Qbank #1
The nurse observes a newly admitted client with a diagnosis of anxiety and panic attacks. The client is shaking, hyperventilating, and unable to breathe through cupped hands as instructed. Which statement by the nurse is therapeutic for the client at this time? SATA. 1. "I will stay here with you for a while" 2. "You are in a hospital, and everything is under control" 3. "I will stay and keep talking with you to help calm you down" 4. "Let me tell you about the ways to identify an impending panic attack" 5. "Try to lie down and take deep breaths to relax" 6. "I'll step away and allow you to be alone until you are ready to talk"
ANSWER: 1 (a client who is experiencing panic attack is expected to have a decreased perceptual field and be unable to follow complex instructions. The nurse offering to stay with the client can help the client feel safe. Short sentences when speaking to the client are also appropriate). Why 2 is wrong: this statement offers false reassurance. Why 3 is wrong: Talking continually to the client who is having a panic attack is more likely to irritate than calm the client. Why 4 is wrong: The client is currently experiencing a panic attack and has a decreased perceptual field. It is best to wait until the client is more receptive before teaching the client new information. Why 5 is wrong: A client who is experiencing a panic attack usually cannot follow instructions and will not respond to relaxation techniques. Why 6 is wrong: A client who is having a panic attack may perceive the statement as the nurse abandoning the client. The nurse should stay near the client, within observable distance until the panic attack has subsided.
Which action does the nurse take to utilize mileu therapy when providing care to clients in a psychiatric inpatient setting? 1. Provide a consistent set of activities and responsibilities for each client. 2. Ask the family to bring in items from home in order to recreate the home environment. 3. Use therapeutic communication with the other staff members to foster community. 4. Set consistent limits on client behaviors.
ANSWER: 1 (in milieu therapy, all aspects of the environment as utilized as instruments of growth for the client's benefit. Clients are encouraged to take responsibility for various tasks and to participate in activities that allow them to develop healthy social behaviors. Milieu therapy is primarily intended to treat behavior and personality disorders). Why 2 is wrong: recreating the home environment may be detrimental to the client, as it may trigger problematic behaviors that the client was exhibiting in the home environment. The goal of milieu therapy is to provide an environment in which new patterns of behavior can be developed. Why 3 is wrong: The purpose of milieu therapy is primarily for client benefit, not the staff. This is not relevant. Why 4 is wrong: Consistent limit-setting is required for clients that are manipulative, but not specific to milieu therapy.
An older adult client's laboratory results reveal an elevated serum blood urea nitrogen (BUN) level. Which assessment data is most helpful when further evaluating the client's condition? 1. Blood pressure 2. Oral temperature 3. Heart tones 4. Lung sounds
ANSWER: 1 (in the older adult client, dehydration is a common cause of an elevated BUN. Blood pressure assessment is most helpful when evaluating the client's fluid volume status. Elevated BUN may also occur due to renal dysfunction, in which case the client would require evaluation with additional lab and diagnostic tests. Why 2 is wrong: Common causes of elevated BUN in older adults include dehydration. The client's fluid volume status is best assessed by measuring BP, not oral temperature. Why 3 is wrong: Dehydration is a common cause of elevated BUN among older adults. Although heart tones may provide a clue as to the client's fluid volume status, BP measurement is most helpful. Why 4 is wrong: In the absence of renal failure, for older adults, elevated BUN is commonly caused by dehydration. Assessment of BP, not lung sounds is most helpful when assessing fluid volume status.
The nurse assesses a client in the ED. Which symptoms cause the nurse to suspect that the client is experiencing a panic attack? 1. Decreased perceptual field, diaphoresis, fear of going crazy, and palpitations. 2. Decreased blood pressure, chest pain, choking feeling. 3. Increased blood pressure, bradycardia, shortness of breath. 4. Increased respiratory rate, increased perceptual field, increased concentration ability.
ANSWER: 1 (panic disorders are characterized by recurrent, unpredictable attacks of intense apprehension or terror that can render a client unable to control a situation or to perform simple tasks. The client can experience palpitations, diaphoresis, a decrease in perceptual field, and a fear of "losing it" or going crazy). Why 2 is wrong: The client experiencing a panic attack will have increased BP related to the stimulation of the SNS. Chest pain and a choking feeling will occur. Why 3 is wrong: The client experiencing a panic attack will have tachycardia due to the stimulation of the SNS. Increased BP and SOB will occur. Why 4 is wrong: The client experiencing a panic attack will have a decrease in perceptual field, become less aware of surroundings, and experience hindered performance. RR will increase.
The nurse provides care for an infant who tested positive for phenylketonuria (PKU). The nurse determines which action is the priority? 1. Offer the client formula without phenylalanine. 2. Administer middle-chain triglyceride (MCT) oil with each feeding. 3. Provide genetic counseling for the family. 4. Administer a mixture of oleic and erucic acids.
ANSWER: 1 (the client diagnosed with PKU lacks the enzyme necessary to convert phenylalanine to tyrosine. Phenylalanine is a type of protein. PKU results in phenylalanine accumulating in the tissues and leads to mental deficiencies. Clients diagnosed with PKU are fed a formula that is low in phenylalanine but contains the minerals and vitamins required by the client). Why 2 is wrong: MCT is made from coconut oil and can be added to formula to provide adequate calories if needed. There is not enough information to know this yet. Why 3 is wrong: PKU is an autosomal-recessive trait. While genetic counseling should be recommended to parents who plan to have another child, the nurse should first address the client's physical needs. Why 4 is wrong: A mixture of oleic and erucic acids is given to children diagnosed with adrenoleukodystrophy (ALD) a hereditary disease of children.
Due to a sudden rise in a nearby river, the nurse at a day camp evacuates the children to an area away from the river. Which action does the nurse take next? 1. Place an identification bracelet on each child. 2. Go back for an adequate supply of water. 3. Notify the parents of the children's location. 4. Comfort the child who are anxious.
ANSWER: 1 (this is a priority, as it aids in communication after rescue or recovery and addresses a pertinent physical safety need). Why 2 is wrong: the nurse should not leave the children alone Why 3 and 4 are wrong: While this action addresses a relevant psychosocial need, physically ensuring identification of the children takes priority over notification.
