OCC Nursing 2 FINAL

NSAIDs activity modification and joint rest arthroscopic surgery

A client has been diagnosed with a rotator cuff tear. What are the options for treating this condition? Select all that apply.

Regurgitation of undigested food

A client has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the client to describe what sign or symptom?

phytonadione (Mephyton).

A client with advanced cirrhosis has a prothrombin time (PT) of 15 seconds, compared with a control time of 11 seconds. The nurse expects to administer:

C) Early diagnosis and treatment of gastroesophageal reflux disease

A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action has the greatest potential to prevent esophageal cancer? A) Promotion of a nutrient-dense, low-fat diet B) Annual screening endoscopy for patients over 50 with a family history of esophageal cancer C) Early diagnosis and treatment of gastroesophageal reflux disease D) Adequate fluid intake and avoidance of spicy foods

Acute Pain Related to Increased Peristalsis and GI Inflammation Activity Intolerance Related to Generalized Weakness Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea

A nurse is caring for a client who has been admitted to the hospital with diverticulitis. What would be appropriate nursing diagnoses for this client? Select all that apply.

Provide oral care every 2-3 hours.

A nurse is caring for a client with acute renal failure and hypernatremia. In this case, which action can be delegated to the nursing assistant?

D) Notify the physician.

A nurse is caring for a patient who has a diagnosis of GI bleed. During shift assessment, the nurse finds the patient to betachycardic and hypotensive, and the patient has an episode of hematemesis while the nurse is in the room. In addition to monitoring the patients vital signs and level of conscious, what would be a priority nursing action for this patient? A) Place the patient in a prone position. B) Provide the patient with ice water to slow any GI bleeding. C) Prepare for the insertion of an NG tube. D) Notify the physician.

D) Inadequate nutrition and decreased saliva production can cause cavities

A nurse is caring for a patient who is acutely ill and has included vigilant oral care in the patients plan of care. Why are patients who are ill at increased risk for developing dental caries? A) Hormonal changes brought on by the stress response cause an acidic oral environment B) Systemic infections frequently migrate to the teeth C) Hydration that is received intravenously lacks fluoride D) Inadequate nutrition and decreased saliva production can cause cavities

D) Frequent screening for osteoporosis

A patient has been experiencing disconcerting GI symptoms that have been worsening in severity. Following medical assessment, the patient has been diagnosed with lactose intolerance. The nurse should recognize an increased need for what form of health promotion? A) Annual screening colonoscopies B) Adherence to recommended immunization schedules C) Regular blood pressure monitoring D) Frequent screening for osteoporosis

D) Psyllium hydrophilic mucilloid (Metamucil)

A patient has been experiencing occasional episodes of constipation and has been unable to achieve consistent relief by increasing physical activity and improving his diet. What pharmacologic intervention should the nurse recommend to the patient for ongoing use? A) Mineral oil enemas B) Bisacodyl (Dulcolax) C) Senna (Senokot) D) Psyllium hydrophilic mucilloid (Metamucil)

BUN

A volume depleted patient has a ______ elevated out of proportion to serum creatinine

D

A woman has just had a therapeutic abortion to end an unintended pregnancy. Afterward, the woman cries because although she wanted to have children in future years, this pregnancy was not well-timed. Which type of grief is this woman most likely to experience? A) Anticipatory grief B) Absence of grief C) Complicated grief D) Disenfranchised grief

A

A woman has just presented at the emergency department after being raped. The initial nursing action would be to A) provide emotional support. B) refer her to a rape crisis hotline. C) encourage her to file charges immediately. D) perform a nursing history and physical as quickly as possible.

Wide resection of the middle and distal portions of the stomach with removal of about 75% of the stomach

After a client received a diagnosis of gastric cancer, the surgical team decides that a Billroth II would be the best approach to treatment. How would the nurse explain this procedure to the family?

Abdominal surgery

After teaching a group of students about intestinal obstruction, the instructor determines that the teaching was effective when the students identify which of the following as a cause of a functional obstruction?

Ingest five or six small meals each day.

An elderly client exhibits blood pressure of 110/76 while prone, 100/72 sitting, and 92/64 standing. The nurse instructs the client to

Instruct the family to remove the toddler from the room for the protection of the client.

An elderly client is hospitalized for treatment related to leukemia. Family members want to visit with a toddler who has a cold. It would be best for the nurse to

Loss of self-esteem

Any change in how a person is valued at work or in relationships or by himself or herself can threaten self-esteem. It may be an actual change or the person's perception of a change in value. death of a loved one, a broken relationship, loss of a job , and retirement are example of change that represent loss and can result in a threat to self-esteem.

Loss of self-esteem

Any change in how a person is valued at work or in relationships or by himself or herself can threaten self-esteem. It may be an actual change or the person's perception of a change in value. death of a loved one, a broken relationship, loss of a job , and retirement are example of change that represent loss and can result in a threat to self-esteem. what type of loss is this?

C

At which point in the stages of aggressive incidents is intervention least likely to be effective in preventing physically aggressive behavior? A) Triggering B) Escalation C) Crisis D) Postcrisis

During the preoperative period

At which time does the nurse realize that it is best to begin teaching about care needed during the postoperative period?

A client who is depressed and suicidal is scheduled for electroconvulsive therapy (ECT), which requires consent. Legally, who should sign the consent for this treatment? A) A member of the treatment team B) The client C) The client's spouse D) The psychiatrist

B

A new graduate nurse has accepted a staff position at an inpatient mental health facility. The graduate nurse can expect to be responsible for basic-level functions, including A) providing clinical supervision. B) using effective communication skills. C) adjusting client medications. D) directing program development.

B

Humerus

The orthopedic nurse should assess for signs and symptoms of Volkmann contracture if a client has fractured which of the following bones?

falls

The leading cause of injury in the elderly population:

chloride, bicarbonate, phosphate, sulfate

The major anions are:

A gastrostomy tube

The nurse expects informed consent to be obtained for insertion of:

Keep the vent lumen above the patient's waist to prevent gastric content reflux.

The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly?

calcium

Bone changes associated with aging frequently result from a loss of

A patient who has continuously experienced severe symptoms of schizoaffective disorder for the past 17 years is experiencing an acute psychotic episode. Which level of care is most appropriate for this patient at this time? A) Partial hospitalization B) Residential treatment C) Inpatient hospital treatment D) Clubhouse

C

schizoid personality disorder

Detached from social relationships; restricted affect; involved with things more than people Nursing interventions: Improve client's functioning in the community; assist client to find case manager

Which of the following would not be included as a symptom of drug-induced parkinsonism? A) Stooped posture B) Cogwheel rigidity C) Drooling D) Tachycardia

D

Which one of the following statements is most accurate regarding the cohesiveness of a group in group therapy? A) It is commonly present in the first meeting of the group. B) It is necessary for the group to have maximum cohesiveness, the more the better. C) Group cohesiveness is the degree to which members think alike and many things are left unspoken. D) Cohesiveness is a desirable group characteristic that is associated with positive group outcomes.

D

Sialadenitis

The nurse notes that a client has inflammation of the salivary glands. The nurse documents which finding?

Serum lipase

The nurse should assess for an important early indicator of acute pancreatitis. What prolonged and elevated level would the nurse determine is an early indicator?

Avoid beer, especially in the evening. Elevate the head of the bed on 6- to 8-inch blocks. Elevate the upper body on pillows.

Health teaching for a patient with GERD is directed toward decreasing lower esophageal sphincter pressure and irritation. The nurse instructs the patient to do which of the following? Select all that apply.

1.020

In a volume depleted patient the urine specific gravity should be greater than ________, indicating healthy renal conservation of fluid

psychotropic drugs

Medications that control, or at least moderate, the manifestations of some mental disorders.

Place the client in the Fowler's position.

The client has returned to the floor following a radical neck dissection. Anesthesia has worn off. What is the nurse's priority action?

Weight loss

Which factor is the focus of nutrition intervention for clients with type 2 diabetes?

Hemorrhage

Which factor may contribute to compartment syndrome?

"I'll wear cotton socks with well-fitting shoes."

Which statement indicates that a client with diabetes mellitus understands proper foot care?

Fillipino Americans

black clothing or armbands; wreaths on casket, black cloth on home of the deceased

Filipino Americans

black clothing or armbands; wreaths on casket; black cloth on home of deceased

stage 4 hepatic encephalopathy

comatose, may not respond to painful stimuli

binge eating

consuming an unusually large amount of food and feeling that the eating is out of control

Histamine

controls alertness, gastric secretions, cardiac stimulationi, peripheral allergic response Under investigation. It is involved in the peripheral allergic responses, control of gastric secretions, cardiac stimulation, and alterness. Results in weight gain, sedation and hypotension

Dopamine

controls complex moements, motivation, cognition; regulates emotional response

Epiniphrine

controls fight or flight response; excitatory drug

schizotypal personality disorder

cute discomfort in relationships; cognitive or perceptual distortions; eccentric behavior Nursing Interventions: Develop self-care skills; improve community functioning; social skills training

clonidine

decreases release of catecholamines (epi and norepi) from adrenergic neurons which decreases catecholamine levels in the blood

Ego-syntonic

describes personality disorders, a person believes that their behaviour is correct (in contrast, ego-dystonic - person sees the illness as something thrust upon them that is intrusive)

Potency

describes the amount of a drug needed to achieve maximum effect

Cluster B

dramatic, emotional, erratic

promotes glycogenolysis

glucagon

cushing syndrom

group of signs and symptoms produced by excess cortisol from the adrenal cortex; haracterized by truncal obesity, "moon face," acne, abdominal striae, and hypertension

peroneal nerve damage

if a patient experiences foot drop what nerve is damaged

phobia

illogical fear of a specific object or social situation that causes extreme distress and interferes with normal functioning

FSH, ATH, ACTH

name three hormones secreted by the anterior pituitary:

Childhood Disintegrative Disorder

normal early physical and cognitive development between ages 2-10 years lose many skills already developed

mourning

outward expression of grief examples: having a wake, sitting shiva, arranging funerals

negative feedback

regulating mechanism in which an increase or decrease in the level of a substance decreases or increases the function of the organ producing the substance

bradycardia hypotension weakness/fatigue drowsiness/dizziness/confusion anticholinergic/ constipation/ dry mouth

side effects of propranolol and clonidine include

influences metabolism that is essential for growth

somatrotropin

Mineralocorticoids

steroid hormones secreted by the adrenal cortex

Glucocorticoids

steroid hormones secreted by the adrenal cortex in response to adrenocorticotropic hormone; produce a rise of liver glycogen and blood glucose

Phase 1 of Crisis Development

stress causes increased anxiety; trying to cope

attempted suicide

suicidal act that either failed or was incomplete

adrenalectomy

surgical removal of one or both adrenal glands

basal metabolic rate

the body's resting rate of energy expenditure

osmosis

the process by which fluid moves across a semipermeable membrane from an area of low solute concentration to an area of high solute concentration; the process continues until the solute concentrations are equal on both sides of the membrane

T4

thyroxine (tetraiodothyronine)

T3

triiodothyronine (thyroid hormone)

complicated grieving

a response outside the norm and occurring when a person is void of emotion, grieves for prolonged periods, or has expressions of grief that seem disproportionate to the event

mild anxiety

a sensation that something is different and warrants special attention

dementia

a slowly progressive decline in mental abilities, including memory, thinking, and judgment, that is often accompanied by personality changes

hypertonic solution

a solution with an osmolality higher than that of serum

severe anxiety

an increased level of anxiety when more primitive survival skills take over, defensive responses ensue, and cognitive skills decrease significantly; person with severe anxiety has trouble thinking and reasoning

social phobia (social anxiety disorder)

an anxiety disorder: fear of humiliation in the presence of others, characterized by intense self-consciousness about one's appearance, behavior, or both

anticipatory anxiety

expected anxiety so the person becomes reclusive

Chinese Americans

strict norms for announcing death, preparing body, arranging funeral and burial, morning after burial. bowls of food on the table for Spirit for 1 year after death

gerontology

study of the aging process

stage 3 hepatic encephalopathy

stuporous, difficult to Rouse, sleeps most of the time, Marked confusion, incoherent speech

behavioral responses

the grieving person may function "automatically" or routinely w/o much thought, indicating that the person is numb- the reality of loss has not set in yet.

A client being served in a busy inpatient psychiatric unit becomes very noisy and combative. The other clients are complaining about the noise and are afraid that they will be hurt by the client. The nurse determines that the best course of action for all involved is to seclude the client until the client is able to regain control of his behavior. On which ethical principle did the nurse base this decision? A) Utilitarianism B) Deontology C) Nonmaleficence D) Veracity

A

A client diagnosed with a mild anxiety disorder has been referred to treatment in a community mental health center. Treatment most likely provided at the center includes A) medical management of symptoms. B) daily psychotherapy. C) constant staff supervision. D) psychological stabilization.

A

A nurse is assisting a patient who is working on the technique of systematic desensitization. When the patient feels anxious, the nurse can best use the principles of this technique by stating, A) ìUse the deep breathing techniques we practiced yesterday.î B) ìWhat is the worst that will happen if you confront this fear?î C) ìTell me how you are feeling right now.î D) ìI can see you are anxious. Let's stop for a minute.î

A

A nurse is meeting with a crisis support group. In efforts to help patients identify with one another, the nurse explains which of the following about the crisis experience? A) ìEven happy events can cause a crisis if the stress is overwhelming.î B) ìOnly people who have unfortunate life events will experience a crisis.î C) ìA person has no control over how a crisis will affect him or her.î D) ìPeople can prevent all crises if they develop good coping skills early.î

A

Potassium 3.0 mEq/L (mmol/L)

A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. The laboratory values are as followssodium is 147 mEq/L (mmol/L)potassium is 3.0 mEq/L (mmol/L)chloride is 112 mEq/L (mmol/L)Magnesium is 2.3 mg/dL (0.95mmol/L)

Acute gastritis

A client reports to the clinic, stating that she rapidly developed headache, abdominal pain, nausea, hiccuping, and fatigue about 2 hours ago. For dinner, she ate buffalo chicken wings and beer. Which of the following medical conditions is most consistent with the client's presenting problems?

"What precipitates the outbursts?"

A client reports to the nurse that her grandmother with Alzheimer's disease recently moved in with her and her two school-aged children. The client states the grandmother becomes agitated and starts yelling and crying frequently. The woman asks, "What can I do?" The nurse first responds:

C

A client says to the nurse, ìI just can't talk in front of the group. I feel like I'm going to pass out.î The nurse assesses the client's anxiety to be at which level? A) Mild B) Moderate C) Severe D) Panic

Drink at least eight glasses of fluid each day. Drink water as an inexpensive way to meet fluid needs. Respond to thirst

A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply.

An effective means of communicating with the nurse

A client who had a hemiglossectomy earlier in the day is assessed postoperatively, revealing a patent airway, stable vital signs, and no bleeding or drainage from the operative site. The nurse notes the client is alert. What is the client's priority need at this time?

D

A female college student comes to the counseling center and tells the nurse she is afraid of her boyfriend. She states, ìHe is so jealous and overprotective; he wants to know where I am and who I'm with every minute.î Which of the following is most likely true of the situation? A) The student is overreacting. B) This is a situation requiring a restraining order. C) The student's boyfriend is simply insecure and needs reassurance. D) This is characteristic of the tension-building phase of the violence cycle.

Emergent

A fractured skull would be classified under which category of surgery based on urgency?

A growing number of people live to a very old age.

A gerontologic nurse is aware of the demographic changes that affect the provision of health care. Which of the following phenomena is currently undergoing the most rapid and profound change?

A nurse is orienting to a new position working the infirmary in the state penitentiary. When working with prisoners who are also mentally ill, the nurse examines her own attitudes. Which of the following beliefs should the nurse discuss with her supervisor before caring for incarcerated patients? A) People with mental illness are inherently violent. B) The mentally ill can get better treatment in prison than in the community. C) People with mental illness are more vulnerable to victimization when incarcerated. D) Many mentally ill would not be in prison if they were stabilized on medication.

A

A patient with bipolar disorder taking lithium returns from a walk outside and reports feeling shaky and dizzy. The nurse suspects the patient is experiencing a toxic reaction to the lithium and immediately notifies the A) psychiatrist. B) psychologist. C) nurse manager. D) recreation therapist.

A

The factor having the most influence on the current trend in treatment settings is the fact in recent years, A) funding for community programs has been inadequate. B) laws have enabled more people to be committed to treatment. C) state hospitals have expanded to meet the demand. D) community programs have been fully developed to meet treatment needs.

A

What is an important role of the nurse with regard to residents opposing plans to establish a group home or residential facility in their neighborhood? A) To provide information to correct misinformation related to stereotypes of persons with mental illnesses B) To persuade neighborhood residents that mentally ill people need safe, affordable, and desirable housing C) To provide for the safety and security of the neighborhood D) To ensure the security of persons in the group home

A

When teaching a client about restrictions for tranylcypromine (Parnate), the nurse will tell the client to avoid which of the following foods? A) Broad beans B) Citrus fruit C) Egg products D) Fried foods

A

Which element would be present in an assertive community treatment (ACT) program? A) 24-hour-a-day services B) Infrequent contact with clients C) Many clients to each staff member D) Limited length of service

A

continuously monitors the sedated client.

A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse:

D

A client lost control of his behavior, broke a window, and made verbal threats to staff and other clients. The client was placed in mechanical restraints. Which statement should the nurse make to explain the use of restraints to the client? A) ìThe length of time you'll be in restraints is undetermined.î B) ìThe staff will monitor your behavior closely.î C) ìThis is what happens when you lose control.î D) ìThis is a means of keeping you and others safe.î

"Ketones will tell us if your body is using other tissues for energy."

A client newly diagnosed with diabetes mellitus asks why he needs ketone testing when the disease affects his blood glucose levels. How should the nurse respond?

"Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food."

A client presents at the ambulatory clinic reporting recurrent sharp stomach pain that is relieved by eating. The nurse suspects that the client may have an ulcer. How should the nurse explain the formation and role of acid in the stomach to the client?

Calcium is 12.9mg/dL (3.2mmol/L)

A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values.sodium is 130 mEq/L (mmol/L)potassium is 4.6 mEq/L (mmol/L)chloride is 94 mEq/L (mmol/L)Calcium is 12.9mg/dL (3.2mmol/L)

Change the dressing no more than weekly.

A nurse is aware of the high incidence of catheter-related bloodstream infections in clients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections?

The use of moderate sedation

A nurse is caring for a client who has been scheduled for endoscopic retrograde cholangiopancreatography (ERCP) the following day. When providing anticipatory guidance for this client, the nurse should describe what aspect of this diagnostic procedure?

Enhancement of verbal communication

A nurse is caring for a client who has had surgery for oral cancer. When addressing the client's long-term needs, the nurse should prioritize interventions and referrals with what goal?

Report this finding promptly to the health care provider and remain with the client.

A nurse is caring for a client who is postoperative day 1 following neck dissection surgery. The nurse is performing an assessment of the client and notes the presence of high-pitched adventitious sounds over the client's trachea on auscultation. The client's oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurse's most appropriate action?

Encourage the family to bring in the client's favorite foods.

A nurse is caring for a client who is postoperative from a neck dissection. What would be the mostappropriate nursing action to enhance the client's appetite?

peptic ulcer disease

A nurse is caring for a client who is undergoing a diagnostic workup for a suspected gastrointestinal problem. The client reports gnawing epigastric pain following meals and heartburn. What would the nurse suspect this client has?

An elevated serum alkaline phosphatase level and a normal serum calcium level

A nurse is caring for a client with Paget disease and is reviewing the client's most recent laboratory values. Which of the following values is most characteristic of Paget disease?

The short-acting insulin is withdrawn before the intermediate-acting insulin.

A nurse is preparing to administer two types of insulin to a client with diabetes mellitus. What is the correct procedure for preparing this medication?

Weight

A nurse is providing afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status?

Limiting visitors to one or two at a time

A nurse is working with the family of a patient with Alzheimer's disease to develop an appropriate plan of care. Which of the following would the nurse suggest to foster socialization?

48-year-old female with BMI 36 k/m2 and uncontrolled type 2 diabetes. 34-year-old male with BMI 30 k/m2 and metabolic syndrome with hypertension.

A nurse working in a bariatric clinic assesses various clients with obesity. Which clients will the nurse recognize as meeting the selction criteria for bariatric surgery? Select all that apply.

B) Insertion of an NG tube for decompression

A patient has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurses priority intervention? A) Administration of antiemetics B) Insertion of an NG tube for decompression C) Infusion of hypotonic IV solution D) Administration of proton pump inhibitors as ordered

"Buffalo hump" Thin extremities "Moon face" Truncal obesity Purple striae

A patient has been diagnosed with Cushing's syndrome. The nurse would expect which of the following features to be present upon physical examination?

Clay-colored feces Pruritus Jaundice

A patient is admitted to the hospital with a possible common bile duct obstruction. What clinical manifestations does the nurse understand are indicators of this problem? (Select all that apply.)

C) Intermittent pain and bloody stool

A patient is undergoing diagnostic testing for a tumor of the small intestine. What are the most likely symptoms that prompted the patient to first seek care? A) Hematemesis and persistent sensation of fullness B) Abdominal bloating and recurrent constipation C) Intermittent pain and bloody stool D) Unexplained bowel incontinence and fatty stools

B) Altered serum calcium levels

A patient is undergoing diagnostic testing for suspected Pagets disease. What assessment finding is most consistent with this diagnosis? A) Altered serum magnesium levels B) Altered serum calcium levels C) Altered serum potassium levels D) Altered serum sodium levels

AC

A patients assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment questions address likely etiologic factors? Select all that apply. A) How many alcoholic drinks do you typically consume in a week? B) Have you ever been tested for diabetes? C) Have you ever been diagnosed with gallstones? D) Would you say that you eat a particularly high-fat diet? E) Does anyone in your family have cystic fibrosis?

A) The patients swallowing ability

A patients neck dissection surgery resulted in damage to the patients superior laryngeal nerve. What area of assessment should the nurse consequently prioritize? A) The patients swallowing ability B) The patients ability to speak C) The patients management of secretions D) The patients airway patency

B) Nontunneled central catheter

A patients physician has determined that for the next 3 to 4 weeks the patient will require parenteral nutrition (PN). The nurse should anticipate the placement of what type of venous access device? A) Peripheral catheter B) Nontunneled central catheter C) Implantable port D) Tunneled central catheter

ACD

A patients physician has ordered a liver panel in response to the patients development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply. A) Alanine aminotransferase (ALT) B) C-reactive protein (CRP) C) Gamma-glutamyl transferase (GGT) D) Aspartate aminotransferase (AST) E) B-type natriuretic peptide (BNP)

A

A school nurse is educating a group of adolescent girls about rape and sexual assault. The nurse evaluates the students' understanding when they report which of the following as a high-risk factor regarding the incidence of rape? A) The highest incidence of rape occurs in adolescents and young adult women. B) Most rapes are committed by strangers. C) Most rapes are random acts of violence. D) A victim is at highest risk in unfamiliar neighborhoods.

sympathetic

A threatening event activates the _______ nervous system for Fight or flight

exercise

A universal health promotion strategy that strengthens the musculoskeletal system and improves all body systems is

No-suicide contract/no-harm contract

A written contract in which the patient agrees not to harm himself or herself but to take an alternative action if feeling suicidal (e.g. talk to staff, call a crisis hotline).

A nurse is leading a medication education group for patients with depression. A patient states he has read that herbal treatments are just as effective as prescription medications. The best response is, A) ìWhen studies are published they can be trusted to be accurate.î B) ìWe need to look at the research very closely to see how reliable the studies are.î C) ìYour prescribed medication is the best for your condition, so you should not read those studies.î D) ìSwitching medications will alter the course of your illness. It is not advised.î

B

An abnormality of which of the following structures of the cerebrum would be associated with schizophrenia? A) Parietal lobes B) Frontal lobe C) Occipital lobe D) Temporal lobes

B

The appropriate action for a student nurse who says the wrong thing is to A) pretend that the student nurse did not say it. B) restate it by saying, ìThat didn't come out right. What I meant was...î C) state that it was a joke. D) ignore the error, since no one is perfect.

B

A teenage patient defies the nurse's repeated requests to turn off the video game and go to sleep. The teen says angrily, ìYou sound just like my mother at home!î and continues to play the video game. The nurse understands that this statement likely indicates A) the need of stricter discipline at home. B) early signs of oppositional defiant disorder. C) viewing the nurse as her mother. D) expression of developing autonomy.

C

The nurse understands that crises are self-limiting. This implies that upon evaluation of crisis intervention, the nurse should assess for which outcome? A) The patient will identify possible causes for the crisis. B) The patient will discover a new sense of self-sufficiency in coping. C) The patient will resume the precrisis level of functioning. D) The patient will express anger regarding the crisis event.

C

The primary goal of a psychiatric rehabilitation program is to promote A) return to prior level of functioning. B) medication compliance. C) complete recovery from mental illness. D) stabilization and management of symptoms.

C

Which is a positive aspect of treating clients with mental illness in a community-based care? A) ìYou will not be allowed to go out with your friends while in the program.î B) ìYou will have to have supervision when you want to go anywhere else in the community.î C) ìYou will be able to live in your own home while you still see a therapist regularly.î D) ìYou will have someone in your home at all times to ask questions if you have any concerns.î

C

The absorption into the bloodstream of nutrient molecules produced by digestion

The nurse is providing health education to a client with a gastrointestinal disorder. What should the nurse describe as a major function of the GI tract?

C) Lying on the left side with legs drawn toward the chest

The nurse is providing health education to a patient scheduled for a colonoscopy. The nurse should explain that she will be placed in what position during this diagnostic test? A) In a knee-chest position (lithotomy position) B) Lying prone with legs drawn toward the chest C) Lying on the left side with legs drawn toward the chest D) In a prone position with two pillows elevating the buttocks

Send the client for a chest x-ray.

The nurse is participating in the care of a client who had a peripherally inserted central catheter (PICC) placed in the right arm. After catheter placement, the nurse should complete which action?

A

The nurse is teaching a client with schizoid personality to function more comfortably with others in the community. Which nursing intervention would be effective to improve the client's social skills? A) Teach the client to make necessary requests in writing or over the phone. B) Accompany the client during initial interactions in the community. C) Suppress the display of any unusual behaviors in public. D) Assist in developing an explanation for bizarre behaviors to offer to others in the community.

C

The nurse is teaching about postoperative wound care. As the wound is uncovered, the client begins mumbling, breathing rapidly, and trying to get out of bed, and the client does not respond when the nurse calls his name. Which of the following should be the nurse's first action? A) Ask the client to describe his feelings. B) Proceed with wound care quickly. C) Replace the dressing on the wound. D) Get the assistance of another nurse.

The client will change positions frequently throughout the procedure.

The nurse is teaching the client about the upcoming endoscopic retrograde cholangiopancreatography (ERCP). Although the nurse instructs on several pertinent points of care, which is emphasized?

D

The nurse is working in the emergency department with a woman who was raped 1 hour ago. Which of the following is most important for the nurse to remember when planning care? A) The client should set aside any angry feelings until physical care is completed. B) Evidence collection according to procedures is not as important as treating the client's injuries. C) The nurse will need to make decisions for this client. D) The woman may feel threatened by some of the procedures.

D

The nurse is working with a client at the battered women's shelter who is in a violent and abusive relationship. The client is considering a separation and asks the nurse, ìWhat do you think about that?î Which is the best response by the nurse? A) ìBatterers never change, so it would be best for you to leave.î B) ìIf you don't leave, he'll think you're going to continue to endure his abuse.î C) ìIf you leave, maybe he'll see that he has to change his behavior.î D) ìYou may be in more physical danger after you leave him.î

A

Which of the following theories about anxiety is based upon intrapsychic theories? A) A person's innate anxiety is the stimulus for behavior. B) Anxiety is generated from problems in interpersonal relationships. C) A nurse can help the client to achieve health by attending to interpersonal and physiologic needs. D) Anxiety is learned through experiences.

Compression

Which of the following type of fracture is associated with osteoporosis?

Fear

Which of the following underlying emotions is commonly seen in avoidant personality disorder? A. depression B. Fear C. Guilt D. insecurity

Diet soda

Which of the following would be considered a "free" item from the exchange list?

B

Which of the following would be key points for the nurse to remember when working with persons who are suffering from anxiety disorders? A) It is important for the nurse to ìfixî the client's problems. B) Remember to practice techniques to manage stress and anxiety in your own life. C) If you have any uncomfortable feelings, do not tell anyone about them. D) Remember that only people who suffer from anxiety disorders have stress that can interfere with daily life and work.

communited

a fracture in which bone has splintered into several fragments

green stick

a fracture in which one side of a bone is broken and the other side is bent

D

The nurse knows that which one of the following statements is true about stress and anxiety? A) All people handle stress in the same way. B) Stress is a person's reaction to anxiety. C) Anxiety occurs when a person has trouble dealing with life situations, problems, and goals. D) Stress is the wear and tear that life causes on the body.

D

The nurse teaches an antisocial client to take a time-out in his room when challenged by another person instigating an argument. What is the main reason for the time-out? A) It allows time for the instigator to leave the area. B) It allows adequate space between the client and the instigating individual. C) It prevents the client from experiencing negative consequences of behavior. D) It allows an opportunity for the client to regain control of emotions.

B

The nursing instructor is conducting a preconference with a group of nursing students on a psychiatric unit. Which statement made by a student reflects the greatest barrier to being able to provide professional care to the client who is suicidal? A) ìI just don't understand why anyone would want to kill themselves.î B) ìI think suicide is wrong and selfish.î C) ìI get frustrated when my client negates all the positives I try to point out.î D) ìI can see how much my client is hurting inside.î

B

The nursing student answers the test item correctly when identifying which one of the following statements is true? A) Anxiety and fear are the same. B) Anxiety is unavoidable. C) Anxiety is always harmful. D) Fear is feeling threatened by an unknown entity.

B

The nursing student understands correctly when identifying which objective is appropriate for all clients with anxiety disorders? A) The client will experience reduced anxiety and accept the fact that underlying conflicts cannot be treated. B) The client will experience reduced anxiety and develop alternative responses to anxiety-provoking situations. C) The client will experience reduced anxiety and learn to control primitive impulses. D) The client will experience reduced anxiety and strive for insight through psychoanalysis.

C

The pediatric nurse is caring for a 15-month-old child recently admitted to the hospital for a fractured femur. Which of the following data obtained during the assessment would raise the nurse's suspicion that the child has suffered physical abuse? A) The parents appearing overprotective of the child B) Bruises over the child's bony prominences C) The injury occurring several days before the parents sought treatment D) Both parents reporting the exact same details pertaining to the injurious event

ACE

Which of the following statements about anger, hostility and aggression are accurate? Select all that apply. A) Anger is an emotional response to a real or perceived provocation. B) Hostility stimulates the sympathetic nervous system. C) Physical aggression involves harming other persons or property. D) Anger, hostility, and physical aggression are normal human emotions. E) Hostility is also referred to as verbal aggression. F) Physical aggression often progresses to hostility.

A

Which of the following statements about the assessment of persons with anxiety and anxiety disorders is most accurate? A) When an elder person has an onset of anxiety for the first time in his or her life, it is possible that the anxiety is associated with another condition. B) Panic attacks are the most common late-life anxiety disorders. C) An elder person with anxiety may be experiencing ruminative thoughts. D) Agoraphobia that occurs in late life may be related to trauma experienced or anticipated.

D

Which of the following statements about the crisis phase of aggression when the client becomes physically aggressive is true? A) All staff should act to take charge of the situation. B) The client must be restrained or sedated at once. C) Staff should avoid communicating with the client. D) Four to six trained staff members are needed to restrain.

ACDF

Which of the following statements about the use of defense mechanisms in persons with anxiety disorders are accurate? Select all that apply. A) Defense mechanisms are a human's attempt to reduce anxiety. B) Persons are usually aware when they are using defense mechanisms. C) Defense mechanisms can be harmful when overused. D) Defense mechanisms are cognitive distortions. E) The use of defense mechanisms should be avoided. F) Defense mechanisms can control the awareness of anxiety.

A history of diabetes

A client is scheduled for a surgical procedure. When planning the client's care, the nurse should consider that which of the following conditions will increase the client's risk of complications after surgery?

0.45% NaCl

A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering?

vasopressin

(antidiuretic hormone) hormone released by posterior pituitary; raises blood pressure and enables kidneys to conserve water

Kubler-Ross stages of grief

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance What is this?

Normal BMI range

18.5-24.9

A patient reports a pattern of being suspicious and mistrusting of others, causing difficulty in sustaining lasting relationships. Which stage according to Erikson's psychosocial development was not successfully completed? A) Trust B) Autonomy C) Initiative D) Industry

A

Phosphate

2.5-4.5

Which type of psychiatric rehabilitation relies on intentional communities and rehabilitation alliances? A) Clubhouse model B) Assertive community treatment C) Group homes D) Respite housing

A

Bicarb

25-29

Overweight BMI

25-29.9

Potassium

3.5-5.0

Obesity BMI

30 or greater

Performing guided imagery Putting on soothing music Changing the client's position

A client who is receiving the maximum levels of pain medication for postoperative recovery asks the nurse if there are other measures that the nurse can employ to ease pain. Which of the following strategies might the nurse employ? Select all that apply.

Eustress

A positive stress that energizes a person and helps a person reach a goal

Myocardial hypotrophy__, ____decreased pacemaker cells___, and _ valvular stenosis

Age-related changes reduce the efficiency of the cardiovascular system. These changes include which result in a decreased stroke volume

dissociative amnesia

Dissociative disorder characterized by the sudden and extensive inability to recall important personal information, usually of a traumatic or stressful nature.

Beta cells

Insulin is secreted by which of the following types of cells?

regulates serum calcium levels

Parathormone

Glutamate

Results in neurotoxicity if levels are too high

Shortened, adducted, and externally rotated

What assessment findings of the leg are consistent with a fracture of the femoral neck?

lithium

a client with a labile mood May benefit from _________ or another mood stabilizer

fear

a cognitive response to something threatening

exophthalmos

abnormal protrusion of the eyeballs

inhibits bone reabsorption

calcitonin

the relaxed muscle

can contribute to urinary incontinence, especially when laughing, coughing, and sneezing.

panic disorder

composed of discrete episodesof panic attacks, that is, 15 to 30 minutes of Rapid intense, escalating anxiety in which the person experiences great emotional fear as well as physiological discomfort

alexithymia

difficulty identifying and expressing feelings

Avoidance

d/c activities that might trigger an attack (anything that causes anxiety)

Japanese Americans

death as life passage; bathing with warm water and dressing in white kimono after purification rites

knock knees

genu valgum

euthyroid

normal thyroid function

Cluster A

paranoid, schizoid, schizotypal

oliguria

urine output less than 400 ml/day

complicated grief

a person has a prolonged or significantly difficult time moving forward after a loss

intellectual disability

(formerly referred to as mental retardation) a condition of limited mental ability, indicated by an intelligence score of 70 or below and difficulty in adapting to the demands of life; varies from mild to profound.

SSRI side effects

*BAD SSRI* B - Body weight increase; A - Anxiety/Agitation; D - Dizziness; Dry mouth S - Serotonin syndrome; S - Stimulated CNS; R - Reproductive/Sexual dysfunction I - Insomnia;

spiritual responses

- Strengthening of a person's spiritual beliefs - Weakening of a person's spiritual beliefs - Causing questions as to the meaning of life and death, beliefs, and values

Magnesium

1.3-2.3

B

A female client with borderline personality was formerly cooperative with the treatment regimen. Suddenly, the client believes the staff is working against her and is refusing all interaction and participation in treatment. The nurse feels very frustrated by this client's behavior. What is the best action for the nurse to take regarding personal frustration with this client? A) Discuss the feelings of frustration with the client in a one-to-one interaction. B) Discuss the frustration with a colleague or supervisor in a private setting. C) Set aside the frustration and focus on reassessing the client's needs. D) Research the client's diagnosis further to better understand the client's behaviors.

B) Below the right nipple

A nurse is caring for a patient with biliary colic and is aware that the patient may experience referred abdominal pain. Where would the nurse most likely expect this patient to experience referred pain? A) Midline near the umbilicus B) Below the right nipple C) Left groin area D) Right lower abdominal quadrant

Impulsivity

act without thinking

C) Signs of neurovascular compromise

An elderly patients hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurses priority assessment? A) The presence of leg shortening B) The patients complaints of pain C) Signs of neurovascular compromise D) The presence of internal or external rotation

disability

Chronic conditions, many of which are preventable or treatable, are the major causes of _______ and pain among older adults.

Adrenal

Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency?

3 times a week

During a class on exercise for clients with diabetes mellitus, a client asks the nurse educator how often to exercise. To meet the goals of planned exercise, the nurse educator should advise the client to exercise:

decrease in hormonal levels

During a client education session, the nurse describes the mechanism of hormone level maintenance. What causes most hormones to be secreted?

