NCLEX study from Adaptive Quizzing

sequence of events occurring during a fever secondary to pyrogens in chronological order

1 Immune system response is triggered 2 The set point of the hypothalamus is raised 3 Body temperature is increased 4 Pyrogens are destroyed 5 Heat loss responses are initiated Rationale: A true fever results from an alteration in the hypothalamic set point. Pyrogens act as antigens that trigger the immune system response. The hypothalamus reacts by raising the set point, thereby increasing the body temperature. Once the pyrogens are removed, the third phase of a febrile episode occurs. Heat loss responses are initiated when the hypothalamus set point drops.

A client has a colon resection with an anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply. 1 Oliguria 2 Lethargy 3 Irritability 4 Hypotension 5 Slurred Speech

1 Oliguria 3 Irritability 4 Hypotension Rationale: Decreased blood flow to the kidneys leads to oliguria or anuria. Irritability, along with restlessness and anxiety, occurs because of a decrease in oxygen to the brain. Hypotension and a narrowing of the pulse pressure occur because of declining blood volume. Restlessness, not lethargy, usually occurs because of decreased cerebral blood flow. There are various changes in sensorium, but slurred speech is not a manifestation of shock.

While assessing a client's vascular system, the nurse finds that pulse strength is diminished or barely palpable. Which documentation is appropriate in this situation? 1 1+ 2 2+ 3 3+ 4 4+

1 1+ Rationale: A diminished or barely palpable pulse is documented as 1+. A normal and expected pulse strength is documented as 2+. A full, strong pulse is documented as 3+. A bounding pulse is documented as 4+.

Which client is most likely to develop IgE antibodies? 1 A client with pollen allergy 2 A client undergoing a poison ivy reaction 3 A client with bacterial infection 4 A client undergoing a blood transfusion

1 A client with pollen allergy Rationale: A client with a pollen allergy develops IgE antibodies that may result in an anaphylactic reaction. A client with poison ivy develops delayed hypersensitivity, which is mediated by T lymphocytes. A client with a bacterial infection develops IgG and IgM antibodies. A client undergoing blood transfusion may develop IgG and IgM type II hypersensitivity reactions.

The nurse is reviewing blood screening tests of the immune system of a client with acquired immunodeficiency syndrome (AIDS). What does the nurse expect to find? 1 A decrease in CD4 T cells 2 An increase in thymic hormones 3 An increase in immunoglobulin E 4 A decrease in the serum level of glucose-6-phosphate dehydrogenase

1 A decrease in CD4 T cells Rationale: The human immunodeficiency virus (HIV) infects helper T-cell lymphocytes; therefore 300 or fewer CD4 T cells per cubic millimeter of blood or CD4 cells accounting for less than 20% of lymphocytes is suggestive of AIDS. The thymic hormones necessary for T-cell growth are decreased. An increase in immunoglobulin E is associated with allergies and parasitic infections. A decrease in the serum level of glucose-6-phosphate dehydrogenase is associated with drug-induced hemolytic anemia and hemolytic disease of the newborn.

After a client on the mental health unit with a known history of opioid addiction has a visit from several friends, a nurse finds the client in a deep sleep and unresponsive to attempts at arousal. The nurse assesses the client's vital signs and determines that an overdose of an opioid has occurred. Which findings support this conclusion? 1 Blood pressure of 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths/min 2 Blood pressure of 180/100 mm Hg, tachycardia, and respiratory rate of 18 breaths/min 3 Blood pressure of 120/80 mm Hg, regular pulse, and respiratory rate of 20 breaths/min 4 Blood pressure of 140/90 mm Hg, irregular pulse, and respiratory rate of 28 breaths/min

1 Blood pressure of 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths/min Rationale: Opioids cause central nervous system depression, resulting in severe respiratory depression, hypotension, tachycardia, and unconsciousness. The other findings, particularly the respirations, are not indicative of an overdose of an opioid.

A client remains depressed even after an 8-week trial on several antidepressant medications. A decision to initiate electroconvulsive therapy (ECT) is being considered by the treatment team. Which condition is a contraindication to ECT? 1 Brain tumor 2 Type 1 diabetes 3 Hypothyroid disorder 4 Urinary tract infection

1 Brain Tumor Rationale: ECT is contraindicated in the presence of a brain tumor, because the treatment causes an increase in intracranial pressure. ECT is not contraindicated in the presence of diabetes, hypothyroid, or urinary tract infection.

When planning for a client's care during the detoxification phase of acute alcohol withdrawal, what need should the nurse anticipate? 1 Checking on the client frequently 2 Keeping the client's room lights dim 3 Addressing the client in a loud, clear voice 4 Restraining the client during periods of agitation

1 Checking on the client frequently During detoxification frequent checks help ensure safety and prevent suicide, which is a real threat. Bright light is preferable to dim light because it minimizes shadows that may contribute to misinterpretation of environmental stimuli (illusions). The client who is going through the detoxification phase of acute alcohol withdrawal usually does not lose his sense of hearing, so there is no need to shout. Restraints may upset the client further; they should be used only if the client is a danger to himself or others.

Addicted clients commonly expect discrimination and lack of empathy from others. How can the nurse best overcome these expectations? 1 Demonstrating a nonjudgmental attitude 2 Explaining that an addiction is a disease 3 Offering reassurance that the client is accepted 4 Confronting these attitudes when they are expressed

1 Demonstrating a nonjudgmental attitude Rationale: Behaviors that reflect acceptance and consistency are the best approaches to overcoming these client expectations. What the nurse does is a better indicator of acceptance than the words or explanations that are verbalized. The nurse's actions over time are better indicators of acceptance than is verbal reassurance. Confrontational measures increase anxiety and are not therapeutic.

Which symptoms are common during the fulminant stage of inhalation of anthrax? Select all that apply. 1 Dyspnea 2 Dry cough 3 Diaphoresis 4 Mild chest pain 5 High temperature

1 Dyspnea 3 Diaphoresis 5 High temperature Rationale: The fulminant stage of inhalation of anthrax is manifested by dyspnea, diaphoresis, and a high body temperature. The prodromal stage of inhalation of anthrax is manifested by a dry cough and mild chest pain.

During an interview of a client with a diagnosis of bipolar I disorder, manic episode, what does the nurse expect the client to demonstrate? 1 Flight of ideas 2 Ritualistic behaviors 3 Associative looseness 4 Auditory hallucinations

1 Flight of ideas Rationale: Flight of ideas is a fragmented, pressured, nonsequential pattern of speech typically used during a manic episode. Ritualistic behaviors are repetitive, purposeful, and intentional behaviors that are carried out in a stereotyped fashion; they are found in clients with obsessive-compulsive disorders. Associative looseness is the pattern of speech found in clients with schizophrenia; usual connections between words and phrases are lost to the listener and meaningful only to the speaker. Hallucinations are false perceptions generated by internal stimuli; they are found in clients with the diagnosis of schizophrenia.

At which stage of Kohlberg's theory does an individual want to fulfill the expectations of one's immediate group? 1 Good boy-nice girl orientation 2 Society-maintaining orientation 3 Instrumental relativist orientation 4 Universal ethical principle orientation

1 Good boy-nice girl orientation Rationale: The good boy-good girl orientation stage involves an individual who wants to win the approval and maintain the expectations of one's immediate group. During the society-maintaining orientation stage, an individual expands focus from a relationship with others to societal concerns. The instrumental relativist orientation stage involves a child who wants to follow his or her parent's rules. The universal ethical principle orientation stage defines "right" by the decision of conscience according to self-chosen ethical principles.

Which type of hepatitis virus spreads through contaminated food and water? 1 Hepatitis A virus 2 Hepatitis B virus 3 Hepatitis C virus 4 Hepatitis D virus

1 Hepatitis A virus Rationale: Hepatitis A virus spreads through contaminated food and water. Hepatitis B, C, and D viruses spread through contaminated needles, syringes, and blood products.

Which sleep disorders are examples of dyssomnias? Select all that apply. 1 Insomnia 2 Nightmares 3 Sleep terrors 4 Restless leg syndrome 5 Obstructive sleep apnea

1 Insomnia 4 Restless leg syndrome 5 Obstructive sleep apnea Rationale: Insomnia, restless leg syndrome, and obstructive sleep apnea are examples of dyssomnias. Nightmares and sleep terrors are examples of parasomnias.

A client with alcoholism was admitted a few hours ago for pancreatitis. For which symptoms should the nurse carefully monitor this client? 1 Irritability and tremors 2 Yawning and convulsions 3 Disorientation and paranoia 4 Fever and profuse diaphoresis

1 Irritability and tremors Rationale: The nurse should carefully monitor a client with alcoholism and pancreatitis for irritability and tremors when it has been a few hours since admission. Alcohol is a central nervous system depressant, and irritability and tremors are the body's neurologic adaptation during withdrawal of alcohol. Tachycardia, irritability, and tremors are the early signs of withdrawal and will appear 24 to 48 hours after the last alcoholic drink has been consumed.

For which clinical indication should a nurse observe a child in whom autism is suspected? 1 Lack of eye contact 2 Crying for attention 3 Catatonia-like rigidity 4 Engaging in parallel play

1 Lack of eye contact Rationale: Children with autism usually have a pervasive impairment of reciprocal social interaction. Lack of eye contact is a typical behavior associated with autism. Crying for attention, rigidity, and parallel play are not indicative of autism.

Two days after having a cesarean birth, a client tells the nurse that she has pain in her right leg. After an assessment the nurse suspects that the client has a thrombus. What is the nurse's primary response at this time? 1 Maintaining bed rest 2 Applying warm soaks 3 Performing leg exercises 4 Massaging the affected area

1 Maintaining bed rest Rationale: Although thrombophlebitis is suspected, before a definitive diagnosis can be made the client should be confined to bed so that further complications may be avoided. Applying warm soaks may cause vasodilation, which could allow a thrombus to dislodge and circulate freely. If a thrombus is present, massage may dislodge it and lead to a pulmonary embolism.

A healthcare provider diagnoses attention deficit hyperactivity disorder (ADHD) in a 7-year-old child and prescribes methylphenidate. The nurse discusses the child's treatment with the parents. What does the nurse emphasize as important for the parents to do? 1 Monitor the effect of the medication on their child's behavior. 2 Increase or decrease the dosage, depending on the child's behavior. 3 Avoid imposing too many rules, because this will frustrate the child. 4 Point out to their child that behavior can be controlled.

1 Monitor the effect of the medication on their child's behavior. Rationale: By monitoring and reporting changes in the child's behavior, the healthcare provider can determine the effectiveness of the medication. Dosage changes are the responsibility of the healthcare provider. Children need structure and rules; they provide a sense of security. Behavior is not deliberate or controllable; this statement may diminish the child's self-esteem if he or she cannot exert control.