The nurse provides care to a client with chronic pain due to knee osteoarthritis. The client asks about ways to manage pain in addition to taking medication. Which non-pharmacological pain relief measure is appropriate for this client? SATA 1. Yoga 2. Water aerobics 3. Cushioning footwear 4. Massage 5. Adequate sleep 6. Application of heat 2-3 times/day
ANSWER: 1, 2, 3, 4, 5, 6 (all) Explanation: Yoga usually includes deep breathing exercises that promote relaxation. it also includes gentle stretching, which increases joint flexibility and reduces pain. Water aerobics is a low-impact exercise that decreases pressure on the joints. It improves fitness and relieves stiffness and pain. Cushioning footwear or orthotics can help reduce the impact on the lower extremities, which in turn can mediate pain in the lower back and legs. Massage promotes relaxation of the muscles around the joints, which improves ROM and relieves pain. Lack of adequate sleep makes a person more vulnerable to pain and depression. Heat improves circulation. It is especially helpful for pain and stiffness related to inactivity.
The nurse changes the dressing on a client's double-lumen peripherally inserted central venous catheter (PICC). Which technique should the nurse use? SATA. 1. Cleanse around the catheter insertion site using a circular motion outward. 2. Apply an occlusive dressing over the insertion site. 3. Use sterile technique during the dressing change. 4. Remove the old dressing by pulling away from the insertion site. 5. Change gloves between removal of the old dressing and application of the new dressing.
ANSWER: 1, 2, 3, 5 Why 4 is wrong: This action increases the risk of accidental displacement of the catheter. The old dressing should be removed in the direction toward the catheter insertion site.
The nurse completes dietary teaching with a client who has chronic kidney failure. The nurse determines more teaching is needed when the client makes which statement? SATA 1. "I will eat more oranges and other foods with vitamin C" 2. "I should increase dairy products in my diet" 3. "I can no longer drink my prune juice in the morning" 4. "I will avoid canned and boxed foods" 5. "I should add protein powder to my fruit smoothies"
ANSWER: 1, 2, 5 (citrus fruits are high in potassium and should be avoided as kidneys cannot excrete excess potassium in the setting of chronic kidney failure. Kidney failure can lead to hypocalcemia, and regular intake of calcium is needed, however, dairy products are high in phosphorus which binds to calcium and should be avoided. Excess dietary protein increases uric acid, a byproduct of protein metabolism which is cleared by the kidneys. In kidney failure, the kidneys will be unable to excrete urea, and low to normal amounts of dietary protein are prescribed. Why 3 is wrong: dried fruits, including raisins and prunes are high in potassium. This statement indicates that client understands that hyperkalemia is a complication of kidney failure. Why 4 is wrong: processed foods are high in sodium and a low-sodium diet should be followed.
The nurse prepares a teaching plan for a client prescribed captopril for hypertension. Which information does the nurse include in the teaching plan? SATA 1. Avoid using salt substitutes 2. Do not stop taking the medication abruptly 3. Take the medication with food 4. Blood glucose should be tested monthly 5. Do not report a dry cough because it is common. 6. Change positions slowly
ANSWER: 1, 2, 6 (salt substitutes contain potassium that can cause hyperkalemia when taken with captopril, an ACE inhibitor. Stopping the medication abruptly can cause rebound hypertension. A sudden change in position can cause orthostatic hypotension, that could result in a fall for a client). Why 3 is wrong: Captopril should be taken on an empty stomach to increase absorption. Why 4 is wrong: Captopril does not affect blood glucose Why 5 is wrong: a dry cough may indicate bronchospasm and should be reporting, as it may be an adverse effect.
The LPN/LVN delegates tasks to the UAP. The nurse intervenes if which action is observed? SATA 1. The UAP administers prescribed eye ointment. 2. The UAP provides catheter care. 3. The UAP delegates client ambulation to another UAP. 4. The UAP takes a phone prescription from the HCP. 5. The UAP stocks the department with supplies. 6. The UAP listens to breath sounds.
ANSWER: 1, 3, 4, 6 (Medication administration, re-delegation, phone prescriptions, and assessments are not within the UAP's scope of practice. Remainder of options are all within the UAP's scope of practice.
The school nurse conducts a workshop for adolescents and their parents on home safety related to opioids. Which statement by a parent indicates that further teaching is needed by the nurse? SATA. 1. "I put my prescription pain medications on the top shelf of our medicine cabinet". 2. "Most adults who abuse drugs began using them when they were younger" 3. "I will decrease the risk of my teen using drugs if I openly disapprove of illegal drug use" 4. " Most teens who misuse opioids get them on the street" 5. " I don't want to give my teens too much information about opioids because they may become more interested in using them"
ANSWER: 1, 4, 5 (all prescription opioid painkillers, sedatives, sleep medications, and stimulants should be kept in a locked drawer or container. Adolescents can easily access them on the top shelf of the medicine cabinet. Most people who misuse opioid pain relievers get them due to easy access within the home or directly from a family member or friend. This includes leftover opioids that are stored somewhere or forgotten or saved for later use. Informing teens of the risks of opioids, other drugs, alcohol, and tobacco is important. Parents should foster open communication and make sure they the information provided is accurate. Parent engagement and family support are protective factors in reducing the risk of substance abuse in teens. Why 2 is wrong: Most adults who have substance use disorder began using substances when they were teens or young adults. Why 3 is wrong: Parental disapproval of illegal substances or medications prescribed for someone else has been shown to be a protective factor in reducing the risk of substance abuse in teens.
A client has a diagnosis of heart failure. Which information will the nurse include when teaching the client about self-management at home? SATA 1. Take medications at the same time each day. 2. Limit the consumption of sodium to 3 to 4 grams per day. 3. Avoid non-steroidal anti-inflammatory agents (NSAIDs). 4. Report increased shortness of breath to the healthcare provider. 5. Inform the healthcare provider about a weight gain greater than 3lb/week
ANSWER: 1,3,4,5 (medication adherence is critical in self-management of meds at home to prevent HF exacerbation. It is known that NSAIDs cause sodium and fluid retention, so they are best avoided for a client diagnosed with HF. The nurse should encourage clients to be proactive in reporting increased symptoms of HF, including SOB. A weight gain greater than 3lb/week signifies fluid retention and must be reported to the health care provider. Why 2 is wrong: Sodium intake is limited to less than 2 grams a day for clients diagnosed with HF.
