Final study questions

What information would the nurse give the client when the client inquires what makes breast milk production?

Prolactin

Which would be included in the teaching plan for a client diagnosed with diabetes mellitus?

An elevated blood glucose concentration contributes to complications of diabetes, such as diminished vision.

A client presents with the skin appearance shown. The nurse is aware that the client's clinical manifestations are consistent with:

Anthrax

A group of nursing students are doing a presentation on hormones. What hormone would the presentation show regulates the metabolic rate and influences the growth and development of the body?

Thyroid hormone

After teaching a group of adolescent girls about female reproductive development, the nurse determines that teaching was successful when the girls state that menarche is defined as a woman's first:

Menstrual period

The skull is the most important factor in relation to the labor and birth processes. The fetal skull must be small enough to travel through the bony pelvis. What feature of the fetal skull helps to make this passage possible?

Molding

The nurse is assisting with the circumcision of a male infant. Which nursing intervention is priority immediately after the procedure?

Monitor the site for bleeding.

The nurse is providing education via phone to a client who called stating that the newly prescribed imipramine (Tofranil) is not working as depression is still a problem. Which question is most important to ask first?

"How long have you been taking the medication?"

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the clients arms and buttocks. The nurse asked the client how the bruises versus stand. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing response?

" I have a legal obligation to report this type of abuse."

A 3-year-old client has been hospitalized for 1 week with her mother rooming-in; however, the mother has gone home to tend to other family responsibilities for a few days. After being inconsolable for the first 24 hours after the mother's departure, the nurse notes the child is now lying quietly in bed sucking her thumb. Which response should the nurse prioritize in this situation?

"Are you feeling sad? Your mom didn't want to leave, but she will be back after two more breakfasts."

The nurse is conducting a health history when a middle-aged client states that her last menstrual period was 6 months ago. Upon further questioning, the client also states that symptoms of hot flashes and mood fluctuations. Which question should the nurse ask next?

"Are you taking any hormone replacement therapy?"

The nurse is providing information about foot care to a client with diabetes. Which of the following would the nurse include?

"Be sure to apply a moisturizer to feet daily."

When referred to a podiatrist, a client newly diagnosed with diabetes mellitus asks, "Why do you need to check my feet when I'm having a problem with my blood sugar?" The nurse's most helpful response to this statement is:

"Diabetes can affect sensation in your feet and you can hurt yourself without realizing it."

A controlled type 2 diabetic client states, "The doctor said if my blood sugars remain stable, I may not need to take any medication." Which response by the nurse is most appropriate?

"Diet, exercise, and weight loss can eliminate the need for medication."

The nurse is caring for a client who has recently lost a spouse. Which question asked by the nurse is essential in guarding the client's immune system?

"Do you have friends and family to support you?"

A nurse is educating a client about the benefits of fruit versus fruit juice in the diabetic diet. The client states, "What difference does it make if you drink the juice or eat the fruit? It is all the same." What are the best responses by the nurse? Select all that apply.

"Eating the fruit instead of drinking juice decreases the glycemic index by slowing absorption." "The fruit has less sugar than the juice."

A home care nurse is visiting with a teenage client on home care during cancer treatments. Which statement by the client's mother warrants intervention by the home care nurse?

"I don't let her drink too many fluids since the bathroom is downstairs."

The nurse is assessing a patient for potential home care. Which patient statement indicates that the patient will be able to take medication that is prescribed for three times a day?

"I will take one pill before breakfast, before lunch, and before dinner"

What statement by the mother of a preschooler indicates the need for further education by the nurse?

"If food falls on the floor, my child should pick it up quickly and wipe it off before eating it."

A client with Cushing syndrome is admitted to the hospital. During the initial assessment, the client tells the nurse, "The worst thing about this disease is how awful I look. I want to cry every time I look in the mirror." Which statements by the nurse is the best response?

"If treated successfully, the major physical changes will disappear with time."

The nurse is teaching a prenatal class on the functions of the various structures involved with a pregnancy. The nurse determines the class is successful when the class correctly chooses which function of amniotic fluid?

"It helps cushion the baby."

One week ago, the client was prescribed Buspirone (Buspar) for anxiety. The client phones the office and reports the medication has not eliminated the symptoms. Which is the best response by the nurse?

"It may take up to 4 weeks for full therapeutic response."

A nursing student asks the instructor why the pituitary gland is called the "master gland." What is the best response by the instructor?

"It regulates the function of other endocrine glands."

During a visit to the prenatal clinic, a pregnant woman asks the nurse, "What causes labor to start?" Which response by the nurse would be appropriate?

"Labor starts from a combination of several maternal and fetal hormones working together."

A child who is immobile states, "I am sad because I cannot do what my friends do." Which response by the nurse is appropriate?

"Let's try to figure out how you can do more."

The nurse is interviewing a client with major depression. Which of the following statements by the client would most indicate to the nurse that the client is at risk for suicide?

"Life has lost its meaning for me."

A client who has attempted to quit smoking and failed two times before is reluctant to make another attempt. Which response by the nurse is most appropriate?

"Most people who have tried and failed ultimately do succeed."

A nurse is interacting with a new mother, whose infant is 6 weeks old. The mother appears exhausted and anxious. Which of the following statements by the mother most indicates a potential risk for maltreatment of the child?

"She cries all the time. I don't know what to do with her. She's just a bad baby, I guess."

The triage nurse receives a phone call from a client stating, "I was just raped and I need help. What should I do?" Which response by the nurse is a priority?

"Tell me if you are in a safe location away from the assailant now."

A client tells the nurse that drinking helps him cope with anxiety. Which response by the nurse would help the client view drinking more objectively?

"Tell me what happened the last time you felt you were under a lot of stress and drinking to cope."

A 43-year-old, physically fit, healthy woman who is newly married tells the nurse that she and her husband would like to have a child. What is an appropriate first response?

"Well, I'm sure you know there are some risks involved so it's helpful that you've been taking such good care of yourself."