What are the most common hormones produced in excess with hyperpituitarism? Select all that apply. 1 Prolactin 2 Growth hormone 3 Luteinizing hormone 4 Antidiuretic hormone 5 Melanocyte-stimulating hormone

1 Prolactin 2 Growth Hormone Rationale: The most common hormones produced in excess with hyperpituitarism are prolactin and growth hormone. Excessive stimulation of luteinizing hormone and antidiuretic hormone is also associated with hyperpituitarism, but less commonly than prolactin and growth hormone. Secretion of melanocyte-stimulating hormone stimulates adrenocorticotropic hormone, which indirectly stimulates the pituitary gland, thus leading to hyperpituitarism.

A client is diagnosed with a brain attack (cerebrovascular accident, CVA). The baseline vital signs are a pulse rate of 78 bpm and a blood pressure (BP) of 120/80 mm Hg. The nurse continues to monitor the vital signs and recognizes that which changes in vital signs indicate increased intracranial pressure (ICP)? 1 Pulse 50 bpm and BP 140/60 mm Hg 2 Pulse 56 bpm and BP 130/110 mm Hg 3 Pulse 60 bpm and BP 126/96 mm Hg 4 Pulse 120 bpm and BP 80/60 mm Hg

1 Pulse 50 bpm and BP 140/60 mm Hg Rationale: Increasing intracranial pressure is evidenced by widening of pulse pressure and a decreased pulse rate.

A 12-year-old child with sickle cell anemia is admitted during a vaso-occlusive crisis. What is the priority of care for this child? 1 Relieving pain 2 Exercising joints 3 Increasing urine output 4 Improving respirations

1 Relieving pain Rationale: A vaso-occlusive crisis is accompanied by severe pain because the clumped red blood cells block small vessels. Swollen limbs are painful and should not be exercised during a pain episode. Although increased urine output, associated with appropriate hydration, is an important objective, pain relief is the priority. Improved respiratory function occurs as pain is relieved.

A client is receiving oxycodone postoperatively for pain. The healthcare provider's prescription indicates that the dose should be administered every 3 hours for eight doses. What should the nurse assess before administering each dose of oxycodone? 1 Respiratory rate and level of consciousness 2 Color, character, and amount of urine output 3 Intravenous site and patency of the intravenous catheter 4 Amount and character of drainage in the portable drainage system

1 Respiratory rate and level of consciousness Rationale: Oxycodone is an opioid that depresses the central nervous system, resulting in a decreased level of consciousness and depressed respirations. The medication should be administered, delayed, or held, depending on the client's status. Although urinary output of postoperative clients should be assessed, urinary output is not related directly to the administration of opioid medications. Oxycodone is administered via tablets, not intravenously. Wound drainage is unrelated to the administration of oxycodone.

During the assessment of a preterm neonate the nurse determines that the infant is experiencing hypothermia. Which action should the nurse take? 1 Rewarm gradually 2 Notify the practitioner 3 Assess for hyperglycemia 4 Record skin temperature hourly

1 Rewarm gradually Rationale: Gradually rewarming an infant experiencing cold stress is essential to avoid compromising the infant's cardiopulmonary status. It is not necessary to notify the practitioner initially. It is the nurse's responsibility to rewarm the infant. An infant experiencing cold stress will become hypoglycemic because glycogen and glucose are metabolized to maintain the core temperature. Skin temperature should be taken at least every 15 minutes until stable.

What are the clinical manifestations during the fulminant stage in a client with inhalation anthrax? Select all that apply. 1 Septic shock 2 Harsh cough 3 Mild chest pain 4 Pleural effusion 5 Body temperature of 104 °F

1 Septic shock 4 Pleural effusion 5 Body Temperature of 104 F Rationale: Inhalation anthrax is a bacterial infection caused by Bacillus anthracis. Manifestations such as septic shock, pleural effusion, and body temperature above 103°F indicate the fulminant stage of inhalation anthrax. The prodromal stage is the early stage of inhalation anthrax; clinical manifestations include a harsh cough and mild chest pain.

According to Erikson's theory, what behavior would the nurse explain a preschooler exhibits? 1 The child develops the superego. 2 The child plays beside other children. 3 The child concentrates on work and play. 4 The child becomes casual about body appearance.

1 The child develops the superego. Rationale: According to Erikson's theory, a preschooler develops superego or conscience during the initiative versus guilt stage. During the autonomy versus shame and doubt stage, the toddler engages in parallel play and starts to play beside other children. A school-age child learns to work and play with his or her peers during the industry versus inferiority stage. During the identity versus role confusion stage, an adolescent can have a marked preoccupation with appearance and body image.

The nurse is teaching the client about wound healing. Which feature is associated with the "maturation phase" of normal wound healing? 1 The scar is firm and inelastic on palpation. 2 Fibrin strands form a scaffold or framework. 3 White blood cells migrate into the wound. 4 Epithelial cells are grown over the granulation tissue bed.

1 The scar is firm and inelastic on palpation. Rationale: The maturation phase of normal wound healing involves a mature scar that is firm and inelastic when palpated. In the proliferative phase, the fibrin strands form a scaffold or framework. White blood cells migrate into the wound during the inflammatory phase. In the proliferative phase, the epithelial cells are grown over the granulation tissue bed.

A nurse, understanding the possible cause of alcohol-induced amnestic disorder, should take into consideration that the client is probably experiencing which imbalance? 1 Thiamine deficiency 2 A reduced iron intake 3 An increase in serotonin 4 Riboflavin malabsorption

1 Thiamine deficiency Rationale: The deficiency of thiamine (vitamin B1) is thought to be a primary cause of alcohol-induced amnestic disorder. Reduced iron intake, increased serotonin, and riboflavin malabsorption are all unrelated to alcohol-induced amnestic disorder.

Which pulse site is used to perform Allen's test? 1 Ulnar 2 Brachial 3 Femoral 4 Dorsalis pedis

1 Ulnar Rationale: The ulnar pulse site is used to perform Allen's test. The brachial pulse site is used to assess the status of circulation to the lower arm and to auscultate blood pressure. The femoral site is used to assess the character of the pulse during physiological shock or cardiac arrest. The dorsalis pedis site is used to assess the status of circulation in the foot.

Which physical or behavioral signs of substance abuse should a nurse look for in an adolescent? Select all that apply. 1 Worrying about being addicted 2 Showing a high performance in social activities 3 Experiencing an overdose or withdrawal symptoms 4 Worrying about a friend or family member who is addicted 5 Manifesting bizarre behavior or confusion

1 Worrying about being addicted 3 Experiencing an overdose or withdrawal symptoms 5 Manifesting bizarre behavior or confusion Rationale: Worrying of being addicted, experiencing overdose or withdrawal symptoms, and manifesting bizarre behavior may be earliest signs of substance abuse. Showing high performance in social activities and worry about a friend or family member's substance abuse are not with a manifestation of substance abuse.

A nurse assesses a client with the diagnosis of an intestinal obstruction in the descending colon. When auscultating the midabdomen, what should the nurse expect to hear? 1 Tympany 2 Borborygmi 3 Abdominal bruit 4 Pleural friction rub

2 Borborygmi Rationale: Borborygmi are rapid, high-pitched bowel sounds that are indicative of the hyperperistalsis that occurs behind an intestinal obstruction. Tympany is not auscultated but percussed, and it is described as high pitched or musical because of the presence of gas. An aortic bruit is auscultated above the umbilicus; a renal bruit is heard laterally above the umbilicus. Neither bruit can be auscultated at the midabdomen, and neither is related to an intestinal obstruction. A pleural friction rub is heard in the chest; it is associated with inflamed lung pleura.

A nurse is caring for a client who had major abdominal surgery one day ago. What factor increases the risk of this client developing a wound dehiscence? 1 Placement of a T-tube 2 Client being overweight 3 Presence of excessive flatus 4 Client receiving prophylactic antibiotics

2 Client being overweight Rationale: Being grossly overweight is a predisposing factor to wound dehiscence because of decreased vascularity and fragility of adipose tissue and the added tension on the suture line. Placement of a T-tube does not contribute to dehiscence; a T-tube helps remove bile from the common bile duct. The presence of excessive flatus causes discomfort, not dehiscence. If the client is receiving the antibiotics because of the presence of a wound infection, then the infection is the risk factor for wound dehiscence. Receiving steroids, not prophylactic antibiotics, increases the risk of dehiscence because steroids slow collagen synthesis necessary for wound healing.

A 15-year-old plans to go to a nightclub without informing his or her parents but is afraid of being caught. Which behavior does this indicate? 1 Seriation 2 Invulnerability 3 Personal fable 4 Imaginary audience

2 Invulnerability Rationale: When an adolescent goes to a club but fears getting caught by his or her parents, this action shows a sense of invulnerability. Feelings of invulnerability frequently lead to risk-taking behaviors. Seriation is the ability to mentally classify objects according to their quantitative dimensions. Personal fable is when adolescents think that their thoughts and feelings are unique. Adolescents have a belief that an imaginary audience constantly scrutinizes their actions.

During a group therapy session one of the clients asks a client with the diagnosis of antisocial personality disorder why the client is in the hospital. What response might the nurse expect from a client with this disorder? 1 "I need a lot of help with my troubles." 2 "Society makes people follow rules that don't apply to me." 3 "This might help me straighten out my life." Incorrect4 "I decided that it's time that I own up to my problems."

2 "Society makes people follow rules that don't apply to me." Rationale: The client is incapable of accepting responsibility for self-created problems and blames society for the behavior. An admission that the client needs a lot of help, that the therapy may help the client straighten out, or that it's time for the client to own up to problems demonstrates insight, and these individuals rarely develop insight into their problems.

A client who uses a complex ritual says to the nurse, "I feel so guilty. None of this makes any sense. Everyone must really think I'm crazy." What is the most therapeutic response by the nurse? 1 "Your behavior is bizarre, but it serves a useful purpose." 2 "You're concerned about what other people are thinking about you." 3 "I am sure people understand that you can't help this behavior right now." 4 "Guilt serves no useful purpose. It just helps you stay stuck where you are." Incorrect3 "I am sure people understand that you can't help this behavior right now." 4 "Guilt serves no useful purpose. It just helps you stay stuck where you are."

2 "You're concerned about what other people are thinking about you." Rationale: Paraphrasing encourages further ventilation of feelings and concerns by the client. Telling the client that the behavior is bizarre but that it serves a useful purpose is a negative response that may increase the client's fears about being "crazy." Saying "I'm sure people understand that you can't help this behavior right now" provides false reassurance and implies that the client is out of control, which may increase the fears. Telling the client that guilt serves no useful purpose and just helps the client stay stuck denies the client's feelings

For which pediatric client should the nurse use the Age and Stages Questionnaire (ASQ) as a developmental screening tool during a health maintenance assessment? 1 A 2-week old newborn client 2 A 15-month-old toddler client 3 A 6-year-old school-age client 4 A 14-year-old adolescent client

2 A 15-month-old toddler client Rationale: The ASQ developmental screening tool is appropriate to use for pediatric clients from 1 month to 4.5 years of age. The nurse would use this screening tool for the 15-month-old toddler. The other clients are not within the age range for the use of the ASQ screening tool.

