EVOLVE QUESTIONS

A mental health nurse is participating in a therapy group. The nurse concludes that the group has reached the working stage when the members do what? Multiple choice question Appear happy in their group interactions. Focus on a variety of needs and concerns. Say what is expected and wanted by the others. Show concern for the feelings of the group leaders.

Focus on a variety of needs and concerns.

An unconscious school-aged child is admitted to the pediatric intensive care unit with a closed head injury. Arterial and central venous pressure lines, an indwelling urinary catheter, and a nasogastric tube are inserted. What is the nurse's primary goal for this child? Multiple choice question Prevention of unnecessary trauma to the vital organs Limitation of stimuli that increase intracranial pressure Establishment of access routes for infusion of medications Enhancement of the health team's management of the illness

Limitation of stimuli that increase intracranial pressure Increased intracranial pressure is associated with a high risk for mortality; stimuli must be minimized. Although prevention of trauma to the vital organs, establishment of routes for the delivery of medications, and fulfilling the health team's needs are all important, none is the priority.

Postoperatively, a client asks, "Could I have a pillow under my knees? My legs feel stretched." With what response can the nurse best reinforce the preoperative teaching? Multiple choice question "I'll get pillows for you. I want you to be as rested as possible." "It's not a good idea, but you do look uncomfortable. I'll get one." "We don't allow pillows under the legs because you will get too warm." "A pillow under the knees can result in clot formation because it slows blood flow."

"A pillow under the knees can result in clot formation because it slows blood flow."

A nursing student is listing various stages of Lawrence Kohlberg's Theory of Moral Development. Which situation indicates that the individual has reached the Instrumental Relativist Orientation stage? Multiple choice question "An individual identifies that there is more than one right view." "An individual notices that punishment is a proof of being wrong." "An individual wants to win consent and maintain the expectations of one's immediate group." "An individual follows societal law, but recognizes the possibility of changing the law to improve society."

"An individual identifies that there is more than one right view." According to Lawrence Kohlberg's Theory of Moral Development, in the "Instrumental Relativist Orientation" stage, an individual identifies that there is more than one right view. The views of a person can be different from others. In the Punishment and Obedience Orientation stage, an individual notices that punishment is a proof of being wrong; this perception changes when the individual steps into the Instrumental Relativist Orientation stage. In the Good Boy-Nice Girl Orientation stage, an individual wants to win consent and maintain the expectations of one's immediate group. In the Social Contract Orientation stage, an individual follows societal law, but also recognizes the possibility of changing the law to improve society.

Which statement by the nurse is true regarding dandruff? Multiple choice question "It is a problem of excessive oil production." "It can occur as a side effect of drug therapy." "It is associated with tenderness of the scalp." "It is a manifestation of hormonal imbalance."

"It is a problem of excessive oil production."

The nurse is caring for a client who survived a severe burn injury. Which action should the nurse perform immediately based on priority? Multiple choice question Obtaining vital signs Assessing airway patency Providing fluid replacement Elevating the extremities if there is no fracture

Assessing airway patency The client who has severe burn injuries may develop an airway obstruction. Therefore the client should be assessed for a patent airway and should be provided oxygen if necessary. The nurse should then assess the client's vital signs and perform nursing interventions accordingly. After completing the assessment, the nurse should insert intravenous lines and provide fluid replacement. The client's extremities should be elevated after checking for fractures. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options .

A child who reports shortness of breath, wheezing, and coughing is found to have pulmonary edema and is prescribed furosemide. Which nursing interventions would be beneficial to the client? Multiple selection question Administering the drug on an empty stomach Checking the child's weight every day Calculating the dose of drug as carefully as possible Exposing the child to sunlight for increasing periods Assessing the child regularly to help prevent electrolyte loss

hecking the child's weight every day Calculating the dose of drug as carefully as possible Assessing the child regularly to help prevent electrolyte loss

What is the priority nursing action when a 3-month-old infant is receiving intravenous (IV) fluids by way of an antecubital vein? Multiple choice question Monitoring for infiltration behind the infant's elbow Applying arm boards to prevent bending at the elbows Checking both of the infant's pupils for dilation every hour Telling the parents why they cannot hold the infant during IV therapy

Applying arm boards to prevent bending at the elbows The extremity should be placed in an arm board so the child will not bend the elbow and restrict the flow of IV fluids. First the flow of fluid must be ensured; then the nurse should inspect often for signs of infiltration at the IV insertion site, not the elbow. Pupil responses are unrelated to dehydration and fluid replacement. The parents can be taught how to hold their infant while an IV infusion is being administered.

