health and illness

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A client is being assessed for hearing loss. Which test would be used for the assessment of the hearing function? (Select all that apply.) A. Weber test B. Phalen's test C. Rinne test D. Whisper test E. Romberg test

ACD Rationale: Assessment screenings for hearing impairment include the whisper test, otoscope examination, tympanogram, and use of a tuning fork to perform the Rinne and Weber tests.

Which topic is important to include in the home care teaching for a client with a urinary tract infection (UTI)? (Select all that apply.) A. Adequate fluid consumption B. Voiding every 5 to 6 hours C. Good hygiene methods D. Proper nutrition E. Wearing polyester underwear

ACD Void every 3-4

The nurse is admitting a client with suspected urinary calculi. Which collaborative activity should the nurse anticipate as part of diagnosing urinary calculi and/or the possible complications associated with this diagnosis? (Select all that apply.) A. Urinalysis B. Chest x-ray C. Renal ultrasound D. Intravenous pyelography (IVP) E. Computed tomography (CT) scan of the kidney

ACDE

The nurse is caring for a client at risk for sensory overload. Which nursing interventions will the nurse implement? (Select all that apply.) A. Shading the windows B. Providing books and newspapers C. Providing earphones for the client D. Scheduling clustered care E. Explaining environmental sounds

ACDE

Which action should the nurse avoid when documenting data in a client's medical record? (Select all that apply.) A. Charting for someone else B. Using objective descriptions C. Leaving blank lines D. Using vague terms E. Altering an entry

ACDE

The graduate nurse expresses a desire to work on the same unit where a student clinical was held because of the nursing staff. Which observation by the graduate likely helped form this opinion? (Select all that apply.) A. Staff nurses compliment each other for a job well done. B. Staff members focus on their individual assignments. C. Staff members laugh with each other. D. Staff members help each other complete assignments. E. Staff nurses ask about each other's families.

ACDE Staff members who focus on their own assignments are placing individual goals over the goals of the group.

The nurse reviews a facility's documentation techniques with a new nurse. Which statement should the nurse include? (Select all that apply.) A. "Document in a timely manner." B. "Use subjective and thorough descriptions." C. "Document the client's responses to interventions." D. "Do not document the client's actual words." E. "Follow organizational policies to correct charting errors."

ACE

Which piece of information should the nurse document in a progress note in the focus charting system? (Select all that apply.) A. Response B. Standards C. Data D. Problems E. Action

ACE

The nurse is caring for a client with visual impairment. The nurse understands that which comorbidity is associated with visual deficits? (Select all that apply.) A. Hypertension B. Dizziness C. Diabetes D. Convergence E. Stroke

ACE Dizziness is associated with hearing loss. Convergence is the ability of the eyes to turn inward together and is a normal finding.

The nurse manages a therapy group in a hospital. Which should be the selection criteria for the participants? (Select all that apply.) A. Behaviors and needs B. Client referrals C. The treatment of choice D. Work-related stress E. Pattern of personalities

ACE Members are selected by health professionals based on the pattern of personalities, behaviors, needs, and identification of group therapy as the treatment of choice

Which action is appropriate when the nurse is communicating with a client whose primary language is not English? (Select all that apply.) A.Avoid using medical jargon. B.Emphasize words with gestures. C.Use an interpreter. D.Speak slowly. E.Avoid using slang.

ACE Rationale: When communicating with a client whose primary language is not English, the nurse should avoid the use of slang and medical jargon. The nurse should pace the conversation so that the client can follow, but not speak too slowly because the client's attention may be lost. Gestures should be used cautiously because they can have different meanings in different cultures. Consider using an interpreter, such as a bilingual staff member.

The nurse is caring for a client diagnosed with urinary incontinence. Which client statement supports the nursing diagnosis of Social Isolation? (Select all that apply.) A. "When I leave home, I worry that I can't find a bathroom in time." B. "I have discovered a brand of absorbent undergarments that fit well." C. "I have found ways to disguise the smell of urine while I am out of the house." D. "I am so embarrassed when I wet myself. Even when I use absorbent pads, I feel like I smell of urine." E. "I time my diuretic for early in the day, so I can leave home later in the day and not have to visit the bathroom as often."

AD Rationale: Embarrassment and odor and the fear of not being able to find a bathroom in time can lead to social isolation.

The nurse case manager is preparing a client for discharge. The client has been successfully taught self-catheterization for urinary retention related to neurogenic bladder. Which other collaborative partner does the nurse involve? (Select all that apply.) A. Family B. Ostomy nurse C. Home health aides D. Infection control nurse E. Home health medical device delivery

ADE

The nurse is caring for a client with renal calculi. Which treatment is considered supportive? (Select all that apply.) A. Increasing fluid intake B. Increasing dietary fat intake C. Maintaining the client on bedrest D. Avoiding excess calcium-containing foods E. Administering ordered medications to help prevent the formation of future stones

ADE Rationale: Thiazide diuretics, allopurinol, and antibiotics may help prevent the formation of future calculi. Increasing fluid intake will prevent future stones from occurring and also prevent side effects of the medications used to treat the renal calculi. Adequate fluid intake will also assist in urine formation to help pass the stones.

A nurse is providing teaching for a client diagnosed with an olfactory deficit. Which interventions specifically related to an olfactory deficit will the nurse include in the teaching? (Select all that apply.) A. Check the expiration dates on food. B. Darken the rooms with shades. C. Set up a schedule for changing the batteries in carbon monoxide detectors. D. Recommend the client purchase smoke detectors with flashing lights. E. Review home cleaning supplies with the client.

AE The client may not detect spoiled food products or recognize toxic chemical odors from cleaning supplies.

A breastfeeding mother of a 2-month-old infant is concerned that her son defecates too frequently. Which response by the nurse should address this mother's concern? A. "Frequent bowel movements can occur with breastfeeding." B. "Feces containing less water may be difficult for infants to expel." C. "The increased frequency in defecation means your baby is at risk of weight loss." D. "Your baby should be able to control defecation by now."

During handoff communication, the condition of one client to be discussed has changed and needs immediate attention. Which action should the nurse take? A. Ask the nurse coming off duty to address the client's need and report the issues during handoff. B. Walk to the client's room together to address the client's need. C. Skip the handoff for the client. D. Find another nurse to attend to the client.

The acute care nurse is caring for a client with urine retention requiring urinary catheterization. Which is the purpose of including the collaborative partner of the infection control nurse in the care of this client? A. To prevent infection that is related to the urinary catheter B. To assist with mobility with the catheter in place C. To interpret diagnostic testing D. To address wound care

The nurse is caring for a client who has been diagnosed with urinary calculi. The client reports a pain level of 0 on a 0-10 scale, is drinking an adequate amount of fluids, and has been taking frequent walks in the hallway. The nurse is responsible for which intervention at this time? A. Teaching the client to retrieve stones by straining all urine B. Requesting an order for bedrest because the client has been taking frequent walks C. Teaching the client the importance of fluid restriction D. Ordering appropriate pain medication if indicated

The nurse is caring for a client who reports pain in the right leg. The nurse asks the client, "How do you rate your pain on a scale of 0 to 10?" Which method of therapeutic communication is the nurse using with this client? A. Being specific B. Seeking clarification C. Providing general leads D. Giving information

The nurse is caring for a client with open-angle glaucoma who is concerned about treatment of the condition. Which statement by the nurse most accurately describes the treatment plan for the client? A. "You will be prescribed medication for treatment." B. "The optometrist will discuss the plan for treatment." C. "Cataract removal will help resolve the glaucoma." D. "There currently is no treatment for glaucoma."

The nurse is caring for a visually impaired client who will be utilizing a service dog. Which statement most accurately describes the nurse's understanding of service dogs? A. "The service dog can assist with activities of daily living." B. "The cost of training a service dog is inexpensive." C. "Service dogs can be easily obtained for the visually impaired." D. "Another family member will need to care for the service dog."

The nurse is caring for an obstetrical client who expresses feeling stressed over the impending delivery of the baby. Which nursing intervention is most appropriate for the client's situation? A. Encourage the expression of concerns. B. Notify social services. C. Provide relaxation techniques. D. Reassure the client that everything will be fine.

The nurse is obtaining a prenatal intake for a pregnant client with a history of kidney stones. Which measure should the nurse instruct the client to take to prevent further kidney stones from forming? A. "Increase fluid intake to 2500dash-3500 mL per day." B. "Empty the bladder frequently." C. "Decrease dietary calcium intake." D. "Collect and strain all urine."

The nurse is preparing to examine the ears of a 2-year-old child. Which intervention should the nurse implement prior to the assessment? A. Have the parent help hold the child's head against their chest. B. Pull the auricle up and back. C. Remove the cerumen prior to the examination with the otoscope. D. Allow the child to play with the otoscope.

The nurse is providing discharge teaching to a client with a urinary tract infection (UTI). Which instruction should the nurse include? A. "It is important to follow this schedule for your antibiotics." B. "You do not need to make a follow-up appointment." C. "Be sure to complete the full course of urinary analgesics." D. "We recommend that you use aseptic technique when cleansing the perineum."

The nurse should understand that which therapeutic communication technique forms the foundation for all other therapeutic communication techniques? A. Attentive listening B. Empathizing C. Reflecting D. Paraphrasing

Which follow-up care should the nurse implement for a child previously treated for urolithiasis? A. 24-hour urine sample B. Urine calcium level C. Urinalysis D. Urine uric acid level

A A urinalysis is an assessment for a UTI. Urine calcium and uric acid levels are included in the 24-hour urine sample.

The nurse is caring for a client diagnosed with struvite urinary calculi (staghorn stones). Which condition should the nurse consider as the cause? A. Bacterium associated with a UTI B. Genetic defect C. Excess dietary intake of calcium D. Excess of uric acid

A Calcium oxalate and calcium phosphate stones are associated with excess dietary intake of calcium. Uric acid stones and stones comprised of calcium are associated with a genetic defect. Uric acid stones are associated with excess uric acid.