A nurse is counseling a client who abuses cocaine. The nurse recognizes that this drug is representative of which drug category? 1 An opioid 2 A stimulant 3 A barbiturate 4 A hallucinogen

2 A stimulant Rationale: Cocaine is classified as a stimulant. It is inhaled in its powdered form or smoked as crack; its use creates experiences similar to but more intense than those experienced with the amphetamines, and its withdrawal results in a deeper crash. Opioids and barbiturates are central nervous system depressants. Hallucinogens produce cerebral excitation that can yield a state similar to psychosis.

What is the function of IgG in the body? 1 Activates the degranulation of mast cells 2 Activates the classic complement pathway 3 Prevents upper respiratory tract infections 4 Prevents lower respiratory tract infections

2 Activates the classic complement pathway Rationale: The classic complement pathway is activated by the IgG and IgM antibodies. IgE antibodies cause a degranulation of mast cells. IgA antibodies are found largely in mucous membrane secretions and play an important role in preventing upper and lower respiratory tract infections.

While assessing the pupils of a client, a healthcare professional notices pupillary dilatation. Which drug intake might have resulted in this condition? 1 Heroin 2 Atropine 3 Morphine 4 Pilocarpine

2 Atropine Rationale: The intake of eye medications such as atropine will cause dilatation of the pupils. Heroin, morphine, and pilocarpine cause pupillary constriction.

A client with hyperthyroidism is treated with radioactive iodine to ablate thyroid tissue. What should the nurse instruct the client to do after the procedure? 1 Remain in the house. 2 Avoid holding an infant. 3 Save urine in a lead-lined container. 4 Refrain from using a bathroom used by others.

2 Avoid holding an infant. Rationale: Infants are particularly sensitive to radioactivity; even the small amount emitted after treatment may affect infants. It is not necessary to avoid leaving the house as long as close proximity to others is avoided. Saving urine in a lead-lined container is not necessary; the same bathroom may be used by all members of the family, but the toilet should be flushed twice after use by the client. Refraining from using a bathroom used by others is not necessary.

A client with a borderline personality disorder is admitted to the mental health unit. What should the nurse do to maintain a therapeutic relationship with the client? 1 Provide an unstructured environment to promote self-expression. 2 Be firm, consistent, and understanding and focus on specific target behaviors. 3 Use an authoritarian approach, because this type of client needs to learn to conform to the rules of society. 4 Record but ignore marked shifts in mood, suicidal threats, and temper displays, because these last only a few hours.

2 Be firm, consistent, and understanding and focus on specific target behaviors. Rationale: Consistency, limit-setting, and supportive confrontation are essential nursing interventions designed to provide a secure, therapeutic environment for clients with borderline personality disorder. To be therapeutic, the environment needs structure, and the staff must help the client set short-term goals for behavioral changes. The use of an authoritarian approach will increase anxiety in this type of client, resulting in feelings of rejection and withdrawal. Ignoring the client's behavior is nontherapeutic and may reinforce underlying fears of abandonment.

How does an individual overcome conflicting thoughts that arise during an Electra complex? 1 By getting proper toilet training process 2 By identifying with the parent of the same sex 3 By indulging in educational and social activities 4 By having physical and emotional availability of the parents

2 By identifying with the parent of the same sex Rationale: A child with an Electra complex fantasizes about the parent of the opposite sex as his or her first love interest. This conflicting thought is overcome by identifying with the parent of the same sex as a way to win recognition and acceptance. Toilet training is related to the anal stage. During the latency stage, a child indulges in education and social activities. Physical and emotional availability of the parents is needed during the oral stage.

A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte? 1 Sodium 2 Calcium 3 Potassium 4 Phosphorus

2 Calcium

Which structure lies inside and parallel to the sclera? 1 Lens 2 Choroid 3 Conjunctiva 4 Ciliary processes

2 Choroid Rationale: The choroid is a highly vascular structure that nourishes the ciliary body, the iris, and the outermost portion of the retina. It lies parallel to the sclera. The lens is located behind the iris. The conjunctiva covers the inner surfaces of the eyelids and also extends over the sclera. The ciliary processes lie behind the peripheral part of the iris.

A nurse is caring for an infant with tetralogy of Fallot. What clinical finding should the nurse expect when assessing this child? 1 Slow respirations 2 Clubbing of the fingers 3 Subcutaneous hemorrhages 4 Decreased red blood cell count

2 Clubbing of the fingers Rationale: The mixing of oxygenated and deoxygenated blood results in tissue hypoxia; clubbing occurs as a result of additional capillary development and tissue hypertrophy of the fingertips.

According to the Piaget's theory, which behavior does a nine-year-old child show? 1 Logical reasoning 2 Concrete thinking 3 Object permanence 4 Imaginary audience

2 Concrete thinking Rationale: A child of nine years of age will exhibit concrete thinking. Logical reasoning is observed in individuals starting from the age of 11. Object permanence is observed in children between birth and two years old. The idea of being constantly observed by an imaginary audience is observed in individuals starting from the age of 11.

Which gross motor skill should the nurse anticipate when assessing a 15-month-old toddler-age client during a scheduled health maintenance visit? 1 Using a cup well 2 Creeping up stairs 3 Scribbling spontaneously 4 Building a tower of two blocks

2 Creeping up stairs Rationale: Creeping up the stairs is a gross motor skill the nurse expects when assessing a 15-month-old toddler-age client during a scheduled health maintenance visit. Using a cup well, scribbling spontaneously, and building a tower with two blocks are all fine, not gross, motor skills the nurse expects when assessing a 15-month-old toddler-age client.

A client who is at 20-weeks' gestation visits the prenatal clinic for the first time. Assessment reveals temperature of 98.8° F (37.1° C), pulse of 80 beats per minute, blood pressure of 128/80 mm Hg, weight of 142 lb (64.4 kg) (pre-pregnancy weight was 132 lb (59.9 kg), fetal heart rate (FHR) of 140 beats per minute, urine that is negative for protein, and fasting blood glucose level of 92 mg/dL (5.2 mmol/L). What should the nurse do after making these assessments? 1 Report the findings because the client needs immediate intervention. 2 Document the results because they are expected at 20-weeks' gestation. 3 Record the findings in the medical record because they are not within the norm but are not critical. 4 Prepare the client for an emergency admission because these findings may represent jeopardy to the client and fetus.

2 Document the results because they are expected at 20-weeks' gestation. Rationale: All data presented are expected for a client at 20-weeks' gestation and should be documented. There is no need for immediate intervention or an emergency admission because all findings are expected.

What step should a nurse take when preparing to administer Rho(D) immune globulin to a postpartum client? 1 Start a primary intravenous (IV) line so that the drug may be administered via IV piggyback. 2 Ensure that the client is Rh negative and the neonate is Rh positive. 3 Obtain a syringe and needle appropriate for the subcutaneous injection. 4 Determine that the client has not eaten since midnight of the previous night.

2 Ensure that the client is Rh negative and the neonate is Rh positive. Rationale: Rho(D) immune globulin is given to Rh-negative mothers not previously sensitized who have Rh-positive neonates; it prevents Rh incompatibility in the next pregnancy. Rho(D) immune globulin is administered intramuscularly, not intravenously or subcutaneously. There is no need for the client to fast; the client may eat and drink before receiving this medication.

Which physiologic activity is associated with the "proliferative phase" of normal wound healing? 1 White blood cells migrate into the wound 2 Epithelial cells grow over the granulation tissue bed 3 Scar tissue gradually becomes thinner and pale in color 4 Vasodilation occurs with increased capillary permeability

2 Epithelial cells grow over the granulation tissue bed Rationale: During the "proliferative phase" of normal wound healing, the epithelial cells grow over the granulation tissue bed. The white blood cells are migrated into the wound during the inflammatory phase. In the maturation phase, the scar tissues gradually become thinner and pale in color. The vasodilation with the increased capillary permeability may occur during the inflammatory phase.

A toddler on the pediatric unit is required to have temporary dietary restrictions after colorectal surgery. What is the best way for the nurse to promote adherence to the restrictions? 1 Limit restrictions to nonessential foods 2 Handle dietary changes in a matter-of-fact way 3 Have the dietitian explain the restrictions to the parents 4 Arrange to have an adult other than a parent stay at mealtime

2 Handle dietary changes in a matter-of-fact way. Rationale: Toddlers are ritualistic and do not tolerate change well; therefore, any change in diet should be done in a matter-of-fact way. Limited restrictions on nonessential foods are not always possible. Although the parents could consult with the dietitian, this action will not change the toddler's response to the dietary restrictions. The toddler is still dependent on the parents and therefore will respond better to them than to a stranger.

The nurse teaches a health class about communicable diseases and states that the virus that causes chickenpox can also cause another disease. Which disease is the nurse describing? 1 Athlete's foot 2 Herpes zoster 3 German measles 4 Infectious hepatitis

2 Herpes Zoster Rationale: Invasion of the posterior (dorsal) root ganglia by the same virus that causes chickenpox can result in herpes zoster, or shingles. This may be caused by reactivation of a previous chickenpox virus that has lain dormant in the body or by recent contact with an individual who has chickenpox. Athlete's foot is caused by a fungus. German measles is caused by a virus, but not the herpes virus. Hepatitis type A is caused by a virus, but not the herpes virus

An unconscious 16-year-old adolescent with type 1 diabetes is brought to the emergency department. The blood glucose level is 742 mg/dL (41.2 mmol/L). What finding does the nurse expect during the initial assessment? 1 Pyrexia 2 Hyperpnea 3 Bradycardia 4 Hypertension

2 Hyperpnea Rationale: Rapid breathing is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a characteristic compensatory mechanism for correcting metabolic acidosis. An increase in temperature will occur if an infection is present; it is not a response to hyperglycemia. Tachycardia, not bradycardia, results from the hypovolemia of dehydration. Hypotension, not hypertension, may result from the decreased vascular volume associated with hyperglycemia.

Which clinical manifestation occurs in a client with vasopressin deficiency? 1 Impotence 2 Hypotension 3 Amenorrhea 4 Decreased libido

2 Hypotension Rationale: Vasopressin regulates fluid level and blood pressure. A vasopressin deficiency causes hypotension. Impotence, amenorrhea, and decreased libido in both men and women are clinical manifestations of luteinizing and follicle-stimulating hormone deficiencies.

What are the clinical manifestations of myocardial infarction in women? Select all that apply. 1 Anoxia 2 Indigestion 3 Unusual fatigue 4 Sleep disturbances 5 Tightness of the chest

2 Indigestion 3 Unusual fatigue 4 Sleep disturbances Rationale: Indigestion, unusual fatigue, and sleep disturbances are clinical manifestations of myocardial infarction in women. Anoxia and tightness of the chest are clinical manifestations of angina pectoris, not myocardial infarction.

