last exam 2025!
the client is hospitalized for conservative treatment of cirrhosis. which intervention should the nurse anticipate in the plan of care? 1. monitor the blood sugar level 2. keep NPO status 3. administer IV antibiotics 4. encourage ambulation Q 4 hr
1. monitor the blood sugar level
clients who were exposed to a white phosphorus chemical spill are arriving to the ED. which intervention should the nurse plan to do first? 1. triage clients before transport to designated areas 2. put on PPE 3. flush the client's skin and clothing with water. 4. brush the chemical off of the client's skin
2. put on PPE
acute graft rejection post liver transplant typically occurs how many days after surgery?
4-10 days
the nurse is preparing to care for the client who has Hep. A. which intervention should the nurse include? 1. teach the client to limit use of booze & drugs containing acetaminophen 2. provide a high-protein, high-carb diet with 3 big meals per day 3. wear gloves, mask, and gown when providing the client's personal cares 4. provide rest periods, alternating this with moderate activity during the day
4. provide rest periods, alternating this with moderate activity during the day
A patient has lab work drawn and it shows a positive HBsAg. What education will you provide to the patient? A. Avoid sexual intercourse or intimacy such as kissing until blood work is negative. B. The patient is now recovered from a previous Hepatitis B infection and is now immune. C. The patient is not a candidate from antiviral or interferon medications. D. The patient is less likely to develop a chronic infection.
A. Avoid sexual intercourse or intimacy such as kissing until blood work is negative.
A patient is admitted with hepatic encephalopathy secondary to cirrhosis. Which meal option selection below should be avoided with this patient? A. Beef tips and broccoli rabe B. Pasta noodles and bread C. Cucumber sandwich with a side of grapes D. Fresh salad with chopped water chestnuts
A. Beef tips and broccoli rabe
Select all the types of viral Hepatitis that have preventive vaccines available in the United States? A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D E. Hepatitis E
A. Hepatitis A B. Hepatitis B
A patient was exposed to Hepatitis B recently. Postexposure precautions include vaccination and administration of HBIg (Hepatitis B Immune globulin). HBIg needs to be given as soon as possible, preferably ___________ after exposure to be effective. A. 2 weeks B. 24 hours C. 1 month D. 7 days
B. 24 hours
Which patient below is at MOST risk for developing a complication related to a Hepatitis E infection? A. A 45-year-old male with diabetes. B. A 26-year-old female in the 3rd trimester of pregnancy. C. A 12-year-old female with a ventricle septal defect. D. A 63-year-old male with cardiovascular disease.
B. A 26-year-old female in the 3rd trimester of pregnancy.
Which patients below are at risk for developing complications related to a chronic hepatitis infection, such as cirrhosis, liver cancer, and liver failure? Select all that apply: A. A 55-year-old male with Hepatitis A. B. An infant who contracted Hepatitis B at birth. C. A 32-year-old female with Hepatitis C who reports using IV drugs. D. A 50-year-old male with alcoholism and Hepatitis D. E. A 30-year-old who contracted Hepatitis E.
B. An infant who contracted Hepatitis B at birth. C. A 32-year-old female with Hepatitis C who reports using IV drugs. D. A 50-year-old male with alcoholism and Hepatitis D.
While providing mouth care to a patient with late-stage cirrhosis, you note a pungent, sweet, musty smell to the breath. This is known as: A. Metallic Hepatico B. Fetor Hepaticus C. Hepaticoacidosis D. Asterixis
B. Fetor Hepaticus
A 36-year-old patient's lab work show anti-HAV and IgG present in the blood. As the nurse you would interpret this blood work as? A. The patient has an active infection of Hepatitis A. B. The patient has recovered from a previous Hepatitis A infection and is now immune to it. C. The patient is in the preicetric phase of viral Hepatitis. D. The patient is in the icteric phase of viral Hepatitis.
B. The patient has recovered from a previous Hepatitis A infection and is now immune to it.
Which of the following is NOT a role of the liver? A. Removing hormones from the body B. Producing bile C. Absorbing water D. Producing albumin
C. Absorbing water
During your morning assessment of a patient with cirrhosis, you note the patient is disoriented to person and place. In addition while assessing the upper extremities, the patient's hands demonstrate a flapping motion. What lab result would explain these abnormal assessment findings? A. Decreased magnesium level B. Increased calcium level C. Increased ammonia level D. Increased creatinine level
C. Increased ammonia level
A patient is prescribed Peginterferon alfa-2a. The nurse will prepare to administer this medication what route? A. Oral B. Intramuscular C. Subcutaneous D. Intravenous
C. Subcutaneous
A patient with Hepatitis A asks you about the treatment options for this condition. Your response is? A. Antiviral medications B. Interferon C. Supportive care D. Hepatitis A vaccine
C. Supportive care
A patient has completed the Hepatitis B vaccine series. What blood result below would demonstrate the vaccine series was successful at providing immunity to Hepatitis B? A. Positive IgG B. Positive HBsAg C. Positive IgM D. Positive anti-HBs
D. Positive anti-HBs
A 45 year old male has cirrhosis. The patient reports concern about the development of enlarged breast tissue. You explain to the patient that this is happening because? A. The liver cells are removing too much estrogen from the body which causes the testicles to produce excessive amounts of estrogen, and this leads to gynecomastia. B. The liver is producing too much estrogen due to the damage to the liver cells, which causes the level to increase in the body, and this leads to gynecomastia. C. The liver cells are failing to recycle estrogen into testosterone, which leads to gynecomastia. D. The liver cells are failing to remove the hormone estrogen properly from the body, which causes the level to increase in the body, and this leads to gynecomastia.
