Julio Cesar Gonzalez

Which clinical manifestations accompany methamphetamine use? Select all that apply. One, some, or all responses may be correct.

Tachycardia Hyperthermia

A client who had a myocardial infarction develops cardiogenic shock despite treatment in the emergency department. Which client responses are related to cardiogenic shock? Select all that apply.

Tachycardia Restlessness Decreased urinary output

A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which classic signs of hepatic coma should the nurse assess this client? Select all that apply.

Mental confusion Flapping hand tremors

The nurse is obtaining a health history from a client with endometriosis. What consequences can occur as a result of this disorder? Select all that apply.

Metrorrhagia Ovarian cancer Bowel strictures Voiding difficulties

Which preventable diseases pose a particular risk for pregnant women and their infants? Select all that apply. One, some, or all responses may be correct.

Rubella Varicella Pertussis Hepatitis B Seasonal influenza

When assessing a toddler with autism, what characteristic findings or behaviors should the nurse expect? Select all that apply.

Sad, blank facial expression Inability to maintain eye contact

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply.

Bradycardia Hypotension Bladder dysfunction

An older African American client with hypertension is admitted to the hospital. Which data from the client's history and diagnostic workup represent risk factors for hypertension? Select all that apply.

Occasional cocaine use African American heritage

Considerations when caring for a client with a total hip replacement should include which of the following? Select all that apply.

Pain control should include regularly scheduled analgesics and may necessitate use of as needed medications as well. Frequent neurovascular assessment should be done distal to the surgical site and compared with the unaffected side. When turning, client should be log rolled to prevent leg from falling forward or backward.

A nurse is assessing a client who is being admitted for surgical repair of a rectocele. What signs or symptoms does the nurse expect the client to report? Select all that apply.

Painful intercourse Bearing-down sensations.

Which responses should a nurse expect a client experiencing hypoglycemia to exhibit? Select all that apply.

Palpitations Tachycardia Nervousness

A nurse is caring for a client whose laboratory values indicate the presence of hyponatremia. For which risk factors should the nurse assess the client that most likely may have caused the hyponatremia? Select all that apply.

Profuse diaphoresis Rapid IV infusion of 5% dextrose in water

After an assessment of a male newborn, the nurse suspects postmaturity. Which observations help confirm this conclusion? Select all that apply.

Profuse scalp hair Parchmentlike skin Creases covering the entire soles

A client is admitted to the hospital with a diagnosis of chronic kidney disease. Which responses should the nurse expect the client to exhibit? Select all that apply.

Paresthesia Hypertension

A client with preeclampsia is to receive a magnesium sulfate infusion, and the nurse assesses the client's status to obtain baseline information. Which assessments are necessary? Select all that apply.

Patellar reflex Output of urine Respiratory rate

Methods of relieving back pain are explained during a childbirth class. What activities identified by the client permit the nurse to conclude that the teaching has been understood? Select all that apply.

Pelvic rocking Forward tilting Sacral pressure

The nurse is caring for a client who is postoperative day 2 open of a cholecystectomy and notes the presence of bibasilar crackles. The nurse suspects atelectasis. Which nursing actions would be appropriate for this client? Select all that apply.

Perform frequent breath sounds assessment. Encourage turning, coughing, and deep breathing exercises.

A nurse is caring for an adolescent in labor an hour after she was admitted to the birthing unit. The adolescent is anxious and tense. She cries during contractions and asks the nurse for epidural anesthesia. The nurse obtains the adolescent's current vital signs and reviews her history and admission information. What nursing interventions are essential before epidural anesthesia is administered? Select all that apply.

Performing a baseline vaginal examination Telling the adolescent what to expect with each procedure Identifying risk factors that contraindicate epidural anesthesia

A 4-year-old child is receiving prednisone. Which immunizations are safe for the child to receive? Select all that apply.

Pertussis Inactivated poliovirus Tetanus immune globulin

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply.

The RR intervals are relatively consistent. One P wave precedes each QRS complex.

The menu for a client with malabsorption syndrome must be limited because of a sensitivity to gluten. Which foods cannot be served to this client? Select all that apply.

Roast beef sandwich Chicken noodle soup Spaghetti and meatballs

The nurse is assessing a client who is admitted to the hospital with a tentative diagnosis of an adrenal cortex tumor. When assessing the client, which of these, if found, are signs of Cushing disease? Select all that apply.

Round face Dependent edema in the feet and ankles Thin, translucent skin with bruising Increased fatty deposition in the neck and back

A nurse is caring for a client who is receiving total parenteral nutrition. Which responses indicate that the client is experiencing hyperglycemia? Select all that apply.

Polyuria Polydipsia

What toys should a nurse offer a young toddler during hospitalization? Select all that apply.

Pounding toy Carton of clay

Which toys should the nurse identify as most appropriate for a 3-year-old child? Select all that apply.

Pounding toy Play telephone Box filled with plastic figures

Which short-term outcome would the nurse use for a client with bulimia nervosa who at times feels helpless in regard to the eating disorder?

Practices effective socialization skills Perceives the body shape as acceptable Decreases preoccupation with delusional thoughts Verbalizes the desire to increase control over stressful situations

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply.

Prayer Hypnosis Aromatherapy Guided imagery

A health care provider orders a contraction stress test (CST) for a client whose nonstress test (NST) was nonreactive. Which maternal complications should prompt the nurse to question the order? Select all that apply.

Preterm labor Incompetent cervix Premature rupture of membranes

The nurse finds that an adolescent has a tattoo on the neck and piercings on the ear and eyebrow. During the next visit, the nurse finds that the adolescent has an additional tattoo on right upper arm and another piercing on the nose. What are the priority nursing interventions in this situation? Select all that apply.

Screen the adolescent for human immunodeficiency virus (HIV). Schedule an appointment for administering the hepatitis vaccine.

What clinical indicators should the nurse expect to identify when assessing an individual with a spontaneous pneumothorax? Select all that apply.

Shortness of breath Unilateral chest pain

The nurse observes a 2-year-old child at play and concludes that the child is engaging in age-appropriate behavior for a toddler. Which activities lead the nurse to this conclusion? Select all that apply.

Is possessive of toys Follows simple directions

SATA de cómo findings del sistema musculoskeletal Que era

Joint crepitation Tenderness spine Muscle pain Muscle atrophy

A client is receiving furosemide (Lasix) to relieve edema. The nurse should monitor the client for which responses? Select all that apply.

Weight loss Excessive loss of potassium ions

The nurse is giving discharge instructions to the parents of a toddler who had a myringotomy. The nurse tells them about which most common complications associated with this surgery. Select all that apply.

Lack of drainage Increasing ear pain

A client has a brain attack (stroke) that involves the right cerebral cortex and cranial nerves. What areas of paralysis should the nurse expect the client to exhibit? Select all that apply.

Left leg Left arm

1- A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply.

Leg cramps, Muscle weakness

A 3-year-old child with nephrotic syndrome has been receiving prednisone (Meticorten) for 1 week. The nurse reviews the child's progress record and determines that the medication has been effective. What information supports this conclusion? Select all that apply.

Weight loss Shorter rest periods Increased urine output

A nurse is caring for a client with chronic kidney failure. Which clinical findings should the nurse expect when assessing this client? Select all that apply.

Lethargy Muscle twitching

A nurse is obtaining a history and performing a physical assessment of a client who has cancer of the tongue. Which clinical findings should the nurse expect to identify? Select all that apply.

Leukoplakia Alterations in taste Enlarged cervical lymph nodes

To reduce the risk of recurrent painful gout attacks, the nurse teaches the client to avoid which foods? Select all that apply.

Liver Shellfish

A nurse is caring for a client with hepatic cirrhosis. Which elements are important to include in this client's diet? Select all that apply.

Low protein Low sodium High vitamins

The nurse is providing care to a client with ascites secondary to liver failure. What is appropriate to include in this client's care? Select all that apply.

Low sodium diet Daily abdominal girth measurements Daily weights

What clinical findings should lead a nurse to suspect that a toddler with a rash has rubella? Select all that apply.

Low-grade fever Lymphadenopathy

A nurse is preparing to administer the prescribed digoxin (Lanoxin) intravenously (IV) to a client. Which nursing interventions are associated with IV digoxin administration? Select all that apply.

Monitor the heart rate closely Check the blood levels of digoxin Monitor the serum potassium level

Clients who have casts applied to the lower extremities must be monitored for complications. Which finding during assessment of the extremities of these clients is indicative of a complication? Select all that apply.

Numbness Prolonged capillary refill

A client is diagnosed with calcium oxalate renal calculi. Which foods should the nurse teach the client to avoid? Select all that apply.

Nuts Spina Rhubarb

Discharge planning for a toddler with newly diagnosed celiac disease includes instructions regarding dietary restrictions. What foods should the nurse recommend? Select all that apply.

Oatmeal Ice cream Rice cakes Corn crisps

What dietary choices should the nurse instruct the client taking spironolactone (Aldactone) to avoid? Select all that apply.

Potatoes Cantaloupe

A client with end-stage kidney disease is receiving continuous ambulatory peritoneal dialysis. The nurse should monitor the client for which manifestations of complications? Select all that apply.

Tachycardia Cloudy outflow Abdominal pain

A nurse provides crisis intervention for a client who recently left her husband because of physical abuse. Which client behaviors indicate to the nurse that the therapy has been successful? Select all that apply.

Utilizes healthier coping skills Describes the current situation realistically

A nurse is conducting a physical assessment of an infant with pyloric stenosis. What clinical findings does the nurse expect? Select all that apply.

Visible peristaltic waves Olive-shaped mass in the right upper quadrant

A nurse is assessing a 10-year-old child admitted to the pediatric unit with acute poststreptococcal glomerulonephritis (APSGN). What specific signs and symptoms does the nurse expect? Select all that apply.

Anorexia/ Periorbital edema/ Increased creatinine

A woman has made the decision to have breast augmentation surgery, and the procedure is to be performed on an outpatient basis. As part of the preoperative protocol, the nurse provides teaching regarding discharge instructions. Which instructions apply to this type of surgery? Select all that apply.

"Avoid taking aspirin or NSAIDs (e.g., ibuprofen [Advil]) for pain relief Sleep with your head and torso elevated for at least 1 week Take your temperature daily and notify the clinic if it goes above 99.6° F.

The nurse is providing postoperative care for a client who has received a prescription for nalbuphine (Nubain) for pain. For which side effects or adverse reactions should the nurse assess this client after administering this medication? Select all that apply.

Dry mouth Palpitations Constipation Orthostatic hypotension

What should the nurse do to prevent deformities of the knee in a client with an exacerbation of arthritis? Select all that apply.

Encourage motion of the joint. Maintain joints in functional alignment when resting.

. Health promotion efforts within the health care system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply.

Encouraging regular dental checkups Teaching the procedure for breast self-examination

A nurse is determining whether a 5-year-old child is displaying appropriate behaviors for this age. What developmental findings does the nurse expect? Select all that apply.

Enjoys imitative play/ Makes up rules for a new game.

A nurse in the child health clinic is assessing a 9-month-old infant. What developmental findings does the nurse expect? Select all that apply.

Enjoys push-pull toys Sits steadily without support Responds to simple commands

Which clinical findings indicate to the nurse that a 6-year-old child has nephrotic syndrome (NS) rather than acute glomerulonephritis (AGN)? Select all that apply.

3 Generalized edema/ Massive proteinuria/ Unchanged blood pressure.

Which statements describe a mentally healthy person? Select all that apply.

One who accepts aging One who engages available strengths One who sustains positive relationships

A client develops internal bleeding after an abdominal surgery. Which signs and symptoms of hemorrhage should the nurse expect the client to exhibit? Select all that apply.

Pallor Tachycardia Smoking

A nurse is assessing a client with a diagnosis of hypoglycemia. What clinical manifestations support this diagnosis? Select all that apply.

Palpitations Diaphoresis Slurred speech

What nursing actions best promote communication when obtaining a nursing history? Select all that apply.

Establishing eye contact Paraphrasing the client's message Using broad, open-ended statements

A nurse is caring for the newborn of a mother with diabetes. For which signs of hypoglycemia should the nurse assess the newborn? Select all that apply.

Irritability Hypotonia Ineffective sucking

A 4½-year-old child is admitted to the pediatric unit in preparation for surgery. What psychological responses to hospitalization does the nurse anticipate from this preschooler? Select all that apply.

Fearfulness regarding intrusive procedures Misgivings about being punished for a misdeed

A nurse is performing a physical assessment of a client with gout. What parts of the client's body should the nurse assess for the presence of tophi (urate deposits)? Select all that apply.

Feet Ears

Which of the following variables are scored on a biophysical profile? Select all that apply.

Fetal tone Fetal movement Amniotic fluid index Fetal breathing movements

A nurse is assessing a client with a brain tumor. Which clinical findings indicate an increase in intracranial pressure? Select all that apply.

Fever Stupor

Which food selections by a client with malabsorption syndrome indicate that the nurse's dietary teaching was successful? Select all that apply.

Green beans Baked potato

An 11-year-old child who recently returned from a camping trip reports chills, fever, and a headache and is taken to the clinic by the parents. What is most important for the nurse to assess initially during the child's history and physical examination? Select all that apply:

History of allergies/ Duration of clinical findings.

When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions? Select all that apply.

Airborne Contact Standard

To prevent bleeding after a suprapubic prostatectomy, the client should be instructed to avoid straining on defecation. Which foods should the nurse encourage the client to eat to help prevent constipation during the recovery period? Select all that apply.

Apple Oatmeal Green peas

Which healthy snacks should the nurse teach the parents to give their 2-year-old child who has a diagnosis of acute asthma? Select all that apply.

Apple slices Sliced vegetables

A client who has just begun breastfeeding complains that her nipples feel very sore. What should the nurse encourage the mother to do? Select all that apply.

Apply cool packs to her breasts to reduce the discomfort/ Take the analgesic medication prescribed to limit the discomfort/ Assume a different position when breastfeeding to adjust the infant's sucking.

What interventions should the nurse anticipate will be prescribed for a client who has a leak of the thoracic duct following radical neck surgery? Select all that apply.

Bed rest to conserve energy Chest tube to drain the fluid Total parenteral nutrition (TPN) to boost immune defenses

Which are neurological manifestations of hyperthyroidism? Select all that apply

Blurred vision Exophthalmos

A client had a laparoscopic cholecystectomy. Postoperatively the client experiences nausea and vomiting and is admitted overnight for observation and hydration. What should the nurse include in the teaching plan when preparing this client for discharge? Select all that apply.

Call the health care provider if you have a fever of 100o F or more for two days. Check the puncture sites daily for redness, tenderness, swelling, heat, or drainage.

A client with hypertension is to begin a 2-gram sodium diet. The nurse should teach the client to avoid which foods. Select all that apply.

Canned chili Luncheon meat

The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply

Capillary refill, Pulse and skin temperature Movement and sensation

1- The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply.

Capillary refill, temperature, pulse

The nurse is instructing the student nurse how to administer percutaneous enterostomal gastrostomy (PEG) tube feeding to a client. What should the nurse tell the student? Please select all that apply.

Check prescription for correct client formula. Connect tube feeding bag to client and feeding pump. Check for residual before beginning feeding.

A 6-year-old child is hospitalized with nephrotic syndrome. The mother asks the nurse what she may bring for her child to play with during the hospitalization. In light of the child's age, what should the nurse suggest? Select all that apply.

Checkers/ Paper and crayons/ Simple card games.

An estrogen-progestin oral contraceptive is prescribed for a client. Which adverse effects should the nurse teach the client to report to the health care provider? Select all that apply.

