Final exam 203

The nurse observes that a patient with paranoid schizophrenia is displaying signs that indicate increased agitation and could be followed by a violent reaction. What are the immediate priorities for the nurse to plan to institute?

-Escort to room or redirect to provide safety for self and others on unit -Do not whisper to them

A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? SATA -Limit visitors in the client's room -Encourage fresh vegetables in the diet -Increase protein intake -Instruct the client to consume 2,000 calories/day -Restrict fresh flowers in the room

-Limit visitors -Increase protein intake -Restrict fresh flowers in the room

The hospitalized patient is in a manic phase of bipolar disorder. When developing the nursing care plan for this patient, how should the nurse expect the patient's behavior to be in social interactions?

-Unpredictable -demanding -competitive

The nurse is mindful of maintaining relationships with patients that are therapeutic. Certain characteristics of the relationships the nurse will foster include:

-establishing boundaries for both the nurse and patient. -maintaining a patient-focus at all times -avoiding concern with whether the patient likes the nurse

What are possible warnings or signals of abuse of the nurse-patient relationship?

-nurse making exceptions to client -keeping secrets -inappropriate conversations in the nurse-client relationship

What are symptoms that would indicate acute dystonic reaction to antipsychotic medications?

-tilted head w tongue & lower jaw stuck out w drooling -NOT relaxation of the pharynx

Identify the serum lithium level for maintenance and safety.

0.5-1.5

A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? a. "I am a superhero and am immortal" b. "I am no one and everyone is me" c. "I feel monsters pinching me all over" d. "I know that you are stealing my thoughts"

B. "I am no one and everyone is me"

A nurse is providing teaching for a male client who has schizophrenia and is taking risperidone. Which of the following instructions should the nurse include in the teaching? A. "Add extra snacks to your diet to prevent weight loss." B. "Notify the provider if you develop trouble sleeping C. "You may begin to have mild seizures while taking this medication" D. "This medication is likely to increase your libido"

B. "Notify the provider if you develop trouble sleeping

A nurse is teaching a client who has schizophrenia strategies to cope with anticholinergic effects of fluphenazine. Which of the following should the nurse suggest to the client to minimize anticholinergic effects? A. Take the medication in the morning to prevent insomnia. B. Chew sugarless gum to moisten the mouth. C. Use cooling measures to decrease fever. D. Take an antacid to relieve nausea.

B. Chew sugarless gum to moisten the mouth

A nurse is caring for a client who has been taking sertraline (Zoloft) for the past 2 days. Which of the following assessment findings should alert the nurse to the possibility that the client is developing serotonin syndrome? A. Bruising B. Fever C. Abdominal pain D. Rash

B. Fever

A nurse is assessing a male client who recently began taking haloperidol (Haldol). Which of the following findings is the highest priority to report to the provider? A. Shuffling gait B. Neck spasms C. Drowsiness D. Impotence

B. Neck spasms

The nurse observes that the patient with paranoid schizophrenia appears very preoccupied. The patient is pacing back and forth in the hall, periodically looking to the side, clenching the fist and saying. "I told you to go away." At this time, the nurse should plan to do which of the following? Select all that apply. A.) Offer frequent orienting stimuli B.) Reduce the pt proximity to others C.) Refrain from using non-verbal hand gestures D.) Avoid touching the pt during conversation E.) Reassure the pt of the safety of environment

B. Reduce the pt proximity to others C.) Refrain from using non-verbal hand gestures D.) Avoid touching the pt during conversation E.) Reassure the pt of the safety of environment

A nurse is involved in a serious prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder? (select all that apply) A. Avoid thinking about the incident when it is over B. Take breaks during the incident for food and water C. Debrief with others following the incident D. Avoid displays of emotion in the days following the incident. E. Take advantage of offered counseling

B. Take breaks during the incident for food and water C. Debrief with others following the incident E. Take advantage of offered counseling

A patient in an inpatient unit is awake at one a.m. and tells the nurse, "I can't sleep because of the light in the hall and the noise from the kitchen. I need to have another sleeping pill." What is the most appropriate nursing intervention? A. Administer PRN sedative B. Move the client to a quieter room C. Close the door to the client's room D. Allow the client to watch television for one hour

C. Close the door to the client's room

How would a nurse respond to a patient who was voluntarily admitted to the inpatient behavioral health facility that is refusing to take the prescribed antipsychotic medication?

