Physiological Adaptation

A client twists his right ankle while playing basketball and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which client statement suggests that ice application has been effective? a) "I need something stronger for pain relief." b) "My ankle appears redder now." c) "My ankle looks less swollen now." d) "My ankle feels very warm."

"My ankle looks less swollen now."

A client is admitted to the health care facility with acute chest pain. When obtaining the client's health history, which question would be most helpful for the nurse to ask? a) "Do you take any medications on a regular basis?" b) "What were you doing when the pain started?" c) "Do you have a history of GERD (gastroesophageal reflux disease)?" d) "Have you ever had pain like this before?"

b) "What were you doing when the pain started?"

A client who has been diagnosed with osteoarthritis asks if he'll eventually begin to notice deformities in his hands and fingers as the condition progresses. Which concept should the nurse include in her response? a) It's impossible to determine at the time of diagnosis how the disease will progress. b) Hand and finger deformities are associated with the development of rheumatoid arthritis. c) A small percentage of osteoarthritis sufferers do eventually develop hand and arm deformities. d) He should discuss this concern with his physician.

b) Hand and finger deformities are associated with the development of rheumatoid arthritis.

When caring for an adolescent who is at risk for injury related to intracranial pathology following a motor vehicle collision, which of the following nursing actions is the priority? a) Monitoring vital signs b) Maintaining stable intracranial pressure c) Maintaining good body alignment d) Monitoring cardiac rhythm

b) Maintaining stable intracranial pressure

A 2-year-old child is being examined in the emergency department for epiglottitis. Which assessment finding supports this diagnosis? a) Mild fever b) Tripod position c) Clear speech d) Gradual onset of symptoms

b) Tripod position

A 10-year-old with glomerulonephritis reports a headache and blurred vision. The nurse should immediately: a) Notify the physician. b) Put the client to bed. c) Administer acetaminophen. d) Obtain the child's blood pressure.

Obtain the child's blood pressure

The nurse notes that the daily white blood cell (WBC) count in a client with aplastic anemia has dropped overnight from 3,900 to 2,900/µl (3.9 to 2.9 X 109/L). Which is the appropriate nursing intervention? a) Call the laboratory to verify the report. b) Document the finding. c) Continue monitoring the client. d) Call the physician and place the client in reverse isolation.

Call the physician and place the client in reverse isolation

(see full question) A client who is 1 day postoperative is using a morphine patient-controlled analgesia (PCA) pump. The client is confused and disoriented. What is the priority intervention by the nurse?

Check respiratory rate and depth as well as oxygen saturation levels.

While attending a support group, the parents of a child with hemophilia become concerned because several of the families have had older children who have died from acquired immunodeficiency syndrome (AIDS). They ask the nurse how these children got the AIDS virus. The nurse bases the response on which of the following as the most likely route of transmission of AIDS to these children? a) Contamination of the factor VIII replacement received during bleeding episodes. b) Exposure in the waiting room to children with AIDS attending the same hematology clinic. c) Use of a contaminated needle to obtain a blood sample for type and crossmatching. d) Casual contact with a child testing positive for human immunodeficiency virus.

Contamination of the factor VIII replacement received during bleeding episodes

The client with acute renal failure is recovering and asks the nurse, "Will my kidneys ever function normally again?" The nurse's response is based on knowledge that the client's renal status will most likely: a) Improve only if the client receives a renal transplant. b) Continue to improve over a period of weeks. c) Result in the need for permanent hemodialysis. d) Result in end-stage renal failure.

Continue to improve over a period of weeks.

(see full question) Which findings best correlate with a diagnosis of osteoarthritis?

Joint stiffness that decreases with activity

The nurse is caring for a client in a diabetic coma. The nurse is aware that this is caused by an excess of which substance in the blood? a) Glucose from rapid carbohydrate metabolism, causing drowsiness b) Sodium bicarbonate, causing alkalosis c) Nitrogen from protein catabolism, causing ammonia intoxication d) Ketones from rapid fat breakdown, causing acidosis

Ketones from rapid fat breakdown, causing acidosis

A client is recovering from abdominal surgery and has a nasogastric (NG) tube inserted. The expected outcome of using the NG tube is gastrointestinal tract

Decompression.

