Level 3 Practice B

A nurse is assessing a client who has depression. Which of the following manifestations should indicate to the nurse that the client is experiencing low self-esteem?

Hypersensitivity to criticism

A nurse is assessing a client who has post-traumatic stress disorder (PTSD) after a workplace explosion 3 months ago. Which of the following findings should the nurse expect?

Hypervigilance

A nurse is assessing a 2-year-old toddler at a well-child visit. For which of the following findings should the nurse refer the toddler for an evaluation for autism spectrum disorder (ASD)?

Reluctance to make eye contact

A nurse is caring for a client who is receiving IV oxytocin for induction of labor. The fetal heart rate tracing reveals multiple variable decelerations. Which of the following actions should the nurse take?

Reposition the client.

A nurse is teaching a client about acute glomerulonephritis. Which of the following information should the nurse include?

Restrict fluid intake based on previous day's urine output.

A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?

Rhinorrhea

A nurse is reviewing the laboratory results for a client who has HELLP syndrome. Which of the following laboratory results should the nurse expect?

Serum uric acid 11 mg/dL

A nurse is assessing a client who had a stroke. The nurse should identify that which of the following findings is a manifestation of a right hemisphere stroke?

Euphoria

A nurse is assessing a client who has amyotrophic lateral sclerosis (ALS). Which of the following findings should the nurse identify as an early manifestation of this illness?

Fasciculations of the face

A nurse is planning care for a client who has alcohol use disorder. Which of the following medications should the nurse expect the provider to prescribe?

Naltrexone

A nurse is providing discharge teaching to the parent of a school-age child who has a severe bee allergy and a new prescription for an epinephrine auto-injector. Which of the following instructions should the nurse include in the teaching?

"Give a second injection if the first fails to entirely reverse your child's reaction."

A nurse is teaching a client who has sickle cell anemia about preventing sickle cell crisis. Which of the following information should the nurse include?

"Avoid going outside when temperatures are extreme."

A nurse is teaching a client who has a new diagnosis of pelvic inflammatory disease (PID) and is starting oral antibiotic therapy. Which of the following information should the nurse include in the teaching?

"Avoid sexual activity until antibiotic therapy is complete."

A nurse is providing discharge teaching for the guardian of a newborn who was recently circumcised. Which of the following statements should the nurse make?

"Clean the penis with warm water until it is healed."

A nurse is teaching the guardian of a child who has juvenile idiopathic arthritis (JIA) about pain management. Which of the following statements should the nurse make?

"Discourage your child from taking naps during the daytime."

A community health nurse is assessing an older adult client. The nurse should identify that which of the following findings is a manifestation of elder neglect?

Sunken eyes

A nurse is teaching a client who is preoperative for an abdominal hysterectomy with a bilateral salpingo-oophorectomy. Which of the following statements should the nurse make?

"You might develop menopausal symptoms after this procedure."

A nurse is providing discharge teaching to a client who is at 34 weeks of gestation and has placenta previa. Which of the following statements by the client indicates an understanding of the instructions?

"I need to make arrangements so that I am not by myself at home."

A nurse is counseling a client who has been undergoing treatment for obsessive-compulsive disorder (OCD). Which of the following statements should the nurse identify as an indication that the client's therapy has been effective?

"I say 'stop' out loud whenever I have a compulsion to wash my hands."

A nurse is caring for a client who has schizophrenia and states, "The government has spies here monitoring me in my room." Which of the following responses should the nurse give?

"I understand that you believe the government is here, but I don't see any evidence of this."

A nurse is teaching the parent of a newborn about the immunization schedule. The nurse should inform the parent that his child will receive the following immunizations in which order? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

1) Hepatitis B 2) Rotavirus 3) Varicella 4) Human papillomavirus

A nurse is providing dietary teaching for a client who is obese and wants to lose 0.91 kg (2 lb) per week. The client currently consumes about 2,500 calories per day. To achieve this weekly weight loss goal, how many calories should the nurse instruct the client to consume per day?

