306 Exam 3/Final Pearson Questions

Which client would benefit from a hearing​ aid? A. A client with stenosis in the ear canal B. A client with Meniere's disease C. A client with bacterial meningitis D. A client taking ototoxic drugs

A A client with a conductive hearing loss such as stenosis in the ear canal will benefit from amplification by a hearing aid.​ Ménière disease, ototoxic​ drugs, and bacterial meningitis are sensorineural kinds of loss for which hearing aids will not be as helpful.

The nurse is caring for a client who can bear weight but has a weak limb. Which assistive device is the most appropriate for this client? A. Cane B. Walker C. Crutches D. Wheelchair

A Assistive devices are used to provide balance and support and increase confidence with independent ambulation. They also reduce pressure on an injured​ limb, prevent further​ injury, and promote healing. Canes are used by clients who can bear weight but are unsteady or have a weak limb. When using a​ walker, the arms support the majority of the body weight. For​ crutches, upper body and trunk strength is needed. A wheelchair will not assist with ambulation.

The nurse is reviewing the prescription for a client requiring a surgical procedure to remove cataracts. The nurse understands that which collaborative team member will most likely perform the​ client's surgery? A. Ophthalmologist B. Otolaryngologist C. Optometrist D. General surgeon

A Cataracts are a clouding of the eye lens that can be corrected by surgery. An ophthalmologist will perform the surgical procedure to remove the​ client's cataracts. An optometrist is trained to perform eye exams and prescribe corrective lenses to correct ordinary problems with visual acuity. A general surgeon does not remove cataracts. An otolaryngologist is trained to diagnose and treat​ ear, nose, and throat disorders and can perform surgery if necessary.

The nurse is performing a focused health history for a client diagnosed with a herniated disc. Which information is most appropriate for the nurse to include in this​ history? A. Work and recreational activities B. Diet recall C. Ethnicity D. Drug use

A Frequent twisting and lifting are significant risk factors for herniated​ disc, so work and recreational activities should be assessed. Substance​ abuse, diet and​ nutrition, and genetic risk factors common to specific ethnicities can be important components of a health history but are not particularly pertinent to herniated discs.

A client has not been told about dying but anticipates that death is near. In which state of awareness is this client? A. Suspected B. Mutual pretense C. Closed D. Open

A In suspected​ awareness, no one directly tells the client about the​ condition, but the client begins to suspect that death is near. In open​ awareness, the​ client, family, and healthcare team know about the​ client's impending death and discuss it openly. In closed​ awareness, the client is unaware of impending​ death, even though the healthcare team and family are aware. In mutual pretense​ awareness, the​ client, family, and healthcare team all know that the​ client's condition is​ terminal, but no one discusses it.

A client in significant pain from metastatic bone cancer begs the nurse to help him die. How should the nurse respond? A. Euthanasia is illegal, but I'll have the pain management team come to see you immediately B. Let me get the appropriate paperwork for you to sign C. Let's talk about hospice care D. You must have your attorney get a court order and bring it to the hospital first

A It is important for the nurse to address and appropriately manage the​ client's pain, even though active euthanasia is illegal in all 50 states. Signing paperwork or getting a court order will not help the client in this situation. Talking about hospice​ care, though it may be​ appropriate, dismisses the​ client's concern at this moment.

A client with eroding cartilage of the left knee asks the nurse why bruising is absent because bruising was present when they injured their knee a few months ago. Which response by the nurse is​ accurate? A. Cartilage does not contain blood vessels B. Cartilage is eroded because blood vessels are harmed C. This injury damaged the blood vessels D. The cartilage has eroded all blood vessels

A Ligaments and tendons contain blood​ vessels, but cartilage does not. Because of​ this, bruising will be absent with cartilage erosion. The previous injury caused a bruise because either ligaments or tendons were injured. Cartilage erosion does not damage blood vessels. Cartilage does not erode blood vessels. Cartilage does not erode because blood vessels are harmed.

A client is prescribed a nonsteroidal​ anti-inflammatory drug​ (NSAID) for arthritis. Which information should the nurse teach the client about this​ medication? A. Report any gastrointestinal distress to the healthcare provider B. Avoid driving or using machinery while taking this medication C. This medication may cause confusion and hallucinations D. Take this medication with calcium supplements

A NSAIDs can cause gastrointestinal​ distress, which should be reported to the healthcare provider. Calcium supplements do not need to be taken with NSAIDs. Antispasmodics can cause confusion and hallucinations. Driving and machinery use should be restricted when taking an antispasmodic.

The hospital administrator is expanding the palliative care area in a major metropolitan city hospital. When planning for this care area, which member of the healthcare team should the administrator realize is most likely to notice subtle changes in the client's condition and communicate them to the rest of the team? A. The nurse B. The healthcare provider C. The social worker D. The spiritual advisor

A Nurses interact with clients most​ frequently, so they are responsible for communicating changes to the rest of the healthcare and collaborative team. The nurse must be vigilant to these changes and ensure appropriate and timely communication with the healthcare​ provider, family​ members, social​ workers, psychologists, or spiritual advisors.

The nurse is caring for a pediatric client with a terminal illness. When should palliative care be initiated for this child? A. Upon diagnosis with a life-threatening illness B. When officially diagnosed as terminal C. At the time the parents are prepared D. As death approaches

A Palliative care is best initiated when a child is first diagnosed with a​ life-threatening illness. This ensures that appropriate and rational care planning can occur early in the course of the​ child's disease when there​ isn't a crisis. Waiting until the child is diagnosed as terminal or death is imminent may cause conflict down the line. The parents may never decide that they are ready for palliative​ care, which can also cause conflict or poor care planning.

The nurse prepares an educational program on palliative care for a group of oncology nurses. For which age group should the nurse emphasize that palliative care is often neglected? A. Infants B. Older adults C. Children D. Adolescents

A Palliative care tends to be neglected in infants and very young​ children, though they should receive this type of care in the same way that adults do. Nurses are more likely to identify​ children, adolescents,​ adults, and older adults as potential candidates for palliative care.

A nurse is caring for a client who delivered a healthy baby boy by cesarean birth 24 hours ago. The nurse notes that the client correctly uses her arms to help transfer in and out of bed. Which type of exercise is the client demonstrating when performing this activity? A. Isotonic B. Aerobic C. Anaerobic D. Isometric

A The client who uses her arms to aid in transfer is demonstrating isotonic activity. Aerobic​ exercise, such as running or​ hiking, conditions the cardiovascular system. Isometric activity is that in which the joint​ doesn't move but the muscle contracts​ (e.g., wall​ sits). Anaerobic exercise utilizes anaerobic pathways to provide additional energy for a short time because muscles are unable to use enough oxygen from the bloodstream. Sprinting is an example of anaerobic exercise.

The nurse is caring for a client who has experienced a permanent hearing loss. Which referral is most beneficial to assist the client in adjusting to the sensory​ deficit? A. Class for American sign language B. Audiologist C. Otolaryngologist D. Ophthalmologist

A The nurse can obtain a referral for the client to attend a class for American sign language. The class for American sign language will help facilitate an adjustment to the sensory loss and enable the client to communicate. An audiologist or otolaryngologist is not the most beneficial referral to assist the client in adjusting to the sensory deficit. An ophthalmologist treats eye disorders.