Bowel perforation

During a colonoscopy with moderate sedation, the patient groans with obvious discomfort and begins bleeding from the rectum. The patient is diaphoretic and has an increase in abdominal girth from distention. What complication of this procedure is the nurse aware may be occurring?

Physiologic loss

Ex: amputation of limb, a mastectomy or hysterectomy, or loss of mobility.

Increases lean muscle mass Increases resting metabolic rate as muscle size increases Decreases total cholesterol Increases glucose uptake by body muscles

Exercise lowers blood glucose levels. Which of the following are the physiologic reasons that explain this statement. Select all that apply.

7

For the client who is taking aspirin, it is important to stop taking this medication at least how many day(s) before surgery?

hypocalcemia.

For the first 72 hours after thyroidectomy surgery, a nurse should assess a client for Chvostek's sign and Trousseau's sign because they indicate:

Serum glycosylated hemoglobin (Hb A1c)

Laboratory studies indicate a client's blood glucose level is 185 mg/dl. Two hours have passed since the client ate breakfast. Which test would yield the most conclusive diagnostic information about the client's glucose use?

SAD PERSONS scale

Sex Age Depression Previous Attempts Ethanol or Other Drugs Rational Thinking Loss Social Supports Lacking Organized Plan No Spouse Sickness

schizophrenia

Prenatal infections may impact the developing brain of the fetus, giving rise to a proposed theory that inflammation may casually contribute to the patho of ____________________

B) Keeping the head of the bed slightly elevated

Results of a patient barium swallow suggest that the patient has GERD. The nurse is planning health education to address the patients knowledge of this new diagnosis. Which of the following should the nurse encourage? A) Eating several small meals daily rather than 3 larger meals B) Keeping the head of the bed slightly elevated C) Drinking carbonated mineral water rather than soft drinks D) Avoiding food or fluid intake after 6:00 p.m.

Buspar side effects

S/E: dizziness, drowsiness, nervousness/excitement, fatigue, headache, nausea, vomiting, tachycardia, clamminess, sweating

Consider potential effects on the client's mobility when selecting a site.

The physician has prescribed a peripheral IV to be inserted before the client goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?

An elevated systolic blood pressure Muscular fatigability Weight loss. Manifestations of hyperthyroidism include an increased appetite and dietary intake, weight loss, fatigability and weakness (difficulty in climbing stairs and rising from a chair), amenorrhea, and changes in bowel function. Atrial fibrillation occurs in 15% of in older adult patients with new-onset hyperthyroidism (Porth & Matfin, 2009). Cardiac effects may include sinus tachycardia or dysrhythmias, increased pulse pressure, and palpitations. These patients are often emotionally hyperexcitable, irritable, and apprehensive; they cannot sit quietly; they suffer from palpitations; and their pulse is abnormally rapid at rest as well as on exertion. They tolerate heat poorly and perspire unusually freely.

What clinical manifestations does the nurse recognize would be associated with a diagnosis of hyperthyroidism? Select all that apply.

Accuracy of the dosage

When administering insulin to a client with type 1 diabetes, which of the following would be most important for the nurse to keep in mind?

Chronic irritation of the esophagus is a known risk factor.

Which is an accurate statement regarding cancer of the esophagus?

postural hypotension

Which is an age-related change associated with the nervous system?

Lispro

Which type of insulin acts most quickly?

stage 2 hepatic encephalopathy

increase drowsiness, disorientation, inappropriate behavior, mood swings, agitation

Atomoxetine (Strattera)

increases concentration of norepinephrine to increase attention span and reduce impulsive behavior and hyperactivity IE: Suicidal Thoughts

osteomyelitis

infection of the bone is known as what

thyroiditis

inflammation of the thyroid gland; may lead to chronic hypothyroidism or may resolve spontaneously

propranolol

inhibits the sympathetic nervous system by blocking receptors

SSRIs (selective serotonin reuptake inhibitors)

end in [pram], [ine] citalopram [Celexa]; escitalopram [Lexapro]; fluoxetine [Prozac]; paroxetine [Paxil]

Purging

engaging in behaviors such as vomiting or misusing laxatives to rid the body of food

Suicide

the intentional killing of oneself

Reduced or absent bile as a result of obstruction impacts digestion.

A client is treated for gastrointestinal problems related to chronic cholecystitis. What pathophysiological process related to cholecystitis does the nurse understand is the reason behind the client's GI problems?

Loss of bone density

An elderly female client has been taking prednisone for breathing problems for many years. The nurse notes that the client's current height is 64 inches. Two years ago, her height was 66 inches. The nurse assesses this loss in height is most likely the result of

A client made threats to harm his parents if they come too close to him. The parents called 911, and the client is now held involuntarily for a psychiatric evaluation. During this time of involuntary admission, the client retains all client rights except for which of the following? A) Confidentiality B) Right to freedom C) Periodic treatment review D) Choice of providers

B

Parotid

A patient reports an inflamed salivary gland below the right ear. The nurse documents probable inflammation of which gland?

A

Upon admission, a client with a personality disorder identified the following as areas of concern for which the client would like help. According to studies, which will most likely be addressed by the health-care team? A) Psychological distress B) Self-care C) Sexual expression D) Budgeting

Rigorous control of the client's blood pressure and serum lipid levels

After a sudden decline in cognition, a 77-year-old man who has been diagnosed with vascular dementia is receiving care in his home. To reduce this man's risk of future infarcts, what action should the nurse most strongly encourage?

D

After an angry outburst, the client is tearful and remorseful. Which statement by the nurse would be most supportive? A) ìYou still need to work on your problem-solving skills.î B) ìI will not allow you to get that angry again.' C) ìYou should not have let your anger buildup like you did.î D) ìWhat could you have done when you first started to feel angry?î

Placing a trapeze on the bed Ensuring that the weights are hanging freely Assessing the client's alignment in the bed Frequently assessing pain level

Which actions by the nurse demonstrate an understanding of caring for a client in traction? Select all that apply.

A nursing supervisor reprimands an employee for being chronically late for work. If the employee handles the reprimand using the defense mechanism of displacement, he would most likely do which of the following? A) Argue with the supervisor that he is usually on time B) Make a special effort to be on time tomorrow C) Tell fellow employees that the supervisor is picking on him D) Tell the unit housekeeper that his work is sloppy

D

Notify the surgeon that the client took warfarin the day before surgery.

During the admission history the client reports to the nurse of taking the usual dose of warfarin the previous day. What is an appropriate nursing action?

good sleep hygiene, cognitive remediation and memory enhancement treatment of depression and treatment of anxiety MMSE used to assess

Name 3 nursing interventions that can be used to help older adults with learning and memory

dementia occurs between ages 50 to 70/ delirium can occur at any age dementia is a slow gradual onset/ delirium is a rapid onset dementia the sleep wake cycle is often impaired with increased wandering and agitation at night/ delirium takes brief naps throughout the day and night

Name at least 3 differences between delirium and dementia with regard to clinical manifestations

100

Once digested, what percentage of carbohydrates is converted to glucose?

Review the scheduled procedure, site, and client.

Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out?

self-efficacy

One's belief in his or her own ability. different people have different reactions to similar situations

General Adaptation System

Seyle's concept that the body responds to stress with alarm, resistance and exhaustion

sodium, potassium, calcium, magnesium and hydrogen ions

The major cations in body fluid are:

Regular

The nurse is administering an insulin drip to a patient in ketoacidosis. What insulin does the nurse know is the only one that can be used intravenously?

C) The absorption into the bloodstream of nutrient molecules produced by digestion

The physiology instructor is discussing the GI system with the pre-nursing class. What should the instructor describe as a major function of the GI tract? A) The breakdown of food particles into cell form for digestion B) The maintenance of fluid and acid-base balance C) The absorption into the bloodstream of nutrient molecules produced by digestion D) The control of absorption and elimination of electrolytes

Inspection

When examining the abdomen of a client with reports of nausea and vomiting, what would the nurse do first?

purging

compensatory behaviors designed to eliminate food by means of self-induced vomiting

diabetes insupidus

condition in which abnormally large volumes of dilute urine are excreted as a result of deficient production of vasopressin

pheochromocytoma

adrenal medulla tumor

Rett's disorder

affects girls almost exclusively normal early growth and development followed by slowing of development (slow brain and head growth, low cognitive ability) loss of purposeful use of the hands (distinctive hand movements) Problems with walking seizures

stimulates reabsorption of sodium and elimination of potassium

aldosterone

cognitive therapy

alter cognitive distortions and develop new thinking patterns and more effective ways to respond to stress

alkalosis

an acid-base imbalance characterized by a reduction in H+ concentration (increased blood pH) (A high arterial pH with increased bicarbonate concentration is called metabolic alkalosis; a high arterial pH due to reduced PCO2 is called respiratory alkalosis.)

Acidosis

an acid-base imbalance characterized by an increase in H+ concentration (decreased blood pH) (A low arterial pH due to reduced bicarbonate concentration is called metabolic acidosis; a low arterial pH due to increased PCO2 is called respiratory acidosis.)

active transport

an acid-base imbalance characterized by an increase in H+ concentration (decreased blood pH) (A low arterial pH due to reduced bicarbonate concentration is called metabolic acidosis; a low arterial pH due to increased PCO2 is called respiratory acidosis.)

bulimia nervosa

an eating disorder characterized by episodes of overeating, usually of high-calorie foods, followed by vomiting, laxative use, fasting, or excessive exercise

Cluster B

antisocial, borderline, histrionic, narcissistic

freudian

anxiety is a psychological response that causes physical symptoms

Fluoxetine

approved for treating bulimia, reduces binge eating and purging behaviors, reduces relapse and improves eating attitudes.

psychotropic medications

are usually tapered off instead of stopped abruptly because of possible rebound or withdrawal

Cluster C

avoidant, dependent, obsessive-compulsive

acetylcholine

controls sleep and wakefulness cycle; signals muscles to become alert. Used in patients with Alzheimers

systematic desensitization

behavior technique used to treat phobias, in which a client is asked to make a list of ordered fears and taught to relax while concentrating on those fears If they are afraid of flying 1) go to the airport 2) next session go to the gate 3) touch the plan 4) next session, sit in the seat and buckle up

pica

eating non food items

right sided CHF

edema and edema in the lower extremities means:

Group and Family Therapy

effective when shared experiences lend support to the patient

hepatocellular jaundice

caused by the inability of damaged liver cells to clear normal amounts of bili from the blood Mild or severlly ill lack of appetite/N+V/weight loss Tired/weakness Flu like symptoms, headache, chills, fever infection

non-viral hepatitis

certain chemicals have toxic effects on the liver and produce acute liver cell necrosis and toxic hepatitis when inhaled, injected parenerally, or taken by mouth. The chemicals most commonly implicated in this disease are carbon tetrachloride, phosphorus, chloroform, and gold compounds

loss of security

change in relationship, such as birth, marriage, divorce, illness or death what type of loss is this?

addisons disease

chronic adrenocortical insufficiency due to inadequate adrenal cortex function

Generalized Anxiety Disorder (GAD)

chronic excessive worry accompanied by three or more of the following symptoms: restlessness, fatigue, concentration problems/ mind going blank, irritability, muscle tension, and sleep disturbance

Derealization

client senses that events are not real, when, in fact, they are

one on one supervision

clients are in direct sight of and no more than 2-3 feet away from the staff member for all activities, including going to the bathroom

B

clients with schizotypal personality disorder are most likely to benefit from which of the following nursing interventions A. cognitive restructuring technique B. improving Community functioning C. providing emotional support, D. teaching social skills

defense mechanism aka ego defense mechanism

cognitive distortions that a person uses unconsciously to maintain a sense of being in control of situation, to lessen discomfort, and to deal with stress

geriatric syndromes

common conditions found in older adults that tend to be multifactorial and do not fall under discrete disease categories; these conditions include falls, delirium, frailty, dizziness, and urinary incontinence

anxiety

emotional response to an external stressor

African Americans

deceased viewed in church before burial in Cemetery; public prayers, black clothing, decreased social activities

African Americans

deceased viewed in church before burial in cemetery; public prayers, black clothing, decreased social activities

individual psychotherapy

discover reason for anxiety; work on understanding them and managing the response

Dissociative Identity Disorder

disorder occurring when a person seems to have two or more distinct personalities within one body may also have dissociative amnesia ex: may forget that they brought groceries or forget how they broke their arm

somatoform disorders

disorders characterized by physical symptoms for which no known physical cause exists

antisocial personality disorder

disregard for and violation of the rights of others, rules and laws Nursing Interventions: Limit setting; confrontation; teach client to solve problems effectively and manage emotions of anger or frustra

EDNOS

eating disorders not otherwise specified - people with combinations of behaviors seen certain eating disorders

Reflects the amount of glucose stored in hemoglobin over past several months.

The nurse is explaining glycosylated hemoglobin testing to a diabetic client. Which of the following provides the best reason for this order?

A decrease in muscle mass and bone density

The nurse is planning an educational event for the nurses on a subacute medical unit on the topic of normal, age-related physiologic changes. What phenomenon should the nurse address?

ABD Paranoid, antisocial, and narcissistic personalities need a serious, straightforward approach that includes limit setting and a matter-of-fact approach. Schizotypal personalities need to improve community functioning through social skills training. Avoidant personalities require support and reassurance to promote self-esteem.

The nurse is planning the type of approach that will be most effective in developing a therapeutic relationship with the client. The nurse should use a matter-of-fact approach with clients with which types of personality disorders? Select all that apply. A) Paranoid B) Antisocial C) Schizotypal D) Narcissistic E) Avoidant

"Are you wearing any jewelry?" "Have you removed your hearing aid?" "Do you have a pacemaker?"

The nurse is preparing the client with a right neck mass for magnetic resonance imaging (MRI). Which question should the nurse ask? Select all that apply.

B) The patient is agitated.

The nurse is preparing to insert a patients ordered NG tube. What factor should the nurse recognize as a risk for incorrect placement? A) The patient is obese and has a short neck. B) The patient is agitated. C) The patient has a history of gastroesophageal reflux disease (GERD). D) The patient is being treated for pneumonia.

Explain the risks of flexion contracture to the client.

The nurse is providing care for a client who has had a below-the-knee amputation. The nurse enters the client's room and finds the client resting in bed with his residual limb supported on pillow. What is the nurse's most appropriate action?

The client must fast for 8 hours before the examination. The throat will be sprayed with a local anesthetic. After gastroscopy, the client cannot eat or drink until the gag reflex returns (1 to 2 hours).

The nurse is providing instructions to a client scheduled for a gastroscopy. What should the nurse be sure to include in the instructions? Select all that apply.

Gigantism

The nurse is reviewing a client's history which reveals that the client has had an over secretion of growth hormone (GH) that occurred before puberty. The nurse interprets this as which of the following?

Smoking history of 20 years Male gender Previous treatment for gastroesophageal reflux disease

The nurse is reviewing the chart of a client with swallowing problems. Which factors would raise suspicion that the client has cancer of the esophagus? Select all that apply.

A

The nurse is teaching a client with paranoid personality disorder to validate ideas with another person before taking action on him. Which is the best rationale for this intervention? A) It will assist the client to start basing decisions and actions on reality. B) It will help the client understand the origins of his or her paranoid thinking. C) It will help the client learn to trust other people. D) It will teach the client to differentiate when his or her suspicions are true.

Flush with 10 mL of water.

The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take?

A

The nurse is working with a client who lost her youngest child 2 months ago. When the nurse approaches, the client, the client yells, ìI don't want to talk to you. You have no idea what it's like to lose a child!î The nurse bases her response to the client on the understanding of which of the following? A) Hostility is a common behavioral response to grief. B) It is too soon after the loss to empathize with the client. C) Personality traits such as aggressiveness are exaggerated during the grief process. D) The nurse may have nonverbally indicated a judgmental attitude toward the client.

D

The nurse is working with a woman who lost her partner nearly 3 weeks prior. The woman has recently become less emotional and expressed that few things in her life have meaning right now. Which response by the nurse is most appropriate at this time? A) ìI am concerned. You are starting to show signs of ineffective grieving.î B) ìYou must feel some anger. It is alright to let that out.î C) ìLet's look at the things in your life that you still enjoy.î D) ìYou are just starting to accept that this loss is real.î

Rovsing sign

The nurse observes the physician palpating the abdomen of a client that is suspected of having acute appendicitis. When the abdomen is pressed in the left lower quadrant the client complains of pain on the right side. What does the nurse understand this assessment technique is referred to?

D

The nurse observes two clients in the day room arguing. One client runs into the corner and huddles while the other follows and continues with verbal abuse. Which is the best action by the nurse? A) Take an authoritatively step between the two clients. B) Comfort the client huddled in the corner. C) Directly address both clients and ask what is going on. D) Engage the attention of the client who is still yelling and ask what is happening.

Do not eat and drink at the same time. Drink plenty of water, from 90 minutes after each meal to 15 minutes before each meal. Avoid fruit drinks and soda.

The nurse reviews dietary guidelines with a client who had a gastric banding. Which teaching points are included? Select all that apply.

ABCE

The nurse understands that which biologic factors may influence the development of an eating disorder? Select all that apply. A) Family history of eating disorders B) Dysfunction of the hypothalamus C) Norepinephrine imbalances D) First-degree relatives with psychotic disorder E) Decreased serotonin levels

A) Increased warmth of the calf

The nursing care plan for a patient in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a patients lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)? A) Increased warmth of the calf B) Decreased circumference of the calf C) Loss of sensation to the calf D) Pale-appearing calf

macular degeneration

The primary cause of age-related vision loss in the elderly is

Hypoxemia and hypercapnia.

The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of:

Catheter hub

The primary source of microorganisms for catheter-related infections are the skin and which of the following?

C) Lordosis

The results of a nurses musculoskeletal examination show an increase in the lumbar curvature of the spine. The nurse should recognize the presence of what health problem? A) Osteoporosis B) Kyphosis C) Lordosis D) Scoliosis

A) Organic fruit juice

The school nurse is planning a health fair for a group of fifth graders and dental health is one topic that the nurse plans to address. What would be most likely to increase the risk of tooth decay? A) Organic fruit juice B) Roasted nuts C) Red meat that is high in fat D) Cheddar cheese

C

The student nurse correctly identifies that according to Selye (1956, 1974), which stage of reaction to stress stimulates the body to send messages from the hypothalamus to the glands and organs to prepare for potential defense needs? A) Resistance B) Exhaustion C) Alarm reaction D) Autonomic

Psychoimmunology

The study of the interrelation of the brain, behavior, and the immune system.

dissociative fugue

The sudden loss of memory for one's personal history, accompanied by an abrupt departure from home and the assumption of a new identity

Restrain the client.

The surgical client has been given general anesthesia. The nurse recognizes that the client is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage?

Peripheral pulses palpable

The surgical client is at risk for injury related to positioning. Which of the following clinical manifestations exhibited by the client would indicate the goal was met of avoiding injury?

vasopressin and oxytocin

The two major hormones secreted by the posterior pituitary

stay with the client and encourage him to eat.

To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should:

Weight loss

What is a major concern for the nurse when caring for a patient with chronic pancreatitis?

An adrenal adenoma

What is the most common cause of hyperaldosteronism?

sudden, sustained abdominal pain abdominal distention

What symptoms of perforation might the nurse observe in a client with an intestinal obstruction? Select all that apply.

On the second or third day

When caring for a patient with alcoholism, when should the nurse assess for symptoms of alcoholic withdrawal?

Preadmission visit

When is the ideal time to discuss preoperative teaching

ACD

When performing a respiratory assessment on an older adult patient, what changes associated with aging does the nurse expect to find? Select all that apply. A) Increased residual volume B) Decreased residual volume C) Loss of elastic tissue surrounding the alveoli D) Reduced vital capacity E) Decrease pulmonary resistance

D

When planning care for a client with passive-aggressive personality disorder, the nurse will need to include interventions for which behavior? A) Avoidance of anxiety-provoking situations B) Compulsive needs for perfection and praise C) Dependence on others for decisions D) Procrastination and intentional inefficiency

High blood sugar decreases blood circulation to nerves.

When the nurse inspects the feet of a diabetic, a tack is found sticking in the sole of one foot. The client denies feeling anything unusual in the foot. Which is the best rationale for this finding?

Hypoglycemia

When the nurse is caring for a patient with type 1 diabetes, what clinical manifestation would be a priority to closely monitor?

Assess the client's heart rhythm and nail beds.

When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation via the O₂ saturation monitor despite the client's breathing appearing normal, what action should the nurse take first?

Encourage the client to keep a list of medications and review it frequently for updates. Use easy-to-open lids. Provide a written medication schedule.

Which actions by the nurse will assist in promoting an older adult's adherence to medication therapy? Select all that apply.

ABC Limit setting is an effective technique that involves three steps: 1. Stating the behavioral limit (describing the unacceptable behavior) 2. Identifying the consequences if the limit is exceeded 3. Identifying the expected or desired behavior Providing choices and allowing flexibility would be counterproductive as the expectations must be consistent.

Which are important in the limit-setting technique to deal with manipulative behavior? Select all that apply. A) Stating the behavioral limit B) Identifying the consequences if the limit is exceeded C) Identifying the expected or desired behavior D) Providing choices E) Allowing flexibility

Heart disease

Which are leading causes of death among the elderly? Select all that apply.

Stage II decubitus ulcer on coccyx; "No one is able to turn or lift me anymore."

Which assessment finding by the nurse and statement by an older adult would require the nurse to report suspected elder abuse?

Blurred vision

Which clinical manifestation of type 2 diabetes occurs if glucose levels are very high?

Acromegaly

Which disorder results from excessive secretion of somatotropin (growth hormone)?

ABDEF

Which factors may contribute to the frequency of eating disorders in adolescents? Select all that apply. A) Media portrayal of slimness as an ideal B) Body dissatisfaction in adolescent females C) Stress-free existence of adolescents D) Body image disturbance E) Seeking autonomy F) Seeking to develop a unique identity

Client has not consumed food and continues to take insulin or oral antidiabetic medications. Client has not consumed sufficient calories. Client has been exercising more than usual.

Which factors will cause hypoglycemia in a client with diabetes? Select all that apply.

Excessive thirst

Which is a clinical manifestation of diabetes insipidus?

Relaxed perineal muscle

Which is a factor that contributes to urinary incontinence in older female adults?

D

Which is a freudian explanation of the etiology of depression? A) Depression is a reaction to a distressing life experience. B) Depression results from being raised by rejecting or unloving parents. C) Depression results from cognitive distortions. D) Depression is anger turned inward.

decreased cardiac output

Which is an age-related change associated with the cardiovascular system?

decreased gas exchange

Which is an age-related change in the respiratory system?

B

Which is most likely to be the subject of an aggressive attack from a client with mental illness? A) Other people B) The client C) Animals D) Objects

High sugar pulls fluid into the bloodstream, which results in more urine production.

Which is the best nursing explanation for the symptom of polyuria in a client with diabetes mellitus?

ABCD

Which may contribute to a staff person being less effective in dealing with a person who is at increased risk for suicide? Select all that apply. A) Negative societal view of suicide B) Feeling inadequate and anxious about suicide and/or his or her own mortality C) Having personally considered suicide but decided against it and not having dealt with the associated anxiety D) Being unaware of his or her own feelings and beliefs about suicide E) Implementing nursing interventions to decrease the risk of suicide

Serotonin

Which neurotransmitter is implicated in depression?

Risk for perioperative positioning injury related to positioning in the OR

Which nursing diagnosis is most important for the client who is undergoing a surgical procedure expected to last several hours?

AC

Which nursing interventions are most important in a plan of care for a client with histrionic personality disorder? Select all that apply. A) Teach social skills. B) Assist the client to eliminate passive behavior. C) Provide factual feedback about behavior. D) Try to meet the client's needs for attention. E) Acceptance of the behavior.

ABC

Which of the following are eventual outcomes of the emotional dimension of grieving? Select all that apply. A) The survivor begins to reestablish a sense of personal identity, direction, and purpose for living. B) The survivor begins to gain independence and confidence. C) The survivor develops new ways of managing life and new relationships. D) The survivor's life returns to the same state as it was before the loss. E) The survivor forgets about the loss.

BC

Which of the following are interpersonal theories regarding the etiologies of major anxiety disorders? Select all that apply. A) Sigmund Freud's theory B) Henry Stack Sullivan's theory C) Hildegard Peplau's theory D) Pavlov's theory

ABE

Which of the following are reasons that the nurse must understand why and how anxiety behaviors work? Select all that apply. A) To provide better care for the client B) To help understand the role anxiety plays in performing nursing responsibilities C) To help the nurse to mask his or her own feelings of anxiety D) So the nurse can identify that his or her own needs are more important than the clients E) To help nurses to function at a high level

ABC

Which of the following are typical characteristics of the perpetrator of intimate partner abuse? Select all that apply. A) The perpetrator often believes that the partner is his own property. B) The perpetrator is often irrationally jealous, even of his own children. C) The perpetrator is emotionally immature and needy. D) The perpetrator respects his partner. E) The perpetrator is intimidated by his partner.

C

Which of the following behaviors would first alert the school nurse or teacher to suspect sexual abuse in a 7-year-old child? A) The child has a preference for associating with peers, rather than adults. B) The child has learning problems and shyness. C) The child tells sexually explicit stories to peers. D) The child wears dirty and threadbare clothing.

Valsalva maneuver

Which of the following clinical manifestations increase the risk for evisceration in the postoperative client?

Nonunion

Which of the following describes failure of the ends of a fractured bone to unite in normal alignment?

ABC

Which of the following interventions are most effective in managing the environment to reduce or eliminate aggressive behavior? Select all that apply. A) Planning group activities such as playing games B) Scheduling one-to-one interactions with the client C) Providing structure and consistency in the unit D) Avoiding discussions among clients on the unit E) Discouraging clients from negotiating solutions

Elevated blood urea nitrogen (BUN) and creatinine Rapid onset More common in type 1 diabetes

Which of the following is a characteristic of diabetic ketoacidosis (DKA)? Select all that apply.

Pepsin

Which of the following is an enzyme secreted by the gastric mucosa?

D

Which of the following is most important to maintain therapeutic boundaries when working with aggressive clients? A) Encourage clients to express how the nurse can avoid causing emotional irritation. B) Discuss difficult patient care situations with a supervisor. C) Reflect on your actions that may have instigated the client's anger, D) Do not personalize a client's anger

BCDE

Which of the following losses are likely to result in disenfranchised grief? Select all that apply. A) A young adult whose spouse has just died suddenly B) A family whose long-time pet snake has just died C) A nurse who has just witnessed the death of a patient D) A couple who has just experienced pregnancy loss E) The gay lover of a man who just died from AIDS F) The mother and sister of a soldier who was killed in war

ACDE

Which of the following persons are most likely experiencing complicated grieving? Select all that apply. A) The spouse of a person who died 7 years ago and visits the grave several times a day. B) The grandchild of a soldier killed in war who visits the grave once a year on Memorial Day. C) A driver whose spouse and children all died as a result of his driving drunk. D) An adult who insisted for many years that he or she hated his or her deceased parent. E) The parent of a child who died after the having left the child in a car on a hot day.

C

Which of the following terms is used to describe the process by which a person experiences the grief? A) Anticipatory grieving B) Disenfranchised grief C) Bereavement D) Mourning

Erectile dysfunction

Which of the following would the nurse most likely assess in a client with diabetes who is experiencing autonomic neuropathy?

A 65-year-old with renal insufficiency

Which older adult is at highest risk for medication-related toxicity?

D

Which one of the following can be a positive outcome of using defense mechanisms? A) Defense mechanisms can inhibit emotional growth. B) Defense mechanisms can lead to poor problem-solving skills. C) Defense mechanisms can create difficulty with relationships. D) Defense mechanisms can help a person to reduce anxiety.

B

Which psychiatric disorder makes a person most susceptible to anger attacks that do not result in physical aggression? A) Delusions B) Depression C) Dementia D) Delirium

Administer 2 to 3 L of IV fluid rapidly.

Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome?

Acute gallbladder infection

Which would be considered to require an urgent surgical procedure?

C

Which would most likely be a type of behavior that would be manifested by a client who has histrionic personality disorder? A) Insisting that others follow the rules of the unit B) Wondering why others are being friendly to her C) Having a tantrum if not getting enough attention D) Getting others to make decisions for her

Older adults may have cardiac or renal disorders.

Why are IV solutions usually given at a slower rate to older adults?

It takes years to change and no medications specifically treat personality disorders

Why is treatment difficult in clients with personality disorders?

Ciliary action decreases, reducing the cough reflex. Fatty tissue increases, prolonging the effects of anesthesia. Liver size decreases, reducing the metabolism of anesthetics.

Why should the nurse be vigilant with assessment of perioperative risks on the older adult client? Select all that apply.

Antidepressants

Why type of treatment can give clients with depression the energy to act on suicidal ideation?

C) 2 to 3 months

You are caring for a patient who was admitted to have a low-profile gastrostomy device (LPGD) placed. How soon after the original gastrostomy tube placement can an LPGD be placed? A) 2 weeks B) 4 to 6 weeks C) 2 to 3 months D) 4 to 6 months

hyperactivity

a condition characterized by excessive restlessness and movement

attention-deficit/hyperactivity disorder (ADHD)

a disorder characterized by restlessness, inattentiveness, and impulsivity MOST COMMON IN CHILDREN

Decatastrophizing

a technique that involves learning to assess situations realistically rather than always assuming a catastrophe will happen What could happen? Is that likely? Could you survive? But did you die?

flooding

a treatment for phobias in which clients are exposed repeatedly and intensively to a feared object and made to see that it is actually harmless try to complete in 1-2 sessions

Calcium

8.6-10.2

An adolescent on the unit is argumentative with staff and peers. The nurse tells the adolescent, ìArguing is not allowed. One more word and you will have to stay in your room the rest of the day.î The nurse's directive is A) inappropriate; room restriction is not treatment in the least restrictive environment. B) inappropriate; the adolescent should be offered a sedative before room restriction. C) appropriate; room restriction is an effective behavior modification technique. D) appropriate; the adolescent should not have conflicts with others.

A

The nurse would recommend individual therapy for the patient who expresses a desire to A) bring about personal changes. B) gain a sense of belonging. C) develop leadership skills. D) learn more about treatment.

A

"Some possible negative effects include difficulty waking up and slow heart rate."

A client asks the nurse about possible ill effects from general anesthesia. What is the best response by the nurse?

D

A client asks the nurse, ìWhy do I have to go to counseling? Why can't I just take medications?î The best response by the nurse would be, A) ìBoth therapies are effective. You can eventually choose one or the other.î B) ìYou cannot get the full effect of your medications without cognitive therapy as well.î C) ìAs soon as your medications reach therapeutic level, you can omit the therapy.î D) ìMedications combined with therapy help you change how well you function.î

Hemorrhoids

A client asks the nursing assistant for a bedpan. When the client is finished, the nursing assistant notifies the nurse that the client has bright red streaking of blood in the stool. The nurse's assessment should focus on what potential cause?

Cholelithiasis

A client comes to the clinic and informs the nurse that he is there to see the physician for right upper abdominal discomfort, nausea, and frequent belching especially after eating a meal high in fat. What disorder do these symptoms correlate with?

Heart rate over 150 beats per minute

A client develops malignant hyperthermia. What client symptom would the nurse most likely observe as the first indicator of the disorder?

Semi-Fowler with the head supported on two pillows

A client has been admitted to the postsurgical unit following a thyroidectomy. To promote comfort and safety, how should the nurse best position the client?

IV administration of 50% dextrose in water

A client has been brought to the emergency department by paramedics after being found unconscious. The client's Medic Alert bracelet indicates that the client has type 1 diabetes and the client's blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should anticipate what intervention?

Potassium-rich foods

A client is being treated for prolonged diarrhea. Which foods should the nurse encourage the client to consume?

Glycosuria Dehydration Hypernatremia Hyperglycemia

A client is brought to the emergency department by the paramedics. The client is a type 2 diabetic and is experiencing hyperglycemic hyperosmolar syndrome (HHS). The nurse should identify what components of HHS? Select all that apply.

C

A client is clenching his fists and yelling at another client on the unit. He appears to be close to losing control of his anger. Which of the following actions by the nurse is appropriate at this time? A) Clear others out of the immediate area. B) Prepare a PRN sedative. C) Tell the client to stop and take a time-out. D) Alert the security department of an impending aggressive outburst.

Hypertonic solution

A client is experiencing edema in the tissue. What type of intravenous fluid would the nurse suspect as being prescribed?

Enlarged liver size Ascites Hemorrhoids

A client is given a diagnosis of hepatic cirrhosis. The client asks the nurse what findings led to this determination. Which of the following clinical manifestations would the nurse correctly identify? Select all that apply.

Administer oxygen.

A client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first?

floor of the mouth

A client is in the initial stages of oral cancer diagnosis and is frightened about the side effects of treatment and subsequent prognosis. The client has many questions regarding this type of cancer and asks where oral cancer typically occurs. What is the nurse's response?

7:45 AM

A client is receiving insulin lispro at 7:30 AM. The nurse ensures that the client has breakfast by which time?

Allow the client to wear the ring and cover it with tape.

A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take?

A

A client states, ìI will just die if I don't get this job.î The nurse then asks the client, ìWhat will be the worst that will happen if you don't get the job?î The nurse is using this response to A) appraise his situation more realistically. B) assist the client to make alternative plans for the future. C) assess if the client has health problems compounded by stress. D) clarify the client's meaning.

glycosylated hemoglobin level.

A client tells the nurse that she has been working hard for the past 3 months to control her type 2 diabetes with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check

pineal gland; melatonin

A client visits the clinic to seek treatment for disturbed sleep cycles and depressed mood. Which glands and hormones help to regulate sleep cycles and mood?

"I cannot seem to catch my breath." "I have a pins-and-needles sensation in my toes." Dorsiplantar weak and unequal bilaterally T 101.2 degrees F; HR 110; RR 28; pulse oximetry 90%

A client with a fractured femur is admitted to the nursing unit. Which assessment finding requires follow up by the nurse? Select all that apply.

Diarrhea

A client with a gastrojejunostomy is beginning to take solid food. Which finding would lead the nurse to suspect that the client is experiencing dumping syndrome?

Ensure that a large tourniquet is in the room.

A client with a right below-the-knee amputation is being transferred from the postanesthesia care unit to a medical-surgical unit. What is the highest priority nursing intervention by the receiving nurse?

Prepare to remove the cast. Provide support to the injured extremity.

A client with a short arm cast is suspected to have compartment syndrome. What actions should the nurse include in the plan of care? Select all that apply.

diuretics albumin

A client with acute pancreatitis has jaundice with diminished bowel sounds and a tender distended abdomen. Additionally, lab results indicate hypovolemia. What will the physician order to treat the large amount of protein-rich fluid that has been released into the client's tissues and peritoneal cavity? Select all that apply.

Reddened area along the path of the vein Tender area around the insertion site

A client with an intravenous infusion is rubbing his arm. The nurse assesses the site and decides to discontinue the current infusion because of concern that the client has developed phlebitis. Which of the following clinical manifestations would the nurse assess with phlebitis? Select all that apply.

C

A client with antisocial personality disorder is begging to use the phone to call his wife, even though it is against the unit rules. The client begs, ìIt is just this once, and she will be so hurt if I don't call her.î Which would be the most appropriate response by the nurse? A) ìOnly to help your wife, you can call this time.î B) ìI will get in trouble with my supervisor if I let you call.î C) ìYou may not use the phone to call your wife.î D) ìYou cannot call because you need to focus on your recovery while you are here, not your wife.î

Administering diuretics Implementing fluid restrictions Enhancing client positioning

A client with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the client's fluid volume excess? Select all that apply.

Decreased kidney mass Decreased renal blood flow Decreased excretion of potassium

A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. What factors contribute to this phenomenon? Select all that apply.

Hypothyroidism

A group of students are reviewing information about osteoporosis in preparation for a class discussion. The students demonstrate a need for additional review when they state which of the following as a risk factor?

Fear of eating

A nurse cares for a client who is postoperative bariatric surgery and has experienced frequent episodes of dumping syndrome. The client now reports anorexia. What is the primary reason for the client's report of anorexia?

Strategies for avoiding irritating foods and beverages

A nurse is caring for a client hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize?

Support the affected extremity with external supports such as splints.

A nurse is caring for a client with a bone tumor. The nurse is providing education to help the client reduce the risk for pathologic fractures. What should the nurse teach the client?

BCD

A nurse is caring for a patient admitted with a suspected malabsorption disorder. The nurse knows that one of the accessory organs of the digestive system is the pancreas. What digestive enzymes does the pancreas secrete? Select all that apply. A) Pepsin B) Lipase C) Amylase D) Trypsin E) Ptyalin

D) Strategies for avoiding irritating foods and beverages

A nurse is caring for a patient hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize? A) Strategies for maintaining an alkaline gastric environment B) Safe technique for self-suctioning C) Techniques for positioning correctly to promote gastric healing D) Strategies for avoiding irritating foods and beverages

A,c,e

A nurse is caring for a patient in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristics of this stage of the disease? Select all that apply. A) Perforation into the mediastinum B) Development of an esophageal lesion C) Erosion into the great vessels D) Painful swallowing E) Obstruction of the esophagus

B) Avoid taking the drug on a long-term basis.