The nurse in the day care center observes a toddler client squatting and panting after chasing a ball. Which action does the nurse take first? 1. Remove the toddler from the playground and encourage rest 2. Check for sweating, color, and tachycardia. 3. Ask the toddler about a sore throat or achy joints. 4. Restrict the toddler from playing ball.
ANSWER: 2 (Squatting, or the knee-chest position, increases pulmonary blood flow and improves systemic arterial oxygen saturation. The toddler may squat to relieve hypoxia. The nurse should confirm s/sx of hypoxia first as this may be an emergency situation. Diaphoresis, cyanosis, and tachycardia are all signs of hypoxia. Why 1 is wrong: first assess for signs of hypoxia and impaired perfusion before taking physical action. Why 3 is wrong: sore throat and achy joints are symptoms of a streptococcal infection. The nurse should assess the cardiovascular system first. Why 4 is wrong: Assess before taking physical action.
The nurse provides care to clients in the outpatient newborn clinic. Which message from a client will the nurse return first? 1. Umbilical cord of a 5-day newborn is dry and hard to the touch. 2. The "soft spot" on the head of a 4-day old newborn feels slightly elevated when the baby sleeps. 3. Circumcision of a 3-day old newborn is covered with yellowish exudate. 4. A 2-day old newborn violently extends the extremities and returns them to the previous position when the crib is bumped.
ANSWER: 2 (The fontanel or the "soft spot" should feel soft and flat. Bluging or an elevation indicates an increase in intracranial pressure that needs to be immediately addressed). Why 1 is wrong: The umbilical cord of a 5-day old newborn is expected to be dry and hard to the touch. The cord will fall off within 1 to 2 weeks. The parents should be instructed to avoid tub baths until the cord falls off. Why 3 is wrong: Yellow exudate at the site of circumcision indicates normal healing. This exudate should not be removed. The circumcision site should be cleaned with warm water. Why 4 is wrong: Violently extending the extremities and then retracting them after the crib is bumped describes the moro (startle) reflex, which is a normal reflex and is expected to disappear after 3 to 4 months.
The nurse on the psychiatric unit overhears one client yelling at another, "You are always borrowing my things. Stay out of my way!". Which response by the nurse is best? 1. "You both seem very upset with one another" 2. "You sound very angry with the other client" 3. "We will have to make a plan to prevent this from happening" 4. "Leave this room immediately because you are out of control"
ANSWER: 2 (The nurse should address the aggressor to try to defuse the anger. This open-ended statement affirms the feelings and opens a conversation in which the nurse can address emotions but reinforce expected behaviors. Remember to avoid asking "why". Why 1 is wrong: The nurse should focus on the client in the question stem to address the aggressor in this situation. The client is the only one known to be angry. Why 3 is wrong: Contracting with the client is appropriate, but the nurse should first de-esculate the situation. Remember to focus on the here and now. Why 4 is wrong: The client is not being physically aggressive at the moment. The nurse should first attempt to defuse the situation and deal directly with the client in the question stem.
The nurse provides care for a client taking fluoxetine for 2 weeks. Which observation most concerns the nurse? 1. The client frequently uses sarcasm. 2. The client has been giving away some possessions. 3. The client has been sleeping 9 hours each night. 4. The client has started waking up at 0600 every morning.
ANSWER: 2 (fluoxetine is a SSRI, which takes about 4 weeks for full effect. The client is at higher risk for suicide early in the course of treatment, typically for 10 to 14 days after starting the medication. The nurse should be aware of suicidal behaviors, such as giving away possessions).
The nurse provides care for a newborn who was circumcised 30 minutes ago. Assessment reveals a moderate amount of bright red bleeding on the dressing. Which action does the nurse take first? 1. Put a clean, loose-fitting diaper on the newborn. 2. Apply gentle pressure to the penis. 3. Notify the HCP. 4. Assess the newborn's pulse and blood pressure.
ANSWER: 2 (if excessive bleeding occurs, gentle pressure is applied to the site) Why 1 is wrong: since pressure on the wound is needed, a loose-fitting diaper on the newborn would not be appropriate. Why 3 is wrong: If pressure does not alleviate the bleeding, the nurse will notify the HCP, who may apply an absorbable gelatin sponge or epinephrine or may suture the small blood vessels. Why 4 is wrong: This provides more assessment data, but the nurse has already identified the issue as excessive bleeding. Obtaining this information does not stop the bleeding or protect the client from harm.
The nurse provides care for a client who is pregnant. The client asks the nurse what an elevated serum alpha-fetoprotein (AFP) may indicate. Which response does the nurse provide? 1. "An elevated serum AFP may indicate gestational diabetes" 2. "An elevated serum AFP may indicate a neural tubal defect" 3. "An elevated serum AFP may indicate down syndrome" 4. "An elevated serum AFP level may indicate lack of lung maturity"
ANSWER: 2 (in a pregnant client, high serum alpha-fetoprotein values can indicate a neural tubal defect. Why 1 is wrong: glucose tolerance test is used Why 3 is wrong: Low AFP levels may indicate down syndrome. Why 4 is wrong: A lecithin sphingomyelin (L:S) ratio is used to determine lung maturity.
The nurse observes that a client does not make eye contact with members of the health care team. The nurse suspects that the client's behavior may have a cultural basis. Which action by the nurse is best? 1. Read books about the client's culture for in-depth information and to have a better understanding of the client. 2. Observe how the client's family and friends interact with each other and with members of the health care team. 3. Accept the client's behavior as part of the client's culture. 4. Ask staff members from a similar culture if this is usual behavior.
ANSWER: 2 (the best way to gather information when assessing whether a client's behavior has a cultural basis is to ask the client directly. However, that answer choice was not provided. The next best way is to observe how the client's family and friends interact with members of the health care team. Family and friends oftentimes share the same cultural behaviors and practices, so observing how they act toward members of the health care team provides the nurse with first-hand data. Why 1 is wrong: Reading books about the client's culture is helpful but doing so takes time and does not provide the tools for immediate assessment. Why 3 is wrong: Before accepting the client's behavior as part of the client's culture, the behavior needs to be addressed and verified. Why 4 is wrong: Asking staff members from a similar culture may be helpful, but culture can vary within a small geographical region.