Suggest a long-acting medication

The nurse assesses that a patient in a state of elevated mood is at risk for self-harm. The nurse then places high priority on including which of the following in the plan of care? a.) A room that is observable from the nurses' station b.) Constant supervision of the patient c.) Administration of all medications intramuscularly rather than orally d.) A quiet, non-stimulating private room for the pat

b.) Constant supervision of the patient

· A client is found unconscious with a Medic-Alert bracelet indicating type 1 diabetes mellitus. What is the highest priority nursing intervention? a. Administer insulin. b. Feed the client orange juice. c. Administer glucagon. d. Perform CPR.

c. Administer glucagon.

Which information should the nurse include in discharge instructions for patients with comminuted left forearm fractures and a long-arm cast? a. Keep left shoulder elevated on pillow or cushion b. Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) c. Call health care provider for numbness of the hand d. Keep hand immobile to prevent soft tissue swelling

c. Call health care provider for numbness of the hand

macrovascular diabetic complications:

coronary artery disease, peripheral arterial disease, and cerebrovascular disease (stroke)

A nurse is reviewing laboratory results for a client who has schizophrenia and is taking Clozapine. Which of the following values should the nurse identify as a contraindication for this medication? 1. WBC 2,500/mm3 2. Hgb 11.5 mg/dL 3. platelets 150,00/mm3 4. RBC 3.5 million/mm3

1. WBC 2,500/mm3

​​A patient diagnosed with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene, avolition and motor agitation. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?

-Avolition -Poor personal hygiene

The nurse is applying a topical corticosteroid to a client with eczema. The nurse understands that it is safe to apply the medication to which body areas? SATA -Back -Axilla -Eyelids -Soles of feet -Palms of the hands

-Back -Soles of feet -Palms of the hands

When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? SATA -An irregularly shaped lesion -A small papule with a dry, rough scale -A firm, nodular lesion topped with crust -A pearly papule with a central crater and a waxy border -Location in the bald spot atop the head that is exposed to outdoor sunlight

-A pearly papule with a central crater and a waxy border -Location in the bald spot atop the head that is exposed to outdoor sunlight

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1. The adolescent gives away a DVD and a cherished autographed picture of a performer 2. The adolescent runs out of the therapy group, swearing at the group leader, and to her room. 3. The adolescent becomes angry while speaking on the telephone and slams down the receiver 4. The adolescent gets angry with the roommate when the roommate borrows the client's clothes without asking

1. The adolescent gives away a DVD and a cherished autographed picture of a performer.

An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position; the lower jaw is thrust forward, and the patient is drooling. What intervention by the nurse is indicated? 1. administer Diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record 2. reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient 3. give Trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time 4. administer atropine sulfate 2 mg subcut from the PRN medication administration record

1. administer Diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record

A client is to receive Humalog (Lispro) insulin at breakfast. The nurse plans to administer the insulin _____ breakfast. 1. 30 minutes after 2. 5 minutes before 3. 30 minutes before 4. 15 minutes after

2. 5 minutes before

The nurse is monitoring a client for evidence of a hypoglycemic reaction. The client received Humulin R insulin at 7 AM. The nurse anticipates that the client will need to be most closely monitored for evidence of a hypoglycemic reaction at which time? 1. 3:00 PM to 6:00 PM 2. 9:00 AM to 11:00 AM 3. Noon to 3:00 PM 4. 8:00 PM to Midnight

2. 9:00 AM to 11:00 AM

The nurse asks Bob if he has any allergies to medications. He reports an allergy to Haldol. The nurse asks him to describe the type of reaction he experienced. Bob states, "My neck got really stiff, and I couldn't move it." What type of reaction should the nurse suspect? 1. akathisia 2. dystonia 3. parkinsonism 4. synergistic