Chest pain/ Breast soreness/ Calf tenderness.

A nurse is teaching a client about a sodium-restricted diet. What foods should the nurse encourage the client to avoid? Select all that apply.

Cold cuts Processed foods

When a client enters the emergency department in a psychiatric emergency, the nurse should perform an assessment in an organized manner. Place the following interventions in their order of priority, beginning with number 1 as the highest priority.

Collect identifying information. Obtain the chief complaint. Identify presenting clinical findings. Explore the previous psychosocial history. Document collected information on the clinical record.

A client is brought into the emergency department with complaints of chest pain. What are possible causes for the client's chest pain? Select all that apply.

Costochondritis Pneumonia, Pleuris Myocardial infarction

Which significant risk factors for coronary heart disease carry a greater risk for women than for men? Select all that apply.

Diabetes mellitus Low levels of high-density lipoprotein (HDL) cholesterol

A toddler is admitted to the pediatric unit with a temperature of 103.5° F (40.0° C), a runny nose, and a productive cough. Respiratory secretion specimens are sent for culture and sensitivity tests. Standard precautions are followed until the results are known. What other precautions should the nurse include? Select all that apply.

Droplet Contact Airborne

A client with left ventricular heart failure is taking digoxin (Lanoxin) 0.25 mg daily. What changes does the nurse expect to find if this medication is therapeutically effective? Select all that apply.

Diuresis Decreased edema Decreased pulse rate

A health care provider determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply.

Double vision Difficulty swallowing saliva Drooping of the upper eye lids

Which clinical findings does the nurse anticipate a client with an exacerbation of multiple sclerosis will experience? Select all that apply.

Double vision Scanning speech

A nurse in the child life center is evaluating a 15-month-old toddler's ability to perform physical tasks. What behavior indicates to the nurse that the child's development is age appropriate? Select all that apply.

Drinking from a cup Walking with a wide-based gait Throwing toys around the room

Which factors should the nurse identify that can precipitate hyponatremia? Select all that apply.

Gastrointestinal (GI) suction Diuretic therapy Continuous bladder irrigation

The nurse is caring for a client with type 1 diabetes. For which signs or symptoms of insulin reaction should the nurse particularly be observant? Select all that apply.

Headache Diaphoresis

A 6-year-old child with sickle cell disease is admitted with a vaso-occlusive crisis (painful episode). What are the priority nursing concerns? Select all that apply.

Hydration/ Pain management.

A client with Addisonian crisis exhibits severe manifestations of glucocorticoid and mineralocorticoid deficiencies. Which responses should the nurse expect the client to exhibit? Select all that apply.

Hyperkalemia Hyponatremia Postural hypotension Vomiting

Neuroleptic malignant syndrome develops in a client who is taking a conventional antipsychotic medication. What signs and symptoms does the nurse expect? Select all that apply.

Hyperpyrexia Increased muscle tone Respiratory depression

A client with a diagnosis of acquired immunodeficiency syndrome (AIDS) has a protozoal infection and is receiving pentamidine (NebuPent). The nurse should monitor the client for which common side effects? Select all that apply.

Hypoglycemia Decreased blood pressure

The nurse is preparing to bathe a neonate born at 30 weeks' gestation. Which practices by the nurse ensure the infant's safety? Select all that apply.

Immerses the neonate fully (except the head) in the tub Measures the body temperature within 2 to 4 hours before giving the bath Uses cleansing agents with neutral pH and minimal dyes while giving the bath

Which actions will the nurse include in the plan of care for a client with a left pneumothorax who has a chest tube in place? Select all that apply. One, some, or all responses may be correct.

Immobilize the left arm in a sling. Check the water-seal chamber for air bubbling. Assist the client to cough and deep breathe every hour while awake.

The nurse and client have entered the working phase of a therapeutic relationship. What can the nurse expect the client to do during this phase? Select all that apply.

Initiate topics of discussion. Accept limits on unacceptable behavior. Express emotions related to transference

Which actions should the nurse include when teaching a client about self-administration of a gastrostomy tube feeding? Select all that apply.

Instill water after the feeding Re-instill gastric contents removed after assessing for residual gastric contents

An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). What interventions are appropriate nursing care for the infant? Select all that apply.

Instilling saline nose drops Maintaining contact precautions Suctioning mucus with a bulb syringe

What clinical manifestations does a nurse expect a client with systemic lupus erythematosus (SLE) most likely to exhibit? Select all that apply.

Joint pain Facial rash Pericarditis

A client is admitted with the diagnosis of acute pancreatitis. For which clinical manifestations should a nurse assess the client? Select all that apply.

Jaundice Acute pain

After surgery a client is started on a clear liquid diet. Which should the nurse offer the client? Select all that apply.

Jell-O Broth Ginger ale

A nurse provides dietary teaching for a client with an acute exacerbation of colitis, and afterward the client makes a list of foods that can be included on the diet. Which food choices indicate that the teaching was effective? Select all that apply.

Jelly sandwich Lean roast beef Scrambled eggs

A 9-year-old child with type 1 diabetes is prone to having hypoglycemic episodes in the morning. Which intervention would be included in the school nurse's plan of care for this child?

Limiting fluid intake during school hours Asking the child each day what was eaten for breakfast

During physical examination of a 3-year-old child, the nurse finds that the child has only 15 teeth. Which foods should be included in the child's diet to promote tooth formation? Select all that apply.

Milk Boiled egg

A client has been diagnosed with hyperthyroidism. The nurse expects the client to exhibit which clinical manifestations? Select all that apply.

Nervousness Increased appetite

A client is diagnosed with gastric cancer, and a subtotal gastrectomy is performed. After surgery the client begins to hemorrhage. What clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? Select all that apply.

Oliguria Diaphoresis Tachycardia

A nurse identifies that a client may be dehydrated. Which clinical manifestations would the client exhibit? Select all that apply.

Oliguria Hypotension Tenting tissue turgor

A client has a colon resection with an anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply.

Oliguria Irritability Hypotension

1- A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? Select all that apply.

Oral temperature of 98.2° F Apical pulse of 88 beats per minute and regular Blood pressure of 116/78 mm Hg while in a sitting position

A nurse is assisting a client to plan a therapeutic diet that is high in vitamin C. What excellent sources of vitamin C should be included in the plan? Select all that apply.

Oranges Broccoli Strawberries

A nurse is developing a teaching plan for a child who has anemia as a result of inadequate nutrition. In addition to iron, which nutrients should the nurse include that are necessary for red blood cell synthesis? Select all that apply.

Protein Vitamin C

A nurse is performing a newborn assessment. What characteristics cause the nurse to suspect that the newborn has Down syndrome? Select all that apply.

Protruding tongue Epicanthal eye folds One transverse palmar crease

What are the best ways for a nurse to be protected legally? Select all that apply.

Provide care within the parameters of the state's nurse practice act. Document consistently and objectively.

A preschooler who has undergone adenoidectomy arrives at the practitioner's office for a follow-up visit. What other adaptations to the surgery should the nurse assess in addition to hearing? Select all that apply.

Sense of taste Sense of smell Speech sounds

A female client has a low hemoglobin level, which is attributed to an iron deficiency. Which foods should the nurse recommend that the client increase in the diet? Select all that apply.

Spinach Beef liver Baked beans

A neonate with an imperforate anus undergoes a colostomy. In which positions should the nurse place the infant during the postoperative period? Select all that apply.

Supine with head of crib elevated Side-lying with head of crib elevated

The nurse is teaching a sex education course to high school students. What should the nurse teach them about why gonorrhea is difficult to control? Select all that apply:

Symptoms of the disease are vague The incubation period is relatively short Causative organisms have become resistant to treatment.

A 12-year-old child with type 2 diabetes is scheduled for abdominal surgery. Which factors are most important for the nurse to consider during the postoperative period? Select all that apply.

The blood glucose level will increase because of the stress of surgery/ Diabetic control is usually maintained with insulin after surgery

A nurse is assessing a 4-year-old child. What age-appropriate language skills does the nurse expect the child to have fulfilled? Select all that apply.

Uses six- and eight-word sentences Has a vocabulary of 150 to 200 words

The practitioner prescribes no weight-bearing on a leg that has been casted because of a fracture of the femur. How should the nurse determine the appropriate length of the crutches for this child? Select all that apply:

The crutches should reach 2 inches below the axillae. The tips of the crutches should rest 6 inches outside the feet.

A 6-month-old infant has a congenital right-to-left shunt defect of the heart. What clinical findings are expected when the nurse completes a history and physical assessment and reviews the child's laboratory reports? Select all that apply.

Tissue hypoxia Increased hematocrit

A pregnant client is concerned that she may have been infected with HIV. What information should a nurse include when counseling this client about HIV testing? Select all that apply.

The risks of passing the virus to the fetus What positive or negative test results indicate The emotional, legal, and medical implications of test results

The mother of an 8-month-old who was recently diagnosed with celiac disease asked for information as to what foods contain gluten. Select all that apply

Wheat Oatmeal Cream of Wheat

A nurse in the pediatric intensive care unit is assessing a 6-month-old infant with bronchiolitis. What physiological responses to this lower respiratory tract infection does the nurse expect? Select all that apply.

Wheezing Sternal retractions Nasal flaring Prolonged expiratory phase

A child with a history of asthma is brought to the emergency department experiencing an acute exacerbation of asthma. Which nursing assessment findings support this conclusion? Select all that apply.

Wheezing Tachycardia

For which clinical indicators should the nurse monitor when caring for a client with cholelithiasis and obstructive jaundice? Select all that apply.

Dark urine Yellow skin Clay-colored stool

A nurse suspects that a newborn's mother had rubella during the first trimester of pregnancy. Which newborn problems support this assumption? Select all that apply.

Deafness Cardiac anomalies

A client's serum potassium level is below the expected range. Which clinical indicators should the nurse determine are consistent with hypokalemia? Select all that apply.

Decreased heart rate Peripheral paresthesia Decreased bowel sounds

A nurse in the pediatric clinic is taking the health history of a toddler with an exacerbation of eczema. What are the nurse's priority assessments of the child? Select all that apply.

Wearing cotton clothes Tolerance of new foods

A client with a history of three spontaneous abortions is now at 16 weeks gestation and attending the high-risk prenatal clinic. She expresses concerns about remaining at home during this pregnancy. Which questions will elicit responses most helpful to the nurse in developing the client's plan of care? Select all that apply.

"Do you have a support system available to help you?" Have you been told about the status of your pregnancy?"

Which clinical indicators identified by the nurse support the probable presence of a fecal impaction in a client? Select all that apply.

Abdominal cramps Fecal liquid seepage Hyperactive bowel sounds

A client has serially decreasing blood pressures after surgery. Which mechanisms involved in the regulation of blood pressure should the nurse consider? Select all that apply.

Activation of regulators that control renal angiotensin II. Increase of left ventricular stroke volume to maintain blood volume. Enervation of the sympathetic nervous system to constrict arterioles.

A client with metastatic breast cancer is started on a multiple drug regimen that includes docetaxel (Taxotere). The nurse assesses the client for which nontherapeutic effects of docetaxel? Select all that apply.

Alopecia Febrile neutropenia Hypersensitivity reaction

Which interventions should the nurse anticipate will be prescribed initially for a client who had a hemorrhoidectomy? Select all that apply.

Applying moist heat Administering stool softeners

An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the nurse must consider? Select all that apply.

Assessment of skin turgor Administration of antiemetic drugs Replacement of fluid and electrolytes

A client who has had an uncomplicated myocardial infarction asks the nurse about the resumption of sexual activity. Which parameters should the nurse consider determining the safe resumption of sexual activity? Select all that apply.

At least between 4 and 6 weeks after the myocardial infarction The point at which two flights of stairs can be climbed without dyspnea

A nurse is caring for a client with end-stage renal disease who has a mature arteriovenous (AV) fistula. What nursing care should be included in the client's plan of care? Select all that apply.

Auscultate for a bruit. Palpate the site to identify a thrill. Avoid drawing blood from the affected extremity.

The nurse is providing preoperative teaching for a client who is to have cataract surgery. Which is appropriate for the nurse to include concerning what the client should do after surgery? Select all that apply.

Avoid bending from the waist. Do not blow your nose.

A nurse is teaching a client who is taking a loop diuretic (e.g., furosemide [Lasix]) about foods that are high in potassium. Which foods should the nurse emphasize? Select all that apply.

Bananas Beef stew Baked potatoes

A nurse is caring for clients with a variety of psychiatric illnesses. For which diagnoses is the establishment of a psychiatric advance directive (PAD) most beneficial? Select all that apply.

Bipolar disease Paranoid schizophrenia

Aspirin is prescribed for a client with rheumatoid arthritis. Which clinical indicators of aspirin toxicity should the nurse teach the client to report? Select all that apply.

Blood in the stool Ringing in the ears

Which clinical manifestations does a nurse expect that a client with renal calculi might report? Select all that apply.

Blood in the urine Frequency and urgency of urination

A nurse is estimating a newborn's gestational age. What parameters should the nurse assess? Select all that apply.

Breast size Genital development

A nurse is teaching a prenatal class about the changes that occur during the second trimester of pregnancy. What cardiovascular changes should the nurse include? Select all that apply.

Cardiac output increases Blood pressure decreases/ The heart is displaced upward.

A nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods should the nurse include in the teaching? Select all that apply.

Carrots Leafy greens

What should the nurse include in a teaching plan for a client taking calcium channel blockers such as Nifedipine (Procardia)? Select all that apply.

Change positions slowly. Report peripheral edema. Avoid drinking grapefruit juice.

A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. The nurse determines that the client understands the dietary instructions when the client identifies the following foods. Select all that apply.

Chicken broth Enriched whole milk Red meats, such as beef Liver and other glandular organ meats

The nurse is monitoring a client who is having a third transfusion of packed red blood cells. Which of these may be evident if the client is experiencing a febrile transfusion reaction? Select all that apply.

Chills, Hypotension Tachycardia

Which response should the nurse expect when assessing a client who is dehydrated? Select all that apply.

Confusion Sunken eyeballs Decreased blood pressure

After surgery, a client is extubated in the post anesthesia care unit. Which clinical manifestations should the nurse expect if the client is experiencing acute respiratory distress? Select all that apply.

Confusion Tachycardia

A nurse assesses a client's intravenous site. What clinical finding leads the nurse to conclude that the intravenous (IV) site has been infiltrated? Select all that apply.

Coolness of skin near the insertion site, Swelling around the insertion site4 Cessation in flow of solution

A client is awaiting surgery for a ruptured lumbar nucleus pulposus. Which activities should the nurse inform the client will most likely increase pain? Select all that apply.

Coughing excessively Bearing down when having a bowel movement

Maintain joints A nurse expects a client with a herniated intervertebral disk to report a sudden increase in pain with which activities? Select all that apply.

Coughing or sneezing Straining when having a bowel movement functional alignment when resting

A client with mild preeclampsia is admitted to the high-risk prenatal unit because her blood pressure is progressively increasing. The nurse reviews the practitioner's prescriptions. What prescriptions does the nurse expect? Select all that apply.

Daily weight Side-lying bed rest Deep tendon reflexes

The nurse observes bleeding into the subgaleal compartment upon reviewing a child's magnetic resonance imaging (MRI) results. What other conditions should the nurse evaluate in the child? Select all that apply.

Decreased platelet level Decreased hematocrit levels

Which of the following symptoms indicates to the nurse that the client has an inadequate fluid volume? Select all that apply.

Decreased urine Hypotension Dry mucous membranes Poor skin turgor

Neuroleptic malignant syndrome is a potentially fatal reaction to antipsychotic therapy. What signs and symptoms of this syndrome should the nurse identify? Select all that apply.

