PassPoint: Extra Alternate-Format
During the admission assessment, the nurse focuses on the client's reflexes, muscle strength, coordination, eye movements, and mental status. What symptoms would the nurse identify as suggestive of vascular dementia? Select all that apply. Swinging leg Losing bladder control Laughing inappropriately Shuffling gait Hyperextending the head Aching joint deformities
Losing bladder control Laughing inappropriately Shuffling gait The typical symptoms of vascular dementia are confusion, memory deficits, wandering, shuffling gait, loss of bladder and bowel control, and inappropriate laughter. Leg swinging, head hyperextension, and joint deformities are not symptoms associated with vascular dementia.
A nurse is caring for a client with anorexia nervosa. Which interventions would be appropriate for this client? Select all that apply. Provide small, frequent meals Monitor weight gain Allow the client to skip meals until the antidepressant levels are therapeutic Encourage the client to keep a journal Encourage the client to eat three substantial meals per day
Provide small, frequent meals Monitor weight gain Encourage the client to keep a journal Due to self-starvation, clients with anorexia can rarely tolerate large meals three times per day. Small, frequent meals may be tolerated better by the anorexic client, and they provide a way to gradually increase daily caloric intake. The nurse should monitor the client's weight carefully because a client with anorexia may try to hide weight loss. The client may be emotionally restrained and afraid to express her feelings; therefore, keeping a journal can serve as an outlet for these feelings. An anorexic client is already underweight and should not be permitted to skip meals.
What would the nurse expect to find in the psychologic history of a client who has an eating disorder? Select all that apply. Easy-going, laissez-faire attitude Rigidity of thinking Seeking to please others Depressed mood Distorted body image
Rigidity of thinking Depressed mood Distorted body image Clients will typically be withdrawn, secretive, and isolative. Their thinking pattern will be black and white. They are often depressed and have a distorted sense of their body. An easy-going, laisssez-faire attitude, and striving to please others are not in the psychologic profile of a client with an eating disorder.
A client with celiac disease is being discharged from the hospital. The nurse determines that discharge instructions are understood when the client makes which statement? Select all that apply. "I will eat oatmeal raisin cookies." "I can eat a bologna sandwich." "I will make pepperoni and cheese pizza with rice flour." "I will have rice cakes for lunch." "I can drink apple juice."
"I will have rice cakes for lunch." "I can drink apple juice." Sources of gluten found in wheat, rye, barley, and oats should be avoided. Rice and corn are suitable substitutes because they don't contain gluten. Pepperoni pizza, luncheon meat, and oatmeal cookies contain gluten and, when broken down, can't be digested by people with celiac disease. Rice cakes and apple juice do not contain gluten.
The nurse reads the chart entry for a client who attends group therapy, and who uses cannabis daily: <handwriting> 2/10/2017 1700 The client is congested, with a dry hacking cough. He could not verbalize his treatment goals when asked in the group session. He laughed when the therapist gave each participant a worksheet to fill out and bring back to the next group, and stated, "I'm not doing that." What health problem is this client experiencing because of extended cannabis use? Amotivational syndrome Delirium tremens Vascular dementia Cognitive distortions
Amotivational syndrome Long-term use of cannabis is associated with amotivational syndrome. Amotivational syndrome is a psychological health condition that is characterized by losing interest in cognitive and social activities. The client will display a sense of apathy. Delirium tremens is associated with alcohol withdrawal. Vascular dementia is associated with an alteration in a person's thought processes caused by disrupted blood flow to the brain. Cognitive distortions are inaccurate thoughts used to reinforce negative thoughts or feelings, and are common in clients with depression.