2. Dystonia

The nurse prepares to provide instructions to a client with low potassium level about the foods that are high in potassium and plans to tell the client to consume which foods? Select all that apply 1. Peas 2. Raisins 3. Potatoes 4. Cantaloupe 5. Cauliflower 6. Strawberries

2. Raisins 3. Potatoes 4. Cantaloupe 6. Strawberries

A nurse reinforces instructions to the mother of a child diagnosed with pediculosis (head lice). Permethrin 1% (Nix) has been prescribed. Which statement by the mother regarding the use of the medication indicates a need for further teaching? Select all that apply 1."We will need to apply another application in 48 hours." 2."The hair should not be shampooed for 24 hours after treatment." 3."The medication can be obtained over the counter in a local pharmacy." 4."The medication is applied to the hair after shampooing and left on for 24 hours." 5."The medication is applied to the hair after shampooing, left on for 5 to 10 minutes, and then rinsed out."

2."The hair should not be shampooed for 24 hours after treatment." 3."The medication can be obtained over the counter in a local pharmacy." 5."The medication is applied to the hair after shampooing, left on for 5 to 10 minutes, and then rinsed out."

A patient receives aspart (NovoLog) insulin at 8:00 AM. At which time would the nurse anticipate the highest risk for hypoglycemia? 1. 12:00 AM 2. 4:00 PM 3. 10:00 AM 4. 2:00 PM

3. 10:00 AM

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? 1. delusions 2. neologisms 3. anhedonia 4. echopraxia

3. Anhedonia

A nurse is caring for a client who has bipolar disorder and a new prescription for Valproate. Which of the following instructions should the nurse give the client about the use of this medication? 1. thyroid function tests should be performed every 6 months 2. a pretreatment electroencephalogram (EEG) will be done 3. liver function tests must be monitored 4. high serum sodium levels can cause toxic levels of Valproate

3. Liver function tests must be monitored

The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? 1. auditory hallucinations 2. delusions of grandeur 3. poor personal hygiene 4. psychomotor agitation

3. Poor personal hygiene

A patient who had open reduction and internal fixation (ORIF) of left lower leg fractures continued to report severe pain in the leg 15 minutes after receiving prescribed IV morphine. The nurse determines pulses are faintly palpable and the foot is cool to touch. Which action should the nurse take next? a. Notify health care provider b. Assess the incision for redness c. Reposition the left leg on pillows d. Check the patient's blood pressure

A. notify the provider

The nurse is caring for a patient who has a massive burn injury and possible hypovolemia. Which assessment data should be of most concern to the nurse? 1. Oral fluid intake is 100 mL for 8 hours. 2. Skin tenting over the sternum is prolonged. 3. Urine output is 30 mL/hr. 4. Blood pressure is 90/40 mm Hg.

4. BP 90/40

The nurse is administering risperidone to a client who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client? 1. Get adequate sunlight 2. Continue driving as usual 3. Avoid foods rich in potassium 4. Get up slowly when changing positions

4. Get up slowly when changing positions

The nurse is collecting assessment data on a client who is suspected to be a victim of violence. Which assessment data would support the suspicion that the client is a victim of abuse? Select all that apply. A) The client has few friends. B) The client holds a dominant role in the family. C) The client is in charge of the family finances. D) There is a moderate amount of alcohol use in the home. E) The client reports that the father was abusive during childhood.

A) The client has few friends. D) There is a moderate amount of alcohol use in the home. E) The client reports that the father was abusive during childhood.

A charge nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following manifestations should the charge nurse identify as being effectively treated by first-generation antipsychotics? Select all that apply A. Auditory hallucinations B. Withdrawal from social situations C. Delusions of grandeur D. Severe agitation E. Anhedonia

A. C. D.

A nurse is completing the discharge teaching to a client who had a wound debridement for osteomyelitis. Which of the following information should the nurse include? A. Antibiotic therapy should continue for 3 months. B. Relief of pain indicates the infection is eradicated C. Airborne precautions are used during the wound care. D. Expect paresthesia distal to the wound

A. Antibiotic therapy should continue for 3 months.

A nurse is having difficulty arousing a client following a EGD. which of the following is the priority action by the nurse? A. Assess the clients airway B. Allow the client to sleep C. Prepare to administer an antidote to the sedative D. Evaluate preprocedure laboratory findings

A. Assess the clients airway

What is your best intervention when you assess that a patient is responding to an auditory hallucination? a. Ask the patient, "Can you tell me what you are hearing?" b. Ask the patient, "Are you afraid of the voice you are hearing?" c. Tell the patient, "Try to ignore the voices you hear." d. Tell the patient, "The voices you hear are not real."

