331 final

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The nurse is working with a client who had an MI and is now active in rehabilitation. The nurse should teach this client to cease activity if which of the following occurs? A. The client experiences chest pain, palpitations, or dyspnea. B. The client experiences a noticeable increase in heart rate during activity. C. The client's oxygen saturation level drops below 96%. D. The client's respiratory rate exceeds 30 breaths/min.

The nurse is working with a client who is newly diagnosed with MS. What basic information should the nurse provide to the client? A. MS is a progressive demyelinating disease of the nervous system. B. MS usually occurs more frequently in men. C. MS typically has an acute onset. D. MS is sometimes caused by a bacterial infection.

The nurse providing care for a client with Cushing syndrome has identified the nursing diagnosis of risk for injury related to weakness. How should the nurse best reduce this risk? A. Establish fall-prevention measures. B. Encourage bed rest whenever possible. C. Encourage the use of assistive devices. D. Provide constant supervision.

The school nurse has been called to the football field, where a player is laying immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? A. Ensure that the player is not moved. B. Obtain the player's vital signs, if possible. C. Perform a rapid assessment of the player's range of motion. D. Assess the player's reflexes.

When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? A. Frustration around changes in function and communication B. Unmet physiologic needs C. Changes in brain activity during sleep and wakefulness D. Temporary changes in metabolism

The nurse is evaluating a client's diagnosis of arterial insufficiency with reference to the adequacy of the client's blood flow. On what physiologic variables does adequate blood flow depend? Select all that apply. A. Efficiency of heart as a pump B. Adequacy of circulating blood volume C. Ratio of platelets to red blood cells D. Size of red blood cells E. Patency and responsiveness of the blood vessels

A, B, E

A nurse is planning client education for a client being discharged home with a diagnosis of rheumatoid arthritis. The client has been prescribed antimalarials for treatment, so the nurse knows to teach the client to self-monitor for what adverse effect? A. Tinnitus B. Visual changes C. Stomatitis D. Hirsutism

A nurse is providing care to a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse understands that the primary problem involves the: A. anterior pituitary gland. B. posterior pituitary gland. C. thyroid gland. D. adrenal gland.

The staff educator is teaching a CPR class. Which of the following aspects of defibrillation should the educator stress to the class? A. Apply the paddles directly to the client's skin. B. Use a conducting medium between the paddles and the skin. C. Always use a petroleum- based gel between the paddles and the skin. D. Any available liquid can be used between the paddles and the skin.

When assessing a client diagnosed with angina pectoris, it is most important for the nurse to gather what information? A. The client's activities, limitations, and level of consciousness after the attacks B. The client's symptoms and the activities that precipitate attacks C. The client's understanding of the pathology of angina D. The client's coping strategies surrounding the attacks

The nurse is providing discharge education for a client with a new diagnosis of Ménière disease. What food should the client be instructed to limit or avoid? A. Sweet pickles B. Frozen yogurt C. Shellfish D. Red meat

A client with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) is being cared for on the critical care unit. What is the priority nursing diagnosis for a client with this condition? A. Risk for peripheral neurovascular dysfunction B. Excess fluid volume C. Hypothermia D. Ineffective airway clearance

How soon does an ECG need to be done if a patient reports pain or arrives at the ED?

10 minutes

A 60-year-old client with chronic myeloid leukemia (CML) will be treated in the home setting, and the nurse is preparing appropriate health education. Which topic should the nurse emphasize? A. The importance of adhering to the prescribed drug regimen B. The need to ensure that vaccinations are up to date C. The importance of daily physical activity D. The need to avoid shellfish and raw foods

A client has been admitted to the intensive care unit (ICU) after an ischemic stroke, and a central venous pressure (CVP) monitoring line was placed. The nurse notes a low CVP. Which condition is the most likely reason for a low CVP? A. Hypovolemia B. Myocardial infarction (MI) C. Left-sided heart failure D. Aortic valve regurgitation

A client is brought to the ED and determined to be experiencing symptomatic sinus bradycardia. The nurse caring for this client is aware the medication of choice for treatment of this dysrhythmia is the administration of atropine. What guidelines will the nurse follow when administering atropine? A. Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg. B. Administer atropine as a continuous infusion until symptoms resolve. C. Administer atropine as a continuous infusion to a maximum of 30 mg in 24 hours. D. Administer atropine 1.0 mg sublingually

A client is undergoing diagnostic testing to determine the etiology of recent joint pain. The client asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? A. "OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." B. "OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the larger, weight-bearing joints like the knees." C. "OA originates with an infection. RA is a result of your body's cells attacking one another." D. "OA is associated with impaired immune function; RA is a consequence of physical damage."

A client newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a client with prolonged, uncontrolled hypertension is at risk for developing which health problem? A. Chronic kidney disease B. Right ventricular hypertrophy C. Glaucoma D. Anemia

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse's response to the family? A. The client should mobilize as soon as physically able. B. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. C. The client should remain on bed rest until the client expresses a desire to mobilize. D. Lack of mobility will greatly increase the clients risk of stroke recurrence

A client who is a candidate for an implantable cardioverter defibrillator (ICD) asks the nurse about the purpose of this device. What would be the nurse's best response? A. "To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia." B. "To detect and treat bradycardia, which is an excessively slow heart rate." C. "To detect and treat atrial fibrillation, in which your heart beats too quickly and inefficiently." D. "To shock your heart if you have a heart attack at home."

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client? A. The client should be approached on the side where visual perception is intact. B. Attention to the affected side should be minimized in order to decrease anxiety. C. The client should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D. The client should be approached on the opposite side of where the visual perception is intact to promote recovery.

A client with a diagnosis of acute myeloid leukemia (AML) is being treated with induction therapy on the oncology unit. What nursing action should be prioritized in the client's care plan? A. Protective isolation and vigilant use of standard precautions B. Provision of a high-calorie, low-texture diet and appropriate oral hygiene C. Including the family in planning the client's activities of daily living D. Monitoring and treating the client's pain

A client with advanced venous insufficiency is confined to bed rest following orthopedic surgery. How can the nurse best prevent skin breakdown in the client's lower extremities? A. Ensure that the client's heels are protected and supported. B. Closely monitor the client's serum albumin and prealbumin levels. C. Perform gentle massage of the client's lower legs, as tolerated. D. Perform passive range-of-motion exercises once per shift.

A client's decreased mobility has been attributed to an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. This client has been diagnosed with which health problem? A. Rheumatoid arthritis (RA) B. Systemic lupus erythematosus (SLE) C. Osteoporosis D. Polymyositis

A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety? A. Place the client in a side-lying position. B. Pad the client's bed rails. C. Administer antianxiety medications as prescribed. D. Reassure the client and family members.

A nurse in the critical care unit is caring for a client with heart failure who has developed an intracardiac thrombus. The nurse should assess for signs and symptoms of which sequela? A. Stroke B. Myocardial infarction (MI) C. Hemorrhage D. Peripheral edema

A nurse is assessing the skin integrity of a client who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces? A. Perianal region and oral mucosa B. Sacral region and lower abdomen C. Scalp and skin over the scapulae D. Axillae and upper thorax

A postoperative cardiac client experiences signs and symptoms of cardiac tamponade. Which action by the nurse would be most appropriate? A. Prepare to assist with pericardiocentesis. B. Reposition the client into a prone position. C. Administer a dose of metoprolol as prescribed. D. Administer a bolus of normal saline as prescribed.

An older adult client has been diagnosed with aortic regurgitation. Which change in blood flow should the nurse expect to see on this client's echocardiogram? A. Blood to flow back from the aorta to the left ventricle B. Obstruction of blood flow from the left ventricle C. Blood to flow back from the left atrium to the left ventricle D. Obstruction of blood from the left atrium to left ventricle

Following an addisonian crisis, a client's adrenal function has been gradually regained. The nurse should ensure that the client knows about the need for supplementary corticosteroid therapy in which circumstance? A. A significant illness B. Periods of dehydration C. Episodes of physical exertion D. Administration of a vaccine

Since the emergence of the human immunodeficiency virus (HIV), there have been significant changes in epidemiologic trends. At present, members of which group are most affected by new cases of HIV? A. Male-to-male sexual contact B. Heterosexual contact C. Male-to-male sexual contact with injection drug use D. People 25 to 29 years of age

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? A. Provide a board of commonly used needs and phrases. B. Have the client speak to loved ones on the phone daily. C. Help the client complete his or her sentences as needed. D. Speak in a loud and deliberate voice to the client.

The nurse identifies a nursing diagnosis of Ineffective Health Maintenance related to nonadherence to therapeutic regimen in a client with hypertension who has not been taking their medication as prescribed. When planning this client's care, which outcome would be appropriate? A. Client takes medication as prescribed and reports any adverse effects. B. Client's BP remains consistently below 140/90 mm Hg. C. Client denies signs and symptoms of hypertensive urgency. D. Client is able to describe modifiable risk factors for hypertension.

The nurse in the ED is caring for a patient recently admitted with a likely myocardial infarction. The nurse understands that the patients heart is pumping an inadequate supply of oxygen to the tissues. For what health problem should the nurse assess? A. Dysrhythmias B. Increased blood pressure C. Increase in heart rate D. Decrease in oxygen demands

The nurse is admitting a 55-year-old client diagnosed with a left eye retinal detachment. While assessing this client, what characteristic symptom would the nurse expect to find? A. Flashing lights in the visual field B. Sudden eye pain C. Loss of color vision D. Colored halos around lights

The nurse is assessing a client with a spinal cord injury that reports a severe headache with a rapid onset. The nurse knows that this could be a symptom of which complication of a spinal cord injury? A. Autonomic dysreflexia B. Spinal shock C. Retinal hemorrhage D. Myocardial infarction

The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? A. Facial droop B. Dysrhythmias C. Periorbital edema D. Projectile vomiting

The nurse is caring for an adult client who has gone into ventricular fibrillation. When assisting with defibrillating the client, what must the nurse do? A. Maintain firm contact between paddles and the client's skin. B. Apply a layer of water as a conducting agent. C. Call "all clear" once before discharging the defibrillator. D. Ensure the defibrillator is in the sync mode.

The nurse is caring for a client whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this client? A. Assessing the client's verbal response B. Assessing the client's ability to follow complex commands C. Assessing the client's judgment D. Assessing the client's response to pain

A Rationale: Assessment of the client with an altered LOC often starts with assessing the verbal response through determining the client's orientation to time, person, and place. In most cases, this assessment will precede each of the other listed assessments, even though each may be indicated.

A nurse is caring for a client who has a diagnosis of acute myelocytic leukemia (AML). Assessment of which factor most directly addresses the most common cause of death among clients with leukemia? A. Infection status B. Nutritional status C. Electrolyte levels D. Liver function

A Rationale: Because of the lack of mature and normal granulocytes that help fight infection, clients with leukemia are prone to infection. In clients with AML, death typically occurs from infection or bleeding. Symptoms of AML include weight loss, fever, night sweats, and fatigue, which would guide the nurse to monitor the client's nutrition and electrolytes. Gastrointestinal problems (nausea and vomiting) and electrolyte imbalances (hyperkalemia and hypocalcemia) may result from chemotherapy use. The liver is responsible for metabolism and metabolic detoxification, so monitoring liver function is important for the client who is receiving chemotherapy. These problems may contribute to and/or result in death but are not the most common cause.

A client with Cushing syndrome as a result of a pituitary tumor has been admitted for a transsphenoidal hypophysectomy. What would be most important for the nurse to monitor before, during, and after surgery? A. Blood glucose B. Assessment of urine for blood C. Weight D. Oral temperature

A Rationale: Before, during, and after this surgery, blood glucose monitoring and assessment of stools for blood are carried out. The client's blood sugar is more likely to be volatile than body weight or temperature. Hematuria is not a common complication.

A client is receiving treatment for a new diagnosis of chronic lymphocytic leukemia (CLL). Based on known risk factors, age, ethnicity, and accompanying clinical conditions, which client is most likely to have this disease? A. 82-year-old Vietnam War veteran with widely disseminated shingles B. 62-year-old client of Asian descent with a left fractured hip C. 69-year-old Gulf War veteran with deep vein thrombosis (DVT) D. 85-year-old client of Native American/First Nation descent with chest pain

A Rationale: CLL is a common malignancy of older adults with an average age of 71 at diagnosis and the most prevalent leukemia in the Western world. It is rarely seen in clients of Native American/First Nation descent and has an infrequent incidence in clients of Asian descent. Veterans of the Vietnam War who were exposed to the herbicide Agent Orange are at risk for CLL. The time period of exposure was from 1962 to 1975 so veterans from the Gulf War in 1991 were not exposed. Infections are common with advanced CLL. None of the other conditions are related to infection, so they are not the best choice. Viral infections such as herpes zoster (shingles) can be widely disseminated with CLL.

