HESI comp exam 1
Which documentation indicates that the nurse correctly evaluated a pain medication's effectiveness after admin? The client
reports decrease in pain Ask the patient if the pain medication helped the pain
A female client tells the nurse that she does not know which day of the month is best to do breast self-exams (BSE). Which instruction should the nurse provide?
Five to seven days after menses cease D/t physiologic alterations in breast size and activity reach their minimal levels after menses
The nurse is teaching staff in a long-term facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the in-service presentation about the care of clients with hypertension?
Frequent blood pressure checks, including readings taken by automated machines, are recommended to evaluate effectiveness of treatment
Which action should the nurse implement when administering a prescription drug that should be given on an empty stomach?
Give one hour before or two hours after a meal Which is the average transit time from the stomach to the duodenum after eating
Which instruction should the nurse include in the discharge teaching for a client who is taking an antipsychotic medication?
Increase daily intake of raw fruits and vegetables Common side effect of this med is constipation. Increase high-fiber food intake to help alleviate the problem
In planning the care of a 3-year-old child with diabetes insipidus, it is most important for the nurse to caution the parents to be alert for which condition?
Increased thirst child with DI doesn't want to eat, only drink. May even drink water from vases or toilets
The nurse is planning a teaching program about prenatal care for a diverse ethnic group of clients. Which factors is most influential for the acceptance of the healthcare practices?
Individual beliefs key to accepting healthcare practices and interventions
Which finding should the nurse identify as an early clinical manifestation of neonatal encephalopathy related to hyperbilirubinemia?
Lethargy or irritability Causes severe brain damage, encephalopathy (kernicterus) that results from the deposition of unconjugated bilirubin in brain cells. Decreased activity, loss of interest in feeding, lethargy, irritability
After 1 month of short-term corticosteroid therapy, a client with an acute exacerbation of rheumatoid arthritis returns to the clinic for a follow-up visit. Which laboratory finding should the nurse review for a therapeutic response?
Erythrocyte sedimentation rate ESR is indicative of active inflammation, so the RN should determine if it has normalized.
A female client tells the nurse that her home pregnancy test is positive and her last menstrual period (LPM) was February 14. The client wants to know the expected date of birth (EDB). How should the nurse respond?
November 21 Nagele's rule. Subtract 3 months and add 7 days to the first day of the last normal menstrual period
Lasix 20 mg PO is prescribed for a client at 0600. The medication is available in a scored tablet of 40 mg. Before breaking the tablet, what action should the nurse take?
Perform hand hygiene To ensure medical asepsis
A child with Tetralogy of Fallot suffers a hypercyanotic episode. Which immediate action by the nurse can lessen the symptoms of this " TET" spell?
Place child in knee-chest compression on back in knee-chest position to increase blood vessel resistance. It reduces the rush of blood through the septal hole and improves blood circulation
The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?
Ptosis on the left eyelid Ptosis = eyelid droop covering large portion of the iris. May result from oculomotor nerve or eyelid muscle disorder.
What information best supports the RN's explanation for promoting the use of alternative or complementary therapies?
Recognizes the value of a client's input into their own care. human-centered based on philosophies that recognize values of input/honor/ beliefs/values/desires
When documenting assessment data, which statement should the nurse record in the narrative nursing notes?
S1 murmur auscultated in supine position Subjective & objective data should be documented using precise, descriptive, clear & accurate information
The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with the client's clinical picture?
Serum potassium of 5.5 mEq and total calcium of 6 mg/dl In renal failure, normal serum electrolyte balance is altered because the kidneys fail to activate vit d, calcium absorption is impaired, and serum calcium decreasesm which stimulates release of PTH causing resorption of calcium and phosphate from the bone.
An older adult client who has been bedridden for a month has admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subq tissue. At which stage should the nurse document this finding?
Stage 3 FULL thickness loss with visible subq fat that does NOT expose bone, tendon, or muscle.
the scope of professional nursing practice is determined by rules promulgated by which organization.?
