HESI RESP FOCUS N MIXED RN
A nurse is caring for a client with a diagnosis of catatonic schizophrenia. What clinical finding does the nurse expect the client to exhibit? Multiple choice question Crying Self-mutilation Immobile posturing Repetitive activities
Immobile posturing
The nurse is teaching parents about the side effects of immunization vaccines. What expected side effect associated with the Haemophilus influenzae (Hib) vaccine will the nurse include in the teaching? Multiple choice question Urticaria Lethargy Low-grade fever Generalized rash
Low-grade fever The Hib vaccine may cause a low-grade fever as the body reacts to the vaccine. Urticaria is more likely to occur with the tetanus and pertussis vaccines. Lethargy is not expected. There may be a mild reaction at the injection site, but a generalized rash is not expected.
Which organism causes Hansen's disease? Multiple choice question Clostridium tetani Haemophilus pertusis Mycobacterium leprae Legionella pneumophila
Mycobacterium leprae
Which diagnostic test would the nurse consider to be the gold standard for diagnosis of pulmonary embolism? Multiple choice question Pulmonary angiography Helical computed tomography (CT) Ventilation-perfusion (V/Q) scans Computed tomography pulmonary angiography (CT-PA)
Pulmonary angiography is considered the gold standard for diagnosis of pulmonary embolism. Helical CT, also known as CT-PA, may also be used as a diagnostic test for pulmonary embolism. This has the added advantage of diagnosing other pulmonary abnormalities. V/Q scans are not as widely used currently, but may be considered in certain circumstances when the client has an allergy to contrast dyes.
An adolescent with a BMI of 30 reports fatigue, frequent urination, and a tingling sensation on the feet. The adolescent is then diagnosed with type 2 diabetes mellitus. Which nursing interventions would be appropriate? Multiple selection question Bariatric surgery Physical activities Dietary restrictions Dietary counseling Behavior modification
An adolescent with type 2 diabetes mellitus should engage in regular physical activity to reduce his or her weight and glucose levels. Dietary counseling helps to improve nutritional intake and decrease saturated fats and sugars. Behavior modification weight programs help adolescents identify and eliminate inappropriate eating behavior habits. Bariatric surgery is recommended for clients with morbid obesity (characterized by a BMI greater than 40). Dietary restriction should not be recommended because this action may cause a lot of nutrients.
The nurse is caring for the survivors of a disaster. Which tag would be assigned to a client who has an open fracture with a distal pulse? Multiple choice question Red Black Green Yellow
A yellow tag is assigned to clients with open fractures that require treatment within 30 minutes to 2 hours. A red tag is assigned to clients with life-threatening conditions such as severe hemorrhage or airway obstruction that require immediate treatment. A black tag is assigned to clients who are dead or expected to die. A green tag is assigned to clients with minor injuries.
Which behavior of the registered nurse would be appropriate for a management position according to Gardner's tasks of leading/managing? Multiple choice question Assisting the staff to interpret organizational values Assisting multidisciplinary leaders to benefit client care delivery Ensuring that organizational systems work on the client's behalf Inspiring management and staff towards appropriate use of clinical services
Assisting the staff to interpret organizational values A behavior of the management position is to assist staff in interpreting organizational values according to Gardner's tasks of leading/managing. A behavior of the executive position is to assist multidisciplinary leaders to benefit client care delivery. A behavior of a clinical position is to ensure that the organizational systems work on the client's behalf. Another behavior of the executive position is to motivate the staff and management to use clinical services appropriately.
A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin; decreased hair growth; and thickened toenails. What might this indicate? Multiple choice question Venous insufficiency Arterial insufficiency Phlebitis Lymphedema
Clients experiencing arterial insufficiency present with extremities that become pale when elevated and dusky red when lowered. Lower extremities may also be cool to touch, pulses may be absent or mild, and skin may be shiny and thin with decreased hair growth and thickened nails. Clients with venous insufficiency often have normal-colored extremities, normal temperature, normal pulses, marked edema, and brown pigmentation around the ankles. Phlebitis is an inflammation of a vein that occurs most often after trauma to the vessel wall, infection, and immobilization. Lymphedema is swelling in one or more extremities that is a direct result of impaired flow of the lymphatic system.
Which statement is true regarding the Hering-Breuer reflex? Multiple choice question Increases tidal volume Decreases respiratory rate Prevents overdistension of the lungs Reduces the number of functional alveoli
Prevents overdistension of the lungs The Hering-Breuer reflex prevents overdistention of the lungs. An increase in hydrogen ion concentration will cause an increase in the tidal volume via central chemoreceptors. A decrease in the hydrogen ion concentration will cause a decreased respiratory rate via peripheral chemoreceptors. The Hering-Breuer reflex does not cause a reduction in the number of functional alveoli.
What is the normal value of inspiratory reserve volume? Multiple choice question 0.5 L 1.0 L 1.5 L 3.0 L
The normal value of inspiratory reserve volume is 3.0 L. The normal value of tidal volume is 0.5 L. The normal value of expiratory reserve volume is 1.0 L. The normal value of residual volume is 1.5 L.
What entity outlined the principles of delegation for registered nurses? Multiple choice question Nurse Practice Act Multilevel nursing model American Nurses Association (ANA) National Council of State Boards of Nursing (NCSBN)
The ANA outlined the principles of delegation for registered nurses. The Nurse Practice Act of each state examines the value of unlicensed personnel in client care delivery and declares that the importance of delegation decisions is the safety and welfare of the public. The multilevel nursing model consists of registered nurses, licensed practical nurses, and unlicensed nursing professionals. The National Council of State Boards of Nursing (NCSBN) stated that the state boards of nursing should regulate nursing assistive personnel across multiple settings.
