Exam 1

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 week's gestation because of which factor? 1. The appearance of the fetal external genitalia 2. The beginning of differentiation in the fetal groin 3. The fetal testes are descended into the scrotal sac 4. The internal differences in males and females become apparent

1

A sixth month old patient enters the floor. The patient seems agitated. The nurse aide takes a set of vitals. RR 18 HR114 TEMP 36.8 O2 94%. Which vital sign poses the most concern? A. Heart rate B. Temperature C. Oxygen D. Respiratory Rate

D

The most effective method of administering a chemotherapy agent that is a vesicant is to: A. Give it orally B. Give it intraarterially C. Use an Ommaya reservoir D. Use a central venous access device

D

A 55-year old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response? 1. "How often do you have sexual relations?" 2. "Please share with me more about your concerns." 3. "You are still young and have nothing to be concerned about." 4. "You should not have a decline in testosterone until you are in your 80's."

2

The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor? 1. Age younger than 50 years 2. History of colorectal polyps 3. Family history of colorectal cancer 4. Chronic inflammatory bowel disease

1

A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess from which manifestations of this complication? 1. Warmth, redness, and pain in the left hand 2. Ecchymosis and audible bruit over the fistula 3. Edema and reddish discoloration of the left arm 4. Pallor, diminished pulse, and pain in the left hand

4

A nursing student is at their psych clinical rotation, when they overhear a nurse say that their assigned patient was newly diagnosed with bipolar disorder. As a nursing student taking a course on psychiatric disorders, you know that bipolar disorder is often the result of which of the following neurotransmitter(s) issues? (Select all that Apply). A. Deficiency of dopamine B. Excess levels of dopamine C. Deficiency of norepinephrine D. Excess levels of norepinephrine E. Deficiency in serotonin F. Excess levels of serotonin

A, C, E

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of posttraumatic stress disorder? Select all that apply. A. "I'm afraid of spiders." B. "I keep reliving the robbery." C. "I see his face everywhere I go." D. "I don't want anything to ear now." E. "I might have died over a few dollars in my pocket." F. "I have to wash my hands over and over again many times."

B, C, E

A psychiatric patient has been acting up in a unit by threatening staff and other patients. This patient constantly yells and invades other people's personal space. After attempting to talk to the patient he still remains agitated and aggressive. How is this behavior best controlled by the nurses on the unit? Select all that apply A. Take the other patients back to their rooms and close the doors B. Place them in solitude for the remainder of the day C. Offer a PRN to the patient D. Distract the patient and attempt to direct them to a quieter place on the unit

C, D

The nurse manager is planning the clinical assignments for the day. Which staff member cannot be assigned to care for a client with herpes zoster? Select all that apply. A. The nurse who never had roseola B. The nurse who never had mumps C. The nurse who never had chickenpox D. The nurse who never had German measles E. The nurse who never received the varicella-zoster vaccine.

C, E

The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? A. Information regarding shelters. B. Instructions regarding calling the police. C. Instructions regarding self-defense classes. D. Explaining the importance of leaving the violent situation.

A

Marge is upset about the change and knows the oral hydromorphone will not be as effective in relieving her "horrific" pain. How should the nurse respond? 1. "I'm sure you are hurting a lot; your surgery was extensive. Tell me why you don't think the oral medication will work as well?" 2. "You know you cannot go home on IV pain meds, so there is not another option if you want to go home." 3. "It probably won't work as well since it's oral, we can increase the dose if it's not effective." 4. "Ketorolac is a strong medication and will relieve your pain."

1

Which symptom(s) can Marge anticipate as she withdraws from heroin? Select all that apply. 1. Nausea. 2. Tremors. 3. Sweating. 4. Nervousness. 5. Flaccid muscles.

1, 2, 3, 4

Marge's medical treatment plan includes the use of longer-acting opioids, partial opioid antagonists and low dose opioid antagonists. Which statement(s) about these drug categories is/are accurate? Select all that apply. 1. Medication management cannot be successful without supportive counseling. 2. Longer-acting opioids like methadone help control drug cravings. 3. Partial opioid antagonists like buprenorphine remain active longer so dosing can be weaned. 4. Partial agonists do not create the same "high" making them less likely to be abused. 5. Opioid antagonists bind to opioid receptor sites and "block" other opioids from activation.

1, 2, 3, 4, 5

Which physiological change(s) would indicate to Marge's co-workers that she is experiencing substance use disorder? Select all that apply. 1. Clumsy or uncoordinated actions. 2. Increase or decrease in appetite. 3. Runny nose or bloodshot eyes. 4. Distracted easily. 5. Unusual breath, body, or clothing odors.