State's Board of Nursing is authorized to promulgate rules and regulations that carry the weight of the law. State Legislature delegates its law-making authority to this administrative law body (passing laws that legally define the scope).
A client is brought into the ED following a sudden cardiac arrest. A full code is started. 5 mins later the family arrives with a durable power of attorney signed by the client requesting that no extraordinary measures be taken, including intubation, to save the client's life. What action should the nurse take next?
Stop the code immediately it documents the clients wishes and supersedes wishes of medical staff -- client wishes are most important
An 80-year old client is given morphine sulfate for post-op pain. Which concomitant med should the nurse question that poses a potential development of urinary retention in this geriatric client?
Tricyclic antidepressants Drugs with anticholinergic properties can exacerbate urinary retention associated with opioids in the older client.
The nurse plans to suction a male client who has just undergone right pneumonectomy for cancer of the lung. Secretions can be seen around the endotracheal tube and the nurse auscultates rattling in the lungs. What safety factors should the nurse consider when suctioning this client?
Use a soft-tip rubber suction catheter and avoid deep, vigorous suctioning
The nurse is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the nurse include?
Wear the brace over a t-shirt 23 hours per day Idiopathic scoliosis is an abnormal lateral curvature of the spine in adolescent females. Milwaukee brace places pressure against the lateral spine curvature, under the neck, and against the iliac crest. Wear 23 hrs/day over t-shirt which reduces friction and chafing.
Which information should the nurse provide a client who has undergone cryosurgery for Stage 1A cervical cancer?
Use a sanitary napkin instead of a tampon Avoid use of tampons for 3-6 weeks after procedure to reduce risk of infection. Heavy watery vaginal discharge is expected. Avoid sex up to 6 weeks
A nurse whose TB skin test result reveals an 8 mm induration obtains a negative chest radiograph, which indicates latent TB. The employee-health nurse should implement which intervention for this nurse?
Administer isoniazid (INH) daily for 6-9 months Latent TB does not become acutely ill, this should be implemented to prevent transmission and the development of clinical disease
The nurse is preparing to administer a prescibed dose of acetylcysteine (Mucomyst) 600 mg PO. The 10 mL vial is labeled "Mucomyst 20% solution (20 g/100 mL)." What volume of medication in mL should the nurse admin? (round to nearest whole)
3 20 g = 20,000 mg 20,000 mg/100 mL = 200 mg/1 mL. desired/have x vol 600 mg/200 mg x 1 mL = 3 mL
The nurse is caring for a client who is the daughter of a local politician. When the nurse approaches a man who is reading the names on the hall doors, he identifies himself as a reporter for the local newspaper and requests information about the client's status. Which standard of nursing practice should the nurse use to respond?
Confidentiality is the RN's primary responsibility and is supported by HIPAA, which mandates that personal information is not disclosed and access to sensitive clients information is limited.
A male client with a history of chronic back pain that was managed with opiate analgesics calls the nurse after having back surgery. The client reports that the back pain is finally gone but after stopping the pain med, the client has been having severe diarrhea and painful muscle cramps. Which assessment information should the nurse obtain next?
When did the symptoms begin after the last done of opiate analgesic? mod/severe opiate withdrawal manifests as mod/severe vom, diarrhea, muscle cramps, and elevated BP >110/70
The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the HCP?
Recalls drinking a glass of juice after midnight Risk of aspiration while under GA is increased when stomach is not empty prior to surgical procedure.
The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 7a and 330p. Which client response should the nurse document that indicates successful outcome?
Drinks 240 mL of fluid 5 times during the shift which indicates fluid intake of 1220-1440 mL meeting the objective.
During the physical assessment, which finding should the nurse recognize as a normal finding?
Regular pulsation at the epigastric area when the client is supine The regular and recurrent expansion and contraction of an artery produced by waves of pressure cause by the ejection of blood from the left ventricle as it contracts
The nurse is giving discharge instructions to the parents of a newborn with a prescription for home phototherapy. Which statement by a parent indicates understanding of phototherapy?