A client presents with a shiny appearance of abdominal skin. The skin also has a taut appearance. Which condition may the client have? Multiple choice question Ascites Cyanosis Accidental injury Bleeding disorder

Ascites Symptoms of ascites include a shiny and taut appearance of the abdominal skin. Cyanosis occurs when there is a bluish discoloration of the skin. Accidental injury and different types of bleeding disorders are characterized by bruises or needle marks on the skin.

The nurse is caring for a client following a laparoscopic cholecystectomy. Which nursing action is priority? Multiple choice question Monitor the abdominal dressing for bleeding Instruct on using patient-controlled analgesia Teach about six-week activity restriction Assess puncture sites for bleeding

Assess puncture sites for bleeding The one to four puncture sites used to perform the surgery laparoscopically should be monitored for any possible bleeding. There will not be an abdominal dressing unless a traditional cholecystectomy is performed. Patient-controlled analgesia is not necessary as there is no abdominal incision. Activity restriction is about one week with a laparoscopic cholecystectomy.

A nurse in the pediatric clinic is assessing an 8-year-old child who has had asthma since infancy. What clinical finding requires immediate intervention? Multiple choice question Barrel chest Audible wheezing Heart rate of 105 beats/min Respiratory rate of 30 breaths/min

Audible wheezing Audible wheezing that is heard without a stethoscope is an indication that the airways are significantly compromised, and this requires immediate medical intervention. Barrel chest is a sign of chronic asthma. Repeated attacks result in a fixed hyperaerated thoracic cavity; this clinical finding does not require intervention. A heart rate of 105 beats/min is expected in an 8-year-old child, as is a respiratory rate of 30 breaths/min.

A client has been given a prescription for furosemide 40 mg every day in conjunction with digoxin. What would prompt the nurse to ask the provider about potassium supplements? Multiple choice question Digoxin causes significant potassium depletion. The liver destroys potassium as digoxin is detoxified. Lasix requires adequate serum potassium to promote diuresis. Digoxin toxicity occurs rapidly in the presence of hypokalemia.

Digoxin toxicity occurs rapidly in the presence of hypokalemia.

Which respiratory measurement is useful in differentiating between obstructive and restrictive pulmonary dysfunction? Multiple choice question Peak expiratory flow rate Forced vital capacity Forced mid-expiratory flow rate Forced expiratory volume/forced vital capacity ratio

Forced expiratory volume/forced vital capacity ratio

A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. The nurse expects the client to report that which joints were involved initially? Multiple selection question Hips Knees Ankles Shoulders Metacarpals

Hips Knees

A client is admitted to the hospital because of incapacitating obsessive-compulsive behavior. Which statement best describes how clients with obsessive-compulsive behavior view this disorder? Multiple choice question "I know there's no reason to do these things, but I can't help myself." "I don't know why everyone's upset with me—I'm doing nothing wrong." "The things I do take a little time, but they make me a productive person." "The devil makes me do it—it's not my fault that I constantly act this way."

I know there's no reason to do these things, but I can't help myself." . Intellectually the person knows that the compulsive acts are senseless but is unable to stop doing them because they control anxiety. "I don't know why everyone is upset with me—I'm doing nothing wrong" is an example of denial. Most people with compulsive behaviors are not in denial. "The things I do take a little time, but they make me a productive person" is rationalization; obsessive-compulsive behavior is usually counterproductive and time consuming and interferes with function. "The devil makes me do it—it's not my fault that I constantly act this way" is an example of delusional thinking.