The nurse develops a plan of care for a client diagnosed with dementia and who was admitted with dehydration. To which nursing concern does the nurse assign as priority? 1. Chronic confusion 2. Hypovolemia 3. Bathing self-care deficit 4. Potential for injury
ANSWER: 2 (the client's physiological needs take priority. Since the client with admitted with dehydration and this is a direct threat to cardiac output and renal function, hypovolemia takes priority over the other nursing concerns).
The nurse provides care for a client receiving haloperidol for 5 days. The client's temperature is 103.5, blood pressure 200/100 and pulse 122. The client is pale and sweating excessively. Which action does the nurse take first? 1. Monitor vital signs every 15 minutes 2. Administer bromocriptine as prescribed. 3. Administer the haloperidol as prescribed. 4. Assess the client's level of consciousness.
ANSWER: 2 (the client's symptoms are consistent with neuroleptic malignant syndrome, which is a serious complication of anti-psychotic medications. The nurse should administer bromocriptine which is counteract the effects of NMS, as well as manage fluid balance, reduce client temperature, and monitor for complications). Why 1 is wrong: While monitoring vital signs frequently in NMS is appropriate, it does not address the client's current problem. Why 3 is wrong: The nurse should immediately discontinue the use of the anti-psychotic medication as this is what is causing the NMS. Why 4 is wrong: While assessing the client's LOC is appropriate, it does not address the client's current problem. There is an implementation that the nurse should immediately take to provide for client safety.
The nurse performs a safety assessment in a home with a toddler. Which finding is the most concerning? 1. A car seat in the back seat of the car faces the rear of the vehicle 2. A bookshelf is not anchored to the wall 3. Medications are in an unlocked box on top of the refrigerator 4. The child's bed is a crib
ANSWER: 2 (toddlers will try to climb bookshelves. Shelves must be anchored to the wall to prevent death or injury from a falling bookshelf). Why 1 is wrong: A rear-facing car seat is recommended until the child is 2 years old or reaches the maximum height and weight recommended by the seat manufacturer. Why 3 is wrong: Medications should not be within reach of the toddler. A lock may be beneficial, but this finding is not most concerning. Why 4 is wrong: A crib is acceptable for a toddler, but should be used with the bed in the lowest position to reduce the risk of falls or can be used with the crib side down to discourage climbing over the side.
The nurse provides care for a client in isolation. Which item must be marked as biohazardous when removing it from the room? SATA. 1. Bed linen 2. Lab specimen 3. Discarded syringes 4. Trash 5. Equipment
ANSWER: 2, 3 (lab specimens contain body fluids and need to be marked as hazardous. Used syringes are disposed of in the red sharps container, which is a biohazard container). Why 1 is wrong: Linens that are removed from an isolation room are to be placed in a plastic bag and taken to the area designated for soiled linens. No special handling precautions are required. Why 4 is wrong: Trash that is removed from an isolation room is disposed of in plastic trash bags and does not need to be marked as biohazardous. Why 5 is wrong: Equipment that was in the isolation room needs to be cleaned properly before being used again. Special precautions are not needed.
A client reports stabbing facial pain and twitching facial muscles a week after having a toothache. The client has a diagnosis of trigeminal neuralgia. Which nursing action does the nurse implement when providing care to this client? SATA. 1. Teach isometric exercises for facial muscles 2. Administer oral carbamazepine as prescribed. 3. Administer intravenous hydrocortisone as prescribed. 4. Teach to chew on opposite side of mouth. 5. Perform facial massage twice daily.
ANSWER: 2, 4 (oral carbamazepine is an appropriate medication to manage trigeminal neuralgia. The client should be instructed to chew on the side of the mouth that is opposite of the pain). Why 1 is wrong: isometric exercises are appropriate for bell palsy. Why 3 is wrong: IV hydrocortisone is appropriate for bell pasly. Why 5 is wrong: Facial massage is inappropriate in the management of trigeminal neuralgia.
A nurse prepares to administer medications to clients at 0900. In which order does the nurse administer the medications? 1. The client receiving digoxin 0.375 mg daily PO with a recent heart rate of 92 bpm. 2. The client receiving 40 mEq potassium chloride intravenously for a potassium level of 2.8. 3. The client receiving hydrochlorothiazide 25mg daily PO with a recent BP of 140/84. 4. The client receiving metronidazole 500mg every 8 hours intravenously for c. diff.
ANSWER: 2, 4, 3, 1 Explanation: hypokalemia can cause respiratory muscle weakness, dysrhythmias, and orthostatic hypotension. This is the priority medication to administer. Metronidazole needs to be maintained at an effective circulating level and therefore delays should be avoided. Hydrochlorothiazide has a half-life of 6-15 hours. Long delays in administration should be avoided. Digoxin has a half life of 36-48 hours, so delays in administration are unlikely to impact the client. The HR is within normal range, so this medication can go last.
The nurse provides care for a client diagnosed with impaired vision. Which intervention will the nurse implement to meet the client's needs? SATA 1. Keep the voice even throughout conversation. 2. Explain the sounds in the environment. 3. Decrease background noise before speaking. 4. Stay in the client's field of vision. 5. Identify self by name and staff position.
ANSWER: 2, 4, 5 (Explaining environmental sounds is appropriate for this client. Remaining in the client's visual field of vision helps the client best see the nurse which will assist the client to see if the nurse is still speaking. Stating name, position, and intent will help the client recognize the person providing care). Why 1 is wrong: keeping an even tone when speaking is an intervention for a client with a hearing impairment. Why 3 is wrong: Decreasing background noise while conversing is an intervention for a client with a hearing impairment.
