General questions
The parents of an adolescent client newly diagnosed with anorexia nervosa are meeting with the nurse during the admission process. Which remarks should the nurse interpret as typical for parents of a client with anorexia nervosa?
"She's been a model child. We've never had any problems with her."
The nurse is caring for a client diagnosed with genitourinary tuberculosis (TB). Which statement, made by the client, about genitourinary TB demonstrates an understanding?
"It's a late manifestation of respiratory tuberculosis."
X-rays reveal a leg fracture in a client who was brought to the emergency department after falling on ice. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs?
"Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together."
A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. How should the nurse respond?
"You must wait at least 1 year before becoming pregnant again."
What is opisthotonos?
Arching of back (entire body) from hyperextension of the neck and ankles, due to severe meningeal irritation or possible brain stem herniation
What is Trousseau's sign?
BP cuff inflated and causes a carpal spasm. (Low calcium)
A nurse works with a client diagnosed with bulimia. What is the most appropriate long-term client goal for this client?
Manage stresses in life without binging or purging.
What is neuroleptic malignant syndrome?
It is a life-threatening condition that can be caused by antipsychotic agents. It is characterized by severe fever, muscle rigidity, altered mental status, cardiovascular instability - diaphoresis?
How should liquid Ferrous sulfate be administered?
Oral and drank through a straw
After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. What is an expected outcome of these exercises?
The alveoli expand and increase the lung surface available for ventilation.
What is intussusception?
The telescoping of one part of the intestinal tract into another
When preparing to give a child with insulin-dependent diabetes his dose of regular insulin and isophane insulin suspension, which of the following actions is most appropriate?
Withdrawing the regular insulin first, then withdrawing the isophane insulin suspension into one syringe.
The most common reason given by mentally ill clients for noncompliance with medications is their uncomfortable adverse effects. When teaching the families, what need should the nurse identify as the greatest?
alternative ways to manage the adverse effects
Which child most needs a screening for scoliosis?
a preadolescent client at the beginning of a growth spurt
What are Montgomery straps?
adhesive straps used to facilitate frequent dressing changes without having to remove and reapply tape
What is Reiki therapy?
based on the principle that energy from hands being placed lightly on or at a distance from the body can be used to heal
A client wants to avoid methods of birth control that contain estrogen. Which method would be the nurse recommend?
depot medroxyprogesterone acetate injection
The nurse is obtaining informed consent from a client. To adhere to ethical and legal standards, the nurse must ensure that the informed consent consists of what? Select all that apply.
discussion of pertinent information the client's agreement to the plan of care freedom from coercion
What is Cullen's sign?
ecchymosis at the umbilicus due to retroperitoneal bleed
After a mastectomy for breast cancer, the nurse teaches the client how to avoid the development of lymphedema. The nurse should teach the client to:
elevate the affected arm on a pillow.
To relieve chest pain associated with pericarditis, which position should the nurse encourage the client to assume
leaning forward while sitting
A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first?
pulse
What is Chvostek's sign?
twitching of the facial muscles in response to tapping over the area of the facial nerve