The nurse has been asked to serve as a point person for a family with a child who is dying in the PICU. Which function should the nurse prepare to perform in this role? A. Develop a trusting relationship with the parents B. Articulate the family's wishes to the healthcare team C. Organize care before, during and after death D. Address the emotional and informational needs of the family

A The point person will develop a trusting and unique relationship with the parents while their child is in the PICU. The family advocate will help to articulate the​ family's wishes to the healthcare team. The family supporter will address the emotional and informational needs of the family. The​ end-of-life coordinator will organize care​ before, during, and after death.

The nurse is assessing a visually impaired​ client's home environment for safety. Which finding is most concerning for the​ nurse? A. Throw rugs B. Colored rims on dishes C. Telephone with large print dial D. Chairs pushed under the table

A Throw rugs place the client at risk for falling. Colored rims on​ dishes, a telephone with​ large-print dial, and chairs pushed under the table are safe environmental findings for the client who is visually impaired.

The nurse is caring for a client with​ open-angle glaucoma who is concerned about treatment of the condition. Which statement by the nurse most accurately describes the treatment plan for the​ client? A. You will be prescribed medication for treatment B. There currently is no treatment for glaucoma C. The optometrist will discuss the plan for treatment D. Cataract removal will help resolve the glaucoma

A Treatment for glaucoma includes medications to control intraocular pressure and preserve vision in​ open-angle glaucoma. Surgery is also used in the treatment of glaucoma. Cataracts are not related to glaucoma. An ophthalmologist will be included in the treatment plan. An optometrist is trained to perform eye exams and prescribe corrective lenses to correct ordinary problems with visual acuity.

The nurse is caring for an adult client with hyperlipidemia. Which assessment finding is most associated with the​ client's diagnosis? A. Xanthelasma B. Exophthalmos C. Ptosis D. Hordeolum

A Yellow plaques noted on or near the lid margins are referred to as xanthelasma and may indicate high lipid levels. Ptosis is a drooping of an eyelid that is associated with a stroke or neuromuscular disorder. A hordeolum is a sty generally caused by a staphylococcal infection. Exophthalmos is an unusual widening of the lids that is often associated with hyperthyroid conditions.

An adolescent client with a terminal illness wishes to discontinue further treatment. Which action should the nurse take at this time? A. Arrange a meeting between the teen, the parents and the healthcare team B. Explain that there is nothing that can be done until the teen turns 18 C. Contact the healthcare provider for a DNR/DNI order D. Give the consent form to the teen to sign

A ​Teens, especially teens with a chronic or terminal medical​ illness, have a strong desire for autonomy and are cognitively able to participate in their​ care, despite the law not allowing them to make formal decisions until they turn 18. The nurse should arrange a meeting between the​ teen, the​ parents, and the healthcare team to discuss the​ teen's feelings and wishes and the different options available.

The nurse begins an early ambulation routine with a client diagnosed with altered mobility. Which benefit of early ambulation should the nurse explain to the​ client? Select all that​ apply. A. Strengthens muscles B. Improves self-esteem C. Improves skin turgor D. Promotes diarrhea E. Reduces risk of thrombophlebitis

A, B, E Early ambulation decreases the risk of complications of​ inactivity, including​ thrombophlebitis, osteoporosis, muscle​ atrophy, constipation, and urinary incontinence. It also strengthens​ muscles, increases joint​ flexibility, stimulates​ circulation, and improves​ self-esteem. Ambulation does not promote diarrhea or improve skin turgor.

A community health nurse is providing education to a group of adults about the types of exercise that promote health. Which statement will the nurse include in the teaching? Select all that apply A. Isotonic exercises like walking and swimming are also known as dynamic exercises B. An example of an anaerobic exercise is weightlifting C. The talk test may be easier to use than the heart rate calculation for determining effort in aerobic exercise D. Isometric exercise or isolated muscle contraction, creates an increase in blood flow to all parts of the body E. Anaerobic exercises are exercises where the amount of oxygen taken into the body during exercise is greater than that used to perform the activity

A, B, C An example of anaerobic exercise is weightlifting. Isotonic exercises are also known as dynamic exercises. The talk test may be easier to use than the​ heart-rate calculation for determining effort in aerobic exercise. Aerobic​ exercises, not​ anaerobic, are exercises where the amount of oxygen taken into the body during exercise is greater than that used to perform the activity. Isometric exercise causes a slight increase in heart rate and cardiac​ output, but it causes no noticeable increase in blood flow to other parts of the body.

The nurse is caring for a pregnant client who appears to be experiencing discomfort related to the pregnancy. What content should the nurse include in the teaching plan to enhance comfort for this client? Select all that apply. A. Getting enough rest B. Drinking enough water C. Eating a balanced diet D. Refraining from daily exercise E. Taking over-the-counter pain medication

A, B, C The pregnant client who is experiencing discomfort related to pregnancy should be taught the importance of adequate​ nutrition, hydration, and sleep and rest. The pregnant client should not be encouraged to take​ over-the-counter pain medication unless directed by the healthcare provider. The nurse would provide tips on daily​ activity, but the pregnant client would not need to refrain from daily exercise.

A client​ states, "My healthcare provider says my problem with mobility is with my connective tissues. What are connective​ tissues?" Which structure should the nurse include in the​ response? (Select all that​ apply.) A. Cartilage B. Tendons C. Ligaments D. Muscle E. Bones

A, B, C ​Tendons, cartilage, and ligaments are all connective tissues. Tendons connect bone to muscle to cause movement. Cartilage is flexible connective tissue and is less flexible than muscle but not as stiff as bone. Ligaments connect bones to other bones to form a joint and serve to strengthen and stabilize the joint. Bones provide the framework for the skeletal structure. Muscles contain fibers that move the bones.

The nurse is planning care for a client with a terminal illness who is nearing the end of life. Which action should the nurse take to ensure the client receives the highest quality of care? Select all that apply. A. Stay with the client until intravenous pain medications takes effect B. Offer family members a quiet area to express emotions C. Remind the healthcare provider to discuss symptom management with the client and family D. Explain interventions to the client and family before performing E. Suggest that family members return home to get rest

A, B, C, D Nurses play an important role in providing quality​ end-of-life care to clients and their families by facilitating communication among​ clients, families, and​ providers; providing emotional​ support; and treating clients and their families with respect. The nurse should offer family members a quiet area to express​ emotions, explain interventions before performing​ them, stay with the client until pain medication takes​ effect, and remind the healthcare provider to talk with the family and client about symptom management. While it is important for family members to receive adequate​ rest, the nurse would not suggest they return home to do this. If rest is​ needed, the family can be provided with a quiet place to recharge.

A client is complaining of difficulty hearing. Which medications on the​ client's home medication list would alert the nurse of the potential risk for hearing​ impairment? Select all that​ apply. A. Alkylating agent B. Salicylate C. Loop diuretic D. Aminoglycoside E. Angiotensin-converting enzyme inhibitor

A, B, C, D Some medications can cause hearing disorders.​ Aminoglycosides, alkylating​ agents, loop​ diuretics, and salicylates can all cause hearing impairment.​ Angiotensin-converting enzyme inhibitors are not associated with hearing loss.

A client reports pain as being an 8 on a scale from 1 to 10. Which finding should the nurse expect when assessing this client? Select all that apply. A. Posturing B. Verbal complaints C. Abnormal gait D. Facial grimaces E. Fever F. Guarding

A, B, C, D, F (not fever)

The family of a client with mobility difficulties asks the​ nurse, "What​ age-related changes to the musculoskeletal system should we expect our father might​ experience?" Which change should the nurse include in the​ response? Select all that apply A. Flexed position of hips B. Ligament tears C. Increased bone density D. Decreased joint fluid E. Muscle fiber atrophy

A, B, D, E Changes in the musculoskeletal system that occur with aging include tears in​ ligaments, atrophy of muscle​ fibers, decreased joint​ fluid, and a flexed position of the hips. Bone density decreases with aging.

