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Mental Health The nurse caring for a client diagnosed with severe depression is planning activities for the client. Which activity would be most appropriate for this client? 1.) Drawing 2.) Playing checkers 3.) Painting by numbers 4.) Putting a puzzle together
Answer: 1 Rationale: Concentration and memory are poor in severe depression. When a client has a diagnosis of severe depression, the nurse needs to provide activities that require little concentration, such as drawing. Activities that have no right or wrong choices and that require no decisions minimize opportunities for the depressed client to experience a sense of failure. The remaining options do not meet the criteria and are incorrect.
Pharmacology Insulin glargine is prescribed for a client with diabetes mellitus. The nurse should tell the client that it is best to take the insulin at which time? 1.) At bedtime every day 2.) 1 hour after each meal 3.) 15 minutes before the morning and evening meals 4.) Before each meal, on the basis of the blood glucose level
Answer: 1 Rationale: Insulin glargine is a long-acting recombinant DNA human insulin that is used to treat type 1 and type 2 diabetes mellitus. It has a 24-hour duration of action and is administered once a day, usually at bedtime. Therefore, the remaining options are incorrect times.
Pharmacology The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching? 1.) Withdraws the NPH insulin first 2.) Withdraws the regular insulin first 3.) Injects air into NPH insulin vial first 4.) Injects an amount of air equal to the desired dose of insulin into each vial
Answer: 1 Rationale: When preparing a mixture of short-acting insulin, such as regular insulin, with another insulin preparation, the short-acting insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of short-acting insulin with insulin of another type. Options 2, 3, and 4 identify correct actions for preparing NPH and short-acting insulin.
Maternity A client calls the health care provider's office to schedule an appointment because she has missed 2 menstrual cycles and has always been very regular. The client receives an appointment for the next day. The nurse should expect which findings to be present at this prenatal visit if the client is pregnant? Select all that apply. 1.) Chadwick's sign. 2.) Vertex presentation 3.) Positive pregnancy test 4.) Fetal heart rate audible by fetoscope 5.) Fetal movement detectable by the mother
Answer: 1, 3 Rationale: Having missed 2 menstrual cycles with a normal history, the client is at approximately 8 weeks' gestation. Hormonal changes lead to vascular congestion in the cervix and vagina. The tissues have an appearance of looking "blue," and this change is identified by the term Chadwick's sign. In early pregnancy, human chorionic gonadotropin (hCG) is produced by trophoblastic cells that surround the developing embryo. This hormone is responsible for a positive pregnancy test. The pregnancy is not advanced significantly enough to be able to determine a presentation. Fetal heart rate is not audible by fetoscope until approximately 20 weeks. The earliest a mother experiences fetal movement is approximately 14 weeks.
Fundamentals The nurse is caring for a client with suspected hepatitis. What diagnostic test results will assist in confirming this client's diagnosis? Select all that apply. 1.) Leukopenia 2.) Elevated hemoglobin 3.) Elevated liver enzymes 4.) Elevated serum bilirubin level 5.) Elevated blood urea nitrogen (BUN) 6.) Elevated serum erythrocyte sediment rate (ESR)
Answer: 1, 3, 4, 6 Rationale: Laboratory indicators of hepatitis include leukopenia, elevated liver enzyme levels, elevated serum bilirubin levels, and elevated ESRs. An elevated BUN level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.
Adult Health The nurse is gathering subjective and objective data from a client with a diagnosis of suspected rheumatoid arthritis (RA). The nurse would expect to note which early signs and symptoms of RA? Select all that apply. 1.) Fatigue 2.) Weight gain 3.) Restlessness 4.) Morning stiffness 5.) Pain with movement only
Answer: 1, 4 Rationale: Early signs and symptoms of RA include fatigue, weight loss, fever, malaise, morning stiffness, pain at rest and with movement, and complaints of night pain. The involved joints appear edematous.
Maternity The nurse is describing cardiovascular system changes that occur during pregnancy to a client. Which findings are normal for a client in the second trimester? Select all that apply. 1.) Increase in pulse rate 2.) Increase in blood pressure 3.) Frequent bowel elimination 4.) Increase in red blood cell production 5.) Decrease in white blood cell production
Answer: 1, 4 Rationale: Numerous cardiovascular adaptations occur during pregnancy. Between 14 and 20 weeks' gestation, the pulse rate increases about 10 to 15 beats/minute, which then persists to term. During pregnancy, there is an accelerated production of red blood cells. During the second trimester, systolic and diastolic pressures decrease by about 5 to 10 mm Hg until 24 to 32 weeks. The blood pressure by term usually is no higher than the pre-pregnancy level. Constipation may occur as a result of decreased gastrointestinal motility or pressure of the uterus.
Pediatrics Which interventions are the priorities for a 10-year-old child diagnosed with acute glomerulonephritis? Select all that apply. 1.) Promoting bed rest 2.) Restricting all oral fluids 3.) Encouraging visits from friends 4.) Allowing the child to play with the other children in the playroom 5.) Providing for quiet play according to the developmental stage of the child.
