midterm

A kidney biopsy has been scheduled for a client with a history of acute kidney injury. The client asks the nurse why this test has been scheduled. What is the nurse's best response? "A biopsy is often ordered for clients before they have a kidney transplant." "A biopsy is routinely ordered for all clients with renal disorders." "A biopsy is sometimes necessary for diagnosing and evaluating the extent of kidney disease." "A biopsy is generally ordered following abnormal x-ray findings of the renal pelvis."

"A biopsy is sometimes necessary for diagnosing and evaluating the extent of kidney disease."

The nurse is teaching a diabetes support group about the importance of self glucose monitoring. The nurse knows that more instruction is required when one of the clients state: "As long as I keep my fasting blood sugar under 150, I should be able to prevent long-term complications." "I should check my blood sugar check my blood sugar when I am feeling funny, so I can correlate a number with the feeling." "I should not exercise when my blood sugar is greater than 250 or I am ill." "I should keep my fasting glucose as close to normal (70-100) as possible to prevent long-term complications."

"As long as I keep my fasting blood sugar under 150, I should be able to prevent long-term complications."."

The nurse is caring for a client admitted with angina who is scheduled for cardiac catheterization. The client is anxious and asks the reason for this test. What is the best response? "Cardiac catheterization is usually done to evaluate cardiovascular response to stress." "Cardiac catheterization is usually done to assess how blocked or open a client's coronary arteries are." "Cardiac catheterization is most commonly done to detect how efficiently a client's heart muscle contracts." "Cardiac catheterization is most commonly done to evaluate cardiac electrical activity."

"Cardiac catheterization is usually done to assess how blocked or open a client's coronary arteries are."

A client with posttraumatic stress disorder (PTSD) has destructive thoughts and has the potential for self-harm or suicide. What instruction should the nurse give to the client to ensure the client's safety? "Try to sleep when you have disturbing thoughts." "Eat candy when you have disturbing thoughts." "Come and sit with me when you are fearful or have disturbing thoughts." "Go to the terrace for some fresh air when you have disturbing thoughts."

"Come and sit with me when you are fearful or have disturbing thoughts."

A nurse is providing teaching to a client who has contact dermatitis. Which statement made by the client indicate an understanding of the information? "Because of my contact dermatitis, I am at an increased risk for having blood transfusion reactions." "Contact dermatitis is usually caused by a viral or bacterial infection in the skin." "Contact dermatitis happens when my skin touches something I am allergic to." "I am contagious to all people I come in contact with."

"Contact dermatitis happens when my skin touches something I am allergic to."

A nursing student is studying delirium. Which of the following student statements indicates that learning has occurred? Select all that apply. "Delirium commonly occurs secondary to another condition." "Delirium is a disturbance of consciousness." "Delirium permanently affects the ability to learn new information>" "Symptoms of delirium include the development of aphasia, apraxia, and agnosia." "The symptoms of delirium develop over a short itme."

"Delirium commonly occurs secondary to another condition." "Delirium is a disturbance of consciousness." "The symptoms of delirium develop over a short itme."

A client who has occasional gastric symptoms is receiving teaching on how to prevent gastroesophageal reflux disease (GERD). Which statement indicates the client understands the teaching? "Eliminating bothersome foods will help." "Taking a nap after meals, when possible." "Eating two large meals a day, instead of three." "Sleeping flat without pillows is beneficial."

"Eliminating bothersome foods will help."

A nurse assesses a patient with renal insufficiency and a low red blood cell count. The patient asks, "Is my anemia related to the renal insufficiency?" How should the nurse respond? "Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow." "Kidney insufficiency inhibits active transportation of red blood cells throughout the blood." "Red blood cells produce erythropoietin, which increases blood flow to the kidneys." "Your anemia and renal insufficiency are related to inadequate vitamin D and a loss of bone density."

"Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow."

The nurse provides care to a client who is newly diagnosed with type 2 diabetes mellitus (DM). Which client statement indicates an adaptation of a healthy coping strategy to deal with this new medical diagnosis? "I like to binge watch television shows." "I eat fresh, not canned, vegetables every day for lunch." "I prefer to drive to the park rather than riding my bike." "I have a bottle of wine each night after dinner."

"I eat fresh, not canned, vegetables every day for lunch."

A client diagnosed with paranoid schizophrenia states, "my roommate is plotting to have others kill me". Which is the appropriate nursing response? "I can totally see your roommate doing that" "What would make you think such a thing" "I know your roommate, he would never do that" "I find that hard to believe."

"I find that hard to believe."

A client diagnosed with panic disorder states, "When an attack happens, I feel like I am going to die." Which is the most appropriate nursing response? Tell me why you think you are going to die every time you have a panic attack." "Death from a panic attack happens so infrequently that there is no need to worry." "Most people who experience panic attacks have feelings of impending doom." "I know it's frightening, but try to remind yourself that this will only last a short time."

"I know it's frightening, but try to remind yourself that this will only last a short time."

Brandon, a patient on the psychiatric unit, has been diagnosed with schizophrenia. He begins to tell the nurse about how the CIA is looking for him and will kill him if they find him. Which of the following is the most appropriate response by the nurse? "The CIA isn't interested in people like you, Brandon." "Why do you think the CIA wants to kill you?" "That's ridiculous, Brandon. No one is going to hurt you." "I know you believe that, Brandon, but it's really hard for me to believe."

"I know you believe that, Brandon, but it's really hard for me to believe."

The client states, "I can't go to group today. I have a very upset stomach this morning." Which would be the nurse's most appropriate response? "I know you don't feel well, but it's important for you to participate in therapy." "You have to go to group. The doctor has ordered it." "You aren't really feeling nauseous. It is part of your illness." "Okay, you can miss this time."

"I know you don't feel well, but it's important for you to participate in therapy."

A client is seeking relief for undiagnosed pain. There is no history of significant physical illness. The history reveals that the client was laid off 4 months ago from a job. The nurses assessment is unremarkable. Which statement made by the client would most strongly suggest a somatoform disorder? "I'm sure they will figure out what is wrong with me." "I have been having a hard time lately. It's hard not working like I'm used to." "I probably just overexerted myself working around the house. It's hard to slow down." "I seem to have more pain now that I got laid off."

"I seem to have more pain now that I got laid off."

The nurse is preparing a client diagnosed with GERD for discharge following an esophagogastroduodenoscopy (EGD). Which statement indicates the client understands the discharge instructions? "I should avoid orange juice and eating tomatoes until my esophagus heals." "I should not eat for at least one day following this procedure." "I can lie down whenever I want after a meal. It won't make a difference." "The stomach contents won't bother my esophagus but will make me nauseous."

"I should avoid orange juice and eating tomatoes until my esophagus heals."

Which statement by the patient being discharged after treatment for acute glomerulonephritis indicates the need for further teaching? "Elevated blood pressure is a clinical manifestation of my condition." "I am at risk for developing acute kidney disease." "I have to decrease my salt intake so that I will not retain fluid." "I will increase the protein in my diet to help me heal."

"I will increase the protein in my diet to help me heal."

When providing patient education for Skyler Hansen, it is important for the nurse to emphasize the peak effect times for insulin. The expected peak for regular insulin is which of the following "I will make sure to eat one snack per day" "I will make sure I have my medic alert bracelet on when I leave the house in the morning." "I will carry a fast acting sugar source like lifesavers with me at all times." "I will rotate my insulin injection sites from abdomen to thighs and upper arms."

"I will make sure to eat one snack per day"

A nurse is teaching a client who has chronic obstructive pulmonary disease about ways to facilitate eating. Which of the following statements indicates a need for further teaching? 1."I will eat five or six small meals each day." 2."I will rest for at least 30 minutes before eating." 3. "I will take my bronchodilators after meals." 4."I will choose foods that are not gas-forming."

"I will take my bronchodilators after meals."

A nurse is caring for a client who has avoidant personality disorder. Which of the following statements is expected from a client who has this type of personality disorder? "I'll go to group therapy if you'll let me smoke." "I need to feel that everyone admires me." "I sometimes feel better if I cut myself." "I'm scared that you're going to leave me."

"I'm scared that you're going to leave me."

The nurse is providing medication education to a patient who was diagnosed with dysthymic disorder. The physician ordered fluoxetine/Prozac 20mg daily. What statement by the patient indicates a lack of understanding? "If I begin to feel worse or develop suicidal ideation I should immediately return to see the physician." "If I miss a dose I should take an additional dose the next day." "This medication may take up to 4 weeks to become effective." "I should not suddenly stop taking this medication."

"If I miss a dose I should take an additional dose the next day."

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?

"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."

A nurse teaches a patient with diabetes mellitus about sick-day management. Which statement would the nurse include in this patient's teaching? "Monitor your blood glucose levels at least every 4 hours while sick." "If vomiting, do not use insulin or take your oral antidiabetic agent." "When ill, avoid eating or drinking to reduce vomiting and diarrhea." "Try to continue your prescribed exercise regimen even if you are sick."

"Monitor your blood glucose levels at least every 4 hours while sick."

The aging client takes an antipsychotic for schizophrenia spectrum disorder and a beta-adrenergic blocking agent for hypertension. Based on an understanding of the combined side effects of these drugs, which statement by a nurse is most appropriate? "Make sure you concentrate on taking slow, deep, cleansing breaths." "Wear sunscreen and try to avoid midday sun exposure." "Rise slowly when you change position from lying to sitting or sitting to standing." "Watch your diet and try to engage in some regular physical activity."

"Rise slowly when you change position from lying to sitting or sitting to standing."

A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following statements should the nurse include? 1."Take a deep breath in through your nose." 2."Puff your cheeks upon exhalation." 3."Place your hand over your stomach" 4."Take quick breaths upon inhalation"

"Take a deep breath in through your nose."

A client diagnosed with major depressive disorder asks, "What part of my brain controls my emotions?" Which nursing response is appropriate? "The occipital lobe governs perceptions, judging them as positive or negative." "The limbic system is largely responsible for one's emotional state." "The parietal lobe has been linked to depression." "The medulla regulates key biological and psychological activities."

"The limbic system is largely responsible for one's emotional state."

A client diagnosed with schizophrenia spectrum disorder states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing response? "The devil only talks to people who are receptive to his influence." "You are not going to hell. You are a good person." "The voices must sound scary, but I do not hear any voices." "Did you take your medicine this morning?"

"The voices must sound scary, but I do not hear any voices."

The spouse of a client with a somatic symptom illness asks the nurse why the doctors cannot find anything wrong. Which would be the appropriate explanation for the nurse to offer? "You are not really experiencing the symptoms. You are making them up to get attention." "You control the symptoms when you are not feeling much stress. It is hard to diagnose when the symptoms are intermittent." "There is a physical cause. It just has not been detected yet." "There is no physical cause. Mental distress is causing the symptoms, even though you are not aware of it."

"There is no physical cause. Mental distress is causing the symptoms, even though you are not aware of it."

The client living in a riverfront community is seeking help with an extreme fear of bridges, which is interfering with daily functioning. The psychiatric nurse practitioner decides to try systematic desensitization. Which best explanation of this treatment should the nurse provide? "Using your imagination, we will attempt to achieve a state of relaxation." "Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety while in a relaxed state." "Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response." "In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate."

"Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety while in a relaxed state."

A client is schedule to have surgery and asks if their spouse can donate blood to be used during surgery. The client's blood type is O+ and the spouse's blood type is A+. How should the nurse respond.

"Unfortunately your blood types are not compatible. You spouse can still donate blood for use by other clients."

HPV

(Human Papillomavirus) a virus that can cause genital warts, cervical cancer, or be asymptomatic. Risk Factors: women <30 years 75-80% of females will get by 50 immunocompromised smoking & STI's S&S: -asymptomatic, unrecognized -genital warts DX: -Pap -HPV test -Colposcopy w/biopsy NO TREATMENT GARDISIL SHOT!!!!

Symptoms that must be assessed

- irreg. vaginal bleeding. -unusual vaginal discharge -unexplained post menopause bleeding -dyspareunia -vulvar or vaginal itch -anorexia -blood in stools

diagnosing prostate cancer

-digital rectal exam (yearly over age of 40) -blood test for PSA (normal is 0-4) -biopsy to confirm cancer, done using transrectal approach Nonsurgical interventions: -watching -radiation -chemo Surgical: -radial proctectomy Surgical care: -indwelling cath w/CBI -strict I&O

Management of PMS

-healthy diet -increase water -avoid caffeine -exercise -NSAIDs -relaxation techniques

Evaluation of infertility

-hx and physical of both parents -sperm analysis -ovulation monitoring -hormonal evaluation -imaging

Signs & symptoms of vaginal wall prolapses

-pelvic heaviness - vaginal bulge - lower back pain -uncontrollable gas -fecal inc. -rectal pressure -constipation

enterocele

-prolapse of the upper posterior vaginal wall between vagina and rectum -often contains loop of bowel

benign disorders of the reproductive tract

-vulvitis - painful itchy -fibroids- most common, increase rapidly in child bearing years. Heavy bleeding, surgically removed & meds, hysterectomy -last option -ovarian cysts: ex: PCOS -cervical polyps: dry thick white polyps

A provider orders levothyroxine 125 mcg by mouth daily. The pharmacy provides tablets containing 250 mcg. Calculate the number of tablets to give. Round to the nearest half tablet. 1.5 tab 2 tab 0.5 tab 1 tab

0.5 tab

Another medication that may have been given in this case would have been glucagon. What does the nurse understand would be the correct dosage for this medication? None of the choices 2 mg IV, IM, or subcutaneous 1 mg IV, IM, or subcutaneous 25 to 50mL IV

1 mg IV, IM, or subcutaneous

preimenopause

1 year left of period S&S: anger, irritability, reduced sex drive, wt. gain, fatigue, mood swings.