A pregnant client asks why she is being screened for certain diseases such as toxoplasmosis and syphilis. Which is the most accurate response from the nurse? A. "These diseases can impact your health and the health of a developing fetus." B. "These diseases can impact your health and need to be cured." C. "These diseases do not impact your health but can affect a developing fetus." D. "These diseases can impact the health of a developing fetus."

A In utero infections with TORCH pathogens (toxoplasmosis, rubella, cytomegalovirus, syphilis, herpes) can impact the health of the woman and a developing fetus, specifically increasing the risk of hearing loss for the infant.

The nurse is caring for an older adult client that requires a visual aid for reading. Based on the client's need, which visual change has the client experienced? A. Presbyopia B. Myopia C. Nearsightedness D. Hyperopia

A Presbyopia is an impairment in near vision resulting from a loss of elasticity of the lens related to aging. Myopia is a change in distant vision. Hyperopia is an impairment of near vision in younger people.

The nurse is providing visual screenings for school-age children. The nurse understands that which visual problem is most commonly diagnosed in school-age children? A. Convergence B. Corneal light reflex C. Strabismus D. Accommodation

A Problems with convergence are usually diagnosed in school-age children when they have difficulty reading and may be interpreted as a learning disability rather than a visual problem

The nurse is caring for an adult client with hyperlipidemia. Which assessment finding is most associated with the client's diagnosis? A. Xanthelasma B. Exophthalmos C. Ptosis D. Hordeolum

A Ptosis is a drooping of an eyelid that is associated with a stroke or neuromuscular disorder. A hordeolum is a sty generally caused by a staphylococcal infection. Exophthalmos is an unusual widening of the lids that is often associated with hyperthyroid conditions.

When caring for a client with severe dehydration, the nurse should ensure which results are documented? A. Intake/output B. Oxygen saturation C. Catheter care D. Respiratory rate

A Rationale: A client's intake and output is an important measurement that can provide information about fluid balance in the body. The nurse should ensure that this is documented correctly in order to monitor for resolving dehydration. Respiratory rate and oxygen saturation are important but not the priority for this client.

The nurse is admitting a client who reports chest pains. The nurse noticed that the client is very anxious and worried. The nurse tells the client "not to worry" and that "it is going to be okay." Which barrier to communication is the nurse using? A.Giving unwarranted reassurance B.Giving common advice C.Changing topics and subjects D.Agreeing and disagreeing

A Rationale: Giving unwarranted reassurances, which are comforting statements of advice, as a means to assure the client should be avoided. Nurses need to be cognizant of these barriers and avoid them. Nurses also need to recognize the barriers when they occur and change to more effective means of communication. Giving common advice is telling the client what to do. These responses deny the client's right to be an equal partner. Agreeing and disagreeing deters clients from thinking through their position and may cause a client to become defensive. Changing topics and subjects implies that what the nurse considers important will be discussed and that clients should not discuss certain topics.

Which information should the nurse provide for an older adult with gout, to prevent uric acid stones? A. "Limit meat intake." B. "Limit dairy products." C. "Increase acidic foods." D. "Decrease sodium intake."

A Rationale: Gout and increased purine intake predispose the client to uric acid stones. The client will be instructed to limit meat intake. Meat is high in purine, which contributes to the formation of uric acid stones.

Toward the end of the shift, the nurse is communicating a client's status to the nurse who will be taking over. Which client outcome is enhanced by the use of handoff communication? A. Continuity of care B. Communication by nurses in all aspects of healthcare C. Nursedash-client relationship D. Therapeutic communication

A Rationale: Reporting through handoff communication is the process of nurse-to-nurse communication that ensures continuity of care for the client from one shift to another. The nurse-client relationship is the outcome of therapeutic communication. Although communication is used by nurses in all aspects of healthcare, this option is too general, and it has no relationship with the scenario.

When caring for an older woman who is pregnant, which factor should the nurse most anticipate as affecting the care and outcome of the pregnancy? A. Medical procedures B. Chronic illness C. Surgical procedures D. Postpartum recovery

A Rationale: The factor that will affect the care and outcome of the pregnancy of an older woman is the increased medical procedures that are offered. Medical procedures such as amniocentesis, ultrasound, and antepartum testing are more likely to be performed for an older woman.

The nurse is using a Doppler device to detect the fetal heart rate. Which fetal heart rate is within the normal range? A. 110dash-160 beats/min B. 160dash-200 beats/min C. 180dash-240 beats/min D. 100dash-140 beats/min

A Rationale: The fetal heart rate is between 110 and 160 beats/min and must be counted and compared with the maternal pulse for differentiation.

The nurse is caring for a client diagnosed with a ureteral stone. Which assessment finding should the nurse anticipate? A. Renal colic B. Colicky pain C. Microscopic hematuria D. Fever

A Rationale: The nurse caring for the client diagnosed with a ureteral stone can anticipate renal colic. Renal colic is an acute, severe flank pain on the affected side.

The nurse notices that the urine output of a client is low during the 8-hour shift, and the client complains of lower abdominal discomfort. A bladder scan confirms urinary retention. Which collaborative member of the healthcare team should the nurse include to investigate the cause of this urinary retention? A. A pharmacist B. An occupational therapist C. An ostomy nurse D. An infection control nurse

A Rationale: The pharmacist and nurse can collaborate on medication review to determine if medication is contributing to changes in the urinary system.

A nurse has noticed a significant rise in catheter-associated infections on the medical floor and is designing a series of new initiatives to help reduce their occurrence. Which current practice should the nurse consider a priority to address with the staff on the medical floor? A. Placement of Foley catheters in all admitted bed-bound clients B. Foley catheters being changed only as needed C. Use of ultrasound to assess bladder volume instead of intermittent catheterization D. Refusal of healthcare providers to order routine bladder irrigation

A Rationale: The use of indwelling catheters should be avoided unless absolutely necessary, and certainly not as a practice for all admitted bed-bound clients. The use of alternatives should be considered and used whenever possible

A client with microscopic hematuria is diagnosed with urinary calculi. Which laboratory assessment should the nurse monitor? A. Hemoglobin and hematocrit B. Serum calcium, phosphorus, and uric acid levels C. BUN and creatinine D. Kidney function studies

A The hemoglobin and hematocrit will be monitored as part of the treatment. BUN and creatinine are monitored with a diagnosis of acute hydronephrosis to determine the extent of kidney damage. The evaluation of kidney function will be monitored for a client with chronic hydronephrosis. Serum calcium, phosphorus, and uric acid levels are obtained to help identify factors contributing to calculus formation.

The home health nurse is caring for a client with recent and ongoing urinary incontinence. The nurse should arrange for which type of referral? A. Medical supply company B. Physical therapist C. Psychologist D. Social worker

A Rationale: A referral to a medical supply company can provide incontinence products such as adult briefs and bed pads.

A nurse is preparing a client for colonoscopy. Which statement by the client indicates an understanding of the instructions? A. "I will have to refrain from eating the night before and morning of the procedure." B. "I will have a large glass of water on the morning of the procedure." C. "I may need an enema after the procedure has been completed." D. "I will have to take a series of laxatives for one week before the procedure."

A Rationale: Because colonoscopy occurs under anesthesia, the client will need to refrain from taking in any food or fluid (including water) starting at midnight the night before the procedure. Laxatives may be needed the day before the test, and not for an entire week. If an enema is required, it will occur before the colonoscopy, not after.

A team of nurses who spend a lot of time answering questions from expectant parents about care for the newborn are having difficulty completing their work. Which type of group should the nurses create to better handle this situation? A. Teaching group B. Awareness week task force C. Self-help group D. Therapy group

A Rationale: The major purpose of a teaching group is to impart information to the participants.

An older adult client is very friendly and likes to talk to the staff. Which action should the nurse take to avoid using elderspeak? (Select all that apply.) A.Use the word "you" when asking questions. B.Avoid using baby talk. C.Use communication aids. D.Use the client's full name. E.Speak slowly and loudly.

A, B, D Rationale: Strategies to avoid elderspeak include referring to the client by the full name; speaking to the client by using the word "you," not "we"; asking direct questions; speaking in a normal tone of voice; and avoiding the use of baby talk. Although the use of communication aids may be helpful when working with an older adult, their use does not help the nurse avoid using elderspeak.

The nurse at the clinic greeted a visiting client happily, but the client did not respond. As they got to the treatment room, the nurse noticed that the client seemed upset and sad. The nurse changed the tone and emphatically asked the client the reason for the visit. Which type of verbal communication is the nurse using in this scenario? A.Adaptability B.Brevity C.Simplicity D.Relevance

A. Rationale: Adaptability is when a nurse adjusts and alters spoken messages in response to the behavioral cues from the client. Nurses carefully consider and individualize what they say and how they say it. This requires both astute assessment and sensitivity. Simplicity of speech refers to the use of commonly understood words to relay the message. Brevity is using the fewest words necessary to relay a message that is simple and clear. Relevance means that the message relates to the person who is the receiver or to the person's interests.

The nurse manager observes a new nurse receive a prescription for a new medication by telephone. For which action should the nurse manager intervene? (Select all that apply.) A. Saying, "Doctor, slow down! How am I supposed to understand you?" B. Signing the healthcare provider's name to the order C. Signing name to indicate who received the order D. Questioning dosages, medications, and potential interactions that seem inappropriate E. Recording the time and date and that it was a telephone order

A client experiencing an acute episode of renal colic rates the pain at a 9 on a scale of 0dash-10. Which prescribed treatment should the nurse anticipate? (Select all that apply.) A. Morphine B. Indomethacin C. Thiazide diuretic D. Potassium citrate

AB A thiazide diuretic is frequently prescribed for calcium calculi, acts to reduce urinary calcium excretion, and is very effective in preventing further stones. Potassium citrate alkalinizes urine (raises the pH) and is often prescribed to prevent stones that tend to form in acidic urine (uric acid, cystine, and some forms of calcium stones).