A nurse is caring for a patient with constipation whose primary care provider has recommended senna (Senokot) for the management of this condition. The nurse should provide which of the following education points? A) Limit your fluid intake temporarily so you dont get diarrhea. B) Avoid taking the drug on a long-term basis. C) Make sure to take a multivitamin with each dose. D) Take this on an empty stomach to ensure maximum effect.

A hip fracture

A nurse is caring for an older adult client who has become increasingly frail and unsteady on her feet. During the assessment, the client indicates that she has fallen three times in the month, though she has not yet suffered an injury. The nurse should take action in the knowledge that this client is at a high risk for what health problem?

C) Joint stiffness, especially in the morning

A nurse is performing the health history and physical assessment of a patient who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA? A) Cool joints with decreased range of motion B) Signs of systemic infection C) Joint stiffness, especially in the morning D) Visible atrophy of the knee and shoulder joints

Dietitian

A nurse is preparing a client with type 1 diabetes for discharge. The client can care for himself; however, he's had a problem with unstable blood glucose levels in the past. Based on the client's history, he should be referred to which health care worker?

consuming a low-carbohydrate, high-protein diet and avoiding fasting.

A nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend:

D) Maintain an open dialogue with the patient and facilitate a referral to the wound-ostomy-continence (WOC) nurse.

A nurse is talking with a patient who is scheduled to have a hemicolectomy with the creation of a colostomy. The patient admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. Which of the following nursing actions is most appropriate? A) Reassure the patient that the procedure is relatively low risk and that patients are usually successful in adjusting to an ostomy. B) Provide the patient with educational materials that match the patients learning style. C) Encourage the patient to write down these concerns and questions to bring forward to the surgeon. D) Maintain an open dialogue with the patient and facilitate a referral to the wound-ostomy-continence (WOC) nurse.

"Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy."

A nurse is teaching a client recovering from diabetic ketoacidosis (DKA) about management of "sick days." The client asks the nurse why it is important to monitor the urine for ketones. Which statement is the nurse's best response?

C

A nurse is teaching a client with borderline personality disorder to reshape thinking patters. Which is an example of a cognitive restructuring technique that would be helpful for this client? A) When negative thoughts begin, tell yourself ìstop.î B) Learn to look at situations realistically rather than assuming the worst. C) Recognize negative thoughts and replace them with positive ones. D) Express needs using ìIî statements.

Glucagon

A nurse is teaching a client with type 1 diabetes how to treat adverse reactions to insulin. To reverse hypoglycemia, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?

D) Change in bowel habits

A nurse is teaching a group of adults about screening and prevention of colorectal cancer. The nurse should describe which of the following as the most common sign of possible colon cancer? A) Development of new hemorrhoids B) Abdominal bloating and flank pain C) Unexplained weight gain D) Change in bowel habits

Arteriography Open reduction of a fracture Cystoscopy Paracentesis

A nurse knows that she must obtain a signed informed consent for which of the following procedures? Select all that apply.

Proton pump inhibitors.

A nurse practitioner, who is treating a patient with GERD, knows that responsiveness to this drug classification is validation of the disease. The drug classification is:

"Insulin permits entry of glucose into the cells of the body." "Insulin promotes synthesis of proteins in various body tissues." "Insulin promotes the storage of fat in adipose tissue."

A nurse prepares teaching for a client with newly-diagnosed diabetes. Which statements about the role of insulin will the nurse include in the teaching? Select all that apply.

Shakiness Tachycardia Weakness Confusion

A nurse suspects that a patient is developing rebound hypoglycemia secondary to parenteral nutrition being discontinued too rapidly. Which of the following would support the nurse's suspicions? Select all that apply.

Levothyroxine (Synthroid) Levothyroxine is the agent of choice for thyroid hormone replacement therapy because its standard hormone content provides predictable results. Methimazole is an antithyroid medication used to treat hyperthyroidism. Thyroid USP desiccated and liothyronine are no longer used for thyroid hormone replacement therapy because they may cause fluctuating plasma drug levels, increasing the risk of adverse effects.

A nurse teaches a client with newly diagnosed hypothyroidism about the need for thyroid hormone replacement therapy to restore normal thyroid function. Which thyroid preparation is the agent of choice for thyroid hormone replacement therapy?

Insulin resistance.

A nurse understands that a major concern with type 2 diabetes is:

D

A nursing student appears to cooperate with the group but does not complete agreed upon tasks at the appropriate time repeatedly and then display negativity. The nursing student may be showing signs of which personality disorder or behavior? A) Paranoid B) Borderline C) Narcissistic D) Passive-aggressive behavior

Ingestion of strong acids Irritating foods Overuse of aspirin

A nursing student is caring for a client with gastritis. Which of the following would the student recognize as a common cause of gastritis? Choose all that apply.

A) Measure and record drainage.

A patient has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction. What is the nurses priority during this aspect of the patients care? A) Measure and record drainage. B) Monitor drainage for change in color. C) Titrate the suction every hour. D) Feed the patient via the G tube as ordered.

A) Glucose tolerance test

A patient has a recent diagnosis of chronic pancreatitis and is undergoing diagnostic testing to determine pancreatic islet cell function. The nurse should anticipate what diagnostic test? A) Glucose tolerance test B) ERCP C) Pancreatic biopsy D) Abdominal ultrasonography

Surgical removal of the diverticulum

A patient has been diagnosed with Zenker's diverticulum. What treatment does the nurse anticipate educating the patient about?

D) Contact the primary care provider immediately.

A patient has had a cast placed for the treatment of a humeral fracture. The nurses most recent assessment shows signs and symptoms of compartment syndrome. What is the nurses most appropriate action? A) Arrange for a STAT assessment of the patients serum calcium levels. B) Perform active range of motion exercises. C) Assess the patients joint function symmetrically. D) Contact the primary care provider immediately.

B) Application of heat 15 to 20 minutes each hour

A patient has had a laparoscopic cholecystectomy. The patient is now complaining of right shoulder pain. What should the nurse suggest to relieve the pain? A) Aspirin every 4 to 6 hours as ordered B) Application of heat 15 to 20 minutes each hour C) Application of an ice pack for no more than 15 minutes D) Application of liniment rub to affected area

A decrease in urine output

A patient is ordered desmopressin (DDAVP) for the treatment of diabetes insipidus. What therapeutic response does the nurse anticipate the patient will experience?

Inhibit the production of glucose by the liver.

A patient is prescribed Glucophage, an oral antidiabetic agent classified as a biguanide. The nurse knows that a primary action of this drug is its ability to:

Achalasia

A patient tells the nurse that it feels like food is "sticking" in the lower portion of the esophagus. What motility disorder does the nurse suspect these symptoms indicate?

C) Rigidity of the abdomen

A patient who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this patient knows to immediately report what assessment finding to the physician? A) Decreased breath sounds B) Drainage of bile-colored fluid onto the abdominal dressing C) Rigidity of the abdomen D) Acute pain with movement

B) Frequent abdominal auscultation

A patient with a diagnosis of colon cancer is 2 days postoperative following bowel resection and anastomosis. The nurse has planned the patients care in the knowledge of potential complications. What assessment should the nurse prioritize? A) Close monitoring of temperature B) Frequent abdominal auscultation C) Assessment of hemoglobin, hematocrit, and red blood cell levels D) Palpation of peripheral pulses and leg girth

C) An absence of blood in stool

A patients health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohns disease, rather that ulcerative colitis, as the cause of the patients signs and symptoms? A) A pattern of distinct exacerbations and remissions B) Severe diarrhea C) An absence of blood in stool D) Involvement of the rectal mucosa

B

A person with temperament traits of high harm avoidance would most likely suffer from which personality disorder? A) Schizoid B) Avoidant C) Narcissistic D) Antisocial

isotonic solution

A solution in which the concentration of solutes is essentially equal to that of the cell which resides in the solution

What is required for a transitional care model to be most effective in promoting the client's health and well-being and prevent relapse and rehospitalization? Select all that apply. A) Collaboration B) Administrative support C) Adequate funding D) Family support E) Completely different providers F) Isolation from peers who successfully live in the community

ABC

The term ìstandards of careî refers to expectations of nursing performance. Standards of care are developed from which of the following? Select all that apply. A) Code of Ethics for Nurses with Interpretive Statements B) Licensure examinations C) State Nurse Practice Acts D) Agency job descriptions E) Professional nursing organizations

ACDE

Administer IV calcium gluconate as ordered.

After a thyroidectomy, the client develops a carpopedal spasm while the nurse is taking a BP reading on the left arm. Which action by the nurse is appropriate?

C

After an angry outburst, a client quickly appears more calm and rational. The nurse approaches the client. Which of the following is the most helpful response to the client at this time? A) ìWe will have to talk about this later.î B) ìYou really scared me. I'm glad you are okay.î C) ìWhat happened that got you so upset?î D) ìWhat can you do differently next time you get angry?î

Increased fiber intake Reduced fat intake

An adult client has been diagnosed with diverticular disease after ongoing challenges with constipation. The client will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply.

D) Streaks of blood present in the stool

An inpatient has returned to the medical unit after a barium enema. When assessing the patients subsequent bowel patterns and stools, what finding should the nurse report to the physician? A) Large, wide stools B) Milky white stools C) Three stools during an 8-hour period of time D) Streaks of blood present in the stool

Promoting weight-bearing exercises

An older adult client with a diagnosis of left-sided stroke is admitted to the facility. To prevent the development of disuse osteoporosis, which objective is most appropriate?

A client is supposed to be ambulating ad lib. Instead, he refuses to get out of bed, asks for a bed bath, and makes many demands of the nurses. He also yells that they are lazy and incompetent. The client's behavior is an example of which of the following defense mechanisms? A) Introjection B) Projection C) Rationalization D) Reaction formation

B

Which of the following is an inhibitory neurotransmitter? A) Dopamine B) GABA C) Norepinephrine D) Epinephrine

B

The nurse is assessing a client who is talking about her son's recent death but who shows no emotion of any kind. The nurse recognizes this behavior as which of the following defense mechanisms? A) Dissociation B) Displacement C) Intellectualization D) Suppression

C

factitious disorder

Condition in which a person acts as if he or she has a physical or mental illness when he or she is not really sick. examples: munchausen tx: cognitive behavioral therapy/ family therapy/ medication for related disorders

A) Following proper hand-washing techniques

During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus? A) Following proper hand-washing techniques B) Avoiding chemicals that are toxic to the liver C) Wearing a condom during sexual contact D) Limiting alcohol intake

B) Increased fluid and fiber intake

During a patients scheduled home visit, an older adult patient has stated to the community health nurse that she has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following? A) Regular application of an OTC antibiotic ointment B) Increased fluid and fiber intake C) Daily use of OTC glycerin suppositories D) Use of an NSAID to reduce inflammation

"You must avoid hyperextending your neck after surgery."

During preoperative teaching for a client who will undergo subtotal thyroidectomy, the nurse should include which statement?

Notify the surgical team to remove all latex-based items.

During the preoperative assessment, the client mentions allergies to avocados, bananas, and hydrocodone. What is the priority action by the nurse?

dantrolene sodium (Dantrium)

During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer:

increase the likelihood of a successful recovery.

In advance of a client's scheduled appendectomy, the nurse spends significant time explaining to the client what will happen,both before the procedure and after the procedure is complete. The primary reason the nurse puts so much effort into preoperative teaching is to:

Safety loss

Loss of a safe environment is evident in domestic violence, child abuse, or public violence.

Aldactone, an aldosterone-blocking agent would be used. Daily salt intake would be restricted to 2 grams or less. The diuretic will be held if the serum sodium level decreases to <134 m Eq/L.

Management of a patient with ascites includes nutritional modifications and diuretic therapy. Which of the following interventions would a nurse expect to be part of patient care? Select all that apply.

Fluoxetine

May reduce binge eating episodes what medication am I?

T3, T4, and calcitonin

Name three hormomes produced by the thyroid

ACD

Of the following personality disorders, which are most likely related to lack of caring about others? Select all that apply. A) Schizotypal personality disorder B) Borderline personality disorder C) Antisocial personality disorder D) Narcissistic personality disorder E) Obsessiveñcompulsive personality disorder

A

One of the first steps that a nurse should take to deal effectively with aggressive clients is which of the following? A) Reflect on abilities to handle own feelings of anger B) Learn professional skills of anger management C) Become proficient using reflective communication techniques D) Understand how to activate crisis response teams

C

Several medications are prescribed for a client who has anorexia. Which medication may be prescribed to help treat the client's distorted body image? A) Amitriptyline (Elavil) B) Cyproheptadine (Periactin) C) Olanzapine (Zyprexa) D) Fluoxetine (Prozac)

shift

The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every

2; 3

The first ___yrs after an attempt represents the highest risk period especially the first ___ months

Elastic compression bandages

The health care provider is preparing to bivalve the client's cast. Which supplies should the nurse assemble?

cardiovascular disease

The leading cause of death in older adults in the United States is

An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide.

The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance?

Offer a prescribed antiemetic medication.

The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance?

Rapid-acting Short-acting

The nurse is administering an insulin drip to a patient in ketoacidosis. What insulin does the nurse know can be used intravenously? Select all that apply.

D

The nurse is assessing a client with an eating disorder. Which personality characteristic would the nurse expect to detect when interacting with the client? A) Careless B) Outspoken C) Defiance D) Eager to please

The client has an absence of bowel sounds.

The nurse is assessing the postoperative client on the second postoperative day. Which assessment finding requires immediate physician notification?

2 in.

The nurse is assisting a client to drain his continent ileostomy (Kock pouch). The nurse should insert the catheter how far through the nipple/valve?

Reorient the patient

The nurse is attempting to take vital signs of an older adult hospitalized following knee surgery. The client continuously yells, "It's 1999 and you are going to hurt me!" What action should the nurse do first?

A

The nurse is caring for a 16-year-old boy with a history of sexual abuse. What might the nurse expect to assess with this client? A) The client will experience long-term emotional trauma. B) The client will have no ill effects due to his age. C) The client will have high self-esteem. D) The client will easily share his concerns with the nurse.

The lungs are not able to blow off carbon dioxide.

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the fall in pH?

Elevated blood pressure

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?

Post-discharge diet

The nurse is caring for a client needing emergency surgery. Which preoperative teaching is least important to prepare the client for surgery?

Facilitate a detailed analysis of the client's electrolyte levels.

The nurse is caring for a client who is admitted to the ER with the diagnosis of acute appendicitis. The nurse notes during the assessment that the client's ribs and xiphoid process are prominent. The client states she exercises two to three times daily and her mother indicates that she is being treated for anorexia nervosa. How should the nurse best follow up these assessment data?

Extravasation of the medication

The nurse is caring for a client who is to receive IV daunorubicin, a chemotherapeutic agent. The nurse starts the infusion and checks the insertion site as per protocol. During the most recent check, the nurse observes that the IV has infiltrated so the nurse stops the infusion. What is the nurse's priority concern with this infiltration?

Blood pressure, heart rate, and rhythm Intake and output, urine volume, and color Skin assessment for edema and turgor

The nurse is caring for a client who was admitted with fluid volume excess (FVE). Which nursing assessments should the nurse include in the ongoing monitoring of the client? Select all that apply.

Confusion

The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition?

Assessing for symptoms of nausea and malaise Monitoring neurologic status Restricting tap water intake

The nurse is caring for a patient with a diagnosis of hyponatremia. What nursing intervention is appropriate to include in the plan of care for this patient? (Select all that apply.)

ADE

The nurse is collecting assessment data on a client who is suspected to be a victim of violence. Which assessment data would support the suspicion that the client is a victim of abuse? Select all that apply. A) The client has few friends. B) The client holds a dominant role in the family. C) The client is in charge of the family finances. D) There is a moderate amount of alcohol use in the home. E) The client reports that the father was abusive during childhood.

The client's hands flap back and forth when the arms are extended.

The nurse is completing a morning assessment of a client with cirrhosis. Which information obtained by the nurse will be of most concern?

B

The nurse is conducting a history and physical exam on a client who is grieving the unwanted loss of a marriage by divorce. Which of the following physical symptoms of grief would the nurse most likely expect to detect in the history? A) Headaches B) Insomnia C) Weight loss D) GI upset

C

The nurse is discussing expectations of raising a child with a pregnant teenager expecting her first baby. The father will not be a participant in the parenting. Which of the following statements made by the expectant mother would be of greatest concern to the nurse? A) ìI am going to rely on my sisters for a lot of help raising my baby.î B) ìI was raised with very strict discipline.î C) ìMy child will love me unlike my parents ever did.î D) ìI am not sure how I am going to pay for all the things my child will need.î

ADE

The nurse is educating a client and family about managing panic attacks after discharge from treatment. The nurse includes which of the following in the discharge teaching? Select all that apply. A) Continued development of positive coping skills B) Weaning off of medications as necessary C) Lessening the amount of daily responsibilities D) Continued practice of relaxation techniques E) Development of a regular exercise program

"We need an adequate amount of exposure to sunshine."

The nurse is educating a group of women on the prevention of osteoporosis. The nurse recognizes the education as being effective when the group members make which statement?

May improve blood glucose levels Decrease the need for exogenous insulin Help reduce cholesterol levels

The nurse is educating the patient with diabetes about the importance of increasing dietary fiber. What should the nurse explain is the rationale for the increase? Select all that apply.

presbycusis

age related hearing loss

delirium

an acutely disturbed state of mind that occurs in fever, intoxication, and other disorders and is characterized by restlessness, illusions, and incoherence of thought and speech.

sprain

an injury to the ligaments and tendons that surround a joint. It is caused by a twisting motion or hyperextension of a joint

Cluster C

anxious, fearful

Vietnamese Americans

bathing deceased and dressing in black clothing; rice in mouth and money; display of body for viewing in home before burial

avoidance behavior

behavior designed to avoid unpleasant consequences or potentially threatening situations

panic attack

between 15 and 30 minutes of rapid, intense, escalating anxiety in which the person experiences great emotional fear as well as physiologic discomfort

Tricyclic Antidepressants (TCAs)

can require 4-6 weeks before the clients experiences optimal therapeutic benefit

goiter

enlargement of the thyroid gland

Imipramine (Tofranil)

enuresis can be treated effectively with what medication?

Depersonalization

feelings of being disconnected from himself or herself; the client feels detached from his or her behavior

Muslim Americans

five steps of burial procedure including washing, dressing and positioning of the body 1st- wash of the body by someone of the same gender

Muslim Americans

five steps of burial procedure including washing, dressing, and positioning of the body 1st:traditional washing of the body by a Muslim of the same gender

Tonicity

fluid tension or the effect that osmotic pressure of a solution with impermeable solutes exerts on cell size because of water movement across the cell membrane

tonicity

fluid tension or the effect that osmotic pressure of a solution with impermeable solutes exerts on cell size because of water movement across the cell membrane

dwarfism

generalized limited growth resulting from insufficient secretion of growth hormone during childhood

bow legged

genu varum

disenfranchised grief

grief over a loss that is not or cannot be mourned publicly or supported socially -a relationship that has no legitimacy -the loss itself is not recognized -the griever is not recognized -the Loss involves social stigma

Milk

he nurse is teaching a client about the dietary restrictions related to his diagnosis of hyperparathyroidism. What foods should the nurse encourage the client to avoid?

corticosteriods

hormones released by the adrenal cortex that play a key role in the body's response to long-term stressors

process

how a person says, thinks, feels

limbic system

hypothalamic and pituitary hormones stimulate the ________ _________

Autism Spectrum Disorder (ASD)

impaired resposiveness to people (avoids eye contact, lacks empathy, does not understand social cues) does not respond to name focuses intently on one object no interactive play, responds passively to other children reduced sensitivity to pain acute sensitivity to sound and touch (RESISTS HUGGING)

Asperger's Syndrome

impaired social interactions, narrow range of interests ~~~ no delay in spoken/receptive language/cognitive development, or self help skills average or above average intelligence language and cognition (thinking and learning) develop normally

Autism

impairment in communication skills, impairment in social interactions, restrictive repertoire of activities or interests, repetitive behaviors many are also identified as having ID

volkmann's ischemic contracture

impairment of motor function and Sensibility, contracture of the fingers and wrist. Contracture the fingers and wrist occurs related to obstructed arterial blood flow

skilled nursing services

in which continuous nursing assistance is provided.

independent dwelling

in which people manage their own needs every day

assisted living

in which people require limited assistance with their daily living needs.

biliary cirrhosis

in which scarring occurs in the liver around the bile ducts. This type of cirrhosis usually results from chronic biliary obstruction and infection it is much less common

alcoholic cirrhosis

in which the scar tissue characteristically surrounds the portal areas. This is most frequently caused by chronic alcoholism and is the most common type of cirrhosis

postnecrotic cirrhosis

in which there are broad bands of scar tissue. This is a late result of previous bout of acute viral hepatitis

lowers blood sugar

insulin

glaucoma

is a disease characterized by increased intra-ocular pressure.

Asenapine

is a sublingual tab, food and drink must be avoided 10-15 min after the med dissolves

kyphosis

is an increased forward curvature of the thoracic spine that causes a Boeing or rounding of the back leading to Hunchback or slouching posture

elective surgery

is classified as a surgery that the client should have

Serotonin

is implicated in the development of depression.

acetylcholine

is released from vesicles and stimulates muscles to contract

fulminant hepatic failure

is the clinical syndrome of sudden and severely impaired liver function in a previously healthy person

cataract

is the development of opacity of the eye lens

borborygmus

is the intestinal rumbling caused by the movement of gas through the intestines that accompanies diarrhea

enmeshment

lack of clear role boundaries between persons

Phase 2 of Crisis Development

lack of coping success increases anxiety; feel helpless, confused disoriented, overwhelmed

left sided CHF

lungs may hear crackles means what:

Homeostasis

maintenance of a constant internal equilibrium in a biologic system that involves positive and negative feedback mechanisms

eating disorders

males with ________ __________ have disturbed body image and sometimes extreme concern with being muscular

herb milk thistle

many patients with end-stage liver disease with cirrhosis use what to treat jaundice and other symptoms

adrenogenital syndrome

masculinization in women, feminization in men, or premature sexual development in children; result of abnormal secretion of adrenocortical hormones, especially androgens

Hypoglycemia

may develop during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin

required surgery

means that the client needs to have surgery.

Propranolol (Inderal) clonidine buspar

medications used to treat anxiety include what?

helps with sleep wake cycle

melatonin

GABA

modulates neurotransmitter

osteoporosis

most common bone disorder in the western world. second to arthritis as a cause of musculoskeletal morbidity in the elderly

autisim spectrum disorder

new category in DSM-5, onset prior to age 3, impairments in: social communication/social interaction and restricted and repetitive behaviors, interests and activities identified between 18months and 3 yo

Hispanic Americans

novena (9-day prayers) and rosary; luto

panic attack symptoms

palpitations sweating trembling/ shaking sensation of smothering; cant breathe sense of choking chest pain/ discomfort feeling dizzy, unsteady, lightheaded or faint derealization or depresonalization (dissociative symptoms) fear of losing control/ going crazy fear of dying paresthesias (numbness or tingling) chills/ hot flashes must have 4+ in order to have this

acute pancreatitis

pancreatic duct becomes obstructed and enzymes back up, causing autodigestion and inflammation of the pancreas

low self-esteem low trusting others, a previous psychiatric disorder, previous suicide threats or attempts, absent or unhelpful family members

people who are vulnerable to complicated grieving include those with the following characteristics: list the characteristics

arthrodesis

perform to relieve pain and to restore stability and Alignment. Results in loss motion. Also known as joint Fusion

Phentermine

perscribed appetite suppresant

agesim

prejudice and discrimination based on a person's age

Grieving/bereavement

process by which person experiences grief

nausea and vomiting, stomach pain, jaundice, dark urine, Galleria, joint pain, dyspepsia, decreased appetite, abdominal pain, malaise

signs and symptoms of hepatitis are

ascites

sodium restriction is also indicated to prevent what

Chinese Americans

strict norms for announcing death, preparing body, arranging funeral and burial, mourning after burial -Bowls of food on table for spirit for 1 year after death

complicated grief or prolonged grief disorder

sudden and violent losses, including natural or man-made disasters, military losses, terrorist attacks or killing sprees by an individual are all more likely to lead to what?

thyroidectomy

surgical removal of the thyroid gland

lordosis

swayback, an exaggerated curvature of the lumbar spine

assertiveness training

techniques using statements to identify feelings and communicate needs and concerns to others; helps the person negotiate interpersonal situations, fosters self-assurance, and ultimately assists the person to take more control over life situations Use "I" statements to identify feelings

Phase 4 of Crisis Development

tension increases and anxiety May reach Panic levels; cognitive function is disordered, emotions are labile and psychosis is possible

parasympathetic

the ____________ nervous system reacts once the stressor is neutralized or avoided. It sends out new signals to calm the body down, slowing the vital signs, relaxing muscles, reactivating digestive juices.

adaptive denial

the client gradually adjusts to the reality of the loss

comorbidity

the co-occurrence of two or more disorders in a single individual

moderate anxiety

the disturbing feeling that something is definitely wrong; the person becomes nervous or agitated

Ego-dystonic

the individual sees the illness as something thrust upon her that is intrusive and bothersome

polypharmacy

the use of multiple medications

suicidal ideation

thinking about ending one's life

esophageal varices

this condition is almost always caused by portal hypertension which results from obstruction of the portal venous circulation within the damaged liver

Bupropion

this is not used with a history of seizures or eating disorders: May decrease reuptake dopamine serotonin and norepinephrine used to treat ADHD

insomnia, headaches, impaired appetite, weight loss, lack of energy, palpitations, indigestion, and changes in the immune and endocrine system.

those grieving May complain of what type of symptoms

fluoxetine, lithium, valproic acid, phenytoin, topiramate, oxcarbazepine

treatment for intermittent explosive disorder includes medications such as what? well these medications reduce aggressive impulses and irritability and many people, they do not eliminate the Outburst of IED

psychotherapy CBT

treatments for eating disorders include what?

Native Americans

tribal Medicine Man or Priestly healer; baptism ceremonies; end of morning noted with ceremony at burial ground with grave covered with blanket or cloth later given to tribe member

true

true or False, only persons with hepatitis B are at risk for hepatitis D

mental changes and motor disturbances

what are early signs of hepatic encephalopathy

accumulation of ammonia and other toxic metabolites in the blood

what are life-threatening complications of hepatic encephalopathy

vitamin D and calcium

what do you need adequate amounts of if diagnosed with osteoporosis

recurrent attacks of severe upper abdominal and back pain accompanied by vomiting

what is a major symptom of chronic pancreatitis

compartment syndrome

what is the most serious complication of casting and splinting

vasopressin, pitressin

what medication may be the initial mode of therapy in urgent situations because it produces constriction of the splanichnic arteriole bed and decreases portal pressure

anticapatory grieving

when people facing an imminent loss begin to Grapple with the very real possibility of the loss or death in the near future

Hyperglycemia

which can increase the risk of surgical wound infection, may result from the stress of surgery, which can trigger increased levels of catecholamine.

spironolactone; aldactone

which diuretic medication would most often be used for a patient with ascites?

stuttering

which is a disturbance of normal fluency and time patterning of speech

Reorient the client. Assess for hypoxia. Assess urine output.

A 76-year-old client had surgery for an abdominal hernia. The PACU nurse observes that the client is confused and is trying to climb out of the bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate? Select all that apply.

A

A client approaches the nurse and loudly states, ìI'm not putting up with this anymore!î The most appropriate response by the nurse would be which of the following? A) ìI can see you are angry. Tell me what's going on.î B) ìYou are not allowed to make threats. Please keep your voice down.î C) ìWhy do you say that?î D) ìYou are here voluntarily. You can leave if you want.î

Encourage the client to connect with a community-based support group.

A client has been treated in the hospital for an episode of acute pancreatitis. The client has acknowledged the role that his alcohol use played in the development of his health problem, but has not expressed specific plans for lifestyle changes. What is the nurse's most appropriate response?

Electrical stimulation

A client has delayed bone healing in a fractured right humerus. What should the nurse prepare the client for that promotes bone growth?

Promotion of adequate nutrition

A client has undergone rigid fixation for the correction of a mandibular fracture suffered in a fight. What area of care should the nurse prioritize when planning this client's discharge education?

Assess for signs and symptoms of fluid volume deficit.

A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate?

B

A client is scheduled for a mastectomy for breast cancer. She is quiet, shows little emotion, and states that she has no questions. The nurse's assessment would need to focus on A) the client's plans for reconstructive surgery. B) the meaning of the mastectomy to the client. C) whether the client truly understands the surgery. D) why the client seems depressed.

postoperative pain control cough and deep-breathing exercises intravenous fluids and other lines and tubes

A client is undergoing a surgical procedure to repair an ulcerated colon. Which client education topics will be discussed preoperatively? Select all that apply.

Splint the incision site using a pillow during deep breathing and coughing exercises.

A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?

B

A student is preparing to give a class presentation. A few minutes before the presentation is to begin, the student seems nervous and distracted. The student is looking at and listening to the peer speaker and occasionally looking at note cards. When the peer speaker asks a question of the group, the student is able to answer correctly. The professor understands that the student is likely experiencing which level of stress? A) Mild B) Moderate C) Severe D) Panic

pituitary disorder

A young client has a significant height deficit and is to be evaluated for diagnostic purposes. What could be the cause of this client's disorder?

A patient has just begun daily participation in a community-based partial hospitalization program. The patient can expect the staff to assist with which of the following treatment goals? Select all that apply. A) Stabilizing psychiatric symptoms B) Finding a better job C) Improving activities of daily living D) Learning to structure time E) Improved family support F) Developing social skills

ACDF

Which of the following statements about mental illness are true? Select all that apply. A) Mental illness can cause significant distress, impaired functioning, or both. B) Mental illness is only due to social/cultural factors. C) Social/cultural factors that relate to mental illness include excessive dependency on or withdrawal from relationships. D) Individuals suffering from mental illness are usually able to cope effectively with daily life. E) Individuals suffering from mental illness may experience dissatisfaction with relationships and self.

ADE

BD

An adult patient has been diagnosed with diverticular disease after ongoing challenges with constipation. The patient will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply. A) Anticholinergic medications B) Increased fiber intake C) Enemas on alternating days D) Reduced fat intake E) Fluid reduction

B For the borderline personality disorder client, personal boundaries are unclear, and clients often have unrealistic expectations. Clients easily can misinterpret the nurse's genuine interest and caring as a personal friendship, and the nurse may feel flattered by a client's compliments. The nurse must be quite clear about establishing the boundaries of the therapeutic relationship to ensure that neither the client's nor the nurse's boundaries are violated.

A client with borderline personality disorder says to the nurse, ìI feel so comfortable talking with you. You seem to have a special way about you that really helps me.î Which would be the most appropriate response by the nurse? A) ìI'm glad you feel comfortable with me.î B) ìI'm here to help you just as all the staffs are.î C) ìYou feel others don't understand you?î D) ìI cannot be your friend. We need to be clear on that.î

"Do you feel any muscle twitches or spasms?"

A client with thyroid cancer has undergone surgery and a significant amount of parathyroid tissue has been removed. The nurse caring for the client should prioritize what question when addressing potential complications?

rapid-acting insulin only.

A client with type 1 diabetes has been on a regimen of multiple daily injection therapy. He's being converted to continuous subcutaneous insulin therapy. While teaching the client about continuous subcutaneous insulin therapy, the nurse should tell him that the regimen includes the use of:

The client's insulin levels are inadequate.

A client with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurse's most plausible conclusion based on this assessment finding?

Muscle wasting and tissue loss

A client with type 1 diabetes is experiencing polyphagia. The nurse knows to assess for which additional clinical manifestation(s) associated with this classic symptom?

An absence of blood in stool

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

C) Increased uric acid levels

A clinic nurse is caring for a patient with suspected gout. While explaining the pathophysiology of gout to the patient, the nurse should describe which of the following? A) Autoimmune processes in the joints B) Chronic metabolic acidosis C) Increased uric acid levels D) Unstable serum calcium levels

C) Inability to take in adequate oral food or fluids within 7 days

A critical care nurse is caring for a patient diagnosed with acute pancreatitis. The nurse knows that the indications for starting parenteral nutrition (PN) for this patient are what? A) 5% deficit in body weight compared to preillness weight and increased caloric need B) Calorie deficit and muscle wasting combined with low electrolyte levels C) Inability to take in adequate oral food or fluids within 7 days D) Significant risk of aspiration coupled with decreased level of consciousness

Excrete bile

A group of students is reviewing information about the liver and associated disorders. The group demonstrates understanding of the information when they identify which of the following as a primary function of the liver?

C

A married couple has just received the news that the husband has terminal cancer. The wife tells the nurse, ìMaybe if we get another opinion and start treatment right way there is a chance of survival.î The nurse documents that the wife is expressing signs of which of Kubler-Ross's stages of grief? A) Denial B) Anger C) Bargaining D) Depression

C

A married man expresses to the nurse that his wife's frequent nagging angers him. The nurse role-plays assertive communication techniques with the husband. Which of the following indicates the husband understands how to use assertive techniques effectively? A) ìI really wish you would stop nagging me.î B) ìYou are not perfect either.î C) ìI feel unappreciated when you criticize me.î D) ìAre you telling me you want me to change?î

Middle-aged or older people with either type 2 diabetes or no known history of diabetes

A medical nurse is aware of the need to screen specific clients for their risk of hyperglycemic hyperosmolar syndrome (HHS). In what client population does hyperosmolar nonketotic syndrome most often occur?

A) Indicates acceptance of altered appearance and demonstrates positive self-image

A medical nurse who is caring for a patient being discharged home after a radical neck dissection has collaborated with the home health nurse to develop a plan of care for this patient. What is a priority psychosocial outcome for a patient who has had a radical neck dissection? A) Indicates acceptance of altered appearance and demonstrates positive self-image B) Freely expresses needs and concerns related to postoperative pain management C) Compensates effectively for alteration in ability to communicate related to dysarthria D) Demonstrates effective stress management techniques to promote muscle relaxation

acute cholecystitis

A middle-aged obese female presents to the ED with severe radiating right-sided flank pain, nausea, vomiting, and fever. A likely cause of these symptoms is:

Weight loss, nervousness, and tachycardia

A nurse is assessing a client with hyperthyroidism. What findings should the nurse expect? You Selected:

D) Right shoulder

A nurse is assessing a patient who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the patients pain, the nurse should anticipate that it may radiate to what region? A) Left upper chest B) Inguinal region C) Neck or jaw D) Right shoulder

ACE

A nurse is caring for a patient who has a gastrointestinal tube in place. Which of the following are indications for gastrointestinal intubation? Select all that apply. A) To remove gas from the stomach B) To administer clotting factors to treat a GI bleed C) To remove toxins from the stomach D) To open sphincters that are closed E) To diagnose GI motility disorders

Which of the following side effects of lithium are frequent causes of noncompliance? Select all that apply. A) Metallic taste in the mouth B) Weight gain C) Acne D) Thirst E) Lethargy

BE

Report the findings to adult protective services.

Based on a client's vague explanations for recurring injuries, the nurse suspects that a community-dwelling older adult may be the victim of abuse. What is the nurse's primary responsibility?

The distance measured from the tip of the nose (N) to the earlobe (E) and from the earlobe to the xiphoid (X) process

Before inserting a gastric or enteric tube, the nurse determines the length of tubing that will be needed to reach the stomach or small intestine. The Levin tube, a commonly used nasogastric tube, has circular markings at specific points. This tube should be inserted to 6 to 10 cm beyond what length?

A client who has depression is admitted to treatment on a voluntary basis. While in the hospital, the client makes several comments about wanting to ìend it all.î The client decides one day to leave against medical advice. Which of the following would be the most appropriate action by the nursing staff? A) Calling security and asking them to detain the client B) Allowing the client to leave with community resources for follow-up care C) Contacting the psychiatrist for initiation of commitment proceedings D) Contacting the client's family to request they convince the client to stay

C

A client with bipolar disorder has been taking lithium, and today his serum blood level is 2.0 mEq/L. What effects would the nurse expect to see? A) Constipation and postural hypotension B) Fever, muscle rigidity, and disorientation C) Nausea, diarrhea, and confusion D) None; the serum level is in therapeutic range

C

A patient is being transferred from a group home to an evolving consumer household. The goal of this transition is for the patient to eventually A) meet with a therapist on a weekly basis. B) resolve crises within a shorter time period. C) fulfill daily responsibilities without supervision. D) use the increased emotional support of paid staff.

C

A patient is seen for frequent exacerbation of schizophrenia due to nonadherence to medication regimen. The nurse should assess for which of the following common contributors to nonadherence? A) The patient is symptom-free and therefore does not need to adhere to the medication regimen. B) The patient cannot clearly see the instructions written on the prescription bottle. C) The patient dislikes the weight gain associated with antipsychotic therapy. D) The patient sells the antipsychotics to addicts in the neighborhood.

C

B) Promptly report these indications of venous congestion.