A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed personnel to report which clinical manifestation? a) Swelling around the incision. b) Elevated temperature. c) Purulent wound drainage. d) Redness around the incision

Elevated temperature

A woman tells the nurse that "there's been a lot of cancer in my family." The nurse should instruct the client to report which possible sign of cervical cancer?

Light bleeding or watery vaginal discharge.

A child with partial- and full-thickness burns is admitted to the pediatric unit. Which of the following should be the priority at this time? a) Maintaining fluid and electrolyte balance. b) Preventing wound infection. c) Evaluating vital signs frequently. d) Managing the child's pain.

Maintaining fluid and electrolyte balance

When developing the plan of care for a child with early Duchenne's muscular dystrophy, which of the following nursing goals is the priority? a) Encouraging early wheelchair use. b) Prevent circulatory impairment. c) Maintaining function of unaffected muscles. d) Fostering social interactions.

Maintaining function of unaffected muscles

Which of the following positions would be best for a client's right arm when she returns to her room after a right modified radical mastectomy with multiple lymph node excisions? a) At her side at the same level as her body. b) On pillows, with her hand higher than her elbow and her elbow higher than her shoulder. c) Across her chest wall. d) In the position that affords her the greatest comfort without placing pressure on the incision

On pillows, with her hand higher than her elbow and her elbow higher than her shoulder

(see full question) At birth, a neonate weighs 7 lb, 3 oz (3,267 g). When assessing the neonate 1 day later, the nurse obtains a weight of 7 lb (3,182 g) and an axillary temperature of 98° F (36.7° C) and notes that the sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should add which nursing diagnosis to the care plan?

Risk for injury related to hyperbilirubinemia

A 10-year-old child is brought to the office with complaints of severe itching in both hands that's especially annoying at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. The physician performs a lesion scraping to assess this condition. Based on the signs and symptoms, what diagnosis should the nurse expect

Scabies

(see full question) Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress?

Suctioning if cough is ineffective.

A client is suspected of having a slow gastrointestinal bleed. The nurse should evaluate the client for which of the following? a) Tarry stools. b) Abdominal cramps. c) Increased pulse. d) Nausea.

Tarry stools.

Which of the following actions should the nurse take when performing external chest compressions on a neonate born at 28 weeks' gestation? a) Alternate chest compressions with ventilation. b) Compress the sternum with the palm of the hand. c) Compress the chest 70 to 80 times per minute. d) Displace the chest wall half the depth of the anterior-posterior diameter of the chest.

a) Alternate chest compressions with ventilation.

A client with chronic hepatitis C is experiencing nausea, anorexia, and fatigue. During the health history, the client states that he is homosexual, drinks 1 to 2 glasses of wine with dinner, takes St. John's Wort for a "bit of depression," and takes acetaminophen for frequent headaches. The nurse should do which of the following? Select all that apply. a) Encourage the client to obtain sufficient rest. b) Advise the client of the need for additional testing for HIV. c) Instruct the client that the wine with meals can be beneficial for cardiovascular health. d) Instruct the client to ask the health care provider about taking any other medications, because they may interact with the client's current medications. e) Instruct the client to increase the protein in his diet and eat less frequently.

a) Encourage the client to obtain sufficient rest. b) Advise the client of the need for additional testing for HIV. d) Instruct the client to ask the health care provider about taking any other medications, because they may interact with the client's current medications.

When assessing a child with juvenile hypothyroidism, the nurse expects which finding? a) Goiter b) Recent weight loss c) Insomnia d) Tachycardia

a) Goiter

A paradoxical pulse occurs in a client who had coronary artery bypass graft (CABG) surgery 2 days ago. Which surgical complication should the nurse suspect? a) Pericardial tamponade b) Aortic regurgitation c) Left-sided heart failure d) Complete heart block

a) Pericardial tamponade

A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client's body. Using the "rule of nines," estimate what percentage of the client's body surface has been burned. a) 64%. b) 18%. c) 45%. d) 27%.

c) 45%.

A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that: a) Nitroglycerin should be avoided if the client is experiencing this serious side effect. b) Taking the nitroglycerin with a few glasses of water will reduce the problem. c) Acetaminophen or ibuprofen can be taken for this common side effect. d) The client should lie in a supine position to alleviate the headache.

c) Acetaminophen or ibuprofen can be taken for this common side effect.