A client was diagnosed with chronic kidney disease. For each potential providers prescription, indicate if the potential prescription is anticipated or contraindicated for the client. 1. Treat hypertension with metoprolol 25mg daily-- 2. Treat fluid retention with lasix 20mg daily--- 3. Increase dietary sodium intake--- 4. Educate on exercise and weight loss --

1. Anticipated 2. Anticipated 3. Contraindicated 4. Contraindicated

Match the following definitions. 1. Urine output less than 0.5ml/kg/hr_____ 2. red blood cells in the urine_____ 3. painful or difficult urination_____ 4. decreased urine output of less than 50ml in 24 hours______ 5. awakening at night to urinate Hematuria, Dysuira, Anuria, Nocturia, Oliguria.

1. oliguria 2. hematuria 3. dysuira 4. anuria 5. nocturia

A client has prescription for fentanyl citrate 75 mcg slow IV bolus. The label on the vial states 100mcg/2ml. How much fentanyl in ml does the nurse need to prepare in the syringe, rounding to the nearest tenth ml? 1 ml 2.2 ml 2.6 ml 1.5 ml

1.5 ml

Orders are for 500 mL D5W to infuse at 40 mL/hr. The drop factor is 15 gtts/mL. Calculate the gtt/min. flow rate. ________ gtts/min. Round to the nearest drop.

10

The provider orders guaifenesin (Mucinex) 200 mg by mouth, every 4 hours. The pharmacy provides guaifenesin in a syrup containing 100 mg in 5 ml. What is the dosage that you will provide? 5 ml 2 ml 10 ml 15 ml

10 ml

A provider orders methylprednisolone (Solu-Medrol) 0.05mg/kg/min for a patient that weighs 147 lbs. The infusion contains 200 mg methylprednisolone (Solu-Medrol) in 100 mL D5W. Calculate the infusion rate in mL/hr. Round to the nearest tenths place. Record only a number.

100.3ml/hr

Give Aminophylline 25 mg/hr. Aminophylline is available as 1 Gram/500ml of fluid. At what rate should the infusion run per hour? ____ ml/hr (Round to the tenths place)

12.5

Give Aminophylline 25 mg/hr. Aminophylline is available as 1 Gram/500ml of fluid. At what rate should the infusion run per hour? ______ ml/hr (Round to the tenths place)

12.5

Ordered: amoxicillin clavulanate potassium oral suspension 0.6 g every 12 hr for a patient with a sinus infection. How many mL will you give for each dose? ______mL (250mg/5ml)

12ml

72 kg = ______lbs *Round to the tenths place

158.4

Because insulin normally decreases with exercise; patients on exogenous (injected) insulin, should eat a _______________ carbohydrate snack before moderate exercise to prevent hypoglycemia.

15g

What symptoms of perforation might the nurse observe in a client with an intestinal obstruction? Select all that apply. 1. sudden drop in body temp 2. abdominal distention 3. sudden sustained abdominal pressure 4. intermittent severe pain

2. abdominal distention 3. sudden, sustained abdominal pain

The nurse is assessing a patient's IV insertion site. What must the nurse look for during the assessment? Select all that apply. 1.Observe for yellow discoloration 2.Asses the site for redness and swelling 3.Check for patency and blood return 4.Ensure that the dressing is clean, dry, and intact 5.Observe for hardness or drainage

2.Asses the site for redness and swelling 3.Check for patency and blood return 4.Ensure that the dressing is clean, dry, and intact 5.Observe for hardness or drainage

For a diabetic in ketoacidosis the physician prescribes regular insulin to infuse at 3units/hr. The IV solution is 60 units of regular insulin in 500 ml. Calculate the mL/hr the client should receive._____ mL/hr

25

The prescription is for cimetadine (Tagamet) 300 mg IV piggyback (IVPB). The IV drug book instructs you to mix 300 mg in 100 mL of D5W and to infuse it in 1 hour. The drop factor is 15 gtt/ml. How many drops per minute should the IVPB infuse? _____ gtts/min. Round to the nearest drop.

25

The prescription is for cimetadine (Tagamet) 300 mg IV piggyback (IVPB). The IV drug book instructs you to mix 300 mg in 100 mL of D5W and to infuse it in 1 hour. The drop factor is 15 gtt/ml. How many drops per minute should the IVPB infuse? _______ gtts/min. (Round to the nearest drop)

25

Order: Deltasone 7.5 mgAvailable: Deltasone 2.5 mg/tablet

3 tablets

A nurse is providing care for a client who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply. 1. chronic gastritis 2.Malignant hyperthermia 3. Hemorrhage 4. Pneumonia 5. Atelectasis

3. Hemorrhage 4. Pneumonia 5. Atelectasis

The nurse is to give a client with a severe allergic reaction 80 mg of diphenhydramine (Benadryl) by IV push. The vial contains 10 mL of diphenhydramine solution with a concentration of 25 mg/mL. Exactly how many milliliters of diphenhydramine is the correct dose to give this client?______mLFill in the exact number. Do not round Do not write a label in the blank

3.2

Ordered: furosemide 38 mg IV, a diuretic, for a patient with edema. How many mL will you give? _______ (40mg/4ml)

3.6ml

A patient is receiving 1 Gm of Cefoxitin in 100 mL of fluid at 40 gtts/min. The drop factor on the tubing is 12 gtt/mL. How long will it take ( in minutes) for the fluid to infuse? Answer with the number value only.

30

The client is receiving ciprofloxacin 400mg in 200ml over 60 minutes IV every 12 hours for a catheter-associated urinary tract infection. The tubing drop factor is 10 gtts/ml. How many drops per minute will the nurse administer? 42 gtts/min 33 gtts/min 21 gtts/min 28 gtts/min

33 gtts/min

A nurse cares for a patient who is prescribed 4 mg of calcium gluconate to infuse over 5 hours. The pharmacy provides two premixed infusion bags with 2 mg of calcium gluconate in 100 mL of D5W. At what rate would the nurse administer this medication? (Record your answer using a whole number.) __ mL/hr

40

A patient is receiving 1 Gm of Cefoxitin in 100 mL of fluid at 30 gtts/min. The drop factor on the tubing is 12 gtt/mL. How long will it take ( in minutes) for the fluid to infuse? Answer with the number value only.

40

The nurse should intervene immediately if a patient has which blood glucose level? 200 mg/dL 80 mg/dL 40 mg/dL 152 mg/dL

40 mg/dL

A provider orders disopyramide (Norpace) to be infused at a rate of 0.4mg/min. The pharmacy supplies the medication in an IV bag containing 250mg in 500 mL of D5W. Calculate the infusion rate in mL/hr. Round to the nearest tenths place. Record only a number

48ml

A patient is to receive 500 ml of dextrose 5% in 0.45NS I.V. at 25 gtts/min. How long will the infusion take with IV tubing that has a drip factor of 15 gtt/ml? ____hrs (Round to the nearest hour)

5

Breast cancer statistics

5-10% of cases are hereditary 2/3 cases are found in women 55 and older

male breast cancer

60-70 years BRCA 1 & or 2 gene fam. hx high alcohol consumption hormonal imbalance r/t obesity Mass in breast tissue; dimpling; discharge from nipple DX: CBE, Ultrasonography, MRI TX: surgical- lumpectomy, simple mastectomy, or radial mastectomy. nonsurgical - chemo, hormone therapy, radiation, targeted therapy.

germinal testicular cancer

90% of testicular cancer -seminoma & nonseminoma

nongerminal testicular cancer

<10% -Ledyig & Sertoli cell tumors

Bioterrorism categories

A - highest priority agent easily transmitted: high mortality rate B - 2nd highest priority spreads easily: high morbidity, low mortality C - Emerging pathogens ( lowest) high morbidity and mortality

The nurse is caring for a patient with dementia in the long-term care facility when the patient has a change in cognitive function. What should the nurse suspect this patient may be experiencing? A UTI An aneurysm A stroke Fecal impaction

A UTI

According to Maslow's hierarchy of needs, which situation on an inpatient psychiatric unit would require priority intervention by a nurse? A client rudely complaining about limited visiting hours A client stating that no one cares A client exhibiting aggressive behavior toward another client A client verbalizing feelings of failure

A client exhibiting aggressive behavior toward another client

Which client would the nurse instruct to obtain routine blood-level monitoring? A client taking buspirone A client taking chlorpromazine A client taking lithium A client taking paroxetine

A client taking lithium

The nurse is preparing to give a group therapy session for clients with posttraumatic stress disorder (PTSD). Which clients are most likely to be included in the group therapy session? Select all that apply. A client who is a victim of a car accident. A client who has lost the client's spouse and children in a natural disaster. A client who has witnessed a murder. A client who has watched the news about a major flood in another country on television. A client who has read disturbing news in the newspaper.

A client who is a victim of a car accident. A client who has lost the client's spouse and children in a natural disaster. A client who has witnessed a murder.

The nurses recognizes that the older adult patient may have a reduced ability to concentrate urine, which is attributed to which of the following? A thickening of the efferent arteriole A reduction in bladder receptors A decrease in the number of functioning nephrons Thickening of the basement membrane of the Bowman's capsule

A decrease in the number of functioning nephrons

The nurse suspects the client is experiencing delirium. Which specific assessment information would support this suspicion? Slow onset of confusion and agitation. A decreased level of consciousness with extreme sensitivity to surroundings. Onset is gradual and relentless. The symptoms last for 2 months.

A decreased level of consciousness with extreme sensitivity to surroundings.

Which individual is most likely to be diagnosed with posttraumatic stress disorder (PTSD)? A 12-year-old girl who has recently moved cross-country and desperately misses her old friends A teenage boy who has begun to be the object of bullying inside and outside the classroom A middle-aged woman with a history of anxiety who suffered a random physical assault An adult male client who has been admitted to the hospital three times for complications of surgery

A middle-aged woman with a history of anxiety who suffered a random physical assault

A client on an inpatient psychiatric unit refuses to take medications because "the pill has a special code written on it that will make it poisonous." What type of delusion is this client experiencing? A grandiose delusion A persecutory delusion A somatic delusion A erotomanic delusion

A persecutory delusion

Gonorrhea

A sexually transmitted bacterial disease caused by a gonococcus bacterium that causes inflammation of the genital mucous membrane, burning pain when urinating, and a discharge. Age 20-24 years old Incubation period: <10-14 days Transmission: any sexual acts & child birth DX: same as chlamydia S&S: - women (asymptomatic) -vaginal/penile discharge -dysuria, dyspareunia - rectal discomfort -men: epididymitis -oral red throat with lesions TX: dual therapy -ceftriaxone IM - 1 does azithromycin Q3month testing

HIV

A virus that attacks and destroys the human immune system and causes AIDS.

After one week of continuous mental confusion, an older African American client is admitted with a preliminary diagnosis of Alzheimer's disease (AD). What should cause the nurse to question this diagnosis? AD does not develop suddenly. There have been no liver function studies ordered. AD does not typically occur in African American clients. The symptoms presented are more indicative of Parkinsonism

AD does not develop suddenly.

A client diagnosed with illness anxiety disorder reports to the nurse that others doubt the seriousness of the client's illness. The client is angry, frustrated, and anxious. Which nursing intervention takes priority? Remind the client that lab tests showed no evidence of physiological problems. Discuss with client's family ways to avoid secondary gains associated with physical complaints. Document the client's unwillingness to accept anxiety as the source of the illness. Acknowledge the client's frustrations without fostering continued focus on physical illness.

Acknowledge the client's frustrations without fostering continued focus on physical illness.

Chlaymdia trachomatis

Age 15-19 years old incubation period: 7-21 days Transmission: anal vaginal oral bodily secretions : child birth DX: swab from vagina, cervix, penis, rectum or a Urine or blood test S&S: -vaginal/urethral/rectal discharge -dysuria, pelvic pain, irreg bleeding TX: -doxycycline BID 7 day -Erythromycin- for pregnant females -abstinence until TX is done -retest Q3months

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? 1.Dysphagia 2.Hypotension 3. Agitation 4.Nausea

Agitation

You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently? 1.Level of consciousness 2.Airway patency 3. Psychologic status 4.Pain level

Airway patency

During a teaching session, a parent asks the nurse which inhaler to use for quick relief if the child has an asthma attack. What teaching should the nurse review with the parent? 1. Albuterol is a short-acting inhalant and will relax muscles quickly. 2. Cromolyn sodium is an inhalant used for asthma. 3. Theophylline is a tablet, so it will take a while to work. 4. Salmeterol is a long-acting inhalant and will not provide relief for an asthma attack.

Albuterol is a short-acting inhalant and will relax muscles quickly.

