Archer Review 13b

What are the cardinal movements of labor and delivery? Answer in the correct ordered sequence. A. Engagement B. Expulsion C. Internal Rotation D. Extension E. Descent and flexion F. Restitution and external rotation

Engagement Descent and flexion Internal Rotation Extension Restitution and external rotation Expulsion Explanation The correct ordered sequence is A, E, C, D, F, and B. For a fetus to pass through the birth canal, the fetal head and body must adjust to the passage and go through positional changes. These positional changes are referred to as cardinal movements. Engagement - occurs when the widest diameter of the presenting part (usually the head) enters the mother's pelvis. Descent & Flexion - Descent is the downward passage of the fetus through the pelvis. Flexion occurs as the fetal head encounters resistance from the pelvic bones and soft tissues of the pelvic floor, causing the embryo to flex the head. Internal rotation - occurs as the head, which is usually in a transverse position, rotates 45 degrees to an A/P position under the symphysis pubis. Extension - follows descent and flexion of the head when the occiput comes into contact with the inferior margin of the symphysis pubis. The force of uterine contractions causes the occiput to extend and rotate around the symphysis. Restitution and external rotation - occurs as the fetal head untwists to the left or right, returning the head to the original anatomical position. Expulsion - the final step. The fetal head is delivered and the anterior shoulder is rotated under the symphysis, followed by the posterior shoulder and the rest of the fetal body. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Positional Changes of the Fetus

Which of the following medication orders for a patient with pulmonary embolism and fever is a priority to clarify with the physician before administration? A. Warfarin 1.0 mg PO [28%] B. Morphine sulfate 2 to 4 mg IV [34%] C. Ceftriaxone 1 g IV [13%] D. Heparin infusion at 1500 units/hr

Explanation Choice A is correct. The trailing zero in this order could be misread/misinterpreted and result in an accidental overdose of medication. It is essential to clarify whether the physician meant 1.0 mg or 10 mg of warfarin. Trailing zeros appear on the Joint Commission on the Accreditation of Hospitals (JCAHO) "Do Not Use" list. The use of a zero after a decimal point (trailing zero) is unnecessary. It may sometimes result in the administration of a drug at ten times its prescribed dose if the decimal point is illegible or not seen. Choices B, C, and D are incorrect. All of these answer choices are appropriate based on the patient's diagnosis. Morphine (Choice B) is appropriate to address the pain that is often associated with a pulmonary embolism - no additional clarification is needed. Pulmonary embolism patients tend to have tachypnea, not baseline respiratory depression. Some get distracted by this answer choice since some are concerned about opioid safety in cases of dyspnea/respiratory distress. Such a thought process is wrong for two reasons. There is no indication of respiratory depression in this case. Many small studies have established the safety of opioids when used in appropriate doses for pain, even in those dyspneic patients with advanced cardiopulmonary disease. The incidence of real respiratory depression in a review of cases where morphine was used for acute moderate to severe pain was 0.5% or less. Low-grade fever can be seen with pulmonary embolism, but it appears like the physician is giving empiric antibiotic coverage with ceftriaxone (Choice C) - no additional clarification is needed. Heparin infusion (Choice D) is appropriate for initial anticoagulation with warfarin. No additional clarification is needed.

The nurse is performing an admission assessment on a client admitted to the behavioral health unit. The client is reporting new-onset blindness after witnessing a traumatic motor vehicle accident. The nurse suspects that this client is using which defense mechanism? A. Suppression [23%] B. Conversion [40%] C. DIsplacement [16%] D. Dissociation [21%]

Explanation Choice B is correct. Converting anxiety into physical symptoms with no organic cause best explains this defense mechanism this client is experiencing. Conversion is a pathological defense that may manifest as a disorder if it continues to recur. This client was traumatized by the accident and converted his anxiety into a physical symptom (blindness). His new-onset blindness has no organic origin; thus, this exemplifies conversion. Choices A, C, and D are incorrect. Suppression is defined as the conscious decision to delay addressing a disturbing situation. The client does not exhibit this avoidance because they have taken their anxiety and manifested it as a physical ailment that cannot be explained. Displacement is the transference of emotions associated with a particular person, object, or situation to another non-threatening person, object, or situation. This client has not transferred their anxiety to someone (or something). Finally, dissociation is a disruption in consciousness, memory, identity, or perception of the environment that results in compartmentalizing uncomfortable or unpleasant aspects of oneself. This client has no evidence of a disruption in their consciousness, memory, or identity. Additional Info Adaptive use of defense mechanisms helps people to lower their levels of anxiety and to achieve their goals in acceptable ways. Maladaptive use of defense mechanisms occurs when one or several are used to excess, particularly immature defenses. Most defense mechanisms can be used in both healthy and unhealthy ways. People generally use a variety of defense mechanisms but not always to the same degree.

The nurse is caring for a client with angle-closure glaucoma. It would be correct to place the client in which position? A. High fowler's [22%] B. Supine [19%] C. Semi fowler's [53%] D. Left lateral recumbent [5%]

Explanation Choice B is correct. Placing the client supine, who has angle-closure glaucoma, is effective as it will assist in the lens falling away from the iris, decreasing the pupillary block. Choices A, C, and D are incorrect. High-fowler's, semi-fowler's, and left-lateral recumbent are all positions unhelpful in the treatment of angle-closure glaucoma. The treatment goal is to decrease the pupillary block by separating the lens from the iris, which can be accomplished by placing the client supine. NCLEX Category: Physiological Adaptation Activity Statement: Medical Emergencies Question type: Knowledge/comprehension Additional Info Angle-closure glaucoma is an ocular emergency that occurs when the intraocular pressure exceeds 30 mm Hg (normal is 10-21 mm Hg). The client may experience manifestations such as ipsilateral headache, brow pain, nausea, and blurred vision. Emergent prescriptions such as timolol eye drops are used to lower intraocular pressure. Other useful agents include oral/intravenous acetazolamide.

The nurse is counseling a group of students on the dosing schedule of Rho(D) Immune Globulin. It would indicate effective understanding if the student states that Rho(D) Immune Globulin should be administered at A. 12 weeks of pregnancy and within 72 hours of delivery. [13%] B. 28 weeks of pregnancy and within 72 hours of delivery. [73%] C. 25 weeks of pregnancy and within 96 hours of delivery. [1%] D. 16 weeks of pregnancy and within 12 hours of delivery. [12%]

Explanation Choice B is correct. Rho(D) Immune Globulin must be given within a specified time window because if it is given too early maternal sensitization occurs in approximately 72 hours. Giving Rho(D) Immune Globulin after 28 weeks of gestation would be too late to prevent isoimmunization during pregnancy because Rh antibodies already have formed. Choices A, C, and D are incorrect. These time frames are incorrect for the administration of Rho(D) Immune Globulin. Additional Info One standard dose of Rho(D) Immune Globulin is administered IM or IV push: At 28 weeks of pregnancy and within 72 hours of delivery of an Rh-positive infant, undergoing chorionic villus sampling, amniocentesis, or intraabdominal trauma. Within 72 hours after termination of a pregnancy of 13 weeks or more of gestation.

An altered physical condition caused by the nervous system adapting to repeated drug use is: A. Addiction [39%] B. Physical dependence [43%] C. Psychological dependence [9%] D. Withdrawal [9%]

Explanation Choice B is correct. Some drugs are frequently abused or have a high potential for addiction. Drugs that cause dependency are restricted to use in situations of medical necessity if they are allowed at all. According to law, drugs that have a significant potential for abuse are placed into categories called schedules. Choices A, C, and D are incorrect. Addiction refers to the overwhelming feeling that drives someone to use a drug repeatedly, although it is not medically necessary. Psychological dependence occurs when an individual has few signs of physical discomfort when a drug is withheld. However, the individual feels an intense, compelling desire to continue the use of the drug. Withdrawal is a term used to describe physical signs of discomfort that an individual experiences when a drug is no longer available. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies

Which of the following clients should the nurse assess first when preparing to do initial rounds? A. The client with diabetes who is being discharged today. [1%] B. A 32-year-old female with a tracheostomy experiencing copious secretions. [97%] C. A 16-year-old scheduled for physical therapy this morning. [1%] D. An 80-year-old male with a decubitus ulcer that needs a dressing change. [2%]

Explanation Choice B is correct. The patient with airway compromise should always be given the highest priority. Remember ABC (Airway, Breathing, Circulation). Choices A, C, and D are incorrect. None of the patients in these answer options indicate a priority for the initial assessment. NCSBN Client Need Topic: Safe and Effective Care Environment - Coordinated Care, Subtopic: Prioritizing Patient Care

A pregnant woman is admitted to the ER with an initial diagnosis of placenta previa. The nurse carries out orders to start an IV infusion, administer oxygen, and extract blood for laboratory tests. The client is getting anxious and asks the nurse what is happening. The nurse tells her not to worry and that everything is under control. What is the best description of the nurse's statement? A. Incorrect, the doctor should be the one to offer information and assurances. [8%] B. Questionable, because the patient has the right to understand the type of treatment and the reason for the treatment. [84%] C. Effective, because the response lowers the client's anxiety. [6%] D. Adequate, because the preparations are routine and need no explanation.

Explanation Choice B is correct. This is a violation of the client's rights. The client has the right to accurate and complete explanations about any procedures to be performed. Choice A is incorrect. In the Patients' Bill of Rights, the patient has the right to be informed by healthcare staff about any procedure that will be done to her. Choice C is incorrect. The nurse has the responsibility to inform the client regarding the procedure that is going to be performed on her. Choice D is incorrect. The procedure may be routine work for the nurse, but it is not routine for the client and should be explained to her.

The nurse is helping a client prepare for his peritoneoscopy tomorrow. All of the following statements from the nurse are accurate regarding the procedure, except: A. "The doctor will inflate your abdomen using carbon dioxide gas." [28%] B. "We will be injecting a dye into your vein in order for us to see the organs better." [45%] C. "You need to avoid eating or drinking after midnight to prepare for the procedure." [7%] D. "Expect to have some discomfort on your shoulders after the procedure; this is because of the air that's left inside your abdomen."

