomnia and gastrointestinal distress

There is an additive effect on the nervous system

The nurse is caring for a patient with genital herpes. Which manifestation alerts the nurse to a potential signal of an impending outbreak? A. Elevation in temperature B. Tingling sensation in the vagina C. Copious vaginal discharge D. Migraine-like headache

Tingling sensation in the vagina *Many women with herpes can predict an outbreak because of tingling or burning in the vagina. Elevations in temperature, increased vaginal discharge, and hadaches are not common precursors of a herpes outbreak

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? A. Tinnitus B. Diarrhea C. Constipation D. Decreased respirations

Tinnitus *Salicylic acid is absorbed readily through the skin and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism

During a family planning session, a young couple confides that they are hoping to conceive. Which action should the nurse suggest to potentially enhave conception? A. Relax together in a sauna or hot tub B. Stimulate the scrotum with a vibrator C. Increased time spent in foreplay D. Use water-soluble lubricant

Use water-soluble lubricant *water soluble lubricant has no spermicidal properties as compared to other lubricants that may damange spern and decrease chances of coneption. Heat to the scrotum depresses spermatogenesis and could decrease chance of conception. Foreplay and vibrators do not increase spermatogenesus and will not increase the chances of conception

Silodosin (Rapaflo) is prescribed, and the nurse explains to the patient that it A. lowers testosterone levels B. lowers PSA levels C. decreases the prostate size by 50% D. promotes relaxation of smooth muscle

promotes relaxation of smooth muscle