Which of the following actions would the nurse take to provide trauma-informed care to a homeless client who is combative? Apply soft wrist restraints. Encourage dependent behavior. Allow the client some control. Place the client in seclusion.

Allow the client some control.

A diabetic nurse is working for the summer at a camp for adolescents with diabetes. When providing information on the prevention and management of hypoglycemia, what action should the nurse promote?

Always carry a form of fast-acting sugar.

A client newly diagnosed with emphysema asks the nurse to explain all about the disease. The nurse would include the following response when defining emphysema: 1. Increased oxygen diffusion with inflammation of the bronchioles 2.Inflammation of the bronchioles with a normal distention of the air spaces 3. An abnormal distention of the air spaces with destruction of the alveolar walls 4. Decreased sputum production with dilation of bronchioles

An abnormal distention of the air spaces with destruction of the alveolar walls

The nurse is assessing a client diagnosed with somatic symptom disorder (SSD). Which findings would the nurse expect to observe? Pretends to be ill, inflicts self-injury, and has many hospitalizations Aphonia, paralysis with no physical reason, and possible hallucinations Presence of multiple personalities, depersonalization, derealization, and "gaps" in memory Anxious, overmedicates, and vague symptoms

Anxious, overmedicates, and vague symptoms

A nurse is working in an outpatient clinic and notices a reddened, skin infection on the right arm of a client. The client reports it's a bug bite that has gotten worse in the last two weeks. What action should the nurse take next? Apply gloves and explore the wound more closely. Encourage the client to apply antibiotic cream and keep it covered. Culture the wound. Ask the client why they waited to be seen.

Apply gloves and explore the wound more closely.

A client with type 2 diabetes with neuropathy is admitted for cellulitis of the right foot after stepping on a nail. What actions should the nurse include when planning care? Select all that apply. Asses the injury Check blood glucose levels every 6 hours Educate about the importance of diabetic foot care Monitor for warmth and redness at the site of injury Apply hot compresses to the injured foot, twice a day

Asses the injury Educate about the importance of diabetic foot care Monitor for warmth and redness at the site of injury

The nurse is planning to teach a 16-year-old client with contact dermatitis. What teaching strategy does the nurse plan to use during the educational session? Assess the client's motivation and ability to learn. Use a formal lecture style when delivering the information. Provide printed information written at the high school reading level. Provide education to the client's mother.

Assess the client's motivation and ability to learn.

The nurse is caring for a client who sustained a spinal cord injury 4 days ago and now has quadriplegia. What assessments are a priority of the nurse in preventing pressure injuries? Select all that apply Auscultate the client's heart and breath sounds. Assess the client's total protein, albumin, and prealbumin levels. Monitor the client's blood pressure. Visualize and touch the client's skin over the sacrum, ischial tuberosity, hips, and heels Assess the client for constipation and urinary retention.

Assess the client's total protein, albumin, and prealbumin levels. Visualize and touch the client's skin over the sacrum, ischial tuberosity, hips, and heels

A college freshman is admitted to the hospital with a diagnosis of schizophrenia. Friends reported that the client had been in their room for 2 days in a trance-like state, not eating nor speaking to anyone. Which is the priority for this client? Completing an assessment of mental status Providing for adequate rest Assessing fluid intake and output Obtaining more data about the client's college experiences

Assessing fluid intake and output

A nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, "Yester noon the sun moon went over the rover to see the lawnmower." Which of the following manifestations is the client exhibiting? Dissociative Disorder Associative looseness Hallucination Anhedonia

Associative looseness

Which assessment finding would be most consistent with advanced emphysema?

Barrel-shaped chest

Which of the following traits indicates healthy mental health? Select all that apply Being resilient Working productively Learning Decreased concentration Low energy

Being resilient Working productively Learning

A nurse is caring for a client with a psychiatric disorder and understands that severe pathologic mood swings, from hyperactivity and euphoria to sadness and depression, occur in which of the following? Depressive disorder Dysthymic disorder Cyclothymic disorder Bipolar disorder

Bipolar disorder

The nurse is caring for a patient who was admitted after being hit by a care. The patient was walking on the interstate at 0300 when struck by a passing car. During care the nurse notes the patient is agitated, speaking rapidly, fidgeting, not sleeping, hair was dirty and tangled, and was unable to concentrate. What disorder might this patient suffering from? Major depressive disorder Bipolar disorder Anxiety disorder Paranoid personality disorder

Bipolar disorder

Benign Conditions of the Breast

Breast pain (mastalgia) Cysts: lumpectomy Fibroadenomas - occurs in young women: -CX: unknown -firm, smooth, rubbery lump, painless and moves easily. -grows larger during pregnancy ; shrinks - menopause -if not treated can increase risk of breast cancer but does not need removed if it doesn't grow or change.

A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning? By avoiding the use of moisturizing lotions on older adults' skin By protecting older adults against shearing injuries By avoiding the use of ice packs to treat muscle pain By protecting older adults against excessive sweat accumulation

By protecting older adults against shearing injuries

genital herpes

Chronic recurrent viral infection: 2 types: HSV-1: cold sores HSV-2: genital Risk factors: -immunocompromised -HSV2 is higher in females due to their anatomy highly contagious through skin, kissing, sexual contact, and direct contact with lesions. S&S: -itching, tingling of skin-followed by a blister -fever, malaise and headache DX: visual, cell culture TX: currently no cure Meds: anti viral - reduce or suppress S&S and shedding and occurrence by 70-80%

Which is the most important risk factor for development of chronic obstructive pulmonary disease (COPD)?

Cigarette smoking

Which of the following risk factors has been associated with renal cancer? Aspirin use Cigarette smoking Alcohol use Use of artificial sweeteners

Cigarette smoking

Complete the following sentence by choosing from the list of options. The client receiving IV fluids is at highest risk for developing________ _______as evidence by the clients_________________.

Circulatory overload bounding pulse and dyspnea

A patient comes to the clinic suspecting a possible UTI. What symptoms of a UTI would the nurse recognize from the assessment data gathered? Cloudy urine An output of 200mL with each voiding Rebound tenderness at McBurney's point Urine with a specific gravity of 1.005-1.022

Cloudy urine

Behaviors described as odd or eccentric Behaviors described as anxious or fearful Behaviors described as dramatic, emotional, or erratic Schizoid personality disorder Histrionic personality disorder

Cluster A personality disorders Cluster C personality disorder Cluster B personality disorders Cluster A personality disorders Cluster C personality disorders

Hospitalized and diagnosed with the 4th stage of NCD due to Alzheimer's disease, a client, when asked about the previous evening, describes a wonderful evening spent on a cruise. Which symptom is the client exhibiting? Apraxia Delerium Aphasia Confabulation

Confabulation

What evidence indicates to the nurse that a client with an arrhythmia has insufficient cardiac output? Select all that apply. Confusion Hypotension Thready pulse Decreased urine output flushed skin

Confusion Hypotension Thready pulse Decreased urine output

Which condition is often misdiagnosed in the older adult patient with acute glomerulonephritis? Congestive heart failure Cerebrovascular accident Aortic aneurysm Transient ischemic attack

Congestive heart failure

A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect? Sudden unexplained loss of peripheral sensation. Prior physical health followed by the need for two surgeries within the last three months. Obsession over a fictitious defect in physical appearance Constant worry about the undiagnosed presence of an illness.

Constant worry about the undiagnosed presence of an illness.

The following data relate to an older client who is 2 hours postoperative after an esophagogastrostomy: : Physical Assessment: Skin dry Urine output 20 mL/hr NG tube patent with 100 mL brown drainage/hr Restless Vital Signs: Pulse: 128 beats/min Blood pressure: 88/50 mm Hg Respiratory rate: 20 on ventilator Cardiac output: 2.1 L/min Oxygen saturation: 99% Physician Orders: Normal saline at 75 mL/hr Morphine sulfate 2 mg IV push every 1 hr PRN pain Intake and output every hour Vital signs every hour Vancomycin (Vancocin) 1 g IV every 8 hr What action by the nurse is best?

Consult the surgeon regarding need for increased IV fluids.

Which is a late sign of hypoxia?

Cyanosis

A client presents to the clinic with reports of feeling down at times and also having episodes of excitability that has been occurring over the last 2 years. The client reports she just received a promotion at work. She denies the use of alcohol or drugs. What diagnosis would the nurse expect? Bipolar II Cyclothymic disorder Borderline personality disorder Panic anxiety

Cyclothymic disorder

Malignant disorders in women's health

DIFFICUL TO DETECT & PREVENT -Cervical cancer -endometrial cancer -ovarian cancer annual pelvic and pap is key for early detection S&S: very few-n nonspecific in early stages

Neurological tests have ruled out pathology in a client's sudden lower-extremity paralysis. Which action should the nurse take? Deal with physical symptoms in a detached manner Meet dependency needs until the physical limitations subside. You Answered Encourage a discussion of feelings about the lower-extremity problem. Challenge the validity of physical symptoms.

Deal with physical symptoms in a detached manner

A nurse is caring for a client who is exhibiting ventricular tachycardia (VT). Because the client is pulseless, the nurse should prepare for what intervention? Implantation of cardioverter defibrillator ECG monitoring Angioplasty Defibrillation

Defibrillation

The nurse asks the client with schizophrenia spectrum disorder, "Do you receive special messages from certain sources, such as the television or radio?" The nurse is assessing which potential symptom of this disorder? Loose associations Magical thinking Delusions of reference Paranoid delusions

Delusions of reference

You are caring for a client with COPD. Select the 4 findings that require follow-up. Reports falling at home Yellow sputum Disorientation Clubbing of fingers SaO2 92% Ankle edema Barrel-shaped chest

Disorientation Yellow sputum Ankle edema falling at home

A client diagnosed with chronic alcoholism says to the nurse, "I'm tired of using and I want to stop. Is there a medication that can help me maintain sobriety?" About which medication would the nurse provide information? Carbamazepine (Tegretol) Clonidine (Catapres) Disulfiram (Antabuse) Folic acid (Folvite)

Disulfiram (Antabuse)

What are the most common side effects of SSRI's? Dizziness, drowsiness, and dry mouth Convulsions and respiratory difficulties Diarrhea and weight gain Jaundice and agranulocytosis

Dizziness, drowsiness, and dry mouth

A client diagnosed with Bipolar II disorder has been prescribed an antipsychotic. What should the nurse include when providing education? Select all that apply Do not discontinue the drug abruptly Continue the medication even if you are feeling well Avoid drinking alcohol You will need routine lab work to evaluate the medicaiton A common side effect is tinnitus

Do not discontinue the drug abruptly Continue the medication even if you are feeling well Avoid drinking alcohol

Which instruction does the nurse give the CNA who has been delegated to check blood pressure on 6 patients being infused with peripheral IV fluids?

Do the blood pressure checks on the opposite arm of the IV infusion

Malignant conditions of the breast

Ductal carcinoma in situ (DCIS) -Proliferation of malignant cells inside the milk ducts without invasion into surrounding tissue. Invasive cancer -Infiltrating ductal carcinoma: most common -Infiltrating lobular carcinoma: thickening

endometrial (uterine) cancer

Endometrial cancer is a cancer that starts in the endometrium, the inner lining of the uterus (womb). 4th most common female cancer Type 1: 90% -estrogen dependent, decreased grade = good prognosis Type 2: 10% -estrogen independent, increases grade = more aggressive African Americans are at a higher risk Signs & symptoms: -irrg. vag. bleeding -postmenopausal bleeding

Mrs. G has been diagnosed with NCD due to Alzheimer's disease. The primary nursing intervention in working with Mrs. G is which of the following? Ensuring that she receives food she likes to prevent hunger Ensuring that she takes care of her own ADLs to prevent dependence Ensuring that she meets the other patients to prevent social isolation Ensuring that the environment is safe to prevent injury

Ensuring that the environment is safe to prevent injury

Mrs. G has been diagnosed with NCD due to Alzheimer's disease. The primary nursing intervention in working with Mrs. G is which of the following? Ensuring the environment is safe to prevent injury. Ensuring that she takes care of her own ADLs to prevent dependence. Ensuring that she recieves food she likes to prevent hunger. Ensuring that she meets the other patients to prevent social isolation.

Ensuring the environment is safe to prevent injury

After a teaching session about grief, a client says to the nurse, "I seem to be stuck in the bargaining stage of grieving over the loss of my daughter." In which phase of the nursing process would this occur, and how would the nurse interpret this statement? Implementation phase; nursing actions have been successful in achieving the objectives of care. Assessment Phase; nursing actions have been successful in achieving accurate data. Diagnosis phase; nursing actions have been successful in achieving accurate data. Evaluation phase; nursing actions have been successful in achieving the objectives of care.

Evaluation phase; nursing actions have been successful in achieving the objectives of care.