The nurse is caring for a client admitted with angina who is scheduled for cardiac catheterization. The client is anxious and asks the reason for this test. The nurse should explain that cardiac catheterization is most commonly done for which purpose? A. To assess how blocked or open a client's coronary arteries are B. To detect how efficiently a client's heart muscle contracts C. To evaluate cardiovascular response to stress D. To evaluate cardiac electrical activity

A Rationale: Cardiac catheterization is usually used to assess coronary artery patency to determine whether revascularization procedures are necessary. A thallium stress test shows myocardial ischemia after stress. An ECG shows the electrical activity of the heart.

A client with a hypertensive emergency is being treated in the intensive care unit. The nurse knows that which client is at risk for developing this type of emergency? A. A client who stops their antihypertensive medication abruptly B. A client with a diagnosis of primary hypertension C. A client with well-controlled hypertension D. A client with hypertension that was diagnosed 2 years ago

A Rationale: Clients who abruptly stop their antihypertensive medications are at risk for developing hypertensive emergencies. Clients with secondary, not primary, hypertension are also at risk. A client who is undiagnosed is at risk, not one who was diagnosed 2 years ago. A client who has good control of their hypertension is less likely to be at risk.

A client has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication? A. Vigilant monitoring of fluid balance B. Continuous BP monitoring C. Serial arterial blood gases (ABGs) D. Monitoring of the client's airway for patency

A Rationale: Diabetes insipidus requires fluid and electrolyte replacement, along with the administration of vasopressin, to replace and slow the urine output. Because of these alterations in fluid balance, careful monitoring is necessary. None of the other listed assessments directly addresses the major manifestations of diabetes insipidus.

The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP? A. Disorientation and restlessness B. Decreased pulse and respirations C. Projectile vomiting D. Loss of corneal reflex

A Rationale: Early indicators of IC include disorientation and restlessness. Later signs include decreased pulse and respirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex.

The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate action? A. Inform the care team and assess for further signs of possible increased ICP. B. Administer bronchodilators as prescribed and monitor the client's LOC. C. Increase the client's bed height and reassess in 30 minutes. D. Administer a bolus of normal saline as prescribed.

A Rationale: Increased respiratory effort can be suggestive of increasing IC, and the care team should be promptly informed. A bolus of IV fluid will not address the problem. Repositioning the client and administering bronchodilators are insufficient responses, even though these actions may later be prescribed.

Nursing care during the immediate recovery period from an ischemic stroke should normally prioritize which intervention? A. Positioning the client to avoid intercranial pressure (ICP) B. Maximizing partial pressure of carbon dioxide (PaCO2) C. Administering hypertonic intravenous (IV) solution D. Initiating early mobilization

A Rationale: Interventions during this period include measures to reduce ICP, such as administering an osmotic diuretic (e.g., mannitol) and positioning to avoid ICP, and handle secretions to avoid aspiration. Hypertonic IV solutions are not used unless sodium depletion is evident. PaCO2 must remain within an acceptable range, not maximized. Mobilization would take place after the immediate threat of increased ICP has passed.

An oncology nurse is providing health education for a client who has recently been diagnosed with leukemia. What should the nurse explain about commonalities between all of the different subtypes of leukemia? A. The different leukemias all involve unregulated proliferation of white blood cells. B. The different leukemias all have unregulated proliferation of red blood cells and decreased bone marrow function. C. The different leukemias all result in a decrease in the production of white blood cells. D. The different leukemias all involve the development of cancer in the lymphatic system.

A Rationale: Leukemia commonly involves unregulated proliferation of white blood cells. Decreased production of red blood cells is associated with anemias. Decreased production of white blood cells is associated with leukopenia. The leukemias are not characterized by their involvement with the lymphatic system.

A nurse is creating an education plan for a client with venous insufficiency. Which measure should the nurse include in the plan? A. Avoid normal stockings that are tight. B. Limit activities, including walking. C. Sleep with legs below heart level. D. Refrain from using graduated compression stockings.

A Rationale: Measures taken to prevent complications include avoiding tight-fitting socks and panty girdles; maintaining activities, such as walking; sleeping with legs elevated; and using pressure stockings. Not included in the teaching plan for venous insufficiency would be reducing activity, sleeping with legs dependent, and avoiding pressure stockings. Each of these actions exacerbates venous insufficiency.

A nurse is teaching an client about the risk factors for hypertension. Which factors should the nurse explain as risk factors for primary hypertension? A. Obesity and high intake of sodium and saturated fat B. Diabetes and use of oral contraceptives C. Metabolic syndrome and smoking D. Renal disease and coarctation of the aorta

A Rationale: Obesity, stress, high intake of sodium or saturated fat, and family history are all risk factors for primary hypertension. Diabetes and oral contraceptives are risk factors for secondary hypertension. Metabolic syndrome, smoking, renal disease, and coarctation of the aorta are causes of secondary hypertension.

A client is admitted to the critical care unit with a diagnosis of cardiomyopathy. When reviewing the client's most recent laboratory results, the nurse would prioritize assessment of which value? A. Sodium B. Aspartate aminotransferase, alanine aminotransferase, and bilirubin C. White blood cell differential D. Blood urea nitrogen (BUN)

A Rationale: Sodium is the major electrolyte involved with cardiomyopathy. Cardiomyopathy often leads to heart failure which develops, in part, from fluid overload. Fluid overload is often associated with elevated sodium levels. Consequently, sodium levels are followed more closely than other important laboratory values, including BUN, leukocytes, and liver function tests.

A client is postoperative day 1 following intracranial surgery. The nurse's assessment reveals that the client's level of consciousness (LOC) is slightly decreased compared with the day of surgery. What is the nurse's best response to this assessment finding? A. Recognize that this may represent the peak of postsurgical cerebral edema. B. Alert the surgeon to the possibility of an intracranial hemorrhage. C. Understand that the surgery may have been unsuccessful. D. Recognize the need to refer the client to the palliative care team.

A Rationale: Some degree of cerebral edema occurs after brain surgery; it tends to peak 24 to 36 hours after surgery, producing decreased responsiveness on the second postoperative day. As such, there is not necessarily any need to deem the surgery unsuccessful or to refer the client to palliative care. A decrease in LOC is not evidence of an intracranial hemorrhage. Any change in the client's LOC should be reported to the healthcare provider.

A client is recovering from intracranial surgery performed approximately 24 hours ago and is reporting a headache that the client rates at 8 on a 10-point pain scale. What nursing action is most appropriate? A. Administer morphine sulfate as prescribed. B. Reposition the client in a prone position. C. Apply a hot pack to the client's scalp. D. Implement distraction techniques.

A Rationale: The client usually has a headache after a craniotomy as a result of stretching and irritation of nerves in the scalp during surgery. Morphine sulfate may also be used in the management of postoperative pain in clients who have undergone a craniotomy. Prone positioning is contraindicated due to the consequent increase in ICP. Distraction would likely be inadequate to reduce pain and a hot pack may cause vasodilation and increased pain.

The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever walking several blocks. The client has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years. The health care provider diagnoses intermittent claudication. The nurse should provide which instruction about long-term care to the client? A. "Be sure to practice meticulous foot care." B. "Consider cutting down on your smoking." C. "Reduce your activity level to accommodate your limitations. D. "Try to make sure you eat enough protein

A Rationale: The client with peripheral vascular disease or diabetes should receive education or reinforcement about skin and foot care. Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing; therefore, meticulous foot care is essential. The client should stop smoking -not just cut down -because nicotine is a vasoconstrictor. Daily walking benefits the client with intermittent claudication. Increased protein intake will not alleviate the client's symptoms.

The nurse is monitoring blood pressure for a client with unstable readings. How often should the nurse check the client's blood pressure? A. Every 5 minutes B. Every 30 minutes C. Every 30 minutes until stable D. Every 2 minutes

A Rationale: The exact frequency of monitoring is a matter of clinical judgment and varies with the client's condition. Taking vital signs every 5 minutes is appropriate if the blood pressure is changing rapidly; taking vital signs at 15- or 30-minute intervals in a more stable situation may be sufficient. A precipitous drop in blood pressure can occur that would require immediate action to restore blood pressure to an acceptable level.

The nurse is caring for a client who has developed SIADH. What intervention is most appropriate? A. Fluid restriction B. Transfusion of platelets C. Transfusion of fresh frozen plasma (FFP) D. Electrolyte restriction

A Rationale: The nurse also assesses for complications of increased ICP, including diabetes insipidus, and SIADH. SIADH requires fluid restriction and monitoring of serum electrolyte levels. Transfusions are unnecessary.

A nurse has a client with a spinal cord injury and is tailoring their care plan to prevent the major causes of death for this client. The nurse's care plan includes assisted coughing techniques, a sequential compression device, and prevention of pressure injuries. Which are the most likely possible causes of death for this client? A. Pneumonia, pulmonary embolism, and sepsis B. Cardiac tamponade, hypoxia, and malnutrition C. Oxygen toxicity in paralytic ileus and electrolyte imbalances D. Seizures, osteomyelitis, and urinary tract infections

A Rationale: The nurse is assisting the client with assisted coughing torprevent pneumonia. Pulmonary infections are managed and prevented by frequent coughing, turning, and deep breathing exercises and chest physiotherapy; aggressive respiratory care and suctioning of the airway if a tracheostomy is present; assisted coughing as needed; and adequate hydration. Low-dose anticoagulation therapy usually is initiated to prevent DV (deep vein thrombosis) and PE (pulmonary embolism), along with the use of anti-embolism stockings or sequential pneumatic compression devices (SCDs). Pressure injuries have the potential complication of sepsis, osteomyelitis, and fistulas. All of the other listed causes may occur in clients with SCI but are not the main causes of death. The interventions discussed above directly assist in the prevention of pneumonia, pulmonary embolism osteomyelitis and sepsis.

The nurse is developing a care plan for a client with Cushing syndrome. What nursing diagnosis should the nurse prioritize? A. Risk for injury related to weakness B. Ineffective breathing pattern related to muscle weakness C. Risk for loneliness related to disturbed body image D. Autonomic dysreflexia related to neurologic changes

A Rationale: The nursing priority is to decrease the risk of injury by establishing a protective environment. The client who is weak may require assistance from the nurse in ambulating to prevent falls or bumping corners of furniture. The client's breathing will not be affected, and autonomic dysreflexia is not a plausible risk. Loneliness may or may not be an issue for the client, but safety is a priority.

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? A. Evidence of hemorrhagic stroke B. Blood pressure of D 180/110 mm Hg C. Evidence of stroke evolution D. Previous thrombolytic therapy within the past 12 months

A Rationale: Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences. Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and effective use.

The nurse is planning care for a client with venous insufficiency. Which nursing intervention would be appropriate for this client's plan of care? A. Elevate lower extremities. B. Educate on decreased protein. C. Apply compression only at night. D. Teach frequent rest periods due to pain.

A Rationale: Venous insufficiency is lack of blood flow back to the heart. Elevation of lower extremities will assist the peripheral blood vessels in returning stasis of blood. Increased protein should be taught. Compression therapy should be used but not only at night. Pain is not usually assessed in clients with venous insufficiency but with arterial insufficiency.

A client has been living with dilated cardiomyopathy for several years but has experienced worsening symptoms despite aggressive medical management. The nurse would anticipate which potential treatment? A. Heart transplantation B. Balloon valvuloplasty C. Cardiac catheterization D. Stent placement

A Rationale: When heart failure progresses and medical treatment is no longer effective, surgical intervention, including heart transplantation, is considered. Valvuloplasty, stent placement, and cardiac catheterization will not address the pathophysiology of cardiomyopathy.

The triage nurse in the ED assesses an adult client who presents with reports of midsternal chest pain that has lasted for the last 5 hours. If the client's symptoms are due to an MI, what will have happened to the myocardium? A. It may have developed an increased area of infarction during the time without treatment. B. It will probably not have more damage than if the client came in immediately. C. It may be responsive to restoration of the area of dead cells with proper treatment. D. It has been irreparably damaged, so immediate treatment is no longer necessary.

