HESI: Fundamentals:

Which bacteria colonies are commonly found in a client's large intestine? 1) Escherichia coli 2) Neisseria gonorrhoeae 3) Staphylococcus aureus 4) Haemophilus influenzae

Escherichia coli are bacteria that are part of the normal flora in the large intestine. Neisseria gonorrhoeae causes gonorrhea and pelvic inflammatory disease. Staphylococcus aureus secretes toxins that damage cells and causes skin infections, pneumonia, urinary tract infections, acute osteomyelitis, and toxic shock syndrome. Haemophilus influenzae causes nasopharyngitis, meningitis, and pneumonia. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly because there usually is no pattern to the answers.

While teaching a nursing student, a registered nurse says "This is a study in which the investigator controls the study variable and randomly assigns subjects to different conditions to test the variable." Which type of research is the above statement? 1 Historical research 2 Evaluation research 3 Exploratory research 4 Experimental research

Experimental research

Which nursing practice is associated with the self-regulation skill? 1 Reflecting on one's experience 2 Reflecting on one's own behavior 3 Supporting one's findings and conclusions 4 Clarifying any data that one is uncertain about

Reflecting on one's experience

Which psychosocial health concern involves accepting descriptive statements stated by a confused older client? 1 Reminiscence 2 Reality orientation 3 Validation therapy 4 Therapeutic communication

Validation therapy

A client weighs 150 lb and is 5 feet 7 inches tall. What is this client's body mass index (BMI)? Record your answer using two decimal places. _____

Body mass index (BMI) can be calculated by dividing the client's weight in kilograms by the height in meters squared. Therefore, a client who weighs 150 lb (68 kg) and stands 5 feet 7 inches (1.7 m) tall will have a BMI of 23.52: 68/1.72 = 23.53.

Which hormone regulates blood levels of calcium? 1 Parathormone 2 Luteinizing hormone 3 Thyroid stimulating hormone 4 Adrenocorticotropic hormone

Parathormone

Which Korotkoff sound represents the diastolic pressure in children? 1) First 2) Second 3) Fourth 4) Fifth

The fourth Korotkoff sound represents the diastolic pressure in children. The first Korotkoff sound represents the systolic pressure. The fifth Korotkoff sound represents the diastolic pressure in adults and adolescents. A blowing or swishing sound occurs in the second Korotkoff sound.

Which organ has only beta1-receptors? 1) Liver 2) Heart 3) Bladder 4) Pancreas

The heart has only beta1 receptors, which increase heart rate and contractility. The liver has only alpha receptors. The bladder and pancreas have both alpha and beta receptors

What gross motor skill is observed in children between 8 and 10 months old? 1) The child can creep on his or her hands and knees. 2) The child has predominant inborn reflexes. 3) The child can sit alone without any kind of support. 4)The child can bear his or her weight on forearms when prone.

A child between 8 and 10 months old can creep on his or her hands and knees. A child between birth and 1 month old has predominant inborn reflexes. A child between 6 and 8 months old can sit alone without support. A child between 2 and 4 months old can bear his or her weight on his or her forearms when in the prone position.

Which interview technique is the nurse using when asking a client to score the pain on a scale from 0 to 10? 1) Probing 2) Back channeling 3) Open-ended questioning 4) Closed-ended questioning

Asking a client to score pain on a scale of 0 to 10 is a type of closed-ended question. These types of questions specify the cause of the problem or the client's experience of the illness. Asking whether anything else is bothering the client is an example of probing. A response by the nurse such as "All right," or "Go on," when a client says something is called back channeling. This interview technique encourages a client to provide more details. The nurse asks open-ended, nonspecific questions such as "What brought you to the hospital today?" to elicit the client's side of story. Such questions are related to the client's health history and can strengthen the nurse-client relationship.

A nurse is recalling common terms that are used in health ethics. What does beneficence in health ethics refer to? 1 Beneficence refers to the agreement to keep promises. 2 Beneficence refers to taking positive actions to help others. 3 Beneficence refers to the ability to answer for one's actions. 4 Beneficence refers to avoiding harming or hurting an individual.

