HESI - Adaptive Quizzing

Before administering a nasogastric feeding to a preterm infant, the nurse aspirates a small amount of residual fluid from the stomach. What is the nurse's next action? A) Returning the aspirate and withholding the feeding B) Discarding the aspirate and administering the full feeding C) Returning the aspirate and subtracting the amount of the aspirate from the feeding D) Discarding the aspirate and adding an equal amount of normal saline solution to the feeding

Returning the aspirate and subtracting the amount of the aspirate from the feeding Rationale: The aspirate should be returned to ensure that the gastric enzymes and acid-base balance are maintained. The amount of the aspirate returned should be subtracted from the volume to be administered in the next feeding. Withholding the feeding will compromise the infant's fluid and electrolyte balance, as will discarding the aspirate from the full feeding. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding will compromise the infant's fluid and electrolyte balance.

A nurse is caring for a client who just had a liver biopsy. After the procedure, the nurse should monitor for which common complication associated with the biopsy? A) Hemorrhage B) Gastroparesis C) Pulmonary embolism D) Tension pneumothorax

Hemorrhage Rationale: In the impaired liver, blood-clotting mechanisms are disrupted, and hemorrhage may occur from the trauma of this invasive procedure. A liver biopsy will not cause the stomach to empty more slowly. Because clotting mechanisms are prolonged, emboli usually are not a complication. A collapsed lung can occur if the needle is not inserted properly; however, this is not a common occurrence.

What causes condylomata acuminate? A) Chlamydia B) Gonorrhea C) Herpes simplex D) Human papillomavirus (HPV)

Human papillomavirus (HPV) Rationale: Condylomata acuminate are genital warts which are caused by the human papillomavirus (HPV). Genital warts are not caused by chlamydia, gonorrhea, or herpes simplex.

A child returns to his room after left-side cardiac catheterization. What is involved in the postprocedure nursing care? A) Encouraging early ambulation B) Monitoring the insertion site for bleeding C) Comparing blood pressures in the two extremities D) Restricting fluids until the blood pressure has stabilized

Monitoring the insertion site for bleeding Rationale: Postprocedure hemorrhage, a life-threatening complication after cardiac catheterization, is possible because arterial blood is under pressure and the catheter has entered an artery. Rest will be encouraged; flexion of the insertion site should be avoided to prevent disturbance of the clot. Comparing blood pressures in the two extremities is unnecessary; the pulse distal to the catheterization insertion site is monitored. The blood pressure will not be unstable unless a problem develops; fluid intake should be encouraged.

A 4-month-old infant is admitted to the pediatric unit with severe tachypnea, flaring of the nares, wheezing, and irritability. The parents are told that the child has bronchiolitis and needs to be hospitalized for observation and treatment. While assessing the infant, the nurse determines that the infant is in respiratory failure. What clinical finding supports the nurse's conclusion? A) Wheezing cough B) Intercostal retractions C) Fine crackles on deep inspiration D) Sudden absence of breath sounds

Sudden absence of breath sounds Rationale: A sudden absence of breath sounds occurs when bronchioles become obstructed and respiratory failure is imminent. A wheezing cough is a common manifestation of bronchiolitis and is caused by the passage of air through the narrowed airways; it does not herald respiratory failure. Intercostal retractions occur with mild and moderate respiratory distress in infants. Fine crackles are a routine occurrence with bronchiolitis, not a sign of respiratory failure.

A nurse in the pediatric clinic is assessing an 11-month-old infant with iron-deficiency anemia. The infant's hemoglobin is 8 g/dL (80 mmol/L). What does the nurse expect to observe when assessing the infant? A) Pallor B) Tremors C) Cyanosis D) Spasticity

Pallor Rationale: Paleness occurs because the hemoglobin within the erythrocytes gives them their red color; a low hemoglobin level in the blood results in pallor. Tremors are not a sign of anemia. The skin is usually pale; cyanosis is not typical. Spasticity is not a sign of anemia.

The nurse is educating student nurses about the anatomy and physiology of the kidneys. What term does the nurse explain is used for the tip of the pyramid of a kidney? A) Calyx B) Papilla C) Renal pelvis D) Renal column

Papilla Rationale: Pyramids are components of renal medulla, and the tip of each pyramid is called a papilla. A calyx is a structure that collects the urine at the end of each pyramid. The renal calices join together to form the renal pelvis. A renal column is a cortical tissue that separates the pyramids.

Which hormone regulates blood levels of calcium? A) Parathormone B) Luteinizing hormone C) Thyroid stimulating hormone D) Adrenocorticotropic hormone

Parathormone Rationale: Parathyroid hormone (PTH), or parathormone, regulates the blood levels of calcium and phosphorus. Luteinizing hormone (LH) stimulates the production of sex hormones, promotes the growth of reproductive organs, and also stimulates reproductive processes. Thyroid stimulating hormone (TSH) stimulates the release of thyroid hormones and the growth and functioning of the thyroid gland. Adrenocorticotropic hormone (ACTH) promotes the growth of the adrenal cortex and stimulates the release of corticosteroids.

The nurse is presenting information about hyperthermia to a group of nursing students. Which activities put a client at risk for this condition? A) Snowmobiling B) Skiing in the winter C) Hiking Alaskan mountains D) Performing strenuous activity in high humidity

Performing strenuous activity in high humidity Rationale: When a client performs strenuous activity in high humidity, it reduces heat loss from the body and results in hyperthermia. Activities such as snowmobiling, skiing, and hiking in cold weather may cause hypothermia because they occur in cold temperatures and may lower the body temperature.

What is the maximum recommended length for enema tube insertion in an adolescent? Record your answer using a whole number.

10cm

A nurse is assessing a client's degree of edema and finds 8 mm of depth. How does the nurse document this condition? A) 1+ B) 2+ C) 3+ D) 4+

4+ Rationale: Edema of 8 mm is documented as 4+. If the edema has a depth of 2 mm, then it is documented as 1+. If the edema has a depth of 4 mm, it is documented as 2+. If the edema has a depth of 6 mm, then it is documented as 3+.

Acetaminophen 15 mg/kg is prescribed for a child with a temperature of 102° F (38.9° C). How much will the nurse tell the parent to administer if the child weighs 9.6 kg and the acetaminophen strength is 160 mg/5 mL? Record your answer using one decimal place.

4.5 mL

Phenytoin suspension 200 mg is prescribed for a client with epilepsy. The suspension contains 125 mg/5 mL. How much solution will the nurse administer? Record your answer using a whole number.

8 mL

What is the percentage of total body water in a premature newborn? A) 55% B) 65% C) 75% D) 85%

Answer: 85% Rationale: The total body water in a premature newborn is 85%. In full-term infants, body water ranges from 70% to 80%. The total body water in a child between the ages of 1 and 12 is approximately 64%.

A 3-year-old child is found to have a pervasive developmental disorder not otherwise specified. What should the nurse consider most unusual for the child to demonstrate? A) Interest in music B) Ritualistic behavior C) Attachment to odd objects D) Responsiveness to the parents

Answer: Responsiveness to the parents Rationale: One of the symptoms that an autistic child displays is lack of responsiveness to others; there is little or no extension to the external environment. Music is nonthreatening, comforting, and soothing. Repetitive behavior provides comfort. Repetitive visual stimuli, such as a spinning top, are nonthreatening and soothing.

Which diagnostic test is used for the direct visualization of ligaments, menisci, and articular surfaces of joints? A) Arthroscopy B) Muscle biopsy C) Ultrasonography D) Electromyography

Arthroscopy Rationale: Arthroscopy is a diagnostic test that uses an arthroscope to directly visualize the ligaments, menisci, and articular surfaces of a joint. A muscle biopsy is conducted to diagnose atrophy and inflammation. An ultrasonography is used to view soft tissue disorders, traumatic joint injuries, and osteomyelitis. An electromyography may be performed to evaluate diffuse or localized muscle weakness.

A client is taking fertility drugs for the first time. Which adverse effect of the drug should the nurse inform the client about? A) Vaginitis B) Constipation C) Joint swelling D) Deep vein thrombosis

Constipation Rationale: Constipation is seen in the clients who are treated with fertility drugs for the first time. Fertility drugs do not cause vaginitis and swelling of joints. Deep vein thrombosis is an adverse effect of prolonged use of fertility drugs.

While awaiting surgery, a client with a long history of Crohn disease is receiving total parenteral nutrition (TPN) on an outpatient basis. The nurse teaches the client that TPN helps to prepare for surgery by which process? A) Decreasing fecal bulk B) Preventing bowel infection C) Providing stimulation of secretions D) Maintaining negative nitrogen balance

Decreasing fecal bulk Rationale By decreasing fecal bulk and bowel stimulation, TPN provides rest for the bowel while the client awaits surgery. TPN does not prevent a bowel infection. TPN does not stimulate gastrointestinal secretions. TPN promotes positive nitrogen balance.

Which parts of the nephron are the sites of action for furosemide? Select all that apply. A) Glomerulus B) Loop of Henle C) Distal tubule D) Proximal tubule E) Bowman capsule

Loop of Henle, Distal tubule, and Proximal tubule Rationale: Furosemide, known as a 'loop diuretic', inhibits sodium and chloride reabsorption from the ascending loop of Henle and proximal and distal tubules. The glomerulus is a site of glomerular filtration. The Bowman capsule (BC) is a site of the collection of glomerular filtrate.

A nurse in the pediatric clinic is testing a 4-year-old child with recurrent otitis media for signs of hearing loss. The child's parent asks what can be done if there is a hearing loss. The nurse responds that the most common treatment is what? A) Myringotomy B) Adenoidectomy C) Neomycin ear drops D) Systemic steroid therapy

Myringotomy Rationale: Myringotomy is surgical incision of the eardrum to permit drainage of infected middle ear fluid and thus improve hearing. Removal of the adenoids will not relieve the pressure from inflamed ears. Antibiotics are administered systemically, not locally, if needed. Systemic antibiotics, not steroids, are prescribed; a myringotomy is performed if antibiotics are ineffective.

Which nursing practice is associated with the self-regulation skill? A) Reflecting on one's experience B) Reflecting on one's own behavior C) Supporting one's findings and conclusions D) Clarifying any data that one is uncertain about

Reflecting on one's experience Rationale: Self-regulation involves reflecting on the nurse's experience. Evaluation involves reflecting on the nurse's own behavior. Explanation involves supporting findings and conclusions. Interpretation involves clarifying any data about which the nurse is uncertain.

A school-aged child with newly diagnosed acute lymphocytic leukemia (ALL) is to undergo induction therapy with prednisone, vincristine, and asparaginase. After several days the child becomes constipated. What does the nurse suspect as the cause? A) Diet, which lacks bulk B) Inactivity, which results from illness C) Vincristine, which decreases peristalsis D) Prednisone, which causes gastric irritability

Vincristine, which decreases peristalsis Rationale: Constipation, which may progress to paralytic ileus, is a side effect of vincristine. Lack of bulk and inactivity each may contribute to constipation, but neither is the primary cause of this child's constipation. Prednisone may cause nausea and vomiting, but it does not cause constipation.

The nurse receives an order to prepare a solution for administering a cleansing enema for a 15-year-old client. What is the volume of solution that the nurse should prepare? A) 150 to 250 mL B) 250 to 350 mL C) 300 to 500 mL D) 500 to 750 mL

500 to 750 mL Rationale: In adolescents, the volume of solution required is 500 to 750 mL. The nurse should prepare 150 to 250 mL of warmed solution for infants. The nurse should prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. In school-age children, the volume of warmed solution is 300 to 500 mL.

A client has surgery for the creation of a colostomy. Postoperatively, what color does the nurse expect a viable stoma to be? A) Brick red B) Pale pink C) Light gray D) Dark purple

Brick red Rationale:Brick red describes a stoma that has adequate vascular perfusion. Pale pink indicates inadequate perfusion of the stoma. Light gray is indicative of poor tissue perfusion. Dark purple indicates inadequate perfusion of the stoma.

Which response by the nurse during a client interview is an example of back channeling? A) "All right, go on..." B) "What else is bothering you?" C) "Tell me what brought you here." D) "How would you rate your pain on a scale of 0 to 10?"

"All right, go on..." Rationale: Back channeling involves the use of active listening prompts such as "Go on...", "all right", and "uh-huh." Such prompts encourage the client to complete the full story. The nurse uses probing by asking the client, "What else is bothering you?" Such open-ended questions help to obtain more information until the client has nothing more to say. The statement, "Tell me what brought you here" is an open-ended statement that allows the client to explain his health concerns in his or her own words. Closed-ended questions such as, "How would you rate your pain on a scale of 0 to 10?" are used to obtain a definite answer. The client answers by stating a number to describe the severity of pain.

A mother who is visiting the pediatric clinic with her 10-month-old son tells the nurse how pleased she is with her chubby infant. She exclaims, "Look how much weight he's gained even though he drinks only orange juice! He won't drink any milk!" What is best response by the nurse? A) "He's a little overweight." B) "Let's talk about his nutrition." C) "Is he getting an iron supplement?" D) "Why is he only drinking orange juice?"

"Let's talk about his nutrition." Rationale: The nurse must determine whether the infant is eating solid foods and receiving vitamin and mineral supplements. Although orange juice contains vitamin C, it is too high in simple sugars and contains insufficient amounts of iron, calcium, and other essential vitamins and minerals. It is inappropriate to comment on the infant's weight; it is also insufficient to comment on just one aspect of the infant's dietary history. Asking why the infant is only drinking orange juice is a judgmental and accusatory question; again, it is insufficient to comment on just one aspect of the infant's diet history.

What is the appropriate blood pressure of a 12-year-old client? A) 95/65 mm Hg B) 105/65 mm Hg C) 110/65 mm Hg D) 119/75 mm Hg

110/65 mm Hg Rationale: A 12-year-old client typically has a blood pressure of 110/65 mm Hg. A 1-year-old client would typically have a blood pressure of 95/65 mm Hg. A 6-year-old client would typically have a blood pressure of 105/65 mm Hg. A 14- to 17-year-old client has a typical blood pressure of 119/75 mm Hg.

What is the normal value of functional residual capacity? A) 2.5 L B) 3.5 L C) 4.5 L D) 6.0 L

2.5 L Rationale: The normal value of functional residual capacity is 2.5 L. The normal value of inspiratory capacity is 3.5 L. The normal value of vital capacity is 4.5 L.The normal value of total lung capacity is 6.0 L.

A young adult with a history of cognitive impairment and tonic-clonic seizures is admitted to a group home. Among the client's medications is a prescription for 125 mg of phenytoin by mouth three times a day. Phenytoin is supplied as an oral suspension of 25 mg/5 mL. How many milliliters of solution will the nurse administer for each dose? Record your answer as a whole number.

25 mL

Atenolol 150 mg by mouth is prescribed for a client with hypertension. Each tablet contains 50 mg. How many tablets should the nurse administer? Record your answer using a whole number.

3 tablets

When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan? A) Kidney dysfunction B) Cardiovascular diseases C) Eye problems, such as glaucoma D) Accidents, including their prevention

Accidents, including their prevention Rationale: Accidents are common during young adulthood because of immature judgment and impulsivity associated with this stage of development. Kidney dysfunction is not a problem specific to any one stage of growth. Cardiovascular disease is a common health problem in middle adulthood. Glaucoma is a common health problem in older adults.

An executive busy at work receives a phone call from a friend relating bad news. The executive makes a conscious effort to put this information out of mind and continues to work at the task at hand. The next day executive remembers that the friend telephoned but is unable to recall the message. Which defense mechanism does this behavior represent? A) Regression B) Suppression C) Reaction formation D) Passive aggression

Answer: Suppression Rationale: Suppression is the voluntary exclusion from awareness of anxiety-producing feelings, ideas, and situations. In regression, a person returns to an earlier and more comfortable developmental level. Passive aggression is the use of behaviors such as passivity, procrastination, and inefficiency that negatively affect others. Reaction formation is a conscious behavior that is the opposite of an unconscious feeling.