A nurse is caring for a client who is hospitalized because of a fractured femur. The client tells the nurse that it is difficult to get any sleep while in the hospital. What action should the nurse take to minimize environmental stimuli in the hospital environment? Select all that apply. A. Placing the client in a single-bed room when possible B. Performing only essential activities in the client's room during sleeping hours C. Adjusting window coverings to block outside lights during the day and night D. Minimizing noise from staff interactions E. Keeping the client's door closed

A, B, D, E To reduce environmental stimuli in the hospital​ environment, the nurse should do all the stated​ actions, except adjust window coverings to block outside lights during the day and night. The window coverings should be adjusted only at​ night; during the​ day, the window coverings should be left open to let in natural light.

A client asks the home care nurse about the difference between acute and chronic illness. Which information does the nurse give the client about characteristics of chronic illness? Select all that apply A. Chronic illness can have remissions B. Chronic illness can remain for life C. Chronic illness does not have exacerbations D. Chronic illness usually lasts 6 months or more E. Chronic illness has a slow onset

A, B, D, E Chronic illness can have both remissions and exacerbations. It usually lasts 6 months or more and can remain for life. It has a slow onset.

The client asks the nurse about biofield therapies to help with chronic pain. Which information should the nurse include about the use of biofield therapies? Select all that apply A. This complementary alternative therapy has no side effects or interactions with other treatments B. They balance the energy fields in the body that are disrupted by physiologic imbalances C. Biofield therapies have been around for quite a long time, but they really have no value other than people thinking that they work. D. There is a large repository of evidence that indicates the clinical efficacy of biofield therapy in effectively reducing pain E. Evidence supports the use of these therapies to help people deal with painful experiences

A, B, E Evidence supports the use of these therapies to help people deal with painful​ experiences; they have no side​ effects, nor do they interact with other​ treatments; and they balance the energy fields in the body that are disrupted by physiologic imbalances.​ However, evidence does not yet support clinical efficacy. The statement that they really have no value is a subjective opinion and should not be included in the information provided to the client.

The mother reports that their​ 9-month-old infant has had a​ fever, is​ irritable, and​ "keeps tugging on her​ ear." Which equipment should the nurse gather while preparing for the​ exam? Select all that​ apply. A. Otoscope B. Thermometer C. Tuning fork D. Ophthalmoscope E. Tympanogram

A, B, E For the assessment of an infant client with symptoms related to the​ ear, a nurse would gather a​ tympanogram, an​ otoscope, and a thermometer. A thermometer would be appropriate to assess the​ fever, and a tympanogram will measure the pressure inside the middle ear. The client is exhibiting signs of an ear​ infection, so this would be an important piece of equipment for the assessment. An otoscope is used to visualize the ear canal for discharge and the condition of the tympanic membrane and would be appropriate for this client. An ophthalmoscope is used to assess​ disorders, complaints, and injuries of the eyes and would not be needed for this client. A tuning fork is used for assessment of tactile and auditory function and would not be appropriate for this client.

The nurse reviews data collected during an assessment of a terminally ill client. Which nursing diagnosis should the nurse select as this client nears death? Select all that apply A. Comfort, impaired B. Sleep pattern, disturbed C. Fluid volume: deficient, risk for D. Nutrition, imbalanced: less than body requirements E. Tissue integrity, impaired

A, B, E The main objective for care as a patient nears death is comfort.​ Therefore, nursing diagnoses appropriate for a client nearing death include ​Comfort, Impaired; Tissue​ Integrity, Impaired​; and Sleep​ Pattern, Disturbed. While a client nearing death will have altered nutrition and fluid volume​ deficit, these would be considered manifestations and not necessarily client problems that the nurse would address at this stage.​ (NANDA-I ©​ 2014)

The nurse is testing a​ client's six cardinal fields of vision. Which cranial nerves is the nurse​ assessing? Select all that​ apply. A. Cranial nerve III (oculomotor) B. Cranial nerve IV (trochlear) C. Cranial nerve X (vagus) D. Cranial nerve II (optic) E. Cranial nerve VI (abducens)

A, B, E The nurse who is testing a​ client's six cardinal fields of gaze is assessing cranial nerves​ IV, VI, and​ III, which are involved in oculomotor movement. Cranial nerves II and X are not involved in oculomotor movement.

The nurse notes that several terminally ill pediatric clients do not have advanced care planning. The nurse should recognize which barriers are the most common ones that hinder the completion of this planning? Select all that apply A. Unrealistic parent expectations B. Differences in understanding of the child's prognosis between clinicians and parents C. Lack of financial means D. Lack of parent readiness to discuss the need for palliative care E. Lack of formal pediatric palliative care training by the healthcare provider

A, B, E The top three barriers to advanced care planning for children are unrealistic parental​ expectations, differences in understanding of the​ child's prognosis between clinicians and​ parents, and lack of parent readiness to discuss the need for palliative care. Lack of financial means and lack of formal pediatric palliative care training are other barriers for care but are not among the top three.

The nurse is developing an educational program regarding exercise for clients with chronic illnesses. What information should the nurse include? Select all that apply. A. Regular exercise can help decrease lipid levels B. Aerobic exercise decreases glycemic control C. Regular exercise improves cardiovascular health and decreases risk of developing heart disease, hypertension, stroke, and heart failure D. Exercise increases joint stability and range of motion E. Those with COPD and asthma should not participate in exercise that increases respiratory rate due to the risk of bronchospasms

A, C, D Regular exercise does decrease cardiovascular risk and decreases risk for developing heart​ disease, hypertension,​ stroke, and heart failure. Exercise also increases joint stability and range of motion. Regular exercise enhances the gut​ microbiome, which improves lipid and carbohydrate metabolism. Those with COPD and asthma should participate in aerobic exercise. Aerobic exercise​ increases, not​ decreases, glycemic control.

The nurse taught a client about ways to prevent alterations in mobility. Which client behavior indicates that the teaching has been​ effective? Select all that​ apply. A. Client consumes fresh fruits and vegetables every day B. Client smokes a half pack of cigarettes per day C. Client walks every day for 30 minutes D. Client drinks milk with every meal E. Client applies ice to inflamed joints twice a day

A, C, D The best way to avoid an alteration in mobility is to prevent the development of musculoskeletal disorders. Prevention strategies include good​ nutrition, adequate calcium​ intake, and regular exercise. Drinking​ milk, walking, and consuming fresh produce indicate actions to prevent the development of musculoskeletal disorders. Smoking is not a healthy activity. Applying ice to inflamed joints indicates an alteration in mobility already exists.

A nurse is caring for a client with a sleep disorder. Which question should the nurse ask about the current problem? Select all that apply A. When did you discomfort start? B. Have you had past experiences that affect the way you view this discomfort? C. Which activities make the discomfort better or worse? D. How would you describe your discomfort? E. How long have you had this discomfort?

A, C, D, E Asking the client about past experiences related to how the client views the current problem would be a question the nurse would ask about health​ history, not the current problem. All other statements are correct.