A Rationale: When the client experiences lack of oxygen to myocardium cells during an MI, the sooner treatment is initiated, the more likely the treatment will prevent or minimize myocardial tissue necrosis. Delays in treatment equate with increased myocardial damage. Despite the length of time the symptoms have been present, treatment needs to be initiated immediately to minimize further damage. Dead cells cannot be restored by any means.

A client with thyroid cancer has undergone surgery and a significant amount of parathyroid tissue has been removed. The nurse caring for the client should prioritize what question when addressing potential complications? A. "Do you feel any muscle twitches or spasms?' B. "Do you feel flushed or sweaty?" C. "Are you experiencing any dizziness or lightheadedness?" D. "Are you having any pain that seems to be radiating from your bones?"

A Rationale: As the blood calcium level falls, hyperirritability of the nerves occurs, with spasms of the hands and feet and muscle twitching. This is characteristic of hypoparathyroidism. Flushing, diaphoresis, dizziness, and pain are atypical signs of the resulting hypocalcemia.

The nurse is educating a group of nursing students about COVID-19 and risk for cerebrovascular disorders. The nurse educator notes that COVID-19 has shown to increase which condition? A. Ischemic stroke B. Decrease inflammation C. Hemorrhagic stroke D. Hypertension

A Rationale: Blood clotting abnormalities have been found to occur in COVID-19 afflicted clients. With the clotting abnormalities, there is an increased risk for ischemic stroke. There is no evidence that COVID-19 causes any of the other conditions.

The nurse is developing a nursing care plan for a client who is being treated for hypertension. Which outcome is most appropriate for the nurse to include? A. Client will reduce Na* intake to less than 2 g daily. B. Client will have a stable BUN and serum creatinine levels. C. Client will abstain from fat intake and reduce calorie intake. D. Client will maintain a normal body weight.

A Rationale: Dietary sodium intake of less than 2 g daily is recommended as a dietary lifestyle modification to prevent and manage hypertension. Also, giving a specific amount of allowable sodium intake makes this a measurable goal and therefore more appropriate than the other goals, which are not quantifiable or measurable.

The nurse is caring for a client who has had an ECG. The nurse notices that leads I, II, and III differ from one another on the cardiac rhythm strip. How should the nurse best respond? A. Recognize that the view of the electrical current changes in relation to the lead placement. B. Recognize that the electrophysiological conduction of the heart differs with lead placement. C. Inform the technician that the ECG equipment has malfunctioned. D. Inform the health care provider that the client is experiencing a new onset of dysrhythmia.

A Rationale: Each lead offers a different reference point to view the electrical activity of the heart. The lead displays the configuration of electrical activity of the heart. Differences between leads are not necessarily attributable to equipment malfunction or dysrhythmias.

The nurse is caring for a client with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the client may be experiencing increased brain compression causing brain stem damage? A. Hyperthermia B. Tachycardia C. Hypertension D. Bradypnea

A Rationale: Signs of increasing IC include slowing of the heart rate (bradycardia), increasing systolic BP, and widening pulse pressure. As brain compression increases, respirations become rapid, BP may decrease, and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia increases the metabolic demands of the brain and may indicate brain stem damage.

The nurse is caring for a client recovering from an ischemic stroke. What intervention (s) best addresses potential complications after an ischemic stroke? Select all that apply. A. Providing frequent small meals rather than three larger meals B. Teaching the client to perform deep breathing and coughing exercises. C. Keeping a urinary catheter in place for the full duration of recovery. D. Limiting intake of insoluble fiber, carbohydrates, and simple sugars. E. Encourage the client to stay in bed and assist with turning and repositioning.

A, B Rationale: Because pneumonia is a potential complication of stroke, deep breathing and coughing exercises should be encouraged unless contraindicated. Providing small frequent meals during recovery will decrease the likelihood of aspiration. Dietary restrictions are based on individual client needs, and fiber, carbohydrates, and sugars are not typically restricted. Urinary catheters should be discontinued as soon as possible to prevent the increased risk of catheter associated urinary tract infections (CAUTI). It is also important to get the client out of bed as soon as possible to prevent pressure ulcers and encourage mobility.

A client with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this client? Select all that apply. A. Orthostatic hypotension B. Autonomic dysreflexia C. DVT D. Salt-wasting syndrome E. Increased ICP

A, B, C Rationale: For a spinal cord-injured client, based on the assessment data, potential complications that may develop include DVT, orthostatic hypotension, and autonomic dysreflexia. Salt-wasting syndrome and increased IC are not typical complications following the immediate recovery period.

The nurse is teaching a client about some of the health consequences of uncontrolled hypertension. What health problems should the nurse describe? Select all that apply. A. Transient ischemic attacks (TIAs) B. Cerebrovascular disease C. Retinal hemorrhage D. Venous insufficiency E. Right ventricular hypertrophy

A, B, C Rationale: Potential complications of hypertension include the following: left ventricular hypertrophy; MI; heart failure; transient ischemic attacks; cerebrovascular disease; renal insufficiency and failure; and retinal hemorrhage. Venous insufficiency and right ventricular hypertrophy are not potential complications of uncontrolled hypertension.

A nurse educator is conducting an inservice for nursing students about how tobacco use impacts coronary artery disease (CAD)? What are the primary ways that tobacco use impacts CAD? Select all that apply. A. Decreases the supply of oxygen to the myocardium B. Increases platelet adhesion C. Raises the heart rate and blood pressure D. Causes the coronary arteries to dilate E. Increases the blood carbon monoxide level

A, B, C, E

The nurse is assessing a client with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply. A. Dyspnea B. Unusual fatigue C. Hypotension D. Syncope E. Peripheral cyanosis

A, B, D

A nurse is completing the nutritional status of a client who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply. A. Serum albumin level B. Weight history C. White blood cell count D. Body mass index E. Blood urea nitrogen (BUN) level

A, B, D, E

A client with Cushing syndrome has been hospitalized after a fall. The dietitian works with the client to improve the client's nutritional intake. What foods should a client with Cushing syndrome eat to optimize health? Select all that apply. A. Foods high in vitamin D B. Foods high in calories C. Foods high in protein D. Foods high in calcium E. Foods high in sodium

A, C, D Rationale: Foods high in vitamin D, protein, and calcium are recommended to minimize muscle wasting and osteoporosis. Referral to a dietitian may assist the client in selecting appropriate foods that are also low in sodium and calories.

The nurse is caring for a 77-year-old client with MS. The client is very concerned about the progress of the disease and what the future holds. The nurse should know that older adult clients with MS are known to be particularly concerned about what variables? Select all that apply. A. Possible nursing home placement B. Pain associated with physical therapy C. Increasing disability D. Becoming a burden on the family E. Loss of appetite

A, C, D Rationale: Older adult clients with MS are particularly concerned about increasing disability, family burden, marital concern, and the possible future need for nursing home care. Older adults with MS are not noted to have particular concerns regarding the pain of therapy or loss of appetite.

An oncology nurse recognizes a client's risk for fluid imbalance while the client is undergoing treatment for leukemia. What related assessments should the nurse include in the client's plan of care? Select all that apply. A. Monitoring the client's electrolyte levels B. Monitoring the client's hepatic function C. Measuring the client's weight on a daily basis D. Measuring and recording the client's intake and output E. Auscultating the client's lungs frequently

A, C, D, E

A health care provider is taking post-exposure prophylaxis (PEP) medications for exposure to a client with human immunodeficiency virus (HIV). Which topics will the health care provider need to understand regarding PEP administration prior to beginning this regimen? Select all that apply. A. Potential drug toxicities B. Needed dietary changes C. Potential drug interactions D. Sleep pattern disturbances E. Adherence requirements

A, C, E

During a client's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help clients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. A. National Institutes of Health Stroke Scale (NIHSS) score B. Race C. LOC at time of admission D. Gender E. Age

A, C, E Rationale: It is helpful for clinicians to be knowledgeable about the relative importance of predictors of stroke outcome (age, NIHSS score, and LOC at time of admission) to provide stroke survivors and their families with realistic goals. Race and gender are not significant predictors of stroke outcome.

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply. A. Young age B. Frequent travel C. African American race D. Male gender E. Alcohol or drug use

A, D, E

A nurse in a long-term care facility is caring for an 83-year-old client who has a history of heart failure (HF) and peripheral arterial disease (PAD). At present, the client is unable to stand or ambulate. The nurse should implement measures to prevent which complication? A. Aortitis B. Deep vein thrombosis C. Thoracic aortic aneurysm D. Raynaud disease

The cardiac nurse is caring for a client who has been diagnosed with dilated cardiomyopathy (DCM). Echocardiography is likely to reveal what pathophysiological finding? A. Decreased ejection fraction B. Decreased heart rate C. Ventricular hypertrophy D. Mitral valve regurgitation

A. Rationale: DCM is distinguished by significant dilation of the ventricles without simultaneous hypertrophy. The ventricles have elevated systolic and diastolic volumes, but a decreased ejection fraction. Bradycardia and mitral valve regurgitation do not typically occur in clients with DCM.

A nurse is caring for clients in a stroke rehabilitation facility. Damage to what area of the brain will most affect a client's ability to swallow? A. Temporal lobe B. Medulla oblongata C. Cerebellum D. Pons

A client with HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education? A. Appropriate use of prophylactic antibiotics B. Importance of personal hygiene C. Signs and symptoms of wasting syndrome D. Strategies for adjusting antiretroviral dosages

A client converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and diltiazem are given. The nurse caring for the client understands that the treatment has what main goal? A. Decrease SA node conduction. B. Control ventricular heart rate. C. Improve oxygenation. D. Maintain anticoagulation.

A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the emergency department (ED). The nurse should first gauge the client's LOC on the results of what diagnostic tool? A. Monro-Kellie hypothesis B. Glasgow Coma scale C. Cranial nerve function D. Mental status examination

A client has been diagnosed with glaucoma and the nurse is preparing health education regarding the client's medication regimen. The client states that eagerness to "beat this disease" and looks forward to the time that the client will no longer require medication. How should the nurse best respond? A. "You have a great attitude. This will likely shorten the amount of time that you need medications." B. "In fact, glaucoma usually requires lifelong treatment with medications." C. "Most people are treated until their intraocular pressure goes below 50 mm Hg." D. "You can likely expect a minimum of 6 months of treatment."

A client has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the client should be kept in a prone position until otherwise ordered. What should the nurse do? A. Clarify the order with the surgeon. B. Follow the order because this bed position is correct. C. Reposition the client after the first dressing change. D. Ask the client to lie in a semi-Fowler position.

A client is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1½ hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure? A. Risk for impaired skin integrity B. Risk for injury C. Risk for autonomic dysreflexia D. Risk for suffocation

A nurse is performing the initial assessment of a client who has a recent diagnosis of systemic lupus erythematosus (SLE). Which skin manifestation would the nurse expect to observe on inspection? A. Petechiae B. Erythematous rash C. Jaundice D. Skin sloughing

A nurse is reviewing the trend of a client's scores on the Glasgow Coma Scale (GCS). This provides what potential information to the nurse about the client's status? A. The client's level of knowledge about preceding events B. An assessment of the client's current level of consciousness C. An assessment of the client's lowest verbal and physical response to stimuli D. An in-depth and real-time neurological assessment of the client's condition

A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? A. Generalized seizure B. Absence seizure C. Focal seizure D. Unclassified seizure

An adult client is admitted to the ED with chest pain. The client states that there was unrelieved chest pain for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions? A. Thrombolytics (fibrinolytics), oxygen administration, and nonsteroidal anti-inflammatories B. Morphine sulphate, oxygen, and bed rest C. Oxygen and beta-adrenergic blockers D. Bed rest, albuterol nebulizer treatments, and oxygen

Following a spinal cord injury, a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? A. Complete the pin site care to decrease risk of infection. B. Notify the neurosurgeon of the occurrence. C. Stabilize the head in a lateral position. D. Reattach the pin to prevent further head trauma.