A client has a pulse deficit. Which documentation by the nurse supports this finding? A) Blood pressure of 130/70 mm Hg indicating pulse deficit of 60. B) Capillary refill greater than 3 seconds indicating pulse deficit. C) Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8. D) Radial pulse 80 and pedal pulse 70 indicating pulse deficit of 10.

Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8 Rationale: The apical rate is more rapid than the radial rate when a pulse deficit exists. An apical pulse of 86 with a radial pulse of 78 is a pulse deficit of 8. A blood pressure of 130/70 mm Hg is a pulse pressure of 60. Capillary refill greater than 3 seconds indicates circulation is sluggish. Radial pulse of 80 and a pedal pulse of 70 do not indicate a pulse deficit; a pulse deficit is the difference between the apical and peripheral pulses.

A hospitalized 10-year-old child is apathetic about eating. What is the best nursing intervention to support the child's nutrition? A) Asking the parents to visit at mealtimes B) Having a nursing assistant feed the child C) Providing diversional activity at mealtimes D) Eliminating the child's between-meal snacks

Asking the parents to visit at mealtimes Rationale: Dinner is frequently a family activity. Having the parents visit during meals may provide the child with additional emotional, social, and physical support, resulting in improved nutritional intake. The child will be resentful if fed by a staff member. Providing diversional activity at mealtimes may further inhibit the child's nutritional intake. Eliminating the child's between-meal snacks may not influence the child's overall intake; snacks may be preferred and will provide a source of nutrition.

A nurse is assessing an infant for developmental dysplasia of the hip. How does the nurse identify the Ortolani sign? A) Unilateral droop of the hip B) Broadening of the perineum C) Apparent shortening of one leg D) Audible click on hip manipulation

Audible click on hip manipulation Rationale: With specific manipulation an audible click may be heard as the femoral head slips into the acetabulum; this is known as the Ortolani sign. Unilateral droop of the hip is the Trendelenburg sign; it is associated with weight bearing. Broadening of the perineum is associated with bilateral dislocation. Apparent shortening of one leg is the Allis sign.

Before effectively responding to a sexually abused victim on the phone, it is essential that the nurse in the rape crisis center do what? A) Get the client's full name and address. B) Call for assistance from the psychiatrist. C) Know some myths and facts about sexual assault. D) Be aware of any personal bias about sexual assault.

Be aware of any personal bias about sexual assault. Rationale: If nurses are unaware of their biases about sexual assault, they will be unprepared to evaluate objectively and meet the client's needs. Getting the client's full name and address may interrupt communication; information can be solicited later. The nurse should be able to help this client without assistance. Although knowing some myths and facts about sexual assault may be important, it is not the priority.

Which radiographic test is used to view the entire skeleton? A) Bone scan B) Gallium and thallium scan C) Computed tomography (CT) D) Magnetic resonance imaging (MRI) scan

Bone scan Rationale: A bone scan is a radionuclide test in which radioactive material is injected so that the client's entire skeleton can be viewed. Gallium and thallium scans are similar to bone scans but are more specific and sensitive in detecting bone disorders. A CT scan is used to detect musculoskeletal problems, primarily in the vertebral column and joints. An MRI scan is used to diagnose musculoskeletal disorders.

The nurse is assessing a client's pulse strength and records it as a 3+. Which description best describes this client's pulse strength? A) Bounding B) Absent C) Expected D) Diminished

Bounding Rationale: A pulse strength of 3+ is considered full or bounding. A pulse strength is considered normal, expected, and easily palpable when it is 2+. The pulse strength is diminished or barely palpable when the score is 1+. An absent pulse is a grade 0 pulse.

The nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selection by the client indicates to the nurse that dietary teaching about thiazide diuretics is successful? A) Apples B) Broccoli C) Cherries D) Cauliflower

Broccoli Rationale: Thiazide diuretics are potassium-depleting agents; broccoli is high in potassium. Apples, cherries, and cauliflower are low sources of potassium.

Which drug is derived from a natural source and may be prescribed for the treatment of osteoporosis? A) Calcitonin B) Raloxifene C) Clomiphene D) Bisphosphonates

Calcitonin Rationale: Calcitonin is derived from natural sources such as fish; this drug may be prescribed to prevent osteoporosis. Raloxifene is prescribed to prevent postmenopausal osteoporosis. Clomiphene is prescribed to induce ovulation. Bisphosphonates are prescribed to treat osteoporosis; this drug is not derived from natural sources.

A pregnant client with severe preeclampsia is receiving intravenous magnesium sulfate. What should the nurse keep at the bedside to prepare for the possibility of magnesium sulfate toxicity? A) Oxygen B) Naloxone C) Calcium gluconate D) Suction equipment

Calcium gluconate Rationale: The antagonist of magnesium sulfate is calcium gluconate. Oxygen is ineffective if the action of magnesium is not reversed. Naloxone is unnecessary; it is an opioid antagonist. Suction equipment may be necessary if the client has excessive secretions after a seizure. The priority intervention is trying to prevent a seizure.

Two hours after a cardiac catheterization that was accessed through the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first? A) Call the primary healthcare provider. B) Check the client's pedal pulses. C) Take the client's blood pressure. D) Recognize the response is expected.

Check the client's pedal pulses Rationale: These symptoms are associated with compromised arterial perfusion. A thrombus is a complication of a femoral arterial cardiac catheterization and must be suspected in the absence of a pedal pulse in the extremity below the entry site. A circulatory assessment should be conducted first; the primary healthcare provider may or may not need to be notified immediately concerning the results of the assessment. Taking the client's blood pressure is unnecessary; the symptoms indicate a local peripheral problem, not a systemic or cardiac problem. These symptoms are not expected.

A 10-year-old child is admitted to the pediatric unit in vaso-occlusive sickle cell crisis. The nurse manager is planning to assign a room. Which child is the best roommate option for this client? A) Child with thalassemia B) Child with osteomyelitis C) Child with viral pneumonia D) Child with acute pharyngitis

Child with thalassemia Rationale: Thalassemia is a hemolytic anemia that is not communicable; roommates with infectious diseases should be avoided because a child with sickle cell anemia is susceptible to infection. Osteomyelitis is an infection of the bone, pneumonia is an infection of the lung, and pharyngitis is an upper respiratory infection; therefore none of these children is a suitable roommate.

A client is diagnosed with hepatitis A. The nurse provides the client with information about untoward signs and symptoms related to hepatitis. The nurse instructs the client to contact the primary healthcare provider if the client develops what symptom? A) Fatigue B) Anorexia C) Yellow urine D) Clay-colored stools

Clay-colored stools Rationale: Clay-colored stools are indicative of hepatic obstruction because bile is prevented from entering the intestines. It is unnecessary to call the healthcare provider because fatigue and anorexia are characteristic of hepatitis from the onset of clinical manifestations. Yellow is the expected color of urine.

A 9-year-old child with chronic kidney disease is undergoing peritoneal dialysis. For which associated complication should the nurse monitor the child? A) Petechiae B) Abdominal bruit C) Cloudy return dialysate D) Increased blood glucose level

Cloudy return dialysate Rationale: The returned dialysate should be clear; cloudy return dialysate solution is indicative of infection. Petechiae do not occur during dialysis treatments. There is no danger of developing an abdominal bruit during dialysis. Dialysis does not affect the blood glucose level.

A client with schizophrenia who is receiving an antipsychotic medication begins to exhibit a shuffling gait and tremors. The primary healthcare provider prescribes the anticholinergic medication benztropine, 2 mg daily. What will the nurse assess the client for daily when administering these medications together? A) Constipation B) Hypertension C) Increased salivation D) Excessive perspiration

Constipation Rationale: The anticholinergic activity of each drug is magnified, and adverse effects such as paralytic ileus may occur. Hypotension, not hypertension, occurs with anticholinergic medications. Dryness of the mouth, not increased salivation, occurs with anticholinergic medications. Decreased, not increased, perspiration occurs with anticholinergic medications.

A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to use when discussing healthcare decisions with the client? A) Contact an interpreter provided by the hospital. B) Contact the client's family member to translate for the client. C) Communicate with the client using Spanish phrases the nurse learned in a college course. D) Communicate with the client with the use of a hospital-approved Spanish dictionary.

Contact an interpreter provided by the hospital Rationale: Interpreters provided by the healthcare organization should be used to communicate with clients with limited English proficiency to ensure accuracy of communicated information. In hospital settings, it is not suitable for family members to translate healthcare information, but they can assist with ongoing interactions during the client's care. The other options do not ensure accurate interpretation of language.

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. Which need is the primary consideration in the care of this client? A) Control of pain B) Immobilization of joints C) Motivation and teaching D) Bladder training and control

Control of pain Rationale: After the need to survive (air, food, water), the need for comfort and freedom from pain closely follow; care should be given in order of the client's basic needs. Joints must be exercised, not immobilized, to prevent stiffness, contractures, and muscle atrophy. Motivation and learning will not occur unless basic needs, such as freedom from pain, are met. Although bladder training should be included in care, it is not the priority when the client is in pain.

Which surgical procedure is appropriate for the removal of a vocal cord due to laryngeal cancer? A) Cordectomy B) Tracheotomy C) Total laryngectomy D) Oropharyngeal resections

Cordectomy Rationale: A cordectomy is a surgical procedure performed in clients with laryngeal cancer; this surgery involves the removal of a vocal cord. A tracheotomy is a surgical incision in the trachea for the purpose of establishing an airway. A total laryngectomy is a surgical procedure in which the entire larynx, hyoid bone, strap muscles, and one or two tracheal rings are removed. A nodal neck dissection is also done in a total laryngectomy if the nodes are involved. An oropharyngeal resection is a surgical procedure performed to treat cancer of the oropharynx.

What clinical finding does a nurse expect when assessing a 4-month-old infant with gastroenteritis and moderate dehydration? A) Urine output of 50 mL/hr B) Depressed anterior fontanel C) History of allergies to certain formulas D) Capillary refill time of less than 2 seconds

Depressed anterior fontanel Rationale: A depressed anterior fontanel is a classic sign of moderate dehydration in infants that results from a decrease in cerebrospinal fluid. Urine output of 50 mL/hr indicates adequate hydration; output will be decreased in dehydration. A history of allergies to certain formulas is unrelated to fluid loss from gastroenteritis. Capillary refill time of less than 2 seconds is an expected capillary refill time and is not indicative of moderate dehydration.

A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns? A) Equal B) Unrelated C) Inversely related D) Directly proportional

Directly proportional Rationale: There is greater extravasation of fluid into the tissues as the amount of tissue involved increases. Thus the relationship of fluid loss to body surface area is directly proportional. Formulas (e.g., Parkland [Baxter]) are used to estimate fluid loss based on percentage of body surface area burned. Equal, unrelated, and inversely related options are incorrect; the relationship is proportional.

A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, what should the nurse remember about clients with OCD? A) Are unaware that the ritual serves no purpose B) Can alter the ritual depending on the situation C) Should be prevented from performing the ritual D) Do not want to repeat the ritual but feel compelled to do so

Do not want to repeat the ritual but feel compelled to do so Rationale: The repeated thought or act defends the client against even higher, more severe levels of anxiety. Clients usually do recognize that the ritual serves little or no purpose. Rituals are usually followed rigidly; setting limits on or altering a ritual increases anxiety. Preventing the client from performing the ritual may precipitate a panic level of anxiety.

A client is undergoing diagnostic testing to determine if the client has myasthenia gravis. The nurse understands that the test that is mostspecific for determining the presence of this disease is what? A) Electromyography B) Pyridostigmine test C) History of physical deterioration D) Edrophonium chloride test

Edrophonium chloride test Rationale: Edrophonium chloride test uses a drug that is a cholinergic and an anticholinesterase; it blocks the action of cholinesterase at the myoneural junction and inhibits the destruction of acetylcholine. Its action of increasing muscle strength is immediate for a short time. The results of an electromyography will be added to the database, but they are nonspecific. Pyridostigmine is a slower-acting anticholinesterase drug that is prescribed commonly to treat myasthenia gravis; edrophonium chloride is used instead of pyridostigmine to diagnose myasthenia gravis because, when injected intravenously, it immediately increases muscle strength for a short time. The results of a history and physical are added to the database, but the data collected are not as definitive as another specific test for the diagnosis of myasthenia gravis.

Which diagnostic scan is used to detect diffuse or localized muscle weakness? A) Arthroscopy B) Radiography C) Myelography D) Electromyography

Electromyography Rationale: An electromyography is performed to detect diffuse or localized muscle weakness by determining the electric potential generated in an individual. Arthroscopy is used for the direct visualization of ligaments, menisci, and articular surfaces of a joint. A radiography is performed to detect bone density, alignment, swelling, and intactness of a joint. A myelography is performed to visualize the vertebral column, intervertebral discs, spinal nerve roots, and blood vessels.

A client with chronic renal failure stops responding to the treatment. On examination, the primary healthcare provider determines that the client is terminally ill. What is the best nursing intervention in this situation? A) Suggest that the family members get a second opinion. B) Suggest that the family members continue to try different treatments. C) Encourage the family members to provide pallative care to the client. D) Inform the family members that the disease is no longer curable and the client will die shortly.

Encourage the family members to provide pallative care to the client Rationale: Clients who are terminally ill and no longer respond to treatment are in need of palliative care. Palliative care promotes client comfort and provides important interventions to support the client and family at the end of life. There is no need to get a second opinion from another primary healthcare provider, because the client is terminally ill. Continuing to attempt different treatment until of the death of the client may cause more client suffering. It is not advisable to inform the family members that the client will die soon because it may lead to emotional stress. The palliative care team will help prepare the family for the client's death.

A nurse is caring for a client with Addison disease. Which information should the nurse include in a teaching plan to encourage this client to modify dietary intake? A) Increased amounts of potassium are needed to replace renal losses. B) Increased protein is needed to heal the adrenal tissue and thus cure the disease. C) Supplemental vitamins are needed to supply energy and assist in regaining the lost weight. D) Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium.

Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium Rationale: Lack of mineralocorticoids (aldosterone) leads to loss of sodium ions in the urine and subsequent hyponatremia. Potassium intake is not encouraged; hyperkalemia is a problem because of insufficient mineralocorticoids. Increasing protein is needed to heal the adrenal tissue and thus cure the disease caused by idiopathic atrophy of the adrenal cortex; tissue repair of the gland is not possible. Vitamins are not directly energy-producing; nor will they help the client gain weight.

The parent of a 5-month-old infant with heart failure questions the necessity of weighing the baby every morning. What does the nurse say that this daily information is important in determining? A) Fluid retention B) Kidney function C) Nutritional status D) Medication dosage

Fluid retention Rationale: Fluid retention is reflected by an excessive weight gain in a short period. Inadequate cardiac output decreases blood flow to the kidneys and thus leads to increased intracellular fluid and hypervolemia. Although this assessment may add information to the data regarding kidney function, other assessments, such as hourly urine output, blood urea nitrogen concentration, and creatinine level more significantly reflect kidney function. Weight gain resulting from nutritional intake is gradual and will not vary greatly on a day-to-day basis. Although weight is used to determine medication dosages, dosages do not need to be recalculated according to changes in daily weights.

A nurse is caring for a school-aged child with type 1 diabetes. There have been problems maintaining euglycemia. What laboratory test does the nurse expect to be prescribed that will reveal the effectiveness of the diabetic regimen over time? A) Serum glucose B) Glucose tolerance C) Fasting blood sugar D) Glycosylated hemoglobin

Glycosylated hemoglobin Rationale: The glycosylated hemoglobin test provides an accurate long-term index of the average blood glucose level for the 100 to 120 days before the test; the test is not affected by short-term variations. A result of less than 8% for this child indicates that the diabetic regimen is effective. Serum glucose reflects short-term (hours) variations in blood glucose. Glucose tolerance reveals carbohydrate metabolism in response to a glucose load. Fasting blood sugar is a screening test to rule out diabetes mellitus.