A nurse determines that a client is pretending to be ill. What does this behavior usually indicate? 1 Psychosis 2 Malingering 3 Use of conversion 4 Lack of contact with reality

2 Malingering Rationale: When an individual consciously pretends to have an illness with no physical basis, it is called malingering. People who are psychotic experience delusions, hallucinations, and disorganized thoughts, speech, or behavior. The use of conversion defenses is not a conscious act. A person out of contact with reality is unable to pretend to be ill.

Which drug is contraindicated in a pregnant client diagnosed with bipolar disorder? 1 Sertraline 2 Paroxetine 3 Venlafaxine 4 Despramine

2 Paroxetine Rationale: Paroxetine is a selective serotonin reuptake inhibitor that should be avoided in a pregnant client because it may cause birth defects. Sertraline, venlafaxine, and despramine can be safely prescribed to a pregnant client.

A nurse advises a client to refrain from adding salt to food as a way to prevent high blood pressure. What kind of health care service is this? 1 Tertiary care 2 Primary care 3 Preventive care 4 Restorative care

2 Primary care Rationale: When a nurse provides nutrition counseling to the client, it qualifies as primary care. In the given scenario, the nurse advises the client to refrain from adding salt in the diet in order to prevent high blood pressure. Tertiary care includes intensive care and subacute care. Preventive care includes blood pressure and cancer screenings, immunizations, mental health counseling and crisis prevention and community legislation. Restorative care includes cardiovascular and pulmonary rehabilitation, sports medicine, spinal cord injury programs, and home care.

What is the action of vasopressin? 1 Promotes sodium reabsorption 2 Reabsorbs water into the capillaries 3 Promotes tubular secretion of sodium 4 Stimulates bone marrow to make red blood cells

2 Reabsorbs water into the capillaries Rationale: Vasopressin is also known as an antidiuretic hormone (ADH). It helps in the reabsorption of water into the capillaries. Aldosterone promotes sodium reabsorption. Natriuretic hormones promote tubular secretion of sodium. Erythropoietin stimulates bone marrow to make red blood cells (RBCs).

Which stage of Kohlberg's theory explains the influence of moral values on an individual's thought? 1 Good boy-nice girl orientation 2 Society-maintaining orientation 3 Instrumental relativist orientation 4 Universal ethical principle orientation

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

The nurse observes a laboring client's amniotic fluid and decides that it is the expected color and consistency. Which finding supports this conclusion? 1 Clear, dark amber colored, and containing shreds of mucus 2 Straw-colored, clear, and containing little white specks 3 Milky, greenish yellow, and containing shreds of mucus 4 Greenish yellow, cloudy, and containing little white specks

2 Straw-colored, clear, and containing little white specks Rationale: By 36 weeks' gestation, amniotic fluid should be pale yellow with small particles of vernix caseosa present. Dark amber-colored fluid suggests the presence of bilirubin, an ominous sign. Greenish-yellow fluid may indicate the presence of meconium and suggests fetal compromise. Cloudy fluid suggests the presence of purulent material.

A client is admitted to the hospital with suspected liver disease, and a needle biopsy of the liver is performed. After the procedure, the nurse should maintain the client in what position? 1 Supine 2 Semi-Fowler 3 Right side-lying 4 Dorsal recumbent

3 Right side-lying Rationale: The liver is on the right side of the body; the right side-lying position provides pressure at the needle insertion site and promotes hemostasis. The supine position does not provide pressure over the liver or promote hemostasis. The semi-Fowler position does not provide pressure over the liver or promote hemostasis. The dorsal recumbent position keeps the liver uppermost, thus no pressure is exerted to promote hemostasis.

A client newly diagnosed with multiple sclerosis asks the nurse if it will be painful. Which response should the nurse give the client first? 1 "Tell me more about your fears regarding pain." 2 "Medications will be prescribed to help control pain." 3 "Pain is a common symptom of this condition." 4 "Let's list your questions for the healthcare provider."

3 "Pain is a common symptom of this condition." Rationale: The response "Pain is a common symptom of this condition" is a truthful answer for the client. Reassuring the client that "medications will be prescribed to help control pain" when the client experiences it is the next helpful response from the nurse. After being truthful about pain and reassuring the client about its medical management, asking the client to "tell more about...fears regarding pain" opens the conversation to discuss it and offers an opportunity for emotional release, which can decrease anxiety. The response "Let's list your questions for the healthcare provider" is a helpful final conversation during this encounter because it teaches the client how to make the most of their visit with the healthcare provider.

The healthcare provider prescribes 1 liter of intravenous (IV) fluid to infuse over 4 hours for a client admitted for a urinary tract infection and hyponatremia. The tubing drop factor is 10 drops/mL. At what rate will the nurse infuse the medications? 1 20 drops/minute 2 34 drops/minute 3 42 drops/minute 4 60 drops/minute

3 42 drops/minute 1000 mL/ 240 mins x 10 drops = 41.67 drops/min = 42 drops/min

The nurse is preparing an intraoperative care plan for a client. Which intervention should be excluded from the care plan? 1 Ensuring the client's skin integrity 2 Reviewing the preoperative instructions 3 Administering general anesthetic to the client 4 Placing the client in the correct position on the operating table

3 Administering general anesthetic to the client Rationale: Only anesthesiologists who are specially trained can administer anesthesia. Therefore, the nurse should exclude this intervention from the nursing care plan. In the operating room, the nurse should ensure the client's skin integrity to prevent complications such as pressure sores. The nurse should review the preoperative care plan to establish or amend the plan if changes are required. The nurse should place the client in the correct position to prevent the client from injury during the operation.

A client with rheumatoid arthritis has been given a prescription for acetylsalicylic acid. The client asks the nurse, "What kind of drug is acetylsalicylic acid?" The nurse recalls that this drug has which property? 1 Sedative 2 Hypnotic 3 Analgesic 4 Antibiotic

3 Analgesic Rationale: Acetylsalicylic acid (aspirin) acts as an analgesic by inhibiting production of inflammatory mediators. Acetylsalicylic acid does not act as a sedative to calm individuals. Acetylsalicylic acid does not act as a hypnotic to induce sleep. Acetylsalicylic acid does not destroy or control microorganisms

A newborn with a myelomeningocele is being transferred immediately from the birthing room to the neonatal intensive care unit (NICU). What is the initial nursing intervention? 1 Start antibiotic prophylaxis 2 Provide routine newborn care 3 Apply a sterile saline dressing 4 Assess the infant for paralysis

3 Apply a sterile saline dressing Rationale: Applying a sterile saline dressing helps prevent infection while keeping the membranes moist. Although the infant should be assessed for paralysis, it is not the priority. Antibiotics are not given prophylactically. This newborn needs more than just routine care because of the outpouching of the meninges.

Which assessment is expected when a client is placed in the lithotomy position during physical examination? 1 Assessment of the heart 2 Assessment of the rectum 3 Assessment of the female genitalia 4 Assessment of the musculoskeletal system

3 Assessment of the female genitalia Rationale: Lithotomy position infemale clients is used to assess and examine female genitalia and genital tracts. The lateral recumbent position is indicated in clients to assess the heart. The knee-chest position and Sims position are recommended for clients undergoing rectal examinations. The prone position is indicated in clients to assess the musculoskeletal system.

A client in labor is admitted to the birthing unit. Assessment reveals that the fetus is in a footling breech presentation. What should the nurse consider regarding breech presentations when caring for this client? 1 Severe back discomfort will occur. 2 Length of labor usually is shortened. 3 Cesarean birth probably will be necessary. 4 Meconium in the amniotic fluid is a sign of fetal hypoxia.

3 Cesarean birth probably will be necessary. Rationale: A cesarean birth may be performed when the fetus is in the breech presentation because the risk of morbidity and mortality is increased. A vertex presentation in the occiput posterior position usually causes back pain. Labor is usually longer with a fetus in the breech presentation because the buttocks are not as effective as the head as a dilating wedge. Meconium is a common finding in the amniotic fluid of a client whose fetus is in a breech presentation, because contractions compress the fetal intestinal tract, causing release of meconium.

A client is ambivalent about making a change in health behavior. Which stage of health behavior does the nurse suspect? 1 Preparation 2 Maintenance 3 Contemplation 4 Precontemplation

3 Contemplation The nurse suspects that the client is in the stage of contemplation. This stage of health behavior is characterized by the client's attitude toward a change and the client is most likely to accept that change over the next 6 months. In the preparation stage, the client believes that a change in behavior will be advantageous. The client may need assistance to bring about the change in behavior. During the maintenance stage, changes need to be implemented in the client's lifestyle. In the precontemplation stage, the client is not willing to receive any information about changes in behavior and may become defensive and confrontational.

A client is experiencing feelings of sadness and is having difficulty concentrating and sleeping. What are additional common signs and symptoms of depression that the nurse should expect when performing an assessment of this client? 1 Rigidity and a narrowing of perception 2 Alternating episodes of fatigue and high energy 3 Diminished pleasure in activities and alteration in appetite 4 Excessive socialization and interest in activities of daily living

3 Diminished pleasure in activities and alteration in appetite Rationale: Depression is characterized by feelings of hopelessness, helplessness, and despair, leaving little room for any pleasure; alteration in appetite (either decreased or increased) is common in depressed clients. Although there is a narrowing of perception, rigidity is uncommon with depression. Fatigue is continually present and does not alternate with a high energy level. There is a loss of interest in socialization and little participation in activities of daily living.

One afternoon the nurse on the unit overhears a young female client having an argument with her boyfriend. A while later the client complains to the nurse that dinner is always late and the meals are terrible. The nurse identifies the defense mechanism that the client is using as what? 1 Projection 2 Dissociation 3 Displacement 4 Intellectualization

3 Displacement Rationale: Displacement reduces anxiety by transferring the emotions associated with an object or person to another emotionally safer object or person. Projection is the attempt to deal with unacceptable feelings by attributing them to another. Dissociation is an attempt to detach emotional involvement or the self from an interaction or the environment. Intellectualization is the use of facts or other logical reasoning rather than feelings to deal with the emotional effect of a problem.

Which entity is responsible for activating the disaster plan during a mass casualty incident (MCI)? 1 Local emergency management system 2 State emergency management system 3 Federal emergency management agency 4 Hospital-level emergency management system

3 Federal emergency management agency

Which period of Piaget's theory marks the end of cognitive development? 1 Sensorimotor 2 Preoperational 3 Formal operations 4 Concrete operation

3 Formal operations Rationale: According to Piaget's theory, the formal operations period marks the end of cognitive development. During this period, adolescents have the capacity to reason with respect to possibilities. The sensorimotor period is the first period when a newborn develops a schema or pattern for dealing with the environment. The second period is the preoperational period when a child develops egocentrism and animism. During the concrete operations period, children are able to perform mental operations.

