Random stuff

A client with hypertension has a new prescription for a medication called moexipril. The nurse plans to provide written directions that tell the client to take the medication at which time?

1 hour before meals Moexipril is an angiotensin-converting enzyme (ACE) inhibitor. The client should be instructed to take the medication at least 1 hour before meals. The other ACE inhibitor that should be taken 1 hour before meals is captopril. The other options are incorrect instructions to the client.

A client diagnosed with depression is scheduled to receive three sessions of electroconvulsive therapy. The nurse should tell the client that he or she will likely start to see improvement in approximately what time frame?

1 week after the 3rd treatment session

The nurse recognizes which assessment and diagnostic data as being associated with a newly diagnosed schizophrenic client? Select all that apply. 1. A birthday of March 30 2. A loss of interest in hobbies 3. A suicide attempt 6 months ago 4. Adopted by family at age 14 months 5. Brain scan shows increased blood flow to the frontal lobes 6. Magnetic resonance imaging shows temporal lobe atrophy

1. A birthday of March 30 2. A loss of interest in hobbies 3. A suicide attempt 6 months ago 6. Magnetic resonance imaging shows temporal lobe atrophy A late winter, early spring birthday (viral theory); apathy and anhedonia (the inability to experience pleasure from activities usually found enjoyable); suicidal ideations; and atrophy of brain tissue are all common to individuals exhibiting symptomatology of schizophrenia. Blood flow within the brain is generally decreased; no data support that adoption itself increases the risk for schizophrenia.

The nurse is conducting staff in-service training on von Willebrand's disease. Which should the nurse include as characteristics of von Willebrand's disease? Select all that apply. 1. Easy bruising occurs. 2.Gum bleeding occurs. 3.It is a hereditary bleeding disorder. 4.Treatment and care are similar to that for hemophilia. 5.It is characterized by extremely high creatinine levels. 6.The disorder causes platelets to adhere to damaged endothelium.

1. Easy bruising occurs. 2.Gum bleeding occurs. 3.It is a hereditary bleeding disorder. 4.Treatment and care are similar to that for hemophilia. 6.The disorder causes platelets to adhere to damaged endothelium. von Willebrand's disease is a hereditary bleeding disorder characterized by a deficiency of or a defect in a protein termed von Willebrand factor. The disorder causes platelets to adhere to damaged endothelium. It is characterized by an increased tendency to bleed from mucous membranes. Assessment findings include epistaxis, gum bleeding, easy bruising, and excessive menstrual bleeding. An elevated creatinine level is not associated with this disorder.

The nurse is monitoring a newborn born to a client who abuses alcohol. Which findings should the nurse expect to note when assessing this newborn? (Select all that apply.) 1. Flaccidity 2. Irritability 3. Minimal response to stimuli 4. Greater than normal birth weight

2. Irritability 3. Minimal response to stimuli Characteristic behaviors of the newborn with fetal alcohol spectrum disorder (FASD) are similar to the behaviors common in the drug-exposed newborn. These behaviors include irritability, tremors, poor feeding, and hypersensitivity to stimuli. Newborns with FASD are smaller at birth and present with failure to thrive. Head circumference and weight are most affected.

Which characteristics would the nurse expect to note for a client with seasonal affective disorder? Select all that apply. 1. Affects males more often than females 2. Is related to abnormal melatonin metabolism 3. Usually results in debilitating symptomatology 4. Improves during the spring and summer months 5. Is a result of alterations in the available amounts of sunlight 6. A craving for carbohydrates lessens during sunnier and spring months

2. Is related to abnormal melatonin metabolism 4. Improves during the spring and summer months 5. Is a result of alterations in the available amounts of sunlight 6. A craving for carbohydrates lessens during sunnier and spring months Seasonal affective disorder (SAD) is believed to be a result of impaired melatonin metabolism because of decreased exposure to sunlight. Symptomatology that includes craving for carbohydrates lessens during the sunnier spring and summer months. This disorder does not result in debilitating symptomatology. It is believed that because clinical symptoms may not dramatically affect quality of life, many clients go undiagnosed, resulting in a lack of research to support that one gender is more greatly affected than the other.