Explanation Choice B is correct. This is an incorrect statement from the nurse, therefore the correct answer to the question. The procedure does not require a contrast medium. The nurse should not say this to the patient. Choice A is incorrect. This is a correct statement from the nurse. The patient's peritoneum is separated from the abdominal wall by pumping 3-4 liters of carbon dioxide. Choice C is incorrect. This is a correct statement from the nurse. The client will be put on NPO after midnight on the night before his procedure. Choice D is incorrect. This is a correct statement from the nurse. Because of pneumoperitoneum, the client should expect discomfort in his shoulder after the procedure up to 24 hours.

Which of the following clients is at greatest risk for developing malnutrition? A. A 72-year-old woman in a nursing home [1%] B. An 81-year-old widow who lives alone [79%] C. A 65-year-old with poor dentition who is married [15%] D. A 79-year-old widower who receives food from 'Meals on Wheels' [6%]

Explanation Choice B is correct. This patient has two risk factors, which make her a higher risk for developing malnutrition. Malnutrition refers to deficiencies, excesses, or imbalances in a person's intake of energy and nutrients. The term malnutrition addresses three broad groups of conditions: Undernutrition, which includes wasting (low weight-for-height), stunting (low height-for-age), and underweight (low weight-for-age) Micronutrient-related malnutrition, which includes micronutrient deficiencies (a lack of important vitamins and minerals) or micronutrient excess Overweight, obesity, and diet-related non-communicable diseases (such as heart disease, stroke, diabetes, and some cancers) Women, infants, children, and adolescents are at particular risk of malnutrition. Optimizing nutrition early in life—including the 1000 days from conception to a child's second birthday—ensures the best possible start in life, with long-term benefits. Poverty amplifies the risk of, and threats from, malnutrition. Poor people are more likely to be affected by different forms of malnutrition. Also, hunger increases health care costs, reduces productivity, and slows economic growth, which can perpetuate a cycle of poverty and ill-health. Choices A, C, and D are incorrect. While each of these clients may experience poor nutrition and develop malnutrition, if untreated, the patient in answer choice B has two risk factors which make her the highest risk for developing malnutrition. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential

When caring for a client with total parenteral nutrition (TPN), what is the most important action by the nurse? A. Record the number of stools per day [1%] B. Maintain strict intake and output records [30%] C. Sterile technique for dressing change at IV site [47%] D. Monitor for cardiac arrhythmias [21%]

Explanation Choice C is correct. Clients receiving TPN are very susceptible to infection. The concentrated glucose solutions are an excellent medium for bacterial growth. Strict sterile technique is crucial in preventing disease at the IV infusion site. Choices A, B, and D are incorrect. Although these are appropriate nursing interventions, they are not the essential action of the nurse in this example. NCSBN Client Need Topic: Physiological Integrity Subtopic: Pharmacological Therapies

Many factors impact on the occurrence of diseases and disorders as well as client recovery from these diseases and disorders. Which of the following is the extrinsic factor that most greatly and most frequently can hurt and interfere with our client's physical and emotional recovery from a disease or disorder? A. Age [24%] B. Genetic makeup [9%] C. Family dynamics [65%] D. Gender [2%]

Explanation Choice C is correct. Family dynamics are the extrinsic factor that most greatly and most frequently hurts and interferes with our clients' physical and emotional recovery from a disease or disorder. All of the other factors are intrinsic risk factors that are associated with a possible negative impact on the recovery of a client. Choice A is incorrect. Age does have a possible negative impact on and interference with our client's physical and emotional recovery from a disease or disorder; however, age is an intrinsic and not an extrinsic factor that could hurt and interfere with our clients' physical and emotional recovery from a disease or disorder. Choice B is incorrect. Genetic makeup does have a possible negative impact on and interference with our clients physical and emotional recovery from a disease or disorder, however, genetic makeup is an intrinsic and not an extrinsic factor that could hurt and interfere with our clients' physical and/or emotional recovery from a disease or disorder. Choice D is incorrect. Gender does have a possible negative impact on and interference with our client's physical and emotional recovery from a disease or disorder; however, gender is an intrinsic and not an extrinsic factor that could hurt and interfere with our clients' physical and emotional recovery from a disease or disorder.

The nurse is teaching a client about isoniazid (INH). Which of the following statements should the nurse include? A. "This medication may turn your secretions reddish/orange." [49%] B. "Yellowing of your eyes is a normal side-effect." [7%] C. "A B-complex vitamin should be taken to help with the neuropathy." [38%] D. "This medication will need to be taken every day for at least one week." [5%]

Explanation Choice C is correct. INH is a first-line therapy treatment for pulmonary tuberculosis. The major adverse effect associated with INH is peripheral neuropathy. This may be ameliorated by a client taking prescribed B-complex vitamins as INH depletes the stores of pyridoxine (Vitamin B6). Choices A, B, and D are incorrect. Reddish/orange secretions are a major effect seen with rifampin - not isoniazid. Yellowing of the eyes is not a normal side-effect as this is an indication of serious hepatoxicity. Antitubercular medications need to be taken for a prolonged period (at least six months). Additional Info INH is the first-line therapy for pulmonary tuberculosis. This agent is often combined with another antitubercular medication because of the emerging drug resistance. Hepatotoxicity is the most common adverse effect of most antitubercular drugs. The client should immediately report signs of hepatotoxicity such as jaundice and clay-colored stools.

The nurse is assessing a client suspected of having the early stages of dementia. Which defense mechanism would the nurse expect? A. Identification [9%] B. Projection [6%] C. Denial [78%] D. Conversion

Explanation Choice C is correct. In the early stages of dementia, it is quite common for family members and the client to exhibit denial. Denial is utilized to avert the unpleasant emotions surrounding the diagnosis of dementia which is progressive in terms of its symptom intensity. Typically, symptoms that may be concerning for dementia are noticed by family or friends. This individual (an informant) usually brings this concern forward to the primary healthcare provider (PHCP). Choices A, B, and D are incorrect. Identification is attributing to oneself the characteristics of another person or group. This is not seen in the early part of dementia, as complete avoidance of memory loss is exhibited. Projection is unconsciously rejecting emotionally unacceptable features and attributing them to others. This is not seen in dementia as the client rarely projects their memory impairments onto others. Conversion is not a feature of this disorder because the client is not taking their psychological symptoms and putting them into physical ones that cannot be explained organically Clinical Features of Dementia The incidence and prevalence of dementia increase exponentially with age, essentially doubling in prevalence every 5 years after the age of 65 years. Insidious onset Poor prognosis as the disease is progressive Idiopathic; however, uncontrolled hypertension and diabetes contribute to vascular dementia Attention is unimpaired in the early part of the disease process Memory impairments start with recent memory and then impact remote memory Difficulty with judgment and executive functioning No alteration in consciousness Flat affect that may progress to behavioral disturbances such as agitation

The nurse in the emergency department is preparing to receive a client exposed to inhalation anthrax. The nurse plans to implement A. droplet precautions. [15%] B. airborne precautions. [40%] C. standard precautions. [32%] D. contact precautions.

Explanation Choice C is correct. Standard precautions are utilized in the management of inhalation anthrax. Inhalation anthrax is not transmitted from person to person and its vector is contaminated materials, such as wool, hides, or hair. Choices A, B, and D are incorrect. Inhalation anthrax does not spread from person to person and implementing contact, droplet, or airborne precautions would be unnecessary. Additional Info Anthrax is a bioterrorism agent and must be taken seriously because it has a high mortality rate. Anthrax may be cutaneous or inhaled and is caused by exposure to the gram-positive bacterium. Nursing care is aimed at stabilizing the client's breathing and promptly initiating treatment, which is antibiotics (levofloxacin) and/or antitoxins such as raxibacumab.

The client has just been given an IV dose of morphine 6 mg for neuropathic pain. A few minutes later, the nurse notes that the client's respirations are now 8, and his blood pressure has dropped from 122/83 mmHg to 88/67 mmHg. Which nursing action is the most appropriate? A. Prepare for intubation [7%] B. Prepare to administer a dopamine infusion [3%] C. Administer naloxone [79%] D. Start an IV infusion of normal saline [10%]

Explanation Choice C is correct. The client is suffering from morphine toxicity. The nurse needs to administer the antidote, which is naloxone (Narcan). Choice A is incorrect. The client is in morphine toxicity. The nurse needs to administer an antidote to reverse the symptoms of respiratory depression. Preparing for intubation should not be the nurse's initial action. Choice B is incorrect. The drop in blood pressure is a result of morphine toxicity. Dopamine infusion is not yet necessary. Choice D is incorrect. Starting an IV infusion may be necessary; however, the first action of the nurse in case of this situation is to administer an antidote to morphine.

The nurse is caring for the following assigned patients. The nurse should prioritize follow-up with which patient first? A. The patient repeatedly washing their hands [5%] B. The patient talking over others during group therapy [1%] C. The patient yelling and shouting at other patients [85%] D. The patient voluntarily admitted and requesting discharge [9%]

Explanation Choice C is correct. The patient yelling and shouting at other patients requires immediate intervention because this situation is hostile and requires the nurse to deescalate the situation before it intensifies. Under Maslow's Hierarchy of Needs framework, safety and security are how this question may be answered. Choices A, B, and D are incorrect. A patient repeatedly washing their hands is a feature of obsessive-compulsive disorder, and the nurse should not intervene unless the act is threatening the patient or others. Further, a patient talking over others in therapy will require intervention, but this is not the immediate need as it is not a hostile situation. Finally, voluntarily admitted patients might request discharge, but this is a low priority item compared to the patient yelling at others. Additional information: When prioritizing patient needs, focus on ensuring that physiological, safety, and security needs are met first. In this question, the patient's safety and security needs are prioritized over the other needs.