A client with ascites has been scheduled for a paracentesis. What intervention should the nurse implement immediately before the procedure? Multiple choice question Instruct the client to void Position the client onto the side Measure the client's abdominal girth Have the client drink a glass of water

Instruct the client to void The bladder should be empty to avoid injury during insertion of the abdominal trocar. The upright position is preferred to allow accumulation of fluid in the lower abdomen by gravity. Although regular monitoring of girth is important, it is not necessary immediately before paracentesis. Having the client drink a glass of water is unrelated to the procedure; however, it is preferable to offer fluids after the procedure if permitted by the healthcare provider.

An older adult is brought to the emergency department after being found in the street without a coat during a snowstorm. What actions should the nurse implement? Multiple selection question Massage extremities. Obtain a rectal temperature. Assess the fingers for areas of frostbite. Determine client's level of consciousness. Ask for client identification.

Obtain a rectal temperature. Assess the fingers for areas of frostbite. Determine client's level of consciousness. Ask for client identification. A rectal temperature provides the most accurate temperature. Older adults have less subcutaneous fat and inefficient temperature-regulating mechanisms, which makes them vulnerable to extremes in environmental temperature. The extremities are more distal sites of circulation and are at increased risk for frostbite. Hypothermia decreases cerebral perfusion, which will result in confusion and a decreased level of consciousness. Getting client identification will help in learning more about the client's previous health history and aid in contacting family members. Massage is contraindicated because it may injure tissues that have sustained frostbite.

When is the most appropriate time for the nurse to plan for chest percussion and postural drainage for a toddler with cystic fibrosis? Multiple choice question After suctioning Before aerosol therapy One hour before meals Fifteen minutes after meals

One hour before meals Performing chest percussion and postural drainage 1 hour before meals will give the child an opportunity to rest before eating. The child should be encouraged to cough; if this is not effective, suctioning may be done after chest percussion and postural drainage. Chest percussion and drainage should be done after aerosol therapy. Performing chest percussion and postural drainage 15 minutes after a meal may cause the child to vomit.

The registered nurse asks a client to rate his or her pain on a scale from 0 to 10, then instructs the nursing student to perform a physical assessment. Which assessments performed by the nursing student would be appropriate?

Palpating for tenderness Inspecting any areas of discomfort To understand the severity of a client's pain, the registered nurse asks the client to rate the pain on a scale from 0 to 10. The nursing student may palpate for tenderness while assessing the severity of pain and inspecting the area of discomfort. Nonverbal cues are used to understand the nature of pain. Physical assessments of the nature of pain may involve the nurse noticing whether the pain is radiated or localized. The client should also be checked for any nonverbal signs of pain.

Before discharge, what suggestion should the nurse give to a nonnursing mother to help limit breast engorgement? Multiple choice question Place raw cabbage leaves over the breast. Stop drinking milk for 1 week. Take an analgesic every 4 hours. Apply warm compresses to the breasts.

Place raw cabbage leaves over the breast. Fresh, raw cabbage leaves placed over the breasts between feedings can help relieve engorgement. It is thought that the effect of the cabbage leaves is related to the coolness of the leaves and the presence of phytoestrogens. Engorgement lasts about 3 to 5 days. Milk and fluids should not be restricted during the postpartum period. Medication will ease pain; however, it will not limit further engorgement. Cold compresses will limit further engorgement in the nonnursing mother. Large bags of frozen peas make easy ice packs.

A client complains of pain in the ear. While examining the client, a nurse finds swelling in front of the left ear. Which lymph node does the nurse expect to be involved? Multiple choice question Mastoid Occipital Submental Pre-auricular

Pre-auricular

A registered nurse is teaching a nursing student about the characteristics of various healthcare plans. Which statements about preferred provider organizations (PPOs) by the nursing student need correction? Multiple selection question Preferred provider organizations are focused on health maintenance. Preferred provider organizations reimburse nursing home payments. Preferred provider organizations cover children who are not poor enough for Medicaid. Preferred provider organizations have deductibles that clients must meet before the insurance pays. In a preferred provider organization, a contractual agreement exists between a set of providers and one or more purchasers.