The community health nurse cares for many clients who have hypertension. What nursing diagnosis is most common among clients who are being treated for this health problem? A. Deficient knowledge regarding the lifestyle modifications for management of hypertension B. Noncompliance with therapeutic regimen related to adverse effects of prescribed therapy C. Deficient knowledge regarding BP monitoring D. Noncompliance with treatment regimen related to medication costs

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? A. Position the client supine. B. Maintain head of bed (HOB) elevated at 30 to 45 degrees. C. Position client in prone position. D. Maintain bed in trendelenburg position

The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the resting state of the client's heart? A. P wave B. T wave C. U wave D. QRS complex

The nurse is auscultating the breath sounds of a client with pericarditis. Which finding is most consistent with this diagnosis? A. Wheezes B. Friction rub C. Fine crackles D. Coarse crackles

The nurse is caring for a client who is believed to have just experienced an MI. The nurse notes changes in the ECG of the client. What change on an ECG most strongly suggests to the nurse that ischemia is occurring? A. P-wave inversion B. T-wave inversion C. Qwave changes with no change in ST or T wave D. P-wave enlargement

The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately? A. Intravenous phenobarbital B. Intravenous diazepam C. Oral lorazepam D. Oral phenytoin

The nurse is caring for a client who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What is the nurse's most appropriate intervention for this diagnosis? A. Change the client's position as indicated. B. Monitor serum electrolytes. C. Maintain NPO status. D. Monitor arterial blood gas (ABG) values.

The nurse is caring for a client with complex cardiac history. How should the nurse best explain the process of depolarization to a colleague? A. Mechanical contraction of the heart muscles B. Electrical stimulation of the heart muscles C. Electrical relaxation of the heart muscles. D. Mechanical relaxation of the heart muscles

The nurse is doing discharge teaching with a client who has coronary artery disease. The client asks why they have to take an aspirin every day if they don't have any pain. Which rationale for this intervention would be the best? A. To help restore the normal function of the heart B. To help prevent blockages that can cause chest pain or heart attacks C. To help the blood penetrate the heart more freely D. To help the blood carry more oxygen than it would otherwise

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority? A. Maintaining accurate records of intake and output B. Maintaining a patent airway C. Inserting a nasogastric (NG) tube as prescribed D. Providing appropriate pain control

The nurse is providing health education to a client diagnosed with glaucoma. The nurse teaches the client that this disease has a familial tendency. The nurse knows that clinical examinations for family members at risk for glaucoma should occur how often? A. At least monthly B. At least once every 2 years C. At least once every 5 years D. At least once every 10 years

The nurse's assessment of a client with significant visual losses reveals that the client cannot count fingers. How should the nurse proceed with assessment of the client's visual acuity? A. Assess the client's vision using a Snellen chart. B. Determine whether the client is able to see the nurse's hand motion. C. Perform a detailed examination of the client's external eye structures. D. Palpate the client's periocular regions.

The nursing lab instructor is teaching student nurses how to take blood pressure. To ensure accurate measurement, the lab instructor would teach the students to avoid which action? A. Measuring the BP after the client has been seated quietly for more than 5 minutes B. Taking the BP 10 minutes after nicotine or coffee ingestion C. Using a cuff with a bladder that encircles at least 80% of the limb D. Using a bare forearm supported at heart level on a firm surface

The staff educator is presenting a workshop on valvular disorders. When discussing the pathophysiology of aortic regurgitation, the educator describes what consequence of this disorder? A. Cardiac tamponade B. Left ventricular hypertrophy C. Right-sided heart failure D. Ventricular insufficiency

A client with a recent stroke history is admitted to a rehabilitation unit and placed on high fall risk precautions. The client is impulsive, easily distracted, frequently forgets his/her cane when walking, and the location of his/her room. What stroke conditions do these signs best indicate? A. Ischemic stroke B. Right hemispheric stroke C. Hemorrhagic stroke D. Left hemispheric stroke

B Rationale. In right hemispheric stroke, signs include a client that is easily distracted and has impulsive behavior and poor judgment. The client can be unaware of deficits likemotor weakness, as demonstrated by the client forgetting the cane. Clients can also have spatial or perceptual deficits. This means they can get lost in familiar and unfamiliar places. This client was unable to find his/her room. The client who has a right hemisphere stroke demonstrates weakness on the left side of the body. The client with left hemispheric stroke has signs such as paralysis or weakness in the right side of the body, right-sided visual deficits, and slow cautious behaviors. Ischemic and hemorrhagic strokes describe what caused the stroke rather than what side of the brain was affected. Signs and symptoms differ for each type of stroke. Ischemic strokes can include numbness to one side of the face. Headache, decreased level of consciousness, and seizures typically are signs of a hemorrhagic stroke.

The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment? A. Computed tomography (CT) scan B. Lumbar puncture C. Magnetic resonance imaging (MRI) D. Venous Doppler studies

B Rationale: A lumbar puncture in a client with increased ICP may cause the brain to herniate from the withdrawal of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. CT, MRI, and venous Doppler are considered noninvasive procedures and they would not affect the ICP itself.

The nurse is taking a health history of a new client who reports pain in the left lower leg and foot when walking. This pain is relieved with rest, and the nurse observes that the left lower leg is slightly edematous and is hairless. When planning this client's care, the nurse should most likely address which health problem? A. Coronary artery disease (CAD) B. Intermittent claudication C. Arterial embolus D. Raynaud disease

B Rationale: A muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest is experienced by clients with peripheral arterial insufficiency. Referred to as intermittent claudication, this pain is caused by the inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demands for nutrients and oxygen during exercise. The nurse would not suspect the client has CAD, arterial embolus, or Raynaud disease; none of these health problems produce this cluster of signs and symptoms.

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? A. Generalized pain B. Alteration in level of consciousness (LOC) C. Tonic-clonic seizures D. Shortness of breath

B Rationale: Alteration in LOC is the earliest sign of deterioration in a client after a hemorrhagic stroke, such as mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Sudden headache may occur, but generalized pain is less common. Seizures and shortness of breath are not identified as early signs of hemorrhagic stroke.

A client is undergoing diagnostic testing for chronic lymphocytic leukemia (CLL). Which assessment finding is certain to be present if the client has CLL? A. Increased numbers of blast cells B. Increased lymphocyte levels C. Intractable bone pain D. Thrombocytopenia with no evidence of bleeding

B Rationale: An increased lymphocyte count (lymphocytosis) is always present in clients with CLL. Each of the other listed symptoms may or may not be present, and none is definitive for CLL.

A client diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen. What should the nurse identify as an expected outcome of this treatment? A. Reduction in the appearance of new lesions on the MRI B. Decreased muscle spasms in the lower extremities C. Increased muscle strength in the upper extremities D. Decreased severity and duration of exacerbations

B Rationale: Baclofen, a -aminobutyric acid (GABA) agonist, is the medication of choice in treating spasms. It can be given orally or by intrathecal injection. Avonex and Betaseron reduce the appearance of new lesions on the MRI. Corticosteroids limit the severity and duration of exacerbations. Anticholinesterase agents increase muscle strength in the upper extremities.

A rapid response and stroke alert/code has been called for a client with deep vein thrombosis (DVT) of the left leg being treated with intravenous heparin. The client's international normalized ratio (INR) is 2.1 and vital signs are: Temperature 100.1°F (37.8°C), heart rate 102, blood pressure 190/100, respirations 14, and saturation 89% on room air. What are priority interventions for a client who is currently on anticoagulant therapy and having an ischemic stroke? A. Immediate intubation and urinary catheter placement B. Supplemental oxygen and monitoring blood glucose levels C. Antipyretics in order to keep the client in a state of hypothermia D. Antihypertensive medications and vital signs every two hours

B Rationale: Careful maintenance of cerebral hemodynamics to maintain cerebral perfusion is extremely important after a stroke. Interventions during this period include measures to reduce ICP. Other treatment measures include: Providing supplemental oxygen if saturation is below 95% and monitoring of blood glucose and management. Intubation is used only if necessary to establish a patent airway. For this client, a more expedient and less invasive measure would be supplemental oxygen. Urinary catheter placement is not a priority measure for this client. It is important to monitor for febrile events, but there is no protocol in place to keep the client hypothermic. Antihypertensive medication goals for blood pressure in the first 24 hours after a stroke remain controversial for a client who has not received thrombolytic therapy; antihypertensive treatment may be given to lower the blood pressure by 15% if the systolic blood pressure exceeds 220 mm Hg or the diastolic blood pressure exceeds 120 mm Hg. Vital signs for this client would be monitored closely and continuously until stable.

A client diagnosed with acute myeloid leukemia has just been admitted to the oncology unit. When writing this client's care plan, which potential complication should the nurse address? A. Pancreatitis B. Hemorrhage C. Arteritis D. Liver dysfunction

B Rationale: Complications of AML include bleeding and infection, which are the major causes of death. The risk of bleeding correlates with the level and duration of platelet deficiency. The low platelet count can cause ecchymoses and petechiae. Major hemorrhages also may develop when the platelet count drops to less than 10,000/mm?. The most common bleeding sources include gastrointestinal (GI), pulmonary, vaginal, and intracranial. Pancreatitis, arteritis, and liver dysfunction are generally not complications of leukemia.

The nurse is reviewing the echocardiography results of a client who has just been diagnosed with dilated cardiomyopathy (DCM). What changes in heart structure is this client experiencing? A. Dilated ventricles with atrophy of the ventricles B. Dilated ventricles without hypertrophy of the ventricles C. Dilation and hypertrophy of all four heart chambers D. Dilation of the atria and hypertrophy of the ventricles

B Rationale: DCM is characterized by significant dilation of the ventricles without significant concomitant hypertrophy and systolic dysfunction. The ventricles do not atrophy in clients with DCM.

A nurse is performing an admission assessment on a client with stage 3 human immunodeficiency virus (HIV). After assessing the client's gastrointestinal system and analyzing the data, which nursing diagnosis is most likely to be the priority? A. Acute abdominal pain B. Diarrhea C. Bowel incontinence D. Constipation

B Rationale: Diarrhea is a problem in many clients with HIV and acquired immunodeficiency syndrome. As such, this nursing diagnosis is more likely than abdominal pain, incontinence, or constipation, though none of these diagnoses is guaranteed not to apply.

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? A. Prevent complications of immobility. B. Maintain and improve cerebral tissue perfusion. C. Relieve anxiety and pain. D. Relieve sensory deprivation.

B Rationale: Each of the listed goals is appropriate in the care of a client recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the client's survival depends.

A client is scheduled to have an electronystagmography as part of a diagnostic workup for Ménière disease. What question is most important for the nurse to ask the client in preparation for this test? A. Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces? B. Do you currently take any tranquilizers or stimulants on a regular basis? C. Do you have a history of falls or problems with loss of balance? D. Do you have a history of either high or low blood pressure?

B Rationale: Electronystagmography measures changes in electrical potentials created by eye movements during induced nystagmus. Medications such as tranquilizers, stimulants, or antivertigo agents are withheld for 5 days before the test. Claustrophobia is not a significant concern associated with this test; rather, it is most often a concern for clients undergoing magnetic resonance imaging (MRI). Balance is impaired by Ménière disease; therefore, a client history of balance problems is important, but is not relevant to test preparation. Hypertension or hypotension, while important health problems, should not be affected by this test.

When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? A. Head turned slightly to the right side B. Elevation of the head of the bed C. Position changes every 15 minutes while awake D. Extension of the neck

B Rationale: Elevation of the head of the bed promotes venous drainage and lowers ICP; the nurse should avoid flexing or extending the neck or turning the head side to side. The head should be in a neutral midline position. Excessively frequent position changes are unnecessary.

The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest? A. Taking a hot bath at least once daily B. Resting in an air-conditioned room whenever possible C. Increasing the dose of muscle relaxants D. Avoiding naps during the day

B Rationale: Fatigue is a common symptom of clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.

A nurse is caring for a client with acute myeloid leukemia who is preparing to undergo induction therapy. In preparing a plan of care for this client, the nurse should assign the highest priority to which nursing diagnosis? A. Activity intolerance B. Risk for infection C. Acute confusion D. Risk for spiritual distress

B Rationale: Induction therapy places the client at risk for infection, thus this is the priority nursing diagnosis. During the time of induction therapy, the client is very ill, with bacterial, fungal, and occasional viral infections; bleeding and severe mucositis, which causes diarrhea; and marked decline in the ability to maintain adequate nutrition. Supportive care consists of administering blood products and promptly treating infections. Immobility, confusion, and spiritual distress are possible, but infection is the client's most acute physiologic threat.