An attractive female client with a diagnosis of body dysmorphic disorder (BDD) presents with high anxiety levels because of her belief that her facial features are large and grotesque. Which additional symptoms would support this diagnosis? (Select all that apply.) Stereotypic Movement Excessive grooming History of delusional thinking Mirror Checking Skin picking

Excessive grooming Mirror Checking Skin picking

The nurse recognizes that which factors may have contributed to Skyler Hansen's low blood glucose in this case? (Select all that apply.) Too much food Excessive physical activity Too little food Dehydration Too much insulin

Excessive physical activity Too little food Too much insulin

Considerations in women's health

Female genital mutilation or cutting Intimate Partner violence Incest and childhood sexual abuse Health issues in women with disabilities Lesbians, bisexual, and transgender women (LGBT) Gerontologic considerations - ALWAYS ask if sexually active

Complications of Chlamydia & Gonorrhea

Females: PID, ectopic pregnancy, infertility, chronic pelvic pain, tubal abscess. Males: epididymitis or prostatitis Gonorrhea only: -joints -endocarditis -meningitis Nursing management: -know the risk factors -VS, pain (w/intercourse) -education -prevention

Which conditions have been known to precipitate delirium in some individuals? (Select all that apply.) Fever of 103.5 Urinary tract infection Temporomandibular joint disorder Seizures Migraine

Fever of 103.5 Urinary tract infection Seizures Migraine

The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by: Granulation Third intention Second intention First intetion

First intetion

A sputum study has been ordered for a client who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample?

First thing in the morning

The nurse correlates which clinical manifestation with the pathophysiology of acute pyelonephritis? (Select all that apply.) Flank pain Abdominal pain Fever Nausea and vomiting Hematuria

Flank pain Fever Nausea and vomiting Hematuria

An example of a treatable (reversible) form of NCD is one that is caused by which of the following? (Select all that apply.) Multiple sclerosis Multiple small brain infarcts HIV disease Folate deficiency Electrolyte imbalances

Folate deficiency Electrolyte imbalances

When assessing a client diagnosed with narcissistic personality disorder, the nurse expects to identify which characteristic behavior? Grandiose sense of self-importance Odd beliefs and magical-importance Pattern of intense and chaotic relationships Submissive and clinging behaviors

Grandiose sense of self-importance

A client comes to the clinic reporting a red rash of small, fluid-filled blisters and is suspected of having herpes zoster. What presentation is most consistent with this diagnosis? Grouped vesicles occurring on lips and oral mucous membranes Grouped vesicles occurring on the genitalia Rough, fresh, or gray skin protrusions Grouped vesicles in linear patches along a dermatome

Grouped vesicles in linear patches along a dermatome

During an admission assessment, a client with schizoaffective disorder states that the client hears the voice of God in the client's head and the voice is telling the client that the client is worthless. What would the nurse document this symptom as? Delusion Avolition Alogia Hallucination

Hallucination

A client is brought into the ED by family members who tell the nurse the client grabbed his chest and complained of substernal chest pain. The care team recognizes the need to monitor the client's cardiac function closely while interventions are performed. What form of monitoring should the nurse anticipate? Cardiac telemetry Left-sided heart catheterization Transesophageal echocardiography Hardwire continuous ECG monitoring

Hardwire continuous ECG monitoring

The nurse would expect that a patient experiencing moderate hypoglycemia would exhibit which of the following sets of signs and symptoms? Bradycardia, polyuria, acidosis Hyperactivity, tachycardia, anorexia Double vision, cool dry skin Headache, light headedness, slurred speech

Headache, light headedness, slurred speech

Women's health assessment questions:

Health HX: (medical, reproductive, sexual) Menstrual HX & pregnancies Vaginal discharge, odor, itching HX of STI's, Surgeries, or procedures Family HX & genetics Dysmenorrhea or Dyspareunia

A brain (B-type) natriuretic peptide (BNP) sample has been drawn from an older adult client who has been experiencing vital fatigue and shortness of breath. This test will allow the care team to investigate the possibility of what diagnosis? Cardiomyopathy Valve dysfunction Heart failure Pleurisy

Heart failure

A nurse is caring for a type 2 diabetic that is having surgery for a total knee replacement. The nurse reads that the client is on both an oral antidiabetic agent and insulin at home. It is well understood that stress hormone causes : 1.Euphoria 2. Pain 3. Hyperglycemia 4. Hypoglycemia

Hyperglycemia

A nurse reviews the health history of a patient with an over secretion of renin. Which disorder should the nurse correlate with this assessment finding? Viral hepatitis Alzheimer's disease Diabetes mellitus Hypertension

Hypertension

In providing care to the patient who may have polycystic kidney disease, the nurse recognizes which finding as the first clinical manifestation of this disease process? Urinary frequency Hypertension Hematuria Urinary calculi

Hypertension

A client has a family history of polycystic kidney disease. As the nurse gathers information and completes an assessment related to a polycystic kidney diagnosis, which findings would the nurse expect to find? Select all that apply. Normal urinalysis Hypertension Polyuria No renal stones Abdominal pain

Hypertension Polyuria Abdominal pain

An older adult client, who is bedridden, is admitted to the unit because of a pressure injury that can no longer be treated in a community setting. During assessment, the nurse finds that the ulcer extends into the muscle and bone. At what stage should the nurse document this injury? IV I II III

IV

The client presents with symptoms of alcohol withdrawal and states, "I haven't eaten in three days." The nurse's assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97°F (36°C) with dry mucous membranes and poor skin turgor. What should be the priority nursing diagnosis? Ineffective individual coping Imbalanced nutrition: less than body requirements Fluid Volume Excess Denial

Imbalanced nutrition: less than body requirements

The nurse identifies which nursing diagnosis as the highest priority for the patient admitted with peptic ulcer disease (PUD) and possible perforation?

Impaired GI tissue integrity

A nurse cares for a patient with a urine specific gravity of 1.040. What action should the nurse take? Assess the patient's creatinine level. Increase the patient's fluid intake. Place the patient on restricted fluids. Obtain a urine culture and sensitivity.

Increase the patient's fluid intake.

The nurse is providing preprocedure teaching about an ultrasound. The nurse informs the client that in preparation for an ultrasound of the lower urinary tract the client will require what action? Increased fluid intake to produce a full bladder IV administration of radiopaque contrast agent Sedation and intubation

Increased fluid intake to produce a full bladder

An 82-year-old client is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the client's course of treatment? Increased thickness of the subcutaneous skin layer Increased time required for wound healing Increased vascular supply to superficial skin layers Changes in the character and quantity of bacterial skin flora

Increased time required for wound healing

The nurse is caring for a client who has a fluid volume deficit. When evaluating this client's urinalysis results, what should the nurse normally anticipate? Decrease in blood urea nitrogen (BUN) Decreased urine osmolality Increased urine specific gravity Less antidiuretic hormone (ADH) released

Increased urine specific gravity

A client has been successfully treated for kidney stones and is preparing for discharge. The nurse recognizes the risk of recurrence and has planned the client's discharge education accordingly. What preventive measure should the nurse encourage the client to adopt? Eating several small meals each day Increasing fluid intake Adopting a high-calcium diet Increasing intake of protein from plant sources

Increasing fluid intake

A client is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this client's care, which of the following nursing diagnoses should the nurse prioritize? impaired skin integrity related to bowl obstructions anxiety related to bowl obstruction and subsequent hospitalization ineffective tissue perfusion related to bowl ischemia imbalanced nutrition: less body requirements related to impairs absorption

Ineffective Tissue Perfusion Related to Bowel Ischemia

A nurse caring for a patient with a neurogenic bladder knows to assess for the major complication of: Permanent distention Daily and painful spasms Infection Consistent pain

Infection

During the admission assessment of a 27-year-old client who has been diagnosed with an anxiety disorder, the nurse observes that the client is becoming increasingly restless and agitated. How should the nurse respond to this development? Provide education regarding the level of anxiety that the client may be experiencing. Increase the speed of the assessment in order to ensure that it is completed sooner and inform the client that the nurse is doing so Inform the client that the assessment can be postponed if the client is finding it overwhelming. Explain to the client that the client's current feelings of anxiety have the potential to foster better coping skills in the future.

Inform the client that the assessment can be postponed if the client is finding it overwhelming.

The nurse assesses the IV site prior to administering 50 mL of dextrose 50% in water (D50W) intravenously to a patient with hypoglycemia per protocol. The nurse identifies redness and swelling at the IV site. Which action should the nurse take? IV push the medication quickly since it is an emergency Inform the patient that it may be painful Insert another IV to administer the D50W Flush the IV site prior to administering the D50W

Insert another IV to administer the D50W

A 35-year-old male client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary provider, what intervention should the nurse prioritize? Insertion of a central venous catheter Administration of a mineral oil enema Insertion of a nasogastric tube Administration of a glycerin suppository and an oral laxative

Insertion of a nasogastric tube

The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for?

Iodine allergy

The partner of a client with obsessive-compulsive disorder (OCD) reports that the client regularly exhibits "strange behaviors." What does the nurse tell the partner about these behaviors? Select all that apply. It is an attempt by the client to overcome anxiety. The client will repeat the act several times during the day. The client is unaware of the act. It is associated with an irrational persistent thought. It is indicative of a degenerative disorder.

It is an attempt by the client to overcome anxiety. The client will repeat the act several times during the day. It is associated with an irrational persistent thought.

A client diagnosed with Dissociative Identity Disorder (DID) switches personalities when confronted with destructive behavior. The nurse recognizes that this dissociation serves which function? It is a means to attain secondary gain. It serves to isolate painful events so that the primary self is protected. It serves to establish personality boundaries and limit inappropriate impulses. It is a means to explore feelings of excessive and inappropriate guilt.

It serves to isolate painful events so that the primary self is protected.

A client is being discharged from the hospital with a new prescription for an SSRI. When educating the patient about the SSRI what information will the nurse include? The patient must avoid foods that contain tyramine. It takes 4 to 6 weeks to experience the benefits of the medication. The patient should take the medication at bedtime to enhance sleep. If the patient develops an upset stomach when taking the medication he should discontinue the medication.

It takes 4 to 6 weeks to experience the benefits of the medication.

Treatment of vaginal wall prolapses

Kegels pessary colpexin sphere surgery

A nurse is caring for a client who has been diagnosed with psoriasis. The nurse is creating an education plan for the client. What information should be included in this plan? Lifelong management is likely needed. Wash skin frequently to prevent infection. Avoid public places until symptoms subside. Liberally apply corticosteroids as needed.

Lifelong management is likely needed.

A client undergoes surgery to remove a malignant tumor followed by a urinary diversion procedure. Which postoperative procedure is the most important for the nurse to perform? Maintain skin and stomal integrity. Show photographs and drawings of the placement of the stoma. Suggest a visit to a local ostomy group. Determine the client's ability to manage stoma care.

Maintain skin and stomal integrity.

A client presents to the clinic with complaints of feeling a loss of interest in activities, decreased concentration, and insomnia. These symptoms have been present for over 2 weeks. What mental health disorder is the client experiencing? Dysthymic disorder Major depressive disorder Schizoid personality disorder Bipolar 1

Major depressive disorder

cervical cancer

Malignant cell growth in the cervix; can be caused by HPV virus. Asymptomatic in early stages. encourage safe sex & yearly exams Early: -thin watery discharge -irreg. bleeding -pain & bleeding after sex. Late: -increased discharge - dark and odorous -increased irregular bleeding -dysuria -rectal bleeding -edema -anemia

infections of the breast

Mastitis: clogged duct - TX: antibiotics Lactational abscess- from mastitis

Which modalities should a nurse recognize as integral parts of a treatment program when planning care for clients diagnosed with schizophrenia spectrum disorder? (Select all that apply.) Medication management Group therapy Deterrent Therapy Supportive family therapy Social skills training

Medication management Group therapy Supportive family therapy Social skills training

Correction of infertility problem (female)

Medications: -increase or initiate ovulation Treat underlying causes: -hormone replacement -metabolic syndrome -underlying infections Artificial insemination IVF

The client was newly diagnosed with 2nd stage NCD due to Alzheimer's disease. Which cognitive change would a nurse observe? Memory disturbance Inability to plan or organize Apraxia Confabulation

Memory disturbance

A client is being treated for renal calculi and suspected hydronephrosis. Which measure should the nurse take to help maintain a record of the kidneys' function? Monitor the client's intake and output. Inspect the skin over the fistula or graft for signs of infection. Palpate for a thrill over the vascular access. Note the nailbeds and mobility of the fingers.

Monitor the client's intake and output.

A client is taking a newly prescribed antidepressant medication. Which of the following class of antidepressant medication puts the client at risk for hypertensive crisis? Tricyclics Monoamine oxidase inhibitors Serotonin-norepinephrine reuptake inhibitors Selective serotonin reuptake inhibitors

Monoamine oxidase inhibitors

The nurse attended a seminar about neurocognitive disorders (NCD). Which information from the nurse indicates a correct understanding of the differences between NCD and pseudodementia (depression)? NCD symptoms include disorientation to time and place, and pseudodementia does not. NCD causes decreased appetite, whereas pseudodementia does not. NCD symptoms improve as the day progresses, but symptoms of pseudodementia worsen. NCD has a rapid onset, whereas pseudodementia does not.

NCD symptoms include disorientation to time and place, and pseudodementia does not.

Microvascular complications of diabetes effect the small to medium blood vessels resulting the following, : Select all that apply Peripheral vascular disease. Nephropathy Retinopathy Neuropathy Sexual dysfunction

Nephropathy Neuropathy Retinopathy Sexual dysfunction

A school nurse has sent home four children who show evidence of pediculosis capitis. What is an important instruction the nurse should include in the note being sent home to parents? The disease is self-limiting and symptoms will abate within 1 week. The child's scalp should be monitored for 48 to 72 hours before starting treatment. Nits may have to be manually removed from the child's hair shafts. Efforts should be made to improve the child's level of hygiene.