The patient is receiving a blood transfusion and develops chills and vomiting. The nurse assesses the patient and finds a temperature of 103.2 degrees F and blood pressure of 100/64 mmHg. Which action should the nurse take first? A. Call the physician to report the adverse reaction. [1%] B. Obtain STAT blood cultures. [1%] C. Discontinue the transfusion. [98%] D. Administer vasopressors. [0%]

Explanation Choice C is correct. This patient is showing signs of a sepsis reaction: rapid onset of chills, high fever, vomiting, and hypotension. The blood transfusion should be stopped immediately to avoid further complications. The IV line should be kept patent with only 0.9% saline solution. The other answers may be appropriate, but this is the nurse's first priority. Choice A is incorrect. The nurse should first stop the transfusion and stabilize the patient before notifying the physician and the blood bank of the reaction. Choice B is incorrect. The nurse will collect blood/urine specimens for testing, but this would not be the most important first action. The blood bag and tubing should also be saved and sent for examination. Choice D is incorrect. This reaction would be treated with a combination of fluids, vasopressors, and antibiotics, but administering medications would not be the first action. The nurse should first stop the transfusion, notify the physician, and implement treatment per MD orders/facility policy. NCSBN Client Need Topic: Critical Care Concepts, Subtopic: Establishing priorities, blood and blood products, the potential for complications of treatments

Your client has consumed an 8-ounce container of milk, a 4-ounce container of gelatin, and a 6-ounce hamburger for lunch. You will document this client's fluid intake as: A. 80 mL [3%] B. 160 mL [8%] C. 360 mL [75%] D. 640 mL [14%]

Explanation Choice C is correct. You will document this client's fluid intake as 360 mL because the client has consumed 12 ounces of fluid and because each ounce has 30 mL, it is calculated as follows: 30 x 12 = 360 mL. The hamburger does not count as fluid. Choice A is incorrect. The client has consumed 12 ounces of fluid, so the total consumed is more than 80 mL. Try this calculation again. Choice B is incorrect. The client has consumed 12 ounces of fluid, so the total consumed is more than 160 mL. Try this calculation again. Choice D is incorrect. The client has consumed 12 ounces of fluid, so the total consumed is less than 640 mL. Try this calculation again. Additional Info Intake and output should be calculated every shift or per facility policy. Intake and output are not accurate measurements of fluid status compared to weight. Intake and output are a crude way of assessing fluid status. Normal hydration is approximately 800-2000 mL of non-caffeinated fluids daily.

The nurse is educating a client who has been prescribed acyclovir for newly diagnosed shingles. Which information would be the most important for the nurse to include? A. Take this medication 30 minutes before meals [11%] B. Continue taking this medication until the rash resolves [15%] C. If a dose is missed, take it with the next scheduled dose [5%] D. Increase fluid intake while taking this medication [69%]

Explanation Choice D is correct. Acyclovir is an antiviral medication that interferes with the synthesis of DNA and viral replication and is primarily excreted through the kidneys. Unless contraindicated, this patient should increase fluid intake while on this medication to reduce the risk of potential nephrotoxic effects. The nurse should also review the symptoms of kidney issues that should be reported, including oliguria, hematuria, and renal pain. Choices A, B, and C are incorrect. This medication can be taken with or without food and would not need to be taken on an empty stomach. The patient may take it with food to lessen GI symptoms if necessary. Oral acyclovir is typically prescribed for shingles for 7-10 days, without regard to the resolution of any shingles-related rash. Doubling up on doses is contraindicated. If a dose is missed, the patient should take the dose as soon as remembered up until 1 hour before the next dose. Additional Info Acyclovir is an antiviral medication indicated in treating herpes simplex, herpes zoster, and varicella. Like all antivirals, the treatment is not curative but decreases the outbreak time. It is best when antiviral medications, such as acyclovir, be initiated at the onset of symptoms.

The nurse is caring for a client who has been prescribed sertraline for major depressive disorder. It would be a priority for the nurse to assess for which of the following? A. Insomnia [3%] B. Sexual side-effects [3%] C. Weight gain [2%] D. Suicidal ideation

Explanation Choice D is correct. Suicidal ideation is always a concern whether a client is taking an SSRI like sertraline or not. SSRIs have demonstrated the ability to ameliorate depressive and anxiety symptoms; however, the risk of suicidal ideation may adversely occur and should be reported immediately. Choices A, B, and C are incorrect. Insomnia, sexual dysfunction, weight gain, and nausea are common symptoms associated with SSRIs. While most of these effects are transient, the client should be educated about these potential side effects. Additional information: Suicidal ideation is a priority concern for any client taking an SSRI, SNRI, mood stabilizer, or antipsychotic medication. Sertraline is an SSRI and may precipitate these thoughts. While SSRIs are effective for depressive symptoms, surveillance for suicidal ideations should consistently be implemented. The nurse should be direct in their line of questioning if a client should express either covert or overt signs of suicidality. Questions such as, "Are you thinking about harming yourself?" are appropriate. NCSBN Client need: Topic: Pharmacological and Parenteral Therapies; Subtopic: Adverse Effects/Contraindications/Side Effects/Interactions

A patient was admitted to the ER due to low serum calcium levels. Upon further examination, he demonstrates carpopedal spasms and reports numbness in his lips and hands. An ECG was taken and revealed a prolonged QT interval. Upon assessment of the client, the nurse should suspect which condition? A. Hyperthyroidism [7%] B. Hypothyroidism [16%] C. Hyperparathyroidism [16%] D. Hypoparathyroidism [61%]

Explanation Choice D is correct. Symptoms of hypoparathyroidism mirror that of hypocalcemia. It manifests as numbness and tingling of the lips and hands, tetany, carpopedal spasms (Trousseau's sign), Chvostek's sign, and muscle/abdominal cramps. ECG analysis may reveal a prolonged QT interval and T-wave abnormalities. Because of low serum calcium, serum phosphorus levels may also be increased. Choice A is incorrect. Patients with hyperthyroidism display a generalized metabolic excitement in almost all their body systems. They can reveal heat intolerance, warm skin, insomnia, irritability, palpitations, tachycardia, diarrhea, fatigue, and weight loss. Choice B is incorrect. Hypothyroidism results in a general metabolic depression of almost all body systems. The patient may manifest low heart rate, low blood pressure, decreased urine output, constipation, shallow, slow respirations, muscle weakness, diminished deep tendon reflexes, cold intolerance, and sometimes a decrease in body temperature. Choice C is incorrect. Symptoms of hyperparathyroidism include a serum calcium level of 10.9 mg/dL or higher. The patient may also display neurological symptoms such as lethargy, fatigue, personality changes, paresthesia, severe stupor, and even coma. GI symptoms would include dyspepsia, nausea, and constipation.

The nurse is reviewing laboratory data for a client with suspected diabetes mellitus (DM). Which of the following actions should the nurse take? See the exhibit. A. Assess the patient for an infection. [3%] B. Instruct the patient that the results are within normal limits. [50%] C. Assess the patient's urine for glycosuria. [10%] D. Educate the patient on a diet with low glycemic foods. [37%]

Explanation Choice D is correct. The hemoglobin A1C value of 6.1 shown in the exhibit is above normal (normal HgbA1c is below 5.7). Additionally, fasting blood glucose is above the desired range (normal fasting blood glucose is below 100 mg/dL). This client is showing evidence of poor glycemic control and has prediabetes. Prediabetes is defined as a hemoglobin A1C value from 5.7 to 6.4 or fasting blood sugar from 100 mg/dL to 125 mg/dL. The nurse should educate the client on lifestyle changes such as exercise and consuming foods low in simple carbohydrates. The HgbA1C and fasting blood glucose levels need to be monitored with the goal of both trending downward. Choices A, B, and C are incorrect. An infection would raise glucose levels, but it would not cause a significant impact on the client's hemoglobin A1C, which reflects on the previous 90-120 days of a client's glucose levels. These results are not within normal limits, and the client needs to be educated to execute lifestyle changes. The urine does not need to be assessed for glycosuria as this is not a diagnostic criterion for diabetes mellitus. Additional Info Risk factors for type two diabetes include family history, gestational diabetes, being overweight, and being over the age of 45. Racially, diabetes impacts Asian Americans, African Americans, and Native Americans more than other races. Diagnosis for type diabetes mellitus includes a hemoglobin A1C of 6.5% or greater. Normal is a level less than 5.7%. A hemoglobin A1C of 5.7% to 6.4% is concerning for prediabetes. A fasting plasma blood glucose of 126 mg/dl or more (normal is less than 100 mg/dl) is a provisional diagnosis for DM.

Which nursing diagnosis is the most appropriate for a hospitalized client who is adversely affected with anxiety, depression, and occasional hallucinations and who, before this hospitalization, had no psychiatric mental health disorder or these symptoms? A. At risk for sensory deprivation related to acute illness. [16%] B. At risk for sensory overload related to hospitalization. [32%] C. Sensory overload related to overwhelming medical information. [16%] D. Sensory deprivation related to hospitalization. [36%]

Explanation Choice D is correct. The most appropriate nursing diagnosis for a hospitalized client who is adversely affected with anxiety, depression, and occasional hallucinations and who, before this hospitalization, has had no psychiatric mental health disorder or these symptoms is "sensory deprivation related to hospitalization." The signs and symptoms of sensory deprivation include anxiety, depression, hallucinations, and other sensory and perceptual alterations. This sensory alteration can occur when a client lacks stimulation in the hospital. Choice A is incorrect. "At risk for sensory deprivation related to acute illness" is not an appropriate nursing diagnosis for this client because this client is already exhibiting signs and symptoms of sensory deprivation. This nursing diagnosis would be more appropriate for a client who is at risk of sensory deprivation issues but is not already experiencing them. Choice B is incorrect. "At risk for sensory overload related to hospitalization" is not an appropriate nursing diagnosis for this client because this client is actually exhibiting signs and symptoms of a sensory alteration other than sensory overload. Choice C is incorrect. "Sensory overload related to overwhelming medical information" is not an appropriate nursing diagnosis for this client because this client is actually exhibiting signs and symptoms of a sensory alteration other than sensory overload.