Beneficence refers to taking positive actions to help others

A nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation? 1) Neurologic 2) Wound 3) Pain 4) Skin

Pain

Kohlberg's theory

Stage 1: a child's response to a moral dilemma is in terms of absolute obedience to authority and rules. Stage 2: A child recognizes that there is more than one correct view. Stage 3: An individual wants to win the approval of and maintain the expectations of one's immediate group. Stage 4: An adolescent who chooses not to attend a party where beer will be served because they know this is wrong.

A 42-year-old client at 39 weeks' gestation has a reactive nonstress test (NST). What should the nurse explain to the client about the positive result? 1 Immediate birth is indicated. 2 This is the desired response at this stage of gestation. 3 Further testing is unnecessary with this desired outcome. 4 The result is inconclusive, indicating the need for further evaluation.

This is the desired response at this stage of gestation.

A client is dying. Hesitatingly, his wife says to the nurse, "I'd like to tell him how much I love him, but I don't want to upset him." Which is the best response by the nurse? 1 "You must keep up a strong appearance for him." 2 "I think he'd have difficulty dealing with that now." 3 "Don't you think he knows that without your telling him?" 4 "Why don't you share your feelings with him while you can?"

"Why don't you share your feelings with him while you can?"

In what order should a nurse follow steps of risk management to identify potential hazards and to eliminate them before harm occurs?

1. Identifying possible risks 2. Analyzing the possible risks 3. Acting to reduce the risks 4. Evaluating the steps taken

A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. The nurse calculates the percentage of total body surface area (TBSA). Which percentage will the nurse report? 1) 20 2) 25 3) 30 4) 36

36

A nurse educates a client about the role played by an individual in taking responsibility for health and wellness and its impact. What instructions should the nurse give? Select all that apply. 1 "An individual should use passive strategies for health promotion." 2 "An individual should know that lifestyle choices affect his or her quality of life and well-being." 3 "An individual should take responsibility of health and wellness by making proper lifestyle choices." 4 "An individual should realize that illness prevention has a positive economic impact on his or her life." 5 "An individual should understand that it is enough to make positive lifestyle choices in order to prevent illness."

A client should understand that making appropriate lifestyle choices can affect his or her quality of life and well-being. An individual should take responsibility for his or her health and wellness by making proper lifestyle choices. The client should also realize that illness prevention has a positive economic impact by decreasing health care costs. Passive health promotion strategies enable people to benefit from the activities of others. These strategies do not require the involvement of the clients. The client should understand that making positive lifestyle choices and discarding negative lifestyle choices contribute to illness prevention.

A client tells the nurse, "I am so worried about the results of the biopsy they took today." The nurse overhears the nursing assistant reply, "Don't worry. I'm sure everything will come out all right." What does the nurse conclude about the nursing assistant's answer? 1) It shows empathy. 2) It uses distraction. 3) It gives false reassurance. 4) It makes a value judgment.

A person cannot know the results of the biopsy until it is examined under a microscope. The response does not allow the client to voice concerns, shuts off communication, and provides reassurance that may not be accurate. This answer does not empathize with the client; it minimizes the client's concerns. This response is not a form of distraction; it minimizes the client's concern and shuts off communication. This response does not contain any value statements.

Which statement indicates a nurse has a correct understanding about trigeminal autonomic cephalalgia (cluster headaches)? 1) It is most common in women. 2) It is manifested by intense bilateral pain. 3) It is caused by an overactive hypothalamus. 4) It is associated with headaches of long duration.

According to neuroimaging studies, the etiology of cluster headaches is related to an overactive and enlarged hypothalamus. Cluster headaches are most commonly seen in men aged 20 to 50 years, and they cause intense unilateral headaches of short duration lasting 30 minutes to 2 hours.

Which statement describes stage 2 of Kohlberg's theory? 1) The child recognizes that there is more than one correct view. 2) An adolescent chooses to avoid a party where they know beer will be served. 3) An individual wants to win the approval of and maintain the expectations of one's immediate group. 4) A child's response to a moral dilemma is in terms of absolute obedience to authority and rules.

