HESI MIXED RN PART 2

The nurse suspects that a client with inhalation anthrax is in the fulminant stage of the disease. Which symptom supports the nurse's conclusion? Multiple choice question Fever Dry cough Hematemesis Mild chest pain

Hematemesis

What would the nurse state is the primary priority for decreasing a client's risk of morbidity and mortality? Multiple choice question Treatment Prevention Rehabilitation Surgical therapy

Prevention

The client's heart monitor shows a regular rhythm made up of wide and bizarre-looking QRS complexes and no P waves. The rate is 40 beats per minute. How should the nurse interpret these findings? Multiple choice question Sinoatrial (SA) and atrioventricular (AV) nodes fail to initiate an impulse. Purkinje fibers are suppressed. SA node is stimulated. AV node is stimulated.

Idioventricular rhythm is a rhythm that is generated by the ventricular ectopic pacemaker. This rhythm emerges only when the SA and AV nodes fail to initiate an impulse. Because this last pacemaker is located in the ventricles, the QRS complex appears wide and bizarre with a slow rate. No P waves are present. Purkinje fibers can be a ventricular type of pacemaker and can be stimulated.

Which sexually transmitted infection is caused by Chlamydia trachomatis? Multiple choice question Cervicitis Gonorrhea Genital warts Genital herpes

Cervicitis Cervicitis is caused by Chlamydia trachomatis. Gonorrhea is a sexually transmitted infection caused by Neisseria gonorrhoeae. Genital warts are caused by the Human papillomavirus. Genital herpes is caused by the Herpes simplex virus.

A nurse is reviewing the physical examination and laboratory tests of a client with malaria. Which important clinical indicators should the nurse watch for when reviewing data about this client? . Multiple selection question Polyuria Leukopenia Hyperthermia Splenomegaly Erythrocytosis

Hyperthermia Splenomegaly A high fever (hyperthermia) results from the disease process. Parasites invade the erythrocytes, subsequently dividing and causing the cell to burst. The spleen enlarges from the sloughing of red blood cells. Oliguria, not polyuria, occurs in malaria-induced kidney failure. Leukopenia does not occur. Erythrocytosis does not occur

A client understands that an increase in both vitamin E and beta-carotene is important for healthier skin. What foods should the nurse include in her teaching that are excellent sources of both? Multiple choice question Spinach and mangoes Fish and peanut butter Oranges and grapefruit Carrots and sweet potatoes

The antioxidants vitamin E and beta-carotene, which help inhibit oxidation and therefore tissue breakdown, are found in spinach and mangoes. Fish and peanut butter are excellent sources of vitamin E, not beta-carotene. Oranges and grapefruits are excellent sources of vitamin C, not vitamin E and beta-carotene. Carrots and sweet potatoes are excellent sources of beta-carotene, not vitamin E.

A nurse is teaching the parents of a toddler with a recent diagnosis of hemophilia about the disease. What area of the body should the nurse include as the most common site for bleeding? Multiple choice question Brain Joints Kidneys Abdomen

The joints are the most commonly involved areas because of weight bearing and constant movement. Neither the brain, nor the kidneys, nor the abdomen is the most common site; however, bleeding may occur in any of these areas.

A client develops a gallstone that becomes lodged in the common bile duct. An endoscopic sphincterotomy is scheduled. The client asks the nurse what will be done to prevent pain. What should the nurse reply? Multiple choice question "All you'll need is an oral painkiller." "Epidural anesthesia usually is given." "You will get a local injection at the site." "An intravenous sedative usually is administered.

"An intravenous sedative usually is administered.

Which finding in a newborn whose temperature over the last 4 hours has fluctuated between 98.0° F (36.7° C) and 97.4° F (36.3° C) would be considered critical? Multiple choice question Respiratory rate of 60 breaths/min White blood count greater than 15,000 mm 3 Serum calcium level of 8 mg/dL (2 mmol/L) Blood glucose level of 36 mg/dL (3.8 mmol/L)

Instability of the newborn's temperature is an indication of hypoglycemia. A glucose level below 40 mg/dL (1.7 mmol/L) does not provide enough energy to maintain the body temperature at a normal level. A serum calcium level of 8 mg/dL (2 mmol/L), respiratory rate of 60 breaths/min, and a white blood cell count greater than 15,000 mm 3 are all normal findings and do not affect body temperature.

A child is brought to the emergency department after sustaining a blow to the head while playing football after school. The nurse performs a neurologic assessment to determine whether the child has an acute head injury. What should the nurse assess first? Multiple choice question Ocular signs Muscle strength Level of consciousness Injuries to the scalp area

Level of consciousness

Which findings in a four-year-old indicates an appropriate development of socialization skills? Multiple selection question The child tends to be selfish and impatient. The child takes pride in his or her accomplishments. The child tells family tales to others with no restraint. The child is eager to do things correctly and please others. The child tries to follow rules during an associative play, but cheats to avoid losing.

The child tends to be selfish and impatient. The child takes pride in his or her accomplishments. The child tells family tales to others with no restraint. Four-year-old children tend to be selfish and impatient, and they take pride in accomplishments. They may tell family tales to others with no restraint. A five-year-old child may be eager to do things correctly and please others. A five-year-old tries to follow rules during associative play, but may cheat to avoid losing.

A 6-year-old child is about to have an intravenous catheter inserted. What is the nurse's best response when the child starts to cry? Multiple choice question "Do you want the IV in your right or left arm?" "Do you want me to come back in a little while?" "The needle will hurt for a second; don't be afraid." "The medication in the IV will make you feel better."

"Do you want the IV in your right or left arm?" Giving the child a choice provides a sense of control over the fearful situation. Children need assistance in coping and should not be left alone when afraid. Six-year-old children fear bodily harm, especially disfigurement. Fears should be acknowledged, not minimized. The child is too fearful to care about the effect of the medication.

The nurse evaluates the statements of a client after teaching about hydrocortisone therapy. Which statement made by the client indicates effective learning? Multiple choice question "I should report if I experience two to three episodes of vomiting." "I should report if there is swelling in the hands or legs." "I should immediately report if my body temperature crosses 37°C (98.6 °F)." "I should immediately report if I experience diarrhea."

"I should report if there is swelling in the hands or legs." Excessive concentration of hydrocortisone causes fluid retention and edema. Therefore the client's statement regarding the development of swelling in the hands or legs indicates effective learning. Vomiting, fevers, and diarrhea are associated with prednisone therapy.

An athlete who specializes in long-distance jumping improves his distance by 3.5 inches (8.9 cm) and earns the praise of his coach, but on another day, when he does not reach his mark, he forcefully kicks the door of his locker. What defense mechanism does his outburst demonstrate? Multiple choice question Anger Projection Displacement Rationalization

Displacement is the discharging of pent-up feelings on a less threatening object, in this case the locker door. Anger is not a defense mechanism. Projection is attributing one's own unacceptable feelings, impulses, or thoughts to another. Rationalization is behavior that attempts to prove that one's feelings or behavior are justifiable.

Which hormone does the nurse state has both inhibiting and releasing action? Multiple choice question Prolactin Somatostatin Somatotropin Gonadotropin

Prolactin Prolactin secreted by the hypothalamus has both inhibiting and releasing action. Somatostatin inhibits the secretion of growth hormone. Somatotropin and gonadotropin are releasing hormones.

Which of these thoughts in an individual correspond to the society-maintaining orientation stage? Multiple selection question "I should avoid parties where alcohol is served." "I should avoid risky driving and follow traffic rules." "I should follow the rules or the teacher will punish me." "I have to follow all state and federal laws." "I should complete my homework so that the teacher will reward me."

"I should avoid parties where alcohol is served." "I should avoid risky driving and follow traffic rules." During the society-maintaining orientation stage, an individual's thoughts are influenced by moral values and societal concerns. These individuals would avoid going to parties where alcohol is served, avoid risky driving, and follow traffic rules in order to be a good member of society. When an individual thinks that breaking the rule will lead to a physical punishment, this thought corresponds to the punishment and obedience orientation stage. Under this stage, an individual's moral dilemma is in terms of absolute obedience to authority and rules. When an individual thinks that he or she should follow all the laws formulated by the government, this thought corresponds to the universal ethical principle orientation. When an individual thinks that completing his or her homework will help win a reward, this thought corresponds to the good boy-nice girl orientation stage.

The nurse is preparing to teach a client about self-injection of insulin. Which action by the nurse will increase the effectiveness of the teaching session? Multiple choice question Wait until a family member is also present. Assess the client's barriers to learning self-injection techniques. Begin with simple written instructions describing the technique. Wait until the client has accepted the new diagnosis of type 1 diabetes mellitus.

Assess the client's barriers to learning self-injection technique Before a teaching plan can be developed, the factors that interfere with learning must be identified. Although family members can be helpful, client involvement in care is most important for promoting independence and self-esteem. Assessment comes before intervention; written instructions may not be the most appropriate teaching modality. The client may never accept the change but must learn to manage care; this may be an unrealistic expectation.

Which are examples of high-reliability organizations? Multiple selection question Aviation Air traffic control Cancer hospitals Nuclear power plants State transport agencies

Aviation, air traffic control, and nuclear power plants are examples of high-reliability organizations because they have to operate in hazardous conditions yet have very few adverse events. Cancer hospitals and state transport agencies are not high-reliability organizations because they do not operate under hazardous conditions.

A health care provider prescribes bisacodyl for a client with cardiac disease. The nurse explains to the client that this drug acts by what mechanism? Multiple choice question Producing bulk Softening feces Lubricating feces Stimulating peristalsis

Bisacodyl stimulates nerve endings in the intestinal mucosa, precipitating a bowel movement. Bisacodyl is not a bulk cathartic. Bulk-forming laxatives, such as psyllium hydrophilic mucilloid, form soft, pliant bulk that promotes physiologic peristalsis. Bisacodyl is not a stool softener. Stool softeners, such as docusate sodium, permit fat and water to penetrate feces, which softens and delays the drying of the feces. Bisacodyl is not an emollient. Emollient laxatives, such as mineral oil, lubricate the feces and decrease absorption of water from the intestinal tract.

The nurse is caring for different clients in a mass casualty event. Which client is assigned the lowest priority for care? Multiple choice question Client with red tag Client with black tag Client with green tag Client with yellow tag

Clients with black tags are expected to die or are already dead; therefore these clients are the lowest priority. The first priority should be given for clients with a red tag because the client's life may be saved with immediate treatment. A client with a yellow tag should be given second priority because he or she can wait for the treatment for some time. A client with a green tag can be given care after some time as his or her condition would be stable.

What is the most important skill of the nurse leader? Multiple choice question Priority setting Time management Clinical decision making Clinical care coordination

Clinical care coordination

While assessing a client with acquired immunodeficiency syndrome, the nurse suspects that the client has developed cryptosporidiosis. Which symptoms support the nurse's suspicion? Multiple selection question Seizures Diarrhea Confusion Weight loss Blurred vision

Diarrhea Weight loss Cryptosporidiosis is an intestinal infection caused by Cryptosporidium. The symptoms of cryptosporidiosis are diarrhea and weight loss. Seizures and confusion are the symptoms of toxoplasmosis encephalitis. Blurred vision is a symptom of cryptococcosis.

A mother brings her 7-year-old son into an outpatient clinic for a follow-up appointment. The mother appears angry and agitated with the boy. Looking at the boy's medical chart, the nurse notes that the boy has a diagnosis of encopresis. What is the primary symptom of encopresis? Multiple choice question Practicing self-mutilation Practicing self-induced vomiting Passing feces either voluntarily or involuntarily into inappropriate places Passing urine either voluntarily or involuntarily into inappropriate places

Encopresis is the passage of feces into inappropriate places such as clothing, closets, floors, or toy boxes, either voluntarily or involuntarily. It may severely limit a child's social development and results in parental disapproval and rejection. Encopresis does not involve self-induced vomiting or self-mutilation. The passage of urine into inappropriate places is called enuresis.

A client with bipolar disorder is aggressive and disruptive in group and social settings. How will the nurse initially work with the client to develop social skills? Multiple choice question Facilitating one-on-one interactions Encouraging self-care with support Developing guidelines for behavior Helping the client decrease the activity level

Facilitating one-on-one interactions The client who is aggressive in groups must begin socialization in one-on-one interactions that are less stimulating and distracting. Promoting self-care avoids addressing behaviors in group and social situations. The client may not be interested in or able to follow guidelines for appropriate conduct at this time. The client may not be able to decrease the activity at this time, and therefore it must be channeled appropriately.

A client has been instructed to stop smoking. The nurse discovers a pack of cigarettes in the client's bathrobe. What is the nurse's initial action? Multiple choice question Notify the healthcare provider. Report this to the nurse manager. Tell the client that the cigarettes were found. Discard the cigarettes without commenting to the client.

Honest nurse-client relationships should be maintained so that trust can develop. Although other healthcare team members may need to be informed eventually, the initial action should involve only the nurse and client. Discarding the cigarettes without commenting to the client does not promote trust or communication between the client and nurse.

A postpartum client tells the nurse, "I was just told that I have an erosion of the cervix. What could have caused this?" What is the nurse's best reply? Multiple choice question "Your labor was long and difficult." "Hormonal imbalance" "Your cervical opening was stretched during birth, resulting in lacerations." "The effacement and dilation of the cervix were not complete at the time of birth."

Hormonal imbalance often seen in women after childbirth can be the reason of cervical erosion in postpartum client. The direct effects of labor and birth do not cause cervical erosion.

What is a common metabolic cause of hypothermia? Multiple choice question Seizure Dehydration Hypoglycemia Hyperthyroidism

Hypoglycemia is a common metabolic cause of hypothermia. Seizure does not cause hypothermia. Dehydration can cause hyperthermia. Hypothyroidism, not hyperthyroidism, can lead to hypothermia.

The nurse determines that the fetus of a client in labor is in the left sacrum anterior position. Where should the nurse place the fetal heart transducer on the client's abdomen? Multiple choice question Left lower quadrant Left upper quadrant Right upper quadrant Midline lower quadrant

Left upper quadrant The left sacrum anterior position indicates that the fetus is in a breech presentation and the head is in the fundus; fetal heart sounds are best heard in the left upper quadrant. Fetal heart sounds will be in the left lower quadrant if the fetus is in the left occiput anterior position. Fetal heart sounds will be in the right upper quadrant if the fetus is in the right sacrum anterior position. The fetal heart sounds will not be heard in the midline part of a lower quadrant in a single-fetus pregnancy.

The nurse is educating the parents of a preschooler on various poisonous plants that children may be exposed to. Which plants does the nurse mention as poisonous? Multiple selection question Plum Azalea Foxglove Gardenia Asparagus fern

Plum Azalea Foxglove all parts of the azalea and foxglove + pit of the plum is poisonous

What does "access to care" include according to the Picker Institute's eight dimensions of patient-centered care? Multiple selection question "Clients often need help to complete activities of daily living (ADL)." "Clients expect privacy and to have their cultural values respected." "Clients want to be able to see a specialist when a referral is made." "Clients want to schedule appointments at convenient times without trouble." "Clients need to be able to find conveyance when travelling to different healthcare settings."

"Clients want to be able to see a specialist when a referral is made." "Clients want to schedule appointments at convenient times without trouble." "Clients need to be able to find conveyance when travelling to different healthcare settings." According to the Picker Institute's eight dimensions of patient-centered care, " access to care" includes several features. Clients want to be able to see a professional when a referral is made. Clients want to schedule appointments at convenient times without trouble. Clients need to be able to find conveyance when travelling to different healthcare settings. According to the Picker Institute's eight dimensions of patient-centered care, "physical comfort" includes aspects such as clients requiring help to complete activities of daily living (ADL) and clients expecting privacy and respect towards their cultural values.

The nurse is assessing a client who is suspected of having candidiasis. Which questions asked by the nurse would help to confirm the diagnosis? Multiple selection question "Do you have interdigital scaling and maceration?" "Do you experience scaliness under the distal nail plate?" "Do you have cheesy plaques in the mouth resembling milk curds?" "Do you have red rashes with satellite lesions around the affected area?" "Do you have white patches in the groin area with increased vaginal discharge?"

"Do you have cheesy plaques in the mouth resembling milk curds?" "Do you have red rashes with satellite lesions around the affected area?" "Do you have white patches in the groin area with increased vaginal discharge?" Candidiasis appears in warm, moist areas such as the groin area, oral mucosa, and submammary folds. Clinical manifestations in the mouth include white, cheesy plaque, resembling milk curds. Erythematous rashes with satellite lesions around the affected area are manifestations of candidiasis on the skin. White patches in the groin area with increased vaginal discharge are a clinical manifestation of candidiasis. Interdigital scaling and maceration is a clinical manifestation of tinea pedis. Scaliness under distal nail plate is a symptom of onychomycosis.

A nurse has provided dietary instructions for a client who is being discharged following a gastroduodenostomy (Billroth I). Which client statement indicates correct understanding of the teaching? Multiple choice question "I plan to have a diet of pureed foods for a few days." "I will now resume my regular eating routine and diet." "I need to eat six small meals every day, limiting bulk."

"I need to eat six small meals every day, limiting bulk." Eating six small meals a day allows smaller boluses of undigested food to enter the duodenum, helping to prevent dumping syndrome. Pureed food usually is not necessary. Resuming a regular eating routine and diet is not realistic. The diet should be high in protein, low in carbohydrates, and moderate in fats.

A registered nurse is teaching the appropriate manner of acting in a professional environment to a student nurse. Which statements mentioned by the student nurse post-training are accurate? Multiple selection question "I should provide care that is consistent with my level of expertise." "I should remember and follow the policies and procedures of the institution." "I should never protest if I am assigned to care for more clients than reasonable." "I should use restraints on a client only after obtaining a written order from a primary healthcare provider." "I should never disclose the client's confidential medical information without the primary healthcare provider's consent."

"I should provide care that is consistent with my level of expertise." "I should remember and follow the policies and procedures of the institution." "I should use restraints on a client only after obtaining a written order from a primary healthcare provider." The nurse should provide care that is consistent with his/her level of expertise. If any injury occurs to the client while performing a procedure on which the nurse is not trained, it may lead to legal complications. The nurse should always remember and follow the policies and procedures of the institution to avoid malpractice. To prevent any legal issues, the nurse should use restraints on a client only after obtaining a written order of a primary healthcare provider. The nurse should bring it to the attention of the nursing supervisor if he/she is assigned to care for more clients than reasonable. The nurse should never disclose the client's confidential medical information without his/her consent.

A nurse caring for a client prioritizes nursing actions on the basis of Maslow's hierarchy of needs. Which statement of the client would meet the self-esteem need? Multiple choice question "I fear that my partner will leave me because of my illness." "I want to stay fit because my aim is to be a successful entrepreneur." "I do not have anyone in my life, as my family has disowned me." "I tend to get worried about every little thing because I cannot do anything successfully."

"I tend to get worried about every little thing because I cannot do anything successfully." According to the Maslow's hierarchy of needs model, certain human needs are more basic than others. When a client says that he or she tends to worry about every little thing because he or she cannot do anything successfully, this is an example of self-esteem needs. When a client says that he or she fears that his or her partner will leave him or her because of his or her illness, this statement is an example of safety and security needs. When a client says that he or she wants to stay fit to become a successful entrepreneur, this statement is an example of self-actualization needs. When a client says that he or she does not have anyone in his or her life because of being disowned by his or her family, this statement is an example of love and belonging needs.