The spouse of a terminally ill client who has just passed away sits at the bedside, holds the client's hand and cries softly. What action should the nurse take to support the spouse at this time? Select all that apply. A. Ask if the spouse would like to talk with someone about the client's death B. Remind the spouse that the client will need to be moved in a short while C. Ask if there is a particular funeral home that should be contacted D. Ask if there is anyone that should be contacted at this time E. Provide the spouse with water and tissues

A, C, D, E Considerations for the family at the end of life include assisting the family to cope with the​ client's health status. Interventions should focus on providing the family with emotional support and referring the family to funeral​ homes, grief​ counseling, and support groups if appropriate. The nurse should provide the spouse with water and tissues to help meet physical needs. Asking if there is anyone that should be contacted helps to meet the​ spouse's psychosocial needs. Asking about a funeral home or if the spouse would like to talk with someone about the​ client's death helps meet the​ spouse's grieving needs. Reminding the spouse that the client will need to be moved does not support any of the​ spouse's needs at this time.

The nurse cares for a client who is approaching the end of life. Which sign indicates that the client is nearing death? Select all that apply A. Increase in confusion B. Periods of intense hunger C. Restlessness D. Increase in sleeping E. Apneic periods

A, C, D, E Signs that indicate a person is nearing death include increased​ confusion, increased periods of​ sleep, apneic​ periods, and restlessness. There is a​ decreased, not an​ increased, need for food at this time.

The nurse is conducting a health interview to determine a​ client's mobility status. Which lifestyle behavior is most appropriate for the nurse to​ assess? Select all that​ apply. A. Primarily working on a computer B. Living alone C. Smoking habits D. Taking no medications E. Long distance running

A, C, E A​ client's lifestyle affects mobility status. Smoking is a negative behavior that adversely affects many aspects of an​ individual's health. Physical activity such as​ long-distance running can affect the​ joints, ligaments, and cartilage. Computer work is a sedentary activity that could potentiate the development of musculoskeletal disorders. Living alone and not taking any medication would not adversely affect an​ individual's musculoskeletal or mobility status.

A nurse is providing teaching for a client diagnosed with an olfactory deficit. Which interventions specifically related to an olfactory deficit will the nurse include in the​ teaching? Select all that​ apply. A. Review home cleaning supplies with the client B. Darken the room with shades C. Set up schedule for changing the batteries in carbon monoxide detectors D. Check the expiration date on food E. Recommend the client purchase smoke detectors with flashing lights

A, D The nurse caring for the client with an olfactory deficit will instruct the client to check the expiration dates on the food and review the safety of cleaning supplies. The client may not detect spoiled food products or recognize toxic chemical odors from cleaning supplies. Darkening the rooms with shades is appropriate for a client at risk for sensory overload. Flashing smoke detectors are beneficial for someone with a hearing deficit. Carbon dioxide is an odorless​ gas, so changing the batteries in the carbon monoxide detector does not specifically address an olfactory deficit.

The nurse is caring for a client who is in pain because of a back spasm. Which independent nursing intervention should the nurse use for this client? Select all that apply A. Applying heat or cold as appropriate B. Ordering physical therapy for the client C. Administering analgesics as ordered D. Positioning the client to promote comfort E. Providing distractions

A, D, E Independent nursing interventions for a client in discomfort include applying heat or cold as​ appropriate, providing​ distractions, and positioning the client to promote comfort. Administering analgesics and ordering physical therapy are collaborative interventions.

The nurse is developing a plan of care for a client experiencing an alteration in mobility. Which objective is most appropriate for the nurse to​ include? Select all that​ apply. A. Prevent injury B. Promote healthy relationships C. Recommend immunizations D. Promote comfort E. Promote education

A, D, E Independent nursing interventions for the client with an alteration in mobility focus on promoting education and comfort as well as preventing injury. Although promoting healthy relationships and recommending immunizations may be important for all​ clients, these nursing interventions are not specifically important to clients with alterations in mobility.

A pregnant client presents with back pain. Which condition is most likely the cause of this​ pain? Select all that​ apply. A. Stretched abdominal muscles B. Bulging discs C. Improper lifting D. Strain from the growing uterus and fetus E. Instability of the pelvis

A, D, E ​Sixty-two percent of women report back pain during pregnancy. This pain is generally caused by strain on the back from the growing uterus and​ fetus, which causes postural​ changes; abdominal weakness from stretched abdominal​ muscles; and hormonal​ changes, which loosen the ligaments in the joints of the pelvis. Bulging discs and improper lifting do not normally cause back pain in pregnancy.

The nurse is monitoring a client who has been using NSAIDs for treatment of chronic back pain for several months. The nurse should instruct the client to take the medicine with food and a full glass of water to address which common side effect? A. Pruritis B. Gastric distress C. Constipation D. Sedation

B Gastric distress is a common side effect of NSAIDS. It can be potentially prevented by taking the medication with food and a full glass of water.​ Pruritus, sedation, and constipation are all side effects of opioids.

The nurse uses Maslow's hierarchy of needs to help identify a client's care issues. What should the nurse recall as being the highest level of this hierarchy? A. Love and belonging B. Self esteem C. Self Actualization D. Safety and Security

B Self actualization According to​ Maslow's hierarchy of​ needs, the highest level of basic human need is​ self-actualization. The other answer choices are levels of the​ hierarchy; however, they are incorrect choices.

A client is transferred from the critical care area to a general medical unit. What action should the nurse take first to help promote sleep? A. Ask the family to decrease the number of visits since the client has improved and needs to rest B. Assess the client's individual circadian rhythm C. Contact the healthcare provider to obtain an order for a hypnotic/sedative D. Encourage the client to take naps when able, to decrease the impact of the sleep disturbance.

B

Which is the major cause of sensorineural hearing deficit? A. Impacted cerumen in the ear canal B. Noise exposure C. Obstruction of the external ear canal D. Edema in the ear canal

B A major cause of sensorineural hearing deficit is damage to the hair cells of the organ of Corti from noise exposure. The most common cause of conductive hearing loss is obstruction of the external ear canal. Impacted cerumen and edema of the canal lining also cause conductive hearing loss.

Which is the greatest risk factor associated with hearing​ impairment? A. Gender B. Age C. Race D. Occupation

B Age is one of the greatest risk factors associated with hearing impairment. Caucasians are twice as likely as African Americans to have hearing loss. Hispanics are less likely than​ non-Hispanics to experience difficulty with hearing. Individuals who are consistently exposed to loud noises on their job are at greater risk of developing hearing impairment. A relation between gender and hearing impairment has not been identified.

A client with gastric cancer receives morphine every 3 hours but is still experiencing pain, despite the last dose 1.5 hours ago. What should the nurse do? A. Provide a gentle massage to help relieve discomfort until the next dose B. Administer a fentanyl lozenge for breakthrough pain per a standing order C. Administer the next dose of morphine a little early D. Return in an hour to administer the next dose of morphine

B Breakthrough pain is a common problem in clients with severe cancer pain. Clients will need a continuous medication for pain in addition to a​ fast-acting medication for breakthrough pain. A massage may not be effective against cancer breakthrough​ pain, and​ it's inappropriate to make the client wait another hour before giving another dose of pain medicine. The nurse should not administer the morphine earlier than it is ordered.

A nurse is caring for an older adult who is hospitalized due to a fractured hip secondary to a ground-level fall. The nurse is assisting the client with oral care when the client asks the nurse, "Why am I having more issues with cavities? I always brush and floss my teeth." Which is the correct response by the nurse? A. This is a normal finding with aging because gum disease causes tooth decay B. This can happen as you age because your teeth lose enamel, making them more susceptible to damage and cavity formation C. This is not an abnormal finding with aging because you brush and floss regularly D. This can happen with aging because saliva production increases, making teeth more susceptible to cavity formation

B As a normal process of​ aging, the teeth become more susceptible to damage and decay due to the thinning of the tooth enamel. The other answer choices include responses that have incorrect​ information: saliva production does not increase​ (it decreases) with​ age; good oral hygiene​ (brushing and flossing​ regularly) would decrease the likelihood of cavity formation even with​ aging; and periodontal disease​ (gum disease) causes the loss of​ teeth, not dental caries.