The nurse is caring for a client with acute kidney injury (AKI). The nurse should test the client's urine for proteinuria to determine which type of AKI? 1. Prerenal 2.Intrinsic 3.Atypical 4.Postrenal

2.Intrinsic In intrinsic failure, there is a fixed specific gravity and the urine tests positive for proteinuria. In prerenal failure, the specific gravity is high, and there is very little or no proteinuria. In postrenal failure, there is a fixed specific gravity and little or no proteinuria. There is no disorder known as atypical renal failure.

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? 1. Witnessing a murder 2.The death of a loved one 3.A fire that destroyed the client's home 4.A recent rape episode experienced by the client

2.The death of a loved one A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis of disaster, is not a part of everyday life, and is unplanned and accidental. Adventitious crises may result from a natural disaster (e.g., floods, fires, tornadoes, earthquakes), a national disaster (e.g., war, riots, airplane crashes), or a crime of violence (e.g., rape, assault, murder in the workplace or school, bombings, or spousal or child abuse).

The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client? 1. Complaints of ringing in the ear 2. An excessive amount of cerumen in the ear canal 3. Intolerance for sound levels that do not bother other people 4. Complaints of dizziness and sensations of being "off balance"

3. Intolerance for sound levels that do not bother other people Hyperacusis is a change in hearing for a client and the intolerance for sound levels that do not bother other people. Ringing in the ears is known as tinnitus. An excessive amount of cerumen in the ear canal is not associated with hyperacusis. Complaints of dizziness and sensations of being "off balance" is known as vertigo.

Several children have contracted rubeola (measles) in a local school, and the school nurse conducts a teaching session for the parents of the schoolchildren. Which statement made by a parent indicates a need for further teachingregarding this communicable disease? 1."Small blue-white spots with a red base may appear in the mouth." 2."The rash usually begins on the face and spreads downward toward the feet." 3."The disease can be spread to others from 10 days before any sign of the disease appears to 15 days after the rash appears." 4."Respiratory symptoms such as a profuse runny nose, cough, and fever occur before the development of a rash."

3."The disease can be spread to others from 10 days before any sign of the disease appears to 15 days after the rash appears." The communicable period for rubeola ranges from 4 days before to 5 days after the rash appears, mainly during the prodromal stage. All other options are accurate descriptions of rubeola, so they would not indicate a need for further teaching. The small blue-white spots found in this communicable disease are called Koplik's spots. The incorrect option describes the incubation period for rubella, not rubeola.

The nurse is giving a client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed touch-down of the affected leg. The nurse should tell the client to perform which action? 1. Advance the crutches along with both legs simultaneously. 2.Advance the crutches along with the right leg, and then advance the left leg. 3.Advance the crutches along with the left leg, and then advance the right leg. 4.Advance the left leg along with right crutch, and then the right leg and left crutch.

3.Advance the crutches along with the left leg, and then advance the right leg. Rationale: A three-point gait requires good balance and arm strength. The crutches are advanced with the affected leg, and then the unaffected leg is moved forward. Option 1 describes a swing-through gait. Option 2 describes a three-point gait used for a right leg problem. Option 4 describes a two-point gait.

Which pre-electroconvulsive therapy intervention will the nurse implement for a hospitalized client? 1. Restrict the client smoking for 12 hours. 2. Enforce nothing by mouth (NPO) status for 16 hours. 3. Limit the client's participation in unit activities for 24 hours. 4. Assure that an electrocardiogram is performed within 24 hours.

4. Assure that an electrocardiogram is performed within 24 hours. Before electroconvulsive therapy (ECT), blood tests are performed and an electrocardiogram is done to determine a baseline status of the client. Maintaining NPO status for 6 to 8 hours before treatment is adequate. The remaining options are incorrect.

The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding prevention of the transmission to siblings and other household members. Which instruction should the nurse provide? 1. Isolate the child from others for 2 weeks because the virus is transmitted by breathing and coughing. 2.Wash sheets and towels used by the child separately in bleach to prevent spread of the infection to others. 3.Have the child use a separate bathroom for urination and bowel movements to prevent the spread of infection. 4.Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through saliva.

4.Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through saliva.

The nurse is reviewing the health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that aspirin is prescribed for the child. Which nursing action is most appropriate? 1. Administer acetaminophen for temperature elevation. 2.Administer the aspirin if the child's temperature is elevated. 3.Administer the aspirin if the child experiences any joint pain. 4.Consult with the health care provider to verify the prescription.