A client who has acquired immunodeficiency syndrome (AIDS) has been admitted for the treatment of Kaposi sarcoma. Which nursing diagnosis should the nurse associate with this complication of AIDS? A. Risk for disuse syndrome related to Kaposi sarcoma B. Impaired skin integrity related to Kaposi sarcoma C. Diarrhea related to Kaposi sarcoma D. Impaired swallowing related to Kaposi sarcoma

B Rationale: Kaposi sarcoma is a type of cancer caused by human herpesvirus-8 that involves the epithelial layer of blood and lymphatic vessels. It exhibits a variable and aggressive course, ranging from localized cutaneous lesions to disseminated disease involving multiple organ systems. Cutaneous signs, which may be the first manifestation of HIV, can appear anywhere on the body and are usually brownish pink to deep purple. They may be flat or raised and surrounded by ecchymosis (hemorrhagic patches) and edema. This malignancy does not directly affect swallowing or bowel motility and it does not constitute a risk for disuse syndrome.

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action? A. Prepare to transfuse packed red blood cells. B. Prepare for interventions to increase the client's BP. C. Place the client in the Trendelenburg position. D. Prepare an ice bath to lower core body temperature.

B Rationale: Manifestations of neurogenic shock include decreased BP and heart rate. Cardiac markers would be expected to rise in cardiogenic shock. Transfusion, repositioning, and ice baths are not indicated interventions.

The nurse is caring for an older adult with a diagnosis of hypertension who is being treated with a diuretic and beta-blocker. Which item should the nurse integrate into the management of this client's hypertension? A. Ensure that the client receives a larger initial dose of antihypertensive medication due to impaired absorption. B. Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion. C. Recognize that an older adult is less likely to adhere to the medication regimen than a younger client. D. Carefully assess for weight loss because of impaired kidney function resulting from normal aging.

B Rationale: Older adults have impaired cardiovascular reflexes and thus are more sensitive to extracellular volume depletion caused by diuretics. The nurse needs to assess hydration status, low BP, and postural hypotension carefully. Older adults may have impaired absorption, but they do not need a higher initial dose of an antihypertensive than a younger person. Adherence to treatment is not necessarily linked to age. Kidney function and absorption decline with age; less, rather than more, antihypertensive medication is prescribed. Weight gain is not necessarily indicative of kidney function decline.

The nurse is creating a plan of care for a client with acute coronary syndrome. What nursing action should be included in the client's care plan? A. Facilitate daily arterial blood gas (ABG) sampling. B. Administer supplementary oxygen, as needed. C. Have client maintain supine positioning when in bed. D. Perform chest physiotherapy, as indicated.

B Rationale: Oxygen should be given along with medication therapy to assist with symptom relief. Administration of oxygen raises the circulating level of oxygen to reduce pain associated with low levels of myocardial oxygen. Physical rest in bed with the head of the bed elevated or in a supportive chair helps decrease chest discomfort and dyspnea. ABGs are diagnostic, not therapeutic, and they are rarely needed on a daily basis. Chest physiotherapy is not used in the treatment of ACS.

The nurse is providing care for a client who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? A. Numbness and tingling in the distal extremities B. Unequal peripheral pulses between extremities C. Visible clubbing of the fingers and toes D. Reddened extremities with muscle atrophy

B Rationale: PAD assessment may manifest as unequal pulses between extremities, with the affected leg cooler and paler than the unaffected leg. Intermittent claudication is far more common than sensations of numbness and tingling. Clubbing and muscle atrophy are not associated with PAD.

A nurse is providing care for a client who has a rheumatic disorder. The nurse's focused assessment includes the client's mood, behavior, level of consciousness, and neurologic status. Which diagnosis is most likely for this client? A. Osteoarthritis (OA) B. Systemic lupus erythematosus (SLE) C. Rheumatoid arthritis (RA) D. Gout

B Rationale: SLE has a high degree of neurologic involvement and can result in central nervous system changes. The client and family members are asked about any behavioral changes, including manifestations of neurosis or psychosis. Signs of depression are noted, as are reports of seizures, chorea, or other central nervous system manifestations. OA, RA, and gout lack this dimension.

A client who is undergoing consolidation therapy for the treatment of leukemia has been experiencing debilitating fatigue. How can the nurse best meet this client's needs for physical activity? A. Teach the client about the risks of immobility and the benefits of exercise. B. Assist the client to a chair during awake times, as tolerated. C. Collaborate with the physical therapist to arrange for stair exercises. D. Teach the client to perform deep breathing and coughing exercises.

B Rationale: Sitting up in a chair is preferable to bed rest, even if a client is experiencing severe fatigue. A client who has debilitating fatigue would not likely be able to perform stair exercises. Teaching about mobility may be necessary, but education must be followed by interventions that actually involve mobility. Deep breathing and coughing reduce the risk of respiratory complications but are not substitutes for physical mobility in preventing deconditioning.

A nurse is assigned four clients with diagnoses that rule out myocardial infarction (MI) due to chest pain. Which client's test results best demonstrate the specific diagnosis of unstable angina (USA)? A. A 63-year-old client with elevated troponins and no elevation in the ST segment. B. A 72-year-old client with an increase in myoglobin, no elevation in the ST segment, and no elevation in troponins. C. A 54-year-old client with elevated creatine kinase myocardial band (CK-MB) and ST segment elevations in two contiguous leads on the electrocardiogram (ECG). D. A 48-year-old client with T wave inversions, ST elevation, and abnormal Q waves.

B Rationale: The 72-year-old client with chest pain had clinical manifestations of coronary ischemia, but the ECG showed no evidence of an acute MI. The 72-year-old client had an elevated myoglobin, which is a biomarker but is not a very specific indicator of a cardiac event because an elevation may also occur due to seizures, muscle diseases, trauma, and surgery. The 63-year-old client had test results consistent with a non-ST-elevated myocardial infarction: elevated cardiac biomarkers but no ECG evidence of an acute MI. The 48- and 54-year-old clients had test results consistent with an ST-elevated myocardial infarction: elevated cardiac biomarkers, ECG changes in two contiguous leads, ST elevation, and Q wave abnormalities.

A nurse is caring for a client who has been diagnosed with leukemia. The nurse's most recent assessment reveals the presence of ecchymoses on the client's sacral area and petechiae on the forearms. In addition to informing the client's primary care provider, the nurse should perform what action? A. Initiate measures to prevent venous thromboembolism (VTE). B. Check the client's most recent platelet level. C. Place the client on protective isolation. D. Ambulate the client to promote circulatory function.

B Rationale: The client's signs are suggestive of thrombocytopenia, thus the nurse should check the client's most recent platelet level. VTE is not a risk and this does not constitute a need for isolation. Ambulation and activity may be contraindicated due to the risk of bleeding.

A client with pericarditis has just been admitted to the critical care unit. The nurse planning the client's care should prioritize which nursing diagnosis? A. Anxiety related to pericarditis B. Acute pain related to pericarditis C. Ineffective tissue perfusion related to pericarditis D. Ineffective breathing pattern related to pericarditis

B Rationale: The most characteristic symptom of pericarditis is chest pain, although pain also may be located beneath the clavicle, in the neck, or in the left trapezius (scapula) region. The pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning. Anxiety is highly plausible and should be addressed, but chest pain is a nearly certain accompaniment to the disease. Breathing and tissue perfusion are likely to be at risk, but pain is certain, especially in the early stages of treatment.

A nurse has written a plan of care for a client diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. Which intervention is the most appropriate for this diagnosis? A. Elevate the legs and arms above the heart when resting. B. Encourage the client to engage in a moderate amount of exercise. C. Encourage extended periods of sitting or standing. D. Discourage walking in order to limit pain.

B Rationale: The nursing diagnosis of altered peripheral tissue perfusion related to compromised circulation requires interventions that focus on improving circulation. Encouraging the client to engage in a moderate amount of exercise serves to improve circulation. Elevating the client's legs and arms above the heart when resting would be passive and fails to promote circulation. Encouraging long periods of sitting or standing would further compromise circulation. The nurse should encourage, not discourage, walking to increase circulation and decrease pain.

A client is in the primary infection stage of human immunodeficiency virus (HIV). Which statement regarding this client's current health status is most accurate? A. The client's HIV antibodies are successfully, but temporarily, killing the virus. B. The client is infected with HIV but lacks HIV-specific antibodies. C. The client's risk for opportunistic infections is at its peak. D. The client may or may not develop long-standing HIV infection.

B Rationale: The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection. The virus is not being eradicated and infection

The nurse's assessment of a client with thyroidectomy suggests tetany, and a review of the most recent blood work corroborates this finding. The nurse should prepare to administer what intervention? A. Oral calcium chloride and vitamin D B. IV calcium gluconate C. STAT levothyroxine D. Administration of parathyroid hormone (PTH)

B Rationale: When hypocalcemia and tetany occur after a thyroidectomy, the immediate treatment is administration of IV calcium gluconate. This has a much faster therapeutic effect than PO calcium or vitamin D supplements. PTH and levothyroxine are not used to treat this complication.

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client? A. Respiratory distress and projectile vomiting B. Bradycardia and hypertension C. Tachycardia and agitation D. Third-spacing and hyperthermia

B Rationale: Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection ("goose bumps"), bradycardia, and hypertension. It occurs in cord lesions above T6 after spinal shock has resolved; it does not result in vomiting, tachycardia, or third-spacing.

The nurse is caring for a client with Addison disease who is scheduled for discharge. When teaching the client about hormone replacement therapy, the nurse should address what topic? A. The possibility of precipitous weight gain B. The need for lifelong steroid replacement C. The need to match the daily steroid dose to immediate symptoms D. The importance of monitoring liver function

B Rationale: Because of the need for lifelong replacement of adrenal cortex hormones to prevent addisonian crises, the client and family members receive explicit education about the rationale for replacement therapy and proper dosage. Doses are not adjusted on a short-term basis. Weight gain and hepatotoxicity are not common adverse effects.

A client with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? A. Arrange for the client to receive a low residue diet. B. Position the client upright during feeding. C. Suction the client following each meal. D. Withhold liquids until the client has finished eating.

B Rationale: Correct, upright positioning is necessary to prevent aspiration in the client with dysphagia. There is no need for a low-residue diet and suctioning should not be performed unless there is an apparent need. Liquids do not need to be withheld during meals in order to prevent aspiration.

During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructor's best response? A. "Cardioversion is done on a beating heart; defibrillation is not." B. "The difference is the timing of the delivery of the electric current." C. "Defibrillation is synchronized with the electrical activity of the heart, but cardioversion is not." D. "Cardioversion is always attempted before defibrillation because it has fewer risks."

B Rationale: One major difference between cardioversion and defibrillation is the timing of the delivery of electrical current. In cardioversion, the delivery of the electrical current is synchronized with the client's electrical events; in defibrillation, the delivery of the current is immediate and unsynchronized. Both can be done on beating heart (i.e., in a dysrhythmia). Cardioversion is not necessarily attempted first.

A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include? A. How to differentiate between hemorrhagic and ischemic stroke B. Risk factors for ischemic stroke C. How to correctly modify the home environment D. Techniques for adjusting the client's medication dosages at home

A client has returned to the floor after having a thyroidectomy for thyroid cancer. What laboratory finding may be an early indication of parathyroid gland injury or removal? A. Hyponatremia B. Hypophosphatemia C. Hypocalcemia D. Hypokalemia

The nurse is reviewing the medication administration record of a client who takes a variety of medications for the treatment of hypertension. What potential therapeutic benefits of antihypertensives should the nurse identify? Select all that apply. A. Increased venous return B. Decreased peripheral resistance C. Decreased blood volume D. Decreased strength and rate of myocardial contractions E. Decreased blood viscosity

B, C, D Rationale: The medications used for treating hypertension decrease peripheral resistance, blood volume, or the strength and rate of myocardial contraction. Antihypertensive medications do not increase venous return or decrease blood viscosity.

A client is brought to the emergency department. The client is a type 2 diabetic and is experiencing hyperglycemic hyperosmolar syndrome (HHS). The nurse should identify what components of HHS? Select all that apply. A. Leukocytosis B. Glycosuria C. Dehydration D. Hypernatremia E. Hyperglycemia

B, C, E

The nurse is caring for a client at risk for an addisonian crisis. For what associated signs and symptoms should the nurse monitor the client? Select all that apply. A. Epistaxis B. Pallor C. Rapid respiratory rate D. Bounding pulse E. Hypotension

B, C, E Rationale: The client at risk is monitored for signs and symptoms indicative of addisonian crisis, which can include shock; hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness. Epistaxis and a bounding pulse are not symptoms or signs of an addisonian crisis.