According to stage 2 of Kohlberg's theory, a child recognizes that there is more than one correct view. An adolescent who chooses not to attend a party where beer will be served because they know this is wrong is acting according to stage 4. Stage 3 states that an individual wants to win the approval of and maintain the expectations of one's immediate group. During stage 1, a child's response to a moral dilemma is in terms of absolute obedience to authority and rules.

A client with cancer of the colon is admitted to the hospital for a hemicolectomy. What does the nurse expect the preoperative plan of care to include? 1 Giving oil-retention enemas daily for two days preoperatively 2 Administering enemas and neomycin 3 Having a Sengstaken-Blakemore tube at the bedside 4 A high-protein and high-carbohydrate regular diet for two days preoperatively

Administering enemas and neomycin

Which hormone does the nurse state binds to the receptor site on the surface of a target cell? 1) Estrogen 2) Adrenaline 3) Aldosterone 4) Hydrocortisone

Adrenaline

Two days after having a cesarean birth, a client tells the nurse that she has pain in her right leg. After an assessment the nurse suspects that the client has a thrombus. What is the nurse's primary response at this time? 1) Maintaining bed rest 2) Applying warm soaks 3) Performing leg exercises 4) Massaging the affected area

Although thrombophlebitis is suspected, before a definitive diagnosis can be made the client should be confined to bed so that further complications may be avoided. Applying warm soaks may cause vasodilation, which could allow a thrombus to dislodge and circulate freely. If a thrombus is present, massage may dislodge it and lead to a pulmonary embolism.

Which domain of the Nursing Interventions Classification taxonomy includes care that supports homeostatic regulation? 1) Domain 1 2) Domain 2 3) Domain 3 4) Domain 4

Domain 2 of the Nursing Interventions Classification taxonomy includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 includes care that supports psychosocial functioning and facilitates life style changes. Domain 4 includes care that supports protection against harm.

A nurse finds that there is an inaccurate match between clinical cues and the nursing diagnosis. What is the category of the diagnostic error? 1) Labeling 2) Collecting 3) Clustering 4) Interpreting

An inaccurate match between clinical cues and the nursing diagnosis is an interpreting error. Interpreting errors include failing to consider conflicting cues, using an insufficient number of cues, and using unreliable or invalid cues errors. A labeling error is a failure to validate data. Collecting errors include inaccurate data, missing data, or disorganization. Errors at the clustering level include an insufficient cluster of cues, premature or early closure, or incorrect clustering.

Which role does a nurse play when helping clients to identify and clarify health problems and to choose appropriate courses of action to solve those problems? 1 Educator 2 Counselor 3 Change agent 4 Case manage

As a counselor, the nurse helps clients identify and clarify health problems and choose appropriate courses of action to solve those problems. As an educator, the nurse teaches clients and their families to assume responsibility for their own health care. A nurse acts as a change agent within a family system or as a mediator for problems within a client's community; this involves identifying and implementing new and more effective approaches to problems. As a case manager, the nurse establishes an appropriate plan of care on the basis of assessment findings and coordinates needed resources and services for the client's well-being along a continuum of care. Test-Taking Tip: Reread the question if the answers do not seem to make sense, because you may have missed words such as not or except in the statement.

While caring for a client who gave birth 1 day ago, the nurse determines that the client's uterine fundus is firm at one fingerbreadth below the umbilicus, blood pressure is 110/70 mm Hg, pulse is 72 beats per minute, and respirations are 16 breaths per minute. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action? 1) Recording these expected findings 2) Obtaining an order for an oxytocic medication 3) Asking the client when she last changed the perineal pad 4) Notifying the primary healthcare provider that the client may be hemorrhaging

Asking the client when she last changed the perineal pad

What factors put a client at risk for bacterial infections? Select all that apply. 1) Dry skin 2) Underweight 3) Atopic dermatitis 4) Diabetes mellitus 5) Systemic antibiotics

Atopic dermatitis, diabetes mellitus, and systemic usage of antibiotics and corticosteroids are predisposing factors for bacterial infections. Dry skin may not cause bacterial infections, as moisture on the skin is important for bacterial growth. Being underweight may not cause bacterial infections, whereas obesity is a risk factor for poor wound healing and diabetes mellitus.