While a nurse is teaching a client with diabetes about food choices, the client states, "I do not like broccoli." Which food should the nurse suggest to substitute for broccoli? A) Peas B) Corn C) Green beans D) Mashed potato

Green beans Rationale: According to exchange lists for meal planning, green beans and broccoli are equivalent vegetable substitutes. Peas are a starch and are not an equivalent vegetable substitute for broccoli. Corn is a starch and is not an equivalent vegetable substitute for broccoli. Mashed potato is a starch and is not an equivalent vegetable substitute for broccoli.

A client who had a transurethral resection of the prostate is transferred to the postanesthesia care unit with an intravenous (IV) line and a urinary retention catheter. For which major complication is it most important for the nurse to assess during the immediate postoperative period? A) Sepsis B) Phlebitis C) Hemorrhage D) Leakage around the IV catheter

Hemorrhage Rationale: After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the area. Sepsis is unusual, and if it occurs it will manifest later in the postoperative course. Phlebitis is assessed for, but it is not the most important complication. Hemorrhage is more important than phlebitis. Leaking around the IV catheter is not a major complication.

After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone? A) Increased blood urea nitrogen (BUN) and hypotension B) Hyperkalemia and poor skin turgor C) Hyponatremia and decreased urine output D) Polyuria and increased specific gravity of urine

Hyponatremia and decreased urine output Rationale: Antidiuretic hormone (ADH) causes water retention, resulting in a decreased urine output and dilution of serum electrolytes. Blood volume may increase, causing hypertension. Diluting the nitrogenous wastes in the blood decreases rather than increases the BUN. Water retention dilutes electrolytes. The client is overhydrated rather than underhydrated, so turgor is not poor. ADH acts on the nephron to cause water to be reabsorbed from the glomerular filtrate, leading to reduced urine volume. The specific gravity of urine is elevated as a result of increased concentration.

A 7-year-old child is admitted for surgery. What is the priority nursing action? A) Allowing a favorite toy to remain with the child B) Documenting the child's ASO titer and C-reactive protein level C) Inspecting the child's mouth for loose teeth and reporting the findings D) Encouraging a parent to stay until the child leaves for the operating room

Inspecting the child's mouth for loose teeth and reporting the findings Rationale: School-aged children lose their primary teeth, which may be aspirated during surgery. Special precautions must be taken to maintain safety. Allowing a favorite toy to remain with the child is a comforting gesture, but it is not essential. There is no reason to obtain an antistreptolysin O (ASO) titer or a C-reactive protein level. Encouraging a parent to stay until the child leaves for the operating room is important but not always possible.

Which cytokine stimulates the liver to produce fibrinogen and protein C? A) Interleukin-1 B) Interleukin-6 C) Thrombopoietin D) Tumor necrosis factor

Interleukin-6 Rationale: Interleukin-6 stimulates the liver to produce fibrinogen and protein C. Interleukin-1 stimulates the production of prostaglandins. Thrombopoietin increases the growth and differentiation of platelets. Tumor necrosis factor stimulates delayed hypersensitivity reactions and allergies.

A healthcare provider prescribes furosemide for a client with hypervolemia. The nurse recalls that furosemide exerts its effects in what part of the renal system? A) Distal tubule B) Collecting duct C) Glomerulus of the nephron D) Loop of Henle

Loop of Henle Rationale: Furosemide acts in the ascending limb of the loop of Henle in the kidney. Thiazides act in the distal tubule in the kidney. Potassium-sparing diuretics act in the collecting duct in the kidney. Plasma expanders, not diuretics, act in the glomerulus of the nephron in the kidney.

A client with hemiparesis is reluctant to use a cane. How does the nurse explain the cane's purpose to the client? A) Maintain balance to improve stability B) Relieve pressure on weight-bearing joints C) Prevent further injury to weakened muscles D) Aid in controlling involuntary muscle movements

Maintain balance to improve stability Rationale: Hemiparesis creates instability. Using a cane provides a wider base of support and, therefore greater stability. Hemiparesis affects muscle strength on one side of the body; the joints are not directly affected. Activity should strengthen, not injure, weakened muscles. The use of a cane will not prevent involuntary movements if they are present.

The nurse assesses a client for orthostatic hypotension. The results are: Lying heart rate = 70 beats/minute, BP = 110/70; Sitting heart rate = 78 beats/minute, BP = 106/66; Standing heart rate = 85 beats/minute, BP = 100/64. The nurse would expect which prescription from the primary healthcare provider? A) Increase furosemide from 20 mg by mouth (PO) to 40 mg PO daily B) Give 1 L of 0.9% normal saline (NS) bolus over 4 hours C) Start intravenous (IV) infusion of D5 ½ NS to run at 150 mL/hr D) No prescription change

No prescription change Rationale: The assessment findings do not indicate postural hypotension (decrease of more than 20 mm Hg of systolic pressure or more than 10 mm Hg of the diastolic pressure). There is no indication from the data that a prescription change is needed for this client. Increasing the furosemide or giving intravenous fluid to this client could result in a fluid imbalance.

A client hospitalized for uncontrolled hypertension and chest pain was started on a daily diuretic 2 days ago upon admission, with prescriptions for a daily basic metabolic panel. The client's potassium level this morning is 2.7 mEq/L (2.7 mmol/L). Which action should the nurse take next? A) Send another blood sample to the lab to retest the serum potassium level B) Notify the healthcare provider that the potassium level is above normal C) Notify the healthcare provider that the potassium level is below normal D) No action is required because the potassium level is within normal limits

Notify the healthcare provider that the potassium level is below normal Rationale: The healthcare provider should be notified immediately because the client's potassium is below normal. The normal potassium level range is 3.5 mEq/L to 5.0 mEq/L (3.5 mmol/L to 5.0 mmol/L). Clients on diuretic therapy require close monitoring of their electrolytes because supplemental potassium may be needed. Retesting the serum potassium level is unnecessary and will delay the treatment required by the client.

A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion? A) Decreased rate of glomerular filtration B) Excessive blood loss through the burned tissues C) Plasma proteins moving out of the intravascular compartment D) Sodium retention occurring as a result of the aldosterone mechanism

Plasma proteins moving out of the intravascular compartment Rationale: The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.

A child has cystic fibrosis. Which verbalization by the parents about their plan for the child's dietary regimen provides evidence that they understand the nurse's instructions? A) Restrict fluids during mealtimes. B) Discontinue the use of salt when cooking. C) Provide high-calorie foods between meals. D) Add whole-milk products from the diet.

Provide high-calorie foods between meals Rationale: The caloric intake should be 150% to 200% more than the expected intake for size and age because absorption of fats and nutrients is compromised by the disease process. Fluids are encouraged to keep bronchial secretions from becoming too thick and tenacious. Salt is added to the diet to compensate for excessive sodium losses in saliva and perspiration. Whole milk may not be tolerated because of its high fat content; skim milk products should be substituted.

What step should the nurse undertake during the administration of eardrops in children ages 1 to 3 years? A) Pulling the auricle down and backward B_ Placing the cotton ball in the innermost part of the canal C) Keeping the toddler in the side-lying position for 10 to 15 minutes D) Holding the dropper 3 cm above the child's ear canal to instill the drops

Pulling the auricle down and backward Rationale: To administer ear drops to a toddler, pull the auricle down and back. The cotton ball is placed in the outermost part of the ear canal. The toddler is kept in the side-lying position for 2 to 3 minutes. The dropper is held 1 cm above the ear canal for the instillation of drops.

What is the action of vasopressin? A) Promotes sodium reabsorption B) Reabsorbs water into the capillaries C) Promotes tubular secretion of sodium D) Stimulates bone marrow to make red blood cells

Reabsorbs water into the capillaries Rationale: Vasopressin is also known as an antidiuretic hormone (ADH). It helps in the reabsorption of water into the capillaries. Aldosterone promotes sodium reabsorption. Natriuretic hormones promote tubular secretion of sodium. Erythropoietin stimulates bone marrow to make red blood cells (RBCs).

A client with rheumatoid arthritis asks the nurse why it is necessary to inject hydrocortisone into the knee joint. What reason should the nurse include in a response to this question? A) Lubricate the joint B) Reduce inflammation C) Provide physiotherapy D) Prevent ankylosis of the joint

Reduce inflammation Rationale: Steroids have an antiinflammatory effect that can reduce arthritic pannus formation. Lubricating the joint does not provide lubrication. Injection of a drug into a joint is not physiotherapy. Ankylosis refers to fusion of joints. It is only indirectly influenced by steroids, which exert their major effect on the inflammatory process.

A client has a diskectomy and fusion for a herniated nucleus pulposus. When getting out of the bed for the first time since surgery, the client reports feeling faint and lightheaded. What should the nurses assisting with the ambulation have the client do? A) Sit on the edge of the bed so they can hold the client upright. B) Slide to the floor so the client will not be injured as a result of a fall. C) Bend forward so that blood flow to the brain is increased. D) Lie down immediately so they can take the client's blood pressure.

Sit on the edge of the bed so they can hold the client upright. Rationale: Sitting maintains alignment of the back and allows the nurses to support the client until orthostatic hypotension subsides. Sliding to the floor and bending forward will induce flexion of the vertebrae, which can traumatize the spinal cord. Rapid movement can flex the vertebrae, which will traumatize the spinal cord; taking the blood pressure at this time is not necessary.

A client with a history of a pulmonary embolus is to receive 3 mg of warfarin daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary? A) Poached eggs B) Spinach salad C) Sweet potatoes D) Cheese sandwich

Spinach salad Rationale: Dark green, leafy vegetables are high in vitamin K. Influencing the level of vitamin K alters the activity of warfarin because vitamin K acts as a catalyst in the liver for the production of blood-clotting factors and prothrombin. The intake of foods containing vitamin K must be consistent to regulate the warfarin dose so that the INR remains within the therapeutic range. Eggs contain protein and are permitted on the diet. Yellow vegetables contain vitamin A and are permitted on the diet. Dairy products containing protein and bread supplying carbohydrates are permitted on the diet.

An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. How can the nurse best assess the client's pain level? A) Asking the client's parent B) Using Wong's "Pain Faces" C) Observing the client's body language D) Explaining the use of a 0 to 10 pain scale

Using Wong's "Pain Faces" Rationale: An adult client with limited mental capacity may not understand the concept of numbers as an indicator of levels of pain; Wong's "Pain Faces" uses pictures to which the individual can relate. The client, irrespective of mental capacity, is the primary source from whom to obtain information about pain because it is a personal experience. Body language provides some information, but it may not accurately reflect the client's level of pain. A client with limitations in mental functioning may not understand the concept of numbers.

A nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. What type of pain does the client experience? A) Visceral pain B) Somatic pain C) Referred pain D) Intractable pain

Visceral pain Rationale: Visceral pain arises from visceral organs such as the pancreas, which results from the stimulation of pain receptors in the abdominal cavity. Somatic pain arises from bone, joint, muscle, skin, or connective tissue and is usually aching or throbbing in quality and well localized. Referred pain is experienced in clients with tumors, in which pain is felt in a part of the body other than its actual source. Intractable pain is a neuropathic pain that is severe, constant pain that is not curable.

A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurologic examination. What should the nurse document in the client's medical record? A) "Has intact plantar reflexes" B) "Exhibits a positive Babinski sign" C) "Demonstrates normal sensory function" D) "Able to perform active range of motion"

"Exhibits a positive Babinski sign" Rationale: This is a positive Babinski sign; it is expected in infants but suggests upper motor neuron disease of the pyramidal tract in adults. The plantar reflex involves flexion of the toes and plantar flexion of the feet. "Demonstrates normal sensory function" is incorrect; positive Babinski is not an indication of normal sensation. "Able to perform active range of motion is inaccurate"; a Babinski is not caused by intentional movement. Active range of motion is a type of exercise, not reflex.

An infant is to be discharged after surgery for pyloric stenosis. What instructions should the nurse give the parents? A) "Offer the baby creamy cereal at each feeding, and follow it with a regular formula." B) "Hold the baby while continuing to feed a regular formula slowly and burp frequently." C) "Allow the baby to drink about 1 oz (30 mL) of a regular formula per hour for a week, and progress slowly to larger amounts." D) "Place the baby on the right side in the crib during feedings with regular formula, and minimize handling for 2 hours after feeding."

"Hold the baby while continuing to feed a regular formula slowly and burp frequently." Rationale: If there are no complications, the infant resumes regular feedings soon after surgery. The infant does not need special dietary modifications. Also, holding the infant should be encouraged because it is an important part of the parent-child relationship.

A 3.5-year-old child hospitalized with nephrotic syndrome. The child has been toilet trained for longer than one year but has been incontinent while in the hospital. The child's parents express concern over this behavior. What is the most therapeutic response by the nurse? A) "Your child is wetting the bed to get attention. Set limits when this occurs." B) "The incontinence is caused by the renal disease. It will stop with physical improvement." C) "This is an expected response to hospitalization. Ignore the regressive behavior and be supportive." D) "Your child is using this regressive behavior to help cope with hospitalization; just use diapers and say nothing."

"This is an expected response to hospitalization. Ignore the regressive behavior and be supportive." Rationale: Regression frequently occurs during and after hospitalization. The child needs support and encouragement from the parents. The child may want more attention due to being sick, but regressing with incontinence is not a likely behavior. Nephrotic syndrome is not associated with neurogenic control of the bladder. Using diapers and saying nothing are both incorrect options because they will shame the child.

At what age does the anterior fontanel of the skull close? A) 12 to 18 months B) 20 to 24 months C) 26 to 30 months D) 32 to 36 months

12 to 18 months Rationale: The anterior fontanel usually closes between 12 and 18 months. Hence, 20 to 24 months, 26 to 30 months, and 32 to 36 months are all incorrect choices.

Aspirin is prescribed on a regular schedule for a client with rheumatoid arthritis. The nurse understands that the drug is being used primarily for which of its properties? A) Analgesic B) Antipyretic C) Antiinflammatory D) Antiplatelet

Answer: Antiinflammatory Rationale: The antiinflammatory action of aspirin reduces joint inflammation. Aspirin reduces fever, but this is not the rationale for prescribing it for clients with rheumatoid arthritis. Aspirin does not preserve bone integrity. Flexion contractures are prevented by exercise, not aspirin.

Which diagnostic test may be used to distinguish vascular from nonvascular structures? A) Chest X-ray B) Pulmonary angiogram C) Computed tomography D) Magnetic resonance imaging

Computed tomography Rationale: Magnetic resonance imaging is used for distinguishing vascular from nonvascular structures. An X-ray is useful to screen, diagnose, and evaluate changes in the respiratory system. A pulmonary angiogram is used to visualize pulmonary vasculature and locate obstruction of pathologic conditions. Computed tomography is performed for diagnosis of lesions difficult to assess by conventional X-ray studies.

A client is experiencing feelings of sadness and is having difficulty concentrating and sleeping. What are additional common signs and symptoms of depression that the nurse should expect when performing an assessment of this client? A) Rigidity and a narrowing of perception B) Alternating episodes of fatigue and high energy C) Diminished pleasure in activities and alteration in appetite D) Excessive socialization and interest in activities of daily living

Diminished pleasure in activities and alteration in appetite Rationale: Depression is characterized by feelings of hopelessness, helplessness, and despair, leaving little room for any pleasure; alteration in appetite (either decreased or increased) is common in depressed clients. Although there is a narrowing of perception, rigidity is uncommon with depression. Fatigue is continually present and does not alternate with a high energy level. There is a loss of interest in socialization and little participation in activities of daily living.