The nurse is caring for a 4-year-old child who is being hospitalized due to complications from an autoimmune disorder, frequent infections, and a low white blood cell count. This child is very nervous about being in the hospital. Which intervention should the nurse implement to address this child's fears? A. Provide the child with a private room [8%] B. Encourage them to play with other children in the common area [6%] C. Advise the parents to only visit during visiting hours [2%] D. Allow the parents to stay as much as they'd like [84%]

Explanation Choice D is correct. While most preschoolers can manage to be away from their parents for school, illness adds another stressor, making separation increasingly tricky. Parents should be encouraged to stay with their children as much as possible. Choice A is incorrect. Staying in a private room may be more anxiety-producing for a child separated from their healthy life. Choice B is incorrect. Because this patient is immunocompromised, they should not be spending time in the commons area with other children, as this may lead to developing infections. Choice C is incorrect. Parents should be encouraged to visit their children as much as possible. NCSBN client need Topic: Health Promotion and Maintenance, Developmental Stages

Which of the following are complications that the nurse should monitor when caring for an infant with a new diagnosis of phenylketonuria (PKU)? Select all that apply. A. Lethargy [27%] B. Irritability [28%] C. Nausea and vomiting [26%] D. Flaccid tone [19%]

Explanation Choices B and C are correct. In phenylketonuria (PKU), there is impaired metabolism of an essential amino acid named phenylalanine. When patients eat foods that contain this amino acid, they cannot break it down, and levels of this amino acid can then become toxic to the patient. Signs of this toxicity include irritability, due to the breakdown of gray and white matter in the brain with phenylalanine toxicity. Other symptoms of toxicity are cognitive deficits, delayed development, hyperactivity, and failure to thrive (Choice B). Signs of this toxicity also include nausea/vomiting, cognitive deficits, delayed development, hyperactivity, and failure to thrive (Choice C). Choice A is incorrect. Lethargy is not a sign of PKU toxicity, rather irritability and hyperactivity would present. Choice D is incorrect. The soft/flaccid tone is not a sign of PKU toxicity. Instead, hyperactivity would be expected. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Pediatric

The nurse is providing education to a group of nursing students regarding the causes of hypercalcemia. Which of the following information should be included? Select all that apply. A. hypoparathyroidism. [20%] B. thiazide diuretics. [24%] C. malignancy. [23%] D. end-stage kidney disease. [28%] E. crohn's disease. [5%]

Explanation Choices B and C are correct. Thiazide diuretics cause calcium retention, making their administration a potential cause of hypercalcemia. Malignancy, especially malignancies with metastasis involving the bones, may induce hypercalcemia from the breakdown of the bone. This causes the calcium to transition into the bloodstream. Choices A, D, and E are incorrect. Hyperparathyroidism can cause hypercalcemia, not hypoparathyroidism. There is too much parathyroid hormone (PTH) when a client has hyperparathyroidism. PTH functions to pull calcium stores from the bones and put it into the serum, increasing the serum calcium. It is usually released when serum calcium is low and the client needs more. End-stage kidney disease commonly causes hypocalcemia because of the body's inability to recycle vitamin D and have it absorb the calcium. Additionally, high phosphorus levels drive down calcium levels (inverse relationship). Crohn's disease may cause malabsorption of vitamins and minerals, and a clinical feature of Crohn's disease is hypocalcemia. Learning Objective Recognize the causes of hypercalcemia. Additional Info The normal serum calcium level is 9-10.5 mg/dL. The causes of hypercalcemia include: Excessive oral intake of calcium Excessive oral intake of vitamin D Use of thiazide diuretics Hyperparathyroidism Malignancy Hyperthyroidism Immobility Use of glucocorticoids Dehydration (not true hypercalcemia, but from hemoconcentration)

Which of the following special considerations should the nurse make when caring for a Hindu patient based on her religion? Select all that apply. A. Provide all vegetarian meals. [17%] B. Handle the client's temple garments with care. [25%] C. Be sure the bathroom is equipped with a shower and not just a tub. [16%] D. Be aware that the patient will likely refuse blood transfusions. [5%] E. Arrange for female nursing staff to provide care for the client as much as possible. [22%] F. Be aware that the patient will likely refuse pain medication. [14%]

Explanation Choices C and E are correct. Hindus prefer to wash in free-flowing water (e.g. a shower instead of a bathtub). If a shower is not available, provide a jug of water for the person to use in the tub. Hindus practice ayurvedic medicine, which encompasses all aspects of life, including diet, sleep, elimination, and hygiene. Most Hindus are lactovegetarians. Most will not eat beef and avoid bovine-derived medications because they believe in the reincarnation of certain gods. Fasting usually means eating only "pure" foods, such as fruit or yogurt, but it is not expected of the sick. Hindu women are modest and usually prefer to be treated by female medical staff (Choice E). Choice A is incorrect. Although some Hindus will eat eggs and even chicken, most are lactovegetarians, consuming milk but no eggs. Choice B is incorrect. Hindus may wear a "sacred thread" or religious jewelry around their body or wrist. Mormons, not Hindus, wear "temple garments". Choice D is incorrect. Jehovah's Witnesses—not Hindus—refuse to accept blood transfusions or blood products, which they view as morally wrong. Choice F is incorrect. Christian Scientists—not Hindus—would be likely to refuse pain medication. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Cultural and Religion

Which of the following IV fluids are isotonic solutions? Select all that apply. A. Normal saline [44%] B. ½ Normal saline [12%] C. Lactated ringers [39%] D. D10W [5%]

Explanation Choices A and C are correct. Normal saline (0.9% NS) is an isotonic solution (Choice A). Lactated ringers (LR) is an isotonic solution (Choice C). Choice B is incorrect. ½ Normal saline (.45% NS) is a hypotonic solution. Choice D is incorrect. D10W is a hypertonic solution. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies, Pharmacological Therapies

The nurse working in the maternity ward is caring for a 24-hour post-partum client. When assessing the client, the nurse notes that her fundus is firm at the level of the umbilicus and is veering a little bit to the right. The initial action for the nurse is to: A. Check for bladder distention [84%] B. Check the client's blood pressure [3%] C. Check if the client has been given oxytocin [3%] D. Check the pad count [9%]

Explanation Choice A is correct. A displaced fundus is an indication of a distended bladder. The nurse should assess the client for bladder distention and encourage the client to empty her bladder. Choice B is incorrect. The nurse can check the client's blood pressure; however, this action is unrelated to the situation. Choice C is incorrect. The nurse has assessed that the client's fundus is firm. Thus, the nurse does not need to check if oxytocin was given. Choice D is incorrect. The nurse does not need to check the client's pad count as the client is not showing any signs of uterine atony.

Your client is at the end of life and experiences guilt for past transgressions. After a number of independent and dependent nursing functions, what is an expected outcome for this client? A. The client will articulate the nature of humans in terms of fallibility. [30%] B. The client will go to confession to ask for forgiveness. [26%] C. The client will perform relaxation techniques to dissolve guilt. [33%] D. The client will not express any more feelings at the end of life. [10%]

Explanation Choice A is correct. An expected outcome for this client could be that the client will articulate the nature of humans in terms of fallibility. The purpose of guilt is to allow the person to know that they have done something wrong, and it also permits the person, at the end of life, to make final amends to those that they have hurt. Choice B is incorrect. Only a few religions use confession to ask for forgiveness; therefore, unless the client has expressed a desire to practice this religious ritual, this would not be an expected outcome. Choice C is incorrect. Although relaxation techniques may be used by the person to decrease their anxiety related to guilt, relaxation techniques do not dissolve guilt. Choice D is incorrect. The client not expressing any more feelings at the end of life would not be an appropriate outcome; all clients should be encouraged to express their opinions freely and without any judgments.

A postpartum client is noted to have soaked 3 perineal pads in 3 hours after delivery. The nurse notes a soft fundus. The initial action for the nurse would be which of the following? A. Insert vaginal packing [2%] B. Massage the client's fundus [91%] C. Apply an ice pack over the client's perineal area [5%] D. Administer packed red blood cells

Explanation Choice B is correct. The bleeding of the client is most likely because of uterine atony. The nurse should massage the client's uterus to stimulate it to contract. Choice A is incorrect. Inserting a vaginal pack does not address the cause of the bleeding. Only the physician can add a vaginal box. Choice C is incorrect. Applying an ice pack over the perineum does not help improve the uterine tone. This does not help in preventing bleeding due to uterine atony. Choice D is incorrect. Administration of blood products such as Packed RBCs is done on a physician's order.

The nurse at a gynecology clinic is talking to a 25-year-old, 32-week pregnant client. The nurse is assessing the client together with her laboratory results. Which finding should the nurse be concerned about? A. Glucose present in the urine [72%] B. The client states that she has +1 pedal edema at the end of the day [10%] C. The client states that she has increased vaginal discharge [16%] D. A hemoglobin level of 14 g/dL

Explanation Choice A is correct. Glucose in the urine indicates gestational diabetes. The nurse should conduct a further assessment regarding this to rule out gestational DM. Choice B is incorrect. This is a regular occurrence in pregnant women. Due to the pressure of the fetus in the vena cava, there is reduced venous return from the lower extremities. Choice C is incorrect. This is a regular occurrence in a pregnant woman. As the woman nears term, there is increased vascularity in the vagina and perineum. The nurse should be worried if the discharge is foul-smelling, bloody, or abnormally colored. Choice D is incorrect. This is an average hemoglobin level for a pregnant client. Normal hemoglobin levels in pregnant women range from 11.5 - 14 g/dL.