Preferred provider organizations reimburse nursing home payments. Preferred provider organizations cover children who are not poor enough for Medicaid. Preferred provider organizations have deductibles that clients must meet before the insurance pays.

A client with chronic kidney disease is receiving medication to manage anemia. Which primary goal should the nurse include in the care plan from this information? Multiple choice question Prevention of uremic frost Prevention of chronic fatigue Prevention of tubular necrosis Prevention of dependent edema

Prevention of chronic fatigue

The nurse is assessing a client admitted to the hospital with a tentative diagnosis of an adrenal cortex tumor. When assessing the client, which of these are signs of Cushing disease? Multiple selection question Round face Dependent edema in the feet and ankles Increased fatty deposition in the extremities Thin, translucent skin with bruising Increased fatty deposition in the neck and back

Round face Dependent edema in the feet and ankles Thin, translucent skin with bruising Increased fatty deposition in the neck and back Changes in fat distribution may result in a round face and fat pads on the neck, back, and shoulders. There are increased levels of steroids and aldosterone, causing sodium and water retention in clients with Cushing syndrome. This increased fluid retention results in dependent peripheral edema. Skin changes result from increased blood vessel fragility and include bruises and thin or translucent skin. The extremities appear thinner from muscle wasting and weakness, not thicker from fatty deposition. Hypertension, not hypotension, is expected because of sodium and water retention.

A nurse instructs a client with viral hepatitis about the type of diet that should be ingested. Which lunch selected by the client indicates understanding about dietary principles associated with this diagnosis? Multiple choice question Turkey salad, french fries, sherbet Cottage cheese, mixed fruit salad, milkshake Salad, sliced chicken sandwich, gelatin dessert Cheeseburger, tortilla chips, chocolate pudding

Salad, sliced chicken sandwich, gelatin dessert The diet should be high in carbohydrates, with moderate protein and fat content. Salad, chicken and gelatin is the best choice. Turkey salad, french fries, and sherbet are too high in fat. Cottage cheese, mixed fruit salad, and a milkshake are dairy products and may cause lactose intolerance; the virus injures the intestinal mucosa. Cheeseburger, tortilla chips, and chocolate pudding are too high in fat.

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus? Multiple choice question Limit the client's fluid intake. Teach the client how to exercise the legs. Encourage use of the incentive spirometer. Maintain the knee gatch position at an angle.

Teach the client how to exercise the legs. The client who is prescribed bed rest must exercise the legs; dorsiflexion of the feet prevents venous stasis and thrombus formation. Limiting fluid intake may lead to hemoconcentration and subsequent thrombus formation. An incentive spirometer improves pulmonary function, but does not prevent venous stasis. Maintaining the knee gatch position at an angle is unsafe because it promotes venous stasis by compressing the popliteal space.

A nurse caring for a client prioritizes nursing actions on the basis of Maslow's hierarchy of needs. Which statement made by the client meets the self-actualization need? Multiple choice question "I need help because I am having trouble breathing properly." "I cannot afford health care because I am homeless." "People always tend to criticize me, even if I do something good." "I want to live because I want to be a good parent to my kids."

"I want to live because I want to be a good parent to my kids."

Which statement made by a nurse indicates being an effective community opinion leader? Multiple choice question "I will try to build a society that treats males and females equally." "I will try to follow new innovations in my organization effectively." "I will try to provide culturally competent care to clients effectively." "I will try to conduct research on diseases that do not have treatment."

"I will try to build a society that treats males and females equally."

A nursing student is listing the goals of theoretical nursing models. Which goal listed by the nursing student needs correction? Multiple choice question "Provide knowledge to validate nursing interventions." "Guide research and expand the knowledge base of nursing." "Provide a systematic structure and rationale for nursing activities." "Formulate legislation governing nursing practices, research, and education."

"Provide knowledge to validate nursing interventions."