A client who has been admitted to a psychiatric care unit points to the window and says, "there are people outside looking in at us". The nurse looks over to the window and sees nothing. Which response by the nurse is appropriate? SATA 1. "I waved at them but they did not wave back" 2. "When did you first begin to see these people?" 3. "You should just ignore them" 4. "We're on the second floor so its impossible for anyone to be looking in at us" 5. "What do you do when you see such things?" 6. "I dont see anyone out there"
ANSWER: 2, 5, 6 (When a client has perceptual alterations, the nurse needs to identify the time, place, and associated stimuli of the perceptions. The nurse also needs to assist the client in developing strategies to cope. Clients with hallucinations should be oriented to reality by explaining that only they are perceiving the hallucination. Why 1 is wrong: Clients with hallucinations should be oriented to reality by explaining that only they are perceiving the hallucination. Waving would be interpreted by the client as the nurse also seeing the hallucination. Why 3 is wrong: Instructing a client to ignore a hallucination avoids exploration of the origins and feelings associated with it. Why 4 is wrong: While this response presents a reality, it could also be embarrassing to the client, which would hamper further discussion.
The nurse provides care for a client diagnosed with bulimia. Which nursing action is most helpful in determining what precipitates the client's eating disorder? 1. Observe the family communication patterns at a monitored mealtime. 2. Distract the client at mealtimes. 3. Assign the client to a food/feelings/thought action journal. 4. Ask the client to write a history of eating behaviors.
ANSWER: 3 (a food/feelings/thought action journal is a helpful tool that will assist the nurse to understand food triggers that begin the binge-purge cycle. The nurse can educate the client about these issues and help identify solutions). Why 1 is wrong: observing family interactions is important but it will not reveal the client's own triggers of binging and purging. Why 2 is wrong: The question is asking for an assessment of bulimia triggers. This answer is an intervention. Why 4 is wrong: Collecting an eating history may be useful, but in bulimia, it is better to assess the client's feelings while eating presently.
The nurse in the ED conducts the initial assessment of a school-age client report severe upper arm pain. When the nurse asks the client how the injury occurred, the client looks at the parents and the parent states that the child fell off the couch. Which action should the nurse first take when the x-ray reveals a spiral fracture of the humerus? 1. Document the inconsistency between the injury and the history provided by the parent. 2. Explain to the parent that the injury does not match the history. 3. Communicate the details of the situation to the nurse's immediate supervisor. 4. Tell the parent to allow the client to answer the nurse's questions.
ANSWER: 3 (reporting of suspected child abuse is mandatory. Using the vertical chain of command, the nurse should notify their immediate supervisor who will contact local authorities for further assessment of the situation).
The nurse notes that a client diagnosed with pancreatic cancer is jaundiced. To which client need will the nurse give the highest priority? 1. Urinary elimination 2. Self-image 3. Nutrition 4. Skin integrity
ANSWER: 3 (severe anorexia and dramatic weight loss occur will pancreatic cancer). Why 1 is wrong: Although the urine is dark related to the obstructive process, kidney function usually is not affected. Why 2 is wrong: Although the client will most likely have a concern about self-image, physiologic needs take priority. Why 4 is wrong: Dry skin and itching can result from jaundice, so skin care is important, but nutritional needs take priority.
A client is admitted to the ED for persistent vomiting following a chemotherapy treatment 1 week ago. Which precaution does the nurse take when handling the client's bodily fluids? 1. Contact 2. Airborne 3. Standard 4. Droplet
ANSWER: 3 (special precautions should be taken when handling the client's bodily fluids 48 hours after receiving chemotherapy. Since this client received chemotherapy a week ago, the nurse needs to use standard precautions while handling the client's bodily fluids).
The nurse interacts with a client who has just accepted a job in an office located on the 36th floor of a building. The client reports experiencing severe anxiety in elevators and enclosed spaces. Which intervention is most important for the nurse to recommend? 1. Psychopharmacological intervention 2. Group therapy 3. Systematic desensitization 4. Biofeedback
ANSWER: 3 (systematic desensitization is a form of behavior modification. It is used in conjunction with deep muscle relaxation designed to decrease the extreme response to anxiety-producing situation. This technique is most effective for clients diagnosed with phobic disorders. Why 1 is wrong: Psychopharmacological interventions can be used, but behavior modification is more effective. Why 2 is wrong: Group therapy can be used, but behavior modification is more effective. Why 4 is wrong: biofeedback is more useful for reducing stress associated with physiologically based disorders. It is not as helpful for clients diagnosed with phobic disorders.
The nurse receives a phone call stating that victims from a bioterrorist attack are being transported to the ED. It is unknown if a biologic or chemical weapon was used. Which action does the nurse take first? 1. Initiate environmental protection measures for the safety of other clients in the area. 2. Decontaminate victims as soon as they arrive. 3. Don PPE 4. Report the incident to the CDC and public health department.
ANSWER: 3 (the nurse's priority is to be ready to provide care for the victims while implementing safety and infection control protocols. By donning PPE first, the nurse ensures that the staff can provide immediate care when the bioterroism victims arrive to the ED). PPE must come first before initiating environmental safety measures and decontaminating the victims. CDC/public health department notification is typically done by staff who is in charge of the unit and is not an immediate priority before the client's assessments.
When assessing a client admitted to a rule out a myocardial infarction, the nurse determines a history of alcohol use disorder. Which question is a priority for the nurse to ask the client? 1. "What over the counter medications do you take?" 2. "How much alcohol do you consume each day?" 3. "When did you have your last drink?" 4. "Have you ever had symptoms of withdrawal?"
ANSWER: 3 (the symptoms of withdrawal can occur as soon as 6 hours after the last drink. This information helps the health care team determine needed medications and ensure client safety). Why 1 is wrong: Although asking about current medications is important, it is more important to determine when the client last had a drink. Why 2 is wrong: The amount of alcohol a client consumes will impact the severity of the withdrawal symptoms, however, it is more important for the nurse to anticipate when withdrawal might occur. Why 4 is wrong: Asking about previous withdrawal episodes is appropriate, but the priority is determining when they may occur.
At the first prenatal visit, the nurse teaches a pregnant client about nutrition during pregnancy. Which statement is appropriate for the nurse to include in the teaching? 1. Increase daily caloric intake by 200 calories during the first trimester. 2. Consume an additional 2 servings of meat per day. 3. Limit fluid intake to 1,000 mL per day. 4. Include at least 1 serving of dark green leafy vegetables for vitamin A.