Which period of Piaget's theory covers the prevalence of egocentrism in adolescents? 1 Sensorimotor 2 Preoperational 3 Formal operations 4 Concrete operations

3 Formal operations Rationale: Formal operations is the fourth period of Piaget's theory. During this period, there is a prevalence of egocentric thought. This egocentricity leads adolescents to demonstrate feelings and behaviors characterized by self-consciousness. The sensorimotor period is the first period of Piaget's theory. In this period, infants develop a schema or action pattern for dealing with the environment. The preoperational period is the second period. During this time, children learn to think with the use of symbols and mental images. Concrete operations is the third period of Piaget's theory. During this period, children are able to coordinate two concrete perspectives in social and scientific thinking.

In which period of Piaget's theory does the adolescent feel a sense of invulnerability? 1 Sensorimotor 2 Preoperational 3 Formal operations 4 Concrete operations

3 Formal operations Rationale: In the formal operation period, the fourth period of Piaget's theory, the adolescent feels a sense of invulnerability. This leads to risk-taking behaviors. In the sensorimotor period, the first period of Piaget's theory, the infant develops a schema or action pattern for dealing with the environment. Period II is the preoperational period. During this time, a child learns to think with the use of symbols and mental images. The period of concrete operations is the third period of Piaget's theory. At this time, the child is able to coordinate two concrete perspectives in social and scientific thinking.

Which Korotkoff sound represents the diastolic blood pressure in toddlers? 1 First 2 Third 3 Fourth 4 Fifth

3 Fourth Rationale: The fourth Korotkoff sound is muffled and low. This sound is the diastolic pressure in toddlers. The first Korotkoff sound is sharp and represents systolic blood pressure. The third Korotkoff sound is crispier and includes intense tapping. The fifth Korotkoff sound marks the disappearance of sound. In adolescents and adults the fifth sound corresponds with the diastolic pressure.

A client has a history of falling while playing football and now reports pain in the nose and difficulty breathing. What condition may the client have? 1 Crepitus 2 Sinusitis 3 Fracture of the nose 4 Upper respiratory tract infection

3 Fracture of the nose Rationale: Fractures of the nose often result from injuries received during falls, sports activities, car crashes, or physical assaults. Nose fractures may lead to difficulty in breathing.

A client with a 40-year history of drinking two alcoholic beverages and smoking two packs of cigarettes daily comes to the outpatient clinic with an ischemic left foot. It is determined that the cause is arterial insufficiency. The nurse concludes that the pain in the client's foot is a result of inadequate blood supply. Which information from the client will cause the nurse to intervene? 1 I have one glass of wine at supper. 2 I lower my limb when sitting. 3 I am a social smoker. 4 I drink a lot of water.

3 I am a social smoker. Rationale: Nicotine (I am a social smoker) causes vasoconstriction and spasm of the peripheral arteries; therefore the nurse will intervene. Alcohol may stimulate dilation of blood vessels; one glass is not harmful. Lowering the limb enhances flow of blood into the foot by gravity to assist with the inadequate blood supply. Consuming water will decrease the viscosity of blood, possibly preventing the formation of thrombi.

To provide appropriate psychosocial support to clients, a nurse must understand development across the life span. What theory is the nurse using in considering relationships and resulting behaviors as the central factors that influence development? 1 Cognitive theory 2 Psychosocial theory 3 Interpersonal theory 4 Psychosexual theory

3 Interpersonal theory Rationale: The interpersonal theory of human development by Harry Stack Sullivan highlights interpersonal behaviors and relationships as the central factors influencing child and adolescent development across six "eras"; the need to satisfy social attachments and a longing to meet biologic and psychological needs are two dimensions associated with this theory. Cognitive theory is associated with Jean Piaget; cognitive theory explains how thought processes develop, are structured, and influence behavior. Psychosocial theory is associated with Erik Erikson; psychosocial theory identifies social interaction as the source that influences human development. Erikson identified eight stages of human life, with each stage built on the previous stages and influenced by past experiences. Psychosexual theory is associated with Sigmund Freud; psychosexual theory views child development as a biologically driven series of conflicts and gratifying internal needs

Which description is associated with fissures? 1 Deep erosions that extend beneath the epidermis 2 Thinning of the skin surface with a loss of skin markings 3 Linear cracks in the epidermis that extend into the dermis 4 Thickened areas of epidermis with accentuated skin markings

3 Linear cracks in the epidermis that extend into the dermis Rationale: Fissures are linear cracks in the epidermis that extend into the dermis. Ulcers may be described as deep erosions extending beneath the epidermis. Atrophy is the thinning of the surface of the skin with a loss of skin markings. Lichenifications are characterized by thick areas of epidermis with accentuated skin markings.

The magnetic resonance image (MRI) of a client who sustained brain trauma reveals injury to the occipital lobe. Which disability might be anticipated in the client? 1 Loss of perception 2 Loss of learning ability 3 Loss of visual capability 4 Loss of auditory sensation

3 Loss of visual capability Rationale: The occipital lobe regulates vision. Therefore damage to it causes marked deficits in visual perception and functioning. The parietal lobe function is linked to perception of body parts. Loss of learning ability is found when there is damage to the limbic lobe. Loss of auditory sensation is related to temporal lobe injury.

A 65-year-old man is admitted to a mental health facility with a diagnosis of substance-induced persisting dementia resulting from chronic alcoholism. When conducting the admitting interview, the nurse determines that the client is using confabulation. What does the nurse recall precipitates the client's use of confabulation? 1 Ideas of grandeur 2 Need for attention 3 Marked memory loss 4 Difficulty in accepting the diagnosis

3 Marked memory loss A client with this disorder has a loss of memory and adapts by filling in areas that cannot be remembered with made-up information. Ideas of grandeur do not occur with this type of dementia. The use of confabulation is not attention-seeking behavior; the individual is attempting to mask memory loss. This person is not coping with the diagnosis; when confabulating, the individual is attempting to mask memory loss.

A nurse is counseling clients who are attending an alcohol rehabilitation program. Which substance poses the greatest risk of addiction for these clients? 1 Heroin 2 Cocaine 3 Nicotine 4 Marijuana

3 Nicotine Rationale: Although polysubstance abuse is common, clients undergoing rehabilitation from alcohol dependence are more likely to use or develop a dependence on nicotine, another legal substance, than on an illegal substance such as heroin, cocaine, or marijuana.

Which hearing disorder is most common in women? 1 Tinnitus 2 Hyperacusis 3 Otosclerosis 4 Meniere's disease

3 Otosclerosis Rationale: Gender of the client may also influence the conditions associated with hearing loss. Women are at a higher risk of otosclerosis compared to men. Both men and women are equally at risk of some hearing loss due to conditions such as tinnitus and hyperacusis. Meniere's disease is common in men compared to women.

A client is receiving furosemide to help treat heart failure. Which laboratory result will cause the nurse to notify the primary healthcare provider? 1 Hematocrit 46% 2 Hemoglobin 14.1 g/dL (141 mmol/L) 3 Potassium 3.0 mEq/L (3.0 mmol/L) 4 White blood cell 9200/mm3 (9.2 × 109/L)

3 Potassium 3.0 mEq/L (3.0 mmol/L) A potassium level of 3.0 mEq/L (3.0 mmol/L) is indicative of hypokalemia. Normal values for an adult are 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Potassium, calcium, and magnesium control the rate and force of heart contractions. Diuretics often are used to reduce fluid volume, so the heart does not work as hard. Furosemide is a potassium-losing diuretic. Hypokalemia can result in death from dysrhythmia; therefore this must be addressed. The hematocrit level of 46% is within the normal range. A hemoglobin of 14.1 (141 mmol/L) is within normal values. White blood cell level of 9200 cells/mm3is within the normal range of 4000 to 11,000 cells/mm3 (4 to 11 × 109/L).

In which stage of Kohlberg's theory of moral development does the nurse anticipate a client who wants to maintain expectations with his or her immediate group? 1 Stage 1 2 Stage 2 3 Stage 3 4 Stage 4

3 Stage 3 Rationale: In level II, conventional reasoning, stage 3, the nurse anticipates a client who wants to win approval and maintain expectations of his or her immediate group. In level I, preconventional reasoning, stage 1, the nurse anticipates absolute obedience to authority and rules. In level I, stage 2, the nurse anticipates that the child will realize there is more than one right view. In level II, stage 4, the client expands focus from the relationship with others to societal concerns.

During the beginning phase of a therapeutic relationship, why is a clear understanding of participants' roles important? 1 The client should understand what will be discussed. 2 The client will know that the nurse is trying to be helpful. 3 The client needs to know what to expect from the relationship. 4 The client will be able to be prepared for termination of the relationship.

3 The client needs to know what to expect from the relationship. Rationale: This understanding clarifies the settings for the relationship and establishes boundaries. This allows the client to focus on the relationship rather than on roles. An understanding of roles is only one factor among many needed to prepare the client for termination. The nurse being helpful and being prepared for the termination of the relationship are not related to an understanding of roles.

What characteristics develop in an adolescent according to Piaget's theory of cognitive development? Select all that apply. 1 The individual shows animism. 2 The individual is able to understand the process of reversibility. 3 The individual develops the ability to reason with respect to possibilities. 4 The individual develops action patterns for dealing with the environment. 5 The individual demonstrates feelings and behaviors characterized by self-consciousness.

3 The individual develops the ability to reason with respect to possibilities. 5 The individual demonstrates feelings and behaviors characterized by self-consciousness. Rationale: According to Piaget's theory of cognitive development, during the formal operations stage, an adolescent develops the capacity to reason with respect to possibilities. They also show egocentrism and demonstrate feelings and behaviors characterized by self-consciousness. During the preoperational stage, a child between the ages of 2 and 7 demonstrates animism, in which they personify objects. According to Piaget's theory, reversibility is one of the primary characteristics that develop in a child between 7 and 11 years old. Infants develop a schema or action pattern for dealing with the environment.

A client has an IV of D5W 250 mL to which 100 mg of morphine is added. The healthcare provider prescribes 14 mg of morphine per hour for end of life palliative treatment of a client . At how many mL per hour should the nurse set the intravenous pump? Record your answer using a whole number. ___mL/hr

35 ml/hr 100/14x250=35

A client with type 1 diabetes asks what causes the several brown spots on the skin. What would be the best response by the nurse? 1 "The brown spots reflect the accumulation of blood fats in the skin; they should disappear." 2 "Those spots indicate a high glucose content in the skin that may get infected if left untreated." 3 "They are the result of diseased small vessels in the shins and may spread if not treated soon." 4 "Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot."

4 "Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot." Rationale: "Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot" is an accurate explanation for the client's concern; brown spots are caused by the deposit of hemosiderin in the tissue. Brown spots reflecting the accumulation of blood fats in the skin and disappearing is the definition of a xanthoma. A high glucose content in the skin that has become infected is not the cause of brown spots on the skin; increased glucose in the skin is not observable by inspection. Brown spots result from the deposition of hemosiderin. Blood vessels may become diseased with diabetes, but this does not cause brown spots.Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early.