A post-adrenalectomy client is admitted to the ICU and is on IV hydrocortisone. Which nursing intervention should be included in the client's plan of care? A. Monitor blood glucose levels frequently. [89%] B. Keep the client supine for 24 hours. [4%] C. Discontinue hydrocortisone once vital signs become stable. [2%] D. Educate the client on how to properly clean his wound at home. [5%]

Explanation Choice A is correct. Hydrocortisone promotes gluconeogenesis and elevates blood glucose levels. The nurse should monitor the client's blood glucose levels frequently. Choice B is incorrect. The nurse should frequently turn the client and change position, cough, and deep breathe to prevent post-operative complications. Choice C is incorrect. The nurse cannot discontinue the medication unless stipulated by the physician. Choice D is incorrect. Discharge teaching should start upon admission. It should not be started once the client has finished his operation.

A prenatal client with gingivitis at her fourth-month clinic visit mentions that she has a tooth extraction planned for the following month and is wondering whether or not she can continue with the procedure. What information will you provide the prenatal client? A. The second trimester is the safest period for dental extractions. [44%] B. She will need to wait until after delivery to have the procedure performed. [35%] C. She should wait until the third trimester to have the procedure performed. [11%] D. She should take anti-viral medications before the procedure to prevent illness. [10%]

Explanation Choice A is correct. Pregnancy increases a woman's risk of developing gingivitis and cavities. The patient has gingivitis and it appears like her dentist recommended tooth extraction for her. There is some concern regarding undergoing dental extractions during pregnancy. However, there is no evidence that a pregnant woman will need to delay dental removal. Delaying dental care could be harmful to the mother and fetus. Emergency treatment can be done at any time during pregnancy. However, elective dental surgery should be deferred until the second trimester (weeks 14 through 20). By the second trimester, fetal organogenesis is complete, and the risk of adverse effects from procedure/medications is lower. The consequences of not treating a dental infection during pregnancy outweigh the possible risks of the medications. The patient has gingivitis that needs to be addressed soon. Also, the blood volume of the pregnant woman significantly increases in 3rd trimester and remains elevated until delivery. Although there is no risk to the fetus during this trimester, the pregnant woman may experience increased discomfort. There is also a risk of hypotension in the supine position, so, short dental appointments are advocated during the 3rd trimester. It is, therefore, better not to perform elective dental extractions during 3rd trimester. Choices B and C are incorrect. The prenatal client should not delay dental care. Choice D is incorrect. Anti-viral medications should not be given to a woman who will be undergoing a dental procedure. NCSBN client need Topic: Maintenance and Health Promotion, Ante / Intra /Postpartum Care

Which of the following is the definition of death established in the Uniform Determination of Death Act of 1981? A. Either irreversible cessation of circulatory and respiratory functions; or irreversible cessation of all functions of the entire brain including the brain-stem. [31%] B. Both irreversible cessation of circulatory and respiratory functions as well as the irreversible cessation of all functions of the entire brain including the brain-stem. [62%] C. Irreversible cessation of circulatory and respiratory functions only. [3%] D. Irreversible cessation of all functions of the entire brain including the brain-stem only. [4%]

Explanation Choice A is correct. The Uniform Determination of Death Act of 1981 defines death as either irreversible cessation of circulatory and respiratory functions OR the irreversible cessation of all functions of the entire brain, including the brainstem. Choice B is incorrect. The Uniform Determination of Death Act of 1981 does not require both the cessation of circulation and respiratory functions AND the irreversible end of all functions of the entire brain, including the brain stem. Choices C and D are incorrect. Although C or D could constitute a death call, the Uniform Determination of Death Act of 1981 states that death is defined as either answer choice "C" or answer choice "D". Hence, these are incorrect because they use the term "only".

The client with osteoarthritis tells the nurse, " I have problems getting up from the toilet bowl." What would be the next action by the nurse? A. Check if the client has grab bars in the bathroom. [79%] B. Instruct the client to take a shower. [1%] C. Refer the client to a physical therapist. [9%] D. Ask if the client takes nonsteroidal anti-inflammatory drugs (NSAIDs).

Explanation Choice A is correct. The initial action should be to assess the client's home for safety modifications. Grab bars in the bathroom give the client leverage when getting up. Choice B is incorrect. Taking a shower may be safer, but the nurse should first assess the client to find out if safety equipment is present in the home. Choice C is incorrect. Referral to a physical therapist could be done for the patient to improve strength and mobility; however, the initial priority must be client safety. Choice D is incorrect. NSAIDs aid the client in mobility by decreasing the pain felt. However, safety must first be ensured by the nurse.

Which of the following are complications of acute tubular necrosis (ATN)? Select all that apply. A. Metabolic acidosis [36%] B. High thyroxine levels [16%] C. Hyponatremia [30%] D. Decreased parathyroid levels [17%]

Explanation Choice A is correct. The kidneys cannot excrete excess hydrogen ions or reabsorb bicarbonate with ATN. Due to the inability to excrete the excess acid (hydrogen ions) paired with the inability to hang on to the needed base (bicarbonate), acidosis ensues. This is due to the malfunction of the kidneys, not the lungs, so it is classified as metabolic acidosis. Choice C is correct. ATN can cause hyponatremia. Due to lower urinary output, there is hypervolemia. With fluid retention and high volume remaining in the blood vessels, the amount of sodium in the body is diluted. This is called relative dilutional hyponatremia. Choice B is incorrect. ATN is associated with low thyroxine levels, not high. Thyroid hormones increase renal blood flow and glomerular filtration rate (GFR). In ATN, there is often lower renal blood flow and a lower GR. Therefore, ATN is often associated with low thyroid levels. Choice D is incorrect. ATN can cause increased parathyroid levels. This is considered a secondary hyperparathyroidism. Secondary hyperparathyroidism occurs when the parathyroid glands release too much parathyroid hormone (PTH), causing a high blood level of PTH. This occurs in ATN because when the kidneys are damaged, they cannot make active vitamin D. Vitamin D is required for the absorption of calcium, and calcium levels are therefore low in patients with ATN. One of the primary functions of PTH is the release of calcium from the bones, into the bloodstream, when blood calcium levels are low. The body recognizes the lower blood calcium level, that has been caused by the ATN, and then secrects more PTH to try to correct the issue. This is when ATN can cause increase PTH levels.

You are the charge nurse on a medical-surgical unit. You have noticed over the last several weeks that one of the nurses on your team is displaying anger and negative feelings, which is not at all characteristic of this experienced nurse. What is this nurse most likely experiencing? A. Burnout [76%] B. Role confusion and dissonance [4%] C. Ineffective role performance [14%] D. Fatigue

Explanation Choice A is correct. This nurse is most likely affected by burnout. Burnout is a complex syndrome that occurs as a result of multiple stressors in the work-life and personal life. This syndrome is highly similar to the last stage of the general adaptation syndrome, which is exhaustion, both physically and emotionally. Choice B is incorrect. Role confusion and dissonance are not characterized by anger and negative feelings; instead, cognitive dissonance is characterized by anxiety, denial, and discomfort. Choice C is incorrect. There is no evidence in this question that indicates that this nurse is not performing their role effectively. Choice D is incorrect. Although this nurse is possibly affected by physical fatigue, this nurse is also affected by a psychological crisis as the result of the multiple stressors in their work and personal life

The nurse reviews the vital signs of a client admitted to the medical-surgical unit. The unlicensed assistive personnel (UAP) indicates that the client's blood pressure was obtained in the client's leg. The nurse should expect which change in the blood pressure when taken in the leg? A. Systolic pressure in the legs is usually higher by 10 to 40 mm Hg [32%] B. Systolic pressure in the legs is decreased by 10 to 40 mm Hg [46%] C. Diastolic pressure is the decreased by 10 to 40 mm Hg [17%] D. Diastolic pressure is higher by 10 to 40 mm Hg [6%]

Explanation Choice A is correct. When blood pressure is obtained in the leg, the systolic blood pressure is increased by up to 10 to 40 mm Hg compared to blood pressure obtained over the brachial artery. The higher SBP is due to the calcification in the distal arteries, which raises the SBP. DBP in the lower extremities is usually the same when compared to the upper extremities. Choices B, C, and D are incorrect. SBP is increased when it is obtained in the lower extremities; it is not decreased. DBP is unaffected when obtained in the lower extremities Additional Info Dressings, casts, IV catheters, arteriovenous fistulas or shunts can make the upper extremities inaccessible for BP measurement. If this is the case, obtain the BP in a lower extremity. Systolic pressure in the legs is usually higher by 10 to 40 mm Hg than in the brachial artery, but the diastolic pressure is the same.

The nurse is reviewing laboratory data. Which laboratory data requires follow-up? A. Total Cholesterol 180 mg/dl [9%] B. Hemoglobin A1C 7.5% [81%] C. Calcium 9.2 mg/dl [5%] D. Creatinine 1.0 mg/dl [4%]

Explanation Choice B is correct. A hemoglobin A1C of 7.5% is elevated and requires follow-up. The normal hemoglobin A1C is any value less than 6.4% as a hemoglobin A1C of 6.5% meets the diagnosis for diabetes. A hemoglobin A1C between 5.7% and 6.4% is concerning to the nurse because this is indicative of prediabetes. Choices A, C, and D are incorrect. Total cholesterol of 180 mg/dl is normal and does not require follow-up. Calcium of 9.2 mg/dl is within the normal range and does not require follow-up. Finally, a creatinine of 1.0 mg/dl is within range. Additional information: Hyperglycemic episodes increase the hemoglobin A1C. This test should be collected every 90 to 120 days. If the patient's A1C is increasing, the nurse should counsel the patient on blood glucose monitoring and low glycemic foods.