A nurse is taking care of a client with swallowing difficulties after a stroke. What are some interventions the nurse can accomplish to prevent the client from aspirating while eating? Select all that apply. A. Encourage the client to increase his/her intake of water and juice. B. Assist the client out of bed and into the chair for meals. C. Instruct the client to tuck his/her chin towards their chest when swallowing. D. Request a swallowing assessment by a speech therapist before the client's discharge E. Recommend the insertion of a percutaneous endoscopic gastrostomy (PEG) tube.

B,C

A client has come into the free clinic asking to be tested for human immunodeficiency virus (HIV) infection. The client asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the acquired immunodeficiency syndrome (AIDS) virus are present in the blood, this indicates that the client has which of the following? A. Immunity to HIV B. An intact immune system C. An AIDS-related complication D. An HIV infection

A 56-year-old client has come to the clinic for a routine eye examination and is told bifocals are needed. The client asks the nurse what change in the eyes has caused this need for bifocals. How should the nurse respond? A. "You know, you are getting older now and we change as we get older." B. "The parts of our eyes age, just like the rest of us, and this is nothing to cause you to worry." C. "There is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation." D. "The eye gets shorter, back to front, as we age and it changes how we see things."

A 79-year-old client is admitted to the medical unit with digital gangrene. The client reports that the problem first began when the client stubbed the toe going to the bathroom in the dark. In addition to this trauma, the nurse should suspect that the client has a history of which health problem? A. Raynaud phenomenon B. Coronary artery disease (CAD) C. Arterial insufficiency D. Varicose veins

A client underwent an antibody test for human immunodeficiency virus (HIV) as part of a screening process and has just been told that the results were positive. Which anticipatory guidance regarding the next step should the nurse provide to the client? A. The client will be started on fluoxetine in 1 month. B. Antiretroviral therapy will begin within 3 months. C. Follow-up testing will be promptly performed to confirm the result. D. The client will be monitored for signs and symptoms of HIV to determine the need for treatment.

A client who has been on long-term phenytoin therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the client's plan of care? A. Monitoring of pulse oximetry B. Administration of a low-protein diet C. Administration of thorough oral hygiene D. Fluid restriction as prescribed

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

A client with AIDS is admitted to the hospital with AIDS-related wasting syndrome and AIDS-related anorexia. What drug has been found to promote significant weight gain in clients with AIDS by increasing body fat stores? A. Psyllium B. Momordica charantia C. Megestrol D. Ranitidine

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? A. Acute pain B. Septicemia C. Bleeding D. Seizures

A client with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the client's risk for orthostatic hypotension? A. Administer an IV bolus of normal saline prior to repositioning. B. Maintain bed rest until normal BP regulation returns. C. Monitor the client's BP before and during position changes. D. Allow the client to initiate repositioning.

A client with increased intracranial pressure (IC) has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? A. Encephalitis B. Cerebral spinal fluid leak C. Meningitis D. Catheter occlusion

A client with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the client has understood health education when the client makes what statement ? A. "I'll make sure I get enough exposure to sunlight to keep up my vitamin D levels." B. "I'll try to be as physically active as possible between flare-ups." C. "I'll make sure to monitor my body temperature on a regular basis." D. "I'll stop taking my steroids when I get relief from my symptoms."

A client's primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the client's immune response. This is known as what physiologic state? A. Static stage B. Latent stage C. Viral set point D. Window period

A nurse is admitting a client to the medical unit who has a history of peripheral artery disease (PAD). While providing the health history, the client reports smoking about two packs of cigarettes a day, having a history of alcohol abuse, and not exercising. Which topic would be the priority health education for this client? A. The lack of exercise, which is the main cause of PAD B. The likelihood that heavy alcohol intake is a significant risk factor for PAD C. The nicotine in cigarettes, which is a powerful vasoconstrictor and may cause or aggravate PAD D. Alcohol, which suppresses the immune system, creates high glucose levels, and may cause PAD

A nurse is performing the health history and physical assessment of a client who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA? A. Cool joints with decreased range of motion B. Signs of systemic infection C. Joint stiffness lasting longer than 1 hour, especially in the morning D. Visible atrophy of the knee and shoulder joints

An adult client with third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most likely show? A. PP interval and R interval are irregular. B. PP interval is equal to RR interval. C. Fewer QRS complexes than P waves D. PR interval is constant.

The nurse is admitting a client with a diagnosis of left ventricular hypertrophy. The client reports dyspnea on exertion, as well as fatigue. Which diagnostic tool would be most helpful in diagnosing this type of myopathy? A. Cardiac catheterization B. Arterial blood gases C. Echocardiogram D. Exercise stress test

The nurse is assessing a new adult client. What characteristic of this client's status should the nurse identify as increasing the client's risk for glaucoma? A. The client uses over-the-counter NSAIDs. B. The client has a history of stroke. C. The client has diabetes. D. The client has Asian ancestry.

The nurse is caring for a client who has had a dysrhythmic event. The nurse is aware of the need to assess for signs of diminished cardiac output (CO). What change in status may signal to the nurse a decrease in cardiac output? A. Increased blood pressure B. Bounding peripheral pulses C. Changes in level of consciousness D. Skin flushing

The nurse is caring for a client who has just had an implantable cardioverter defibrillator (ICD) placed. What is the priority area for the nurse's assessment? A. Assessing the client's mobility B. Facilitating transthoracic echocardiography C. Vigilant monitoring of the client's ECG D. Close monitoring of the clients peripheral perfusion.

The nurse is caring for an adult client who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina? A. Ineffective breathing pattern related to decreased cardiac output B. Anxiety related to fear of death C. Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD) D. Impaired skin integrity related to CAD

The nurse is performing an intake assessment on a client with a new diagnosis of coronary artery disease. What would be the most important determination to make during this intake assessment? A. Whether the client and involved family members understand the role of genetics in the etiology of the disease B. Whether the client and involved family members understand dietary changes and the role of nutrition C. Whether the client and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately D. Whether the client and involved family members understand the importance of social support and community agencies

The nurse is planning the care of a client with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this client's care? A. Risk for disturbed sensory perception B. Risk for unilateral neglect C. Risk for falls D. Risk for ineffective health maintenance

The nurse recognizes that a client with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? A. Position the client in a high-Fowler position when in bed. B. Support the knees with a pillow when the client is in bed. C. Perform passive ROM exercises as prescribed. D. Administer NSAIDs as prescribed.

The nursing educator is presenting a case study of an adult client who has abnormal ventricular depolarization. This pathologic change would be most evident in what component of the ECG? A. P wave B. T wave C. QRS complex D. U wave

A client with a left hemispheric stroke is having difficulty with their normal speech patterns. The nurse is not sure whether the client has expressive aphasia or apraxia. Which statement would most likely be reflective of apraxia? A. The nurse gives direction to get out of bed but the client does not understand. B. The client points and gestures to an object needed on the overhead table. C. The client starts by saying "good morning" but finishes with saying "good day" to the nurse. D. The client sits up and turns to one side to see the object and states what is needed.

C Rationale: Apraxia is an inability to perform a previously learned action as may be seen when a client makes verbal substitutions for desired syllables or words. The client changed "good morning" to "good day," which is suggestive of this condition. Aphasia which can be expressive aphasia (inability to express oneself) or receptive aphasia (inability to understand language) is more likely represented with the client being unable to understand directions to get out of bed and by pointing and gesturing to an object needed rather than speaking. The client turning to one side so he/she can see the object may be more indicative of blindness to one side (homonymous hemianopsia).

A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client? A. Risk for impaired skin integrity related to immobility and sensory loss B. Impaired physical mobility related to loss of motor function C. Ineffective breathing patterns related to weakness of the intercostal muscles D. Urinary retention related to inability to void spontaneously

C Rationale: A nursing diagnosis related to breathing pattern would be the priority for this client. A C4 spinal cord injury will require ventilatory support, due to the diaphragm and intercostals being affected. The other nursing diagnoses would be used in the care plan, but not designated as a higher priority than ineffective breathing patterns.

Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data? A. The symptoms indicate angina and should be treated as such. B. The symptoms indicate a pulmonary etiology rather than a cardiac etiology. C. The symptoms indicate an acute coronary episode and should be treated as such. D. Treatment should be determined pending the results of an exercise stress test.

C Rationale: Angina and MI have similar symptoms and are considered the same process but are on different points along a continuum. That the client's symptoms are unrelieved by rest suggests an acute coronary episode rather than angina. Pale, cool skin and sudden onset are inconsistent with a pulmonary etiology. Treatment should be initiated immediately regardless of diagnosis.

A client with rheumatoid arthritis comes into the clinic for a routine check-up. On assessment the nurse notes that the client appears to have lost some ability to function since the last office visit. What is the nurse's most appropriate action? A. Arrange a family meeting in order to explore assisted living options. B. Refer the client to a support group. C. Arrange for the client to be assessed in the home environment. D. Refer the client to social work.

C Rationale: Assessment in the client's home setting can often reveal more meaningful data than an assessment in the health care setting. There is no indication that assisted living is a pressing need or that the client would benefit from social work or a support group.

The nurse is participating in the care conference for a client with ACS. What goal should guide the care team's selection of assessments, interventions, and treatments? A. Maximizing cardiac output while minimizing heart rate B. Decreasing energy expenditure of the myocardium C. Balancing myocardial oxygen supply with demand D. Increasing the size of the myocardial muscle

C Rationale: Balancing myocardial oxygen supply with demand (e.g., as evidenced by the relief of chest pain) is the top priority in the care of the client with ACS. Treatment is not aimed directly at minimizing heart rate because some clients experience bradycardia. Increasing the size of the myocardium is never a goal. Reducing the myocardium's energy expenditure is often beneficial, but this must be balanced with productivity.

The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? A. Confusion B. Uncertainty C. Depression D. Disassociation

C Rationale: Depression is a common and serious problem in the client who has had a stroke. It can result from a profound disruption in his or her life and changes in total function, leaving the client with a loss of independence. The nurse needs to encourage the client to verbalize feelings to assess the effect of the stroke on self-esteem. Confusion, uncertainty, and disassociation are not the most common client response to a change in body image, although each can occur in some clients.

A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? A. Unclassified seizure B. Absence seizure C. Generalized seizure D. Focal seizure

C Rationale: Generalized seizures often involve both hemispheres of the brain, causing both sides of the body to react. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction). This pattern of rigidity does not occur in clients who experience unclassified, absence, or focal seizures.

The nurse is caring for a client diagnosed with an ischemic stroke and knows that effective positioning of the client is important. Which of the following should be integrated into the client's plan of care? A. The client's hip joint should be maintained in a flexed position. B. The client should be in a supine position unless ambulating. C. The client should be placed in a prone position for 15 to 30 minutes several times a day. D. The client should be placed in a Trendelenburg position two to three times daily to promote cerebral perfusion.

C Rationale: If possible, the clients placed in a prone position for 15 to 30 minutes several times a day. A small pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper third of the thigh. This helps to promote hyperextension of the hip joints, which is essential for normal gait, and helps prevent knee and hip flexion contractures. The hip joints should not be maintained in flexion and the Trendelenburg position is not indicated.

A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A. Epidural hemorrhage B. Hypertensive emergency C. Spinal shock D. Hypovolemia

C Rationale: In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur. Hypovolemia, hemorrhage, and hypertension do not cause this sudden change in neurologic function.

A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? A. Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes B. Flexor spasm, clonus, and negative Babinski reflex C. Blurred vision, intention tremor, and urinary hesitancy D. Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

C Rationale: Optic neuritis, leading to blurred vision, is a common early sign of MS, as is intention tremor (tremor when performing an activity). Nerve damage can cause urinary hesitancy. In MS, deep tendon reflexes are increased or hyperactive. A positive Babinski reflex is found in MS. Abdominal reflexes are absent with MS.

How should the nurse best position a client who has leg ulcers that are venous in origin? A. Keep the client's legs flat and straight. B. Keep the client's knees bent to a 45-degree angle and supported with pillows. C. Elevate the client's lower extremities. D. Dangle the client's legs over the side of the bed.