Diaphoresis Hyperrigidity Hyperthermia

A client is diagnosed as having colitis. Which clinical findings should the nurse expect the client to report? Select all that apply.

Diarrhea Abdominal cramps

A 2-year-old child is admitted with multiple fractures and bruises, and abuse is suspected. Which nursing assessment findings support this suspicion? Select all that apply.

Difficulty consoling Underdevelopment for age

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls what expected sensory losses associated with aging? Select all that apply.

Diminished sensation of pain Impaired hearing of high-frequency sounds

Which of the following are congenital anomalies or birth defects seen in children? Select all that apply.

Dysplasias Disruptions Deformations Malformations

A nurse is caring for several postoperative clients. For what clinical manifestations of a pulmonary embolus should the nurse monitor these clients? Select all that apply.

Dyspnea Hemoptysis Feeling of impending doom

The nurse is creating a discharge teaching plan for a client that had a subtotal gastrectomy. The nurse should include what instructions about minimizing dumping syndrome? Select all that apply.

Eat small frequent meals Lie down for one hour after eating

A nurse is performing the physical assessment of a client admitted to the hospital with a diagnosis of cirrhosis. The nurse expects to observe what skin conditions? Select all that apply.

Ecchymoses Telangiectasis

The nurse is providing care for a client with small-cell carcinoma of the lung that develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What clinical findings correspond with the secretion of antidiuretic hormone (ADH)? Select all that apply.

Edema Hyponatremia

Fludrocortisone (Florinef) is prescribed for a client with adrenal insufficiency. Which responses to the medication should the nurse teach the client to report? Select all that apply.

Edema Rapid weight gain

A pregnant client with sickle cell anemia visits the clinic each month for a routine examination. What additional assessment should be made during every visit? Select all that apply.

Evidence of urinary tract infection Presence of hyperemesis gravidarum

A client's nipples become sore and tender as a result of her newborn's vigorous suckling. What should the nurse recommend that the mother do to alleviate the soreness? Select all that apply.

Expose the nipples to air several times a day/ Apply hydrogel pads to the nipples after each feeding.

Before a client's discharge after a thyroidectomy, the nurse teaches the client to observe for signs of surgically induced hypothyroidism. What clinical indicators identified by the client provide evidence that the nurse's instructions are understood? Select all that apply

Fatigue Dry skin

The nurse is planning discharge instructions for a client who had a thyroidectomy. For which signs of surgically induced hypothyroidism should the nurse alert the client? Select all that apply.

Fatigue Dry skin

A client who had surgery for a ruptured appendix develops peritonitis. What clinical findings related to peritonitis should the nurse expect the client to exhibit? Select all that apply.

Fever Abdominal muscle rigidity

A client recovering from a gastric resection for gastric cancer is started on small frequent meals. The nurse evaluates the client's response 30 minutes after nutritional intake and determines that the client is experiencing dumping syndrome if which of the following signs and symptoms are observed? Select all that apply.

Flushing Diarrhea Sweating

Which intervention may be delegated to nursing assistive personnel (NAP)? Select all that apply.

Having a client care technician obtain routine vital signs Having a client care technician ambulate a stable client

A nurse is teaching a female client about using oral contraceptives and when to report complications. What clinical findings should alert the client to stop taking the contraceptive and notify the health care provider immediately? Select all that apply.

Headaches Visual disturbances.

Giving an explanation of how the injury occurred that is not consistent with the injury. Which functions are registered nurses legally permitted to perform in a mental health hospital? Select all that apply.

Health promotion Case management Treating human responses

A nurse is caring for a pregnant client with thrombophlebitis. Which anticoagulant medication may be prescribed? Select all that apply.

Heparin (Hep-Lock) Enoxaparin (Lovenox)

A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. The nurse expects the client to report that which joints were involved initially? Select all that apply.

Hips Knees

A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify? Select all that apply.

Hirsutism Buffalo hump

The laboratory results of a woman in labor indicate the presence of cocaine and alcohol. Which characteristics should cause the nurse to recognize fetal alcohol syndrome (FAS) in the newborn? Select all that apply.

Hypotonia Hypoplastic maxilla Small, upturned nose

An infant with persistent diarrhea is subject to significant fluid and electrolyte alterations. What physiological imbalances will the nurse most likely encounter? Select all that apply.

Hypovolemia Metabolic acidosis

A client's diet is modified to eliminate foods that act as cardiac stimulants. The nurse should teach the client to avoid what foods? Select all that apply.

Iced tea, Hot cocoa Chocolate pudding

A 25-year-old woman is seeking outpatient counseling after thinking about suicide. The nurse realizes that there some factors place individuals at a higher risk for suicide. Which of these factors increases the risk for suicide? Select all that apply.

Impulsivity Panic attacks Unemployment Substance abuse

A neonate is returned to the pediatric surgical unit after repair of a myelomeningocele. What priority assessments should be performed in the immediate postoperative period for this infant? Select all that apply.

Incision, for signs of CSF leak Urinary bladder, for distention Vital signs, for signs of infection Head circumference, for increase

The laboratory report of a school-aged child with celiac disease reveals that the child has anemia. What does the nurse suspect as the most likely causes of the anemia? Select all that apply. Incomplete absorption of iron/ Incomplete absorption of folic acid.

Incomplete absorption of iron/ Incomplete absorption of folic acid.

After a craniotomy to remove a brain tumor, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which clinical indicators should the nurse monitor the client? Select all that apply.

Increased weight Decreased serum sodium Decreased level of consciousness

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse should assess for which complications? Select all that apply.

Infection Hyperglycemia Electrolyte imbalance

A health care provider diagnoses a client with acute cholecystitis with biliary colic. What clinical findings should the nurse expect when performing a health history and physical assessment? Select all that apply.

Intolerance to foods high in fat Pain in the upper right quadrant of the abdomen

Which assessment leads a nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP)? Select all that apply.

Irritability High-pitched cry Ineffective feeding behavior

The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply.

Rapid pulse, Decreased urinary output

A client with ascites has a paracentesis, and 1500 mL of fluid is removed. The nurse recognizes that it is important to monitor the client for what signs of complications that may occur immediately after the procedure? Select all that apply.

Rapid thready pulse Decreased blood pressure

After a difficult birth, a neonate has an Apgar score of 8 after 5 minutes. Which assessments are assigned 2 points for their categories? Select all that apply. One, some, or all responses may be correct.

Reflex irritability: cry Heart rate: 110 beats/min Respiratory rate: good cry

After a difficult birth, a neonate has an Apgar score of 8 after 5 minutes. Which signs met the criteria of 2 points? Select all that apply.

Reflex irritability: cry Respiratory rate: a good cry Heart rate: 110 beats/min

A school-aged child with sickle cell anemia is admitted to the pediatric unit in a vaso-occlusive crisis. The nurse's priority is to relieve the excruciating pain. What interventions should be implemented after the pain is under control? Select all that apply.

Rehydration/ Oxygen therapy.

A toddler has just had a cast applied for a fractured wrist. The wrist and elbow are immobilized. What information should the nurse include in the home care instructions before discharge? Select all that apply.

Report swelling of fingers. Elevate casted arm when the child is standing.

A nurse is caring for a client with a diagnosis of varicose veins. Which clinical findings can the nurse expect to identify when assessing this client? Select all that apply.

Reports of leg fatigue, Tortuous veins in the legs Pain in lower extremities when standing

A nurse is teaching a client about prophylactic measures that minimize the risk of contracting hepatitis B. Which actions should be included in this teaching plan? Select all that apply.

Screening of blood donors Maintaining a monogamous sexual relationship

A nurse is assessing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? Select all that apply.

Sneezing Hyperactivity High-pitched cry

The nurse understands that in a second degree atrioventricular (AV) block: Select all that apply.

Some P waves are conducted to the ventricles. Treatment consists of atropine or a pacemaker.

A nurse is assessing the legs of a client with a history of chronic venous insufficiency. What physiologic changes should the nurse conclude are the result of this disease process? Select all that apply.

Stasis ulcer Brown discoloration Indigestion not relieved by antacids Acute chest pain after rigorous exercise

A nurse is teaching a class about behavioral expectations of infants and children to a group of parents. What does the nurse include as behaviors expected of 8-month-old infants? Select all that apply.

Stranger anxiety Playing peek-a-boo Standing by holding on to furniture

A nurse in the pediatric clinic is advising the mother of a toddler who has a pinworm infestation. What should the nurse teach the mother about caring for her child during and after treatment? Select all that apply.

Strategies to prevent re-infestation The need for medication for the entire family

A client with end-stage kidney disease (ESKD) is scheduled to receive peritoneal dialysis. What should the nurse include when teaching the client about the signs and symptoms associated with complications of peritoneal dialysis? Select all that apply.

Tachycardia Cloudy outflow Abdominal pain

A nurse caring for a pregnant client and her partner suspects domestic violence. Which assessments support this suspicion? Select all that apply.

The woman has injuries to the breasts and abdomen/ The partner answers questions that are asked of the woman/ The woman has visited the clinic several times in the last month.

A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristic indicates to the nurse that the newborn has fetal alcohol syndrome (FAS)? Select all that apply.

Thin upper lip Small, upturned nose Smooth vertical ridge in the upper lip

Which of the following signs are indications of hydration status during a sickle cell crisis? Select all that apply.

Turgor of tissue Texture of mucous membranes

The nurse is educating a client who is being discharged after insertion of a coronary artery stent. For what signs and symptoms should the nurse instruct the client to seek immediate medical attention? Select all that apply.

Unexplainable profuse diaphoresis

A client has a diagnosis of an unruptured tubal pregnancy. Which assessment findings correlate with this diagnosis? Select all that apply.

Unilateral abdominal pain History of a sexually transmitted infection

A client is diagnosed with hyperthyroidism and is experiencing exophthalmia. Which measures should the nurse include when teaching this client how to manage the discomfort associated with exophthalmia? Select all that apply.

Use tinted glasses. Elevate the head of the bed 45 degrees. Tape eyelids shut at night if they do not close.

Optimal teaching for the client with multiple sclerosis (MS) who is experiencing urinary retention includes: select all that apply

Using Crede's maneuver Monitoring for and reporting signs of urinary tract infection

A 6-year-old child is in the acute phase of nephrotic syndrome. The mother asks the nurse about play activities for her child. What should the nurse suggest? Select all that apply.

Video games/ Children's books.

A ventroperitoneal shunt is inserted in a 4-month-old infant with hydrocephalus. Which signs of shunt failure should the nurse teach the parents during preparations for the infant's discharge? Select all that apply.

Vomiting Distended fontanels

The nurse, caring for a 3-year-old child with meningitis, should be alert for which signs and symptoms of increased intracranial pressure? Select all that apply.

Vomiting Headache Irritability

A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? Select all that apply.

Vomiting Muscle weakness Irregular heart rate

A client is admitted with a diagnosis of Cushing syndrome. For which clinical manifestations should the nurse observe when assessing this client? Select all that apply.

Weakness Hypertension Truncal obesity

A nurse is teaching an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? Select all that apply.

What is diabetes?" Can you tell me how the glucose monitor works?"

1- A client who is HIV positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissible through: (Select all that apply.)

semen. Blood

A 9-year-old child is admitted to the pediatric unit with a tentative diagnosis of acute lymphocytic leukemia (ALL). What early signs and symptoms of leukemia does the nurse expect to identify? Select all that apply:

Anorexia/ Limb pain/ Splenomegaly.

A nurse is assessing a client with a diagnosis of hypothyroidism. Which clinical manifestations should the nurse expect when assessing this client? Select all that apply.

Dry skin Brittle hair

The nurse is caring for a client who is experiencing cardiogenic shock. Which clinical findings support this diagnosis? Select all that apply.

Dyspnea Diaphoresis Tachycardia

What clinical indicators is the nurse most likely to identify when taking the admission history of a client with right ventricular failure? Select all that apply.

Edema Dyspnea

A nurse teaches a pregnant woman about the need to increase her intake of complete proteins. Which foods identified by the client indicate that the teaching is effective? Select all that apply Milk

Eggs Cheese

The nurse provides a dietary list to a client who is taking oral anticoagulants with foods that should be avoided because they are high in vitamin K. What foods should be included on the list? Select all that apply.

Eggs Liver Cheese

A nurse is assessing a client with the diagnosis of scleroderma for signs of calcium deposits in organs, Raynaud phenomenon, esophageal dysfunction, sclerodactyly (scleroderma of the digits), and telangiectasia (vascular lesions formed by dilation of a group of small blood vessels [CREST syndrome]). What clinical indicators should the nurse expect to identify? Select all that apply.

Esophageal reflux Spider-like hemangiomas Episodic blanching of the fingers

A nurse is caring for an 8-year-old child with acute poststreptococcal glomerulonephritis (APSGN). What medications does the nurse expect the practitioner to prescribe? Select all that apply.

Furosemide/ Hydralazine.

Which statements by a client with hyperemesis gravidarum would confirm that the client needs further teaching? Select all that apply:

I'll start limiting my carbohydrates/ I'll lie down for at least 2 hours after I eat.

A nurse is caring for a child with a diagnosis of meningitis. What clinical findings indicate an increase in intracranial pressure? Select all that apply.

Irritability Bradycardia

A nurse is caring for an older client who had non-insulin dependent diabetes for 15 years that progressed to insulin dependent diabetes 2 years ago. What common complications of diabetes should the nurse assess for when examining this client? Select all that apply.

Leg ulcers Loss of visual acuity Prolonged capillary refill in the toes Decreased sensation in the lower extremities

A nurse is caring for an older client who had non-insulin-dependent diabetes for 15 years that progressed to insulin dependent diabetes 2 years ago. What common complications of diabetes should the nurse assess for when examining this client? Select all that apply.

Leg ulcers Loss of visual acuity Prolonged capillary refill in the toes Decreased sensation in the lower extremities

A client who has been taking spironolactone (Aldactone) is admitted to the hospital with hypokalemia. The nurse will assess the client for which clinical findings? Select all that apply.

Lethargy Thready, weak pulse Muscle weakness

What clinical indicators should the nurse expect when interviewing and assessing a client with Ménière's disease? Select all that apply.

Nausea Dizziness Jerky lateral eye movements

A client is diagnosed with malabsorption syndrome. Which foods should the nurse teach the client to avoid? Select all that apply.

Oatmeal Rye bread

The client has been admitted for possible acute cholecystitis with biliary colic. What clinical findings should the nurse expect when performing a health history and physical assessment? Select all that apply.

Pain triggered by a large or high-fat meal Pain in the upper right quadrant of the abdomen Positive Blumberg's sign

What are the clinical indicators that a nurse expects when an intravenous (IV) line has infiltrated? Select all that apply

Pallor Edema Decreased flow rate

What clinical indicators should a nurse expect when assessing a client with hyperthyroidism? Select all that apply.

Weight loss Tachycardia Restlessness Exophthalmos

The nurse is teaching growth and development activities to the parents of a 3-month-old infant. Which statements does the nurse include in the teaching plan? Select all that apply.

Your child should be able to coo, babble, and chuckle/ Your child should be able to pull at blankets or clothes/ Your child's head can come up to a 45- to 90-degree angle from the table.

Which clinical indicators does the nurse expect a client with Parkinson disease to exhibit? Select all that apply.

Resting tremors Flattened affect Slow voluntary movements

A client has rotator cuff surgery. What should be included when the nurse performs a neurovascular assessment of the affected extremity immediately after surgery? Select all that apply.

Skin color Movement of the hand Sensations in the extremity

A nurse is assessing an older adult client. Which clinical findings are expected responses to the aging process? Select all that apply.