A nurse is caring for a patient who has undergone neck resection with a radial forearm free flap. The nurses most recent assessment of the graft reveals that it has a bluish color and that mottling is visible. What is the nurses most appropriate action? A) Document the findings as being consistent with a viable graft. B) Promptly report these indications of venous congestion. C) Closely monitor the patient and reassess in 30 minutes. D) Reposition the patient to promote peripheral circulation.

Which approach to therapy is most effective when planning for a client with negative thinking? A) Behavior modification B) Client-centered therapy C) Cognitive therapy D) Reality therapy

C

Which of the following increases the risk for neuroleptic malignant syndrome (NMS)? A) Overhydration B) Intake of vitamins C) Dehydration D) Vegetarian diet

C

Which of the following is a major developmental task of middle adulthood? A) Developing intimacy B) Learning to manage conflict C) Reexamining life goals D) Resolving the past

C

Which of the following is defined as an advanced-level function in the practice area of psychiatric mental health nursing? A) Case management B) Counseling C) Evaluation D) Health teaching

C

Which of the following is the highest priority for admission to inpatient care? A) Confusion or disorientation B) Need for medication changes C) Safety of self or others D) Withdrawal from alcohol or other drugs

C

tumor excision.

An example of a curative surgical procedure is

ABD

Anger management is likely to be included in the care of clients with which of the following psychiatric diagnoses? Select all that apply. A) Alzheimer's dementia B) Schizophrenia C) Anorexia nervosa D) Acute alcohol intoxication E) Generalized anxiety disorder

Emotional Response

Anger, sadness and anxiety are what type of response? "He should have stopped smoking years ago." "If i took her to the doctor earlier, maybe this wouldnt have happened." "It took you to long to diagnosis his illness."

Which of the following is the primary consideration with clients taking antidepressants? A) Decreased mobility B) Emotional changes C) Suicide D) Increased sleep

C

A college student decides to go to a party the night before a major exam instead of studying. After receiving a low score on the exam, the student tells a fellow student, ìI have to work too much and don't have time to study. It wouldn't matter anyway because the teacher is so unreasonable.î The defense mechanisms the student is using are A) denial and displacement B) rationalization and projection C) reaction formation and resistance D) regression and compensation

B

A 22-year-old client has been manipulative of staff and disruptive in the milieu. Although she is not dangerous to herself or others, she has created problems on the unit and clearly is not making progress. The nurses offer prescribed medication, but she consistently refuses ìany drugs.î The staff realizes that legally this client can A) be coerced to accept treatment. B) be committed by her family to receive needed treatment. C) have her family sign permission for treatment. D) continue to refuse treatment.

D

A client has a lithium level of 1.2 mEq/L. Which of the following interventions by the nurse is indicated? A) Call the physician for an increase in dosage. B) Do not give the next dose, and call the physician. C) Increase fluid intake for the next week. D) No intervention is necessary at this time.

D

A client was brought to the emergency department by police after neighbors complained that he was loud and disruptive. The client is paranoid and upset and states, ìNo one can be trusted.î Which of the criteria for involuntary admission does this client meet? A) Dangerous to self. B) Dangerous to others. C) Gravely disabled. D) He does not meet any of the necessary criteria.

D

A malpractice lawsuit was filed after a nurse restrained the client for screaming at and attempting to strike anyone who was within striking distance. The nurse followed agency procedures that were consistent with Joint Commission Standards. For which reason is this malpractice lawsuit most likely to be unsuccessful? A) The nurse did not have a duty. B) The nurse did not breach duty. C) The client did not suffer some type of loss, damage, or injury. D) There was no evidence that a breach of duty was a direct cause of the loss, damage, or injury.

B

D) Report this finding promptly to the physician and remain with the patient.

A nurse is caring for a patient who is postoperative day 1 following neck dissection surgery. The nurse is performing an assessment of the patient and notes the presence of high-pitched adventitious sounds over the patients trachea on auscultation. The patients oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurses most appropriate action? A) Encourage the patient to perform deep breathing and coughing exercises hourly. B) Reposition the patient into a prone or semi-Fowlers position and apply supplementary oxygen by nasal cannula. C) Activate the emergency response system. D) Report this finding promptly to the physician and remain with the patient.

A) A dull, deep ache that is boring in nature

A nurse is caring for a patient whose cancer metastasis has resulted in bone pain. Which of the following are typical characteristics of bone pain? A) A dull, deep ache that is boring in nature B) Soreness or aching that may include cramping C) Sharp, piercing pain that is relieved by immobilization D) Spastic or sharp pain that radiates

C) Alkaline phosphatase

A nurse is caring for a patient with a diagnosis of cancer that has metastasized. What laboratory value would the nurse expect to be elevated in this patient? A) Bilirubin B) Potassium C) Alkaline phosphatase D) Creatinine

Stress on the weakened bone must be avoided.

A nurse is collaborating with the physical therapist to plan the care of a client with osteomyelitis. What principle should guide the management of activity and mobility in this client?

C) Smokes one pack of cigarettes daily.

A nurse is completing a health history on a patient whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the patients health problem? A) Consumes one or more protein drinks daily. B) Takes over-the-counter antacids frequently throughout the day. C) Smokes one pack of cigarettes daily. D) Reports a history of social drinking on a weekly basis.

A nurse is performing safety assessments on a client in mechanical restrains as required by policy. Which action by the nurse demonstrates the ethical principle of nonmaleficence? A) Explaining the behavioral requirements for release of restraint to the client B) Assuring that the restraints are not causing injury to the client C) Applying restraints based solely on assessment findings and not on attitude toward the client D) Releasing the client when stated behavioral control is achieved

B

A patient who has been working on controlling impulsive behavior shows a strengthening ego through which of the following behaviors? A) Going to therapy only when there is nothing more desirable to do B) Weighing the advantages and disadvantages before making a decision C) Telling others in the group the right way to act D) Reporting having fun at a recent social event

B

How old you feel will be determined by your physical and cognitive abilities.

A nurse is educating a group of middle-aged adults on aging. What information should the nurse include in the teaching?

C) Limiting intake of alcohol

A nurse is educating a patient with gout about lifestyle modifications that can help control the signs and symptoms of the disease. What recommendation should the nurse make? A) Ensuring adequate rest B) Limiting exposure to sunlight C) Limiting intake of alcohol D) Smoking cessation

D) Inform the surgeon of this finding.

A nurse is emptying an orthopedic surgery patients closed suction drainage at the end of a shift. The nurse notes that the volume is within expected parameters but that the drainage has a foul odor. What is the nurses best action? A) Aspirate a small amount of drainage for culturing. B) Advance the drain 1 to 1.5 cm. C) Irrigate the drain with normal saline. D) Inform the surgeon of this finding.

A,B,C

A nurse is explaining a patients decreasing bone density in terms of the balance between bone resorption and formation. What dietary nutrients and hormones play a role in the resorption and formation of adult bones? Select all that apply. A) Thyroid hormone B) Growth hormone C) Estrogen D) Vitamin B12 E) Luteinizing hormone

B) Initiating the infusion slowly and monitoring the patients fluid and glucose tolerance

A nurse is initiating parenteral nutrition (PN) to a postoperative patient who has developed complications. The nurse should initiate therapy by performing which of the following actions? A) Starting with a rapid infusion rate to meet the patients nutritional needs as quickly as possible B) Initiating the infusion slowly and monitoring the patients fluid and glucose tolerance C) Changing the rate of administration every 2 hours based on serum electrolyte values D) Increasing the rate of infusion at mealtimes to mimic the circadian rhythm of the body

A patient with depression has been taking paroxetine (Paxil) for the last 3 months and has noticed improvement of symptoms. Which of the following side effects would the nurse expect the patient to report? A) A headache after eating wine and cheese B) A decrease in sexual pleasure during intimacy C) An intense need to move about D) Persistent runny nose

B

A nurse is participating in the emergency care of a client who has just developed variceal bleeding. What intervention should the nurse anticipate?

A nurse is participating in the emergency care of a client who has just developed variceal bleeding. What intervention should the nurse anticipate?

D) IV administration of octreotide (Sandostatin)

A nurse is participating in the emergency care of a patient who has just developed variceal bleeding. What intervention should the nurse anticipate? A) Infusion of intravenous heparin B) IV administration of albumin C) STAT administration of vitamin K by the intramuscular route D) IV administration of octreotide (Sandostatin)

D) Crepitus

A nurse is performing a musculoskeletal assessment of a patient with arthritis. During passive range-of-motion exercises, the nurse hears an audible grating sound. The nurse should document the presence of which of the following? A) Fasciculations B) Clonus C) Effusion D) Crepitus

D) A slightly decreased size of the liver

A nurse is performing an admission assessment for an 81-year-old patient who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding? A) Similar liver size and texture as in younger adults B) A nonpalpable liver C) A slightly enlarged liver with palpably hard edges D) A slightly decreased size of the liver

An adult client is put in restraints after all other attempts to reduce aggression have failed. Which of the following is required now that restraints have been instituted? A) Review of the appropriateness of restraints every 8 hours B) A face-to-face evaluation by a licensed independent practitioner within 1 hour of restraint. C) A documented nursing assessment every 4 hours D) Constant one-on-one supervision during the first hour and then video monitoring

B

C) The familys ability to provide emotional support

A nurse is planning discharge teaching for a 21-year-old patient with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the patients coping after discharge? A) The familys ability to take care of the patients special diet needs B) The familys ability to monitor the patients changing health status C) The familys ability to provide emotional support D) The familys ability to manage the patients medication regimen

A patient is blaming his impending divorce on the fact that his wife goes out frequently with her girlfriends. If using reality therapy, the nurse would help the patient with which of the following responses? A) ìIf you really love her, she should love you as well.î B) ìWhat does being divorced mean for you?î C) ìHow do you feel about your marriage ending?î D) ìWhat role do you think you have played in the end of your marriage?î

D

"It can evaluate the presence and location of ductal stones and aid in stone removal." "It can assess the anatomy of the pancreas and the pancreatic and biliary ducts." "It can detect unhealthy tissues in the pancreas and assess for abscesses and pseudocysts."

A nurse is preparing a client for endoscopic retrograde cholangiopancreatography (ERCP). The client asks what this test is used for. Which statements by the nurse explains how ERCP can determine the difference between pancreatitis and other biliary disorders? Select all that apply.

B) Impaired Skin Integrity

A nurse is preparing a plan of care for a patient with pancreatic cysts that have necessitated drainage through the abdominal wall. What nursing diagnosis should the nurse prioritize? A) Disturbed Body Image B) Impaired Skin Integrity C) Nausea D) Risk for Deficient Fluid Volume

The family members of a patient with bipolar disorder express frustration with the unpredictable behaviors of their loved one. Which group should the nurse suggest as most helpful to this family? A) Family therapy group B) Family education group C) Psychotherapy group D) Self-help support group

B

The goal of the 1963 Community Mental Health Centers Act was to A) ensure patients' rights for the mentally ill. B) deinstitutionalize state hospitals. C) provide funds to build hospitals with psychiatric units. D) treat people with mental illness in a humane fashion.

B

The nurse has established a therapeutic relationship with a patient. The patient is beginning to share feelings openly with the nurse. The relationship has entered which phase according to Peplau's theory? A) Orientation B) Identification C) Exploitation D) Resolution

B

The nurse is assessing the factors contributing to the well-being of a newly admitted client. Which of the following would the nurse identify as having a positive impact on the individual's mental health? A) Not needing others for companionship B) The ability to effectively manage stress C) A family history of mental illness D) Striving for total self-reliance

B

The nurse is attending an in-service training on safe take-down techniques for aggressive clients. Preparation for safe physical handling prepares the nurse to practice which ethical principle? A) Veracity B) Nonmaleficence C) Justice D) Autonomy

B

The primary advantage of an evolving consumer household is that clients A) are provided with adequate income to combat poverty. B) do not have to relocate as they become more independent. C) have on-site staff supervision 24 hours a day. D) receive on-site medical care.

B

The primary purpose for generalist nurses to develop skills with psychosocial interventions is A) psychosocial interventions are included on the nursing licensure examinations. B) psychosocial interventions are needed in all nursing practice settings. C) nurses will be consulted to assist in the care of psychiatric patients in acute care settings. D) there are a growing number of nursing practice opportunities in mental health settings.

B

Which of the following antidepressant drugs is a preferred drug for clients at high risk of suicide? A) Tranylcypromine (Parnate) B) Sertraline (Zoloft) C) Imipramine (Tofranil) D) Phenelzine (Nardil)

B

Which of the following factors is primarily responsible for the changes in inpatient hospital treatment between the 1980s and the present? A) Progress in treatment options for mentally ill persons B) The growth of managed care C) Less stigma associated with mental illness D) The current use of milieu therapy

B

Which of the following is a standard of practice? A) Quality of care B) Outcome identification C) Collegiality D) Performance appraisal

B

Which of the following is a standard of professional performance? A) Assessment B) Education C) Planning D) Implementation

B

During the initial interview with a client in crisis, the initial priority is to A) assess the adequacy of the support system. B) assess for substance use. C) determine the precrisis level of functioning. D) evaluate the potential for self-harm.

D

For a client taking clozapine (Clozaril), which of the following symptoms should the nurse report to the physician immediately as it may be indicative of a potentially fatal side effect? A) Inability to stand still for 1 minute B) Mild rash C) Photosensitivity reaction D) Sore throat and malaise

D

In planning for a client's discharge, the nurse must know that the most serious risk for the client taking a tricyclic antidepressant is which of the following? A) Hypotension B) Narrow-angle glaucoma C) Seizures D) Suicide by overdose

D

Patients on an inpatient psychiatric unit can earn off-unit privileges for daily use of socially appropriate behavior. This is an example of employing which concept of behavior modification? A) Systematic desensitization B) Negative reinforcement C) Classical conditioning D) Operant conditioning

D

Placing a client in restraints before using other methods of intervention violates which of the client's rights? A) Receive confidential and respectful care B) Provide informed consent C) Refuse treatment D) Receive treatment in the least restrictive environment

D

Atelectasis Pneumonia Hemorrhage

A nurse is providing care for a client who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply.

The nurse is part of a group setting up a mobile crisis service in conjunction with the local police department. Community education on which of the following this team will focus includes? A) Teaching police officers counseling skills B) Crisis counseling services to be provided in the prison system C) Educating about the dangers of the mentally ill in the community D) Assisting police officers to recognize mental illness

D

SIADH

-Excessive secretion of ADH (Water Retaining hormone), & HYPOnatremia (water intoxication) -*Clinical Manifestations*: Cerebral edema; headache, muscle weakness, muscle changes, weight gain, personality changes, confusion, irritability, seizures, coma

Kubler-Ross stages of grief

1. Denial- shock/disbelief 2. Anger- expressed towards god, family, friends or healthcare providers 3. Bargaining- asking god or fate for more time; delay the inevitable 4. Depression- awareness of loss becomes acute 5. Acceptance- coming to terms with the loss

Chloride

97-107

Underweight BMI

<18.5

A basic assumption of Freud's psychoanalytic theory is that A) all human behavior can be caused and can be explained. B) human behavior is entirely unconscious. C) free association is the key to understanding. D) sexuality does not relate to behavior.

A

Which of the following is a neuromodulator? A) Neuropeptides B) Glutamate C) Dopamine D) GABA

A

The presence of a tingling sensation

A nurse is assessing a client who has diabetes for the presence of peripheral neuropathy. The nurse should question the client about what sign or symptom that would suggest the possible development of peripheral neuropathy?

ABD

A nurse is caring for a patient who has been admitted to the hospital with diverticulitis. Which of the following would be appropriate nursing diagnoses for this patient? Select all that apply. A) Acute Pain Related to Increased Peristalsis and GI Inflammation B) Activity Intolerance Related to Generalized Weakness C) Bowel Incontinence Related to Increased Intestinal Peristalsis D) Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea E) Impaired Urinary Elimination Related to GI Pressure on the Bladder

Encircle the client's neck with both hands, have the client slightly extend his neck, and ask him to swallow.

A nurse is preparing to palpate a client's thyroid gland. Which action by the nurse is appropriate?

A) Patient will accurately identify foods that trigger symptoms.

A nurse is providing care for a patient who has a diagnosis of irritable bowel syndrome (IBS). When planning this patients care, the nurse should collaborate with the patient and prioritize what goal? A) Patient will accurately identify foods that trigger symptoms. B) Patient will demonstrate appropriate care of his ileostomy. C) Patient will demonstrate appropriate use of standard infection control precautions. D) Patient will adhere to recommended guidelines for mobility and activity.

Ultrasonography

A patient is admitted to the hospital with possible cholelithiasis. What diagnostic test of choice will the nurse prepare the patient for?

BCD

A nurse is providing care for a patient who is postoperative day 2 following gastric surgery. The nurses assessment should be planned in light of the possibility of what potential complications? Select all that apply. A) Malignant hyperthermia B) Atelectasis C) Pneumonia D) Metabolic imbalances E) Chronic gastritis

A) Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food.

A patient presents at the walk-in clinic complaining of recurrent sharp stomach pain that is relieved by eating. The nurse suspects that the patient may have an ulcer. How would the nurse explain the formation and role of acid in the stomach to the patient? A) Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food. B) As digestion occurs in the stomach, the stomach combines free hydrogen ions from the food to form acid. C) The body requires an acidic environment in order to synthesize pancreatic digestive enzymes; the stomach provides this environment. D) The acidic environment in the stomach exists to buffer the highly alkaline environment in the esophagus.

D) Gangrene of the gallbladder

A patient presents to the emergency department (ED) complaining of severe right upper quadrant pain. The patient states that his family doctor told him he had gallstones. The ED nurse should recognize what possible complication of gallstones? A) Acute pancreatitis B) Atrophy of the gallbladder C) Gallbladder cancer D) Gangrene of the gallbladder

A) Make sure you dont bring your knees close together.

A patient was brought to the emergency department after a fall. The patient is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize? A) Make sure you dont bring your knees close together. B) Try to lie as still as possible for the first few days. C) Try to avoid bending your knees until next week. D) Keep your legs higher than your chest whenever you can.

C) Promoting maximum shoulder function

A patient who has had a radical neck dissection is being prepared for discharge. The discharge plan includes referral to an outpatient rehabilitation center for physical therapy. What would the goals of physical therapy for this patient include? A) Muscle training to relieve dysphagia B) Relieving nerve paralysis in the cervical plexus C) Promoting maximum shoulder function D) Alleviating achalasia by decreasing esophageal peristalsis

Need exogenous insulin.

A patient who is diagnosed with type 1 diabetes would be expected to:

C) Regurgitation and aspiration are less likely.

A patient who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The patient has since become comatose and the patients family asks the nurse why the physician is recommending the removal of the patients NG tube and the insertion of a gastrostomy tube. What is the nurses best response? A) It eliminates the risk for infection. B) Feeds can be infused at a faster rate. C) Regurgitation and aspiration are less likely. D) It allows caregivers to provide personal hygiene more easily.

C) Positioning the patient to prevent gastric reflux

A patient who underwent surgery for esophageal cancer is admitted to the critical care unit following postanesthetic recovery. Which of the following should be included in the patients immediate postoperative plan of care? A) Teaching the patient to self-suction B) Performing chest physiotherapy to promote oxygenation C) Positioning the patient to prevent gastric reflux D) Providing a regular diet as tolerated

A) Metoclopramide (Reglan)

A patient with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the patient may be prescribed what drug? A) Metoclopramide (Reglan) B) Omeprazole (Prilosec) C) Lansoprazole (Prevacid) D) Famotidine (Pepcid)

Transjugular intrahepatic portosystemic shunting (TIPS)

A patient with bleeding esophageal varices has had pharmacologic therapy with Octreotide (Sandostatin) and endoscopic therapy with esophageal varices banding, but the patient has continued to have bleeding. What procedure that will lower portal pressure does the nurse prepare the patient for?

age

A physically fit 86-year-old is scheduled for right knee replacement. Which factor the client at increased risk for complications during or after surgery?

Educate on activity limitations. Discuss wound care. Have the spouse review when to notify the physician. Provide information on health promotion topics.

A postoperative client is being discharged home after minor surgery. The PACU nurse is reviewing discharge instructions with the client and the client's spouse. What actions by the nurse are appropriate? Select all that apply.

Quickly attempt to determine the cause of hemorrhage.

A postoperative client rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the client is experiencing a hemorrhage. What should be the nurse's first action?

B) Arthritis

A public health nurse is organizing a campaign that will address the leading cause of musculoskeletal-related disability in the United States. The nurse should focus on what health problem? A) Osteoporosis B) Arthritis C) Hip fractures D) Lower back pain

Trousseau's sign

A sign of hypocalcemia . Carpal spasm caused by inflating a blood pressure cuff above the client's systolic pressure and leaving it in place for 3 minutes.

B

A young female immigrant presents in the rural health clinic with facial bruising and a fractured nose. The client is reluctant to give details of the nature of her injuries. Which of the following should be a consideration in providing care for this client? A) Most views regarding domestic violence are universal across cultures. B) She may fear deportation if she seeks public assistance. C) Immigrants have expedited access to public legal services. D) The nurse should ignore the details and focus on treatment.

A

A young woman telephones the emergency department and loudly tells the nurse, ìI've been raped! Please help me!î Which of the following is the priority for the nurse to determine? A) If the client was in a safe place, her condition, and if transportation is available B) If the client knew her assailant, knew her location, and had notified the police C) If the client has insurance, if she could get to the hospital by herself, and if pregnancy is a possibility D) If the client had bathed, douched, or changed clothes

Which of the following dilemmas involve the ethical principle of fidelity? Select all that apply. A) When the nurse is unable to agree with the policies or common practices of an agency B) When the nurse is faced with a decision to violate a policy that is harmful to the client C) When the nurse is certain that clients of different racial and ethnic backgrounds are being treated the same as other clients D) When the nurse understands that a combative client must be secluded against their will to prevent harm to others E) When the client refuses to take medication and the nurse respects the client's right to refuse medication

AB

Which of the following are core skill areas that are needed of any effective team member of an interdisciplinary team? Select all that apply. A) Interpersonal skills B) Teamwork skills C) Communication skills D) The ability to work independently E) Risk assessment and risk management skills

ABCE

Under which conditions would it be in the client's best interest for the court to appoint a conservator, or legal guardian? Select all that apply. A) Gravely disabled B) Mentally incompetent C) Noncompliant D) Unable to provide basic needs when resources exist E) Act only on his or her own interests

ABD

D

After being laid off from work, a client becomes increasingly withdrawn and fatigued, spends entire days in bed, is unkempt, and is eating and sleeping poorly. The nurse would recognize that the client is in which stage of grieving, according to Kubler-Ross? A) Anger B) Bargaining C) Denial D) Depression

potassium

After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent dysrhythmias?

Fluids must be increased to facilitate the evacuation of the stool.

An adult client is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the client has completed the test?

Loss related to self-actualization

An external or internal crisis that blocks or inhibits striving toward fulfillment may threaten personal goals and individual potential. A person who wanted to go to college, write books, and teach at a university reaches a point in life when it becomes evident that those plans will never materialize. Or a person loses hope that he or she will find a mate and have children. These are losses that the person will grieve.

myxedema coma.

An incoherent client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and periorbital area. Knowing that these findings suggest severe hypothyroidism, the nurse prepares to take emergency action to prevent the potential complication of:

Absence of reflexes Diminished ability to communicate Loss of pain sensation

An intraoperative nurse is applying interventions that will address surgical clients' risks for perioperative positioning injury. What factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply.

Diabetes mellitus is more common in Hispanics and Blacks than in Whites.

An obese Hispanic client, age 65, is diagnosed with type 2 diabetes. Which statement about diabetes mellitus is true?

Risk for falls related to polypharmacy and impaired balance

An older adult client has returned to the community following knee replacement surgery. The community health nurse recognizes that the client has prescriptions for nine different medications for the treatment of varied health problems. In addition, she has experienced occasional episodes of dizziness and lightheadedness since her discharge. The nurse should identify which of the following nursing diagnoses?

Assess for the potential for self-harm.

An older adult has a score of 12 on the Geriatric Depression Scale (GDS). What action should the nurse complete first?

Evaluate the client's understanding of the procedure.

As a nurse completes the admission assessment of a client admitted for gastric bypass surgery, the client states, "Finally! I'll be thin and able to eat without much concern." How should the nurse intervene?

A client grieving the recent loss of her husband asks if she is becoming mentally ill because she is so sad. The nurse's best response would be, A) ìYou may have a temporary mental illness because you are experiencing so much pain.î B) ìYou are not mentally ill. This is an expected reaction to the loss you have experienced.î C) ìWere you generally dissatisfied with your relationship before your husband's death?î D) ìTry not to worry about that right now. You never know what the future brings.î

B

Which cognitive mode, according to Harry Stack Sullivan, begins in early childhood as the child begins to connect experiences in sequence? A) Prototaxic mode B) Parataxic mode C) Bitaxic mode D) Syntaxic mode

B

Which one of the following is an important characteristic of an effective therapistñclient relationship in individual psychotherapy? A) Homogeneity between the client and the therapist. B) Mutual benefit for the client and the therapist. C) The client must adapt to the therapist's style of therapy and theoretical beliefs. D) Match between the theoretical beliefs and style of therapy and the client's needs and expectations of therapy.

B

Which one of the following types of antipsychotic medications is most likely to produce extrapyramidal effects? A) Atypical antipsychotic drugs B) First-generation antipsychotic drugs C) Third-generation antipsychotic drugs D) Dopamine system stabilizers

B

Which of the following are advantages of a crisis resolution team or home treatment team? Select all that apply. A) It is a residential treatment setting. B) It is more likely to help a client to perceive his or her situation more accurately. C) It is designed to assist clients in dealing with mental health crises without hospitalization. D) The client may feel better about asking for help. E) The client must meet multiple criteria to receive this type of

BCD

Which of the following are examples of adventitious crises? Select all that apply. A) Death of a loved one B) Natural disasters C) Violent crimes D) War E) Leaving home for the first time

BCD

A client begins to take stock of his life and look into the future. The nurse assesses that this client is in which of Erikson's developmental stages? A) Identity versus role confusion B) Industry versus inferiority C) Integrity versus despair D) Generativity versus stagnation

C

A client underwent a procedure before the nurse verified the client's signature on the consent form. The client actually did not sign the form before the procedure. If the client is dissatisfied with the outcome of the procedure and files a suit against the health-care team, which kind of case can the client file? A) Negligence B) Malpractice C) Battery D) False Imprisonment

C

A client who had agreed to be hospitalized for depression problems has decided that now she wants to leave the hospital. The mental health staff caring for her realizes that at present she can legally A) be discharged if evaluated through administrative hearings. B) be retained in the hospital against her will. C) leave the hospital after giving written notice of her intent to do so. D) leave without discussing the situation with anyone.

C

Which of the following statements is true of treatment of people with mental illness in the United States today? A) Substance abuse is effectively treated with brief hospitalization. B) Financial resources are reallocated from state hospitals to community programs and support. C) Only 25% of people needing mental health services are receiving those services. D) Emergency department visits by persons who are acutely disturbed are declining.

C

Which of the following was the first nonstimulant medication specifically designed and tested for ADHD? A) Methylphenidate (Ritalin) B) Amphetamine (Adderall) C) Atomoxetine (Strattera) D) Pemoline (Cylert)

C

Which one of the following drugs should the nurse expect the patient to require serum level monitoring? A) Anticonvulsants B) Wellbutrin C) Lithium D) Prozac

C

Which one of the following is one of the American Nurses Association standards of practice for psychiatricñmental health nursing? A) Prescriptive authority is granted to psychiatricñmental health registered nurses. B) All aspects of Standard 5: Implementation may be carried out by psychiatricñmental health registered nurses. C) Some aspects of Standard 5: Implementation may only be carried out by psychiatricñmental health advanced practice nurses. D) Psychiatricñmental health advanced practice nurses are the only ones who may provide milieu therapy.

C

A client is seen in the clinic with clinical manifestations of an inability to sit still and a rigid posture. These side effects would be correctly identified as which of the following? A) Tardive dyskinesia B) Neuroleptic malignant syndrome C) Dystonia D) Akathisia

D

A patient is being admitted to an inpatient unit for treatment of anorexia nervosa. Of the following assessment data, which should the nurse place as highest priority in the plan of care? A) Weight 24% below normal for height B) Distorted body image C) Feelings of inadequacy D) Frequent vomiting after meals

D

The priority of inpatient care for people with severe mental illness is A) family issues. B) insight into illness. C) social skills. D) symptom management.

D

Which drug classification is the primary medication treatment for schizophrenia? A) Anticoagulants B) Antidepressants C) Antimanics D) Antipsychotics

D

neuropeptides

Enhance, prolong, inhibit or limit the effecrts of principal neurotransmitters

histrionic personality disorder

Excessive emotionality and attention seeking Nursing Interventions: Teach social skills; provide factual feedback about behavior

Assess the grandmother for adventitious lung sounds

Family members report to the nurse that their elderly grandmother has had a sudden onset of confusion and that they are having difficulty providing care for her. What is the nurse's best response?

Petechiae possibly due to a transient thrombocytopenia Substernal chest pain Hypoxia

Fat emboli are a major cause of death for patients with fractures. What are the significant signs and symptoms? Select all that apply.

Maintaining room temperature in the low-normal range

For a client with Graves' disease, which nursing intervention promotes comfort?

A

Friends of a teenage male recently killed in a car accident are discussing their sense of loss. Which of the following comments best indicates that the friends are trying to make sense of the loss cognitively? A) ìWhy did he have to die so young?î B) ìHe shouldn't have been driving so recklessly.î C) ìIf we had only stayed longer, he would not have been on that road.î D) ìIt took the ambulance too long to get there.î

narcissistic personality disorder

Grandiose; lack of empathy; need for admiration Nursing Interventions: Matter-of-fact approach; gain cooperation with needed treatment; teach client any needed self-care skills

There is a deficiency of activated vitamin D (calcitriol). Calcium and phosphate are not moved to the bones. The bone mass is structurally weaker, and bone deformities occur.

Identify descriptors of the pathophysiologic process seen in osteomalacia. Select all that apply.

B

In the psychiatric setting, what is the most effective intervention in preventing the hostile client's behavior from escalating to physical aggression? A) Getting as far away from him or her as possible B) Engaging the hostile person in dialogue C) Yelling at the client to settle down now D) Ensuring that the client gets his or her way

C

Kubler-Ross developed a model of five stages to explain what people experience as they grieve and mourn. Which is stage V of Kubler-Ross's stages of grieving? A) Denial B) Bargaining C) Acceptance D) Anger

C) Frequent lung auscultation

A nurse is providing care for a patient with a diagnosis of late-stage Alzheimers disease. The patient has just returned to the medical unit to begin supplemental feedings through an NG tube. Which of the nurses assessments addresses this patients most significant potential complication of feeding? A) Frequent assessment of the patients abdominal girth B) Assessment for hemorrhage from the nasal insertion site C) Frequent lung auscultation D) Vigilant monitoring of the frequency and character of bowel movements

dumping syndrome

A nurse is providing follow-up teaching at a clinic visit for a client recovering from gastric resection. The client reports sweating, diarrhea, nausea, palpitations, and the desire to lie down 15 to 30 minutes after meals. Based on the client's assessment, what will the nurse suspect?

2500mL -2900mL

Normal daily urine output range is what?

2600mL

Normal fluid intake daily is how many mLs

ASR Aspartate aminotransferase

Not specific to the liver but sig elevated with metastatic disease to the liver

Depression

Nursing students are reviewing different types of mental health problems in the older adult population. The students demonstrate an understanding of this information when they identify which condition as the most common affective disorder?

depression

Nursing students are reviewing different types of mental health problems in the older adult population. The students demonstrate an understanding of this information when they identify which condition as the most common affective disorder?

obsessive-compulsive disorder

Preoccupation with orderliness, perfectionism, and control Nursing Interventions: Encourage negotiation with others; assist client to make timely decisions and complete work; cognitive restructuring techniques

C) Determining the patients ability to understand and cooperate with the procedure

Prior to a patients scheduled jejunostomy, the nurse is performing the preoperative assessment. What goal should the nurse prioritize during the preoperative assessment? A) Determining the patients nutritional needs B) Determining that the patient fully understands the postoperative care required C) Determining the patients ability to understand and cooperate with the procedure D) Determining the patients ability to cope with an altered body image

chronic pancreatitis

Progressive inflammatory disorder with struction of the pancreas, cells are replaced by fibrous tissue, pressure within the pancreas increases, obstructing the pancreatic and common bile ducts

D) Brushing the patients teeth with a toothbrush and small amount of toothpaste

A nurse is providing oral care to a patient who is comatose. What action best addresses the patients risk of tooth decay and plaque accumulation? A) Irrigating the mouth using a syringe filled with a bacteriocidal mouthwash B) Applying a water-soluble gel to the teeth and gums C) Wiping the teeth and gums clean with a gauze pad D) Brushing the patients teeth with a toothbrush and small amount of toothpaste

Side effects of benzodiazepines

Sedation Dizzy Weakness Atazia Decreased motor performance Dependence Withdrawl

1 hour

Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding?

Cosmetic Diagnostic Palliative

Several of the clients at the clinic are preparing to have surgery within the next 2 weeks. They are completing preoperative paperwork today with their visit. What are some of the reasons that people might need to have surgery? Select all that apply.

Clay-colored stools Dark urine Jaundice Pruritis

Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region obstruct the common bile duct. Which of the following clinical manifestations would indicate a common bile duct obstruction associated with a tumor in the head of the pancreas? Choose all that apply.

avoidant personality disorder

Social inhibitions; feelings of inadequacy; hypersensitive to negative evaluation Nursing Interventions: Support and reassurance; cognitive restructuring techniques; promote self-esteem

ventricles

Some patents that have schizophrenia have been shown to have enlarged ____________ on CT scans

chvostek sign

Spasm of facial muscles after a tap over the facial nerve; evidence of tetany; hypocalcemia

C) Flat bones

The human body is designed to protect its vital parts. A fracture of what type of bone may interfere with the protection of vital organs? A) Long bones B) Short bones C) Flat bones D) Irregular bones

depression

The most common affective or mood disorder of old age is

Alterations in mood Agitation Insomnia

The nurse is assessing a client with hepatic cirrhosis for mental deterioration. For what clinical manifestations will the nurse monitor? Select all that apply.

by occluding the blood flow to the arm for 3 minutes with the use of a blood pressure cuff.

Trousseau sign is elicited

Urine excretion

What does the nurse understand is the primary method by which fluid volume is regulated?

A

When teaching a client with generalized anxiety disorder, which is the highest priority for the nurse to teach the client to avoid? A) Caffeine B) High-fat foods C) Refined sugars D) Sodium

ABCE

Which of the following are cognitiveñbehavioral therapy techniques that may be used effectively with anxious clients? Select all that apply. A) Positive reframing B) Decatastrophizing C) Assertiveness training D) Humor E) Unlearning

C

Which one of the following statements regarding intimate partner violence is true? A) Males are never the victim in intimate partner violence. B) It is common for abusers to use one type of abuse only. C) Intimate partner violence can exist with former partners. D) Psychological abuse is not as harmful as physical abuse.

"When is the last time you ate or drank?"

Which question is most important for the nurse to ask the client when obtaining the preoperative admission history?

presbyopia

Which refers to the decrease in lens flexibility that occurs with age, resulting in the near point of focus getting farther away?

grief

_______ can precipitate major depression in a person with a history of the disorder

fear

________ can trigger anxiety

sleep disturbances

___________ ___________are among the most frequent and persistent bereavement Associated symptoms

C) It protects the stomachs lining

A nurse is providing patient education for a patient with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. The patient has recently been prescribed misoprostol (Cytotec). What would the nurse be most accurate in informing the patient about the drug? A) It reduces the stomachs volume of hydrochloric acid B) It increases the speed of gastric emptying C) It protects the stomachs lining D) It increases lower esophageal sphincter pressure

asterixis

an involuntary flapping of the hands may be seen in stage 2 and cephalopathy

C) Youll need to have enemas the day before the test.

A nurse is providing preprocedure education for a patient who will undergo a lower GI tract study the following week. What should the nurse teach the patient about bowel preparation? A) Youll need to fast for at least 18 hours prior to your test. B) Starting today, take over-the-counter stool softeners twice daily. C) Youll need to have enemas the day before the test. D) For 24 hours before the test, insert a glycerin suppository every 4 hours.

constructional apraxia

inability to reproduce a simple figure in two or three dimensions is referred to as what

Panic anxiety

intense anxiety, may be a response to a life-threatening situation

urgent surgery

occurs when the client requires prompt attention

Qsymia

prescribed weight loss medication that can be taken over long period of time

Xenical

prescripting weight loss drug that inhibits fat absorption and is approved for loner term use (2years) Sold over the counter as Alli

acute pancreatitis

presents with fever, jaundice, confusion, agitation, ecchymosis in the flank or umbilical area, and abdominal guarding

acromegaly

progressive enlargement of peripheral body parts resulting from excessive secretion of growth hormone

promotes secretion of milk

prolactin

cognitive response

questioning, trying to make sense of loss Attempting to keep lost one present "why did this have to happen? He took such good care of himself?' "Why did such a young person have to die?' What type of response is this?

tenesmus

refers to ineffectual straining at stool. Azotorrhea refers to excess of nitrogenous matter in the feces or urine

diverticulitits

refers to inflammation of a diverticulum from obstruction (by fecal matter) resulting in abscess formation.