Nits may have to be manually removed from the child's hair shafts.

Treatment of BPH

Nonsurgical TX: -watchful waiting: no growth, yearly exams, avoid excessive fluids in evening. Medications: -5-alpha reductase inhibitors - decrease prostate -Alpha-adrenergic blockers - relaxes smooth muscles of prostate - takes the constriction off the urethra and improves urinary flow. Alternative therapies: -frequent intercourse -avoid: lg amounts of fluid, alcohol, caffeine. Surgical management: TURP- resection of prostate -bleeding & infection

A nurse is planning a group teaching session on the topic of urinary tract infection (UTI) prevention. Which point should the nurse include? Take medication ordered for a UTI until the symptoms subside Limit fluid intake to reduce the need to urinate. Wear only nylon underwear to reduce the chance of irritation. Notify the physician if urinary urgency, burning, frequency, or difficulty occurs.

Notify the physician if urinary urgency, burning, frequency, or difficulty occurs.

Patients with irritable bowel disease (IBD) are at significantly increased risk for which of the following?

Osteoporosis

Which of the following may indicate a coworker struggles with substance abuse? (Select all that apply) Higher incidences of incorrect narcotic counts Patient complaints of inadequate pain control Increase in wasting of controlled substances Increased ability to focus and concentrate Punctual in meeting deadlines

Patient complaints of inadequate pain control Increase in wasting of controlled substances

PID

Pelvic Inflammatory Disease; inflammation of a woman's reproductive organs. CX: by untreated chlamydia/gonorrhea risk factors: -excessive douching -intercourse during menses -alcohol, smoking, drug use. -IUD S&S: -vaginal purulent discharge -fever >101 -dysuria -N/V -dyspareunia DX: -elevated CRP -+ chlamydia or gonnorrhea TX: -antibiotics -hospitalizations if pt. does not respond to anitbiotics Complications: -chronic abdominal pain and pelvic -infertility -pelvic abscess or adhesions AVOID DOUCHING, TAMPON USE, BATH TUBS, SEX

A client postoperatively reports to the nurse the need to urinate, but is unable to void. What should the nurse expect the healthcare provider to order? Select all that apply. Perform a Bladder Scan Place an indwelling catheterization. Ambulate the client. Schedule a suprapubic catheter insertion. Complete a straight catheterization.

Perform a Bladder Scan Complete a straight catheterization

A nurse in an emergency department is caring for a client who is experiencing alcohol withdrawal. Which of the following actions should the nurse take first? Perform a neurological exam. Obtain a blood specimen. Insert an IV access site Implement seizure precautions.

Perform a neurological exam.

A female client is undergoing a bladder training program as a treatment for urinary incontinence. Which technique would be the most appropriate for the nurse to suggest? Attempting to hold the urine for five minutes until the sensation is felt Taking warm sitz baths Reducing fluid intake Perform kegel exercises

Performing Kegel exercises

When a client develops ventricular fibrillation, what nursing action is most appropriate initially? Taking temperature, pulse, and blood pressure (BP) Assessing the client for electrolyte imbalance Preparing the client for pacemaker insertion Performing immediate defibrillation

Performing immediate defibrillation

A nurse is aware that the outer layer of the skin consists of dead cells that contain large amounts of keratin. The physiologic functions of keratin include which of the following? Select all that apply. Maintaining acid-base balance Absorbing electrolytes Producing antibodies Physically repelling pathogens Preventing fluid loss

Physically repelling pathogens Preventing fluid loss

A client has developed urinary incontinence after having a urinary catheter in place for a few weeks. What is the initial nursing intervention the nurse should use to start the client with bladder training? Perform straight catheterizations at specific times each day. Place client on a timed voiding schedule. Instruct the client to drink more fluids at night for a full bladder in the morning. Instruct the client to drink more fluids at night for a full bladder in the morning.

Place client on a timed voiding schedule.

The nurse discovers a client's suicide note that details the time, place, and means to commit suicide. Which would be the priority nursing intervention and the rationale for this action? Calling an emergency treatment team meeting, because the client's threat must be addressed Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide Establishing room restrictions, because the client's threat is an attempt to manipulate the staff Administering lorazepam (Ativan) prn, because the client is angry about the discovery of the note

Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide

A common clinical manifestation of the four different forms of diabetes are the Three P's, aka:

Polyuria Polydypsia Polyphagia

The health care provider has placed a central venous pressure (CVP) monitoring line in an acutely ill client so right ventricular function and venous blood return can be closely monitored. The results show decreased CVP. What does this indicate? Aortic valve regurgitation Possible myocardial infarction (MI) Possible hypovolemia Left-sided heart failure

Possible hypovolemia

A nurse is caring for a client who is a veteran with thoughts of missiles screaming and exploding. The client reexperiences feelings of terror first experienced in combat. Upon assessment, the nurse knows these recurrent events are part of which disorder? Acute stress disorder Generalized anxiety disorder Posttraumatic stress disorder (PTSD) Adjustment disorder

Posttraumatic stress disorder (PTSD)

Risk factors for vulvovaginal infections

Premenarche/perimenopause/menopause/low estrogen levels Pregnancy/oral contraceptive use Poor hygiene Tight garments and synthetic clothing Frequent douching Allergies DM Intercourse with infected

A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? (Select all that apply). Prepare the client for a CT scan. Check the client's pupil reactivity. Perform a developmental screening test. Contact the laboratory to obtain a blood sample Obtain a urine specimen.

Prepare the client for a CT scan. Check the client's pupil reactivity. Contact the laboratory to obtain a blood sample Obtain a urine specimen.

A nurse is admitting a client who is exhibiting manic behavior. The client reports recent personal stressors including the loss of her mother and a divorce. Which of the following is the priority nursing action? Preventing self-directed violence. Encouraging self-care Assisting the client in identifying coping behaviors. Identifying support systems

Preventing self-directed violence.

Disasters Emergency preparedness

Prevention Preparedness Response Recovery

Which nursing intervention was most important in the immediate care of Barbara Dolan? Promoting a quiet, restful environment Monitoring intake and output Encouraging ambulation at least twice each shift Encouraging family to remain at the bedside

Promoting a quiet, restful environment

The nurse monitors for which clinical manifestations in the patient diagnosed with acute glomerulonephritis? Select all that apply. Proteinuria Increased urine output Serum creatinine 2.4 mg/dL Hematuria Serum BUN 8.0 mg/dL

Proteinuria Serum creatinine 2.4 mg/dL Hematuria

Once the Type 1 diabetic from the simulation lab regained consciousness after receiving 50% Dextrose in water to treat his hypoglycemia which of the following interventions by the nurse would be appropriate to prevent another decrease in blood glucose? Administer another dose of D50W Provide 6 hard candies to eat Provide a snack of cheese and crackers Administer 6 ounces of fruit juice

Provide a snack of cheese and crackers

A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, "I can't function any longer under all this stress." Which type of crisis is the client experiencing? Maturational/developmental crisis Traumatic stress crisis Anticipated life transition crisis Psychiatric emergency crisis

Psychiatric emergency crisis

Pustule Cyanosis Erythema Nevi Petechiae

Pus-filled vesicle Bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood. Redness of the skin caused by dilation of the capillaries due to injury, irritation, or inflammation. A benign growth on the skin that is formed by a cluster of melanocytes, also known as a mole. Pinpoint red spots that appear on the skin as a result of blood leakage into the skin.

The nurse is caring for a client diagnosed with generalized anxiety disorder. Which activities would the nurse encourage for this client? (Select all that apply.) Recognize the signs of escalating anxiety. Cognitively reframe thoughts about situations that generate anxiety. Employ newly learned relaxation techniques. Avoid caffeinated products. Avoid any situation that causes stress.

Recognize the signs of escalating anxiety. Cognitively reframe thoughts about situations that generate anxiety. Employ newly learned relaxation techniques. Avoid caffeinated products.

The provider prescribed lorazepam for Barbara Dolan. Which manifestations indicate that the medication had the desired effect in the management of her alcohol withdrawal? (Select all that apply). Reduced heart rate Decreased blood pressure Increased blood pressure Increased respiratory rate Elevated body temperature

Reduced heart rate Decreased blood pressure

According to psychodynamic theory, which primary defense mechanism would the nurse expect to find in a client with dissociative amnesia? Suppression Repression Sublimation Displacemen

Repression

The nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect? (Select all that Apply) Unaltered level of conciousness History of gradual memory loss Restlessness Hallucinations Inappropriate speech

Restlessness Hallucinations Inappropriate speech

The nurse's assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should consequently identify what nursing diagnosis in the client's plan of care? Risk for ineffective role performance related to hypotension Risk for ineffective breathing pattern related to hypotension Risk for falls related to orthostatic hypotension Risk for imbalanced fluid balance related to hemodynamic variability

Risk for falls related to orthostatic hypotension

Which nursing diagnosis is appropriate for a client with renal calculi? Decreased cardiac output Functional urinary incontinence Risk for infection Ineffective tissue perfusion (renal)

Risk for infection

Assessment of BPH

S&S: -frequency & urgency -hesitancy & straining -reduced force & size of stream -sensation of incomplete emptying -dribbling or leaking -nocturia -fever chills -hematuria -prostatitis Physical assessment: -inspect & palpate abdomen -bladder scanner -DRE Laboratory: -CBC -Bun -Creatinine -UA W/C&S Psychosocial assessment: -irritability & frustration -lack of sleep -impact on sex life

The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the SA node and then proceeds in what sequence? SA node to AV node to bundle of His to Purkinje fibers SA node to bundle of His to Purkinje fibers to AV node SA node to bundle of His to AV node to Purkinje fibers SA node to AV node to Purkinje fibers to bundle of His

SA node to AV node to bundle of His to Purkinje fibers

A client with major depressive disorder is admitted to the hospital for medication adjustment. What is the nurse's priority intervention? Safety Encouragement Comfort Education

Safety

A nurse is caring for a client who begins to yell and scream at staff members. Which of the following should be the nurse's priority action? Administer haloperidol IM to the client Engage the client is an activity Move the client to a seclusion room with continuous observation Say to the client, "I can tell that you are upset."

Say to the client, "I can tell that you are upset."

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? Second-intention healing Primary-intention healing Third-intention healing First-intention healing

Second-intention healing

The nurse correlates which laboratory result as the most reliable indicator of impaired renal function? Serum sodium 150 mEq/L Serum BUN 35 mg/dL Serum potassium 5.8 mEq/L Serum creatinine 2.4 mg/dL

Serum creatinine 2.4 mg/dL

breast assessment

Shape & size, Are they soft, firm or filling? Any discharge - type & amount, Nipples cracked/lesions? Unusual contour? Lumps & tenderness med & fam. HX -adolescent - firm & lobular -postmenopausal- thinner & fatter -pregnancy/lactation - firm, larger, lobular -cysts: well-defined, freely moveable, tender. Found when mensurating. -malignant: hard, poorly defined & nontender

While in the hospital, Skyler Hansen receives short-acting and intermediate-acting insulin. The nurse knows that when preparing the two insulins, which insulin should be drawn into the syringe first? Short-acting Intermediate-acting It does not matter, either one may be drawn up first Neither, they should be administered in two different syringes

Short-acting

A nurse is caring for a client who has borderline personality disorder. The client says, "The nurse on evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client's statement as an example of which of the following defense mechanisms? Undoing Repression Identification Spitting

Spitting

A patient comes to the clinic for the third time in 2 months with chronic bronchitis. What clinical symptoms does the nurse anticipate assessing for this patient? 1.Sputum and a productive cough 2. Tachypnea and tachycardia 3. Fever, chills, and diaphoresis 4. Chest pain during respiration

Sputum and a productive cough

While assessing a client's skin, the nurse notes reddened spot on the sacral area that is nonblanching. The skin in this area is warm, swollen, and painful. The nurse plans care knowing this client has which classification of pressure injury? Stage 1 Not a pressure injury Stage 2 Unstageable

Stage 1

A client has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m2. Based on this GFR, the nurse interprets that the client's chronic kidney disease is at what stage?

Stage 3

A client diagnosed with Alzheimer's disease (AD) can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalizations. The nurse recognizes these symptoms as indicative of which stage of the illness? Stage 4: Mild-to-Moderate Cognitive Decline Stage 5: Moderate Cognitive Decline Stage 6: Moderate-to-Severe Cognitive Decline Stage 7: Severe Cognitive Decline

Stage 7: Severe Cognitive Decline

A patient with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The patient's blood pressure when lying down is 122/80 mm Hg and when standing was 98/52 mm Hg. What priority action by the nurse is most appropriate?

Start a large-bore IV with normal saline (NS)

The nurse is caring for a client who is being treated in the emergency department for a panic attack. Which nursing intervention would be most appropriate? Tell the client that the nurse must leave to go report the client's symptoms to the psychiatrist on duty. Stay with the client, emphasizing that the client is safe and that the nurse will remain with the client. Demonstrate empathy for the client by trying to mimic the client's state of anxiety. Tell the client this is an acute exacerbation with a positive prognosis and low morbidity.