The nurse has just admitted a client to the telemetry floor with reports of acute chest pain radiating down the left arm. Which laboratory studies should the nurse order to evaluate myocardial damage? Select all that apply. Hemoglobin and hematocrit Serum glucose Creatinine phosphokinase (CK-MB) Troponin T and troponin I Myoglobin Blood urea nitrogen (BUN)
Creatinine phosphokinase (CK-MB) Troponin T and troponin I Myoglobin Levels of CK-MB, troponin T, and troponin I rise because of cellular damage. Myoglobin elevation is an early indicator of myocardial damage. Neither hemoglobin, hematocrit, serum glucose, nor BUN levels provide information related to myocardial ischemia.
A school nurse is developing a new prevention program regarding sexually transmitted infection (STI). Which preventative behaviors should be addressed in this program? Select all that apply. Delaying first sexual intercourse Using the rhythm method safely and effectively Reducing the number of sexual partners . Encouraging adolescents to not talk about sex with others Increasing use of condoms
Delaying first sexual intercourse Reducing the number of sexual partners Increasing use of condoms Sexually-transmitted infection prevention programs have had a significant impact on reducing sexual risk behaviors by addressing the importance of condom use, reducing the number of sexual partners, and delaying the initial sexual contact. The rhythm method has no impact on prevention of STIs. Adolescents are less likely to adhere to what is taught if they are not encouraged to discuss sex with other people.
he nurse is assessing a child recently brought to the emergency department. Based on the following notes, which observations would cause the nurse to suspect epiglottitis? Select all that apply. History and physical 10/15/16 0215 23-month-old infant brought in by ambulance. Parents noted infant was doing fine when put to bed, but suddenly woke very agitated with breathing difficulties. Mild tactile temperature noted. Child crying excessively. Child tachypneic, drooling. Child refusing to lie down.
Drooling Refusal to lie down Drooling of saliva is common due to the pain of swallowing excessive secretions, and a sore throat. The child will usually have a high fever, but no spontaneous cough. The child may place themselves in a tripod position with their mouth open and tongue protruding.
The care team has determined that an infant, being treated for congenital hypothyroidism, is not responding adequately to treatment. What assessment findings would support this conclusion? Select all that apply. Irritability Fatigue Sleepiness Increased appetite Diarrhea
Fatigue Sleepiness Signs of inadequate treatment are fatigue, sleepiness, decreased appetite, and constipation
The nurse is assisting with the delivery of a fetus where the mentum is the presenting part. Which illustration shows this fetal presentation?
In the cephalic, or head-down, presentation, the position of the fetus may be classified by the presenting skull landmark: mentum or chin (illustration one), brow (illustration two), sinciput (illustration three), or vertex (illustration four).
The nurse is caring for a child with tricuspid atresia who develops polycythemia. Which statements most accurately describe this manifestation?
Polycythemia is an increased number of red blood cells, thereby increasing the ability of the blood to carry oxygen to the cells. It is the body's attempt at compensating for the chronic hypoxia associated with this heart defect. Due to this clinical manifestation, the viscosity of the blood increases, which leaves the child at risk for developing a thrombus, particularly when dehydrated. There is also not as much room for clotting factors, which can leave the child at risk for blood clotting disorders.
A two-year-old child is being monitored after cardiac surgery. Which assessment findings would represent a decrease in cardiac output? Select all that apply.
Signs of decreased cardiac output include weak peripheral pulses, hypotension, low urine output, delayed capillary refill, and cool extremities.
A 12-year-old client is two days postoperative from an open reduction, internal fixation procedure for a fractured femur. The client's chart reads: Breakfast: 1 - 4 oz cup of hot chocolate (4 oz × 30 ml = 120 ml) 1 - 4 oz carton of milk (4 oz × 30 ml = 120 ml) 1 bowl of oatmeal (n/a) 1 - 6 oz glass of orange juice (6 oz × 30 ml = 180ml) Additional information for 8-hour shift: IV of lactated Ringers is running at 125 ml/hr. A 1 g cefazolin injection was administered q8h. The pharmacy sent the cefazolin injection 1 g in 100 ml 50% dextrose. Calculate this client's intake for the 7 am to 3 pm shift. Record your answer using a whole number.