The parent of a 2-year-old calls a nurse who is a neighbor and reports that the child just ate several multivitamins with iron. What should the nurse say to the parent? Multiple choice question "Give your child orange juice." "Call the Poison Control Center." "Iron-fortified multivitamins are safe for your child." "Administer an emetic—syrup of ipecac, if you have it." Eugene on target
The Poison Control Center will provide the best guidance for treatment of excess ingestion of a substance; enemas, lavage, or chelation therapy with deferoxamine (Desferal), a heavy metal antagonist, may be recommended, depending on the amount ingested and the child's age and response. Orange juice will enhance absorption of the iron and will create a greater risk for toxicity. Iron is the most toxic substance in multivitamins. Although signs and symptoms may not be evident for several hours, treatment should be initiated before a problem develops. Emetics are not used for poisonings; they are not effective in removing the toxic substance, and causing the child to vomit creates a risk for aspiration.
The nurse is teaching a nursing student about the use of magnetic resonance imaging (MRIs). Which statement of the nursing student indicates effective learning? Multiple choice question "Clients with claustrophobia can have an MRI." "Clients who are allergic to iodine should not have an MRI." "Clients with pacemakers can have an MRI." "Clients with surgical clips can go through an MRI."
"Clients with claustrophobia can have an MRI." Clients with a fear of closed spaces may develop anxiety; a closed MRI can be used, but the nurse should provide relaxation techniques or other modes to cope. MRIs do not involve the use of iodine or iodized products, so any clients allergic to iodine can still undergo the procedure. The magnetic field of an MRI may cause dysfunctions in pacemaker activity. Clients with surgical clips should remove all metal accessories before an MRI.
What intervention should a nurse perform during a chest examination of a female client with a suspected lung disorder? Multiple choice question Perform the test in a dark room Examine only the anterior chest Observe for any evidence of respiratory distress Begin the chest examination on the posterior chest
A female's chest examination should begin with the posterior chest in order to prevent interference from the breast tissue. A chest examination is best performed in a well-lighted, warm room with measures to ensure the client`s privacy. The nurse should perform the exam on both the anterior and posterior chest of clients. Observing any evidence of respiratory distress should be conducted on both males and females.
A client with a suspected pulmonary embolism is scheduled for a spiral computed tomography scan. Which intervention should the nurse perform when preparing the client for the test? Multiple choice question Check the client's blood glucose levels. Obtain informed consent from the client. Assess if the client is allergic to shellfish. Instruct the client to remove his or her dentures.
Assess if the client is allergic to shellfish.
A client is diagnosed as having expressive aphasia. Which type of impairment does the nurse expect the client to exhibit? Multiple choice question Speaking or writing Following specific instructions Understanding speech or writing Recognizing words for familiar objects
Speaking or writing Damage to the Broca area, located in the posterior frontal region of the dominant hemisphere, causes problems in the motor aspect of speech, like speaking and writing. Impairments such as following specific instructions, understanding speech or writing, and recognizing words for familiar objects are associated with receptive aphasia, not expressive aphasia; receptive aphasia is associated with disease of the Wernicke area of the brain.
After assessing a client's breath sounds, the nurse suspects bronchospasm. Which adventitious breath sound has prompted the nurse's suspicion? Multiple choice question Wheezing Rhonchi Pleural friction rub Low-pitched crackles
wheezes
While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response? Multiple choice question "I don't mind it." "You seem upset." "This is part of my job." "Nurses get used to this."
"You seem upset." The nurse should identify clues to a client's anxiety and encourage verbalization of feelings. Saying it is part of the job focuses on the task rather than on the client's feelings. Saying "I don't mind it" or "Nurses get used to this" negates the client's feelings and presents a negative connotation.
The nurse finds that a client becomes dyspneic during activities of daily living, such as showering and dressing. The client can walk for more than a city block but at his or her own pace and cannot keep up with others. Which class of dyspnea describes this client? Multiple choice question Class I Class II Class III Class IV
3 Dyspnea during activities such as showering and dressing and the ability to walk for more than a city block, but only at their own pace without being able to keep up with others, indicates class III dyspnea. The client belonging to class I shows dyspnea on more-than-normal or strenuous exertion. The client belonging to class II shows dyspnea on climbing stairs or on walking on an incline but not during level walking. The client belonging to class IV dyspnea requires assistance in some essential activities of daily living such as dressing and bathing due to dyspnea. This client is not usually dyspneic at rest.
A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment should the nurse make it a priority to use? Multiple selection question Goggles Surgical mask Shoe covers Gown Gloves N95 hepa mask
A gown, mask, and gloves when bathing the client prevent contact with feces, sputum, or other body fluids during intimate body care. Goggles would only be important if the client was on mechanical ventilation to avoid contact with sputum. An N95 hepa mask would be necessary if the client had tuberculosis, but not for Cryptococcal pneumonia alone. Shoe covers are designed for protecting a sterile environment such as a surgery suite and are not necessary for giving patient care at the bedside.
What does "information salience," a characteristic of communication, refer to according to Anthony and Vidal? Multiple choice question Decay of information Clarity of information Change in client's health status Change in client's health information
According to Anthony and Vidal, "information salience" is a characteristic of communication that refers to the clarity of information shared between the delegator and the delegate. Decay of information, change in client's health status, and change in client's health information are described by the term "information decay."