A client with diabetes comes to the clinic for a follow-up visit. The nurse reviews the client's glycosylated hemoglobin test results. Which result would indicate to the nurse that the client's blood glucose level has been well controlled?

6.5%

A 5-year-old child is brought to the emergency room with an open chin laceration following a bike accident. The child appears extremely frightened and asks if he will bleed to death. Which nursing action should the nurse prioritize to best assist this child?

Allow him to sit on his parent's lap until time to suture the laceration.

Which of the following is the result of progressive deterioration of the brain?

Alzheimer's disease

A mother has come to meet with local school officials regarding admission of her child with spina bifida. The child requires catheterizations several times a day and the mother is requesting information on admission of the child for school and what accommodations can be made for the child's health care needs. What is the best response to the mother?

"Your child may be mainstreamed into a regular classroom and assisted with catheterizations by the school nurse."

A couple reveals that they are going to tell both their biological children and adoptive children they are filing for divorce. Prior to having this family discussion, they met with a counselor about the possible impact this may have on the children. The counselor suggests to be on the lookout for which possible consequences on the adoptive children related to the divorce? Select all that apply.

-Adoptive children may feel they are the cause of the divorce. -Adoptive children experience insecurity for a second time.

The nurse is educating a group of student nurses on symptoms of sexually abused women. What symptoms will the nurse include in the teaching?

-Chronic pelvic pain -Substance abuse -Headaches -Social withdrawal

A nurse is working with the burn clinic at a local hospital. Which types of burns would the nurse address with the health care provider and social worker? Select all that apply.

-Small, round burns -Hand burns with a pattern -Linear pattern burns

The school nurse is concerned that a young girl is being sexually abused. Which assessment finding supports this concern? Select all that apply.

-expresses fear about going home -reports frequent urinary tract infections -demonstrates low self esteem

The nurse is assisting a 30-year-old client in scheduling an appointment for a cervical biopsy. The nurse would recommend that the client schedule the testing at which time?

1 week after completion of the client's menstrual cycle

A nurse is providing a community seminar about eating disorders. Which age group would the nurse be most likely to target because of their increased risk?

12 to 25 years

you have just taken report on your four clients this morning and are ready to start your rounds, it is 630. arrange the clients from 1-4 with 1 being the one you would examine first. you need to determine which client is the most critical.

1: a 21-year-old MVA victim 2: 72-year-old client 3: The can reports that her 56-year-old patient 4: A 67-year-old male

how many weeks noticed should you give your employer when termination your employment

2 weeks

Your client's noon blood glucose level with type 1 Diabetes Mellitus is 255 mg/dl. The physician orders a sliding scale insulin regimen based on the client's blood glucose. The order reads: " Give regular insulin SubQ using the following scale." How many units will you give?

6 units

The nurse is caring for four clients on the pediatric unit. Which client scenario provides the highest concern of suspected abuse?

A 7-month-old with multiple bruises on the legs

A suspicious breast lump is noted on a mammogram. The client asks the nurse which diagnostic test confirms if the lump is cancerous or benign. Which response by the nurse is most correct?

A biopsy

An LVN is planning the client assignments for the day. Which of the following is the most appropriate assignment for the CNA? -

A client who needs assistance with eating meals because of right-sided weakness.

A nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department for treatment on the evening shift. The nurse would assign the highest priority to which of the following clients?

A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

The nurse is spending time with a client who has just learned, unexpectedly, that she is pregnant. Which initial task should the nurse assist the client to focus on?

Accepting the pregnancy

As a nurse manager you hold staff members responsible for their actions and require them to document pertinent information about their patients , what is the term for this ?

Accountability

A nurse understands that for the parathyroid hormone to exert its effect, what must be present?

Adequate vitamin D level

The family of a client, stung by a bee, rushed the client to the emergency room. The client is experiencing hives and redness at the site. Upon arrival, the client states, "I feel a lump in my throat and I am sweating. I can't breathe. I think I am going to die!" The nurse anticipates which emergency treatment next?

Administer an injection of epinephrine IV stat

The nurse explains to the client's family the alcoholic's recovery. What is the first step in recovering from excessive alcohol use?

Admitting an inability to control drinking

The nursing student is preparing a teaching presentation on disaster preparedness for a nursing class assignment. Which action(s) would the student include in the presentation? Select all that apply.

Affix a tag to a pet's collar with contact information Store a supply kit with extra batteries, flashlight, and radio Create a network of persons who can provide support during and after the disaster

A client is being treated for alcoholism. Which organization can be recommended to assist the family in coping with this disease?

Al-Anon

Which of the following is the primary hormone for the long-term regulation of sodium balance?

Aldosterone

What are the primary components of medical management for anorexia nervosa? Select all that apply.

All answers are correct.

Forms of communication by the LVN should include:

All of the above.

Passive-aggressive behavior is demonstrated by the nurse who?

All the above

The nurse discharging a newly delivered mother and her newborn infant needs to assess the mother's knowledge about how to take care of herself and her baby. This is her second child. Which approach would be best to verify the client's understanding of these topics?

Ask her questions and observe her caring for the baby.

The nurse is assessing a child of a different cultural background. Which nursing action should the nurse prioritize when providing care?

Ask the family for input into their care based on their cultural beliefs.

The nurse is assigned a client who is admitted for complications after a scheduled abortion. The nurses personal standards value adoption over abortion and will best serve the client by

Asking the charge nurse for an alternative assignment.

Before an LVN can delegate a function to the CNA, he/she must:

Assess the pt. carefully.

A nurse is preparing to assess a family which recently went through a divorce. The family now consists of a 40-year-old female, her 16-year-old son and 5-year-old daughter. The mother will continue as the primary wage earner with her current employment and has full custody of the children. Which action should the nurse prioritize with this family?

Assess the son for emotional trauma.

One way an LVN can expand practice without becoming an RN is to:

Attain certification in a specific are, such as IV therapy.

A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?