A client with tuberculosis is prescribed isoniazid. What statements should the nurse tell the client? Multiple selection question "Take the drug on an empty stomach." "Report any changes in vision to your primary healthcare physician." "Take daily multiple vitamins that contain B-complex." "Wear protective clothing when going outdoors during the day." "Report darkening of the urine or a yellowish skin discoloration."

"Take the drug on an empty stomach." Take daily multiple vitamins that contain B-complex." "Report darkening of the urine or a yellowish skin discoloration." Isoniazid should be taken on an empty stomach because food prevents absorption of the drug. Multiple vitamins that contain the vitamin B-complex should be taken along with isoniazid because the drug depletes vitamin B. A client on isoniazid should report darkening of the urine and yellowish skin discoloration because these conditions are signs of liver toxicity. A client on ethambutol should be taught to report changes in vision. A client on pyrazinamide is instructed to wear protective clothing if he or she will be exposed to sunlight.

A nursing student is evaluating different examples of quality and performance improvement. Which situation should the nurse consider to be an example of quality improvement? Multiple choice question A team of nurses designs a strategy for improving the technique of administering injections. A team of nurses identifies the possible reasons for the delays of client admission into special units. A team of nurses implements a new system for following aseptic techniques during wound debridement. A team of nurses evaluates the effectiveness of initiating weekly professional training programs.

A team of nurses identifies the possible reasons for the delays of client admission into special units. Quality improvement focuses on studying and improving the processes of providing healthcare services to clients. An example of this improvement is a team of nurses trying to determine the cause for delays of client admission into special units. Performance improvement focuses on evaluating current performance in order to initiate a qualitative change. A team designing a strategy for improving the performance of nurses when administering injections would be a performance improvement. Similarly, a team implementing a new system to improve the performance of nurses to prevent infections during wound debridement is an example of a performance improvement. Evaluating the effectiveness of weekly professional training programs is also an example of a performance improvement.

While caring for a terminally ill child the nurse notes that the parents' visits have become less frequent. What should the nurse do to resolve this situation? Multiple choice question Ask the parents why they are visiting so seldom. Accept the parents' need to maintain a distance at this time. Explain to the parents why visiting is so important to their child. Suggest to the parents that they visit more often while spending less time at each visit.

Accept the parents' need to maintain a distance at this time. Accepting the parents' need to distance themselves communicates empathy for this adaptive response to grief. Asking the parents why they don't visit more often is confrontational and may precipitate or increase feelings of guilt. Teaching the parents how to relate to their child, either by explaining why visits are important or by suggesting that the parents make more frequent but shorter visits, may precipitate or increase feelings of guilt.

A young child who has ingested liquid dishwater detergent is brought to the emergency department. Which does the nurse understand as appropriate treatment methods for this client? Multiple selection question Gastric emptying by emesis is recommended. Analgesics can be administered. Neutralization can be used to effectively treat ingestion of corrosives. Activated charcoal is an appropriate treatment for ingestion of corrosives. Water or milk, usually less than or equal to 120 mL or 4 oz, can be used to dilute the corrosive.

Analgesics can be administered. Water or milk, usually less than or equal to 120 mL or 4 oz, can be used to dilute the corrosive. Treatment for ingestion of corrosives includes administration of analgesics. The poison control center (PCC) should be contacted immediately after it is known that the client has ingested corrosives. If the PCC or medical advice and treatment are not immediately available, it may be appropriate to dilute the corrosive with water or milk, usually with less than or equal to 120 mL or 4 oz of fluid. Gastric emptying by emesis or lavage is contraindicated as it reexposes the upper gastrointestinal tract to the caustic agent. Neutralization is contraindicated as it can cause an exothermic reaction, which produces heat and causes increased symptoms or produces a thermal burn in addition to a chemical burn. Activated charcoal is also contraindicated because it may infiltrate burned tissue.

The registered nurse (RN) is caring for a client who underwent ileostomy. Which activity performed by the nurse indicates following the principle of right circumstance of delegation? Multiple selection question Assessing the willingness of the delegatee Assessing the equipment to determine vital signs Providing supervision of the delegatee during the task Teaching institutional policies about caring for a client with ileostomy Communicating with the delegatee about care management of the client

Assessing the equipment to determine vital signs Providing supervision of the delegatee during the task Assessing the equipment and resources available to perform the task determines right circumstance of delegation. Supervising the delegatee during the task indicates right circumstance of delegation. Assessing the willingness of the delegatee determines the principle of right person of delegation. Determining if the task can be performed based on institutional policies indicates principle of right task of delegation. Communicating with the delegatee falls under right communication of delegation.

How is the term "beneficence" in health ethics different from "nonmaleficence"? Multiple choice question Beneficence refers to fairness, whereas nonmaleficence refers to the agreement to keep promises. Beneficence involves taking positive actions to help other,s whereas nonmaleficence is the avoidance of harm or hurt. Beneficence stands for all health care professionals, whereas nonmaleficence stands for nursing professionals. Beneficence refers to the support of a particular cause, whereas nonmaleficence refers to a willingness to respect one's professional obligations.

Beneficence involves taking positive actions to help other,s whereas nonmaleficence is the avoidance of harm or hurt. Beneficence is the act of taking positive actions to help others; nonmaleficence is the avoidance of harm or hurt. Justice refers to fairness; fidelity refers to the agreement to keep promises. Both beneficence and nonmaleficence stand for all healthcare professionals. Advocacy refers to the support of a particular cause; responsibility refers to a willingness to respect one's professional obligations.

The preoperative nurse is reviewing a child's history and physical before repair of a ventricular septal defect. Which assessment finding should the nurse expect? Multiple choice question Severe cyanosis High hemoglobin and hematocrit levels Bilateral lung sounds with rales and rhonchi High blood pressure in the arms and low blood pressure in the legs

Bilateral lung sounds with rales and rhonchi Defects that allow blood flow from the higher pressure left side of the heart to the lower pressure right side (left-to-right shunt) result in increased pulmonary blood flow and cause heart failure. A child with a ventricular septal defect would exhibit bilateral lung sounds with rales and rhonchi. In a right-to-left shunt, desaturated blood moves from right to left, causing desaturation in the left side of the heart and in the systemic circulation. Clinically these patients have polycythemia (high hemoglobin and hematocrit levels) and hypoxemia, and they usually appear cyanotic. Tetralogy of Fallot and tricuspid atresia are the most common defects in this group. Coarctation of the aorta involves localized narrowing near the insertion of the ductus arteriosus, which results in increased pressure proximal to the defect (head and upper extremities) and decreased pressure distal to the obstruction (body and lower extremities). The blood pressure is high in the arms and low in the legs

The nurse admits a client with preeclampsia to the high-risk prenatal unit. What is the next nursing action after the vital signs have been obtained? Multiple choice question Calling the primary healthcare provider Checking the client's reflexes Determining the client's blood type Administering the prescribed intravenous (IV) normal saline

Checking the client's reflexes The client is exhibiting signs of preeclampsia. The presence of hyperreflexia indicates central nervous system irritability, a sign of a worsening condition. Checking the client's reflexes will help direct the primary healthcare provider to appropriate interventions and alert the nurse to the possibility of seizures. Although the primary healthcare provider will be called, a complete assessment should be performed first to obtain the information needed. Determining the client's blood type is not necessary at this time; assessment of neurologic status is the priority. An IV may be started after the assessment; however, a more dilute saline solution will be prescribed.

An adult with the diagnosis of schizophrenia is admitted to the psychiatric hospital. The client is ungroomed, appears to be hearing voices, is withdrawn, and has not spoken to anyone for several days. What should the nurse do during the first few hospital days? Multiple choice question See that the client bathes and changes clothes daily. Wait and see whether the client approaches the staff. Conduct an admission assessment interview with the client. Seek out the client frequently to spend short periods of time together.

Conduct an admission assessment interview with the client.

A client has an abdominal perineal resection with the formation of a colostomy for cancer of the rectum. The nurse evaluates that teaching about colostomy care is understood when the client makes what statement? Multiple choice question "I will call the clinic and report if I notice a loss of sensation to touch in the stoma tissue." "I will call the clinic and report when mucus is passed from the stoma between irrigations." "I will call the clinic and report expulsion of flatus while the irrigating fluid is running out." "I will call the clinic and report if I have difficulty inserting the irrigating tube into the stoma."

Difficulty inserting the irrigating tube into the stoma occurs with stenosis of the stoma; forcing insertion of the tube may cause injury. Loss of sensation to touch in the stomal tissue is expected; there is no need to call the clinic. Mucus exiting the stoma between irrigations is expected; there is no need to call the clinic. Expulsion of flatus while irrigating fluid is running out is expected; feces and flatus accompany fluid expulsion.

A 4-year-old child is admitted to the pediatric unit with a tentative diagnosis of acute lymphocytic leukemia (ALL). The mother states that changes in her child's behavior and the "black and blue" marks were noticed several days ago. She blames herself for not bringing her child to the clinic sooner. On what information about the pathophysiology of leukemia should the nurse base a response? Multiple choice question The diagnosis can be certain only after a blood smear is analyzed. If leukemia is diagnosed, the child's prognosis is probably guarded. Early signs and symptoms of leukemia are similar to those of other mild illnesses of childhood. The description of the clinical findings indicates that the child has been ill for longer than a single week.

Early signs and symptoms of leukemia are similar to those of other mild illnesses of childhood. To allay parental guilt and anxiety, it is important to acknowledge how difficult it is to recognize severe illness on the basis of changes in the child's behavior and ecchymoses that can result when a child bangs into an object, a common occurrence in young children. A bone marrow aspiration or biopsy is required for a definitive diagnosis. ALL in children has a favorable prognosis, depending on several factors, including the child's age at diagnosis, the white blood cell count, and the type of cell involved. Even if the mother missed the fact that her child was so ill, mentioning this may cause more anxiety and guilt and interfere with the development or a nurse-client rapport.

What intervention should be included in the nursing plan of care to help a 10-year-old girl live with Crohn disease? Multiple choice question Recommending several rest periods throughout the day Emphasizing that high-residue foods be included in the diet Assuring her that when she reaches puberty she may discontinue her medication Encouraging her to express feelings while focusing on the ways she is like her friends

Encouraging her to express feelings while focusing on the ways she is like her friends Focusing on feelings and abilities promotes effective coping and increases self-esteem. Children do not like to be different from their friends. The child will self-limit activity during an exacerbation; at other times the child should not need any more rest than her healthy peers. High-roughage foods are limited because they can trigger intestinal inflammation. Telling the child that she may discontinue the special diet once she reaches puberty is false reassurance; there is no time limit as to when or if medications can be discontinued.

A client is admitted with trigeminal neuralgia (tic douloureux). Which clinical indicators does the nurse expect to identify when assessing this client? . Multiple selection question Prolonged periods of sleep because of anxiety Hyperactivity because of medications received Exhaustion and fatigue because of the extreme pain Excessive talkativeness because of anxiety and apprehension Inadequate nutritional intake because of fear of precipitating an attack

Exhaustion and fatigue because of the extreme pain Inadequate nutritional intake because of fear of precipitating an attack Severe, constant pain, emotional stress, muscle tensing, and diminished nutritional intake can lead to exhaustion and fatigue. The movements associated with chewing and swallowing may precipitate a painful attack. Because clients are apprehensive and have pain, prolonged periods of sleep usually do not occur. Pain medications do not normally cause hyperactivity. The client may be very quiet for fear of precipitating an attack.

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? . Multiple selection question Spasticity Incontinence Flaccid paralysis Respiratory failure Lack of reflexes below the injury

Flaccid paralysis Lack of reflexes below the injury Spinal shock (spinal shock syndrome) is immediate after a transection of the spinal cord; it results in flaccid paralysis of all skeletal muscles and usually lasts for 48 hours, but may persist for several weeks. Spinal shock is caused by transection of the spinal cord and results in a loss of reflex activity below the level of the injury. Spasticity occurs after spinal shock has subsided. During the acute phase, retention of urine and feces occurs as a result of decreased tone of the bladder and bowel; thus, incontinence is unusual. Respirations are labored, but spontaneous breathing continues, indicating that the level of injury is below C4 and respirations are not affected.

What are the differences between the pubertal growth of girls and boys? Multiple selection question Girls tend to begin their physical changes two years prior to boys. Girls grow till the age of 17 years whereas boys grow till 20 years of age. Girls gain weight at an increased rate whereas boys gain height at an increased rate. Girls show alteration in the width of hips whereas boys show alteration in shoulder width. Girls who mature early are less happy with their body appearance whereas boys who mature early are satisfied.

Girls tend to begin their physical changes two years prior to boys. Girls grow till the age of 17 years whereas boys grow till 20 years of age. Girls who mature early are less happy with their body appearance whereas boys who mature early are satisfied. The physical changes in girls start two years prior to that in the boys. The growth spurt in girls occurs around 12 years of age whereas in boys, the growth spurt occurs at about 14 years. Girls grow till the onset of menarche (16 or 17 years old) whereas boys continue to grow until 18 to 20 years of age. Girls who mature early are shorter and heavy compared to girls who mature late. Because of this, girls are less satisfied with their body appearance. Boys who mature early are more athletic as compared to boys who mature late; boys who mature earlier are more satisfied with their appearance. The proportion of weight and height gain is almost the same in boys and girls. Sex-specific changes such as changes in shoulder and hip width are seen in both girls and boys.

Which immunization protocol should be followed by a nurse administering a hepatitis B vaccine to an infant whose mother is diagnosed HBsAg-positive during pregnancy? Multiple choice question Hepatitis B immune globulin is given within a week after obtaining the mother's laboratory reports. Hepatitis B immune globulin is not administered because the first dose of recombivax HB itself is sufficient. Hepatitis B immune globulin 0.5 mL is given along with the first dose of recombivax HB. Hepatitis B immune globulin is not administered, however the second dose of the hepatitis B vaccine is given after 1 month.

Hepatitis B immune globulin 0.5 mL is given along with the first dose of recombivax HB. The immunization protocol recommended for an infant born to a mother who is HBsAg-positive would be to administer 5 mcg of recombivax HB within 12 hours of birth along with 0.5 mL of hepatitis B immune globulin (HBIG) at the same time but at a different site. This HBIG provides the infant immediate protection against HBsAg acquired from the mother. In cases of infants born to mothers whose HBsAg status is unknown at the time of birth, the immunization protocol is decided based on laboratory reports obtained after analyzing the maternal blood sample. If the reports suggest that the mother is HBsAg-positive, HBIG should be administered within 1 week. In cases of infants born to mothers who are HBsAg-negative, the first dose of 5-mcg recombivax HB administered within 12 hours of birth is sufficient. Generally, this is followed by a second dose after 1 month and a third dose 6 months after administering the first dose.

The nurse is giving unlicensed assistive personnel (UAP) strategies to care for a 2-year-old child admitted to the hospital with severe diarrhea. Which strategies should the nurse provide? Multiple choice question Limiting fluid intake Counting the number of wet diapers Weighing the child at the same time every day Encouraging a BRAT diet (bananas, rice, applesauce, and toast)

If the child with acute diarrhea and dehydration is hospitalized, accurate weights must be obtained, as well as careful measurements of fluid intake and output. Counting the number of wet diapers is not as accurate as weighing the diapers. Fluids should be encouraged. A BRAT diet (bananas, rice, applesauce, and toast or tea) is contraindicated for children and especially for infants with acute diarrhea because it has little nutritional value (low in energy and protein) and is high in carbohydrates and low in electrolytes.

A nurse educates the client about the relationship between the kidneys and blood pressure. Which term should the nurse use to describe the part of the kidney that senses changes in blood pressure? Multiple choice question Calices Glomerulus Macula densa Juxtaglomerular cells

Macula densa The macula densa, a part of the distal convoluted tubule, consists of cells that sense changes in the volume and pressure of blood. Calices are cup-like structures, present at the end of each papilla that collect urine. The glomerulus is the initial part of the nephron, which filters blood to make urine. Juxtaglomerular cells secrete renin. Renin is produced when sensing cells in the macula densa sense changes in blood volume and pressure.

The nurse is providing postoperative care for a client who had an extensive surgical revision of the head of the pancreas. To decrease the risk of hemorrhage at the operative site, what action should the nurse take? Multiple choice question Keep the client in the supine position. Maintain patency of the nasogastric tube. Replace fat-soluble vitamins as necessary. Administer prescribed tube feedings to the client slowly.

Maintain patency of the nasogastric tube. A patent nasogastric tube prevents distention and compression in the surgical area. The supine position will place too much tension on the abdominal wall. A low-Fowler position is preferred; movement should be encouraged. Replacement of vitamins is a dependent function; vitamins must be prescribed by the healthcare provider. Tube feedings are contraindicated because peristalsis is absent for one to three days after surgery and because the feeding will place pressure on the suture line.

Which actions should a nurse leader avoid in order to implement changes effectively? Multiple choice question Answering tough questions raised by the staff Asking the staff what is not working well for them Maintaining a boss-employee relationship with the staff Asking questions of the staff related to daily functions

Maintaining a boss-employee relationship with the staff To effectively implement change, a leader nurse should establish and maintain rapport with staff. Therefore maintaining a rigid boss-employee relationship should be discouraged. Answering tough questions faced by the staff will promote a good work culture of helping. Asking the staff about what is not working well for them helps identify problems and solve them. Asking questions of the staff related to daily functions will promote a friendly environment and help track their work.

When a client is receiving dexamethasone for adrenocortical insufficiency, what action does the nurse take to monitor for an adverse effect of the medication? Multiple choice question Auscultate for bowel sounds. Assess deep tendon reflexes. Culture respiratory secretions. Measure blood glucose levels.

Measure blood glucose levels. Corticosteroids, such as dexamethasone, have a hyperglycemic effect, and blood glucose levels should be monitored routinely. Assessing bowel sounds is unnecessary; corticosteroids are not known to precipitate cessation of gastrointestinal activity. Although corticosteroids may increase the risk of developing an infection, routine culturing of respiratory secretions is unnecessary. Culturing respiratory secretions becomes necessary when the client exhibits adaptations of a respiratory infection. Monitoring deep tendon reflexes is required when administering magnesium sulfate, not dexamethasone.

The primary healthcare provider prescribes thioridazine and assigns the nurse to assess the client for orthostatic hypotension. Which interventions would the nurse perform? Multiple selection question Measuring the blood pressure before dosing Reducing the dose if the blood pressure is low Measuring the blood pressure one hour after dosing Measuring the blood pressure one or two minutes after the client sits or stands Avoiding the measurement of blood pressure when the client is lying down

Measuring the blood pressure before dosing Measuring the blood pressure one hour after dosing Measuring the blood pressure one or two minutes after the client sits or stands Antipsychotic drugs such as thioridazine may cause orthostatic hypotension as a side effect. Before delivering a dose, the nurse should measure the client's blood pressure. The blood pressure should be measured one hour after dosing to check the drug's effects on the client's blood pressure. Orthostatic hypotension may occur when the client sits or stands suddenly; therefore, the nurse should measure the client's blood pressure one or two minutes after the client sits or stands. If the client's blood pressure is low, the nurse should stop the administration and contact the primary healthcare provider. The client's blood pressure should be measured even while the client is lying down. This action helps the nurse understand the blood pressure variations in the client while lying down, standing, and sitting.