What should the nurse consider as the goal of therapy when administering allopurinol to a client with gout? Multiple choice question Increase bone density Decrease synovial swelling Decrease uric acid production Prevent crystallization of uric acid
Allopurinol interferes with the final steps in uric acid formation by inhibiting the production of xanthine oxidase. This drug prevents the formation of uric acid; it does not affect bone density. Allopurinol has no effect on swelling of the synovial membranes. This medication prevents the synthesis of uric acid, not its crystallization.
The nurse is providing instructions to a client on how to reduce the dietary intake of sodium. Which information should the nurse include in the instructions? Multiple choice question Avoid carbonated beverages Use steak sauce for flavoring foods Increase the intake of dairy products Restrict the use of artificial sweeteners Eugene on target
Carbonated beverages generally are high in sodium and should be avoided. Steak sauce is high in sodium and should be avoided. Many dairy products contain sodium and should be avoided. Artificial sweeteners do not contain sodium and do not have to be restricted.
A client is admitted to the hospital and benazepril is prescribed for hypertension. Which is an appropriate nursing action for clients taking this medication? Multiple choice question Monitor the electroencephalogram (EEG). Assess for dizziness. Administer the drug after meals. Assess for dark, tarry stools.
Dizziness may occur during the first few weeks of therapy until the client adapts physiologically to the medication. An EEG is unnecessary. Cardiac monitoring may be instituted because of possible dysrhythmias. Administering the drug after meals is unnecessary; however, if nausea occurs, the medication may be taken with food or at bedtime. The blood pressure should be monitored before and after administration. Dark, tarry stools are not a side effect of benazepril.
Which findings should the nurse expect to see in a client with chronic obstructive pulmonary disease? Multiple selection question Elevated levels of partial arterial oxygen Elevated levels of eosinophils Elevated levels of neutrophils Elevated levels of red blood cells Elevated levels of peripheral capillary oxygen saturation
Elevated levels of eosinophils Elevated levels of neutrophils Elevated levels of red blood cells Elevated levels of eosinophils, neutrophils, and red blood cells are often related to the excessive production of erythropoietin in response to a chronic hypoxic state and indicates possible chronic obstructive pulmonary disease. Elevated levels of partial arterial oxygen and peripheral capillary oxygen saturation are not associated with chronic obstructive pulmonary disease. However, elevated levels of partial arterial oxygen indicate possible excessive oxygen administration. Decreased levels of peripheral capillary oxygen saturation indicate possible impaired ability of hemoglobin to release oxygen to tissues.
Which condition may lead to collapse of the walls of the bronchioles and alveolar air sacs? Multiple choice question Asthma Emphysema Chronic bronchitis Centrilobular emphysema
Emphysema Emphysema is a condition in which a dysregulation of lung proteases may lead to the collapse of the walls of the bronchioles and alveolar air sacs. Asthma is a condition that involves a reversible airflow obstruction in the airways. In chronic bronchitis, infections or bronchial irritants cause increased secretions, edema, bronchospasm, and impaired mucociliary clearance. Centriacinar or centrilobular emphysema affect the respiratory bronchioles most severely.
Which preoperative and postoperative care points should be included when providing education and intervention to a client scheduled for a septoplasty? Multiple selection question Teach the client about hot compresses. Encourage the client to quit smoking before surgery. Observe the surgical site for edema. Teach the client about post-surgery activities that are restricted. Assess the client's respiratory status. Encourage the client to take aspirin before the surgery.
Encourage the client to quit smoking before surgery. Observe the surgical site for edema. Teach the client about post-surgery activities that are restricted. Assess the client's respiratory status.
Who should the nurse contact to receive training as a Community Emergency Response Team (CERT) member? Multiple choice question National Disaster Life Support Foundation Federal Emergency Management Agency (FEMA) Centers for Disease Control and Prevention (CDC) Centers for Medicare and Medicaid Services (CMS)
Federal Emergency Management Agency (FEMA)
After a left cataract extraction, a client reports severe discomfort in the operated eye. The nurse concludes that this problem may be caused by which condition? Multiple choice question Hemorrhage into the eye Expected postoperative discomfort Isolation related to sensory deprivation Pressure on the eye from the protective shield
Hemorrhage into the eye Acute postoperative pain is a sign of increased intraocular pressure and is caused by hemorrhaging; this is a medical emergency. Postoperative discomfort usually is minimal. Isolation and sensory deprivation will not occur because only one eye is patched. The shield may be slightly uncomfortable but will not cause severe discomfort.
A client with vesiculopustular lesions with honey-colored crusts on the face visits a primary healthcare provider. Which bacterial condition is suspected? Multiple choice question Cellulitis Impetigo Carbuncle Erysipelas
Impetigo is associated with vesiculopustular lesions that have honey-colored crusts. Impetigo usually manifests on the face. Cellulitis is a bacterial infection in which hot, tender, erythematous and edematous areas with diffuse borders are present. Carbuncle is a bacterial infection with many pustules in an erythematous area. Erysipelas is a bacterial infection with red, hot sharply demarcated plaque that is indurate and painful.
A male client diagnosed with bipolar disorder is prescribed medication that has caused a decreased libido. Which drugs would be appropriate to be prescribed by the primary healthcare provider to treat this condition? Multiple selection question Asenapine Quetiapine Haloperidol Aripiprazole Chlorpromazine
In men, first-generation antipsychotics can suppress the libido. Therefore, the primary healthcare provider should prescribe second-generation antipsychotics such as asenapine, quetiapine, or aripiprazole. Haloperidol and chlorpromazine are first-generation antipsychotics that may suppress the libido and cause erectile and ejaculatory dysfunction.