An intravenous (IV) line is inserted in the scalp vein of an infant. The mother asks why the IV is not placed in the hand or arm as for an adult. How should the nurse respond? Multiple choice question "Using a scalp vein improves the absorption rate." "Inserting the IV in a scalp vein decreases the need for restraints." "Usually veins in the arm or hand are used, but your baby's were too small." "IV solutions are too irritating for the line to be inserted into a vein in the arm or hand."

"Usually veins in the arm or hand are used, but your baby's were too small." Telling the mother that the arm or hand veins were too small is an accurate explanation of why scalp veins are used in infants; access through hand veins is always attempted first, before scalp veins are tried. The absorption rate through either a peripheral vein or a scalp vein is the same, regardless of placement. Restraints will be necessary to prevent the infant from pulling out the IV or rolling over on it. Placement of the catheter is not related to whether a solution to be administered through it is irritating.

The nurse, providing discharge instructions to the parents of a newly circumcised male newborn, asks them to repeat the findings that should prompt them to call the primary healthcare provider. Which finding is reassuring and would not require notification of the provider? Multiple choice question Failure to urinate Displacement of the Plastibell A yellowish exudate around the incision Bleeding of more than a few drops after the first diaper changes

A yellowish exudate around the incision A yellowish exudate forms around the circumcision site during normal healing. Bleeding should be minimal after the procedure and should stop after the first few diaper changes. Signs of complications after circumcision are failure of the infant to urinate after 8 hours; displacement of the Plastibell, which could cause injury and swelling of the glans; and the continued presence of blood in the diaper after the first few changes,.

A client who had a cerebrovascular accident (also known as a "brain attack") becomes incontinent of feces. What is the most important nursing action to support the success of a bowel training program? Multiple choice question Using medication to induce elimination Adhering to a definite time for attempted evacuations Considering previous habits associated with defecation Timing of elimination to take advantage of the gastrocolic reflex

Adhering to a definite time for attempted evacuations Bowel training is a program for the development of a conditioned reflex that controls regular emptying of the bowel. The key to success is adherence to a strict time for evacuation based on the client's individual schedule. The indiscriminate use of laxatives can result in dependency. Although previous habits should be considered, the brain attack affects the responses of the client by altering motility, peristalsis, and sphincter control despite adherence to previous habits. The passage of food into the stomach does stimulate peristalsis, but it is only one factor that should be considered when planning a specific time for evacuation.

The client reports excessive bleeding during the menstruation. Which herbal therapies are unlikely to be prescribed by the primary healthcare provider? Raspberry Chamomile Lady's mantle Chaste tree fruit Shepherd's purse

Chamomile Chaste tree fruit Chamomile is an antispasmodic agent that helps to reduce breast pain. Chaste tree fruit is used to reduce breast pain by reducing the prolactin levels. Raspberry, lady's mantle, and shepherd's purse are uterotonic drugs used to treat menorrhea.

Which type of leadership theory explains the effectiveness of leadership and depends on the match between a leader's style and the demands of a situation? Multiple choice question Path-Goal theory Two-Factor theory Contingency Model Normative-Decision Making Model

Contingency Model Fiedler developed the Contingency Model, which explains that the effectiveness of the group depends on an appropriate match between a leader's style and the demands of a situation. Path-Goal theory was developed by House and Mitchell and explains the personal characteristics of followers and environmental demands. The Two-factor theory was developed by Herzberg for motivation in leadership. Normative-Decision Making Model is a problem solving approach developed by Vroom and Yetton.

An 18-month-old toddler who stepped on a rusty nail 4 days ago shows signs of generalized tetanus, including neck and jaw stiffness and facial muscle spasms. The toddler is receiving intravenous diazepam as a muscle relaxant every 4 hours. What response to the medication does the nurse anticipate? Control of hypertonicity and prevention of seizures Control of laryngospasms and neck and jaw rigidity Prevention of excess oxygen and caloric expenditure Prevention of restlessness and resistance to assisted ventilation

Control of hypertonicity and prevention of seizures. Diazepam is commonly used to manage generalized muscular spasms. Laryngospasm and nuchal rigidity are responses to the exotoxin and are treated with tetanus immune globulin. Diazepam is not administered to decrease the metabolic rate. Pancuronium bromide, an acetylcholine antagonist, is given to children who do not respond to sedatives and muscle relaxants and therefore resist ventilatory assistance.