A school nurse knows that school-aged children often use defense mechanisms to cope with situations that might negatively affect their self-esteem. The nurse hears a child who was not invited to a sleepover say, "I don't have time to go to that sleepover. I have better things to do." The nurse concludes that the student is using which defense mechanism? 1 Denial 2 Projection 3 Regression 4 Rationalization

4 Rationalization Rationalization is the offering of an explanation to one's self or others to allay anxiety. Denial involves avoiding the reality of a situation. Projection is blaming others for one's shortcomings. Regression is returning to an earlier more familiar mode of behavior.

A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's arterial blood studies indicate pH 7.30, PO2 60 mm Hg, PCO2 55 mm Hg, and HCO3 23 mEq/L (23 mmol/L). How should the nurse interpret these findings? 1 Hypocapnia 2 Hyperkalemia 3 Generalized anemia 4 Respiratory acidosis

4 Respiratory acidosis Rationale: The client is experiencing respiratory acidosis. The pH is less than the norm of 7.35 to 7.45, indicating acidosis. The PO2 is less than the norm of 80 to 100 mm Hg. The PCO2 is increased more than the norm of 35 to 45 mm Hg. The HCO3 is within the norm of 21 to 28 mEq/L (21 to 28 mmol/L). These results indicate a respiratory etiology. The client's carbon dioxide level is increased (hypercapnia), not decreased. These values are unrelated to hyperkalemia; a serum potassium level of more than 5 mEq/L (5 mmol/L) indicates hyperkalemia. These values are unrelated to anemia; decreased levels of red blood cells (RBCs), hemoglobin, and hematocrit are related to anemia.

Which of these thoughts in an adolescent corresponds to a sense of "invulnerability"? 1 "My doll will cry if I will ignore her for too long." 2 "I need to look beautiful because everyone has their eyes on me." 3 "If my football gets deflated, I can reinflate it." 4 "Even if I drive my car at 120 km per hour, nothing will happen to me."

4 "Even if I drive my car at 120 km per hour, nothing will happen to me." Rationale: An adolescent who thinks that risky driving does not pose a threat demonstrates a sense of "invulnerability." A preschooler concerned about his or her doll demonstrates animism. When a teen believes that everyone is paying attention to him or her, this thought denotes the feeling of personal fable. When an individual thinks that a deflated football can be inflated again, this thought shows the concept of reversibility.

A client with the diagnosis of obsessive-compulsive disorder who has a need to wash his hands 50 to 60 times a day tearfully tells the nurse, "I know that my hands aren't dirty, but I just can't stop washing them." What is the best response by the nurse? 1 "Let's talk about why you feel that you have to wash your hands." 2 "I think you're getting better; you're beginning to understand your problem." 3 "Don't worry about it; these actions are part of your illness, and the feelings will pass." 4 "I understand that—maybe we can work together to limit the number of times you wash them."

4 "I understand that—maybe we can work together to limit the number of times you wash them." Rationale: The nurse shows an understanding of the client's needs by not totally restricting the handwashing and by working with the client to set limits on the behavior. At this time the client is still too anxious to be capable of coping with the reasons for handwashing. Continued handwashing does not reveal an understanding of the underlying problem, nor is it a sign of progress. Telling the client not to worry denies the client's feelings and may close off communication.

At which age should the nurse assess the school-age client for mastery of the concept of conservation of volume? 1 6 years 2 7 years 3 8 years 4 9 years

4 9 years Rationale: Mastery of the concept of conservation of volume occurs between the ages of 9 and 12 years; therefore, the nurse would include this in the assessment for the 9-year-old school-age client. Volume conservation is not assessed for the 6-, 7-, or 8-year-old school-age child

When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action? 1 Obtain vital signs. 2 Notify the healthcare provider. 3 Reinsert the protruding organs using aseptic technique. 4 Cover the wound with a sterile towel moistened with normal saline.

4 Cover the wound with a sterile towel moistened with normal saline. Rationale: A sterile towel moistened with normal saline will not adhere to the wound, and it will protect the area until the healthcare provider arrives. Obtaining vital signs and notifying the healthcare provider are not the priority; the client has needs that must be met first. Reinserting the protruding organs is contraindicated because it may injure delicate tissues and organs; also it is not within the scope of nursing practice.

What is the nurse's priority concern when caring for an infant born with exstrophy of the bladder? 1 Urine retention 2 Excoriation of the skin 3 Impending dehydration 4 Development of an infection

4 Development of an infection Rationale: The constant seepage of urine from the exposed ureteral orifices makes the area susceptible to infection; infection must be prevented or controlled because it may ultimately lead to renal failure. Urine retention will not occur because of the constant seepage of urine. Although skin excoriation is a major concern, it is secondary to the development of a life-threatening infection. Although dehydration is a major concern, risk for infection is the priority for the infant at this time.

A nurse is teaching a class about child abuse. What defense mechanism most often used by the physically abusive individual should the nurse include? 1 Repression 2 Manipulation 3 Transference 4 Displacement

4 Displacement Rationale: Displacement is a defense mechanism in which one's pent-up feelings toward a threatening person are discharged on those who are less threatening. Repression is the unintentional putting out of the mind unacceptable or troubling thoughts, desires, or experiences. Transference is a mechanism by which affects or emotional tones are shifted from one individual to another; it is unrelated to child abuse. Manipulation is a mechanism by which individuals attempt to manage, control, or use others to suit their own purpose or to gain an advantage; it is unrelated to child abuse.

A client is receiving haloperidol for agitation, and the nurse is monitoring the client for side effects. Which response identified by the nurse is unrelated to an extrapyramidal tract effect? 1 Akathisia 2 Opisthotonos 3 Oculogyric crisis 4 Hypertensive crisis

4 Hypertensive Crisis Rationale: A hypertensive crisis is not associated with extrapyramidal tract symptoms. Akathisia, characterized by restlessness and twitching or crawling sensations in the muscles, is an extrapyramidal side effect. Opisthotonos, characterized by hyperextension and arching of the back, is an extrapyramidal side effect. Oculogyric crisis, characterized by the uncontrolled upward movement of the eyes, is an extrapyramidal side effect.

The postoperative prescriptions for a client who had repair of an inguinal hernia include docusate sodium daily. Before discharge, the nurse instructs the client about what potential side effect? 1 Rectal bleeding 2 Fecal impaction 3 Nausea and vomiting 4 Mild abdominal cramping

4 Mild abdominal cramping Rationale: Mild abdominal cramping is the only side effect of docusate sodium; this emollient laxative permits water and fatty substances to penetrate and mix with fecal material. Rectal bleeding is more likely to occur with a saline-osmotic laxative. Docusate sodium promotes defecation, not constipation. Nausea and vomiting are more likely to occur with a saline-osmotic laxative.

Which period of Piaget's theory explains self-consciousness in an adolescent? 1 Period I 2 Period II 3 Period III 4 Period IV

4 Period IV Rationale: In period IV of Piaget's theory, an adolescent demonstrates feelings and behaviors characterized by self-consciousness. During period I, an infant develops a schema or action pattern for dealing with the environment. During period II, the child demonstrates animism, in which he or she personifies objects. While going through period III, the child thinks about an action that earlier was performed physically.

A nurse administers the prescribed intravenous dose of magnesium sulfate to a client with severe preeclampsia. What adverse effect should the nurse address when evaluating the client's response to the medication? 1 Blurred vision 2 Epigastric pain 3 Fetal tachycardia 4 Respiratory depression

4 Respiratory Depression

The nurse is reviewing the amount of drainage on the dressing of a client after discharge from the postanesthesia care unit (PACU). On which area should the nurse focus for this assessment? 1 Foley catheter 2 Nasogastric tube 3 Intravenous fluids 4 Surgical incision site

4 Surgical incision site Rationale: Reviewing the amount of drainage on the dressing of a client is an observation the nurse would make when reviewing the surgical incision site. Focused assessment of the Foley catheter and the nasogastric tube should be made when observing tubes attached to client after an operation. When observing the intravenous fluids, the nurse should check for the type of infused solution.

Which finding could be described as visibly dilated, superficial, and cutaneous small blood vessels found on the face and thighs? 1 Tenting 2 Angioma 3 Varicosity 4 Telangiectasia

4 Telangiectasia Rationale: Telangiectasia is a permanent condition characterized by cutaneous blood vessels that are superficial and visibly dilated.

Which of these characteristics are found in an adolescent according to Erikson's theory of psychosocial development? Select all that apply. 1 The adolescent concentrates on work and play. 2 The adolescent develops autonomy by making choices. 3 The adolescent develops a conscience. Correct4 The adolescent is concerned about his or her appearance and body image. Correct5 The adolescent acquires a sense of identity by participating in decision-making.

4 The adolescent is concerned about his or her appearance and body image. 5 The adolescent acquires a sense of identity by participating in decision-making. Rationale: According to Erikson's theory, an adolescent has a marked preoccupation with his or her appearance and body image. Also during this stage, the adolescents develop a sense of identity by participating in decision-making. A toddler develops his or her autonomy by making choices. A child between three and six years old develops a superego or conscience. According to Erikson's theory of psychosocial development, ages 3-5 years old concentrates on work and play, not adolescents.

What gross motor skill is found in children between two to four months of age? 1 The child can creep on its hands and knees. 2 The child has predominant inborn reflexes. 3 The child can sit alone without any kind of support. 4 The child can bear weight on forearms when prone.

4 The child can bear weight on forearms when prone. Rationale: A child between two and four months of age is able to bear his or her weight on the forearms when in the prone position. A child between eight and 10 months of age can creep on their hands and knees. A child between birth and one month has predominant inborn reflexes. A child between six and eight months of age can sit alone without support

antisocial personality disorder

A personality disorder in which the person (usually a man) exhibits a lack of conscience for wrongdoing, even toward friends and family members. May be aggressive and ruthless or a clever con artist.

upper respiratory tract infection

a stuffy nose and itching results in difficulty breathing

Angioma

a tumor that consists of blood and lymph vessels

Tension Pneumothorax

a type of pneumothorax in which air that enters the chest cavity is prevented from escaping

Hyperacusis

is a hearing disorder that makes it hard to deal with everyday sounds. You might also hear it called sound or noise sensitivity. If you have it, certain sounds may seem unbearably loud even though people around you don't seem to notice them. Hyperacusis is rare.

Slipped epiphysis

is a hip condition that occurs in teens and pre-teens who are still growing. For reasons that are not well understood, the ball at the head of the femur (thighbone) slips off the neck of the bone in a backwards direction.

Ischemia or ischaemia

is a restriction in blood supply to tissues, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems with blood vessels, with resultant damage to or dysfunction of tissue.

myelomeningocele

is a severe form of spina bifida in which the spinal cord and nerves develop outside of the body and are contained in a fluid-filled sac that is visible outside of the back area. These babies typically have weakness and loss of sensation below the sac.