A. Can you tell me what you are hearing?

A nurse is preparing to perform a follow-up assessment on a client who takes chlorpromazine (Thorazine) for the treatment of schizophrenia. The nurse should expect to find the greatest improvement in which of the following manifestations? (Select all that apply.) A. Disorganized speech B. Bizarre behavior C. Impaired social interactions D. Hallucinations E. Decreased motivation

A. Disorganized speech B. Bizarre behavior D. Hallucinations

The nurse in the ER receives a patient who sustained a severe burn injury. What is the priority action by the nurse in this situation? A. Establish a patent airway B. Insert an indwelling cath C. Replace fluids D. Administer pain medication

A. Establish a patent airway

A nurse is planning care for a client who has a new prescription for TPN. Which of the following interventions should be included in the plan of care? Select all that apply A. Obtain a capillary blood glucose four times daily B. Administer prescribed medications through a secondary port on the TPN IV tubing C. Monitor vital signs 3 times during the 12-hr shift D. Change the TPN IV tubing every 24 hours E. Ensure a daily aPTT is obtained

A. Obtain a capillary blood glucose four times daily C. Monitor vital signs 3 times during the 12-hr shift D. Change the TPN IV tubing every 24 hours

A nurse is reviewing laboratory findings and notes that a client's plasma lithium level is 2.1 mEq/L. Which of the following is an appropriate action by the nurse? A. Perform immediate gastric lavage. B. Prepare the client for hemodialysis. C. Administer an additional oral dose of lithium. D. Request a stat repeat of the laboratory test.

A. Perform immediate gastric lavage.

The nurse is caring for a client who is receiving TPN solution. The current bag of solution was hung 24 hrs ago, and 400mL remains to infuse. Which of the following is the appropriate action for the nurse to take? A. Remove the current bag and hang a new bag. B. Infuse the remaining solution at the current rate and then hang a new bag. C. Increase the infusion rate so the remaining solution is administered within the hr and hang a new bag D. Remove the current bag and hang a bag of LR's

A. Remove the current bag and hang a new bag

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? SATA A. Restating B. Active listening C. Asking the client why D. Maintaining neutral responses E. Providing acknowledgement and feedback F. Giving advice and approval or disapproval

A. Restating B. Active listening D. Maintaining mutual responses E. Providing acknowledgment and feedback

A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg orally twice daily for 3 weeks. What symptoms if assessed by the nurse would indicate Pseudo parkinsonism? a.) Shuffling, propulsive gate b.) Masklike face c.) Hyperthermia d.) Hypertension e.) Drooling

A. Shuffling, propulsive gate B. Masklike face E. Drooling

A schizophrenic client is experiencing auditory hallucinations. Which of the following nursing actions is best in response to this client? a. Speak loudly and simply. b. Wait for the hallucination to stop before talking to the client. c. Tell the auditory hallucination to stop bothering the client. d. Ignore the client and the hallucination should stop.

A. Speak loudly and simply

The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? A. Temperature of 101.6 F orally B. Complaints of discomfort during repositing C. Old bloody drainage outlined on the surgical dressing. D. Discomfort during coughing and deep-breathing exercises

A. Temperature of 101.6 F orally

A nurse is caring for a client who manifests indications of hypovolemia while in the PACU. Which of the following requires action by the nurse? Select all that apply. A. Urine output less than 25 mL/hr B. Hematocrit 53% C. BUN 24 mg/dL D. Tenting of skin over the sternum E. Apical pulse rate 62/min

A. Urine output less than 25 mL/hr B. Hematocrit 53% C. BUN 24 mg/dL D. Tenting of skin over the sternum

A homeless patient with severe anorexia, fatigue, jaundice, and hepatomegaly is diagnosed with viral hepatitis and has just been admitted to the hospital. In planning care for the patient, the nurse assigns the highest priority to the patient outcome of.... a. maintaining adequate nutrition. b. establishing a stable home environment. c. increasing activity level. d. identifying the source of exposure to hepatitis.

