Trainer #1

The nurse cares for a client diagnosed with reflux due to a hiatal hernia. The client asks the nurse why he has been instructed to withhold food and fluids just before going to bed. Which of the following responses by the nurse is MOST appropriate? 1. "You are less likely to awaken during the night with heartburn if the stomach is empty." 2. "Early-morning vomiting will be less of a problem if the stomach is empty." 3. "Drinking or eating before lying down causes decreased respirations due to increased pressure on the lungs." 4. "You may develop fluid overload if fluids are taken just before going to bed."

1. "You are less likely to awaken during the night with heartburn if the stomach is empty." full stomach is more likely to slide (reflux) through the hernia, causing regurgitation and heartburn vomiting, decreased respirations, and fluid overload are not related to hiatal hernia

A woman is evaluated for infertility, and the physician prescribes clomiphene citrate (Clomid) 50 mg daily for 5 days. The client asks the nurse about how the medication works. Which of the following responses by the nurse is BEST? 1. Clomiphene citrate (Clomid) induces ovulation by changing hormonal effects on the ovary. 2. Clomiphene citrate (Clomid) changes the uterine lining to be more conducive to implantation. 3. Clomiphene citrate (Clomid) alters the vaginal pH to increase sperm motility. 4. Clomiphene citrate (Clomid) produces multiple pregnancy for those who desire twins.

1. Clomiphene citrate (Clomid) induces ovulation by changing hormonal effects on the ovary. clomiphene citrate (Clomid) induces ovulation by altering estrogen and stimulating follicular growth to produce a mature ovum

1. Delusions of persecution. 2. Command hallucinations. 3. Delusions of reference.

1. Delusions of persecution = delusion is a strongly held belief that is not validated by reality 2. Command hallucinations = hallucinations are sensory perceptions that take place without external stimuli; most common are auditory, or hearing voices; other types of hallucinations are tactile, visual, gustatory, and olfactory; command hallucinations involve client experiencing auditory hallucinations that are telling him/her to do something; for example, to kill someone 3. Delusions of reference = false belief that public events or people are directly related to the individual

5 Stages of Grief

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance "DABDA"

The nurse cares for an older patient scheduled for a colon resection this morning. The nurse notes the patient had polyethylene glycol-electrolyte solution (GoLYTELY) and a soapsuds enema the previous evening. This morning the patient passes a medium amount of soft brown stool. Which of the following conclusions by the nurse is MOST accurate? 1. The bowel preparation is incomplete. 2. The patient ate something after midnight. 3. This is an expected finding before this type of surgery. 4. The patient passed the last stool left in the colon.

1. The bowel preparation is incomplete. colon should not have remaining soft stool

The outpatient clinic nurse cares for an elderly client diagnosed with type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for sugar and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which of the following? 1. The renal threshold for glucose is elevated in the elderly. 2. Blood glucose monitoring is easier and less costly for clients to perform. 3. Urine testing for glucose provides false-positive readings. 4. Determination of the color on a reagent strip varies from person to person.

1.) The renal threshold for glucose is elevated in the elderly. the level at which glucose starts to appear in the urine increases, leading to false-negative readings; results in elevated glucose levels (really high threshold, before it can be detected)

Several days after the delivery of a stillborn, the parents say, "We wish we could talk with other couples who have gone through this trauma." Which of the following responses by the nurse is BEST? 1. "SIDS will provide you with this opportunity." 2. "SHARE will provide you with this opportunity." 3. "RESOLVE will provide you with this opportunity." 4. "CANDLELIGHTERS will provide you with this opportunity."

2. "SHARE will provide you with this opportunity." RESOLVE-infertile CANDLELIGHTERS-cancer

The nurse cares for clients in the outpatient clinic. Which of the following messages should the nurse return FIRST? 1. A mother reports the umbilical cord of her 5-day-old infant is dry and hard to the touch. 2. A mother reports the "soft spot" on the head of her 4-day-old infant feels slightly elevated when the baby sleeps. 3. A mother reports that the circumcision of her 3-day-old infant is covered with yellowish exudate. 4. A father reports that he bumped the crib of his 2-day-old infant and she violently extended her extremities and returned them to their previous position.

2. A mother reports the "soft spot" on the head of her 4-day-old infant feels slightly elevated when the baby sleeps. Fontanelle should feel soft and flat; fullness or bulging indicates IICP. Moro (Startle) Reflex- gone after 3 mo.