"I will keep the baby's eyes covered when the baby is under the light" Neonatal jaundice is r/t subq deposition of fat-soluable (indirect) bilirubin, which is converted to a water-soluble form when the skin is exposed to an ultraviolet light, so the infants eyes should be protected by closing the eyes and placing patches over them before placing the baby under the light source.
A nurse takes a female client to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman states, "I have special undergarments that I do not remove for religious reasons." How should the nurse respond?
"Tell me about your undergarments so we can discuss how you can have your examination comfortably" respect the unique qualities that cultural diversity brings to individuals
A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, "Why do you have to wear a gown and mask when you are in my room?" How should the nurse respond?
"To protect you because you can get an infection very easily" Reverse isolation precaution implement measures to protect the client from exposure to microorganism from others.
A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg of body weight, plus 50 mL/kg per day for each kg between 10 and 20. How many mL/hour should the nurse program the infusion pump for a child who weights 19.5 kg?
61 1-10 kg, 100 ml/kg/day; or 10-20 kg, 1000 ml for the first 10 kg plus's 50ml/kg/day for each kg between 10 and 20. To determine hourly, divide mL/day by 24. 19.5 kg x 50 mg/kg = 475 ml + 1000 ml = 1475 ml / 24 hours = 61 ml/hour
A 56-year-old female client is receiving intracavitary radiation via a radium implant. Which nurse should be assigned to care for this client?
A nurse with Marfan's syndrome who is postmenopausal Poses a radiation hazard while source is in place. Marfan's is not effected. Goal is to limit any one staff member's exposure to the calculated time span based on the half-life of radium, such as the number of minutes at the bedside per day
A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of anger." Which nursing intervention is most important to include in the client's plan of care?
Ask client to describe triggers of anger Awareness is first step in dealing with anger (or any other feeling), so RN efforts should be directed toward increasing pt awareness of feelings
To assess a client's pupillary response to accommodation, a nurse should perform which activity?
Ask the client to look at distant object and then at an object help 10 cm from the nose to identify pupillary constriction as the client focuses on the near object
The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the questions for the client. Which action is best for the nurse to implement?
Ask the spouse to step out for a few minutes this maintains the client's privacy and allows the client to respond, without confronting the spouse
A nurse is planning to teach self-care measures to a female client about prevention of yeast infections. Which instruction should the nurse provide?
Avoid tight-fitting clothing and do not use bubble-bath or bath salts it is an overgrowth of the normal flora Candida albicans which thrives in warm moist environments
A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat, low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals. What intervention should RN implement?
Confront the client about the consequences of the behavior Provide reality check
Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between healthcare providers?
Case Manager role is to assist the continuum of care for the client, & coordinate the plan of care, evaluate client needs & collaborate with interdisciplinary HC team to ensure goals are met, quality is maintained, and progress toward discharge is made.
During a well-woman exam, a sexually active female client asks the nurse about a recent vaginal infection and says she is afraid she has another sexually transmitted infection. The client discloses her history of previous STI. Which condition should the nurse identify as the most prevalent STI in the United States among women?
Chlamydia Most common and fastest spreading; estimated 3 million new cases each year
The nurse identifies a client's needs and formulates the nursing problem of, "Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 lbs over the last 6 months." Which short term goal is best for this pt?
Eat 50% of six small meals each day by the end of one week Short term goals: realistic & attainable, time frame 7-10 days before discharge
Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should follow in resolving the conflict?
Deal with the issues and not personalities Issues are concrete and is 1 of 7 important key behaviors in managing conflict. Personalities include emotional reactions (not concrete).
Which approach should the nurse use when preparing a toddler for a procedure?
Demonstrate the procedure using a doll Imitation; it enables a non-threatening, dramatic experience that can help prepare the toddler for the actual procedure
Which assessment finding should make the nurse suspect that a 21-year-old male client is taking anabolic steroids?
Describes working hard to develop muscles They increase muscle mass. Acne is a common occurrence but not the main indication of steroid use
Prenatal diagnostic testing is recommended for a couple expecting their first child who have a family history of congenital disorders. The couple tells the nurse that they are opposed to abortion for religious reasons. Which concept should the nurse consider when responding to this couple?