A. maintaining adequate nutrition

A patient diagnosed with schizophrenia is acutely disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse makes assessments that she recognizes as acute dystonic reaction. Which of the following symptoms would indicate this? Select all that apply a.) the patient's head rotated to one side in a stiff position. b.) protrusion of the tounge. c.) the lower jaw is thrust forward d.) the patient is drooling. e.) relaxation of the pharnyx.

A. the patient's head rotated to one side in a stiff position B. protrusion of the tounge. C. the lower jaw is thrust forward. D. the patient is drooling.

A nurse works with a patient diagnosed with schizophrenia regarding the importance of medication management. The patient repeatedly says, "I don't like taking pills." Which treatment strategy should the nurse discuss with the health care provider? a.) Addition for a benzo such as Ativan b.) Use a long-acting antipsychotic injection c.) Adjunctive use of an antidepressant such as Elavil d.) Inpatient hospitalization because of high-risk exacerbation of symptoms

B. Use a long-acting antipsychotic injections

A patient diagnosed with schizophrenia says, "corn, potatoes, jump up, play games" What type of verbalization is evident? a.) Stilted language b.) Word salad c.) Preservation d.) Echolalia

B. Word salad

The nurse observes that the patient with paranoid schizophrenia appears very preoccupied. The patient is pacing back and forth in the hall, periodically looking to the side, clenching the fist and saying. "I told you to go away." At this time, the nurse should plan to do which of the following? Select all that apply. A.) Offer frequent orienting stimuli B.) Reduce the pt proximity to others C.) Refrain from using non-verbal hand gestures D.) Avoid touching the pt during conversation E.) Reassure the pt of the safety of environment

B.) Reduce the pt proximity to others C.) Refrain from using non-verbal hand gestures D.) Avoid touching the pt during conversation E.) Reassure the pt of the safety of environment

A client who is learning about electroconvulsive therapy (ECT) treatment asks a nurse "Isn't this treatment dangerous?" Which is the most appropriate nursing reply? A. "No, this treatment is side-effect free." B. "There can be temporary paralysis but full functioning returns within 3 hours of treatment." C. "There are some risks, but a thorough examination will determine your candidacy for ECT." D. "Transient ischemic attacks (TIA) can occur but are rare."

C. "There are some risks, but a thorough examination will determine your candidacy for ECT."

A nurse is preparing to administer morning doses of insulin glargine and regular insulin to a client who has a blood glucose of 278 mg/dL. Which of the following actions should the nurse take? A. Draw up the regular insulin and then the glargine insulin in the same syringe. B. Draw up the glargine insulin then the regular insulin in the same syringe. C. Draw up and administer regular and glargine in separate syringes. D. Administer the regular insulin, wait 1 hr, and then administer the glargine insulin.

C. Draw up and administer regular and glargine in separate syringes.

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? A. Redness around the pin sites B. Pain on palpation at the pin sites C. Thick, yellow drainage from the pin sites D. Clear, watery drainage from the pin sites

C. Thick, yellow drainage from the pin sites

A patient is admitted to a secure psychiatric inpatient unit for the treatment of bipolar disorder. The nurse begins the intake assessment, but the patient stands up and begins to walk around the room and shouts, "You can't do this to me! Do you know who I am? I want out of here!!" The best action of the nurse at this time focuses on which of the following? A.) Obtaining the assessment info limited to 20 mins at a time allowing for rest periods B.) Providing pt with adequate food and fluids to maintain homeostasis C.) Providing the pt and self with safe environment D.) Admin the prescribed prn neuroleptic meds to prevent escalation of behavior

C.) Providing the pt and self with safe environment

The health care provider diagnoses impetigo in a patient who has crusty vesicopustular lesions on the lower face. Which instructions should the nurse include in the teaching plan?