A client has been taking methadone 40 mg/day for treatment of an opioid addiction. During a methadone clinic visit she tells the counselor that she is 3 months pregnant and receiving prenatal care. The counselor notifies the nurse in the prenatal clinic about the client's addiction history. What should the nurse in the prenatal clinic recommend that the client do? Multiple choice question Withdraw the methadone slowly over the next several weeks. Continue the prescribed methadone to prevent withdrawal symptoms. Temporarily discontinue the methadone to improve maternal and neonatal outcome. Leave the methadone maintenance program during the pregnancy and reenter it after the birth

Methadone is the only medication approved for the treatment of pregnant women with opioid addiction. Although methadone crosses the placenta, it is considered safer for the newborn than the acute opioid detoxification that would result if the methadone was not administered. Withdrawing the methadone slowly over the next several weeks is not recommended. Detoxification from methadone, a long-acting opioid, takes longer than several weeks. Discontinuing methadone treatment can lead to withdrawal problems and put the client at risk for a return to opioid abuse. If methadone is discontinued during the pregnancy, both client and fetus will be at risk.

Which reactions does a nurse expect of a 4-year-old child in response to illness and hospitalization? Multiple choice question Anger, resentment over depersonalization, and loss of peer support Boredom, depression over separation from family, and fear of death Out-of-control behavior, regression to overdependency, and fear of bodily mutilation Intense panic, loss of security over separation from parents, and low frustration tolerance

Out-of-control behavior, regression to overdependency, and fear of bodily mutilation Preschoolers experience loss of control caused by physical restriction, loss of routines, and enforced dependency, which may make them feel out of control. Preschoolers are also likely to experience feelings of regression or overdependency and fear of bodily mutilation. Anger, resentment over depersonalization, and loss of peer support are typical feelings expressed in adolescence. Boredom, depression over separation from family, and fear of death are typical feelings expressed by school-age children. Intense panic, loss of security over separation from parents, and low frustration tolerance are feelings usually experienced by toddlers.

A primary healthcare provider prescribes oxazepam for a client who is beginning to experience withdrawal symptoms while undergoing detoxification. What are the primary reasons that oxazepam is given during detoxification? Multiple choice question Prevents injury and protects the client when seizures occur Enables the client to sleep and eat better during periods of agitation Encourages the client to cooperate with and accept treatment for alcoholism Reduces the anxiety-tremor state and prevents more serious withdrawal symptoms

Reduces the anxiety-tremor state and prevents more serious withdrawal symptoms Oxazepam potentiates the actions of gamma-aminobutyric acid, especially in the limbic system and reticular formation and thus minimizes withdrawal symptoms. This drug helps reduce the risk for seizures but does not prevent injury or protect the client during a seizure. Enabling the client to sleep and eat better during periods of agitation is not the purpose of the drug. The ability of the client to accept treatment depends on the client's readiness to accept the reality of the problem.

Which microorganism causes maternal mastitis? Multiple choice question Escherichia coli Group B streptococcus Staphylococcus aureus Chlamydia trachomatis

Staphylococcus aureus is a resident organism of the skin; it is the causative agent of 95% of the infections that result in maternal mastitis. Escherichia coli is found in the lower intestinal tract; it is not associated with mastitis. Group B streptococcus rarely causes mastitis. Chlamydia trachomatis can cause neonatal pneumonia and conjunctivitis, not mastitis. Frequent hand washing by staff and clients may reduce the risk of infection

The nurse is providing discharge teaching to the parents of a 3-day-old infant. The mother expresses concern regarding sudden infant death syndrome (SIDS). To reduce the risk of SIDS during sleep, how does the nurse instruct the parents to position the infant? Multiple choice question Prone Supine Side-lying Next to an adult in bed for closer monitoring

Studies have shown that SIDS occurs less frequently in infants who are placed in the supine position for sleep. This position allows maximal air movement. Placing an infant in the prone position may increase the risk of upper airway obstruction and rebreathing of expired air. Infants placed on their sides may roll forward into a prone position. Because an adult may roll onto an infant when they are sleeping in the same bed, this practice is not encouraged.

Which cervical changes are observed during pregnancy? Multiple selection question The cervical tip becomes soft. The fragility of cervical tissues decreases. The volume of cervical muscles increases. The external cervical os appears as a jagged slit. The elasticity of cervical collagen-rich connective tissue increases.

The cervical tip becomes soft. The volume of cervical muscles increases. The elasticity of cervical collagen-rich connective tissue increases. By the beginning of the sixth week of pregnancy, the cervical tip softens. During pregnancy, the cervical muscles and its collagen-rich connective tissues increase in volume and become loose and highly elastic. Cervical tissue fragility also increases. The external cervical os appears as a jagged slit postpartum; however, not during pregnancy.

A 2-year-old child who has been restricted to bed rest because of a diagnosis of meningitis is now allowed out of bed. The nurse suggests going to the playroom. The child responds by shaking the head vigorously from side to side, screaming, "No! Won't!" However, the child is trying to climb out of the crib at the same time. In light of these behaviors, what is the most likely conclusion by the nurse? Multiple choice question The child is trying to assert independence. The child is eager to resume regular play activities. The child is unsure of the difference between yes and no. The child is confused as a result of increased intracranial pressure.

The child is trying to assert independence. The toddler is exhibiting typical behavior for this developmental level; most toddlers will say no as a means of asserting their independence. Although the child may be eager to resume playing, the behavior described is related to the child's assertion of autonomy. Although toddlers who are attempting to assert independence will say no even when they mean yes, they do understand the difference. This child's behavior does not indicate confusion; it is typical of 2-year-old children, who will say no to most things as a means of asserting their independence.

A 10-year-old child is found to have hemophilia. The nurse is explaining how hemophilia is inherited. What is the best explanation of the genetic factor that is involved? Multiple choice question It follows the Mendelian law of inherited disorders. The mother is a carrier of the disorder but is not affected by it. It is an autosomal dominant disorder in which the woman carries the trait. A carrier may be male or female, but the disease occurs in the sex opposite that of the carrier.

The mother is a carrier of the disorder but is not affected by it. The hemophilia gene is carried on the X chromosome but is recessive. Therefore the female is the carrier (an unaffected XO and an affected XH). If the male receives the affected XH (XHYO), he will have the disorder. Hemophilia is carried by the female; the Mendelian laws of inheritance are not sex specific. Hemophilia is a sex-linked recessive disorder. Females only carry the trait; usually males are affected.

An older adult who lives alone tells a nurse at the community health center, "I really don't need anyone to talk to. The TV is my best friend." What defense mechanism does the nurse identify? Multiple choice question Denial Projection Sublimation Displacement

denial

What other name can the nurse use for vasopressin? Multiple choice question Growth hormone Luteinizing hormone Antidiuretic hormone Thyroid-stimulating hormone

Antidiuretic hormone Antidiuretic hormone is also called vasopressin. Growth hormone can be called somatotropin. Luteinizing hormone is a gonadotropin. Thyroid-stimulating hormone can be called thyrotropin.

Which muscle helps in moving the eye diagonally downward towards the middle of the head? Multiple selection question Lateral rectus muscle Medial rectus muscle Inferior rectus muscle Inferior oblique muscle Superior oblique muscle

Inferior rectus muscle Inferior oblique muscle The inferior rectus muscle together with the medial rectus moves the eye diagonally downward towards the middle of the head. The lateral rectus muscle together with the medial rectus muscle holds the eye straight. The medial rectus muscle helps in turning the eye towards the nose. The inferior oblique muscle will pull the eye upward. The superior oblique muscle pulls the eye downward.

The registered nurse is teaching the nursing student about the realms of family life. Which component does the registered nurse include while teaching about integrity processes? Multiple choice question Family rituals Family relationships Family life stressors and daily hassles Family care takings and responsibilities

Family rituals The family health system includes five realms, or processes, of family life. These realms are interactive, developmental, coping, integrity, and health. This approach is a method for family assessment used to determine areas of concern and strengths and to help develop an effective care plan. The component of integrity includes family rituals. Family relationships are a part of interactive processes. Family life stressors and daily hassles are considered components of coping processes. Health processes include family care takings and responsibilities.

What is the priority nursing management for a client in myasthenic crisis? Multiple choice question Performing plasmapheresis Administering intravenous atropine Maintaining adequate respiratory function Administering intravenous immunoglobulins

The priority nursing management of a client with myasthenic crisis is maintaining adequate respiratory function to promote gas exchange. Plasmapheresis is used as a short-term management of an exacerbation, but it is not the priority nursing intervention. Atropine is administered after maintaining adequate respiratory function. Intravenous immunoglobulins are administered as a long-term option for disease refractory to other treatment.

An infant with a cleft lip is fed with a special nipple. What should the nurse teach the parents about feeding their infant to minimize regurgitation? Multiple choice question Offer a thickened formula. Burp frequently during a feeding. Place the child in an infant seat during feedings. Position the child on the side with the bottle propped.

Because of the cleft (opening) in the lip, infants with this condition tend to suck in excessive air; burping helps prevent regurgitation of formula. Thickened formula is given to infants with reflux problems, such as vomiting after each feeding. The semi-Fowler position may be used for infants with reflux problems; this infant should be held during feedings. The bottle should never be propped, because aspiration may occur.

A mother of a seven-month-old infant reports that her baby still cannot sit without support. Upon asking further questions, the nurse realizes that the child's gross-motor skills are not properly developed. Which question did the nurse most likely ask the mother? Multiple choice question Can your child hold on to furniture? Can your child show hand preference? Does your child move on his or her hands and knees? Can your child place objects in containers?

Can your child hold on to furniture? Gross-motor skill development features in a seven-month-old include sitting alone without any support. Another sign is the infant's ability to hold on to furniture. An infant between 8 and 10 months may show hand preference as a part of fine-motor skill development. Moving on hands and knees may represent gross-motor skill development in an 8 to 10 month old. A 10 to 12 months infant may have the ability to place objects in containers; this action is a part of fine-motor skill development.

Clozapine, an atypical antipsychotic, is prescribed for a client with psychosis. It is important for client to have frequent blood tests for which possible complication? Multiple choice question Anemia Hemophilia Agranulocytosis Thrombocytopenia

Although the complication is rare, clients taking clozapine are at increased risk of agranulocytosis, a marked decrease in granulated white blood cells. All clients taking clozapine require frequent blood testing during the therapy and for as long as 4 weeks after the medication is discontinued. Clozapine does not cause anemia or thrombocytopenia. Hemophilia is a genetic deficiency of certain proteins needed to help blood to clot.

Which complication will the nurse suspect in a client with genital herpes disease? Multiple choice question Infertility Cold sores Reactive arthritis Bartholin's abscess

Cold sores are the autoinoculation of the virus to extragenital sites, such as the fingers and lips. It is a complication of genital herpes disease. Infertility and reactive arthritis are the complications of chlamydial infection. Bartholin's abscess is a complication of gonorrhea.

A nurse is caring for a client who is having difficulty digesting fatty foods. To what deficiency does the nurse attribute this difficulty? Multiple choice question Bile Lipase Amylase Cholesterol

Fatty acids are insoluble and must combine with bile to form water-soluble substances. Lipase is a pancreatic enzyme. Amylase, which digests starch, is found in saliva and pancreatic juice. Although cholesterol is produced in the liver and stored in the gallbladder, it is not the component of bile that emulsifies fats.

The primary healthcare provider sees a client who reports a small pustule at a hair follicle opening with minimal erythema on the scalp. What could be the condition of the client? Multiple choice question Furuncle Cellulitis Folliculitis Carbuncle

Folliculitis

A 7-year-old child sustains a fractured femur in a bicycle accident. The admission x-ray films reveal evidence of fractures of other long bones in various stages of healing. What does the nurse suspect as the cause of the fracture? Multiple choice question Child abuse Vitamin D deficiency Osteogenesis imperfecta Inadequate calcium intake

Injuries in various stages of healing are the classic sign of child abuse. Vitamin D deficiency, osteogenesis imperfecta, and inadequate calcium intake may all be investigated after child abuse has been ruled out.

The nurse is seeking a position as a clinical nurse leader in a major city hospital. What should the nurse prepare to do in order to secure this type of nursing role? Multiple selection question Pass the certification exam. Complete a master's degree in nursing. Learn how to prepare clinical pathways. Attend 30 hours of continuing education about the role. Pass the NCLEX-RN state board of nursing examination

Pass the certification exam. Complete a master's degree in nursing. The clinical nurse leader is an advanced generalist clinician with education at the master's degree level and who has successfully completed the clinical nurse leader (CNL) certification examination. Writing clinical pathways would be an activity completed by case managers. There are no identified continuing education requirements for the clinical nurse leader role. Passing the NCLEX-RN state board of nursing would have been achieved prior to the nurse having employment as a nurse.

Which preparations use toxoids but not live viruses? Multiple selection question Rotarix Varivax M-M-R II PEDIARIX DAPTACEL

PEDIARIX consists of diphtheria and tetanus toxoids plus inactivated bacterial components of pertussis, inactive viral antigen of hepatitis B, and inactivated poliovirus vaccine. DAPTACEL is a preparation consisting of toxoids plus inactive bacterial and viral components of diphtheria and tetanus toxoids and acellular pertussis vaccine. Rotarix, Varivax, and M-M-R II are preparations containing live viruses.

Which hormone regulates blood levels of calcium? Multiple choice question Parathormone Luteinizing hormone Thyroid stimulating hormone Adrenocorticotropic hormone

Parathyroid hormone (PTH), or parathormone, regulates the blood levels of calcium and phosphorus. Luteinizing hormone (LH) stimulates the production of sex hormones, promotes the growth of reproductive organs, and also stimulates reproductive processes. Thyroid stimulating hormone (TSH) stimulates the release of thyroid hormones and the growth and functioning of the thyroid gland. Adrenocorticotropic hormone (ACTH) promotes the growth of the adrenal cortex and stimulates the release of corticosteroids.

A healthcare provider prescribes a diuretic for a client with hypertension. What should the nurse include in the teaching when explaining how diuretics reduce blood pressure? Multiple choice question Facilitates vasodilation Promotes smooth muscle relaxation Reduces the circulating blood volume Blocks the sympathetic nervous system

Reduces the circulating blood volume Diuretics block sodium reabsorption and promote fluid loss, decreasing blood volume and reducing arterial pressure. Direct relaxation of arteriolar smooth muscle is accomplished by vasodilators, not diuretics. Vasodilators, not diuretics, act on vascular smooth muscle. Drugs that act on the nervous system, not diuretics, inhibit sympathetic vasoconstriction.

What is the average weight of a three-year-old child? Multiple choice question 26.5 lb (12 kg) 32 lb (14.5 kg) 41 lb (18.5 kg) 36.5 lb (16.5 kg)

The average weight of a three-year-old child is 32 lb (14.5 kg). The average weight of a two-year-old child is 26.5 lb (12 kg). The average weight of a five-year-old child is 41 lb (18.5 kg). The average weight of a four-year-old child is 36.5 lb (16.5 kg).

A mental health crisis occurs as a result of what stress-related factor? Multiple choice question The stress is chronic and maturational in nature. The stress is perceived rather than real in nature. The stress is extremely severe and situational in its origin. The stress is not managed by the individual's usual methods.

The stress is not managed by the individual's usual methods. An individual experiences a crisis when stress, either real or imagined, cannot be controlled by the person's usual coping mechanisms. It would not be considered a crisis if it was chronic and maturational, severe and situational, or perceived rather than real.

A client with arthritis is taking large doses of aspirin. What symptom does the nurse include when teaching the client about the clinical manifestations of aspirin toxicity? Multiple choice question Feelings of drowsiness Disturbances in hearing Intermittent constipation Metallic taste in the mouth

inging in the ears occurs because of its effect on the eighth cranial nerve and is a classic symptom of aspirin toxicity. Feelings of drowsiness are not side effects of aspirin; aspirin promotes comfort, which may permit rest. Aspirin may cause diarrhea, nausea, and vomiting, not intermittent constipation. A metallic taste in the mouth is not a side effect of salicylates such as aspirin.

A client is admitted with severe burns, is obese, and has pre-existing respiratory problems. Which complication should the nurse anticipate? Multiple choice question Necrosis Pneumonia Dysrhythmias Venous thromboembolism

venous thromboembolism is the complication of the client with severe burns, who is obese and has pre-existing respiratory problems. Necrosis is an untreated complication of the cardiovascular system. Pneumonia is a complication for the client with pre-existing respiratory problems. Dysrhythmias are a complication of the cardiovascular system.

A client is being treated for influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which patient statement indicates a need for further instruction? Multiple choice question "I should practice respiratory hygiene/cough etiquette." "I should avoid contact with the elderly or children." "I should obtain a pneumococcal vaccination each year." "I should allow visitors for short periods of time only."

"I should obtain a pneumococcal vaccination each year. The client should be encouraged to receive an influenza vaccine each year. Pneumococcal vaccines will not prevent influenza. The nurse should stress the importance of practicing respiratory hygiene/cough etiquette. The client should avoid contact with vulnerable populations such as the elderly and children. Visitors for clients in isolation for influenza should be limited to persons who are necessary for the client's emotional well-being and care. Visitors who have been in contact with the client before and during hospitalization are a possible source of influenza for other clients, visitors, and staff.

A client with tuberculosis asks the nurse why vitamin B 6 (pyridoxine) is given with isoniazid. What explanation should the nurse provide? Multiple choice question "It will improve your immunologic defenses." "The tuberculostatic effect of isoniazid is enhanced." "Isoniazid interferes with the synthesis of this vitamin." "Destruction of the tuberculosis organisms is accelerated."

"Isoniazid interferes with the synthesis of this vitamin." Isoniazid often leads to vitamin B 6 (pyridoxine) deficiency because it competes with the vitamin for the same enzyme; this deficiency most often is manifested by peripheral neuritis, which can be controlled by regular administration of vitamin B 6. Vitamin B 6 does not improve immune status. Pyridoxine does not enhance isoniazid effects. Pyridoxine does not destroy organisms.

A near-term client reports that her fetus is moving less this week than last week. Which responses by the nurse are appropriate at this time? Multiple selection question "Don't worry—the fetus sleeps a lot near the end of the pregnancy." "It would be good for you to come to labor and delivery to be evaluated today." "Always call the healthcare provider if you're worried that your baby isn't moving enough." "Let me teach you how to conduct a kick count, and then you can call me when you've done one.

"It would be good for you to come to labor and delivery to be evaluated today." Always call the healthcare provider if you're worried that your baby isn't moving enough." "Let me teach you how to conduct a kick count, and then you can call me when you've done one." If a client is reporting decreased fetal movement, it is appropriate to advise her to contact her healthcare provider, be evaluated, and conduct a kick count. Infant movement is a sign of infant well-being, and a reported decrease should not be ignored. The mother should also always be encouraged to call her healthcare provider, at any time, if she has concerns about her pregnancy and the well-being of her baby.

Which teaching points regarding fine motor skills should the nurse include during the health maintenance visit for a 30-month-old toddler-age client? Multiple selection question "Your child should be able to draw circles." "Your child should be able to jump from a chair." "Your child should be able to jump with both feet." "Your child should have good hand-eye coordination." "Your child should be able to build a tower using eight blocks."

"Your child should be able to draw circles." "Your child should have good hand-eye coordination." "Your child should be able to build a tower using eight blocks."