The nurse cares for a newborn infant diagnosed with fetal alcohol syndrome. The nurse expects to see which of the following physical characteristics? 1. An infant large for gestational age (LGA), craniofacial abnormalities, and hydrocephalus. 2. An infant with a small head circumference, low birth weight, and undeveloped cheekbones. 3. An infant with a large head circumference, low birth weight, and excessive rooting and sucking behaviors. 4. An infant with a normal head circumference, low birth weight, and respiratory distress syndrome.

2. An infant with a small head circumference, low birth weight, and undeveloped cheekbones. SGA, have feeding difficulties and poor sucking ability, head circumference usually small, respiratory distress r/t preterm birth, neurologic damage, small trachea, floppy epiglottis

The nurse prepares an adult client diagnosed with mental retardation for discharge. The physician ordered warfarin sodium (Coumadin), 5 mg each day. To maintain client safety, which of the following actions should the nurse take FIRST? 1. Instruct a significant other about the medication regimen. 2. Determine the client's comprehension of the medication administration. 3. Prepackage the medication to encourage correct administration. 4. Encourage a return demonstration of medication self-administration.

2. Determine the client's comprehension of the medication administration. assessment; mentally retarded client should be carefully evaluated to ensure complete comprehension of the dosage regimen to prevent overdosage and underdosage

The physician inserts a temporary pacemaker in a client following a myocardial infarction. The nurse knows that the primary purpose of the pacemaker is which of the following? 1. Increases the force of myocardial contraction. 2. Increases the cardiac output. 3. Prevents premature ventricular contractions (PVCs). 4. Prevents systemic overload.

2. Increases the cardiac output. acts to regulate cardiac rhythm

The nurse cares for a 3-month-old infant scheduled for a BARIUM SWALLOW in the morning. Prior to the procedure, it is MOST appropriate for the nurse to take which of the following actions? 1. Offer the infant only clear liquids. 2. Make the infant NPO for 3 hours. 3. Feed the infant regular formula. 4. Maintain the infant NPO for 6 hours.

2. Make the infant NPO for 3 hours.

The nurse should caution the client with hypothyroidism to avoid which of the following? 1. Warm environmental temperatures. 2. Narcotic sedatives. 3. Increased physical exercise. 4. A diet high in fiber.

2. Narcotic sedatives. client is very sensitive to narcotics, barbiturates, and anesthetics. cannot tolerate cold temperatures. requires high fiber, high cellulose foods to prevent constipation

Which of the following observations suggests to the nurse that the client has developed an addisonian crisis? 1. Muscular weakness and fatigue. 2. Restlessness and rapid, weak pulse. 3. Dark pigmentation of the skin. 4. Gastrointestinal disturbances and anorexia

2. Restlessness and rapid, weak pulse. Muscular weakness and fatigue,Dark pigmentation of the skin, Gastrointestinal disturbances and anorexia (all sx/s of Addison's disease, but do not indicate a crisis)

A 6-month-old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe which of the following? 1. A pincer grasp. 2. Sitting with support. 3. Tripling of the birth weight. 4. Presence of the posterior fontanelle.

2. Sitting with support. 6 mo. = 2x birth wt. 12 mo. = 3 x birth wt. Pincer Grasp = 9 mo.

The nurse performs the Rinne tests on a 6-year-old girl. Which of the following is an accurate statement of how this test should be performed? 1. The stem of a vibrating tuning fork is held against the auditory canal until the child indicates that she can no longer hear the sound. Then the tuning fork is moved away from the canal. 2. The stem of a vibrating tuning fork is held against the mastoid bone until the child indicates that she can no longer hear the sound. Then the tuning fork is moved in front of the auditory canal. 3. The stem of a vibrating tuning fork is held in the middle of the forehead, and the girl's hearing is assessed in both ears. 4. The stem of a vibrating tuning fork is positioned 2 in behind the girl's head, and the length of time she hears the sound is documented.

2. The stem of a vibrating tuning fork is held against the mastoid bone until the child indicates that she can no longer hear the sound. Then the tuning fork is moved in front of the auditory canal.

The parents of a child diagnosed with hemophilia ask the nurse to explain the cause of the disease. Which of the following responses by the nurse is BEST? 1. "The father transmits the gene to his son." 2. "Both the mother and the father carry a recessive trait." 3. "The mother transmits the gene to her son." 4. "There is a 50% chance that the mother will pass the trait to each of her daughters."