A 4-year-old child from a Third World country is admitted to the pediatric unit for surgery to correct a congenital heart defect. The mother asks the nurse why her child squats after exertion. The nurse responds, in language that the mother understands, that this position does what? Multiple choice question Reduces muscle aches Increases the pull of gravity Decreases cardiac workload Helps blood return to the heart

Decreases cardiac workload When the child squats, blood pools in the lower extremities because of flexion of the hips and knees; less blood returns to the heart, decreasing the cardiac workload. Squatting does not reduce muscle aches. Squatting is not related to the pull of gravity. Squatting decreases blood return to the heart.

A client with acute kidney injury moves into the diuretic phase after 1 week of therapy. For which clinical indicators during this phase should the nurse assess the client? Multiple selection question Skin rash Dehydration Hypovolemia Hyperkalemia Metabolic acidosis

Dehydration Hypovolemia In the diuretic phase, fluid retained during the oliguric phase is excreted and may reach 3 to 5 L daily; dehydration and hypovolemia may occur unless fluids are replaced. Skin rash is not associated with the diuretic phase. Hyperkalemia develops in the oliguric phase when glomerular filtration is inadequate. Metabolic acidosis occurs in the oliguric, not diuretic, phase.

The registered nurse of a disaster management team teaches the staff nurse about Ebola. Which statements made by the staff nurse requires further teaching? Multiple selection question "A vaccine is not yet approved for Ebola." "Ebola can be treated with antiviral therapy." "Ebola is transmitted through water and food." "Clients affected with Ebola should be isolated." "An Ebola infection is suspected in the client with unexplained bleeding."

Ebola can be treated with antiviral therapy." "Ebola is transmitted through water and food." Antiviral drug therapy is not yet available for Ebola infection, so it cannot be treated. Ebola is transmitted by direct contact with body fluids of the affected client. The vaccine for Ebola is not yet approved by the FDA for use in the market. Isolation of a client with Ebola is required to prevent the spread of the virus. The Ebola infection is suspected if the client experiences unexplained bleeding.

A client is admitted to the hospital with diabetic ketoacidosis. The nurse concludes that the client's elevated ketone level is caused by incomplete oxidation of which nutrient? Multiple choice question Fats Protein Potassium Carbohydrates

Fats Incomplete oxidation of fat results in fatty acids that further break down to ketones. Protein metabolism produces nitrogenous waste, causing elevated blood urea nitrogen (BUN), not ketones. Potassium is not oxidized; potassium is not directly associated with ketones. Carbohydrates do not contain fatty acids that are broken down into ketones.

The grieving spouse of a client who has just died says to the nurse, "We should have spent more time together. I always felt that my work came first." What should the nurse conclude that the spouse is experiencing? Multiple choice question Displaced anger Feelings of guilt Shame for past behavior Ambivalent feelings about the spouse

Feelings of guilt

A client who had surgery for a ruptured appendix develops peritonitis. Which clinical findings related to peritonitis should the nurse expect the client to exhibit? . Multiple selection question Fever Hyperactivity Extreme hunger Urinary retention Abdominal muscle rigidity

Fever Abdominal muscle rigidity

A staff nurse is called into work because the organization is experiencing an internal disaster. What should the nurse expect when she/he arrives at work? Multiple choice question Fire in the information technology department Clients with inhalation injuries from an apartment fire Victims of a dirty bomb in the emergency department Community members sitting in the lobby waiting for the storm to stop

Fire in the information technology department

A nurse is reviewing several charts. Which condition is an autoimmune disorder? Multiple choice question Addison's disease Cushing's syndrome Hashimoto's disease Sheehan's syndrome

Hashimoto's disease Hashimoto's disease is an autoimmune disorder, wherein the immune system attacks the thyroid gland. Addison's disease is caused by adrenal insufficiency. Cushing's syndrome is caused by increased body levels of cortisol. Sheehan's syndrome is hemorrhage-associated hypopituitarism after delivery of a child.