Answer: 1, 5 Rationale: Acute glomerulonephritis is the sudden onset of hematuria, proteinuria, and red blood cell (RBC) casts in the urine. Bed rest is promoted during the acute phase, and activity is gradually increased as the condition improves. Providing for quiet play according to the developmental stage of the child is important. Fluids would not be restricted but allowed based on primary health care provider prescription. Visitors would be limited to allow for adequate rest. Allowing the child to play in the playroom is not advisable at the time of acute illness.
Pediatrics The nurse is creating a plan of care for a 7-year-old child diagnosed with acute glomerulonephritis (GN). The nurse would include which priority intervention in the plan of care? 1.) Force oral fluids to prevent hypovolemic shock 2.) Encourage limited activity, and provide safety measures 3.) Catheterize the child to strictly monitor intake and output (I&O) 4.) Encourage classmates to visit and to keep the child informed of school events
Answer: 2 Rationale: Acute GN is the sudden onset of hematuria, proteinuria, and red blood cell (RBC) casts in the urine. Activity is limited, and most children, because of fatigue voluntarily restrict their activities during the active phase of acute glomerulonephritis. Fluids would not be forced. Catheterization may cause infection. Visitors would be limited to allow for adequate rest.
Pharmacology math A nurse has an order to give paracetamol 20 mg/kg to a 6-year-old child. The nurse weighs the child and finds that he weighs 48 pounds. How much of the medication would the nurse give to this child? 1.) 550 mg 2.) 440 mg 3.) 510 mg 4.) 400 mg
Answer: 2 To determine how much of the dose to give, the nurse must first convert the child's weight from pounds to kilograms. The nurse follows the following formula:1 kilogram = 2.2 lbs. 1 pound = .454 kilograms. So, 48 lbs. x .454 = 21.8 kg.The nurse then multiplies the outcome by the amount of the dose, which is 20 mg per kilogram, or 20mg x 22 kg = 440 mg.
Adult Health Which tests can be used to diagnose gout? Select all that apply. 1.) Renal ultrasound 2.) Serum uric acid level 3.) Bone marrow biopsy 4.) Urinalysis with culture 5.) Synovial fluid aspiration 6.) 24-hour urine uric acid level
Answer: 2, 5, 6 Rationale: Diagnostic tests for gout include serum uric acid level and 24-hour urine uric acid level, as well as synovial fluid aspiration and x-ray of the affected areas. Renal ultrasound, bone marrow biopsy, and urinalysis with culture are not specifically associated with gout; they test for a variety of other conditions.
Phenobarbital is supplied as 60 mg/mL. You need to administer 160 mg IV stat. How many milliliters should you administer? 1.) 0.4 mL 2.) 1.7 mL 3.) 2 mL 4.) 2.7 mL
Answer: 2.7 mL 160 mg/60 mg= 2.66 round up to 2.7 mL
Fundamentals The clinic nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests for thyroxine (T4) and thyroid-stimulating hormone (TSH). Which laboratory finding indicates a diagnosis of primary hypothyroidism? 1.) A normal T4 level 2.) An elevated T4 level 3.) An elevated TSH level 4.) A decreased TSH level
Answer: 3 Rationale: Diagnostic findings in primary hypothyroidism include a low T4 level and a high TSH level. The remaining options are not diagnostic findings of this condition.
Management, Prioritization and Delegation The nurse obtains this information about a 60-year-old client with who has a shingles infection. Which finding is of most concern? 1.) The client has had symptoms for about 2 days 2.) The client has a severe burning-type discomfort 3.) The has not had the herpes zoster vaccination 4.) The client's spouse is currently receiving cancer chemotherapy
Answer: 4 Rationale: Because exposure to clients with shingles may cause herpes zoster infection (including systemic infection) in individuals who are immune suppressed, teaching about how to prevent transmission and possible evaluation and treatment of the client's spouse is needed. Antiviral treatment is most effective when started within 72 hours of symptom development. The client will need analgesics to treat the pain associated with shingles and may receive vaccination, but the biggest concern is possible infection of the client's spouse.
Mental Health The home health nurse visits an agoraphobic client who experiences panic attacks. Which statement by the client would indicate a therapeutic response to behavioral and pharmacological treatment? 1.) "I took an extra pill for anxiety and got through the funeral fairly well". 2.) "I worry that if I don't take my anxiety pill on time, I'll have one of those attacks". 3.) "Taking my anxiety pills before I leave has helped me to cross the bridge and go to work every morning." 4.) "I went to the movies with my family and stayed through the whole film by sitting in a seat along the aisle."
Answer: 4 Rationale: Generalizing fears to a specific place or situation is the hallmark of agoraphobia. Improvement is observed when the client is able to demonstrate appropriate coping behaviors for anxiety reduction. Taking extra anxiety medication would not indicate improvement. "Clock-watching" with regard to the medication schedule is also not a sign that the client is responding well to the treatment.
Management, Prioritization and Delegation A client admitted to the emergency department reports new-onset itching of the trunk and groin. The nurse notes multiple reddened wheals on the chest, back, and groin. Which question should the nurse ask next? 1.) "Do you have a family history of eczema?" 2.) "Have you been using sunscreen regularly?" 3.) "How do you usually manage stress?" 4.) "Are you taking any new medications?"
Answer: 4 Rationale: Wheals are frequently associated with allergic reactions, so asking about exposure to new medications is the most appropriate question for this client. The other questions would be useful in assessing the skin health history but do not directly relate to the client's symptoms.