A nurse is teaching a high school student about scoliosis treatment options. On what should the nurse focus? A) Effect on body image B) Least invasive treatment C) Continuation with schooling D) Maintenance of contact with peers

Effect on body image Rationale: Establishing an identity, the major developmental task of the adolescent, is related to the affirmation of self-image. To achieve this task there is a need to conform to group norms, one of which is appearance. The type of treatment is not an issue. Although it is important to continue schooling and to maintain contact with peers, the effect on body image is more important.

A client is in the intensive care unit. The nurse observing the telemetry monitor identifies flattening T waves and peaked P waves. What problem should the nurse consider based on these ECG changes? A) Hypokalemia B) Hypocalcemia C) Hyponatremia D) Hypomagnesemia

Hypokalemia Rationale: Flattened or inverted T waves, peaked P waves, depressed ST segments, and elevated U waves are associated with hypokalemia. Prolongation of the QT interval may indicate hypocalcemia. Hyponatremia is not reflected in the heart's electrical conduction. Although flattening of T waves may occur with hypomagnesemia, the ST segment may be shortened, and the PR and QRS intervals may be prolonged.

According to the nurse describing Erikson's theory, in which stage does a preschooler start to pretend? A) Initiative versus guilt stage B) Integrity versus despair stage C) Autonomy versus sense of shame and doubt stage D) Generativity versus self-absorption and stagnation stage

Initiative versus guilt stage Rationale: The initiative versus guilt stage is the third stage of Erikson's theory. During this stage, children like to pretend and try out new roles. Integrity versus despair is the eighth stage of Erikson's theory. At this stage, many older adults view their lives with a sense of satisfaction. The development of self-care activities in a toddler occurs at the stage of autonomy versus sense of shame and doubt. This is the second stage of Erikson's theory. Middle-aged adults achieve success at the stage of generativity versus self-absorption and stagnation. Individuals contribute to future generations through parenthood, teaching, and community involvement.

A nurse is caring for an infant born with a myelomeningocele who is scheduled for surgery. What is the priority preoperative goal for this infant? A) Keeping the infant sedated B) Keeping the infant infection free C) Ensuring maintenance of leg movement D) Ensuring development of a strong sucking reflex

Keeping the infant infection free Rationale: Prevention of infection is the priority both before and after the repair of the sac. Sedatives are not indicated; analgesics are administered as needed. Leg movement may be a postoperative goal, although it may be unrealistic because these infants' lower bodies are usually paralyzed. The sucking reflex is not associated with myelomeningocele.

The parents of an infant ask a nurse why their baby is not receiving the measles, mumps, and rubella (MMR) vaccine at the same time that other immunizations are being given. What explanation should the nurse give about why the MMR vaccine is administered at 12 to 15 months of age? A) There is an increased risk of side effects in infants. B) Maternal antibodies provide immunity for about 1 year. C) It interferes with the effectiveness of vaccines given during infancy. D) There are rare instances of these infections occurring during the first year of life.

Maternal antibodies provide immunity for about 1 year. Rationale: Maternal antibodies to measles, mumps, and rubella infection persist in the infant until approximately 15 months of age. Side effects are no more common among infants than in toddlers. The measles vaccination does not interfere with the effectiveness of other vaccines. Although the measles, mumps, and rubella do occasionally occur after the administration of the MMR vaccine during the first year of life, the vaccine is not given during this time because of the presence of maternal antibodies.

The parent of a 3-month-old infant asks the nurse about selecting toys for the infant. Which toy should the nurse tell the parent is most appropriate at this age? A) Stuffed animal B) Metallic mirror C) Push-pull wagon D) Large plastic ball

Metallic mirror Rationale: A 3-month-old infant is interested in self-recognition and playing with the baby in the mirror. The stuffed animal, push-pull wagon, and large plastic ball are all appropriate for a toddler.

Which is the first line treatment for Paget disease? A) Oral alendronate B) 1500 mg of calcium C) Intravenous pamidronate D) Intravenous zoledronic acid

Oral alendronate Rationale: Oral alendronate, a bisphosphonate, is the first line treatment for Paget disease. 1500 mg of calcium is given as a supplement to reduce the risk for hypocalcemia. When oral drugs are not effective, pamidronate and zoledronic acid are administered intravenously.

The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is the best choice for a client with this disorder? A) Ham sandwich with cheese, whole milk, and potato chips B) Penne pasta, spinach, banana, and decaffeinated iced tea C) Baked lasagna with sausage, salad, and milkshake D) Hamburger, french fries, and cola

Penne pasta, spinach, banana, and decaffeinated iced tea Rationale: A client with cirrhosis and ascites will require moderate to low fat and low sodium (penne pasta, spinach, banana, and decaffeinated iced tea). Caffeine can stimulate and cause distention. Ham, cheese, whole milk, potato chips, baked lasagna with sausage, milkshake, hamburger, french fries, and cola all have more fat and sodium than a client with cirrhosis should consume.

After a teaching session a nurse determines that an adolescent with newly diagnosed type 1 diabetes has sufficient knowledge of the disorder. What is the next nursing action? A) Setting goals with the client B) Developing a rapport with the client C) Teaching the client how to give insulin injections D) Instructing the client how to monitor blood glucose

Setting goals with the client Rationale: A negotiation of goals is essential to successful learning; mutual goal-setting provides a focus for learning. A rapport should have developed before teaching of the adolescent about diabetes was started. Teaching the client how to give injections or monitor the blood glucose level is premature. If the client does not identify a specific need or set a goal, motivation may be minimal.

A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet (183 cm) tall and weighs 293 pounds (133 kg) puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? Select all that apply. A) Age B) Height C) Weight D) Smoking E) Family history

Weight and smoking Rationale: Obesity is a modifiable risk factor that is associated with coronary artery disease (CAD); an increased fat intake contributes to an increased serum cholesterol and atherosclerosis. Smoking, which constricts the blood vessels, is a modifiable risk factor for CAD. The incidence of CAD does increase with age. However, age is not a modifiable risk factor. Height is unrelated to the incidence of CAD. Family history is not a modifiable risk factor for CAD because one cannot control heredity.

A nurse is planning to provide self-care health information to several clients. Which client should the nurse anticipate will be mostmotivated to learn? A) A 55-year-old client who had a mastectomy and is very anxious about her body image B) An 18-year-old client who smokes cigarettes and is in denial about the dangers of smoking C) A 56-year-old client who had a heart attack last week and is requesting information about exercise D) A 47-year-old client who has a long-leg cast after sustaining a broken leg and is still experiencing severe pain

A 56-year-old client who had a heart attack last week and is requesting information about exercise Rationale: A client who is requesting information is indicating a readiness to learn. When a nurse is caring for a person who is coping with the diagnosis of cancer and a change in body image, the nurse should encourage the expression of feelings, not engage in teaching. People in denial are not ready to learn because they do not admit they have a problem. In addition, many adolescents believe that they are invincible. A person who is in pain is attempting to cope with a physiological need. This client is not a candidate for teaching until the pain can be lessened; pain can preoccupy the client and prevent focusing on the information being presented.

When teaching an adolescent with type 1 diabetes about dietary management, what instruction should the nurse include? A) Meals should be eaten at home. B) Foods should be weighed on a gram scale. C) A ready source of glucose should be available. D) Specific foods should be cooked for the adolescent.

A ready source of glucose should be available. Rationale: An adolescent with type 1 diabetes must carry a source of simple sugar (e.g., glucose tablets, Insta-Glucose, sugar-containing candy such as LifeSavers) to rapidly counteract the effects of hypoglycemia. This should be followed by a complex carbohydrate and a protein. Stating that meals should be eaten at home is an unrealistic and unnatural instruction for an adolescent. Stating that foods should be weighed on a gram scale is an unnecessary and time-consuming procedure. The adolescent should be made to feel a part of the family; the recommended diet is nutritious and no different from that of the rest of the family.

To which client should the nurse provide education regarding the pubertal growth spurt? A) An 8-year-old school-age male client B) A 16-year-old adolescent male client C) A 12-year-old school-age female client D) An 18-year-old adolescent female client

Answer: A 12-year-old school-age female client Rationale: The pubertal growth spurt reaches a peak for female clients at 12 years of age; therefore, the nurse should provide education to this client regarding expected growth during this time period. The 8-year-old male client would not be expected to experience the pubertal growth spurt until the age of 14 years. The 16-year-old and the 18-year-old adolescent clients would have already experienced the pubertal growth spurt.

A client tells the nurse about recent recurrent episodes of bleeding hemorrhoids. What should the nurse advise the client to do to help prevent future hemorrhoidal episodes? A) Exercise to improve circulation B) Eat bland foods and avoid spices C) Consume a high-fiber diet and drink adequate water D) Use laxatives to avoid constipation and the Valsalva maneuver

Consume a high-fiber diet and drink adequate water Rationale: Consuming a high-fiber diet and drinking adequate water promote regular bowel function, prevents constipation, and prevent straining, which can make hemorrhoids worse; a high-fiber diet provides bulk that stimulates peristalsis, and water promotes a soft stool. Exercise is advisable, but the purpose in this instance is to increase peristalsis, not improve circulation. Bland foods and spices are unrelated to hemorrhoids; bland foods are preferred for clients with gastric or intestinal problems. Laxatives are contraindicated because they are irritating to the bowel, decrease intestinal tone, and promote dependency. The Valsalva maneuver should also be avoided.

A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea? A) Increased fiber intake B) Bacterial contamination C) Inappropriate positioning D) High osmolarity of the feedings

High osmolarity of the feedings Rationale: The increased osmolarity (concentration) of many formulas draws fluid into the intestinal tract, which can cause diarrhea; such feedings may need to be diluted initially until the client develops tolerance or is changed to a more iso-osmolar strength formula. Formulas frequently have reduced fiber content. Bacterial contamination is not a factor if the manufacturer's recommendations are followed. Inappropriate positioning may increase the risk for aspiration, but it does not cause diarrhea.

Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? A) Pouring warm water over the perineum B) Ensuring the patency of the catheter C) Removing the catheter within 24 hours D) Cleaning the catheter insertion site

Removing the catheter within 24 hours Rationale: Clients who undergo surgery are at a greater risk of acquiring catheter-associated urinary tract infections. Infections can be prevented by removing the catheter within 24 hours, if the client does not need it. Therefore removing the catheter within 24 hours would be the best intervention. While pouring warm water over the perineum helps voiding in the postoperative client and also reduces the chances of infection, this action would not be as beneficial as the former intervention. The catheter should be maintained in its place to avoid leakage and infection. Cleaning the catheter insertion site will definitely reduce the risk of infection, but this action cannot prevent infections if the catheter is inserted for a long time.

A 6-year-old child comes to the school nurse reporting a sore throat, and the nurse verifies that the child has a fever and a red, inflamed throat. When a parent of the child arrives at school to take the child home, the nurse urges the parent to seek treatment. If the sore throat is not treated, what illness is of most concern to the nurse? A) Tetanus B) Influenza C) Scarlet fever D) Rheumatic fever

Rheumatic fever Rationale: The child's symptoms are suggestive of hemolytic Streptococcus infection. Rheumatic fever is an inflammatory disease involving the joints, heart, central nervous system, and subcutaneous tissue that can occur if the infection is not treated. It is thought to be an autoimmune process that causes connective tissue damage. Tetanus is not caused by a streptococcal infection. The disorder described is not influenza or scarlet fever.

A preadolescent brings home a note from the school nurse informing the parents that the child should be evaluated for scoliosis. The mother calls the school nurse to ask for a description of scoliosis. Before responding, what does the nurse recall about scoliosis? A) The concave lumbar curvature is exaggerated. B) There are pathological changes in the vertebrae. C) There is a rotary deformity of the lateral curvature of the spine. D) The curvature of the thoracic spine has an increased convex angulation.

There is a rotary deformity of the lateral curvature of the spine Rationale: A rotary deformity of the lateral curvature of the spine is the correct definition of scoliosis. An exaggerated concave lumbar curvature is a description of lordosis. There are no pathological changes in the vertebrae with scoliosis. A curvature of the thoracic spine with an increased convex angulation is a description of kyphosis.

What is the average optimal blood pressure of an adolescent? A) 85/54 mm Hg B) 95/65 mm Hg C) 105/65 mm Hg D) 110/65 mm Hg

110/65 mm Hg Rationale: The optimal blood pressure of an adolescent is 110/65 mm Hg. The average optimal blood pressure in an infant is 85/54 mm Hg. The average optimal pressure in a toddler is 95/65 mm Hg. The average optimal blood pressure seen in children between the ages of 6 and 13 is 105/65 mm Hg.

A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? A) "Moderate amount of drainage." B) "No change in drainage since yesterday." C) "A 10-mm-diameter area of drainage at 1900 hours." D) "Drainage is doubled in size since last dressing change."

"A 10-mm-diameter area of drainage at 1900 hours." Rationale: A 10-mm-diameter area of drainage at 1900 hours is objective data and gives specific details regarding the assessment and a timeframe. By providing size, it establishes parameters to compare with previous assessments and to further evaluate the drainage. "Moderate amount of drainage," "No change in drainage since yesterday," and "Drainage is doubled in size since last dressing change" are not specific, objective, or measurable.

A client who is receiving phenytoin to control a seizure disorder questions the nurse regarding this medication after discharge. How will the nurse respond? A) "Antiseizure drugs will probably be continued for life." B) "Phenytoin prevents any further occurrence of seizures." C) "This drug needs to be taken during periods of emotional stress." D) "Your antiseizure drug usually can be stopped after a year's absence of seizures."

"Antiseizure drugs will probably be continued for life." Rationale: Seizure disorders usually are associated with marked changes in the electrical activity of the cerebral cortex, requiring prolonged or lifelong therapy. Seizures may occur despite drug therapy; the dosage may need to be adjusted. A therapeutic blood level must be maintained through consistent administration of the drug irrespective of emotional stress. Absence of seizures will probably result from medication effectiveness rather than from correction of the pathophysiologic condition.

After a cleft lip repair a nurse places elbow restraints on the infant. The parents ask the nurse, "Why does our child have to have restraints?" How should the nurse respond? A) "They're used routinely on infants who have had lip surgery." B) "Legally we're required to put them on infants after lip surgery." C) "The staff can't be with your baby continuously to prevent touching of the mouth." D) "Because we're keeping the arms straight, your baby won't be able to touch the mouth."

"Because we're keeping the arms straight, your baby won't be able to touch the mouth." Rationale: An explanation of how the restraints work and why they are used may reassure the parents. Touching the suture line may cause a separation of the wound edges, predisposing the infant to infection and compromised wound healing. Explaining routine use of restraints does not explain why they are being used now. Restraints are not a legal requirement; applying elbow restraints is a postoperative prescription. Stating that the nurse cannot be with the infant continuously may give the parents the feeling that their baby's needs are not being met.

The home health nurse provides education to a client with cancer of the tongue who will begin gastrostomy feedings at home. Which statement by the client indicates teaching by the nurse is effective? A) "Before I start the procedure, I will don sterile gloves." B) "Before I start the procedure, I will obtain my body weight." C) "Before I start the procedure, I will measure the residual volume." D) "Before I start the procedure, I will instill one ounce (30 mL) of a carbonated liquid."

"Before I start the procedure, I will measure the residual volume." Rationale: Measuring the residual volume establishes whether an adequate volume of the previous feeding was absorbed. If a residual exceeds the parameter identified by the healthcare provider or is over 200 mL, a feeding may be held. This prevents adding excess feeding solution that may lead to abdominal distention, nausea, vomiting, and aspiration. Clean, not sterile, gloves are necessary to protect the client from contamination with gastric secretions. Weights are taken and reported weekly or monthly depending on the client's condition and clinical goals. A carbonated beverage may be used if the tube becomes clogged; it is not used routinely.

