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When used in combination with certain foods and drugs, monoamine oxidase inhibitors (MAOIs) can cause serious side effects. Which condition could occur in clients treated with MAOIs for depression?

A serious increase in blood pressure

A client with cancer is told by a health care provider that the cancer has metastasized to other organs and is untreatable. The client tells the nurse, "I think they made a mistake. I don't think I have cancer. I feel too good to be dying." Which stage of grief does the nurse conclude that the client is experiencing?

Denial

Neuroleptic malignant syndrome develops in a client who is taking a conventional antipsychotic medication . What signs and symptoms does the nurse expect? Select all that apply. Hyperpyrexia

Increased muscle tone Respiratory depression

A client in the mental health clinic who has been seeing a therapist for more than 6 months begins to talk and act like a therapist who is analyzing coworkers. What defense mechanism does the nurse identify?

Introjection

A client in a psychiatric hospital requests an unaccompanied pass, but it is denied, and the client vocalizes his anger toward the staff. The nurse concludes that this anger results from feelings of:

Powerlessness

An anxious client reports experiencing pain in the abdomen and feeling empty and hollow. A diagnostic workup reveals no physical causes of these clinical findings. What term best reflects what the client is experiencing?

Somatization

Children's patterns of play change as they grow from infancy through school-age. Rank the order of appearance of each type of play, starting with infant play:

Solitary/ Parallel/ Associative/ Cooperative

A nurse is teaching a class about child abuse. What defense mechanism most often used by the physically abusive individual should the nurse include?

Displacement

A client is receiving fresh frozen plasma (FFP). The nurse would expect to see improvement in which condition?

Clotting factor deficiency

A 4-year-old child is admitted to the pediatric unit for a tonsillectomy. During preoperative planning a nurse reviews the child's laboratory report. Which lab value is of most significance in this situation?

Coagulation studies

To prevent skin breakdown on the scalp of an infant with hydrocephalus, how should the nurse position the infant?

Supine, with the head elevated about 45 degrees.

A nurse is caring for a client who is experiencing a crisis. Which nervous system is primarily responsible for the clinical manifestations that the nurse is likely to identify?

Sympathetic nervous system

What type of an environment should the nurse provide for a confused client?

Familiar

A nurse is assessing an infant for developmental dysplasia of the hip. How does the nurse identify the Ortolani sign?

Audible click on hip manipulation

What developmental task should the nurse consider when caring for toddlers?

Autonomy

A client who consented to electroconvulsive therapy (ECT) is being prepared for the second session. The client tells the nurse, "I've decided that I don't want this treatment." What is the best response by the nurse?

"I'll tell your psychiatrist that you don't want the treatment."

What is a nurse's responsibility when administering prescribed opioid analgesics? Select all that apply.

- Count the client's respirations. - Document the intensity of the client's pain. - Verify the number of doses in the locked cabinet before administering the prescribed dose.

The nurse is teaching a mother about the developmental behaviors of a 7-month-old infant. Which statement by the mother indicates effective learning? Select all that apply.

- I should start oral hygiene in my child." - "I should call my child by her name." - I should not leave the child with an unfamiliar relative." - Phenytoin (Dilantin) 75 mg twice daily is prescribed for a school-aged child with a seizure disorder. - What instruction should the nurse include when teaching the parents about activities to limit the - consequences of long-term phenytoin therapy? - Provide oral hygiene, including gum massage and flossing of the teeth.

Anorexia nervosa follows a cyclical pattern. Place the following statements in order of progression through this cycle, with 1 as the first step and 4 as the last step.

- Sociocultural attitudes exert pressure to attain an idolized body. - Dieting is an attempt to maintain control - Self-esteem increases as weight is lost. - Secondary gains reinforce the anorectic client's behaviors.

A client with a history of severe diarrhea for the past 3 days is admitted for dehydration. The nurse anticipates that which intravenous solution will be prescribed initially?

0.9% sodium chloride

How long after the last dose should the nurse schedule to have a client's blood drawn to evaluate the serum lithium level?

8 to 12 hours

A health care provider prescribes an intravenous (IV) infusion of ampicillin 375 mg every six hours. The drug is supplied as 500 mg of powder in a vial. The directions are to mix the powder with 1.8 mL of diluent, which yields 250 mg/mL. How much prepared solution should the nurse administer? Record the answer using one decimal place

1.5,mL

Because of a measles epidemic a 6-month-old infant receives measles immunoglobulin. The nurse should help the parents understand that to ensure continuous protection against measles the infant should be revaccinated around the age of

12 months.