Slowed neurological responses Forgetfulness about recent events Reduced ability to maintain an erection

A client with a history of cardiac dysrhythmias is admitted to the hospital with dehydration. What does the nurse expect to be listed on the client's plan of care?

Small frequent intake of juices broth or milk.

A home care nurse is counseling a client with amyotrophic lateral sclerosis (ALS). What information should the nurse include in the discussion? Select all that apply.

Space activities throughout the day. Anticipate the use of alternate ways to communicate.

The mother of a 30-month-old toddler who has been treated for pinworm infestation is taught how to prevent a recurrence. Which statement by the mother indicates that the teaching has been effective? Select all that apply.

We'll need to wash all of our sheets every day." I'll have the whole family take the medication again in 2 weeks."

A client with depression has not responded to a tricyclic antidepressant and outpatient electroconvulsive therapy (ECT). The health care provider prescribes selegiline (Eldepryl), and the nurse teaches the client about food to be avoided while taking this medication. Which foods identified by the client allow the nurse to conclude that the instructions have been understood? Select all that apply.

Aged cheese Chocolate drinks

The nurse is caring for a 76-year-old obese client with a history of epigastric distress, esophageal burning, binge drinking, and frequent episodes of bronchitis. A diagnosis of hiatal hernia is made. Which health problems most likely contributed to the development of the hiatal hernia? Select all that apply.

Aging Obesity Alcoholism

A mother of a 7-year-old child complains to the nurse that her child wets the bed at night. Upon interaction with the child, the nurse learns that the child is afraid of the dark. What does the nurse recommend to the mother? Select all that apply.

Allow your child to keep a light on in the bedroom at night" Encourage your child to copy his siblings who sleep alone in their room.

A client diagnosed with bone cancer of the leg will receive radiation therapy as part of the treatment plan. The client has voiced concern about the side effects of the radiation treatments. The nurse will prepare the patient for which major side effects of radiation therapy? Select all that apply.

Altered taste sensations Fatigue

The nurse is assessing a client with hyperthyroidism. For which signs and symptoms should the nurse assess the client? Select all that apply.

Amenorrhea Flushed appearance Short attention span

A client has a diagnosis of hemorrhoids. Which signs and symptoms does the nurse expect the client to report? Select all that apply.

Anal itching Blood in stool Rectal pressure Pain when defecating

A nurse is reviewing the history, physical examination, and diagnostic test results of a client with colitis. What clinical findings are associated with this disorder? Select all that apply.

Anemia Diarrhea Abdominal cramps

A client with end-stage renal disease is hospitalized. For what signs and symptoms of complications should the nurse monitor the client? Select all that apply

Anemia Dyspnea Anasarca

A client with end-stage renal disease is hospitalized. For what signs and symptoms of complications should the nurse monitor the client? Select all that apply.

Anemia Dyspnea Anasarca

A client's laboratory report indicates the presence of hypokalemia. For which clinical manifestations associated with hypokalemia should the nurse assess the client? Select all that apply.

Anorexia Leg cramps

A client comes to the ambulatory surgery unit on the morning of an elective surgical procedure. The client reports shortness of breath, dizziness, and palpitations. The nurse observes profuse diaphoresis and is concerned that the client may be having either a panic attack or a myocardial infarction. Which assessments support the conclusion that the client may be experiencing a myocardial infarction? Select all that apply.

Anxiety Chest pain Irregular pulse

An older client asks, "How do I know that all the medications that I take are safe?" What information should the nurse include in a response to this client's question? Select all that apply.

Ask your health care provider how and when you should be taking your medications."

A nurse inserts a nasogastric tube into a preterm infant's esophagus for feedings. Which assessment findings signify correct placement of the tube? Select all that apply.

Aspiration produces a small quantity of light-yellow or light-green liquid. Testing of the aspirate with the use of a Nitrazine strip reveals that the gastric fluid is acidic.

The nurse provides postoperative care to the client following subtotal thyroidectomy by: Select all that apply.

Assessing for frequent swallowing Ambulating the client the evening of surgery Assessing for facial spasms, apprehension, or tingling of the lips, fingers, or toes Ensuring that oxygen, suction equipment, and a tracheosomy tray are at the bedside

A client is in the intensive care unit after sustaining a T2 spinal cord injury. Which priority interventions should the nurse include in the client's plan of care? Select all that apply.

Assessing for respiratory complications Monitoring and maintaining blood pressure

Which nursing activities are examples of primary prevention? Select all that apply.

Assisting with immunization programs Facilitating a program about smoking cessation

A client with gastroesophageal reflux disease (GERD) should make diet and lifestyle changes. What instructions should the nurse include in the client's discharge teaching? Select all that apply.

Avoid caffeine-containing products. Chew thoroughly while eating slowly.

A client with the diagnosis of Cushing syndrome has the following laboratory results: Na (sodium) 149 mEq/L; K (potassium) 3.2 mEq/L; Hb (hemoglobin) 17 g/dL; and glucose 90 mg/dL. What should the nurse teach the client? Select all that apply.

Avoid foods high in salt. Eat foods high in potassium.

A nurse is providing discharge instructions for a client with a diagnosis of gastroesophageal reflux disease (GERD). What should the nurse advise the client to do to limit symptoms of GERD? Select all that apply.

Avoid heavy lifting.

A nurse teaches a client with calcium-based renal calculi about foods that can be eaten on a low-calcium diet (400 mg/day). The nurse concludes that the teaching was effective when the client selects what food items from the menu. Select all that apply.

Baked chicken Roast beef with mashed potato

The nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods would the nurse include in the teaching? Select all that apply. One, some, or all responses may be correct.

Carrots Leafy greens Cantaloupe

A nurse is counseling a client who is at risk for developing osteoporosis. Which foods should the nurse recommend? Select all that apply.

Chicken breasts Broiled beef steak

A client with the diagnosis of chronic kidney disease develops hypocalcemia. Which clinical manifestations should the nurse expect the client with hypocalcemia to exhibit? Select all that apply.

Chvostek sign Muscle cramps

Which nursing interventions require a nurse to wear gloves? Select all that apply.

Cleaning a newborn immediately after delivery Emptying a portable wound drainage system

A 4-month-old infant is being treated for talipes equinovarus (clubfoot). The infant has a cast change every 2 to 3 weeks. When the infant is brought to the well-baby clinic for a routine visit, a nurse evaluates the foot in the cast. Which assessments should the nurse include? Select all that apply.

Color of the toes of the foot in the cast Movement of the toes of the foot in the cast

A client has a decreased serum sodium level. The nurse should assess the client for which signs of hyponatremia? Select all that apply.

Confusion Muscle weakness

A nurse is assessing a client with the diagnosis of hemorrhoids. Which factors in the client's history probably played a role in the development of the client's hemorrhoids? Select all that apply.

Constipation Numerous pregnancies

The nurse plans interventions for a client with smoke inhalation based on a negative chest x-ray and arterial blood gases that show a Po2 of 85 mm Hg, a PCO2 of 45 mm Hg, and a pH of 7.35. Which interventions should the nurse anticipate will be prescribed? Select all that apply.

Coughing Deep breathing Humidified oxygen

A client with a history of heart failure is admitted to the hospital with the diagnosis of pulmonary edema. For which signs and symptoms specific to pulmonary edema should the nurse assess the client? Select all that apply.

Coughing Orthopnea Diaphoresis

A client who has been immobile for a prolonged time develops hypercalcemia. Which findings are consistent with this condition? Select all that apply

Deep bone pain Depressed deep tendon reflexes

A nurse is assessing and obtaining the health history of a 6-year-old child with celiac disease. Which characteristic signs of this disorder does the nurse expect the child to exhibit? Select all that appl

Diarrhea/ Muscle wasting/ Abdominal distention.

A nurse administers oxygen at 2 L/min via nasal cannula to a client with emphysema. For which clinical indicators should the nurse closely observe the client? Select all that apply.

Drowsiness Mental confusion

A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? Select all that apply.

Dry cerumen Difficulty hearing high-pitched voices

The nurse is caring for a client who recently returned from another country who exhibits signs and symptoms suspicious of severe acute respiratory syndrome (SARS). Which clinical manifestations support this diagnosis? Select all that apply.

Dry cough Shortness of breath Fever greater than 100.4° F

A female client whose ECG exhibits multiple premature ventricular complexes is to take oral disopyramide (Norpace). Which side effects should the nurse include when teaching the client about this drug? Select all that apply.

Dry mouth Constipation

A nurse is caring for a school-aged child with type 1 diabetes and determines that the child is experiencing an episode of hyperglycemia. What assessments led the nurse to this conclusion? Select all that apply.

Dry skin/ Increased thirst/ Deep, rapid breathing.

An 83-year-old client is diagnosed with left-sided congestive heart failure. Which assessment findings should the nurse expect to find on this client? Select all that apply.

Dyspnea Crackles Cool extremities

A nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). What recommendations are essential for the nurse to include? Select all that apply.

Eat foods high in vitamin C. Take your temperature daily. Balance periods of rest and activity.

To help prevent long-term complications associated with gastric bypass surgery, the nurse needs to educate the client. Identify the factors that should be included in the nurse's teaching plan for this client. Select all that apply.

Eat foods rich in calcium. Consume a diet high in protein. Receive vitamin B12 injections routinely.

When preparing a child with asthma for discharge, what instructions must the nurse emphasize to the family? Select all that apply.

Eliminate allergens in the home. Continue the medications even if the child is asymptomatic.

What dietary information should the nurse include in the teaching plan for parents of an infant with galactosemia? Select all that apply.

Eliminate milk. Provide soybean-based formulas.

A nurse provides instruction to a client who was treated for renal colic as a result of uric acid stones. What should the nurse include in the teaching plan? Select all that apply.

Eliminate organ meats from diet. Drink two glasses of water at bedtime. Increase fluid intake to three quarts daily.

The nurse is assessing a client with hyperthyroidism. Which clinical indicators are consistent with this diagnosis? Select all that apply.

Emotional lability Dyspnea on exertion Hyperactive deep tendon reflexes

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The parents ask what are the symptoms of bleeding for which they should be looking in the future. What are the signs for which to look? Select all that apply.

Epistaxis Hematuria Hemarthrosis Easy bruising Dark colored tarry stool

A nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. What interventions should the nurse include, that will decrease the risk of complications? Select all that apply.

Examining the feet daily Wearing well-fitting shoes Performing regular exercise

A nurse is collecting information about a client who has type 1 diabetes and who is being admitted because of diabetic ketoacidotic coma. Which factors can predispose a client to this condition? Select all that apply.

Excessive emotional stress Running a fever with the flu

A nurse is assessing a client with a diagnosis of diabetes insipidus. For which signs indicative of diabetes insipidus should the nurse assess the client? Select all that apply.

Excessive thirst Dry mucous membranes Decreased urine specific gravity

Which clinical indicators does the nurse expect to identify when assessing a client with tic douloureux? Select all that apply.

Excruciating facial pain Twitching of the mouth

A pregnant client complains of constipation. Which strategies should the nurse recommend? Select all that apply.

Exercise regularly Add a few tablespoons of wheat bran to cereal at breakfast. Plan to have a bowel movement at the same time every day.

A nurse who suspects that a newly admitted infant is the victim of child abuse assesses the parents' interaction with their baby. What parental behaviors might support the diagnosis of child abuse? Select all that apply.

Exhibiting difficulty in showing concern for their child Procrastinating in obtaining treatment for their child's injuries

A client asks the nurse about the use of an intrauterine device (IUD) for contraception. What information should the nurse include in the response? Select all that apply.

Expulsion of the device/ Occasional dyspareunia/ Risk for perforation of the uterus.

A paracentesis is prescribed for a client recently admitted to a medical unit. The nurse recalls that the procedure is performed for what reasons? Select all that apply.

Extract peritoneal fluid Improve respiratory status Obtain peritoneal fluid for culture

The nurse is planning to teach a client with heart failure about the signs and symptoms of cardiac decompensation. What clinical manifestations should the nurse include? Select all that apply.

Extreme fatigue Coughing at night Difficulty breathing

The school nurse is working with a child with a hearing deficit. The child arrives at school today without hearing aids. When the nurse talks with the child about the reasons for not wearing the aids, the nurse will need to ensure that the child hears what is being said. What actions by the nurse will promote effective communication? Select all that apply.

Facing the child directly when talking to the child/ Avoiding chewing gum while communicating with the child

A nurse assesses a newly admitted client with a diagnosis of pulmonary tuberculosis (TB). Which clinical findings support this diagnosis? Select all that apply.

Fatigue Hemoptysis Night sweats

A client is taught how to recognize indications of a hypoglycemic reaction. Which signs and symptoms identified by the client indicate to the nurse that the teaching was effective? Select all that apply.

Fatigue Weakness Nervousness Increased perspiration

The nurse teaches the client about foods to help prevent constipation after pelvic surgery. Which foods selected by the client indicate that the teaching is understood? Select all that apply.

Green vegetables Whole grain bread

A nurse, caring for a client with uncontrolled diabetes, suspects that a client is experiencing hypoglycemia in response to insulin administration. What clinical manifestations lead the nurse to this conclusion? Select all that apply.

Headache Confusion Profuse sweating

A client with a history of heart failure admits to the nurse that a salt-restricted diet has not been followed. The client reports increased ankle swelling and shortness of breath that is relieved by sitting up. For what other clinical indicators of fluid retention should the nurse monitor the client? Select all that apply.

Headache Crackles on lung auscultation

A child is admitted with a diagnosis of acute poststreptococcal glomerulonephritis. While performing a physical assessment and reviewing the child's laboratory reports, what clinical findings does the nurse expect? Select all that apply.

Hematuria/ Proteinuria/ Periorbital edema/ Increased specific gravity/ Slight increase in blood pressure.

The nurse should refer a client to the pulmonary clinic for suspected tuberculosis based on which clinical indicators reported during the initial client interview? Select all that apply.

Hemoptysis Night sweats

The nurse is reviewing discharge instructions for a mother whose school-aged child was recently found to have celiac disease. Which statements by the mother demonstrate understanding of the child's nutritional needs? Select all that apply.

I'll try to provide meals that are lower in fats and higher in carbohydrates She loves raw carrots for snacking, so I'll have to avoid those when the disease is worse/ I'll be sure to look at the labels more closely from now on—we need to avoid hydrolyzed vegetable protein.

A nurse is planning education for a parent group related to procedures to be taken if accidental poisoning is suspected. What should the nurse include? Select all that apply.

Identify the material ingested Call the poison control center

A nurse is caring for a client after a thyroidectomy. For which signs of thyroid storm should the client be monitored? Select all that apply.

Increased heart rate Increased temperature

While reviewing the health history of a newborn with suspected jaundice, the nurse recalls that some risk factors place infants at a higher risk of developing jaundice. Which conditions are risk factors for jaundice? Select all that apply.

Infection Prematurity Breastfeeding Maternal diabetes

Which medications would the nurse plan to use when administering chelation therapy to a toddler-age client to decrease the pain associated with intramuscular administration? Select all that apply. One, some, or all responses may be correct.

LMX-4 Procaine

Which clinical indicators can the nurse expect when assessing a client with Cushing syndrome? Select all that apply.

Lability of mood Slow wound healing

For a client with schizophrenia, which symptoms are classified as negative symptoms? Select all that apply. One, some, or all responses may be correct.

Lack of energy Anhedonia

A nurse is caring for a client who has had type 1 diabetes for 25 years. The client states, "I have been really bad for the last 15 years. I have not paid attention to my diet and have done little to control my diabetes." What signs of common complications of diabetes might the nurse expect to identify when assessing this client? Select all that apply.