C Rationale: Positioning of the legs depends on whether the ulcer is of arterial or venous origin. With ulcers of venous origin, the lower extremities should be elevated to avoid dependent edema. Simply bending the knees to a 45-degree angle would not prevent dependent edema, as they must be elevated above the level of the heart. Dangling the client's legs and applying pillows may further compromise venous return.

A client has undergone diagnostic testing and received a diagnosis of sinus bradycardia attributable to sinus node dysfunction. When planning this client's care, which nursing diagnosis is most appropriate? A. Risk for acute pain B. Risk for unilateral neglect C. Risk for activity intolerance D. Risk for fluid volume excess

C Rationale: Sinus bradycardia causes decreased cardiac output that is likely to cause activity intolerance. It does not typically cause pain, fluid imbalances, or neglect of a unilateral nature.

The nurse is providing health education to an older adult client. What should the nurse teach the client about the relationship between hypertension and age? A. "Because of reduced smooth muscle tone in blood vessels, blood pressure tends to go down with age, not up." B. "Decreases in the strength of arteries and the presence of venous insufficiency cause hypertension in older adults." C. "Structural and functional changes in the cardiovascular system that occur with age contribute to an increase in blood pressure." D. "The neurologic system of older adults is less efficient at monitoring and regulating blood pressure."

C Rationale: Structural and functional changes in the heart and blood vessels contribute to an increase in BP that occurs with aging. Venous insufficiency does not cause hypertension, however. Increased BP is not primarily a result of neurologic changes.

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose? A. To decrease cerebral edema B. To prevent seizure activity that is common following a TIA C. To remove atherosclerotic plaques blocking cerebral flow D. To determine the cause of the TIA

C Rationale: The main surgical procedure for select clients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in clients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.

A client with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond? A. "Complementary therapies generally have not been approved, so clients are usually discouraged from using them." B. "Researchers have not looked at the benefits of alternative therapy for clients with HIV, so we suggest that you stay away from these therapies until there is solid research data available." C. "Many clients with HIV use some type of alternative therapy and, as with most health treatments, there are benefits and risks. D. "You'll need to meet with your doctor to choose between an alternative approach to treatment and a medical approach.

C Rationale: The nurse should approach the topic of alternative or complementary therapies from an open-ended, supportive approach, emphasizing the need to communicate with care providers. Complementary therapies and medical treatment are not mutually exclusive, though some contraindications exist. Research supports the efficacy of some forms of complementary and alternative treatment.

The nurse is creating a plan of care for a client with cardiomyopathy. Which goal would be a priority for the client? A. Absence of complications B. Adherence to the self-care program C. Improved cardiac output D. Increased activity tolerance

C Rationale: The priority nursing diagnosis of a client with cardiomyopathy would include improved or maintained cardiac output. Regardless of the category and cause, cardiomyopathy may lead to severe heart failure, lethal dysrhythmias, and death. The pathophysiology of all cardiomyopathies is a series of progressive events that culminate in impaired cardiac output. Absence of complications, adherence to the self-care program, and increased activity tolerance should be included in the care plan, but they do not have the priority of improved cardiac output.

The nurse is caring for a client with acute pericarditis. Which nursing management would be instituted to minimize complications? A. The nurse keeps the client isolated to prevent nosocomial infections. B. The nurse encourages coughing and deep breathing. C. The nurse helps the client with activities until the pain and fever subside. D. The nurse encourages increased fluid intake until the infection resolves.

C Rationale: To minimize complications, the nurse helps the client with activity restrictions until the pain and fever subside. As the client's condition improves, the nurse encourages gradual increases of activity. Actions to minimize complications of acute pericarditis do not include keeping the client isolated. Due to pain, coughing and deep breathing are not normally encouraged. An increase in fluid intake is not always necessary.

A 17-year-old client is being treated in the intensive care unit after going into cardiac arrest during a football practice. Diagnostic testing reveals cardiomyopathy as the cause of the arrest. Which type of cardiomyopathy is particularly common among young people who appear otherwise healthy? A. Dilated cardiomyopathy (DCM) B. Arrhythmogenic right ventricular cardiomyopathy (ARVC) C. Hypertrophic cardiomyopathy (HM) D. Restrictive or constrictive cardiomyopathy (RCM)

C Rationale: With HCM, cardiac arrest (i.e., sudden cardiac death) may be the initial manifestation in young people, including athletes. DCM, ARVC, and RCM are not typically present in younger adults who appear otherwise healthy.

A nurse is assisting a client who had a recent stroke with getting dressed for physical therapy. The client looks at each piece of clothing before putting it on the body. The client states, "This is how I know what item I am holding." What impairment is this client likely experiencing? A. Homonymous hemianopsia B. Receptive aphasia C. Agnosia D. Hemiplegia

C Rationale: Agnosia is the loss of the ability to recognize objects through a particular sensory system; it may be visual, auditory, or tactile. The client was able to see what was being held but was not recognizing specific garments by just touching them. Because the client was able to see homonymous hemianopsia, which is blindness in half of the visual field in one or both eyes, is unlikely. Receptive aphasia is an inability to understand language. Hemiplegia is a motor/ambulatory dysfunction. The presented scenario did not support these findings.

The nurse is caring for a client with a diagnosis of Addison disease. What sign or symptom is most closely associated with this health problem? A. Truncal obesity B. Hypertension C. Muscle weakness D. Moon face

C Rationale: Clients with Addison disease demonstrate muscular weakness, anorexia, gastrointestinal symptoms, fatigue, emaciation, dark pigmentation of the skin, and hypotension. Clients with Cushing syndrome demonstrate truncal obesity, "moon" face, acne, abdominal striae, and hypertension.

The nurse is providing education to a client that is to undergo a thyroidectomy. When planning care for this client, the nurse should include which example in their education? A. Pharmacological therapy is not necessary prior to the surgery. B. Symptoms of the disease will disappear immediately after surgery. C. Balance periods of activity and exercise with rest. D. There is no risk for hypothyroidism after the surgery.

C Rationale: Due to the fatigue of the disease process itself and the stress of surgery, there needs to be an even balance of activity and rest for the client. Pharmacological therapy is needed prior to surgery. Symptoms of the disease will gradually taper off after surgery. There is a risk for hypothyroidism after surgery due to the partial or complete removal of thyroid gland.

The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action? A. Position the client the high Fowler position as tolerated. B. Administer osmotic diuretics as prescribed. C. Participate in interventions to increase cerebral perfusion pressure (CPP). D. Prepare the client for craniotomy.

C Rationale: The CPP is 55 mm Hg, which is considered low. The normal CP is 70 to 100 mm Hg. Clients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. As a result, interventions are necessary. A craniotomy is not directly indicated. Diuretics and increased height of bed would exacerbate the client's condition.

The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A. Mild, intermittent seizures can be expected. B. Take ibuprofen for a serious headache. C. Take antihypertensive medication as prescribed. D. Drowsiness is normal for the first week after discharge.

C Rationale: The client and family are provided with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke and to prepare the client to return home. Client and family teaching includes information about the causes of hemorrhagic stroke and its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness and behavioral changes. Hypertension is the most serious risk factor, suggesting that appropriate antihypertensive treatment is essential for a client being discharged. Seizure activity is not normal; reports of a serious headache should be reported to the health care provider before any medication is taken. Drowsiness is not normal or expected.

A client has been admitted to the postsurgical unit following a thyroidectomy. To promote comfort and safety, how should the nurse best position the client? A. Side-lying with one pillow under the head B. Head of the bed elevated 30 degrees and no pillows placed under the head C. Semi-Fowler with the head supported on two pillows D. Supine, with a small roll supporting the neck

C Rationale: When moving and turning the client, the nurse carefully supports the client's head and avoids tension on the sutures. The most comfortable position is the semi-Fowler position, with the head elevated and supported by pillows.

Diagnostic testing has resulted in a diagnosis of acute myeloid leukemia (AML) in an adult client who is otherwise healthy. The client and the care team have collaborated and the client will soon begin induction therapy. The nurse should prepare the client for: A. daily treatment with targeted therapy medications. B. radiation therapy on a daily basis. C. hematopoietic stem cell transplantation. D. an aggressive course of chemotherapy.

A 35-year-old client is admitted to the hospital reporting severe headaches, vomiting, and testicular pain. The client's blood work shows reduced numbers of platelets, leukocytes, and erythrocytes, with a high proportion of immature cells. The nurse caring for this client suspects which diagnosis? A. Acute myeloid leukemia (AML) B. Chronic myeloid leukemia (CML) C. Myelodysplastic syndromes (MDS) D. Acute lymphocytic leukemia (ALL)

A 55-year-old client comes to the clinic for a routine check-up. The client's BP is 159/100 mm Hg and the health care provider diagnoses hypertension after referring to previous readings. The client asks why it is important to treat hypertension, since the client denies any discomfort. What would be the nurse's best response? A. "Hypertension can cause you to develop dangerous blood clots in your legs that can migrate to your lungs." B. "Hypertension puts you at increased risk of type 1 diabetes and cancer in your age group." C. "Hypertension is the leading cause of death in people your age." D. "Hypertension greatly increases your risk of stroke and heart disease."

The nurse is creating a plan of care for a client who has a recent diagnosis of MS. Which of the following should the nurse include in the client's care plan? A. Encourage the client to void every hour. B. Order a low-residue diet. C. Provide total assistance with all ADLs. D. Instruct the client on daily muscle stretching.

A client is brought into the emergency department (ED) by family members, who tell the nurse the client grabbed their chest and reported substernal chest pain. The care team recognizes the need to monitor the client's cardiac function closely while interventions are performed. Which form of monitoring should the nurse anticipate? A. Left-sided heart catheterization B. Cardiac telemetry C. Transesophageal echocardiography D. Hardwire continuous electrocardiogram (ECG) monitoring

A client is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this client's care? A. Antioxidant supplements, vitamin C and E, beta-carotene, and selenium B. Eyeglasses or magnifying lenses C. Corticosteroid eye drops D. Surgical intervention

A client is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the client's statements best demonstrates an adequate understanding? A. "I need to call the doctor if I get nauseated." B. "I need to call the doctor if I have a light morning discharge." C. "I need to call the doctor if I get a scratchy feeling." D. "I need to call the doctor if I see flashing lights."

A client presents to the ED reporting a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The client mentions to the nurse experiencing a sudden hearing loss. What would the nurse suspect the client's diagnosis will be? A. Ossiculitis B. Ménière disease C. Ototoxicity D. Labyrinthitis

A client presents to the clinic reporting intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the client that angina is most often attributable to what cause? A. Decreased cardiac output B. Decreased cardiac contractility C. Infarction of the myocardium D. Coronary arteriosclerosis

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event? A. The client received a blood transfusion. B. The client's analgesia regimen was recently changed. C. The client was not repositioned during the night shift. D. The client's urinary catheter became occluded.

A client with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education? A. Risk factors for postoperative cytomegalovirus (CMV) B. Compensating for vision loss for the next several weeks C. Nonpharmacologic pain management strategies D. Signs and symptoms of increased intraocular pressure

A client with an ischemic stroke has been brought to the emergency room. The health care provider institutes measures to restore cerebral blood flow. What area of the brain would most likely benefit from this immediate intervention? A. Cerebral cortex B. Temporal lobe C. Central sulcus D. Penumbra region

A community health nurse is performing a visit to the home of a client who has a history of rheumatoid arthritis (RA). On which aspect of the client's health should the nurse focus most closely during the visit? A. Understanding of rheumatoid arthritis B. Risk for cardiopulmonary complications C. Social support system D. Functional status

A group of nurses is participating in orientation to a telemetry unit. The nurse who is providing the education should tell the class that ST segments: A. are the part of an ECG that reflects systole. B. are the part of an ECG used to calculate ventricular rate and rhythm. C. are the part of an ECG that reflects the time from ventricular depolarization through repolarization. D. represent early ventricular repolarization.

A middle-aged client has sought care from the primary provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the client to seek care? A. Cognitive declines B. Personality changes C. Contractures D. Difficulty in coordination

A nurse in the rehabilitation unit is caring for an older adult client who is in cardiac rehabilitation following an MI. The nurse's plan of care calls for the client to walk for 10 minutes 3 times a day. The client questions the relationship between walking and heart function. How should the nurse best reply? A. "The arteries in your legs constrict when you walk and allow the blood to move faster and with more pressure on the tissue." B. "Walking increases your heart rate and blood pressure. Therefore, your heart is under less stress." C. "Walking helps your heart adjust to your new arteries and helps build your self-esteem." D. "When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart."