A depressed client has been prescribed a tricyclic antidepressant. How long should the nurse inform the client that it will take before the client notices a significant change in the depression?

2 to 4 weeks,

What is the maximum length of time a nurse should allow an intravenous (IV) bag of solution to infuse?

24 hours

An intravenous piggyback (IVPB) of cefazolin (Kefzol) 500 mg in 50 mL of 5% dextrose in water is to be administered over a 20-minute period. The tubing has a drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run? Record the answer using a whole number. ______ gtts/min

38

A client receiving fluphenazine decanoate (Prolixin Decanoate) develops dystonia early during therapy. What medication does the nurse expect to be prescribed to reverse this side effect?

Benztropine (Cogentin)

What clinical finding indicates to the nurse that a client may have hypokalemia?

Abdominal distention

client with a history of atrial fibrillation has a brain attack, and vascular dementia (multi-infarct dementia) is diagnosed. In a comparison of assessment findings in clients with vascular dementia and dementia of the Alzheimer type, which factor is unique to vascular dementia?

Abrupt onset of symptoms,

A terminally ill client is moving gradually toward resolution of feelings about impending death. In a plan of care based on Elisabeth Kübler-Ross' research, the nurse should use nonverbal interventions after having assessed that the client is in the:

Acceptance stage

The nurse is planning care for a preschooler with Kawasaki disease. Which intervention should the nurse plan to implement?

Administering intravenous immune globulin (IVIG) as prescribed

A client is prescribed a monoamine oxidase inhibitor. The nurse teaches the client about what foods to avoid when taking this medication. Select all that apply.

Aged cheese Ripe avocados Delicatessen meats

A monoamine oxidase inhibitor (MAOI) is prescribed, and the nurse is formulating a teaching plan. What should the nurse instruct the client to avoid while taking this drug?

Aged cheeses

Clozapine (Clozaril) is an atypical antipsychotic used to treat psychotic conditions. It is important for clients taking this medication to have their blood checked frequently for:

Agranulocytosis

On the psychiatric unit a client has been receiving high doses of haloperidol (Haldol) for 2 weeks. The client says, "I just can't sit still, and I feel jittery." Which side effect does the nurse suspect that the client is experiencing?

Akathisia

A nurse decides to use the CAGE screening questionnaire with a client admitted for substance abuse. What is the client abusing?

Alcohol

A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen?

Alcohol

A newborn with a cleft lip is fed with a special nipple. What instructions should the nurse give the parents to reduce the incidence of regurgitation of the feedings?

Burp frequently during feedings.

Without knocking, a nurse enters the room of a young male client with the diagnosis of panic disorder and finds him masturbating. What should the nurse do?

Apologize and leave the room

An 18-year-old woman is brought to the emergency department by her two roommates after being found unconscious in the bathroom. Laboratory tests are ordered. The nurse reviewing the findings notes that the urinalysis is positive for flunitrazepam (Rohypnol). The nurse knows that flunitrazepam is often used:

As a date rape drug

A cognitively impaired older adult is brought to the emergency department for treatment of a cut on the forehead. Based on the following assessment information the nurse concludes that the individual's priority need is:

Assessment for possible physical abuse

The nurse manager is planning to assign an unlicensed assistive personnel (UAP) to care for clients. What care can be delegated on a medical-surgical unit to a UAP? Select all that apply. Performing a bed bath for a client on bed rest

Assisting a client who has patient-controlled analgesia (PCA) to the bathroom

A 3-year-old child is found to have autism. Which behaviors should the nurse expect when assessing this child? Select all that apply.

Avoids eye-to-eye contact Performs repetitive activities

Thirty minutes after administering fluphenazine (Prolixin) to a client, the nurse notes that the client's jaw is rigid, the client is drooling, and her speech is slurred. There are a number of as-needed prescriptions in the client's chart. What should the nurse administer?

Benztropine (Cogentin), 2 mg intramuscularly,,

A community health nurse discusses with a group of parents in the well-baby clinic the appropriate car restraints to be used for children. The nurse determines that one of the parents understands the teaching about car restraints for newborns when the parent says that infants should be buckled into an infant car seat and that the car seat must be in the:

Back seat, facing backward.

The nurse is caring for a group of patients who require various interventions. What patient care may be delegated to unlicensed assistive personnel (UAP)?