1, 2, 3, 4, 5

Which behavioral change(s) would indicate to Marge's co-workers that she is experiencing substance use disorder? Select all that apply. 1. Change in job performance. 2. Frequent trips to the bathroom. 3. Making frequent errors. 4. Excessive amount of helpfulness. 5. Arriving late to the shift.

1, 2, 3, 5

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply. 1. Check the level of the drainage bag 2. Reposition the client to his or her side 3. Contact the health care provider (HCP) 4. Place the client in good body alignment 5. Check the peritoneal dialysis system for kinks 6. Increase the flow rate of the peritoneal dialysis solution

1, 2, 4, 5

After two weeks, the pain does not improve with comfort measures and over-the-counter pain medication, so Marge makes an appointment with her primary health care provider. What prescription(s) should Marge anticipate? Select all that apply. 1. CT scan of the back. 2. Outpatient physical therapy. 3. Surgery. 4. Stronger pain medicine. 5. Referral to a pain specialist. 6. Light duty activities.

1, 2, 4, 6

A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the health care provider will request which prescriptions? Select all that apply 1. Radiation 2. Chemotherapy 3. Increased fluid intake 4. Decreased oral sodium intake 5. Serum sodium level determination 6. Medication that is antagonistic to antidiuretic hormone

1, 2, 5, 6

What comfort measure(s) should Marge choose to help minimize the pain for this acute injury? Select all that apply. 1. Imagery and relaxation. 2. Back strengthening exercises. 3. Heat and/or Ice. 4. Massage to the back. 5. Proper use of body mechanics.

1, 3, 4, 5

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate? 1. "Did you ever have surgery?" 2. "Do you plan to have any other children?" 3. "Do either of your have diabetes mellitus?" 4. "Do either of you have problems with high blood pressure?"

2

After reviewing the order for hydromorphone, what should the nurse consider? 1. Hydromorphone is contraindicated for someone who has recently been taking oxycodone. 2. The hydromorphone dose is too low for someone who has previously been taking opioids. 3. Hydromorphone at that dosage will cause respiratory depression and arrest. 4. Delivery of postoperative opioids will cause addiction.

2

As a registered nurse taking prescribed narcotic pain medicine, which statement is true about the legal responsibility Marge has to her patients, employer, and state licensing board? 1. Marge is required to tell everyone that she is taking a prescribed narcotic. 2. Marge should disclose to her manager that she is taking a prescribed narcotic for pain. 3. Marge is not able to take any narcotics during the shift at work. 4. Marge must notify the state licensing board of her prescription.

2

Marge has been able to stay clean and sober for several months with daily support group meetings. She contacts the state board of nursing about returning to work. What is likely the outcome? 1. She will have to re-take the NCLEX-RN® examination. 2. She may be able to work, depending on the status of her license. 3. She will be able to work part-time only. 4. She will only be able to work in non-patient care areas.

2

Marge tries to stop using the opioids but finds heroin is now her drug of choice. Her family is concerned she will accidentally hurt or kill herself. Which statement would lead her family to believe she may be in danger? 1. "I'm so disappointed with my life choices; I'll never be able to face my co-workers again." 2. "I have to use more and more heroin to feel better." 3. "I don't need you to tell me how to be happy; I'll be fine without you." 4. "It's not my fault this happened; the doctors should have known and stopped it sooner."

2

The nurse is assessing the motor and sensory function of an unconscious client The nurse should use which technique to test the client's peripheral response to pain? 1. Sternal rub 2. Nail bed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle

2

Which psychological and emotional change(s) would indicate to Marge's co-workers that she is experiencing substance use disorder? Select all that apply. 1. Spending more time with old friends. 2. Acting unusually anxious. 3. Exhibiting outbursts of anger for no reason. 4. Appearing sleepy. 5. Undergoing personality changes.

2, 3, 4, 5

What free community resource(s) is/are available to Marge's husband and children to deal with this life change? Select all that apply. 1. Narcotics Anonymous. 2. Nar-Anon family groups. 3. Private counseling. 4. Clergy at their place of worship. 5. Alcoholics Anonymous.

2, 4

As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement? 1. "I should avoid blowing my nose" 2. "I many need a platelet transfusion if my platelet count is too low" 3. "I'm going to take aspirin for my headache as soon as I get home" 4. "I will count the number of pads and tampons I use when menstruating"

3

One of Marge's co-workers, Juan sees her place a narcotic vial into her pocket rather than wasting it with a co-signature. He approaches her asking about it, and she laughs saying, "I was going to get someone to co-sign the waste later." What should be Juan's next action? 1. Nothing, Marge is his charge nurse. 2. Watch to see if it is done later. 3. Offer to observe the waste and co-sign now. 4. Report the incident to the supervisor.

3

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? 1. "It promotes the fertilized ovum's chances of survival." 2. "It promotes the fertilized ovum's exposure to estrogen and progesterone." 3. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." 4. "It promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone."