4.Consult with the health care provider to verify the prescription. Antiinflammatory agents, including aspirin, may be prescribed for the child with rheumatic fever. Aspirin should not be given to a child who has chickenpox or other viral infections because of the risk of Reye's syndrome. Therefore, the nurse should consult with the health care provider (HCP) to verify the prescription. The nurse would not administer acetaminophen without specific HCP prescriptions. Administering aspirin is not an appropriate action without consulting the HCP first.

A health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV). The nurse anticipates that which laboratory study will be prescribed for the infant? 1. Chest x-ray 2.Western blot 3.CD4+ cell count 4.p24 antigen assay

4.p24 antigen assay

A child is sent to the school nurse by the teacher. On assessment of the child the nurse notes the presence of a rash. The nurse suspects that the child has erythema infectiosum (fifth disease) based on which assessment finding?

Erythema on the face, giving a "slapped cheeks" appearance

A client is taking clorazepate. The client asks the nurse if there is a risk of addiction with this medication. Which information should the nurse provide?

It leads to physical and psychological dependence with prolonged high-dose therapy. clorazepate is classified as an anticonvulsant, an anxiolytic (antianxiety agent), and a sedative-hypnotic (benzodiazepine). One of the nursing implications of clorazepate therapy is that the medication can lead to physical or psychological dependence with prolonged therapy at high doses. For this reason, the amount of medication that is readily available to the client at any one time is restricted.

Effleurage

is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Effleurage also provides tactile stimulation to the fetus.

Ménière's disease

is an inner-ear condition that can cause vertigo, a specific type of dizziness in which you feel as though you're spinning.

gynecoid pelvis

most favorable for labor and birth.

milieu therapy

viewing all team members as equally important in helping the clients to meet their goals.

Which interventions should the nurse take for a deceased client whose eyes will be donated? Select all that apply. 1. Close the client's eyes. 2.Elevate the head of the bed. 3.Place a warm compress on the eyes. 4.Place a dry sterile dressing over the eyes. 5.Place wet saline gauze pads and a cool pack on the eyes.

1, 2, 5

The nurse determines that a history of which mental health disorder would support the prescription of taking donepezil hydrochloride? 1. Dementia 2. Schizophrenia 3. Seizure disorder 4. Obsessive-compulsive disorder

1. Dementia Donepezil hydrochloride is a cholinergic agent that is used in the treatment of mild to moderate dementia of the Alzheimer's type. It increases concentration of acetylcholine, which slows the progression of Alzheimer's disease. The other options are incorrect and are not indications for use of this medication.

A nulliparous woman asks the nurse when she will begin to feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately how many weeks of gestation?

18 weeks the first recognition of fetal movements, or feeling life, by the multiparous woman may occur as early as 14 to 16 weeks' gestation. The nulliparous woman may not notice these sensations until 18 weeks' gestation or later, as she has no prior experience and the uterus has not been previously stretched during pregnancy adaptation. The first recognition of fetal movement is called quickening.

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve? 1. Ask the client to puff out the cheeks. 2. Separate the client's jaw by pushing down on the chin. 3. Place a small amount of sugar on the client's tongue and ask him or her to identify the taste. 4. Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin.

2. Separate the client's jaw by pushing down on the chin.

A preschooler with a history of cleft palate repair comes to the clinic for a routine well-child checkup. To determine if this child is experiencing a long-term effect of cleft palate, which question should the nurse ask? 1. "Was the child recently treated for pneumonia?" 2."Does the child play with an imaginary friend?" 3. "Is the child unresponsive when given directions?" 4. "Has the child had any difficulty swallowing food?"

3. "Is the child unresponsive when given directions?" Unresponsiveness may be an indication of hearing loss. A child who has a history of cleft palate should be routinely checked for hearing loss.