Bathing a child with an intravenous line and a PCA pump

A female client in the terminal stage of cancer is admitted to the hospital in severe pain. The client refuses the prescribed intramuscular analgesic for pain because it puts her to sleep and she wants to be awake. One day, despite the client's objection, a nurse administers the pain medication saying, "You know that this will make you more comfortable." The nurse in this situation could be charged with:

Battery.

A newborn is circumcised. What is the most essential nursing assessment during the initial postoperative period?

Bleeding

A client who is admitted for surgery for a ruptured tubal pregnancy tells the nurse that she has shoulder pain. The nurse concludes that the pain is caused by:

Blood accumulation under the diaphragm.

A nurse is counseling a client who is taking lithium carbonate. What is the priority nursing assessment when a client is taking this medication?

Blood level of the drug

A nurse arrives at the scene of an accident and finds a 5-month-old infant unconscious. After performing the initial steps of cardiopulmonary resuscitation, the nurse plans to locate the infant's pulse. Which pulse site in the accompanying figure should be palpated?

C (BRACHIAL PULSE)

After a client's membranes rupture spontaneously, the nurse visualizes the umbilical cord protruding from the vagina. Place the nursing interventions in order of priority

Call for assistance and don sterile gloves. Insert two fingers into the vagina and exert upward pressure against the fetal presenting part. Put a rolled towel under one hip and place the patient in the modified Sims position. Administer oxygen to the mother and monitor fetal heart tones.

A client is to receive doxorubicin (Adriamycin) as part of a chemotherapy protocol. The nurse should assess for which major life-threatening side effect?

Cardiotoxicity

A married woman is brought to the emergency department of a local hospital. Her eyes are swollen shut, and she has a bruise on her neck. She reports that she is being beaten by her husband. How does the nurse expect the husband to behave when he arrives at the emergency department?

Charming.

The nurse is teaching a client who is receiving a monoamine oxidase inhibitor about dietary restrictions. The nurse plans to caution the client to avoid:

Cheese, beer, and products with chocolate

A nurse is obtaining the health history from the mother of a preschooler with Reye syndrome. The nurse should ask the mother if the child has recently had

Chickenpox

A client who has a long history of alcoholism has not worked for the past 10 years. When the nurse asks about daily activities the client responds, "I currently work in the office of a local construction company." Which mental mechanism should the nurse suspect that the client is using?

Confabulation--

A nurse is providing immediate postoperative care to a client that had a lung resection for a malignancy. The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse?

Constant bubbling in the water seal chamber,

A nurse is caring for a client that has developed dysphagia and is unable to swallow. The client is receiving around-the-clock opioid pain medications for cancer pain, and hospice has recently begun caring for the client. What is the best nursing intervention in preparing for the client's discharge?

Contact the client's health care provider to discuss use of transdermal medications for pain control.

A client on the psychiatric unit who is receiving high-dosage risperidone (Risperdal) is exhibiting tremors of the hands. What should be the nurse's first intervention?

Contacting the health care provider

The alkylating chemotherapeutic agent cyclophosphamide (Cytoxan) is prescribed for a school-aged child with cancer. What is the most important nursing assessment while the child is receiving this medication?

Daily intake and output

A nurse is caring for a client with albuminuria resulting in edema. What pressure change does the nurse determine to be the cause of the edema?

Decrease in plasma colloid oncotic pressure (COP)

When planning nursing care for clients who are grieving the potential death of a family member, it is helpful to draw on the understanding of the five stages of grieving identified and described by Elisabeth Kübler-Ross. Place these stages in order of progression from first to last.

Denial Anger Bargaining Depression Acceptance

A young woman who is experiencing stress at a new job turns to food for comfort and induces vomiting to keep from gaining weight. When the binge-purge behaviors begin to interfere with the client's ability to meet her job responsibilities, the young woman visits the local mental health clinic. The priority nursing assessment during the initial appointment is the client's level of:

Depression

A client with type I diabetes complains of hunger, thirst, tiredness, and frequent urination. Based on these findings, the nurse should take what action?

Determine the client's blood glucose level.

A woman who is emotionally and physically abused by her husband calls a crisis hotline for help. The nurse works with the client to develop a plan for safety. What should be included in the safety plan? Select all that apply.

Determining a safe place to go in an emergency Memorizing the domestic violence hotline number

Neuroleptic malignant syndrome is a potentially fatal reaction to antipsychotic therapy. What signs and symptoms of this syndrome should the nurse identify? Select all that apply.

Diaphoresis Hyperrigidity Hyperthermia

A client who is on the third day of detoxification therapy becomes agitated and restless. What are the signs and symptoms that indicate impending alcohol withdrawal delirium? Select all that apply.