Distress

refers to negative stress

Efficacy

refers to the max therapeutic effect the drug can achieve

Orthodox Jewish Americans

relative staying with dying person; body covered with sheet; eyes closed; burial within 24 hours of death unless Sabbath; Shiva

hypophysectomy

removal of the pituitary gland

rumination

repeatedly thinking and talking about past experiences; can contribute to depression

Obstructive Jaundice

resulting from extra hepatic obstruction may be caused by occlusion of the bile duct from a gallstone and inflammatory process, a tumor, or pressure from an enlarged organ dark organge-brown urine, steattorhea dyspepsia and intolerance of fats, impaired digestion pruritus can not flow normally into intestines and backs up into the liver

death of a spouse or a child, death of a parent, sudden unexpected untimely death, multiple deaths, death by Suicide or murder

risk factors leading to vulnerability

Examples of disenfranchised grief

same-sex relationships, cohabitation without marriage and extramarital affairs further examples include: prenatal death, abortion, relinquishing a child for adoption, death of a pet, job loss, separation, divorce, and children leaving home

exocrine

secreting externally; hormonal secretion from excretory ducts

endocrine

secreting internally; hormonal secretion of a ductless gland

myxedema

severe hypothyroidism

secondary gain

the internal or personal benefits received from others because one is sick, such as attention from family members, comfort measures, and being excused from usual responsibilities or tasks

adrenal function

A nurse is reviewing the laboratory order for a client suspected of having an endocrine disorder. The lab slip includes obtaining cortisol levels. What is being tested?

A) Evaluating the effects of the musculoskeletal disorder on the patients function

A nurse is taking a health history on a patient with musculoskeletal dysfunction. What is the primary focus of this phase of the nurses assessment? A) Evaluating the effects of the musculoskeletal disorder on the patients function B) Evaluating the patients adherence to the existing treatment regimen C) Evaluating the presence of genetic risk factors for further musculoskeletal disorders D) Evaluating the patients active and passive range of motion

A) A 65-year-old man with alcoholism who smokes

A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What patient most likely faces the highest immediate risk of oral cancer? A) A 65-year-old man with alcoholism who smokes B) A 45-year-old woman who has type 1 diabetes and who wears dentures C) A 32-year-old man who is obese and uses smokeless tobacco D) A 57-year-old man with GERD and dental caries

An older client has less subcutaneous tissue and less muscle mass than a younger client.

A nurse will conduct an influenza vaccination campaign at an extended care facility. The nurse will be administering intramuscular (IM) doses of the vaccine. Of what age-related change should the nurse be aware when planning the appropriate administration of this drug?

C) Scoliosis

A nurses assessment of a teenage girl reveals that her shoulders are not level and that she has one prominent scapula that is accentuated by bending forward. The nurse should expect to read about what health problem in the patients electronic health record? A) Lordosis B) Kyphosis C) Scoliosis D) Muscular dystrophy

D) Maintaining fluid and electrolyte balance

A patient has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurses care should prioritize which of the following outcomes? A) Preventing infection B) Maintaining skin and tissue integrity C) Preventing nausea and vomiting D) Maintaining fluid and electrolyte balance

D) Hospice care

A patient has been diagnosed with pancreatic cancer and has been admitted for care. Following initial treatment, the nurse should be aware that the patient is most likely to require which of the following? A) Inpatient rehabilitation B) Rehabilitation in the home setting C) Intensive physical therapy D) Hospice care

Oliguria Tachycardia Tachypnea

A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanisms associated with hypovolemia would cause what clinical manifestations? (Select all that apply.)

B) Risk For Impaired Skin Integrity Related to Peptic Ulcers

A patient has been scheduled for a urea breath test in one months time. What nursing diagnosis most likely prompted this diagnostic test? A) Impaired Dentition Related to Gingivitis B) Risk For Impaired Skin Integrity Related to Peptic Ulcers C) Imbalanced Nutrition: Less Than Body Requirements Related to Enzyme Deficiency D) Diarrhea Related to Clostridium Difficile Infection

A) Colonoscopy

A patient has come to the outpatient radiology department for diagnostic testing. Which of the following diagnostic procedures will allow the care team to evaluate and remove polyps? A) Colonoscopy B) Barium enema C) ERCP D) Upper gastrointestinal fibroscopy

C) Promotion of adequate nutrition

A patient has undergone rigid fixation for the correction of a mandibular fracture suffered in a fight. What area of care should the nurse prioritize when planning this patients discharge education? A) Resumption of activities of daily living B) Pain control C) Promotion of adequate nutrition D) Strategies for promoting communication

C) Placing the patient in Fowlers position

A patient has undergone surgery for oral cancer and has just been extubated in postanesthetic recovery. What nursing action best promotes comfort and facilitates spontaneous breathing for this patient? A) Placing the patient in a left lateral position B) Administering opioids as ordered C) Placing the patient in Fowlers position D) Teaching the patient to use the patient-controlled analgesia (PCA) system

C) Cortical bone

A patient injured in a motor vehicle accident has sustained a fracture to the diaphysis of the right femur. Of what is the diaphysis of the femur mainly constructed? A) Epiphyses B) Cartilage C) Cortical bone D) Cancellous bone

C) Bucks extension traction

A patient is admitted to the unit in traction for a fractured proximal femur and requires traction prior to surgery. What is the most appropriate type of traction to apply to a fractured proximal femur? A) Russells traction B) Dunlops traction C) Bucks extension traction D) Cervical head halter

Ketosis-prone Little endogenous insulin Younger than 30 years of age

A patient is diagnosed with type 1 diabetes. What clinical characteristics does the nurse expect to see in this patient? Select all that apply.

Hang a solution of dextrose 10% and water until the new solution is available.

A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate?

The moon face and acne will resolve when the medication is tapered off.

A patient taking corticosteroids for exacerbation of Crohn's disease comes to the clinic and informs the nurse that he wants to stop taking them because of the increase in acne and moon face. What can the nurse educate the patient regarding these symptoms?

B) Assess the surgical site and the affected extremity.

A patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of a new onset of pain at the surgical site. What is the nurses best action? A) Administer pain medication as ordered. B) Assess the surgical site and the affected extremity. C) Reassure the patient that pain is a direct result of increased activity. D) Assess the patient for signs and symptoms of systemic infection.

D) An internal retention disc secures the tube against the stomach wall.

A patient with dysphagia is scheduled for PEG tube insertion and asks the nurse how the tube will stay in place. What is the nurses best response? A) Adhesive holds a flange in place against the abdominal skin. B) A stitch holds the tube in place externally. C) The tube is stitched to the abdominal skin externally and the stomach wall internally. D) An internal retention disc secures the tube against the stomach wall.

A) The patient will require an upper endoscopy every 6 months to detect malignant changes.

A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barretts esophagus with minor cell changes. Which of the following principles should be integrated into the patients subsequent care? A) The patient will require an upper endoscopy every 6 months to detect malignant changes. B) Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage. C) Small amounts of blood are likely to be present in the stools and are not cause for concern. D) Antacids may be discontinued when symptoms of heartburn subside.

ABCD

A patient with pancreatic cancer has been scheduled for a pancreaticoduodenectomy (Whipple procedure). During health education, the patient should be informed that this procedure will involve the removal of which of the following? Select all that apply. A) Gallbladder B) Part of the stomach C) Duodenum D) Part of the common bile duct E) Part of the rectum

Weigh the client every day. Check blood glucose level every 6 hours. Document intake and output.

The client cannot tolerate oral feedings due to an intestinal obstruction and is NPO. A central line has been inserted, and the client is being started on parenteral nutrition (PN). What actions would the nurse perform while the client receives PN? Select all that apply.

C

The client says to the nurse, ìI really want to see my first grandchild born before I die. Is that too much to ask?î The nurse would recognize that the client is in which stage of grieving, according to Kubler-Ross? A) Acceptance B) Anger C) Bargaining D) Depression

the increased potential for aspiration.

The most significant complication related to continuous tube feedings is

joint stiffness decreased range of motion decreased endurance

The nurse is admitting an older adult to a skilled nursing facility. What assessment parameters will the nurse expect to find with the musculoskeletal assessment? Select all that apply.

Osteomalacia

Which condition is a metabolic bone disease characterized by inadequate mineralization of bone?

BCD

Which of the following are critical components to assess in a grieving person? Select all that apply. A) Genetic risk B) Perception of the loss C) Support system D) Coping behaviors E) Religion

strain

injury to a muscle or tendon from overuse, overstretching, or excessive stress may cause what

physiologic

loss of limb, hysterectomy, loss of mobility what type of loss is this?

D) Antibiotics, proton pump inhibitors, and bismuth salts

32. A patient has been diagnosed with peptic ulcer disease and the nurse is reviewing his prescribed medication regimen with him. What is currently the most commonly used drug regimen for peptic ulcers? A) Bismuth salts, antivirals, and histamine-2 (H2) antagonists B) H2 antagonists, antibiotics, and bicarbonate salts C) Bicarbonate salts, antibiotics, and ZES D) Antibiotics, proton pump inhibitors, and bismuth salts

A nurse is questioning whether it is ethical to seclude a client because of loud and intrusive behavior on the unit. What is the ethical principle that will best guide the decision on appropriate use of seclusion? A) Autonomy B) Beneficence C) Justice D) Veracity

A

A patient is being seen in the crisis unit reporting that poison letters are coming in the mail. The patient has no history of psychiatric illness. Which of the following medications would the patient most likely be started on? A) Aripiprazole (Abilify) B) Risperidone (Risperdal Consta) C) Fluphenazine (Prolixin) D) Fluoxetine (Prozac)

A

A patient with bipolar disorder has a long history of both hospitalizations and incarcerations. The patient has no permanent residence and has infrequent contact with his family. Upon admission to the inpatient psychiatric unit for stabilization, the nurse documents all of the following in the record. Which of the following data most suggests a positive outcome for this patient? A) Reporting meeting with the same case manager monthly for the last 3 years B) History of residential stays at several local homeless shelters C) Last contact with siblings 4 years ago D) Income from day labor for 10 days last month

A

The legislation enacted in 1963 was largely responsible for which of the following shifts in care for the mentally ill? A) The widespread use of community-based services B) The advancement in pharmacotherapies C) Increased access to hospitalization D) Improved rights for clients in long-term institutional care

A

The nurse is assessing a patient suffering a head injury as a result of an altercation with two other individuals. The patient has difficulty accurately reporting the events of the altercation and appears very emotional during the assessment. The nurse suspects which part of the brain received the greatest amount of injury? A) Cerebrum B) Cerebellum C) Medulla D) Amygdala

A

The nurse on an addictive disorders unit receives a phone call inquiring about the status of a client. The caller is not on the client's allowed contact list. Which of the following is the appropriate response by the nurse to the caller? A) ìI cannot confirm or deny the existence of any client here.î B) ìYou will need to be placed on the client's contact list before I can discuss any information with you.î C) ìThe person you are asking for is not a client here.î D) ìHold 1 minute while I get the client for you.î

A

The physician has prescribed Haldol 10 mg for a severely psychotic client. The client refuses the medication. Which nursing intervention is an appropriate response? A) Accept the client's decision B) Obtain a discharge order for noncompliance C) Tell the client that he is too sick to refuse D) Restrain the client and give the medication IM

A

The staff on an inpatient psychiatric unit is very busy and fall behind on periodic assessment of a severely depressed client. During the rounds, the client is discovered to have completed a suicide attempt in the bathroom. Which type of lawsuit could the client's family file? A) Malpractice B) Breach of duty C) Assault D) Injury or damage

A

What are the two essential components of transitional care discharge model that is used in Canada and Scotland? A) Peer support and bridging staff B) Collaboration and funding C) Relapse and hospitalization D) Poverty and entitlements

A

Which of the following clients would most likely be mandated outpatient treatment? A) A client who is addicted to alcohol who has two DUI offenses B) A client with schizophrenia who lives in a single family home with siblings C) A client with bipolar disorder who has quit three jobs in the last 6 months D) A homeless client who has been arrested for petty theft of groceries from a convenience store.

A

Which of the following considerations should have the most influence in the nurse's choice of the treatment for the client? A) The client's feelings and perceptions about his or her situation B) The nurse's beliefs about the theories of psychosocial development C) The nurse's familiarity with the type of treatment D) Any approach to treatment should work with any client.

A

Which of the following is most essential when planning care for a client who is experiencing a crisis? A) Explore previous coping strategies B) Explore underlying personality dynamics C) Focus on emotional deficits D) Offer a referral to a self-help group

A

Which of the following medications rarely causes extrapyramidal side effects (EPS)? A) Ziprasidone (Geodon) B) Chlorpromazine (Thorazine) C) Haloperidol (Haldol) D) Fluphenazine (Prolixin)

A

Which one of the following is the most common reason for ethical dilemmas being a challenge to nurses? A) Ethical dilemmas are often charged with emotion. B) There are no clear ethical codes established for guidance. C) A multitude of laws must be understood to make a clear decision. D) Clients are not familiar with the ethical code that nurses must follow.

A

A

A 15-year-old female is admitted for treatment of anorexia nervosa. Which is characteristic of anorexia nervosa? A) Body weight less than normal for age, height, and overall physical health B) Amenorrhea for at least two cycles C) Absence of hunger feelings D) Erosion of dental enamel

"Your body is using protein and fat for energy instead of glucose."

A 16-year-old client newly diagnosed with type 1 diabetes has a very low body weight despite eating regular meals. The client is upset because friends frequently state, "You look anorexic." Which statement by the nurse would be the best response to help this client understand the cause of weight loss due to this condition?

a corticotropin secreting pituitary adenoma

A 35-year-old female client who complains of weight gain, facial hair, absent menstruation, frequent bruising, and acne is diagnosed with Cushing's syndrome. Cushing's syndrome is most likely caused by:

A) Severe pancreatitis with possible peritonitis

A 37-year-old male patient presents at the emergency department (ED) complaining of nausea and vomiting and severe abdominal pain. The patients abdomen is rigid, and there is bruising to the patients flank. The patients wife states that he was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the patient for what health problem? A) Severe pancreatitis with possible peritonitis B) Acute cholecystitis C) Chronic pancreatitis D) Acute appendicitis with possible perforation

D) The enzymes that your pancreas produces have damaged the pancreas itself.

A 55-year-old man has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse most likely explain the pathophysiology of this patients health problem? A) Toxins have accumulated and inflamed your pancreas. B) Bacteria likely migrated from your intestines and became lodged in your pancreas. C) A virus that was likely already present in your body has begun to attack your pancreatic cells. D) The enzymes that your pancreas produces have damaged the pancreas itself.

Increased hunger

A 60-year-old client comes to the ED reporting weakness, vision problems, increased thirst, increased urination, and frequent infections that do not seem to heal easily. The physician suspects that the client has diabetes. Which classic symptom should the nurse watch for to confirm the diagnosis of diabetes?

Pneumonia Skin breakdown Sepsis Delirium

A 75-year-old client had surgery for a left hip fracture yesterday. When completing the plan of care, the nurse should include assessment for which complications? Select all that apply.

C) Use of a pressure-relieving mattress

A 91-year-old patient is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the patients plan of care. What intervention is most justified in the care of this patient? A) Administration of prophylactic antibiotics B) Total parenteral nutrition (TPN) C) Use of a pressure-relieving mattress D) Use of a Foley catheter until discharge

B) Assessment for pain

A bone biopsy has just been completed on a patient with suspected bone metastases. What assessment should the nurse prioritize in the immediate recovery period? A) Assessment for dehiscence at the biopsy site B) Assessment for pain C) Assessment for hematoma formation D) Assessment for infection

A) Osteoblasts

A child is growing at a rate appropriate for his age. What cells are responsible for the secretion of bone matrix that eventually results in bone growth? A) Osteoblasts B) Osteocytes C) Osteoclasts D) Lamellae

D

A child who has witnessed the murder of his classmate while at school would experience which kind of loss? A) Physiologic loss B) Loss of self-esteem C) Loss related to self-actualization D) Safety loss

C

A client asks how his prescribed alprazolam (Xanax) helps his anxiety disorder. The nurse explains that antianxiety medications such as alprazolam affect the function of which neurotransmitter that is believed to be dysfunctional in anxiety disorders? A) Serotonin B) Norepinephrine C) GABA D) Dopamine

C

A client comes to the physician's office for an annual checkup. During the interview, the nurse learns that the client's husband died unexpectedly of a heart attack 2 months ago. The most appropriate response by the nurse would be, A) ìAt least you and your husband enjoyed life right until the end.î B) ìIt's better to go quickly like your husband did instead of suffering.î C) ìThe loss of your husband must be very painful for you.î D) ìYou'll feel better after you get over the shock of your husband's death.î

A

A client experiences panic attacks when confronted with riding in elevators. The therapist is teaching the client ways to relax while incrementally exposing the client to getting on an elevator. This technique is called A) systematic desensitization. B) flooding. C) cognitive restructuring. D) exposure therapy.

Measure and record drainage.

A client has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction. What is the nurse's priority during this aspect of the client's care?

Compares exposed tube length with original measurement Visually assesses the color of the aspirate Checks the pH of the gastric contents

A client has a nasogastric tube for continuous tube feeding. The nurse does all the following every shift to verify placement (select all options that apply):

Instructing the client to remove salty and salted foods from the diet Administering prescribed spironolactone (Aldactone) Assisting with placement of a transjugular intrahepatic portosystemic shunt

A client has ascites. Which of the following interventions would the nurse prepare to assist with implementing to help the client control this condition? Select all that apply.

Administering beta blockers to reduce heart rate Applying interventions to reduce the client's temperature

A client has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in this client's immediate care? Select all that apply.

Insertion of an NG tube for decompression

A client has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention?

Metastases are common and respond poorly to treatment.

A client has been diagnosed with a malignancy of the oral cavity and is undergoing oncologic treatment. The oncologic nurse is aware that the prognosis for recovery from head and neck cancers is often poor because of what characteristic of these malignancies?

Hypothermia Hypotension Hypoventilation Severe hypothyroidism is called myxedema. Advanced, untreated myxedema can progress to myxedemic coma. Signs of this life-threatening event are hypothermia, hypotension, and hypoventilation. Hypertension and hyperventilation indicate increased metabolic responses, which are the opposite of what the client would be experiencing.

A client has been diagnosed with myxedema from long-standing hypothyroidism. What clinical manifestations of this disorder does the nurse recognize are progressing to myxedema coma? Select all that apply.

polyphagia

A client has been recently diagnosed with type 2 diabetes, and reports continued weight loss despite increased hunger and food consumption. This condition is called:

"You'll need less insulin when you exercise or reduce your food intake."

A client has just been diagnosed with type 1 diabetes. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline?

Ensure that the mother does not have access to car keys or drive an automobile.

A client has recently brought her elderly mother home to live with her family. The client states that her mother has moderate Alzheimer's disease and asks about appropriate activities for her mother. The nurse tells the client to

Streaks of blood present in the stool

A client has returned to the medical unit after a barium enema. When assessing the client's subsequent bowel patterns and stools, what finding would warrant reporting to the health care provider?

7 to 10 days

A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery?

profound neuromuscular irritability.

A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of:

Assess the client's breath odor

A client is admitted to the health care center with abdominal pain, nausea, and vomiting. The medical reports indicate a history of type 1 diabetes. The nurse suspects the client's symptoms to be those of diabetic ketoacidosis (DKA). Which action will help the nurse confirm the diagnosis?

Serum potassium level of 5.8 mEq/L Addison's disease decreases the production of aldosterone, cortisol, and androgen, causing urinary sodium and fluid losses, an increased serum potassium level, and hypoglycemia. Therefore, an elevated serum potassium level of 5.8 mEq/L best supports a diagnosis of Addison's disease. A BUN level of 12 mg/dl and a blood glucose level of 90 mg/dl are within normal limits. In a client with Addison's disease, the serum sodium level would be much lower than 134 mEq/L, a nearly normal level.

A client is admitted to the health care facility for evaluation for Addison's disease. Which laboratory test result best supports a diagnosis of Addison's disease?

Deep vein thrombosis Compartment syndrome Fat embolism

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this client? Select all that apply.

Keep the vent lumen above the client's waist.

A client is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube?

C

A client is currently experiencing a panic attack. Which of the following is the most appropriate response by the nurse? A) ìJust try to relax.î B) ìThere is nothing here to harm you.î C) ìYou are safe. Take a deep breath.î D) ìWhat are you feeling right now?î

Intrinsic factor

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The health care provider begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?

A

A client is learning to cope with anxiety and stress. The expected outcome is that the client will A) change reactions to stressors. B) ignore situations that cause stress. C) limit major stressors in his or her life. D) avoid anxiety at all costs.

B

A client is observed pacing the hall with clenched fists and swearing at others. The nurse intervenes immediately to prevent the client from moving to which phase of the aggressing cycle? A) Triggering B) Escalation C) Crisis D) Recovery

Realignment of the fracture Reduction of deformity Minimization of muscle spasms

A client is placed in traction for a femur facture. The nurse would document which expected outcomes of traction? Select all that apply.

Fever, increased heart rate and decreased blood pressure

A client is receiving care in the intensive care unit for acute pancreatitis. The nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Consequently, the nurse should assess for what signs or symptoms of this complication?

No land line; cell phone available and taken by family member during working hours

A client is receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC) and will be discharged home with PN. The home health nurse evaluates the home setting and would make a recommendation when noticing which circumstance?

Make appropriate referrals to services that provide psychosocial support.

A client is recovering in the hospital following gastrectomy. The nurse notes that the client has become increasingly difficult to engage and has had several angry outbursts at staff members in recent days. The nurse's attempts at therapeutic dialogue have been rebuffed. What is the nurse's most appropriate action?

Glucose tolerance test in combination with a GH measurement

A client is suspected of having acromegaly. What definitive diagnostic testing is the most reliable method of confirming acromegaly?

D

A client suddenly jumps up from the chair and begins yelling and cursing at the nurse. Which would be the best response by the nurse? A) ìI can see that you need attention; you should calmly ask for what you want.î B) ìI don't want to hear that kind of language; don't ever do that again.î C) ìI will limit your smoking privileges if you can't control yourself.î D) ìYou seem angry. Tell me more about how you're feeling.î

dehydration

A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition?

D

A client who has been grieving the loss of his wife 2 weeks ago says to the nurse, ìThe best part of my day is when I am back at work. Is that wrong?î The nurse educates that work and other daily activities serve which purpose? A) ìYou cannot work effectively this soon. You should finish grieving first.î B) ìWorking reminds you of your loss. It may be too early to go back.î C) ìWorking is your way of avoiding grief, which will make it harder for you to move on.î D) ìWorking is letting you take an emotional break from grieving. There's nothing wrong with that.î

C

A client who has been physically aggressive arrives at the emergency room for a psychiatric assessment. Which would be the best approach for the nurse to use? A) Have a sense of humor to show a lack of fear. B) Provide close contact to increase the client's sense of safety. C) Use brief statements and questions to obtain information. D) Use open-ended questions, so the client can elaborate.

"Immobilization of the fracture will promote healing by maximizing contact of bone fragments." "Fractured bones require a good blood supply and adequate nutrition for healing." "Weight bearing stimulates healing of the long bones of the leg, if the fracture is stabilized."

A client who has fractured the radial head asks the nurse about factors that will promote bone healing. Which statement should the nurse include when responding to the client? Select all that apply.

"Apply a heating pad to your shoulder for 15 minutes hourly as needed."

A client who is 24 hours post op from laparoscopic cholecystectomy calls the nurse and reports pain in the right shoulder. How should the nurse respond to the client's report of symptoms?

A

A client who is depressed states, ìI think my family would be better off without me. They don't need to worry.î Which would be the most appropriate response by the nurse? A) ìAre you planning to commit suicide?î B) ìWhat do you think they are worried about?î C) ìWhere are you going?î D) ìYou don't mean that. Your family loves you.î

D

A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which nursing diagnosis has the highest priority? A) Hopelessness related to recent divorce B) Ineffective coping related to inadequate stress management C) Spiritual distress related to conflicting thoughts about suicide and sin D) Risk for suicide related to a highly lethal plan

B

A client who suffers from frequent panic attacks describes the attack as feeling disconnected from himself. The nurse notes in the client's chart that the client reports experiencing A) hallucinations. B) depersonalization. C) derealization. D) denial.

Distract the client with a familiar object or music.

A client with Alzheimer disease becomes agitated while the nurse is attempting to take vital signs. What action by the nurse is most appropriate?

Risk for caregiver role strain related to increased client care needs

A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The client's spouse tells the nurse about feeling guilty for letting the accident happen and reports not sleeping well lately because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse?

Foods high in vitamin D Foods high in protein Foods high in calcium Foods high in vitamin D, protein, and calcium are recommended to minimize muscle wasting and osteoporosis. Referral to a dietitian may assist the client in selecting appropriate foods that are also low in sodium and calories.

A client with Cushing syndrome has been hospitalized after a fall. The dietician consulted works with the client to improve the patient's nutritional intake. What foods should a client with Cushing syndrome eat to optimize health? Select all that apply

Metoclopramide

A client with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the client may be prescribed what drug?

A

A client with dependent personality disorder has a goal to increase her problem-solving skills. Which client behavior would indicate progress toward meeting that goal? A) Asking questions B) Being polite C) Controlling emotional outbursts D) Requesting assistance appropriately

6.5%

A client with diabetes comes to the clinic for a follow-up visit. The nurse reviews the client's glycosylated hemoglobin test results. Which result would indicate to the nurse that the client's blood glucose level has been well-controlled?

They increase the need for insulin.

A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect do these findings have on his need for insulin?

Serum glucose level of 52 mg/dl

A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?

Low blood glucose concentration

A client with diabetes mellitus is prescribed to switch from animal to synthesized human insulin. Which factor should the nurse monitor when caring for the client?

Polydipsia

A client with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which symptom when caring for this client?

hypoglycemia

A client with diabetes mellitus is receiving an oral antidiabetic agent. When caring for this client, the nurse should observe for signs of:

"Rotate injection sites within the same anatomic region, not among different regions."

A client with diabetes mellitus must learn how to self-administer insulin. The physician has ordered 10 units of U-100 regular insulin and 35 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?

tachycardia

A client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should the nurse recognize as an adverse reaction to the drug?

Deficient knowledge (treatment regimen).

A client with long-standing type 1 diabetes is admitted to the hospital with unstable angina pectoris. After the client's condition stabilizes, the nurse evaluates the diabetes management regimen. The nurse learns that the client sees the physician every 4 weeks, injects insulin after breakfast and dinner, and measures blood glucose before breakfast and at bedtime. Consequently, the nurse should formulate a nursing diagnosis of:

Daily weights and abdominal girth measurement

A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments?

Sweating, tremors, and tachycardia

A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia?

D

A client with terminal cancer has been told he has 3 or 4 months to live. Which of the following would indicate to the nurse that further interventions are needed? A) The client says he wants to live life to the fullest. B) The client hopes for a peaceful and dignified death. C) The client is reviewing his life and talking about death. D) The client says he is well and is making future plans.

C) Hemorrhoids

A clinic patient has described recent dark-colored stools;the nurse recognizes the need for fecal occult blood testing (FOBT). What aspect of the patients current health status would contraindicate FOBT? A) Gastroesophageal reflux disease (GERD) B) Peptic ulcers C) Hemorrhoids D) Recurrent nausea and vomiting

D

A coherent elderly woman has been financially and emotionally abused by her adult children for the past several years, but has failed to report the abuse to anyone. Which is the most likely reason that the woman neglects to report the abuse? A) She cannot claim abuse if there is no evidence of physical harm. B) Laws do not provide protection against abuse when the suspect(s) is/are family members. C) She has no financial resources to hire legal representation against her children. D) She is emotionally close to her children and does not want to bring them harm.

D) Monthly administration of injections of vitamin B12

A community health nurse is preparing for an initial home visit to a patient discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include? A) Enteral feeding via gastrostomy tube (G tube) B) Gastrointestinal decompression by nasogastric tube C) Periodic assessment for esophageal distension D) Monthly administration of injections of vitamin B12

C) An older adult whose medication regimen includes an anticholinergic

A community health nurse serves a diverse population. What individual would likely face the highest risk for parotitis? A) A patient who is receiving intravenous antibiotic therapy in the home setting B) A patient who has a chronic venous ulcer C) An older adult whose medication regimen includes an anticholinergic D) A patient with poorly controlled diabetes who receives weekly wound care

D

A couple came to the emergency department with their 5-month-old son. He was pronounced dead of sudden infant death syndrome (SIDS). In the next day or two, it will be important for this couple to A) accept that they could do nothing to prevent this death. B) delay the grieving process until they are ready to cope. C) minimize their discussion of the death with others. D) plan funeral arrangements for their son.

"I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours."

A diabetic educator is discussing "sick day rules" with a newly diagnosed type 1 diabetic. The educator is aware that the client will require further teaching when the client states what?

Always carry a form of fast-acting sugar.

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

0830

A health care provider prescribes short-acting insulin for a patient, instructing the patient to take the insulin 20 to 30 minutes before a meal. The nurse explains to the patient that Humulin-R taken at 6:30 AM will reach peak effectiveness by:

Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment.

A health care team is involved in caring for a client with advanced Alzheimer's disease. During a team conference, a newly hired nurse indicates that she has never cared for a client with advanced Alzheimer's disease. Which key point about the disease should the charge nurse include when teaching this nurse?

D) Malabsorption and hyperglycemia

A home health nurse is caring for a patient discharged home after pancreatic surgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than Body Requirements on the care plan based on the potential complications that may occur after surgery. What are the most likely complications for the patient who has had pancreatic surgery? A) Proteinuria and hyperkalemia B) Hemorrhage and hypercalcemia C) Weight loss and hypoglycemia D) Malabsorption and hyperglycemia

Normal bedtime blood glucose Increase in blood glucose from 3:00 AM until breakfast Decrease in blood sugar to a hypoglycemic level between 2:00 to 3:00 AM

A hospitalized, insulin-dependent patient with diabetes has been experiencing morning hyperglycemia. The patient will be awakened once or twice during the night to test blood glucose levels. The health care provider suspects that the cause is related to the Somogyi effect. Which of the following indicators support this diagnosis? Select all that apply.

The client's consumption of carbohydrates

A male client, aged 42 years, is diagnosed with diabetes mellitus. He visits the gym regularly and is a vegetarian. Which of the following factors is important when assessing the client?

Norepinephrine

A neurotransmitter involved in arousal, as well as in learning and mood regulation. Causes changes in attention, learning and memory, sleep and wakefulness, mood

Seratonin

A neurotransmitter that affects mood, hunger, sleep, and arousal; linked to depression and treated by Prozac. (Blocks reuptake of seratonin, activating more seratonin in neural pathways, therefore elevating mood.) Controls food intake, sleep and wakefulness, temp reg, pain control, sexual behaviors, regulation of emotions Plays an important roll in anciety and mood disorders and schizophrenia. It has been found to contribute to the delusions, hallucinations and withdrawn behavior seen in schizo

Ask the client to remain inactive for 5 minutes.

A nurse applies an ostomy appliance to a client who is recovering from ileostomy surgery. Which intervention should the nurse utilize to prevent leakage from the appliance?

Stage 2

A nurse assesses a patient diagnosed with hepatic encephalopathy. She observes a number of clinical signs, including asterixis and fetor hepaticus; the patient's electroencephalogram (EEG) is abnormal. The nurse documents that the patient is exhibiting signs of which stage of hepatic encephalopathy?

B) Eat several small meals daily spaced at equal intervals.

A nurse caring for a patient who has had bariatric surgery is developing a teaching plan in anticipation of the patients discharge. Which of the following is essential to include? A) Drink a minimum of 12 ounces of fluid with each meal. B) Eat several small meals daily spaced at equal intervals. C) Choose foods that are high in simple carbohydrates. D) Sit upright when eating and for 30 minutes afterward.

Control blood glucose levels.

A nurse educates a group of clients with diabetes mellitus on the prevention of diabetic nephropathy. Which of the following suggestions would be most important?

D

A nurse has been caring for a gunshot victim who has just died. Various family and friends are present. One of the visitors privately discloses to the nurse that she and the client were having an illicit affair. Which of the following is the best action by the nurse after learning of this relationship? A) Give the name of a clergy to the visitor and suggest she contact him for support B) Encourage the visitor to ask for support from the friends who are present C) Ignore the information about the affair and tend to the family D) Privately offer support to the visitor who was having the affair with the client

D) Report this finding to the patients primary care provider.

A nurse has obtained an order to remove a patients NG tube and has prepared the patient accordingly. After flushing the tube and removing the nasal tape, the nurse attempts removal but is met with resistance. Because the nurse is unable to overcome this resistance, what is the most appropriate action? A) Gently twist the tube before pulling. B) Instill a digestive enzyme solution and reattempt removal in 10 to 15 minutes. C) Flush the tube with hot tap water and reattempt removal. D) Report this finding to the patients primary care provider.

B) Medulla oblongata

A nurse in a stroke rehabilitation facility recognizes that the brain regulates swallowing. Damage to what area of the brain will most affect the patients ability to swallow? A) Temporal lobe B) Medulla oblongata C) Cerebellum D) Pons

B) Use warm saline to rinse the mouth as needed.

A nurse in an oral surgery practice is working with a patient scheduled for removal of an abscessed tooth. When providing discharge education, the nurse should recommend which of the following actions? A) Rinse the mouth with alcohol before bedtime for the next 7 days. B) Use warm saline to rinse the mouth as needed. C) Brush around the area with a firm toothbrush to prevent infection. D) Use a toothpick to dislodge any debris that gets lodged in the socket.

A) Fowlers

A nurse in the postanesthesia care unit admits a patient following resection of a gastric tumor. Following immediate recovery, the patient should be placed in which position to facilitate patient comfort and gastric emptying? A) Fowlers B) Supine C) Left lateral D) Left Sims

Early diagnosis and treatment of gastroesophageal reflux disease

A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action should the nurse recommend as having the greatest potential to prevent esophageal cancer?

D) The early symptoms of gastric cancer are usually not alarming or highly unusual.

A nurse is admitting a patient diagnosed with late-stage gastric cancer. The patients family is distraught and angry that she was not diagnosed earlier in the course of her disease. What factor contributes to the fact that gastric cancer is often detected at a later stage? A) Gastric cancer does not cause signs or symptoms until metastasis has occurred. B) Adherence to screening recommendations for gastric cancer is exceptionally low. C) Early symptoms of gastric cancer are usually attributed to constipation. D) The early symptoms of gastric cancer are usually not alarming or highly unusual.

A) Premature removal of the G tube

A nurse is admitting a patient to the postsurgical unit following a gastrostomy. When planning assessments, the nurse should be aware of what potential postoperative complication of a gastrostomy? A) Premature removal of the G tube B) Bowel perforation C) Constipation D) Development of peptic ulcer disease (PUD)

D) Spasticity

A nurse is assessing a child who has a diagnosis of muscular dystrophy. Assessment reveals that the childs muscles have greater-than-normal tone. The nurse should document the presence of which of the following? A) Tonus B) Flaccidity C) Atony D) Spasticity

"All of a sudden my dad seemed to become confused."

A nurse is assessing a client brought to the emergency room by his daughter. Which statement by the daughter would most likely lead the nurse to suspect that the client may have an infection?

Diarrhea Tachycardia Diaphoresis

A nurse is assessing a client receiving tube feedings and suspects dumping syndrome. What would lead the nurse to suspect this? Select all that apply

deposits of adipose tissue in the trunk and dorsocervical area.

A nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse expects to find:

B) The patients body mass index is 34 (obese).

A nurse is assessing a patient for risk factors known to contribute to osteoarthritis. What assessment finding would the nurse interpret as a risk factor? A) The patient has a 30 pack-year smoking history. B) The patients body mass index is 34 (obese). C) The patient has primary hypertension. D) The patient is 58 years old.

B) Infection typically occurs due to ingestion of contaminated food and water.

A nurse is assessing a patient who has peptic ulcer disease. The patient requests more information about the typical causes of Helicobacter pyloriinfection. What would it be appropriate for the nurse to instruct the patient? A) Most affected patients acquired the infection during international travel. B) Infection typically occurs due to ingestion of contaminated food and water. C) Many people possess genetic factors causing a predisposition to H. pyloriinfection. D) The H. pylori microorganism is endemic in warm, moist climates.

B) Absence of feeling, capillary refill of 4 to 5 seconds, and cool

A nurse is assessing a patient who is experiencing peripheral neurovascular dysfunction. What assessment findings are most consistent with this diagnosis? A) Hot skin with a capillary refill of 1 to 2 seconds B) Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin C) Pain, diaphoresis, and erythema D) Jaundiced skin, weakness, and capillary refill of 3 seconds

C) Document that the stoma appears healthy and well perfused.