The nurse is caring for a client with urinary retention. Which action should the nurse include to promote normal voiding? (Select all that apply.) A. Using a sitz bath B. Providing privacy C. Turning the sink on to run water D. Running cool water over the perineum E. Lying the client in bed flat to use the bedpan

ABC Rationale: A sitz bath, privacy, and running water all promote normal voiding. Running warm water!

The nurse is a member of a nursing journal club. Which interpersonal perspective is most likely demonstrated by the group? (Select all that apply.) A. Providing socialization toward growth and development B. Providing a source of collegiality and support C. Promoting a feeling of goodwill among members D. Empowering group members to promote change E. Providing a context for setting priorities

ABC Rationale: Interpersonal characteristics of groups include socialization, support, and camaraderie. Functional characteristics of groups include empowering of group members to promote change and providing a context for setting priorities.

The nurse is preparing to assess a client's sensory function. Which neurosensory assessments will the nurse include? (Select all that apply.) A. Distinguishing sharp from dull B. Identification of vibration C. Testing kinesthesia D. Hot and cold sensation E. Administering the Romberg test

ABCD

Which question should the nurse ask the healthcare provider to verify the medication when taking a medication prescription by phone? (Select all that apply.) A. "Can I read this order back to you before you hang up?" B. "Can you please speak a little slower?" C. "Did you say 15 mL an hour or 50 mL an hour for the IV fluids?" D. "Will you please repeat the type of IV fluids?" E. "Can you ask your secretary to put this order in the computer?"

ABCD

The nurse is planning care for the client with urinary incontinence. Which goal should be included in the care plan? (Select all that apply.) A. Avoiding infection B. Preventing skin breakdown C. Exhibiting solid self-esteem D. Restoring a normal voiding pattern E. Performing toileting without assistive devices

ABCD Assistive devices may be necessary to help voiding, particularly with mobility, so toileting with a device may not be a goal of care in all scenarios.

The critical care nurse experiences high levels of vocational stress. Which type of support should the nurse expect from the nurse's work-related social support group? (Select all that apply.) A. Providing alternative strategies for intervention B. Active listening without giving advice C. Sharing the joys of success D. Active listening without making judgments E. Defining a specific task to accomplish

ABCD Task forces or ad hoc committees are work-related groups that usually have a defined task that is limited in duration.

Which communication technique should the nurse evaluate when caring for clients from different cultures? (Select all that apply.) A.Use of touch B.Use of elderspeak C.Use of gestures D.Use of eye contact E.Use of facial expressions

ABCDE Consider using the following strategies when caring for clients from different cultures: (1) Be aware of what a smile or other facial expressions mean in the client's culture, (2) remember that not all gestures have a universal meaning, and (3) be aware of what eye contact means. Many cultures have specific rules or practices regarding the use of touch, especially between individuals of different genders. Elderspeak is not a good strategy to use in any culture because it implies that the client is dependent and incompetent. The nurse who is culturally competent will be appreciated by the client.

The nurse is conducting a health history for a client with manifestations of urinary calculi. Which data should the nurse collect? (Select all that apply.) A. Immobility B. Dehydration C. Excess dietary oxalate D. Dietary potassium deficiency E. Familial history of urinary calculi

ABCE

The student nurse doing a clinical rotation needs to access client information for an assignment at school. For which reason should a student nurse have access to client information? (Select all that apply.) A. Presenting client studies B. Presenting at clinical conferences C. Participating in clinical rounds D. Studying for exams E. Writing papers

ABCE

Which action should the nurse use to establish rapport with a pediatric client? (Select all that apply.) A. Commenting that the child has pretty hair or eyes B. Sitting on the bed with the child C. Asking the child to choose between milk and juice to drink D. Coming into the room to hang an intravenous (IV) medication and then leaving E. Listening to the child talk about a favorite teacher

ABCE

Which statement by the nurse is reflective of a therapeutic nurse-client relationship? (Select all that apply.) A. "I know that you don't eat meat on Fridays, so would you like a piece of fish with dinner?" B. "Is there anything that I can do to help you feel more comfortable now?" C. "When would you like to have your bed linens changed?" D. "It's a shame you have this disease. You are such a nice person." E. "I can wait until your spouse leaves to change the dressing so that you can spend quality time together."

ABCE

Which nursing intervention is appropriate for a client with hearing loss? (Select all that apply.) A. Replacing batteries in hearing aids as needed B. Providing information on types of hearing loss C. Repeating important information D. Encouraging coughing E. Encouraging interactions with friends and family

ABCE Coughing is not encouraged in a client with hearing loss.

The nurse is providing care to older adult clients at a long-term care facility. Which factor places these clients at risk for urinary incontinence? (Select all that apply.) A. Age B. Stroke C. Depression D. Pelvic floor muscle exercises (Kegel exercises) E. More than two urinary tract infections (UTIs) in a year

ABCE Rationale: Risk factors for urinary incontinence include age, gender (women are more susceptible than are men), obesity, smoking, diabetes, inactivity, pregnancy, depression, neurologic disorders (e.g., stroke), two or more UTIs per year, and medications (medications affecting the adrenergic system, diuretics, and calcium channel blockers).

The nurse is completing an assessment on a client. Which assessment finding supports the suspicion of urinary incontinence? (Select all that apply.) A. Odor of urine B. Soiled clothing C. Irritated perineal tissue D. Strong pelvic muscle tone E. Frequent bathroom breaks

ABCE Weak, not strong, pelvic floor muscles would be a concern for urinary incontinence.

The nurse is preparing to provide an oral change-of-shift report on assigned clients. Which piece of information should be included in this report? (Select all that apply.) A. Changes in the clients' conditions B. Information about clients who were discharged C. Name of the prescribing healthcare provider D. Any client's needs for emotional support E. Clients' baseline vital signs and nursing interventions

ABD

The nurse is preparing to use physical attending when communicating with a client. Which behavior should the nurse implement? (Select all that apply.) A. Responding with gestures that are natural and unhurried B. Placing arms and legs in relaxed positions C. Leaning away from the client D. Maintaining eye contact with the client E. Sitting next to the client

ABD

The nurse is caring for a client diagnosed with a urinary tract infection (UTI). Which assessment finding supports this diagnosis? (Select all that apply.) A. Flank pain B. Abdominal pain C. Clear urine D. Burning sensation on urination E. Hypothermia

ABD Cloudy, dark, foul-smelling urine is also expected with a UTI. Hyperthermia (fever), not hypothermia, supports the diagnosis of a UTI.

During an office visit, a client reports infrequent and difficult bowel movements. Which teaching topic should the nurse include when developing the client's plan of care? (Select all that apply.) A. The importance of staying active B. The use of laxatives or stool softeners C. The importance of cooking and storing food correctly D. The importance of consuming adequate amounts of fluid and fiber E. The avoidance of raw fruit, vegetables, and meat when traveling abroad

ABD Cooking and storing food properly and avoiding raw foods during travel would address diarrhea, not constipation.

The nurse is reviewing the organization's policy on handoff communication and the use of the SHARE method with a group of new nurses. Which piece of information regarding this method should the nurse emphasize? (Select all that apply.) A. Provides standardized training in the handoff process B. Ensures that the nurse provides the essential content during the transfer C. Ensures that the nurse uses personal narrative and charting during the transfer D. Provides timely feedback to staff who fail to follow the process E. Provides an opportunity to ask questions during the transfer

ABDE

The nurse is the president of the nursing organization committee for the hospital. Which role should the nurse be expected to perform? (Select all that apply.) A. Clarifying communication protocols B. Identifying specific tasks C. Assessing the individual functional role of members D. Assisting in expressing ideas E. Assisting in expressing solutions

ABDE

The nurse needs to send a fax containing a client's protected health information (PHI) to another healthcare facility. Which action should the nurse take to protect the client's PHI? (Select all that apply.) A. Using a cover sheet with a disclaimer statement B. Verifying the fax number before sending the information C. Ensuring that PHI is contained in the transmittal D. Requiring the receiving agency to send a signed receipt E. Obtaining consent from the client to fax the information

ABDE

Which risk factor should the nurse assess in a client with bladder incontinence? (Select all that apply.) A. Obesity B. Depression C. Eating a high-fiber diet D. Medications that affect the adrenergic system E. Two or more urinary tract infections (UTIs) per year

ABDE

The nurse should anticipate conducting which assessment when preparing to provide care for a client experiencing alterations in bowel function? (Select all that apply.) A. Client interview B. Skin assessment C. Renal assessment D. Abdominal assessment E. Inguinal area assessment

ABDE Renal would be for urinary

The nurse is testing a client's six cardinal fields of vision. Which cranial nerves is the nurse assessing? (Select all that apply.) A. Cranial nerve VI (abducens) B. Cranial nerve III (oculomotor) C. Cranial nerve II (optic) D. Cranial nerve X (vagus) E. Cranial nerve IV (trochlear)

ABE Cranial nerves II and X are not involved in oculomotor movement

A client is experiencing acute hydronephrosis. Which prescribed clinical therapy should the nurse expect will be initiated? (Select all that apply.) A. IV therapy B. Oral hydration C. Thiazide diuretic D. Calcium-binding agents

AC Acute hydronephrosis is caused by the development of a sudden obstruction of urine flow. Prescribed clinical treatment includes IV therapy. A thiazide diuretic and calcium-binding agent are only administered if the stone is caused by excess calcium

The nurse is caring for a client with pyelonephritis. Which clinical manifestation should the nurse assess in the client? (Select all that apply.) A. Flank pain B. Dysuria C. Fever D. Vomiting E. Enuresis

ACD Enuresis and dysuria occur with cystitis.