A nurse is assessing a new client who is diagnosed with peripheral artery disease. The nurse cannot feel the pulse in the client's left foot. How should the nurse proceed with assessment? A. Have the primary care provider prescribe a computed tomography (CT) scan. B. Apply a tourniquet for 3 to 5 minutes and then reassess. C. Elevate the extremity and attempt to palpate the pulses. D. Use Doppler ultrasound to identify the pulses.

A nurse is educating a group of nursing students about signs and symptoms of a hemorrhagic stroke. Which is true of hemorrhagic stroke? A. Occurs with vascular occlusion. B. Is also known as thrombotic stroke. C. Can be known as lacunar strokes. D. Can occur in the subarachnoid space.

An ECG has been ordered for a newly admitted client. What should the nurse do prior to electrode placement? A. Clean the skin with povidone-iodine solution. B. Ensure that the area for electrode placement is dry. C. Apply tincture of benzoin to the electrode sites and wait for it to become "tacky." D. Gently abrade the skin by rubbing the electrode sites with dry gauze or cloth.

An ED nurse has just received a call from EMS that they are transporting a 17-year-old client who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what event? A. Syncope (fainting) B. Suicide attempts C. Workplace injuries D. Motor vehicle accidents

The registered nurse taking shift report learns that an assigned client is blind. How should the nurse best communicate with this client? A. The nurse should provide instructions in simple, clear terms. B. Using a loud voice, the nurse should offer an introduction while in the doorway of the room. C. Lightly touch the client's arm and then say the nurse's name. D. The nurse should state the nurse's name and role immediately after entering the client's room.

The staff educator is teaching emergency department nurses about hypertensive crisis. The nurse educator should explain that hypertensive urgency differs from hypertensive emergency in which way? A. The blood pressure (BP) is always higher in a hypertensive emergency. B. Vigilant hemodynamic monitoring is required during treatment of hypertensive emergencies. C. Hypertensive urgency is treated with rest and benzodiazepines to lower BP. D. Hypertensive emergencies are associated with evidence of target organ damage.

What should be included in the client's care plan when establishing an exercise program for a client affected by a stroke? A. Schedule passive range of motion every other day. B. Keep activity limited, as the client may be overstimulated. C. Have the client perform active range-of-motion (ROM) exercises once a day. D. Exercise the affected extremities passively four or five times a day.

Which of the following nurse's actions carries the greatest potential to prevent hearing loss due to ototoxicity? A. Ensure that clients understand the differences between sensory hearing loss and conductive hearing loss, B. Educate clients about expected age-related changes in hearing perception, C. Educate clients about the risks associated with prolonged exposure to environmental noise D. Be aware of clients' medication regimens and collaborate with other professionals accordingly.

A nurse is providing ongoing care for a client who is positive for human immunodeficiency virus (HIV), and assessment reveals a client with a newly delayed and shortened speech pattern. The client, who previously had no neurological or motor deficits, has forgotten that they are in the hospital and has trouble getting out of bed. Which problem is the client most likely experiencing related to these signs and symptoms? A. Cryptococcal meningitis B. Cytomegalovirus retinitis C. Peripheral neuropathy D. Subcortical neurodegenerative disease

D Rationale Subcortical neurodegenerative disease is known as HIV-associated neurocognitive disorder (HAND). Signs can be subtle and include changes in language, memory, and problem solving, as well as slowing psychomotor skills. Early identification is important as HAND can be treated by changing antiretroviral medications. Cryptococcal meningitis is a form of subacute meningitis. Signs include fever, malaise, and headache. Retinitis caused by cytomegalovirus retinitis is the leading cause of blindness in clients with acquired immunodeficiency syndrome. Peripheral neuropathy is a common neurological symptom at any stage of HIV infection. Signs and symptoms are pain in the feet and functional impairment.

A client has a diagnosis of AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate? A. Position the client in the high Fowler position whenever possible. B. Temporarily eliminate animal protein from the client's diet. C. Make sure the client eats at least two servings of raw fruit each day. D. Obtain a stool culture to identify possible pathogens.

D Rationale: A stool culture should be obtained to determine the possible presence of microorganisms that cause diarrhea. Clients should generally avoid raw fruit when having diarrhea. There is no need to avoid animal protein or increase the height of the bed.

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? A. Restrain the client to prevent injury. B. Open the client's jaws to insert an oral airway. C. Place client in high Fowler position. D. Loosen the client's restrictive clothing.

D Rationale: An appropriate nursing intervention would include loosening any restrictive clothing on the client. No attempt should be made to restrain the client during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the client on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus.

A client is being treated for polycythemia vera, and the nurse is providing health education. Which practice should the nurse recommend to prevent the complications of this health problem? A. Avoiding natural sources of vitamin K B. Avoiding altitudes of D1500 feet (457 meters) C. Performing active range of motion exercises daily D. Avoiding tight and restrictive clothing on the legs

D Rationale: Because of the risk of deep vein thrombosis, clients with polycythemia vera should avoid tight and restrictive clothing. There is no need to avoid foods with vitamin K or to avoid higher altitudes. Activity levels should be maintained, but there is no specific need for range of motion exercises.

A nurse on the neurologic unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurologic and functional status should the nurse consider? A. Inability to use a wheelchair B. Unable to swallow liquid and solid food C. Incontinent in bowel movements D. Requires full assistance for elimination

D Rationale: Clients with a lesion at C4 are fully dependent for elimination. The client is dependent for feeding, but is able to swallow. The client will be capable of using an electric wheelchair.

A nurse's plan of care for a client with rheumatoid arthritis includes several exercise-based interventions. What goal should the nurse prioritize? A. Maximize range of motion while minimizing exertion. B. Increase joint size and strength. C. Limit energy output in order to preserve strength for healing. D. Preserve or increase range of motion while limiting joint stress.

D Rationale: Exercise is vital to the management of rheumatic disorders. Goals should be preserving and promoting mobility and joint function while limiting stress on the joint and possible damage. Cardiovascular exertion should remain within age-based limits and individual ability, but it is not a goal to minimize exertion. Increasing joint size is not a valid goal.

A nurse working in a long-term care facility is performing the admission assessment of a newly admitted 85-year-old resident. During inspection of the resident's feet, the nurse notes early evidence of gangrene on one of the resident's great toes. The nurse should assess for further evidence of which health problem? A. Chronic venous insufficiency B. Raynaud phenomenon C. Venous thromboembolism (VTE) D. Peripheral artery disease (PAD)

D Rationale: In older adults, symptoms of PAD may be more pronounced than in younger people. In older adult clients who are inactive, gangrene may be the first sign of disease. Venous insufficiency does not normally manifest with gangrene. Similarly, VTE and Raynaud phenomenon do not cause the ischemia that underlies gangrene.

A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's IC increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? A. Hemiplegia B. Dry mucous membranes C. Signs of internal bleeding D. Loss of brain stem reflexes

D Rationale: Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death. Dry mucous membranes, hemiplegia, and bleeding must be promptly addressed, but none of these is a common sign of impending death.

During the examination of an unconscious client, the nurse observes that the client's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding? A. It suggests onset of metabolic problems. B. It indicates paralysis on the right side of the body. C. It indicates paralysis of cranial nerve X (CN X). D. It indicates an injury at the midbrain level.

D Rationale: Pupils that are fixed and dilated indicate injury at the midbrain level. This finding is not suggestive of unilateral paralysis, metabolic deficits, or damage to CN X.

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (IC). What nursing intervention would be most appropriate for this client? A. Passive range-of-motion exercises to prevent contractures B. Supine positioning C. Early initiation of physical therapy D. Absolute bed rest in a quiet, non stimulating environment

D Rationale: The client is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors are restricted. The nurse administers all personal care. The client is fed and bathed to prevent any exertion that might raise BP. Clients with increased ICP are normally positioned with the HOB elevated.

A nursing student is writing a care plan for a newly admitted client who has been agnosed with a stroke. What major nursing diagnosis should most likely be included in le client's plan of care? A. Adult failure to thrive B. Post-trauma syndrome C. Hyperthermia D. Disturbed sensory perception

D Rationale: The client who has experienced a stroke is at a high risk for disturbed sensory perception. Stroke is associated with multiple other nursing diagnoses, but hyperthermia, adult failure to thrive, and post-trauma syndrome are not among these.

A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage the potential sensory and perceptional difficulties? A. Keep the lighting in the client's room low. B. Place the client's clock on the affected side. C. Approach the client on the side where vision is impaired. D. Place the client's extremities where the client can see them.

D Rationale: The client with homonymous hemianopsia (loss of half of the visual field) turns away from the affected side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis. In such instances, the client cannot see food on half of the tray, and only half of the room is visible. It is important for the nurse to remind the client constantly of the other side of the body, to maintain alignment of the extremities, and if possible, to place the extremities where the client can see them. Clients with a decreased field of vision should be approached on the side where visual perception is intact. All visual stimuli (clock, calendar, and television) should be placed on this side. The client can be taught to turn the head in the direction of the defective visual field to compensate for this loss. Increasing the natural or artificial lighting in the room and providing eyeglasses are important in increasing vision. There is no reason to keep the lights dim.

A clinic nurse is working with a client who has a long-standing diagnosis of polycythemia vera. How can the nurse best gauge the course of the client's disease? A. Document the color of the client's palms and face during each visit. B. Follow the client's erythrocyte sedimentation rate over time. C. Document the client's response to erythropoietin injections. D. Follow the trends of the client's hematocrit.

D Rationale: The course of polycythemia vera can be best ascertained by monitoring the client's hematocrit, which should remain below 45%. Erythropoietin injections would exacerbate the condition. Skin tone should be observed, but is a subjective assessment finding. The client's erythrocyte sedimentation rate is not relevant to the course of the disease

The home health nurse is caring for a client who has a diagnosis of hypertension. What assessment question most directly addresses the possibility of worsening hypertension? A. "Are you eating less salt in your diet?" B. "How is your energy level these days?" C. "Do you ever get chest pain when you exercise?" D. "Do you ever see spots in front of your eyes?"

D Rationale: To identify complications or worsening hypertension, the client is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity. The heart, nervous system, and kidneys are also carefully assessed, but angina pain and decreased energy are not normally suggestive of worsening hypertension. Sodium limitation is a beneficial lifestyle modification, but nonadherence to this is not necessarily a direct sign of worsening symptoms.

A client recovering from a stroke has severe shoulder pain from subluxation of the shoulder. To prevent further injury and pain, the nurse caring for this client is aware of what principle of care? A. The client should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder. B. Elevation of the arm and hand can lead to further complications associated with edema. C. Passively exercising the affected extremity is avoided in order to minimize pain. D. The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to the shoulder

D Rationale: To prevent shoulder pain, the nurse should never lift a client by the flaccid shoulder or pull on the affected arm or shoulder. The client is taught how to move and exercise the affected arm/shoulder through proper movement and positioning. The client is instructed to interlace the fingers, place the palms together, and push the clasped hands slowly forward to bring the scapulae forward; he or she then raises both hands above the head. This is repeated throughout the day. The use of a properly worn sling when the client is out of bed prevents the paralyzed upper extremity from dangling without support. Range-of-motion exercises are still vitally important in preventing a frozen shoulder and ultimately atrophy of subcutaneous tissues, which can cause more pain. Elevation of the arm and hand is also important in preventing dependent edema of the hand.

The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? A. The ability of the client to follow instructions during the seizure. B. The success or failure of the care team to physically restrain the client. C. The client's ability to explain his seizure during the postictal period. D. The client's activities immediately prior to the seizure.

D Rationale: Before and during a seizure, the nurse observes the circumstances before the seizure, including visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and hyperventilation. Communication with the client is not possible during a seizure and physical restraint is not attempted. The client's ability to explain the seizure may not be accurate since the client is often still confused during the postictal period.

An ED nurse is assessing a 71-year-old female client for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female clients? Select all that apply. A. Shortness of breath B. Chest pain C. Anxiety D. Indigestion E. Nausea

D, E

Invasive procedures of ACS that can prevent MI

PTCA

What is a TEE (transesophageal echocardiogram)?

Ultrasound that camera goes down throat to see heart and you can see back of heart because ribs aren't in the way.

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