A child diagnosed with scarlet fever is being cared for at home. The home health nurse performs an assessment on the child and checks for which clinical manifestations of this disease? Select all that apply. 1. Pastia's sign 2. Koplik's spots 3. White strawberry tongue 4. Edematous and beefy-red pharynx 5. Petechial red, pinpoint spots on the soft palate 6. Small red spots with a bluish-white center and a red base located on the buccal mucosa

1. Pastia's sign 3. White strawberry tongue 4. Edematous and beefy-red pharynx

An improvement in symptoms following administration of edrophonium indicates myasthenic crisis.The health care provider is preparing to administer edrophonium to the client with myasthenia gravis. In planning care, the nurse understands which about the administration of edrophonium? Select all that apply. 1. Edrophonium is a long-acting cholinesterase inhibitor. 2. Atropine is used to reverse the effects of edrophonium. 3. If symptoms worsen following administration of edrophonium, the crisis is cholinergic. 4. Edrophonium is used to distinguish between a myasthenic crisis and a cholinergic crisis. 5. An improvement in symptoms following administration of edrophonium indicates myasthenic crisis.

2. Atropine is used to reverse the effects of edrophonium. 3. If symptoms worsen following administration of edrophonium, the crisis is cholinergic. 4. Edrophonium is used to distinguish between a myasthenic crisis and a cholinergic crisis. 5. An improvement in symptoms following administration of edrophonium indicates myasthenic crisis. Rationale: Edrophonium is an ultra-short-acting reversible cholinesterase inhibitor that can be used to distinguish between a cholinergic and a myasthenic crisis. To distinguish between overtreatment (cholinergic crisis) and undertreatment (myasthenic crisis), edrophonium is administered; this is often referred to as a Tensilon test. Overtreatment of myasthenia gravis with reversible cholinesterase inhibitors results in a cholinergic crisis. Undertreatment can result in a myasthenic crisis. Both cholinergic and myasthenic crises result in increased muscle weakness or paralysis. If symptoms improve after the administration of edrophonium, the crisis is myasthenic; if symptoms worsen, the crisis is cholinergic. Atropine must be readily available so that edrophonium can be reversed if the symptoms worsen.

The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction? 1. "It is extremely contagious." 2."It is most common in humid weather." 3."Lesions most often are located on the arms and chest." 4."It might show up in an area of broken skin, such as an insect bite."

3."Lesions most often are located on the arms and chest." Impetigo is a contagious bacterial infection of the skin caused by β-hemolytic streptococci or staphylococci, or both. Impetigo is most common during hot, humid summer months. Impetigo may begin in an area of broken skin, such as an insect bite or atopic dermatitis. Impetigo is extremely contagious. Lesions usually are located around the mouth and nose, but may be present on the hands and extremities.

The nurse is assessing for the presence of pallor in a dark-skinned client. What finding should the nurse look for? 1. A yellow tinge to the skin 2.Bluish discoloration of the skin 3.Loss of normal red tones in the skin 4.An ashen-gray appearance to the skin

3.Loss of normal red tones in the skin In dark-skinned clients, pallor results in the loss of normal red tones in the skin. The brown-skinned client may have yellow-tinged skin when pallor is present. Bluish discoloration of the skin most often is associated with cyanosis. In the black-skinned client, pallor produces an ashen-gray color.

The nurse is preparing to perform an abdominal examination on a client. The nurse should place the client in which position for this examination? 1. Sims' position 2.Supine with the head and feet flat 3.Supine with the head raised slightly and the knees slightly flexed 4.Semi Fowler's position with the head raised 45 degrees and the knees flat

3.Supine with the head raised slightly and the knees slightly flexed

The nurse should monitor a client with a history of opioid abuse for which signs and symptoms associated with opioid withdrawal? 1. Increased appetite, irritability, anxiety, restlessness, and altered concentration 2. Tachycardia, mild hypertension and fever, sweating, nausea, vomiting, and marked tremor 3. Depression, high drug craving, fatigue, altered sleep patterns, hypertension, agitation, and paranoia 4. Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, diarrhea, and mydriasis

4. Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, diarrhea, and mydriasis Opioids are central nervous system depressants. They generally cause drowsiness and the feeling of being out of touch with the world. Withdrawal occurs within 12 hours after the last dose. Option 4 identifies the signs and symptoms associated with opioid withdrawal. Option 1 describes cocaine withdrawal. Option 2 identifies signs associated with nicotine withdrawal. Option 3 describes alcohol withdrawal.