Stay with the client, emphasizing that the client is safe and that the nurse will remain with the client.

The nurse is attempting to insert a peripheral IV when the patient reports tingling and a feeling of "pins and needles". What does the nurse do next?

Stop immediately, remove the catheter, and choose a new site

The nurse is caring for a client who is undergoing an exercise stress test. Prior to reaching the target heart rate, the client develops chest pain. What is the nurse's most appropriate response? Administer analgesia and slow the test. Stop the test and monitor the client closely. Initiate cardiopulmonary resuscitation. Administer sublingual nitroglycerin to allow the client to finish the test.

Stop the test and monitor the client closely.

The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take?

Stop the transfusion immediately.

A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event? Psychosocial stress Hypersensitivity to an immunization Menarche Streptococcal infection

Streptococcal infection

A client is admitted with a diagnosis of brief psychotic disorder, with catatonic features. Which symptoms are associated with the catatonic specifier? Ataxia and akinesia Substance abuse and cachexia Stupor, muscle rigidity, and negativism Strong ego boundaries and abstract thinking

Stupor, muscle rigidity, and negativism

Which statement best describes the classification of suicide? Suicide is a mental disorder Suicide is a behavior Suicide is an antisocial disorder Suicide is a mental illness

Suicide is a behavior

A client is admitted with nephrolithiasis. What symptoms does the nurse expect the client to experience? Select all that apply. Constipation Suprapubic pain Difficulty starting a urine stream Hematuria Elevated temperature

Suprapubic pain Difficulty starting a urine stream Hematuria Elevated temperature

A client with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention? Biopsy of sample tissue Surgical excision Radiation therapy Chemotherapy

Surgical excision

A nurse is performing patient teaching and is helping the client to understand that the process by which blood is ejected into circulation as the chambers of the heart become smaller is defined as? Systole Repolarization Ejection fraction Diastole

Systole

A client with severe and persistent mental illness has been taking antipsychotic medication for 20 years. The nurse observes during a therapy session that the client's behavior includes repetitive movements of the mouth and tongue and facial grimacing. The nurse recognizes these behaviors as indicative of what? Posturing Tardive dyskinesia Extrapyramidal side effects You Answered Loss of voluntary muscle control

Tardive dyskinesia

A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants' risks of basal cell carcinoma (BCC)? Teaching participants to improve their overall health through nutrition Teaching participants to limit their sun exposure Encouraging participants to identify their family history of cancer Teaching participants to control exposure to environmental and occupational radiation

Teaching participants to limit their sun exposure

Which of the following best defines stroke volume? The amount of blood ejected with each heartbeat Ability of the cardiac muscle to shorten in response to an electrical impulse Degree of stretch of the cardiac muscle fibers at the end of diastole Amount of blood pumped by the ventricle in liters per minute

The amount of blood ejected with each heartbeat

Which assessment findings in a client who is suspected of having a delusional disorder would be suggestive of a diagnosis of schizophrenia? The client responds to group psychotherapy. The client does not have insight into his or her delusions. The client's beliefs are considered delusional but nonbizarre. The client experiences frequent and sustained hallucinations.

The client experiences frequent and sustained hallucinations.

Which client symptoms should lead a nurse to suspect a diagnosis of obsessive-compulsive personality disorder? The client experiences inflexibility and lack of spontaneity when dealing with others. The client experiences unwanted, repetitive behavior patterns. The client experiences unwanted, intrusive, and persistent thoughts. The client experiences obsessive thoughts that are externally imposed.

The client experiences inflexibility and lack of spontaneity when dealing with others.

An inpatient client with a known history of violence suddenly begins to pace. Which additional client behavior would alert a nurse to escalating anger and aggression? The client refuses to eat lunch. The client sits in group with back to peers. The client has a tense facial expression. The client requests prn medications.

The client has a tense facial expression.

The nurse is working with a 17-year-old client with a complex and dysfunctional family background. What aspect of this client's history should the nurse identify as the most significant risk factor for posttraumatic stress disorder (PTSD)? The client was placed in foster care for the first 4 months of life The client moved more than 12 times before turning 10 years old The client was physically abused by the mother's boyfriend at a young age The client's mother has a long history of alcohol abuse

The client was physically abused by the mother's boyfriend at a young age

A nurse is determining a client's pressure ulcer risk using the Braden scale. What is important for the nurse to assess? Select all that apply If the client has any risk factors for melanom. The client's ability to sense pain or discomfort in the extremities. If the client experiences pain while turning onto the side. The client's 3-day food diary. How well the client moves in the bed and chair.

The client's ability to sense pain or discomfort in the extremities. The client's 3-day food diary. How well the client moves in the bed and chair.

A nurse is assessing a client who experiences occasional feelings of sadness because of the recent death of a beloved pet. The client's appetite, sleep patterns, and daily routine have not changed. How would the nurse interpret the client's behaviors? The client's behaviors are not congruent with cultural norms. The client's behaviors demonstrate mental illness in the form of depression. The client's behaviors demonstrate no functional impairment, indicating no mental illness. The client's behaviors are inappropriate, which indicates the presence of mental illness.

The client's behaviors demonstrate no functional impairment, indicating no mental illness.

A nurse is assessing a client who experiences occasional feelings of sadness because of the recent death of a beloved pet. The client's appetite, sleep patterns, and daily routine have not changed. How would the nurse interpret the client's behaviors? The client's behaviors are not congruent with cultural norms. The client's behaviors demonstrate no functional impairment, indicating no mental illness. The client's behaviors demonstrate mental illness in the form of depression. The client's behaviors are inappropriate, which indicates the presence of mental illness.

The client's behaviors demonstrate no functional impairment, indicating no mental illness.

The nurse is assessing a client's bladder by percussion. The nurse elicits dullness after the client has voided. How should the nurse interpret this assessment finding? The client has a ureteral obstruction. The client has a fluid volume deficit. The client's bladder is not completely empty. The client has kidney enlargement.

The client's bladder is not completely empty.

A client developed conversion blindness after witnessing the death of the client's twin in a car accident. When teaching the client's parent about the client's illness, the nurse explains what? The clients blindness will gradually disappear if proper ophthalmologic care is provided. The client's blindness results in increased anxiety and attention from family and friends. The client's blindness is a reaction to the trauma of losing the twin and has no physiologic basis. The client's blindness requires a conscious effort to maintain the feigned symptom.

The client's blindness is a reaction to the trauma of losing the twin and has no physiologic basis.

A client's neck dissection surgery resulted in damage to the client's superior laryngeal nerve. What area of assessment should the nurse consequently prioritize?

The client's swallowing ability

Endometrosis

The condition when tissue from the lining of the uterus is found outside the uterine cavity. -CX is not understood -Major CX of chronic pelvic pain & infertility Risk factors: -no children; having children late -short menses <27 days -flow longer than 7 days -young age getting period -risk for endometrial cancer Signs & symptoms: -sharp dull pain during ovulation, sex, BM & urinating -heavy painful periods -indigestion, diarrhea, constipation -fatigue & infertility Treatment: -NSAIDS pain med - hormones - androgens - decrease estrogen production -hysterectomy

A client with a pressure ulcer is receiving negative-pressure wound therapy. What finding indicates the need for follow-up by the nurse? The diameter of the wound has not changed since a week ago. The client rates pain as a 3 on a 0-10 pain scale. There is a small amount of clear, odorless drainage from the wound. The negative-pressure wound therapy unit is hanging on the side of the bed.

The negative-pressure wound therapy unit is hanging on the side of the bed.

Battery Slander Beneficence Malpractice

The touching of another person without consent Verbalizing false and malicious information about a person An ethical principle that refers to one's duty to benefit or promote the good of others The failure of a professional to perform or to refrain from performing in a manner in which a reputable member within the profession would be expected to do

The nurse is caring for a client admitted with unstable angina. The laboratory result for the initial troponin is elevated in this client. The nurse should recognize what implication of this assessment finding? Because the client has a history of unstable angina, this is a poor indicator of myocardial injury. This is an accurate indicator of myocardial injury. This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours. This result indicates muscle injury, but does not specify the source.

This is an accurate indicator of myocardial injury.

The nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention? To assess for Wernicke-Korsakoff syndrome To assess for tachycardia To assess for fine tremors To assess for emotional strength

To assess for fine tremors

A client is brought to the ED. The client is aggressive, has slurred speech, and impaired motor coordination. Blood alcohol level is 347 mg/dl. Among the physician's orders is thiamine. Which is the rationale for this intervention? To prevent alcoholic hepatitis To prevent nutritional deficits To prevent Wernicke's encephalopathy To prevent pancreatitis

To prevent Wernicke's encephalopathy

The dressing surrounding a client's Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion? Trace the outline of the drainage on the dressing for future comparison. Photograph the client's abdomen for later comparison using a smartphone. Remove and weigh the dressing, reapply it, and then repeat in 8 hours. Document the findings

Trace the outline of the drainage on the dressing for future comparison.

The client presented to the emergency department with a report of chest pain. The nurse performs a thorough physical examination for this client, who has a history of a somatic symptom illness. Which is the best rationale for the physical exam? Ease the client's mind that the nurse is looking for physical illness. Physical exams are reimbursed by third-party payers. Underlying pathology should be ruled out. Physical disorders underlie somatic disorders.

Underlying pathology should be ruled out.

The nurse is teaching a client with recurrent urinary tract infections (UTIs) ways to decrease risk for additional UTIs. The nurse includes which information? Void immediately after sexual intercourse. Increase intake of coffee, tea, and colas. Void every 5 hours during the day. Take tub baths instead of showers.

Void immediately after sexual intercourse.

Which of the following is not a primary symptom of COPD? Dyspnea upon exertion Weight gain Cough Sputum production

Weight gain

The client has been extremely anxious ever since relocating to another state because of a job transfer. When assessing for the diagnosis of adjustment disorder (AD), within what time frame should the nurse expect the client to exhibit symptoms? Within 3 months of the move Within 1 year of the move Within 9 months of the move Within 6 months of the move

Within 3 months of the move

Dermatophytes (also called tinea) are parasitic fungi that invade the skin, scalp, and nails. How is a diagnosis made for this condition? Select all that apply. excoriation from scratching Visual examination Wood's light Intense itching, especially at night

Wood's light

The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing? Uncontrolled pain Hyperthermia Atelectasis Wound infection

Wound infection

Syphilis

a bacterial STD that causes ulcers or chancres; if untreated, it can lead to mental and physical disabilities and premature death. 5 stages: 1- inoculation (no symptoms) 3 weeks 2- Chancre on gentials painless 3-6 weeks - 1st symp. 3- rash (feet) still contagious 6w-6m 4- no symptoms (early/late) slightly contagious 1 year after intercourse 5- gumma of skin 4-20 years after: lesions can occur in deep organs/CNS degeneration which can lead to meningitis and decrease mental function DX: -serological testing -dx of neurosyphilis TX: Penicillin

retrograde ejaculation

a condition in which orgasm in the male is not accompanied by an external ejaculation; instead, the ejaculate goes into the urinary bladder

spermatocele

a cyst that develops in the epididymis and is filled with a milky fluid containing sperm

inhibited ejaculation

a male's inability to ejaculate when he wants to, if at all

priapism

a painful erection that lasts 4 hours or more but is not accompanied by sexual excitement. 3 types: ischemic - low flow non-ischemic - high flow stuttering - intermittent

toxic shock syndrome (TSS)

a severe illness characterized by high fever, rash, vomiting, diarrhea, and myalgia, followed by hypotension and, in severe cases, shock and death; usually affects menstruating women using tampons; caused by Staphylococcus aureus and Streptococcus pyogenes Pt education is necessary

varicocele

abnormal dilation of the veins of the spermatic cord; can lead to infertility. asymptomatic can be corrected surgically.

vesicovaginal fistula

abnormal opening between the bladder and the vagina. Urine comes from the vagina

rectovaginal fistula

abnormal opening between the rectum and the vagina. stool inc. & flatus from vagina CX: congenital d/t traumatic vaginal delivery, radiation therapy. TX: may heal on own, surgery, good pericare

amenorrhea

absence of menstrual flow Primary: by age 15 has not begun developing secondary sexual characteristics or by 16 develops secondary sexual characteristics but no menstrual flow. CX: genetics, anorexia, PCOS, Turner syndrome Secondary: absence of meses for 3 cycles or 6 months after normal menese. CX: endocrine disorder, pregnancy, breast feeding, menopause, PCOS. TX: correct causes.

anovulation

absence of ovulation

Peyronie's disease

acquired benign condition involving build up of fibrous plaques in the sheath of corpus carvemosum. Causes a curvature of the penis when erect. can be painful and make sex difficult

A client is receiving a blood transfusion and the nurse notes hives and itching to the clients arms and chest. What type of reaction is the client experiencing?

allergic reaction

genital warts

an STD caused by the human papilloma virus (HPV); highly contagious. No cure

Trichmoniasis

an infection caused by parasite usually asymptomatic, frothy discharge, itching and burning TX: flagale