An older adult client is in tears upon receiving a diagnosis of terminal cancer. Which nonverbal communication from the nurse shows empathy? A.Using touch B.Being silent C.Crying with the client D.Wiping the client's tears

A Rationale: The use of touch is nonverbal communication that often conveys more about what an individual is feeling than what the person actually says. Being silent may come across as not caring. Crying with the client and wiping the client's tears may be nice gestures but are not the best options to show empathy.

A healthcare organization uses the problem-oriented medical record (POMR) system for documenting client care. Which individual should be identified as responsible for generating the plan of care once a client problem has been identified? A. Nurse assigned to the client for that shift B. Nurse or healthcare provider identifying the problem C. Manager or charge nurse for the unit D. Primary care provider for the client

A healthcare provider prescribes an antibiotic by way of telephone order to treat an upper respiratory infection. After hanging up the phone and charting the order, the nurse notices that the client is taking another medication that will interact with the antibiotic. Which action should the nurse take? A. Ignoring the telephone order and deleting it from the chart because it hasn't been signed yet B. Clarifying the telephone order with the healthcare provider C. Administering the medications because the client is obviously having trouble breathing D. Notifying the charge nurse about the concern

A 12-year-old client scheduled for a painful medical procedure asks the nurse about the procedure. How should the nurse respond? A. Explaining the procedure to the parents first and having the parents tell the child B. Being honest while being sure to end the conversation on a positive note C. Redirecting the child's attention to something else D. Giving handouts with more information about the procedure

The daughter of a wheelchair-bound older adult client is concerned because her mother has been experiencing urinary incontinence. Which statement should the nurse use to explain the condition to the daughter? A. "Renal blood flow and ability to concentrate urine decrease in older adults." B. "Mobility issues may cause urinary incontinence." C. "The kidneys reach maximum size at ages 35 to 40." D. "The frequency of voiding varies in older adults and may cause urinary incontinence."

The home health nurse is visiting an older adult client. The nurse notices the scent of urine and the client states difficulty with urinary continence. Which intervention should the nurse implement? A. Insert a urinary catheter. B. Assess mobility and bathroom access. C. Suggest around-the-clock home care. D. Implement fluid restriction.

The mother of a 3-year-old child is concerned about continued urinary incontinence of the child at night and asks the nurse what she should do. Which information should the nurse include in teaching this mother? A. Control of the bladder during the night is related to fluid intake during the day. B. Control of the bladder during the night will follow control of the bladder during the day. C. Control of the bladder during the night will not occur until after the age of 5. D. Control of the bladder during the night should have been accomplished by now.

The nurse is caring for a client in the first trimester of pregnancy who is concerned about having sexual intercourse. Which response by the nurse is the most appropriate? A. "It is best that you abstain from intercourse until you are in your second trimester." B. "As long as there are no complications, intercourse is safe." C. "Intercourse is safe during the first two trimesters of pregnancy." D. "It is best if you discuss this with your healthcare provider."

The nurse is caring for a client who has experienced a permanent hearing loss. Which referral is most beneficial to assist the client in adjusting to the sensory deficit? A. Audiologist B. Class for American sign language C. Ophthalmologist D. Otolaryngologist

The nurse is preparing to discharge an adolescent client who is 2 days' postpartum. Which question by the nurse addresses the developmental task of the client? A. "Is the father of the baby involved?" B. "Do you plan on returning to school?" C. "Have you made the follow-up appointment for the baby?" D. "Have you thought about what birth control you will be using?"

The nurse is teaching a class about empathizing. Which should be the correct order of establishing empathetic understanding in the teaching? A. Detachment, identification, incorporation, reverberation B. Identification, incorporation, reverberation, detachment C. Detachment, reverberation, incorporation, identification D. Identification, reverberation, incorporation, detachment

The nurse should encourage the client to consume how much fluid each day to promote healthy bowel movements? A. 4000dash-5000 mL B. 2000dash-3000 mL C. 1000dash-2000 mL D. 3000dash-4000 mL

The nursing staff at a women's health clinic uses the charting-by-exception method for appointments with regular clients. Which entry should the nurse document when following this method? A. Stretch marks on bilateral flanks in 20th week of pregnancy B. Fetal heart rate 200 with late decelerations C. IUD still in proper position; no side effects noted D. Group B strep test negative

Which symptom indicates to the nurse that the client may still have an infection related to renal calculi? A. Right flank pain B. Cloudy urine C. Nausea and vomiting D. Oral temperature of 99.1degrees°F

B A client with renal calculi is at risk of developing a urinary tract infection. Cloudy urine would be an indicator of infection.

The nurse is caring for a primigravida who is 38 years of age. Which factor should the nurse understand is associated with delaying childbearing? A. The minimal options available for birth control for older women B. The incidence of later marriage C. Increasing issues of infertility D. Psychosocial issues

B Infertility and psychosocial issues are factors in delaying pregnancy. There are more, not minimal, birth control options available.

The nurse is caring for a client with chronic urinary tract infections (UTIs) suspected of having a vesicoureteral reflux. Which collaborative intervention should the nurse anticipate? A. Renal ultrasound B. Intravenous pyelography C. Cystoscopy D. Voiding cystourethrography

B Intravenous pyelography is used to detect structural and functional abnormalities such as vesicoureteral reflux. Cystoscopy provides direct visualization of the urethra and bladder. Renal ultrasound is used to detect pyelonephritis. Voiding cystourethrography is utilized to assess structural and functional abnormalities of the bladder and urethra.

The nurse is caring for a client who has a positive fecal test for occult blood. The nurse should anticipate which collaborative activity to further identify the cause of the client's problem? A. Direct rectal examination (DRE) B. Colonoscopy C. Ultrasonic bladder scan D. Cystoscopy

B Rationale: A positive occult blood test requires further testing for colon cancer or gastrointestinal bleeding due to peptic ulcers, ulcerative colitis, or diverticulosis. Colonoscopy is used to evaluate the colon and rectum; to detect polyps, cysts, tumors, or areas of inflammation and bleeding; and to remove tissue samples. Ultrasonic bladder scans are used to evaluate bladder emptying. Cystoscopy is used to evaluate the bladder wall and urethra and to remove small stones and tissue samples. DRE is performed to reveal abnormalities in the rectum and evaluate the strength of the sphincter muscles.

A pregnant client who has been diagnosed with a yeast, Candida, infection says she never had one before. Which is an appropriate response by the nurse? A. "The increased blood flow to the vagina increases the risk of yeast infections." B. "There is a decrease in the acidity of the vaginal fluid, which favors yeast." C. "There is an increase in the acidity of the vaginal fluid, which favors yeast." D. "The decreased blood flow to the vagina increases the risk of yeast infections."

B Rationale: During pregnancy, estrogen causes a thickening of the vaginal mucosa, a loosening of the connective tissue, and an increase in vaginal secretions. These secretions are thick, white, and acidic (pH 3.5dash-6.0).Blood flow to the vagina is increased during pregnancy but this does not increase the risk of developing a yeast infection.

Prior to performing an assessment, the nurse states to the client, "This weather we are having is so unpredictable, isn't it?" Which phase of the therapeutic relationship is the nurse applying? A. Preinteraction B. Introductory C. Termination D. Working

B Rationale: In the introductory phase, the nurse may discuss the weather or another general topic to put the client at ease. The preinteraction phase occurs prior to any face-to-face contact. During the working phase, the nurse helps the client identify feelings in order to help the client make decisions. The termination phase occurs at the end of the therapeutic relationship.

The nurse is preparing health education for men about urinary retention and urinary incontinence. Which statement should the nurse include? A. "Urinary incontinence and retention are indications of kidney failure." B. "Urinary incontinence is often associated with treatment for prostate enlargement." C. "Urinary retention in more common in women than it is in men." D. "Urinary incontinence is less common than is urinary retention."

B Rationale: More than half of men over 60 report urinary incontinence with treatment of prostate enlargement.

The nurse caring for a client with stress incontinence should identify which condition as a cause? A. The lack of normal detrusor muscle function causes bladder overfilling and increased bladder pressure. B. Pelvic muscle relaxation, a weak urethra, and surrounding tissues cause decreased urethral resistance. C. There is an inability to respond to the need to urinate. D. An overactive detrusor muscle increases bladder pressure.

B Rationale: Stress incontinence occurs when the pelvic muscle relaxes and a weak urethra and surrounding tissues cause decreased urethral resistance. Urge incontinence is when an overactive detrusor muscle increases bladder pressure. Overflow incontinence is when the lack of normal detrusor muscle function causes bladder overfilling and increased bladder pressure. Functional incontinence occurs when the client is unable to respond to the need to urinate.

Which type of communication should the nurse use to promote a helping nursed-client relationship? A. Handoff communication B. Therapeutic communication C. Group communication D. Documentation

B Rationale: Therapeutic communication is an essential tool for developing a helping nurse-client relationship. Therapeutic communication can be used to gather assessment data, teach, collaborate with other healthcare professionals, advocate for clients, express caring, and provide comfort. Other types of communication that are helpful in the nursing process but do not necessarily help the nurse-client relationship and are not the best option for this scenario are as follows: (1) Documentation is the primary form of written communication used by nurses in all aspects of healthcare, (2) group communication is used in the process of making decisions in the current healthcare system, and (3) handoff communication is the continuity of care for the client from one shift change or visit to another.

The nurse assessing the lacrimal glands of a newborn observes excessive tearing in the right eye. Which most accurately describes the etiology of the assessment finding? A. Allergies B. Blockage of nasolacrimal duct C. Neurologic disorder D. Infection

B Tenderness and drainage are findings associated with infection.

The nurse is caring for a 48-year-old obstetrical client. Which factor may be of most concern for the client based on the age of the client? A. Health B. Childrearing C. Financial D. Career

B The ability to deal with the needs of an older child as the client ages is of great concern

The nurse is caring for a pregnant client who expresses concern about the older siblings adjusting to the baby. Which response by the nurse will help promote the older siblings' acceptance of the baby? A. "They will most likely get used to the new baby after the birth." B. "You are welcome to bring your children to your prenatal appointment." C. "Make sure you give them extra attention after the baby is born." D. "It is important you spend time with your older children before the baby is born."

