S3 Unit 1 adaptive quizzing

A child who has undergone surgery to revise a ventriculoperitoneal shunt is to be discharged. The nurse would advise the parents to call the clinic if the child has which behavior? 1 Appears drowsy after a nap and becomes irritable 2 Talks incessantly regardless of the presence of others 3 Becomes angry when frustrated and has a temper tantrum 4 Starts arguments with playmates, claiming that their toys are the child's

1 Drowsiness and irritability are characteristic signs of increasing intracranial pressure; other signs and symptoms include nausea, projectile vomiting, headache, and diminished physical activity. Incessant talking, temper tantrums, and the inability to share are all expected behaviors in a 2.5-year-old toddler.

Which clinical manifestations are associated with tuberculosis? Select all that apply. One, some, or all responses may be correct. 1 Fatigue 2 Nausea 3 Weight gain 4 Low-grade fever 5 Increased appetite

124 Tuberculosis is an infectious respiratory disease caused by Mycobacterium tuberculosis. The symptoms of tuberculosis are fatigue, nausea, low-grade fever, weight loss, and anorexia.

At which point in the daily routine do clients who experience alterations in perception tend to have more problems with vivid hallucinations? 1 Before meals 2 After going to bed 3 During group activities 4 While watching television

2

Which type of hallucination is the most common? 1 Visual 2 Tactile 3 Auditory 4 Olfactory

3

what stage of schizophrenia relapse is bizarre behaviors and speech

3

The nurse understands that which medications are considered typical antipsychotics? Select all that apply. One, some, or all responses may be correct. 1 Asenapine 2 Lurasidone 3 Aripiprazole 4 Thioridazine 5 Chlorpromazine

45

what phase of hep b is anorexia common

anicteric (before jaundice)

chronic hep b and c treatment

antivirals

what types of hep are often asymptomatic

b and c

Which finding for a client with a head injury indicates increasing intracranial pressure? 1 Polyuria 2 Tachypnea 3 Increased restlessness 4 Intermittent tachycardia

3 Increased restlessness indicates a lack of oxygen to the brainstem; cerebral hypoxia impairs the reticular activating system. Urine output is not related to increased intracranial pressure. The respiratory rate will decrease. The pulse will be slow and bounding.

Albumin Lab Value

3.5-5.0 g/dL

symptoms of hep c

Asymptomatic Infection becomes chronic

biliary atresia

Congenital absence of the opening from the common bile duct into small intestine (duodenum). earliest sign is jaundice

anicteric hepatitis

Hepatitis without jaundice

meningitis can cause

IICP and hydrocephalus

Kernig's sign

Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees. sign of meningitis

kind of meningitis is more severe

bacterial

what lab value peaks 5-10 days after jaundice appears with hep

biliruben

who would consider prolonged eye contact to be confrontational

chinease SE asian

hypoglycemia causes

confusion brain does not store glucose

what does status epilepticus do to glucose, metabolism, and oxygen

depleted glucose stores increased metabilic rate increased oxygen consumption

precautions for viral meningitis

droplet

Which action would the nurse take for a newly admitted client with schizophrenia who refuses to remove dirty clothing? 1 Allow the client to undress when ready to help maintain identity. 2 Provide two outfits and help the client decide which one to wear. 3 Explain that clean clothes will look more attractive and increase self-esteem. 4 Get assistance to remove the clothing to meet the client's basic hygiene needs.

1

what stage of schizophrenia relapse is expressing being overwhelmed

1

Alanine aminotransferase (ALT)

10-40 units/L

Which intervention will the nurse include in a care plan for a client with dementia who wanders? Select all that apply. One, some, or all responses may be correct. 1 Assess and treat pain. 2 Avoid loud music, television, and glaring lights. 3 Have family members monitor client activity when possible. 4 Use chemical or physical restraint at night to keep the client in bed. 5 Place the client at the end of the hall to allow use of the hall for wandering.

123 Assessing and treating pain in clients with dementia promotes relaxation and prevents unsafe wandering. Avoiding loud music, television, and glaring lights helps decrease confusion and unsafe sensory overload. When possible, family members or volunteers can be "sitters" for clients by providing safe supervision. Chemical or physical restraint is only used as a last resort; it is generally avoided. Clients with dementia who are prone to wander need to be placed away from stairs and elevators, preferably close to the nurse's station to allow for close monitoring of their activity.