A 17-year-old client with diabetes has a decreased level of consciousness, with a fingerstick glucose level of 45. Her family reports that she has been skipping meals in an effort to lose weight. Which nursing intervention is most appropriate? a) Administering a 500-ml bolus of normal saline solution b) Placing a Salem sump tube and providing tube feedings c) Administering 1 mg of glucagon intramuscularly or subcutaneously d) Calling the physician for orders

c) Administering 1 mg of glucagon intramuscularly or subcutaneously

Which of the following nursing interventions should have the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting? a) Teaching about planned diagnostic tests. b) Maintaining hydration. c) Administering pain medication. d) Completing the admission history.

c) Administering pain medication.

A nurse recognizes that labor is divided into how many stages? a) Five b) Three c) Four d) Two

c) Four

Which of the following discharge instructions should the nurse give the parents of an infant with a temporary colostomy? a) Flush the stoma with tap water at least once a day. b) Expect the stoma to become dusky red within 2 weeks. c) Give the infant plenty of liquids to drink. d) Allow the diaper to absorb the colostomy drainage.

c) Give the infant plenty of liquids to drink.

A mother asks the nurse, "How did my children get pinworms?" The nurse explains that pinworms are most commonly spread by which of the following when contaminated? a) Toilet seats. b) Animals. c) Hands. d) Food

c) Hands

A client has a sucking stab wound to the chest. Which action should the nurse take first? a) Prepare a chest tube insertion tray. b) Prepare to start an I.V. line. c) Draw blood for a hematocrit and hemoglobin level. d) Apply a dressing over the wound and tape it on three sides.

d) Apply a dressing over the wound and tape it on three sides.

A nurse would expect to prepare a client with ulcerative colitis for surgery if the client develops which condition? a) Bowel outpouching b) Gastritis c) Bowel herniation d) Bowel perforation

d) Bowel perforation

The nurse is reviewing the diagnoses of her assigned clients and notes that one of the clients has Cushing's syndrome. The nurse is aware that this client is at risk for which of the following? a) Hypoglycemia and dehydration b) Hypotension and hyperglycemia c) Hyponatremia and dehydration d) Hypertension and heart failure

d) Hypertension and heart failure

An older adult had a myocardial infarction (MI) 4 days ago. At 9:30 am, the client's blood pressure is 102/64. After reviewing the client's progress notes (see chart), the nurse should first: a) Administer furosemide as prescribed. b) Assist the client to walk. c) Give a fluid challenge/bolus. d) Notify the health care provider.

d) Notify the health care provider.

A child is receiving peritoneal dialysis to treat renal failure. To detect early signs of peritonitis, the nurse should stay alert for: a) redness at the catheter site. b) abdominal fullness. c) headache. d) abdominal tenderness.

d) abdominal tenderness.

A client had coronary artery bypass graft (CABG) surgery 3 days ago. The nurse notes a decrease in the client's platelet count from 230,000/μl to 5,000/μl. The nurse determines the client may be developing: a) idiopathic thrombocytopenic purpura (ITP). b) disseminated intravascular coagulation (DIC). c) pancytopenia. d) heparin-associated thrombosis and thrombocytopenia (HATT).

d) heparin-associated thrombosis and thrombocytopenia (HATT).

A nurse suspects that a client with a recent fracture has compartment syndrome. Assessment findings may include: a) a growth in and around the bone tissue. b) inability to perform passive movement and pain with active movement. c) body-wide decrease in bone mass. d) inability to perform active movement and pain with passive movement.

inability to perform active movement and pain with passive movement.

A client with gestational hypertension is likely to exhibit:

proteinuria, headaches, and double vision.

A nurse is calling report to the medical-surgical (med-surge) floor staff regarding a client with acute diverticulitis. Which symptoms does the med-surge nurse anticipate? Select all that apply. a) Intervals of diarrhea. b) Cramping pain in the left lower abdominal quadrant. c) Hiccuping. d) Vomiting. e) Heartburn. f) Bowel irregularity.

• Cramping pain in the left lower abdominal quadrant. • Bowel irregularity. • Intervals of diarrhea

(see full question) The parent of a young child diagnosed with low-dose lead exposure asks about long-term effects. Which of the following should the nurse mention as possible long-term effects to this mother? Select all that apply.