The nurse assessing the lacrimal glands of a newborn observes excessive tearing in the right eye. Which most accurately describes the etiology of the assessment​ finding? A. Allergies B. Blockage of nasolacrimal duct C. Neurologic disorder D. Infection

B Excessive tearing noted during the assessment of the lacrimal gland is indicative of a blockage of the nasolacrimal duct. Tenderness and drainage are findings associated with infection. Excessive tearing is not a finding associated with allergies or a neurological disorder in a newborn.

The nurse is providing care for a child who is experiencing discomfort due to intermittent urinary catheterizations. Which should the nurse encourage the family to do during the procedure to most appropriately enhance comfort for the child? A. Hold the child while the procedure is being performed. B. Offer a distraction during the procedure C. Explain the procedure each time before it is performed to ensure understanding D. Offer the child a treat such as a sticker or a small toy after the procedure

B For the child experiencing discomfort during a procedure such as​ this, it would be most appropriate to encourage the parents to distract the child. Holding the child would likely complicate completion of the procedure and would not be the best option. While offering the child a treat or small toy after the procedure may help encourage them to cooperate with the​ procedure, it would not be the most appropriate option to enhance comfort. Explaining procedures can help to decrease​ anxiety, but doing so each time may not necessarily enhance comfort.

Which type of exercise should the nurse implement to maintain the strength of a limb with an immobilized​ joint? A. Range of motion exercise B. Isometric exercise C. Resistive exercise D. Passive exercise

B Isometric exercise is used to maintain strength when a joint is immobilized. It is performed by contracting a specific muscle group against another muscle group or immovable object. Resistive exercise is an active exercise where the client works against resistance to increase muscle strength.​ Range-of-motion exercises help maintain joint mobility during periods of restricted activity. Passive exercises are performed by a physical therapist or nurse for the client.

The nurse is providing visual screenings for​ school-age children. The nurse understands that which visual problem is most commonly diagnosed in​ school-age children? A. Accommodation B. Convergence C. Corneal light reflex D. Strabismus

B Problems with convergence are usually diagnosed in​ school-age children when they have difficulty reading and may be interpreted as a learning disability rather than a visual problem. Problems with​ strabismus, accommodation, and corneal light reflex are not commonly diagnosed in​ school-age children.

A nurse is performing an oral health nursing assessment on an adult client/ The nurse notes the presence of pyorrhea. Which does this finding indicate? A. The presence of glossitis B. The presence of periodontal disease C. The presence of stomatitis D. The presence of fungal disease

B Pyorrhea is the presence of pus at the gums when pressed. This is a manifestation of periodontal​ disease, not fungal disease. Stomatitis is the inflammation of the​ mouth, whereas glossitis is the inflammation of the tongue.

The nurse observes a client who is approaching end of life. Which clinical finding correlates with a decreasing blood pressure? A. Rapid heart rate B. Increasing confusion C. Warm, clammy skin D. Decreasing body temperature

B Signs and symptoms of hypotension include​ confusion, cool​ skin, irregular​ pulse, blurry​ vision, and dizziness. Rapid heart​ rate, decreasing body​ temperature, and clammy skin are not indicative of hypotension.

A nurse is caring for a client who is postoperative from an open appendectomy. The client uses an overhead trapeze bar to transfer position in bed. Which type of exercise is demonstrated with this action? A. Isokinetic B. Isotonic C. Isodynamic D. Isometric

B The client who uses an overhead trapeze bar to aid in transfer is demonstrating isotonic activity. Isometric activity is when the joint​ doesn't move but the muscle contracts​ (e.g., wall​ sits). Isokinetic exercise is when the muscle contracts against resistance. There are no exercises called isodynamic.

Which diagnostic test should the nurse review to determine if a client's discomfort is caused by an infection? A. Liver function studies B. White blood cell count C. Hematocrit and hemoglobin D. Urine analysis

B The white blood cell count would be the best study to use to determine if the cause of pain may be due to infection. A urine​ analysis, liver function​ studies, and hematocrit and hemoglobin can provide information about other potential​ issues, but are not the best to determine infection.

A nurse is caring for a newborn with a congenital malformation of the oral soft palate. Which problem will this client be at risk for if the malformation is not repaired? Select all that apply A. Breathing problems because the soft palate includes cilia, which keep foreign bodies out of the trachea B. Swallowing problems because the soft palate includes the uvula, which aids in swallowing C. Swallowing problems because the soft palate rises during swallowing to direct food into the esophagus D. Breathing problems because the soft palate stents the airway open E. Breathing problems because the soft palate closes off the trachea when swallowing

B, C Alterations of the soft palate may lead to swallowing​ problems, increasing the risk of aspiration. This is because the soft palate rises during swallowing to direct food into the esophagus. The soft palate ends at the back of the mouth at a fold called the uvula. The pressure of the bolus against the uvula causes a​ reflex, and the soft palate rises in order to close off the nasopharynx to prevent food from entering into the nasal cavity. Congenital soft palate malformations do not cause problems with the act of external respiration. The soft palate does not contain cilia.

The nurse wants to help with a terminally ill client's discomfort. Which complementary and alternative therapy should the nurse consider for this client? Select all that apply A. Yoga B. Simple touch C. Massage D. Biofeedback E. Acupressure

B, C The interventions of massage and simple touch have been found effective to reduce pain and improve mood in the client nearing the end of life.​ Yoga, biofeedback, and acupressure are not identified as complementary and alternative therapies used during​ end-of-life nursing care.

The nurse is reviewing the chart of an older adult client. Which sensory changes does the nurse anticipate have​ occurred? Select all that​ apply. A. Increased sense of taste B. Impaired sense of smell C. Decreased sense of taste D. Decreased sense of hearing E. Increased tactile sensation

B, C, D The effects of aging on sensory perception include a decreased sense of​ hearing, a decreased sense of​ taste, and an impaired sense of smell. Changes in tactile sensations are not associated with aging.

The nurse is caring for a client who is experiencing discomfort from the nasogastric tube that is necessary for gastric suctioning. What relaxation technique should the nurse teach the client to aid in client comfort? Select all that apply. A. Laughter B. Guided imagery C. Movement techniques D. Muscle relaxation E. Breathing exercises

B, C, D, E (everything but laughter) Relaxation techniques used to aid in client comfort include movement​ techniques, breathing​ exercises, muscle​ relaxation, and guided imagery. Laughter is​ beneficial; however, it promotes psychosocial​ well-being, not relaxation.

The nurse is caring for a client at risk for sensory overload. Which nursing interventions will the nurse implement? Select all that apply. A. Providing books and newspapers B. Providing earphones for the client C. Scheduling clustered care D. Explaining environmental sounds E. Shading the windows

B, C, D, E The interventions the nurse will implement to prevent sensory overload include shading the​ windows, scheduling cluster​ care, explaining environmental​ sounds, and providing earphones for the client. Providing books and newspapers is an intervention for a client experiencing a sensory​ deficit, not sensory overload.