14.Which activities would the nurse initiate for a client with Alzheimer disease who is admitted to a long-term care facility? Select all that apply. One, some, or all responses may be correct. 1 Weighing the client once a week 2 Having specialized rehabilitation equipment available 3 Keeping the client in pajamas and robe most of the day 4 Establishing a schedule with periods of rest after activities 5 Reviewing the client's weekly budget and use of community resources 6 Setting up a plan for weekly entertainment through a senior citizens' travel group

124

The nurse recognizes which atypical antipsychotics as being approved for long-term use to prevent the recurrence of mood episodes in clients with bipolar disease? Select all that apply. One, some, or all responses may be correct. 1 Olanzapine 2 Quetiapine 3 Ziprasidone 4 Risperidone 5 Aripiprazole

135

An older client who is usually cheerful and cooperative demonstrates irritability and restlessness during morning hygiene. Which assessments would the nurse perform first? 1 Level of stress and ability to cope 2 Changes in mental status and cognition 3 Deviations from baseline mood and affect 4 Feelings related to loss of independence

2

The nurse would identify which medication as the most common cause of extrapyramidal side effects (EPSs)? 1 Clozapine 2 Haloperidol 3 Risperidone 4 Aripiprazole

2

Which type of delusion would the nurse chart about a client who says, "I've figured out how foreign agents have infiltrated the news media. Now they want to shut me up"? 1 Nihilistic 2 Persecution 3 Control 4 Grandeur

2

what stage of schizophrenia relapse is expressing feelings of anxiety

2

Donepezil is prescribed for a client who has mild dementia of the Alzheimer type. Which information would the nurse include when discussing this medication with the client and family? 1 Fluids should be limited to 4 large glasses per day. 2 Constipation should be reported to the primary health care provider immediately. 3 Blood tests that reflect liver function will be performed routinely. 4 The client's medication dosage may be self-adjusted according to the client's response.

3 Donepezil may affect the liver because alanine aminotransferase (ALT) is found predominantly in the liver; most ALT increases indicate hepatocellular disease. Clients taking this medication should have regular liver function tests and report light stools and jaundice to the primary health care provider. Fluids should not be limited, because a side effect of donepezil is constipation. A side effect of constipation is expected; therefore, fluids, high-fiber foods, and exercise should be recommended to help keep the stools soft.

Which approach would the nurse take for a client with schizophrenia who refuses to get out of bed and becomes upset? 1 Requiring the client to get out of bed at once 2 Allowing the client to stay in bed for a while 3 Staying at the bedside until the client calms down 4 Giving the prescribed as-needed tranquilizer to the client

3 The nurse would stay at the bedside until the client calms down. This approach provides support and security without rejecting the client or placing value judgments on behavior. Eventually limits will have to be set (to get out of bed), but this is not the immediate nursing action and it does not have to be at once. Allowing the client to stay in bed for a while ignores the problem, and isolation may imply punishment. Although medication will calm the client, it does not address the immediate problem that requires support from the nurse

After receiving streptomycin sulfate for 2 weeks as part of the medical regimen for tuberculosis, the client reports feeling dizzy and having some hearing loss. Which part of the body is the medication affecting? 1 Pyramidal tracts 2 Cerebellar tissue 3 Peripheral motor end plates 4 Eighth cranial nerve's vestibular branch

4

Nursing management of a client with dementia who is disoriented, forgetful, and with inappropriate behaviors would be directed toward which? 1 Restricting gross motor activity to prevent injury 2 Preventing further deterioration in the client's condition 3 Maintaining scheduled activities through behavior modification 4 Rechanneling the client's energies into more appropriate behaviors

4

The nurse is caring for several clients with major thought disorders such as those occurring in clients with schizophrenia. They are all being treated with neuroleptic medications. How do these medications act in the body to promote mental health? 1 They inhibit enzymes at the postsynaptic receptor site. 2 They decrease serotonin at the postsynaptic receptor site. 3 They increase dopamine uptake at the postsynaptic receptor site. 4 They block access to dopamine receptors at the postsynaptic receptor site.

4

Which behavior would the nurse recognize as a sign of a hearing deficit in a 7-month-old infant? 1 The infant does not always turn the head when called by name. 2 The mother says that the infant is unable to learn the word mama. 3 The infant fails to demonstrate the Moro reflex in response to handclapping. 4 The mother says the infant stopped making verbal sounds about a month ago.

4

Which clinical manifestation would best indicate to the nurse that the mental status of a client with schizophrenia and paranoid delusions is improving? 1 Absence of mild to moderate anxiety 2 Development of insight into the problem 3 Decreased need to use defense mechanisms 4 Ability to function effectively in activities of daily living

4

Which complication would the nurse expect if strabismus is not corrected in early childhood? 1 Cataracts 2 Glaucoma 3 Refractive errors 4 Partial loss of sight

4

what stage of schizophrenia relapse is hallucinations

4

The parents of a child diagnosed with hepatitis A express concern that other family members may contract hepatitis because they only have one bathroom. Which response would the nurse reply? 1 "I suggest you buy an individual commode seat to use exclusively for your child's bathroom needs." 2 "Your child may use the bathroom, but you need to use disposable toilet seat covers." 3 "You will need to clean the bathroom from top to bottom every time a family member uses it." 4 "All family members, including your child, need to wash their hands after using the bathroom."