B The children are encouraged to become involved in prenatal care and to ask any questions they may have. They are also given the opportunity to hear the fetal heartbeat, either with a stethoscope or with the Doppler device. This helps make the baby more real to them. The remaining statements do not promote the acceptance of a new baby.

The nurse is caring for a client with a urinary catheter who is diagnosed with asymptomatic bacteriuria. Which collaborative treatment should the nurse anticipate as the first action? A. A short course of antibiotic therapy B. Removal of the catheter C. A 10- to 14-day course of antibiotic therapy D. Replacement of the catheter

B The nurse can anticipate the healthcare provider to prescribe a 10- to 14-day course of antibiotic therapy after removal of the catheter.

A client with a history of kidney stones formed from calcium phosphate asks the nurse, "Why are you recommending exercise to prevent another kidney stone?" Which response by the nurse is accurate? A. "Exercise will help move the calcium back into your bones." B. "Exercise will help excrete the calcium from your body." C. "Exercise will help you decrease your weight, which is a contributing factor to kidney stones." D. "Exercise promotes the retention of calcium in the bones."

B Rationale: A high blood level of calcium can result in the formation of calcium phosphate kidney stones. Exercise promotes the retention of calcium in the bones. If the client's blood level of calcium is high, weight-bearing exercise is an intervention that can help return the calcium to the bones.

An unlicensed assistive personnel (UAP) is overheard telling a client, "I don't have all day. Let me put those shoes on you." Which type of communication style is the UAP demonstrating? A.Assertive B.Aggressive C.Passive D.Passive-aggressive

B Rationale: The UAP is impatient and is displaying aggressive communication. Passive communication involves a nurse being focused on the needs, demands, and requests of the client without regard for the nurse's own feelings and needs. Assertive communication conveys concern for the needs of others. Passive-aggressive communication combines the attributes of focusing on the needs of others and then lashing out and being impatient when personal needs are not met.

A client who has experienced a stroke is struggling with urinary continence due to difficulty with manipulating clothing at the toilet. Which collaborative team member would benefit this client's management of incontinence? A. An infection control nurse B. An occupational therapist C. A radiologist D. An ostomy nurse

B Rationale: The occupational therapist can assist the client with fine motor skills, mobility, and adaptive devices with clothing to help prevent urinary incontinence.

The client asks the nurse how over-the-counter pregnancy tests work. Which hormone should the nurse identify a being recognized by the test to confirm a positive result? A. Follicle-stimulating hormone (FSH) B. Human chorionic gonadotropin (hCG) C. Luteinizing hormone (LH) D. Gonadotropin-releasing hormone (GnRH)

B Rationale: The over-the-counter pregnancy tests detect a subunit of hCG to confirm a pregnancy. LH, FSH, and GnRH are not hormones measured to confirm a pregnancy.

While logging into the bedside computer system to document in a client's medical record, the nurse is asked to help with another immediate issue. Which action should the nurse take? A. Leaving to help with the immediate issue B. Logging out of the system before responding to the pressing request C. Explaining to the client the reason to leave the room D. Placing notes to be documented under the keyboard

B Rationale: To ensure the confidentiality and security of electronic records, the nurse must not leave a computer terminal unattended after logging into the system.

A client comes to the clinic to pick up a report from the nurse. Which distance should the nurse use when communicating with a client sitting in a waiting room? A.Intimate B.Social C.Personal D.Public

B. Rationale: Social distance is 4-12 feet. At this distance, the entire person can be seen. Eye contact is increased, and verbal communication is loud enough for others to hear. This is the distance the nurse uses when communicating with a client sitting in a waiting room, such as the client who has come to pick up a report. Intimate distance is touching to 1½ feet. This distance is used when providing care that involves touching the client. Personal distance is 1.5-4 feet. This distance is used to provide medications or administer an intravenous infusion. Public distance is 12-15 feet. Nurses rarely communicate across this distance, which is typical in a crowded hallway or community setting.

During a home visit, an older adult male client mentions that he has experienced an increase in the frequency of urination at night. Which condition should the nurse discuss as a possible factor related to increased urinary elimination at night? (Select all that apply.) A. Oliguria B. Nocturia C. Infection D. Residual urine E. Recognition of bladder fullness

BCD Alterations in the ability to recognize bladder fullness is usually a result of neurologic impairment and results in the inability to control the urinary sphincters, frequently causing involuntary urination. Oliguria is a decrease in urination, which is the opposite of what this client is experiencing.

Which behavior by the nurse indicates that the nurse is an aggressive communicator? (Select all that apply.) A.Expressing feelings using "I" language B.Blaming others for errors C.Telling a staff member to move out of the way D.Stating that a nursing assistant is "worthless" E.Denying feelings of anger

BCD Rationale: Aggressive individuals tend to focus on their own needs and become impatient when needs are not met. Examples of this type of communication are screaming, sarcasm, rudeness, belittling jokes, and direct personal insults. The word "you" is frequently used in aggressive communication. Passive communicators tend to deny their feelings and put others first. This style is used to avoid conflict. Expressing feelings or asking for help using the word "I" is an example of assertive communication.

Which behavior should nurses demonstrate as highly committed members of a group? (Select all that apply.) A. Give priority to the opinions of the leader. B. Enjoy working with each other. C. Value each other's opinions. D. Support each other with difficulties. E. Strive to place blame on one person.

BCD Rationale: Individuals who are committed to the group feel close to each other and work together to achieve group goals and objectives. Indications that members are committed include enjoying each other, supporting each other with difficulties, valuing the contributions of other members (not just the leader), and identifying positive contributions. Striving to place blame on one person is a characteristic of scapegoating.

Which nursing intervention is appropriate when providing care for a client with hearing impairment? (Select all that apply.) A. Using the dominant hand for intravenous (IV) placement B. Restating sentences when the client has difficulty understanding C. Encouraging the client to discuss the effect on activities of daily living (ADL) D. Replacing batteries in hearing aids regularly and as needed E. Discussing appropriate communication techniques

BCDE It is not appropriate to place an IV in the client's dominant hand, because it may be needed for communication.

A client is admitted to the emergency department for possible acute pyelonephritis. Which manifestation should the nurse consider to be consistent with this disorder? (Select all that apply.) A. Nocturia B. Flank tenderness C. Urinary frequency D. Diarrhea E. Vomiting

BCDE Other manifestations the client may present with are high fever, chills, costovertebral angle tenderness, and moderate to severe dehydration. Nocturia is a manifestation of cystitis, not acute pyelonephritis.

Which approach by the nurse is appropriate to use to communicate with pediatric clients? (Select all that apply.) A.Use reminiscing. B.Engage in play. C.Draw pictures. D.Read a story. E.Use word games.

BCDE Rationale: Communication techniques that the nurse can use to work effectively with pediatric clients include playing, drawing pictures, storytelling, word games, and reading books with a theme similar to the child's condition or problem and then discussing the meaning. Reminiscing is a strategy used with older adults.

The nurse is caring for a client with a urinary tract infection (UTI). Which condition should the nurse determine as a possible cause? (Select all that apply.) A. Excessive oral fluid intake B. Vesicoureteral reflux C. Renal scarring D. Use of antibiotics E. Structural deviations

BCE

The nurse is reviewing the chart of an older adult client. Which sensory changes does the nurse anticipate have occurred? (Select all that apply.) A. Increased tactile sensation B. Impaired sense of smell C. Decreased sense of hearing D. Increased sense of taste E. Decreased sense of taste

BCE

Which step should the nurse take when completing a telephone order? (Select all that apply.) A. Writing "20 U insulin given daily subcutaneously at 1800" B. Reading the order back to the healthcare provider C. Identifying it as a verbal order or telephone order D. Accepting a voice-mail order E. Writing the complete order down

BCE

The client is a business professional who is used to giving orders and making important decisions. The client tends to argue and challenge the nurses. Which technique is appropriate for the nurse use to present assertive communication? (Select all that apply.) A.Submission B.Fogging C.Avoidance D.Negative assertion E.Name calling

BD Rationale: Strategies associated with assertive communication include fogging, which involves finding a point of agreement from which to start, and negative assertion, which is agreeing with criticism without becoming upset. Avoidance and submission are characteristics of passive communication. Name calling is characteristic of aggressive communication.

The nurse is participating on a committee that will select a universal nursing documentation system for the hospital. Which advantage should the committee consider when looking at the focus charting documentation format? (Select all that apply.) A. Ensures that the nursing-focused assessment is the priority of care B. Allows use of checklists or flow sheets to record routine nursing tasks C. Ensures that each progress note includes data, action, and the response D. Provides a complete perspective of the client and the client's care needs E. Provides a structure for the progress notes

BDE

Which nursing intervention would be appropriate for a client with urinary retention? (Select all that apply.) A. Increasing fluid intake B. Reviewing medications C. Inserting a vaginal device D. Using the Credé maneuver E. Inserting a urinary catheter

BDE Rationale: A review of medications for those that may cause urinary retention and use of the Credéé maneuver or a urinary catheter all contribute to treatment of urinary retention.

The nurse is planning to assess a client's communication approach. Which client characteristic should the nurse consider when conducting this assessment? (Select all that apply.) A.Primary health problem B.Developmental level C.Employment status D.Age E.Culture

BDE Rationale: The nurse needs to consider the client's age, developmental level, and culture when determining the client's communication approach. Employment status may or may not affect the client's approach to communication. The client's primary health problem may or may not influence the client's approach to communication.