Calculate the breakfast intake in milliliters: 1 - 4 oz cup of hot chocolate (4 oz × 30 ml = 120 ml) 1 - 4 oz carton of milk (4 oz × 30 ml = 120 ml) 1 bowl of oatmeal (n/a) 1 - 6 oz glass of orange juice (6 oz × 30 ml = 180 ml) Additional information needed: 1,000 (IV 125 ml/hr × 8 hr) plus 100 ml (cefazolin injection, one dose). 120 ml + 120 ml + 180 ml + 1,000 ml + 100 ml = 1,520 ml
Which findings would support cardiac tamponade? Bradycardia Hypertension Restlessness Muffled heart sounds Widened pulse pressure Distended neck veins
Restlessness Muffled heart sounds Distended neck veins Cardiac tamponade is a life-threatening condition caused by the accumulation of fluid in the pericardium. This fluid, which can be blood, pus, or air, compresses the heart and restricts blood flow to the ventricles. Symptoms of cardiac tamponade include elevated venous pressure, distended neck veins, Kussmaul's sign, hypotension and narrowed pulse pressure, tachycardia, dyspnea, restlessness, and anxiety, cyanosis of the lips and nails, diaphoresis, muffled heart sounds, pulsus paradoxus, decreased friction rub, decreased QRS voltage, and electrical alternans.
A client is admitted with hemophilia A. Which sports should the nurse recommend as safe for the client to participate? Select all that apply.
Swimming Golf Hemophilia A or classic hemophilia is a bleeding disorder that results from a deficiency or abnormality of clotting factor VIII. A client with hemophilia should avoid contact sports like soccer, baseball, and basketball because of the risk of bleeding with injury. The client can safely participate in noncontact sports such as swimming and golf.
Which characteristics would the nurse anticipate in a child diagnosed with tricuspid atresia? Select all that apply. Cyanosis Machine-like murmur Decreased respiratory rate Capillary refill more than two seconds Clubbed fingers
Cyanosis Capillary refill more than two seconds Clubbed fingers Cyanosis is the most consistent clinical sign of tricuspid atresia. Tachypnea and dyspnea are commonly present because of the decreased pulmonary blood flow and right-to-left shunting. Tricuspid atresia doesn't have a characteristic murmur. A machine-like murmur is characteristic of a patent ductus arteriosus. Decreased oxygenation would increase capillary refill time. Clubbed fingers in children result from chronic hypoxia, and may be seen in children with this defect.
A nurse is evaluating a client to determine the extent of Parkinson's disease. Which symptoms would the nurse expect to see? Select all that apply. Bulging eyeballs Diminished distal sensation Shuffling gait Muscle rigidity Changes in speech
Shuffling gait Muscle rigidity Changes in speech Parkinson's disease is characterized by the slowing of voluntary muscle movement, muscular rigidity, and resting tremors. Clients with Parkinson's disease often have a distinctive shuffling gait. Clients may speak in a softened voice, often in monotone manner, and may slur or hesitate before speaking. Exophthalmos occurs in Graves' disease. Diminished distal sensation does not occur in Parkinson's disease.
The nurse is assessing a client's arterial pulses. Which photo illustrates the appropriate site for palpating the dorsalis pedis pulse?
To palpate the dorsalis pedis pulse, the nurse places the fingers on the medial dorsum of the foot while the client points his toes down. The first photo illustrates palpation of the femoral, located along the crease, midway between the pubic bone and the anterior iliac crest. The second photo illustrates palpation of the popliteal pulse in the popliteal fossa of the back of the knee. The third photo illustrates palpation of the posterior tibial pulse, slightly below the malleolus of the ankle.
The parents of an infant recently diagnosed with tricuspid atresia have been told that their child will need a series of surgeries, in three stages, during the first few years of life. Which statements indicate that the parents have an understanding of the procedures? Select all that apply. "My child will have this dusky color for the rest of his life." "These procedures will make my child have a normal heart." "Once fixed, my baby will not have to take any more medicine." "My baby will be just like all of the other children once the surgeries are all done." "My child will have to be closely monitored for signs of a stroke.