A 13-month-old child is undergoing lumbar puncture for confirmation of a diagnosis of bacterial meningitis. During the procedure the nurse notes that the spinal fluid is cloudy. What does this finding indicate? Multiple choice question Healthy spinal fluid Increased glucose level Increased white blood cell (WBC) count Rising number of red blood cells (RBCs)
Increased white blood cell (WBC) count A high WBC count causes spinal fluid to appear cloudy and possibly milky white; it is a sign of infection. Healthy spinal fluid is clear. An increased glucose level does not affect the color or clarity of the spinal fluid. RBCs give the spinal fluid a sanguineous, not cloudy, appearance.
While assessing a client with schizophrenia who is receiving chlorpromazine, the nurse finds lead pipe rigidity, sudden high fever, and sweating. Which drugs would be prescribed by the healthcare provider? Multiple selection question Loxapine Dantrolene Thiothixene Haloperidol Bromocriptine
Lead pipe rigidity, sudden high fevers, and sweating are symptoms of neuroleptic malignant syndrome; this condition is an adverse effect of chlorpromazine. Drugs used to treat this syndrome are dantrolene and bromocriptine. Loxapine, thiothixene, and haloperidol are the first-generation antipsychotics that should not be prescribed because these may lead to severe complications.
Which part of the respiratory system is referred to as Angle of Louis? Multiple choice question Hilum Carina Alveoli Epiglottis
Located at the level of the manubriosternal junction, the carina is also referred to as the Angle of Louis. The mainstream bronchi, pulmonary vessels, and nerves enter the lungs through a slit called the hilum. Alveoli are small sacs that are the primary site of gas exchange in the lungs. The epiglottis is a small flap located behind the tongue that closes over the larynx during swallowing.
Which position should the nurse instruct a client to avoid when the client is experiencing severe back pain during labor? Multiple choice question Sims Sitting Supine Side-lying
Low back pain is aggravated when the mother is in the supine position because of increased pressure from the fetus. The Sims, sitting, and side-lying positions will all help relieve back pain.
The primary healthcare provider instructs the client to increase their intake of seafood and protein in the diet. What could be the reason for this instruction? Multiple choice question The client has vitiligo. The client has hypothyroidism. The client has diabetes mellitus. The client has a urinary infection.
Nutritional deficiencies due to inadequate diet, especially decreases in protein and iodine intake, may be a cause for certain endocrine disorders, such as hypothyroidism. Therefore, to meet nutritional requirements clients with hypothyroidism are instructed to increase the intake of seafood and proteins to 60 mg/day. Because of hypofunction of the adrenal gland, clients with skin pigmentation conditions, such as vitiligo, are mainly instructed to consume more water. To improve metabolism, clients with diabetes mellitus are advised to add high-fiber food to their diet. A client with a urinary infection may not be advised to add seafood and proteins to their diet.
An obese smoker complains of feeling sleepy during the daytime, waking up tired in the morning, and snoring heavily while sleeping. The client is found to have enlarged tonsils. Which condition may the client have? Multiple choice question Laryngeal trauma Vocal cord paralysis Obstructive sleep apnea Subcutaneous emphysema
Obstructive sleep apnea Obstructive sleep apnea (OSA) is a condition in which the client may feel tired upon waking in the morning and may feel sleepy during the daytime. These clients may also snore heavily while sleeping. Smoking and enlarged tonsils increase the risk of sleep apnea. Laryngeal trauma occurs secondary to a crushing or direct blow injury, fracture, or prolonged endotracheal intubation. Vocal cord paralysis occurs in clients with neurologic disorders or with conditions that damage either the vagus nerve or the laryngeal nerves. Subcutaneous emphysema is a manifestation of laryngeal trauma, a condition in which there is the presence of air in the subcutaneous tissue.
While assessing a client, the nurse finds increased vibrations over the chest wall. What condition can be inferred from this finding? Multiple choice question Atelectasis Pneumonia Orthopnea Pneumothorax
Pneumonia A chest wall vibration produced via vocalization is called fremitus. During an assessment if increased vibrations are observed, the lung may be filled with fluid. This condition may signify pneumonia, lung tumors, or thick bronchial secretions. Atelectasis is due to a collapse of alveoli; this condition is characterized by reduced vibrations. Orthopnea is a condition that causes a shortness of breath when lying down. Pneumothorax is the presence of air in the sacs around the lungs, which in turn reduces the vibrations in fremitus.
Which interventions should the nurse perform while collecting subjective data from a client during a focused respiratory assessment? Multiple selection question Palpate the chest and back for masses Question the client about shortness of breath Check the hematocrit and hemoglobin values Inspect the skin and nails for integrity and color Ask the client about color and quantity of sputum
Question the client about shortness of breath Ask the client about color and quantity of sputum
A 65-year old client is found to have dilatation of the bronchioles and alveolar ducts. Which suggestions of the nurse would help the client overcome this situation? Multiple selection question Suggest the use of incentive spirometry. Suggest that the client takes an adequate amount of calcium daily. Suggest that the client perform vigorous pulmonary hygiene activities. Suggest that the client maintain an upright position as much as possible. Suggest that the client talk face-to face with others as much as possible.
Suggest the use of incentive spirometry. Suggest that the client perform vigorous pulmonary hygiene activities. Suggest that the client maintain an upright position as much as possible. Dilatation of the bronchioles and alveolar ducts is a respiratory system change related to aging. Using incentive spirometry may help clients improve functioning of the lungs. This action may help the client take breaths more easily and more comfortably. Performing vigorous pulmonary hygiene activities, such as clearing the mucus or other secretions from the airways, may help an older adult prevent respiratory infections or complications. The upright position may help in minimizing the mismatching of ventilation perfusion. Clients should take in adequate amounts of calcium daily to overcome decreased chest mobility due to osteoporosis. Face-to-face conversations are required for clients with muscle atrophy and clients whose vocal cords may have become slack.