The nurse is preparing to provide a newly prescribed laxative medication to a client with chronic constipation. Which should the nurse assess prior to administering the medication? (Select all that apply) A. The client's fluid and electrolyte balance B. Whether the client has recently had abdominal surgery C. The client's blood urea nitrogen (BUN) and creatinine values D. Whether the client has been experiencing nausea, vomiting, or cramps E. Preventive measures for constipation to avoid overdependence on laxatives

BDE The other answer choices address alterations in urinary function, not constipation.

When communicating discharge instructions to a client, the nurse states exactly what needs to be done using the fewest number of words. Which characteristic of verbal communication is the nurse using? (Select all that apply.) Brevity Intonation Clarity Simplicity Pace

Brevity Clarity Rationale: Clarity is saying exactly what is meant. Brevity is using the fewest number of words to convey the message. Simplicity is using words that are not associated with medical jargon. The pace, rhythm, or intonation of speech affects the meaning and impact of the message.

The nurse is caring for a postpartum client. Which intervention is the most important for the nurse to integrate into the plan of care to prevent a urinary tract infection (UTI)? A. "Increase fluid intake." B. "Use an antiseptic preparation after voiding." C. "Empty the bladder completely." D. "Change peri pads every 4 hours."

The nurse is creating a plan of care for a client with pyelonephritis. Which outcome reflects the client's ability to decrease the severity of the bacteria in the urinary tract? A. The client will complete the course of antibiotics. B. The client will wipe from back to front after voiding and defecating. C. The client will drink at least 1500 mL of fluid per day and void every 2dash-3 hours while awake. D. The client will use antiseptic spray regularly on the perineal area.

Which mnemonic should the nurse identify as correct for SBAR? A. State of the client, background, assessment, remediation B. Situation, behaviors, actions, remediation C. Situation, background, assessment, recommendation D. State of the client, behaviors, actions, recommendation

Which nursing goal is appropriate for a client who is admitted to the hospital with urinary calculi? A. The client will receive 80% of fluids while hospitalized. B. The client will consume at least 30% of the prescribed diet while hospitalized. C. The client will maintain urine output of 2500 mL/24 hours while hospitalized. D. The client will rate the pain at 5 on a 0dash-10 scale in 20 minutes after receiving IV morphine.

The nurse is caring for a client who requires intermittent straight catheterization for impaired urinary elimination. Which nursing intervention should the nurse include in the plan of care to help prevent a urinary tract infection (UTI)? A. Inflating the balloon when it is in the bladder B. Maintaining a closed drainage system C. Using aseptic technique when inserting the straight catheter D. Maintaining gravity flow to prevent urine reflux

C Maintaining a closed drainage system, inflating the balloon, and maintaining gravity flow are principles for preventing infection when using an indwelling catheter.

The nurse determines that a client needs emotional support after the recent death of the client's child. Which group should the nurse recommend to the client? A. Child fatality review team B. Teaching group C. Self-help group D. Quality improvement team

C Rationale: A self-help group is a group of individuals who come together to face a common problem or difficulty.

The father of a 3-year-old boy is concerned that his child still wets the bed at night. Which explanation by the nurse is most appropriate regarding bedwetting? A. "Sometimes children experience nocturia." B. "Oliguria is not uncommon in children." C. "Children often achieve daytime bladder control prior to nighttime control." D. "By 24 months, children are capable of holding urine beyond the urge to void."

C Rationale: Bladder control is attained by ages 2 to 5 years, often with daytime control attained prior to nighttime control.

The pregnant client asks the nurse why she must do a glucose tolerance test. Which is an appropriate response by the nurse? A. "Hormones can alter carbohydrate metabolism and decrease maternal glucose levels." B. "High fetus glucose levels can increase the mother's carbohydrate metabolism." C. "Hormones can alter carbohydrate metabolism and increase maternal glucose levels." D. "Low fetus glucose levels can increase the mother's carbohydrate metabolism."

C Rationale: Hormonal influences may alter carbohydrate metabolism during pregnancy, leading to the development of gestational diabetes mellitus (GDM).

A client asks the nurse "When is the most fertile time of a woman?" Which is the most appropriate answer? A. Day 14 of the menstrual cycle B. Day 16 of the menstrual cycle C. 12dash-24 hours after ovulation D. 24dash-48 hours after ovulation

C Rationale: Ova are considered fertile for about 12dash-24 hours after ovulation. Menstruation usually occurs around day 14 of the menstrual cycle with a normal 28-day cycle.

A client is diagnosed with a calculus in the ureter. Which term should the nurse use to describe the client's condition? A. Nephrolithiasis B. Cystine C. Urolithiasis D. Calcium stone

C Rationale: Stone or calculus formation in urinary structures other than the kidney is termed urolithiasis. Cystine is a substance that contributes to stone formation. A calcium stone indicates that the stone is made of calcium. Stones or calculi formed in the kidney are termed nephrolithiasis.

The nurse has admitted a client to the unit for treatment of acute pyelonephritis. Which collaborative intervention does the nurse anticipate initiating as a priority? A. Administration of intravenous (IV) antibiotics B. Order for a complete blood count (CBC) with a differential C. Order for a urine specimen for culture and sensitivity D. Administration of an analgesic

C The nurse can anticipate an order for a urine specimen for a culture and sensitivity to identify the infecting organism before antibiotics are started.

The nurse caring for a client with incontinence should consider the client at risk for low self-esteem and social isolation for which reason? A. It results in institutionalization. B. It requires new self-care skills to manage. C. It is considered socially unacceptable. D. It is the result of self-care deficits in toileting.

C it can be physically and emotionally distressing. Oftentimes, the client is embarrassed about dribbling or having an accident and may therefore restrict normal activities.

The nurse is teaching a female client about the prevention of urinary tract infections (UTIs). Which information should the nurse include? A. "Void after intercourse." B. "Empty the bladder every 2 hours." C. "Avoid bubble baths." D. "Wash the perineum after intercourse."

C void b4 and after

The nurse is caring for a client with newly diagnosed urinary retention. The nurse should question a medication order that falls into which classification? A. Diuretic B. Cholinergic agent C. Anticholinergic agent D. Antiflatulence agent

C Rationale: An anticholinergic agent is contraindicated in the client with urinary retention. Anticholinergics affect the autonomic nervous system and interfere with the normal urination process leading to the retention of urine.

The nurse is assessing a pregnant client at 30 weeks' gestation. Which cardiovascular change should the nurse consider when taking the client's vital signs? A. Red blood cell count is decreased. B. Plasma volume is decreased. C. Cardiac output is increased. D. Heart rate is decreased.

C Rationale: The cardiovascular change that occurs during pregnancy is an increased cardiac output. Cardiac output begins to increase early in pregnancy and peaks at 25-30 weeks' gestation at 30-50% above pre-pregnancy levels. It generally remains elevated in the third trimester. The heart rate increases to accommodate the additional cardiovascular volume. The plasma volume increases by 50%, while the red blood cell count only increases 25%, resulting in physiologic anemia of pregnancy.

Which activity should the nurse instruct a client with a genetic defect of the urinary tract to perform? A. Increase exercise. B. Limit foods high in oxalate. C. Restrict dietary sodium. D. Decrease dietary purine.

C Rationale: Cystine stones are the most common type of stone formation in clients with genetic defects. Restriction of dietary sodium and increased hydration are recommended to prevent further stone formation.

A healthcare provider yells at a nurse for not knowing a client's latest laboratory values. Which response by the nurse demonstrates assertive communication? (Select all that apply.) A."I can't do anything right for you." B."I'm sorry. I'll see where those results are." C."The lab has not phoned in the results yet." D."You can look them up on the computer." E."I will locate the values and get them to you."

C, E Rationale: Assertive communication is demonstrated by using "I" statements, such as "I will locate the values and get them to you." Fogging is a technique that causes both parties to focus on something that is agreed. In this case, the statement "The lab has not phoned in the results yet" takes the focus off the healthcare provider's anger toward the nurse and places it on the fact that the values are not yet available. Saying "I can't do anything right for you" and "I'm sorry" are both passive responses. Saying "You can look them up on the computer" is an aggressive response.

The nurse is caring for an older adult who has experienced a loss of vision. Which will the nurse implement into the plan of care? A. Using finger spelling as appropriate B. Speaking at a moderate rate C. Announcing presence when entering the room D. Decreasing background noises before communicating

C.Rationale: The nurse will announce their presence when entering the room as well as identify themselves by name so the client is aware of their presence.

A client asks which fluids to avoid in light of repeated urinary tract infections (UTIs). Which food should the nurse teach the client to avoid? (Select all that apply.) A. Milk B. Cranberry juice C. Alcoholic beverages D. Citrus juices E. Coffee

CDE

The nurse is reviewing the physiology of sensory perception. Which sensory perceptions are associated with internal stimuli? (Select all that apply.) A. Visual B. Olfactory C. Stereognosis D. Visceral E. Gustatory

CDE Visual data (obtained from sight) and olfactory data (sense of smell) are associated with external stimuli

A group of nurses from a hospital's emergency department is very close-knit. Which characteristic of the group classifies it as a primary group? (Select all that apply.) A. Impersonal communication B. Task-oriented approach C. Face-to-face communication time D. Unity E. Spontaneity

CDE Rationale: Primary groups are small and intimate groups where the group members have a relationship that can be personal, spontaneous, sentimental, cooperative, and inclusive. Communication in this group is primarily face to face. The individuals support each other during stressful situations as group members develop unity and "oneness" and adopt a sense of "we" and "our." Secondary groups focus on a task and communicate by impersonal means, not face to face.

The nurse educator is planning a presentation on involuntary urinary elimination for a group of new nurse graduates. The nurse educator should include which condition related to the types of involuntary urinary elimination? (Select all that apply.) A. Anuria B. Oliguria C. Enuresis D. Impaction E. Incontinence

CE Oliguria and anuria are alterations in urinary elimination but are not considered involuntary. Impaction is a term that refers to an accumulation of dry fecal contents in the bowel that cannot be expelled.