A client on treatment for depression visited the primary healthcare provider with a complaint of blurred vision and constipation. Which drugs are responsible for these adverse effects? Multiple selection question Phenelzine Amoxapine Maprotiline Desipramine Amitriptyline

ALL OF THEM Amoxapine, desipramine, and amitriptyline are first-generation antidepressants drugs with potential adverse effects of blurred vision and constipation. Phenelzine is a monoamine oxidase inhibitor. Dizziness and dyskinesias are the adverse effects of this drug. Maprotiline is a second-generation antidepressant drug with potential adverse effects of drowsiness and abnormal dreams.

Methylphenidate is prescribed for a 6-year-old boy with the diagnosis of attention deficit-hyperactivity disorder (ADHD). The nurse teaches the father about safe medication administration and concludes that the instructions have been understood when the father says that he should administer it at which time? Multiple choice question At bedtime After breakfast When the child gets hungry When the child's behavior is out of control

After breakfast - because this med decreases appetite when they take it

The nurse is planning care for a middle-aged woman who has been admitted for a vaginal hysterectomy and anterior and posterior repair of the vaginal wall. What should the nurse tell the client to expect in the immediate postoperative period? Multiple choice question Placement of a pessary Insertion of a rectal tube Use of a douche periodically Presence of a urinary catheter

After surgery the urethral orifice may be distorted and edematous; a urine retention catheter keeps the bladder empty, limiting pressure on the operative site. A pessary placed in the vagina is used for a displaced uterus; after an anteroposterior repair (colporrhaphy), vaginal packing is used to support the surgical repair. A rectal tube is used for abdominal distention caused by flatulence; it is rarely necessary. A cleansing douche may be prescribed before, not after, surgery.

To prevent bleeding after a suprapubic prostatectomy, the client should be instructed to avoid straining on defecation. Which foods should the nurse encourage the client to eat to help prevent constipation during the recovery period? Multiple selection question Milk Apples Oatmeal Green peas Scrambled eggs

Apples Oatmeal Green peas Apples, oatmeal, and green peas are high in fiber, which helps prevent constipation. Milk and milk products can be constipating; they do not contain bulk. Scrambled eggs contain little dietary fiber and do not prevent constipation.

When a nurse brings a newborn to the new mother, the mother comments about the milia on her infant's face. What information should the nurse include when responding? Multiple choice question They are common and will disappear in 2 to 3 days. Avoid squeezing them and don't try to wash them off. They are birthmarks that will disappear in 3 to 4 months. Proper handwashing technique is important because milia are infectious.

Attempts to remove milia will irritate the infant's skin, and such attempts are not needed because the milia will disappear during the first month of life. Although milia are common, they do not disappear for several weeks after birth. Milia are not birthmarks; the tiny plugged sebaceous glands are the result of maternal hormonal influence. The white material is not purulent and is not infectious.

An infant with a diagnosis of heart failure is being given furosemide twice a day. Which laboratory value will the nurse report to the healthcare provider? Multiple choice question Sodium of 140 mEq/L (140 mmol/L) Ionized calcium of 2.35 mEq/L (1.2 mmol/L) Chloride of 102 mEq/L (102 mmol/L) Potassium of 3.0 mEq/L (3.0 mmol/L)

Because furosemide is a potassium-losing diuretic, the potassium should be frequently checked. Normal potassium concentration in infants is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium concentration of 3.0 mEq/L (3.0 mmol/L) should be reported to the healthcare provider. The normal range for sodium is 139 to 146 mEq/L (139 to 146 mmol/L), ionized calcium is normally 2.24 to 2.46 mEq/L (1.12 to 1.23 mmol/L), and chloride is normally 98 to 106 mEq/L (98 to 106 mmol/L). The sodium, calcium, and chloride readings are normal.

A nurse is reviewing the diagnostic blood tests of a client with a diagnosis of type 1 diabetes. Which laboratory results support the nurse's suspicion that the client is experiencing ketoacidosis? Multiple choice question Blood glucose of 40 mg/100 mL (2.2 mmol/L), blood pH of 7.37 Blood glucose of 130 mg/100 mL (7.2 mmol/L), blood pH of 7.35 Blood glucose of 650 mg/100 mL (36.1 mmol/L), blood pH of 7.42 Blood glucose of 300 mg/100 mL (16.7 mmol/L), blood pH of 7.20

Blood glucose of 300 mg/100 mL (16.7 mmol/L), blood pH of 7.20

What items should the nurse instruct community members to include in a personal preparedness bag? Multiple selection question Toiletries Laptop computer Cell phone and charger Three-day supply of clothing Three-day supply of non-perishable food items

Cell phone and charger Three-day supply of clothing Three-day supply of non-perishable food items Toiletries Items that should be included in a person preparedness go bag include toiletries, cell phone and charger, and a three-day supply of clothing and non-perishable food items. Although a laptop computer may be desired it is unlikely that this item can be stored in a location for potential use. Also, the chances that this device would be helpful during a disaster will depend upon a power source and access to the internet.

An 18-month-old toddler who stepped on a rusty nail 4 days ago shows signs of generalized tetanus, including neck and jaw stiffness and facial muscle spasms. The toddler is receiving intravenous diazepam as a muscle relaxant every 4 hours. What response to the medication does the nurse anticipate? Multiple choice question Control of hypertonicity and prevention of seizures Control of laryngospasms and neck and jaw rigidity Prevention of excess oxygen and caloric expenditure Prevention of restlessness and resistance to assisted ventilation

Control of hypertonicity and prevention of seizures Diazepam is commonly used to manage generalized muscular spasms. Laryngospasm and nuchal rigidity are responses to the exotoxin and are treated with tetanus immune globulin. Diazepam is not administered to decrease the metabolic rate. Pancuronium bromide, an acetylcholine antagonist, is given to children who do not respond to sedatives and muscle relaxants and therefore resist ventilatory assistance.

When an intestinal obstruction is suspected, a client has a nasogastric tube inserted and attached to suction. What response should the nurse critically assess on this client? Multiple choice question Edema Belching Fluid deficit Excessive salivation

Dehydration is a danger because of fluid loss with gastrointestinal (GI) suction. Based on the data provided, edema, belching, and excessive salivation are not likely to occur.

A client has cancer of the cervix. Which response after radium insertion should cause the nurse to recognize that the client is having an adverse reaction to the radium? Multiple choice question Vomiting Back pain Vaginal discharge Increased temperature

Increased temperature Infection may develop as a result of sloughing of tissue beyond what is expected in response to the administration of internal radiation. Vomiting is an expected side effect of internal radiotherapy. Back pain is expected because the client must remain flat in bed and it is difficult to relieve back pressure. Vaginal discharge is an expected side effect of internal radiotherapy.

What characteristic of the environment is most therapeutic for clients with the diagnosis of bulimia nervosa? Multiple choice question Controlling Empathetic Focused on food Based on realistic limits

Realistic guidelines reduce anxiety, increase feelings of security, and increase adherence to the therapeutic regimen. A controlling environment sets up a power struggle between these clients and the nurse. These clients need realistic rules and regulations that they identify as helpful, not as empathetic. Focusing on food is not therapeutic as it may result in a power struggle between these clients and the nurse.

vA nurse is assessing a client with a suspected pituitary tumor. Which assessment finding is consistent with a pituitary tumor? Multiple choice question Tetany Seizures Lethargy Hyperreflexi

Seizures Seizures are common in clients who have pituitary tumors. Tetany is associated with severe hypocalcemia; that condition can be caused by hypoparathyroidism. Lethargy is found in clients with hypothyroidism. Hyperreflexia is observed in clients with hyperthyroidism and hypoparathyroidism.

Metoprolol is prescribed for a client. Which condition in the client's electronic medical record will cause the nurse to question the prescription? Multiple choice question Hypertension Angina pectoris Sinus bradycardia Myocardial infarction

Sinus bradycardia

The nurse is preparing to assess several clients at a pediatric clinic. Which client would require a developmental screening versus developmental surveillance during a scheduled health maintenance visit? Multiple choice question A 9-month-old infant A 2-week-old newborn A 15-month-old toddler A 4-year-old preschooler

The nurse would conduct a developmental screening for the 9-month-old infant during a scheduled health maintenance visit. The 2-week-old newborn, the 15-month-old toddler, and the 4-year-old preschooler would all require developmental surveillance during a health maintenance visit.

Obesity in children is an ever-worsening problem. What concept should a nurse consider when caring for school-aged children who are obese? Multiple choice question Enjoyment of specific foods is inherited. There are familial influences on childhood eating habits. Childhood obesity is usually not a predictor of adult obesity. Children with obese parents are destined to become obese themselves.

There are familial influences on childhood eating habits Studies have demonstrated that culture and family eating habits have an impact on a child's eating habits. Inheritance is not known to influence eating habits, although it is believed that other hereditary factors are associated with obesity. Childhood obesity is a known predictor of adult obesity. Children with obese parents are not necessarily destined to become obese themselves.

What steps should the nurse take for managing an adolescent that sustained drug poisoning? Multiple selection question Induce gastric lavage. Give ipecac syrup to the client. Turn the head of the client to the side. Empty the mouth to clean the residue of the drug. Call local poison control center before any intervention.

Turn the head of the client to the side. Empty the mouth to clean the residue of the drug. Call local poison control center before any intervention. The nurse should turn the head of the client to the side to avoid aspiration. The nurse should empty the mouth if there is any remaining drug. If the victim is conscious and alert, the nurse should call the local poison control center or the national toll-free poison control center number before attempting any intervention. The nurse should refrain from inducing vomiting in the client as there is a risk of aspiration. Ipecac syrup causes vomiting so it is no longer recommended for routine treatment of poisoning.

A 2-month-old infant is to have a nasogastric tube inserted. What does the nurse expect to happen? Multiple choice question A pacifier will be offered to decrease gagging and allow easier insertion of the tube. Gastric contents will not appear in the tube if the infant is receiving nothing by mouth. Coughing, irregular breathing, and slight cyanosis will occur during introduction of the tube. The tube will be passed a distance equal to the length from the chin to the tip of the sternum.

A pacifier will be offered to decrease gagging and allow easier insertion of the tube. Sucking and swallowing (the infant's response to a pacifier) reduce gagging and facilitate the insertion of the nasogastric tube. A small amount of gastric fluid is always present and will appear in the tube. The tube is passed the distance from the ear to the tip of the nose to the distal end of the sternum. Coughing, gagging, and cyanosis are indications that the tube has passed into the larynx, not the stomach.

After a vaginal hysterectomy and an anterior and posterior repair of the vaginal wall a client is returned to her room. Which action does the nurse include in the plan of care for this client? Multiple choice question Check vaginal packing. Elevate lower extremities. Observe dressing for bleeding. Start sitz baths tomorrow morning.

Check vaginal packing. Vaginal packing supports the repair and provides slight pressure to prevent bleeding; the packing should be checked for bleeding. Elevating the legs is unnecessary; leg exercises and a gradual increase in ambulation are encouraged to prevent pulmonary emboli. There is no dressing, only vaginal packing and a sanitary pad. Sitz baths are not instituted until the packing is removed; an ice pack, heat lamp, or both may be used to promote comfort.

The echoviruses can cause which diseases in clients? Multiple selection question Parotitis Gastroenteritis Mononucleosis Aseptic meningitis Burkitt's lymphoma

Gastroenteritis Aseptic meningitis Echoviruses cause gastroenteritis and aseptic meningitis. Parotitis is caused by mumps. Burkitt's lymphoma and mononucleosis are caused by the Epstein-Barr virus.

Which drug is used in the treatment of a client with intervertebral disc disease? Multiple choice question Etidronate Zoledronic acid Cyclobenzaprine Salmon calcitonin

Intervertebral disc disease often causes myalgia. Therefore, muscle relaxants, such as cyclobenzaprine, are used in its treatment. Etidronate, zoledronic acid, and salmon calcitonin are effective in the treatment of osteoporosis.

A healthcare provider prescribes digoxin for a client. The nurse teaches the client to be alert for which common early indication of digoxin toxicity? Multiple choice question Nausea Urticaria Photophobia Yellow vision

Nausea Nausea and loss of appetite are the first indications of toxicity in approximately 50% of clients who take a cardiac glycoside, such as digoxin. Urticaria is a rare, not common, manifestation of digoxin toxicity. Photophobia is a later, not early, manifestation of digoxin toxicity. Yellow vision is a later, not early, manifestation of digoxin toxicity.

What should be a priority of nursing care for a client with dementia resulting from acquired immune deficiency syndrome (AIDS)? Multiple choice question Frequent assessments for pain Planning for remotivational therapy Arranging for long-term custodial care Providing basic intellectual stimulation

Providing basic intellectual stimulation Providing basic intellectual stimulation maintains, for as long as possible, the client's remaining intellectual functions by providing an opportunity to use them. Although pain syndromes can occur in clients with dementia resulting from AIDS, frequent pain assessment is not a priority; providing cognitive stimulation facilitates the use of nonpharmacologic treatments for pain management as long as possible. Remotivation is not always possible with extensive organic brain damage. There are no data to indicate that the client needs custodial care at this time.

Which disease is caused by Coronaviruses? Multiple choice question Pertussis Inhalation anthrax Coccidioidomycosis Severe acute respiratory syndrome

Severe acute respiratory syndrome Severe acute respiratory syndrome is a respiratory infection caused by Coronaviruses. Pertussis is caused by the bacterium Bordetella pertussis. Inhalation anthrax is caused by Bacillus anthracis. Coccidioidomycosis is caused by Coccidioides.

A nurse identifies that a client seems to be depressed after a thymectomy for treatment of myasthenia gravis. Which nursing action is most appropriate at this point? Multiple choice question Recognize that depression often occurs after surgery Ask the primary healthcare provider to arrange for a psychologic consultation Reassure the client that things will feel better after the discharge date has been set Talk with the client about the prognosis and emphasize activities the client is still able to perform

Talk with the client about the prognosis and emphasize activities the client is still able to perform

The diagnostic report of a client indicates a positive specific treponemal antibody test. The signs and symptoms of syphilis are absent. What does the nurse infer from this finding? Multiple choice question The client is in the late stage of syphilis The client is in the latent stage of syphilis The client is in the primary stage of syphilis The client is in the secondary stage of syphilis

The client is in the latent stage of syphilis A positive specific treponemal antibody test[1][2][3] indicates the client has syphilis. In the latent stage of syphilis, the signs and symptoms are absent and it is a noninfectious stage. Chronic destructive lesions are present in the late stage of syphilis. Painless indurated lesions are present in the primary stage of syphilis. Flu-like symptoms are present in secondary syphilis.

Which physiologic changes of the musculoskeletal system are related to aging? Multiple selection question Slowed movement Cartilage degeneration Increased bone density Increased range of motion Increased bone prominence

The physiologic changes of the musculoskeletal system related to aging are slowed movements, cartilage degeneration, increased bone prominence, decreased bone density, and decreased range of motion.

A newborn is found to have a diaphragmatic hernia. What is the immediate intervention after the neonate is admitted to the neonatal intensive care unit? Multiple choice question Hydrating the infant with isotonic enemas Limiting formula feedings to small amounts Placing the infant in the Trendelenburg position Providing gastric decompression via nasogastric tube

When a diaphragmatic hernia is present, intra-abdominal pressure must be minimized; this is accomplished with the use of gastric decompression. Hydrating the infant with isotonic enemas is not beneficial. These infants are not fed orally; intravenous fluids are given with careful measurement of electrolytes and intake and output to guide replacement therapy. The Trendelenburg position is contraindicated; the abdominal organs will increase pressure on the diaphragm.

The laboratory report of a client indicates that the urinary urea nitrogen levels are 9 g/24 hr. What does the nurse anticipate from this finding? Multiple choice question Client has sepsis Client has dehydration Client has high-protein intake Client has potential kidney damage

Kidney damage or liver disease is suspected when the urea nitrogen is less than normal levels. The normal level of urea nitrogen in the urine ranges from 12 to 20 g/24 hr (0.43-0.71 mmol/24 hr). Normal kidneys are able to filter urea and other toxic byproducts of ammonia. An increased level of urea nitrogen is indicative of sepsis, dehydration, or high protein diet in the client.

A client with metastatic melanoma is being treated with interferon gamma 1b. The nurse concludes that the teaching about this drug is understood when the client makes which statement? Multiple choice question "I will increase my fluid intake to several quarts (liters) every day." "I need to discard any reconstituted solution at the end of the week." "I can continue driving my car as before as long as I have the stamina." "I should be able to continue my usual activity while taking this medication."

"I will increase my fluid intake to several quarts (liters) every day." Increasing fluid intake to several quarts (liters) every day helps flush the kidneys and prevent nephrotoxicity, especially during the early phase of treatment. Reconstituted solution can be stored in the refrigerator for one month. Confusion, dizziness, and hallucinations are side effects of this drug; the client should avoid hazardous tasks, such as driving or using machinery. Activity may have to be altered because fatigue and other flulike symptoms are common with this drug.

A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should the nurse respond? Multiple choice question "Are you disappointed in how your baby looks?" "Don't worry—your baby's head will be round in a few days." "Is there anyone in your family whose head shape is similar to your baby's?" "This often happens as the baby's head moves down the birth canal—the bones move for easier passage."

"This often happens as the baby's head moves down the birth canal—the bones move for easier passage." The shape of the newborn's head is most likely the result of " molding." As the baby's head moves down the birth canal, the bones move for easier passage of the head through the birth canal. The mother needs information that is straightforward and understandable. Telling the client that this often happens as the baby's head moves down the birth canal is accurate information. Asking whether the mother is disappointed in her baby's appearance is an assumed reflection of the mother's feelings and does not address her concern; the nurse should recognize that the mother is disappointed and offer an explanation. Telling the mother that her baby's head will be round in a few days may add to the mother's anxiety because the reason for the infant's appearance has not been explained. It will take several days to determine whether the head is malformed. Asking whether anyone else in the client's family has a similarly shaped head may add to the mother's anxiety.

The nurse is collecting the health history of a client suspected to have a pulmonary disorder. Which questions should the nurse ask the client related to health perception and health management? . Multiple selection question "Do you experience a morning headache?" "Have you ever smoked elicit street drugs?" "What do you do when you get short of breath?" "Are you able to maintain a typical activity pattern?" "What equipment helps you manage your respiratory problems?"

"What equipment helps you manage your respiratory problems?" "Have you ever smoked elicit street drugs?" The nurse asks the client questions related to health perception and health management to determine if there is a perceived change in the client's health status within the last several days, months, or years. The questions that fall under this category include smoking of elicit street drugs and using any equipment to manage respiratory problems. To determine the sleep-rest pattern, the nurse asks the client about the occurrence of a morning headache. To determine the activity-exercise pattern, the nurse asks the client about the techniques used if shortness of breath occurs and about the maintenance of a typical activity pattern.

A nurse is completing the discharge protocol for a 14-year-old adolescent with osteomyelitis. The nurse teaches the parents how and when to administer the intravenous antibiotic at home. The schedule for administration is four times a day. At what times should the parents administer the antibiotic? Multiple choice question 8:00 AM, 12:00PM, 4:00 PM, 8:00 PM 8:00 AM, 4:00 PM, 12:00 AM, 4:00 AM 10:00 AM, 2:00 PM, 10:00 PM, 2:00 AM 6:00 AM, 12:00 PM, 6:00 PM, 12:00 AM

6:00 AM, 12:00 PM, 6:00 PM, 12:00 AM Intravenous antibiotics should be administered with doses equally spaced over 24 hours so a constant blood level of the drug is maintained. The 12 hours between the 8:00 PM and 8:00 AM doses in the 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM dosing schedule is too long; the blood level of the antibiotic will drop, and the therapy will not be as effective. Administering doses at 8:00 AM, 4:00 PM, 12:00 AM, and 4:00 AM or at 10:00 AM, 2:00 PM, 10:00 PM, and 2:00 AM will not work because the doses are not equally spaced over 24 hours and the blood level of the antibiotic will not remain constant.