Leg ulcers Loss of visual acuity Thick, yellow toenails Decreased sensation in the feet

A client has a low hemoglobin level that is attributed to a nutritional deficiency. Which foods should the nurse teach the client to increase in the diet? Select all that apply.

Liver Raisins Spinach

At 42 weeks' gestation a client gives birth to an 8-lb 5-oz newborn. On examining the infant, what does the nurse expect to observe? Select all that apply.

Long nails Wrinkled skin

A woman at 40 weeks' gestation is admitted in active labor. After appropriate progress of her labor, the woman asks for and receives epidural analgesia. Once the epidural catheter has been inserted, which nursing assessments and interventions should be performed? Select all that apply.

Maintaining intravenous fluid administration Having oxygen available in case of hypotension Checking the bladder for distention every 2 hours Monitoring fetal heart rate and labor progress per hospital protocol

A nurse in the pediatric clinic is caring for a child with lead poisoning (plumbism). For which associated complications should the nurse assess the child? Select all that apply.

Marked anemia/ Kidney damage/ Encephalopathy.

The pathology report states that a client's urinary calculus is composed of uric acid. The nurse should instruct the client to avoid which food items. Select all that apply

Meat extracts Organ meats

A nurse is assigned to lead a relaxation group. Which techniques should the nurse incorporate? Select all that apply.

Meditation Mental imagery Deep-breathing exercises

A nurse teaches a client with gastrointestinal (GI) irritability to minimize the intake of dietary irritants. Which products did the nurse teach the client to avoid? Select all that apply.

Milk Cheese Chocolate candy

A health care provider prescribes doxorubicin for a client with acute myelogenous leukemia. Which specific interventions should the nurse implement? Select all that apply.

Monitor for jaundice Increase fluids by mouth Provide frequent oral care Assess vital signs routinely

The client is admitted to the hospital with a large goiter, and a thyroidectomy is performed. What should the nurse do during the first four hours after the surgery? Select all that apply

Monitor for stridor or dyspnea Assess the sides and back of the client's neck for evidence of bleeding.

A client is diagnosed with Crohn's disease, and parenteral vitamins are prescribed. The client asks why the vitamins have to be given intravenously (IV) rather than by mouth. What rationales for this route should the nurse include in a response to the question? Select all that apply.

More rapid action results. They are ineffective orally. Intestinal absorption may be inadequate.

Which signs cause the nurse to suspect cardiac tamponade after a client has cardiac surgery? Select all that apply.

Muffled heart sounds Increased central venous pressure (CVP), Jugular vein distention

When receiving hemodialysis, the complication of the removal of too much sodium may occur. For which clinical findings associated with hyponatremia should the nurse assess the client? Select all that apply.

Muscle cramps Extreme fatigue

A client is receiving total parenteral nutrition solution. Potassium has not been added to the solution. The nurse monitors the client for which signs of hypokalemia? Select all that apply.

Muscle weakness Cardiac dysrhythmias

A client with chronic obstructive pulmonary disease will be taking long-term oral corticosteroid therapy. After the nurse conducts a teaching session, which statement by the client indicates that further education is needed? Select all that apply.

My urine may become discolored." "I will lose weight while on this medication." The medication should be taken between meals." "When I'm feeling better, I can stop taking this medication."

During the initial assessment of a newborn the nurse suspects a congenital heart defect. Which clinical manifestations support this suspicion? Select all that apply.

Nasal flaring Sternal retractions Grunting respirations

A client with heart failure is receiving digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). The nurse will assess for which signs and symptoms of digoxin toxicity? Select all that apply.

Nausea Yellow vision Irregular pulse

A nurse is planning a childbirth education class about maternal psychological and physiological changes as pregnancy nears term. Which problems and concerns should the nurse include in the presentation? Select all that apply.

Nesting needs increase Anxiety about childbirth increases Gastrointestinal motility decreases

Which common initial clinical effects should the nurse expect a client with multiple sclerosis to exhibit? Select all that apply.

Nystagmus Scanning speech Intention tremors

A client is diagnosed with sprue (adult celiac disease). What should the nurse teach the client to avoid when providing dietary teaching? Select all that apply.

Oatmeal Spaghetti

A nurse is assessing a 55-year-old client who is experiencing postmenopausal bleeding. The tentative diagnosis is endometrial cancer. Which findings in the client's history are risk factors associated with endometrial cancer? Select all that apply.

Obesity Family history of endometrial cancer Previous hormone replacement therapy.

Which are the nurse's priority assessments of the breathing component of a primary survey of a client? Select all that apply. One, some, or all responses may be correct.

Observe for chest wall trauma. Assess breath sounds and respiratory effort

A client with small cell carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH). What signs should the nurse expect to observe? Select all that apply.

Oliguria Seizures Vomiting

A nurse is caring for a child with newly diagnosed acute lymphoblastic leukemia. What clinical findings does the nurse anticipate when assessing the child? Select all that apply.

Pallor Fatigue Multiple bruises

A client with a large fetus is to have a pudendal block during the second stage of labor. What does the nurse plan to instruct the client about the effectiveness of the block? Select all that apply.

Perineal pain will not be felt/ The bearing-down reflex will be diminished.

A nurse is teaching a preoperative client about postoperative breathing exercises. What information should the nurse include? Select all that apply.

Place a hand on the abdomen while feeling it rise Hold the breath for several seconds at the height of inspiration

A nurse is caring for a new mother who has a chlamydial infection. For which complications should the nurse assess the client's neonate? Select all that apply.

Pneumonia Preterm birth Conjunctivitis

A client who has been receiving hemodialysis for several years is to receive a kidney transplant. What should the nurse say in the client's preoperative teaching plan? Select all that apply.

Precautions are needed to prevent infection The kidney may not function immediately A urinary catheter will be present postoperatively

A nurse is caring for a client with varicose veins. Which clinical manifestations should the nurse expect with this diagnosis? Select all that apply.

Presence of ankle edema Increased muscle fatigue Report of nocturnal leg cramps

Women who become pregnant for the first time at a later reproductive age (35 years or older) are at risk for what complications? Select all that apply.

Preterm labor Multiple gestation Chromosomal anomalies Bleeding in the first trimester

A nurse is caring for a client with a Venturi mask who is receiving 40% oxygen. What nursing actions are indicated? Select all that apply.

Prevent the client's blanket from covering the adaptor's orifices. Check that the appropriate adaptor to deliver the prescribed FiO2 is attached to the mask.

The nurse provides care to the client with diabetes insipidus (DI) following head injury by: Select all that apply.

Providing adequate fluids within easy reach Assessing for and reporting changes in neurological status Monitoring for constipation, weight loss, hypotension, and tachycardia

The nurse provides care to the client with syndrome of inappropriate antidiuretic hormone (SIADH) by: Select all that apply.

Providing frequent oral care Instituting fall risk precautions Monitoring for and reporting neurologic changes

Which nursing activities are specifically focused on achieving Healthy People 2010's mental health objectives? Select all that apply.

Providing suicide screening for a senior citizens group Initiating outpatient services for homeless schizophrenic adults Teaching stress-management techniques to those housed in the local jail Advocating for culturally competent mental health care within each state

The nurse is teaching a client who has asthma about using a peak flow meter. Which statement by the client reflects a correct understanding of the use of a peak flow meter? Select all that apply.

Readings in the green zone mean that my asthma is under control." "If I get a reading in the red zone, then I need to take my reliever drug and have my wife take me to the hospital." "I should check the peak flow readings at least twice a day."

A client who is at risk for seizures as a result of severe preeclampsia is receiving an IV infusion of magnesium sulfate. What findings cause the nurse to determine that the client is showing signs of magnesium sulfate toxicity? Select all that apply.

Respirations of 10/min Loss of patellar reflexes

An emergency tracheotomy is performed on a toddler in acute respiratory distress from laryngotracheobronchitis (viral croup). What early signs of respiratory distress indicate that it is necessary for the nurse to suction the tracheotomy? Select all that apply.

Restlessness Increased pulse rate

A client is admitted with the diagnosis of tetanus. For which clinical indicators should the nurse assess the client? Select all that apply.

Restlessness Muscular rigidity, Respiratory tract spasms Spastic voluntary muscle contractions.

What are the primary nursing interventions when a client is receiving an infusion of magnesium sulfate for severe preeclampsia? Select all that apply.

Restricting visitors Maintaining a quiet environment

he nurse is assessing a client who is admitted to the hospital with a tentative diagnosis of an adrenal cortex tumor. When assessing the client, which of these, if found, are signs of Cushing disease? Select all that apply.

Round face Dependent edema in the feet and ankles Thin, translucent skin with bruising Increased fatty deposition in the neck and back

A client appears at the clinic after getting a positive result on a home pregnancy test. She states that her last menstrual period began 10 weeks ago. The client expresses fear because she has been recently found to have syphilis. What prescriptions will the nurse expect to receive from the health care provider because of this information? Select all that apply.

Screening and testing of sexual partners/ Intramuscular benzathine penicillin G, 2.4 million units, one dose.

A postpartum nurse is reviewing principles related to automobile infant restraint systems with the parents of a newborn who is to be discharged in the morning. What information should be included in the teaching session? Select all that apply.

Secure the infant seat so that it faces the rear. Follow the manufacturer's directions to secure the infant seat in the back seat. Be sure to follow weight guidelines set forth in the manufacturer's instructions.

A nurse is caring for a 2-year-old child with meningitis. For which clinical manifestations of increasing intracranial pressure should the nurse assess the child? Select all that apply.

Seizures Vomiting Decreased respiratory rate

A nurse is assessing a male newborn. Which characteristics should alert the nurse to conclude that the newborn is a preterm infant? Select all that apply.

Small breast buds Wrinkled thin skin Pinnae that remain flat when folded

A nurse is teaching an adult health and wellness class about bladder cancer. The nurse informs the class participants that which activities put a person at risk for bladder cancer? Select all that apply.

Smoking two packs of cigarettes a day Working with dyes and ink every day

A nurse discusses dietary instructions with the parents of a toddler with acute glomerulonephritis. What nutrients does the nurse list that are restricted? Select all that apply.

Sodium Potassium

The nurse is providing teaching to a client with atrial flutter who has received a prescription for an oral anticoagulant. The client asks the nurse to provide a list of foods that are high in vitamin K and that should be avoided. What should the nurse include on the list? Select all that apply.

Spinach Broccoli

What gross motor skills should the nurse expect a developmentally appropriate 3-year-old child to perform? Select all that apply.

Standing on one foot for a few seconds Alternating the feet when walking up stairs

A 4-year-old child has been found to have Kawasaki disease and is to be treated with intravenous immunoglobulin (IVIG). Before administration of the IVIG, what action(s) should the nurse take? Select all that apply.

Start an intravenous line. Have the parents sign permission for blood product administration.

The nurse is assessing a 2-year-old child for the presence of celiac disease. For what specific signs and symptoms should the nurse be alert? Select all that apply.

Steatorrhea Distended abdomen Iron-deficiency anemia

A person is brought to the emergency department after prolonged exposure to cold weather. What clinical manifestations of hypothermia does the nurse expect? Select all that apply.

Stupor Paresthesia in affected body parts

A nurse is caring for a client with complications associated with peritoneal dialysis. For which signs and symptoms should the nurse monitor the client? Select all that apply.

Tachycardia Cloudy outflow Abdominal pain

Which clinical findings should the nurse expect when assessing a client with hyperthyroidism? Select all that apply.

Tachycardia Exophthalmos

A nurse is assigned to care for an infant in the newborn nursery who was born 4 hours ago. Maternal substance abuse is strongly suspected. Which symptoms are seen in neonates demonstrating signs of drug withdrawal? Select all that apply.

Tachypnea Exaggerated Moro reflex Prolonged, high-pitched cry Restlessness and excessive activity

A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? Select all that apply.

Tachypnea Hypotension

In the first 2 ½ hours after a radical neck dissection, 40 mL of medium red, bloody fluid is obtained from the client's drainage system. What should the nurse do? Select all that apply.

Take vital signs. Notify the health care provider.

After multiple upper respiratory infections, a school-aged child undergoes a tonsillectomy and adenoidectomy. Two weeks after surgery the nurse assesses the child's condition. On what should the nurse focus? Select all that apply.

Taste/ Smell/ Hearing/ Breathing.

A client with human immunodeficiency virus (HIV)-associated Pneumocystis jiroveci pneumonia is to receive pentamidine (Pentam) intravenously (IV) once daily. What should the nurse do to ensure client safety? Select all that apply.

Tell the client to report any evidence of bleeding immediately. Assess blood glucose levels daily and several times after therapy is completed.

A nurse is caring for a client who just had major abdominal surgery. What client responses indicate the possibility of developing a superficial venous thrombosis? Select all that apply.

Tender area in the posterior lower leg Warmth along the course of the involved vessel

A nurse is caring for a client who had pelvic surgery. The nurse should monitor for which clinical manifestations of thrombophlebitis? Select all that apply.

Tender area on the leg Warm area over the calf

A nurse is assessing a newborn with myelomeningocele. What clinical findings prompt the nurse to suspect hydrocephalus? Select all that apply.

Tense fontanels High-pitched crying A defect in the lumbosacral area

A nurse teaches a mother about appropriate play for an 8-month-old infant. Which of the mother's suggestions indicates that the teaching has been understood? Select all that apply.

Textured book Stuffed animal Hanging mobile

Evidence-based nursing uses a variety of sources to support nursing practice. Which are sources of evidence-based practice? Select all that apply.

Theory Research Clinical expertise

The nurse provides education related to manifestations of hyperglycemia to a client with type 1 diabetes. Which signs and symptoms identified by the client indicate that the teaching was effective? Select all that apply.

Thirst Fruity breath odor Excessive urination

A client has been admitted with severe edema and hypertension. Intravenous furosemide (Lasix) has been prescribed. Which subjective clinical manifestations lead the nurse to suspect that the furosemide is infusing too rapidly? Select all that apply.

Tinnitus Weakness Leg cramps

A client undergoes pituitary surgery via the transsphenoidal route. Which foods should the nurse instruct the client to avoid after surgery? Select all that apply.

Toast Celery

The laboratory blood tests of a client at 10 weeks' gestation reveal that she has anemia. The client refuses iron supplements. The nurse teaches her that the best source of iron is liver. What other foods does the nurse encourage the client to eat? Select all that apply.

Tofu Ground beef patty

Typical signs of neonatal abstinence syndrome related to opioid withdrawal usually begin within 24 hours after birth. What characteristics should the nurse anticipate in the infant of a suspected or known drug abuser? Select all that apply.

Tremors

A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus should the nurse assess this client? Select all that apply.

Unilateral chest pain Acute onset of dyspnea

The nurse is caring for a client that has undergone a total hip replacement. The nurse recognizes which clinical manifestations indicate a pulmonary embolism. Select all that apply.

Unilateral chest pain Sudden onset of shortness of breath

A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? Select all that apply.

Unusual fatigue Dependent edema Nocturnal dyspnea

Which symptoms present in a child indicate Turner syndrome? Select all that apply.

Webbed neck Low position of posterior hairline Shield-shaped chest with wide space between the nipples

A client is taking an antithyroid medication for hyperthyroidism. The nurse provides education about serious health problems that may develop if the medication is not effective and tachycardia continues. The nurse instructs the client to seek medical attention immediately if any of the problems occur. Which should be included in the teaching? Select all that apply.

Weight gain Pedal edema

A nurse is caring for a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). The IV infiltrates and needs to be restarted. What is necessary to protect the nurse when restarting the IV? Select all that apply.

Gloves Hand hygiene

A school-aged child is admitted to the pediatric unit with the diagnosis of a brain tumor. During breakfast the child vomits. What are the priority nursing interventions? Select all that apply.