A client with dementia and a percutaneous endoscopic gastrostomy (PEG) tube is being cared for at home. Which action provides evidence that a family member is effectively managing the client's care? Multiple choice question Empty feeding bag stays attached to the tubing. Tube is flushed with air after medication is given. Replacement of the tube is done on a weekly basis. Head of the bed remains elevated after the feeding.

Head of the bed remains elevated after the feeding. The client's upper body must be elevated to prevent aspiration and promote digestion. Attaching the empty feeding bag to the tubing is not necessary. The end of the gastrostomy tube just needs to be covered. The tube is flushed with water, not air, before and after food or medication is given; excess air in the gastrointestinal tract can cause abdominal distention and cramping. Because the tube was inserted by a surgical procedure, it is replaced only when a problem is identified, and usually only by the healthcare provider.

A nurse is writing a plan of care in the medical record of a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs. What is an intermediate outcome for this client? "The client will develop faith in his wife." "The client will develop better self-control." "The client will develop feelings of self-worth." "The client will develop insight into his behavior."

Helping the client develop feelings of self-worth will reduce the client's need to use pathologic defenses. Faith in his wife, or the lack thereof, is not the basic underlying problem, merely a symptom of it. Self-control, or the lack thereof, is not the basic underlying problem, merely a symptom of it. Insight can develop only when the need to use the defense is reduced; this is a long-term goal.

A client who has been breastfeeding tells the nurse on the third postpartum day that her breasts are painful and that she is afraid that the baby will hurt her while grasping the nipple and suckling. How should the nurse respond at this time? Multiple choice question Offering the client an analgesic before breastfeeding Recommending that the client limit fluids for several days Suggesting that the client formula feed the baby for 2 days Helping the client express some milk manually before feeding

Helping the client express some milk manually before feeding The pressure and tenderness resulting from accumulated milk can be relieved by manually expressing some of the fluid before feeding. Pain medication may be offered if other measures are unsuccessful; however, medication can be transferred to the infant through breast milk. Also, giving medication is a dependent function of the nurse that requires a prescription. The mother should not limit fluids, especially if she is breastfeeding. Breastfeeding, not formula feeding, should continue as a means of limiting engorgement and aiding milk production.

How should a nurse direct care for a client in the transition phase of the first stage of labor? Multiple choice question Decreasing intravenous fluid intake Helping the client maintain control Reducing the client's discomfort with medications Having the client use simple breathing patterns during contractions

Helping the client maintain control Assisting the client in maintaining control is the most difficult part of labor. The client needs encouragement and support to cope. Intravenous fluids may need to be increased because of the increase in metabolism. Medication at this time will depress the newborn and is contraindicated. Breathing patterns at this time should be complex and require a high level of concentration to distract the client.

A nurse is assessing the oral cavity of a 6-month-old infant. The parent asks which teeth will erupt first. What is the nurse's response? Multiple choice question Incisors Canines Upper molars Lower molars

Incisors The bottom incisors are the first teeth to erupt, between 6 and 8 months of age. The canine teeth appear around 18 months. The first molars, both upper and lower, appear around 20 months.

A nurse is assessing a client whose mouth is drooping over to the left. Which cranial nerve should the nurse assess further? Multiple choice question Left facial nerve Right facial nerve Left abducens nerve Right abducens nerve

Left facial nerve The facial nerve (seventh cranial) has motor and sensory functions. The motor function is concerned with facial movement, including smiling and pursing the lips. Nonconduction of the facial nerve will cause drooping on the side of the problem. Nonconduction of the facial nerve on the right side will cause that side of the face to droop. Nonconduction of the left abducens nerve will prevent abduction of the left eye. Nonconduction of the right abducens nerve will prevent abduction of the right eye.