3

What is the priority assessment before the delivery of pain medication for Marge? 1. Client's perception of pain on a 1-10 scale. 2. Assessment of surgical site. 3. Vital signs. 4. Location of pain.

3

A nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia? 1. Nocturia 2. Scrotal edema 3. Occasional constipation 4. Decreased force in the stream of urine

4

As the nurse is discharging Marge, she asks about how often she should attend the community support group meetings. What should the nurse recommend? 1. "Only go when you feel you need it." 2. "Daily is sufficient." 3. "Once a week is adequate." 4. "Go several times a day, if needed."

4

Marge's friends and family convince her to go into an inpatient acute detoxification unit for withdrawal from heroin. Which statement is true about heroin? 1. It is quickly removed from the body and withdrawal symptoms resolve in 24 hours. 2. Medical supervision of withdrawal is suggested but not required. 3. Withdrawal symptoms begin within 2-3 days of the last dose. 4. Symptoms of withdrawal are worse the longer that heroin is used.

4

A client with severe back pain and hematuria is fond to have hydronephrosis due to urolithiasis. The nurse anticipates which treatment will be done to relieve the obstruction? Select all that apply. 1. Peritoneal dialysis 2. Analysis of the urinary stone 3. Intravenous opioid analgesics 4. Insertion of a nephrostomy tube 5. Placement of ureteral stent with ureteroscopy

4, 5

A patient has recently been diagnosed with early stages of breast cancer. What is most appropriate for the nurse to focus on? A. Maintaining the patient's hope B. Preparing a will and advanced directives C. Discussing replacement child care for the patient's children D. Discussing the patient's past experiences with her grandmother's cancer

A

Because of the incident, Marge's supervisor begins to watch her more closely. She recognizes several symptoms of substance use disorder at work. Place the actions in the order in which the manager should complete them... 1. Arrange for Marge to have a ride home. 2. Notify the state board of nursing. 3. Ask Marge if she is using substances. 4. Perform a for-cause drug screen per agency policy. 5. Remove Marge from the patient care area.

5, 3, 4, 1, 2

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? A. "I no longer feel that I deserve the beatings my husband inflicts on me." B. "My attendance at the meetings has helped me to see that I provoke my husband's violence." C. "I enjoy attending the meetings because they get me out of the house and away from my husband." D. "I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics."

A

The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? A. One-to-one suicide precautions. B. Suicide precautions with 30-minute checks. C. Checking the whereabouts of the client every 15-minutes. D. Asking the client to report suicidal thoughts immediately.

A

The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to mote specifically in this disorder? 1. Increased calcium level 2. Increased white blood cells 3. Decreased blood urea nitrogen level 4 Decreased number of plasma cells in the bone marrow

A

Which of the following describes social intelligence? A. The ability of oneself to communicate and relate effectively to others B. The ability and identify and monitor emotions and to remain aware of how emotions affect thoughts and actions. C. The ability to perform skills such as administering medications or injections. D. The ability of oneself to self-reflect on mistakes made

A

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding? A. An inflammation of the epidermis only. B. A skin infection of the dermis and underlying hypodermis. C. An acute superficial infection of the dermis and lymphatics. D. An epidermal and lymphatic infection caused by Staphylococcus.

B

The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? A. Positive patch test B. Positive culture results C. Abnormal biopsy results D. Wood's light examination indicative of infection

B

The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors? A. Signs of depression. B. Reactions to a devastating event. C. Evidence that the client is a high suicide risk. D. Indicative of the need for hospital admission.

B

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? A. "You need to stop that behavior now." B. "You will need t be placed in seclusion." C. "You seem restless; tell me what is happening." D. "You will need to be restrained if you do not change your behavior."

C

Which characteristic shown by a four-month-old child, helps the nursing staff to know that the child is NOT reaching their development milestones on track? A. The child knows that their hand is their own. B. The child can track the nurse 180 degrees across the room. C. The child can pull themselves to a sitting position with their head following after. D. The child turns to the sound of a rattle.

C

A depressed client on an inpatient unit says to the nurse, "my family would be better off without me." Which is the nurse's best response? A. "Have you talked to your family about this?" B. "Everyone feels this way when they are depressed." C. "You will feel better once your medication begins to work." D. "You sound very upset. Are you thinking of hurting yourself?"

D

You are a labor and delivery nurse assessing your patient two hours after a vaginal delivery. Upon your abdominal assessment, you find that the fundus is soft. What is your priority action? A. Administer mag sulfate B. Assess your patient's blood pressure C. Do nothing as this is a normal finding at this point in recovery D. Massage the fundus

D

What is the number one reason for a seizure in the ED?

noncompliance with meds