1500 calories

A nurse is teaching about adalimumab with a client who has rheumatoid arthritis. Which of the following information should the nurse include in the teaching?

Have a tuberculin skin test prior to administration of adalimumab.

A nurse is assessing a client who has a benign tumor resulting from fibrocystic breast condition. Which of the following findings should the nurse expect?

Breast pain

A nurse in an emergency department is assessing a newly admitted client. The nurse should identify that which of the following findings is a manifestation of acute cocaine toxicity?

Agitation

A nurse is reviewing the laboratory findings of a client who has acute pancreatitis. Which of the following findings should the nurse expect?

Amylase 300 units/L

A nurse is performing a skin assessment for a client who has a history of melanoma. Which of the following findings should the nurse expect?

An irregularly shaped, colored papule

A nurse is caring for an infant born at 31 weeks of gestation. For which of the following complications should the nurse anticipate and monitor the newborn? (Select all that apply.)

Apnea Necrotizing enterocolitis Hypoglycemia

A hospice nurse is providing palliative care for a client who is near death and not responding to verbal stimuli. Which of the following actions should the nurse take?

Apply a scopolamine transdermal patch for increased oral or respiratory secretions.

A hospice nurse is caring for a client who has end-stage cancer. The client's partner asked about ways to help reduce the client's pain. Which of the following palliative actions should the nurse recommend for tactile distraction?

Applying warm compresses

A nurse is admitting a toddler who has Wilms' tumor. Which of the following actions is the nurse's priority?

Avoid palpation of the abdomen.

A nurse is caring for a client who is at 13 weeks of gestation and has a positive gonorrhea culture. Which of the following medications should the nurse plan to administer?

Ceftriaxone

A school nurse is planning an educational program for parents about bullying. Which of the following information should the nurse include?

Children who are victims of bullying behavior have an increased risk of suicidal ideation.

A nurse assessing an adolescent client who has Ewing sarcoma. Which of the following manifestations should the nurse expect?

Client reports pain in the upper thigh.

A nurse is assessing a newly admitted client who has major depressive disorder. Which of the following manifestations should the nurse expect in this client?

Experiences delusions of persecution

A nurse is caring for a client who is 4 hr postpartum and is experiencing excessive vaginal bleeding. Which of the following actions is the nurse's priority?

Massage the client's fundus.

A nurse is caring for a client who is experiencing a postpartum hemorrhage. Which of the following medications should the nurse plan to administer?

Methylergonovine

A nurse is reviewing the medical record of a client who requests a prescription for an oral contraceptive. Which of the following findings should the nurse identify as a contraindication to an oral contraceptive?

Migraine with aura

A nurse in a mental health facility is assessing a client who has a history of alcohol use disorder. The client states their last drink was 24 hr ago. For which of the following manifestations of alcohol withdrawal should the nurse monitor?

Tremors

A nurse is assessing a client who is at 35 weeks of gestation and is experiencing a placental abruption. Which of the following findings should the nurse expect?

Uterine hypertonicity

A nurse is caring for a client who is experiencing a sickle cell crisis. Which of the following actions should the nurse take?

Monitor the temperature of the client's toes.

A nurse is caring for a client who is experiencing infertility. Which of the following medications should the nurse expect the provider to prescribe?

Clomiphene

A nurse is providing teaching to a client who has bipolar disorder and a new prescription for lithium. Which of the following statements should the nurse make?

"Drink at least 1.5 liters of fluid per day while taking this medication."

A nurse is evaluating the plan of care for an adolescent who has attention deficit hyperactive disorder (ADHD). Which of the following statements made by the adolescent should indicate to the nurse an improvement in the adolescent's social interaction?

"I work well in groups of two or three people."

A nurse is providing discharge teaching to a client who is at 32 weeks of gestation and had an episode of preterm labor. Which of the following should the nurse include in the instructions?