Notifying the practitioner/ Requesting a reevaluation.

A client is suspected of having rabies after being bitten by a raccoon. For which clinical indicators should the nurse assess the client? Select all that apply.

Nuchal rigidity Pharyngeal spasm

A client presents to the emergency department with a fever, headache, loss of appetite, and malaise. The nurse identifies raised red bumps on the client's arms and legs. A diagnosis of chickenpox is made. The client should be placed in a private room with what kind of precautions? Select all that apply.

Contact precautions Airborne precautions

The nurse is caring for an infant who has been prescribed nystatin (Mycostatin). The nurse teaches the mother how to prevent aggravation of oral thrush. Which statements by the mother indicate the need for further teaching? Select all that apply.

"I should boil the pacifier for at least 20 minutes on alternate days." "I should apply the medication at least 20 minutes before feeding." "I should boil the reusable nipples for at least 5 minutes after washing."

A nurse is assessing a client with hypothyroidism. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply.

Cool skin Constipation Periorbital edema Decreased appetite

1- An older client asks, "How do I know that all the medications that I take are safe?" What information should the nurse include in a response to this client's question? Select all that apply.

"Ask your health care provider how and when you should be taking your medications." "Check the name, dose, and instructions about administration of drugs each time before leaving the pharmacy."

A client with hyperthyroidism is being treated with propylthiouracil (PTU). What instruction should the nurse plan to include in the teaching plan regarding this drug? Select all that apply.

"Avoid abrupt discontinuation of the medication." Monitor your weight, pulse, and mood routinely." "Report side effects, such as sore throat, fever, joint pain, or oral lesions."

A client has left ventricular heart failure. For which clinical indicators should the nurse assess the client? Select all that apply.

Crackles Dyspnea on exertion

The nurse assesses a client with the diagnosis of bipolar disorder, manic episode. Which clinical findings support the diagnosis? Select all that apply.

Grandiosity Talkativeness Distractibility

A child in sickle cell crisis is admitted to the pediatric unit. Supportive care includes Select all that apply.

Bedrest, Oxygen via nasal cannula Acetaminophen (Tylenol) Age-appropriate activities Intravenous hydration

The nurse prepares a list of recommended foods for a client with hypertension that is to begin a 2-gram sodium diet. The list should include which foods? Select all that apply.

Beef steaks Cooked broccoli

A pregnant woman tells a nurse in the prenatal clinic that she knows that folic acid is very important during pregnancy and that she is taking a prescribed supplement. She asks the nurse what foods contain folic acid (folate) so she may add them to her diet in its natural form. Which foods should the nurse recommend? Select all that apply.

Black and pinto beans Enriched bread and pasta

Which physiological responses should a nurse expect when assessing a client with hyperthyroidism? Select all that apply.

Blurred vision Increased appetite Widened pulse pressure

A nurse confers with the nutritionist about the diet of a 4-year-old child with spina bifida who spends many hours in a wheelchair. What should the nurse encourage the mother to increase in her child's diet? Select all that apply.

Fiber Protein

Which of the following clinical findings should the nurse expect to find during the assessment of a child with acute glomerulonephritis (AGN)? Select all that apply.

Flank pain/ Periorbital edema.

Neonates have difficulty maintaining their body temperature, but their bodies have several mechanisms to help them do so. Which ones should a nurse remember when caring for a newborn? Select all that apply.

Flexed fetal position Brown fat metabolism

A client at 7 weeks' gestation tells the nurse in the prenatal clinic that she has been bothered by episodes of nausea, but no vomiting, throughout the day. What should the nurse recommend? Select all that apply.

Focus on and repeat a rhythmic chant Eat small, frequent meals and eat dry crackers in between

An injured child is brought to the emergency department by the parents. While interviewing the parents, the nurse begins to suspect child abuse. Which parental behaviors might support this conclusion? Select all that apply.

Focusing on the child's role in sustaining the injury Changing the story of how the child sustained the injury

A client expresses concern about insomnia and asks, "What can I do to get better sleep?" What activities should the nurse recommend? Select all that apply.

Follow the same bedtime ritual each night Perform deep-breathing exercises

An active adolescent is admitted to the hospital for surgery for an ileostomy. When planning a teaching session about self-care, the nurse includes sports that should be avoided by a client with an ileostomy. Which should be included on the list of sports to be avoided? Select all that apply.

Football Ice hockey

A client on a low-residue diet asks the nurse about foods that must be avoided. Which foods should the nurse instruct the client to avoid? Select all that apply.

Fresh fruit Whole wheat bread

A nurse is taking care of a client with cirrhosis of the liver. For which clinical manifestations should the nurse assess? Select all that apply.

Ascites Pruritus Jaundice

A nurse is caring for a client with end-stage renal disease. Which clinical indicators of end-stage renal disease should the nurse expect? Select all that apply.

Azotemia Hypertension

A nurse is caring for a client who is receiving a unit of packed red blood cells. Which findings lead the nurse to suspect a transfusion reaction caused by incompatible blood? Select all that apply.

Backache Shivering

The nurse is caring for a female client who is receiving rifampin for tuberculosis. Which statements indicate that the client understands the teaching about rifampin? Select all that apply. One, some, or all responses may be correct.

'This medication may be hard on my liver, so I must avoid alcoholic drinks while taking it.' 'This medication may reduce the effectiveness of the oral contraceptive I am taking.' 'My health care provider must be called immediately if my eyes and skin become yellow.'

A child with attention-deficit/hyperactivity disorder (ADHD) is prescribed methylphenidate. The mother asks about its action and side effects. Which response by the nurse is most appropriate?

'This medicine increases the appetite.' 'This medicine must be continued until adulthood.' 'It is a short-acting medicine that must be given with each meal.' 'It is a stimulant that has a calming effect on children with ADHD.'

A nurse provides discharge teaching for a client who had a total hip replacement. Which statements made by the client indicate an understanding of the education? Select all that apply.

I should not cross my legs. I should not sit in a low chair.

The nurse is caring for a client who is scheduled to have a percutaneous liver biopsy. Which assessment findings warrant the postponement of the procedure? Select all that apply.

Marked ascites Hemoglobin of less than 9 g/dL

A new mother is concerned about a lump on the right side of her infant's head that wasn't there at birth 36 hours ago. After assessment of the infant, which response by the nurse is appropriate?

'Your baby's head is just slightly elongated, and that's nothing to be concerned about.' 'Your baby will be examined again by the pediatrician before you leave later today, so there's no need to worry right now.' 'Your baby may have a condition called cephalhematoma. It's common; however, I'll make a note to have the pediatrician assess it.'

A nurse is reviewing previous education with the parents and a 12-year-old child with cystic fibrosis (CF). The disease was diagnosed when the child was 3 years old and has resulted in one hospitalization for a respiratory infection. For which potential complications of CF should the family be alert? Select all that apply.

Diabetes/ Nasal polyps/ Prolapsed rectum/ Pulmonary infections.

For which side effects should a nurse assess a client with cancer who is being treated with chemotherapeutic agents? Select all that apply.

Diarrhea Bleeding tendencies

The nurse epidemiologist of a large urban hospital is called to the pediatric unit to provide information about an outbreak of diarrhea caused by Salmonella. Which common foods does the nurse suspect as the cause of the outbreak? Select all that apply.

Hamburgers Soft-boiled eggs

A nurse is assessing a client for dehydration, The client has had diarrhea and vomiting for 48 hours. What are indicators of dehydration? Select all that apply.

Headache The skin on the client's forehead remains tented after being pinched

Which medications does the nurse expect to be prescribed for a preschooler with newly diagnosed cystic fibrosis? Select all that apply.

Antibiotics Pancreatic enzymes Fat-soluble vitamin

Encouraging Ibuprofen (Motrin) and hydroxychloroquine (Plaquenil) are prescribed for an older client with arthritis. The nurse teaches the client about these medications. What responses to the medication should the client be taught to report? Select all that apply.

Blurred vision Bleeding tendencies

A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider most desirable? Select all that apply.

Boiled spinach Sweet potatoes

During a clinical assessment, what secondary sex characteristics does the nurse observe in a teenage patient? Select all that apply.

Change in voice Development of facial hair

A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which postmature signs does the nurse identify? Select all that apply.

Cracked and peeling skin Long scalp hair and fingernails Creases covering the neonate's full soles and palms

What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply.

Crackles Atelectasis Hypoxemia Severe dyspnea

A nurse is caring for a client with cholelithiasis and obstructive jaundice. When assessing this client, the nurse should be alert for which common clinical indicators associated with these conditions? Select all that apply.

Ecchymosis Yellow sclera Pain in the right upper quadrant

1- Health promotion efforts within the health care system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply.

Encouraging regular dental checkups Teaching the procedure for breast self-examination

The nurse is providing teaching to a client who recently has been diagnosed with type 1 diabetes. The nurse reinforces the importance of monitoring for ketoacidosis. What are the signs and symptoms of ketoacidosis? Select all that apply.

Excessive thirst Fruity-scented breath Confusion

A nurse is discussing informed consent with a client who is scheduled for a hysterectomy. What should the informed consent include? Select all that apply.

Explanation of available alternative treatments Answers to questions and concerns about the procedure Complete description of the possible dangers and discomforts.

A nurse is discussing an infant's diet with a mother who is breastfeeding. Why should the nurse recommend that the infant be offered solid foods by 5 or 6 months of age? Select all that apply.

Fetal iron reserves are depleted. Food can be taken from a spoon.

- What clinical findings does a nurse expect when assessing a child with acute laryngotracheobronchitis. Select all that apply:

Fever/ Hoarseness/ Barking cough/ Inspiratory stridor.

A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply.

Rye Oats Wheat

A 12-year-old child with Down syndrome is admitted to the hospital for intravenous antibiotics for pneumonia. Which clinical findings associated with Down syndrome should the nurse expect when performing a physical assessment? Select all that apply.

Saddle nose/ Inner epicanthic folds/ Transverse palmar crease.

The client is returned to the surgical unit from the post anesthesia care unit (PACU) after a having a splenectomy. In the immediate postoperative period, the nurse specifically should monitor for which potential complications? Select all that apply.

Shock Abdominal distention Pulmonary complications

A client who is taking an oral contraceptive calls the nurse with concerns about side effects of the medication. Which adverse effect of this medication should alert the nurse to inform the client to immediately stop the contraceptive and contact the health care provider? Select all that apply.

Visual disturbances Persistent headaches

All women of childbearing age are advised to include at least 400 micrograms of folic acid in the daily diet to lessen the risk of neural tube defects in pregnancy. What should the nurse recommend meeting the recommendation? Select all that apply.

Vitamin B9/ Legumes, dark-green leafy vegetables, and citrus fruits.

The nurse is making rounds on a client who has developed severe bone marrow depression after receiving chemotherapy for cancer. Which of these actions by the nurse is appropriate? Select all that apply.

Wash hands before entering the client's room. Advise use of a soft toothbrush for oral hygiene. Report an elevation in temperature immediately.

An adolescent child is in the terminal stage of cancer. The parents ask how they will know when death is imminent. The nurse discusses the physical manifestations with the parents. What are the signs and symptoms of approaching death? Select all that apply.

Weak pulse /Difficulty swallowing/ Loss of bladder control

The registered nurse determines that the new graduate understands the type(s) of hepatitis that generally develop into a chronic hepatitis infection if the graduate identifies which of the following? Select all that apply

C AND D

A client with the diagnosis of chronic kidney disease develops hypocalcemia. Which clinical manifestations should the nurse expect the client with hypocalcemia to exhibit? Select all that apply

Chvostek sign Muscle cramps

A nurse in a campus health clinic is assessing female students for risk factors associated with the future development of osteoporosis. What factors are included in this assessment? Select all that apply:

Cigarette smoking/ Familial predisposition/ Inadequate intake of dietary calcium.

A nurse is assessing a client with diabetic ketoacidosis. Which clinical manifestations should the nurse expect? Select all that apply.

Dry skin Abdominal pain Kussmaul respirations

What statement is true of ventricular dysrhythmias? Select all that apply.

The QRS complex appears widened and has a bizarre shape. The polarity of the T wave is opposite that of the QRS complex. Most ventricular dysrhythmias have no apparent P wave.

A nurse provides education to a client about how to prevent constipation. Does the nurse conclude that the teaching has been understood when the client makes what statement? Select all that apply.

"I should drink eight glasses of water every day." "I can include bran muffins in my breakfast daily." "I will walk every day as part of my exercise regimen

Isoniazid (INH) is prescribed as a prophylactic measure for a client whose spouse has active tuberculosis (TB). What statements by the client indicate that there is a need for further teaching? Select all that apply.

"I sometimes allow our children to sleep in our bed at night." "I know I also have tuberculosis because the skin test was positive." "I'll be skipping the wine but enjoying the cheese at my neighbor's party

The nurse is providing discharge teaching to a client with acquired immunodeficiency syndrome (AIDS) whose white blood cell count (WBC) is low. Which statement indicates a need for further education? Select all that apply.

"I will eat at least one piece of fresh fruit every day." I will walk at the mall twice a week to keep up my strength."

A client with an exacerbation of colitis is placed on a low-residue, bland, high-protein diet. Vitamins B, C, and K are being administered parenterally. The client asks why this dietary regimen has been prescribed. How should the nurse respond? Select all that apply.

"Intestinal absorption will improve." "There will be less abdominal cramping." Fluids and electrolytes will not be depleted."

An almost term client reports that her fetus is moving less this week than last week. Which responses are appropriate? Select all that apply.

"It would be good for you to come to labor and delivery to be evaluated today." Always call the health care provider if you're worried that your baby isn't moving enough." "Let me teach you how to conduct a kick count, and then you can call me when you've done one."

Which question would the nurse ask to determine a client's potential for injury because of sleep deprivation? Select all that apply. One, some, or all responses may be correct.

'Do you operate heavy machinery at work?' 'Does sleepiness affect your performance at work?'

Four days after a vaginal hysterectomy a client calls the follow-up service and tells the nurse that she has a yellowish-green vaginal discharge. The nurse advises the client to return to the clinic for an evaluation. What does the nurse need to assess when a vaginal infection is suspected? Select all that apply:

Abdominal pain Rising temperature.

A nurse is caring for an 8-year-old child who has been admitted to the pediatric unit with a tentative diagnosis of acute poststreptococcal glomerulonephritis (APSGN). Diagnostic tests are ordered. Which tests will help confirm the diagnosis? Select all that apply.

ASO titer/ Urinalysis/ Blood chemistry.

A client with achalasia is to undergo bougienage to dilate the lower esophagus and cardiac sphincter. For which clinical manifestations should the nurse assess the client after the procedure? Select all that apply.

Abdominal pain Increased heart rate Increased blood pressure

A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? Select all that apply

Absence of hair on the toes Reports of pain associated with exercising

A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? Select all that apply.

Absence of hair on the toes Reports of pain associated with exercising

A nurse is caring for a client admitted to the hospital for diabetic ketoacidosis. Which clinical findings related to this event should the nurse document in the client's clinical record? Select all that apply.

Acetone breath Decreased arterial carbon dioxide level

A client is admitted with a tentative diagnosis of pancreatitis. The medical and nursing measures for this client are aimed toward maintaining nutrition, promoting rest, maintaining fluid and electrolyte balance, and decreasing anxiety. Which interventions should the nurse implement? Select all that apply.

Administer analgesics. Teach relaxation exercises. Monitor cardiac rate and rhythm.

A client in her 10th week of pregnancy exhibits presumptive signs of pregnancy that the nurse may detect, including which of the following? Select all that apply.