Autocratic

Which of the following instructions should a nurse provide a client with alcohol dependence who is prescribed disulfiram?

Avoid mixing disulfiram and alcohol.

To develop a therapeutic relationship with an anxious client, the nurse looks for ways to build trust. What nursing intervention is most likely to help the nurse gain the client's trust?

Be available and attentive to the client's requirements.

While making a home visit, the nurse suspects that a child is experiencing psychological maltreatment. What did the nurse observe in the home?

Belittling the child in front of the nurse and other siblings

Communication occurs when:

Both the sender and receiver have understood the meaning of communication

When teaching a client with generalized anxiety disorder, the nurse instructs the client to avoid which of the following?

Caffeine

A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed?

Check blood glucose.

Your client is a 72-year-old male who has just undergone a transurethral resection of the prostate (TURP) and is returned to the nursing unit with a 3-way catheter for administering bladder irrigation. Your client complains of bladder discomfort and a feeling or urgency to void, Which nursing action is best to take first?

Check that the urinary drainage catheter is patent and not kinked.

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?

Check the identification badge of any health care worker before releasing baby from room.

What changes, if any, should the nurse expect in the dietary patterns of a client who is clinically depressed?

Client either overeats excessively or under eats with little nutritional input

nurse is conducting a home care assessment of a pediatric client and the home. Which aspects might the nurse include to determine any safety concerns? Select all that apply.

Client medications Home layout Developmental Status

The emergency department nurse manager is orienting the new nurse regarding bioterrorism. The nurse manager would include which indicator(s) as an example of bioterrorism. Select all that apply.

Clusters of sick people from a shared locale High outbreak of similar symptoms among previously healthy people Increased numbers of sick people seeking health care

Which type of therapy assists the clients to alter their irrational thinking?

Cognitive Therapy

Which of the following is an important role of the nurse manager?

Coordinate the unit's activities.

A nurse has performed disease prevention teaching with a client who has genital herpes. Which client behavior indicates that the teaching has been successful?

The client washes their hands before and after touching lesions.

An instructor is preparing a teaching plan for a group of students about reproductive structures and sexual arousal. Which female reproductive structure would the instructor include?

The clitoris

The nurse is caring for a client with an immunodeficiency disorder. Lab results show that the client does not have an adequate number of T lymphocytes needed to improve immune function. Which gland should be investigated for dysfunction?

Thymus

A client with bipolar disorder has been taking lithium, as prescribed, for the past 3 years. Today, family members brought this client to the hospital because the client hadn't slept, bathed, or changed clothes for 4 days; had lost 10 lb (4.5 kg) in the past month; and woke the entire family at 4 a.m. with plans to fly them to Hawaii for a vacation. Based on this information, what may the nurse assume?

The lithium level should be measured before the client receives the next lithium dose.

A nurse is working with a child she suspects may be a victim of maltreatment in her home. Which combination of characteristics related to the parent, the child, and the circumstances would most strongly indicate the risk for maltreatment of this child?

The mother was maltreated as a child; the child was born prematurely; the father recently lost his job

a nurse is making an initial home visit to a child requiring home intravenous antibiotic therapy for treatments of a bone infection. When assessing the home environment, which area is the priority for the nurse to assess? Select all that apply

Electricity, Refrigeration

A client at 27 weeks' gestation still walks daily but reports "terrible" heartburn at night. Which action should the nurse point out will best address this situation?

Elevate the head of the bed.

The nurse is working with a 12-year-old who is hospitalized with a chronic illness. Which action by the nurse might help the chronically ill preteen thrive while hospitalized?

Encourage the client to wear his or her own clothes, talk to friends on the phone, and interact with other clients who have similar illnesses.

A culture indicates that your client has nonspecific urethritis from Chlamydia Trachomatis, a sexually transmitted infection. Which nursing instruction is best to provide to the client to prevent a recurrence of the infection?

Encourage your sexual partners to be tested and treated.

A client with bulimia nervosa tells a nurse she was doing well until last week, when she had a fight with her father. Which nursing intervention would be most helpful?

Examining the relationship between feelings and eating

Which is a clinical manifestation of diabetes insipidus?

Excessive thirst

A young patient tells the nurse, "I have the best family in the world." When questioned about who is in the family, the patient replies, "I have lots of people in my family ... my mom, my dad, two brothers, grandma and grandpa, two uncles, two aunts, and three cousins." This patient is describing which type of family?

Extended

In which manner is the fetal status best assessed during the active and transition stages of labor?

Fetal heart rate at the peak of a contraction

A 4-year-old is brought to the emergency department by a grandparent who states, "His father beat him with a belt, and he has marks all over his back." What responsibility does the nurse have to report this incident?

The nurse has the responsibility to report the incident as suspected child abuse (child maltreatment).

A client arrives at the mental health acute clinic. He had been ordered a tricyclic antidepressant about a month ago. The client states that he has been taking it correctly every day. What observation below would indicate that the client is actually taking the medication?

He arrives at the clinic on time for his appointment with neat appearance and clean clothes.

after the nurse has gathered information about potential jobs, what should be done with that information?

The nurse should keep an organize list of potential employers

The parents are bonding with their newborn when the nurse notes the infant's axillary temperature is 97.2oF (36.2oC) an hour after birth. Which intervention should the nurse prioritize for this family?

Help the mother provide skin-to-skin (kangaroo) care.

The nurse observes a nursing assistant assigned to a client who just returned from having a bronchoscopy. Which action by the nursing assistant would prompt the nurse to intervene?

The nursing assistant offers the client some water.

The nurse is observing a nursing assistant transfer a client from bed to chair. Which observation needs correction? Select all that apply.

The nursing assistant stands with feet close together and knees and back straight when helping the client to move. The nursing assistant lifts the client up by tugging on the client's arms. * The nursing assistant tells the client to grab on to her any place during the transfer

The nurse is planning care for a family whose 3-year-old child is in the final stages of dying. Which outcome demonstrates that the interventions have been successful? Select all that apply.