A client on the psychiatric unit asks a nurse about psychiatric advance directives (PADs). What information should form the basis of the nurse's response? Multiple choice question The appointment of a surrogate decision-maker is unnecessary. A client is permitted to dictate the treatments that will be given during future hospitalizations. The need for involuntary admissions is eliminated when a client poses a threat to self or others. A client is allowed to consent to or refuse potential psychiatric treatments if a future incapacitating mental health crisis occurs.

A client is allowed to consent to or refuse potential psychiatric treatments if a future incapacitating mental health crisis occurs. The purpose of a PAD is to allow psychiatric clients the opportunity to provide input into future treatment decisions. Having a surrogate decision-maker can help ensure that the client's wishes are followed. A client may have both a PAD and a healthcare proxy. The client cannot dictate what treatments will be offered or given. The primary healthcare provider and treatment team will decide on a plan of care, which the client may accept or reject. If the client is a threat to self or others, involuntary admission may be required whether a PAD exists or not.

While grading a client's muscle strength, the nurse records a score of 4. What does this indicate? Multiple choice question No detection of muscular contraction A barely detectable flicker or trace of contraction Active movement against gravity and some resistance Active movement against gravity only, not against resistance

Active movement against gravity and some resistance According to the muscle-strength scale, a sore of 4 indicates active movement of the muscle against gravity and some resistance. A score of 0 indicates no muscular contraction. A score of 1 indicates a barely detectable flicker or trace of contraction. A score of 3 indicates active movement against gravity only, not against resistance.

The nurse manager enlists 10 direct care nurses for a project addressing the needs of the human immunodeficiency virus (HIV). The project successfully completes within the timeline. What would be the most essential factor for the success of the nursing manager? Multiple choice question Offering ideas to the direct care nurses Providing training to the direct care nurses Allowing the direct care nurse to share ideas Promoting discipline among the direct care nurses

Allowing the direct care nurse to share ideas The most important element of success for the nursing manager is to allow the direct care nurses to share their ideas about the project and participate in decision making. This approach will increase their organizational commitment and increase the feeling of self-worth. The nurses will then be more likely to invest extra effort for successful completion of the project. The other factors necessary for successful completion of the project include providing ideas, training the nurses, and promoting discipline.

When answering questions from the family of a client with Alzheimer disease, how does the nurse describe the disease? Multiple choice question Emerges in the fourth decade of life Is a slow, relentless deterioration of the mind Is functional in origin and occurs in the later years Is diagnosed through laboratory and psychological tests

Alzheimer disease[1][2][3] is a slow and relentless deterioration of the mind; clients become progressively worse over time. The disease usually appears in people 60 years of age and older. Alzheimer disease is an organic, not a functional, disorder. At this time there are no diagnostic tools other than autopsy that can provide a definite confirmation of Alzheimer disease.

A nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestations should the nurse assess in the client? Multiple selection question Ascites Hunger Pruritus Jaundice Headache

Ascites Pruritus Jaundice Ascites is a result of portal hypertension that occurs with cirrhosis. Pruritus is common because bile pigments seep into the skin from the bloodstream. Jaundice occurs because the bile duct becomes obstructed and bile enters the bloodstream. The appetite decreases because of the pressure on the abdominal organs from the ascites and the liver's decreased ability to metabolize food. Headache is not a common manifestation of cirrhosis of the liver.

A client has thin, dark-red vertical lines about 1 to 3 mm long in the nails. Which diseases are associated with this physiologic alteration in the client? . Multiple selection question Psoriasis Trichinosis Cardiac failure Diabetes mellitus Bacterial endocarditis

Bacterial endocarditis Trichinosis Thin, dark-red vertical lines about 1 to 3 mm long in the nails are associated with trichinosis (parasitic disease) and bacterial endocarditis (infection of the innermost layer of the heart and heart valves). Psoriasis, diabetes mellitus, and cardiac failure are associated with yellow-brown discoloration of the nails.

A terminally ill client is furious with one of the staff nurses. The client refuses the nurse's care and insists on doing self-care. A different nurse is assigned to care for the client. What should be the newly assigned nurse's initial step in revising the client's plan of care? Multiple choice question Get a full report from the first nurse and adjust the plan accordingly. Ask the primary healthcare provider for a report on the client's condition and plan appropriately. Tell the client about the change in staff responsibilities and assess the client's reaction. Assess the client's present status and include the client in a discussion of revisions to the plan of care.

Because the client is feeling a loss of control, it is most important to include the client in revision of the plan of care. Getting a full report from the first nurse does not consider changes in the client or obtain the client's input. Planning nursing care is within the nurse's function and judgment, not the primary healthcare provider's; also, the client should be included. Telling the client of the change in staff responsibilities is an authoritarian approach and does not include the client in planning future care.

Which drug is contraindicated in clients with eating and seizure disorders? Multiple choice question Bupropion Trazodone Amitriptyline Lithium citrate

Bupropion (antidepressant drug to stop smoking also act for depression) is contraindicated in clients with eating and seizure disorders. Trazodone is contraindicated in clients with a known allergic reaction to this drug. Amitriptyline is contraindicated in clients who are pregnant and have known allergic reactions to this drug. Lithium citrate is contraindicated in clients with renal or cardiovascular disease.

How is the brachioradialis reflex elicited? Multiple choice question By striking the triceps tendon above the elbow By striking the radius 3 to 5 cm above the wrist By striking the patellar tendon just below the patella By striking the Achilles tendon when the client's leg is flexed

By striking the radius 3 to 5 cm above the wrist The brachioradialis reflex can be elicited by striking the radius 3 to 5 cm above the wrist while the client's arm is relaxed. Striking the triceps tendon above the elbow elicits the triceps reflex. Striking the patellar tendon just below the patella elicits the patellar reflex. Striking the Achilles tendon elicits the Achilles tendon reflex when the client's leg is flexed.

While caring for a client with a nasal injury, the nurse also suspects a skull fracture. Which manifestation might have led the nurse to conclude this? Multiple choice question Positive dipstick test Crackling of the skin on palpation Clearly visible fracture in the X-ray report Clear yellow halo ring structure on a filter paper

Clear yellow halo ring structure on a filter paper The drainage of cerebrospinal fluid (CSF) from the injured area indicates a skull fracture. The presence of a clear yellow halo ring-shape structure appearing on a piece of filter paper indicates the presence of CSF, an indication of a skull fracture. A positive dipstick test indicates the presence of sugar in the CSF. Crackling of the skin occurs with a normal nose injury. An X-ray may not detect the presence of CSF.

A nurse is assessing the skin of a client with a cortisol deficiency. Which integumentary assessment finding will most likely be observed in this client? Multiple choice question Dry skin Ulcerated skin Generalized edema Diminished axillary hair

Clients with cortisol deficiencies will have diminished axillary and pubic hair. Dry skin is associated with hypothyroidism. Ulcerated skin is a sign of peripheral neuropathy and peripheral vascular disease. Generalized edema is seen in clients with hypothyroidism due to mucopolysaccharide accumulation in the tissues.

A nurse is planning care for a client with cancer who is receiving the plant alkaloid vincristine. In contrast to the side effects of most chemotherapeutic agents, what is a common side effect of vincristine that the nurse must address in the client's care plan? Multiple choice question Nausea Alopecia Constipation Hyperuricemia

Constipation Although most chemotherapy causes diarrhea, vincristine can cause severe constipation, impaction, or paralytic ileus. Nausea, alopecia, and hyperuricemia are side effects shared with most other chemotherapeutic agents.

A client complains of weight gain and purplish-blue striae on the abdomen. Which condition does the nurse anticipate in the client? Multiple choice question Hypothyroidism Addison's disease Cushing's syndrome Pheochromocytoma

Cushing's syndrome occurs because of chronic exposure to excess corticosteroids. Weight gain and purplish-blue striae are the clinical manifestations of Cushing's syndrome. Anemia, weight gain, and cold dry skin are the common manifestations of hypothyroidism. Weight loss and fatigue are the manifestations observed in Addison's disease. Severe, pounding headache, tachycardia, and profuse sweating are the clinical manifestations observed in pheochromocytoma.

Which physical changes may cause longitudinal nail ridges? Multiple choice question Decreased rate of growth Decreased cell division Decreased blood flow Decreased vitamin D production

Decreased blood flow Longitudinal ridges may be due to decreased blood flow to the nail beds. Decreased cell division in the skin may cause a delay in wound healing. Increased risk of fungal infections is due to decreased rate of growth. Increased risk of osteomalacia is due to a decrease in vitamin D levels.

Which stage of Kohlberg's theory explains the influence of moral values on an individual's thought? Multiple choice question Good boy-nice girl orientation Society-maintaining orientation Instrumental relativist orientation Universal ethical principle orientation

During the society-maintaining orientation stage, an individual expands focus from a relationship with others to societal concerns. These individuals may be influenced by moral values. During the good boy-nice girl orientation stage, an individual wants to win the approval of and maintain the expectations of one's immediate group. When a child wants to be on time for dinner, this action explains the instrumental relativist orientation stage. The universal ethical principle orientation stage defines "right" in accordance with self-chosen ethical principles.

An adolescent reports scrotal pain, redness, dysuria, and fever. Which condition does this adolescent have? Multiple choice question Varicocele Epididymitis Testicular torsion Testicular cancer

Epididymitis is a condition associated with scrotal pain, dysuria, redness, and fever. Varicocele can be palpated as a worm-like mass situated above the testicles. Manifestations of testicular torsion include nausea, vomiting, and abdominal pain. The presence of a heavy, hard mass that is palpable accompanied by back pain and shortness of breath is associated with testicular cancer.

A client is admitted to the hospital with a diagnosis of liver disease, and a liver biopsy is prescribed. After the liver biopsy, how often and for how long should the nurse take the client's vital signs? Every 15 minutes for two hours Every 30 minutes for four hours Every hour for 8 hours Every 2 hours for 12 hours

Every 15 minutes for two hours is an appropriate frequency to take the vital signs after a liver biopsy. The risk of internal bleeding is highest immediately after the biopsy; diseases of the liver result in impaired blood-clotting mechanisms. Every 30 minutes after a liver biopsy is too infrequent; two hours after the procedure the vital signs can be taken every 30 minutes instead of every 15 minutes if they are stable. Every hour for 8 hours is too infrequent and unsafe if hemorrhage is to be detected before shock occurs. Every 2 hours for 12 hours is too infrequent and unsafe if hemorrhage is to be detected before shock occurs.

When assessing for hemorrhage on a client who has a total hip replacement, what is the most important nursing action to implement? Multiple choice question Measure the girth of the thigh. Examine the bedding under the client. Check the vital signs every 4 hours. Observe for ecchymosis at the operative site.

Examine the bedding under the client. Because of the recumbent position, drainage may flow by gravity under the client and not be noticed unless the bedding is examined. Measuring the girth of the thigh is inaccurate when there is a dressing in place. In the immediate postoperative period, vital signs should be taken more frequently than every 4 hours; in addition, observation of the site is a more reliable indicator of hemorrhage. Dressings impede an accurate assessment of the site for ecchymosis.

A nurse is assessing a client with diabetes insipidus. Which signs indicative of diabetes insipidus should the nurse identify when assessing the client? . Multiple selection question Excessive thirst Increased blood glucose Dry mucous membranes Increased blood pressure Decreased serum osmolarity Decreased urine specific gravity

Excessive thirst Dry mucous membranes Increased blood pressure Decreased urine specific gravity

A client with a diagnosis of schizophrenia is discharged from the hospital. At home the client forgets to take the medication, is unable to function, and must be rehospitalized. What medication may be prescribed that can be administered on an outpatient basis every 2 to 3 weeks? Multiple choice question Lithium Diazepam Fluvoxamine Fluphenazine

Fluphenazine can be given intramuscularly every 2 to 3 weeks to clients who are unreliable about taking oral medications; it allows them to live in the community while keeping the disorder under control. Lithium is a mood-stabilizing medication that is given to clients with bipolar disorder. This drug is not given for schizophrenia. Diazepam is an antianxiety/anticonvulsant/skeletal muscle relaxant that is not given for schizophrenia. Fluvoxamine is a selective serotonin reuptake inhibitor; it is administered for depression, not schizophrenia.

What is the source of an Integra graft? Multiple choice question Porcine skin Cadaveric skin Glycosaminoglycan bonded to silicone membrane Porcine collagen bonded to silicone membrane

Glycosaminoglycan bonded to silicone membrane Glycosaminoglycan bonded to silicone membrane is the source of an Integra artificial skin graft. Porcine skin is the source of a xenograft. Cadaveric skin is the source of an allograft. Porcine collagen bonded to silicone membrane is the source of a biobrane graft.

A nurse is evaluating scenarios that are based on the responses of several clients. Which statement of a client confirms that he or she has reached the Intimacy versus Isolation stage according to Erikson's theory of psychosocial development? Multiple choice question "I donate a large sum of money to the local school every year." "I want to enjoy my motherhood and that's why I am leaving the job." "In the winter of my life, I feel that I do not have anyone to take care of me." "I did so much for my partner but I was dumped for someone more attractive."

In the Intimacy versus Isolation stage, a young adult develops a sense of identity and deepens his or her capacity to love and care for others. A statement that exemplifies this stage is one from a client who says that he or she did so much for his or her partner but still got dumped for someone more attractive. An example of the Generativity versus Self-Absorption and Stagnation stage is if a client says that he or she donates a large sum of money to the local school every year. An older adult says that he/she feels that he/she does not have anyone to take care of him or her is in the Integrity versus Despair stage.

A client reports redness, itching, burning, and pain in the palms and elbows. On assessing, the nurse finds demarcated, silvery, scaling plaques in the area. Which drug does the nurse expect in the client's prescription? Multiple choice question Oral famcyclovir Intravenous ceftriaxone Topical benzoyl peroxide Intralesional injection of corticosteroids

Intralesional injection of corticosteroids Psoriasis is an autoimmune chronic dermatitis that is sharply demarcated with silvery, scaling plaques with reddish colored skin most often on palms and elbows. The main goal is to reduce inflammation and suppress rapid turnover of epidermal cells. Intralesional injection of corticosteroids is beneficial in treating chronic plaques. Famcyclovir is an antiviral that may be used to treat infections such as herpes zoster. Intravenous ceftriaxone may be used to treat severe cases of Lyme disease that include cardiac, arthritic, and neurologic symptoms. Topical benzoyl peroxide is an antimicrobial that may be used to treat conditions such as acne vulgaris.

Which statement about levonorgestrel requires correction? Multiple choice question Levonorgestrel is an over the counter drug. Levonorgestrel is an emergency contraceptive. Levonorgestrel is taken in combination with methotrexate. Levonorgestrel should be taken within 72 hours of intercourse.

Methotrexate is a drug prescribed for inducing abortion; this drug is used in combination with misoprostol. Levonorgestrel is an over-the-counter medication that is given without a prescription. It is an emergency contraceptive that should be taken within 72 hours of intercourse.

A registered nurse is teaching isometric exercises to an 80-year-old client. Which age change in the client necessitates the teaching of this exercise? Multiple choice question Kyphotic posture Muscular atrophy Decreased bone density Cartilaginous degeneration

Muscular atrophy Isometric exercises that increase muscle strength are indicated in older clients with muscular atrophy. Clients with kyphotic posture are taught exercises to maintain body mechanics. Clients with decreased bone density are taught weight-bearing exercises and safety tips to prevent falls. Clients with cartilaginous degeneration are advised to take moist heat showers because they increase blood flow to the region.

The nurse encourages a client with Raynaud disease to stop smoking. Which primary goal is the nurse trying to achieve? Multiple choice question Prevent pain and tingling Prevent cyanosis and necrosis Prevent peripheral vasoconstriction Prevent excessive blood oxygen content

Nicotine causes spasms and constriction of the smooth muscles of the arterial vasculature, compromising blood flow to the distal extremities. Nicotine does not directly cause pain and tingling, although these may occur as consequences of nicotine-induced vasoconstriction. Vasoconstriction from nicotine will not result in such severe effects as cyanosis and necrosis. Smoking increases the carboxyhemoglobin level in the blood; carbon monoxide combines with hemoglobin and occupies the sites on the hemoglobin molecule that bind with oxygen, thus decreasing oxygen content.

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 105° F. Which condition does the nurse suspect in the client? Multiple choice question Heat stroke Heat exhaustion Accidental hypothermia Malignant hyperthermia

Older adults are more at a risk of heat stroke. Symptoms of heat stroke include giddiness, excessive thirst, nausea, and increased body temperature. Heat exhaustion is indicated by a fluid volume deficient. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss. Accidental hypothermia usually develops gradually and goes unnoticed for several hours. When the skin temperature drops below 95° F, the client suffers from uncontrolled shivering, memory loss, depression, and poor judgment. Malignant hyperthermia is an adverse effect of inhalational anesthesia that is indicated by a sudden rise in body temperature in intraoperative or postoperative clients.

Which phrases best describe functional nursing? Multiple selection question Focuses on holistic care Originated during a nursing shortage Care provided similar to an assembly line Tasks assigned according to scope of practice Charge nurse coordinates care and assignments

Originated during a nursing shortage Care provided similar to an assembly line Tasks assigned according to scope of practice Charge nurse coordinates care and assignments Functional nursing originated during World War II when there was a severe nursing shortage in the United States. The division of aspects of care in functional nursing is similar to the assembly line system used by manufacturing industries. In functional nursing, tasks are in part determined by the scope of practice defined for each type of caregiver. The charge nurse coordinates care and assignments and may ultimately be the only person familiar with all the needs of any individual client. Holistic care is not a characteristic of functional nursing because the client is cared for by many different providers.

A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the drug, the client complains of feeling dizzy. What action should the nurse take? Multiple choice question Determine if this is an allergic reaction. Elevate the client's head and keep the extremities warm. Place the client in the supine position and take the vital signs. Tell the client that this is not a typical sensation after receiving morphine sulfate.

Place the client in the supine position and take the vital signs Vertigo is a symptom of hypotension, a side effect of morphine sulfate. The supine position increases venous return, increases cardiac output, and increases blood flow to the brain. Dizziness is a symptom of hypotension that is a side effect, not an allergic response, to morphine sulfate. Raising the client's head may aggravate dizziness. Dizziness is a typical side effect of morphine sulfate.

After fertilizer plant explosion, the nearest healthcare facility services were flooded with clients. The green-tagged clients who self-transported to the hospital from the site unknowingly carried toxins. Which emergency response plan devised by the emergency department (ED) does the registered nurse consider to be most suitable to reduce the risk of potentially disastrous consequences in the hospital? Multiple choice question Providing appropriate decontamination measures at the facility Determining the number of actual casualties who will be arriving Making provisions to handle them at the field as a part of the disaster plan Preventing green-tagged clients from receiving care prior to other category clients

Providing appropriate decontamination measures at the facility The ED should devise emergency response plans that cover a broad range of contingencies including appropriate decontamination capabilities. In a mass casualty scenario, the hospital may not be able to determine how many actual casualties will arrive because green-tagged clients mainly self-transport, so making provisions to handle them in the field as a part of the disaster plan may be helpful. Generally in a mass casualty event, black-tagged clients are not treated but green-tagged clients are.