D. The liver cells are failing to remove the hormone estrogen properly from the body, which causes the level to increase in the body, and this leads to gynecomastia.
a nurse is caring for a patient who has cirrhosis. what medications should the nurse administer to this patient?
Diuretic, beta-blocker agent, & lactulose
TRUE or FALSE: A patient with Hepatitis A is contagious about 2 weeks before signs and symptoms appear and 1-3 weeks after the symptoms appear.
TRUE
Which is the priority nursing action while caring for a client with esophageal varices? a. Assessing for hemorrhage b. Controlling blood pressure c. Encouraging nutritional intake d. Teaching the client about varices
a. Assessing for hemorrhage
What is the nurse's priority while caring for a client with spontaneous bacterial peritonitis? a. Fluid and electrolyte b. Gastric irrigation c. Pain management d. Psychosocial issues
a. Fluid and electrolyte
The physician has determined that the client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? a. Hepatitis A b. Hepatitis B c. Hepatitis C d. Hepatitis D
a. Hepatitis A
A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which of the following? a. Malaise b. Dark stools c. Weight gain d. LUQ pain
a. Malaise
A nurse is caring for a client who has bipolar disorder and a new prescription for valproic acid. Which of the following actions should the nurse take? a. Monitor the liver function b. Avoid giving the medication with food or milk c. Counsel the client regarding medication dependency d. Limit intake of foods containing tyramine
a. Monitor the liver function
A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy, which of the following laboratory findings should the nurse monitor prior to the procedure? a. PTT b. Lipase c. Bilirubin d. Calcium
a. PTT
A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the findings is the priority for the nurse to report to the MD? a. Temperature 102.9 F b. Headache c. Constipation d. Dry mouth
a. Temperature 102.9 F
A 57 year old male with diagnosis of hepatitis A is admitted to the unit. He is also recovering from vascular surgery and has an open wound on his left lower leg. Which type of isolation is likely to be requested for this client? a. Universal standard precautions b. Respiratory c. Wound d. Reverse
a. Universal standard precautions
RN caring for a pt who has BPD & experiencing hypomania. during a conversation with other clients she becomes agitated and begins speaking in a loud, angry voice. which of the following actions should the nurse take? a. ask the client to take a walk b. reprimand the client for her rude behavior c. point out inappropriate behaviors to the client d. administer trazodone to the client
a. ask the client to take a walk
a nurse is assisting a provider with performing a paracentesis. which of the following actions should the nurse take? a. ask the pt to empty bladder before b. place the pt leaning forward over the bedside table c. inform the pt he will be sedated d. instruct the pt to fast for 6 hr before
a. ask the pt to empty bladder
the ED charge nurse is informed that an unknown number of clients were exposed to a nerve agent. which medication should the nurse plan to have available in sufficient quantities to treat the clients? a. atropine sulfate b. labetalol c. dopamine d. phentolamine
a. atropine sulfate
a charge nurse is discussing manifestations of schizophrenia with a new RN. which of the following manifestations should the charge nurse identify as being effectively treated by first-generation antipsychotics? SATA a. auditory hallucinations b. withdrawal from social situations c. delusions of grandeur d. severe agitation e. anhedonia
a. auditory hallucinations c. delusions of grandeur d. severe agitation
RN teaching a pt with End stage CKD. which nutrients should the nurse instruct the pt to increase in her diet? a. calcium b. phosphorous c. potassium d. sodium
a. calcium
RN is assessing a client who has BPD. which actions is an indication the client is experiencing manic stage? a. client speaks rapidly with a sense of urgency b. the client touches everything within her reach c. the client states that she is unable to enjoy her favorite activities d. the client moves slowly and maintains a fixed gaze
a. client speaks rapidly with a sense of urgency
which of the following would the nurse expect to assess in a client who has inhaled Clostridium botulinum? SATA a. diplopia b. dysphagia c. asymmetric ascending spastic paralysis d. fever e. dry mouth
a. diplopia b. dysphagia d. fever e. dry mouth
a nurse is preparing to perform the follow-up assessment on a client who takes chlorpromazine for tx of schizophrenia. the nurse should expect to find the greatest improvement in which of the following manifestations? SATA. a. disorganized speech b. bizarre behavior c. impaired social interactions d. hallucinations e. decreased motivation
a. disorganized speech b. bizarre behavior d. hallucinations
A nurse does an assessment on a client after an endoscopic retrograde cholangiopancreatography (ERCP). The nurse reports to the health care provider which finding? a. Distended firm abdomen b. Absence of a gag reflex c. Left-sided hip soreness Colicky abdominal pain
a. distended firm abdomen
RN in an urgent care is collecting data from a client who reports exposure to anthrax. which of the following findings is an indication of the prodromal stage of inhalation of anthrax? a. dry cough b. rhinitis c. sore throat d. swollen lymph nodes
a. dry cough
a charge nurse in an emergency department is informed that a tornado touched down in a nearby town, and make casualties are on the way. which of the following actions should the nurse take? a. follow facility policy to activate the disaster plan b. prepare the triage rooms c. obtain additional supplies d. call in off duty staff members
a. following facility policy to activate the disaster plan
RN in an acute mental health facility observes a client who has BPD begin to shout and use offensive language toward a visitor. which of the following actions should the nurse take? a. give the client 2 options for ending the situation b. move quickly to stand directly in front of the client before speaking c. direct other clients to move toward the client as a show of force (YIKES!) d. tell the client that the conversation will be ended if the shouting continues