The parents identify coping measures that are helping. The family prepares a scrapbook with favorite photos. The child remains free of pain during the end stage of life. The parents identify a support group for their family.

Anthrax acquired by which method develops into the most severe?

Inhalation

The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize?

Instill 0.5% ophthalmic erythromycin.

A client is experiencing an increase in blood glucose levels. The nurse understands that which of the following hormones would be important in lowering the client's blood glucose level?

Insulin

A woman arrives at the prenatal clinic and is accompanied by her partner. Which behaviors would be suggestive of intimate partner violence (IPV)? Select all that apply.

The partner answers questions for the pregnant client. The partner is overly protective of the pregnant client. Poor weight gain during the pregnancy and low-birth-weight infant

The nurse is caring for a victim of a chemical disaster. Medications given in the treatment of this client include amyl nitrite, sodium nitrite, and sodium thiosulphate. What chemical agent does the nurse know this client has been exposed to?

Cyanide

A patient is having diagnostic testing for suspected hyperthyroidism. Which of the following diagnostics correlate with this endocrine disorder? Select all that apply.

Decrease in serum thyroid-stimulating hormone (TSH), Increased T3 , Increased T4 , Increase in radioactive iodine uptake

In caring for clients, a healthcare team often uses critical pathways. Which of the following are reasons critical pathways are used?

Decreases cost for the client and hospital is followed by all members of the healthcare team, provides organization for the care of the client, includes all treatments and procedures

A nurse assigns an unlicensed assistive personnel (UAP) to take 2 Tylenol tablets to a pt. c/o a headache. In assigning this task the nurse is:

Delegating an inappropriate task to ancillary personnel.

A client has just learned of having a terminal illness. Which assessment finding(s) indicate to the nurse that the client is experiencing a sympathetic nervous system response to this diagnosis? Select all that apply.

Dilated pupils Heart rate 112 Blood pressure 170/90 mm Hg Serum glucose level 140 mg/dL Respiratory rate 26 and shallow

Severe levels of anxiety result in what?

Distorted sensory awareness

Lately, a 75-year-old client is having difficulty emptying their bladder. They are unable to empty completely and yet it feels full, causing discomfort. The physician suspects prostate cancer. Which question(s) would you expect the physician to ask the client? Select all that apply.

Do you pass blood in your urine?" "Do you have a family history of prostate cancer?" "Do you have difficulty urinating?"

While the nurse is recording the health history of a client who is scheduled for a thyroid test, the client informs the nurse about an allergy to seafood. What is the nurse's most appropriate response?

Document the allergy and inform the physician

Impaired balance and uncontrolled tremors of Parkinson's disease is correlated with which neurotransmitter?

Dopamine

There are many things you can do to prepare for your job interview. Which of the following is critical to success of the interview?

Dress in clothing that demonstrates a professional appearance

Which action would the nurse include in a primary prevention program in the community to help reduce the incidence of HIV infection?

Educate clients in how to practice safe sex

How can nurses help the nation achieve its 2020 national health goals related to violence in the family? Select all that apply?

Educate parents about effective parenting skills, identify children in schools who have been maltreated, acute care and clinic nurses will identify victims of abuse, Refer parents for counseling when under sever stress and reports suspected abuse to the appropriate protective services.

A group of students is reviewing material about endocrine system function. The students demonstrate understanding of the information when they identify which of the following as secreted by the adrenal medulla?

Epinephrine

A patient is noted to be anemic. Which hormone will affect the development of red blood cells in this patient?

Erythropoietin

A nurse is caring for a client with social phobia. Which statement is most accurate regarding clients with social phobia?

They avoid social situations.

As part of the first prenatal visit, the nurse is assessing a pregnant woman's obstetrical history, which includes an 18-month-old daughter, born 2 days after her estimated date of birth; a 3-year-old son born at 35 weeks' gestation; and two lost pregnancies, one at 12 weeks and one at 21 weeks. How should the nurse document this history?

G5 T1 P2 A1 L2

The nurse is caring for a client with diabetes who developed hypoglycemia. What can the nurse administer to the client to raise the blood sugar level?

Glucagon

the nurse is helping a family explore the various options available to provide health care for a child who will require medical assistance. the nurse will point out that individuals with which conditions can be safely cared for by qualified professionals in the home environment? Select all that apply.

HIV, need for iv antibiotics, ventilator dependence and postoperative orthopedic corrective surgery

A school-aged child is in isolation at the hospital and her family members ask what they can do to help the child feel less lonely. What would the nurse suggest to this family? Select all that apply.

Have the child's classmates send cards to the child. Have parents bring the child's electronic game system Draw a smile on the nurse's mask before entering the room

A woman delivered her infant 2 hours ago and calls to tell the nurse that she needs to go to the bathroom. When the nurse arrives, the mother is getting out of bed alone. What should the nurse do?

Have the client sit dangling her legs off the side of the bed for 5 minutes.

A nurse is preparing to discharge a client with coronary artery disease and hypertension who is at risk for type 2 diabetes. Which information is important to include in the discharge teaching?

How to control blood glucose through lifestyle modification with diet and exercise

The nurse is instructing an adolescent who is not sexually active on potential vaccinations available. Which vaccination would the nurse state that decreases the risk of cervical cancer?

Human papilloma viral (HPV)

which statement by the child who is being bullied demonstrates appropriate behavior?

I will have a teacher accompany me to the bus so I am protected

a community-based nurse is precepting a student nurse. the students nurse asks the preceptor to explain a communal family. how would the nurse respond. Select all that apply.

In a communal family, all members share the responsibilities for homemaking, and communal families are seen in many cultures.

The nurse is relating health education to students when asked where sperm is actually made. Which location is most correct?

In the testes within the scrotum

A client who binges on alcohol during the weekends denies having an alcohol dependency problem. Which is the best understanding, by the nurse, in regards to binge drinking?

Inability to control drinking is a sign of dependency.

A nurse presenting an educational event for a local community group is addressing premenstrual syndrome (PMS). What treatment guideline should the nurse teach this group?