How would the student nurse describe a quasi-intentional tort occurring during the practice of nursing? 1 It is a willful act violating a client's rights. 2 It is a civil wrong made against a person or property. 3 It is an act that lacks intent but involves volitional action. 4 It is an unintentional act that includes negligence and malpractice.

It is an act that lacks intent but involves volitional action

Which response by the nurse during a client interview is an example of back channeling? 1) "All right, go on..." 2) "What else is bothering you?" 3) "Tell me what brought you here." 4) "How would you rate your pain on a scale of 0 to 10?"

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.

Which term describes the practice of placing clients with the same infection in a semi-private room? 1) Isolating 2) Cohorting 3) Colonizing 4) Cross-referencing

Cohorting is the practice of grouping clients who are colonized or infected with the same pathogen. Isolating is limiting the exposure to individuals with an infection. Colonizing refers to the development of an infection in the body. Cross-referencing has nothing to do with an infectious process.

What is the etiology for the development of pressure ulcers in an 80-year-old client? 1 Atrophy of the sweat glands 2 Decreased subcutaneous fat 3 Stiffening of the collagen fibers 4 Degeneration of the elastic fibers

Decreased subcutaneous fat

A client is diagnosed with cancer of the pancreas and is apprehensive and restless. Which nursing action should be included in the plan of care? 1 Encouraging expression of concerns 2 Administering antibiotics as prescribed 3 Teaching the importance of getting rest 4 Explaining that everything will be all right

Encouraging expression of concerns

While obtaining the client's health history, which factor does the nurse identify that predisposes the client to type 2 diabetes 1) Having diabetes insipidus 2)Eating low-cholesterol foods 3) Being 20 pounds (9 kilograms) overweight 4) Drinking a daily alcoholic beverage

Excessive body weight is a known predisposing factor to type 2 diabetes; the exact relationship is unknown. Diabetes insipidus is caused by too little antidiuretic hormone (ADH) and has no relationship to type 2 diabetes. High-cholesterol diets and atherosclerotic heart disease are associated with type 2 diabetes. Alcohol intake is not known to predispose a person to type 2 diabetes.

The laboratory report of a client reveals increased serum cholesterol levels. Which other finding indicates growth hormone deficiency in the client? 1 Scalp alopecia 2 Intolerance to cold 3 Pathological fractures 4 Increased urine outpu

Growth hormone deficiency results in thinning of bones and increases the risk for pathological fractures. Thyrotropin deficiency results in scalp alopecia and intolerance to cold. Marked increase in the volume of urine output is a sign of diabetes insipidus caused by vasopressin deficiency.

What services do community health centers provide in preventive and primary care services? Select all that apply. 1 Day care 2 Health screenings 3 Physical assessments 4 Disease management 5 Acute and chronic care management

Health screenings, physical assessments, and disease management services are provided by community health centers in preventive and primary care services. Day care and acute and chronic care management services are provided by nurse-managed clinics.

What are the primary causes of adrenal insufficiency? Select all that apply. 1) Hemorrhage 2) Tuberculosis 3) Pituitary tumors 4) Postpartum pituitary necrosis 5)Acquired immune deficiency syndrome

Hemorrhage, TB, AIDS

Which clinical manifestation is characterized by eczematous eruption with well-defined geometric margins? 1) Drug eruption 2) Atopic dermatitis 3) Contact dermatitis 4) Nonspecific eczematous dermatitis

In contact dermatitis, localized eczematous eruptions are seen with well-defined geometric margins. In drug eruption, bright-red erythematosus macules and papules are seen. In atopic dermatitis, lichenification with scaling and excoriation is observed. Lichenification with weeping papules and macules is seen in nonspecific eczematous dermatitis. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.

A registered nurse is educating a nursing student about the stages of changes in a client's health behavior. Which statement describes the stage of contemplation? 1 "The client considers a change within the next 6 months." 2 "The client does not intend to make changes within the next 6 months." 3 "The client is actively engaged in strategies to change behavior; this lasts up to 6 months." 4 "The client displays sustained change over time; this begins 6 months after action has started and continues indefinitely."