3. "The mother transmits the gene to her son." hemophilia is a sex-linked disorder

The nurse cares for a postoperative client diagnosed with type 2 diabetes controlled with oral antihyperglycemic agents. The client asks why the physician ordered subcutaneous insulin injections after surgery. The nurse's response should be based on which of the following statements? 1. Tissue injury after surgery decreases blood sugar. 2. Anesthesia acts to increase glycogen stores. 3. Being NPO inhibits normal blood sugar control. 4. Surgery often leads to insulin dependency.

3. Being NPO inhibits normal blood sugar control.

The nurse knows that cortisol is responsible for which of the following? 1. Preparing the body for "flight or fight." 2. Regulating the calcium metabolism. 3. Converting proteins and fat into glucose. 4. Enhancing musculoskeletal activity.

3. Converting proteins and fat into glucose. cortisol = antiinflammatory fight/flight = epi enhance musculoskeletal acvtivity = norepi reg. Ca+ metabolism = parathyroid hormone

A client, gravida 2 para 1, is admitted with hypertension and complains that her wedding band is tight. The nurse should assess which of the following indications of EARLY pre-eclampsia? 1. Blurred vision and proteinuria. 2. Epigastric pain and headache. 3. Facial swelling and proteinuria. 4. Polyuria and hypertonic reflexes.

3. Facial swelling and proteinuria. complete triad seen with pre-eclampsia blurred vision appears later, with eclampsia oliguria is seen later with eclampsia, not polyuria

The nurse recognizes which of the following are early signs of LITHIUM TOXICITY? 1. Restlessness, shuffling gait, involuntary muscle movements. 2. Ataxia, confusion, seizures. 3. Fine tremors, nausea, vomiting, diarrhea. 4. Elevated white blood cell count, fever, orthostatic hypotension.

3. Fine tremors, N/V/D

The physician orders naproxen sodium (Naprosyn) for an elderly client. The nurse should assess the patient for which of the following? 1. Stomatitis and photosensitivity. 2. Brachycardia and dry mouth. 3. Fluid retention and dizziness. 4. Gynecomastia and impotence.

3. Fluid retention and dizziness. NSAID (nonsteroidal anti-inflammatory drug) used as analgesic; side effects include HA/dizziness, GI distress, pruritus, and rash

A client had a kidney transplant yesterday, and the client's son has come to visit. The nurse should instruct the son to do which of the following? 1. No special isolation techniques are necessary. 2. Wear a double mask and gloves. 3. Perform good hand washing. 4. Wear a gown and a mask.

3. Perform good hand washing. good hand washing is the most effective method of reducing infection; very important with immunosuppressed clients. Masks are unnecessary for this patient

The nurse cares for a client receiving a blood transfusion for approximately 30 minutes. Which of these assessments, if made by the nurse, indicates an allergic reaction? 1. Hypotension. 2. Chills. 3. Respiratory wheezing. 4. Lower back discomfort.

3. Respiratory wheezing. Allergic Rx= is characterized by wheezing, urticaria (hives), facial flushing, and epiglottal edema Hemolytic Rx=hypotension,chills,lower back discomfort

Which information should the nurse recognize as being the MOST pertinent to the diagnosis of cholecystitis? 1. Flatulence. 2. Nausea and vomiting. 3. Right upper abdominal pain. 4. Dyspepsia.

3. Right upper abdominal pain. Cholecystitis (inflammed gallbladder), by Liver.

Which of the following might alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness? 1. Depression, difficulty falling asleep, decreased concentration. 2. Elevated liver enzymes, cirrhosis, decreased platelets. 3. Tremors, elevated temperature, nocturnal leg cramps, complaints of pain symptoms. 4. Flulike symptoms, night sweats, elevated temperature, decreased deep tendon reflexes.

3. Tremors, elevated temperature, nocturnal leg cramps, complaints of pain symptoms. client who has several complaints of pain that do not appear to be correlated to the admissions problem requires further investigation; tremors, hyperthermia, and pain symptoms are indicative of an alcohol-related problem

The nurse is discussing growth and development with the parents of a 4-year-old child. The nurse identifies which of the following as the type of play characteristic of this age group? 1. Solitary play 2. Parallel play 3. Associative play 4. Aggressive play

3.) ASSOCIATIVE PLAY 1. Solitary (infant) 2. Parallel (toddler, 1-3) child mimics other child, doesn't engage w/ them 3. Associative (pre-school, 4-5) more interested in each other, not toys

The nurse cares for a child diagnosed with pediculosis capitis (head lice) and is being treated with 1% gamma benzene hexachloride (Kwell) shampoo. The nurse should include which of the following when instructing the child's parents? 1. Continue treatment every other day for 1 week. 2. Wash the child's clothing and personal belongings in soap and cool water. 3. Repeat the application of the shampoo in 7 to 10 days. 4. One treatment with Kwell kills both lice and nits.