In addition to clients who are receiving insulin for type 1 diabetes, the nurse should assess for signs and symptoms of hypoglycemia in clients who have which diagnosis? Multiple choice question Liver disease Type 2 diabetes Hyperthyroidism Stage 3 hypertension

Liver disease

Which test is used to specifically detect intracranial aneurysms in clients? Multiple choice question Diffusion imaging Magnetic resonance imaging Magnetic resonance angiography Magnetic resonance spectroscopy

Magnetic resonance angiography

After a lateral crushing chest injury, obvious right-sided paradoxical motion of a client's chest demonstrates multiple rib fractures, resulting in a flail chest. Which complication associated with this injury should the nurse assess in this client? Multiple choice question Mediastinal shift Tracheal laceration Open pneumothorax Pericardial tamponade

Mediastinal shift

A client has just awakened from her first electroconvulsive therapy (ECT) treatment. What is the most appropriate initial intervention by the nurse? Multiple choice question Immediately getting the client out of bed and back into the unit's routine Sitting the client up and arranging for the dietary staff to deliver a lunch tray Orienting the client to time and place and explaining that the treatment is over Taking the client's pulse and blood pressure every 15 minutes until the client is fully awake

Orienting the client to time and place and explaining that the treatment is over Clients are confused when they awaken after ECT. They have loss of recent memory, so it is important to orient them to time, place, and situation. The client should be monitored until vital signs are stable and the client is alert, oriented, and able to walk without assistance; this generally takes 1 to 3 hours. Sitting the client up may be done later if the client asks for food. Vital signs are monitored until stable; they may become stable before the client is fully awake.

When assessing a client with pleural effusion, what does the nurse expect to identify? Multiple choice question Moist crackles at the posterior of the lungs Deviation of the trachea toward the involved side Reduced or absent breath sounds at the base of the lung Increased resonance with percussion of the involved area

Reduced or absent breath sounds at the base of the lung Compression of the lung by fluid that accumulates at the base of the lungs reduces lung expansion and air exchange. There is no fluid in the alveoli, so no crackles are produced. If there is tracheal deviation, it is away from the involved side. Dullness is produced on percussion of the involved area.

A client is admitted to the hospital for a subtotal thyroidectomy. When discussing postoperative drug therapy with the client, what will the nurse include in the teaching? Multiple choice question Take the iodine daily to increase the formation of thyroid hormone. Understand that medication will be temporary until the body adjusts to postsurgical activities. Take the propylthiouracil that is prescribed to stimulate the secretion of thyroid-stimulating hormone. Report palpitations, nervousness, tremors, or loss of weight that may indicate an overdose of thyroid hormone.

Report palpitations, nervousness, tremors, or loss of weight that may indicate an overdose of thyroid hormone.

A pregnant client is now in the third trimester. The client tells the nurse, "I want to be knocked out for the birth." How should the nurse respond? Multiple choice question "You are worried about too much pain." "You don't want to be awake during the birth." "I can understand that because labor is uncomfortable." "I will tell your healthcare provider about this request."

You don't want to be awake during the birth." Paraphrasing encourages the client to express the rationale for this request. Suggesting the client is worried about pain expresses an assumption without enough information. Saying labor is uncomfortable may increase the client's anxiety. Although this request should be forwarded to the healthcare provider, the reason for the choice of general anesthesia should be explored.

A nurse in a long-term health care setting will introduce a client who has a PhD to the other clients. The client tells the nurse, "I wish to be called Doctor." How should the nurse respond? "Your wish will be respected." "Why do you want to be called Doctor?" "Residents here call one another by their first names." "Wouldn't it be better if the others do not know you are a doctor?"

Your wish will be respected." The client has the right to make this decision, and the staff should accept the client's wishes. The client is a doctor, and the nurse's statement "Why do you want to be called Doctor?" attacks the client's self-concept. The informality of using first names is not encouraged unless it is the client's choice. The nurse can and should honor the client's request.