The nurse is assisting a primary healthcare practitioner to perform an examination of the reproductive tract of a female client. Which nursing action is beneficial for the client? Multiple choice question Providing judgmental support to the client Placing the client to move her hands away from the body Asking the client to remove her drape while undergoing the test Asking the client to empty the bladder before the examination
The client should empty her bladder before the examination to ensure appropriate test results. The nurse should provide nonjudgmental support and relaxation techniques to the client to increase her comfort during the examination. The client should place her arms towards her sides to allow better relaxation of the abdominal muscles. The client should be draped adequately to provide modesty throughout the examination. Drapes will be removed and replaced after examining the specific area.
During a follow-up visit, a nurse finds that the client has a slow rate of healing after laryngeal cancer surgery. The nurse also finds that the client is at risk of developing lung cancer. What would be the reason behind the nurse's suspicion? Multiple choice question The client leans forward while coughing. The client smokes four cigarettes per day. The client avoids showering and swimming. The client uses a non-oil-based ointment to lubricate the stoma. Eugene on target
The client smokes four cigarettes per day. Smoking can increase the risk for developing other cancers such as lung cancer and can decrease the rate of healing from laryngeal surgeries. Leaning forward while coughing promotes healing. Avoiding showering and swimming helps to prevent water from entering the airways through the stoma. Using a non-oil-based ointment to lubricate the stoma may aid in quick healing.
During the activation of an emergency preparedness plan, which individual should communicate with the media? Multiple choice question Medical director Emergency room nurse Director of Human Resources Hospital chief executive officer
The person who would most likely serve as a liaison between the healthcare facility and the media would be the Director of Human Resources. The Medical Director would most likely decide the number, acuity, and resource needs of clients. The Emergency Room Nurse would most likely evaluate each client to determine priorities for treatment. The Hospital Chief Executive Officer would most likely assume overall leadership for implementing the emergency plan.
Which nurse collaborates directly with the client to establish and implement a basic plan of care after admission? Multiple choice question Primary nurse Nurse clinician Nurse coordinator Clinical nurse specialist
The primary nurse provides or oversees all aspects of care, including assessment, implementation, and evaluation of that care. A clinician is an expert teacher or healthcare provider in the clinical area. The nurse coordinator oversees all the staff and clients on a unit and coordinates care. Clinical nurse specialist is a title given to a nurse specially prepared for one very specific clinical role. It requires a master's degree level of education.
A client who works in the leather industry complains of a bloody discharge and persistent pain after the treatment of sinusitis. The client has a history of smoking. The nurse suggests the client consult a primary healthcare provider immediately. Which risk does the nurse suspect in the client? Multiple choice question Epistaxis Facial trauma Fracture of the nose Tumor of the nasal cavity
Tumor of the nasal cavity Tumors of the nasal cavity and sinuses are rare but are a result of a loss of cellular regulation. These tumors commonly develop in people who are regularly exposed to leather dust. Cigarette smoking coupled with leather exposure further increases the risk of tumors. The symptoms of a tumor include persistent nasal obstruction, bloody discharge, and pain that persists even after sinusitis treatment. Epistaxis is the condition where there is excessive bleeding from the nose. Facial trauma occurs where there is excessive bleeding from the face due to any type of physical trauma to the face. A fracture of the nose may occur due to falls or sports activities.
A nurse teaches a client with a nose fracture about routine care after rhinoplasty surgery. Which statement of the client indicates the need for further teaching? Multiple choice question "I should not sniff upwards or blow my nose." "I should take aspirin if I experience bleeding." "I should move slowly and remain in the semi-Fowler's position whenever possible." "I should not cough forcefully or strain during bowel movements."
"I should take aspirin if I experience bleeding."
Several individuals who sustained urgent but nonemergent injuries are seated in the emergency department when an ambulance arrives with a client suspected of having a myocardial infarction. The nurse must explain to the waiting clients that they will have to wait longer for care. Which is the best explanation for the nurse to give? Multiple choice question "We will be busy for a while. Unfortunately, we have to take care of this other client first." "I recognize that you have been waiting for quite a while, but it now looks like you will have to wait even longer." "There is going to be an additional delay. The client who just arrived had a heart attack, and that client needs care first." "I know you have been waiting, but a client's life depends on immediate treatment. You will receive the same attention when you are seen." Eugene on target
"I know you have been waiting, but a client's life depends on immediate treatment. You will receive the same attention when you are seen." Eugene on target The response "I know you have been waiting, but a client's life depends on immediate treatment. You will receive the same attention when you are seen" describes the delay while not divulging the nature of the problem as required by Health Insurance Portability and Accountability Act (HIPAA); Canada: Personal Health Information Protection Act (PHIPA). It requests their patience and indirectly asks for their understanding. Also, they are promised the same conscientious level of care when they are treated. The response "We will be busy for a while. Unfortunately, we have to take care of this other client first" is curt and uncaring. Although the response "I recognize that you have been waiting for quite a while, but it now looks like you will have to wait even longer" requests their patience; it does not explain why there is a delay. The response "There is going to be an additional delay. The client who just arrived had a heart attack, and that client needs care first" violates HIPAA confidentiality requirements.