Which signs in a child would lead the nurse to recommend a hearing evaluation? (Select all that apply.) A. Startling to loud sounds B. Behavior issues C. Language delays D. Listening to the television at higher volume E. Difficulty understanding speech when background noise is present

CE Startling to loud sounds, attention or behavior problems, and listening to television or radio at a higher volume are not signs of hearing loss in children.

The nurse is assessing a client who complains of urine leakage when laughing or coughing. Which urinary disorder should the nurse suspect? A. Polyuria B. Retention C. Incontinence D. Oliguria

C Rationale: The clinical manifestation of urinary incontinence is uncontrolled leakage of urine. Oliguria is a decrease in urine production, and polyuria is an increase in urine production. Urinary retention is the failure to empty the bladder.

A nurse is assessing a client who is complaining of black stools. About which medication that the client might be taking should the nurse inquire? A. Antibiotics B. Antacids C. Iron supplements D. Stool softener

C Rationale: The oxidation of iron in supplements can cause the stools to appear black; the nurse should ask about any vitamins and supplements that the client is taking. Antacids can cause the stools to appear whitish or have white specks. Antibiotics can cause a gray-green discoloration. Stool softeners do not alter the color of stool.

A nurse is mentoring a new graduate nurse about caring for a Foley catheter. Which action by the new graduate nurse requires immediate intervention? A. The nurse washes hands before donning gloves. B. The nurse provides regular perineal care. C. The nurse checks the collection system to ensure that it has remained closed. D. The nurse puts on a pair of non-sterile gloves before inserting the Foley catheter.

A pregnant client asks the nurse, "What is this dark line on my abdomen?" Which response should the nurse provide the client? A. "That line is referred to as linea alba and occurs commonly during pregnancy." B. "That is called a linea ova and only occurs during pregnancy." C. "That is called a linear demarcation and is common during pregnancy." D. "That is known as linea nigra and is a common finding during pregnancy."

The nurse accesses a client's database within the problem-oriented medical record (POMR). Which client information should the nurse document in this area? A. Nursing diagnosis B. Spiritual needs C. Plan of care D. Health history

The nurse at a residential treatment facility is preparing a telephone report about a client for an emergency department. Which statement should the nurse make? A. "I'm not sure about the pills the client took. She's unconscious." B. "I don't have my chart handy, but the client's vital signs have been pretty stable until now." C. "I can't believe the mother would give a bottle of Tylenol to someone in detox on suicide watch." D. "The client was found unconscious in her room, and an empty Tylenol bottle was found near her."

The nurse is admitting a client who is bent over and guarding the left lower side of the back. The client appears pale and has cool and clammy skin. Which is the nurse's priority intervention? A. Obtain a urine sample. B. Initiate IV therapy. C. Assist the client into a supine position. D. Assess the client's vital signs.

The nurse is assessing a visually impaired client's home environment for safety. Which finding is most concerning for the nurse? A. Chairs pushed under the table B. Colored rims on dishes C. Telephone with large-print dial D. Throw rugs

The nurse is caring for a client experiencing urinary retention. Which preventive catheter-associated urinary tract infection (CAUTI) measure should the nurse take to protect the client from a urinary tract infection (UTI)? A. Initiate an antibiotic before inserting a catheter. B. Obtain a urine sample for a urinalysis. C. Review the criteria for catheter insertion. D. Consider an alternative to an indwelling catheter.

The nurse is teaching parents of school-age children practices that should decrease the risk of urinary tract infections (UTIs). Which information should the nurse include? A. "Encourage juices to increase the acidity of the child's urine." B. "Avoid large amounts of dairy in the child's diet." C. "Provide drinks with sugar substitutes when possible." D. "Encourage the child to void five to six times a day."

The nurse is teaching the parents of an 18-month-old female toddler with a urinary tract infection (UTI). Which should be included in the teaching to prevent the future risk of a UTI? A. Increase the child's intake of vitamin C. B. Provide the child with a daily cup of low-sugar cranberry juice. C. Increase the child's fluid intake. D. Cleanse the perineal area front to back.

The nurse is working in a free clinic. A pregnant client presents with her first child and states she is feeling the baby move. The client asks how far along she is. Which is the correct response by the nurse? A. 20-22 weeks B. 16-18 weeks C. 14-16 weeks D. 18-20 weeks

The nurse manager is planning a presentation for the staff nurses regarding urinary health after several members of the staff have recently been diagnosed with urinary tract infections (UTIs). Which topic is appropriate for the nurse manager to include in the presentation? A. The importance of increasing the number of caffeinated beverages while working B. The importance of decreasing fluid consumption during the nursing shift to decrease the need to void C. The importance of avoiding cranberry juice because it is a cause of UTI D. The importance of not ignoring the urge to eliminate

The nurse working in a prenatal clinic provides care for clients of diverse cultures. Which action will foster the delivery of more effective, culturally competent care by the nurse? A. Sharing the nurse's cultural beliefs with the clients B. Including the use of family members as language interpreters C. Identifying personal religious and cultural beliefs D. Identifying personal biases and prejudices

Which factor may more significantly impact an older woman experiencing a spontaneous abortion compared to a younger woman? A. Loss of maternal identity B. Grief over the loss C. Financial loss D. Anxiety over the ability to conceive again

Which information should be included as handoff information for new client admissions? A. Comprehensive medical history and diagnostic tests and therapies within the last 24 hours B. Comprehensive medical history, date of surgery, and therapies within the preceding 72 hours C. Reason for admission and diagnosis, date of surgery, and therapies within the last 72 hours D. Reason for admission and diagnosis, date of surgery, and diagnostic tests and therapies within the last 24 hours

Which client would benefit from a hearing aid? A. A client taking ototoxic drugs B. A client with bacterial meningitis C. A client with Méénièère disease D. A client with stenosis in the ear canal

D A client with a conductive hearing loss such as stenosis in the ear canal will benefit from amplification by a hearing aid. Ménière disease, ototoxic drugs, and bacterial meningitis are sensorineural kinds of loss for which hearing aids will not be as helpful.

Which is the major cause of sensorineural hearing deficit? A. Edema in the ear canal B. Obstruction of the external ear canal C. Impacted cerumen in the ear canal D. Noise exposure

D A major cause of sensorineural hearing deficit is damage to the hair cells of the organ of Corti from noise exposure. The most common cause of conductive hearing loss is obstruction of the external ear canal. Impacted cerumen and edema of the canal lining also cause conductive hearing loss.

The nurse is reviewing the prescription for a client requiring a surgical procedure to remove cataracts. The nurse understands that which collaborative team member will most likely perform the client's surgery? A. Optometrist B. General surgeon C. Otolaryngologist D. Ophthalmologist

D An ophthalmologist will perform the surgical procedure to remove the client's cataracts. An optometrist is trained to perform eye exams and prescribe corrective lenses to correct ordinary problems with visual acuity. An otolaryngologist is trained to diagnose and treat ear, nose, and throat disorders and can perform surgery if necessary.

A client with sudden sensorineural hearing loss comes to the clinic. Which medication should the nurse expect to be prescribed? A. Loop diuretic B. Alkylating agent C. Aminoglycoside D. Corticosteroid

D Corticosteroids are used to reduce inflammation and can help with temporary hearing loss. Medications such as aminoglycosides, alkylating agents, and loop diuretics can all cause hearing impairment. OK

The nurse is admitting a client for the treatment of closed-angle glaucoma. Which procedure should the nurse anticipate will be performed? A. Photodynamic therapy B. Lens implantation C. Laser surgery D. Laser iridotomy

D Laser surgery and photodynamic therapy are used to treat age-related macular degeneration. Lens implantation is used to treat cataracts.

A client has been diagnosed with a calcium phosphate kidney stone. Which contributing factor should the nurse assess? A. Consumption of foods high in phosphate B. Consumption of foods high in acid C. Consumption of foods high in purine D. Consumption of foods high in calcium

D Management includes limiting foods high in calcium and increasing foods that acidify the urine. Foods high in purine contribute to the formation of uric acid stones. Phosphates bind with calcium to decrease the blood level of calcium.

The nurse is reviewing the chart of a client diagnosed with strabismus. Which most accurately describes the nurse's understanding of the diagnosis? A. Change in distant vision B. Eyes turned inward toward each other C. Pupils' inability to constrict D. Misalignment of the eyes

D Myopia is a change in distant vision. The pupil's inability to constrict reflects a failure to accommodate. Eyes that can turn in toward each other is a normal finding termed convergence.

Which is the greatest risk factor associated with hearing impairment? A. Occupation B. Gender C. Race D. Age

D Occupations and race are also risks but not number one

The nurse is assessing a client who is receiving morphine sulfate IV for pain from urinary calculi. Which assessment finding is a priority to communicate to the healthcare provider? A. The client is hyperventilating. B. The client has nausea. C. The client has frequent loose stools. D. The client has respirations of 8 breaths per min and oxygen saturation of 90%.

D Rationale: A decreased respiratory rate with low blood oxygen levels are side effects of IV morphine. Nausea is a side effect of morphine but is not a priority.

The nurse is a member of a work group in which the members like, trust, and provide each other with support. Which characteristic is this group demonstrating? A. Atmosphere B. Creativity C. Power D. Cohesion

D Rationale: Group cohesion is facilitated through high levels of inclusion, trust, liking, and support. Power is determined by the members' abilities and the information they possess. Creativity is when there is room within the group for members to become self-actualized and interpersonally effective. A criticism-free atmosphere helps promote the exchange of ideas.

The nurse tells the pediatric client, "I saw that you walked up and down the hallway twice today already. Good job!" Which therapeutic communication technique is the nurse using to establish rapport with the client? A. Offering self B. Listening actively C. Validating perceptions D. Giving recognition

D Rationale: Offering self, which the nurse might do by sitting with the child or walking with the child down the hall, shows that the nurse is accessible and willing to listen to the child. Validating perceptions provides an opportunity for the client to reflect on the explanations that the nurse has made. Active listening involves being present with the client in a discussion and encouraging the client to share thoughts and feelings.