Amenorrhea Breast changes Urinary frequency

A nurse is reviewing the health history and laboratory report of a child with lead poisoning. What complications does the nurse expect in relation to lead toxicity? Select all that apply.

Anemia, Proteinuria Encephalopathy

A client with chronic heart failure is taking a diuretic twice a day. The health care provider prescribes a diet that includes the intake of dietary potassium. What foods that have a higher amount of potassium should the nurse instruct the client to consume? Select all that apply.

Bananas Baked potatoes with skins

When caring for a client with a head injury that may have involved the medulla, the nurse bases assessments on the knowledge that the medulla controls a variety of functions. Select all that apply.

Breathing Pulse rate Blood vessel diameter

A nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which common responses to this disease can the nurse expect the client to exhibit? Select all that apply.

Butterfly facial rash Inflammation of the joints

A parent of four is remanded to the psychiatric unit by the court for observation. The client was arrested and charged with abusing a 2-year-old son, who is in the pediatric intensive care unit in critical condition. The nurse approaches the client for the first time. How should the nurse anticipate that the client will likely respond? Select all that apply.

By denying beating the son By avoiding talking about the situation By exhibiting an emotional response that is inconsistent with degree of injury

The nurse teaches a client about the increased need for vitamin A to meet the demands imposed by rapid fetal tissue growth during pregnancy. Which foods should the nurse encourage the client to ingest to meet this increased need? Select all that apply.

Carrots Sweet potatoes.

A beta-blocker, atenolol (Tenormin), is prescribed for a client with moderate hypertension. What information should the nurse include when teaching the client about this medication? Select all that apply.

Change positions slowly Count the pulse before taking the medication Mild weakness and fatigue are common side effects

The nurse is teaching a class of expectant parents about changes that are to be expected during pregnancy. Which changes would the nurse explain result from melanocyte-stimulating hormone? Select all that apply. One, some, or all responses may be correct.

Chloasma Linea nigra

A nurse is teaching a class of expectant parents about changes that are to be expected during pregnancy. What changes does the nurse explain result from the melanocyte-stimulating hormone? Select all that apply.

Chloasma Linea nigra.

A client with rheumatoid arthritis does not want the prescribed cortisone and informs the nurse. Later, the nurse attempts to administer cortisone. When the client asks what the medication is, the nurse gives an evasive answer. The client takes the medication and later discovers that it was cortisone. The client states an intent to sue. What factors in this situation must be considered in a legal action? Select all that apply.

Clients have a right to refuse treatment. Nurses are required to answer clients truthfully. The health care provider should have been notified.

A 1-year-old child is found to have nutritional iron-deficiency anemia. What nursing interventions are most important in the care of an infant with iron-deficiency anemia? Select all that apply.

Conserving the infant's energy Protecting the infant from infection Teaching the parents about nutrition

A 9-year-old child who has successfully completed the emergency (resuscitative) phase of treatment for a severe burn injury is started on a high-protein, high-calorie diet. Which snacks should the nurse encourage between meals? Select all that apply.

Crackers and cheese/ Banana pudding and whipped cream/ Frozen yogurt and chocolate Sprinkles.

A client had thoracic surgery. The nurse should monitor for what clinical manifestations that may indicate acute pulmonary edema? Select all that apply.

Crackles Cyanosis Frothy sputum

A chelating agent is prescribed for a child with lead poisoning. Because chelating agents may cause hypocalcemia, the nurse encourages the child to eat foods that are high in calcium. Which meals are good sources of calcium? Select all that apply.

Cream of mushroom soup, macaroni and cheese, broccoli, and milk/ Pea soup, roast chicken breast, mashed potatoes, creamed spinach, and orange juice.

A nurse is assessing the development of an 8-month-old infant. Which behaviors are expected at this stage of development? Select all that apply.

Creeping purposefully Displaying a pincer grasp

The nurse provides care to the client with Parkinson disease, who experiences freezing of gait (FOG), by select all that apply

Cuing the client with rhythmic clapping Encouraging the client to step over an imaginary line

The nurse provides care to the client with Parkinson disease, who experiences freezing of gait (FOG), by: select all that apply

Cuing the client with rhythmic clapping Encouraging the client to step over an imaginary line

A nurse determines that a newborn is in respiratory distress. Which signs confirm this assessment? Select all that apply.

Cyanosis Tachypnea Retractions

During a client's routine physical examination, a chest x-ray film reveals a lesion in the right upper lobe. What information in the client's history supports the health care provider's diagnosis of pulmonary tuberculosis? Select all that apply.

Fever Night sweats Blood-tinged sputum

A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? Select all that apply.

Fever Tachypnea Abdominal rigidity

A toddler is admitted to the pediatric unit with diarrhea and severe dehydration. After several days of treatment, the child is evaluated. What clinical findings indicate that the child is rehydrated? Select all that apply.

Decreased hematocrit Increase in daily weight Decreased blood urea nitrogen level

A client has a hysterectomy, salpingo-oophorectomy, tumor removal, and multiple abdominal biopsies for ovarian cancer. For which clinical manifestations should the nurse assess the client that indicates that the client may be experiencing a pulmonary embolus? Select all that apply.

Decreased oxygen saturation level Sudden onset of shortness of breath

The adverse hemodynamic effects of a fast heart rate may be caused by: Select all that apply

Decreased ventricular filling time. Less cardiac output.

Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson's disease. The nurse monitors The neurologic assessment of a client who had a craniotomy includes the Glasgow Coma Scale. What does the nurse evaluate to assess the client's score on the Glasgow Coma Scale? Select all that apply.

Degree of purposeful movement by the client Appropriateness of the client's verbal responses Stimulus necessary to cause the client's eyes to open

A client with acute renal failure moves into the diuretic phase after one week of therapy. For which signs during this phase should the nurse assess the client? Select all that apply.

Dehydration Hypovolemia

A nurse is caring for a client with right-sided heart failure. Which are key features of right-sided heart failure? Select all that apply.

Dependent edema Distended abdomen Polyuria at night

A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply.

Dependent edema Swollen hands and fingers Right upper quadrant discomfort

When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestations? Select all that apply.

Dependent rubor Ulcers on the toes Delayed capillary refill

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply.

Diarrhea Weakness Dysrhythmias

A 5-year-old child who is HIV positive is taken to the health department for immunizations before the start of school. The CD4 count shows severe immunosuppression. What immunizations can the child be given safely at this time? Select all that apply.

Hepatitis A/ Polio vaccine (IPV)/ Diphtheria, tetanus, pertussis (DTaP).

A nurse is assessing a client with Cushing syndrome. Which signs should the nurse expect the client to exhibit? Select all that apply.

Hirsutism Round face Buffalo hump

A nurse is reviewing the physical examination and laboratory tests of a client with malaria. For which important clinical indicators should the nurse be alert when reviewing data about this client? Select all that apply.

Hyperthermia Splenomegaly

A nurse obtains a health history from the parents of a toddler who is admitted to the pediatric unit with the diagnosis of acute lymphocytic leukemia (ALL). What problems does the nurse expect the parents to report? Select all that apply.

Loss of appetite Paleness of the skin Purplish spots on the skin

A client comes to the emergency department reporting symptoms of the flu. When the health history reveals intravenous drug use and multiple sexual partners, acute retroviral syndrome is suspected, and a test for the human immunodeficiency virus (HIV) is performed. Which clinical responses are associated most commonly with this syndrome? Select all that apply.

Malaise Swollen lymph glands

A health care provider prescribes two units of blood for a client who is bleeding. Which nursing interventions are necessary before the blood transfusion is administered? Select all that apply.

Obtaining the client's vital signs Determining typing and crossmatching of blood Using a Y-type infusion set to initiate 0.9% normal saline

A client has a colon resection with anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply.

Oliguria Irritability Hypotension

A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation is completed? Select all that apply.

On admission to the hospital Before transfer to a rehabilitation facility

A client at 39 weeks' gestation is admitted for induction of labor. Knowing that several medications are used to induce labor, a nurse identifies those that may be prescribed. Select all that apply.

Oxytocin (Pitocin) Misoprostol (Cytotec) Dinoprostone (Prepidil)

Clearly document a client's non-adherence to the medical regimen. While recovering from abdominal surgery a client develops thrombophlebitis. Which clinical indicators of this complication should the nurse expect to identify when assessing the client? Select all that apply.

Pain in the calf Redness in the affected area Localized warmth in the lower extremity

A 32-year-old woman is admitted to the unit with a history of fibroids and menorrhagia. Which findings does the nurse expect to encounter during assessment of the client? Select all that apply.

Pale mucous membranes Difficulty emptying the bladder.

A nurse is obtaining a health history from the parents of a toddler who has recently diagnosed acute lymphocytic leukemia. Which early physiologic changes does the nurse expect the parents to report? Select all that apply.

Pale skin Eating less food Purplish spots on the skin

A nurse is assessing a client with cardiogenic shock. Which clinical findings should the nurse expect? Select all that apply.

Pallor Tachycardia Narrow pulse pressure

During a routine examination, an enlarged thyroid gland is discovered in a client, and hyperthyroidism is suspected. What clinical findings should the nurse expect to identify when completing a nursing admission history and physical for this client? Select all that apply.

Palpitations Tachycardia Menstrual disturbances

An 8-year-old child is admitted to the pediatric unit with nephrotic syndrome. What measures should the nurse expect to include in the plan of care for this child? Select all that apply.

Providing symptom at-

What are the different patterns of physical development and maturation of neuromuscular functions in a child? Select all that apply

Proximodistal Cephalocaudal Differentiation

A nurse advises a client receiving furosemide (Lasix) to increase potassium intake. Which fruit should the nurse encourage the client to eat? Select all that apply.

Prune Banana

The nurse is caring for a client with increased intracranial pressure (ICP). What clinical manifestations are associated with increased ICP? Select all that apply.

Psychotic behaviors Jacksonian seizures Nausea and vomiting

A nurse is assessing a toddler and the family dynamics of the child's family, in which abuse is suspected. What behaviors are expected? Select all that apply.

The child cringes when approached The child has unexplained healed injuries. The child lies still while surveying the environment.

A client has been taking levothyroxine (Synthroid) for hypothyroidism for three weeks. The nurse suspects that a decrease in dosage is needed when the client exhibits which clinical manifestations? Select all that apply.

Tremors Heat intolerance

A nurse is assessing a 1-year-old infant. What behavior does the nurse expect to observe? Select all that apply.

Tries to ascend stairs Explores away from the parent

A child who has been undergoing prolonged steroid therapy takes on a cushingoid appearance. What will the nursing assessment probably reveal? Select all that apply.

Truncal obesity Thin extremities

The nurse supports cognitive ability in clients with Alzheimer dementia by: Select all that apply.

Using calendars, clocks, and pictures to support memory Encouraging caregivers to support protected independence Providing a limited number of choices to support decision making

A client reports pain as a result of a gastric ulcer. What clinical findings is the nurse most likely to identify during an assessment of the client's pain? Select all that apply.

Vomiting relieves pain. Pain described as gnawing. Pain occurs a half hour after meals

A client has a new diagnosis of hyperthyroidism. Which skin conditions should the nurse expect when performing a physical assessment? Select all that apply

Warm Moist Smooth

A client who sustained serious burns now has a stress ulcer. When caring for this client, what clinical indicators should the nurse immediately report to the health care provider? Select all that apply.

Weakness Diaphoresis Tachycardia Cold extremities

A client on prolonged cortisone therapy for adrenal insufficiency is being discharged. Which side effects should the nurse teach the client and family to expect? Select all that apply.

Weakness Moon face Weight gain

A client who has schizophrenia is receiving a phenothiazine antipsychotic medication. Which serious client responses to the medication should the nurse immediately report to the practitioner? Select all that apply.

Yellow sclerae Involuntary tongue movements

What advice is appropriate for a growing child to prevent obesity? Select all that apply:

You should drink fewer sweetened beverages every day You should eat small meals throughout the day/ You should watch television for less than 2 hours every day.

The nurse manager is planning to assign unlicensed assistive personnel (UAP) to care for clients. What care can be delegated on a medical-surgical unit to a UAP? Select all that apply.

Performing a bed bath for a client on bed rest Assisting a client who has patient-controlled analgesia (PCA) to the bathroom

A nurse is providing dietary counseling to a client at 14 weeks' gestation. The client is a recent immigrant from Asia, and the nurse explores the foods that the client usually eats. Which foods should the nurse counsel the client to avoid during pregnancy? Select all that apply.

Raw shellfish Herbal supplements Soft-scrambled eggs.

A nurse is caring for a female client who is receiving rifampin (Rifadin) for tuberculosis. Which statements indicate that the client understands the teaching about rifampin? Select all that apply.

"This drug may be hard on my liver so I must avoid alcoholic drinks while taking it." This drug may reduce the effectiveness of the oral contraceptive I am taking." My health care provider must be called immediately if my eyes and skin become yellow."

A newly immigrated older Chinese adult is brought to a mental health clinic when family members become concerned that their parent is depressed. In an attempt to conduct a culturally competent assessment interview, the nurse asks certain questions. Select all that apply.

"What brought you here for treatment today?" "What do you believe is the cause of your depression?" "Does religion have a role in your perception of health and wellness?" Have you ever sought treatment for a mental health problem previously?"

A school-age child with end-stage cancer has a continuous infusion of morphine to manage their pain. Breakthrough pain occurs and a fentanyl 'lollipop' is prescribed. Which instruction would the nurse give the child regarding the use of the lollipop when pain occurs?

'Chew it and then swallow every 4 hours.' 'Suck on it for half an hour every 6 hours.' 'Hold it in your cheek only until the pain is relieved.'

A nurse is caring for a client with a tentative diagnosis of pheochromocytoma who is receiving chlorpromazine (Thorazine). A 24-hour urine specimen to assess the presence of vanillylmandelic acid (VMA) is prescribed to assist in the confirmation of the diagnosis. What information should the nurse include in the client teaching regarding this test? Select all that apply.

All urine excreted over the 24-hour period must be saved and refrigerated. Avoid coffee, chocolate, and citrus fruit for three days before and during the test.

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. What data should the nurse use to determine a client's score on this scale? Select all that apply.

Anorexia Hemiplegia History of diabetes Urinary incontinence

A 4-year-old child is admitted to the pediatric unit with a tentative diagnosis of acute lymphocytic leukemia (ALL). What signs and symptoms does the nurse expect when obtaining the health history and performing a physical assessment? Select all that apply.

Anorexia Petechiae

A health care provider diagnoses acute nonlymphoid leukemia in a 2½-year-old child and the child is admitted to the hospital. What clinical manifestations of the disease should the nurse expect when assessing the child? Select all that apply.

Anorexia Petechiae Irritability Skin pallor Listlessness

The nurse is caring for the unconscious neurological client. In her assessment she notes increased restlessness. What could the client be exhibiting? Select all that apply.

Anoxia A return to consciousness Distended bladder

A client is admitted with thrombocytopenia. What specific nursing actions are appropriate to include in the plan of care for this client? Select all that apply.

Avoid intramuscular injections. Examine the skin for ecchymotic areas.

Which instructions should the nurse include in the teaching plan for a client who will be taking simvastatin (Zocor) when discharged? Select all that apply.

Avoid prolonged exposure to the sun. Schedule regular ophthalmic examinations. Contact your health care provider if skin becomes gray bronze.

Discharge instructions for the client diagnosed with cirrhosis with varices should include information about the importance of: Select all that apply.

Avoiding aspirin and aspirin-containing products Avoiding acetaminophen and products containing acetaminophen Avoiding coughing, sneezing, and straining to have a bowel movement

An ambulatory female client with relapsing-remitting multiple sclerosis is to receive every-other-day injections of interferon beta-1a (Avonex). What adverse effects should the nurse explain may occur when taking this medication? Select all that apply.