A client who is recuperating from a spinal cord injury at the L2 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity? Multiple choice question Push-ups to strengthen arm muscles Leg lifts to prevent hip contractures Balancing exercises to promote equilibrium Quadriceps-setting exercises to maintain muscle tone

Push-ups to strengthen arm muscles

A client and her partner are working together to achieve an unmedicated birth. The client's cervix is now dilated to 7 cm, and the presenting part is low in the midpelvis. What should the nurse instruct the client to do that will alleviate discomfort during contractions? Multiple choice question Deep-breathe slowly. Perform pelvic rocking. Use the panting technique. Begin patterned, paced breathing.

Slow, deep breathing expands the spaces between the ribs and raises the abdominal muscles, giving the uterus room to expand and preventing painful pressure of the uterus against the abdominal wall. Pelvic rocking is used to relieve pressure from back labor. Panting is used to halt or delay the expulsion of the infant's head before complete dilation has occurred. Patterned, paced breathing is used during the transition phase of the first stage; the client has not yet reached this phase.

What are the clinical manifestations of actinic keratosis in a client? Multiple selection question Firm, nodular lesions Small papules with dry skin Wrinkled, weather-beaten skin Pearly papules with a central crater Irregularly shaped, pigmented papule

Small papules with dry skin Wrinkled, weather-beaten skin Small papules with dry skin and wrinkled, weather-beaten skin are clinical manifestations of actinic keratosis. Firm, nodular lesions are clinical manifestations of squamous cell carcinoma. Pearly papules with a central crater are the clinical manifestations of basal cell carcinoma. Irregularly shaped, pigmented papules are the clinical manifestations of melanoma.

The nursing manager issued orders to take the utmost care of a client with myocardial infarction and expects the staff to obey and follow the rules immediately. Which type of decision making is the manager using? Multiple choice question Autocratic Optimizing Laissez-faire Bureaucratic

The autocratic method results in rapid decision-making and is more appropriate in a crisis situation. Optimizing decision making is when the nurse considers both pros and cons of each position. Laissez-faire is a "hands-off" approach, which is taken by manager who chooses to do nothing when intervention is indicated. The bureaucratic style is focused on organizational rules and policies.

Which geometric figure is often the last to be mastered during the preschool stage of development? Multiple choice question Circle Square Triangle Rectangle

The last geometric figures that the preschool-age client masters include the triangle and the diamond. The circle is often mastered by the age of 3 while the square and rectangle are mastered by the age of 5.

What are the functions of a client's subcutaneous layer of skin? . Multiple selection question It provides insulation. It acts as an energy reservoir. It prevents systemic dehydration. It provides cells for wound healing. It acts as a mechanical shock absorber.

The subcutaneous layer provides insulation and acts as an energy reservoir and mechanical shock absorber. The epidermal layer prevents systemic dehydration. The dermal layer provides cells for wound healing.

A client with colon cancer is receiving hospice care at home. What is the focus of hospice care? Multiple choice question To ease the pain from illness To provide curative treatment To assist with activities of daily living To adapt to the limitations due to illness Eugene on target

To ease the pain from illness The focus of hospice care is palliative care to ease the pain caused by the illness. It is a system of family-centered care that allows clients to live at home with dignity. Hospice care does not provide curative treatment. The health care team follows an individualized plan of care for the client. Assisted living facilities offer long-term care for the older client in settings with a home-like environment. These facilities assist the client with activities of daily living. Rehabilitation facilities provide restorative care that helps the client to adapt the limitations caused by the illness.

A nurse is caring for a client who reports urinary problems, and the healthcare provider prescribes a cholinergic medication. Which urinary problem will this medication correct? Multiple choice question Urinary frequency due to bladder spasticity Urinary retention due to bladder atony Pain due to urinary tract calculi Urinary urgency due to urinary tract infections

Urinary retention due to bladder atony Cholinergics intensify and prolong the action of acetylcholine, which increases tone in the genitourinary tract, preventing urinary retention. Anticholinergics are prescribed for frequency and urgency associated with a spastic bladder. Cholinergics will not prevent renal calculi. Urinary tract infections are a secondary gain because cholinergics help prevent urinary retention that can lead to urinary tract infection, but this is not the primary purpose for administering a cholinergic.

What does a nurse understand by the quality improvement competency, according to Quality and Safety Education (QSEN)? Multiple choice question Using information and technology to communicate, manage knowledge, mitigate errors, and support decision-making Integrating best current evidence with clinical expertise along with client and family preferences and values for the delivery of quality healthcare Functioning effectively within nursing and interprofessional teams by fostering open communication, mutual respect, and shared decision making to achieve quality client care Using data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care system

Using data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care system The quality improvement competency states that a nurse should use data to monitor the outcomes of healthcare processes and uses improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems. According to the competency called informatics, a nurse should use information and technology to communicate, manage knowledge, mitigate errors, and support decision-making. As per the competency called evidence-based practice, a nurse should integrate best current evidence with clinical expertise and client and family preferences and values for the delivery of quality healthcare. According to the competency called teamwork and collaboration, a nurse should function effectively within nursing and interprofessional teams by fostering open communication, mutual respect, and shared decision making to achieve quality client care.

Before a cholecystectomy, vitamin K is prescribed. The nurse recognizes that this is ordered because vitamin K contributes to the formation of which substance? Multiple choice question Bilirubin Prothrombin Thromboplastin Cholecystokinin

Vitamin K is necessary in the formation of prothrombin to prevent bleeding. It is a fat-soluble vitamin and is not absorbed from the gastrointestinal (GI) tract in the absence of bile. Bilirubin is the bile pigment formed by the breakdown of erythrocytes. Thromboplastin converts prothrombin into thrombin during the process of coagulation. Cholecystokinin is the hormone that stimulates contraction of the gallbladder.

The nurse is reviewing a client's current medication therapy and suspects hematuria. Which medication is responsible for the client's condition? Multiple choice question Warfarin Cimetidine Phenazopyridine Nitrofurantoin

Warfarin Warfarin is an anticoagulant. Anticoagulants may cause hematuria, which is the presence of blood in the urine. Cimetidine is an antihistamine. Antihistamines affect the normal contraction and relaxation of the urinary bladder. Phenazopyridine and nitrofurantoin cause urine discoloration.

The nurse as a leader provides feedback to a newly recruited nursing student after checking the student's progress report. Which action of the registered nurse is most closely aligned with the application of two-factor theory during the feedback session? Multiple choice question Creating enthusiasm for practice Ignoring negative behaviors of the student nurse Promoting job enrichment by creating job satisfaction Providing specific feedback about positive performance

two-factor theory of leadership indicates that motivating factors such as promoting job enrichment by creating job satisfaction inspire the work performance of the staff. Creating enthusiasm for staff practice characterizes the transformational theory of leadership. Ignoring the negative behaviors of student nurses indicates an application of the Organizational Behavior Modification theory of leadership. Providing specific feedback about positive performance indicates the application of the Expectancy theory of leadership.

n older adult in an acute care setting is experiencing emotional stress because of a recent surgery. Which intervention would be most appropriate for the client? Multiple choice question Touch Reminiscence Reality orientation Validation therapy

A client who has undergone surgery may experience emotional stress leading to disorientation. Reality orientation is an appropriate intervention to minimize the client's disorientation. Touch is a therapeutic tool that helps to induce relaxation, provide physical and emotional comfort, and communicate interest. Reminiscence helps to bring meaning and understanding to the present and resolve current conflicts by recollecting the past. Validation therapy is a communication technique that can help a client in a confused state.

An infant has developmental dysplasia of the hip. What clinical finding should the nurse expect to note during an assessment? Multiple choice question Apparent shortening of one leg Limited ability to adduct the affected leg Narrowing of the perineum with an anal stricture Inability to palpate movement of the femoral head

Apparent shortening of one leg The affected leg appears to be shorter because the femoral head is displaced upward. The child's ability to abduct, not adduct, the affected leg is limited. Narrowing of the perineum with an anal stricture does not occur with hip dysplasia. When the femoral head slips out of the acetabulum, it is palpable.

The nurse understands that research demonstrates that malnutrition occurs in as many as 50% of hospitalized clients. The nurse should assess a postoperative client with anorexia for what sign of malnutrition? Multiple choice question Dependent edema Spoon-shaped nails Loose, decayed teeth Delayed wound healing

Delayed wound healing Delayed wound healing often is caused by a lack of nutrients, such as protein and vitamin C, in the diet. Dependent edema usually occurs with severe protein deficiency and heart failure. Spoon-shaped nails usually occur with iron deficiency anemia. Loose, decayed teeth usually indicate prolonged malnutrition.

A young woman is diagnosed as having genetically related amenorrhea. What is the primary nursing intervention at this time? Multiple choice question Supporting her physical abilities Discussing her altered body image Trying to meet her emotional needs Exploring other reproductive options with her

Emotional needs are of primary importance, because genetic amenorrhea is usually not treatable. Supporting the client's physical abilities is not a priority at this time. There are no data to indicate that the client is experiencing an alteration in her body image. Exploring other reproductive options with her is nontherapeutic; emotional needs should be met by establishing a trusting relationship before discussing alternate reproductive options.

A nurse is interacting with a depressed, suicidal client. What themes in the client's conversation are of most concern to the nurse? Multiple selection question Power Betrayal Loneliness Hopelessness Indecisiveness

Loneliness Hopelessness Loneliness and a sense of isolation may play a role in the intent to commit suicide. A real or perceived lack of support increases the risk for suicide because there is no "lifeline of caring." The main factor leading to acting on suicidal impulses is the feeling of hopelessness; there are no longer reasons to live. The struggle for power and dominance is more commonly encountered in the verbalizations of clients with paranoid schizophrenia. Betrayal is a feeling more often verbalized by clients with a diagnosis of a borderline personality disorder. An indecisive individual usually will not make the decision to commit suicide.

For which side effects should a nurse assess a client with cancer who is being treated with chemotherapeutic agents? . Multiple selection question Diarrhea Leukocytosis Bleeding tendencies Lowered sedimentation rate Increased hemoglobin levels

Most chemotherapeutic agentsinterfere with mitosis. The rapidly dividing cells of the mucous membranes of the gastrointestinal tract are affected, causing stomatitis and diarrhea. Bone marrow depression often causes thrombocytopenia, resulting in bleeding tendencies. The bone marrow consists of rapidly dividing cells, and therefore its activity is depressed. Leukopenia, not leukocytosis, can occur. The erythrocyte sedimentation rate generally increases in the presence of tissue inflammation or necrosis. Hemoglobin and hematocrit levels may decrease because of an inadequate number of red blood cells related to bone marrow depression.

A pregnant adolescent reports discomfort in her lower abdomen and watery-to-purulent vaginal discharge. The adolescent is diagnosed with a herpes simplex virus infection. Which medication would the nurse expect the primary healthcare provider to prescribe? Multiple choice question Acyclovir Penciclovir Famciclovir Valacyclovir

Of the drugs used to treat herpes simplex virus, acyclovir is the drug of choice. Penciclovir is used for herpes labialis. Famciclovir and valacyclovir are not prescribed for pregnant adolescents due to their potentially teratogenic effects.

A parent is worried about the infant's excessive dependence on nonnutritive sucking. Which intervention will help decrease this dependence? Multiple choice question Prolonging the feeding time Using infant formulas frequently Using a pacifier as soon as the crying begins Wrapping the infant snugly most of the time

Prolonging the feeding time An infant's dependence on nonnutritive sucking can be reduced by prolonging the feeding time, so that the sucking pleasure is increased. Using infant formulas will not help prevent nonnutritive sucking, because the child needs the pleasure of sucking. Using a pacifier as soon as the crying begins increases the child's dependence on nonnutritive sucking, because it reinforces a pattern of distress-relief. Wrapping the infant snugly most of the time may not be possible, because it may cause the infant to feel uncomfortable.

A nurse is assessing the effectiveness of a teaching plan regarding self-care and conservative management of gestational hypertension. The nurse confirms that the teaching has been understood when the client notes the importance of what? Multiple choice question Eating a low-protein diet Ensuring adequate sodium intake Joining a weight-reduction program Following the prescribed diuretic regimen

Sodium is not restricted, because restriction decreases blood volume, which in turn reduces placental perfusion. Women at risk for preeclampsia are advised to eat a high-protein diet. Losing weight is contraindicated during pregnancy and does not reduce the risk of preeclampsia. Diuretic therapy is contraindicated because it decreases blood volume, which in turn reduces placental perfusion.

A client had surgery for a strangulated hernia. One hour after surgery the client's blood pressure drops from 134/80 to 114/76 mm Hg. Assessment reveals that the client does not have postoperative bleeding. What action should the nurse take? Multiple choice question Place the client in the left side-lying position. Instruct the client to move both legs. Notify the primary healthcare provider immediately. Administer the prescribed pain medication.

The lowered blood pressure may be caused by pooling of blood in peripheral vessels; moving the legs will aid venous return. Turning the client onto the left side will not increase the blood pressure; this intervention is used for pregnant women to move the gravid uterus off the vena cava, which increases placental perfusion. Calling the healthcare provider eventually may be done after performing the initial interventions and evaluating results. Opioid analgesics may decrease the blood pressure further.

A nurse is teaching about near-miss events to a group of nursing students. What is appropriate for the nurse to include in the education? Multiple selection question They do not cause actual harm to the patient. They may cause moderate harm to the patient. They are caused by a variation in standard care. They are caused by impaired immune functioning. Their cause can be analyzed by failure mode effective analysis

They do not cause actual harm to the patient. They are caused by a variation in standard care. Their cause can be analyzed by failure mode effective analysis

A school-aged child with newly diagnosed acute lymphocytic leukemia (ALL) is to undergo induction therapy with prednisone, vincristine, and asparaginase. After several days the child becomes constipated. What does the nurse suspect as the cause? Multiple choice question Diet, which lacks bulk Inactivity, which results from illness Vincristine, which decreases peristalsis Prednisone, which causes gastric irritability

Vincristine, which decreases peristalsis Constipation, which may progress to paralytic ileus, is a side effect of vincristine. Lack of bulk and inactivity each may contribute to constipation, but neither is the primary cause of this child's constipation. Prednisone may cause nausea and vomiting, but it does not cause constipation.

A nurse is learning about the maturation of systems in a school-age child. Which statement made by the nurse indicates effective learning? Multiple choice question "The heart grows slower in the school-age child than at any other period of life." "Physical maturity in the school-age child correlates with emotional and social maturity." "The school-age child has less efficient maintenance of blood sugar levels than a preschooler." "Facial proportions change in the school-age child as the face grows slower in relation to the remainder of the cranium."

"The heart grows slower in the school-age child than at any other period of life." The heart grows more slowly during the middle childhood years and is smaller in relation to the rest of the body than at any other period of life. Physical maturity in the school-age child is not necessarily correlated with emotional and social maturity. Children will generally have the emotional and social maturity that corresponds to their age. As the gastrointestinal system in a school-age child is more mature than that in a preschooler, the school-age child has better maintenance of blood sugar levels than preschoolers. In the school-age child, facial proportions change as the face grows faster in relation to the remainder of the cranium. The skull and brain grow very slowly during this period and increase little in size thereafter.

A client visiting the prenatal clinic for the first time asks the nurse about the probability of having twins because her husband is one of a pair of fraternal twins. What is the appropriate response by the nurse? Multiple choice question "A sonogram will tell us if there's a twin pregnancy." "There's a 25 percent probability of you having twins." "Your husband's history of being a twin increases your chance of having twins." "There's no greater probability of you having twins than in the general population."

"There's no greater probability of you having twins than in the general population." Fraternal twins may occur as a result of a hereditary trait; however, it is related to the release of two eggs during one ovulation; the fact that the father is a fraternal twin would not influence the female's ovaries to release two eggs during one ovulation. Although it is true that a sonogram will reveal the presence of twins, this response does not answer the client's question. If there is no maternal family history of twin pregnancies, this client's pregnancy with twins would be a chance occurrence equal to the probability found in the general population.

Which is an example of indirect contact transmission of microorganisms? Multiple choice question Kissing Deer tick Dirty hands Contaminated water

Dirty hands Indirect contact transmission involves the transfer of microorganisms from a source to a host by passive transfer from a contaminated article or hands. With direct contact, the source and host have physical contact from skin to skin or from mucous membrane to mucous membrane through kissing. A deer tick is an example of the transmission of infection between a vector or an insect that carries pathogens between two or more hosts. Ingesting infected water is a form of direct contact transmission of microorganisms.

A nurse is interviewing a client with the diagnosis of dementia of the Alzheimer type. What question should the nurse ask to assess the client's orientation to place? Multiple choice question "Where are you?" "Who brought you here?" "Do you know where you are?" "How long have you been here?"

where are you "Where are you?" is the best question with which to elicit information about the client's orientation to place, because it encourages a response that can be assessed. Asking who brought the client focuses on recent memory; it does not assess orientation to place. "Do you know where you are?" can be answered yes or no and will not objectively reveal the client's orientation. "How long have you been here?" focuses on orientation to time, not place.

The nurse is teaching a group of students about the manifestation of alkalosis in the central nervous system. Which statements by a student nurse are accurate? Multiple selection question "The client's Chvostek sign would be negative." "The client's Trousseau sign would be positive." "The client would be suffering from paresthesias." "The client would show signs of anxiety and irritability." "The client's central nervous system should have a decrease activity in case alkalosis."

"The client's Trousseau sign would be positive." "The client would be suffering from paresthesias." "The client would show signs of anxiety and irritability." If clients suffer from the alkalosis, the manifestation in the nervous system would involve paresthesias. The client will also have a positive Trousseau sign and have anxiety and irritability. The Chvostek sign would also be positive, not negative. The client would show signs of anxiety and irritability. The central nervous system should have increased activity with alkalosis, not decreased.

The registered nurse is evaluating the actions of a nursing student who is providing emergency care to a client with an extremity fracture. Which action of the nursing student does the registered nurse think needs a correction? Multiple choice question Keeping the client warm Removing the shoes of the client Immobilizing the affected extremity Allowing the client to lie in supine position

A client with an extremity fracture has severe pain in the affected area. The client's shoes should not be removed because doing so can increase trauma in the client. The client with an extremity fracture should be kept warm and comfortable. The affected extremity should be immobilized to prevent further damage. The client with an extremity fracture should be allowed to lie in a supine position because this provides comfort.

At which stage of Kohlberg's theory does an individual show societal concerns? Multiple choice question Stage I Stage II Stage III Stage IV

According to Kohlberg's theory of moral development, at stage IV the individual expands focus from a relationship with others towards societal concerns. At stage I, the child is afraid of punishment. A child in this stage reasons, "I must follow the rules; otherwise I will be punished." At stage II, the child recognizes that there is more than one right view. At stage III, the child wants to win approval and maintains the expectations of one's immediate group.

The parents of a preschooler tell the nurse that they try to inculcate good eating habits by asking the child to be at the table until the "plate is clean." What condition is the child at risk for? Multiple choice question Anorexia Depression Aggression Poor eating habits

Asking the child to be at the table until the "plate is clean" results in overeating and develops poor eating habits later in life. Anorexia is seen if the child does not consume the required amount of food. Depression may be seen in a child if there are any psychological issues. Aggression occurs from sociocultural and familial influences on the child.