The nurse is preparing to assess a​ client's sensory function. Which neurosensory assessments will the nurse​ include? Select all that​ apply. A. Administering the Romberg test B. Testing kinesthesia C. Distinguishing sharp from dull D. Hot and cold sensation E. Identification of vibration

B, C, D, E The neurosensory assessments included in the assessment of sensory function are testing​ kinesthesia, distinguishing between hot and cold​ sensation, identification of​ vibration, and distinguishing between sharp and dull sensations. The Romberg test is not used to not evaluate sensory perception

The family of an older adult client tells the nurse that they want their mother to remain as active as possible for as long as possible. Which instruction should the nurse provide the​ family? Select all that​ apply. A. Adequate rest and sleep B. Regular exercise C. Good nutritional intake D. Daily stretching E. Adequate calcium intake

B, C, E The best way to avoid an alteration in mobility is to prevent the development of musculoskeletal disorders. Prevention strategies include good​ nutrition, adequate calcium​ intake, and regular exercise. Daily stretching and adequate rest and sleep are not specific strategies to prevent the development of musculoskeletal status disorders.

A client is diagnosed with several fractures of the axial skeleton. Which bone fracture should the nurse anticipate providing care for in this​ client? Select all that​ apply. A. Lower leg B. Vertebra C. Arm D. Ribs E. Femur

B, D The axial skeleton is made up of the​ ribs, sternum, vertebral​ column, and skull. The appendicular skeleton is made up of the pectoral​ girdles, upper​ limbs, pelvic​ girdle, and lower limbs.

The nurse is reviewing the physiology of sensory perception. Which sensory perceptions are associated with internal​ stimuli? Select all that​ apply. A. Visual B. Gustatory C. Olfactory D. Stereognosis E. Visceral

B, D, E The sensory perceptions associated with internal stimuli include gustatory​ (ability to​ taste), visceral​ (stimuli from a large​ organ), and stereognosis​ (the ability to perceive and understand objects through​ touch). Visual data​ (obtained from​ sight) and olfactory data​ (sense of​ smell) are associated with external stimuli.

Which factor influences the expression of pain regardless of culture and is important for the nurse to consider for all clients? Select all that apply A. Underlying health of the client B. Client's skills at reporting pain and discomfort C. Cues from client's family or significant others D. Client's level of trust in the healthcare provider E. Client's ability to cope with pain

B, D, E The​ client's ability to cope with​ pain, skills at reporting pain and​ discomfort, and level of trust in the healthcare provider are important factors to consider for all​ clients, regardless of culture. Underlying health issues and cues from significant others are not vital to understanding how clients express pain.

A client is requesting to sign a document that designates someone to make healthcare decisions in case they are not able to do it. Which document should the nurse recommend to this client? A. DNR order B. Durable power of attorney C. Healthcare proxy D. Living will

C A healthcare proxy designates an individual to make healthcare decisions in case the client is not able. A durable power of attorney allows the selected individual to make legal decision for the client. A living will describes the​ client's treatment preferences for​ life-prolonging treatment. A DNR order is also known as a​ do-not-resuscitate order and allows the healthcare team to withhold​ life-saving measures in the event of a cardiac or respiratory arrest.

A client who is recovering from a spontaneous arm fracture is prescribed a calcium supplement. Which information is most appropriate for the nurse to explain the relationship between calcium and bone​ strength? A. The thyroid gland works to make calcium B. Calcium fills in the spaces caused by the fracture C. The body will break down bone if calcium levels are low D. Calcium helps break down bone tissue

C Bone resorption is the process where the bone is broken down and minerals are released into the bloodstream. Resorption occurs when the minerals are needed for other body functions. When calcium levels are​ low, the parathyroid hormone is released to cause osteoclast action or activity that breaks down bone tissue. The breakdown increases blood calcium levels. If calcium levels in the blood are​ elevated, calcitonin is​ released, which stops osteoclast activity and increases the mineralization of bones. Calcium does not break down bone tissue. The thyroid gland does not make calcium. Calcium does not fill in the spaces caused by the fracture.

The nurse is providing care to a client at a sleep disorder clinic. Which assessment finding does the nurse expect during REM sleep? A. Tachycardia B. Decrease in eye movement C. Decrease in voluntary muscle tone D. Tachypnea

C During REM​ sleep, the nurse would expect the client to have a decrease in voluntary muscle tone. A decrease in heart rate and respiratory rate is also​ expected, not tachycardia or tachypnea. An​ increase, not a​ decrease, in eye movement is expected during REM sleep.

A nurse is caring for a client diagnosed with hypertension. The client's healthcare provider suggests the client begin a regular exercise schedule. The client asks the nurse, "The healthcare provider said that exercise benefits the brain, but I don't see how it can." Which is the correct response by the nurse? A. Exercise increases brain oxygen, resulting in an increase in the number of neurons in the brain B. Exercise increases oxygen flow to the brain, increasing the number of brain cells C. Exercise leads to increased oxygen to the brain, which improves the brain's thinking abilities D. Exercise opens the cerebral arteries which improves short term memory

C Exercise increases ventilation and oxygen​ intake, improving gas​ exchange, eliminating more​ toxins, and increasing oxygen to the​ brain, thus enhancing the​ brain's cognitive​ (thinking) function.​ Short-term memory is not improved with​ exercise, and the number of brain cells and neurons does not increase with exercise and increased oxygen flow.

Which assistive device should the nurse expect to be ordered for an older client who is unsteady when​ ambulating? A. Cane B. Lofstrand crutches C. Walker D. Axillary crutches

C For​ older, unsteady​ adults, the best assistive device for ambulation is a walker. A walker provides maximum stability for the client. Crutches can be unsteady for older adults to​ use, and a cane is used only when a minimum amount of support is required.

During a preschool screening the caregiver of a 3 year-old child asks the nurse how many hours of sleep the child requires each night. Which response by the nurse is appropriate? A. A 3 year-old child needs 7 to 9 hours of sleep each night B. A 3 year-old child needs 14 to 17 hours of sleep each night C. A 3 year-old needs 10 to 13 hours of sleep each night D. A 3 year-old child needs 8 to 10 hours of sleep each night

C Growing children require more sleep than adults. The​ 3-year-old child requires 10 to 13 hours of sleep each night. Infants need 14 to 17 hours of sleep in 24 hours. Adolescents require 8 to 10 hours of sleep each night. Adults need 7 to 9 hours of sleep each night.

The nurse is providing care to a client who is approaching the end of life. Which intervention most directly helps to promote psychosocial comfort? A. Reviewing advance directives to ensure end-of-life care desires B. Removing all tubes and medical monitoring devices C. Offering to arrange a visit from a spiritual leader or loved ones D. Providing adequate pain relief with pharmacologic agents

C Offering to arrange a visit by a spiritual leader or loved ones can help to enhance psychosocial comfort.​ Pain-relief medications can help to enhance physical comfort. Reviewing advance directives can help to ensure that​ end-of-life decisions are honored. Removing all tubes and medical devices will not necessarily enhance psychosocial comfort.

A client with altered mobility is unable to bear weight on their wrists. Which type of assistive device should the nurse expect to be prescribed for the​ client? A. Lofstrand crutches B. Axillary crutches C. Platform crutches D. Cane

C Platform crutches are used for clients unable to bear weight on their wrists. When using axillary​ crutches, the body weight is supported by the wrists. Lofstrand crutches use a forearm piece for​ stability, but the weight is still supported by the wrists. A cane is less supportive than​ crutches, and the body weight is still supported on the wrist.