A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a history of a severe allergy to which substance? 1. Eggs 2. Penicillin 3. Sulfonamides 4. A previous dose of hepatitis B vaccine or component

4. A previous dose of hepatitis B vaccine or component

Before giving the client the initial dose of disulfiram, what should the psychiatric home health nurse determine? 1. if there is a history of hyperthyroidism 2.When the last full meal was consumed 3. If there is a history of diabetes insipidus 4. When the last alcoholic drink was consumed

4. When the last alcoholic drink was consumed Disulfiram is an adjunctive treatment for some clients with chronic alcoholism to assist in maintaining enforced sobriety. Because clients must abstain from alcohol for at least 12 hours before the initial dose, the most important assessment is when the last alcoholic intake was consumed.

Which activity should the nurse include in the plan of care for a client who is experiencing psychomotor agitation? 1. Playing checkers with members of the staff 2.Reading in a quiet, low-stimulus environment 3.Engaging in a card game with other clients on the unit 4.Attending a clay-molding class that is scheduled for today

4.Attending a clay-molding class that is scheduled for today When a client is experiencing psychomotor agitation, it is best to provide activities that involve the use of hands and gross motor movements. Such activities can include volleyball, finger-painting, drawing, and working with clay. These activities provide an appropriate way for the client to discharge motor tension. Reading and simple card games are sedentary activities. Playing checkers requires concentration and more intensive use of thought processes.

In formulating a discharge teaching plan, the nurse should include which precaution for a client who is prescribed lithium carbonate therapy? 1. Avoid soy sauce, wine, and aged cheese. 2.Have the blood lithium level checked every 2 weeks. 3.Take the medication only as prescribed to avoid becoming addicted. 4.Check with the psychiatrist before using any over-the-counter medications.

4.Check with the psychiatrist before using any over-the-counter medications. Lithium is a mood stabilizer and a medication to treat bipolar disorder. Its exact mechanism of action remains speculative; however, equilibrium of sodium and potassium must be maintained at the intracellular membrane to maintain therapeutic effects. Lithium competes with sodium in the cell. Many over-the-counter medications contain sodium, and often prescription medications (diuretics) change the sodium-potassium ratios of the cell, thereby affecting lithium concentrations so that it is more difficult to achieve therapeutic levels of the medication. Food restriction (tyramine-restricted diet) is associated with monoamine oxidase inhibitors. Lithium blood levels are recommended for the client taking lithium, but these tests generally are prescribed every 3 to 4 months. Lithium is not addictive.

During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease?

Abdominal distention

In discussing the topic of cochlear implants, the educator notes that this surgical procedure is contraindicated in which client?

Adults who were born deaf or became deaf before learning to speak usually are not candidates for this type of surgery.

A child with rubeola (measles) is being admitted to the hospital. In preparing for the admission of the child, the nurse should plan to place the child on which precautions?

Airborne

The nurse reviewing a client's diagnostic results recognizes that which is a possible positive indication for a diagnosis of schizophrenia?

Atrophy of the lateral and/or third ventricles of the brain

Diet for someone who has Meniere's Disease

Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for a client

The nurse is providing care for a client with new onset of a dysrhythmia. The nurse anticipates which prescriptions from the health care provider? Oxygen therapy 2. An echocardiogram 3. An intravenous dose of metoprolol 4. One dose of atropine to promote slowing of the rate 5. A bolus of intravenous heparin followed by a continuous infusion

Oxygen therapy 2. An echocardiogram 3. An intravenous dose of metoprolol 5. A bolus of intravenous heparin followed by a continuous infusion

Which medication, if present in the client's history, indicates a need for teaching related to the woman's potential risk for carrying a fetus with a congenital cleft lip or cleft palate?

Phenytoin

Enoxaparin sodium antidote?

Protamine sulfate

A mother brings her 6-year-old child to the clinic because the child has developed a rash on the trunk and scalp. The mother reports that the child has had a low-grade fever, has not felt like eating, and has been tired. The child is diagnosed with chickenpox. The mother inquires about the communicable period associated with chickenpox, and the nurse bases the response on which statement?

The communicable period is 1 to 2 days before the onset of the rash to 6 days, when crusts have formed.