Which patients are ideal candidates for interpreter service in order to prevent contributing health disparities? Multiple selection question An English-speaking patient with a speech disorder An African American patient with a hearing impairment A non-English-speaking patient in the emergency department A Spanish-speaking patient ready to be discharged from the facility An Indian American who does not speak the language used at the facility
A non-English-speaking patient in the emergency department A Spanish-speaking patient ready to be discharged from the facility An Indian American who does not speak the language used at the facility The health care facility should provide an interpreter to limit communication barriers that contribute to health disparities. A non-English-speaking patient in the emergency department should have an interpreter to ensure all aspects of care. While providing discharge instructions to a patient who speaks Spanish, the nurse should have the help of a language interpreter. The nurse should use an interpreter for an Indian American patient who does not speak the language used at the facility. When caring for an English-speaking patient who has a speech disorder, an interpreter is not required. Instead, the nurse can communicate using other adaptations appropriate for the disorder. When caring for an African American patient who has a hearing impairment, sign language or a hearing aid may be required.
A nurse is assessing a newborn born after 32 weeks' gestation. Which clinical finding does the nurse anticipate? Multiple choice question Barely visible areola and nipple Zero-degree square window sign Pinnae that spring back when folded Palms and soles with clearly defined creases
Barely visible areola and nipple Breast tissue is not developed or palpable in an infant of less than 33 weeks' gestation. A zero-degree square window sign is present in an infant of 40 to 42 weeks' gestation. The pinnae spring back after being folded in an infant of 36 weeks' gestation. Creases in the palms and on the soles are not clearly defined until after the 37th week of gestation.
An adolescent girl with a seizure disorder refuses to wear a medical alert bracelet. What should the nurse tell the girl that may help her wear the bracelet consistently? Multiple choice question Hide the bracelet under long-sleeved clothes. Wear the bracelet when engaging in contact sports. Ask her friends to wear bracelets that look like hers. Select a bracelet similar to bracelets worn by her peers.
Because adolescents have a developmental need to conform to their peers, the teenager should be able to select a bracelet of a design similar to that of those worn by her peers. Hiding the bracelet under long-sleeved clothes might be acceptable in cool weather, but not when it is warm and friends are wearing T-shirts. The bracelet should be worn at all times when the girl is not with responsible family members. Asking friends to wear a similar bracelet may be difficult, especially if the girl does not wish to tell her friends why she needs the bracelet.
A nurse is caring for two clients newly diagnosed with diabetes. One client has type 1 diabetes, and the other client has type 2 diabetes. When determining the main difference between type 1 and type 2 diabetes, the nurse recognizes what clinical presentation about type 1? Multiple choice question Onset of the disease is slow. Excessive weight is a contributing factor. Complications are not present at the time of diagnosis. Treatment involves diet, exercise, and oral medications.
Complications are not present at the time of diagnosis. Clinical presentation of type 1 diabetes is characterized by acute onset, and therefore there is no time to develop the long-term complications that are common with long-standing disease; 20% of newly diagnosed clients with type 2 diabetes demonstrate complications because the diabetes has gone undetected for an extended period of time. Clinical presentation of type 1 diabetes is rapid, not slow, as pancreatic beta cells are destroyed by an autoimmune process; in type 2 diabetes, the body is still producing some insulin, and therefore the onset of signs and symptoms is slow. In type 1 diabetes, clients are generally lean or have an ideal weight; 80% to 90% of clients with type 2 diabetes are overweight. Type 1 diabetes requires diet control, exercise, and subcutaneous administration of insulin, not oral medications; oral medications are used for type 2 diabetes because some insulin is still being produced.
Which assessment finding is considered the earliest sign of decreased tissue oxygenation? Multiple choice question Cyanosis Cool, clammy skin Unexplained restlessness Retraction of interspaces on inspiration
Unexplained restlessness Unexplained restlessness is considered the earliest sign of decreased oxygenation. The other assessment findings, such as cyanosis, cool, clammy skin, and retraction of interspaces on inspiration, are considered late signs of decreased oxygenation.
A nurse is teaching a client about self-management techniques for smoking cessation. Which statement made by the client indicates the need for further teaching? Multiple choice question "I should list the reasons why I should stop smoking." "I should visit all the places where I started smoking." "I should remove all ashtrays and lighters." "I should try replacing tobacco with sugarless mints and gum."
"I should visit all the places where I started smoking."
After a difficult labor a client gives birth to a 9-lb (4 kg) boy who expires shortly afterward. That evening the client tearfully describes to the nurse her projected image of her son and what his future might have been. What is the nurse's most therapeutic response? Multiple choice question "I guess you wanted a son very much." "It must be difficult to think of him now." "I'm sure he would have been a wonderful child." "If you dwell on this now, your grief will be harder to bear."
"It must be difficult to think of him now." Stating that it must be difficult to think of him now demonstrates empathy; the nurse is attempting to show understanding of the client's feelings. Stating that the patient must have wanted a son very much is nontherapeutic; the nurse has no way of knowing this. Stating the certainty that the infant would have been a wonderful child switches the focus away from the client, whose needs should be met at this time. Stating that dwelling on the death will make her grief harder to bear denies the client's feelings and implies that the client should curb painful emotions.
Based on Erikson's theory of development, what should the nurse suggest to a mother of a toddler who harshly disciplines her child? Multiple choice question "Your behavior may induce a feeling of isolation in your child." "You need to establish a sense of trust or the child may lose trust in you." "Your child needs support and love or may develop feelings of shame and doubt." "You need to control the child's impulses or the child may suffer guilt and frustration."
According to Erikson, a child of 2 years old is in the autonomy versus sense of shame and doubt stage. The nurse should counsel the mother that harshly disciplining her child may lead to a feeling of shame and doubt. The intimacy versus isolation stage leads to a feeling of isolation in young adults. A feeling of mistrust can be seen in infants less than 1 year of age. Guilt and frustration can be seen in preschoolers in the stage of initiative versus guilt.