Diaphoresis Tachycardia Hypertension

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply.

Diarrhea Weakness Dysrhythmias

During a therapy session with a recently formed group, two members who like to talk want to take the floor simultaneously. Another member interrupts and says angrily, "I wish both of you would shut up. I'm tired of listening to you." What response

Discussing the behavior and feelings observed in the group

A practitioner prescribes alprazolam (Xanax) 0.25 mg by mouth three times a day for a client with anxiety and physical symptoms related to work pressures. For what most common side effect of this drug should the nurse monitor the client?

Drowsiness

A depressed client is given sertraline (Zoloft) 50 mg at bedtime. For what drug-related side effects should the nurse monitor the client? Select all that apply.

Dry mouth Constipation

A nurse is teaching a client about tricyclic antidepressants. Which potential side effects should the nurse include? Select all that apply.

Dry mouth Drowsiness Constipation Orthostatic hypotension

A disturbed client starts to repeat phrases that others have just said. How should the nurse document this speech?

Echolalia

What treatment should a nurse anticipate will be prescribed for a client with severe, persistent, intractable depression and suicidal ideation?

Electroconvulsive therapy

What characteristic is most essential for the nurse caring for a client undergoing mental health care?

Empathy

A nurse has been caring for a female client with the diagnosis of major depressive disorder. The nurse concludes that a trusting relationship is beginning to develop when the client:

Establishes eye contact with the nurse

A client is found to have a borderline personality disorder. What is a realistic initial intervention for this client?

Establishing clear boundaries

A client's arterial blood gas report indicates the pH is 7.52, PCO2 is 32 mm Hg, and HCO3 is 24 mEq/L. What does the nurse identify as a possible cause of these results?

Excessive mechanical ventilation.

The grieving wife of a client who has just died says to the nurse, "We should've spent more time together. I always felt that the children's needs came first." The nurse recognizes that the wife is experiencing:

Expected feelings of guilt

A nurse knows that children with attention deficit-hyperactivity disorder (ADHD) may be learning disabled. This means that these children:

Experience perceptual difficulties that interfere with learning.

According to Erikson, an individual who fails to master the maturational crisis of adolescence will most often:

Experience role confusion

client has just been admitted with the diagnosis of borderline personality disorder. There is a history of suicidal behavior and self-mutilation. The nurse remembers that the main reason that clients use self-mutilation is to:

Express anger or frustration.

Lithium carbonate 600 mg by mouth three times a day is prescribed for a client. The nurse concludes that the teaching about its side effects is understood when the client says that she will call her primary health care provider immediately if she notices any:

Fine hand tremor or slurred speech

What medication should the nurse expect to administer to actively reverse the overdose sedative effects of benzodiazepines?

Flumazenil,

Bupropion (Wellbutrin) has a unique side effect not shared by most other drugs of its class. The nurse should assess the client for which unique possible side effect of this drug?

Generalized seizures

According to Erikson, a person's adjustment to the period of senescence will depend largely on the adjustment the individual made to the developmental stage of:

Generativity versus stagnation

The nurse assesses a client with the diagnosis of bipolar disorder, manic episode. Which clinical findings support the diagnosis? Select all that apply.

Grandiosity Talkativeness Distractibilit

A nurse is working with children who have been sexually abused by a family member. What overwhelming feelings do these children usually express? Select all that apply.

Guilt Anger Self-blame

A 17-year-old client at 38 weeks' gestation is being prepared for an emergency cesarean birth because of abruptio placentae and severe fetal compromise. The client received nalbuphine (Nubain) 10 mg IV 30 minutes ago. Because the client is too sedated to sign the consent form, the nurse should:

Have the surgeon and attending practitioner sign the consent form.

Imipramine (Tofranil), 75 mg three times per day, is prescribed for a client. What nursing action is appropriate when this medication is being administered?

Having the client checked for increased intraocular pressure and teaching about symptoms of glaucoma

Which observation during a developmental appraisal of a 6-month-old infant is most important to the nurse in light of a diagnosis of hydrocephalus?

Head lag.

A client is receiving haloperidol (Haldol) for agitation, and the nurse is monitoring the client for side effects. Which response identified by the nurse is unrelated to an extrapyramidal tract effect?

Hypertensive crisis

The nurse should teach a client receiving isocarboxazid (Marplan) that failure to adhere to the necessary dietary restrictions can result in:

Hypertensive crisis

A client is receiving epoetin (Epogen) for the treatment of anemia associated with chronic renal failure. Which client statement indicates to the nurse that further teaching about this medication is necessary?