A nurse teaches the mother of a child with a pinworm infestation how pinworms are transmitted. Which statement indicates that the teaching has been effective? A) "I need to make sure the cat stays off her bed at night." B) "I'll have to reinforce her hand washing habits, especially before she handles food." C) "I need to be sure to disinfect the toilet seat after she has a bowel movement for the next few days." D) "I'll report to the school nurse that the school's dirty toilet seats caused my child to get pinworms."

"I'll have to reinforce her hand washing habits, especially before she handles food." Rationale: Pinworms are transferred by way of the anal-oral route; hand washing is the most effective method for preventing transmission. Cats do not transmit pinworms. It is unnecessary to disinfect the toilet seat because pinworms are found in the rectum or colon and travel to the perianal area only when the person sleeps. Dirty toilet seats are not the usual mode of transmission.

A parent receives a note from school reporting that a student in class has head lice. The parent calls the school nurse to ask how to check for head lice. What instruction should the nurse provide? A) "Ask the child where it itches." B) "Check to see whether your dog has ear mites." C) "Look at your child's head along the scalp line for white dots." D) "Inspect your child's hands and look between the fingers for red lines."

"Look at your child's head along the scalp line for white dots." Rationale: The white dots are nits, the eggs of head lice ( Pediculosis capitis); they can be seen on the shaft of hair along the scalp line, behind the ears, and at the nape of the neck. Asking the child where it itches is too vague; objective visualization will confirm the presence of nits. Canine ear mites are not transferable to humans. Red lines between the fingers are a sign of scabies, infestation with the Sarcoptes scabiei mite.

A client newly diagnosed with multiple sclerosis asks the nurse if it will be painful. Which response should the nurse give the client first? A) "Tell me more about your fears regarding pain." B) "Medications will be prescribed to help control pain." C) "Pain is a common symptom of this condition." D) "Let's list your questions for the healthcare provider."

"Pain is a common symptom of this condition." Rationale: The response "Pain is a common symptom of this condition" is a truthful answer for the client. Reassuring the client that "medications will be prescribed to help control pain" when the client experiences it is the next helpful response from the nurse. After being truthful about pain and reassuring the client about its medical management, asking the client to "tell more about...fears regarding pain" opens the conversation to discuss it and offers an opportunity for emotional release, which can decrease anxiety. The response "Let's list your questions for the healthcare provider" is a helpful final conversation during this encounter because it teaches the client how to make the most of their visit with the healthcare provider.

A client who is considering sclerotherapy asks the nurse to explain what causes varicose veins. Which response by the nurse is best? A) "The cause is abnormal configurations of the veins." B) "The cause is incompetent valves of superficial veins." C) "The cause is decreased pressure within the deep veins." D) "The cause is atherosclerotic plaque formation in the veins."

"The cause is incompetent valves of superficial veins." Rationale: Incompetent valves result in retrograde venous flow and subsequent dilation of veins. Abnormal configurations of the veins are considered a result of, rather than a cause of, varicose veins. Pressure within the deep veins is increased, not decreased. Plaque formation is considered an arterial, rather than a venous, problem and is associated with atherosclerosis.

A 17-year-old adolescent was recently found to have type 2 diabetes mellitus. What information will the nurse include when providing education to the family? A) "Your teen will need insulin injections for the rest of her life." B) "The most important interventions are good nutrition and portion control." C) "This is a condition where the body produces antibodies against its own cells." D) "This condition causes weight loss and increased appetite, thirst, and urination."

"The most important interventions are good nutrition and portion control." Rationale: Most children with type 2 diabetes are overweight or at risk for becoming overweight. With nutritional intervention to promote proper weight, the condition may often be managed with diet and exercise alone. A lifelong insulin regimen; the production of antibodies against the child's own cells; and weight loss with increased appetite, thirst, and urination are all typical of type 1 diabetes.

The clinic nurse is teaching the parents of a 3½-year-old child who is up to date on all vaccinations when it will be necessary to return to the clinic for the next set of vaccinations. Which statement indicates that the parents understand the teaching? A) "We won't need to come back for any more vaccinations." B) "We need to come back to the clinic in 1 year for more vaccinations." C) "We need to come back to the clinic in 2 months for more vaccinations." D) "We need to come back to the clinic in 6 months for more vaccinations."

"We need to come back to the clinic in 1 year for more vaccinations." Rationale: The child who is up to date on vaccinations at 3½ years of age will need to return to the clinic for an annual influenza vaccination. In addition, between 4 and 6 years of age the child will need the diphtheria, tetanus, pertussis (DTaP); measles, mumps, rubella (MMR); inactivated polio (IPV); and varicella vaccination boosters. The child will not need any additional vaccinations until the 1-year milestone, so returning in 2 or 6 months would be too soon.

An IV catheter is to be inserted into a 3-year-old toddler's peripheral vein. As local topical anesthetic is applied, the toddler starts to cry and asks whether the insertion is going to hurt. How should the nurse respond? A) "Yes, it will hurt, but not for very long." B) "Maybe it will hurt, but remember that big kids don't cry." C) "Yes, it may hurt, but if you hold still it won't hurt too much." D) "It will hurt a little, but I'm good at getting the needle into your arm."

"Yes, it will hurt, but not for very long." Rationale: Although the local anesthetic will help minimize the discomfort, the needle insertion may still hurt. Telling the child that the insertion will hurt but not for very long is an honest, simple answer that is appropriate for a 3-year-old child. Telling the child that big kids don't cry is a judgmental response that is inappropriate for a 3-year-old child; children sometimes need to cry to express their feelings. Although the child should hold still, there is no guarantee that doing this will cause the insertion to hurt less. Saying, "Maybe it will hurt" or "It may hurt" constitutes false reassurance. Saying that the insertion will hurt just a little because the nurse is skilled is also false reassurance; there is no guarantee of success, despite the nurse's self-proclaimed expertise.

A client who uses a complex ritual says to the nurse, "I feel so guilty. None of this makes any sense. Everyone must really think I'm crazy." What is the most therapeutic response by the nurse? A) "Your behavior is bizarre, but it serves a useful purpose." B) "You're concerned about what other people are thinking about you." C) "I am sure people understand that you can't help this behavior right now." D) "Guilt serves no useful purpose. It just helps you stay stuck where you are."

"You're concerned about what other people are thinking about you." Rationale: Paraphrasing encourages further ventilation of feelings and concerns by the client. Telling the client that the behavior is bizarre but that it serves a useful purpose is a negative response that may increase the client's fears about being "crazy." Saying "I'm sure people understand that you can't help this behavior right now" provides false reassurance and implies that the client is out of control, which may increase the fears. Telling the client that guilt serves no useful purpose and just helps the client stay stuck denies the client's feelings.

What is the concentration of estradiol in the blood during the follicular phase of the menstrual cycle? A) 130 pg/mL B) 159 pg/mL C) 165 pg/mL D) 171 pg/mL

130 pg/mL Rationale: In the follicular phase of the menstrual cycle, 20-150 pg/mL of estradiol is released. Therefore 130 pg/mL of estradiol would be its concentration during the follicular phase of the menstrual cycle. Concentrations of 159, 165, and 171 pg/mL are greater than the reference range.

After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. What is the nurse's greatest concern at this time? A) Addressing the pain B) Reversing feelings of hopelessness C) Promoting mobility in the residual limb D) Acknowledging the grieving for the lost limb

Addressing the pain Rationale: Phantom limb sensation is a real experience with no known cause or cure. The pain must be acknowledged and interventions to relieve the discomfort explored. There are no data indicating that the client is hopeless. Although promoting mobility in the residual limb may be effective for some people, it may not be effective for others; all possible interventions should be explored. There are no data indicating that the client is grieving.

Immediately after cataract surgery a client reports feeling nauseated. What should the nurse do? A) Provide some dry crackers to eat B) Administer the prescribed antiemetic C) Explain that this is expected after surgery D) Encourage deep breathing until the nausea subsides

Administer the prescribed antiemetic Rationale: An antiemetic will prevent vomiting; vomiting increases intraocular pressure and should be avoided. Aggressive intervention is required rather than dry crackers. Explaining that this is expected after surgery is incorrect. Deep breathing will not minimize nausea; aggressive intervention is required to prevent vomiting.

A nurse decides to use the CAGE screening questionnaire with a client admitted for substance abuse. What is the client abusing? A) Alcohol B) Barbiturates C) Hallucinogens D) Multiple drugs

Alcohol Rationale: The CAGE questionnaire is one of the simplest and most reliable screening tools for alcohol abuse. CAGE is an acronym for the key words ( Cut down, Annoyed, Guilty, and Eye-opener) in the four questions asked of people suspected of abusing alcohol. The CAGE questionnaire is not designed to screen clients for barbiturate, hallucinogen, or multiple drug abuse.

A client is going for a magnetic resonance imaging (MRI). What should the nurse ascertain before taking the client to the procedure? A) Scheduled medications have been given. B) All metal, such as jewelry and hair ornaments, has been removed. C) Adequate prehydration has been given. D) The client has emptied the bladder.

All metal, such as jewelry and hair ornaments, has been removed. Rationale: All metal must be removed because the MRI emits a strong magnetic field. All medications may not be necessary before the test. Prehydration is not necessary and may cause interruptions for client to void. The client should have the opportunity to void before going for the test.

A client with a history of hypertension has a blood pressure of 180/102 mm Hg. When the nurse asks whether the client has been taking any medications, the client replies, "I took the blood pressure pills the healthcare provider prescribed for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick." What is the best initial response by the nurse? A) "You must be quite frightened about having high blood pressure." B) "I'm glad to hear you have felt well enough to stop the medication." C) "It is important to take your medications daily to achieve optimal results." D) "You will need to document daily whether you took your medication or not."

Answer: "It is important to take your medications daily to achieve optimal results." Rationale: "It is important to take your medications daily to achieve optimal results" is a nonjudgmental response that does not pressure the client but does indicate clearly that treatment is necessary. The response "I'm glad to hear you felt well enough to stop the medication" is not supported by the client's statement. The response "You must be quite frightened about having high blood pressure" does not address the correlation between blood pressure medication and controlling hypertension. Although it is important to document medication taking, the initial response should address the importance of medication to control the client's hypertension.

A 14-month-old child is admitted to the pediatric hospital with a fractured right femur. The child is placed in Bryant traction. When the parents see the child for the first time in traction, they are surprised to see both legs in traction and ask why. What information should the nurse share about Bryant traction? A) Putting both legs in traction keeps one leg from becoming longer than the other B) Putting both legs in traction keeps the baby from turning over in bed and breaking his leg again C) As a means of ensuring countertraction, both legs are placed in traction, and the buttocks are suspended off the bed D) When the legs was x-rayed, the HCP apparently discovered that the other leg was broken as well

Answer: As a means of ensuring countertraction, both legs are placed in traction, and the buttocks are suspended off the bed Rationale: In young infants the body weight doesn't provide adequate countertraction to overcome the spasm of the muscles. With both legs in traction and the buttocks suspended off the bed, countertraction is sufficient to realign the femur. Putting both legs in traction does not keep the child from having one leg longer than the other. A bed jacket could keep the child from turning over in bed; keeping the baby from turning over in bed is not the reason for putting both legs in traction. This type of traction can be used for one fractured femur; it is not reserved for bilateral fractures.

Which would the nurse consider to be a potential respiratory system-related complication of surgery? A) Atelectasis B) Hyperthermia C) Wound dehiscence D) Hypovolemic shock

Answer: Atelectasis Rationale: Atelectasis is a potential complication of the respiratory system that can occur after surgery. Hyperthermia is a potential neuromuscular complication. Wound dehiscence is a potential skin complication. Hypovolemic shock is a cardiovascular complication that can occur after surgery.

A nurse is preparing a teaching plan for the parents of a child with celiac disease. What information on the basic problem in celiac disease does the nurse include? A) Green stools B) Intolerance of gluten C) Absence of intestinal villi D) Susceptibility to severe dehydration

Answer: Intolerance of gluten Rationale: Celiac disease is an immunological small intestine enteropathy characterized by the inability to metabolize the gliadin component of gluten found in grains such as wheat, barley, rye, and oats; this results in excessive glutamine that is toxic to the mucosal cells. The stools are fatty and yellow. The intestinal villi are present but will atrophy if exposed to foods containing gluten. Fluid balance is not the basic problem with celiac disease; however, dehydration may occur in celiac crisis.

The plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. The client asks why all activity is restricted. The nurse's response should be based on what principle about bed rest? A) It prevents the further aggregation of platelets. B) It enhances the peripheral circulation in the deep vessels. C) It decreases the potential for further dislodgment of emboli. D) It maximizes the amount of blood available to damaged tissues.

Answer: It decreases the potential for further dislodgment of emboli Rationale: Activity may encourage the dislodgment of more microemboli. Bed rest may enhance platelet aggregation and the formation of thrombi because of venous stasis. Bed rest supports venous stasis, rather than enhanced circulation or the circulation of blood to damaged tissues.

After surgery for a ruptured appendix, a 12-year-old child is receiving morphine for pain control by way of a patient-controlled analgesia (PCA) infusion. A bolus of morphine can be delivered every 6 minutes. A parent will be staying with the child during the immediate postoperative period. What statement indicates to the nurse that the instructions about the PCA pump have been understood? A) I'll make sure that she pushes the PCA button every 6 minutes B) She needs to push the PCA button whenever she needs pain medication C) I'll have to wake her up on a regular basis so she can push the PCA button D) I'll press the PCA button every 6 minutes so she gets enough pain medication while she's sleeping

Answer: She needs to push the PCA button whenever she needs pain medication Rationale: Morphine, an opioid analgesic, relieves pain; when control of pain is given to the child, anxiety and pain are usually diminished, resulting in a decreased need for the analgesic; only the child should press the PCA button. Having the child press the PCA button every 6 minutes is unnecessary. Although pain medication can be delivered as often as every 6 minutes, it should be used only if necessary. If the child is sleeping, the pain is under control; waking the child will interfere with rest. If the child is sleeping, the pain is under control; also, this will result in an unnecessary and excessive dosage of the opioid.

A 2-year-old child who has been restricted to bed rest because of a diagnosis of meningitis is now allowed out of bed. The nurse suggests going to the playroom. The child responds by shaking the head vigorously from side to side, screaming, "No! Won't!" However, the child is trying to climb out of the crib at the same time. In light of these behaviors, what is the most likely conclusion by the nurse? A) The child is trying to assert independence B) The child is eager to resume regular play activities. C) The child is unsure of the difference between yes and no. D) The child is confused as a result of increased intracranial pressure.

Answer: The child is trying to assert independence Rationale: The toddler is exhibiting typical behavior for this developmental level; most toddlers will say no as a means of asserting their independence. Although the child may be eager to resume playing, the behavior described is related to the child's assertion of autonomy. Although toddlers who are attempting to assert independence will say no even when they mean yes, they do understand the difference. This child's behavior does not indicate confusion; it is typical of 2-year-old children, who will say no to most things as a means of asserting their independence.

The parents of a 6-week-old infant who was born without an immune system ask the nurse why their baby is still so healthy. What is the best response by the nurse? A) Exposure to pathogens during this time can be limited. B) Some antibodies are produced by the infant's colonic bacteria. C) Bottle feeding with soy formula has boosted the immune system. D) Antibodies are passively received from the mother through the placenta and breast milk.

Antibodies are passively received from the mother through the placenta and breast milk. Rationale: Antibodies received in utero through the placenta and by the newborn in the mother's breast milk provide the infant with immunity against most viral, bacterial, and fungal infections during the first several weeks after birth. Then, as the titer of maternal antibodies drops and is not replaced by the infant's own antibodies, prolonged and repeated infections may occur. Limiting exposure to pathogens during this time is not enough to prevent infections in an immunocompromised infant. Bacteria do not produce antibodies. Bottle feeding with soy formula has not been proved to boost immunity in infants.