a. give the client 2 options for ending the situation
a community health nurse is performing client triage while participating in a disaster drill. the nurse should recommend that which of the following client injuries receive treatment first? a. hemothorax b. open humeral fracture c. multiple deep abrasions on the arms
a. hemothorax
You're providing an in-service on viral hepatitis to a group of healthcare workers. You are teaching them about the types of viral hepatitis that can turn into chronic infections. Which types are known to cause ACUTE infections ONLY? Select all that apply: A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D E. Hepatitis E
a. hepatitis A e. hepatitis E AcutE only - others can cause acute or chronic
the nurse is caring for the client who developed ARF. which findings support the nurse's conclusion that the client is in the recovery phase of ARF? SATA a. increased urine specific gravity b. increased serum creatinine level c. decreased serum potassium level d. absence of N/V e. absence of muscle twitching
a. increased urine specific gravity c. decreased serum potassium level d. absence of N/V e. absence of muscle twitching
the nurse is educating the client about prescription antidepressant meds & the appropriate expectations when taking these medications. which statement by the nurse is the most accurate? a. it is important to continue taking antidepressant meds even after you feel better b. your symptoms will subside about 72 hr. after starting the meds c. you will be taking fluoxetine, which is the most potent SSRI antidepressant med d. some common side effects of SSRIs are dry mouth, blurred vision, and urinary retention
a. it is important to continue taking antidepressant meds even after you feel better
a nurse is teaching a client who has CKD. which of the following instructions should the nurse include? a. limit fluid intake b. limit caloric intake c. eat a diet high in phosphorus d. eat a diet high in protein
a. limit fluid intake
a nurse is planning care for a client who will undergo peritoneal dialysis. which of the following actions should the nurse take? (SATA) a. monitor serum glucose levels b. report cloudy dialysate return c. warm the dialysate in a microwave oven d. assess for SOB e. check the access site dressing for wetness. f. maintain medical asepsis when accessing the catheter insertion site
a. monitor serum glucose levels b. report cloudy dialysate return d. assess for SOB e. check the access site dressing for wetness.
RN caring for a client who has BPD & new Rx for Valproic Acid. which of the following actions should the nurse take? a. monitor the client's liver function b. avoid giving the medication with food or milk c. counsel the client regarding medication dependency d. limit the intake of foods containing tyramine
a. monitor the client's liver function
a nurse is caring for a client who has schizophrenia and a prescription for chlorpromazine. for which of the following adverse effects should the nurse monitor? a. orthostatic hypotension b. diarrhea c. urinary frequency d. bradycardia
a. orthostatic hypotension
RN reviewing lab results of Lithium of 2.1 mEq/L. which of the following is an appropriate action by the nurse? a. perform immediate gastric lavage b. prepare the client for hemodialysis c. administer an additional oral dose of Lithium d. Request a stat repeat of the lab test
a. perform immediate gastric lavage if > 2.5, then dialysis
a nurse is checking the laboratory values of a client who has CKD the nurse should expect elevation of which of the following values? a. potassium & magnesium b. calcium & bicarbonate c. H&H d. Arterial pH and PaCO2
a. potassium & magnesium
a nurse is teaching a client with chronic kidney disease about predialysis dietary recommendations. the nurse should recommending restricting the intake of which of the following nutrients? a. protein b. carbs c. calcium d. monounsaturated fats
a. protein
which of the following are associated with catatonic schizophrenia? a. purposeless motor agitations b. tactile hallucinations c. word salad and flight of ideas d. eccentric behaviors or odd beliefs
a. purposeless motor agitations
a nurse is caring for a client who has CKD. the kidneys regulate body fluids as well as assisting in which of the following functions? a. regulation of acid-base balance b. reabsorption of nutrients for cellular growth c. regulation of body temp. d. secretion of hormones needed for growth
a. regulation of acid-base balance
a nurse is preparing to initiate hemodialysis for a client who has AKI. which of the following actions should the nurse take? (SATA) a. review the medications the client currently takes b. assess the AV fistula for a bruit c. calculate the client's hourly urine output d. measure the client's weight e. check serum electrolytes f. use the access site are for venipuncture
a. review the medications the client currently takes b. assess the AV fistula for a bruit d. measure the client's weight e. check serum electrolytes
Your patient with cirrhosis has severe splenomegaly. As the nurse you will make it priority to monitor the patient for signs and symptoms of? Select all that apply: A. Thrombocytopenia B. Vision changes C. Increased PT/INR D. Leukopenia
a. thrombocytopenia c. increased PT/INR d. leukopenia
a nurse is caring for an infant who has biliary atresia. which of the following manifestations should the nurse expect (SATA) a. yellow sclerae b. rapid weight gain c. tar-colored stools d. abdominal distention e. dark urine
a. yellow sclerae d. abdominal distention e. dark urine
A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take? a. Stop the interview at this point, and resume later when the client is better able to concentrate b. Ask the client, "Are you seeing something on the ceiling?" c. Tell the client, "you seem to be looking at something on the ceiling, I see something there, too." d. Continue the interview without comment on the client's behavior
b. Ask the client, "Are you seeing something on the ceiling?"