I realize it is important to take this medication because it will cure my anemia.

A client who is receiving haloperidol (Haldol), 5 mg three times a day, complains of twitching of the fingers. What is the best response by the nurse?

I'll ask the doctor to prescribe a medication that'll help overcome this. It's a side effect of the drug you're taking."

A young client is admitted to the hospital with a diagnosis of acute schizophrenia. The family reports that one day the client looked at a linen sheet on a clothesline and thought it was a ghost. What is the most appropriate conclusion to make about what the client was experiencing?

Illusion

A college student is brought to the mental health clinic by his parents. The diagnosis is borderline personality disorder. Which factors in the client's history support this diagnosis? Select all that apply.

Impulsiveness Lability of mood Self-destructive behavior

A nurse is caring for a school-aged child with acute lymphoid leukemia. While examining the child's laboratory results, the nurse notes that the child is neutropenic. What does the nurse recognize as the cause of the neutropenia?

Increased immature cell growth

A client with a history of methamphetamine use is admitted to the medical unit. What clinical manifestation does the nurse expect when assessing the client?

Increased heart rate

A married male client with three children has lost his job and states that he feels useless. He is tearful, upset, and embarrassed. What is an appropriate objective of care for this client?

Increasing self-esteem

While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse?

Initiate oxygen via a nasal cannula

The nurse explains to the mother of a preschool child that Erikson identified the developmental conflict of children from 3 to 5 years as:

Initiative versus guilt

A mother brings her 6-month-old infant to the emergency department with a 3-day history of gastroenteritis. What priority intervention does the nurse anticipate?

Insertion of an intravenous catheter

A 65-year-old man is admitted to the hospital with a history of depression. The client, who speaks little English and has had few outside interests since retiring, says, "I feel useless and unneeded." The nurse concludes that the client is in Erikson's developmental stage of:

Integrity versus despair

What conflict associated with Erikson's psychosocial stages of development should the nurse remember when caring for a client 30 years of age?

Intimacy versus isolation,

A nurse is conducting an assessment interview with a client who has lost a life partner. In light of the information elicited, the nurse suspects that the client:

Is experiencing dysfunctional grief

A primary nurse notes that a client has become jaundiced after 2 weeks of antipsychotic drug therapy. The nurse continues to administer the antipsychotic until the health care provider can be consulted. What does the nurse manager conclude about this situation?

Jaundice is sufficient reason to discontinue the antipsychotic.

The nurse is caring for a client that is on a low carbohydrate diet. With this diet, there is decreased glucose available for energy, and fat is metabolized for energy resulting in an increased production of which substance in the urine?

Ketones

An infant with tetralogy of Fallot becomes cyanotic and dyspneic after a crying episode. In what position should the nurse place the infant to relieve the cyanosis and dyspnea?

Knee-chest

A parent of a 13-year-old adolescent with recently diagnosed Hodgkin disease tells a nurse, "I don't want her to know about the diagnosis." How should the nurse respond?

Let's talk about how you're feeling about your child's diagnosis."

An effective mood-stabilizing drug used in clients with bipolar disorder in the acute treatment of mania and prevention of recurrent mania and depressive episodes is:

Lithium carbonate (Lithium)

The nurse anticipates that the medication that will be used to prevent symptoms of withdrawal in clients with a long history of alcohol abuse is:

Lorazepam (Ativan)

A client reports vomiting and diarrhea for three days. What clinical finding most accurately will indicate that the client has a fluid deficit?

Loss of body weight

What is most important for the nurse to do when caring for a client who is experiencing a paranoid delusion?

Maintain eye contact when talking with the client

A nurse is caring for a client who is angry and agitated. What is the best approach for the nurse to use with this client?

Maintaining a calm, consistent approach with the client

A nurse is teaching the parents of a child with attention deficit-hyperactivity disorder. What should the nurse include as the most frequently prescribed medication for this disorder?

Methylphenidate (Ritalin)

What is the priority nursing intervention for an infant during the immediate postoperative period after surgical repair of a cleft lip?

Minimize crying.

A nurse is caring for an infant who has just undergone myelomeningocele repair. What should the nursing plan of care include?

Monitoring for cerebrospinal fluid leakage.

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant Entercoccus (VRE). After notifying the physician, which action should the nurse take to decrease the risk of transmission to others?

Move the client to a private room.