A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock? A) Arteriolar constriction occurs. B) The cardiac workload decreases. C) Contractility of the heart decreases. D) The parasympathetic nervous system is triggered.

Arteriolar constriction occurs Rationale: The early compensation of shock is cardiovascular and is reflected in changes in pulse, blood pressure, and pulse pressure; blood is shunted to vital organs, particularly the heart and brain. The cardiac workload will increase, not decrease, as the heart attempts to pump more blood to the vital organs. The heart compensates by increasing its contractility, which will increase, not decrease, the cardiac output. The sympathetic, not parasympathetic, nervous system is triggered to produce vasoconstriction.

A client who just returned from a cardiac catheterization reports to the nurse that the pressure bandage on the right groin is tight. What action should the nurse take? A) Loosen the dressing slightly. B) Notify the primary healthcare provider. C) Assess the pulses distal to the dressing. D) Have the client flex the joints of the right leg.

Assess the pulses distal to the dressing. Rationale Assessing the circulatory status of the extremity will determine whether the dressing is too tight. Loosening the dressing slightly may result in bleeding from the catheter insertion site and is contraindicated. Notifying the primary healthcare provider is premature; the primary healthcare provider should be notified if circulation to the leg is compromised. Having the client flex the joints of the right leg may result in bleeding from the catheter insertion site and is contraindicated. The leg should remain extended for several hours.

A client is scheduled for head and neck surgery. Although the healthcare provider has explained the surgery, the client still has moderate to severe anxiety. Which action should the nurse take initially? A) Attempt to discover what the client is concerned about. B) Elaborate on what the healthcare provider has already said. C) Teach the client to use the suction equipment preoperatively. D) Plan for postoperative communication because a tracheostomy is likely.

Attempt to discover what the client is concerned about Rationale: Various aspects of hospitalization and diagnosis may cause the client to become anxious. The nurse should identify what concerns the client the most. Anxiety interferes with learning, and it is the healthcare provider's responsibility to explain the surgery. Teaching the client to use the suction equipment preoperatively may cause the client unnecessary anxiety. A tracheostomy may not be performed; it depends on the type of surgery.

An infant with a diaphragmatic hernia undergoes corrective surgery. What nursing assessment indicates that the infant's respiratory condition has improved? A) Cessation of crying B) Retention of 1 oz (30 mL) of formula C) Reduction of arterial blood pH to 7.31 D) Auscultation of breath sounds bilaterally

Auscultation of breath sounds bilaterally Rationale: Bilateral breath sounds indicate that the lungs are expanded and functioning. Lack of crying is not a reliable indicator that the respiratory status is improving; it may indicate that the infant is hypoxic and too fatigued to cry. The expected pH is 7.35 to 7.45; a decreasing pH indicates respiratory acidosis, which can be attributed to decreased gas exchange. Retention of formula is unrelated to gas exchange.

What is the nurse's primary consideration when caring for a client with rheumatoid arthritis? A) Surgery B) Comfort C) Education D) Motivation

Comfort Rationale: Because pain is an all-encompassing and often demoralizing experience, the client should be kept as pain-free as possible. Surgery is used to correct deformities and facilitate movement, which is not the priority. Concentration and motivation are difficult when a client is in severe pain.

The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings? A) Azotemia B) Hypokalemia C) Metabolic alkalosis D) Respiratory alkalosis

Azotemia Rationale: The BUN is greater than the expected value of 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Urea nitrogen is the major nitrogenous end product of protein and amino acid catabolism; azotemia is the accumulation of excessive nitrogenous compounds, such as BUN and creatinine, in the blood. The client has hyperkalemia; the expected value for potassium is 3.5 to 5.5 mEq/L (3.5 to 5.5 mmol/L). Although the client does have a metabolic acid-base imbalance, it is acidosis, not alkalosis, because the pH is less than the expected range of 7.35 to 7.45. The PO 2 is within the expected range of 80 to 100 mm Hg, which indicates that the problem is metabolic, not respiratory.

An adolescent who has had a leg amputated because of bone cancer begins to experience phantom limb sensations. How should the nurse respond when the client complains of pain and requests medication? A) By withholding the medication to help prevent addiction B) By stating that the limb has been removed and that the pain is psychological C) By acknowledging that the pain is real and administering medication to relieve it D) By explaining that the phantom limb sensation will subside within a few more days

By acknowledging that the pain is real and administering medication to relieve it Rationale: Pain medication is required, along with intensive supportive nursing care. To the client the pain is real, requiring pain medication; addiction is not a concern at this time. Explaining that the pain is psychological in origin does not help relieve the pain; medication and emotional support are required. The pain may not recede within a few days; pain medication should be administered.

How can a nurse best meet a preschooler's developmental needs just before a physical examination? A) By allowing the child to handle the examination equipment B) By explaining to the child what will happen during the examination C) By arranging for a peer who has had the same examination to talk to the child D) By requesting that one of the parents stay with the child during the examination

By allowing the child to handle the examination equipment Rationale: Handling the equipment permits the child to investigate and become familiar with the instruments to be used. An explanation is beyond the comprehension of the average 4-year-old and will do little to ease anxiety. Another child's explanation is beyond the ability of a 4-year-old to understand and will do little to reduce anxiety. Having a parent present is supportive; however, the child should be given an opportunity to handle the equipment before the procedure, whether or not a parent is present.

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by doing what? A) Promoting analgesia and circulation B) Numbing the nerves and dilating the blood vessels C) Promoting circulation and reducing muscle spasms D) Causing local vasoconstriction, preventing edema and muscle spasms

Causing local vasoconstriction, preventing edema and muscle spasms Rationale: Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and therefore muscle spasms. Cold does promote analgesia but not circulation. It may numb nerves but does not dilate blood vessels. Cold therapy also may numb the nerves and surrounding tissues, thus reducing pain.

Which type of bone tumor is commonly seen in elderly clients? A) Endochroma B) Osteosarcoma C) Chondrosarcoma D) Osteochondroma

Chondrosarcoma Rationale: Chondrosarcoma occurs most commonly in cartilage in the arm, leg, and pelvic bones of older adults in the age group of 50 to 70 years old. Endochroma occurs in clients in the age group of 10 to 20 years old. Osteosarcoma and osteochondroma occur in the age group of 10 to 25 years old.

A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the primary healthcare provider? A) Client pushes the airway out. B) Client has snoring respirations. C) Client's respirations are 16 breaths per minute and unlabored. D) Client's systolic blood pressure drops from 130 to 90 mm Hg.

Client's systolic blood pressure drops from 130 to 90 mm Hg Rationale: A drop in blood pressure; rapid pulse rate; cold, clammy skin; and oliguria are signs of decreased blood volume and shock, which if not treated promptly can lead to death. The client pushing the airway out is an expected response; the client will push out the airway as the effects of anesthesia subside. Respirations of 16 breaths per minute is a common response postoperatively. If the client is experiencing a depressant effect of anesthesia, the nurse will assess shallow and slow respirations.

A 12-year-old child is to be bedridden at home for several weeks after orthopedic surgery. What activity should the nurse encourage the parents to plan? A) Drawing pictures B) Playing card games C) Watching television D) Continuing schoolwork

Continuing schoolwork Rationale: Schoolwork provides the child with a familiar routine; it encompasses the age-appropriate developmental tasks of industry versus inferiority. Drawing pictures is an appropriate activity for the preschooler. Although social interaction and mental stimulation are important at this age, continuing with schooling is the priority. Television watching is satisfactory but should not replace active participation.

A nurse assesses a client's intravenous site. What clinical finding, unique to infiltration, leads the nurse to conclude that the intravenous (IV) site has infiltrated, rather than become inflamed? A) Pain B) Coolness C) Localized swelling D) Cessation in flow of solution

Coolness Rationale: When an IV infiltrates, the IV solution entering the interstitial space is at room temperature (approximately 75° F [23.9° C]), whereas body temperature is approximately 98.6° F (37° C); therefore, the client's skin will feel cool to the touch at the site of an IV infiltration. The site of an inflammation will feel warm to the touch because of vasodilation and hyperemia. Pain may occur with both an inflammation and an infiltration. The pain of an inflammation is related to the pressure of edema on nerve endings. The pain of an infiltration is related to the IV solution in the interstitial compartment pressing on nerve endings. An increase in interstitial fluid occurs with both an inflammation and an infiltration. With an inflammation there is increased vascular permeability at the site; fluid, proteins, and leukocytes then move from the intravascular compartment into the interstitial compartment. With an infiltration the IV solution enters the interstitial compartment rather than the intravascular compartment. A cessation in flow of solution occurs with both an inflammation and an infiltration. An inflammation in the vein at the insertion site may close the lumen of the vessel, interfering with the flow of solution. An infiltration will cause excess fluid in the interstitial compartment to the extent that it will not accommodate more solution, interfering with the flow of the solution.

Which disorder of the foot is caused by continual pressure over bony prominences? A) Corn B) Plantar wart C) Hammer toe D) Hallux rigidus

Corn Rationale: A corn is a foot disorder caused by continual pressure over bony prominences. A plantar wart is a foot disorder caused by a virus. Hammer toe is a foot disorder caused by flexion and deformity in the joints. Hallux rigidus is caused by osteoarthritis.

Which urodynamic study provides information on bladder capacity, bladder pressure, and voiding reflexes? A) Radiography B) Renal arteriography C) Electromyography (EMG) D) Cystometrography (CMG)

Cystometrography (CMG) Rationale: Cystometrography (CMG) is an urodynamic study that provides information on bladder capacity, bladder pressure, and voiding reflexes. Radiography is a diagnostic test for clients with disorders of kidney and urinary system to screen for the presence of two kidneys, to measure kidney size, and to detect gross obstruction in kidneys or urinary tract. Renal arteriography is a diagnostic study used to determine renal blood vessel size and abnormalities. Electromyography (EMG) is an urodynamic study used to test the strength of perineal muscles in voiding.

Thick mucous gland secretions, elevated sweat electrolytes, meconium ileus, and difficulty maintaining and gaining weight are associated with which autosomal recessive disorder? A) Cerebral palsy B) Cystic fibrosis C) Muscular dystrophy D) Multiple sclerosis

Cystic fibrosis Rationale: The early symptom of cystic fibrosis is meconium ileus, which is impacted stool in the newborn. Thick mucous secretions, salty sweat, and difficulty gaining weight because of high caloric demands are characteristics of the condition. Cerebral palsy is a motor disorder caused by damage to the brain. Muscular dystrophy is a muscular disorder. Multiple sclerosis is a condition with progressive disintegration of the myelin sheath.

What is the best way for the nurse to promote the social development of a 9-month-old infant? A) Engaging in peek-a-boo B) Offering soft clay to manipulate C) Providing a pegboard for pounding D) Demonstrating how to speak words

Engaging in peek-a-boo Rationale: Playing peek-a-boo is age appropriate because it aids the infant's social development by fostering a sense of object constancy and object permanence. Playing with soft clay is age appropriate for the toddler; it promotes gross and fine motor development. Pounding on a pegboard is age appropriate play for toddlers and preschoolers; it helps release tension and develops motor skills. Repeating words is age appropriate for the 1-year-old child.

The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. What is the purpose of the nurse's action? A) Data collection B) Data validation C) Data clustering D) Data interpretation

Data collection Rationale: The nurse is gathering objective data to support the subjective data. The client's report of difficulty breathing is subjective data that needs to be supported by data from physical examination. The nurse reviews the database after data collection to decide if it is accurate and complete. This step is called data validation. Grouping of data that forms a pattern is called data clusters. The nurse uses critical thinking to interpret the data and analyze it before it is classified and organized into data clusters.

A client who is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to do what? A) Decrease peristalsis B) Minimize electrolyte imbalance C) Decrease bacteria in the intestines D) Treat inflammation caused by the malignancy

Decrease bacteria in the intestines Rationale: To decrease the possibility of contamination, the bacteria count in the colon is lowered with antibiotics before surgery. Preoperative antibiotics do not have an effect on peristalsis, electrolyte balance, or treating inflammation.

Which musculoskeletal system change is associated in older adult clients? A) Decreased in height B) Decreased neck rigidity C) Increased fine-motor dexterity D) Increased range of motion (ROM)

Decreased in height Rationale: Loss of height and deformity and shortening of the trunk are common in older adults due to vertebral compression and degeneration. Rigidity in the neck, shoulders, back, hips, and knees increases with age due to loss of elasticity in ligaments, tendons, and cartilage. A decline in fine-motor dexterity occurs in the older adult due to slow impulse conduction along motor units. Range of motion (ROM) is limited in the older adult due to cartilage erosion, increased friction between the bones, and overgrowth of bone around joint margins.

The nurse understands that research demonstrates that malnutrition occurs in as many as 50% of hospitalized clients. The nurse should assess a postoperative client with anorexia for what sign of malnutrition? A) Dependent edema B) Spoon-shaped nails C) Loose, decayed teeth D) Delayed wound healing

Delayed wound healing Rationale: Delayed wound healing often is caused by a lack of nutrients, such as protein and vitamin C, in the diet. Dependent edema usually occurs with severe protein deficiency and heart failure. Spoon-shaped nails usually occur with iron deficiency anemia. Loose, decayed teeth usually indicate prolonged malnutrition.

Which drug can cause diabetes insipidus? A) Cabergoline B) Metyrapone C) Demeclocycline D) Aminoglutethimide

Demeclocycline Rationale: Prolonged administration of demeclocycline may cause diabetes insipidus, as this drug decreases the production of antidiuretic hormone by the kidneys. Cabergoline inhibits the release of growth hormone and prolactin by stimulating dopamine receptors in the brain. Metyrapone and aminoglutethimide decrease cortisol production.

The nurse is caring for a 4-year-old child who has been hospitalized with an acute asthma exacerbation. Which assessment finding requires action by the nurse? A) Diminished breath sounds B) Pulse rate of 110 beats/min C) Pulse oximetry reading of 95% D) Respiratory rate of 24 breaths/min

Diminished breath sounds Rationale: At the beginning of an asthma episode, wheezing may be heard only with a stethoscope. As the severity of the episode increases, wheezing may become audible to the unaided ear. Children in severe respiratory distress may not demonstrate wheezing because of decreased air movement; diminished breath sounds in a child may signal an inability to move air, so this finding requires action. The normal pulse range for a 4-year-old is 80 to 125 beats/min; a pulse of 110 beats/min does not require action. The normal respiratory range for a 4-year-old is 20 to 30 breaths/min, so a respiratory rate of 24 breaths/min does not require action. A pulse oximetry reading of 95% is acceptable. Once the child has been hospitalized with an acute asthma attack, oxygen saturation should be kept at 95% or higher.

A client had a gastric bypass procedure to treat morbid obesity. After surgery the client reports weakness, sweating, palpitations, and dizziness after eating. What should the nurse encourage the client to do? A) Reduce the intake of protein-rich foods B) Drink 8 ounces (240 mL) of water with meals C) Divide the daily caloric intake into six smaller meals D) Remain in an upright position for one hour after eating

Divide the daily caloric intake into six smaller meals Rationale: The client's clinical manifestations are related to the dumping syndrome from the gastric bypass procedure. Smaller meals along with other interventions will help minimize this response. After gastric bypass, a bolus of hypertonic fluid enters the intestines before carbohydrates and electrolytes are diluted. Extracellular fluid is drawn into the bowel lumen; this causes a decrease in plasma volume, distention of the bowel lumen, and rapid intestinal transit. Protein intake should be increased, not decreased, to meet energy needs and promote healing. Fluids should be avoided at mealtimes because they increase the volume in the stomach and decrease the transit time of gastric contents moving from the stomach to the intestine, which contributes to dumping syndrome. An upright position decreases the transit time of gastric contents moving from the stomach to the intestines via gravity, which contributes to the dumping syndrome; clients may lie flat after eating for a short time.