A nurse is assessing a patients stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding? A) Irrigate the ostomy to clear a possible obstruction. B) Contact the primary care provider to report this finding. C) Document that the stoma appears healthy and well perfused. D) Document a nursing diagnosis of Impaired Skin Integrity.

D) Signs and symptoms of septic shock

A nurse is assessing an elderly patient with gallstones. The nurse is aware that the patient may not exhibit typical symptoms, and that particular symptoms that may be exhibited in the elderly patient may include what? A) Fever and pain B) Chills and jaundice C) Nausea and vomiting D) Signs and symptoms of septic shock

C) GI diseases often produce skin changes.

A nurse is assessing the abdomen of a patient just admitted to the unit with a suspected GI disease. Inspection reveals several diverse lesions on the patients abdomen. How should the nurse best interpret this assessment finding? A) Abdominal lesions are usually due to age-related skin changes. B) Integumentary diseases often cause GI disorders. C) GI diseases often produce skin changes. D) The patient needs to be assessed for self-harm.

Blurred or deteriorating vision Fatigue and irritability Polyuria and polydipsia Wounds that heal slowly or respond poorly to treatment

A nurse is assigned to care for a patient who is suspected of having type 2 diabetes. Select all the clinical manifestations that the nurse knows could be consistent with this diagnosis.

A) Fried chicken

A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? A) Fried chicken B) Mashed potatoes C) Dinner roll D) Tapioca pudding

B) Change the dressing no more than weekly.

A nurse is aware of the high incidence of catheter-related bloodstream infections in patients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections? A) Use clean technique and wear a mask during dressing changes. B) Change the dressing no more than weekly. C) Apply antibiotic ointment around the site with each dressing change. D) Irrigate the insertion site with sterile water during each dressing change.

Urine specific gravity of 1.001 Serum osmolality of 310 mOsm/kg Serum sodium level of 149 mEq/L All are indicative of diabetes insipidus, except for B and D, which are normal results. Refer to Table 31-1.

A nurse is aware that several laboratory results are present in a patient diagnosed with diabetes insipidus. Select all that apply.

A) The patient will express satisfaction with her ability to perform ADLs.

A nurse is caring for a 78-year-old patient with a history of osteoarthritis (OA). When planning the patients care, what goal should the nurse include? A) The patient will express satisfaction with her ability to perform ADLs. B) The patient will recover from OA within 6 months. C) The patient will adhere to the prescribed plan of care. D) The patient will deny signs or symptoms of OA.

Cardiovascular complications Pulmonary complications

A nurse is caring for a bariatric client prior to a surgical procedure. What surgical complications would the nurse monitor the bariatric client for post operatively? Select all that apply.

Daily weights Intake and output monitoring Calorie counts for oral nutrients

A nurse is caring for a client receiving parenteral nutrition at home. The client was discharged from the acute care facility 4 days ago. What would the nurse include in the client's plan of care? Select all that apply.

Assess for neurologic changes. Closely monitor nasal packing and postnasal drainage. The client undergoes frequent neurologic assessments to detect signs of increased intracranial pressure and meningitis. The nurse monitors drainage from the nose and postnasal drainage for the presence of cerebrospinal fluid. The client is advised to avoid drinking from a straw, sneezing, coughing, and bending over to prevent dislodging the graft that seals the operative area between the cranium and nose.

A nurse is caring for a client recovering from a hypophysectomy. What would be included in the client's care plan? Select all that apply.

Encouraging the client to turn from side to side and to assume a prone position

A nurse is caring for a client who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. What nursing action will best achieve these goals?

To remove gas from the stomach To remove toxins from the stomach To diagnose GI motility disorders

A nurse is caring for a client who has a gastrointestinal tube in place. Which of the following are indications for gastrointestinal intubation? Select all that apply.

C) Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists.

A nurse is caring for a patient who has a leg cast. The nurse observes that the patient uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? A) Allow the patient to continue to scratch inside the cast with a pencil but encourage him to be cautious. B) Give the patient a sterile tongue depressor to use for scratching instead of the pencil. C) Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists. D) Obtain an order for a sedative, such as lorazepam (Ativan), to prevent the patient from scratching.

A) Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN.

A nurse is caring for a patient who has an order to discontinue the administration of parenteral nutrition. What should the nurse do to prevent the occurrence of rebound hypoglycemia in the patient? A) Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN. B) Administer a hypertonic dextrose solution for 1 to 2 hours after discontinuing the PN. C) Administer 3 ampules of dextrose 50% immediately prior to discontinuing the PN. D) Administer 3 ampules of dextrose 50% 1 hour after discontinuing the PN.

B) Assessment for variceal bleeding

A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patients plan of care? A) Measurement of abdominal girth and body weight B) Assessment for variceal bleeding C) Assessment for signs and symptoms of jaundice D) Monitoring of results of liver function testing

C) Youll be encouraged to drink water after the administration of the radioisotope injection.

A nurse is caring for a patient who has been scheduled for a bone scan. What should the nurse teach the patient about this diagnostic test? A) The test is brief and requires that you drink a calcium solution 2 hours before the test. B) You will not be allowed fluid for 2 hours before and 3 hours after the test. C) Youll be encouraged to drink water after the administration of the radioisotope injection. D) This is a common test that can be safely performed on anyone.

B) The use of moderate sedation

A nurse is caring for a patient who has been scheduled for endoscopic retrograde cholangiopancreatography (ERCP) the following day. When providing anticipatory guidance for this patient, the nurse should describe what aspect of this diagnostic procedure? A) The need to protect the incision postprocedure B) The use of moderate sedation C) The need to infuse 50% dextrose during the procedure D) The use of general anesthesia

B) Avoiding chewing food for the specified number of weeks after surgery

A nurse is caring for a patient who has just had a rigid fixation of a mandibular fracture. When planning the discharge teaching for this patient, what would the nurse be sure to include? A) Increasing calcium intake to promote bone healing B) Avoiding chewing food for the specified number of weeks after surgery C) Techniques for managing parenteral nutrition in the home setting D) Techniques for managing a gastrostomy

D) Assess the pin insertion site every 8 hours.

A nurse is caring for a patient who is in skeletal traction. To prevent the complication of skin breakdown in a patient with skeletal traction, what action should be included in the plan of care? A) Apply occlusive dressings to the pin sites. B) Encourage the patient to push up with the elbows when repositioning. C) Encourage the patient to perform isometric exercises once a shift. D) Assess the pin insertion site every 8 hours.

A) Keep the patients hips in abduction at all times.

A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position the patient? A) Keep the patients hips in abduction at all times. B) Keep hips flexed at no less than 90 degrees. C) Elevate the head of the bed to high Fowlers. D) Seat the patient in a low chair as soon as possible.

A) Encourage the family to bring in the patients favored foods.

A nurse is caring for a patient who is postoperative from a neck dissection. What would be the most appropriate nursing action to enhance the patients appetite? A) Encourage the family to bring in the patients favored foods. B) Limit visitors at mealtimes so that the patient is not distracted. C) Avoid offering food unless the patient initiates. D) Provide thorough oral care immediately after the patient eats.

A) Inflammatory bowel disease

A nurse is caring for a patient who is scheduled for a colonoscopy and whose bowel preparation will include polyethylene glycol electrolyte lavage prior to the procedure. The presence of what health problem would contraindicate the use of this form of bowel preparation? A) Inflammatory bowel disease B) Intestinal polyps C) Diverticulitis D) Colon cancer

B) Erosion of the lining of the stomach or intestine

A nurse is caring for a patient who just has been diagnosed with a peptic ulcer. When teaching the patient about his new diagnosis, how should the nurse best describe a peptic ulcer? A) Inflammation of the lining of the stomach B) Erosion of the lining of the stomach or intestine C) Bleeding from the mucosa in the stomach D) Viral invasion of the stomach wall

D) Report possible signs of aspiration pneumonia to the primary care provider.

A nurse is caring for a patient with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The patients oxygen saturation is 89% by pulse oximetry. After ensuring the patients immediate safety, what is the nurses most appropriate action? A) Perform chest physiotherapy. B) Reduce the height of the patients bed and remove the NG tube. C) Liaise with the dietitian to obtain a feeding solution with lower osmolarity. D) Report possible signs of aspiration pneumonia to the primary care provider.

B) Risk for Infection Related to the Presence of a Subclavian Catheter

A nurse is caring for a patient with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this patient, what nursing diagnosis should the nurse prioritize? A) Risk for Activity Intolerance Related to the Presence of a Subclavian Catheter B) Risk for Infection Related to the Presence of a Subclavian Catheter C) Risk for Functional Urinary Incontinence Related to the Presence of a Subclavian Catheter D) Risk for Sleep Deprivation Related to the presence of a Subclavian Catheter

B) Report this finding to the primary care provider due to the possibility of hepatic encephalopathy.

A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurses most recent assessment reveals subtle changes in the patients cognition and behavior. What is the nurses most appropriate response? A) Ensure that the patients sodium intake does not exceed recommended levels. B) Report this finding to the primary care provider due to the possibility of hepatic encephalopathy. C) Inform the primary care provider that the patient should be assessed for alcoholic hepatitis. D) Implement interventions aimed at ensuring a calm and therapeutic care environment.

D) Apply local anesthetic to the back of the patients throat.

A nurse is caring for a patient with recurrent hematemesis who is scheduled for upper gastrointestinal fibroscopy (UGF). How should the nurse in the radiology department prepare this patient? A) Insert a nasogastric tube. B) Administer a micro Fleet enema at least 3 hours before the procedure. C) Have the patient lie in a supine position for the procedure. D) Apply local anesthetic to the back of the patients throat.

A) Stomach emptying takes place more slowly.

A nurse is caring for an 83-year-old patient who is being assessed for recurrent and intractable nausea. What age-related change to the GI system may be a contributor to the patients health complaint? A) Stomach emptying takes place more slowly. B) The villi and epithelium of the small intestine become thinner. C) The esophageal sphincter becomes incompetent. D) Saliva production decreases.

incorporate the client's toileting schedule into the pattern of his wandering.

A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontinence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should:

D) Potassium level

A nurse is caring for an older adult who has been experiencing severeClostridium difficile-related diarrhea. When reviewing the patients most recent laboratory tests, the nurse should prioritize which of the following? A) White blood cell level B) Creatinine level C) Hemoglobin level D) Potassium level

Clotted or displaced catheter Pneumothorax Hyperglycemia Line sepsis

A nurse is creating a care plan for a client who is receiving parenteral nutrition. The client's care plan should include nursing actions relevant to what potential complications? Select all that apply.

Ans: B, C, D, E

A nurse is creating a care plan for a patient who is receiving parenteral nutrition. The patients care plan should include nursing actions relevant to what potential complications? Select all that apply. A) Dumping syndrome B) Clotted or displaced catheter C) Pneumothorax D) Hyperglycemia E) Line sepsis

D) Use a combination of at least two accepted methods for confirming placement. measurement of the tube auscultation xray

A nurse is creating a care plan for a patient with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube? A) Auscultate the patients abdomen after injecting air through the tube. B) Assess the color and pH of aspirate. C) Locate the marking made after the initial x-ray confirming placement. D) Use a combination of at least two accepted methods for confirming placement.

C) Bed rest lowers the metabolic rate and reduces enzyme production.

A nurse is creating a care plan for a patient with acute pancreatitis. The care plan includes reduced activity. What rationale for this intervention should be cited in the care plan? A) Bed rest reduces the patients metabolism and reduces the risk of metabolic acidosis. B) Reduced activity protects the physical integrity of pancreatic cells. C) Bed rest lowers the metabolic rate and reduces enzyme production. D) Inactivity reduces caloric need and gastrointestinal motility.

Sit the client in an upright position Apply gloves to the nurse's hands Measure the length of the tube that will be inserted Apply water-soluble lubricant to the tip of the tube Tilt the client's nose upward Instruct the client to lower the head and swallow

A nurse is inserting a nasogastric tube for feeding a client. Place in order the steps from 1 to 6 for correctly inserting the tube.

Tachycardia Hypotension A rigid, board-like abdomen

A nurse is monitoring a client with peptic ulcer disease. Which assessment findings would most likely indicate perforation of the ulcer? Select all that apply.

Complaints about frequently waking up during the night

A nurse is obtaining the health history of a 72-year-old woman who has come to the ambulatory care center for an evaluation. When obtaining information about the woman's sleep patterns, which of the following would the nurse expect to assess?

D) Decreased mucus secretion

A nurse is performing an abdominal assessment of an older adult patient. When collecting and analyzing data, the nurse should be cognizant of what age-related change in gastrointestinal structure and function? A) Increased gastric motility B) Decreased gastric pH C) Increased gag reflex D) Decreased mucus secretion

C) Place hand under right lower rib cage and press down lightly with the other hand.

A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patients liver? A) Place hand under the right lower abdominal quadrant and press down lightly with the other hand. B) Place the left hand over the abdomen and behind the left side at the 11th rib. C) Place hand under right lower rib cage and press down lightly with the other hand. D) Hold hand 90 degrees to right side of the abdomen and push down firmly.

D) Imbalanced Nutrition: Less Than Body Requirements

A nurse is performing health education with a patient who has a history of frequent, serious dental caries. When planning educational interventions, the nurse should identify a risk for what nursing diagnosis? A) Ineffective Tissue Perfusion B) Impaired Skin Integrity C) Aspiration D) Imbalanced Nutrition: Less Than Body Requirements

A) Examine ones own attitudes towards obesity in general and the patient in particular.

A nurse is performing the admission assessment of a patient whose high body mass index (BMI) corresponds to class III obesity. In order to ensure empathic and patient-centered care, the nurse should do which of the following? A) Examine ones own attitudes towards obesity in general and the patient in particular. B) Dialogue with the patient about the lifestyle and psychosocial factors that resulted in obesity. C) Describe ones own struggles with weight gain and weight loss to the patient. D) Elicit the patients short-term and long-term goals for weight loss.

B) Visual changes

A nurse is planning patient education for a patient being discharged home with a diagnosis of rheumatoid arthritis. The patient has been prescribed antimalarials for treatment, so the nurse knows to teach the patient to self-monitor for what adverse effect? A) Tinnitus B) Visual changes C) Stomatitis D) Hirsutism

Increased fatty tissue prolongs elimination of anesthesia. Decreased ability to compensate for hypoxia increases the risk of an embolism. Loss of collagen increases the risk of skin complications. Reduced tactile sensitivity can lead to assessment and communication problems.

A nurse is planning preopertive teaching for an older client. Which structural or functional changes in the older adult impact the surgical experience? Select all that apply.

A) Improving the patients level of function

A nurse is planning the care of a patient who has undergone orthopedic surgery. What main goal should guide the nurses choice of interventions? A) Improving the patients level of function B) Helping the patient come to terms with limitations C) Administering medications safely D) Improving the patients adherence to treatment

Regular bone density testing A high-calcium diet Use of falls prevention precautions Weight-bearing exercise

A nurse is planning the care of an older adult client who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage what actions? Select all that apply.

A) Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered.

A nurse is preparing to administer a patients intravenous fat emulsion simultaneously with parenteral nutrition (PN). Which of the following principles should guide the nurses action? A) Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. B) The nurse should prepare for placement of another intravenous line, as intravenous fat emulsions may not be infused simultaneously through the line used for PN. C) Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site after running the emulsion through a filter. D) The intravenous fat emulsions can be piggy-backed into any existing IV solution that is infusing.

D) Contact the pharmacy to obtain a new bag of PN.

A nurse is preparing to administer a patients scheduled parenteral nutrition (PN). Upon inspecting the bag, the nurse notices that the presence of small amounts of white precipitate are present in the bag. What is the nurses best action? A) Recognize this as an expected finding. B) Place the bag in a warm environment for 30 minutes. C) Shake the bag vigorously for 10 to 20 seconds. D) Contact the pharmacy to obtain a new bag of PN.

C) The patient maintains or gains weight.

A nurse is preparing to discharge a patient after recovery from gastric surgery. What is an appropriate discharge outcome for this patient? A) The patients bowel movements maintain a loose consistency. B) The patient is able to tolerate three large meals a day. C) The patient maintains or gains weight. D) The patient consumes a diet high in calcium.

ABC

A nurse is preparing to discharge a patient home on parenteral nutrition. What should an effective home care teaching program address? Select all that apply. A) Preparing the patient to troubleshoot for problems B) Teaching the patient and family strict aseptic technique C) Teaching the patient and family how to set up the infusion D) Teaching the patient to flush the line with sterile water E) Teaching the patient when it is safe to leave the access site open to air

Masks Skin antiseptic Alcohol wipes Sterile gauze pads

A nurse is preparing to perform a dressing change to the site of a client's central venous catheter used for parenteral nutrition. Which equipment and supplies would the nurse need to gather? Select all that apply.

A) Watery with blood and mucus

A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patients stools will have what characteristics? A) Watery with blood and mucus B) Hard and black or tarry C) Dry and streaked with blood D) Loose with visible fatty streaks

A) High levels of alcohol consumption

A nurse is presenting an educational event to a local community group. When speaking about colorectal cancer, what risk factor should the nurse cite? A) High levels of alcohol consumption B) History of bowel obstruction C) History of diverticulitis D) Longstanding psychosocial stress

A) Pepsin

A nurse is promoting increased protein intake to enhance a patients wound healing. The nurse knows that enzymes are essential in the digestion of nutrients such as protein. What is the enzyme that initiates the digestion of protein? A) Pepsin B) Intrinsic factor C) Lipase D) Amylase

Vasomotor symptoms associated with dumping syndrome

A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. What will the nurse suspect?

Maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse.

A nurse is talking with a client who is scheduled to have a hemicolectomy with the creation of a colostomy. The client admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. What nursing action is most appropriate?

Presence of autoantibodies against islet cells

A nurse is teaching a diabetic support group about the causes of type 1 diabetes. The teaching is determined to be effective when the group is able to attribute which factor as a cause of type 1 diabetes?

Request that the surgeon come and answer the questions.

A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?

B

A nurse is working with a client to develop assertive communication skills. The nurse documents achievement of treatment outcomes when the client makes a statement such as, A) ìI'm sorry. I'm not picking this up very quickly.î B) ìI feel upset when you interrupt me.î C) ìYou are pushing me too hard.î D) ìI'm not going to let people push me around anymore.î

A

A nurse is working with a client who has a history of repeated abusive intimate relationships. The nurse has difficulty understanding why a woman would repeatedly enter into relationships with abusive partners. When working with this client, the nurse can best maintain a therapeutic relationship through which of the following approaches? A) Keeping focused on the client's feelings about her life situation B) Honestly asking the client why she repeats the cycles of victimization C) Convincing the client to develop a self-rescue plan D) Not prying into the details of the client's private life

A

A nurse is working with a client who has frequent angry outbursts. Which of the following statements is most helpful when working with this client? A) ìAnger is a normal feeling, and you can use it to solve problems.î B) ìYou need to learn to suppress your angry feelings.î C) ìYou can reduce your anger by hitting a punching bag.î D) ìYou need to learn how to be less assertive in your communications.î

A) I have this ringing in my ears that just wont go away.

A nurse is working with a patient with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the patient is experiencing adverse effects of this drug? A) I have this ringing in my ears that just wont go away. B) I feel so foggy in the mornings and it takes me so long to wake up. C) When I eat a meal thats high in fat, I get really nauseous. D) I seem to have lost my appetite, which is unusual for me.

A) Pricking the skin between the great and second toe

A nurse on the orthopedic unit is assessing a patients peroneal nerve. The nurse will perform this assessment by doing which of the following actions? A) Pricking the skin between the great and second toe B) Stroking the skin on the sole of the patients foot C) Pinching the skin between the thumb and index finger D) Stroking the distal fat pad of the small finger

C) A 39-year-old man with chronic alcoholism

A nurse who provides care in a walk-in clinic assesses a wide range of individuals. The nurse should identify which of the following patients as having the highest risk for chronic pancreatitis? A) A 45-year-old obese woman with a high-fat diet B) An 18-year-old man who is a weekend binge drinker C) A 39-year-old man with chronic alcoholism D) A 51-year-old woman who smokes one-and-a-half packs of cigarettes per day

B) Prevent aspiration

A nursing educator is reviewing the care of patients with feeding tubes and endotracheal tubes (ET). The educator has emphasized the need to check for tube placement in the stomach as well as residual volume. What is the main purpose of this nursing action? A) Prevent gastric ulcers B) Prevent aspiration C) Prevent abdominal distention D) Prevent diarrhea

B) A pregnant woman at 28 weeks gestation

A nursing instructor is discussing hemorrhoids with the nursing class. Which patients would the nursing instructor identify as most likely to develop hemorrhoids? A) A 45-year-old teacher who stands for 6 hours per day B) A pregnant woman at 28 weeks gestation C) A 37-year-old construction worker who does heavy lifting D) A 60-year-old professional who is under stress

Remove gas and fluids from the stomach Diagnose gastrointestinal motility disorders Flush ingested toxins from the stomach Administer nutritional substances

A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply.

B) Contact the primary care provider promptly and report these signs of perforation.

A patient admitted with acute diverticulitis has experienced a sudden increase in temperature and complains of a sudden onset of exquisite abdominal tenderness. The nurses rapid assessment reveals that the patients abdomen is uncharacteristically rigid on palpation. What is the nurses best response? A) Administer a Fleet enema as ordered and remain with the patient. B) Contact the primary care provider promptly and report these signs of perforation. C) Position the patient supine and insert an NG tube. D) Page the primary care provider and report that the patient may be obstructed.

A) Does your pain resolve when you have something to eat?

A patient comes to the clinic complaining of pain in the epigastric region. What assessment question during the health interview would most help the nurse determine if the patient has a peptic ulcer? A) Does your pain resolve when you have something to eat? B) Do over-the-counter pain medications help your pain? C) Does your pain get worse if you get up and do some exercise? D) Do you find that your pain is worse when you need to have a bowel movement?

D) Metastases are common and respond poorly to treatment.

A patient has been diagnosed with a malignancy of the oral cavity and is undergoing oncologic treatment. The oncologic nurse is aware that the prognosis for recovery from head and neck cancers is often poor because of what characteristic of these malignancies? A) Radiation therapy often results in secondary brain tumors. B) Surgical complications are exceedingly common. C) Diagnosis rarely occurs until the cancer is endstage. D) Metastases are common and respond poorly to treatment.

B) Abdominal pain and hepatomegaly

A patient has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the patient may have developed liver metastases? A) Persistent fever and cognitive changes B) Abdominal pain and hepatomegaly C) Peripheral edema unresponsive to diuresis D) Spontaneous bleeding and jaundice

B) Regurgitation of undigested food

A patient has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the patient to describe what sign or symptom? A) Burning pain on swallowing B) Regurgitation of undigested food C) Symptoms mimicking a heart attack D) Chronic parotid abscesses

ABD

A patient has been discharged home on parenteral nutrition (PN). Much of the nurses discharge education focused on coping. What must a patient on PN likely learn to cope with? Select all that apply. A) Changes in lifestyle B) Loss of eating as a social behavior C) Chronic bowel incontinence from GI changes D) Sleep disturbances related to frequent urination during nighttime infusions E) Stress of choosing the correct PN formulation

A) Injection of a contrast agent into the knee joint prior to ROM exercises

A patient has been experiencing an unexplained decline in knee function and has consequently been scheduled for arthrography. The nurse should teach the patient about what process? A) Injection of a contrast agent into the knee joint prior to ROM exercises B) Aspiration of synovial fluid for serologic testing C) Injection of corticosteroids into the patients knee joint to facilitate ROM D) Replacement of the patients synovial fluid with a synthetic substitute

C) Arthrocentesis

A patient has been experiencing progressive increases in knee pain and diagnostic imaging reveals a worsening effusion in the synovial capsule. The nurse should anticipate which of the following? A) Arthrography B) Knee biopsy C) Arthrocentesis D) Electromyography

Hypertension Alterations in glucose metabolism Poor wound healing side effects of corticosteroid therapy include hypertension, alterations in glucose metabolism, weight gain, and poor wound healing.

A patient has been placed on corticosteroid therapy for an Addison's disease. The nurse should be aware of which of the following side effects with this type of therapy? Select all that apply.

A) Have the patient refrain from food and fluids after midnight.

A patient has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study? A) Have the patient refrain from food and fluids after midnight. B) Administer the contrast agent orally 10 to 12 hours before the study. C) Administer the radioactive agent intravenously the evening before the study. D) Encourage the intake of 64 ounces of water 8 hours before the study.

D) Encourage the patient to connect with a community-based support group.

A patient has been treated in the hospital for an episode of acute pancreatitis. The patient has acknowledged the role that his alcohol use played in the development of his health problem, but has not expressed specific plans for lifestyle changes after discharge. What is the nurses most appropriate response? A) Educate the patient about the link between alcohol use and pancreatitis. B) Ensure that the patient knows the importance of attending follow-up appointments. C) Refer the patient to social work or spiritual care. D) Encourage the patient to connect with a community-based support group.

B) A quantitative fecal immunochemical test

A patient has come to the clinic complaining of blood in his stool. A FOBT test is performed but is negative. Based on the patients history, the physician suggests a colonoscopy, but the patient refuses, citing a strong aversion to the invasive nature of the test. What other test might the physician order to check for blood in the stool? A) A laparoscopic intestinal mucosa biopsy B) A quantitative fecal immunochemical test C) Computed tomography (CT) D) Magnetic resonance imagery (MRI)

A) Two to 3 soft bowel movements daily

A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patients current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A) Two to 3 soft bowel movements daily B) Significant increase in appetite and food intake C) Absence of nausea and vomiting D) Absence of blood or mucus in stool

D) A sudden release of peptides

A patient has experienced symptoms of dumping syndrome following bariatric surgery. To what physiologic phenomenon does the nurse attribute this syndrome? A) Irritation of the phrenic nerve due to diaphragmatic pressure B) Chronic malabsorption of iron and vitamins A and C C) Reflux of bile into the distal esophagus D) A sudden release of peptides

B) Apply a skin barrier to the peristomal skin prior to applying the pouch.

A patient has had an ileostomy created for the treatment of irritable bowel disease and the patient is now preparing for discharge. What should the patient be taught about changing this device in the home setting? A) Apply antibiotic ointment as ordered after cleaning the stoma. B) Apply a skin barrier to the peristomal skin prior to applying the pouch. C) Dispose of the clamp with each bag change. D) Cleanse the area surrounding the stoma with alcohol or chlorhexidine.

D) Providing the patient with physical and emotional support

A patient has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. What would be the nursing care most needed by the patient at this time? A) Teaching the patient about necessary nutritional modification B) Helping the patient weigh treatment options C) Teaching the patient about the etiology of gastritis D) Providing the patient with physical and emotional support

A) Wrap the joint in a compression dressing.

A patient has just had an arthroscopy performed to assess a knee injury. What nursing intervention should the nurse implement following this procedure? A) Wrap the joint in a compression dressing. B) Perform passive range of motion exercises. C) Maintain the knee in flexion for up to 30 minutes. D) Apply heat to the knee.

A) Ensure that none of the patients visitors has an infection.

A patient has received treatment for oral cancer. The combination of medications and radiotherapy has resulted in leukopenia. Which of the following is an appropriate response to this change in health status? A) Ensure that none of the patients visitors has an infection. B) Arrange for a diet that is high in protein and low in fat. C) Administer colony stimulating factors (CSFs) as ordered. D) Prepare to administer chemotherapeutics as ordered.

B) Document this as an expected assessment finding.

A patient has recently been admitted to the orthopedic unit following total hip arthroplasty. The patient has a closed suction device in place and the nurse has determined that there were 320 mL of output in the first 24 hours. How should the nurse best respond to this assessment finding? A) Inform the primary care provider promptly. B) Document this as an expected assessment finding. C) Limit the patients fluid intake to 2 liters for the next 24 hours. D) Administer a loop diuretic as ordered.

A) NSAIDs

A patient has sought care because of recent dark-colored stools. As a result, a fecal occult blood test has been ordered. The nurse should instruct the patient to avoid which of the following prior to collecting a stool sample? A) NSAIDs B) Acetaminophen C) OTC vitamin D supplements D) Fiber supplements

C) Signs and symptoms of intra-abdominal complications

A patient has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize which of the following topics? A) Management of fluid balance in the home setting B) The need for blood glucose monitoring for the next week C) Signs and symptoms of intra-abdominal complications D) Appropriate use of prescribed pancreatic enzymes

B) Surgery is delayed until the acute symptoms subside.

A patient is admitted to the unit with acute cholecystitis. The physician has noted that surgery will be scheduled in 4 days. The patient asks why the surgery is being put off for a week when he has a sick gallbladder. What rationale would underlie the nurses response? A) Surgery is delayed until the patient can eat a regular diet without vomiting. B) Surgery is delayed until the acute symptoms subside. C) The patient requires aggressive nutritional support prior to surgery. D) Time is needed to determine whether a laparoscopic procedure can be used.

D) Persistently low hemoglobin and hematocrit

A patient is being assessed for a suspected deficit in intrinsic factor synthesis. What diagnostic or assessment finding is the most likely rationale for this examination of intrinsic factor production? A) Muscle wasting B) Chronic jaundice in the absence of liver disease C) The presence of fat in the patients stool D) Persistently low hemoglobin and hematocrit

D) Maintain the patient in a semi-Fowlers position whenever possible.

A patient is being treated on the acute medical unit for acute pancreatitis. The nurse has identified a diagnosis of Ineffective Breathing Pattern Related to Pain. What intervention should the nurse perform in order to best address this diagnosis? A) Position the patient supine to facilitate diaphragm movement. B) Administer corticosteroids by nebulizer as ordered. C) Perform oral suctioning as needed to remove secretions. D) Maintain the patient in a semi-Fowlers position whenever possible.

Leakage of spinal fluid from the subarachnoid space Size of the spinal needle used Degree of patient hydration

A patient is complaining of a headache after receiving spinal anesthesia. What does the nurse understand may be the cause of the headache related to the spinal anesthesia? (Select all that apply.)

C) Compartment syndrome

A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. The nurse should identify the warning signs of what complication? A) Subcutaneous emphysema B) Skin breakdown C) Compartment syndrome D) Disuse syndrome

Pain Erythema Fever

A patient is diagnosed with osteomyelitis of the right leg. What signs and symptoms does the nurse recognize that are associated with this diagnosis? (Select all that apply.)

A) Eating more slowly and chewing food more thoroughly

A patient is one month postoperative following restrictive bariatric surgery. The patient tells the clinic nurse that he has been having trouble swallowing for the past few days. What recommendation should the nurse make? A) Eating more slowly and chewing food more thoroughly B) Taking an OTC antacid or drinking a glass of milk prior to each meal C) Chewing gum to cause relaxation of the lower esophageal sphincter D) Drinking at least 12 ounces of liquid with each meal

B) Wash the area around the tube with soap and water daily.

A patient is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate? A) Administer antibiotics via the tube as ordered. B) Wash the area around the tube with soap and water daily. C) Cleanse the skin within 2 cm of the insertion site with hydrogen peroxide once per shift. D) Irrigate the skin surrounding the insertion site with normal saline before each use.

B) Shuffling gait

A patient is receiving ongoing nursing care for the treatment of Parkinsons disease. When assessing this patients gait, what finding is most closely associated with this health problem? A) Spastic hemiparesis gait B) Shuffling gait C) Rapid gait D) Steppage gait

D) Make appropriate referrals to services that provide psychosocial support.

A patient is recovering in the hospital following gastrectomy. The nurse notes that the patient has become increasingly difficult to engage and has had several angry outbursts at various staff members in recent days. The nurses attempts at therapeutic dialogue have been rebuffed. What is the nurses most appropriate action? A) Ask the patients primary care provider to liaise between the nurse and the patient. B) Delegate care of the patient to a colleague. C) Limit contact with the patient in order to provide privacy. D) Make appropriate referrals to services that provide psychosocial support.

B) That the patient emptied the bladder

A patient is scheduled for a bone scan to rule out osteosarcoma of the pelvic bones. What would be most important for the nurse to assess before the patients scan? A) That the patient completed the bowel cleansing regimen B) That the patient emptied the bladder C) That the patient is not allergic to penicillins D) That the patient has fasted for at least 8 hours

D) Arthocentesis

A patient is suspected of having rheumatoid arthritis and her diagnostic regimen includes aspiration of synovial fluid from the knee for a definitive diagnosis. The nurse knows that which of the following procedures will be involved? A) Angiography B) Myelography C) Paracentesis D) Arthocentesis

An abnormal glucose tolerance Glucosuria Hyperglycemia

A patient is suspected to have pancreatic carcinoma and is having diagnostic testing to determine insulin deficiency. What would the nurse determine is an indicator for insulin deficiency in this patient? (Select all that apply).

A) OA is a considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints.

A patient is undergoing diagnostic testing to determine the etiology of recent joint pain. The patient asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? A) OA is a considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints. B) OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the larger, weight-bearing joints like the knees. C) OA originates with an infection. RA is a result of your bodys cells attacking one another. D) OA is associated with impaired immune function; RA is a consequence of physical damage.

A) Infection with Helicobacter pylori

A patient presents to the walk-in clinic complaining of vomiting and burning in her mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the physician is likely to order a diagnostic test to detect the presence of what? A) Infection with Helicobacter pylori B) Excessive stomach acid secretion C) An incompetent pyloric sphincter D) A metabolic acidbase imbalance

C) Dilute the concentration of the feeding solution.

A patient receiving tube feedings is experiencing diarrhea. The nurse and the physician suspect that the patient is experiencing dumping syndrome. What intervention is most appropriate? A) Stop the tube feed and aspirate stomach contents. B) Increase the hourly feed rate so it finishes earlier. C) Dilute the concentration of the feeding solution. D) Administer fluid replacement by IV.

B) Decubitus ulcer

A patient returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the patient for signs and symptoms of what serious potential complication of this surgery? A) Diabetic coma B) Decubitus ulcer C) Wound evisceration D) Bile duct injury

B) 60 mL of milky or cloudy drainage

A patient returns to the unit after a neck dissection. The surgeon placed a Jackson Pratt drain in the wound. When assessing the wound drainage over the first 24 postoperative hours the nurse would notify the physician immediately for what? A) Presence of small blood clots in the drainage B) 60 mL of milky or cloudy drainage C) Spots of drainage on the dressings surrounding the drain D) 120 mL of serosanguinous drainage

D) Instead of eating three meals a day, try eating smaller amounts more often.

A patient seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education? A) Drinking beverages after your meal, rather than with your meal, may bring some relief. B) Its best to avoid dry foods, such as rice and chicken, because theyre harder to swallow. C) Many patients obtain relief by taking over-the-counter antacids 30 minutes before eating. D) Instead of eating three meals a day, try eating smaller amounts more often.

Covering the area with a clean dressing if the fracture is open Immobilizing the affected site Splinting the injured limb

A patient sustains an open fracture of the left arm after an accident at the roller skating rink. What does emergency management of this fracture involve? (Select all that apply.)

A) Esophageal or pyloric obstruction related to scarring

A patient was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize? A) Esophageal or pyloric obstruction related to scarring B) Uncontrolled proliferation of H. pylori C) Gastric hyperacidity related to excessive gastrin secretion D) Chronic referred pain in the lower abdomen

A) Tachycardia, hypotension, and tachypnea

A patient who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the patients condition is now stable. For the next several hours, the nurse caring for this patient should assess for what signs and symptoms of recurrence? A) Tachycardia, hypotension, and tachypnea B) Tarry, foul-smelling stools C) Diaphoresis and sudden onset of abdominal pain D) Sudden thirst, unrelieved by oral fluid administration

B) An effective means of communicating with the nurse

A patient who had a hemiglossectomy earlier in the day is assessed postoperatively, revealing a patent airway, stable vital signs, and no bleeding or drainage from the operative site. The nurse notes the patient is alert. What is the patients priority need at this time? A) Emotional support from visitors and staff B) An effective means of communicating with the nurse C) Referral to a speech therapist D) Dietary teaching focused on consistency of food and frequency of feedings

C) Increase fluid intake to evacuate the barium

A patient who has been experiencing changes in his bowel function is scheduled for a barium enema. What instruction should the nurse provide for postprocedure recovery? A) Remain NPO for 6 hours postprocedure. B) Administer a Fleet enema to cleanse the bowel of the barium. C) Increase fluid intake to evacuate the barium. D) Avoid dairy products for 24 hours postprocedure.

Hairy leukoplakia

A patient who is HIV positive comes to the clinic and is experiencing white patches with rough hairlike projections. The nurse observes the lesions on the lateral border of the tongue. What abnormality of the mouth does the nurse determine these lesions are?

C) Monitor the patient closely for further signs of dumping syndrome.

A patient who underwent gastric banding 3 days ago is having her diet progressed on a daily basis. Following her latest meal, the patient complains of dizziness and palpitations. Inspection reveals that the patient is diaphoretic. What is the nurses best action? A) Insert a nasogastric tube promptly. B) Reposition the patient supine. C) Monitor the patient closely for further signs of dumping syndrome. D) Assess the patient for signs and symptoms of aspiration.