Barbara Dolan who is going through alcohol withdrawal is very agitated and restless. Which of the following medication classifications may be prescribed to manage this condition? benzodiazepines beta blockers diuretics vitamins

benzodiazepines

BSE

breast self-examination: monthly 1 week after period

prostate cancer

cancer of the prostate gland. 2nd most common cancer in men. slow growing and asymptomatic until its advanced. unnoticed until their is pain. can metastasis to lymph nodes, bone, rectum, and bladder. Risk factors: - age >50, greatest risk is older then 65 -African American -BRCA 1 & 2 gene -obesity -diet high in red meat and diary S&S: EARLY -weak urine stream - diff. starting urine stream -retention -sexual dysfunction -bladder infections LATE SIGNS: -nocturia -fatigued -hemospermia -pain w/urine & ejaculation -swollen lymph nodes

testicular cancer

cancer of the testicle, usually occurring in men 15 to 35 years of age. 95% curable w/early detection = TSE Can occur in both testes usually only one Risk Factors: -Fam HX -HIV pos. Testicular cancer spreads through blood supply, the tube responsible for sperm transport & lymph system. - can metastasize to brain, lungs, bone, abdomen. S&S: -painless, hard mass -enlargement, swelling, or hardness of scrotum. -heaviness or aching in lower abdomen -back pain & respiratory symptoms. TX: -orchiectomy- surgical: retroperitoneal lymph node dissection silicone prosthesis -Laparoscopic (preferred) small incision-less recovery -chemotherapy- non surgical -radiation - decreases sperm count and affect erectile function

ovarian cancer

cancerous tumor formed within ovary. 1/70 people very difficult to detect - no screenings Risk factors: -HX -BRCA 1 & 2 gene -early menarche -late menopause -obesity Signs & Symptoms: nonspecific & vague -increased abdominal girth - fluid -pelvic pressure/pain -bloating -leg/back pain -palpable ovary -constipation

Distributed Justice

concerned with the fair distribution of society's benefits and burdens

Paraphimosis

condition in which a retracted prepuce cannot be pulled forward to cover the glans. CX: -venous congestion, inflammation, edema, enlargement glans can lead to necrosis. TX: -firm compression of glans for 5 mins. incisional intervention.

Family planning & contraception's

condoms - 99% only STI protection option IUD 99% Abstinence - 100% Oral- 91% Transdermal-91% Injectable-94% Vag. ring - 91% considerations: safety- allergies protection against STI effectiveness side effects availability expense religious beliefs Oral contraception warnings: ACHES

dyspareunia

difficult or painful intercourse CX: injury D/T childbirth, lack of lubrication, HX of incest, sexual abuse, assault, endometriosis & vag. infectoins, STI, UTI's.

Nonmaleficence

do no harm

Sue, who is Barbara Dolan's friend, covertly supports her substance-abuse behavior is called? enabler codependent conspirator participant

enabler

benign prostatic hyperplasia (BPH)

enlargement of the prostate gland. 50% of men 51-60years ; 90% of men over 80years disrupts flow of urine and this develops over a long period of time ( non cancerous) Risk factors: -smoking; high alcohol intake -high animal fats & protein, with low fiber diet -obesity -DM -hormonal supplement -lack of physical activity Complications of BPH: -UTI -Bladder stone -bladder damage- overflow inc. -kidney damage-hydronephrosis -acute urinary retention - EMERGENCY could mean sepsis!

menorrhagia

excessive menstrual bleeding during regular menses - can cause anemia

menometrorrhagia

excessive uterine bleeding at both the usual time of menstrual periods and at other irregular intervals. risk for anemia

Teenagers at risk for STI's

feeling of invincibility unprotected sex- no access to condoms or BC short term relationships

hydrocele

fluid around testes - 1/10 infants at birth -in adults TX is not usually required Hydrocelectomy if tx is needed.

phimosis

foreskin cannot be retracted back over the glans on a uncircumcised man. - inflammation, edema, constriction from secretions, adhesions. this causes poor hygiene TX: -steroidal cream or circumcision

Signs & symptoms of breast issues

found anywhere usually on the upper quadrants nontender, fixed, hard with irreg. boarders advanced signs - skin dimpling, nipple retraction, skin ulceration

rectocele

hernia of the rectum into the vagina constipation, rectal pressure.

STI risk factors

hx STI infection multiple/new sex partners unprotected sex sex with high-risk partner sex with partner HIV+ women more at risk due to their anatomy.

Augmentation of breast

implants

erectile dysfunction

inability of an adult male to achieve an erection for sexual intercourse DX: based on medical HX, s&s, thorough physical assess & testing. Organic causes: CVD, obesity, substance abuse, meds, DM. Psychogenic causes: anxiety, depression, neg. body image, fatique. Management: PDE - 5 Inhibitor meds: -sildenafil (viagra) -Vardenafil (levitra) -Tadalafil (cialis) take these one hour before intercourse

Correction of infertility problem (men)

increase sperm count and motility obstruction - steroids artificial insemination

Atonomy

individuals select actions that fulfil their goals

A nurse is preparing to administer intravenous fluids, including accessing a vein. What is the most potentially harmful risk posed for the client when accessing the vein?

infection

canadidiasis

infection with the yeastlike fungus antibiotics can cause this vag. discharge - cottage cheese - decreases pH TX: Diflucan (antifungal)

orchitis

inflammation of one or both testicles S&S: -fever, pain, tenderness/swelling in testes, discharge, increased WBC. TX: -based on causative factors, support, mumps vaccine.

epididymitis

inflammation of the epididymis DX: -UA, CBC, Urethral discharge, STI test S&S: - low grade fever, heaviness of effected testicle, pain in teste. TX: - depends on cause: meds & elevate testicles.

vaginitis

inflammation of the lining of the vagina -bacterial: multiple partners, same sex partner, -grey/white/yellow discharge -increased pH TX: flagale (overgrowth of bacteria)

prostatitis

inflammation of the prostate gland -S&S: sudden onset of: -fever -dysuria -LUTS -sex discomfort & dysfunction -perineal prostatic pain Management: depends on causative factors -Culture & sensitivity -meds: antibiotics, anti-inflammatory, pain, stool softener. -non pharm: pelvic floor training, promote ejaculation.

abnormal uterine bleeding

irregular painless bleeding between menses; includes infrequent, excessive, prolonged, or postmenopausal bleeding

metorrhagia

irregular uterine bleeding between menses tell your DR - can indicate cancer

A provider orders normal saline IV 120ml/hr to a client that was admitted for pneumonia. The nurse knows this type of IV fluid is

isotonic

total mastectomy

mastectomy that involves excision of an entire breast, nipple, areola, and lymph nodes

Benefience

maximize benefits and minimize risks

Testicular trauma

mild injury to the testicles can cause severe pain, bruising or swelling. common in males 25-40 years old

Conditions of the nipple

nipple discharge: sign of breast cancer ; bleeding Fissure: cracks in nipple

Chronic glomerulonephritis is an inflammatory response in the glomerular capillary membrane, and causes disruption of the renal filtration system. Although diagnostic urinalysis can reveal glomerulonephritis, many clients with glomerulonephritis exhibit: polyuria. headache. no symptoms. fever.

no symptoms.

The client experiences inflexibility and lack of spontaneity when dealing with others. What diagnosis does the nurse suspect? Borderline Personality Disorder Bipolar Disorder Depression obsessive-compulsive personality disorder

obsessive-compulsive personality disorder

postmenopausal

ovaries and ova dont mature anymore 45-50 years. combination of endocrine and psychological changes (estrogen deficiency)

dysmenorrhea

pain caused by uterine cramps before or shortly after onset of menstrual flow. CX: overproduction of prostaglandins TX: NSAIDS Secondary: R/T underlying CX: pain occurs for days before menses w/ ovulation and at times with intercourse S&S: N/V, diarrhea, dizziness, and back ache

Complications of STI's

pelvic inflammatory disease (PID) infertility chronic pelvic pain Cancer Peer pressure Cultures dont believe in condoms

cystocele

protrusion of the bladder - anterior wall of vagina prolapses the bladder and urethra protrude downward into vagina. incomplete bladder emptying, increased LUTS, stress inc.

Physical assessment and screenings

regular exams and screenings (breast & cervix) -early detection is key BSE 7-9 days after menses CBE PAP - after 21 MAMMO- fam HX Pelvic exam

Select the electrical activity of the heart that corresponds to the PR: both depolsrization and repolarization of the ventricles repolarization of the ventricles represents atrial depolarization and conduction through the AV node depolarization of the ventricles SA node initiates the impulse. Impulse travels to the AV node in 0.12 to 0.2 second. PR interval: 0.12-0.2 seconds

represents atrial depolarization and conduction through the AV node

A client asks for information about Alcoholics Anonymous. Select the nurse's best response. "Alcoholics Anonymous is a: self-help group for which the goal is sobriety." form of group therapy led by a psychiatrist." group that learns about the consequences of drinking from a group leader." network that advocates strong punishment for drunk drivers."

self-help group for which the goal is sobriety."

Sexual Assessment

sexual history determine their sexual concerns assess medical conditions and medications that might have an affect on sexual functioning physical assessment individual's expectations factors affecting sexuality sexual dysfunction ASK

n the treatment of anxiety disorders, benzodiazepines (such as Ativan and Xanax) are indicated for ______ use and have a ______ abuse potential. short-term; low long-term; low long-term; high short-term; high

short-term; high

Premenopause

still having a period

Advocacy

support; active pleading on behalf of someone or something

mammoplasty

surgical reconstruction of the breast(s) to change the size, shape, or position

hysterectomy

surgical removal of the uterus total: uterus & cervix partial: uterus, cervix, surrounding tissue, 1/3 of upper vag, & lymph nodes. Management: -monitor for hemorrhage, DVT, bladder distention, infection. Nursing care: -relief of anxiety, pain & discomfort

premenstrual syndrome (PMS)

symptoms that develop just prior to onset of menstrual period; can include irritability, headache, tender breasts, and anxiety CX: unknown most likely related to hormones 75-95% of women.

The nurse has completed an assessment of the renal and urinary system, indicate which assessment finding indicates a need for additional follow up. (Select all that apply) tenderness with kidney palpation acute confusion decreased libido flank bruising unable to palpate left kidney

tenderness with kidney palpation acute confusion flank bruising

Infertility

the inability to conceive a child after trying for at least a year. -primary: never had a child -Secondary: 1 child - unable to conceive again -wastage: conceives but unable to carry to full term 10-20% struggle couples are waiting till older to start a family: fertility decreases with age. Male factors: abnormalities of sperm: #, structure, and function Female factors: needs-reg. production of normal ova. open pathway from cervix to fallopian tube to uterus. uterine endometrium that supports pregnancy

Ethics

the principles of right and wrong that guide an individual in making decisions

menopause

the time of natural cessation of menstruation; also refers to the biological changes a woman experiences as her ability to reproduce declines. Management: hormone therapy -estrogen and progesterone if still have a uterus. -estrogen if had a hysterectomy - increased risk for breast cancer and uterine cancer Management of symptoms: -lube, hydration, estrogen alternatives, Kegels, hygiene.

Modified Radial Mastectomy

tissue, nipple & areola.

Clients with ___________risk factors are at higher risk of developing renal cell carcinoma that can easily metastasize to _________.

tobacco use and HTN lungs and liver

Torsion

twisted spermatic cord & blood vessels

A female patient has been diagnosed with "metabolic syndrome" or "insulin resistance." What findings support this diagnosis? Select all that apply. ↓ HDL of 30 mg/dL BMI of 30 kg/m2 Fasting blood glucose of 105 mg/dL Abdominal girth measurement of 40 Blood pressure of 145/90 ↑Triglycerides greater than 150 mg/dL

↓ HDL of 30 mg/dL BMI of 30 kg/m2 Blood pressure of 145/90 ↑Triglycerides greater than 150 mg/dL Abdominal girth measurement of 40

A diabetic client has come to see their provider for their annual physical. When the nurse returns to the room after the hospital gown has been put on, the client climbs up onto the exam table. It is noticed that there is a wound on the bottom of the foot. The client is unaware that it was present. The nurse knows that Diabetic foot ulcers are: select all that apply 1. Due to impaired ability of the leukocytes to destroy bacteria resulting in infections. 2. Due to regular use of specialized diabetic socks and shoes resulting in a decrease in pressure points on the foot. 3. Due to the application of lotion to the bottom of the foot surfaces resulting in smooth, supple skin. 4. Due to poor circulation in the lower extremities contributing to poor healing. 5.Due to the changes in the nerves resulting in the loss in sensation.

Due to impaired ability of the leukocytes to destroy bacteria resulting in infections. Due to poor sirculation in the lower extremeties contributing to poor healing. Due to the changes in the nerves resulting in the loss in sensation.

Which statement correctly identifies a difference between duodenal and gastric ulcers?

Duodenal ulcer pain is aggravated by fasting

A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn's disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms?

An absence of blood in stool

A patient with a history of hypertension is diagnosed with chronic kidney disease. When the patient asks the nurse how this occurred, which response by the nurse is the best? "Thickening of the kidney structures and gradual death of nephrons has caused this diagnosis." "Cysts compress renal tissue, which destroy the kidneys, causing this diagnosis." "Immune complexes form in the kidney tissue and produce inflammation, causing this diagnosis." "High blood pressure reduces renal blood flow and harms the kidney tissue, causing this diagnosis."