RN should recognize that which of the following is expected for a client who has stage 4 chronic kidney disease? a. BUN 15 b. GFR 20 c. Creatinine 1.1 d. K 5.0
b. GFR 20
A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? a. I am a superhero and am immortal b. I am no one, and everyone is me c. I feel monsters pinching me all over d. I know that you are stealing my thoughts
b. I am no one, and everyone is me
A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are telling her to "kill your doctor" Which of the following actions should the nurse take first? a. Use therapeutic communication to discuss the hallucination with the client b. Initiate one-to-one observation of the client c. Focus the client on reality d. Notify the MD of the client's statement
b. Initiate one-to-one observation of the client
the 75-y.o. client is hospitalized with ESRD. which finding in the client's medical record should the nurse associate with the diagnosis of ESRD? a. a u/o of < 100 mL in 24 hours b. a GFR < 15 c. a creatinine level > 12.0 d. BUN > 100
b. a GFR < 15
a triage nurse in the emergency department when several hundred clients who were injured in a train collision arrive at the facility for treatment. which of the following clients requires immediate attention? a. a client who has neck pain and was transported to the facility on a backboard? b. a client who has epigastric and left arm pain and is diaphoretic c. a client who has nasal and orbital ecchymosis and a RR of 16 d. a client who has abdominal pain and is 2 months preggers
b. a client who has epigastric and left arm pain is diaphoretic
3 weeks after developing ARF trauma, the hospitalized patient has a significantly increased u/o. which assessment finding should the nurse report to the MD immediately? a. absence of adventitious breath sounds b. a drop in BP & an increased in pulse rate c. a 3-pound weight loss over 24 horus d. a serum K level of 3.7
b. a drop in BP & an increase pulse rate
RN teaching a client who has schizophrenia strategies to cope w/ anticholinergic effects of fluphenazine. which of the following should the nurse suggest to the client to minimize the anticholinergic effects? a. take the med in the am to prevent insomnia b. chew sugarless gum to moisten the mouth c. use cooling measures to decrease fever d. take an antacid to relieve nausea
b. chew sugarless gum to moisten the mouth
a nurse on a bioterrorism committee is developing a brochure to increase public awareness about the threat on inhalation anthrax. which of the following pieces of information should the nurse plan to include in the brochure? a. an immunization for inhalation anthrax is recommended for administration to children b. clients who have manifestations of inhalation anthrax will need antibiotic treatment for 60 days c. the initial manifestations of inhalation anthrax include an itchy skin lesion that blisters and scabs d. clients exposed to housemates who have inhalation anthrax must receive prophylactic treatment
b. clients who have manifestations of inhalation anthrax will need antibiotic treatment for 60 days
the nurse is assessing the client receiving peritoneal dialysis. which finding suggests that the client may be developing peritonitis? a. abdominal numbness b. cloudy dialysis output c. radiating sternal pain d. decreased WBC
b. cloudy dialysis output
a nurse is assessing a client who takes lithium carbonate for the tx of BPD. the nurse should recognize which of the following findings as possible indication of toxicity to this medication? a. severe HTN b. course tremors c. constipation d. muscle spasms
b. course tremors
You are receiving shift report on a patient with cirrhosis. The nurse tells you the patient's bilirubin levels are very high. Based on this, what assessment findings may you expect to find during your head-to-toe assessment? Select all that apply: A. Frothy light-colored urine B. Dark brown urine C. Yellowing of the sclera D. Dark brown stool E. Jaundice of the skin F. Bluish mucous membranes
b. dark brown urine c. yellowing of the sclera e. jaundice of the skin
a nurse is caring for a client with BPD who is experiencing mania. which of the following actions is the nurse's priority? a. offer the pt finger foods q 2 hr. b. determine if the pt is a danger to herself c. monitor the pt.'s VS q 2 hr. d. move the pt to a quiet area
b. determine if the pt is a danger to herself
RN is discussing relapse prevention w/ a pt w/ BPD. which of the following info. should the nurse include in the teaching? SATA a. use caffeine in moderation b. difficulty sleeping can indicate a relapse c. begin taking your meds as soon as a relapse starts d. participating in psychotherapy can help prevent a relapse e. anhedonia is a clinical manifestation of a depressive relapse
b. difficulty sleeping can indicate a relapse d. participating in psychotherapy can help prevent a relapse e. anhedonia is a clinical manifestation of a depressive relapse
the nurse is educating the client with schizophrenia. which interventions should the nurse encourage the client to use to help prevent the relapse of schizophrenic symptoms? SATA a. ignore auditory hallucinations b. engage in regular physical exercise c. report changes in sleeping patterns d. enroll in stress-management classes e. avoid employment that is demanding
b. engage in regular physical exercise c. report changes in sleeping patterns d. enroll in stress-management classes