A client who was discharged from the hospital after a rhinoplasty for a fractured nose complains of nasal bleeding. Which activity of the client might have led to this condition? Multiple choice question Eating solid foods Consuming antibiotics Performing Valsalva maneuvers Using cool compresses on the nose
After a rhinoplasty, bleeding of the nose occurs if the client performs Valsalva maneuvers (such as coughing forcefully or straining during a bowel movement). Soft solid foods are given to a client who has recently recovered from anesthesia. Eating solid foods after a rhinoplasty does not cause nose bleeding. Antibiotics are usually prescribed to clients after a rhinoplasty to prevent infections. Cool compresses on the nose, eye, and face are used to reduce swelling and bruising.
The nurse is interpreting responses to tuberculin skin testing in a 58-year-old client with end-stage kidney disease secondary to diabetes mellitus. Which finding would indicate a positive reaction? Multiple choice question Presence of acid-fast bacilli in the sputum A 6-mm area of induration at the test's injection site An 11-mm area of induration at the test's injection site Presence of reddened, flat areas at the test's injection site
An 11-mm area of induration at the test's injection site An area of induration ≥10 mm would be a positive reaction in a client with end-stage kidney disease. The presence of acid-fast bacilli in the sputum indicates active tuberculosis. An area of induration ≥5 mm would be a positive reaction in clients with HIV infection, clients who are immunosuppressed, and in clients with organ transplants. The presence of reddened, flat areas does not indicate a positive reaction. These areas are not measured.
What condition would a nurse suspect in a client with abnormal respirations with alternating periods of apnea and rapid breathing? Multiple choice question Pectus carinatum Pectus excavatum Kussmaul breathing Cheyne-Stokes respirations
Cheyne-Stokes respirations Kussmaul breathing is a rapid and deep breathing abnormality.
A nurse is caring for a client who just has had surgery on the ear. The nurse should assess for which early indicator of potential damage to the motor branch of the facial nerve? Multiple choice question Pain behind the ear Bitter, metallic taste Dryness of the mouth Inability to wrinkle the forehead
Inability to wrinkle the forehead The motor fibers of the facial nerve innervate the superficial muscles of the face and scalp, allowing facial movement such as wrinkling the forehead. Pain behind the ear; a bitter, metallic taste; and dryness of the mouth are sensory responses that may be manifested when the injury is to the sensory, not motor, branch of the facial nerve.
A client is admitted to the hospital with numbness of the hands and feet, which has progressed upward and now involves the arms, legs, and lower trunk. The client tells the nurse that approximately two weeks ago, the client experienced 48 hours of chills, fever, and upper respiratory congestion. A tentative diagnosis of Guillain-Barré syndrome is made. The nurse assesses for what major clinical manifestations of the syndrome? Multiple choice question Ptosis and dysphagia Paresthesias and paralysis Atrophy and fasciculations Muscle weakness and drooling
Paresthesias and paralysis result from patchy demyelinization of the peripheral nerves, nerve roots, root ganglia, and spinal cord and are related to a diagnosis of Guillain-Barré syndrome. Ptosis and dysphagia are related to myasthenia gravis. Atrophy and fasciculations are related to amyotrophic lateral sclerosis. Muscle weakness and drooling are related to Parkinson disease.
Which client would have relatively smaller tidal volumes due to limited chest wall movement? Multiple choice question A client with asthma A client with pneumonia A client with pulmonary fibrosis A client with phrenic nerve paralysis
Some respiratory conditions such as phrenic nerve paralysis may limit the diaphragm or chest wall movement and may result in smaller tidal volumes. In this condition, the lungs do not fully inflate, and the gas exchange may be impaired. Exacerbations of asthma may cause expiration to become an active labored process. Pneumonia may result in decreased lung compliance due to an accumulation of fluid in the lungs. As the lung tissue becomes less elastic or distensible, the client with pulmonary fibrosis may have decreased lung compliance.
The nurse is caring for a client admitted with shock secondary to severe gastrointestinal bleeding. Once the client is stabilized, what intervention should the nurse do next? Multiple choice question Monitor the peripheral pulses. Check the level of consciousness. Take a blood sample for laboratory tests. Control the bleeding with a pressure dressing.
Take a blood sample for laboratory tests. The primary nursing intervention that should be followed in the client's condition with gastrointestinal bleeding is collection of a blood sample for laboratory diagnosis. Peripheral pulses are monitored in an ongoing manner. Level of consciousness may not be required to be monitored based on the client's condition. Controlling bleeding with a pressure dressing is usually done in case of deep lacerations and wounds.
An older adult client who complains of difficulty breathing after a surgery is found to have decreased vital capacity on spirometry. Which nursing intervention should be performed in this situation? Multiple choice question Assess the client's mobility. Monitor respirations and breathing effort. Teach coughing and deep-breathing exercises. Determine normal activity levels and note when the client tires.
Teach coughing and deep-breathing exercises. Older adults are at an increased risk for complications from both anesthesia and surgery. One of the age-related risk factors after surgery is a decrease in vital capacity. Teaching coughing and deep-breathing exercises may help in preventing pulmonary complications. Assessing the client's mobility may help an older client with a risk of musculoskeletal problems. Monitoring respirations and breathing effort is required for an older client with decreased blood oxygenation. An older adult with cardiovascular changes requires determination of normal activity levels and noting when the client tires.