"High blood pressure reduces renal blood flow and harms the kidney tissue, causing this diagnosis."

Which patient statement indicates effective teaching related to acute gastritis? "I will eat a diet rich in milk and cream to decrease the secretion of hydrochloric acid." "I will need to fully cook all meat, poultry, and egg products." "I need to avoid using aspirin or nonsteroidal medications for routine pain relief." "I will need to return for yearly upper endoscopy examinations."

"I need to avoid using aspirin or nonsteroidal medications for routine pain relief."

A nurse is caring for a client who has a peripheral line to the left arm. Assessment findings include: redness, heat, and warmth to the IV site, temperature 100.4, and the infusion has slowed. Based on the information above what actions should the nurse take? Select all that apply. 1.Elevate the extremity 2.Increase the infusion rate 3.Leave IV in place and add a second line 4.Discontinue the IV site 5.Stop infusion

1. Elevate the extremity 4.Discontinue the IV site 5. Stop infusion

The nurse is preparing to give a patient IV drug therapy. What information should the nurse know before administering the drug? Select all that apply. 1. Parameters to monitor related to immediate drug effects 2.Indications, contraindications, and precautions for IV therapy 3.Compatibility with other IV medications 4.Rate of infusion and dosage of drugs 5.Appropriate dilution, pH, and osmolarity of solution 6. Percentage of adverse events for the drug

1. Parameters to monitor related to immediate drug effects 2.Indications, contraindications, and precautions for IV therapy 3.Compatibility with other IV medications 4.Rate of infusion and dosage of drugs 5.Appropriate dilution, pH, and osmolarity of solution

Review the assessment findings and indicate if the findings need immediate follow-up by the nurse or other medical professionals. 1. A client is receiving a blood transfusion and has developed a temperature of 100.6 degrees Fahrenheit. 2. A client has an IV in the left hand with pain, swelling, and redness. 3. A client is receiving a blood transfusion and has a blood pressure of 124/64 4. A client has an IV to right hand with LR 100ml/hr

1. immediate follow up 2. no immediate follow up 3. Immediate follow up 4. No immediate follow up

The order is for Kefzol 500 mg. The label says Kefzol 1 Gram/ 3mL. How many mL of the medication will the nurse give? ________mL

1.5ml

A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line with 0.45% normal saline that is infiltrated Which action should the nurse take first? 1. Administer 1 mg of intramuscular or subcutaneous glucagon. 2. Administer 25 mL dextrose 50% (D50) IV push. 3. Put honey between the client's cheek and gums 4. Insert a new intravenous access line.

Administer 1 mg of intramuscular or subcutaneous glucagon.

A community health nurse serves a diverse population. What individual would likely face the highest risk for parotitis?

An older adult whose medication regimen includes an anticholinergic

A patient has dumping syndrome after a partial gastrectomy. Which action by the nurse would be most helpful?

Arrange a dietary consult

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

Cheyne-Stokes respirations

A student nurse is providing care to an older patient with stomatitis and dysphagia. What action by the student nurse requires the registered nurse to intervene?

Preparing to administer a viscous lidocaine gargle.

Which finding indicates that the airway is patent after suctioning the tracheostomy tube? 1. Increased pulse rate, rapid respirations, and cyanosis of the skin and nail beds 2. A respiratory rate of 28 breaths/minute with accessory muscle use 3. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds 4. Effective breathing at a rate of 16 breaths/minute through the established airway

Effective breathing at a rate of 16 breaths/minute through the established airway

A nurse is working with an client who has been newly diagnosed with Type 1 Diabetes., and knows that finger tips can get tender quickly when learning to perform self monitoring blood glucose (SMBG). The nurse shares other sites that are commonly used: select all that apply. Palm forearm thumb thigh upper arm calf

Palm forearm thumb thigh upper arm calf

The nurse is caring for a client who has returned to the unit following a bronchoscopy. The client is asking for something to drink. Which criterion will determine when the nurse should allow the client to drink fluids? 1.Absence of nausea 2.Ability to demonstrate deep inspiration 3.Oxygen saturation of ≥92% 4.Presence of a cough and gag reflex

Presence of a cough and gag reflex

The nurse has been caring for a client who has been prescribed an antibiotic for pharyngitis and has been instructed to take the antibiotic for 10 days. One day 4, the client is feeling better and plans to stop taking the medication. What information should the nurse provide to this client?

The importance of finishing all antibiotics as prescribed.

A nurse working in an endoscopy clinic is screening patients for the risk of developing Barrett's esophagus. The nurse should consider which patient at greatest risk? 1. pt who has had untreated GERD for 30 years 2. pt with a 30 pack per year smoking history 3. pt with a 20 year history of alcohol abuse 4. pt who has ingested lye as a child and is now 47 years old

The patient who has had untreated GERD for 30 years

The nurse is supervising a student who is preparing an IV bag with IV administration tubing. For which action by the student nurse must the nurse intervene?

The student touches the tubing spike

Which of the following mechanisms can facilitate the development of diverticulosis into diverticulitis?

Undigested food blocking the diverticulum, predisposing the area to bacterial invasion

A nursing instructor is discussing Diabetic Ketoacidosis with her students. They learn that the the following factors could lead to the development of this dangerous illness: Select all that apply. sedentary lifestyle New diagnosis of Type 1 Diabetes intentional skipping of insulin doses Error in drawing up insulin illness and infections

intentional skipping of insulin doses Error in drawing up insulin New diagnosis of Type 1 Diabetes illness and infections

A client has symptoms suggestive of peritonitis. Nursing management would not include: inserting a nasogastric tube. limiting analgesics to avoid the formation of paralytic ileus. accurate recording of input and output. inserting a urinary retention catheter.

limiting analgesics to avoid the formation of paralytic ileus.

When interpreting the results of a Mantoux test, the nurse explains to the client that a reaction occurs when the intradermal injection site shows:

redness, roundness, and elevation (enduration)

A client presents to the emergency room after a vehicle accident. The client is actively bleeding and the physician orders packed red blood cells stat. With the administration of blood the nurse should_______________________________________ and ___________________________________..

1. verify client and component information with another RN 2. Stay with the client for the 1st 15-30 minutes of infusion

Tube feedings are advised for a client who is recovering from oral surgery. The nurse manages the tube feedings to minimize the risk of aspiration. Which measures should the nurse include in the care plan to reduce the risk of aspiration? Select all that apply. 1.change tube feeding container and tubing 2. administer 15 to 30 mL of water before and after medications and feedings 3. Place client in semi-Fowler's position during and 30 to 60 minutes after an intermittent feeding. 4. Check tube placement and gastric residual prior to feedings.

2. administer 15 to 30 mL of water before and after medications and feedings 3. Place client in semi-Fowler's position during and 30 to 60 minutes after an intermittent feeding. 4. Check tube placement and gastric residual prior to feedings.

Your patient in the ED presents with a distended rigid and board-like abdomen, severe abdominal pain, an oral temperature of 102o F, the inability to pass gas, and nausea and vomiting. Upon obtaining a history you learn he had a colon resection a week ago for a bowel obstruction. What are the priority medical interventions for this patient ? (select all that apply) 1. admit the pt to the med-surg unit to observe for the next 24 hours 2. prepare the patient for exploratory surgery to identify the cause of his symptoms 3. IV antibiotic therapy 4. Give a laxative or stool softener and monitor bowl movements for the next 24 hours 5. Decrease abdominal distention by decompression with NG tube

2. prepare the patient for exploratory surgery to identify the cause of his symptoms. 5. Decrease abdominal distention by decompression with NG tube

The charge nurse is reviewing IV therapy orders. What information must be included in each order? Select all that apply. 1.Method for diluting drugs for the solution 2.Specific type of administration equipment 3.Specific drug dose to be added to the solution 4.Specific type of solution 5.Rate of administration 6.Frequency of drug administration

3.Specific drug dose to be added to the solution 4.Specific type of solution 5.Rate of administration 6.Frequency of drug administration

An emergency department nurse cares for a patient who is severely dehydrated and is prescribed 3 L of intravenous fluid over 6 hours. At what rate (mL/hr) would the nurse set the intravenous pump to infuse the fluids? (Record your answer using a whole number.) __________ mL/hr

500 ml/hr = 1000ml/1L X 3L/6hr = 500mL

You are providing nutrition education to a patient that has been just diagnosed with type 1 diabetes mellitus and specifically discussing the exchange system. The following is an example of a meal the patient ate at supper last night. What are the total number of carbohydrate exchanges for this meal? Round to the nearest whole number. Lean 3 oz. chicken breast = 0 g carbs 1 cup of cooked white rice = 45 g carbs 1 cup of sweet corn = 29 g carbs 1 cup of 2% milk - 12 g carbs

6 exchanges

The nurse is caring for a patient with COPD. The patient is receiving oxygen therapy via nasal cannula. The nurse understands that the goal of oxygen therapy is to maintain the patient's SaO2 level at or above what percent?

90%

The nurse is assessing a client whose respiratory disease in characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this client? 1.Signs of oxygen toxicity 2. Chronic chest pain 3.Long, thin fingers 4.A barrel chest

A barrel chest

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? A room that is within view of the nurses' station A room in the ICU A room with another nonsurgical client A room with air exhaust directly to the outdoor environment [negative pressure]

A room with air exhaust directly to the outdoor environment [negative pressure]

A nurse is assessing a client who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize? Assess for ability to communicate. Assess for a patent airway. Assess for signs of infection. Assess ability to clear oral secretions.

Assess for a patent airway.

A nurse is caring for a diabetic client in a long-term care facility where they are receiving rehabilitation services. It is noted that blood glucose readings are consistently higher than expected on the carbohydrate restricted diet that is provided. When the nurse sees the client eating candy, the client is confronted. The reply is "oh, these? They are sugar-free." When the label is read, it states "sugar-free", but when the nutrition label is read , the nurse shows the client that the sorbitol (sugar alcohol) has the same number of calories that the same candy that is NOT sugar free has. This is a case of: select all that apply. 1. An education opportunity 2. Full disclosure 3.Nutritive sweeteners 4. Misleading labels 5. Nonnutritive sweeteners

An education opportunity Nutritive sweeteners Misleading labels

A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority? 1. Assessing the client's respiratory status, orientation, and skin color 2. Applying an oil-based lubricant to the client's mouth and nose 3. Posting a "No smoking" sign over the client's bed 4. Changing the mask and tubing daily

Assessing the client's respiratory status, orientation, and skin color

A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education? Encourage the patient to take approximately 10 breaths per hour, while awake. Inform the patient that using the spirometer is not necessary if the patient is experiencing pain. Encourage the patient to try to stop coughing during and after using the spirometer. Have the patient lie in a supine position during the use of the spirometer.

Encourage the patient to take approximately 10 breaths per hour, while awake.

A patient is receiving IV therapy via an infusion pump. What is the priority nursing responsibility related to the equipment?

Ensure the IV pump is programmed correctly

A patient is having testing to diagnose type 1 diabetes mellitus. Which diagnostic tests might be prescribed for this patient? Select all that apply. Serum triglycerides Fasting blood glucose Hemoglobin A1c 2-hour postprandial Random blood glucose

Fasting blood glucose Hemoglobin A1c 2-hour postprandial Random blood glucose

A nurse assesses a patient with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, welling area at the site the patient uses most frequently for insulin injection. What action would the nurse take? 1. Assess the patient for other signs of cellulitis. 2.Instruct the patient to rotate sites for insulin injection. 3.Apply ice to the site to reduce inflammation. 4.Consult the provider for a new administration route.

Instruct the patient to rotate sites for insulin injection.

A client presents to the ER after a car accident and has had trauma resulting in blood loss. What fluid does the nurse expect the provider to order?

Lactated ringers

A client presents to the ED with acute abdominal pain, fever, nausea, and vomiting. During the client's examination, the lower left abdominal quadrant is palpated, causing the client to report pain in the RLQ. This positive sign is referred to as ________________and suggests the client may be experiencing ________________.

Rovsing's sign; acute appendicitis

A client scheduled for surgery has arranged for an autologous transfusion. What type of blood transfusion is this?

The client donates his or her own blood.

A patient is taking insulin and has a fasting blood glucose of 85 mg/dL, a postprandial blood glucose level of 160mg/dL, and a hemoglobin A1c level of 5.5%. What is the nurse's interpretation of these findings? 1. The client is at increased risk for low blood glucose at night 2. The client is at increased risk for developing hyperglycemia. 3.The client is demonstrating a need for a higher insulin dosage. 4. The client is demonstrating good control of blood glucose.

The client is demonstrating good control of blood glucose.

An adult client has tested positive for tuberculosis (TB). While providing client teaching, what information should the nurse prioritize? 1.The fact that the disease is a lifelong, chronic condition that will affect ADLs 2.The need to work closely with the occupational and physical therapists 3.The fact that TB is self-limiting, but can take up to 2 years to resolve 4.The importance of adhering closely to the prescribed medication regimen

The importance of adhering closely to the prescribed medication regimen

Type 1 diabetes the insulin-producing beta cells in the pancreas are destroyed by a combination of the following factors? Select all that apply. environmental substance abuse access to food Genetic Immunologic

environmental genetic immulogic

After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client?

every 72 hours