Which of the following statements about security in healthcare environments is accurate? A. Healthcare facilities must have egress alarms on all doors, except client doors, to maintain security within the facility. [9%] B. All members of the healthcare facility must have education and training relating to security in the facility. [89%] C. Members of the healthcare facility who do not have clinical access do not need education and training relating to security in the facility. [1%] D. Members of the healthcare facility who have only clerical roles do not need education and training relating to security in the facility. [0%]

Explanation Choice B is correct. All healthcare facility members must have education and training relating to security in the facility. Choice A is incorrect. Healthcare facilities are not mandated to have egress alarms on all doors, except client doors, to maintain security within the facility. Egress alarms are, however, prescribed for high-security risk areas. Choice C is incorrect. Members of the healthcare facility who do not have clinical access are required to have education and training relating to security in the facility because all areas and all departments are at risk for security breaches. Choice D is incorrect. Members of the healthcare facility who have only clerical roles are required to have education and training relating to security in the facility because all areas and all departments are at risk for security breaches.

A psychiatric client taking perphenazine per orem for 48 hours is seen by the nurse manifesting the following symptoms: head-turning to the left with his neck arched as well as stiffness and muscle spasms in the neck. Which medication would the nurse expect to give the client? A. Promazine [19%] B. Biperiden [37%] C. Olanzapine [20%] D. Haloperidol [24%]

Explanation Choice B is correct. An antiparkinsonian medication that helps alleviate extrapyramidal symptoms. Choice A is incorrect. An antipsychotic; does not help alleviate extrapyramidal symptoms. Choice C is incorrect. An antipsychotic; does not help alleviate extrapyramidal symptoms. Choice D is incorrect. An antipsychotic; does not help alleviate extrapyramidal symptoms.

The nurse is counseling an adolescent who is pregnant and reports frequent eating at fast-food restaurants. The nurse should make which recommendation to help optimize her nutritional intake? A. Choose french fries over a baked potato [2%] B. Select a cheeseburger over a regular hamburger [31%] C. Pick sandwiches instead of wraps [39%] D. Breaded chicken is a better choice than broiled

Explanation Choice B is correct. Fast food is not desired during pregnancy because of the abundance of oils, dressings, and breading that supply a high degree of saturated fats, sodium, and calories. To optimize the client's nutritional intake, if the client insists on fast food, the nurse should recommend a cheeseburger because the cheese will add protein and calcium. Choices A, C, and D are incorrect. A baked potato is preferred over french fries because a baked potato's skin is dense with vitamins. Wraps are preferred over sandwiches because of the fewer calories in the breading of a sandwich. Grilled and broiled chicken is superior to breaded chicken because of the decrease in calories. Additional Info Teaching the adolescent about nutrition can be a challenge for nurses. It is essential to establish an accepting, relaxed atmosphere and show a willingness to listen to the teenager's concerns. The nurse should keep suggestions to a minimum and focus on only the most important changes. If an adolescent believes she must eliminate all her favorite foods, she is likely to rebel. Although not a popular choice for its nutritional value, strategic ways to optimize the intake of fast food include Add cheese to hamburgers to increase calcium and protein. Include lettuce and tomato for vitamins A and C. Avoid dressings on hamburgers because they tend to be high in calories and fat. To reduce fat and calories, choose broiled, roasted, and barbecued foods (e.g., chicken breast, roast beef). Avoid fried foods (e.g., French fries, fried zucchini, onion rings, fried cheese) because they are high in fat and the high heat may destroy some vitamins. Breaded foods such as chicken nuggets and breaded clams are high in calories and absorb more oil if they are fried. Try wraps instead of sandwiches to decrease calories. Baked potatoes with broccoli, cheese, and meat fillings provide better nutrition than French fries. Milk, milkshakes, and orange juice provide more nutrients than carbonated beverages, which are high in sodium and calories. Avoid pickles, olives, and other salty foods. Too much sodium may increase swelling of the ankles. Add only small amounts of salt to foods to prevent or decrease swelling.

Among Erickson's Stages of Development, which of the following stages of development would the nurse expect a 4-year-old patient to be in? A. Trust vs. Mistrust [9%] B. Initiative vs. Guilt [73%] C. Identity vs. Role confusion [4%] D. Industry vs. Inferiority

Explanation Choice B is correct. Initiative vs. Guilt is the typical stage of development for preschool children, who are 3 to 5-year-olds, so this is correct for your 4-year-old patient. In Initiative vs. Guilt, children start to assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval end up feeling guilty. Choice A is incorrect. Trust vs. Mistrust is the typical stage of development for infancy, which lasts from birth to 18 months. In this stage, children develop a sense of confidence when caregivers provide reliability, care, and affection. When infants do not have that, they will develop mistrust. Choice C is incorrect. Identity vs. Role confusion is the typical stage of development for adolescents, who are 12 to 18-year-olds. In this stage, adolescents develop a sense of personal identity. When they are successful, it leads them to the ability to be true to themselves and have a character they are proud of. When they are not successful, there is role confusion and a weak sense of self. Choice D is incorrect. Industry vs. Inferiority is the typical stage of development for school-age children, who are 6 to 11-year-olds. In this stage, children need to cope with new social and academic demands. When they are successful with this, they feel competent and achieve the industry. When they are not successful, they handle failure, and it results in inferiority. NCSBN Client Need: Topic: Psychosocial Integrity; Pediatric Development

The nurse cares for a client diagnosed with pelvic inflammatory disease (PID). The nurse anticipates the primary healthcare provider (PHCP) to prescribe which medication? A. Voriconazole [13%] B. Doxycycline [59%] C. Phenazopyridine [18%] D. Famciclovir

Explanation Choice B is correct. Pelvic inflammatory disease (PID) is most likely caused by sexually transmitted infections or bacterial vaginosis. Doxycycline is an effective antibiotic utilized in PID. Choices A, C, and D are incorrect. Voriconazole is an antifungal agent and is not utilized in PID. Phenazopyridine is a urinary analgesic and may be indicated for pain associated with urinary infections. Famciclovir is an antiviral agent and is indicated for viral infections such as herpes simplex. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Expected Actions/Outcomes Question type: Knowledge/comprehension Additional Info Risk factors for PID include sexually transmitted infections and multiple sexual partners. Antibiotics such as doxycycline are effective in the management of PID. Doxycycline is a tetracycline antibiotic, and the client taking doxycycline should not take it with products rich in calcium, magnesium, aluminum, or iron. Tetracycline antibiotics are contraindicated if the client is pregnant.

The Certified Nurse Assistant (CNA) is helping a female patient with early ambulation post-surgery. The CNA has just applied a gait belt to the patient's waist. Which of the following actions by the CNA will need interference and correction by the supervising nurse? A. Holding onto the belt's outer edge or center, preventing the patient from leaning or drooping to one side. [8%] B. Pulling from the front of the belt, keeping forward momentum. [79%] C. Bringing the client to a nearby chair when she feels dizzy. [4%] D. Keeping the patient's body weight close to her own.

Explanation Choice B is correct. The nurse will need to correct the CNA if the CNA is found pulling the patient in any direction. Pulling unsteady or unfit patients is dangerous and should never be performed. Instead, the nurse's aide should walk alongside the patient, moving only at the pace the patient can maintain. Choice A is incorrect. Holding the belt's side or center while the patient moves is a safe nursing action when using a gait belt. Choice C is incorrect. The CNA is practicing safe nursing skills by bringing the patient to a chair, or the bed should the patient feel light-headed or dizzy. Choice D is incorrect. The CNA is protecting herself from straining or pulling her muscles by keeping the patient's bodyweight pulled in close to her own body. This is the proper way to use a gait belt and does not need correction. NCSBN client need Topic: Basic Care and Comfort: Assistive Devices

A 14-year-old was taken to the emergency department after stepping on a broken piece of glass. The wound is cleansed and a dressing was applied. The nurse asks the adolescent to receive a tetanus shot. He responds by saying that all his immunizations are up to date. All the other antibiotics were given and the client is sent home with instructions to return whenever changes in the wound occur. After a few days, the client was admitted to the hospital due to tetanus. What is the nurse's legal responsibility in this situation? A. The nurse displayed adequate judgment and the client was treated accordingly. [8%] B. The nurse performed an incomplete assessment. [38%] C. Tetanus was not foreseen because of the clients' complete immunization status. [5%] D. The nurse should have routinely given the Tetanus shot after such an injury. [49%]

Explanation Choice B is correct. The nurse's assessment was inadequate and incomplete, thus leading to inadequate judgment regarding the situation. The nurse should have asked for the date the last tetanus immunization was received. Choice A is incorrect. The nurse's assessment was incomplete, thus leading to inadequate judgment regarding the situation. The nurse should have asked for the date the last tetanus immunization was received. Choice C is incorrect. The clients' wound would have alerted the nurse to ask more regarding tetanus immunizations since a puncture wound is a "tetanus-prone" wound. Choice D is incorrect. The function of a nurse does not include giving orders for tetanus immunization. The nurse should have assessed further by asking for the immunization date.