Placenta previa

Painless, bright red vaginal bleeding Location in the lower uterine segment

pernicious anemia treatment

Vitamin B12 injections

Lyme disease treatment

A 14 to 21 day course of doxycycline

The clinic nurse is reviewing the health care provider's prescription for a child who has been diagnosed with scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is noted in the child's record? 1. The child is 18 months old. 2.The child is being bottle-fed. 3.A sibling is using lindane for the treatment of scabies. 4.The child has a history of frequent respiratory infections.

1. The child is 18 months old. child needs to be at least 2 years old for this med, skin is more permeable when they are younger

Parents bring their child to the emergency department and tell the nurse that the child has been complaining of colicky abdominal pain located in the lower right quadrant of the abdomen. The nurse suspects that the child has which disorder? 1. Peritonitis 2.Appendicitis 3.Intussusception 4.Hirschsprung's disease

2.Appendicitis

A 10-year-old child with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer which prescription? 1. Injection of factor X 2. Intravenous infusion of iron 3. Intravenous infusion of factor VIII 4. Intramuscular injection of iron using the Z-track method

3. Intravenous infusion of factor VIII

A child with β-thalassemia is receiving long-term blood transfusion therapy for the treatment of the disorder. Chelation therapy is prescribed as a result of too much iron from the transfusions. Which medication should the nurse anticipate to be prescribed? 1. Fragmin 2.Meropenem 3.Metoprolol 4.Deferoxamine

4.Deferoxamine To prevent organ damage from too much iron, chelation therapy with either Exjade or deferoxamine may be prescribed.

Side effect of beta blockers

A common side effect of beta-adrenergic blocking agents such as pindolol is impotence. Other common side effects include fatigue and weakness. Central nervous system side effects are rarer and include mental status changes, nervousness, depression, and insomnia.

The community health nurse is providing an educational session to a group of community members regarding the issue of organ donation. A member of the group asks the nurse, "How old does someone have to be to provide consent for organ donation?" Which response should the nurse make?

A donor must be 18 years of age or older to provide consent." Any person 18 years of age or older may become an organ donor by written consent. In the absence of appropriate documentation, a family member or legal guardian may authorize donation of the decedent's organs. Therefore, the statements in the remaining options are incorrect.

The nurse notes a persistent, dry cough in an adult client being seen in the ambulatory clinic. When questioned, the client states that the cough began approximately 2 months ago. On further assessment, the nurse learns that the client began taking quinapril shortly before the time that the cough began. How should the nurse interpret the development of the cough?

An expected although bothersome side effect of therapy A frequent side effect of therapy with any angiotensin-converting enzyme (ACE) inhibitor, including quinapril, is a persistent, dry cough. In general, the cough does not resolve during the course of medication therapy, so clients should be advised to notify the health care provider if the cough becomes very troublesome.

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client?

Assess for signs and symptoms of labor. As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor.

The nurse is reviewing the record of a pregnant woman and notes that the health care provider has documented the presence of Chadwick's sign. Which assessment finding supports the presence of Chadwick's sign?

Bluish discoloration of cervix and vagina

The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency?

Butorphanol tartrate Butorphanol tartrate is an opioid analgesic that can precipitate withdrawal symptoms in an opioid-dependent client. Therefore, it is contraindicated if the client has a history of opioid dependency. Fentanyl, morphine sulfate, and meperidine are opioid analgesics but do not tend to precipitate withdrawal symptoms in opioid-dependent clients.

The nurse has a prescription to administer a medication to a client who is experiencing shivering as a result of hyperthermia. Which medication should the nurse anticipate to be prescribed?

Chlorpromazine

On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease?

Conjunctival hyperemia Kawasaki disease, also known as mucocutaneous lymph node syndrome, is an acute systemic inflammatory illness. In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present.

A 3-year-old child is seen in the health care clinic, and a diagnosis of encopresis is made. The nurse expects to provide teaching about which client problem? 1. Odor 2.Nausea 3.Malaise 4.Diarrhea

Odor Encopresis is the repeated voluntary or involuntary passage of feces of normal or near-normal consistency in places not appropriate for that purpose according to the individual's own sociocultural setting. Signs include evidence of soiled clothing, scratching or rubbing the anal area because of irritation, fecal odor without apparent awareness by the child, and social withdrawal.

The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest?