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration? A) Elevate the head of the bed between 30 and 45 degrees. B) Decrease flow rate at night. C) Check for residual daily. D) Irrigate regularly with warm tap water.

Elevate the head of the bed between 30 and 45 degrees Rationale: To prevent aspiration, the nurse should keep the head of the bed elevated between 30 and 45 degrees. Elevating the head any higher causes increased sacral pressure and increases the risk of skin breakdown. Decreasing flow rate, checking residual, and irrigating regularly will not prevent aspiration.

Which hormone secretion does the nurse state is an example of a positive feedback mechanism? A) Insulin B) Estradiol C) Parathormone D) Catecholamines

Estradiol Rationale: Estradiol secretion pattern is an example of a positive feedback mechanism. Insulin secretion pattern is an example of a negative feedback mechanism. The relationship between calcium and parathormone is also an example of a negative feedback mechanism. Catecholamines secretion is controlled by the nervous system. It is secreted by the sympathetic nervous system.

After surgery for creation of an ileostomy, a client is to be discharged. Before discharge, what is the primary nursing intervention? A) Emphasizing that it is essential that the client can care for the ileostomy without assistance B) Evaluating the client's ability to care for the ileostomy C) Ensuring that the client understands the dietary limitations that must be followed D) Ensuring that the client is competent at changing the dry sterile dressing on the incision

Evaluating the client's ability to care for the ileostomy Rationale: The client's feelings, knowledge, and skills concerning the ileostomy must be assessed before discharge. People should not be pressured into performing self-care before they are physically and emotionally ready. The diet is not limited; however, the client should be encouraged to eat a high-protein diet or a regular diet with supplemental protein. A high-fluid intake should be maintained. Often the client no longer needs a dressing on the incision at the time of discharge; a collection pouch is used over the stoma.

A client with Hodgkin disease is placed on an ABVD combination chemotherapy regimen. Because doxorubicin is part of this therapy, what education will the nurse provide about this drug? A) Cease taking any medication that contains vitamin D. B) Keep the doxorubicin in a dark place protected from light. C) Expect urine to turn red for a few days after taking this drug. D) Take the doxorubicin on an empty stomach with large amounts of fluids.

Expect urine to turn red for a few days after taking this drug Rationale: Doxorubicin causes the urine to turn red for a few days; the client should be informed of this expectation so as not to become alarmed when it occurs. Discontinuing the intake of vitamin D is true for plicamycin, not the drugs in this protocol. It is unnecessary to keep doxorubicin in a dark area, protected from light. Doxorubicin is not given orally, only via the intravenous route.

A slightly overweight client is to be discharged from the hospital after a cholecystectomy. What is most important for the nurse to include in teaching the client about nutrition? A) Listing low-protein foods that may be included in the diet B) Explaining that fatty foods may not be tolerated for several weeks C) Teaching the importance of a low-calorie diet to promote weight reduction D) Encouraging the intake of high vitamin C, vitamin A, and zinc foods at each meal

Explaining that fatty foods may not be tolerated for several weeks Rationale: Bile, which aids in fat digestion, is not as concentrated as before surgery. Once the body adapts to the absence of the gallbladder, the client should be able to tolerate a regular diet that contains fat. Initially the client should avoid fatty foods unless otherwise indicated. A low-protein diet is not necessary. Although teaching the client about a low-calorie diet to promote weight reduction is important, it is not as important as temporary avoidance of fatty foods with the gradual resumption of a regular diet. While vitamin C, vitamin A, and zinc are important, they are not the priority.

A client is admitted to the emergency department after ingesting a tricyclic antidepressant in an amount 30 times the daily recommended dose. What is the immediate treatment anticipated by the nurse? A) Administration of physostigmine as soon as possible B) Closer monitoring to prevent further suicidal attempts C) Gastric lavage with activated charcoal and support of physiologic function D) Intravenous administration of an anticholinergic in response to changes in vital signs

Gastric lavage with activated charcoal and support of physiologic function Rationale: Gastric lavage with charcoal may help decrease the level of tricyclic antidepressant overdose. Supportive measures such as mechanical ventilation may be needed until the medical crisis passes. Physostigmine salicylate was used in the past to promote improvement in consciousness. Now its use is contraindicated because it can cause bradycardia, asystole, and seizures in clients with tricyclic antidepressant toxicity. Prevention of suicidal behavior is always advantageous; however, in this case immediate emergency intervention is necessary. The acetylcholine level is depressed as a result of the tricyclic antidepressant; anticholinergics are most effective in managing the side effects of antipsychotic and neuroleptic drugs, not tricyclic antidepressant drugs.

During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. Which action should the receiving nurse take first? A) Suggest that an antiemetic be prescribed B) Change the feeding schedule to omit nights C) Request that the type of solution be changed D Gather more data from the night nurse about the technique used

Gather more data from the night nurse about the technique used Rationale: Rapid administration, incorrect positioning, and inadequate solution temperature are common causes of intolerance to tube feedings. Although suggesting that an antiemetic be prescribed may be done eventually, the feeding technique should be assessed first. Feedings generally are tolerated better if given frequently in small amounts over the entire 24 hours. Although changing the feeding schedule to omit nights and requesting that the type of solution be changed may be done eventually, the feeding technique should be assessed first.

Which hormone aids in regulating intestinal calcium and phosphorous absorption? A) Insulin B) Thyroxine C) Glucocorticoids D) Parathyroid hormone

Glucocorticoids Rationale: Adrenal glucocorticoids aid in regulating intestinal calcium and phosphorous absorption by increasing or decreasing protein metabolism. Insulin acts together with growth hormone to build and maintain healthy bone tissue. Thyroxine increases the rate of protein synthesis in all types of tissues. Parathyroid hormone secretion increases in response to decreased serum calcium concentration and stimulates the bones to promote osteoclastic activity.

A 4-year-old child is being prepared for a myringotomy in the ambulatory care unit. What is most important for the nurse to do when the child is called to the operating room? A) Removing the child's undergarments B) Placing the child's toys on the bedside table C) Allowing the child to climb onto the stretcher D) Having the parents accompany the child to the operating suite

Having the parents accompany the child to the operating suite Rationale: Current practice encourages parents to stay with the child as long as possible; this helps reduce stress related to a frightening experience. Removing undergarments is usually not necessary for a myringotomy procedure. Toys, especially a favorite one, should accompany the child until sedation is induced. The child is too young to climb onto a stretcher.

A nurse is caring for a client with scabies. Which information about scabies should the nurse consider when planning care for this client? A) Highly contagious B) Caused by a fungus C) Chronic with exacerbations D) Associated with other allergies

Highly contagious Rationale: Scabies is caused by the itch mite (Sarcoptes scabiei), the female of which burrows under the skin to deposit eggs. It is intensely pruritic and is transmitted by direct contact or in a limited way by soiled sheets or undergarments. It is not caused by a fungus. Scabies is an acute infestation; there are no remissions and exacerbations. It is a disease unrelated to allergies.

During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for? A) Hypokalemia and hyponatremia B) Hyperkalemia and hyponatremia C) Hypokalemia and hypernatremia ' D) Hyperkalemia and hypernatremia

Hyperkalemia and hyponatremia Rationale: Massive amounts of potassium are released from the injured cells into the extracellular fluid compartment; large amounts of sodium are lost in edema. Serum potassium will rise, leading to hyperkalemia. Serum sodium deficit will occur, leading to hyponatremia.

A client who is in the advanced stages of illness asks the nurse to contact pastoral services for support. According to the Macmillan model, what is the best nursing intervention in this situation? A) Immediately involve pastoral services while caring for the client. B) Involve the family member in the client's care instead of pastoral support. C) Listen to the client's request for support then carry on with the clinical work. D) Falsely promise that pastoral services has been contacted and plan to see the client.

Immediately involve pastoral services while caring for the client. Rationale: The Macmillan nurse usually has the knowledge of advanced practice and possesses specialty training. This practice enhances the nurse to gain an in-depth knowledge about spiritual, social, and psychologic needs and the pathophysiology of clients living with advanced diseases. Therefore the nurse involves pastoral services while caring for the client. Involving a family member may decrease anxiety in the client but may not fulfill the wishes of the client. Just listening to the client's request without implementation or giving false promises can cause loss of trust in the client.

A child with nephrotic syndrome visits the clinic for follow-up. During the visit the parent states that the child is always tired and has no appetite. The nurse notes that the child has a muddy, pale complexion. What problem does the nurse suspect? A) Impending renal failure B) Being too active in school C) A developing viral infection D) Refusal of the prescribed medications

Impending renal failure Rationale: Poor appetite and decreased energy are associated with the accumulation of toxic waste; anemia accounts for the pallor. Activity does not cause these signs and symptoms. An increased temperature will probably be present, but an infection will not cause a muddy pallor. Discontinuing the corticosteroids and diuretics that are usually prescribed will probably result in recurrence of edema in a steroid-dependent child.

A nurse bases the plan of care for a 15-month-old toddler with celiac disease on the pathophysiology of the disorder, which is characterized by what? A) Inability to metabolize gluten B) Absence of the enzyme phenylalanine C) Excessive amount of salt in the sweat glands D) Increase in the viscosity of mucous secretions

Inability to metabolize gluten Rationale: Children with celiac disease are unable to digest the gliadin component of gluten, resulting in fatty, foul-smelling diarrheal stools. Phenylketonuria is caused by the absence of phenylalanine; it is not related to celiac disease. Excessive salt in the sweat glands is a manifestation of cystic fibrosis. Increased viscosity of secretions from mucous glands is also related to cystic fibrosis.

A 3-month-old infant is admitted to the pediatric unit with a diagnosis of tetralogy of Fallot. The nurse's assessment reveals that the infant's weight has declined from the 25th percentile to the 5th. The nurse concludes that what is the most likely reason for this inadequate weight gain? A) Cyanosis resulting in cerebral changes B) Decreased arterial oxygen level resulting in polycythemia C) Pulmonary hypertension resulting in recurrent respiratory infections D) Inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse

Inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse Rationale: Because of quick fatigue it is difficult for the infant to consume sufficient calories for adequate weight gain. Increased caloric intake is needed to meet the infant's nutritional needs. Although cyanosis is present, it may not lead to cerebral changes. Cyanosis is not directly related to inadequate weight gain. Although decreased Po 2 does lead to polycythemia, it does not affect the infant's ability to gain adequate weight. Although there is pulmonary hypertension, it is not directly related to inadequate weight gain or respiratory infections.

A 16-year-old high school student who has anorexia nervosa tells the school nurse that she thinks she is pregnant even though she has had intercourse only once, more than a year ago. What is the most appropriate inference for the nurse to make about the student? A) Using magical thinking B) Submitting to peer pressure C) Lying about the last time she had intercourse D) Lacking knowledge that anorexia can cause amenorrhea

Lacking knowledge that anorexia can cause amenorrhea Rationale: The loss of body fat from anorexia can cause amenorrhea; the client needs information. No data are available to support the fact that the client is using magical thinking, which is characterized by the belief that thinking or wishing something can cause it to occur; in light of the client's diagnosis of anorexia, this is not the first conclusion. Submitting to peer pressure is not related to this type of concern. Although the nurse should question the timeline again, the client's nutritional status should be explored first.

What is the priority nursing action in the care of a young child with severe diarrhea? A) Measuring daily urine output B) Maintaining fluid and electrolyte balance C) Replacing the lost calories with high-fiber foods D) Promoting perianal skin integrity by bathing often

Maintaining fluid and electrolyte balance Rationale: Maintaining fluid and electrolyte balance is the priority intervention to reduce risk of harm to the client. Measuring daily urine output is important as a means of checking kidney function, but maintaining overall fluid and electrolyte balance is the priority. If a child is severely dehydrated, urine output needs to be checked more often than daily. Nutrition is not a priority above fluid and electrolyte balance at this time. Although important, skin integrity is not the priority.

A client with malignant hot nodules of the thyroid gland has a thyroidectomy. What is the nurse's priority action immediately postoperative? A) Check the neck dressing and behind neck for excessive bleeding. B) Monitor the trachea for deviation to the right or left. C) Assess the client's level of discomfort and medicate as prescribed. D) Encourage coughing and deep breathing to prevent atelectasis.

Monitor the trachea for deviation to the right or left. Rationale: A deviated trachea is an imminent sign of airway compromise which requires immediate intervention. The client is at high risk for bleeding within the first 24 hours postoperative. Bleeding can accumulate at the incision site as well as in the neck causing tracheal compression with swelling that may compromise the client's ability to breath. Checking for bleeding may alert the nurse of an increasing risk of airway compromise. Pain management and breathing exercises are standard postoperative interventions.

What is the priority nursing intervention for a 6-month-old infant with bronchiolitis? A) Discouraging parental visits to conserve energy B) Monitoring skin color, anterior fontanel, and vital signs C) Wearing gown, cap, mask, and gloves when rendering care D) Promoting stimulating activities to meet developmental needs

Monitoring skin color, anterior fontanel, and vital signs Rationale: Continuous assessments are vital in determining the infant's oxygenation and hydration status and responses to the disease process. The infant needs the parents' presence to fulfill the developmental goal of infancy, the establishment of trust. Respiratory syncytial virus is the most common cause of bronchiolitis in an infant. Contact precautions are recommended for an infant with bronchiolitis; airborne precautions are not necessary. The infant is too ill to be involved in stimulating activities; energy should be conserved and oxygen demands kept to a minimum.

After a client has a total gastrectomy, the nurse plans to include in the discharge teaching the need for what treatment? A) Monthly injections of cyanocobalamin B) Regular daily use of a stool softener C) Weekly injections of iron dextran D) Daily replacement therapy of pancreatic enzymes

Monthly injections of cyanocobalamin Rationale: Intrinsic factor is lost with removal of the stomach, and cyanocobalamin is needed to maintain the hemoglobin level once the client is stabilized; injections are given monthly for life. Adequate diet, fluid intake, and exercise should prevent constipation. Weekly injections of iron dextran are not considered routine. Daily replacement therapy of pancreatic enzymes does not affect pancreatic enzymes.

A nurse is assessing a client's ECG reading. The client's atrial and ventricular heart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this rhythm? A) Normal sinus rhythm B) Sinus tachycardia C) Sinus bradycardia D) Sinus arrhythmia

Normal sinus rhythm Rationale: Normal sinus rhythm reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.04 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the sinoatrial (SA) node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate slightly increases during inspiration and slightly slows during exhalation because of changes in vagal tone.

During follow-up visits, the client's child reports to the nurse, "I tell my parent every day about what may happen if medications aren't taken as prescribed. Despite that, my parent does not take the medication regularly and is depressed." What can be inferred about the client's motivational level? A) Not motivated B) Intrinsically motivated C) Extrinsically motivated with self-determination D) Extrinsically motivated without self-determination

Not motivated Rationale: If the client is not motivated, then the client may not attempt to eradicate the illness and feel depressed because of the illness. If the client is intrinsically motivated, then the client shows more interest in taking their medications on their own rather than because of pressure from other individuals. The client is motivated extrinsically with or without self-determination when they may take medication regularly when reminded to do so or when pressured by others.

The nurse finds that a client has reduced urinary output. Which condition would the nurse document in the client's medical record? A) Anuria B) Dysuria C) Oliguria D) Nocturia

Oliguria Rationale: A reduced urinary output of less than 400 mL in a 24-hour interval is called oliguria. Anuria is the absence of urination. Painful or difficult urination is called dysuria. Frequent urination at night is called nocturia.