"If contractions recur, drink two or three glasses of water."

A nurse is assessing a 2-year-old toddler who has Down syndrome during a well-child visit. The parent reports concerns regarding his child's delayed developmental achievement. Which of the following responses should the nurse make?

"Is your child receiving the physical therapy we recommended?"

A nurse is educating a group of staff nurses about the difference between non-Hodgkin's lymphoma (NHL) and Hodgkin's lymphoma (HL). The nurse should include which of the following statements in the teaching?

"Non-Hodgkin's lymphoma progresses erratically through the lymphatic system."

A nurse is teaching about managing fatigue with a client who has end-stage COPD. Which of the following statements should the nurse include in the teaching?

"Rest your elbows on a table when doing an activity."

A nurse is teaching about disease management with a client who has Parkinson's disease. Which of the following statements should the nurse include in the teaching?

"Take medications at the same time each day."

A nurse is teaching a client who is scheduled for the placement of a penile implant for the treatment of erectile dysfunction. Which of the following statements by the client indicates an understanding of the teaching?

"This implant can be deflated by pushing a button in my scrotum."

A nurse is teaching about self-management of sexually transmitted infections with a client who has genital herpes. Which of the following instructions should the nurse include in the teaching?

"Wear gloves when applying anesthetic ointments."

A nurse in an emergency department is counseling a client who experienced sexual violence. After addressing the client's physical needs, which of the following statements is the priority for the nurse to make?

"You are safe here."

A nurse is caring for a client who has Alzheimer's disease (AD). The client's daughter asks the nurse if she will have AD as well. Which of the following responses should the nurse make regarding the genetic predisposition of this disease?

"You can be tested for the presence of apolipoprotein, an indication of an increased risk of developing AD."

A nurse is teaching about uterine artery embolization with a client who has uterine fibroids. Which of the following information should the nurse include in the teaching?

"You may experience flu-like illness for 7 days after the procedure."

A nurse is providing teaching to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse make?

"You should be refitted for a new diaphragm if your weight changes by 20 percent or more."

A nurse is providing dietary management to a client who is at 10 weeks of gestation and has hyperemesis gravidarum. Which of the following statements should the nurse make?

"You should eat at least every 2 hours."

A nurse is preparing to administer phenytoin via intermittent IV bolus to a client who is having a tonic-clonic seizure caused by epilepsy. Which of the following factors should the nurse consider when administering IV phenytoin?

Administer phenytoin at a rate no greater than 50 mg/min.

A nurse is caring for a newborn who has hyperbilirubinemia. The newborn is prescribed phototherapy to treat this newborn complication. To provide for the safety of the newborn, the nurse should shield which area during phototherapy? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Area C (eyes)

A nurse in a mental health clinic is planning care for a client who has post-traumatic stress disorder (PTSD). Which of the following strategies should the nurse include?

Assist the client to identify their stage in the grief process.

A nurse in a pediatric clinic is planning an education program for guardians of school-age children about preventing obesity. Which of the following information should the nurse include?

Avoid using food as a reward for good behavior.

A nurse is reviewing the recent laboratory reports for a client who has anorexia nervosa with recurrent purging behavior. Which of the following laboratory values indicates a therapeutic response to the treatment plan?

BUN 18 mg/dL

A nurse is teaching a client who has chronic pain about biofeedback. Which of the following information should the nurse include about this complementary therapy?

Biofeedback provides audio and visual signals to induce a physiological change.

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?

Bradykinesia

A nurse is teaching a family member of a client who has Alzheimer's disease about minimizing behavioral problems at home. Which of the following information should the nurse include in the teaching?

Briefly leave the room when the client becomes agitated.

A nurse is teaching the parents of a newborn about using a bulb syringe to clear the newborn's nose and mouth of excess secretions. Which of the following instructions should the nurse include?

Discontinue suctioning when the newborn's cry sounds clear.