Over the fifth intercostal space in the left midclavicular line

The nurse assesses a client for the presence of Homans' sign. Which could be an indication that this sign is positive?

Pain with dorsiflexion of the foot

The nurse is preparing to administer furosemide to a client with a diagnosis of heart failure. Which is the most important laboratory test result for the nurse to check before administering this medication

Potassium level

A client is receiving ganciclovir. Which nursing action is appropriate during the time the client is receiving this medication?

Providing the client with a soft toothbrush and an electric razor Ganciclovir is an antiviral medication. Common adverse effects of ganciclovir are neutropenia and thrombocytopenia. For this reason, the nurse implements the same precautions that are used for a client receiving anticoagulant therapy. These include providing a soft toothbrush and an electric razor to minimize risk of trauma that could result in bleeding. The medication may cause hypoglycemia, but not hyperglycemia. The medication does not have to be taken on an empty stomach. Pressure on venipuncture sites should be held for approximately 10 minutes.

The nurse is performing an assessment on a client being admitted with a diagnosis of alcohol dependence who reports it's been 6 hours since the last drink. The information supports which assumption about the appearance of withdrawal symptoms?

Signs may appear at any time. Alcohol withdrawal is most likely to occur within the first 6 to 8 hours after abrupt cessation; however, it can occur over the next several days. Therefore, the option suggesting the danger has passed as well as the one suggesting that a specific time can be predicted can be eliminated. The option that withdrawal has already started is not supported by the information presented.

The clinic nurse prepares to administer a measles, mumps, and rubella (MMR) vaccine to a 5-year-old child. The nurse should administer this vaccine by which method?

Subcutaneously in the outer aspect of the upper arm

What information regarding possible prognosis will the nurse provide to the parents of a 15-year-old newly diagnosed with schizophrenia?

Their child will be treated for an imbalance of the chemical dopamine.

Which is a primary behavior of a client diagnosed with antisocial personality disorder?

Will take personal items from other clients' rooms

The prenatal client asks the nurse about substances that can cross the placental barrier and potentially affect the fetus. The nurse most appropriately explains that which substances can cross this barrier? Select all that apply. Viruses Bacteria Nutrients Antibodies Medications

all but bacteria they are too large to pass

Loperamide

antidiarrheal agent

Eosinophils

attack and destroy foreign particles that have been coated with antibodies of the immunoglobulin E (IgE) class. Their usual target is helminths (parasitic worms).

What is the limbic system responsible for?

emotions and feelings

senna

increase peristalsis

Idiopathic autoimmune hemolytic anemia

is a decrease in the number of red blood cells due to increased destruction by the body's defense (immune) system. It is an acquired disease that occurs when antibodies form against a person's own red blood cells. In the idiopathic form of this disease, the cause is unknown. Idiopathic autoimmune hemolytic anemia is treated with corticosteroids. Other treatments that may be prescribed as necessary include transfusions, splenectomy, and, occasionally, immunosuppressive medications. Radiation therapy is not used to treat this disorder.

triple screen test

is a screening tool. Maternal blood is drawn and alpha-fetoprotein, human chorionic gonadotropin, and estriol values are assessed to determine if the mother is at an increased risk for neural tube defects or chromosomal trisomies. Spina bifida and Down syndrome are the two most common risks that fall into these categories, respectively. These results must be followed by additional diagnostic testing, as the triple screen is only a screening result.

Paroxysmal nocturnal dyspnea or paroxysmal nocturnal dyspnoea (PND)

is an attack of severe shortness of breath and coughing that generally occur at night. It usually awakens the person from sleep, and may be quite frightening.

The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site?

Mitral area

The nurse should monitor the client with a history of heroin addiction for which signs/symptoms of heroin withdrawal?

Nausea, vomiting, diarrhea, muscle aches, and diaphoresis The client who is experiencing opioid withdrawal (such as from heroin) may experience dysphoric mood, nausea, vomiting, diarrhea, abdominal cramping, muscle aches, diaphoresis and piloerection, runny eyes (lacrimation) and nose (rhinorrhea), yawning, low-grade fever, restlessness, insomnia, anxiety, mydriasis, and increased pulse and blood pressure. Therefore, the other options are incorrect.

The nurse has a prescription to give a first dose of hydrochlorothiazide to an assigned client. The nurse would question the prescription if the client has a history of allergy to which item?