In the contemplation stage, the client considers a change within the next 6 months. In the precontemplation stage, the client does not intend to make changes within the next 6 months. In the action stage, the client is actively engaged in strategies to change behavior. This stage lasts up to 6 months. When sustained change is noticed over time and begins 6 months after action has started and continues indefinitely, the client has reached the maintenance stage.

Which is the target tissue for the parathyroid hormone? 1 Intestines 2 All body cells 3 Mammary glands 4 Sympathetic effectors

Intestines

Which component of skin maintains optimal barrier function? 1 Keratin 2 Melanin 3 Collagen 4 Adipose tissue

Keratin is a protein produced by keratinocytes that helps to maintain optimal barrier function. Melanin pigment is produced by melanocytes and gives color to the skin. Collagen is a protein produced by fibroblasts. Its production is increased during tissue injury and helps form scar tissue. Adipose tissue is the subcutaneous fat that insulates the body and absorbs shock.

Maslow's Hierarchy 1. Physiological need 2. Safety and security 3. Love and belonging needs 4. Self-esteem needs 5. Self-actualization

Maslow's hierarchy of needs helps the nurse understand the interrelationships of basic human needs. These basic needs are a major factor in determining a person's level of health. The first level includes basic physiological needs such as oxygen, fluids, nutrition, body temperature, elimination, shelter, and sex. The second level is safety and security needs, which involve physical and psychological security. The third level is the need of love and belonging. The fourth level encompasses self-esteem needs. The fifth level is the need for self-actualization. It is the highest expression of one's individual potential and allows for continual discovery of self.

Which statement made by a nursing student about Swanson's theory of caring needs correction? 1) The components of Swanson's theory of caring provide a foundation of knowledge for nurses to direct and deliver caring nursing practices. 2) Swanson's theory of caring defines five components of caring: knowing, being with, doing for, enabling, and maintaining belief. 3) Swanson's theory of caring provides a basis to help nurses understand how clients cope with uncertainty and the illness response. 4) Swanson's theory of caring was developed by Kristin Swanson by conducting extensive interviews with clients and their professional caregivers.

Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response not Swanson's theory. Swanson's theory of caring provides a basis for identifying and testing nurse caring behaviors to determine if caring will improve client health outcomes. The components of Swanson's theory of caring provide a foundation of knowledge for nurses to direct and deliver caring nursing practices. Swanson's theory of caring defines five components of caring: knowing, being with, doing for, enabling, and maintaining belief. Swanson's theory of caring was developed by Kristin Swanson by conducting extensive interviews with clients and their professional caregivers. Test-Taking Tip: Reread the question if the answers do not seem to make sense, because you may have missed words such as not or except in the statement.

A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client does what? 1) Picks up the walker and carries it for short distances 2) Uses the walker only when someone else is present 3) Moves the walker no more than 12 inches (30.5 cm) in front of the client during use 4) States that a walker will be purchased on the way home from the hospital

Moves the walker no more than 12 inches (30.5 cm) in front of the client during use

What services do nurse-managed clinics provide in preventive and primary care services? Select all that apply. 1 Crisis intervention 2 Wellness counseling 3 Health risk appraisal 4 Employment readiness 5 Communicable disease control

Nurse-managed clinics provide wellness counseling, health risk appraisal, and employment readiness. Crisis intervention services are provided by school health centers. Communicable disease control services are provided by occupational health centers.

On the third postoperative day after a subtotal gastrectomy, a client reports having severe abdominal pain. The nurse palpates the client's abdomen and determines rigidity. What should be the nurse's first action? 1 Assist the client to ambulate. 2 Obtain the client's vital signs. 3 Administer the prescribed analgesic. 4 Encourage using the incentive spirometer.