Clean the infected areas with soap and water

A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patient's arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness

D) Full-thickness

Which focused data should the nurse assess after identifying 4+ pitting edema on patient who has cirrhosis? a. Hemoglobin b. Temperature c. Activity level d. Albumin level

D. Albumin

A patient is admitted with thyroid storm. Which sign and symptoms are NOT present with this condition? SELECT ALL THAT APPLY A. Temperature of 104.9'F B. Heart rate of 125 bpm C. Respirations of 42 D. Heart rate of 20 bpm E. Intolerance to cold F. Restless

D. Heart rate of 20 bpm E. Intolerance to cold

What is the rationale for a person taking lithium to have enough water and salt in his or her diet? A. salt and water are necessary to dilute lithium to avoid toxicity. B. Water and salt convert lithium into a usable solute. C. Lithium is metabolized in the liver, necessitating increased water and salt. D. Lithium is a salt that has a greater affinity for receptor sites than sodium chloride.

D. Lithium is a salt that has a greater affinity for receptor sites than sodium chloride.

A nurse is obtaining ABG's for a client who has vomited 24hrs. The nurse should expect which of the following acid-base imbalances as a result? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

D. Metabolic alkalosis

A nurse is teaching foot care to a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching? Select all that apply. A. Remove calluses using over the counter remedies. B. Apply lotion between the toes. C. Test water temperature with the fingers before bathing. D. Trim toenails straight across. E. Wear closed toe shoes.

D. Trim toenails straight across. E. Wear closed toe shoes.

A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 10:30 AM. By noon, the patient is diaphoretic, drooling, and has difficulty swallowing. By 4:00 PM, vital signs are body temperature, 102.8° F; pulse, 110 beats per minute; respirations, 26 breaths per minute; and blood pressure, 150/90 mm Hg. Select the nurse's best analysis and action. A.) Agranulocytosis, Institute reverse isolation B.) Tardive dyskinesia, with hold the next dose of medication C.) Cholestatic Jaundice, begin high- protein, low fat diet D.) Neuroleptic malignant syndrome, immediately notify the healthcare provider

D.) Neuroleptic malignant syndrome, immediately notify the healthcare provider

Know which labs are used to diagnosis HPP

High B6 Very low ALP

The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage ll pressure injury in the sacral area. Which findings would the nurse expect to note on assessment of the clients sacral area? -Intact skin -Full-thickness skin loss -Exposed bone, tendon, or muscle -Partial-thickness skin loss of dermis

Partial-thickness skin loss of dermis

A 7-month-old is admitted to the pediatric unit following a surgical repair for a cleft lip and palate. The nurse is preparing a plan of care. Which of the following are to be included? (Select all that apply) a. Application of elbow immobilizers. b. Analgesia for pain management. c. Feeding resumed when tolerated. d. Rectal temperature checks. e. Oral pacifiers for restlessness.

a. Application of elbow immobilizers. b. Analgesia for pain management. c. Feeding resumed when tolerated. d. Rectal temperature checks.

The nurse is providing care for an adolescent with complex needs after surgical correction of a bowel obstruction. On entering the room, the nurse prioritizes care and decides to complete which task first? a. Change the central intravenous line dressing, which is loose and gaping. b. Empty the ileostomy bag, which is moderately full of liquid stool. c. Change the gauze dressing around the Jackson Pratt drain. d. Offer the adolescent ice chips to ease their dry mouth.

a. Change the central intravenous line dressing, which is loose and gaping.

Nurse educators in the orthopedic trauma unit are reviewing safe and effective use of traction with some recent nursing graduates. What principle should the educator promote? a. Knots in the rope should not be resting against pulleys b. Weights should rest against the bed rails c. End of the limb in traction should be braced by the footboard of the bed d. Skeletal traction may be removed for brief periods to facilitate patient's independence

a. Knots in the rope should not be resting against pulleys

A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (Select all that apply) a. auditory hallucination b. lack of motivation c. use of clang associations d. delusion of persecution e. constantly waving arms f. flat affect

a. auditory hallucination c. use of clang associations d. delusion of persecution e. constantly waving arms

A nurse is assessing an infant admitted to the pediatric unit with suspected hypertrophic pyloric stenosis. Which of the following findings would the nurse expect to see? (Select all that apply) a. Steady weight gain since birth. b. Chronic hunger. c. Projectile vomiting after feedings. d. Distended upper abdomen e. Visible gastric peristaltic waves.

b. Chronic hunger. c. Projectile vomiting after feedings. d. Distended upper abdomen.