Grandeur

splendor and impressiveness, especially of appearance or style.

anastomosis

surgical joining of two ducts, vessels, or bowel segments to allow flow from one to another

Diaphoresis (Diaphoretic)

sweat, perspiration, or sweaty

Otosclerosis

the abnormal growth of bone of the MIDDLE ear. This bone prevents structures within the ear from working properly and causes hearing loss. For some people with otosclerosis, the hearing loss may become severe.

ascites

the accumulation of fluid in the peritoneal cavity, causing abdominal swelling

Transference

the action of transferring something or the process of being transferred.

footling breech presentation

the baby's feet are actually pointing downward and will enter first into the birth canal ahead of the butt. Footling breech is more common in premature babies. Fooling has the second highest occurrence rate of all breech positions.

Tenting

the failure of the skin to immediately return to the normal position after a gentle pinch.

hemorrhage

the loss of a large amount of blood in a short time

Anhedonia

the loss of enjoyment of things that were formerly enjoyed

Which of these behaviors does an adolescent exhibit? 1 Temper tantrums 2 Attempts to control situations 3 Synchronization of moral skills 4 Eagerness for formal education

3 Synchronization of moral skills Rationale: Adolescents refine and synchronize physical, psychosocial, cognitive, and moral skills to become an accepted member of society. Toddlers tend to have temper tantrums. Toddlers also learn about how to control situations. Preschoolers refine the mastery of their bodies and eagerly await the beginning of formal education

Freud: Psychosexual development

-said that libido (sex drive) is present at birth -libidinal energy & drive to reduce libidinal tension underlie forces that account for psychological processes * 5 stages in psychosocial development (oral stage, anal stage, phallic stage, latency, genital stage) -In each stage, children are faced with a conflict b/w societal demands & desire to reduce libidinal tension associated w/ different erogenous zones in body

Which of these skills should be present in a six to eight month old child? 1 The child pulls himself or herself to stand or sit. 2 The child is able to pick small objects. 3 The child can sit alone without support. 4 The child can place objects into containers

3 The child can sit alone without support. Rationale: A child of six to eight months of age should be able to sit alone without support. A child after 8 months of age should be able to pick up small objects, place objects in containers, and pull himself or herself up to stand or sit.

What behavior does the nurse suggest a parent will notice in her 2-year-old child after the death of a family member? 1 The child shows resiliency over the loss. 2 The child understands the cause of the loss. 3 The child exhibits changes in sleeping patterns. 4 The child is unable to develop an autonomous sense of self.

3 The child exhibits changes in sleeping patterns. Rationale: The parent will notice that after the death of a family member, her child is exhibits changes in eating and sleeping patterns. Older adults, not toddlers, show resiliency over the loss of a family member. Toddlers do not understand the cause of the loss. The loss of a family member may disrupt the development of autonomy in young adults.

dehiscence

Bursting open of a wound, especially a surgical abdominal wound

A client has a tuberculin purified protein derivative test as part of a yearly physical examination. The area of induration is 10 mm within 48 hours after having the test. What does the nurse conclude about the client based on this response? 1 The client has contracted clinical tuberculosis. 2 The client has passive immunity to tuberculosis. 3 The client has been exposed to the tubercle bacillus. 4 The client has developed a resistance to the tubercle bacillus.

3 The client has been exposed to the tubercle bacillus.

What are the symptoms of tuberculosis? Select all that apply. 1 Fatigue 2 Nausea 3 Weight gain 4 Low-grade fever 5 Increased appetite

1 Fatigue 2 Nausea 4 Low-grade fever Rationale: Tuberculosis is an infectious respiratory disease caused by Mycobacterium tuberculosis. The symptoms of tuberculosis are fatigue, nausea, low-grade fever, weight loss, and anorexia.

A nurse is caring for a client on mechanical ventilation. The nurse should monitor for which sign of hyperventilation? 1 Tetany 2 Hypercapnia 3 Metabolic acidosis 4 Respiratory alkalosis

4 Respiratory alkalosis Rationale: Increased rate and depth of breathing result in excessive elimination of CO2, and respiratory alkalosis [1] [2] can result. Tetany is associated with hypocalcemia. With hyperventilation, CO2 levels will be decreased (hypocapnia), not elevated. Metabolic acidosis results from excess hydrogen ions caused by a metabolic problem, not a respiratory problem.

A client returns from a radical neck dissection with a tracheotomy and two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority requiring immediate nursing intervention? 1 Cloudy wound drainage 2 Poor gag reflex 3 Decreased urinary output 4 Restlessness with dyspnea

4 Restlessness with dyspnea Rationale: The client is at risk for airway obstruction; restlessness and dyspnea indicate hypoxia. Cloudy drainage may indicate infection, which is not an immediate postoperative complication. Loss of the gag reflex is unimportant. The pharyngeal opening is sutured closed and a tracheal stoma is formed; the trachea is anatomically separate from the esophagus. Decreased urinary output needs to be monitored but does not take priority.

Piaget Cognitive/ Moral Development

1. sensorimotor 2. pre-operational 3. concrete operational 4. formal operational

tetany

A condition that is due usually to low blood calcium (hypocalcemia) and is characterized by spasms of the hands and feet, cramps, spasm of the voice box (larynx), and overactive neurological reflexes. Tetany is generally considered to result from very low calcium levels in the blood.

tetralogy of Fallot

A congenital heart condition presenting a combination of four defects in the structure of the heart.

alcohol-induced amnestic disorder

A mental disorder associated with chronic ethanol abuse (ALCOHOLISM) and nutritional deficiencies characterized by short term memory loss, confabulations, and disturbances of attention

Mentally healthy person

A mentally healthy person is one who accepts the aging self as an active being. A mentally healthy person is one who engages available strengths to compensate for weaknesses in order to create personal meaning. A mentally healthy person is one who sustains positive relationships with others. A mentally healthy person is one who maintains maximum autonomy by mastering the environment. A mentally healthy person does not engage available weaknesses.

Hering-Breuer reflex

A procedure involving the use of a bougie. A bougie is a thin cylinder of rubber, plastic, metal or another material that a physician inserts into or though a body passageway, such as the esophagus, to widen the passageway, guide another instrument into a passageway, or dislodge an object.

bouginage

A procedure involving the use of a bougie. A bougie is a thin cylinder of rubber, plastic, metal or another material that a physician inserts into or though a body passageway, such as the esophagus, to widen the passageway, guide another instrument into a passageway, or dislodge an object.

A client is seen in the clinic with sickle cell anemia. A nurse teaches the client about sickle cell anemia. Which information from the client indicates a correct understanding of the condition? 1 "I have abnormal platelets." 2 "I have abnormal hemoglobin." 3 "I have abnormal hematocrit." 4 "I have abnormal white blood cells."

2 "I have abnormal hemoglobin." Rationale: The client with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffen and elongate into a sickle. While it can affect hematocrit, it is really a result of the abnormal hemoglobin. The disorder affects hemoglobin rather than platelets or white blood cells.

The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump?

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. Aspiration can occur if a feeding is started with excessive residual. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Knowledge of last nausea medication is not necessary at this time. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees

evisceration

The displacement of organs outside of the body. (especially those in the abdominal cavity)

ascites

abnormal accumulation of fluid in the peritoneal cavity, causing abdominal swelling

Hip dysplasia

abnormal development of the pelvic joint causing the head of the femur and the acetabulum not to be aligned properly; Asymmetrical hip and thigh folds are indicative of developmental dysplasia of the hip; they are caused by upward and outward displacement of the femoral head on the affected side.

amenorrhea

absence of menstruation

extrapyramidal tract effect

also called drug-induced movement disorders, describe the side effects caused by certain antipsychotic and other drugs. These side effects include: involuntary or uncontrollable movements. tremors.

Leadership

an earned honor, right, and privilege and an action-oriented responsibility that requires time commitment.

Sinusitis

an inflammation of the tissues lining the sinuses

Exploratory Research

an initial study designed to develop or refine the dimensions of phenomena or to develop or refine a hypothesis about the relationships among phenomena.

dyssomnias

are a broad classification of sleeping disorders involving difficulty getting to sleep, remaining asleep, or of excessive sleepiness.

aminoglycoside therapy

are a class of antibiotics used mainly in the treatment of aerobic gram-negative bacilli infections, although they are also effective against other bacteria including Staphylococci and Mycobacterium tuberculosis. They are often used in combination with other antibiotics.

Subjective Data

are information from the client's point of view ("symptoms"), including feelings, perceptions, and concerns obtained through interviews

Objective Data

are observable and measurable data ("signs") obtained through observation, physical examination, and laboratory and diagnostic testing.

Folliculitis

bacterial infection in which erythematous pustules appear singly or in groups on the skin.

Battle's sign

characterized by postauricular ecchymosis

depressed anterior fontanel

classic sign of moderate dehydration in infants that results from a decrease in cerebrospinal fluid

Pulmonary Embolism

clot or other material lodges in vessels of the lung

exstrophy

condition in which an organ is turned inside out

Repression

coping with overwhelming emotions by blocking awareness or memory of the stressful event.

Crepitus

crackling of the skin on palpitation

Erikson: Psychosocial Development

created stages of personality development these stages are based on a series of crises/event that come from conflicts between ones own individual needs and social demands emphasizes on emotional development and interactions with the social enviroment he thought that a person could fail at accomplishing the conflict presented at one stage - but could still move onto another stage the mastery of one stage was not dependent to move onto the next stage the test to see if someone mastered the stage was to give them a question that demonstrated the skills and traits that would show that they surpassed that stage stages: 1. trust vs mistrust (0-1) 2. autonomy vs shame and doubt (1-3) 3. initiative vs guilt (3-6) 4. industry vs inferiority (6-12) 5. identity vs role confusion (adolescence) 6. intimacy vs isolation (young adulthood) 7. generativity vs stagnation (middle age) 8. integrity vs despair

Glasgow Coma Scale

eyes, verbal, motor Max- 15 pts, below 8= coma Actions: Eyes open, best verbal response, and best motor response

Achalasia (cardiospasm)

failure of the lower esophagus sphincter muscle to relax

Macule

flat, nonpalpable change in skin color, which is smaller than 1 cm

Dermatophytosis

fungal infection in which single or multiple patches appear on the skin.

Ambivalent

having mixed feelings or contradictory ideas about something or someone

Halo Sign

indicates the presence of blood in the cerebrospinal fluid; found by way of CT

gastroenteritis

inflammation of the stomach and intestines

Furuncle

is a bacterial infection in which small, tender, erythematous nodules filled with pus appear on the skin.

Methylphenidate (Ritalin)

is a central nervous system stimulant. It affects chemicals in the brain and nerves that contribute to hyperactivity and impulse control. Methylphenidate is used to treat attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), and narcolepsy.

Allen's test

is a first-line standard test used to assess the arterial blood supply of the hand

Hypertensive crisis

is a severe increase in blood pressure that can lead to a stroke. Extremely high blood pressure — a top number (systolic pressure) of 180 millimeters of mercury (mm Hg) or higher or a bottom number (diastolic pressure) of 120 mm Hg or higher — can damage blood vessels.

Confabulation

is a type of memory error in which gaps in a person's memory are unconsciously filled with fabricated, misinterpreted, or distorted information. 1 When someone confabulates, they are confusing things they have imagined with real memories. A person who is confabulating is not lying.