Increase the frequency and intensity of exercise.

The nurse understands that a single dose of azithromycin as treatment for a chlamydia infection is prescribed by the health care provider for what reason?

It can be administered to the client at the health care provider's office.

which comes first?

Leadership

A nurse teaches a client with newly diagnosed hypothyroidism about the need for thyroid hormone replacement therapy to restore normal thyroid function. Which thyroid preparation is the agent of choice for thyroid hormone replacement therapy?

Levothyroxine (Synthroid)

Which of the following hormones causes the ovary to release an ovum during ovulation?

Luteinizing hormone (LH)

An important part of assertiveness for a nurse is to recognize that he/she has limitations. What are components that enable him/her to function safely on the job?

Make sure that he/she is oriented adequately if he/she has to do something he/she hasn't done before.

The nurse is caring for a boy who states that his mother is a psychologist while his father is unemployed. His mother is the one who remained remind him to take his medicine Ann also comforts his sister when she cries. Analyzing this description of his parents roles you would conclude that his

Mother is the provider and nurture

The caregiver of a 2-year-old child reports to the nurse that the child vomits at least five or six times a day, sometimes continuously. The child is admitted for observation and the mother continues to report the child is vomiting, but the nurses never see the child vomit or any evidence the child has vomited. The child will likely be found to have:

Munchausen syndrome by proxy.

The nurse is admitting a pediatric client for a common pediatric surgical procedure. When completing the domestic violence screening, which statements require clarification? Select all that apply.

My Mom will hit my Dad when she is drunk but it doesn't hurt." "I see my Dad drive by our new house to see who is here." "My Dad yells a lot but never means it and doesn't hit anyone."

The school nurse observes an elementary school child arriving in the winter in shorts and a short-sleeved shirt with no coat. The nurse would consider this as which type of abuse?

Neglect

A nurse is caring for an older female client whose husband died 6 months ago. Which behavior by the client indicates ineffective coping?

Neglecting her personal grooming and refusing to take showers/baths

Why is networking important for the novice nurse?

Networking is an effective way to informally share goals, concerns, or desires.

Licensed nurses have the authority to delegate duties. Which of the following gives nurses that authority?

Nurse Practice Act

A nurse is providing home care to several families who live in a community with limited resources. Which action is an example of how the nurse can best "nurse the community"?

Organize a free flu vaccination in the community.

A client has a dysfunction in one of his glands that is causing a decrease in the level of calcium in the blood. What gland should be evaluated for dysfunction?

Parathyroid gland

Which of the following assessment findings is most important in determining the presence of alcohol dependency in a client? Select all that apply.

Patterns of use Absenteeism from work Blackouts

A postpartum woman is concerned about constipation following delivery. What factor(s) contribute to this problem? Select all that apply.

Perineal pain Hemorrhoidal discomfort Iron supplements

An older adult patient that has type 2 diabetes comes to the emergency department with second-degree burns to the bottom of both feet and states, "I didn't feel too hot but my feet must have been too close to the heater." What does the nurse understand is most likely the reason for the decrease in temperature sensation?

Peripheral neuropathy

The client recounts to the nurse an instance of jumping onto the hood of a car to avoid an approaching dog, and reports feeling embarrassed by this reaction. The client discloses suffering from a severe dog bite in childhood. The nurse classifies this symptom as which of the following?

Phobic disorder

The nurse is taking a nursing history on a client who has come to the clinic with complaints of fatigue, weight gain, and constipation. The client states, "I'm just depressed." The nurse knows that before the health care provider institutes therapy, the client will receive a full physical assessment for what reason?

Physical conditions such as hypothyroidism can mimic the symptoms of depression.

a family member of a patient comes to you and complains about the lack of care that a specific staff member is providing for his mother. how should you respond

Please tell me what you know. Then we will investigate further to determine if there is a problem

The nurse is caring for a client in active labor who states, "I need to go to the bathroom to have a bowel movement, now." Which action should the nurse take first?

Position the client for and perform a cervical assessment.

ADH is secreted by which gland?

Posterior pituitary

A client was in a plane crash a year ago and several people were killed. The client is now experiencing nightmares, insomnia, headaches, loss of appetite, and fatigue. Which disorder is the client most likely experiencing?

Posttraumatic stress disorder

A client presents with symptoms of menstrual difficulties and infertility. Which hormone is essential in the maintenance of the endometrium?

Progesterone

A young couple are asking the nurse for suggestions on the best way to help their newborn develop properly. Which is the best response by the nurse?

Provide a variety of brightly colored toys.

The nurse removed a client's indwelling urinary catheter 24 hours after the cesarean birth. Four hours later, the client has not yet voided. The client reports 6/10 incisional pain and no urge to void. The nurse can palpate a full bladder. What action(s) will the nurse take? Select all that apply.

Provide analgesic for incisional pain Run water while the client attempts to void.

Exposure to gamma radiation can be decreased by completing which action?

Providing distance from radiation source

It is illegal for an interviewer to ask you which of the following?

Questions about your age, religion and birthplace

A mother tells the nurse that her toddler does not want to go to bed at night and keeps getting back up when she is put to bed. What recommendations would the nurse make to this mother to foster sleep in the toddler?

Read the child a book in bed and take time to calm the child down before turning out the lights.

A client is admitted to an inpatient psychiatric unit for treatment of obsessive-compulsive symptoms. Obsessive-compulsive disorder (OCD) is associated with:

Repetitive thoughts and recurring impulses

A nurse just off orientation arrives at work and is told to float to the pediatric unit for the day because the unit is understaffed and needs another nurse. This nurse has never worked in the pediatric unit. Which of the following is the most appropriate response.

Report to the pediatric unit, request a 4hr orientation and identify tasks that he/she can safely perform.