Sulfa medications Rationale: Thiazide diuretics, such as hydrochlorothiazide, are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. A sulfa allergy must be communicated to the pharmacist, health care providers (HCPs), and nurse. The other options are not contraindications for administering the medication.

The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability? Select all that apply.

Tachycardia Fetal hypoxia Metabolic acidemia Congenital anomalies

A registered nurse (RN) who is working with a nursing student assigns the student to care for a client with a diagnosis of Cushing's syndrome. The RN asks the student questions about this disorder. Which statement made by the student indicates understanding of Cushing's syndrome?

"Cushing's syndrome is caused by excessive amounts of cortisol."

The nurse is reviewing the record of a client admitted to the nursing unit and notes that the client has a history of Laënnec's cirrhosis. Which question related to the client's history would be most important to ask?

"Do you abuse alcohol?"

The nurse is caring for a client with a diagnosis of agoraphobia. Which statement made by the client would support this diagnosis?

"I'd be sure to have a panic attack if I left my house."

A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client?

Enlarged lymph nodes

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply.

In a pregnant client, DIC is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Dead fetus syndrome is considered a risk factor for DIC. Severe preeclampsia is considered a risk factor for DIC; a mild case is not.

The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique? 1. Tapping the Achilles tendon using the reflex hammer 2.Gently pricking the client's skin on the dorsum of the foot in 2 places 3.Firmly stroking the lateral sole of the foot and under the toes with a blunt instrument 4.Holding the sides of the client's great toe and, while moving it, asking what position it is in

.Holding the sides of the client's great toe and, while moving it, asking what position it is in A method of testing for proprioception is to hold the sides of the client's great toe and, while moving it, asking the client what position it is in. Tapping the Achilles tendon with a reflex hammer describes gastrocnemius muscle contraction. Pricking the skin on the dorsum of the foot in two different places describes 2-point discrimination. The plantar reflex is tested when the sole of the foot is stroked with a blunt instrument.

A hospitalized client is receiving clozapine for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study? 1. Platelet count 2.Cholesterol level 3.Blood urea nitrogen 4.White blood cell count

4.White blood cell count

A postsurgical client with a history of heavy alcohol intake has returned to the nursing unit. Which signs/symptoms of delirium tremens should the nurse plan to continuously assess for?

Fever, hypertension, changes in level of consciousness, and hallucinations

Atorvastatin has been prescribed for a client, and the client asks the nurse about the side and adverse effects of the medication. What should the nurse tell the client is a frequent side effect of this medication?

Headache Rationale: Atorvastatin is a reductase inhibitor (HMG-CoA reductase inhibitor) that is used to treat hypercholesterolemia and hypertriglyceridemia. A frequent side effect is headache. Occasional side effects include myalgia, rash or pruritus (signs of an allergic reaction), flatulence, and dyspepsia.

The nurse is creating a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse should include monitoring the child for signs of which condition? Bleeding 2.Heart failure 3.Failure to thrive 4.Decreased tolerance to stimulation

Heart failure

The nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and perform which action? 1. Identify an object placed in the client's hand. 2. Identify 3 numbers or letters traced in the client's palm. 3. State whether 1 or 2 pinpricks are felt when the skin is pricked bilaterally in the same place. 4. Identify the smallest distance between 2 detectable pinpricks, made with 2 pins held at various distances.

Identify an object placed in the client's hand. Astereognosis is the inability to discern the form or configuration of common objects using the sense of touch. Agraphesthesia is the inability to recognize the form of written symbols. The remaining options test for extinction phenomena and 2-point stimulation, respectively.

The nurse has been assigned to care for a neonate just delivered who has gastroschisis. Which concern should the nurse address in the client's plan of care 1.Infection 2.Poor body image 3.Decreased urinary elimination 4.Cracking oral mucous membranes

Infection Gastroschisis occurs when the bowel herniates through a defect in the abdominal wall to the right of the umbilical cord. There is no membrane covering the exposed bowel. Surgical repair will be done as soon as possible because of the risk of infection in the unprotected bowel. Therefore, the greatest risk immediately after delivery is infection.

The nurse is conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by doing which action?

Massaging the abdomen during contractions, using both hands in a circular motion