Diagnostic testing may indicate a fetal problem that could be treated prior to delivery can be treated in utero or immediately after birth with favorable results
Following major abdominal surgery, a male client's arterial blood gas analysis reveals Pa02 95 mmHg and PaC02 50 mmHg. He is receiving oxygen by nasal cannula at 4 liters/minute and is reluctant to move in bed or deep breathe. Based on this information, what action should the nurse implement at this time?
Encourage the use of an incentive spirometer Blood gas reveals adequate oxygenation (Pa02 95) and hypoventilation (PaCO2 <45). Encourage pt to increase depth of breathing (with incentive spirometer)
The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder?
Grave's Disease Aka hyperthyroidism; an autoimmune condition
The nurse is planning a wellness program aimed at primary prevention in the community. Which action should the nurse implement?
Immunizations that decrease occurrences of many contagious diseases Primary=promotion/prevention activities that decrease occurrence of illness and enhance general health and QOL
The clinic nurse identifies an elevation in the results of the triple marker screening test for a client who id in the first trimester of pregnancy. Which action should the nurse prepare the client for?
Preparing for other diagnostic testing it measures maternal serum levels for alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and estriol which screens for indications of possible fetal defects. Elevated result may be false positive so more screening is indicated
Which nursing intervention is an example of competent performance criterion for an occupational and environmental health nurse?
Implements health programs for construction workers monitoring of the quality and effectiveness of vendor services
A client who is one week postoperative after an aortic valve replacement suddenly develops severe pain in the left leg. On assessment, the nurse determines that the client's leg is pale and cool, and no pulses are palpable in the left leg. After notifying the healthcare provider, which action should the nurse take?
Keep the client in bed in the supine position common post-op complication (arterial occlusion from a clot) which requires anticoagulant therapy to prevent further enlargement of the thrombus and reduce the risk of embolization
A male client who lives in an endemic with Lyme disease asks the nurse what to do if he thinks he may have been exposed. Which response should the nurse provide?
Look for early signs of a lesion that increases in size with a red border, clear center. AKA erythema migrans -- skin lesion that slowly expands to form a large round lesion with a bright red border and clear center at the site of a tick bite
A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is at least likely to exacerbate asthma?
Metoprolol tartrate (Lopressor) Best antihypertensive med for asthmatics. Beta2 blocking agent -- also a cardioselective and less likely to cause bronchoconstriction.
A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission?
Monitor for increased blood pressure and pulse will experience withdrawal symptoms (elevated BP, pulse, temp). thiamine (B1) to prevent korsakoff's is secondary
A young adult female arrives at the ED with a black right eye and is bleeding from the left side of her head. She reports that her boyfriend has been physically abusing her. The nurse performs a history and physical examination. How should the nurse document?
Young adult female presents with periorbital ecchymosis on the right side, 3 cm laceration on left parietal area, approximately 1 cm deep with tissue bridging. States her boyfriend is abusive. Crucial! Specific & gives accurate description of the events without documentation of judge mental inferences
A client with chronic osteomyelitis is scheduled for surgery to treat the infection which has not responded to 3 months of intravenous antibiotic therapy. The client asks the nurse why surgery is necessary. Which response is best?
The infection has walled off into an area of infected bone creating a barrier to antibiotics Sequestrum (dead bone) is separated from the living bone and has no blood supple, so neither antibiotics nor WBCs can reach the infected area
Prior to a cardiac catheterization, which activity should the nurse have the client practice?
Valsalva's maneuver and coughing and deep breathing -- all used during the procedure
Which statement by the community health nurse is most helpful to an adult who is in a crisis situation?
"You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it? acknowledging the stress and encouraging client to discuss options to deal with problems
A nurse-manager sees a colleague taking drugs from the unit. What action should the nurse-manager take?
Report the incident to the immediate supervisor even if they are not narcotics; responsibility to report these findings to the person in charge of the unit
During a client assessment, the client says, "I can't walk very well." Which action should the nurse implement first?