ANSWER: 4 (A client who is pregnant and of normal weight should consume 3 to 5 servings of vegetables per day, including one dark green or deep yellow vegetable to ensure adequate vitamin A intake). Why 1 is wrong: A client who is pregnant and of normal weight should consume the usual amount of calories during the first trimester, then increase by 300 calories/day during the second and third trimester. Why 2 is wrong: A client who is pregnant and of normal weight should consume 2 additional servings of milk and 1 serving of meat or an alternative during the second and third trimester. Why 3 is wrong: A client who is pregnant and of normal weight should drink a minimum of 2,000 mL of fluid per day, half of which should be water. The client should avoid beverages with caffeine due to the diuretic effect.
The nurse is teaching a postpartum client to perform Kegel exercises. Which information is appropriate for the nurse to include? 1. "You should contract the perineal muscles while bearing down" 2. "These exercises are only necessary if you experience incontinence" 3. "You should tighten and relax your abdominal muscles ten times" 4. "Avoid flexing your thigh or buttock muscle while performing the exercises"
ANSWER: 4 (Kegel exercises are intended to target the pelvic floor muscles. The client should avoid flexing or contracting the abdominal, thigh, or buttock muscles during these exercises). Why 1 is wrong: The client should avoid bearing down or straining during the exercises. Kegel exercises are focused on the pelvic floor muscles. Why 2 is wrong: Kegel exercises are recommended for pregnant and postpartum women to strengthen the pelvic floor muscles and prevent incontinence. The client should perform them even if the client has not experienced incontinence. Why 3 is wrong: The client should tightened and relax the pelvic floor muscles, rather than abdominal muscles.
The nurse provides instructions to a pregnant client who is 28 weeks gestation. The client has a prescription for a 1-hour oral glucose tolerance test (OGTT). Which instrution does the nurse include in the teaching? 1. "You will be diagnosed with gestational diabetes if the blood sugar at 1 hour is greater than 140" 2. "This test requires you to be connected to a glucose drip" 3. "This test will determine if you have gestational diabetes" 4. "You can continue to eat your normal diet prior to test day".
ANSWER: 4 (The client should continue to consume a normal diet until the day of the test). Why 1 is wrong: If the client's blood glucose is greater than 140 at 1 hour post-glucose intake, the client will be referred for a 3 hour oral OGTT for further evaluation. Why 2 is wrong: The client is not connected to a glucose drip. The client will drink a glucose solution, a blood draw will be done 1 hour after. Why 3 is wrong: This 1-hour oral glucose test is a screening examination, but generally it will not be the only diagnostic test used. If the client's blood glucose is greater than 140 at 1 hour post glucose intake, the client will be referred for a 3 hour oral glucose test for further evaluation.
A client recovers from a cardiac catheterization that was preformed using the brachial artery. Which action is most important for the nurse to take? 1. Place a warm pack on the affected foot. 2. Measure vital signs every 2 hours. 3. Compare the quality of the pulses on both legs. 4. Determine the presence of the radial pulse bilaterally.
ANSWER: 4 (The nurse should compare the radial pulse along with assessing for pallor, pain, temperature, and cap. refill time of the hand on the arm that was used for the catheterization). Why 1 is wrong: There is no reason to apply a warm pack to the foot because the brachial artery was used. The brachial artery is in the arm. Why 2 is wrong: The nurse should assess the client's vital signs every 15 minutes for 2 hours. Why 3 is wrong: The nurse should assess the pulses distal to the insertion site.
The parish nurse observes children at the church picnic. Which observation concerns the nurse? 1. The spine of a 2-month old client is flexed forward and rounded when held in a seated position. 2. The legs on an 18-month old client bend outward at the knees while standing or walking. 3. The legs of a 4-year old client touch at the knees when standing with feet spread apart. 4. The arms of a 14-year old client appear different in length and there is a slight limp during ambulation.
ANSWER: 4 (This indicates scoliosis, a spinal curvature deformity that is most noticeable during the growth spurt in preadolescence). Why 1 is wrong: This is a normal finding. The spine is rounded or C shaped in infants younger than 3 months of age due to the thoracic and pelvic curves. During the third and fourth months the cervical curve develops, and by 12 to 18 months the lumbar curve develops. Why 2 is wrong: This is a normal finding for a toddler. This is called genu varum and is referred to as bow-leg. It is caused by lateral bowing of the tibia and lasts until all leg and lower back muscles are well developed, usually by 2 years of age. Why 3 is wrong: This is a normal variation for a child of 2 to 7 years of age. It is called genus valgum and referred to as knock-knee.
The nurse in the outpatient psychiatric clinic is meeting in a room with a client. Another client diagnosed with antisocial personality disorder comes into the room and sits down. Which response by the nurse is best? 1. "If you sit quietly, you may stay in the room" 2. "Is there something that you need?" 3. "How do you feel about another client joining us?" 4. "I am talking with this client. Please return to the waiting room"
ANSWER: 4 (This sets limits on inappropriate behavior in a non-judgmental way). Why 1 is wrong: This violates the client's right to privacy. Why 2 is wrong: This does not limit behavior. This nurse should not allow this client to infringe on the other client's rights. Why 3 is wrong: It is not appropriate for the client to interrupt. This validates the client's behavior.
The nurse provides care to four clients. Which client does the nurse recognize is at risk for experiencing sensory overload? 1. A teenager listening to loud music with earphones. 2. A middle-age client in isolation with no family. 3. A young adult quadriplegic in a private room. 4. An older adult admitted for emergency surgery.
ANSWER: 4 (a sudden, unexpected admission for surgery may involve many experiences such as lab work, x-rays, and signing surgical consent forms while the client is in discomfort. After surgery, the client may be in pain and possibly in a critical care setting. Why 1 is wrong: Listening to music at an increased volume is a normal activity for a person of this age. Why 2 is wrong: Isolation reflects a greater risk for sensory deprivation than overload. Why 3 is wrong: Privacy and reduced ability to move about the room reflects a greater risk for sensory deprivation, rather than overload.
The nurse assesses a client who received a blunt head injury from a motorcycle crash. Which finding indicates a basal skull fracture? 1. Periorbital edema 2. Epistaxis 3. Purulent drainage from the auditory canal 4. Bloody or clear drainage from the auditory canal.
ANSWER: 4 (bloody or clean drainage from the auditory canal indicates a cerebrospinal fluid leak following trauma and suggests a basal skull fracture). Why 1 is wrong: Periorbital edema is not specific to a basal skull fracture. Why 2 is wrong: A nose bleed is not specific to a basal skull fracture. Why 3 is wrong: Purulent drainage from the auditory canal is not specific to a basal skull fracture and may indicate an ear infection.