The nurse is caring for an adult who was admitted for observation following an automobile accident. The client has several lacerations that were sutured in the emergency department and a fractures left leg that has been casted. The baseline V/S were BP 130/90, P 76, RR 16. One hr after arriving to your unit you note that his left pedal pulses were decreased and his repeat V/S were : BP 98/60, P 96, RR 22. Arrange the following steps in the proper order.

Reposition the leg and assess for pain Notify the physician of the changes Start an IV Give IV fluids Draw labs

A nurse has been working with a bulimic college student to help control the eating disorder. Which recommendation by the nurse is most likely to be effective in helping the client control bulimia?

Restrict using the bathroom for at least 2 hours after meals

A school nurse is visiting with a father who has custody of his children. Prior to this, the father provided child support for the children but had not been involved in the day-to-day raising of the kids. The father has never had to take children to school before. The priority diagnosis of the father during this conversation would include which potential effect on the change in his parenting role?

Risk for low self-esteem

The parent of a toddler observes the child play next to another child but not with the child. What should the nurse explain to the parent about this type of play behavior?

This is parallel play and is expected.

The nurse is caring for a client who states he is not feeling very well. When asking the client for specific symptoms, the client is vague with details but does state feeling better when the sun is shining. With this information, the nurse would document which disorder as a possibility?

Seasonal affective disorder

The nurse is assessing a client at her first prenatal visit and reports her LMP started December 1. Which date will the nurse predict for the EDD?

September 8

A 16-year-old girl has been diagnosed with gonorrhea and chlamydia and has been given a one-time IM dose of Recephin and a prescription for doxycycline for 7 days to treat the chlamydia. Before leaving the clinic asks the nurse, "When can I be certain that I am no longer infectious?" The nurse correctly advises the client that she is still considered infectious until which time?

She has a negative culture taken after being off antibiotics for at least 7 days.

a new nurse on your unit is constantly questioning the procedures that are in place for patient care. she tells other staff and the nurse's manager that their methods are outdated and ridiculous and wants to change procedures to the latest methods she learned in school. the nurse manager agrees to meet with her to discuss the situation and tells the new nurse that she could have what kind of basis for change in procedure?

She has evidence-based practice that explains why the procedures need to be changed and provide documentation.

A client with alcoholism has just completed a residential treatment program. What can this client reasonably expect?

She'll need ongoing support to remain abstinent.

The school nurse is aware that providing proper care involves cooperation from the adolescent. Which technique will the nurse prioritize to develop open communication with the adolescents?

Show interest in the adolescent and develop a rapport before asking questions.

A primigravida is 1 cm dilated, in early latent labor, and interested in avoiding epidural anesthesia. After asking about which nonpharmacologic options for pain relief she can use at this time, which option(s) should the nurse point out to the client? Select all that apply.

Simple breathing exercises Effleurage ,Walking and then using a birthing ball

When preparing for an emergency bioterrorism drill, the nurse instructs the drill volunteers that each biological agent requires specific client management and medications to combat the virus, bacteria, or toxin. Which statement reflects the client management of variola virus (smallpox)?

Smallpox spreads rapidly and requires immediate isolation.

A 3-year-old child is reverting to previous behavior and showing levels of anxiety after his parents bring home his new baby sister. What advice given to the 3-year-old's mother is most appropriate for relieving the child's anxiety?

Spend some quality time alone with the older child.

The client who is waiting to be transported to the operating room tells the nurse of a fear of waking up during the operation. The client is visibly upset with sweaty palms, wringing of the hands, and increased heart rate. Which is the best action to be taken by the nurse?

Stay with the client until anesthesiologist evaluates situation.

The nurse is caring for a client who is being treated in the emergency department for a panic attack. Which of the following nursing interventions would be most appropriate?

Stay with the client, emphasizing that he is safe and that you will remain with him.

A pregnant client is planning a vacation to a different state and questions the nurse concerning precautions. Which suggestion should the nurse prioritize for this client who will be traveling by automobile?

Stop and walk every 2 hours.

A nurse explains to a client with thyroid disease that the thyroid gland normally produces:

T3, thyroxine (T4), and calcitonin.

The nurse has completed assessing the vital signs of several clients who are from 36 to 48 hours postpartum. For which set of vital signs should the nurse prioritize for interaction?

Temp: 98.6° F (37° C), HR 74, RR 16, BP 150/85

A client with obsessive-compulsive disorder describes all doorknobs as being contaminated with a variety of viruses. He cleans each knob three times with paper towels before use. Such behavior allows the client to:

Temporarily reduce anxiety

A teenage male client has not developed facial hair, a deeper voice, or other secondary sex characteristics. What hormone would the nurse expect would be checked for this client?

Testosterone

In which situation(s) will the nurse anticipate client admission to the labor and delivery unit? Select all that apply.

The client reports experiencing regular contractions every 5 minutes. The nurse notes that the cervix has thinned with 7 cm dilation (dilatation). The health care provider has documented pelvic change from the client's last visit. The client reports a gush of fluid from the perineal region.

A client has a blood alcohol level that is double the legal limit for driving yet does not exhibit behaviors of intoxication. The nurse knows that this is due to which effect?

Tolerance

The greatest percentage of people have which type of diabetes?

Type 2

A client is being admitted for suspected toxic shock syndrome (TSS). Which of the following would be most important for the nurse to determine?

Use of super absorbent tampons

A 6-year-old has been administered a hypnotic before going to surgery. The child remains kicking and screaming. The nurse is considering whether restraints should be used in this situation. Which guidelines should the nurse follow in this instance? Select all that apply.

Use the least amount of restraint necessary. Obtain a primary care provider's prescription for restraint. Explain to the parents the need to restrain their child.

A nurse has been working in the hospital setting and has decided to change careers to the community-based setting. What skill(s) will this nurse need to be successful in the new role? Select all that apply.

Use the nursing process for the family instead of the individual. Apply educational theory and techniques. Develop communication techniques with family members. Become an advocate for the family.

The nurse is caring for a client who has remained in stable condition at 37 weeks' gestation. The client's condition suddenly changes. Which assessment change should the nurse prioritize?