A client with altered mobility reports gastric upset. Which medication should the nurse suspect is causing the​ client's symptoms? A. Bone growth stimulator B. Direct-acting antispasmodic C. Nonsteroidal anti-inflammatory drug (NSAID) D. Skeletal muscle relaxant

C Side effects of nonsteroidal​ anti-inflammatory drugs​ (NSAIDs) include gastric upset and bleeding. Central nervous system​ (CNS) effects are commonly caused by skeletal muscle relaxants. Bone growth stimulators may cause renal or liver impairment.​ Direct-acting antispasmodics may cause​ angina, difficulty​ breathing, and muscle weakness.

A nurse is providing discharge instructions for a client who has been diagnosed with angina. The nurse educates the client on aerobic exercise, as per the healthcare provider's orders. The client asks the nurse, "How will I know when I am working out adequately?" Which is the correct response from the nurse? A. When you are performing aerobic exercise, you shouldn't be able to carry on a conversation B. The goal for aerobic exercise is to maintain target heart rate within 40-55% of maximum heart rate C. When you are performing aerobic exercise, you should be able to carry on a conversation without labored breathing D. The goal for aerobic exercise is to maintain target heart rate within 60-85% of resting heart rate

C The goal for aerobic exercise is to maintain a target heart rate within 60-​85% of the maximum heart​ rate, not 60-​85% of the resting heart rate or 40-​55% of the maximum heart rate.​ However, because heart rates vary among​ individuals, the talk test​ (the ability to carry on a conversation while​ exercising) is being used to replace the target heart rate goal and is the best answer response.

The nurse is caring for an older adult who has experienced a loss of vision. Which will the nurse implement into the plan of​ care? A. Decreasing background noises before communicating B. Using finger spelling as appropriate C. Announcing presence when entering the room D. Speaking at a moderate rate

C The nurse will announce their presence when entering the room as well as identify themselves by name so the client is aware of their presence. Speaking at a moderate​ rate, fingerspelling, and decreasing background noises before communicating are interventions for the hearing impaired.

The nurse is caring for an older adult client that requires a visual aid for reading. Based on the​ client's need, which visual change has the client​ experienced? A. Myopia B. Nearsightedness C. Presbyopia D. Hyperopia

C The older adult client that requires a visual aid for reading is experiencing presbyopia. Presbyopia is an impairment in near vision resulting from a loss of elasticity of the lens related to aging. Myopia is a change in distant vision. Hyperopia is an impairment of near vision in younger people. Nearsightedness is the term used to describe myopia.

A new mother who gained 55 pounds during her pregnancy is seen by the nurse-midwife for a 6-week follow-up after her delivery. The mother reports that she has 30 pounds of "baby weight" to lose. The mother tells the nurse that she is having trouble sleeping and asks why this is occurring because her infant is now sleeping through the night. Which response by the nurse is the most appropriate? A. Once you become a parent, you have to get used to sleepless nights B. Hormonal shifts are causing insomnia. I will prescribe you a sedative C. Your lack of weight loss may be the problem. Let's discuss a plan for this D. You must be worried about the baby's health. I will refer you to a counselor

C Weight gain has been associated with reduced total sleep​ time, interrupted​ sleep, and earlier awakening. It is appropriate for the nurse and the midwife to discuss a plan for this new mother to lose weight. Hormonal shifts can cause alterations in sleep​ patterns/insomnia in a new mother 6 weeks postpartum.​ Sedation, however, is not the appropriate treatment. There is no evidence to support that the client is worried about her​ baby's health. Becoming a parent does not automatically cause sleep disturbances.

A nurse is caring for an older adult in the hospital and is providing the client with instruction on proper oral care. Which instructions will the nurse include in the teaching? A. Use an alcohol-based mouth rinse after brushing B. Use a circular technique when brushing C. Use plain water to rinse the mouth after meals D. Use mineral oil as a lip moisturizer if needed

C When teaching the older adult about oral​ care, the nurse should instruct the client to rinse the mouth with plain water after meals to help remove residual food debris. Circular brushing techniques are not recommended. Use of mineral oil as a lip moisturizer is not recommended because aspiration of this may cause pneumonia.​ Alcohol-based mouth rinses are not recommended because these can irritate oral tissues.

The nurse is caring for a client with visual impairment. The nurse understands that which comorbidity is associated with visual deficits? Select all that apply. A. Dizziness B. Convergence C. Stroke D. Hypertension E. Diabetes

C, D, E The comorbidities associated with visual deficits include​ diabetes, hypertension, and stroke. Dizziness is associated with hearing loss. Convergence is the ability of the eyes to turn inward together and is a normal finding.

The nurse admitted a client suspected of having nerve problems. Which diagnostic test should the nurse expect the​ client's healthcare provider to​ order? Select all that​ apply. A. Peripheral bone density B. Dual-energy x-ray absorptiometry C. Electromyography D. Dual-photon absorptiometry E. Nerve conduction studies

C, E Electrical studies are used to determine electrical activity of the muscles or identify nerve compression and include electromyography and nerve conduction studies. Diagnostic tests that produce an image include peripheral bone​ density, dual-photon​ absorptiometry, and​ dual-energy x-ray absorptiometry.

The nurse notices that a client who is dying is refusing to visit with family. What should the nurse consider this client is demonstrating? A. Unresolved family problems B. Major depression C. Dysfunctional grieving D. Anticipatory grief

D Anticipatory grief can result in a dying person distancing themselves from family or friends in an attempt to minimize the pain of loss. This is not a sign of unresolved family​ problems, dysfunctional​ grieving, or major depression.

A terminally ill client has a dry mouth and refuses to take any food or fluids by mouth. Which intervention should the nurse implement for this client? A. Place a nasogastric tube to administer artificial feeding B. Feed the client ice chips or popsicles C. Administer intravenous fluids to maintain hydration level D. Apply moist sponges to the mouth and lips

D Application of moist sponges to the mouth and lips can help relieve dry mouth in clients who are refusing to eat or drink. Administration of intravenous fluids or a nasogastric tube may be possible interventions but require an order from the healthcare provider and may be refused by the client or the healthcare proxy. Attempting to feed the client ice chips or popsicles after refusal of taking in other foods or liquids is insensitive to the wishes of the client.

A client with a terminal illness does not want to receive cardiopulmonary resuscitation. Which medical order should the nurse expect to be written for this client? A. Do-not-intubate (DNI) B. Involuntary euthanasia C. Voluntary euthanasia D. Do-not-resuscitate (DNR)

D A​ do-not-resuscitate order​ (DNR) is a medical order that states the​ client's wishes to withhold cardiopulmonary resuscitation​ (CPR) in the event of respiratory or cardiac arrest. A​ do-not-intubate order​ (DNI) prohibits endotracheal intubation in the event of severe respiratory failure or respiratory arrest. Voluntary euthanasia occurs when the client or the​ client's family gives consent for the actions that will result in death for the client. Involuntary euthanasia is defined as euthanasia performed against the wishes of the client or the​ client's family.

During a​ well-child visit, a female high school student complains about their inability to do as much physically as their twin brother. Which response by the nurse is​ accurate? A. Muscle growth in girls peaks at age 13 B. Girls have less muscle after the age of 16 C. Girls need to eat more to have more muscle D. Boys have more muscle mass than girls

D Boys have more muscle mass than girls. Muscle growth in girls peaks between the ages of 16 and 20. Eating more will not increase the amount of muscle. Boys and girls have the same amount of muscle until age 13.

Which type of exercise is also known as dynamic exercise? A. Isometric B. Isokinetic C. Isodynamic D. Isotonic

D Isotonic exercises are also known as dynamic exercises. These exercises are said to be practiced when active movement occurs and muscles shorten and contract. There are no exercises called isodynamic. Isometric exercises are also known as static exercises because the muscle contracts but the joint does not move. Isokinetic exercises are known as​ resistive, where the muscle contracts against resistance.