Galactorrhea All choices are indicators of a pituitary tumor, but the most common form is indicated by the spontaneous and inappropriate flow of milk from the male or female breast in the absence of pregnancy or breastfeeding. A normal prolactin level is less than 20 ng/mL

A patient whose laboratory studies indicates a prolactin level of 200 ng/mL is assessed for a pituitary tumor. During the physical exam, the nurse practitioner notices a number of signs and/or symptoms suggestive of this condition. Which of the following is the most common indicator of a pituitary tumor?

A) The patients BUN and creatinine levels are within reference range following the CT.

A patient will be undergoing abdominal computed tomography (CT) with contrast. The nurse has administered IV sodium bicarbonate and oral acetylcysteine (Mucomyst) before the study as ordered. What would indicate that these medications have had the desired therapeutic effect? A) The patients BUN and creatinine levels are within reference range following the CT. B) The CT yields high-quality images. C) The patients electrolytes are stable in the 48 hours following the CT. D) The patients intake and output are in balance on the day after the CT.

B) Keep patient NPO until the patients gag reflex returns.

A patient with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform? A) Keep patient NPO until the results of test are known. B) Keep patient NPO until the patients gag reflex returns. C) Administer analgesia until post-procedure tenderness is relieved. D) Give the patient a cold beverage to promote swallowing ability.

A) This medication will reduce the amount of acid secreted in your stomach.

A patient with a diagnosis of peptic ulcer disease has just been prescribed omeprazole (Prilosec). How should the nurse best describe this medications therapeutic action? A) This medication will reduce the amount of acid secreted in your stomach. B) This medication will make the lining of your stomach more resistant to damage. C) This medication will specifically address the pain that accompanies peptic ulcer disease. D) This medication will help your stomach lining to repair itself.

B) The patient has a rigid, boardlike abdomen that is tender.

A patient with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the patient has a perforated ulcer? A) The patient has abdominal bloating that developed rapidly. B) The patient has a rigid, boardlike abdomen that is tender. C) The patient is experiencing intense lower right quadrant pain. D) The patient is experiencing dizziness and confusion with no apparent hemodynamic changes.

D) Avoid drinking alcohol while taking the drug.

A patient with a peptic ulcer disease has had metronidazole (Flagyl) added to his current medication regimen. What health education related to this medication should the nurse provide? A) Take the medication on an empty stomach. B) Take up to one extra dose per day if stomach pain persists. C) Take at bedtime to mitigate the effects of drowsiness. D) Avoid drinking alcohol while taking the drug.

B) Keep your right leg elevated above heart level

A patient with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the patients cast care? A) Cover the cast with a blanket until the cast dries. B) Keep your right leg elevated above heart level. C) Use a clean object to scratch itches inside the cast. D) A foul smell from the cast is normal after the first few days.

A) You seem like youre feeling angry. Is that something that we could talk about?

A patient with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on the medical unit. The nurse observes that the patient expresses angerand irritation when her call bell isnt answered immediately. What would be the most appropriate response? A) You seem like youre feeling angry. Is that something that we could talk about? B) Try to remember that stress can make your symptoms worse. C) Would you like to talk about the problem with the nursing supervisor? D) I can see youre angry. Ill come back when youve calmed down.

C) Respiratory status and airway clearance

A patient with cancer of the tongue has had a radical neck dissection. What nursing assessment would be a priority for this patient? A) Presence of acute pain and anxiety B) Tissue integrity and color of the operative site C) Respiratory status and airway clearance D) Self-esteem and body image

B) Pain relief occurs by 6 months in most patients who undergo this procedure, but some people experience a recurrence of their pain.

A patient with chronic pancreatitis had a pancreaticojejunostomy created 3 months ago for relief of pain and to restore drainage of pancreatic secretions. The patient has come to the office for a routine postsurgical appointment. The patient is frustrated that the pain has not decreased. What is the most appropriate initial response by the nurse? A) The majority of patients who have a pancreaticojejunostomy have their normal digestion restored but do not achieve pain relief. B) Pain relief occurs by 6 months in most patients who undergo this procedure, but some people experience a recurrence of their pain. C) Your physician will likely want to discuss the removal of your gallbladder to achieve pain relief. D) You are probably not appropriately taking the medications for your pancreatitis and pain, so we will need to discuss your medication regimen in detail.

D) Digestion of proteins

A patient with cystic fibrosis takes pancreatic enzyme replacements on a regular basis. The patients intake of trypsin facilitates what aspect of GI function? A) Vitamin D synthesis B) Digestion of fats C) Maintenance of peristalsis D) Digestion of proteins

ACE

A patient with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patients fluid volume excess? Select all that apply. A) Administering diuretics B) Administering calcium channel blockers C) Implementing fluid restrictions D) Implementing a 1500 kcal/day restriction E) Enhancing patient positioning

B) I will take this medication for 2 weeks and then gradually stop taking it.

A patient with gallstones has been prescribed ursodeoxycholic acid (UDCA). The nurse understands that additional teaching is needed regarding this medication when the patient states: A) It is important that I see my physician for scheduled follow-up appointments while taking this medication. B) I will take this medication for 2 weeks and then gradually stop taking it. C) If I lose weight, the dose of the medication may need to be changed. D) This medication will help dissolve small gallstones made of cholesterol.

A) Does anyone in your family have experience at giving injections?

A patient with gastritis required hospital treatment for an exacerbation of symptoms and receives a subsequent diagnosis of pernicious anemia due to malabsorption. When planning the patients continuing care in the home setting, what assessment question is most relevant? A) Does anyone in your family have experience at giving injections? B) Are you going to be anywhere with strong sunlight in the next few months? C) Are you aware of your blood type? D) Do any of your family members have training in first aid? Ans: A

C) Reduction in sodium intake

A patient with liver disease has developed jaundice; the nurse is collaborating with the patient to develop a nutritional plan. The nurse should prioritize which of the following in the patients plan? A) Increased potassium intake B) Fluid restriction to 2 L per day C) Reduction in sodium intake D) High-protein, low-fat diet

B) Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.

A patients NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next? A) Withdraw the NG tube 3 to 5 cm and reattempt aspiration. B) Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating. C) Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers. D) Remove the NG tube promptly and obtain an order for reinsertion from the primary care provider.

A) Increased bilirubin

A patients abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the patients laboratory studies, what finding is most closely associated with this diagnosis? A) Increased bilirubin B) Decreased serum cholesterol C) Increased blood urea nitrogen (BUN) D) Decreased serum alkaline phosphatase level

A) Rheumatoid arthritis (RA)

A patients decreased mobility is ultimately the result of an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. This patient has been diagnosed with what health problem? A) Rheumatoid arthritis (RA) B) Systemic lupus erythematosus C) Osteoporosis D) Polymyositis

B) Entry of large amounts of water into the small intestine because of osmotic pressure

A patients enteral feedings have been determined to be too concentrated based on the patients development of dumping syndrome. What physiologic phenomenon caused this patients complication of enteral feeding? A) Increased gastric secretion of HCl and gastrin because of high osmolality of feeds B) Entry of large amounts of water into the small intestine because of osmotic pressure C) Mucosal irritation of the stomach and small intestine by the high concentration of the feed D) Acidbase imbalance resulting from the high volume of solutes in the feed

A) Chemical phlebitis

A patients health decline necessitates the use of total parenteral nutrition. The patient has questioned the need for insertion of a central venous catheter, expressing a preference for a normal IV. The nurse should know that peripheral administration of high-concentration PN formulas is contraindicated because of the risk for what complication? A) Chemical phlebitis B) Hyperglycemia C) Dumping syndrome D) Line sepsis

D) Preparing the patient for surgical bowel resection

A patients large bowel obstruction has failed to resolve spontaneously and the patients worsening condition has warranted admission to the medical unit. Which of the following aspects of nursing care is most appropriate for this patient? A) Administering bowel stimulants as ordered B) Administering bulk-forming laxatives as ordered C) Performing deep palpation as ordered to promote peristalsis D) Preparing the patient for surgical bowel resection

A) Confirm placement of the tube prior to each medication administration.

A patients new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patients care plan accordingly. What intervention should the nurse include in the patients plan of care? A) Confirm placement of the tube prior to each medication administration. B) Have the patient sip cool water to stimulate saliva production. C) Keep the patient in a low Fowlers position when at rest. D) Connect the tube to continuous wall suction when not in use.

B) The patient can resume a normal routine immediately.

A patients sigmoidoscopy has been successfully completed and the patient is preparing to return home. Which of the following teaching points should the nurse include in the patients discharge education? A) The patient should drink at least 2 liters of fluid in the next 12 hours. B) The patient can resume a normal routine immediately. C) The patient should expect fecal urgency for several hours. D) The patient can expect some scant rectal bleeding.

low platelet count.

A physician has ordered a liver biopsy for a client with cirrhosis whose condition has recently deteriorated. The nurse reviews the client's recent laboratory findings and recognizes that the client is at risk for complications due to:

No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test

A physician orders laboratory tests to confirm hyperthyroidism in a client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?

D) Assessing the patency of the ulnar artery

A radial graft is planned in the treatment of a patients oropharyngeal cancer. In order to ensure that the surgery will be successful, the care team must perform what assessment prior to surgery? A) Assessing function of cranial nerves V, VI, and IX B) Assessing for a history of GERD C) Assessing for signs or symptoms of atherosclerosis D) Assessing the patency of the ulnar artery

B) Lower esophageal sphincter

A staff educator is reviewing the causes of gastroesophageal reflux disease (GERD) with new staff nurses. What area of the GI tract should the educator identify as the cause of reduced pressure associated with GERD? A) Pyloric sphincter B) Lower esophageal sphincter C) Hypopharyngeal sphincter D) Upper esophageal sphincter

C) Blood glucose levels

A student nurse is caring for a patient who has a diagnosis of acute pancreatitis and who is receiving parenteral nutrition. The student should prioritize which of the following assessments? A) Fluid output B) Oral intake C) Blood glucose levels D) BUN and creatinine levels

Identify the client using two identifiers. Verify the surgical site and mark it appropriately. Review the medical records.

A surgical client has been transferred to the holding area. What nursing intervention(s) promote safe and effective nursing care? Select all that apply.

B

A visitor comes to see a client who is suicidal. Upon entering the unit, the nurse notices that the visitor has brought the client a can of his favorite soda. Which action should the nurse take at his time? A) Confiscate the soda can as a restricted item. B) Pour the soda into a plastic cup. C) Ask the visitor to place the soda can at the nurse's desk until he or she leaves. D) Ask the visitor not to bring outside items on the unit in the future.

D

A woman has just been served divorce papers from her husband. She has no financial resources and little social support. She states, ìHe's not really leaving. He'll be back.î The most appropriate response by the nurse would be which of the following? A) ìHas he done this before?î B) ìI'll call social services and get you signed up for financial assistance.î C) ìYou have to face reality. Here are the papers.î D) ìHow is this affecting you right now?î

D

A woman has just delivered a stillborn baby boy. Which of the following would be the most appropriate nursing response? A) ìCan I do anything for you?î B) ìIf something was wrong, it's better this way.î C) ìYour son is in heaven with God now.î D) ìWould you like to hold your son?î

B

A woman is in treatment for an anxiety disorder. Her history reveals that she was sexually abused repeatedly by her husband. Which of the following interventions would be appropriate in relation to this piece of data? A) Avoid discussing the abuse so as not to upset her. B) Encourage her to talk about feelings related to the abuse. C) Request an anxiolytic to reduce her anxiety levels. D) Help her explore her role in perpetuating the abuse.

Goiter

A woman with a progressively enlarging neck comes into the clinic. She mentions that she has been in a foreign country for the previous 3 months and that she didn't eat much while she was there because she didn't like the food. She also mentions that she becomes dizzy when lifting her arms to do normal household chores or when dressing. What endocrine disorder should the nurse expect the physician to diagnose?

C

A young client tells the nurse that her husband died 3 months ago, and she is feeling alone and vulnerable. Which statement by the client would indicate that her coping skills are adequate? A) ìI can't understand why this happened to me.î B) ìI'm mentally healthy. I can solve my own problems.î C) ìI will find a support group.î D) ìWhat can I do? My husband abandoned me.î

B

A young couple just ended their relationship after a 9-month engagement. The one of the individuals is seeking short-term counseling to assist in grieving this loss. Which type of loss best describes what this client is experiencing? A) Safety loss B) Loss of security and sense of belonging C) Loss of self-esteem D) Loss related to self-actualization

Which of the following disorders are extrapyramidal symptoms that may be caused by antipsychotic drugs? Select all that apply. A) Akathisia B) Pseudoparkinsonism C) Neuroleptic malignant syndrome D) Dystonia E) Anticholinergic effects F) Breast tenderness in men and women

ABD

Discharge planning from inpatient care for people with severe mental illness must address which of the following to be effective? Select all that apply. A) Finding housing for the client B) Finding a job for the client C) Finding transportation for the client D) Improving family support E) Identifying ideal recreational activities

AC

The major problems with large state institutions are: Select all that apply. A) attendants were accused of abusing the residents. B) stigma associated with residence in an insane asylum. C) clients were geographically isolated from family and community. D) increasing financial costs to individual residents.

AC

Which of the following are criteria that must be adhered to when instituting the short- term use of restraint or seclusion? Select all that apply. A) The client is aggressive. B) The client is being punished. C) The client is imminently dangerous to himself or herself or to others. D) The client is physically and emotionally self-controlled. E) All other means of calming the client have been unsuccessful.

ACE

Which of the following would be circumstances when a client could be subjected to involuntary hospitalization? Select all that apply. A) When a client states that he or she intends to commit suicide and is making plans to do so. B) When a client does not bathe regularly or change clothes often. C) When a client states that he or she intends to harm others by a deliberate act. D) When a client who has diabetes refuses to follow the prescribed diet. E) When a client is unable to control his or her rage and is assaulting everyone around him or her.

ACE

Delirium of this type is treatable and her cognition will return to previous levels.

An 84-year-old client has returned from the post-anesthetic care unit (PACU) following hip arthroplasty. The client is oriented to name only. The client's family is very upset because, before having surgery, the client had no cognitive deficits. The client is subsequently diagnosed with postoperative delirium. What should the nurse explain to the client's family?

C) Fluids must be increased to facilitate the evacuation of the stool.

An adult patient is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the patient has completed the test? A) Stool will be yellow for the first 24 hours postprocedure. B) The barium may cause diarrhea for the next 24 hours. C) Fluids must be increased to facilitate the evacuation of the stool. D) Slight anal bleeding may be noted as the barium is passed.

A

An angry client has just thrown a chair across the room and is racing to pick up another chair to throw. The most appropriate action by the nurse would be which of the following? A) Call for an emergency response from trained personnel. B) Approach the client and firmly say, ìStop, put it down.î C) Calmly call the client by name and encourage verbal expression of anger. D) Assist the client to use problem-solving techniques instead of aggression.

D

An anxiolytic agent, lorazepam (Ativan), has been prescribed for the client. Which of the following statements by the client would indicate to the nurse that client education about this medication has been effective? A) ìMy anxiety will be eliminated if I take this medication as prescribed.î B) ìThis medication presents no risk of addiction or dependence.î C) ìI will probably always need to take this medication for my anxiety.î D) ìThis medication will relax me, so I can focus on problem solving.î

anorexia nervosa

An eating disorder characterized by an obstinate and willful refusal to eat, a distorted body image, and an intense fear of being fat

Improvement in ambulation

An elderly client experienced a cerebrovascular accident (CVA) and was unable to ambulate following his CVA. The client was transferred from a hospital and is now at a subacute care facility. For continuation of Medicare coverage, the nurse evaluates that the client must demonstrate

Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients.

An elderly client is preparing to undergo surgery. The nurse participates in preoperative care knowing that which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults?

Increase fluid intake.

An elderly client is reporting changes in bowel movements from every day to every 3 to 4 days. The client also states that the stools are hard. Nursing interventions include instructing the client to

Exhibiting hemoglobin A1C 8.2

An elderly client states, "I don't understand why I have so many caries in my teeth." What assessment made by the nurse places the client at risk for dental caries?

Avoiding foot ulcers may mean the difference between institutionalization and continued independent living.

An elderly client with diabetes comes to the clinic with her daughter. The nurse reviews foot care with the client and her daughter. Why would the nurse feel that foot care is so important to this client?

Avoid straining when having a bowel movement.

An elderly client with heart failure reports constipation that has progressively worsened over the last several months. The client's vital signs are pulse 86 beats per minute, blood pressure 94/56, and respirations 18 breaths per minute. It would be best for the nurse to instruct the client to

A) Palpate the patients parotid glands to detect swelling and tenderness.

An elderly patient comes into the emergency department complaining of an earache. The patient and has an oral temperature of 100.2F and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next? A) Palpate the patients parotid glands to detect swelling and tenderness. B) Assess the temporomandibular joint for evidence of a malocclusion. C) Test the integrity of cranial nerve XII by asking the patient to protrude the tongue. D) Inspect the patients gums for bleeding and hyperpigmentation.

C

An elderly woman who lives alone is beginning to have difficulty maintaining her household and performing daily tasks. The nurse asks her to identify someone who can help her. The woman replies, ìI don't need help. I've been managing for years.î Which of the following responses helps the client shift from denial to consciously coping with her situation? A) ìYou don't think you need any help? But your family is worried about you.î B) ìIt must be hard to lose your independence. I'll ask a social worker to see what can be arranged.î C) ìIf you were to need help with your house, who might you ask for help?î D) ìIf you don't ask for some help. then the only option is to move to an assisted living facility.î

D) Kyphosis

An older adult patient has come to the clinic for a regular check-up. The nurses initial inspection reveals an increased thoracic curvature of the patients spine. The nurse should document the presence of which of the following? A) Scoliosis B) Epiphyses C) Lordosis D) Kyphosis

A) Bone densitometry

An older adult patient has symptoms of osteoporosis and is being assessed during her annual physical examination. The assessment shows that the patient will require further testing related to a possible exacerbation of her osteoporosis. The nurse should anticipate what diagnostic test? A) Bone densitometry B) Hip bone radiography C) Computed tomography (CT) D) Magnetic resonance imaging (MRI)

A nurse is working with a patient with an eating disorder who refuses to eat a muffin. The nurse asks the patient ìIs there any way that you could see the muffin as just flour and water, basic nutrients your body needs?î In this statement, the nurse is using which type of therapy? A) Rational emotive therapy B) Cognitive therapy C) Gestalt therapy D) Reality therapy

B

A patient is encouraged to join in daily outdoor games with peers on the unit. The interdisciplinary team member who will monitor the patient's involvement will be the A) occupational therapist. B) recreation therapist. C) vocational rehabilitation therapist. D) psychiatric nurse.

B

A psychiatric nurse is planning an educational program addressing primary prevention strategies in the community. The nurse explores current research regarding which health-care need? A) Influencing schizophrenic patients to adhere to medication regimens B) Assisting high school students to effectively manage stress C) Coaching patients with depression to obtain employment D) Teaching parents the early signs of attention deficit disorder in children

B

Disclosure of client information beyond the interdisciplinary team without consent of the client is a breach of A) beneficence. B) confidentiality. C) duty. D) veracity.

B

How should the nurse respond to a family member who asks how Alzheimer's disease is diagnosed? A) It is impossible to know for certain that a person has Alzheimer's disease until the person dies and his or her brain can be examined via autopsy. B) Positron emission tomography (PET) scans can identify the amyloid plaques and tangles of Alzheimer's disease in living clients. C) Alzheimer's disease can be diagnosed by using chemical markers that demonstrate decreased cerebral blood flow. D) It will be necessary for the patient to undergo positron emission tomography (PET) scans regularly for a long period of time to know if the patient has Alzheimer's disease.

B

The creation of asylums during the 1800s was meant to A) improve treatment of mental disorders. B) provide food and shelter for the mentally ill. C) punish people with mental illness who were believed to be possessed. D) remove dangerous people with mental illness from the community.

B

Two nurses are discussing the rights of hospitalized psychiatric clients. Which of the following statements is an error? A) Confidentiality allows for the disclosure of information under specific circumstances. B) If a committed client is also found to be incompetent, he loses his rights under the Patient's Bill of Rights. C) Privileged communication does not apply to medical records, and they can be used in court. D) Clients can never be held against their will.

B

What is meant by the term ìrevolving door effectî in mental health care? A) An overall reduction in incidence of severe mental illness B) Shorter and more frequent hospital stays for persons with severe and persistent mental illness C) Flexible treatment settings for mentally ill D) Most effective and least expensive treatment settings

B

When is a nurse legally obligated to breach confidentiality? A) At any time a client is threatening B) If threats are made to an identifiable third party C) Whenever the client becomes aggressive D) When the client violates the nurse's boundaries

B

When the client asks the nurse how long it will take before the SSRI antidepressant medication will be effective, which of the following replies is most accurate and therapeutic? A) ìThis is a good medication! It will be effective within 20 minutes of the first dose.î B) ìYou will have gradual improvement in symptoms over the next few weeks, but the changes may be so subtle that you may not notice them for a while. It is important for you to keep taking the medication.î C) ìIt will probably take months for the medication to work. In the meantime, you should work on improving your attitude.î D) ìIf you believe it will work, then it will. You have to have faith!î

B

When the client experiences facial flushing, a throbbing headache, nausea and vomiting after consuming alcohol while taking Disulfiram (Antabuse), the nurse is aware that this is due to which of the following? A) A mild side effect of the medication. B) The intended therapeutic result. C) An idiosyncratic reaction D) A severe allergy to the medication.

B

Which is included in Healthy People 2020 objectives? A) To decrease the incidence of mental illness B) To increase the number of people who are identified, diagnosed, treated, and helped to live healthier lives C) To provide mental health services only in the community D) To decrease the numbers of people who are being treated for mental illness

B

Which of the following is a term used to describe the occurrence of the eye rolling back in a locked position, which occurs with acute dystonia? A) Opisthotonus B) Oculogyric crisis C) Torticollis D) Pseudoparkinsonism

B

Which one of the following is a result of federal legislation? A) Making it easier to commit people for mental health treatment against their will. B) Making it more difficult to commit people for mental health treatment against their will. C) State mental institutions being the primary source of care for mentally ill persons. D) Improved care for mentally ill persons.

B

The nurse is educating a patient and family about strategies to minimize the side effects of antipsychotic drugs. Which of the following should be included in the plan? Select all that apply. A) Drink plenty of fruit juice. B) Developing an exercise program is important. C) Increase foods high in fiber. D) Laxatives can be used as needed. E) Use sunscreen when outdoors. F) For missed doses, take double the dose at the next scheduled time.

BCE

Which of the following theories could be classified as humanistic theories? Select all that apply. A) Cognitive therapy B) Maslow's hierarchy of needs C) Gestalt therapy D) Rogers' client-centered therapy E) Rational emotive therapy F) Piaget's cognitive stages of development

BD

A patient has just been referred to a psychosocial rehabilitation program. The nurse explains that the benefits of being involved in such a program include: Select all that apply. A) continuous monitoring of symptoms. B) increased independence. C) increased involvement in treatment decisions. D) recovery from mental illness. E) increased community integration. F) greater opportunities for personal growth.

BDE

A student appears very nervous on the first day of clinical in a psychiatric setting. The student reviews the instructor's guidelines and appropriately takes which of the following actions? Select all that apply. A) Tells the client about personal events and interests B) Discusses the anxious feelings with the instructor C) Assumes that the client's unwillingness to talk to a student nurse is a personal insult or failure D) Builds rapport with the patient before asking personal questions E) Consults the instructor if a shocking situation arises F) Gravitates to clients that the student may know personally

BDE

A client who is taking paroxetine (Paxil) reports to the nurse that he has been nauseated since beginning the medication. Which of the following actions is indicated initially? A) Instruct the client to stop the medication for a few days to see if the nausea goes away. B) Reassure the client that this is an expected side effect that will improve with time. C) Suggest that the client take the medication with food. D) Tell the client to contact the physician for a change in medication.

C

A nurse documents that a patient has successfully acquired a job performing janitorial services at a local manufacturing company. The goal of which of the following levels of prevention has been achieved? A) Primary prevention B) Secondary prevention C) Tertiary prevention D) Community prevention

C

A nurse is meeting with the city council to advocate for mentally ill persons and the establishment of a group home in a neighborhood where the plans have been strongly opposed by the neighbors. The nurse can effectively educate the public on the realities of group home by citing research that indicates A) property values quickly rebound in neighborhoods that have group homes. B) police surveillance will be increased to avert any violence by residents. C) most people with mental illness do not represent a significant danger to others. D) neighborhoods that provide park areas provide children a centralized and safe place to play.

C

A patient has been started on antidepressants. The interdisciplinary team member most responsible for monitoring effectiveness and side effects of this new medication is the A) pharmacist. B) psychiatrist. C) psychiatric nurse. D) psychologist.

C

A patient with bipolar disorder takes lithium 300 mg three times daily. The nurse evaluates that the dose is appropriate when the patient reports A) feeling sleepy and less energetic. B) weight gain of 7 pounds in the last 6 months. C) minimal mood swings. D) increased feelings of self-worth.

C

A student nurse attends a self-help group as part of a class assignment. While there the student recognizes a family friend. Upon returning home, the student talks about the experience with the family. The student's actions can be described as A) appropriate; persons familiar with group members are allowed self-help group membership. B) appropriate; self-help groups are not professional and therefore are open to public knowledge. C) inappropriate; most self-help groups have a rule of confidentiality. D) inappropriate; the student should not have been allowed to attend the group.

C

Before the period of the enlightenment, treatment of the mentally ill included A) creating large institutions to provide custodial care. B) focusing on religious education to improve their souls. C) placing the mentally ill on display for the public's amusement. D) providing a safe refuge or haven offering protection.

C

Group members are actively discussing a common topic. Members are sharing that they identify with what others are saying. The nurse leader recognizes that the group is in which stage of group development? A) Planning B) Initial C) Working D) Termination

C

One of the unforeseen effects of the movement toward community mental health services is A) fewer clients suffering from persistent mental illnesses. B) an increased number of hospital beds available for clients seeking treatment. C) an increased number of admissions to available hospital services. D) Longer hospital stays for people needing mental health services.

C

One week after beginning therapy with thiothixene (Navane), the client demonstrates muscle rigidity, a temperature of 103∞F, an elevated serum creatinine phosphokinase level, stupor, and incontinence. The nurse should notify the physician because these symptoms are indicative of A) acute dystonic reaction. B) extrapyramidal side effects. C) neuroleptic malignant syndrome. D) tardive dyskinesia.

C

The nurse has completed health teaching about dietary restrictions for a client taking a monoamine oxidase inhibitor. The nurse will know that teaching has been effective by which of the following client statements? A) ìI'm glad I can eat pizza since it's my favorite food.î B) ìI must follow this diet or I will have severe vomiting.î C) ìIt will be difficult for me to avoid pepperoni.î D) ìNone of the foods that are restricted are part of a regular daily diet.î

C

The nurse is working with a client who has a history of inflicting spousal abuse. Although the nurse does not condone domestic violence, the nurse treats the client with unconditional positive regard through which of the following? A) The nurse tries to understand the feelings that might have led to violent behavior. B) The nurse uses honest emotional expression in relating to client. C) The client is still viewed as someone worthy of respect and assistance. D) The nurse relates to the client as if he were her own spouse.

C

Which of the following are true regarding mental health and mental illness? A) Behavior that may be viewed as acceptable in one culture is always unacceptable in other cultures. B) It is easy to determine if a person is mentally healthy or mentally ill. C) In most cases, mental health is a state of emotional, psychological, and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self-concept, and emotional stability. D) Persons who engage in fantasies are mentally ill.

C

A client on the unit suddenly cries out in fear. The nurse notices that the client's head is twisted to one side, his back is arched, and his eyes have rolled back in their sockets. The client has recently begun drug therapy with haloperidol (Haldol). Based on this assessment, the first action of the nurse would be to A) get a stat. order for a serum drug level. B) hold the client's medication until the symptoms subside. C) place an urgent call to the client's physician. D) give a PRN dose of benztropine (Cogentin) IM.

D

A client with severe and persistent mental illness has been taking antipsychotic medication for 20 years. The nurse observes that the client's behavior includes repetitive movements of the mouth and tongue, facial grimacing, and rocking back and forth. The nurse recognizes these behaviors as indicative of A) extrapyramidal side effects B) loss of voluntary muscle control C) posturing D) tardive dyskinesia

D

A patient has just been told she has cervical cancer. When asked about how this is impacting her, she states, ìIt's just an infection; it will clear up.î The statement indicates that this patient A) needs education on cervical cancer. B) is unable to express her true emotions. C) should be immediately referred to a cancer support group. D) is using denial to protect herself from an emotionally painful thought.

D

A patient states, ìI hate spending time with my family. They're always on my back about something! I won't do anything they ask me to do.î Which response by the nurse reflects a behavioral perspective? A) ìLet's play like I'm your parent, and we'll practice some better ways to communicate that won't result in an argument.î B) ìSome medicines really help with anger. Are you interested in talking to your physician about starting you on something?î C) ìThat's probably your way of getting back at them for being strict with you when you were younger.î D) ìIf you agree to start doing what your parents request, then they have agreed to respect your privacy more.î

D

A patient with bipolar disorder asks the nurse, ìWhy did I get this illness? I don't want to be sick.î The nurse would best respond with, A) ìPeople who develop mental illnesses often had very traumatic childhood experiences.î B) ìThere is some evidence that contracting a virus during childhood can lead to mental disorders.î C) ìSometimes people with mental illness have an overactive immune system.î D) ìWe don't fully understand the cause, but mental illnesses do seem to run in families.î

D

A patient with depression is admitted to an inpatient hospital unit for treatment. The type of therapy most likely provided in this setting includes A) leisure skills. B) self-monitoring of treatment. C) skills for daily living. D) talk therapy.

D

A patient with schizophrenia is being treated with olanzapine (Zyprexa) 10 mg. daily. The patient asks the nurse how this medicine works. The nurse explains that the mechanism by which the olanzapine controls the patient's psychotic symptoms is believed to be A) increasing the amount of serotonin and norepinephrine in the brain. B) decreasing the amount of an enzyme that breaks down neurotransmitters. C) normalizing the levels of serotonin, norepinephrine, and dopamine. D) blocking dopamine receptors in the brain.

D

A psychiatric nurse is planning activities aimed at secondary prevention of mental illness. Which activity would be most appropriate to develop? A) Self-esteem building with a local after-school program B) Social skills training for chronic schizophrenics C) Parenthood classes at a local community center D) Depression screening in an assisted living facility

D

A significant change in the treatment of people with mental illness occurred in the 1950s when A) community support services were established. B) legislation dramatically changed civil commitment procedures. C) the Patient's Bill of Rights was enacted. D) psychotropic drugs became available for use.

D

Some residential treatment settings are transitional. This means that clients are eventually expected to A) become self-sufficient. B) find employment. C) no longer need medication. D) relocate to another setting.

D

The nurse consults the DSM for which of the following purposes? A) To devise a plan of care for a newly admitted client B) To predict the client's prognosis of treatment outcomes C) To document the appropriate diagnostic code in the client's medical record D) To serve as a guide for client assessment

D

The nurse is preparing a patient for an MRI scan of the head. The nurse should ask the patient, A) ìHave you ever had an allergic reaction to radioactive dye?î B) ìHave you had anything to eat in the last 24 hours?î C) ìDoes your insurance cover the cost of this scan?î D) ìAre you anxious about being in tight spaces?î

D

The nurse knows that the client understands the rationale for dietary restrictions when taking MAOI when the client makes which of the following statements? A) ìI am now allergic to foods that are high in the amino acid tyramine such as aged cheese, organ meats, wine, and chocolate.î B) ìCertain foods will cause me to have sexual dysfunction when I take this medication.î C) ìFoods that are high in tyramine will reduce the medication's effectiveness.î D) ìI should avoid foods that are high in the amino acid tyramine such as aged cheese, meats, and chocolate because this drug causes the level of tyramine to go up to dangerous levels.î

D

Which is the orientation of assertive community treatment (ACT)? A) Setting limits on mundane life issues B) Making a wide range of referrals C) Providing services in offices D) Problem-solving orientation

D

Which of the following client situations most urgently requires the nurse to break confidentiality and warn a third party? A) An abused woman states, ìI have dreams that he is dead.î B) A mother states, ìSometimes I feel like killing my kids!î C) A paranoid woman states, ìI'll get them before they get me.î D) A jealous man states, ìI am getting my gun and going to shoot my wife's lover!î

D

Which of the following is the priority of the Healthy People 2020 objectives for mental health? A) Improved inpatient care B) Primary prevention of emotional problems C) Stress reduction and management D) Treatment of mental illness

D

Which of the following statements about the neurobiologic causes of mental illness is most accurate? A) Genetics and heredity can explain all causes of mental illness. B) Viral infection has been proven to be the cause of schizophrenia. C) There is no evidence that the immune system is related to mental illness. D) Several mental disorders may be linked to genetic and nongenetic factors.

D

Which type of community residential treatment setting is most likely to be permanent in any state? A) Halfway house B) Respite housing C) Independent living programs D) Evolving consumer household

D

Which would be a reason for a student nurse to use the DSM? A) Identifying the medical diagnosis B) Treat clients C) Evaluate treatments D) Understand the reason for the admission and the nature of psychiatric illnesses.

D

`Ensuring that the client has informed consent before agreeing to a treatment regimen displays which of the following ethical principles? A) Fidelity B) Nonmaleficence C) Justice D) Autonomy

D

Multifactorial health conditions that occur when the accumulated effects of impairments in multiple systems render. Pressure ulcers / incontinence / Falls / delirium.

Define the term geriatric syndromes. Provide examples.

A) Peritonitis

Diagnostic imaging and physical assessment have revealed that a patient with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? A) Peritonitis B) Gastritis C) Gastroesophageal reflux D) Acute pancreatitis

A) For many people, lack of nutrition can cause a loss of bone density.

Diagnostic tests show that a patients bone density has decreased over the past several years. The patient asks the nurse what factors contribute to bone density decreasing. What would be the nurses best response? A) For many people, lack of nutrition can cause a loss of bone density. B) Progressive loss of bone density is mostly related to your genes. C) Stress is known to have many unhealthy effects, including reduced bone density. D) Bone density decreases with age, but scientists are not exactly sure why this is the case.

Safety Loss

Loss of a safe environment is evident in domestic violence, child abuse, or public violence. what type of loss is this?

calcitonin

Lowers blood calcium levels; thyroid

D) Avoid vitamin C for 72 hours before you start the test.

Probably the most widely used in-office or at-home occult blood test is the Hemoccult II. The patient has come to the clinic because he thinks there is blood in his stool. When you reviewed his medications, you noted he is on antihypertensive drugs and NSAIDs for early arthritic pain. You are sending the patient home with the supplies necessary to perform 2 hemoccult tests on his stool and mail the samples back to the clinic. What instruction would you give this patient? A) Take all your medications as usual. B) Take all your medications except the antihypertensive medications. C) Dont eat highly acidic foods 72 hours before you start the test. D) Avoid vitamin C for 72 hours before you start the test.

dependent personality disorder

Submissive and clinging behavior; excessive need to be taken care of Nursing Interventions: Foster client's self-reliance and autonomy; teach problem-solving and decision-making skills; cognitive restructuring techniques

"Advance directives are limited only to health care instructions and directives."

The admissions department at a local hospital is registering a male older adult for an outpatient diagnostic test. The admissions nurse asks the man if he has an advanced directive. The man responds that he does not want to complete an advance directive because he does not want anyone controlling his finances. What would be appropriate information for the nurse to share with this client?

Trauma, such as penetrating wounds or compound fractures Vascular insufficiency in clients with diabetes or peripheral vascular disease Surgical contamination, such as pin sites of skeletal traction

The client has just been diagnosed with osteomyelitis. What are possible causes of osteomyelitis? Select all that apply.

B

The client identifies anger management as a problem. What is the next step in planning therapeutic interactions? A) Give the client a variety of choices on how to express anger. B) Give the client permission to be angry. C) Point out the senselessness of anger. D) Tell the client not to be angry all the time.

Increases ability for glucose to get into the cell and lowers blood sugar

The client who is managing diabetes through diet and insulin control asks the nurse why exercise is important. Which is the best response by the nurse to support adding exercise to the daily routine?

Risperidone (Risperdal)

The client who presents a clear danger to others may be prescribed an anti-psychotic medication such as what?

C

The client with a history of explosive outbursts becomes angry and states, ìI am really getting angry.î The nurse sees this as A) controlling. B) manipulation. C) progress. D) regression.

B

The client's son is yelling and is hitting his hand with a rolled up newspaper. Which stage of aggression does the nurse identify that the client's son is exhibiting? A) Triggering B) Escalation C) Crisis D) Recovery

D

The community health nurse meets with the family members of an elderly client. The nurse includes which of the following in the plan of care as a preventive measure to guard against elder abuse? A) Reassure the primary caregiver that he or she in the best position to provide care to the elder B) Teach the primary caregiver skills to meet all of the elder's needs C) Assist in the transfer of legal authority for elder care to the primary caregiver D) Provide the primary caregiver with additional resources to meet the elder's needs

Loss of security and a sense of belonging

The loss of a loved one affects the need to love and the feeling of being loved. loss accompanies changes in relationships, such as birth, marriage, divorce, illness, and death' as the meaning of a relationship changes, a person may lose roles within a family or group.