A nurse is teaching the parents of a toddler with newly diagnosed celiac disease about the condition. What typical characteristic of this age group makes this child most susceptible to a celiac crisis? Multiple choice question Invention Autonomy Narcissism Negativism

Autonomy leads to exploration and self-feeding. The child may eat food that is not on the diet, so the parents should be cautioned to keep restricted foods out of their toddler's reach. Although invention, narcissism, and negativism are all common characteristics of the toddler, none leads to the child's eating restricted foods.

A client reports neck stiffness, severe headache, and a decreased level of consciousness. What condition does the nurse suspect? Multiple choice question Encephalitis Brain abscess Viral meningitis Bacterial meningitis

Bacterial meningitis is caused by a bacterium such as Streptococcus pneumonia. Fever, severe headache, neck stiffness, photophobia, and decreased levels of consciousness are symptoms that indicate bacterial meningitis. Encephalitis is the acute inflammation of brain. Nausea and vomiting are symptoms of encephalitis. Headache, fever, nausea, and vomiting are the symptoms of brain abscess. Headache, fever, and photophobia are the symptoms of viral meningitis.

Which clinical manifestation is characterized by eczematous eruption with well-defined geometric margins? Multiple choice question Drug eruption Atopic dermatitis Contact dermatitis Nonspecific eczematous dermatitis

Contact dermatitis In contact dermatitis, localized eczematous eruptions are seen with well-defined geometric margins. In drug eruption, bright-red erythematosus macules and papules are seen. In atopic dermatitis, lichenification with scaling and excoriation is observed. Lichenification with weeping papules and macules is seen in nonspecific eczematous dermatitis.

The laboratory reports of a client reveal selective hypopituitarism related to growth hormone (GH). What other findings does the nurse anticipate in the client? Multiple selection question Decreased body hair Decreased serum cortisol Decreased muscle strength Increased serum cholesterol Decreased tolerance to cold

Decreased muscle strength Increased serum cholesterol The deficiency of GH results in a decrease in the body's muscle strength because GH regulates bone and muscle growth. GH deficiency also results in an increase in serum cholesterol levels because GH also plays a role in lipid metabolism. Hyposecretion of gonadotropins results in decreased body hair. The serum cortisol levels decrease when there is deficiency of adrenocorticotropic hormone that regulates cortisol secretion. Thyroid-stimulating hormone (TSH) regulates thyroid hormones secretions, which are involved in thermoregulation. Therefore hyposecretion of TSH results in decreased tolerance to cold.

A client has bright-red erythematosus macules and papules on the skin. What could be the diagnosis? Multiple choice question Drug eruption Atopic dermatitis Contact dermatitis Nonspecific eczematous dermatitis

Drug eruptions are characterized by bright-red erythematosus macules and papules on the skin, which occur because of an adverse reaction to a drug. Atopic dermatitis is characterized by scaling and excoriation, which occurs due to food allergies, chemicals, or stress. Contact dermatitis manifests as localized eczematous eruption when the skin comes into direct contact with irritants or allergens. Nonspecific eczematous dermatitis results in evolution of lesions from vesicles to weeping papules and plaques.

Which teaching statement related to the growth of a preschool-age client is appropriate when educating the family during a scheduled health maintenance visit? Multiple choice question "The rate of physical growth accelerates during this stage of development." "Muscle and bone development is mature during this stage of development." "You can expect your child to keep the potbelly appearance during this stage of development." "Your child's legs will grow in length versus the trunk of the body during this stage of development.

During the preschool stage of development the legs will grow in length versus the trunk as seen during the previous stages of development. The rate of physical growth slows and stabilizes during the preschool stage of development. Muscle and bone development continue to be immature. The potbelly appearance disappears during the preschool stage of development; the preschooler is slender but sturdy, graceful, agile, and posturally erect.

A client had a bypass graft because of an abdominal aortic aneurysm. Postoperative prescriptions include measurements of the client's abdominal girth. Which serious problem may be indicated by an increasing abdominal girth? Multiple choice question Graft leakage Bowel puncture Abdominal infection Postoperative flatulence

Graft leakage During the first 24 hours after surgery, a sudden increase in abdominal girth most likely is graft related and needs to be investigated. Bowel puncture is a remote possibility but will present with classic signs (e.g., boardlike abdomen, abdominal pain) other than increasing abdominal girth. It is too early for an infection to manifest signs and symptoms. It is too early for postoperative flatulence to occur.

The nurse is providing care to a toddler-age client who is admitted to the medical unit with symptoms of lead poisoning. Which assessment question will help the nurse determine the source of the lead? Multiple choice question "What year was your home built?" "Do you have plants in your home?" "Does your child consume fish in the diet?" "Where do you store your cleaning solutions?"

Homes built before 1978 are often painted with lead-based paint, which increases the risk for lead poisoning; therefore, this is an appropriate question for the nurse to ask the parents of this child. Plants, fish, and cleaning solutions are not associated with lead poisoning.

What thought is common in an individual during the social contract orientation stage? Multiple choice question "I should avoid parties where alcohol is served." "I should follow rules or else the teacher will punish me." "I should work to change a law to better society." "I should complete my homework so that the teacher will reward me."

I should work to change a law to better society." When an individual thinks of changing a law according to his or her own personal view, this thought corresponds to the social contract orientation stage. People at this stage sometimes disobey rules if they believe that these rules are unfair or are harmful to society. When an individual thinks of avoiding parties where alcohol is served, this thought corresponds to the society maintaining orientation stage. When an individual thinks that breaking a rule will lead to a physical punishment, this thought corresponds to the punishment and obedience orientation stage. When an individual feels that doing a certain task will help win a reward, this thought corresponds to the good boy-nice girl orientation stage.

What is the purpose of block and parish nursing? Multiple choice question To provide services to older clients To promote health throughout a school curriculum To provide nursing services with a focus on health promotion and education To provide primary care to a client population living in a community

In block and parish nursing, nurses living within a neighborhood provide services to older clients or those unable to leave their homes. Health promotion throughout a school curriculum is provided by school health. Nurse-managed clinics provide nursing services with a focus on health promotion and education, chronic disease assessment management, and support for self-care and caregivers. Community health centers are outpatient clinics that provide primary care to a client population living in a community.

A nurse is planning an educational program for family members of clients with bipolar disorder. What clinical manifestations indicating the beginning of an episode of mania should the nurse include? Multiple selection question Insomnia Irritability Excessive eating Decreased libido Financial irresponsibility

Insomnia Irritability Financial irresponsibility During a manic episode there is a decreased need for sleep and clients do not feel tired. During a manic episode the primary mood is irritability; the emotions often fluctuate between euphoria and anger. During a manic episode impulsivity, impaired judgment, and involvement in pleasurable activities may result in spending sprees that can have negative consequences. During a manic episode there is a decrease in appetite. The client's increased activity and inability to sit still interfere with the ability to eat and drink. Hypersexuality, rather than decreased libido, is common during a manic episode.

The registered nurse is teaching a female client about the precautions to be taken while administering isotretinoin. Which statement made by the client indicates a need for further teaching? Multiple choice question "I should avoid the medicine when I am pregnant." "I should get liver function tests checked regularly." "I can donate blood within 2 weeks after treatment ends." "I should avoid the drug when am I planning for pregnancy."

Isotretinoin is prescribed for clients with acne vulgaris and severe nodulocystic acne. This drug has many complications. Blood donation is prohibited for those taking the drug and for 1 month after treatment ends. This drug is teratogenic, which means it causes serious damage to a developing fetus and should be avoided during pregnancy. Isotretinoin is linked to liver function test abnormalities. Isotretinoin is contraindicated in women who are intending to become pregnant while on the drug.

The nurse is caring for a client who has been admitted with partial- and full-thickness burns over 25% of the total body surface area. Lactated Ringer solution and 5% dextrose have been prescribed. What is the purpose of these fluids? Multiple choice question Prevent fluid shifts Expand the plasma Maintain blood volume Replace electrolytes lost

Maintain blood volume Fluids during the first 48 hours are given to replace fluid lost from the intravascular compartment to interstitial spaces. Administration of fluids treats the fluid shifts but does not prevent them. Lactated Ringer solution and 5% dextrose in saline are not plasma expanders, as is albumin. Electrolytes specifically are replaced based on serial assessments of serum electrolytes and arterial blood gases.

The medical history of a client with osteoporosis indicates renal calculi. Which medication would be contraindicated? Multiple choice question Os-cal Raloxifene Ibandronate Zoledronic acid

Os-cal Os-cal (a calcium supplement) should not be prescribed to a client with osteoporosis with a history of urinary stones. Raloxifene may increase liver function test values and worsen hepatic disease. Ibandronate should not be prescribed to clients with gastric problems because of the risks of esophagitis and gastric ulcers. Zoledronic acid should not be prescribed to clients with poor oral hygiene because the medication may cause maxillary osteonecrosis

An infant with a myelomeningocele is admitted to the pediatric intensive care unit. While the infant is awaiting surgical correction of the defect, what is the most appropriate nursing intervention? Multiple choice question Using disposable diapers Placing the infant in the prone position Performing neurologic checks above the site of the lesion Washing the area below the defect with a nontoxic antiseptic

Placing the infant in the prone position The prone position is the best position for preventing pressure on the sac. Diapers should not be applied because they may irritate or contaminate the sac. Assessment of the area below the defect is essential in determining motor and sensory function. There is no indication for the use of an antiseptic.

The geographic location of a community makes it vulnerable to storms. The community health nurse teaches the community about safety measures to be taken during a storm. Which phase of disaster management is this action? Multiple choice question Recovery Response Mitigation Preparedness

Preparedness is the phase in which a plan is designed before the disaster event to best structure the response. Teaching safety measures to the people of a locality is the preparedness phase. The recovery phase involves stabilizing the community after a disaster event. Response is the implementation of the disaster plan. Mitigation is a phase of disaster management in which attempts are made to limit the disaster's impact.

Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? Multiple choice question Pouring warm water over the perineum Ensuring the patency of the catheter Removing the catheter within 24 hours Cleaning the catheter insertion site

Removing the catheter within 24 hours Clients who undergo surgery are at a greater risk of acquiring catheter-associated urinary tract infections. Infections can be prevented by removing the catheter within 24 hours, if the client does not need it. Therefore removing the catheter within 24 hours would be the best intervention. While pouring warm water over the perineum helps voiding in the postoperative client and also reduces the chances of infection, this action would not be as beneficial as the former intervention. The catheter should be maintained in its place to avoid leakage and infection. Cleaning the catheter insertion site will definitely reduce the risk of infection, but this action cannot prevent infections if the catheter is inserted for a long time.

A client with a diagnosis of borderline personality disorder (BPD) has negative feelings toward the other clients on the unit and considers them all "bad." Which defense mechanism is the client using when identifying the other clients? Multiple choice question Splitting Ambivalence Passive aggression Reaction formation

Splitting is the compartmentalization of opposite-affect states and failure to integrate the positive and negative aspects of self or others. Ambivalence is the experience of feeling opposite emotions at the same time. Passive aggression is the expression of hostility toward another in an indirect, nonassertive way. Reaction formation is the expression of unacceptable desires by adopting opposite behaviors in an exaggerated way.

A client newly diagnosed with type 2 diabetes is receiving glyburide and asks the nurse how this drug works. What mechanism of action does the nurse provide? Multiple choice question Stimulates the pancreas to produce insulin Accelerates the liver's release of stored glycogen Increases glucose transport across the cell membrane Lowers blood glucose in the absence of pancreatic function

Stimulates the pancreas to produce insulin Glyburide, an antidiabetic sulfonylurea, stimulates insulin production by the beta cells of the pancreas. Accelerating the liver's release of stored glycogen occurs when serum glucose drops below normal levels. Increasing glucose transport across the cell membrane occurs in the presence of insulin and potassium. Antidiabetic medications of the chemical class of biguanide improve sensitivity of peripheral tissue to insulin, which ultimately increases glucose transport into cells. Beta cells must have some function to enable this drug to be effective.

A client receiving intravenous vancomycin reports ringing in both ears. Which initial action should the nurse take? Multiple choice question Notify the primary healthcare provider. Consult an audiologist. Stop the infusion. Document the finding and continue to monitor the client.

Stop the infusion. The first action the nurse should take is to stop the infusion immediately. Vancomycin can cause temporary or permanent hearing loss. The nurse should stop the medication infusion and then notify the healthcare provider at once if a client reports any hearing problems or ringing in the ears. An audiologist may need to be consulted at a later date, but this is not the best first action. The nurse should document the findings; however, it is not the initial action.

A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important? Multiple choice question Sodium Calcium Chloride Potassium

The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a critical factor in the cell's ability to function. Sodium is the most abundant cation of the extracellular compartment, not the intracellular compartment. Calcium is the most abundant electrolyte in the body; 99% is concentrated in the teeth and bones, and only 1% is available for bodily functions. Chloride is an extracellular, not intracellular, anion.

A male client is preparing to leave the hospital and return to college. When saying goodbye he hugs the nurse and kisses her on the cheek. What is the most appropriate response by the nurse? Multiple choice question Hug the client in return. Smile at the client but say nothing. Encourage him to visit periodically. Wish him well with his future studies.

Wish him well with his future studies An explicit termination statement is most appropriate; offering an expression of well-wishes sets an optimistic, positive tone while maintaining the nurse-client relationship. A repeat of the physical contact should be avoided because it may precipitate anxiety in the client or be interpreted as a desire to change the relationship from professional to personal. Smiling and saying nothing may indicate acceptance of the physical exchange and blurs boundaries. Encouraging the client to visit periodically is nontherapeutic because it indicates an ongoing rather than a terminating relationship.

While caring for a female client, the nursing student feels tenderness and a lump in the client's breast. The nursing student tells the registered nurse, "I think this client has breast cancer." Which statements of the registered nurse would be appropriate in accordance with the knowing element of Swanson's theory? Multiple selection question "Try to comfort the client." "Avoid making assumptions." "Assess the client thoroughly." "Check for other signs of breast cancer." "Try to provide support and care to the client."

"Avoid making assumptions." "Assess the client thoroughly." "Check for other signs of breast cancer." The knowing element of the caring process involves understanding an event. Avoiding assumptions, performing a thorough assessment of the client, and checking for other signs of breast cancer and are related to the knowing element of Swanson's theory of caring. The doing for element includes comforting the client. The caring process of being with involves the nurse providing emotional support.

An 8-year-old child has experienced the death of a sister. The child begins to ask many questions about what happens to the body after death. The parents wonder whether this is abnormal or morbid behavior picked up from playing video games. What is the best response by the nurse? Multiple choice question "Playing video games can cause morbid behaviors." "Children handle the event of death more realistically than adults do." "School-aged children are inquisitive and ask a lot of questions about death." "Giggling, attracting attention, and playing are the usual ways of dealing with death."

"Children handle the event of death more realistically than adults do." School-aged children handle death by asking questions and gaining information. Playing video games does not change the essential ways in which children deal with the deaths of loved ones. Children are unable to understand the finality of death until they have reached school age; they begin to think about it in idealistic ways by adolescence. Giggling and playing are a preschooler's reactions to death.

A client with a history of obsessive-compulsive behaviors has a marked decrease in symptoms and expresses a wish to obtain a part-time job. On the day of a job interview the client arrives at the mental health center with signs of anxiety. What is the most therapeutic response to the client's behavior by the nurse? Multiple choice question "I know you're anxious, but by forcing yourself to go to the interview you may conquer your fear." "If going to an interview makes you this anxious, you're probably not ready to go back to work." "It must be that you really don't want that job after all. I think you should reconsider going to the interview." "Going for your interview triggered some feelings in you. Perhaps you could call a friend to drive you there."

"Going for your interview triggered some feelings in you. Perhaps you could call a friend to drive you there." The symptoms are a defense against anxiety resulting from decision-making, which triggers old fears; the client needs support. Forcing the client to go to the interview ultimately denies the client's overwhelming anxiety and lacks realistic support. Stating that the client is not ready to go back to work is judgmental; the client should be encouraged to work through symptoms, not avoid risk. Stating that the client doesn't really want the job is judgmental; an increase in anxiety does not necessarily mean the client does not want to attain the goal.

The nurse teaches a client with exophthalmos how to reduce discomfort and prevent corneal ulceration. Which statement by the client indicates that teaching was effective? Multiple choice question "I should eliminate excessive blinking." "I should not move my extraocular muscles." "I should elevate the head of my bed at night." "I should avoid using a sleeping mask at night."

"I should avoid using a sleeping mask at night." The mask may irritate or scratch the eyes if the mask moves during sleep. Blinking of the eyes will bathe the eyes and prevent corneal ulceration. Not moving extraocular muscles will not relieve edema or prevent ulceration of the eyes. Although elevating the head of the bed at night will help reduce periorbital edema, it will not prevent ulceration of the cornea.

Which parental statements indicate correct understanding for the prevention of sunburn for a toddler-age client? Multiple selection question "I will keep my child indoors between 10 AM and 2 PM." "I will make sure my child wears a baseball cap while outside." "I will use a sunscreen with an SPF of 15 or higher for my child." "I will be sure to reapply sunscreen if my child sweats more than usual." "I will make sure my child wears cotton clothing with a tight weave while outside."

"I will keep my child indoors between 10 AM and 2 PM." "I will make sure my child wears a baseball cap while outside." "I will be sure to reapply sunscreen if my child sweats more than usual." "I will make sure my child wears cotton clothing with a tight weave while outside." In order to protect the toddler-age client from sunburn it is important to keep him or her out of the sun between 10 AM and 2 PM, ensure the child wears a baseball cap while outside, reapply sunscreen with profuse sweating, and make sure the child is dressed in cotton clothing with a tight weave. These statements all indicate correct understanding of the information presented by the nurse. An SPF of 30, not 15, or higher should be applied to prevent sunburn.

The parents of a child often try to persuade their preschooler to touch their pet dog because they want to reduce the child's fear of dogs. Instead, the child's fears and anxiety increase. What does the nurse suggest the parents do to help overcome their child's fear? Multiple choice question "Ask the child to touch the dog's back gently." "Keep the child away from dogs for a few years." "Let the child watch other children playing with dogs." "Bring in a pet cat to familiarize the child with animals."

"Let the child watch other children playing with dogs." The parents should allow the child to become comfortable with animals at a gradual pace, while maintaining the child's feeling of well-being. One way to do this is to encourage the child to watch as other children play with dogs. Encouraging the child to touch the dog's back gently is not effective for overcoming the child's fear, because the child should not be forced to touch the animal until he or she is comfortable. Trying to keep the child away from dogs will not be effective in reducing fear and may not be practical. Introducing the child to other animals, such as cats, may be ineffective, because the child's fear may be specific to dogs.

A preschool child is found to have atopic dermatitis. The nurse emphasizes that the child should be discouraged from scratching. The child's mother asks why scratching should be prevented. What is the nurse's response? Multiple choice question "Scratching causes lesions to become more contagious." "Scratching spreads dermatitis to other areas of the body." "Scratching results in skin breaks that can lead to infection." "Scratching produces changes that are precursors to skin cancer.

"Scratching results in skin breaks that can lead to infection." Scratching can break the integrity of the skin, leaving it vulnerable to infection. Dermatitis is a response to an allergen; it is not contagious. Scratching will not cause the dermatitis to spread. There are no data to indicate that scratching or dermatitis is a precursor to skin cancer.