RN reviewing plan of care for a client who has BPD. which of the following is an effect of using CBT. a. prevents the need for mood stabilizing medications b. helps the client deal with distorted thought processes c. aids communication among family members d. replaces the need for lifestyle interventions
b. helps the client deal with distorted thought processes
a nurse is monitoring a client who had a kidney biopsy for postoperative complications. which of the following complications should the nurse identify as causing the greatest risk to the client? a. infection b. hemorrhage c. hematuria d. pain
b. hemorrhage
a nurse is caring for a client on an inpatient mental health unit. the client reports hearing voices that are telling her to "kill your roommate." Which of the following actions should the nurse take? a. tell the client that she is imagining the voices b. initiate one-to-one observations of the client c. place the client in a restraint d. ask another client to sit with the client
b. initiate one-to-one observation of the client
RN is assessing a male client who recently began taking haloperidol. which of the following findings is the highest priority to report to the provider? a. shuffling gait b. neck spasms c. drowsiness d. impotence
b. neck spasms - neck spasms are an indication of acute dystonia which is a crisis situation requiring rapid treatment. this is the greatest risk to the client and is therefore the priority finding
a nurse is providing teaching for a male client who has schizophrenia and is taking risperidone. which of the following instructions should the nurse include in the teaching? a. add extra snacks to your diet to prevent weight loss b. notify the provider if you develop breast enlargement c. you may begin to have mild seizures while taking this medication d. this medication is likely to increase your libido
b. notify the provider if you develop breast enlargement
the serum ammonia level of the patient with cirrhosis is elevated. what should the nurse do? a. monitor for temp elevation b. observe for increasing confusion c. measure the urine specific gravity d. restrict the intake of oral fluids
b. observe for increasing confusion
RN is planning care for a pt w/ BPD & is experiencing a manic episode. which of the following interventions should the nurse include in the plan of care? SATA a. provide flexible client behavior expectations b. offer concise explanations c. establish consistent limits d. disregard clients complaints e. use firm approach with communication
b. offer concise explanations c. establish consistent limits e. use firm approach with communication
the triage nurse in an ED is caring for clients injured in a mass casualty disaster. which client should the nurse establish as the priority client? a. unresponsive client with a penetrating head injury b. partially responsive client with a sucking chest wound c. client with a maxilla fracture and facial wounds without airway compromise d. client with third degree burns over 65% of the body surface area
b. partially responsive client with a sucking chest wound
a nurse is discussing early indications of toxicity with a client who has a new Rx for lithium carbonate for BPD. the nurse should include which of the following manifestations in the teaching? SATA a. constipation b. polyuria c. rash d. muscle weakness e. tinnitus
b. polyuria d. muscle weakness
the nurse assesses that the client with ARF has a serum K level of 6.8. which meds, if ordered, should the nurse give now? SATA a. erythropoietin b. regular insulin c. 0.45% saline bolus d. calcium gluconate e. sodium polystyrene sulfonate
b. regular insulin d. calcium gluconate e. sodium polystyrene sulfonate
a community that experienced a damaging tornado activated the community emergency response plan. which activity constitutes the emergency response phase? SATA a. establishing emergency operations centers b. repairing utilities c. opening shelters d. establishing critical care services e. implementing warning systems
b. repairing utilities c. opening shelters d. establishing critical care services
the experienced nurse and new nurse are caring for 4 clients with CRF. which statement by the new nurse should the experience nurse CORRECT? a. the client with CRF is starting on peritoneal dialysis and should have a high-protein diet b. the amount of outflow from peritoneal dialysis should equal the amount the was instilled c. i should hold the client's dose of lisinopril because the client is going for hemodialysis now d. i will ensure that the client with CRF has more carbohydrates because protein is restricted
b. the amount of outflow from peritoneal dialysis should equal the amount the was instilled
The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? a. Dorsiflex the client's foot b. Measure the abdominal girth c. Ask the client to extend their arms d. Instruct the client to learn forward
c. Ask the client to extend their arms
Which of the follow is NOT a treatment for an upper GI tract bleed? a. Octreotide b. Endoscopy c. Colon resection d. Balloon tamponade
c. Colon resection
RN is teaching new RN about the use of ECT for tx of BPD. which of the following statements by the new RN indicates an understanding? a. ECT is the recommended initial treatment for BPD b. ECT is contraindicated for clients who have suicidal ideation c. ECT is effective for clients who are experiencing severe mania d. ECT is prescribed to prevent relapse of BPD.