A client is receiving an antipsychotic medication. When assessing the client for signs and symptoms of pseudoparkinsonism, the nurse should be alert for:

Muscle tremors

A client is receiving doxepin (Sinequan). For which most dangerous side effect of tricyclic antidepressants should a nurse monitor the client?

Mydriasis

What drug should a nurse anticipate that the health care provider will prescribe for a client demonstrating clinical manifestations associated with an opioid overdose?

Naloxone

A health care provider prescribes digoxin (Lanoxin) for a client. The nurse teaches the client to be alert for which common early indication of digoxin toxicity?

Nausea

A health care provider prescribes carbamazepine (Tegretol) for a client. The nurse teaches the client about effects of the drug that should be reported to the health care provider. Which effects identified by the client as cause to call the provider indicate an understanding of the teaching? Select all that apply.

Nausea or vomiting Unusual bleeding or bruising

During a nursing assessment, a nurse notes that a client has begun to create new words. What term does the nurse use to document this finding?

Neologism

A client with schizophrenia is speaking made-up words that have no meaning to other people. What term should the nurse use to document these verbalizations?

Neologisms

A client reports severe pain two days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next?

Obtain vital signs.

A nurse is teaching clients about dietary restrictions during monoamine oxidase inhibitor (MAOI) therapy. What response does the nurse tell them to anticipate if they do not follow these restrictions?

Occipital headaches

An older client with the diagnosis of dementia of the Alzheimer type is admitted to a long-term care facility. When planning care for this client, the nurse recalls that confusion:

Occurs with a transfer to new surroundings

A child undergoes tonsillectomy and adenoidectomy for numerous recurrent respiratory tract infections. After the surgery, the nurse should teach the parents to:

Offer ice chips on which to suck.

A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation is completed? Select all that apply.

On admission to the hospital Before transfer to a rehabilitation facility

The nurse is providing post-procedure care for a client that had a liver biopsy. To prevent hemorrhage, it is the nurse's highest priority to place the client in what position?

On the right side

What are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)? Select all that apply.

Pain relief Antipyresis Reduced inflammation

What are the clinical indicators that a nurse expects when an intravenous (IV) line has infiltrated? Select all that apply.

Pallor Edema Decreased flow rate

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question?

Parenteral albumin (Albuminar)..O

What should the nurse assess before continuing the administration of IV magnesium sulfate therapy to a client with preeclampsia?

Patellar reflexes and urinary output

What findings should a nurse expect when examining the laboratory report of a preschooler with rheumatic fever?

Positive antistreptolysin titer

A client had extensive, prolonged surgery. Which electrolyte level should the nurse monitor most closely?

Potassium

A nurse teaches dietary guidelines to a client who will be receiving tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor (MAOI). The client compiles a list of foods to avoid. Which foods included on the list indicate that the teaching has been effective? Select all that apply.

Pepperoni pizza Bologna sandwich

When assessing the characteristics of an adolescent with anorexia nervosa, the nurse expects the adolescent to be:

Perfectionistic

The nurse should monitor for which involuntary physiological response in a client who is experiencing pain?

Perspiring

When talking with a client who has alcoholism, the nurse notes that the client becomes irritable, makes excuses, and blames family and friends for the drinking problem. Which defense mechanisms does the nurse conclude that the client is using? Select all that apply.

Projection Rationalization

A nurse anticipates that most clients with phobias will use the defense mechanisms of:

Projection and displacement

A client who was sexually assaulted 3 hours ago comes to the emergency department of the hospital. The priority is for the staff to help the client feel:

Protected,,

A 13-year-old girl is brought to the emergency department by her mother, who tells the nurse that she just found out that her daughter has been sexually abused by her grandfather for almost 2 years. What is the nurse's priority intervention?

Providing a safe, nonjudgmental environment

A client says, "Since my husband died I've got nothing to live for. I just want to die." The nurse hears the nursing assistant say, "Things will get better soon." The nurse identifies this response as:

Providing false reassurance

In a mental health day treatment program, a psychiatric nurse is assessing a client's activity level. The client starts to walk swiftly around the room while rubbing the hands together. What should the nurse conclude that the client is exhibiting?

Psychomotor agitation

A client in the mental health clinic who has concerns about getting married says to the nurse, "I guess I'd better get married. All the plans are made and paid for, and the invitations have all been mailed." What defense mechanism is the client using?

Rationalization

Incidences of child molestation often are revealed years later when the victim is an adult. Which defense mechanism reflects this situation?