Identify the problem Sequential problem solving steps: 1) Identify the problem, 2) consider alternatives, 3) consider outcomes of the alternatives, 4) predict the likelihood of the outcomes occurring and choose best chance of success.
The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem "Imbalanced nutrition: more than body requirements"?
Inadequate lifestyle changes in diet and exercise Obesity is 20% above desirable weight for age/sex/height/body build/BMI. These best contribute to the formulation of the nursing diagnosis
A client with metastatic caner is preparing to make decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is most accurate?
It will identify someone that can make decisions for your health care if you are in a coma or vegetative state DPOA identifies someone to make decisions for health care, how aggressive treatment should be if in coma/vegetative state, and lists medical treatments they would never want performed.
The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy demands?
A pregnant woman metabolic demands are 20-24% more than basic metabolic rate
A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain. Which organ function is most important for the nurse to monitor?
Liver Acetaminophen & alcohol both metabolized in the liver. Pt at risk of hepatotoxicity & potentially fatal liver damage.
The nurse is monitoring neurological VS for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most sensitive indication of altered cerebral function?
Change in LOC First and most sensitive sign of change in cerebral function neurologic VS include TPR, BP, glasgow coma scale (verbal/musculoskeletal and pupillary)
After eye drops are instilled, which instruction should the nurse provide to the client?
Close your eyelids Gently closing eyelids without blinking allows med to spread over the eye. Pt can tilt head back during admin
The nurse is preparing to administer atropine, an anticholinergic, to a client who is scheduled for a cholecystectomy. The client asks the nurse to explain the reason for the prescribed medication. What response is best for the nurse to provide?
Decrease the risk of bradycardia during surgery Atropine may be prescribed preoperatively to increase the automaticity of the sinoatrial node and prevent a dangerous reduction in heart rate during surgical anesthesia.
A client assigned to a female practical nurse (PN) needs total morning care and sterile wound packing with a wet to dry dressing. The PN tells the nurse that she has never performed a wound packing. Which intervention should the charge nurse implement?
Demonstrate the wound care procedure to the PN while the PN assists. Within scope of practice; bets learning is through demonstration and return demo; allows best opportunity to learn
Which information should the nurse give a client with chronic kidney disease (CKD)?
Avoid salt substitutes CKD pts should restrict sodium & potassium intake. Salt substitutes usually contain potassium (so, avoid!)
A client is admitted with a medical diagnosis of Addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations?
Hypotension, rapid weak pulse, and rapid respiratory rate. often the manifestations of shock and at risk of circulatory collapse and shock.
A client is being admitted to the medical unit from the emergency department after having a chest tube inserted. What equipment should be brought to this client's room?
Rubber-tipped clamps should be kept at the bedside for assessment of possible chest tube air leaks, with the prescription of the healthcare provider.
After receiving report, the nurse prioritizes the client care assignment. Which client should the nurse assess first?
The client who has a new onset of difficulty breathing Maslow's hierarchy of needs (ABC's - airway, breathing, circulation)
Prior to transferred a client to a chair using a mechanical lift, what is the most important client characteristic the nurse should assess?
Tolerance of exertion Awareness of the clients ability to tolerate exertion allows the nurse to plan how to prepare the client for the use of the lift.
Preoperatively, a client is to receive 75mg of meperidine (demerol) IM. The Demerol solution contains 50 mg/mL. How much solution should the nurse administer?
1.5 mL desired/on hand
A low potassium diet is prescribed for a client. What foods should the nurse try to avoid?
Dried prunes Dried prunes contain >300mg of K Rich dietary sources of K are unprocessed foods (especially fruits), many veggies, & some dairy products. Aim for foods with less than 150 mg of K
The nurse is preparing to administer IV fluid to a client with a strict fluid restriction. IV tubing with which feature is most important for the nurse to select?