A client has a colon resection with an anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply. Select all that apply A) Oliguria B) Lethargy C) Irritability D) Hypotension E) Slurred speech

Oliguria, Irritability, Hypotension Rationale: Decreased blood flow to the kidneys leads to oliguria or anuria. Irritability, along with restlessness and anxiety, occurs because of a decrease in oxygen to the brain. Hypotension and a narrowing of the pulse pressure occur because of declining blood volume. Restlessness, not lethargy, usually occurs because of decreased cerebral blood flow. There are various changes in sensorium, but slurred speech is not a manifestation of shock.

After surgery for a fractured hip, a client states, "I don't remember when I have ever been so uncomfortable." What should the nurse's initial response be? A) Notify the primary healthcare provider. B) Use distraction techniques. C) Medicate the client as prescribed. D) Perform a complete pain assessment.

Perform a complete pain assessment Rationale A complete assessment must be performed to determine the location, characteristics, intensity, and duration of the pain. The pain may be incisional, result from a pulmonary embolus, or be caused by neurovascular trauma to the affected leg, and the intervention for each is different. Notifying the primary healthcare provider, using distraction techniques, and medicating the client as prescribed may be done after a complete assessment reveals that this is the appropriate intervention; assessment is the priority.

The nurse is counseling a woman who has just been identified as having a multiple gestation. Why does the nurse consider this pregnancy high risk? A) Postpartum hemorrhage is an expected complication. B) Perinatal mortality is two to three times more likely in multiple than in single births. C) Optimal psychological adjustment after a multiple birth requires 6 months to 1 year. D) Maternal mortality is higher during the prenatal period in the setting of multiple gestation.

Perinatal mortality is two to three times more likely in multiple than in single births. Rationale: Perinatal morbidity and mortality rates are higher with multiple-gestation pregnancies, because the greater metabolic demands and the possibility of malpositioning of one or more fetuses increases the risk for complications. Although postpartum hemorrhage does occur more frequently after multiple births, it is not an expected occurrence. Adjustment to a multiple gestation and birth is individual; the time needed for adjustment does not place the pregnancy at high risk. Maternal mortality during the prenatal period is not increased in the presence of a multiple gestation.

Which phase of the woman's sexual response is characterized by elevation of the uterus? A) Plateau phase B) Orgasmic phase C) Excitation phase D) Resolution phase

Plateau phase Rationale: The plateau phase occurs after the excitation phase, and excitation is maintained through the plateau phase, wherein the vagina expands and the uterus is elevated. Therefore elevation of the uterus is a characteristic of the plateau phase of a woman's sexual response. The orgasmic phase is characterized by uterine and vaginal contractions. In the excitation phase, the clitoris is congested and vaginal lubrication increases. The resolution phase is characterized by returning to the preexisting state.

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1 to 2 hours? A) Maintain comfort B) Prevent pressure ulcers C) Prevent flexion contractures of the extremities D) Improve venous circulation in the lower extremities

Prevent pressure ulcers Rationale: Pressure ulcers easily develop when a particular position is maintained; the body weight, directed continuously in one region, restricts circulation and results in tissue necrosis. Denervated tissue has less perfusion and is more prone to pressure ulcers. Clients often state that they are comfortable and wish to remain in one position. Proper positioning with supportive devices and range of motion are more effective measures to prevent contractures. Because turning usually is done laterally, the circulation to the lower extremities is not dramatically affected.

What should nursing care for a child admitted with acute glomerulonephritis be directed toward? A) Enforcing bed rest B) Promoting diuresis C) Encouraging fluids D) Removing dietary salt

Promoting diuresis Rationale: With the reduction of edema the child's health improves, the appetite increases, and the blood pressure normalizes. Ambulation does not have an adverse effect on this disorder; most children voluntarily restrict their activities and remain in bed during the acute phase. Fluids are not encouraged because the kidneys are inflamed and cannot tolerate large amounts of fluid. Sodium intake is decreased, not eliminated; sodium restriction is not tolerated well by children and may further decrease their appetite.

For what additional defect should the nurse assess an infant with exstrophy of the bladder? A) Imperforate anus B) Absence of one kidney C) Congenital heart disease D) Pubic bone malformation

Pubic bone malformation Rationale: The pubic bone and the bladder form during the same period of embryonic development. Imperforate anus, absence of a kidney, and congenital heart disease are not associated with exstrophy of the bladder.

What should a nurse who is caring for a hospitalized older client with dementia consider before planning care? A) Physical contact will increase dependency needs. B) Routines provide stability for clients with dementia. C) Regressive behavior should be interrupted immediately. D) Procedures do not have to be explained to clients with dementia.

Routines provide stability for clients with dementia. Rationale: Rituals and routines in activities of daily living provide a framework and structure for clients with dementia, adding to their sense of safety and security. Touch is a universal message that denotes caring; it can be soothing and will not encourage dependency. Regressive behavior under stress has a calming effect and should be allowed. Care should be explained to all clients; simple declarative statements are usually understood.

A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply. A) Rye B) Oats C) Rice D) Corn E)Wheat

Rye, oats, and wheat Rationale: Rye, oats, and wheat should be avoided because they are irritating to the gastrointestinal mucosa. Gluten is not found in rice or corn; therefore, these items do not have to be avoided.

The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client? A) Fluid volume B) Skin integrity C) Physical mobility D) Urinary elimination

Skin integrity Rationale: Necrotizing fasciitis destroys subcutaneous tissue and fascia and predisposes the client to infection and sepsis. Although fluid volume and physical mobility are important, they are not the primary concern at this time. Necrotizing fasciitis is a problem of the integumentary, not the urinary, system.

The primary healthcare provider prescribes one unit of packed red blood cells to be administered to the client who suffered a hip fracture. Several minutes after the start of the infusion, the client reports itching. Upon further assessment, the nurse observes hives on the client's chest. Which action should the nurse take next? A) Call the primary healthcare provider to obtain a prescription for an antihistamine. B) Flush packed red blood cells with 5% dextrose and 0.45% normal saline. C) Slow down the rate of the infusion. D) Stop the transfusion immediately.

Stop the transfusion immediately. Rationale: The client is experiencing an allergic reaction to the transfusion. The nurse should stop the transfusion immediately. The health care provider then should be notified. Flushing red blood cells with dextrose and normal saline will cause hemolysis and will not be effective in stopping the reaction. Slowing down the rate will make the situation worse.

A client with mild chronic heart failure is to be discharged with prescriptions for daily oral doses of an antidysrhythmic, potassium chloride 40 mEq, docusate sodium 100 mg, and furosemide 40 mg twice a day. The client reports having no family members who can help after discharge. What should the nurse help this client identify? A) Support systems that can assist the client at home B) Potential nursing homes in which the client can recuperate C) Agencies that can help the client regain activities of daily living D) Ways that the client can develop relationships with neighbors

Support systems that can assist the client at home Rationale: The rehabilitative phase requires a balance between activity and rest; supportive individuals are needed to perform more strenuous household tasks and to provide emotional support. A client with mild heart failure does not need inpatient care. A support system should be identified before considering community agencies. More information is needed before encouraging the development of relationships with neighbors.

The client is admitted to the emergency department after a fall from a roof. After determining that the client sustained a head injury, the nurse observes clear fluid coming from the client's left ear. What will the nurse do next? A) Turn the client to the unaffected side B) Cleanse the client's ear with sterile gauze C) Place sterile cotton loosely in the external canal of the left ear D) Test the drainage from the client's ear with a glucose reagent strip

Test the drainage from the client's ear with a glucose reagent strip Rationale: If a basilar skull fracture has occurred, the cerebrospinal fluid (CSF) may drain through the client's ears or nose. This clear fluid may be tested with a glucose reagent strip; if the result is positive for glucose, then the fluid might be CSF. However, this test is not always reliable. Turning the client to the unaffected side will allow fluid to collect in the ear, and more importantly, manipulation of the neck while turning the client may cause further injury. Placing sterile cotton loosely in the external ear will absorb the drainage without causing further trauma, but it does not help in determining the source of the fluid.

A nurse is obtaining the health history of a 5-year-old child who has been admitted to the child health unit with acute glomerulonephritis. What does the nurse expect the child's mother to report? A) The child had a sore throat a few weeks ago. B) The child has just recovered from the measles. C) The child's father has a family history of urinary tract infections. D) The child's immunizations were administered at the start of school.

The child had a sore throat a few weeks ago. Rationale: Acute poststreptococcal glomerulonephritis (APSGN) is associated with a history of streptococcal infection of the throat. The measles virus is not associated with the development of APSGN. APSGN is not an inherited disease. No immunizations can cause glomerulonephritis.

A nurse determines that the client's apical pulse rate is higher than the radial pulse and documents the pulse deficit. What does the nurse consider is the primary reason for the pulse deficit? A) The client's heart may be beating faster temporarily. B) The nurse may not know how to take an accurate pulse. C) The radial pulse site may be surrounded by too much subcutaneous fat. D) The client may have atrial fibrillation.

The client may have atrial fibrillation Rationale: Clients who have atrial fibrillation have a pulse deficit caused by reduction of preload. An accelerated heart rate is known as tachycardia, not a pulse deficit. It is unlikely the nurse does not know how to take a pulse accurately; nurses are trained in assessment. If a pulse deficit identified at a pulse site is attributed to the presence of excessive subcutaneous fat, the nurse should obtain the peripheral pulse at a different site.

Which feature is characteristic of a risk nursing diagnosis? A) The diagnosis does not have related factors. B) The diagnosis can be used in any health state. C) The defining characteristics support the diagnostic judgment. D) The defining characteristics are supported by a client's readiness.

The diagnosis does not have related factors Rationale: A risk nursing diagnosis describes human responses to health conditions that may develop in a vulnerable individual, family, or community. Risk diagnoses do not have related factors or defining characteristics because they have not occurred yet. A risk diagnosis has risk factors that help the nurse plan preventive measures. A health promotion nursing diagnosis can be applied to any individual with a desire to enhance health behaviors in any health state. An actual diagnosis is formed when the defining characteristics support the diagnostic judgment. There must be sufficient nursing assessment data to establish an actual diagnosis. A health promotion nursing diagnosis is a clinical judgment of an individual's readiness to increase well-being.

While assessing a client for the dorsalis pedis pulse, a nurse documents the reading as 1+. What can be inferred from this finding? A) There is absence of a pulse. B) The pulse strength is normal. C) The pulse strength is bounding. D) The pulse strength is barely palpable.

The pulse strength is barely palpable Rationale: A pulse strength of 1+ indicates a diminished or barely palpable pulse and requires immediate intervention. Absence of pulse is documented as 0. Normal pulse strength is documented as 2+. If the pulse strength is bounding, then it is documented as 4+.

The nurse is caring for two clients with a below-the-knee amputation. The first client was in a motor vehicle collision. The second client had chronically decreased arterial perfusion. Which information has caused the nurse to conclude that the postoperative courses of these two clients may differ? A) The first client probably will adjust more quickly. B) The second client's incision will take longer to heal. C) These clients are likely to have very different occupations. D) The first client is more likely to have phantom limb sensations.

The second client's incision will take longer to heal Rationale: Decreased arterial circulation in the second client will delay healing. The first client received an amputation without preoperative preparation for the loss of the limb and will most likely have greater difficulty adapting. Clients with chronic limb pain before surgery (e.g., the second client with chronically decreased arterial perfusion) are more likely to have phantom limb sensations. Both clients' responses may be influenced by their occupations, but there are no data to support this conclusion.

Which statement is true for collaborative problems in a client receiving healthcare? A) They are the identification of a disease condition. B) They include problems treated primarily by nurses. C) They are identified by the primary healthcare provider. D) They are identified by the nurse during the nursing diagnosis stage.

They are identified by the nurse during the nursing diagnosis stage Rationale: The nurse assesses the client to gather information to reach diagnostic conclusions. Collaborative problems are identified by the nurse during this process. If the client's health problem requires treatment by other disciplines such as medical or physical therapy, the client has a collaborative problem. A medical diagnosis is the identification of a disease condition. Problems that require treatment by the nurse are referred to as nursing diagnoses. A medical diagnosis is identified by the primary healthcare provider based on the results of diagnostic tests.

Why is Phalen's test performed in a client? A) To diagnose atrophy B) To diagnose bone tumor C) To detect rotator cuff injuries D) To detect carpal tunnel syndrome

To detect carpal tunnel syndrome Rationale: Phalen's test is used to detect carpal tunnel syndrome. A muscle biopsy is done for the diagnosis of atrophy. A computed tomography scan is done to diagnose a bone tumor. The drop arm test is performed to detect rotator cuff injuries.

A client newly diagnosed with type 1 diabetes is taught to exercise on a regular basis. What is the primary reason for instruction on exercise? A) To decrease insulin sensitivity B) To stimulate glucagon production C) To improve the cellular uptake of glucose D) To reduce metabolic requirements for glucose

To improve the cellular uptake of glucose Rationale: Exercise increases the metabolic rate, and glucose is needed for cellular metabolism; therefore, excess glucose is consumed during exercise. Regular vigorous exercise increases cell sensitivity to insulin. Glucagon action raises blood glucose but does not affect cell uptake or use of glucose. Cellular requirements for glucose increase with exercise.

How should a nurse intervene when a confused and anxious client voids on the floor in the sitting room of the mental health unit? A) Make the client mop the floor. B) Restrict the client's fluids for the rest of the day. C) Toilet the client more frequently with supervision. D) Withhold the client's privileges each time the client voids on the floor.

Toilet the client more frequently with supervision. Rationale: The client is voiding on the floor not to express hostility but because of confusion. Taking the client to the toilet frequently reduces the risk of voiding in inappropriate places. Making the client mop the floor is a form of punishment for something the client cannot control. Restricting the client's fluids for the rest of the day is not realistic; it will have no effect on the problem and may lead to physiologic problems. If the client were doing this to express hostility, withholding privileges might be effective, but not when the client is unable to control the behavior.

While examining a client, a nurse finds a circumscribed elevation of the skin filled with serous fluid on the cheek. The lesion is 0.6 cm in diameter. What does the nurse suspect the finding to be? A) Papule B) Vesicle C) Nodule D) Pustule

Vesicle Rationale: A circumscribed elevation of the skin that is filled with serous fluid and a lesion size of less than 1 cm describes a vesicle. A papule is palpable, circumscribed, and has a solid elevation and a size smaller than 1 cm. A nodule is an elevated solid mass, deeper and firmer than a papule and of 1-2 cm in diameter. A pustule is a circumscribed elevation of the skin that is similar to a vesicle but filled with pus and varies in size.

A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? A) Increase fluids. B) Increase fiber in the diet. C) Wash hands with soap and water. D) Wash hands with an alcohol-based hand sanitizer.

Wash hands with soap and water. Rationale: Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol-based hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission of C. difficile.

A nurse is caring for a 9-month-old infant with severe dehydration. What does the nurse expect to note while completing a physical assessment of this infant? A) Frothy stools B) Weak, rapid pulse C) Pale, copious urine D) Bulging anterior fontanel

Weak, rapid pulse Rationale: A weak, rapid pulse is an expected adaptation with a state of severe dehydration because of hypovolemia. Children with untreated cystic fibrosis and celiac disease have frothy stools. There is no indication that this infant has either of these disorders. Severe dehydration results in decreased urine output and concentrated urine. One of the signs of dehydration in an infant is a sunken, not bulging, anterior fontanel.

The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right-sided heart failure after discharge. What does the nurse instruct the client to assess for? A) Increased appetite B) Clubbing of the nail beds C) Hypertension D) Weight gain

Weight gain Rationale: The most common signs and symptoms of right-sided heart failure are hepatomegaly, weight gain, jugular vein distention, and peripheral edema. Clients with right-sided heart failure often have decreased appetites. Clubbing is indicative of hypoxemia. Hypertension is associated with left-sided heart failure.