The nurse provides care for clients on the psychiatric unit. The nurse identifies which comment by a client as indicative of a dissociative disorder? 1. "I keep having recurring nightmares" 2. "I have a headache and my stomach has bothered me for a week" 3. "I always check the door locks three times before I leave home" 4. "I do not know who I am or where I live"
ANSWER: 4 (dissociative disorders are characterized by either a sudden or gradual disruption in the integrative functions of identity, memory, or conciousness. The disruption may be transient or become a well-established pattern. The development of a dissociative disorder is often associated with an exposure to a traumatic event). Why 1 is wrong: This statement may be true for other psychiatric disorders as well. Why 2 is wrong: This statement may indicate hypochondria but is not indicative of dissociative disorder. Why 3 is wrong: This statement reflects compulsive behavior or anxiety associated with OCD.
The nurse attaches an external electronic fetal monitor to the abdomen of a pregnant client in labor. Which action does the nurse take next? 1. Determine the frequency of contractions. 2. Identify the types of accelerations. 3. Determine the intensity of the contractions. 4. Assess the baseline fetal heart rate.
ANSWER: 4 (the baseline fetal cardiac rate is the most important initial assessment so that abnormal variation of the baseline rate can be identified if they occur).
The nurse provides care for a client 2 hours after a placement of a cuffed tracheostomy tube. When the nurse enters the client's room, the tracheostomy tube is displaced out of the stoma. Which action does the nurse take first? 1. Place oxygen at 6L per minute over the stoma opening. 2. Auscultate bilateral breath sounds 3. Check the client's pulse oxygenation reading. 4. Use a hemostat to dilate the opening of the stoma.
ANSWER: 4 (the client's issue is the loss of an airway. The first action is to open the airway. A newly placed tracheostomy will not stay open without the tube. Some stoma swelling is expected due to the recent surgical procedure as well. The nurse should utilize a hemostat to open the airway). Why 1 is wrong: Unless the airway is opened, the client will not be able to access the oxygen. With a newly placed tracheostomy, the stoma will not stay open. The nurse should first dilate the opening, then place oxygen. Why 2 is wrong: This assessment is not relevant at this time, as the client cannot breathe with a closed stoma. Why 3 is wrong: This assessment is not relevant at this time, as the issue is the client does not have a patent airway. The nurse should first establish an airway.
The nurse provides discharge teaching for a client diagnosed with uric acid renal calculi. Which type of diet does the nurse instruct the client to avoid? 1. Low-calcium diet 2. Low-oxalate diet 3. High-oxalate diet 4. High-purine diet
ANSWER: 4 (this diet should be avoided and instead a low-purine diet, which excludes foods such as organ meats, should be consumed. Why 1 is wrong: a low-calcium diet decreases the risk for oxalate renal calculi. Why 2 is wrong: A low-oxalate diet is used to control calcium or oxalate calculi. Why 3 is wrong: This type of diet is to be avoided by clients with calcium or oxalate calculi.
The nurse provides care for a toddler client who exhibits persistent vomiting. The nurse should monitor the client for which complication? 1. Frequent diarrhea 2. Hyperactive bowel sounds 3. Metabolic acidosis 4. Metabolic alkalosis
ANSWER: 4 (vomiting causes the loss of hydrochloric acid, which can lead to metabolic alkalosis). Why 1 is wrong: Depending on the cause, diarrhea may not accompany vomiting. Why 2 is wrong: Hyperactive bowel sounds are not necessarily associated with vomitng and are not a complication. Why 3 is wrong: acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate.
The nurse provides care for toddler clients in the pediatric clinic. Which order does the nurse present the information to each toddler's parents? Arrange the developmental milestones in the proper order. 1. Builds a tower of 3 to 4 blocks. 2. Jumps with both feet. 3. Uses 2 to 3 word phrases. 4. Walks without help
ANSWER: 4, 1, 3, 2 (Toddlers begin to walk without help beginning at 12 to 15 months. Toddlers can build a tower of 3 to 4 blocks at 18 months. The toddler will be able to use 2 to 3 word phrases at 24 months. Jumping with both feet occurs at 30 months)
A client is terminally ill and days away from death. The hospice nurse wants to help the client cope by discussing end-of-life needs. Which topic is appropriate to discuss at the end of life? SATA. 1. Who should inherit the client's estate 2. The client's interest in active euthanasia 3. The client's desire for a cure from current illness 4. The effects of dehydration 5. The possibility of hallucinations 6. Fears of the unknown
ANSWER: 4, 5, 6 (Clients will often refuse liquids in their finals days. It is important that the client be aware of the effects of dehydration on mental status. Clients should be prepared to know that is common to experience restlessness, agitation, or hallucinations. The terminally ill may experience high levels of fear of the unknown. It is helpful to discuss those fears at this time). Why 1 is wrong: Business decisions must be made with family members and legal advisors. This is inappropriate for nurse-client discussion. Why 2 is wrong: Active euthanasia is illegal is most circumstances. This discussion would not aid the client's coping. Why 3 is wrong: With days to live, a cure is an unrealistic point of discussion. It would not help the client cope with impending death.
The nurse in the outpatient clinic receives a phone call from a young adult client who says a friend has overdosed. In caring for the overdosed client, which action does the nurse take first? 1. Instruct the friend to call emergency medical services. 2. Instruct the friend to call the poison control center. 3. Find out what the client ingested and in what amount. 4. Determine if the client is responsive and alert.
Answer: 4 (ask the friend if the overdosed client is conscious, if there are breathing difficulties, and what the respiratory rate is. Guide the friend through this assessment). Why 1 is wrong: after assessing ABCs, the nurse instructs the friend to notify EMS. Why 2 is wrong: The nurse should complete an assessment before implementing. The client may not benefit from the service of the poison control center. Why 3 is wrong: Determining what the client overdosed on is important information, but the priority is determining the client's current condition.
The nurse prepares to perform a breast examination on a 20-year old client. Which question is important for the nurse to ask before beginning the examination? 1. "When was your last menstrual period?" 2. "Do you have a family history of breast cancer?" 3. "How much caffeine do you consume a day?" 4. "Have you ever had a mammography?"