"My child will have this dusky color for the rest of his life." "My child will have to be closely monitored for signs of a stroke." The child will be dusky, particularly around mucous membranes and nail beds, for the rest of his life as a result of chronic hypoxemia. The resultant polycythemia and increased blood viscosity increase the child's chances of developing a thrombus, leading to a cerebrovascular accident or stroke. The three surgeries do give the child a "normal" heart, as they do not fix the original defect. The child will more than likely be on medications for the rest of his life, and will likely be smaller in stature than other children.
A nurse receives an order to start an infusion of blood for a client who is hemorrhaging due to a placenta previa. Which equipment will the nurse need to initiate the infusion? Select all that apply.
Blood transfusions require Y tubing, normal saline solution to mix with the blood product, and an 18-gauge catheter to avoid lysing the red blood cells. Lactated Ringer's solution is contraindicated.
A nurse is teaching a group of nursing students about dilated cardiomyopathy (DCM). Which statements, made by the students, would indicate that teaching was effective? Select all that apply. "Pregnancy may play a role in developing this form of cardiomyopathy." "Initial symptoms of DCM are often increasing fatigue and dyspnea." "Management of DCM focuses on decreasing cardiac workload." "DCM is a rare form of cardiomyopathy." "Obesity is a possible risk factor for DCM." "DCM is curable with prompt, effective treatment."
"Pregnancy may play a role in developing this form of cardiomyopathy." "Initial symptoms of DCM are often increasing fatigue and dyspnea." "Management of DCM focuses on decreasing cardiac workload." "Obesity is a possible risk factor for DCM." DCM, the most common form of cardiomyopathy, is associated with risk factors that include pregnancy and obesity. Initial symptoms include increasing fatigue, dyspnea and activity intolerance as well as the classic symptoms of heart failure. While DCM is a chronic, non-curable disease, management focuses on decreasing cardiac workload.
A child fell while playing basketball and sustained a greenstick fracture of the tibia. Which illustration represents a greenstick fracture?
A greenstick fracture occurs when the bone is bent beyond its limit, causing an incomplete fracture. The first illustration shows a plastic deformation or bend, with a microscopic fracture line where the bone bends. The second illustration shows a buckle fracture, which occurs when porous bone is compressed, causing a raised area or bulge at the fracture site. The fourth illustration shows a complete fracture in which the bone is broken into separate pieces.
A child, just been admitted to the emergency department, has the following chart entry: Progress notes 10/15/16 1800 Parents describe recent weight loss and lack of energy. Client's ears and cheeks are flushed; acetone-smelling breath noted. Blood glucose 324 mg/dl (18.0 mmol/L), BP: 104/60 mmHg; P: 88/bpm; RR: 16 breaths/min. What intervention would the nurse should anticipate Subcutaneous administration of glucagon Administration of IV regular insulin by continuous infusion pump Administration of regular insulin subcutaneously Q4H as needed per sliding scale Administration of IV fluids in boluses of 20 ml/kg
Administration of IV regular insulin by continuous infusion pump Weight loss, lack of energy, acetone odor to breath, and a blood glucose level of 324 mg/dl (18.0 mmol/L) would indicate diabetic ketoacidosis. Insulin would be given IV by continuous infusion pump. Glucagon is administered for mild hypoglycemia. Sliding scale insulin isn't as effective as the administration of insulin by continuous infusion pump. Administration of IV fluids in boluses of 20 ml/kg is recommended for the treatment of shock.