c. ECT is effective for clients who are experiencing severe mania
Asterixis is regarded as a sign of the development of which condition? a. Left ventricular failure b. Acute calcium disturbance c. Hepatic encephalopathy d. Seizures
c. Hepatic encephalopathy
a nurse is providing teaching to a client who has a diagnosis of hepatitis A. which of the following statements by the client indicates an understanding of the teaching? a. I am unable to donate blood b. I will need to get a booster shot of immune serum globulin every year c. I should stop eating raw clams d. I can develop this disease by getting a tattoo
c. I should stop eating raw clams
Which diagnostic test will confirm a diagnosis of cirrhosis? a. Albumin level b. Bromsulphthalein dye excretion c. Liver biopsy d. Liver enzyme tests
c. Liver biopsy
a nurse is caring for a client who is receiving peritoneal dialysis. the nurse notes that the client's dialysate output is less than input and that his abdomen is distended. which of the following actions should the nurse take? a. insert an indwelling urinary catheter b. administer pain medication to the client c. change the client's position d. place the drainage bag above the client's abdomen
c. change the client's position
a nurse is caring for a client who schizophrenia. the client states, 'I like to play ball. walk down the hall. be careful don't fall" the nurse should identify that the client is using which of the following speech patterns? a. pressured speech b. circumstantial speech c. clang association d. flight of ideas
c. clang association
RN caring for pt w/ BPD. which of the following manifestations is the priority finding for the nurse to identify? a. inability to concentrate b. poor hygiene c. hyperactivity d. pressured speech
c. hyperactivity rationale: greatest risk to this client is an injury from hyperactivity.
the nurse is working at a natural disaster scene. a client was found to have a compound fracture of the left lower leg. he was triaged accordingly... a. expectant b. delayed c. immediate d. minimal
c. immediate
after a diagnosis of CRF, the client was started on epoetin alfa. which finding indicates that the medication has been effective? a. decrease in serum creatinine levels b. increase in WBCs c. increase in hct d. decrease in BP
c. increase in hct
the student nurse is caring for the client following a liver biopsy. which observation of the student nurses's care demonstrates the the RN that the student understands the post-procedure care? a. VS q 1 hr b. walks the client 1 hr post-op c. positions the client onto the right side d. has the client cough and deep breathe hourly
c. positions the client onto the right side
a nurse is planning care for a client who has prerenal AKI following abdominal aortic aneurysm repair. u/o is 60 mL in the past 2 hr, BP 92/58. the nurse should anticipate which of the following interventions? a. prepare the client for a CT w/ contrast dye b. plan to administer nitroprusside c. prepare to administer a fluid challenge d. plan to position the client in Trendelenburg
c. prepare to administer a fluid challenge
the nurse is reviewing info from a recent disaster management training session. the nurse knows that all the following activities are part of the preparedness phase of disaster management except which of the following? a. develop early warning systems and evacuation routes b. designate locations of shelters c. provide emergency care d. conduct training and mock disaster response drills
c. provide emergency care
a nurse is assessing a client who has prerenal AKI. which of the following findings should the nurse expect? SATA a. reduced BUN b. elevated cardiac enzymes c. reduced u/o d. elevated serum creatinine e. elevated serum calcium
c. reduced u/o d. elevated serum creatinine
a nurse is caring for a client who has schizophrenia & exhibits a lack of grooming and a flat affect. the nurse should anticipate a prescription of which of the following medications? a. chlorpromazine b. thiothixene c. risperidone d. haloperidol
c. risperidone second-generation antipsychotics, such as risperidone, are effective in treating negative symptoms of schizophrenia, such as lack of grooming and flat affect
signs of cutaneous anthrax while assessing a pt who came in contact with a white powder leaking from an envelope. which early sx of anthrax should the nurse look for in this patient? a. nausea and loss of appetite b. sore throat, mild fever, and muscle aches c. small sores that become blisters d. bloody diarrhea and high fever
c. small sores that become blisters
a nurse is assessing a client who has schizophrenia and takes haloperidol TID. the client develops involuntary writhing movements of the tongue and constant lip smacking. the nurse should identify that these manifestations indicated which of the following effects of haloperidol? a. akathisia b. acute dystonia c. tardive dyskinesia d. pseudoparkinsonism
c. tardive dyskinesia
the nurse assesses that the client with acute mania has coarse hand tremors, and the Lithium level is 1.8 mEq/L. what should the nurse do? a. advise the pt to limit the intake of fluids b. continue to administer Lithium as prescribed c. withhold the dose and notify HCP d. request a medication to treat the hand tremors
c. withhold the dose and notify HCP
what are indicators of hepatic encephalopathy?