Obtain the client's vital signs

A client who had an incision and drainage of an oral abscess is to be discharged. Which clinical finding, if it should occur, should the nurse instruct the client to report to the healthcare provider? 1 Foul odor to the breath 2 Pain associated with swallowing 3 Pain with swelling after one week 4 Tenderness in the mouth when chewing

Pain with swelling after one week

A nursing student is listing examples of active and passive health promotion strategies. Which strategy is an example of a passive health promotion strategy? 1 Weight-reduction program 2 Smoking-cessation program 3 Drug abuse prevention strategy Correct 4 Fluoridation of municipal drinking water

Passive strategies of health promotion help people benefit from the activities of others without direct involvement. The fluoridation of municipal drinking water is an example of a passive health promotion strategy. Active strategies of health promotion require clients to adopt specific programs for improving health. Weight-reduction programs, smoking-cessation programs, and drug abuse prevention strategies are examples of active health promotion activities. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses

Which is the definition of photophobia? 1) Double vision 2) Foreign body sensation 3) Persistent abnormal intolerance to light 4) Gradual or sudden inability to see clearly

Photophobia is a persistent abnormal intolerance to light. Diplopia is double vision. Foreign body sensation results in pain. A gradual or sudden inability to see clearly is called blurred vision.

Which statement is true about prescriptive theories? 1 Prescriptive theories are action-oriented. 2 Prescriptive theories help to explain client assessment. Incorrect 3 Prescriptive theories focus on a specific field of nursing. 4 Prescriptive theories are the first level of theory development.

Prescriptive theories are action-oriented

What is the primary focus of the nurse when providing evidence-based care to the client? 1 Practice trends 2 Research studies 3 Clinical experience 4 Problem-solving approach

Problem-solving approach

A client is admitted to the birthing unit in active labor. Which physiologic changes should the nurse anticipate after an amniotomy is performed? 1 Diminished bloody show 2 Increased and more variable fetal heart rate 3 Less discomfort with contractions 4 Progressive dilation and effacement

Progressive dilation and effacement

The nurse is providing care to a client being treated for bacterial cystitis. What is the goal before discharge for this client? 1 Understand the need to drink 4 L of water per day, an essential measure to prevent dehydration 2 Be able to identify dietary restrictions and plan menus 3 Achieve relief of symptoms and maintain kidney function 4 Recognize signs of bleeding, a complication associated with this type of procedure

Relief of symptoms and continued urine output are measurable responses to therapy and are the desired outcomes. Four liters of water per day is too much fluid; 2 to 3 liters a day is recommended to flush the bladder and urethra. Dietary restrictions are not necessary with cystitis. Bleeding is not a complication associated with this procedure.

Which theory provides a basis for identifying and testing nursing care behaviors to determine if caring improves patient health outcomes? 1) Neuman's system theory 2) Swanson's theory of caring 3) Orem's self-care deficit theory 4) Mishel's theory of uncertainty in illness

Swanson's theory of caring provides a basis for identifying and testing nursing care behaviors to determine if caring improves patient health outcomes. Neuman's system theory focuses on stressors perceived by the client or caregiver. Orem's self-care deficit theory explains the factors within a client's living situation that support or interfere with his or her self-care ability. Mishel's theory of uncertainty in illness focuses on a client's experiences with cancer while living with continual uncertainty.

According to the Erikson's theory, which stage in a young adult describes the development of the sense of caring for others? 1) Initiative versus guilt 2) Integrity versus despair 3) Intimacy versus isolation 4) Identity versus role confusion

The development of a sense of caring for others in a young adult occurs at the stage of intimacy versus isolation. During the initiative versus guilt stage, a child likes to pretend and try out new roles. At the integrity versus despair stage, many older adults view their lives with a sense of satisfaction. During the identity versus role confusion stage, a child's identity development begins with the goal of achieving some perspective or direction. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.

What is the best advice a nurse can provide to a pregnant woman in her first trimester? 1) "Cut down on drugs, alcohol, and cigarettes." 2) "Avoid drugs and don't smoke or drink alcohol." 3) "Avoid smoking, limit alcohol consumption, and don't take aspirin." 4) "Take only prescription drugs, especially in the second and third trimesters."

The first trimester is the period when all major embryonic organs are forming; drugs, alcohol, and tobacco may cause major defects. Cutting down on these substances is insufficient; they are teratogens and should be eliminated. Even 1 oz of an alcoholic drink is considered harmful; baby aspirin may be prescribed to some women who are considered at risk for pregnancy-induced hypertension; however, not during the first trimester. Medications, unless absolutely necessary, should be avoided throughout pregnancy; however, the first trimester is most significant.