The psychiatric nurse is providing care for a patient who has just calmed down after exhibiting inappropriate behaviors related to bipolar disorder. The nurse knows that which of the following is the best way to help prevent another unseemly episode? A. Identify the consequences of the behavior. [5%] B. Assist the client in understanding triggering events or feelings that may have lead to the outburst. [78%] C. Ensure that the patient's safety is upheld. [13%] D. Offer the patient clear options to deal with their current behavior. [4%]

Explanation Choice B is correct. The psychiatric nurse would be most effective in preventing further inappropriate episodes by assisting the client in understanding what may have triggered the event. Choice A is incorrect. Identifying the consequences of inappropriate behavior would be a more appropriate intervention before the patient's response began escalating. Since this patient is calm, identifying values is not the most effective option to prevent reoccurring episodes. Choice C is incorrect. Ensuring the patient's safety is intact is always a priority but is a more appropriate action during the patient's episode of inappropriate behavior rather than while the patient is calm. Choice D is incorrect. A patient experiencing an episode of inappropriate behavior related to bipolar disorder is unlikely to absorb patient teaching. Teaching is best understood when the patient is calm and states readiness to learn. NCSBN client need Topic: Psychosocial adaptation, Mental Health Concepts

While teaching a client who has recently begun a vegan diet, the nurse should highly recommend supplementing with which of the following vitamins? A. Vitamin C [3%] B. Vitamin B12 [80%] C. Vitamin A [3%] D. Vitamin D [14%]

Explanation Choice B is correct. Vitamin B12 is abundantly present in food products of animal origin. These include eggs, poultry, dairy products, fish, and meat. No strict vegetarian source has sufficient vitamin B12 to meet the recommended daily allowance (RDA). Vegans refrain from consuming all animal products, including eggs and dairy. Therefore, vegans are at a very high risk of developing vitamin B12 deficiency. Vegans should be counseled to consume alternative sources of vitamin B12 such as vitamin B12 supplements foods fortified with vitamin B12 ( fortified nutritional yeasts, fortified cereals) to reduce the risk of B12 deficiency significantly. Choices A, C, and D are incorrect. Vegans are generally not more prone to vitamin A and C deficiencies than non-vegans. Vegans consume plenty of fruits and vegetables. Vitamin A ( Choice C) is present abundantly in carrots, apricots, sweet potatoes, and dark green leafy vegetables ( spinach, kale, and collard greens). Vitamin C ( Choice A) is present abundantly in fruits ( orange, apple, kiwi, etc.) and vegetables ( bell peppers, brussel sprouts, broccoli, and so on). While vitamin D ( Choice D) is not abundant in a vegan diet, there are still some good vegan sources, including mushrooms, spinach, and bananas. Also, vitamin D can be abundantly obtained from sunlight. Vegans may be more prone to vitamin D deficiency than non-vegans. However, the vegans' highest risk is for vitamin b12 deficiency, and the nurse should prioritize this recommendation. NCSBN client need Topic: Basic Care and Comfort: Nutritional Learning Objective Recognize that strict vegans are prone to significant vitamin B12 deficiency. Vegans should be counseled to consume alternative B12 resources. Additional Info Vitamin B12 deficiency can lead to fatigue, dementia, glossitis ( tongue inflammation), macrocytic anemia ( anemia with large red blood cells), pancytopenia ( reduced blood counts along all cell lines, i.e., reduced red cells, white blood cells, and platelets ), and neurological manifestations ( neuropathy, paresthesias. tingling and numbness in extremities). Vitamin B12 is abundantly stored in the body (up to 1000 times recommended daily allowance). Therefore, it generally takes several years of suboptimal b12 intake or poor absorption for vitamin B12 deficiency to develop. The population at risk for vitamin B12 deficiency include:\ Vegans who consume no animal or dairy products. Exclusively breastfed infants of vegan women. Clients with vitamin b12 malabsorptive conditions ( pernicious anemia, celiac disease, Crohn's disease) Clients with gastric bypass surgery or other surgeries where the stomach is removed. Older adults Long term use of proton pump inhibitors Long term use of metformin

You are a home health nurse caring for an elderly client in her home. She has children and grandchildren. However, they live far from the couple and they typically visit only once or twice a year. The client is beginning to show some signs of Alzheimer's. The husband is 88-years-old and had a stroke that left him with right-sided weakness. What support should you give the husband in terms of caring for his wife? A. You should advise the couple to move closer to their children so that they can care for their father. [12%] B. You should teach the husband about the progression of Alzheimer's and the need to promote as much independence as possible. [63%] C. You should teach the husband about this progressive disease and the need to do all that he can for his wife to help prevent anxiety and depression. [24%] D. You should advise the couple to decrease their social activities in order to preserve the wife's dignity and self-esteem.

Explanation Choice B is correct. You should teach the husband about Alzheimer's and the need to promote as much independence as possible. Adults diagnosed with dementia are faced with a disease that is irreversible and progressive. The loss of judgment, reasoning, memory, and communication skills leads to an inability to discern risk and danger. Dementia can limit a person's ability to live independently, which can be very distressing for the individual and family members. Caregivers need to embrace a patient-centered approach that allows people with dementia to maintain as much autonomy and control as possible, while still preserving their safety. Choice A is incorrect. Moving closer to the children may not be appropriate advice, mainly if the children are unable or unwilling to care for their mother. Choice C is incorrect. Client's with Alzheimer's disease and other disabilities, including physical disabilities, should be coached and encouraged to be as independent as possible. Choice D is incorrect. The couple should be advised to continue their social activities.

A 55-year-old client with osteoarthritis develops coagulopathy due to long term NSAID use. The nurse caring for the client understands that the coagulopathy is mostly the result of: A. Impaired synthesis of vitamin K [22%] B. Blocked prothrombin conversion [19%] C. Decreased platelet adhesiveness [39%] D. Destruction of factor VIII

Explanation Choice C is correct. NSAIDs reduce platelet adhesiveness, thus impairing coagulation. Choices A, B, and D are incorrect. They do not impair vitamin K synthesis, block prothrombin conversion, or destroy factor VIII.

The nurse is caring for a client with pulmonary edema. Which oxygen delivery device should the nurse apply to the client? A. Simple facemask [14%] B. Nasal cannula [30%] C. Nonrebreather mask [49%] D. Partial rebreather mask

Explanation Choice C is correct. Pulmonary edema is a medical emergency that may cause a client to develop respiratory arrest. Immediate treatment measures for pulmonary edema include providing oxygen at its highest concentration via a nonrebreather mask. This device may deliver up to 95% FiO2. If this is not effective, the provider may consider BiPAP, CPAP, or intubation with mechanical ventilation. Choices A, B, and D are incorrect. A simple facemask, nasal cannula, and a partial rebreather mask simply do not deliver the amount of oxygen required for this emergency. NCLEX Category: Physiological Adaptation Activity Statement: Medical Emergencies Question type: Knowledge/comprehension Additional Info Nasal cannula oxygen can deliver 24%-44% FiO2 at 1-6 liters/minute. A simple face mask can deliver 40%-60% FiO2 at 5-8 L/min; the flow rate must be set at least at 5 L/min to flush the mask of carbon dioxide. A partial rebreather can deliver 60%-75% at 6-11 L/min, a liter flow rate high enough to maintain a reservoir bag two-thirds full during inspiration and expiration. A nonrebreather mask can deliver 80%-95% FiO2 at a liter flow high enough to maintain a reservoir bag two-thirds full.

You are educating a mother about the association between autism and the MMR vaccine. You know that the mother understands your instructions when she says: A. "My child should not get the vaccine since it is known to cause autism." [1%] B. "My child should get the individual immunizations for measles, mumps, and rubella since the individual vaccines do not cause autism." [19%] C. "My child should get the MMR immunization since there is no evidence that it causes autism." [78%] D. "My child should not get the immunization because it contains mercury." [1%

Explanation Choice C is correct. The CDC and experts at the American Academy of Pediatrics agree that there is no credible evidence that the MMR vaccine causes autism spectrum disorder (ASD). Some of the concerns may be because children typically get the MMR vaccine at about the same time that signs of ASD appear. In fact, in 2013, the CDC conducted a study that showed that vaccines do not cause ASD. This study showed that the antigens in vaccines that produce antibodies were the same between children diagnosed with ASD and children without ASD. Currently, there are no MMR vaccines that contain mercury. Although there is no evidence that mercury causes ASD, mercury was removed from all childhood vaccinations by 2001. The exception to that is that some multi-dose flu vaccines may still contain traces of thimerosal (a chemical containing mercury). Choices A, B, and D are incorrect. These statements are incorrect. NCSBN Client Need Topic: Health Promotion and Maintenance, Sub-Topic: Health Promotion/Disease Prevention, Safety/Infection Control

A 15-year-old female comes into the gynecology clinic asking for an oral contraceptive pills prescription. Fifteen minutes later, her mother comes in and scolds the teenager about her decision. She tells the doctor not to give her daughter the pills because she is still too young. What should be the most appropriate action by the nurse? A. Withdraw the prescription for contraceptive pills. [1%] B. Call Child Protective Services. [3%] C. Explain to the mother that in cases of birth control services, her daughter has the right to give consent on her own. [73%] D. Explain to the teenager that her mother still has consenting authority over her decisions.

Explanation Choice C is correct. When the minor is seeking birth control treatments, the minor's consent is sufficient and does not warrant the permission of her parents. Choice A is incorrect. Parental or guardian consent should be obtained before treatment is initiated for a minor except in an emergency. There are certain situations in which the permission of the minor is sufficient enough, i.e. birth control treatments. Choice B is incorrect. There is no sign of abuse; the nurse does not need to call child protective services. Choice D is incorrect. The mother no longer has consenting authority over her child when it comes to birth control treatments.

The nurse is teaching a group of students about tertiary prevention. Which of the following would be a form of tertiary prevention? Select all that apply. A. Yearly fecal occult blood testing [19%] B. Testicular self exams [17%] C. Digital rectal exams [16%] D. Rehabilitation programs [35%] E. Support groups for chronic illness [12%]

Explanation Choice D and E are correct. Rehabilitation programs are considered tertiary prevention strategies. Support groups for a chronic illness are tertiary prevention as this enables individuals to share management strategies. Tertiary prevention focuses on maximizing the function of an individual and preventing further complications. Choices A, B, and C are incorrect. Yearly fecal occult blood testing is a screening. Therefore it is a secondary prevention strategy. Testicular self-exams are a screening. Therefore it is a secondary prevention strategy. Digital rectal exams are a screening. Therefore it is a secondary prevention strategy. Additional Info Primary prevention is true prevention. Its goal is to reduce the incidence of disease. Primary prevention includes health education programs, nutritional programs, and physical fitness activities. It includes all health promotion efforts and wellness education activities that focus on maintaining or improving the general health of individuals, families, and communities Secondary prevention focuses on preventing the spread of disease, illness, or infection once it occurs. Activities are directed at diagnosis and prompt intervention, thereby reducing its severity. Examples include identifying people who have a new case of a disease or following people who have been exposed to a disease but do not have it yet. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration. Activities are directed at rehabilitation rather than diagnosis and treatment.