Vaginal bleeding and no pain

The nurse is caring for a male patient with gonorrhea. The patient asks how he can reduce his risk of contracting another sexually transmitted infection (STI). The nurse should instruct the patient to do which of the following?

Wear a condom every time he has intercourse.

The nurse is instructing a couple in the early stages of infertility testing who has just found that the male has a slightly low sperm count. Which easy change can a nurse suggest to a male client?

Wear loose fitting underwear instead of tight ones.

A client with newly diagnosed type 2 diabetes is admitted to the metabolic unit. The primary goal for this admission is education. Which goal should the nurse incorporate into her teaching plan?

Weight reduction through diet and exercise

If a known substance abuser presents to the emergency department with tachycardia and chest pain, what is the most appropriate question for the nurse to ask?

When did you last use cocaine?

A group of nursing students are analyzing the various aspects of a family. At the end of the session the students correctly point out the family structure is illustrated best by which information?

Who its members are

The client, who has recently stopped smoking, is irritable and complaining of a feeling hungry. The nurse would interpret this as which of the following?

Withdrawal

a situation has arisen on the unit where you work. you work 12 hours shifts. the day shifts are complaining that there are too many errors on the medication administration record. the night shifts nurses, who are responsible for correcting the MAR, state that they often don't have time to correct the mar because they are too busy with other responsibilities. Your supervisor assigns 2 people from the day shift and 2 people from the night shift to a committee to determine the best way to solve the problem. which of the following techniques would be the most successful resolution

Work in a collaborative manner to attempt to find a successful resolution

The nurse in the emergency department is caring for a client who has an elevated blood pressure and elevated respirations. The nurse is aware that the client may be experiencing withdrawal from heroin if the client displays which other signs and symptoms? Select all that apply.

Yawning Goosebumps Diarrhea

The nurse is triaging victims during a mass casualty incident. The nurse uses which color tag for a victim whose care can be delayed?

Yellow

Why is it important to be involve in local, state, or national organizations that support your profession?

You can become aware of laws and practices that affect your practice.

A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct?

You should not lift anything heavier than your infant in its carrier.

The nurse educator is planning a health promotion class with a focus on sexually transmitted infections. What points regarding risk factors for chlamydia and gonorrhea should the nurse educator include? Select all that apply."

Your chances of contracting these infections are higher the more sexual partners you have." "Young adults and teenagers are a high risk age group for both these infections."

Which of the following people should be the first one informed when you are terminating your employment?

Your nurse manager

all the following adults are admitted to the surgical unit. which client should the nurse prepare for immediate surgery

a 28-year-old man who has lower abdominal pain

the nurse has received her assignment for the day and is to care for the following clients. which client should the nurse visit first

a 69-year-old who was admitted last evening

A nurse teaching family member about the brain's connection to behaviors commonly seen in mental illnesses is using the term "neurotransmitter." The nurse should explain that a neurotransmitter is:

a chemical that is released in the brain.

A client has gained 100 lb over the past 20 years, and wants to lose weight. What strategy will greatly contribute to this client's success?

a sensible weight loss regimen prescribed by a dietitian

When a staff member makes a mistake, the nurse manager should:

accept the mistake and help the person learn from the mistake.

The pediatric nurse is aware that chronic illness can affect which of the following for a child?

all of the above

you have received morning report and are getting ready to assess your clients, which of the following clients would you assess first

an asthmatic pediatric client with inspiratory-expiratory wheezes

To prepare the community for the possible threat of anthrax, a nurse must teach that:

anthrax can infect the integumentary, GI, and respiratory systems.

your boss has decided that you were behaving inappropriately and talked to you about it in front of your co-workers. what is the most appropriate way to handle this situation

ask to have the discussion somewhere private

in a managed care environment, the nurse has an ethical responsibility to the patient to

assume the role of patient advocate

A client is developing increasing symptoms of anxiety disorder and reports having urges to self-harm. The nurse secures admission to a residential treatment facility and the client begins to shout at the nurse for betraying trust and ruining the client's life. What is the nurse's role in this situation?

assuring the client's safety

The maternal health nurse is caring for a pregnant client with pre-existing heart disease. Which concept will the nurse identify as a priority?

balancing weight gain

In providing culturally competent care to clients, the home care nurse should assess health care practices. What should be included in the home care nurse's assessment? Select all that apply.

barriers to health care cultural practices health-promotion behaviors education level

It is important for a nurse not to argue about the validity of a schizophrenic client's delusions or try and convince him or her that they are wrong because clients may:

become more fixated on their delusions.

During a facility disaster drill, an "injured client" presents to the emergency department with complaints of dry mouth, inability to focus his vision, and double vision. A nurse notes that the client has an unsteady gait and appears to be very weak. The client states, "My arms and legs feel like they just can't move." A nurse suspects the client may be a victim of bioterrorism with:

botulism.

The nurse reviews the notes (above) of a pregnant client. What would concern the nurse the most?

caring for indoor cats

A client is scheduled to have her first Pap test and asks the nurse why this test is necessary. The nurse should tell the client that this test is used to detect early cancer of the:

cervix.

The mother of a 4-year-old is concerned her child is not eating well. In addressing the concerns of this mother, which foods should the nurse point out are high in protein? Select all that apply.

cheese and crackers whole grain granola with yogurt turkey sandwich

effective delegation involves which of the following

clear identification of the needs of the delegated tasks

you have an employee that is always 5-10 minutes late, what should you do about the situation

collect all pertinent information with documentation and call him/her in privately to give a verbal warning with consequences if he/she doesn't comply

A postpartum client tells the nurse that she feels like crying for no apparent reason and is unable to sleep well. What should the nurse point out to the client that this may be related to?

decreased progesterone levels

a rule of delegation is

determine if the person is qualified to perform the task

The nurse provides care for a client who is diagnosed with anorexia nervosa. Which is the priority prescription for the nurse to implement based on the most recent laboratory data shown above?

electrocardiogram (ECG)

In order to gain the cooperation of staff members, you ask for their input on patient care and share information regarding patient care. These actions are examples of

empowerment.