C) I flush my tube with water before and after each of my medications.

The management of the patients gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the patient is managing the tube correctly? A) I clean my stoma twice a day with alcohol. B) The only time I flush my tube is when Im putting in medications. C) I flush my tube with water before and after each of my medications. D) I try to stay still most of the time to avoid dislodging my tube.

Benzodiazepines

The most common group of antianxiety drugs, which includes diazepam and alprazolam.

C

The most effective way for the nurse to provide culturally competent care to individuals who are grieving is which of the following? A) Understand the practices associated with a client's culture. B) Suggest developing a new ritual to make mourning meaningful. C) Ask the client what rituals are personally meaningful. D) Contact a spiritual leader from the client's culture to become involved.

C

The nurse approaches a client who looks very sad and is sitting alone crying. The best response by the nurse in this situation is, A) ìI'm sorry you are sad. Is there anything I can do to help you feel better?î B) ìPlease don't cry. It will get better.î C) ìYou look very sad. What is happening?î D) ìWhat is bothering you?î

"Often the area of pain is referred from another area."

The nurse asks a client to point to where pain is felt. The client asks why this is important. What is the nurse's best response?

nutritional status age physical condition health status

The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors? Select all that apply.

C

The nurse at a university health services clinic has been asked to meet with a freshman class of women about warning signs of relationship violence. The nurse points out which of the following danger signs the students should be alert for in a date? A) Dislikes your fiends B) Acts indifferent to your life choices C) Is excessively jealous D) Views you as superior to himself

Monitoring the feeding closely.

The nurse cares for a client who receivies continuous enteral tube feedings and who is at low risk for aspiration. The nurse assesses the gastric residual volume to be 350 mL. The nurse determines which action is correct?

Place the client in semi-Fowler's position.

The nurse cares for a client with cholecystitis with severe biliary colic symptoms. Which nursing intervention best promotes adequate respirations in a client with these symptoms?

continuous

The nurse collaborates with the physician and dietician to determine the best type of tube feeding for a client at risk for diarrhea due to hypertonic feeding solutions. Which type of feedings should the nurse suggest?

B

The nurse decides to place an aggressive and violent client in mechanical restraints. The nurse bases this decision on which of the following? A) Client's mood B) Client's safety C) Court order D) Physician's order

To notify the surgeon

The nurse discovers that the client did not sign the operative consent before receiving the preoperative medication. The appropriate nursing action is:

Splenic vein Inferior mesenteric vein Gastric vein

The nurse educator is reviewing the blood supply of the GI tract with a group of medical nurses. The nurse is explaining the fact that the veins that return blood from the digestive organs and the spleen form the portal venous system. What large veins will the nurse list when describing this system? Select all that apply.

ABC

The nurse educator is reviewing the blood supply of the GI tract with a group of medical nurses. The nurse is explaining the fact that the veins that return blood from the digestive organs and the spleen form the portal venous system. What large veins will the nurse list when describing this system? Select all that apply. A) Splenic vein B) Inferior mesenteric vein C) Gastric vein D) Inferior vena cava E) Saphenous vein

D

The nurse enters the client's room and finds the client anxiously pacing the floor. The client begins shouting at the nurse, ìGet out of my room!î The best intervention by the nurse would be to A) approach the client and ask, ìWhat's wrong?î B) call for help and say, ìCalm down.î C) turn and walk away from the room without saying anything. D) stand at the doorway and say, ìYou seem upset.î

Propylthiouracil Antithyroid drugs, such as propylthiouracil and methimazole are given to block the production of thyroid hormone preoperatively or for long-term treatment for clients who are not candidates for surgery or radiation treatment. Levothyroxine would increase the level of thyroid and be contraindicated in this client. Spironolactone is a diuretic and does not have the action of blocking production of thyroid hormone and neither does propranolol, which is a beta-blocker.

The nurse is administering a medication to a client with hyperthyroidism to block the production of thyroid hormone. The client is not a candidate for surgical intervention at this time. What medication should the nurse administer to the client?

The nurse is administering lispro insulin. Based on the onset of action, how long before breakfast should the nurse administer the injection?

The nurse is administering lispro insulin. Based on the onset of action, how long before breakfast should the nurse administer the injection?

A) Checking the patients capillary blood glucose levels regularly

The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurses assessments most directly addresses a major complication of TPN? A) Checking the patients capillary blood glucose levels regularly B) Having the patient frequently rate his or her hunger on a 10-point scale C) Measuring the patients heart rhythm at least every 6 hours D) Monitoring the patients level of consciousness each shift

Severe mid-abdominal to upper abdominal pain radiating to both sides and to the back

The nurse is asking the client with acute pancreatitis to describe the pain. What pain symptoms does the client describe related to acute pancreatitis?

BCE

The nurse is assessing a client with bulimia nervosa. Which of the following symptoms would the nurse expect to find? Select all that apply. A) Cold intolerance B) Normal weight for height C) Dental erosion D) Hypotension E) Metabolic alkalosis

AC

The nurse is assessing a patient for dietary factors that may influence her risk for osteoporosis. The nurse should question the patient about her intake of what nutrients? Select all that apply. A) Calcium B) Simple carbohydrates C) Vitamin D D) Protein E) Soluble fiber

A

The nurse is assessing an elderly female in the emergency department. There are many bruises present on her body in varying stages of healing. After documenting the bruising in the assessment, what should the nurse do next? A) Ask the client when and how the bruises occurred B) Call the nursing supervisor immediately C) Follow the facility's policy and procedures for reporting abuse D) Notify the physician that abuse is suspected

C) Leave the tube in its present position.

The nurse is assessing placement of a nasogastric tube that the patient has had in place for 2 days. The tube is draining green aspirate. What is the nurses most appropriate action? A) Inform the physician that the tube may be in the patients pleural space. B) Withdraw the tube 2 to 4 cm. C) Leave the tube in its present position. D) Advance the tube up to 8 cm

Avoid touching sterile items unless necessary. Alert the surgical team of any breaches of sterile technique. Wear a long-sleeved, sterile gown and gloves.

The nurse is aware that infection is a potential complication of surgery. Which intervention should the nurse implement to prevent infection? Select all that apply.

Assess for bleeding

The nurse is caring for a client in the postanesthesia care unit (PACU). The client has the following vital signs: pulse 115, respirations 20, oral temperature 97.2°F, blood pressure 84/50. What should the nurse do first?

Fecal incontinence

The nurse is caring for a client with a suspected megacolon. The nurse anticipates that one of the findings of assessment will be

ACE

The nurse is caring for a hospice client whose death is imminent. In preparing the family for the death of their loved one, then nurse prepares to assist the family in which of the following, regardless of the family's cultural preferences? Select all that apply. A) Dealing with the shock of losing a loved one B) Burial plans after death had occurred C) Efforts to stay connected to the client after death D) Use of support from family and friends E) Anger at the loss of a loved one

D) Inform the primary care provider of this finding.

The nurse is caring for a patient who has a diagnosis of AIDS. Inspection of the patients mouth reveals the new presence of white lesions on the patients oral mucosa. What is the nurses most appropriate response? A) Encourage the patient to gargle with salt water twice daily. B) Attempt to remove the lesions with a tongue depressor. C) Make a referral to the units dietitian. D) Inform the primary care provider of this finding.

Measure abdominal girth daily. Perform daily weights.

The nurse is caring for a patient who has ascites as a result of hepatic dysfunction. What intervention can the nurse provide to determine if the ascites is increasing? (Select all that apply.)

B) Bleeding and perforation

The nurse is caring for a patient who has just returned from the ERCP removal of gallstones. The nurse should monitor the patient for signs of what complications? A) Pain and peritonitis B) Bleeding and perforation C) Acidosis and hypoglycemia D) Gangrene of the gallbladder and hyperglycemia

C) Gently rotate the tube.

The nurse is caring for a patient who is postoperative from having a gastrostomy tube placed. What should the nurse do on a daily basis to prevent skin breakdown? A) Verify tube placement. B) Loop adhesive tape around the tube and connect it securely to the abdomen. C) Gently rotate the tube. D) Change the wet-to-dry dressing.

B) Foul-smelling diarrhea that contains fat

The nurse is caring for a patient who is undergoing diagnostic testing for suspected malabsorption. When taking this patients health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis? A) Recurrent constipation coupled with weight loss B) Foul-smelling diarrhea that contains fat C) Fever accompanied by a rigid, tender abdomen D) Bloody bowel movements accompanied by fecal incontinence

C) Protect the affected leg from internal rotation.

The nurse is caring for a patient who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis? A) Keep the affected leg in a position of adduction. B) Have the patient reposition himself independently. C) Protect the affected leg from internal rotation. D) Keep the hip flexed by placing pillows under the patients knee.

CDE

The nurse is caring for a patient with a duodenal ulcer and is relating the patients symptoms to the physiologic functions of the small intestine. What do these functions include? Select all that apply. A) Secretion of hydrochloric acid (HCl) B) Reabsorption of water C) Secretion of mucus D) Absorption of nutrients E) Movement of nutrients into the bloodstream

Checking the urine for hematuria Palpating peripheral pulses in both lower extremities Testing the stool for occult blood

The nurse is caring for a patient with a pelvic fracture. What nursing assessment for a pelvic fracture should be included? (Select all that apply.)

Administration of calcitonin Intravenous isotonic saline solution in large quantities Monitoring the patient for fluid overload

The nurse is caring for a patient with hyperparathyroidism and observes a calcium level of 16.2 mg/dL. What interventions does the nurse prepare to provide to reduce the calcium level? Select all that apply

The client expresses interest in the dressing change. The client is willing to look at the incision during a dressing change. The client assists in opening the packages of dressing material for the nurse.

The nurse is caring for a postoperative client who needs daily dressing changes. The client is 3 days postoperative and is scheduled for discharge the next day. Until now, the client has refused to learn how to change her dressing. What would indicate to the nurse the client's possible readiness to learn how to change her dressing? Select all that apply.

Peroneal

The nurse is conducting a musculoskeletal assessment of a client in a nursing home. The client is unable to dorsiflex the right foot or extend the toes. The nurse evaluates this finding as an injury to which nerve?

A

The nurse is establishing outcomes for a grieving client. Which of the following is an appropriate outcome? A) The client will develop a plan for coping with the loss. B) The client will demonstrate self-reliance during the grief process. C) The client will suppress emotions related to the loss. D) The client will verbalize that loss will not adversely affect the quality of life.

A) Within 30 minutes, then every 1 to 2 hours

The nurse is helping to set up Bucks traction on an orthopedic patient. How often should the nurse assess circulation to the affected leg? A) Within 30 minutes, then every 1 to 2 hours B) Within 30 minutes, then every 4 hours C) Within 30 minutes, then every 8 hours D) Within 30 minutes, then every shift

Until bowel sound is present Until flatus is passed Until peristalsis is resumed

The nurse is inserting a nasoenteric tube for a patient with a paralytic ileus. How long does the nurse anticipate the tube will be required? (Select all that apply.)

Serum antibodies for H. pylori

The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client?

B

The nurse is interviewing a client with a history of physical aggression. Which of the following should the nurse avoid? A) Anticipating that a loss of control is possible and planning accordingly B) Explaining the consequences the client will face if control is lost C) Interviewing the client with another staff member present D) Responding to verbal threats by terminating the interview and obtaining assistance

A

The nurse is involved in a community education program for new parents and plans to include information on child abuse. The nurse will teach the parents that the most common form of child abuse is which of the following? A) Neglect B) Physical abuse C) Sexual abuse D) Emotional abuse

B

The nurse is meeting a client for the first time who has just spontaneously lost her unborn child. After establishing rapport, the priority nursing intervention should focus on which of the following? A) Assessing the client's support system B) Exploring what this loss means for the client C) Discussing helpful ways to cope with the loss D) Assessing what knowledge the client desires about the situation

Pale, cyanotic, or mottled color Cool temperature of the extremity More than 3-second capillary refill

The nurse is performing an assessment for a patient who may have peripheral neurovascular dysfunction. What signs does the patient present with that indicate circulation is impaired? (Select all that apply.)

A) Compare parts of the body symmetrically.

The nurse is performing an assessment of a patients musculoskeletal system and is appraising the patients bone integrity. What action should the nurse perform during this phase of assessment? A) Compare parts of the body symmetrically. B) Assess extremities when in motion rather than at rest. C) Percuss as many joints as are accessible. D) Administer analgesia 30 to 60 minutes before assessment.

Risk for injury related to altered clotting mechanisms Activity intolerance related to fatigue, general debility, muscle wasting, and discomfort Disturbed body image related to changes in appearance, sexual dysfunction, and role function

The nurse is preparing a care plan for a client with hepatic cirrhosis. Which nursing diagnoses are appropriate? Select all that apply.

C

The nurse is providing education to a group of persons from several community agencies about hoarding by elder persons. Which of the following is important for the nurse to emphasize? A) Treatment will likely start to be effective in the short term. B) If the person had help to clean up his or her environment, the hoarding would be cured. C) It is not beneficial to tell the client that his or her thoughts and rituals interfere with his or her life or that his or her ritual actions really have no lasting effect on anxiety. D) One agency should be able to address all of the client's needs.

D

The nurse is talking to a client with schizoid personality disorder about finding a job. Which suggestion by the nurse would be most helpful? A) ìBeing a loner really limits your employment opportunities.î B) ìMaybe your friend could see if there is a night position available at the convenience store.î C) ìPerhaps working part-time at a fast-food restaurant would be something you could do.î D) ìThere is a job posting at the hospital for a file clerk in medical records.î

B

The nurse is teaching a client to recognize early signs of anger and aggression. The nurse explores ways that the client can recognize which of the following? A) Decreased problem-solving ability B) Restlessness and irritability C) Remorse D) Severe muscle tension

Pancakes with butter and honey, and orange juice

The nurse is teaching a client who was admitted to the hospital with acute hepatic encephalopathy and ascites about an appropriate diet. The nurse determines that the teaching has been effective when the client chooses which food choice from the menu?

C

The nurse is teaching a client with an anxiety disorder ways to manage anxiety. The nurse suggests which of the following schedules for practicing stress management techniques? A) Practice the techniques each morning and night as part of a daily routine. B) Use the techniques as needed when experiencing severe anxiety. C) Practice the techniques when relatively calm. D) Expect to practice the techniques when meeting with a therapist.

A) Avoid applying suction on or near the suture line.

The nurse notes that a patient who has undergone skin, tissue, and muscle grafting following a modified radical neck dissection requires suctioning. What is the most important consideration for the nurse when suctioning this patient? A) Avoid applying suction on or near the suture line. B) Position patient on the non operative side with the head of the bed down. C) Assess the patients ability to perform self-suctioning. D) Evaluate the patients ability to swallow saliva and clear fluids.

Outline the drainage with a pen and record the date and time next to the drainage.

The nurse observes bloody drainage on the surgical dressing of the client who has just arrived on the nursing unit. Which intervention should the nurse plan to do next?

Provide frequent mouth care.

The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also reports unpleasant tastes and odors. Which measure should be included in the client's plan of care?

D

The nurse plans to teach a client about dietary modifications to manage diabetes. Teaching would be most effective if the client displayed which one of the following characteristics? A) Focusing only on immediate task B) Faster rate of speech C) Narrowed perceptual field D) Heightened focus

A

The nurse uses cognitiveñbehavioral approaches to assist the client with bulimia toward recovery. Which statement by the nurse would be consistent with this approach? A) ìIs there any way you can look at that sandwich as fuel for your body?î B) ìYou have to eat in moderation for good nutrition.î C) ìYou seem to have a really hard time controlling your eating patterns.î D) ìIs this your way of showing your family that you can make decisions?î

B) Presence of a painless sore with raised edges

The nurses comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages? A) Dull pain radiating to the ears and teeth B) Presence of a painless sore with raised edges C) Areas of tenderness that make chewing difficult D) Diffuse inflammation of the buccal mucosa

C) Instruct the patient to walk away from the nurse for a short distance and then toward the nurse.

The nurses comprehensive assessment of an older adult involves the assessment of the patients gait. How should the nurse best perform this assessment? A) Instruct the patient to walk heel-to-toe for 15 to 20 steps. B) Instruct the patient to walk in a straight line while not looking at the floor. C) Instruct the patient to walk away from the nurse for a short distance and then toward the nurse. D) Instruct the patient to balance on one foot for as long as possible and then walk in a circle around the room.

B) Balanced traction allows for greater patient movement and independence than other forms of traction.

The orthopedic surgeon has prescribed balanced skeletal traction for a patient. What advantage is conferred by balanced traction? A) Balanced traction can be applied at night and removed during the day. B) Balanced traction allows for greater patient movement and independence than other forms of traction. C) Balanced traction is portable and may accompany the patients movements. D) Balanced traction facilitates bone remodeling in as little as 4 days.

5:00pm An overnight dexamethasone suppression test is used to diagnose pituitary and adrenal causes of Cushing syndrome. It can be performed on an outpatient basis. Dexamethasone is administered orally late in the evening or at bedtime, and a plasma cortisol concentration is measured at 8 AM the next day. However, in a client who sleeps during the day, the medication would be given before bed and the plasma concentration would be measured soon after awakening in the late afternoon.

The physician has ordered an outpatient dexamethasone suppression test to diagnose the cause of Cushing syndrome in a client who works at night, from 11:00 PM to 7:00 AM, and normally sleeps from 8:00 AM to 4:00 PM. The client has been given the dexamethasone. To ensure the most reliable test results, the nurse arranges for the plasma cortisol concentration to be tested at which time?

ABCD

The school nurse is teaching a health class about recognizing the signs of abusive relationships. The nurse describes the cycle of violence. The nurse would document effective teaching if the students identify the cycle of violence to be which of the following patterns? Select the order in which the events occur. A. Tension building B. Honeymoon period C. Violent behavior D. Period of remorse

B

The student nurse correctly identifies that which one of the following statements applies to the parasympathetic nervous system? A) It is activated during the alarm reaction stage. B) It is activated during the resistance stage. C) It is activated during the exhaustion stage. D) It is commonly referred to as the fight, flight, or freeze response.

Hypocalcemia

The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The client reports tingling in her lips and fingers. She states that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should the nurse first suspect?

Consent must be freely given. Consent must normally be obtained by a physician. Signature must be witnessed by a professional staff member.

The surgical nurse is preparing to send a client from the presurgical area to the OR and is reviewing the client's informed consent form. What are the criteria for legally valid informed consent? Select all that apply.

Ambulating the client as soon as possible

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes:

borderline personality disorder

Unstable relationships, self-image, and affect; impulsivity; self-mutilation Nursing Interventions: Promote safety; help client to cope and control emotions; cognitive restructuring techniques; structure time; teach social skills

Causes anxiety or concern can be short or long term perceived as outside of our coping abilities feels unpleasant decreases performances can lead to mental and physical problems

What are some characteristics of Distress?

motivates; focuses energy short term is perceived within our coping abilities feels exciting improves performance

What are some characteristics of Eustress?

Educate the client on cast care and complications

What is the best action by the nurse to achieve optimal outcomes when caring for a client with a musculoskeletal disorder who is using a cast?

B

What is the primary difference between anorexia nervosa and bulimia nervosa? A) Anorexia has a psychological basis, whereas the cause of bulimia is biologic. B) Clients who are anorexic are proud of their control over eating, and clients with bulimia are ashamed of their behavior. C) Bulimia can be life threatening, whereas anorexia is seldom so. D) There is no real difference between these two types of disorders.

C

What would the nurse expect to assess in a client with narcissistic personality disorder? A) Genuine concern for others B) Mistrust of others C) Grandiose and superior self-concept D) Dependence on others for decision making

AD

When a client is experiencing a panic attack while in the recreation room, what interventions are the nurse's first priorities? Select all that apply. A) Provide a safe environment. B) Request a prescription for an antianxiety agent. C) Offer the client therapy to calm down D) Ensure the client's privacy. E) Engage the client in recreational activities.

72 hours after alcohol withdrawl

When a client with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the client may show signs of alcohol withdrawal delirium during which time period?

Barbiturates

When administering medications to an older adult patient, which medication does the nurse understand may remain in the body longer due to increased body fat?

CDE

When assessing a client with borderline personality disorder (BPD), which would a nurse expect to assess? Select all that apply. A. Free sharing of feelings with others B. Exaggerated sense of self C. Control necessary for a relationship D. Fear of rejection E. Self-injurious behavior

Residual lung volume

When assessing an older adult, the nurse anticipates an increase in which component of respiratory status?

change in mental status signs of GI bleeding

When caring for a client with cirrhosis, which symptoms should a nurse report immediately? Select all that apply.

Encouraging bed rest to decrease the metabolic rate Withholding oral feedings to limit the release of secretin Administering parenteral opioid analgesics as ordered

When caring for the patient with acute pancreatitis, the nurse must consider pain relief measures. What nursing interventions could the nurse provide? (Select all that apply.)

C

When establishing a relationship with a client who has borderline personality disorder, which is most important for the nurse to do? A) Aggressively confront the client about boundary violations. B) Limit interactions to 10 minutes at a time. C) Respect the client's boundaries at all times. D) Tell the client the relationship will last as long as the client wishes.

A

When interacting with a client in the day room, the nurse determines that a violent outburst is imminent. Which of the following should the nurse do first? A) Call for assistance. B) Give the client choices. C) Remove the other clients. D) Talk to the client calmly.

A

When preparing a client with bulimia for discharge, the nurse suggests that the client and family continue with family therapy on an outpatient basis. Which of the following is the rationale for this suggestion? A) Family members often need to learn role independence and autonomy. B) Family members need to learn to monitor for signs of client relapse. C) Family relationships need to be strengthened due to a lifetime of disengagement. D) Family members often feel jealous of the attention the client has been receiving in treatment.

Most disorders result from over- or underproduction of the hormone.

When preparing teaching plan for a client with an endocrine disorder, the nurse includes information about hormone regulation. Which of the following would the nurse include?

C

Which best explains the neurochemical processes responsible for depression? A) Increased activity of dopamine B) Decreased glucocorticoid activity C) Decreased serotonin and norepinephrine activity D) Potentiating of the kindling process

BCDE

Which challenges are posed when working with clients with personality disorders? Select all that apply. A) Clients with personality disorders are obviously unable to function more effectively. B) It can take a long time to change their behaviors, attitudes, or coping skills. C) The nurse can easily but mistakenly believe the client simply lacks motivation or the willingness to make changes. D) Clients with personality disorders challenge the ability of therapeutic staff to work as a team. E) Team members may have differing opinions about individual clients.

C

Which characteristic of the abuser should the nurse look for when completing the family assessment of a victim on intimate partner violence? A) Encourages the partner to have a life outside the intimate relationship B) An inflated sense of self-esteem C) Needy and possessive of the partner D) An ability to feel remorse for the abuse

C

Which client is at highest risk for carrying out a suicide plan? A) A client who plans to take a bottle of sleeping pills. B) A client who says, ìMy life is over.î C) A client who has a private gun collection. D) A client who says, ìI'm going to jump off the next bridge I see.î

hypercalcemia

Which condition should a nurse expect to find in a client diagnosed with hyperparathyroidism?

A

Which disorder is characterized by pervasive mistrust and suspiciousness of others? A) Paranoid personality disorder B) Schizoid personality disorder C) Histrionic personality disorder D) Dependent personality disorder

B

Which eating disorder is characterized by consuming an amount of food much larger than a person would normally eat and of near-normal weight? Afterward, the client may purge the food or exercise excessively, and between binges, the client may eat low- calorie foods or fast. A) Anorexia nervosa B) Bulimia nervosa C) Pica D) Rumination

A

Which individual is at highest risk for committing suicide? A) A 71-year-old male, alcohol user, independent minded B) A 16-year-old female, diabetic, two best friends C) A 47-year-old male, schizophrenic, unemployed D) A 57-year-old female, depression, active in church

"Test your blood glucose every 4 hours."

Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"?

Have regular follow-up care.

Which instruction should be included in the discharge teaching plan for a client after thyroidectomy for Graves' disease?

"Place pillows between your legs when you lay on your side." "Avoid bending forward when sitting in a chair." "Use a raised toilet seat and high-seated chair."

Which instruction should the nurse include when teaching the client following hip replacement surgery? (Select all that apply.)

Using sterile technique

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer?

Using sterile technique during the dressing change

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer?

A

Which is a possible explanation for the increased risk of suicide in persons who have had a relative who committed suicide? A) The relative's suicide offers a sense of ìpermissionî or acceptance of suicide as a method of escaping a difficult situation. B) Many people with depression who have suicidal ideation lack the energy to implement suicide plans, but antidepressant treatment can actually give clients with depression the energy to act on suicidal ideation. C) Suicide is more likely to occur in April when natural energy from increased sunlight may give the client the energy to act on suicidal ideation. D) The relative's suicide caused the family members to realize that suicide is emotionally harmful to the ones left behind and vow not to consider suicide.

D

Which is the main reason why the periodic team meetings are important when caring for a client with antisocial personality? A) The team needs to consider updating treatment recommendations as the client improves. B) Rotating team members need to be apprised of the care planned for the client. C) Staff frustrations in caring for the client need to be processed. D) Team consistency is important to prevent manipulation by the client.

B

Which may help a person to overcome an eating disorder that causes weight gain? A) Being ashamed of his or her body image B) Believing that gaining weight is a side effect of unhealthy lifestyle behaviors and losing weight is a side effect of healthy lifestyle behaviors C) Being reminded that every morsel of food he or she consumes will make him or her fat D) Knowing that his or her current weight is abnormal

ABCE

Which of the following are common behavioral and emotional responses to abuse? Select all that apply. A) One third of abusive men are likely to have come from violent homes. B) Women who grew up in violent homes are 50% more likely to expect or accept violence in their own relationships. C) Dependency on the abuser is a common trait found in victims of domestic violence. D) The victim caused the abuse. E) It is critical for the nurse to demonstrate acceptance after hearing about the abuse so that the victim may begin to gain self-acceptance.

ABCD

Which of the following are common characteristics of violent families regardless of the type of abuse that exists? Select all that apply. A) Abuse of power and control B) Alcohol and other drug abuse C) Intergenerational transmission D) Social isolation E) Victim instigates

ABCDE

Which of the following are common reasons why abused women remain with the abusive partner? Select all that apply. A) The abused person is personally and financially dependent on the abuser. B) The abused person has low self-esteem and defines her success as a person by the ability to make the relationship work. C) The abused person is convinced that she has been abusive toward the abuser at some point and that the abuse is her fault. D) The abused person believes that she is unable to function without her husband. E) The abused person is afraid that the abuser will kill her if she tries to leave.

ACE

Which of the following are critical components in assessment of a person's grief? Select all that apply. A) Adequate perception regarding the loss B) Adequate time to experience the loss C) Adequate support while grieving for the loss D) Adequate opportunities to say goodbye to the person E) Adequate coping behaviors during the process

ADE

Which of the following are important issues for nurses to be aware of when working with angry, hostile, or aggressive clients? Select all that apply. A) Nurses must be aware of their own feelings about anger and their use of assertive communication and conflict resolution. B) Nurses must not allow themselves to become angry under any circumstances. C) Nurses must know that a client's anger or aggressive behavior is preventable by a skilled nurse. D) Nurses must discuss situations or the care of potentially aggressive clients with experienced nurses. E) Nurses must be calm, nonjudgmental, and nonpunitive when using techniques to control a client's aggressive behavior.

A

Which of the following best explains the etiology of anxiety disorders from an interpersonal perspective? A) Anxiety is learned in childhood through interactions with caregivers. B) Anxiety is learned throughout life as a response to life experiences. C) Anxiety stems from an unconscious attempt to control awareness. D) Anxiety results from conforming to the norms of a cultural group.

B

Which of the following interventions would assist the client with the appropriate expression of anger? A) Encourage catharsis B) Encourage verbalization C) Improve self-esteem D) Isolate the client from others

C

Which of the following interventions would be appropriate for a client with anorexia nervosa? A) Allowing the client to eat whenever she feels hungry B) Insisting that the client sit in the dining room until all food is eaten C) Having the client in view of staff for 90 minutes after each meal D) Permitting the client to eat any food she chooses, as long as she is eating

C

Which of the following is a psychosocial explanation for the development of personality disorders? A) Highly self-directed people reflect uncooperativeness and intolerance. B) Cooperative people become increasingly helpless over time. C) Failure to complete a developmental task jeopardizes future personality development. D) Self-transcendence contributes to self-consciousness and materialism.

D The treatment focus often is behavioral change. Although treatment is unlikely to affect the client's insight or view of the world and others, it is possible to make changes in behavior.

Which of the following is a realistic outcome for the care of a person with a personality disorder? A) Outcomes that focus on satisfaction with daily life B) Outcomes that focus on the client's perception of others C) Outcomes that focus on increased client insight D) Outcomes that focus on change in behavior

C

Which of the following is most likely to prevent the client from experiencing complicated grief? A) Tendency to suppress emotions B) History of depression C) Places trusts familiar others D) Dependent on others to meet needs

B

Which of the following is the best explanation for why family violence tends to occur over multiple generations of families? A) A tendency toward violence is hereditary. B) Family violence may be perpetuated between generations of families by role modeling and social learning. C) All persons who have become victims of family violence will grow up to perpetrate family violence. D) Family violence does not tend to have an intergenerational transmission process.

D

Which one of the following statements about anger is most accurate? A) Anger is an abnormal human emotion that is always negative. B) It is best to express anger by whatever means possible to minimize its consequences. C) Most men are socialized to suppress anger. D) Anger awareness and expression are necessary for women's growth and development.

AC

Which techniques are important for nurses caring for clients with personality disorders to use in order to effectively provide care? Select all that apply. A) Discuss feelings of anger or frustration with colleagues to help them recognize and cope with their own feelings. B) Considering the client to be a personal friend. C) Employ ongoing communication with team members to remain firm and consistent about expectations for clients. D) Solving the problems of the client. E) Understanding that behavior changes in clients with personality disorders can occur quickly.

AC

Which techniques would be most effective for a client who has situational phobias? Select all that apply. A) Flooding B) Reminding the person to calm down C) Systematic desensitization D) Assertiveness training E) Decatastrophizing

C

Which term describes the extent to which a person considers himself to be an integral part of the universe? A) Cooperativeness B) Self-directedness C) Self-transcendence D) Character

D

Which thought process would cause a client with antisocial personality disorder to want to do everything for himself? A) Belief in his own self-worth B) Inability to delay gratification C) Rewards for competitive behavior D) Sense of mistrust of others

ACDE

Which time periods during antidepressant therapy are persons most likely to commit suicide? Select all that apply. A) After starting antidepressant therapy but not having reached the therapeutic level B) After having reached the therapeutic level of antidepressants and maintained it for several years C) If the client has made a choice to discontinue antidepressant therapy without medical supervision and is becoming gradually more depressed D) If the client does not adhere to the medication regimen and takes antidepressant medications irregularly E) Prior to initiating antidepressant therapy but before the depression results in lack of energy

Infiltration

While assessing a client's peripheral IV site, the nurse observes edema around the insertion site. How should the nurse document this complication related to IV therapy?

D) Clonus

While assessing a patient, the patient tells the nurse that she is experiencing rhythmic muscle contractions when the nurse performs passive extension of her wrist. What is this pattern of muscle contraction referred to as? A) Fasciculations B) Contractures C) Effusion D) Clonus

D

While assessing the family dynamics of a client with an eating disorder, which of the following does the nurse most likely discover? A) Multiple siblings B) Lack of interest in the client by other family members C) Supportive and encouraging relationships D) Over controlling parents

Approximately 80 to 120 mL

While caring for a patient who has had radical neck surgery, the nurse notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What does the nurse know is an expected amount of drainage in the wound unit?

"Many people have diagnostic or short therapeutic surgical procedures."

You are the nurse working in an ambulatory surgery center. A teenage son of your clients ask you why so many people have surgery. What would be your best reply?

panic attack

____________________ is not a panic disorder intense anxiety; can feel like a heart attack can occur at any time peaks in about 10 min attack may not be associated with an event

acetaminophen

_____has been identified as the leading cause of acute liver failure

self monitoring

a cognitive behavior technique designed to help clients manage their own behavior

positive reframing

a cognitive-behavioral technique involving turning negative messages into positive ones

graves disease

a form of hyperthyroidism; characterized by a diffuse goiter and exophthalmos

durable power of attorney

a formal, legally endorsed document that identifies a proxy decision maker who can make decisions if the signer becomes incapacitated

avulsion

a fracture in which a fragment of bone has been pulled away by a tendon and its attachment

oblique

a fracture occurring at an angle across the bone

Adrencorticotropic Hormone (ACTH)

a hormone that stimulates the secretion of adrenal cortical hormones, which work to maintain electrolytic homeostasis in the body

scoliosis

a lateral curving deviation of the spine

paranoid personality disorder

a personality disorder marked by a pattern of distrust and suspiciousness of others; guarded and restricted affect Nursing interventions: erious, straightforward approach; teach client to validate ideas before taking action; involve client in treatment planning

hypotonic solution

a solution with an osmolality lower than that of serum

GGT

levels are associated with cholestasis; alcoholic liver disease

ALT alanine aminotransferase

levels increase primarily in liver disorders, used to monitor the course of hepatitis, cirrhosis, the effects of tx that may be toxic to the liver

binge eating disorder (EDNOS)

loss of control over eating with recurrent binge-eating episodes but NO COMPENSATORY BEHAVIORS

Disscociative disorder

loss of integrated mental functions (consciousness, memory, identity or perception? splits mental contents apart from conscious awareness

stage 1 of hepatic encephalopathy

normal level of Consciousness with periods of lethargy and Euphoria reversal day night sleep patterns

a third-degree sprain

occurs when a ligament is completely torn or ruptured. May also cause an avulsion of the bone. Symptoms include severe pain, tenderness, increase the Dima, and abnormal joint motion

body image disturbance

occurs when there is an extreme discrepancy between one's body image and the perceptions of others and extreme dissatisfaction with one's body image

Cluster A

odd, eccentric

increases the force of uterine contractions during parturition

oxytocin

PDDNOS

pervasive developmental disorder not otherwise specified Significant problems with communication and play some difficulty interacting with others too social to be considered autistic

orthodox Jewish

relative staying w/ dying person; body covered with a sheet; eyes closed; burial within 24 hrs of death unless Sabbath; Shivah autopsy not permitted

thyroid storm

severe life-threatening hyperthyroidism precipitated by stress; characterized by high fever, extreme tachycardia, and altered mental state

osmolality

the number of milliosmoles (the standard unit of osmotic pressure) per kilogram of solvent; expressed as milliosmoles per kilogram (mOsm/kg). (The term osmolality is used more often than osmolarity to evaluate serum and urine.)

osmolarity

the number of milliosmoles (the standard unit of osmotic pressure) per liter of solution; expressed as milliosmoles per liter (mOsm/L); describes the concentration of solutes or dissolved particles

Incomplete suicide attempt

the person did not finish the act because a. someone recognized the suicide attempt as a cry for help and intervened b. the person was discovered and rescued

elder abuse

the physical, emotional, or financial harm to an older person by one or more of the individual's children, caregivers, or others; includes neglect

hydrostatic pressure

the pressure created by the weight of fluid against the wall that contains it. In the body, hydrostatic pressure in blood vessels results from the weight of fluid itself and the force resulting from cardiac contraction.

diffusion

the process by which solutes move from an area of higher concentration to one of lower concentration; does not require expenditure of energy

primary gain

the relief of anxiety achieved by performing the specific anxiety-driven behavior; the direct external benefits that being sick provides, such as relief of anxiety, conflict, or distress

body image

the way you see your body

Native Americans

tribal medicine man or priestly healer; baptism ceremonies; end of mourning noted w/ ceremony at burial ground with grave covered with blanket or cloth later given to tribe member

false

true or false, bleeding esophageal varices result in an increase in renal perfusion

Crisis

turning point or deciding event in history

toxic hepatitis and drug-induced hepatitis

two forms of non-viral hepatitis are

presbyopia

usually begins in the fifth decade of life, when reading glasses are required to magnify objects

controls excretion of water by the kidneys

vasopressin

Haitian Americans

vodun (voodoo)

Stress

wear and tear that life causes on the body

content

what a person says, thinks, feels

Methylphenidate (Ritalin)

which medication is effective in 70% to 80% of children with attention-deficit hyperactivity disorder

1. adequate perception regarding the loss 2.adequate support while grieving for the loss 3. adequate coping behaviors during the process

while observing the client responses in the dimensions of greiving, the nurse explores three critical components in assessment:

Phase 3 of Crisis Development

with helps employs all internal and external strengths learned new problem solving techniques which relieve anxiety two possible outcomes include: 1. level of function restored or improved 2. level of function lowered and move to the next phase