change in orientation, asterixis, & fetor hepaticus
RN providing discharge teaching to a pt who has a new Rx for Clozapine. which of the following statements should the nurse include in the teaching? a. "You should have a high-carb snack before meals & at bed time" b. "You are likely to develop hand tremors is you take this medication for a long period time" c. "You may experience temporary numbness of your mouth after each dose" d. "You should have your WBC monitored weekly."
d. "You should have your WBC monitored weekly."
A client is experiencing respiratory distress related to ascites. What treatment will help to relieve the distress? a. Placing the client in a supine position b. Endoscopy c. Protein restriction in the diet d. Administration of diuretics and sodium restriction
d. Administration of diuretics and sodium restriction
a nurse is observing a client with schizophrenia in the dayroom. Another client asks him if several items of clothing match. He replies, "A match. I like matches. They are givers of light, the light of the world. Let your light shine on" the nurse should identify these statements as which of the following speech alterations? a. Clang association b. Echolalia c. Word salad d. Associative looseness
d. Associative looseness
A nurse is teaching a client who has cirrhosis of the liver and a history of alcohol consumption. The nurse should explain that alcohol can cause liver cirrhosis through which of the following actions? a. Increasing the workload of the liver by releasing stored glycogen b. Causing ulceration of liver tissue that can lead to bleeding c. Dilating veins in the portal circulation d. Destroying liver cells that are later replaced with scar tissue
d. Destroying liver cells that are later replaced with scar tissue
A nurse is monitoring a client who has schizophrenia and is receiving treatment with fluphenazine hydrochloride. Which of the following findings is an indication of NMS that the nurse should report to the provider? a. Blurred vision b. Urinary retention c. Muscle flaccidity d. Elevated temperature
d. Elevated temperature
A client with cirrhosis reports that their skin always feels itchy. Which abnormality, associated with cirrhosis, results in itching? a. Prolonged prothrombin time b. Decreased protein level c. Increased aspartate aminotransferase (AST) d. Increased bilirubin level
d. Increased bilirubin level
A nurse is monitoring the laboratory results of a client who has end-stage liver failure. Which of the following results should the nurse expect? a. Decreased lactate dehydrogenase b. Increased serum albumin c. Decreased serum ammonia d. Increased prothrombin time
d. Increased prothrombin time
A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan? a. Contact the triage officer b. Implement the client tracking system c. Ask the communications officer to release a press statement d. Notify the incident commander
d. Notify the incident commander
A nurse is providing teaching to a client who has cirrhosis and a new prescription for lactulose. The nurse should instruct the client that lactulose ahs which of the following therapeutic effects? a. Increases BP b. Prevents esophageal bleeding c. Decreases heart rate d. Reduce ammonia levels
d. Reduce ammonia levels
A nurse is performing a gastrointestinal assessment of a client who has liver cirrhosis with abdominal distention. Which of the following actions should the nurse take to assess for changes in the client's abdominal distention? a. Percuss the abdomen for tympanic sounds b. Inspect the contour of the abdominal wall c. Instruct the client to report increased abdominal discomfort d. Take serial measurements of the abdomen with a tape measure
d. Take serial measurements of the abdomen with a tape measure
the nurse is planning meals for a client on hemodialysis and fluid restriction secondary to ARF. which afternoon snack should the nurse include? a. large banana b. glass of milk c. ham sandwhich d. a small apple
d. a small apple
a nurse is reviewing the laboratory data for a client who is receiving clozapine for schizophrenia. the nurse should identify which of the following findings as a potential adverse effect of this medication? a. fasting blood glucose 95 b. triglycerides 135 c. total cholesterol 175 d. absolute neutrophil count 1,200
d. absolute neutrophil count 1,200
a nurse is observing a client with schizophrenia in the day room. another client asks him several items of clothing match. he replies, "a match. i like matches. they are givers of light, the light of the world, let your light shine on." the nurse should identify these statements as which of the following speech alterations? a. clang association b. echolalia c. word salad d. associated looseness
d. associative looseness
RN is responding to a community wide request for HCP to assist at the scene of an explosion. when using the north atlantic treaty organization triage system, the nurse should put which of the following tags on a client who is unresponsive and has 3rd-degree burns over 75% of her body? a. red b. yellow c. green d. black
d. black
RN is triaging clients during a mass casualty event. which of the following labels should the nurse assign to a client who has a head injury w/ dilated pupils? a. red tag b. yellow tag c. green tag d. black tag e. name tag
d. black tag
RN is monitoring a client who has schizophrenia & is receiving treatment with fluphenazine hydrochloride. which of the following findings is an indication of NMS that the nurse should report to the provider? a. blurred vision b. urinary retention c. muscle flaccidity d. elevated temp.