The nursing instructor is teaching a class on the nutritional needs of the pregnant client. The instructor determines the session is successful when the students correctly choose which supplement as being known to prevent up to 70% of CNS birth defects?

folic acid

The nurse is educating a couple who has had difficulty with conception. The client asks about the hormone, which is responsible for the production of eggs. The nurse answers that this hormone is called:

follicle-stimulating hormone (FSH)

One role of the nurse in a community-based setting focuses on primary prevention. An example of primary prevention would be:

giving an information session on bicycle safety in an after-school program

when working in a long-term care facility, which one of the following actions would be considered unethical and is a HIPPA violation going to the dementia unit and looking at your neighbor's chart, your neighbor is a patient in the unit

going to the dementia unit and looking at your neighbor's chart, your neighbor is a patient in the unit

A family in the second phase of divorce are actually separating and moving to new homes and perhaps new schools. The school-age children may experience which type of feeling at this phase in the divorce?

grief for the missing parent

A group of nursing students are preparing a presentation depicting the fetal circulation. The instructor determines the presentation is successful when the students correctly illustrate which route for the ductus arteriosus?

he pulmonary artery to the aorta

The nurse is preparing to assess a toddler during a routine health maintenance visit. Which assessment will the nurse perform to determine the child's growth milestone?

height and weight

A family that regularly takes in foster children is visiting the junior high school nurse to inform the staff that there will be a new 8th grade foster child beginning school the following week. The school nurse should monitor this new student for which psychosocial response to being moved to the foster care system?

high level of insecurity

A single mother is staying with her 8-month-old daughter admitted for dehydration secondary to gastroenteritis. After the third hospital day the exhausted mother states she would like to go home to shower and get clean clothes but she does not want to leave her daughter. The nurse should:

inquire if another family member is available to stay in her absence

Which condition is the most common cause of anemia in pregnancy?

iron-deficiency anemia

The most common reason for employee error is:

lack of knowledge.

The nurse is caring for a small child who has been admitted with a diagnosis of abusive head trauma (shaken baby syndrome). Which condition or concern often occurs with shaken baby syndrome?

loss of vision and intellectual disability loss of vision and intellectual disability

Four clients injured in an automobile accident enter the emergency department at the same time. The triage nurse evaluates them immediately. The nurse should assign the highest priority to the client with the:

maxillofacial injury and gurgling respirations.

The nurse reviews the above chart note with a list of symptoms for a client seeking medical attention in the community clinic. Which substance should the nurse suspect the client is using?

methamphetamine

The nurse is completing discharge teaching with a client with hyperthyroidism who has been treated with radioactive iodine at an outpatient clinic. The nurse instructs the client to

monitor for symptoms of hypothyroidism.

you are a new leader, and you want to develop specialized skills for your job that include making a personal analysis of all problems, making proposals to your group based on these analyses, inviting comments and criticisms from the group, but making the final decision yourself. what type of leader are you

multicractic( participative)

A new mother asks the nurse when she should begin caring for her baby's teeth. Which response is the most appropriate for the nurse to make at this time?

now

A pregnant client reports difficulty sleeping well. Which suggestion for sleeping should the nurse prioritize to assist this client?

on her side with the weight of the uterus on the bed

a nurse has delegated several nursing tasks to staff numbers. the nurse primary responsibility after the delegation of the test is to

perform follow up with each staff member regarding the performance of the task and the outcomes related to the implementation of the task

A client seeks treatment for disturbed sleep cycles and depressed mood. Which gland and hormone are involved in regulating sleep cycles and mood?

pineal gland; melatonin

Assessment for surfactant level via lecithin/sphingomyelin (L/S) ratio in the amniotic fluid is a primary estimation of fetal maturity. The purpose of surfactant is to:

prevent alveoli from collapsing on expiration.

licensing law ( nurse practice act) regulate the practice of nursing to

protect the public from injury

A client visits the physician's office complaining of agitation, restlessness, and weight loss. The physical examination reveals exophthalmos, a classic sign of Graves' disease. Based on history and physical findings, the nurse suspects hyperthyroidism. Exophthalmos is characterized by:

protruding eyes and a fixed stare.

A client in labor received an opioid close to the time of birth. At the time of the birth, the nurse will assess for which effect?

respiratory depression in the newborn

a nurse is developing a program for families to promote spending time together. which causes of decreased family togetherness will the nurse incorporate into the program

rise in children participating in extracurricular activities increase in television use greater focus on material things rather than relationships

A 6-year-old is brought to the emergency department numerous times over 3 months with the same symptoms of gastric upset and nightmares. The child acts very hostile with the nurses while there. What should the nurse suspect?

sexual abuse

Because of high divorce rates and separations in recent years, there has been a significant increase in the family structure termed:

single parent

During the second stage of labor, a woman is generally:

turning inward to concentrate on body sensations.

A group of nursing students are analyzing the fetal circulation. After the session, the students correctly point out which fetal structure contains the highest concentration of oxygen?

umbilical vein

A client is in the third stage of labor. Which finding alerts the nurse that the placenta is separating?

uterus becomes globular

Following an explosion at a chemical plant, a nurse is triaging clients. One client has a penetrating abdominal wound from a piece of shrapnel. What color coordinate would the nurse assign to this client?

yellow

A 10-year-old child is receiving end-of-life care at home (above). The home care nurse recommends repositioning the client every 2 hours. The caregiver responds, "My child has been through so much already! Why can't we just let the child stay in a comfortable position?" How will the nurse address the parents' concerns?

· "A pressure injury could cause additional pain; we can gently reposition your child to reduce this risk."

The nurse assesses a 5-year-old client for a well-child visit prior to the start of school (above). What finding from the assessment requires follow-up?

· speech and language

A nurse is providing care to a client and actively involves the client's family members in the care planning and implementation, dealing with the client and family as a unit. The nurse is engaging in:

• family-centered care.