A nurse is assessing a client who has multiple sclerosis (MS). Which of the following manifestations should the nurse expect?

Decreased visual acuity

A nurse is assessing an infant who has Down syndrome. Which of the following manifestations should the nurse expect?

Depressed nasal bridge

A nurse is caring for a client who has a newborn and exhibits manifestations of postpartum depression. Which of the following assessments is the nurse's priority?

Determine whether the client plans to harm herself.

A nurse is counseling a client who has experienced intimate partner violence. Which of the following instructions is the priority for the nurse to include in the teaching?

Develop a safety plan.

A nurse is assessing a newly admitted client following a stroke. Which of the following findings should indicate to the nurse the client has experienced a left hemispheric stroke?

Difficulty reading

A nurse is assessing a client who has acute leukemia and has received an allogeneic bone marrow transplant. The nurse should identify that which of the following findings is a manifestation of graft versus host disease (GVHD)?

Diffuse rash

A nurse is assessing a client who has end-stage COPD. Which of the following images should the nurse identify as a late manifestation of this terminal illness?

Digital Clubbing (picture of swollen finger tips and rounded nails)

A nurse is assessing a client who is at 24 weeks of gestation during a monthly antepartum visit. Which of the following manifestations is a potential prenatal complication and should be reported to the provider?

Facial swelling

A nurse is performing an admission assessment on a client. Which of the following findings should the nurse expect? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Foul-smelling bulky stool

A nurse is teaching a client who is at 22 weeks of gestation and has gestational hypertension. Which of the following information should the nurse include in the teaching?

Gestational hypertension usually resolves during the first postpartum week.

A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of the following actions should the nurse take?

Give the client short, firm directions when communicating.

A nurse is reviewing the medical record of a 9-month-old infant. Which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Gross motor skills

A nurse at a crisis center is meeting with a client who reports that his adolescent daughter has been increasingly defiant since his divorce 2 years ago. The client states, "I'm so stressed that I can't take this anymore." Which of the following actions should the nurse take first?

Identify the client's current coping strategies.

A nurse is assessing a client who has borderline personality disorder. Which of the following characteristics should the nurse expect?

Impulsiveness

A nurse is teaching about home safety with a parent of a newborn. Which of the following information should the nurse include?

Increase the temperature of the room prior to bathing the newborn.

A nurse is reviewing the laboratory report of a school-age child who has acute poststreptococcal glomerulonephritis. Which of the following laboratory values should the nurse expect?

Increased specific gravity

A nurse is planning to administer recommended immunizations to a 65-year-old client. Which of the following immunizations should the nurse plan to administer? (Select all that apply.)

Influenza vaccine Herpes zoster (Shingles) vaccine Pneumococcal vaccine

A nurse is admitting a client who is at 36 weeks of gestation and has placenta previa. The client is experiencing moderate vaginal bleeding. Which of the following actions should the nurse take?

Initiate IV access for the client.

A nurse is planning care to decrease the risk of bowel perforation for a client who is in the acute phase of diverticulitis. Which of the following interventions should the nurse include in the plan?

Instruct the client to avoid coughing.

A nurse is admitting a client who is at 36 weeks of gestation and is experiencing eclampsia. Which of the following actions is the nurse's priority?

Keep the client's head to one side.

A nurse is reviewing the medical record for a client who is in active labor. Which of the following findings should the nurse identify as a risk factor for postpartum hemorrhage?

Labor induced with oxytocin

A nurse is assessing a client who has schizophrenia. Which of the following manifestations should the nurse identify as positive symptoms of schizophrenia? (Select all that apply.)

Magical thinking Clang association Auditory hallucinations

A nurse is teaching a client who has a new prescription for sildenafil to treat erectile dysfunction. Which of the following information should the nurse include in the teaching?

Monitor for dizziness while on this medication.