A Buretrol attachment it is used to restrict the total volume of IV fluids that a client receives
Two hours after the vaginal delivery of a 7 lb 3 oz infant, a clients fund us is 3 cm above the umbilicus, boggy, and located to the right of midline. Which action should the nurse take first?
Palpate above the symphysis for the bladder 2 hours after giving birth uterus should be firm, midline, and below umbilicus. If high, dextroverted, and boggy then urinary retention is likely distending into the bladder - aka palpate for a full bladder first
The nurse is caring for a client who is one day post-op after a total knee arthroplasty (TKA). Which intervention should should the nurse include in the plan of care?
Progressive leg exercises to obtain 90-degree flexion Isometric quad setting begins the 1st day after TKA surgery an progresses to straight-leg raises, then gentle ROM to increase muscle strength until 90 degree flexion is obtained
The nurse plans a teaching session with a client but postpones the planned session based on which nursing problem?
Activity intolerance related to post-op pain Pain, fatigue, or anxiety can interfere with the ability to pay attention & participate in learning.
The nurse is planning care for a client who is having abdominal surgery. To achieve desired desired postoperative outcomes, the nurse includes interventions that promote progressive mobilization, such as turn, cough, deep breathe, and early ambulation. Which additional intervention should the nurse include?
Administer analgesics prior to encouraging progressive activities and ambulation effective pain management in the postoperative period promotes participation in exercises that promote optimal healing and prevent complications, so the client should be given an analgesic prior to mobilization.
The nurse obtains a heart rate of 92 and a BP of 110/76 prior to administering a scheduled does of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?
Administer the dose as prescribed. Verapamil slows SA nodal automaticity, delays AV nodal conduction, slowing ventricular rate & treats atrial flutter. HR is above 60 and BP is WNL.
A client who has active TB is admitted to the medical unit. What action is most important for the nurse to implement?
Assign the client to a negative air-flow room active TB requires airborne precautions
A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which information is most important for the nurse to include in the teaching plan?
Avoid sharing towels and washcloths with siblings avoids the spread of bacterial infection. Should also stay home from school for first 24 hours after antibiotics start; take Tylenol for pain, sunglasses, warm compresses all true but not most important
The nurse is developing a series of childbirth prep classes for primigravida women and their significant others. What is the priority expected outcome for these classes?
Participants can identify at least 3 coping strategies to use during labor expected outcomes are specific, measurable change in client state that occurs in response to nursing interventions
When meeting with the client and the family, which nursing intervention demonstrates the nurses role as collaborator of care?
Coordinating and educating about multidisciplinary services Clinical decisions to achieve client outcomes require collaborative efforts between the interdisciplinary team and the client-family cooperation. RN role as collaborator of care is BEST displayed by coordinating and educating the client and family about multidisciplinary services.
A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set the table for her deceased husband. What nursing problem best describes this problem?
Denial related to the loss of a loved one Exhibits symptoms of anxiety and the pain is too great for her to acknowledge, so is denying the situation. Using it as a defense mechanism
The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean-cut and personable to "grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing behaviors. Which information is best for the nurse to provide?
Early adolescence is a developmental state of normal experimentation Support parents about the stage spurred by hormonal increases in pubescence and teenage experimentation with values, choices, and peer acceptance.
A male client, who has been smoking 1 pack of cigarettes every day for the last 20 years, is scheduled for surgery and will be unable to smoke after surgery. During preoperative teaching, the client asks the nurse what symptoms he may expect after surgery from nicotine withdrawal. Which response is best for the nurse to provide?
Headache and hyper-irritability are common cravings, restlessness and hyper-irritability, headache, insomnia, depression, decreased blood pressure, and increased appetite. Nicotine is a highly addictive substance that precipitates an intensive withdrawal syndrome
The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse plots the child's weight on the growth chart and notes that the child's weight is in the 95th percentile for the child's height. What action should the nurse take?
Question the type and quantity of foods eaten in a typical day Daily diet needs to be assessed because child is overweight
The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction?
Wanting the drug is all that matters to an addict hallmark is impaired control; all that matters is obtaining the drug of choice
The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take?