An African-American woman is diagnosed with primary hypertension. She asks, "Is hypertension a disease of African-American people?" What is the nurse's best response? Multiple choice question "The prevalence of hypertension is about equal for women of all races." "The higher-risk population is composed of African-American men and women." "The highest-risk population consists of older Caucasian-American men and women." "The prevalence of hypertension is greater for African-American men than for African-American women."

"The higher-risk population is composed of African-American men and women." African-Americans represent a higher-risk population than Caucasian-Americans for hypertension; the reason is unknown. African-American women are more frequently affected by hypertension than are Caucasian women. African-Americans of both sexes have a higher prevalence than Caucasian-Americans of both sexes. African-American women have a higher risk than African-American men.

A nurse is caring for several clients with the diagnosis of bulimia nervosa. What primary feeling does the nurse anticipate that these clients experience after an episode of bingeing? Multiple choice question Guilt Paranoia Euphoria Satisfaction

A sense of being out of control accompanies the consumption of large amounts of food, resulting in guilt, depression, and disgust with one's self. Paranoia is associated with paranoid schizophrenia, not with bulimia nervosa. After bingeing, a person with bulimia nervosa usually feels depressed rather than euphoric or satisfied.

How many words in the vocabulary of a 3-year-old client would indicate the need for further assessment by the nurse? Multiple choice question 500 words 900 words 1500 words 2100 words

A vocabulary of 500 words at the age of 3 would indicate the need for the nurse to further assess the client's language development. Nine hundred words are expected and would not require further investigation by the nurse. Fifteen hundred words is expected by the age of 4 and 2100 words is expected by 5 years of age; therefore, these findings would not indicate the need for further assessment by the nurse.

A grand multipara at 34 weeks' gestation is brought to the emergency department because of vaginal bleeding. The nurse suspects that the client has a placenta previa. Which characteristic typical of placenta previa supports the nurse's conclusion? Multiple choice question Painful vaginal bleeding in the first trimester Painful vaginal bleeding in the third trimester Painless vaginal bleeding in the first trimester Painless vaginal bleeding in the third trimester

As the lower uterine segment stretches and thins, painless tearing and bleeding occur at the low implantation site. First-trimester bleeding, painful or painless, is associated with spontaneous abortion or inadequate implantation, not placenta previa. Painful vaginal bleeding in the third trimester is usually associated with abruptio placentae rather than placenta previa.

A client is scheduled for surgery to repair an irreducible (incarcerated) hernia. What nursing intervention is of primary importance? Multiple choice question Assessing the client's bowel movement Maintaining the client in the supine position Checking the client's vital signs periodically Monitoring the client's serum enzyme levels

Assessing the client's bowel movement A possible complication of a hernia is intestinal obstruction. If an obstruction occurs, there is no passage of flatus or bowel movements. The supine position will have no effect on an incarcerated hernia. Checking the client's vital signs periodically is done for all clients; it is not specific for a client with a hernia and is not the primary assessment. Monitoring the client's serum enzyme levels will not facilitate the identification of complications.

The nurse is assessing a client with a laryngeal trauma. This client presents with hemoptysis, aphonia, hoarseness, dyspnea, and subcutaneous emphysema. Which condition of the client stands first in the priority list? Multiple choice question Dyspnea Aphonia Hoarseness Subcutaneous emphysema

Bleeding from the airway, aphonia, hoarseness, and subcutaneous emphysema are the clinical manifestations of laryngeal trauma. Maintaining a patent airway is a priority; therefore, dyspnea should be corrected to prevent life-threatening consequences. Aphonia is of moderate priority and can be corrected by clearing the throat. Hoarseness can be cleared slowly since it does not threaten the client's life. Subcutaneous emphysema is of moderate priority since it does not affect the client's life directly.

A female client reports a white, thick, odorless discharge from the vulva. Upon examination, the nurse finds that the vulva are swollen. What does the nurse suspect in the client? Multiple choice question Candida infection Bacterial vaginosis infection Trichomonas vaginalis infection Chlamydia trachomatis infection

Candida infection is manifested by a white, thick, odorless discharge from the vulva along with inflammation. Therefore the nurse suspects Candida infection in the client. Bacterial vaginosis infection is manifested by a thin, white, and fishy smelling discharge from the vulva along with irritation. Trichomonas vaginalis infection is manifested by a frothy green- or yellow-colored, malodorous discharge from the vulva. Chlamydia trachomatis infection is manifested by a bloody discharge from the vulva.

What is the most appropriate assessment with which to detect the development of complications associated with acute glomerulonephritis (AGN) in a school-aged child? Multiple choice question Assessing the joints for stiffness daily Measuring the pH of each urine specimen Checking the blood pressure every 4 hours Testing the urine from each voiding for glucose

Checking the blood pressure every 4 hours One characteristic of AGN is hypertension. Arthralgia does not accompany AGN. The pathophysiology of AGN has no effect on the pH of urine. Testing for glycosuria is unnecessary because the kidneys have not lost their ability to reabsorb glucose.

The nurse is caring for a 70-year-old client who presents with dilute urine even when fluid intake is low. What could be the possible cause of the client's condition? Multiple choice question Decreased glucose tolerance Decreased general metabolism Decreased ovarian production of estrogen Decreased antidiuretic hormone production

Dilute urine with decreased fluid intake indicates a decrease in antidiuretic hormone production. Decreased glucose tolerance causes elevated fasting and random blood glucose levels. The clinical manifestations of decreased general metabolism are decreased heart rate and blood pressure, decreased appetite, and decreased tolerance to cold. Decreased ovarian production of estrogen may result in decreased bone density and thin and dry skin.

A nurse is caring for a school-aged child after an emergency appendectomy for a ruptured appendix. How should the nurse explain to the parents the reason for placing the child in the semi-Fowler position or right Sims position with the head of the mattress slightly elevated? Multiple choice question Aeration of the lungs is best accomplished in these positions. Drainage is facilitated, preventing subdiaphragmatic abscesses. Movement is easier, and complications from immobility are reduced. Splinting of the wound occurs because of pressure on the surgical site.

Drainage is facilitated, preventing subdiaphragmatic abscesses. Drainage (to the pelvic floor or through a portable wound drainage system) is facilitated by the principle of gravity, which prevents fluid accumulation and possible abscess formation. The lungs are aerated well in any position if a subdiaphragmatic abscess does not form. Deep breathing and coughing, leg exercises, and ambulation must be employed to prevent problems with immobility; maintaining a constant position does not provide mobility. Splinting of an abdominal wound is best accomplished with direct external pressure to the site, not with position changes. Splinting of the surgical site is done during coughing and deep breathing.

A primiparous client reports to the maternity unit stating that her contractions are occurring every 5 minutes. Upon further inquiry the nurse learns that the client has not attended any childbirth classes. A cervical assessment reveals that she is in true labor. When is the best time for the nurse to include education on simple breathing and relaxation techniques? Multiple choice question During the latent phase of the first stage of labor During the active phase of the first stage of labor During the active phase of the second stage of labor During the transition phase of the first stage of labor

During the latent phase of the first stage of labor the client is excited and open to learning. The contractions are not as strong as they are going to be, so the client has time between contractions to absorb the nurse's teaching. Contractions are more frequent and stronger in the active phase of the first stage. The increased frequency decreases the client's ability to absorb information. During the active phase of the second stage of labor the client will be bearing down to expel the fetus, and simple breathing techniques are not appropriate. During the transition phase of the first stage of labor the contractions are at their maximum intensity, which inhibits the client's ability to listen.

A client has had two weeks of bile drainage from a T-tube following the client's cholecystectomy. To monitor for a lack of fat-soluble vitamins, the nurse should observe for what symptom? Multiple choice question Easy bruising Muscle twitching Excessive jaundice Tingling of the fingers

Easy bruising Phytonadione, a precursor for prothrombin, cannot be absorbed without bile. Muscle twitching is commonly related to electrolyte imbalances, not fat-soluble vitamin deficiency. Jaundice results from a backup of bile, not a deficiency of fat-soluble vitamins. Tingling of the fingers may be related to electrolyte imbalances or deficiency of B vitamins, which are water soluble.

A nurse is implementing interventions to assist an aggressive client in deescalating the agitated behavior. Multiple selection question Physical contact with the client to show caring Encouraging the client to express perceived needs Avoiding verbal struggles in an attempt to demonstrate authority Providing the client with clear options to the unacceptable behavior Referring to the client in an authoritarian manner to demonstrate control of the situation Explaining the expected outcomes if the client is unable to control the unacceptable behavior

Encouraging the client to express perceived needs Avoiding verbal struggles in an attempt to demonstrate authority Providing the client with clear options to the unacceptable behavior Explaining the expected outcomes if the client is unable to control the unacceptable behavior Encouraging the client to express perceived needs provides the client with a sense of being heard and respected. Verbal struggling will likely increase the tension and aggressive behavior of the client. Providing options will allow the client to effectively change behaviors if capable of doing so. Explaining outcomes for continued unacceptable behavior allows the client to make a decision to change behaviors if capable of doing so. Touching the client will likely be viewed as aggressive and lead to an increase in the client's agitation. It is important to present a calm, firm persona but avoid being authoritarian, because this will likely lead to a power struggle.

Which cytokine medication is administered to treat chemotherapy-induced neutropenia? Multiple choice question Filgrastim Oprelvekin Aldesleukin Darbepoetin alfa

Filgrastim Colony-stimulating factors such as filgrastim are administered to treat chemotherapy-induced neutropenia. Oprelvekin is used to prevent thrombocytopenia. Aldesleukin is used to treat metastatic renal cell carcinoma. Darbepoetin alfa is administered to treat anemia related to chronic cancer and anemia related to chronic kidney disease.

A parent of a 13-year-old adolescent with recently diagnosed Hodgkin disease tells a nurse, "I don't want my child to know about the diagnosis." How should the nurse respond? Multiple choice question "It's best for your child to know the diagnosis." "Did you know that the cure rate for Hodgkin disease is high?" "Would you like someone with Hodgkin disease to talk with you?" "Let's talk about how you're feeling about your child's diagnosis."

Initiating a conversation about the client's feelings does not prejudge the parent; it encourages communication. Stating that it is best for the child to know the diagnosis disregards the parent's feelings and cuts off further communication. Asking the client about the cure rate may stop communication and does not recognize the parent's concerns. Offering to have someone with Hodgkin disease speak to the client is premature and does not recognize the parent's concerns.

A direct care nurse performs exceedingly well on a cancer project. As a result, the managerial team decides to promote the nurse to a managerial position. Which actions by the nurse would justify the decision of the panel? . Multiple selection question Inspiring new ideas Establishing short-term goals Demonstrating positive feelings Maximizing results from existing resources Showing willingness to both lead and follow peers

Inspiring new ideas Establishing short-term goals Demonstrating positive feelings Maximizing results from existing resources The leader provides new ideas with a long-term effect on the progress of the organization. He or she should also provide a positive atmosphere by giving an equal importance to the followers. Providing short-term goals and maximizing results from existing resources are the job responsibilities of a manager. The willingness to lead and follow peers is the quality of a good follower.

Before discharging a 9-year-old child who is being treated for acute poststreptococcal glomerulonephritis (APSGN), what information should the nurse plan to give the parents? Multiple choice question How to obtain the vital signs daily Date on which to return to prepare for renal dialysis Instructions about which high-sodium foods to avoid List of activities that will encourage the child to remain active

Instructions about which high-sodium foods to avoid Sodium is usually limited to control or prevent edema or hypertension until the child is asymptomatic. The child is usually on a regular diet with sodium restrictions (e.g., salty snacks [potato chips, pretzels, tortilla chips] and hot dogs, bacon, bologna, and other processed meats). It is not necessary to check the vital signs daily, but the healthcare provider may suggest weighing the child daily. Usually recovery from APSGN is complete. The condition does not cause such severe kidney damage that dialysis is necessary. The child should not be kept active, because rest is needed until the child is asymptomatic

An external monitor is placed on the abdomen of a client admitted in active labor. The nurse notes that during each contraction the fetal heart rate decelerates as the contraction peaks. What is the priority nursing intervention at this time? Multiple choice question Help the client into a knee-chest position to help prevent cord compression. Notify the healthcare provider of the possibility of head compression. Monitor the fetal heart rate until it returns to baseline when the contraction ends. Place the client in a semi-Fowler position to prevent compression of the vena cava.

Monitor the fetal heart rate until it returns to baseline when the contraction ends. The fetal heart rate (FHR) is expected to decelerate when the head is compressed during a contraction. If the FHR returns to baseline at the end of the contraction, fetal well-being is indicated. Cord compression during a contraction is common; no intervention is necessary if the FHR returns to baseline by the end of the contraction. Possible head compression does not necessitate further intervention; this is an expected occurrence as long as the FHR returns to baseline at the end of the contraction. The semi-Fowler position will increase pressure on the vena cava, thus decreasing placental perfusion.

A nurse is caring for a client who is delusional and talking about people who are plotting to do harm. The staff members note that the client is pacing more than usual, and the primary nurse concludes that the client is beginning to lose control. What is the most therapeutic nursing intervention? Multiple choice question Moving the client to a quiet place Urging the client to sit down for a short time Encouraging the client to use a punching bag Allowing the client to continue pacing under supervision

Moving the client to a quiet place Clients losing control feel frightened and threatened; they need external controls and a reduction in external stimuli. The client will be unable to sit at this time; the agitation is building. Encouraging the client to use a punching bag is helpful for pent-up aggressive behavior, but not for agitation associated with delusions. The pacing is not adequately relieving the client's agitation. Another intervention is needed to prevent acting-out behaviors.

Two hours after a client gives birth, her physical assessment findings include a blood pressure of 86/40 mm Hg; temperature of 98° F (36.7° C); pulse rate of 100 beats/min; respirations of 22 breaths/min; a firm fundus, four fingerbreadths above the umbilicus; small spots of lochia rubra on the perineal pad; and a distended bladder. After a urinary catheterization the client's fundus remains firm and four fingerbreadths above the umbilicus. What should the nurse do next? Multiple choice question Catheterize the client again Palpate the client's fundus every 2 hours Notify the client's primary healthcare provider immediately Recheck the client's vital signs in 30 minutes

Notify the client's primary healthcare provider immediately The primary healthcare provider should be notified, because the increased height of the uterus may be the result of accumulation of blood in the uterus caused by internal hemorrhaging. Also, the blood pressure is low and the pulse is rapid, possibly indicating impending shock. Any other intervention will delay the immediate, urgent response that is needed, because the client may be hemorrhaging.

Which action of the nurse as a leader is supported by the Style theories of leadership? Multiple choice question Providing intellectual stimulation Pursuing effective relationships with subordinates Using positive reinforcement to motivate followers Assessing the situation and determining the appropriate action

Pursuing effective relationships with subordinates Style theories or group and exchange theories of leadership state that leaders should pursue effective relationships with their subordinates. Transformational theories of leadership focus on providing intellectual stimulation. The organizational behavior motivation theory of leadership indicates that leaders use positive reinforcement to motivate followers. Assessing the situation and determining the appropriate action based on the people involved characterize situational-contingency theories.

An administrator for a community hospital notes that actions to help with emergency room visits caused by adverse weather events have not been successful over the last few months. What should the administrator consider implementing to address ongoing issues? Multiple choice question Interprofessional team Monthly data collection processes Permanent quality improvement (QI) team Evidence-based practice research guidelines

Some organizations that have used the quality management philosophy for several years establish permanent QI teams or committees. These QI teams do not disband after implementing one project or idea but, rather, may meet regularly to focus on improvements in specific areas of client care. Permanent QI teams provide continuity and prevent duplication of efforts within the quality teams. An interprofessional team should be established when analyzing quality improvement data. However this type of team alone is not sufficient to address ongoing quality of care issues. A monthly data collection process would not be sufficient if a quality improvement team is not in place. Evidence-based practice research guidelines would not be appropriate to address this organization's quality of care issues.

What is the priority when a nurse is formulating a plan of care for a client with a diagnosis of dementia of the Alzheimer type? Multiple choice question Implementing remotivational therapy Structuring the environment for safety Arranging for long-term custodial care Stimulating thinking with new experiences

Structuring the environment for safety supports the client's ability to function in a protected, safe milieu. Attempting to remotivate the client is not the priority; also, it is not always possible to remotivate a client with organic brain damage. There are no data to indicate the client needs long-term care at this time. Structure and routines will decrease anxiety and increase performance of activities of daily living. Cognitive maintenance should be part of the focus of care.

Six weeks after discharge a client returns to the clinic for her postpartum check-up. While at the clinic, the client seeks advice on preventing toxic shock syndrome. She states that she plans to use tampons. What should the nurse instruct the client to do? Multiple choice question Change the tampon about every 4 hours. Use sanitary napkins rather than tampons. Douche just before inserting each tampon. Replace the tampon at least two times a day.

Tampons should be changed frequently because Staphylococcus aureus, which causes toxic shock syndrome (TSS), multiplies and produces more toxin in the presence of the bloody fluid on tampons. Although sanitary napkins may be preferable to tampons in preventing TSS, the client's wishes should be respected; the client should be taught to reduce the risk of TSS by changing tampons frequently. Douching, unless specifically prescribed, is no longer recommended, because it alters the flora of the vaginal vault. Twice a day is too infrequent for tampon changes; the organism responsible for TSS thrives in the presence of bloody fluid on tampons that are not changed frequently.

A parent receives a note from school reporting that a student in class has head lice. The parent calls the school nurse to ask how to check for head lice. What instruction should the nurse provide? Multiple choice question "Ask the child where it itches." "Check to see whether your dog has ear mites." "Look at your child's head along the scalp line for white dots." "Inspect your child's hands and look between the fingers for red lines."

The white dots are nits, the eggs of head lice ( Pediculosis capitis); they can be seen on the shaft of hair along the scalp line, behind the ears, and at the nape of the neck. Asking the child where it itches is too vague; objective visualization will confirm the presence of nits. Canine ear mites are not transferable to humans. Red lines between the fingers are a sign of scabies, infestation with the Sarcoptes scabiei mite.

Which nursing actions indicate effective implementation of systems thinking theory principle with respect to "thinking of the Big Picture"? Multiple selection question Focusing on the needs of all the residents in a long-term care facility Knowing about the complications of emergency department overcrowding in an urban setting Focusing on analyzing morale, working relationships, team work, and the number of clients Identifying and understanding the relationships of clients, families, communities, and local economies Recognizing the long-term effects of actions on the organization or client care

ocusing on the needs of all the residents in a long-term care facility Knowing about the complications of emergency department overcrowding in an urban setting Focusing on the needs of all residents in a long-term care facility and knowing about the complications of emergency department overcrowding in an urban setting are actions that indicate effective implementation of the "Big Picture" principle by helping the nurse envision his/her work beyond the immediate tasks. Focusing on analyzing morale, working relationships, team work, and the number of clients indicates effective implementation of "Using Measurable versus Nonmeasurable Data Systems" principle of systems thinking theory. Identifying and understanding the relationships of clients, families, communities, and local economies indicates effective implementation of "Recognizing the Dynamic, Complex, and Interdependent Nature of Systems" principle. Recognizing the long-term effects of actions on the organization or client care indicates the "Balancing Short-Term and Long-Term Objectives" principle of systems thinking theory.