The nurse is performing a sterile dressing change on a postoperative client. Which actions would indicate that sterile technique has been broken? (Select all that apply). a. Cleaning the wound from the midline to outer edges. b. Cleaning the wound from outer edges to midline. c. Lipping the normal saline bottle. d. The patient touches the nurse's gloved hand. e. A piece of dust falls on the sterile field when the air conditioning kicks on.

b. Cleaning the wound from outer edges to midline. d. The patient touches the nurse's gloved hand. e. A piece of dust falls on the sterile field when the air conditioning kicks on.

Patient with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relation to the patient's cast care? a. Cover cast with a blanket until cast dries b. Keep your right leg elevated above heart level c. Use a clean object to scratch itches inside the cast d. A foul smell from the cast is normal after the first few days

b. Keep your right leg elevated above heart level

What action should a nurse take after assisting with a needle biopsy of the liver at the patient's bedside? a. Elevate head of the bed to facilitate breathing b. Place patient on right side with bed flat c. Check patient's post-biopsy coagulation studies d. Position a sandbag over the liver to provide pressure

b. Place patient on right side with bed flat

A nurse is caring for an infant with a confirmed diagnosis of cleft lip and palate. The nurse is creating a plan of care for the infant. Which of the following are included? (Select all that apply). a. Explain to the mother it is best for her to observe the nurse feed the infant b. Position the infant in an upright position for feedings. c. Pause during feedings to burp the infant d Use a tongue blade to assess the palate for bleeding. e. Utilize a bottle with a narrow-based nipple.

b. Position the infant in an upright position for feedings. c. Pause during feedings to burp the infant.

Nurse is caring for a patient who has a leg cast. The nurse observes that the patient uses a pencil to scratch skin under the edge of the cast. How should the nurse respond to this observation? a. Allow patient to continue to scratch inside cast with a pencil but encourage him to be cautious b. Give patient sterile tongue depressor to use for scratching instead of pencil c. Encourage patient to avoid scratching, and obtain order for antihistamine if severe itching persists d. Obtain order for sedative, such as lorazepam (Ativan), to prevent patient from scratching

c. Encourage patient to avoid scratching, and obtain order for antihistamine if severe itching persists

Typical, or First-Generation Antipsychotic medications may help relieve which of the following symptoms of schizophrenia? a. Anhedonia b. Flat affect and alogia c. Hallucinations, delusions, and disordered thoughts d. Avolition

c. Hallucinations, delusions, and disordered thoughts

A child is admitted to the pediatric unit with suspected intussusception. The parents ask the nurse why their child is ordered an air enema. Select the nurse's most appropriate response. a. The enema will confirm the diagnosis. If the test result is positive, your child will need to have surgery to correct the intussusception. b. The enema will confirm the diagnosis. Although unlikely, the enema may help fix the intussusception so that your child will not immediately need surgery. c. The enema will help confirm the diagnosis and has a good chance of fixing the intussusception. d. The enema will help confirm the diagnosis and may temporarily fix the intussusception. If the bowel returns to normal, there is a strong likelihood that intussusception will recur.

c. The enema will help confirm the diagnosis and has a good chance of fixing the intussusception.

When a patient arrives in the emergency department with a facial fracture, which action should the nurse take first? a. Assess for nasal bleeding and pain b. Apply ice to the face to reduce swelling c. Use cervical collar to stabilize the spine d. Check patient's alertness and orientation

c. Use cervical collar to stabilize the spine

A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response. a.) Why are you laughing b.) Please share the joke with me c.) I don't think I said anything funny d.) You are laughing. Tell me what's happening.

d.) You are laughing. Tell me what's happening.

What side effects of lithium can be expected at therapeutic levels?

hand tremors & polyuria