• Hyperactivity. • Aggression. • Impulsiveness.

A nurse is caring for an infant who is in critical condition. The nurse notes that the child weighs 11 lb (5 kg) and has had a blood loss of 100 mL. Assessment reveals a decreased urine output, mild tachycardia, and restlessness. Which of the following should be the priority action for the nurse to take? a) IV administration of lactated Ringer's b) Insertion of a Foley indwelling catheter c) Neurologic assessment with the Glasgow Coma Scale d) Application of telemetry monitoring

IV administration of lactated Ringer's

The primary reason that a herpes simplex virus (HSV) infection is a serious concern to a client with human immunodeficiency virus (HIV) infection is that it: a) Is an acquired immunodeficiency virus (AIDS)-defining illness. b) Causes severe electrolyte imbalances. c) Leads to cervical cancer. d) Is curable only after 1 year of antiviral therapy.

Is an acquired immunodeficiency virus (AIDS)-defining illness

A nurse is caring for a 2-year-old child with tetralogy of Fallot (TOF) who is scheduled for surgery in 24 hours. What intervention is the most important for the nurse to include in the plan of care? a) Meperidine for pain b) Position the child with knees to the chest c) Encourage activity in the playroom d) Oxygen at 2L/nasal cannula

Oxygen at 2L/nasal cannula

The nurse is caring for a client who has been diagnosed with pernicious anemia. Which of the following statements by the client indicates an understanding of the treatment of pernicious anemia? a) "I understand that the oral form of vitamin B12 is preferred because it is safer and less expensive than the injection form." b) "I will need to increase my dietary intake of foods that are high in vitamin B12." c) "I will receive my first injection of vitamin B12 tomorrow, and I will return for a follow-up injection in 1 month." d) "I will need to take vitamin B12 replacements for the rest of my life."

"I will need to take vitamin B12 replacements for the rest of my life."

(see full question) The nurse is assessing a client's respiratory status. Which assessment data indicate a problem?

28 breaths/min and audible

Which of the following indicates that the client with diabetes insipidus understands how to manage care? a) The client will maintain normal fluid and electrolyte balance. b) The client will state dietary restrictions. c) The client will exhibit serum glucose level within normal range. d) The client will select a diabetic diet correctly.

The client will maintain normal fluid and electrolyte balance

Craniocerebral injury in a child differs substantially from craniocerebral trauma in an adult. Which statement identifies a difference between children and adults that could produce a life-threatening complication for a child? a) Greater portions of a child's blood volume flows to the head. b) Hematomas in children can include subdural, epidural, and intracerebral. c) Cerebral tissues in children are softer, thinner, and more flexible. d) A child's skull can expand more than an adult's can.

Greater portions of a child's blood volume flows to the head.

A client has been in an automobile accident and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for: a) Hemoptysis. b) Sudden, sharp chest pain. c) Wheezing breath sounds over affected side. d) Cyanosis.

b) Sudden, sharp chest pain.

Which of the following should the nurse include in the teaching plan of a female client with bilateral adrenalectomy? a) Informing the client that steroids will be required only until her body can manufacture sufficient quantities. b) Emphasizing that the client will need steroid replacement for the rest of her life. c) Instructing the client about the importance of tapering steroid medication carefully to prevent crisis. d) Emphasizing that the client will need to take steroids whenever her life involves physical or emotional stress.

Emphasizing that the client will need steroid replacement for the rest of her life

The nurse should assess which of the following in a child newly diagnosed with hyperthyroidism? Select all that apply. a) Heat intolerance. b) Dry skin. c) Rapid pulse. d) Weight gain. e) Constipation.

• Rapid pulse. • Heat intolerance

A nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication? a) Thyroid storm b) Hemorrhage c) Tetany d) Laryngeal nerve damage

c) Tetany

The client who has undergone a bilateral adrenalectomy is concerned about persistent body changes and unpredictable moods. The nurse should tell the client that: a) The physical changes are permanent, but the mood swings will disappear. b) The body changes are permanent and the client will not be the same as before this condition. c) The body and mood will gradually return to normal. d) The physical changes are temporary, but the mood swings are permanent.

c) The body and mood will gradually return to normal.