ANSWER: 1 (Breast examination is ideally done about 1 week after the onset of menses, when hormonal influences on the breast are at a low level). The other questions are simply not needed before a breast examination.
The nurse provides care for a client diagnosed with mild preeclampsia. Which assessment data, identified by the nurse, supports this diagnosis? SATA. 1. Blood pressure of 150/96 2. Urine output of 460 mL in 24 hours 3. Platelet count of 110,000 4. 4+ proteinuria 5. ALT level 30
ANSWER: 1, 5 (the criteria for mild preeclampsia include BP greater than or equal to 140/90 but less than or equal to 160/110. Liver enzymes remain normal with mild preeclampsia (normal ALT is 10-40). Elevated liver enzymes are seen with severe preeclampsia (HELLP syndrome). Why 2 is wrong: an adequate urine output is seen with mild preeclampsia. oliguria (less than 30 mL/hr) is seen with severe preeclampsia. Why 3 is wrong: a normal platelet count is seen with mild preeclampsia. Thrombocytopenia is seen with severe preeclampsia (HELLP syndrome) Why 4 is wrong: 1+ proteinuria is seen with mild preeclampsia. Greater than or equal to 3+ proteinuria is seen with severe preeclampsia.
The clinical instructor teaches nursing students the tasks required to insert an indwelling urinary catheter into a client. In which order will the instructor review these tasks? 1. Insert catheter using sterile technique 2. Perform hand hygiene 3. Fill balloon with sterile water 4. Apply clean gloves and clean perineal area with soap and water. 5. Position and drape client with bath blanket or small sheet. 6. Open catheter kit and apply sterile gloves from kit.
ANSWER: 2, 5,4,6,1,3
The nurse assesses the skin of an older adult client. Which assessment finding indicates to the nurse that the client is experiencing a potential complication? 1. Wrinkling 2. Deepening of expression lines 3. Crusting 4. Thinning and loss of elasticity
ANSWER: 3 (crusting on the skin indicates a potential complication such as infection, allergic reaction, or injury). All other findings are normal physiological changes related to aging.
A client reports difficult falling asleep at night. Which activity will the nurse recommend to this client? SATA 1. Eat a heavy meal within 2 hours of bedtime. 2. Have a glass of wine 30 minutes before bedtime. 3. Arise at a specific hour every morning. 4. Exercise 1 hour before bedtime. 5. Drink warm milk before bedtime. 6. Take a warm bath before bedtime.
ANSWER: 3, 5, 6 (arising at a specific hour every morning promotes sleep by following a set schedule. Warm milk promotes sleep because milk may encourage the release of serotonin, which has a calming effect. A warm bath promotes sleep by helping with relaxation). Why 1 is wrong: eating a heavy meal within 2 hours of bedtime prevents sleep for most people. Why 2 is wrong: ingesting alcohol 30 minutes before bedtime prevents sleep for most people. Why 4 is wrong: Exercise before bedtime prevents sleep by stimulating the body and increasing the metabolism.
The nurse prepares to apply sequential compression devices (SCDs) on a postoperative adult client. Which aspect of care is included in the nursing care plan? SATA. 1. Remove SCDs at least once every 8 hours 2. Assess circulation of the client's lower extremities 3. After applying SCDs, monitor SCD functioning for one full cycle 4. Maintain SCD use until the client is fully ambulatory 5. Monitor skin integrity 6. Instruct the client on the purpose and procedure of SCD use
ANSWER: all SCDs should be removed routinely for skin assessment and client ambulation. Monitor SCD for one full cycle to ensure proper functioning. Impaired skin integrity (open or infected wounds) may contraindicate the use of SCDs.
The nurse provides care for a client admitted with bed bugs. Which type of precautions will the nurse implement?
Standard precautions
The nurse administers insulin glulisine by subcutaneous injection at 0900 to a client diagnosed with diabetes mellitus (DM). Which time after the injection will the nurse expect the greatest risk for hypoglycemia to occur? 1. 1000 2. 0930 3. 0915 4. 0912
ANSWER: 1 (as insulin glulisine peaks, hypoglycemia risk is greatest. Insulin glulisine reaches its peak concentration 60 to 90 minutes after subcutaneous administration.
The nurse provides care for a client diagnosed with a conversion reaction. Which assessment finding does the nurse expect to observe? 1. The client is experiencing delusions of messianic grandeur. 2. The client believes that the world is ending on a specific date. 3. The client is experiencing persistent pain after the resolution of herpes zoster. 4. The client is experiencing blindness without an identified physical cause.
ANSWER: 4 (Conversion disorder is diagnosed when the client present with neurologic symptoms such as blindness, deafness, or paralysis that cannot be explained by medical evaluation). Why 1 is wrong: more likely to be seen in a client diagnosed with schizophrenia. Why 2 is wrong: not expected finding in conversion reaction. Why 3 is wrong: This describes shingles
The nurse provides care to a client who is experiencing a manic episode of bipolar disorder. Which statement by the client is most expected during a manic episode? 1. "When I am discharged, I will be starting my own company" 2. "I feel frustrated and angry" 3. "The housekeepers are reporting my behaviors to the government" 4. "After treatment, I think I will feel better:
ANSWER: 1 (Characteristic behaviors associated with an acute manic episode include agitation, grandiose delusions, euphoria, and concentration problems. Mania is a mood of extreme euphoria and is manifested by more extreme levels of behavior. In a manic behavior, clients may express grandiose plans. Why 2 is wrong: difficulty in decision-making, preoccupation with self, and distorted perceptions are characteristics of depression. Why 3 is wrong: This is an example of paranoia, delusion, and disturbed thought processes associated with schizophrenia. Why 4 is wrong: This is a neutral, hopeful statement not associated with any disorder.
The nurse screens clients for the risk of developing bladder cancer. Which question does the nurse ask during the assessment process? 1. "Do you smoke cigarettes?" 2. "How often do you consume alcoholic beverages?" 3. "Do you have a sedentary lifestyle?" 4. "How often do you take aspirin?"
ANSWER: 1 (There is a strong correlation between bladder cancer and smoking cigarettes). Alcohol, sedentary lifestyles and aspirin are not identified risk factors for bladder cancer.