For which client should the nurse question the healthcare provider's order for a 7- to 10-day course of antibiotics? A. A female client with urinary tract abnormalities B. A male client with a history of antibiotic-resistant infections C. A male client with pyelonephritis D. A female client with uncomplicated cystitis

D Single-dose therapy is associated with a higher rate of recurrent infection and continued vaginal colonization with Escherichia coli, making a 3-day course of treatment the preferred option for uncomplicated cystitis.

The nurse is caring for a client experiencing pain related to a urinary tract infection (UTI). Which intervention should the nurse initiate to address the client's discomfort? A. Cleansing of the urinary meatus with antiseptic wipes B. Avoidance of contact with undergarments made of cotton C. Application of cold compresses D. Increase in fluid intake

D Sitz baths, warm packs, and heating pads, not cold compresses are used to relax the muscles

A client has been diagnosed with severe hearing loss and otosclerosis. Which treatment should the nurse expect will be prescribed? A. Antibiotics B. Tympanoplasty C. Hearing aid D. Stapedectomy

D Stapedectomy, the removal and replacement of the stapes, is used to treat hearing loss related to otosclerosis. With tympanoplasty, structures of the middle ear are reconstructed to improve conductive hearing deficits. A hearing aid may not restore hearing in otosclerosis. Otosclerosis is not an infection, so antibiotics would not be useful.

The nurse is caring for a newborn infant who has not yet voided in the first 48 hours of life. Which action should the nurse take? A. Wait another 24 hours. B. Insert a urinary catheter. C. Initiate IV fluid therapy. D. Assess for bladder distention.

D Rationale: Bladder distention should be assessed in the newborn who has not yet voided in the first 48 hours of life. Actions should also include notifying the healthcare provider and assessing fluid status, not waiting another 24 hours. IV fluid and urinary catheterization would not be initiated without healthcare provider orders.

A pregnant client wants to know the cause for bloating and constipation. Which should be the nurse's reply? A. "Deceased progesterone causes delayed gastric emptying." B. "Decreased estrogen causes delayed gastric emptying." C. "Increased estrogen causes delayed gastric emptying." D. "Increased progesterone causes delayed gastric emptying."

D Rationale: Elevated progesterone levels result in smooth muscle relaxation, resulting in delayed gastric emptying and decreased peristalsis. The cardiac sphincter also relaxes, and heartburn (pyrosis) may occur because of reflux of acidic secretions into the lower esophagus.

The nurse caring for a client with possible pneumonia states, "The doctor wants an x-ray of your chest to visualize what is in your lungs." Which therapeutic communication technique is the nurse using? A. Focusing B. Acknowledging C. Clarifying time D. Giving information

D Rationale: The nurse is utilizing the technique of giving information to provide the client with specific, accurate information. Focusing is used when the nurse supports the client to expand on and advance a topic of importance, which is often an emotion disguised behind words. Acknowledging is used when the nurse gives broad-minded recognition to the client for a client effort or change in behavior.

The nurse is assessing a client who presents with abdominal distention and cramping, vomiting, and inability to pass gas. The nurse should prepare for which collaborative intervention? A. Administration of an enema B. Insertion of a Foley tube C. Removal of a fecal impaction D. Insertion of a nasogastric tube

D Rationale: The symptoms suggest that the client is suffering from a bowel obstruction, which will require the insertion of a nasogastric tube.

The nurse is assessing a client who is experiencing lower abdominal pain. Which abnormal finding requires the nurse to evaluate further? A. Absence of bruits over the renal arteries B. Midline urinary meatus C. Absence of tenderness on kidney palpation D. Palpable bladder after urination

D Rationale: Normally, the bladder isn't palpable over the pubic bone, especially if the client has just urinated.

The nurse is caring for a client in the emergency department who is complaining of severe gas pain. The nurse should anticipate the administration of which medication to the client? A. Stool softener, such as ducusate sodium B. Bulk-forming agent, such as methylcellulose C. Antidiarrheal agent, such as loperamide D. Antiflatuent, such as simethicone

D Rationale: Simethicone is an antiflatulence agent that breaks up gas bubbles and facilitates their passage

The nurse at a local clinic is determining the best way to communicate abnormal test results to a client who has requested that all communication be sent by email. Which option should the nurse select in this situation? A.Email the test results directly to the client. B.Email the client with a request to call the office. C.Ask the healthcare provider to email the test results to the client. D.Send the test results by regular mail.

Email the client with a request to call the office. Rationale: Email should not be used to communicate abnormal laboratory data or highly sensitive information about which the client may have questions. The best option in this situation is to email the client with a request to call the office. Sending the test results by regular mail may result in unnecessary delays and would not be following the client's request to use email.

A client recovering from abdominal surgery reports pain. The nurse tells the client that the pain medication will be prepared and that the nurse will return in 10 minutes to administer it. Which characteristic of verbal communication is the nurse using? A. Pace B. Intonation C. Humor D. Credibility

credibility Rationale: By assessing the client's pain and stating a return time to administer the pain medication, the nurse is relaying credibility. The nurse is being trustworthy and reliable in responding to the client's report of postoperative pain. Pace and intonation are often used when communicating with a client who is anxious, but this scenario does not indicate that the client has anxiety. There is no indication that the nurse is using humor while communicating with this client.

An older adult client is being screened for hearing loss. Which signs should alert the nurse to hearing loss? (Select all that apply.) A. Depression in the client B. Unsociable behavior C. Increased mobility D. Increased forgetfulness E. Difficulty understanding speech

ABDE Rationale: The older adult client with a hearing impairment may be described as unsociable, increasingly forgetful, and depressed. Functional problems such as reduced mobility are also associated with hearing loss. Nurses need to be alert for signs of impaired hearing, such as difficulty understanding verbal communication.

A client is complaining of difficulty hearing. Which medications on the client's home medication list would alert the nurse of the potential risk for hearing impairment? (Select all that apply.) A. Angiotensin-converting enzyme inhibitor B. Aminoglycoside C. Salicylate D. Loop diuretic E. Alkylating agent

BCDE Aminoglycosides, alkylating agents, loop diuretics, and salicylates can all cause hearing impairment.

The nurse is preparing to teach a client who speaks limited English. Which should the nurse do to convey the information to the client? (Select all that apply.) A.Show a video. B.Have the client search the internet. C.Use appropriate layman's terminology. D.Use written illustrations. E.Use an interpreter.

C, D, E Rationale: When communicating with a client who does not understand English, the nurse may use written illustrations. Simple layman's terminology and an interpreter may also be helpful in conveying the correct information to the client. Although videos and the internet may be good sources of additional information, these are not the best option for this scenario.

The mother reports that their 9-month-old infant has had a fever, is irritable, and "keeps tugging on her ear." Which equipment should the nurse gather while preparing for the exam? (Select all that apply.) A. Tuning fork B. Ophthalmoscope C. Tympanogram D. Thermometer E. Otoscope

CDE Rationale: For the assessment of an infant client with symptoms related to the ear, a nurse would gather a tympanogram, an otoscope, and a thermometer. A thermometer would be appropriate to assess the fever, and a tympanogram will measure the pressure inside the middle ear. An otoscope is used to visualize the ear canal for discharge and the condition of the tympanic membrane and would be appropriate for this client.

The nurse is caring for an adolescent client who is alert but unable to speak due to being intubated and on a respirator. Which communication strategy is the most developmentally appropriate for the nurse to use? A. Grease pencil and whiteboard B. Hand signals C. Flash cards D. Text messages

D Rationale: Text messaging, popular among adolescents, would be the best communication method for this client. Flash cards, hand signals, and grease pencil with a whiteboard might work as a method of communication to some extent; however, these may or may not support the client's physical and developmental needs.

The nurse is caring for a female client who complains of urine leakage when lifting moderate to heavy items at home. Which intervention should the nurse recommend to the client? A. Walking around the block daily B. Abdominal crunches C. Yoga D. Pelvic floor exercises

D Rationale: This client is experiencing urinary incontinence that may be reduced through the strengthening of the pelvic floor muscles with pelvic floor exercises.

The nurse is caring for a client who has been diagnosed with physiologic anemia of pregnancy. Which accurately describes the nurse's understanding of physiologic anemia in relation to pregnancy? A. The client has increased red blood cells. B. The client has increased plasma. C. The client has decreased concentration of red blood cells. D. The client has decreased plasma.

Rationale: A plasma increase of 50% results in physiologic anemia of pregnancy. During pregnancy, the red blood cell (RBC) count increases by 25%, but this is considered decreased secondary to the hemodilution.

A nurse is caring for a young woman with a suspected urinary tract infection (UTI). Which finding should confirm the nurse's suspicion? A. Clear urine B. Three white blood cells (WBCs) per low-powered field C. pH of 9.2 D. Specific gravity of 1.012

Rationale: Normal pH should be between 4.5 and 8.0.

The nurse is assessing a first-time pregnant client who is 19 weeks after her last menstrual period (LMP). Which finding should the nurse expect to be first noted at this time? A. Urinary frequency B. Nausea and vomiting C. Breast tenderness D. Fluttering sensation in the abdomen

Rationale: Quickening, or the mother's perception of fetal movement, occurs about 18-20 weeks after the last menstrual period (LMP) in a woman pregnant for the first time, but may occur as early as 16 weeks in a woman who has been pregnant before. Quickening is a fluttering sensation in the abdomen that gradually increases in intensity and frequency. Nausea and vomiting can occur anytime during the day and occur frequently during the first trimester. Changes in breast tissue, often noted by tenderness and tingling, occur early in the pregnancy. Urinary frequency is experienced in the first trimester as the enlarging uterus presses on the bladder

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