3.) Repeat the application of the shampoo in 7 to 10 days Kwell is an organic solvent, can be toxic, absorbed through scalp; may be repeated 1 week after first application. Permethrin 1% crème rinse (Nix) kills both lice and nits after one application. HOT water for clothing/belongings!

The nurse leads a parenting class for a group of expectant mothers. The nurse should advise that the breast-feeding mother should increase her daily caloric intake by how many calories? 1. 200. 2. 300. 3. 400. 4. 500.

4. 500 calories/day (breastfeeding)

The nurse knows which of the following would have the greatest impact on an elderly client's ability to complete activities of daily living (ADLs)? 1. Perseveration. 2. Aphasia. 3. Mnemonic disturbance. 4. Apraxia.

4. Apraxia. loss of purposeful movement. affects an ADL, such as dressing, the client may not be able to put clothes on properly. Others are speech disturbances = greatest impact on Communication Ability

The nurse cares for a client admitted with a diagnosis of cerebrovascular accident (CVA) and facial paralysis. Nursing care should be planned to prevent which of the following complications? 1. Inability to talk. 2. Loss of the gag reflex. 3. Inability to open the affected eye. 4. Corneal abrasion.

4. Corneal abrasion. client will be unable to close eye voluntarily; when facial nerve (cranial nerve VII) is affected, the lacrimal gland will no longer supply secretions that protect eye

A client with an ETvrequires suctioning. Which of the following statements is an accurate description of how the nurse should perform the procedure? 1. Insert the suction catheter 4 in into the tube. Apply suction for 30 seconds, using a twirling motion as the catheter is withdrawn. 2. Hyperoxygenate the client. Insert the suction catheter into the tube, and suction while removing the catheter in a back and forth motion. 3. Explain the procedure to the patient. Insert the catheter gently while applying suction, and withdraw using a twisting motion. 4. Insert the suction catheter until resistance is met, and then withdraw it slightly. Apply suction intermittently as the catheter is withdrawn.

4. Insert the suction catheter until resistance is met, and then withdraw it slightly. Apply suction intermittently as the catheter is withdrawn.

Which of the following is the BEST way for a nurse to assess the fluid balance of an elderly client? 1. Assess the client's blood pressure. 2. Check the client's tissue turgor. 3. Ask the client if he/she is thirsty. 4. Maintain an accurate intake and output.

4. Maintain an accurate I&O BP may be elevated d/t age related HTN.

The nurse knows which of the following mood-altering drugs is most often associated with an increased risk for HIV infection related to intravenous drug use? 1. Benzodiazepines. 2. Marijuana. 3. Barbiturates. 4. Narcotics.

4. Narcotics (most often used intravenously) HIV/IV drug use = cellulitis & narcotics

Which of the following instructions should the nurse give to an adult client to prepare for a plasma cholesterol screening? 1. Eat a vegetarian diet for 1 week before the test. 2. Limit alcohol intake to two glasses of wine the day before the test. 3. Abstain from dairy products for 48 hours before the test. 4. Only sips of water should be taken for 12 hours before the test.

4. Only sips of water should be taken for 12 hours before the test. normal diet should be eaten the week before the test alcohol intake will interfere with test results

An 18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB). During the initial assessment, the nurse expects to find which of the following EARLY symptoms? 1. Kussmaul respirations and bradycardia. 2. Elevated temperature and slow respiratory rate 3. Expiratory wheezing and substernal retractions. 4. Inspiratory stridor and restlessness.

4.) Inspiratory stridor and restlessness. condition is characterized by edema and inflammation of upper airways. Expiratory wheezing and substernal retractions= Resp. Distress in Newborn

During the mother's fourth stage of labor, the nurse should palpate the client's fundus in which of the following locations?

At Umbilicus

Infant's first solid food? age ?

Rice Cereal @ 4 mo.

VDRL Test

Screening for Syphillis