4 Hepatitis A is spread via the fecal-oral route; transmission is prevented by proper hand washing. Buying a commode exclusively for the child's use is unnecessary; cleansing the toilet and washing the hands should control the transmission of microorganisms. Cleaning the bathroom "from top to bottom" after each use is not feasible. The use of disposable toilet covers is inadequate to prevent the spread of microorganisms if the bathroom used by the child also is used by others. Hand washing by all family members must be part of the plan to prevent the spread of hepatitis to other family members.

Which manifestation is an extrapyramidal side effect of chlorpromazine? Select all that apply. One, some, or all responses may be correct. 1 Drooling 2 Facial tics 3 Shuffling gait 4 Tongue rolling 5 Restless movements

all

urticaria

allergic reaction of the skin characterized by the eruption of pale red, elevated patches called wheals or hives common with icteric phase of hep b

a 3 foot distance without a mask is required for what precautions

droplet

common side effect of chlorpromazine

drowsiness

what stage of alzheimers is donepezil used for

early

adolescent manifestations of meningitis

fevere severe headache vomit photophobia nuchal rigidity

bacterial meningitis manifestations

high fever change in LOC nuchal rigidity positive kernig positive brudzinski

what phase of hep b is jaundice, urticaria, dark urine, and light stools

icteric

what happens in alzheimers when the frontal lobe is impaired

inability to make decisions

icteric phase of hepatitis

jaundice

ataxia

lack of muscle coordination

when is INH given and for how long

laten TB 9-12 mo

risk factors for TB in children

malnutrition chronic illness close contact with IV drug users immigration from places with high incidences urban, low-income

people from __ are sometimes uncomfortable with touch

middle eastern native american

classid triad of meningitis

muscle rigidity sidden high fever altered mental status

common side effect of INH

neuropathy

Is asking why therapeutic?

no

is giving approval therapeutic

no

is making value judgements therapeutic

no

cure for hep a and b

none

vertigo is a clinical manifestation of

otitis media

onset of hep A

rapid and acute

precautions for hep a

standard

Is "Voicing Doubt," Therapeutic, or Non-Therapeutic?

therapeutic

Is Silence a therapeutic or non-therapeutic communication technique?

therapeutic

most common type of meningitis

viral

A client who was diagnosed recently with early dementia is admitted to the hospital for acute pain in the hip, and a total hip replacement surgery is scheduled. The client is oriented, alert, and responds appropriately when interviewed. The client says, "I don't want to have that surgery." The client's spouse asks that the team proceed with the surgery to provide pain relief for the client. How would the nurse respond? 1 Discuss feelings about having surgery with the client. 2 Ask the client if a power of attorney for health care has been established. 3 Continue with preparation for surgery as the spouse has requested. 4 Continue with teaching, ensuring that the client understands the process.

2 Consent for surgery should be given by the client; the spouse cannot do this unless he or she has power of attorney for health care. Although it is important to discuss feelings with the client, this does not address the legal issue. The legal issue needs to be clarified first. If the client does not want surgery, preoperative teaching probably will not be effective, because the client will not be receptive. The legal issue needs to be clarified first.

The primary health care provider prescribes a neuroleptic medication to a client diagnosed with schizophrenia. The nurse understands which to be the reasoning the health care provider would choose this medication? 1 Symptoms 2 Side effects 3 Therapeutic effects 4 Underlying pathology

2 First-generation antipsychotic medications are also known as neuroleptics. The selection of these medications is based more on side effects than therapeutic effects. Because all symptoms respond equally to antipsychotic medications, the medication selection may not be based on symptoms. Because these medications do not alter the underlying pathology, the selection may not be based on underlying pathology.

A client with a diagnosis of schizophrenia is prescribed an antipsychotic medication. The nurse understands which side effect of antipsychotic medications may be irreversible? 1 Akathisia 2 Tardive dyskinesia 3 Parkinsonian syndrome 4 Acute dystonic reaction

2 Tardive dyskinesia, an extrapyramidal response characterized by vermicular movements and protrusion of the tongue, chewing and puckering movements of the mouth, and puffing of the cheeks, is often irreversible, even when the antipsychotic medication is withdrawn. Akathisia (motor restlessness), parkinsonian syndrome (a disorder featuring signs and symptoms of Parkinson's disease such as resting tremors, muscle weakness, reduced movement, and festinating gait), and dystonia (impairment of muscle tonus) usually can be treated with antiparkinsonian or anticholinergic medications while the antipsychotic medication is continued.