According to Erikson's theory, at which stage does a child start to have fantasies and an active imagination? 1)Trust versus mistrust 2) Initiative versus guilt 3) Identity versus role confusion 4) Autonomy versus sense of shame and doubt

The initiative versus guilt stage is characterized by a child having fantasies and imaginations that motivate the child to explore the environment. The stage from birth to one year old when an infant develops trust towards his or her parents or caregivers is known as the trust versus mistrust stage. The identity versus role confusion stage begins after adolescence; during this stage, an individual tries to figure out his or her own identity. Between the ages of one to three years old, a child starts walking, feeding, using the toilet, and handling some basic self-care activities. This stage is one of autonomy versus sense of shame and doubt. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

What legal complications might a nurse face for using a restraint without a legal warrant on a client? 1 The nurse may be charged with libel. 2 The nurse may be charged with negligence. 3 The nurse may be charged with malpractice. 4 The nurse may be charged with false imprisonment.

The nurse may be charged with false imprisonment.

A client is in a state of ambivalence. Which of these stages of health behavior will the nurse suspect? 1) Preparation 2) Maintenance 3) Contemplation 4) Precontemplation

The nurse will suspect the stage of contemplation. This stage of health behavior is characterized by a client's attitude towards a change; the client is most likely to accept that change in the next six months. The stage of preparation is when a client believes that a change in his or her behavior is advantageous. During the maintenance stage, changes need to be implemented in the client's lifestyle. In the precontemplation stage, the client is not willing to hear any information about the changes in the behavior.

A client with esophageal varices has severe hematemesis, and a Sengstaken-Blakemore tube is inserted. What design and purpose does the tube have? 1 Single-lumen; for gastric lavage 2 Double-lumen; for intestinal decompression 3 Triple-lumen; for esophageal compression 4 Multilumen; for gastric and intestinal decompression

Triple-lumen; for esophageal compression

Which condition will the nurse monitor for in a client with interruption of venous return? 1) Tenting 2) Varicosity 3) Petechiae 4) Ecchymosis

Varicosity is the interruption of venous return that will cause a bulge and prominence of superficial veins. Tenting is the failure of skin to return immediately to normal position after gentle pinching, which occurs because of aging, dehydration, and cachexia. Petechiae are flat, pinpoint (<1 to 2 mm in size), discrete deposits of blood found on the extravascular tissues that result from decreased platelet count in blood. Ecchymosis is a small, bruise-like lesion, larger than a petechia, caused by the collection of extravascular blood in the dermis and subcutaneous tissue that occurs due to trauma and bleeding disorders.

The nurse performs a respiratory assessment and auscultates breath sounds that are high pitched, creaking, and accentuated on expiration. Which term best describes the findings? 1) Rhonchi 2) Wheezes 3) Pleural friction rub 4) Bronchovesicula

Wheezes are one of the most common breath sounds assessed and auscultated in clients with asthma and chronic obstructive pulmonary disease (COPD). Wheezes are produced as air flows through narrowed passageways. Rhonchi are coarse, rattling sounds similar to snoring and are usually caused by secretions in the bronchial airways. A pleural friction rub is an abrasive sound made by two acutely inflamed serous surfaces rubbing together during the respiratory cycle. Bronchovesicular sounds are intermediate between bronchial (upper) and vesicular (lower) breath sounds; they are normal when heard between the first and second intercostal spaces anteriorly and posteriorly between scapulae.

A nursing student notes that a nurse is required to integrate best current research with clinical expertise and client preferences and values in order to provide quality healthcare. Which Quality and Safety Education for Nurses (QSEN) competency does this comply with? 1 Safety 2 Quality improvement 3 Patient-centered care 4 Evidence-based practice

the QSEN competency evidence-based practice states that a nurse should integrate best current research with clinical expertise and client's preferences and values in order to provide quality healthcare. Safety involves nursing actions aimed at minimizing the risk of harm to clients and healthcare workers by ensuring system effectiveness and improving individual performance. Quality improvement involves the use of data to monitor outcomes of processes and implementation of methods to improve the healthcare delivery system. Patient-centered care states that the client is the source of control in providing healthcare. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.