Repression

A neuromuscular blocking agent is administered to a client before electroconvulsive therapy. At this time, the nurse should monitor the client for:

Respiratory difficulties

A client with schizophrenia has been experiencing hallucinations. During what client behaviors should the nurse expect the hallucinations to be more frequent?

Rest

A nurse is caring for a group of clients on the psychiatric unit. What clinical findings should alert the nurse that serotonin syndrome has developed in one of the clients?

Restlessness, tachycardia, fever, diarrhea, and altered mental status

A client who has been sexually assaulted and is aware of the possible legal implications decides to seek prosecution of the rapist. The nurse carefully listens and documents all assessments. This is done because with a charge of rape the burden of proof:

Rests with the criminal justice system in collaboration with the victim

Antipsychotic drugs can cause extrapyramidal side effects. Which responses should the nurse document as indicating pseudoparkinsonism? Select all that apply.

Rigidity Tremors Bradykinesia

A nurse is teaching a parent how to prevent accidents while caring for a 6-month-old infant. What ability should be emphasized with regard to the infant's motor development?

Rolls over.

When lithium therapy is instituted, the nurse should teach the client to maintain an adequate daily intake of:

Sodium

A 12-year-old child who has a history of school failure and destructive acting out is admitted to a child psychiatric unit with the diagnosis of conduct disorder. The youngest of three children, the child is identified by both the parents and the siblings as the family problem. The nurse recognizes the family's pattern of relating to the child as:

Scapegoating

An adult with the diagnosis of schizophrenia is admitted to the psychiatric hospital. The client is ungroomed, appears to be hearing voices, is withdrawn, and has not spoken to anyone for several days. What should the nurse do during the first few hospital days?

Seek out the client frequently to spend short periods of time together

A nurse is planning to teach activities of daily living to a developmentally disabled 3-year-old child. What activity should the nurse plan to teach to the child first?

Self-feeding

What is the first activity of daily living (ADL) that the nurse should help teach a developmentally disabled 8-year-old child?

Self-feeding

The nurse is caring for a 30-year-old woman who was admitted yesterday with borderline personality disorder (BPD). The most important intervention for the nurse caring for a client with BPD is:

Setting limits

Three days after bariatric surgery, the client puts the call light on and states, "I felt a 'pop' in my belly after I had a coughing spell." The nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence?

Sharp increase in serosanguineous drainage

A client with schizophrenia, undifferentiated type, is receiving a typical antipsychotic/neuroleptic. For which extrapyramidal effects should the nurse be alert?

Shuffling gait, tremors, and restlessness

A nurse is caring for several extremely depressed clients. The nurse determines that these clients seem to do best in settings where they have:

Simple daily routines

What is the most appropriate intervention for the nurse to implement after finding a disturbed client in bed in the fetal position?

Sitting down in a chair by the client and saying, "I'm here to spend time with you."

A client with the diagnosis of schizophrenia refuses to get out of bed and becomes upset. What is the nurse's initial therapeutic response?

Staying at the bedside until the client calms down

A client with mental health problems is given a prescription for fluphenazine (Prolixin). The nurse develops a teaching plan about the medication. What should the nurse caution the client to avoid?

Staying in the sun

The nurse is teaching a parent group about the reason to adhere to the immunization schedule. What complication of mumps is important for adolescents to avoid?

Sterility.

A client receiving intravenous vancomycin (Vancocin) reports ringing in both ears. Which initial action should the nurse take?

Stop the infusion

A nurse is caring for a client with pulmonary tuberculosis who is to receive several antitubercular medications. Which of the first-line antitubercular medications is associated with damage to the eighth cranial nerve?

Streptomycin

A nurse interviews a young female client with anorexia nervosa to obtain information for the nursing history. What will the client's history most likely reveal?

Strong desire to improve her body image

A nurse is providing immediate postoperative care to a client with a tracheostomy tube in place. The client suddenly develops noisy, increased respirations and an elevated heart rate. What action should the nurse take immediately?

Suction the tracheostomy.

What is the most appropriate response by a nurse to a parent's question about childhood suicide?

Suicide threats in children should be taken seriously."

A client is started on fluphenazine decanoate (Prolixin Decanoate). What should the nurse emphasize when teaching the client about taking this medication?

Sunscreen should be used for outdoor activities.

A nurse on a mental health unit administers a variety of antipsychotic medications. The nurse concludes that olanzapine (Zyprexa, Zydis) has a distinct advantage over other antipsychotics because:

Tablets disintegrate immediately in the mouth, preventing tablet "cheeking."