Withhold the medication and contact the healthcare provider bradycardia is an early sign of digoxin toxicity. Infant HR <100 bpm, then withhold med and notify HCP.
The nurse is caring for critically ill clients. Which client should be monitored for the development of neurogenic shock? A client with
spinal cord injury places pt's at high risk for development of neurogenic distributive shock
A 6-year-old child is alert by quiet when brought the the ER with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with a basilar skull fracture?
Rhinorrhoea or otorrhoea with Halo sign Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ears over mastoid process) are both signs of a basilar skill fracture. Nurse should assess possible meningeal tear that manifest as a Halo sign with CSF leakage from ears or nose.
A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza. Which categories of illness should the nurse develop goals for the client's plan of care?
One chronic and one acute illness Adult onset DM is life-long chronic disease. Influenza is acute illness with short term duration.
What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period?
Primary nursing is a model of delivery of care where a nurse us accountable for planning care for clients around the clock.
A client is receiving atenolol (Tenormin) 25 mg PO after a MI. The nurse determines the client's apical pulse is 65 bpm. What action should the nurse implement next?
Administer the medication Apical pulse is >60 bpm
The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation?
An African-American client may have slightly yellow sclerae Helps differentiate early signs of pathology Normal for AA
A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry mouth. Which action should the nurse implement?
Apply a water-soluble lubricant to the lips, oral mucosa and nares. Will ease discomfort and keep the mucous membranes moist. Petroleum-based is flammable DO NOT USE
A male client who has been taking propranolol (Inderal) for 18 months tells the nurse that the healthcare provider discontinued the medication because his blood pressure has been normal for the past 3 months. Which instruction should the nurse provide?
Ask the healthcare provider about tapering the drug dose over the next week. HCP discontinued drug BUT measures to prevent rebound cardiac excitation, such as progressively reducing the dose over 1 or 2 weeks, should be recommended to prevent rebound tachycardia, hypertension, and ventricular dysrhythmias.
Prior to discharge of a healthy 4-day-old newborn, the nurse is collecting the blood specimens to screen for phenylketonuria (PKU), the Guthrie inhibition assay blood test. Which action should the nurse implement to ensure the validity of the test?
Assess the newborn's feeding patterns of formula or breast milk which has "come in" PKU screening is mandatory in most states and requires that the newborn has ingested adequate amounts (2-3 days) of milk proteins to detect metabolism errors, which result in abnormal phenylalanine (an amino acid) in the newborn's blood and predisposes the infant to mental retardation.
A client with osteoarthritis is given a new script for a NSAID. The client asks the nurse, "How is this med different from the acetaminophen I have been taking?" Which information about the therapeutic action of NSAIDs should the nurse provide?
Provide anti-inflammatory response NSAIDs relieve pain associated with osteoarthritis and differs from acetaminophen(a non-narcotic & antipyretic). Also potentially hepatotoxic.
The nurse is assessing a client and identifies the presence of petechiae. Which documentation best describes this finding?
Purplish-red pinpoint lesions of the skin non-blanchable tiny hemorrhages within the dermal or submucosal layers
The nurse is preparing to administer a high volume saline enema to a client. Which information is most important for the nurse to obtain prior to administering the enema?
History of inflammatory bowel disorders enemas should be avoided (or used with extreme caution) with pt's with this history
A client who is taking clonidine ( Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?
How long has the client been taking the medication? Drowsiness can occur in the early weeks of treatment with clonidine and with continued use becomes less intense, so the length of time the client has been on the medication provides information to direct additional instruction.
The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation?
Hyperthyroidism enlargement of the thyroid gland (AKA goiter). Bruit may be auscultated d/t increase in glandular vascularity which increases as it becomes hyperactive.
The nurse identifies bright-red drainage, about 6 cm in diameter, on the dressing, on the dressing of a client who is one day post abdominal surgery. Which action should the nurse take next?
Mark the drainage on the dressing and take vital signs Drainage on a surgical dressing should be described by type, amount, color, consistency, and odor, and the surgeon should be notified of any excessive or abnormal drainage and significant changes in vital signs.