A nurse is caring for a client who is at 33 weeks of gestation and has a new diagnosis of preeclampsia. Which of the following medications should the nurse expect the provider to prescribe?

Nifedipine

A nurse is planning care for a client who is being admitted for treatment of anorexia nervosa. Which of the following actions should the nurse include in the plan?

Observe the client for 60 min after meals.

A nurse is caring for an infant who has a patent ductus arteriosus and heart failure. Which of the following interventions should the nurse perform?

Offer the infant small, frequent feedings.

A nurse is updating the meal plan for a client who has resolving diverticulitis and is being advanced to a high-fiber diet. The nurse should recognize that which of the following foods is the best source of fiber?

One medium banana

A nurse is caring for a client who has gastroenteritis and reports diarrhea and vomiting for 3 days. Which of the following findings should the nurse recognize as a manifestation of this inflammatory bowel disease?

Orthostatic hypotension

A nurse is caring for a client following a stroke. Which of the following actions should the nurse take to increase the client's cerebral perfusion?

Position the client's head in a midline position.

A nurse is planning care for a newborn who was born at 33 weeks of gestation and is 2 days old. Which of the following interventions should the nurse include?

Position the newborn side-lying or prone while in the nursery.

A nurse is obtaining a history from a client who has major depressive disorder. Which of the following findings should the nurse identify as a risk factor for suicide?

Recent move across the country to look for work

A nurse is planning care for a client who has a gambling disorder. Which of the following interventions should the nurse include in the plan?

Recommend joining a self-help group.

A nurse in a provider's office is reviewing the laboratory report of a client who takes lithium for bipolar disorder. Which of the following laboratory results should the nurse report to the provider?

Sodium 128 mEq/L

A nurse is reviewing the medication record of a client who was recently diagnosed with Alzheimer's disease and has a new prescription for memantine. The nurse should instruct the client that which of the following medications can interact adversely with memantine?

Sodium bicarbonate

A nurse is reviewing the medical history of a client. The nurse should identify that which of the following findings indicates the client is at risk for a stroke?

Takes a combination oral contraceptive

A nurse is teaching a client who has melanoma about nonsurgical treatment options. The nurse should include which of the following options in the teaching?

Targeted therapy

A nurse in a mental health clinic is assessing a client who states, "I don't think my gambling is as big of a problem as my friends think it is." Which of the following findings should the nurse identify as meeting the diagnostic criteria of gambling disorder?

The client asks others for money to compensate for gambling losses.

A nurse is assessing a client who is a survivor of intimate partner violence. Which of the following findings indicates that the client is in the tension-building phase of battering?

The client rationalizes the partner's battering behavior.

A nurse is providing teaching to a client who has preeclampsia without severe features. Which of the following instructions should the nurse include?

Use a side-lying position when resting in bed or on the couch.

A nurse is caring for a client who has moderate dementia and is experiencing frequent episodes of confusion. Which of the following actions should the nurse take?

Use large calendars that are easy for the client to read.

A nurse is teaching about approaches to care with the family of a client who has a new diagnosis of dementia with confusion. Which of the following information should the nurse include in the teaching?

Use pictures and gestures when giving instructions.

A nurse is preparing discharge instructions for a client who experienced an anaphylactic reaction to seafood. Which of the following instructions should the nurse plan to include regarding the client's new prescription for an epinephrine injector pen?

Use the injector pen regardless of severity of manifestations.

A nurse is teaching about pancreatic enzyme replacement therapy with a client who has chronic pancreatitis and is starting to take pancrelipase capsules. Which of the following information should the nurse include when teaching about pancrelipase?

Vary the amount of medication taken based on the amount of food consumed.

A nurse is assessing a client following a stroke. The nurse should identify that which of the following findings is a manifestation of increased intracranial pressure?

Vomiting

A nurse is teaching a client who has epilepsy and a prescription for valproic acid. The nurse should instruct the client to report which of the following as an adverse effect of the medication?

Yellow sclera