Herpes zoster

is a viral infection in which lesions are present on an erythematous base

Granulation tissue

is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size.

Echolalia

is parrotlike echoing of spoken words or sounds

Mediastinitis

is swelling and irritation (inflammation) of the chest area between the lungs (mediastinum). This area contains the heart, large blood vessels, windpipe (trachea), food tube (esophagus), thymus gland, lymph nodes, and connective tissue.

Oculogyric crisis

is the name of a dystonic reaction to certain drugs or medical conditions characterized by a prolonged involuntary upward deviation of the eyes. The term "oculogyric" refers to the bilateral elevation of the visual gaze, but several other responses are associated with the crisis.

Encopresis

is the passage of feces into inappropriate places such as clothing, closets, floors, or toy boxes, either voluntarily or involuntarily. It may severely limit a child's social development and results in parental disapproval and rejection.

lethargy

lack of energy; sluggishness

Avolition

lack of motivation associated with a reduced emotion expression (flat affect)

Nurse Practice Act

law established to regulate nursing practice

Otorrhea

leakage of cerebrospinal fluid from the ear

Rhinorrhea

leakage of cerebrospinal fluid from the nose.

inguinal hernia

occurs when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles. The resulting bulge can be painful, especially when you cough, bend over or lift a heavy object. An inguinal hernia isn't necessarily dangerous.

lithotomy position

often used during childbirth and surgery in the pelvic area. It involves lying on your back with your legs flexed 90 degrees at your hips. Your knees will be bent at 70 to 90 degrees, and padded foot rests attached to the table will support your legs.

Cranial Nerve I: Olfactory

originates at the olfactory bulb and assists with the perception of smell. Damage to this nerve may cause a decrease in olfactory acuity.

Papule

palpable, circumscribed solid elevations in the skin, smaller than 1 cm

Gastroparesis

partial paralysis of the stomach

Pyrexia

raised body temperature, fever

Borborygmi

rapid, high-pitched bowel sounds that are indicative of the hyperperistalsis that occurs behind an intestinal obstruction

tuberculin purified protein derivative test

skin test is a test that determines if you have tuberculosis (TB).

Vesicle

small, circumscribed skin elevation, filled with serous fluid

Pleural effusion

sometimes referred to as "water on the lungs," is the build-up of excess fluid between the layers of the pleura outside the lungs. The pleura are thin membranes that line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing.

Opisthotonos

spasm of the muscles causing backward arching of the head, neck, and spine, as in severe tetanus, some kinds of meningitis, and strychnine poisoning.

hyperorality

the compulsive need to taste and chew inedible objects

Varicosity

the increased prominence of superficial veins.

Tinnitus

the perception of noise or ringing in the ears. A common problem, tinnitus affects about 15 to 20 percent of people. Tinnitus isn't a condition itself — it's a symptom of an underlying condition, such as age-related hearing loss, ear injury or a circulatory system disorder.

Catharsis

the process of releasing, and thereby providing relief from, strong or repressed emotions.

oliguria

the production of abnormally small amounts of urine

Universality

the quality of involving or being shared by all people or things in the world or in a particular group. The sense that one is not alone in any situation.

Introjection

the unconscious adoption of the ideas or attitudes of others.

Suppression

the voluntary exclusion from awareness of anxiety-producing feelings, ideas, and situations.

Thyrotoxic Crisis

toxic condition characterized by hyperthermia, tachycardia, nervous symptoms, and rapid metabolism; also known as thyroid storm.

Neologisms

unique words with personal meanings only to the client

Altruism

unselfish regard for the welfare of others

Maslow's Hierarchy of Needs

(level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization

Kohlberg: development of moral reasoning

-expanded on piaget's theory -interviewed boys ages 10, 13, & 16 -identified six stages of moral development must mature -both cognitive & moral development must mature

Which clinical manifestation would cause the nurse to suspect that a preschool-age client ingested a corrosive agent, such as bleach? 1 Choking 2 Gagging 3 Drooling 4 Vomiting

3 Drooling Rationale: Drooling is often associated with the ingestion of a corrosive agent, such as bleach. Choking, gagging, and vomiting are clinical manifestations associated with the ingestion of hydrocarbons, not corrosive agents.

The nurse places fetal and uterine monitors on the abdomen of a client in labor. While observing the relationship between the fetal heart rate and uterine contractions, the nurse identifies four late decelerations. Which condition is most commonly associated with late decelerations? 1 Head compression 2 Maternal hypothyroidism 3 Uteroplacental insufficiency 4 Umbilical cord compression

3 Uteroplacental insufficiency Late decelerations, suggestive of fetal hypoxia, occur in the setting of uteroplacental insufficiency. Head compression results in early decelerations; this finding is considered benign. Hypothyroidism is unrelated to late decelerations. Umbilical cord compression results in variable decelerations.

Evaluation (Nursing Process)

Acquisition of verbal and nonverbal feedback; Comparison of actual and expected outcomes; Identification of factors affecting outcomes; Modification and update of care plan; Verbal and/or written explanation of revisions of care plan to patient

The nurse is caring for four clients admitted at the same time under mass casualty conditions. Based on this data, which client should be given the highest priority for treatment? Client A Massive head trauma Client B Open fracture with a distal pulse Client c Shock Client D Strains

Client C Shock Rationale: Client C reporting with shock is identified with a red tag, indicating an immediate threat to life. The client with massive head trauma is labeled with a black tag, which indicates the client is deceased or is expected to die, so treatment will not be provided in order to maximize resources to save the most clients possible. The client reporting with an open fracture with distal pulse is triaged as class 3 where the treatment is considered urgent but less so than for a red-tagged client. Strains and contusions are minor injuries and are considered nonurgent; client D should be triaged as class III.

According to current studies, what percentage of adolescents has used alcohol by the end of high school? Record your answer using a whole number. _____%

Current statistics show that by the end of their high school years, 85% of adolescents have used alcohol.

Implementation (Nursing Process)

Delegation and verbal discussion with health care team; Verbal, visual, auditory, and tactile health teaching activities; Provision of support via therapeutic communication techniques; contact with other health resources; Written documentation of patient's progress in medical record

Physical Findings of the Skin Indicative of Substance Abuse

Diaphoresis: Sedative hypnotic (including alcohol) Spider angiomas: Alcohol, stimulants Burns (especially fingers): Alcohol Needle marks: Opioids Contusion, abrasions, cuts, scars: Alcohol, other sedative hypnotics, intravenous (IV) opioids "Homemade" tattoos: Cocaine, IV opioids (prevents detection of injection sites) Vasculitis: Cocaine Red, dry skin: Phencyclidine (PCP)

Triage under mass casualty conditions: Classifications

Emergent or Class I (Red tag, immediate threat to life) Urgent or Class II (Yellow tag, major injuries that require treatment) Nonurgent or Class III (Green tag, minor injuries that do not require immediate treatment) Expectant or Class IV (Black tag, expected and allowed to die)

Hypocalcemic tetany

Intermittent tonic muscular spasms caused by a low concentration of calcium in the blood.

Planning (Nursing Process)

Interpersonal or small-group health care team planning sessions; Interpersonal collaboration with patient and family to determine implementation methods; Written documentation of expected outcomes; Written or verbal referral to health care team members

Nursing Diagnosis (Nursing Process)

Intrapersonal analysis of assessment findings; Validation of health care needs and priorities via verbal discussion with patient; Documentation of nursing diagnosis

Naloxone

Naloxone (Narcan) is a narcotic antagonist that displaces opioids from receptors in the brain, thereby reversing respiratory depression. Methadone is a synthetic opioid that causes central nervous system depression; it will add to the problem of overdose. Epinephrine and amphetamine will have no effect on respiratory depression related to opioid overdose.

Phencyclidine

PCP; drug originally developed as a surgical anesthetic that was discontinued due to adverse patients reactions; abusers of the drug often experience severe psychiatric manifestations; mind-altering drug that may lead to hallucinations (a profound distortion in a person's perception of reality). It is considered a dissociative drug, leading to a distortion of sights, colors, sounds, self, and one's environment.

Key Features of Inhalation of Anthrax

Prodromal Stage (Early): Fever, fatigue, mild chest pain, dry cough, no manifestations of upper respiratory infection, Mediastinal "widening" on chest x-ray Fulminant Stage (Late): Sudden onset of breathlessness, dyspnea, diaphoresis, stridor on inhalation and exhalation, hypoxia, high fever, mediastinitis, pleural effusion, hypotension, septic shock

Reactive Attachment Disorder (RAD)

RAD is a psychological and developmental disorder that occurs in children who are neglected by their primary caregivers. Children with RAD are not cuddly with parents and fail to make eye contact. They also exhibit poor impulse control and may be destructive to themselves and others.

Hyperpnea

Rapid breathing An attempt by the respiratory system to eliminate excess carbon dioxide

paracentesis

Surgical puncture to remove fluid from the abdomen or peritoneal cavity; abdominocentesis.

Stages of Change Model

Theoretical model describing a five-step process by which individuals give up bad habits and adopt healthier lifestyles. 1 Precontemplation 2 Contemplation 3 Preparation/determination 4 Action/willpower 5 Maintenance 6 Relapse

radical neck dissection

This operation has been used for almost 100 years and describes the removal of lateral neck nodes and tissues to surgically remove cancer in the neck. Included in this tissue, which extends from the collarbone (clavicle) inferiorly to the jawbone (mandible) superiorly are dozens of lymph nodes.

Assessment (Nursing Process)

Verbal interviewing and history taking; Visual and intuitive observation of nonverbal behavior; Visual, tactile, and auditory data gathering during physical examination; Written medical records, diagnostic tests, and literature review

talipes equinovarus (clubfoot)

a congenital deformity (present at birth) in which the affected foot appears rotated internally at the ankle - the foot points down and inwards and the soles of the feet face each other.

Meniere's disease

a disorder of the inner ear that can lead to dizzy spells (vertigo) and hearing loss. In most cases, Meniere's disease affects only one ear.

Hypoxia

a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection. Any type of bacteria can cause the infection. Fungi such as candida and viruses can also be a cause, although this is rare. At first the infection can lead to a reaction called sepsis.

Septic Shock

a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection. Any type of bacteria can cause the infection. Fungi such as candida and viruses can also be a cause, although this is rare. At first the infection can lead to a reaction called sepsis.

Wheal

a localized edema, usually caused by a mosquito bite; irregular in shape and have elevated surfaces.

Telangiectasia

a permanent condition characterized by cutaneous blood vessels that are superficial and visibly dilated.

Electra complex

a psychoanalytic term used to describe a girl's sense of competition with her mother for the affections of her father. It is comparable to the Oedipus complex in males. According to Freud, during female psychosexual development, a young girl is initially attached to her mother.

Akathisia

a state of agitation, distress, and restlessness that is an occasional side-effect of antipsychotic and antidepressant drugs.