A 10-year-old child is found to have hemophilia. The nurse is explaining how hemophilia is inherited. What is the best explanation of the genetic factor that is involved? Multiple choice question It follows the Mendelian law of inherited disorders. The mother is a carrier of the disorder but is not affected by it. It is an autosomal dominant disorder in which the woman carries the trait. A carrier may be male or female, but the disease occurs in the sex opposite that of the carrier.
The hemophilia gene is carried on the X chromosome but is recessive. Therefore the female is the carrier (an unaffected XO and an affected XH). If the male receives the affected XH (XHYO), he will have the disorder. Hemophilia is carried by the female; the Mendelian laws of inheritance are not sex specific. Hemophilia is a sex-linked recessive disorder. Females only carry the trait; usually males are affected.
The nurse is assessing a newborn immediately after birth. Which finding indicates normal development? Multiple choice question A body weight of 3500 g Blood pressure of 70/60 mm Hg A core body temperature of 96° F (35.6° C) Head circumference 3 cm less than chest circumference
The newborn has a body weight of 3500 g, which is within the normal range of 2700 to 4000 g. Therefore this indicates normal development. The core body temperature of the newborn is 96° F (35.6° C), which is less than the normal range of 97.7° F to 99.7° F (36.5° C to 37.6° C). Therefore the core body temperature of 96° F (35.6° C) indicates hypothermia. The normal blood pressure of a newborn on the first day of birth is 65/45 mm Hg. A blood pressure finding of 70/60 mm Hg indicates very high blood pressure. The head circumference of the newborn is less than the chest circumference, which indicates that the newborn may have microcephaly
Which question should the nurse ask the parents of a 3-year-old client to assess fine motor skills? Multiple choice question "Is your child able to use scissors?" "Is your child able to ride a tricycle?" "Is your child able to climb stairs using alternate feet?" "Is your child able to build a tower using 9 or 10 blocks?"
The nurse would ask the parent of a 3-year-old if the child is able to build a tower using 9 or 10 blocks to assess fine motor skills. A preschool-age child is not expected to use scissors, also a fine motor skill, until 4 years of age. Riding a tricycle and climbing stairs using alternate feet are both gross, not fine, motor skills.
What points should be considered when a client with a respiratory disorder undergoes a spiral-computed tomography (CT) scan to diagnose a pulmonary embolism? Multiple selection question The test involves the administration of a contrast medium. Clients should have their hydration levels assessed. Clients are instructed to lie still on a hard table. Clients are served shellfish before the test. A client's serum creatinine level is evaluated after the test.
The test involves the administration of a contrast medium. Clients should have their hydration levels assessed. Clients are instructed to lie still on a hard table. A contrast medium may be given intravenously when performing a spiral-computed tomography (CT). The nurse should make sure that the client is well hydrated before and after the procedure to help flush out the contrast medium. The nurse should instruct the client to lie still on the hard table and that the scanner will revolve around the body with clicking noises. The nurse should assess if the client is allergic to shellfish because the contrast medium used is iodine-based. The nurse should evaluate the client's blood urea nitrogen and serum creatinine before the test to assess renal function.
An older client complains of confusion, dry mouth, and constipation. The client was treated for rhinitis a week ago and is taking chlorpheniramine. Which information provided by the nurse would be beneficial to the client? Multiple choice question Chlorpheniramine needs to be stopped immediately. These are common side effects of chlorpheniramine. Hydroxyzine needs to be taken with chlorpheniramine. The chlorpheniramine prescription needs to be changed.
These are common side effects of chlorpheniramine. First-generation antihistamines such as chlorpheniramine have side effects such of confusion, dry mouth, and constipation in older adults. Making the older client aware of the adverse effects may be beneficial for the client. The nurse does not need to order the client to stop the prescribed drug treatment immediately. Hydroxyzine also has the same side effects, so suggesting this drug will not be beneficial. A nurse should first consult the primary healthcare provider before recommending changing the medication.
Histoplasmosis is suspected in a client. Which risk factor is the nurse likely to find in the history? Multiple choice question The client is a chain smoker. The client works in a cement factory. The client has a history of a minor hand fracture. The client has a history of travel to central parts of North America.
Travel and geographic area of residence reveal the potential for exposure to certain diseases. Histoplasmosis is a fungal disease caused by inhalation of contaminated dust in the central parts of America and Canada. Smoking will not lead to histoplasmosis. Working in a cement factory is not related to histoplasmosis. A minor hand fracture is not related to histoplasmosis.
During an acquired immunodeficiency syndrome (AIDS) education class a client states, "Vaseline works great when I use condoms." Which conclusion about the client's knowledge of condom use can the nurse draw from this statement? Multiple choice question An understanding of safer sex An ability to assume self-responsibility Ignorance related to correct condom use Ignorance concerning the transmission of human immunodeficiency virus (HIV)
Vaseline (petroleum jelly) breaks down condom integrity and will increase the risk for condom failure. Using Vaseline instead of a water-soluble lubricant shows a lack of knowledge about condom use, a form of safer sex. Although the person is attempting to be responsible, there is a lack of knowledge and the behavior is unsafe. Condom use shows the client has some understanding about the transmission of HIV.
Which suggestion of the nurse would help the client prevent respiratory problems? Multiple choice question "You should start painting your house." "You should engage in heavy physical activity." "You should wear a mask while working in certain industries." "You should move from a rural to an urban area."
Wearing a mask can protect the client from any harmful dust that may lead to respiratory problems. Paints may contain harmful chemicals; avoiding painting may be helpful in preventing respiratory problems. Clients performing heavy physical activities are at a higher risk of suffering from respiratory problems. Urban areas have more air pollution than rural areas.