While completing an assessment after administration of morphine for acute pain the nurse notes that the client's respiratory rate is 10 and that the client is very lethargic. Which should the nurse do first in response to these assessment findings? A. Immediately obtain a complete set of vital signs to establish a baseline B. Continue to monitor for any further decrease in respirations or change in level of consciousness C. Contact the healthcare provider immediately to advise of client changes D. Administer naloxone as prescribed in incremental doses until symptoms of overdose are resolved.

D Morphine can cause respiratory depression. If this​ occurs, naloxone should be immediately administered as prescribed in incremental doses until the overdose is resolved. A baseline set of vital signs should be obtained as soon as possible but vital signs are not the first priority. Once naloxone is​ begun, the healthcare provider should be contacted. The nurse would not just continue to monitor for further changes as this could result in death.

A nurse is caring for an older adult who complains of dry mouth. The client states "food just doesn't taste the same anymore." The nurse understands that the client's dry mouth may be the cause of the client's altered taste. Which statement is true regarding saliva and taste? A. Because saliva is produced in the tongue, a decrease in saliva will decrease taste B. A decrease in saliva will decrease taste because saliva mechanically breaks down food into smaller parts C. Saliva increases taste by increasing the function of the taste buds, so a decrease in saliva will decrease taste D. Decreased saliva production thins the oral mucosa and contributes to dry mouth, so a decrease in saliva will decrease taste

D Saliva moistens food and provides enzymes to digest starches. As saliva​ decreases, it contributes to thinning of the oral​ mucosa, contributing to dry mouth and altered taste. Saliva does not increase the function of the taste buds. Saliva is produced by the salivary​ glands, not the tongue. Saliva chemically breaks down​ food; teeth mechanically break down food.

A caregiver of a 10 year-old fifth grader reports to the nurse about the current behavior of the child. The teacher reported to the caregiver that the student is falling asleep in class, is distracted in interactions with the peer group, and has trouble concentrating, leading to poor grades on assignments. The caregiver also reports that the child often plays video games late into the night. Which issue does the nurse suspect as the cause of the behavior? A. Sundown syndrome B. Nocturnal emissions C. Waking up frequently at night due to nightmares D. Screen time at night

D School-age children need 10-11 hours of sleep per night. They may spend more time at the​ computer, playing video​ games, and watching​ TV, leading to difficulty falling asleep and fewer hours of sleep. A regular and consistent sleep schedule and bedtime routine need to be established. The client is not experiencing sundown syndrome. Nocturnal emissions and nightmares are not the cause of the​ client's symptoms.

The nurse is caring for a visually impaired client who will be utilizing a service dog. Which statement most accurately describes the​ nurse's understanding of service​ dogs? A. Service dogs can be easily obtained for the visually impaired B. Another family member will need to care for the service dog C. The cost of training a service dog is inexpensive D. The service dog can assist with activities of daily living

D Service dogs protect individuals with sensory impairments from risk and assist them with activities of daily living​ (ADLs), such as opening doors and fetching objects. The cost of training a service dog is​ expensive, service dogs are not easily​ obtained, and another family member does not need to care for them.

The nurse enters the room of a sleeping client whose eyes are rolling from side to side and whose respiratory rate and heart rate have decreased. The client is easily aroused and​ states, "I​ wasn't asleep." Which state of​ non-REM (NREM) sleep was the client​ in? A. Stage N4 B. Stage N3 C. Stage N2 D. Stage N1

D Stage N1 is the stage of light sleep in which the client is easily​ aroused, the respiratory rate and heart rate decrease​ slightly, and the eyes roll slowly from side to side. Stage N2 is the stage of light sleep in which body processes slow down and the eyes are still. Stage N3 is the stage of deep sleep in which it is difficult to arouse the​ client, muscles are​ relaxed, and reflexes are diminished. Stage N4 is the stage of deep sleep that differs from Stage N3 in the number of delta waves produced.

The nurse is admitting a client for the treatment of​ closed-angle glaucoma. Which procedure should the nurse anticipate will be​ performed? A. Laser surgery B. Lens implantation C. Photodynamic therapy D. Laser iridotomy

D The nurse can anticipate a laser iridotomy to be performed to treat the​ client's closed-angle glaucoma. Laser surgery and photodynamic therapy are used to treat​ age-related macular degeneration. Lens implantation is used to treat cataracts.

The adult daughter of a client who is nearing death questions the quality of care being provided to the client. What should the nurse do to support the daughter's needs during the dying process? A. Suggest that the daughter go home to get some rest B. Permit the daughter to spend uninterrupted time with the client C. Ask the healthcare provider to talk with the daughter D. Respond to the daughter's concerns

D The nurse needs to support the family through the grieving process. To do​ this, the nurse should respond to the​ daughter's concerns. Suggesting that the daughter go home to get some rest does not address the​ daughter's concerns about quality of care. The nurse can talk to the daughter about the quality of care and does not need to contact the healthcare provider. Permitting the daughter to spend uninterrupted time with the client might exacerbate the feeling that care is less than optimal.

The nurse is reviewing the chart of a client diagnosed with strabismus. Which most accurately describes the​ nurse's understanding of the​ diagnosis? A. Pupils' inability to constrict B. Eyes turned inward toward each other C. Change in distant vision D. Misalignment of the eyes

D The nurse understands that the diagnosis of strabismus is a misalignment of the eyes. Myopia is a change in distant vision. The​ pupil's inability to constrict reflects a failure to accommodate. Eyes that can turn in toward each other is a normal finding termed convergence.

The nurse is preparing to examine the ears of a​ 2-year-old child. Which intervention should the nurse implement prior to the​ assessment? A. Remove the cerumen prior to examination with the otoscope B. Pull the auricle up and back C. Allow the child to play with the otoscope D. Have the parent help hold the child's head against their chest

D The nurse will have the parent help hold the young​ child's head against their chest to prevent movement. The auricle of a child over 3 years of age will be pulled up and back prior to​ assessment; for a child under 3 years of​ age, the auricle will be pulled down and back. An older child may be allowed to play with the equipment prior to the assessment. Cerumen is not removed prior to the examination with an otoscope.

A nurse in a primary care clinic is caring for a client who has osteoporosis but no significant health history. Which statement made by the nurse is most appropriate when teaching this client? A. Isometric exercise is an excellent choice for your condition B. Non-weight-bearing exercise is most beneficial in your condition C. Swimming is most beneficial for your condition D. Walking is an excellent choice of exercise for your condition

D ​Walking, or​ weight-bearing exercise, is most beneficial for the client with osteoporosis who can bear weight. Bone density and strength are maintained through​ weight-bearing activities. The stress of​ weight-bearing and​ high-impact movement maintains a balance between osteoblasts​ (bone-building cells) and osteoclasts​ (bone-resorption and​ bone-breakdown cells). Although swimming is a great choice for those who cannot bear​ weight, this client would best benefit from walking. Isometric exercises are beneficial for muscles but do not provide​ weight-bearing benefits for the client with osteoporosis.

The nurse is providing education to the client on the effect of lifestyle factors on sleep. Which should the nurse include as a factor that negatively influences sleep? Select all that apply A. Morning exercise B. Relaxation C. Regular nighttime schedule D. Irregular work schedule E. Evening exercise

D, E Factors that negatively impact sleep include evening exercise and an irregular work schedule. Morning​ exercise, relaxation, and regular nighttime schedule are known to enhance sleep.