A nurse is developing a teaching plan for sleep hygiene. Which interventions should the nurse include? Select all that apply. Keep the room very warm Eat a large meal and drink fluids before bedtime Schedule bedtime when you feel tired Avoid caffeine, alcohol, and nicotine before bedtime Prepare the room for sleep and turn off distracting noise Participate in a bedtime routine
Avoid caffeine, alcohol, and nicotine before bedtime Prepare the room for sleep and turn off distracting noise Participate in a bedtime routine Caffeine, alcohol, and substances such as nicotine act as stimulants, avoiding them should help promote sleep. Maintaining a cool temperature in the room will facilitate optimal sleep. Excessive fullness or hunger can disrupt or interfere with sleep. A regular sleep-wake time facilitates physiologic patterns, rather than waiting until an individual begins to feel tired. The room should be conducive to sleep. Eliminate distractions such as a television or radio. Participation in a relaxation, prayer, or meditation routine can help prepare an individual for a restful night.
The nurse is caring for a child who has been diagnosed with a brain tumor. Which assessment findings are recognized as early signs of increased intracranial pressure? Select all that apply. Headache Fixed and dilated pupils Irritability Decerebrate posturing Dizziness
Headache Irritability Dizziness Headache, irritability and dizziness are early signs; fixed dilated pupils and decerebrate positioning are late signs.
The nurse is prioritizing care of a client in the immediate postpartum period. What is the nurse's priority assessment? Select all that apply. Blood glucose level Electrocardiogram (ECG) Height of fundus Blood pressure Urinary output
Height of fundus Blood pressure Urinary output A focused physical assessment should be performed every 15 minutes for the first one to two hours postpartum, including an assessment of the fundus, lochia, perineum, blood pressure, pulse, and bladder function. A blood glucose level needs to be obtained only if the woman has risk factors for an unstable blood glucose level, or if she has symptoms of an altered blood glucose level. An ECG would only be necessary if the woman is at risk for cardiac difficulty.
A client is diagnosed with postpartum preeclampsia and asks the nurse what could have caused this to occur. Which causative factors should the nurse include in her teaching? Select all that apply. Obesity Prolonged labor Fetal distress at birth Poor diet Damage to blood vessels during birth
Obesity Poor diet Damage to blood vessels during birth While preeclampsia occurs primarily during pregnancy, and is resolved at birth, it can occur up to six weeks postpartum. Identified risk factors are obesity, damage to uterine blood vessels during birth and poor maternal diet. Fetal distress and prolonged labor do not contribute to the occurrence of this disorder.
When reviewing a client's chart, the nurse reads the progress note below. <handwriting> Progress notes 10/15/2016 1130 Client, age 28, admitted to unit with diagnosis of antisocial personality disorder and suicide attempt after cutting his right wrist. Right wrist dressing appears dry and intact. Client states, "I don't want to be here and I'm not following your treatment plan or any of your rules. I'm going to tell everyone here not to follow your rules." —Barbara Jones, RN Which statement, about the client's condition, is most accurate? The client is refusing the required psychotropic drugs used to treat his condition. The client manipulates others, but not his family. The client is not be motivated to change his behavior or his lifestyle. The client can quickly make behavior changes if motivated
The client is not be motivated to change his behavior or his lifestyle. Clients with antisocial personality disorder feel nothing is wrong with their behavior, and they have no desire to change. These clients don't benefit from psychotropic drug therapy. They attempt to manipulate the people around them. A quick behavior change isn't a realistic expectation for clients with this disorder.
The nurse is evaluating an external fetal monitoring strip of a client in labor. What condition is the nurse concerned about? Cephalopelvic disproportion Oligohydramnios Uteroplacental insufficiency Hydramnios
Uteroplacental insufficiency This fetal monitoring strip illustrates a late deceleration. The decrease in fetal heart rate begins after the peak of the contraction and doesn't return to baseline until the contraction is over. Late decelerations are associated with uteroplacental insufficiency, shock, or fetal metabolic acidosis. Cephalopelvic disproportion may cause early, not late, decelerations early in labor. Oligohydramnios be associated with variable decelerations. Hydramnios may be associated with uterine rupture.