Depression Constipation Flulike symptoms Increased heart rate

A newly arrived Russian immigrant attends the prenatal clinic for the first time. Although she states that she has had immunizations, she does not know which ones. Which immunizations should the nurse recommend? Select all that apply.

Diphtheria Hepatitis B

After a short hospitalization for an episode of a transient ischemic attack (TIA) related to hypertension, a client is discharged on a regimen that includes chlorothiazide (Diuril). What should the nurse instruct the client to do regarding nutrition? Select all that apply.

Eat more citrus fruits Increase intake of dried cooked beans

What suggestions should a nurse give to a parent to help a 2-month-old infant who has colic? Select all that apply.

Giving smaller, more frequent feedings Burping frequently when giving a feeding Placing a warm heating pad on the abdomen

A nurse is providing colostomy care to a client with a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) should the nurse use? (Select all that apply.)

Gloves Gown Goggles

An adult who has been in a gay relationship for 3 years arrives at the emergency department in a state of near panic. The client says, "My partner just left me. I'm a wreck." What should the nurse do to help the client cope with this loss? Select all that apply.

Identify the client's support systems. Encourage the client to talk about the situation.

A client is admitted to the hospital with a diagnosis of restrictive airway disease. The nurse expects the client to exhibit which early signs of respiratory acidosis? Select all that apply.

Headache Irritability Restlessness

A nurse is administering intravenous aminophylline to a client with asthma. Which clinical findings support the conclusion that the client is experiencing an adverse reaction to aminophylline? Select all that apply.

Hypotension Cardiac dysrhythmia Muscle hyperactivity

A nurse is counseling an obese postmenopausal client how to prevent bone loss. Which statements indicate understanding of the strategies to prevent bone loss? Select all that apply.

I should take 1200 mg of calcium every day Going to an aerobics class three times a week will help my bones.

The nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which statement by the client indicates a good understanding of preventing dumping syndrome after meals? Select all that apply.

I will not drink fluids when I eat meals." "I will eat small, frequent meals instead of three large meals a day." "I will avoid sweetened and spicy foods."

A family member brings a relative to the local community hospital because the relative "has been acting strange." Which statements meet involuntary hospitalization criteria? Select all that apply.

I'd like to end it all with sleeping pills." "The voices say I should kill all prostitutes."

A toddler is being discharged after myringotomy. What potential complications should the nurse teach the child's parents to report? Select all that apply.

Increased pain Lack of drainage

Which age-related change should the nurse consider when formulating a plan of care for an older adult? Select all that apply.

Increased sensitivity to glare A diminished sensation of pain

A nurse plans to take the temperature of a 4-year-old child with a diagnosis of leukemia who has a fever. Which thermometers can the nurse use safely with most accurate results for this child? Select all that apply.

Infrared, tympanic Chemical dot, axilla

Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson disease. The nurse assesses for which adverse responses that are associated with this medication? Select all that apply.

Nausea Emotional changes

A nurse is caring for a 6-year-old child who has undergone laparoscopic appendectomy. What interventions should the nurse document on the child's clinical record? Select all that apply.

Intake and output/ Measurement of pain/ Presence or absence of bowel sounds.

The client is admitted with supraventricular tachycardia at a rate of 140 beats per minute. The client's blood pressure is 110/55 mm Hg, and he is asymptomatic except for a "fluttering feeling" in his chest. Which of the following treatments would be appropriate? Select all that apply:

Intravenous adenosine (Adenocard) Intravenous beta blockers Intravenous calcium channel blockers Intravenous amiodarone

Valsartan (Diovan), an angiotensin II receptor antagonist, is prescribed for a client. For which possible side effects should the nurse monitor the client? Select all that apply.

Irregular pulse rate Orthostatic hypotension

A nurse concludes that a client has a hypoglycemic reaction to insulin. Which clinical findings support this conclusion? Select all that apply.

Irritability Heart palpitations

A 15-year-old adolescent is admitted with partial- and full-thickness burns of the arms and upper torso. What are the purposes of administering pain medication by way of the intravenous route rather than the intramuscular route? Select all that apply.

It decreases the risk of tissue irritation Severe pain is reduced more effectively. Impaired peripheral circulation is bypassed.

A client with a primary brain tumor has developed syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse will expect to see which clinical findings upon assessment. Select all that apply.

Nausea and vomiting Increased weight Decreased serum sodium Decreased level of consciousness

A client arrives at the outpatient clinic with a painful leg ulcer, and the nurse performs a physical assessment. Which clinical findings in the lower extremity support a diagnosis of an arterial ulcer? Select all that apply.

Lack of hair Thickened toenails Pain at the ulcer site Diminished pedal pulse

nurse is caring for an older client who had non-insulin dependent diabetes for 15 years that progressed to insulin dependent diabetes 2 years ago. What common complications of diabetes should the nurse assess for when examining this client? Select all that apply.

Leg ulcers Loss of visual acuity Prolonged capillary refill in the toes Decreased sensation in the lower extremities

A nurse is reviewing the health history and laboratory results of a school-age child admitted to the pediatric unit with acute nonlymphoid leukemia (acute myeloid leukemia). What clinical findings does the nurse expect? Select all that apply.

Listlessness/ Bone marrow depression.

A nurse is aware that an older adult is at risk for social isolation as a result of certain factors. Select all that apply.

Living alone since a spouse's death 3 years ago Experiencing progressive macular degeneration

The nurse is reviewing the problems that may occur after frequent episodes of otitis media in infants. What complications may be precipitated by this infection? Select all that apply.

Mastoiditis Hearing loss Bacterial meningitis

A client is diagnosed with acute lymphoid leukemia and is receiving chemotherapy. The nurse should monitor what thrombocytopenic side effects of chemotherapy? Select all that apply.

Melena Purpura Hematuria

When reviewing the results of a toddler's complete blood count, a nurse concludes on the basis of decreased hemoglobin and hematocrit levels that the child has iron-deficiency anemia. Which other laboratory findings are indicative of iron-deficiency anemia? Select all that apply.

Microcytic red blood cells Slightly reduced reticulocyte count

1- The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? Select all that apply.

Milk and eggs, Whole grains, Cooked fruit and vegetables

The nurse, teaching a client in early pregnancy about the need to increase her intake of complete proteins, asks the client to identify foods that contain these proteins. Which response indicates that client understands the teaching? Select all that apply.

Milk, eggs, and cheese Fish, hamburger, and chicken.

When entering a room on a medical unit, the nurse identifies that a client is having a seizure. What should the nurse do in addition to protecting the client from self-injury? Select all that apply.

Monitor the seizure activity. Turn the client on the left side.

Which interventions are included in the nursing care for a client receiving magnesium sulfate for severe preeclampsia? Select all that apply.

Monitoring deep tendon reflexes Maintaining a dark, quiet environment Using a pump to regulate the medication Having calcium gluconate available at the bedside

Which aspects of the "self" do children assess while forming an evaluation of their self-esteem? Select all that apply

Moral worth Competence Sense of control Worthiness of love

A health care provider prescribes carbamazepine (Tegretol) for a client. The nurse teaches the client about effects of the drug that should be reported to the health care provider. Which effects identified by the client as cause to call the provider indicate an understanding of the teaching? Select all that apply.

Nausea or vomiting Unusual bleeding or bruising

An adolescent who has had type 1 diabetes for 5 years stops adhering to the therapeutic regimen. Which would the nurse conclude based on the client's developmental level?

Need for attention Struggle for identity

A nurse is caring for a child who is receiving vincristine (Oncovin) as a part of a chemotherapy protocol. What body systems are most important for the nurse to assess after drug administration? Select all that apply.

Neurological/ Hematological/ Integumentary.

A nurse is trying to determine whether a pregnant woman's membranes have ruptured. What findings support the conclusion that they have ruptured? Select all that apply.

Nitrazine paper turns blue on contact with the fluid. Microscopic examination of the fluid reveals ferning.

A nurse is performing the history and physical examination of a client with Parkinson disease. Which assessments identified by the nurse support this diagnosis? Select all that apply.

Non intention tremors Masklike facial expression Low-pitched monotonous voice

A nurse teaches the parents of a school-aged child with celiac disease about the foods that should be eliminated from the diet. Which foods do the parents name that indicate to the nurse that the teaching has been understood? Select all that apply

Oatmeal/ Whole-wheat bread

A nurse is caring for a client with a diagnosis of Cushing syndrome. Which clinical manifestations does the nurse expect to identify? Select all that apply.

Obese trunk Sleep disturbance Thin arms and legs

Identify personal attitudes and feelings about homosexuality An older adult is brought to the emergency department after being found in the street without a coat during a snowstorm. What actions should the nurse implement? Select all that apply.

Obtain a rectal temperature. Assess the fingers for areas of frostbite. Determine client's level of consciousness. Ask for client identification.

The nurse accompanies a 3-year-old child to the playroom. The toddler seems afraid to select a toy or activity. What age-appropriate play materials should the nurse offer? Select all that apply.

Plastic tea set Mold and clay Play telephone

After tolerating an oral rehydration solution (Pedialyte) being given because of dehydration resulting from diarrhea, a 20-month-old toddler's condition improves, and a regular diet is started. What foods should the nurse suggest that the parents offer their child? Select all that apply.

Poached eggs Strained carrots Animal crackers

After assessing a client, a nurse concludes that the client may be experiencing hyperglycemia. Which clinical findings commonly associated with hyperglycemia support the nurse's conclusion? Select all that apply.

Polyuria Polydipsia Polyphagia

A nurse is discussing the diet of an 8-month-old infant with the parents. Which foods can an infant of this age on a regular diet safely be fed? Select all that apply.

Pureed pears Pureed carrots Mashed sweet potatoes

A 1-year-old infant is brought to the well-baby clinic. Which toys should the nurse select from the play area for this infant's growth and developmental level? Select all that apply.

Push-pull toy Nested boxes Squeaking plastic toy

Which safety intervention would the nurse include in a plan of care for a client with somatic disorder who reports loss of vision?

Put the call light within reach. Orient the client to surroundings.

A client has a low hemoglobin level, which is attributed to nutritional deficiency, and the nurse provides dietary teaching. Which food choices by the client indicate that the nurse's instructions are effective? Select all that apply.

Raisins Spinach

A client is admitted with dehydration. Which findings should the nurse expect the client to exhibit? Select all that apply.

Rapid, thready pulse Elevated specific gravity

A client is admitted to the hospital for surgery for rectosigmoid colon cancer, and the nurse is obtaining a health history as part of the admission process. What clinical findings associated with rectosigmoid colon cancer does the nurse expect the client to report? Select all that apply.

Rectal bleeding Change in the shape of stools Feeling of abdominal bloating

A nurse is caring for a preschool-age child with leukemia who is undergoing chemotherapy and may have a fever. What factors should the nurse consider before taking this child's temperature? Select all that apply.

Rectal temperatures are too upsetting for this age group. Oral temperatures are accurate in children with leukemia. Rectal temperatures are avoided to reduce the risk of rectal trauma

A hospitalized client is receiving pyridostigmine (Mestinon) for control of myasthenia gravis. In the middle of the night, the nurse finds the client weak and barely able to move. Which additional clinical findings support the conclusion that these responses are related to pyridostigmine? Select all that apply.

Respiratory depression Decreased blood pressure High-pitched gurgling bowel sounds

A woman visits the prenatal clinic because an over-the-counter pregnancy test has rendered a positive result. After the initial examination verifies the pregnancy, the nurse explains some of the metabolic changes that occur during the first trimester of pregnancy. Select all that apply.

Sleep needs increase/ Fluid retention increases/ Calcium requirements increase.

A client is recovering from an acute episode of alcoholism that included esophageal involvement. What are the components of a therapeutic diet that are most appropriate for the nurse to include in the teaching plan for this client? Select all that apply.

Soft diet High-protein diet High-carbohydrate diet

A 9-year-old child who is undergoing intravenous antibiotic therapy becomes bored and irritable. What activities for school-aged children should the nurse suggest? Select all that apply.

Starting a collection/ Making a model airplane.

A 3-year-old child is brought into the emergency department after the sudden onset of high fever, drooling, and respiratory distress. What nursing actions should the nurse perform? Select all that apply.

Starting an intravenous line Drawing a blood sample for a complete blood count and differential Assessing oxygen saturation of the blood and administering oxygen by mask if it is below 94% Assessing the child's temperature and administering an antipyretic if the rectal temperature is higher than 101° F (38.3° C).

The nurse is caring for a 12-month-old infant with a diagnosis of failure to thrive. The infant's weight is below the third percentile, and development is delayed. Which behaviors of the child suggest to the nurse the possibility of parental neglect? Select all that apply.

Stiff Withdrawn Minimal smiling Little interest in the environment

The nurse cares for a client who develops pyrexia three days after surgery. The nurse should monitor the client for which signs and symptoms commonly associated with pyrexia? Select all that apply.

Tachypnea Increased pulse rate

How should a nurse prepare an intravenous piggyback (IVPB) medication for administration to a client receiving an IV infusion? Select all that apply.

Wear clean gloves to check the IV site. Rotate the bag after adding the medication to mix. Use a sterile technique when preparing the medication

The nurse is providing instructions about foot care for a client with diabetes mellitus. What should the nurse include in the instructions? Select all that apply.

Wear shoes when out of bed. Dry between the toes after bathing.

A nurse assessing a newborn identifies several characteristics of Turner syndrome. Which features did the nurse observe? Select all that apply.

Webbed neck Female sex organs Widely spaced nipples

What should a nurse incorporate into the plan of care for a school-aged child hospitalized with acute glomerulonephritis (AGN)? Select all that apply.

Weighing daily/ Restricting fluids

A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet tall and weighs 293 pounds puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? Select all that apply.

Weight Smoking

A nurse is caring for a client with an underactive thyroid gland. Which responses should the nurse expect the client to exhibit as a result of decreased levels of triiodothyronine (T3) and thyroxine (T4)? Select all that apply.

Weight gain Cold intolerance

A nurse is assessing a 6-month-old infant's motor skills. Which skills does the nurse expect this infant to exhibit? Select all that apply.

Bears weight on hands when prone Turns from prone to supine position at will

Which clinical indicators does the nurse identify that suggest that a client is experiencing urinary retention and overflow after a cerebrovascular accident (also known as a "brain attack")? Select all that apply.

Frequent voiding's Suprapubic distention

A client was admitted to the hospital with blunt trauma as a result of a collision with the steering wheel during a motor vehicle accident. The client was treated for a lacerated liver and abdominal hemorrhage. Which clinical findings should the nurse be alert for when assessing the client for peritonitis during the recovery period? Select all that apply.

Muscle rigidity Abdominal tenderness Decreased bowel sounds

A client receives spinal anesthesia during labor and birth. Twenty-four hours later, she tells a nurse that she has a headache. Which statements indicate to the nurse that the headache is a reaction to the anesthesia? Select all that apply."

My ears are ringing." It gets better when I lie down." Bright lights really bother my eyes." My head hurts more when I'm sitting watching TV

A health care provider prescribes acetylsalicylic acid (aspirin) therapy for a client with arthritis, and the nurse provides teaching about the undesirable side effects of this medication. What responses should the client identify as reasons to notify the health care provider? Select all that apply.

Nausea Easy bruising Ringing in the ears

A nurse is teaching a group of clients about risk factors for heart disease. Which factors increase a client's risk for a myocardial infarction (MI)? Select all that apply.

Obesity Hypertension

After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which manifestations of excessive levels of ADH should the nurse assess the client? Select all that apply.

Weight gain Hyponatremia