A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? Select all that apply.

Tachypnea Hypotension

A client with schizophrenia is taking benztropine (Cogentin) in conjunction with an antipsychotic. The client tells a nurse, "Sometimes I forget to take the Cogentin." What should the nurse teach the client to do if this happens again?

Take a dose as soon as possible, up to 2 hours before the next dose.

A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? Select all that apply.

Take the aspirin with meals or a snack. Do not chew enteric-coated tablets. Report persistent abdominal pain.

An adolescent on the psychiatric unit has an angry outburst toward another client who cut in front of people standing in line to get their mail. Later the nurse conducts a one-on-one therapeutic session with the angry client. What is an appropriate short-term goal for the client to strive for?

Talking about the situation that precipitated the anger

A client with chronic undifferentiated schizophrenia is receiving an antipsychotic medication. For which potentially irreversible extrapyramidal side effect should a nurse monitor the client?

Tardive dyskinesia

A client with schizophrenia is given an antipsychotic drug. The nurse recalls that of all the extrapyramidal effects associated with this type of medication, the one that requires discontinuation of the drug is:

Tardive dyskinesia

A client with newly diagnosed multiple myeloma asks, "How long do you think I have to live?" The most appropriate response by the nurse is:

Tell me about your concerns right now."

A nurse determines that the information about falling down the stairs given by a parent suspected of child abuse contradicts the information given by the child. What should the nurse say to the parent?

Tell me again how your child fell down the stairs.

A shy, reserved 15-year-old male client just admitted to the adolescent unit of a mental health facility exposes his genitals to the female admitting nurse. What is the most immediate therapeutic response by the nurse?

Telling him that this type of behavior is unacceptable,

A nurse in the pediatric clinic is assessing an infant who had a revision of a ventriculoperitoneal shunt. What clinical finding alerts the nurse that intracranial pressure has increased?

Tension of the anterior fontanel.

A nurse is working with a child who was physically abused by a parent. What is the most important goal for this family?

The child will live in a safe environment.

A client who has been taking a conventional antipsychotic for several days comes to the clinic complaining of neck spasms. The figure illustrates the client's physical status observed by the nurse. What extrapyramidal side effect has the client developed?

Torticollis

A client with schizophrenia is receiving intramuscular injections of fluphenazine decanoate (Prolixin Decanoate). After therapy is initiated, dystonia develops. What clinical manifestations does the nurse document during the assessment? Select all that apply.

Torticollis Oculogyric crisis,

According to Erikson, a child's increased vulnerability to anxiety in response to separation or pending separation from significant others results from failure to complete a developmental stage. What does the nurse call this stage?

Trust

A nurse administers an antipsychotic medication to a client. For which common manageable side effect should the nurse assess the client?

Unintentional tremor

A client is receiving imipramine (Tofranil), a tricyclic antidepressant, for depression. The nurse assesses the client for side effects and adverse effects. Which adverse effect requires further assessment and possible medical intervention?

Urinary hesitancy

A nurse is providing care to a client eight hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the surgeon?

Urine output of 20 mL/h

When presenting a workshop on adolescent suicide, a community health nurse identifies risk factors. Select all that apply.

Victim of family violence Dependence on alcohol, drugs, or both Uncertainty related to sexual orientation Repeated demonstration of poor impulse control

A client receiving the medication buspirone hydrochloride (BuSpar) is admitted to the hospital with the diagnosis of possible hepatitis. The nurse identifies that the client's sclerae look yellow. What should be the nurse's initial action?

Withhold the medication.

A nurse is working with a client who has emotional problems. During what stage of the therapeutic nurse-client relationship does the nurse anticipate that most of the client's problem-solving will occur?

Working stage

Which assessment finding alerts the nurse to stop administering haloperidol (Haldol) to a client until further laboratory work is done?

Yellow sclerae

A client who has schizophrenia is receiving a phenothiazine antipsychotic medication. Which serious client responses to the medication should the nurse immediately report to the practitioner? Select all that apply.

Yellow sclerae Involuntary tongue movements,

As a young male client is undergoing a dialysis treatment, the nurse notes that he is not talking with the other clients and that his eyes are lowered and his jaw clenched. The nurse says, "You look discouraged." The client replies, "I'm a bother. My wife would at least get some insurance money if I died." Which is the most therapeutic response by the nurse?

You feel so bad you wish you were dead

A nurse teaches a client about Coumadin (warfarin) and concludes that the teaching is effective when the client states, "I must not drink:

cranberry juice