The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment?
Medication administration Med admin is based on a prescribed schedule that is time-sensitive in the delivery of nursing care and should be priority in scheduling nursing activities in a daily assignment.
a work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to besot effective in developing the new care map?
Multidisciplinary group where a number of individuals from a variety of disciplines are involved in developing a care map, but each works independently to implement the care plan.
A dyspneic male client refuses to wear an O2 face mask because he states it is "smothering" him. What O2 delivery system is best for this client?
Nasal cannula will provide O2 without covering the clients face
A female client reports to the nurse that her sleep was interrupted by "thoughts of anger toward my husband". What type of thoughts is this client having?
Obsessive thoughts unable to control
A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The HCP explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent?
Obtain the permission of the custodial parent for the surgery. Pt is a minor and cannot legally sign his own consent unless he is an emancipated minor. Consent should be obtained from the guardian, custodial parent.
Clinical portfolios are being introduced into the performance apprasial process for the nurses employed at the hospital. What should the nurse-manager request that each staff nurse include in the portfolio?
A self-evaluation that identifies how the nurse has met professional objectives and goals. It should include pertinent information that assists in providing in providing a comprehensive view of the employee's performance. Also provides an important assessment of the nurse's strength/weaknesses/progress toward achievement of professional goals.
When engaging in planned change on the unit, what should the nurse-manager establish first?
Staff members are aware of the need for change 1st step in planed change involves establishing a relationship with those involved in the change oricess and instilling knowledge and awareness for the need for change. Then options, goals, resources.
A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this situation?
Secondary Prevention attempts to halt the progression of the disease process, in this case, an escalation in the battering, by educating the client about prevention strategies. (since nurse suspects battering/domestic violence)
Following an emergency Cesarean delivery the nurse encourages the new mother to breastfed her newborn. The client asks why she should breastfeed now. Which info should the nurse provide?
Stimulate contraction of the uterus Infant suckling breast releases oxytocin by the posterior pituitary and stimulates the "letdown" reflex. Causing release of colostrum & contracts the uterus to prevent uterine hemorrhage.
Which intervention should the nurse include in the plan of care for a female client with severe postpartum depression who is admitted to the inpatient psychiatric unit?
Supervised and guided visits with infant. Structured visits provide an opportunity for the mother and infant to bond and should be facilitated and encouraged according to the client's pace of progress.
A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client?
Supine with the foot of the bed elevated Trendelenburg alleviates gravitational pressure by the fetus on the prolapsed umbilical cord
The school nurse is reviewing health risks associated with extracurricular activities of grade-school children. Regular participation in which activity places child at highest risk for developing external otitis?
Swimming lessons in an indoor pool commonly caused by exposure to bacteria while swimming. Chlorine also tends to alter normal flora
During the assessment of a 21-year-old female client with bipolar disorder, the client tells the nurse that she has not taken her med for 3 years, her mother will not let her return home, and she does not have transportation or a job. Which client goal is most important for this client?
Taking medication, with community follow-up it will stabilize her mood and promote optimum level of functioning
The nurse attempts to notify the HCP about a client who is exhibiting an extrapyramidal reaction to psychotropic meds. When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take?
Tell the receptionist to have the HCP return the phone call the nurse must maintain the client's confidentiality
A nurse is anwsering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to explain the use of tamoxifen (Nolvadex). Which response should the nurse provide?
This anti-estrogen drug inhibits malignancy growth tamoxifen (Nolvadex) is used in postmenopausal women with breast cancer to prevent and treat recurrent cancer and inhibit the growth-stimulating effects of estrogen by blocking their receptor sites on malignant cells. Use for women with estrogen receptor-positive breast cancer (not all women)
A male client is angry and is leaving the hospital AMA. The client demands to take his chart with him and states it's "his" and doesn't want contact with the hospital anymore. How should the nurse respond?
The chart is the property of the hospital but I will see that a cope is made for you. Pt has legal right to the information in it even if leaving AMA