d. elevated temp.
a nurse in an outpatient mental health clinic is interviewing a client who has schizophrenia and appears ot be experiencing auditory hallucinations. which of the following actions should the nurse take first? a. teach the client strategies to decrease the hallucinations b. identify whether the client is on anti-psychotic medications c. distract the client from the hallucination d. explore what the voices are saying to the client
d. explore what the voices are saying to the client
a nurse is admitting a client who has schizophrenia. during the initial interview, which of the following behaviors should the nurse identify as a positive manifestation of schizophrenia? a. anhedonia b. avolition c. flat affect d. hallucination
d. hallucinations
a nursing home resident returns to the facility after receiving a hemodialysis treatment. which symptom observed by the nurse suggests that the client may have developed disequilibrium syndrome? a. SOB w/ a nonproductive cough b. pitting edema in both of the hands and feet c. inability to palpate a thrill in the AV fistula d. headache with a decreased LOC
d. headache with a decreased LOC
RN caring for a pt who has a new Rx for Lithium. when teaching the client about ways to prevent toxicity, the RN should advise the client to do which of the following? a. avoid use of acetaminophen for HA b. restrict intake of foods rich in sodium c. decrease fluid intake to less than 1,500 mL daily d. limit aerobic activity in hot weather
d. limit aerobic activity in hot weather
RN in an acute mental health facility is caring for a client who has BPD. which of the following is the priority nursing action? a. set consistent limits for expected client behavior b. administer prescribed meds as scheduled c. provide the client with step by step instructions during hygiene activities d. monitor the client for escalating behavior
d. monitor the client for escalating behavior
a nurse is assessing a client who has schizophrenia. the client states, "I need to get my gummamoshu from by my house" the nurse recognizes this statement as an example of which of the following? a. flight of ideas b. echolalia c. perservation d. neologism
d. neologism
the nurse is caring for the client with CRF. which statement should the nurse document as an appropriate outcome in the plan of care? a. eats 3 large meals daily w/o nausea b. daily weight gain of no more than 3 lbs c. reduced serum albumin levels within 1 week d. no evidence of bleeding
d. no evidence of bleeding
a nurse is assessing a client who has AKI. according to the RIFLE classification system, which of the following findings indicates that the client has end-stage kidney disease? a. <0.5 mL/kg of u/o for 12 hr b. no u/o for 12 hr c. no u/p without renal replacement therapy for 4-12 weeks d. no u/o without renal replacement therapy for more than 3 months
d. no u/o without renal replacement therapy for more than 3 months
the client is diagnosed with major depressive disorder and was started on an antidepressant 2 days ago. the nurse observes that 2 days ago the client appeared sad and remained in bed. now the client is awake at 4am and planning a unit party. which conclusion should the nurse make regarding the client's change in behavior? a. pt is responding positively to the antidepressant medication b. tx was effective and the pt plans on being discharged soon c. pt is more familiar with the unit and is able to be self-expressive d. pt may have been misdiagnosed and may have a bipolar disorder
d. pt may have been misdiagnosed and may have a bipolar disorder
a nurse is providing teaching to the family of a client who has schizophrenia. which of the following statements by a family member indicates an understanding of the teaching? a. we will not set time limits for discussing her delusions b. we will avoid reacting to her command hallucinations c. she might lose weight d/t her meds d. she might be having a relapse if she stops attending social events
d. she might be having a relapse if she stops attending social events
a nurse is caring for a patient with schizophrenia and is experiencing negative symptoms. which of the following manifestations should the nurse expect? a. hallucinations b. impaired memory c. dysphoria d. social discomfort
d. social discomfort
a nurse is caring fora client who has schizophrenia. the client states aliens came into my room and took a sample of my blood. which of the following responses should the nurse make a. aliens don't exist b. has your daughter had her baby? c. do you mean to say a phlebotomist drew your blood last night? d. that does not sound real
d. that does not sound real
A 23 yr old female admitted to the unit after being found unresponsive by paramedics. No overt signs or symptoms of injury or physical abuse. After starting an intravenous drip, you accidentally stick yourself with the same needle used for venipuncture. a. Based on the preceding information, to what type of hepatitis would you most likely be exposed? i. Hepatitis A ii. Hepatitis B and C iii. Hepatitis D iv. No risk of hepatitis acquisition
ii. Hepatitis B and C
The physician elects to place an esophageal balloon (sengstaken-blakemore tube) to aid bleeding control. Which of the following is NOT a potential complication of the esophageal balloon treatment? i. Tracheal occlusion ii. Esophageal necrosis iii. Esophageal rupture iv. Reversal of portal blood flow
iv. Reversal of portal blood flow
a nurse is caring for a client who has a new diagnosis of hepatitis C. which laboratory findings should the nurse expect?
positive EIA test