A 1-year-old infant has been admitted with a tentative diagnosis of bacterial meningitis. Which cerebrospinal fluid (CSF) laboratory finding would support this diagnosis? 1 Decreased cell count 2 Increased protein level 3 Increased glucose level 4 Low spinal fluid pressure

2 The blood-brain barrier is affected in bacterial meningitis, permitting the passage of protein into the cerebrospinal fluid (CSF). The cell count will be increased. The glucose level is decreased in proportion to the duration of the disease. Spinal fluid pressure will be increased.

Which therapeutic intervention would be included in the plan of care for a confused, delusional client? 1 Minimize stimuli by maintaining a quiet, darkened environment. 2 Encourage realistic activity based on the client's ability. 3 Focus frequently on the content of the delusions. 4 Perform physical hygiene even if the client is capable

2 The nurse would encourage realistic activity based on the client's ability. These clients need sensory stimulation to maintain orientation and should be encouraged to do as much as possible for themselves, depending on their ability. Surroundings should be bright (not darkened) to minimize confusion.

Which immediate action would the nurse take for an adolescent boy with schizophrenia who exposes his genitals to a nurse? 1 Ignore the client at this time. 2 State that this behavior is unacceptable. 3 Move him to his room for a short time-out. 4 Tell the client to come to the office later to discuss the behavior.

2 The nurse would immediately state that his behavior is unacceptable. When clients enter a new milieu, limits should be set on unacceptable behavior and acceptable behavior should be reinforced. Neither clients nor unacceptable behavior should be ignored. Moving the client to his room for a short time-out is punishment. Unacceptable attention-getting behavior must be addressed immediately; also, the focus should be on appropriate behavior.

Which activity would the nurse include in the plan of care for a client with vascular neurocognitive disorder? 1 Reeducation program 2 Supportive care interventions 3 Introduction of new leisure-time activities 4 Involvement in group therapy sessions

2 The nurse would include supportive care interventions in the plan of care. Damaged brain cells do not regenerate. Care is directed toward preventing further damage and providing protection and support for vascular neurocognitive disorders. The deterioration of the brain cells makes plans for a reeducation program unrealistic. A client with this disorder may not be able to grasp, understand, or enjoy new leisure activities. It is beyond the scope of the client's ability to function in a group therapy session.

Which action would the nurse take when caring for a client who is experiencing a paranoid delusion? 1 Touch the client's arm gently to convey concern. 2 Maintain eye contact when talking with the client. 3 Attempt to disprove the client's delusional thoughts. 4 Speak softly when talking with others near the client.

2 The nurse would maintain eye contact when talking with the client. Eye contact focuses the client's attention on the nurse; it also conveys caring and tells the client that the nurse considers the client important. The nurse would respect the client's personal space; touching the client, particularly without warning, may reinforce suspicious thoughts or precipitate agitation. Attempting to disprove the client's delusional thoughts is useless, because a delusion is real to the client. Whispering or laughing in the presence of a paranoid delusional client may reinforce the delusional state and further agitate the client.

When providing a change-of-shift report, which explanation would the nurse use to describe a schizophrenic client who is experiencing opposing emotions simultaneously? 1 Double bind 2 Ambivalence 3 Loose association 4 Inappropriate affect

2 The nurse would use the term ambivalence to describe opposing emotions simultaneously. Ambivalence is the existence of two conflicting emotions, impulses, or desires. Double bind means having two conflicting messages, not emotions, in a single communication. Loose associations are not two conflicting emotions but instead the loosening of connections between thoughts. Inappropriate affect is the incongruous expression of emotions when compared with behavior or content of speech.

when is isolation discontinued for TB

2-3 weeks after beginning meds

An emaciated older adult with dementia develops a large pressure ulcer after refusing to change position for extended periods. The family blames the nurses and threatens to sue. Which is considered when determining the source of blame for the pressure ulcer? 1 The client should have been turned regularly. 2 Older clients frequently develop pressure ulcers. 3 The nurse is not responsible to the client's family. 4 Nurses should respect a client's right not to be moved.

4 Clients should change position at least every 2 hours to prevent pressure ulcers. The nurse would not deviate from this standard of practice because of the cognitively impaired client's refusal to move. The nurse was negligent for not changing the client's position. Although pressure ulcers may occur, nursing care must include preventive measures. If the client refuses to change position for extended periods, the nurse would consult the agency policy or management for a strategy to handle this situation. For example, a formal shared decision-making (SDM) protocol can be instituted upon admission or as soon as refusal has started to involve the client, the client's family, and the health care staff with a collaborative agreement on how to resolve the problem. The family is included in the health care team, so the nurse is responsible to them. When a capable client refuses necessary health care, the nurse would provide health teaching to promote understanding of the treatment plan. If the client makes an informed decision after an explanation, then the client's rights must be respected; however, this client is

what cultural factors contributes to behavior

values beliefs history religion not biases

common side effects of atypical antipsychotics

weight gain, diabetes, high cholesterol

is summarizing therapeutic

yes