Which of the following is an appropriate outcome for a client who is adversely affected with an impairment of their 2nd cranial nerve? A. The client will not experience sensory overload in the hospital. [19%] B. The client will list ways to effectively decrease their blood pressure. [3%] C. The client will participate in physical therapy to improve balance. [21%] D. The client will remain free of falls despite 2nd cranial nerve impairment. [57%]

Explanation Choice D is correct. "The client will remain free of falls despite 2nd cranial nerve impairment" is an appropriate client outcome for a client who is adversely affected with an impairment of their 2nd cranial nerve. This client has a visual deficit because the 2nd cranial nerve is the optic nerve; visual deficits place clients at risk for falls. Choice A is incorrect. "The client will not experience sensory overload in the hospital" is not an appropriate client outcome for a client who is adversely affected with an impairment of their 2nd cranial nerve. This client has a visual deficit because the 2nd cranial nerve is the optic nerve and visual deficits place clients at risk for sensory deprivation in the hospital, rather than sensory overload. Choice B is incorrect. "The client will list ways to effectively decrease their blood pressure" is not an appropriate client outcome for a client who is adversely affected with an impairment of their 2nd cranial nerve. This client has a visual deficit because the 2nd cranial nerve is the optic nerve and visual deficits are not associated with hypertension. Choice C is incorrect. "The client will participate in physical therapy to improve balance" is not an appropriate client outcome for a client who is adversely affected with an impairment of their 2nd cranial nerve. This client has a visual deficit because the 2nd cranial nerve is the optic nerve and visual deficits are not corrected with physical therapy, but instead with low vision specialists and other members of the ophthalmology team.

Which assessment question would be most appropriate for a patient who is experiencing dyspareunia? A. "Do you take anti-hypertensive medication?" [12%] B. "Do you currently have a new partner?" [46%] C. "Have you been diagnosed with a neurological disorder?" [21%] D. "Do you use antihistamines?"

Explanation Choice D is correct. Factors contributing to dyspareunia include diabetes, hormonal imbalances, vaginal, cervical, or rectal disorders, antihistamine, alcohol, tranquilizer, or illicit drug use, and cosmetic or chemical irritants to the genitals. Dyspareunia is painful sexual intercourse due to medical or psychological causes. The pain can primarily be on the external surface of the genitalia, or more profound in the pelvis upon deep pressure against the cervix. It can affect a small portion of the vulva or vagina or be felt all over the surface. Choice A is incorrect. Anti-hypertensive medications are not associated with the occurrence of dyspareunia. Choice B is incorrect. Dyspareunia occurs due to medical or psychological causes, not because of the change in partners. Choice C is incorrect. Neurological disorders are not associated with dyspareunia. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Female Primary Sexual Dysfunctions

The nurse participates in a committee reviewing the hospital security plan regarding infant abduction. Which of the following recommendations should the nurse make to the committee? A. Rearrange rooms so that the crib is near the door. [5%] B. Carry infants in the hallway instead of using the bassinet. [11%] C. Issue staff identification badges without a photo. [11%] D. Take photographs of all visitors.

Explanation Choice D is correct. Photographing all visitors and requiring visitors to sign in is fundamental to preventing infant abduction. This creates a record of the visitor, and the photograph is helpful if an abduction should occur. Choices A, B, and C are incorrect. Cribs should be located away from doors to prevent rapid abduction. Infants should always be transported in the hallway with bassinets and not carried. Carrying an infant in the hallway should raise suspicion as this is not a standard mode of transport. Staff identification badges should be unique, contain a recent photo of the employee, and have the ability to be deactivated if it is lost. Additional Info Strategies to prevent infant abduction include - Annual staff training on prevention strategies Robust logging of visitors including photographs Staff identification badges that are unique and able to be deactivated if the badge is lost. A lockdown plan that is reviewed annually. Security cameras positioned in multiple areas. High presence of security.

The nurse is assessing a client with suspected venous thromboembolism (VTE). The nurse anticipates that the primary healthcare provider (PHCP) will order which diagnostic test? A. Dual-Energy X-ray Absorptiometry (DEXA) scan [6%] B. Ankle-Brachial Index [6%] C. Radiograph (X-Ray) [4%] D. Venous Duplex Ultrasonography [84%]

Explanation Choice D is correct. The gold standard in diagnosing a VTE is venous duplex ultrasonography. This noninvasive test is an ultrasound that assesses the flow of blood through the veins of the arms and legs. Choices A, B, and C are incorrect. DEXA scan is testing to determine bone mineral density. The ankle-brachial index (ABI) can be used to assess the vascular status of the lower extremities and is primarily used to determine distal arterial blood flow. Radiography is not used because it does not provide the necessary view of the veins. Additional Info Risk factors for venous thromboembolism include active cancer, reduced mobility, hormonal treatment, obesity, recent trauma/surgery, and a known thrombophilic condition. Classic symptoms of a VTE include pain, erythema, warmth, and swelling. Diagnosing a VTE is commonly done through non-invasive venous duplex ultrasonography. Treatment is either through oral or parenteral anticoagulants, and the nurse must surveil for pulmonary embolism, which can be fatal if not promptly recognized.

Which of the following IV fluids are hypotonic solutions? Select all that apply. A. D2.5W [28%] B. D51/4NS [15%] C. 0.33% NS [40%] D. D5NS [17%]

Explanation Choices A and C are correct. D2.5 W is a hypotonic solution (Choice A). 0.33% NS is a hypotonic solution (Choice C). Choice B is incorrect. D51/4NS is an isotonic solution. Choice D is incorrect. D5NS is a hypertonic solution. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies, Fluids

The nurse reviews the client's continuous telemetry monitor and observes the following. As the nurse reviews the client's current medications, which prescribed medication is most likely causing this tracing? See the image below. A. Losartan [15%] B. Nitroglycerin transdermal patch [24%] C. Clonidine [18%] D. Verapamil

Explanation Choice D is correct. This tracing reflects sinus bradycardia. Verapamil is a calcium channel blocker, and a property unique to verapamil is that it decreases both blood pressure and heart rate. Verapamil may be indicated for the prevention of migraine headaches, hypertension, or vascular spasms. Choices A, B, and C are incorrect. Losartan is an ARB and may be used for hypertension or congestive heart failure. This medication does not lower heart rate. Nitroglycerin via a transdermal patch would increase the heart rate because of the reflex tachycardia it causes as it decreases blood pressure. Clonidine is an effective agent in treating hypertension and does not lower heart rate. Additional Info Sinus bradycardia is a regular rhythm with a rate of less than sixty. Sinus bradycardia is only concerning if the client is symptomatic. Pathological causes of bradycardia include severe hypothyroidism, hypothermia, anorexia nervosa, and prolonged hypoxia.

The nurse is teaching a client with Addison's disease that requires dietary modifications. The nurse should encourage the client to consume a diet that is Select all that apply. A. low in potassium. [27%] B. high in sodium. [29%] C. high in potassium. [14%] D. low in sodium. [12%] E. high in magnesium. [18%]

Explanation Choices A and B are correct. Adrenal insufficiency may be a lifelong disorder that requires dietary and lifestyle modifications. A clinical feature of Addison's disease is hyponatremia and elevated potassium levels. It is appropriate for the nurse to counsel the client to consume a diet rich in sodium and low in potassium to prevent complications. Choices C, D, and E are incorrect. Because adrenal insufficiency has a clinical feature of hyponatremia and elevated potassium, it is appropriate for the nurse to recommend a diet rich in sodium and restrictive in potassium. A diet that limits or encourages magnesium-rich foods is not relevant to adrenal insufficiency. Additional Info Addison's disease (adrenal insufficiency) is characterized by an insufficient amount of glucocorticoid and mineralocorticoid. Lifelong steroid replacement is often necessary to manage this condition. Teaching points for a client with adrenal insufficiency include - Medication adherence to the prescribed corticosteroid Dietary management involves adequate sodium and reducing potassium Self-monitoring of weight and blood pressure Notifying the primary healthcare provider of any stressful events or illnesses which may trigger a crisis Wear a medical alert ID bracelet or tag Keep a dose of emergency hydrocortisone at all times, and know when and how to administer the injection Understand and be alert for the signs of an Addisonian crisis (profound fatigue, dizziness, abdominal cramping, confusion)

You are working with older adults in the clinic. The 80-year-old woman is brought to the clinic by her family with fever and changes in her mental status. When attempting to differentiate between delirium and dementia, you know that delirium is characterized by which of the following? Select all that apply. A. Abrupt onset [46%] B. Change in psychomotor activity [41%] C. Irreversible [6%] D. Lasts for months to years [7%]

Explanation Choices A and B are correct. An acute illness (fever, sepsis, infection) typically causes delirium, so delirium often has an abrupt onset (Choice A) with rapid progression. There are significant changes in activity resulting in hyperactivity or hypoactivity (Choice B). Delirium is typically reversible when the underlying illness is resolved. Delirium typically lasts for hours to days, whereas dementia lasts for months to years and is usually irreversible. Choices C and D are incorrect. These two characterize dementia. Dementia has a variety of causes with gradual changes in mentation. In dementia, psychomotor changes occur later in the disease; speech is sparse and may progress to mutism as the disease advances. NCSBN Client Need Topic: Physiological Adaptation; Sub-topic: Alterations in Body Systems

While working in the emergency department, you are assessing a 3-month-old infant who was brought in by parents for poor feeding, irritability, and vomiting. Upon auscultating the heart sounds, you note a machine-like murmur. Which conditions does the nurse suspect? Select all that apply. A. Patent Ductus Arteriosus (PDA) [36%] B. Congestive Heart Failure (CHF) [16%] C. Aortic Stenosis [20%] D. Ventricular Septal Defect (VSD) [28%]

Explanation Choices A and B are correct. The objective here is to identify that a patent ductus arteriosus can lead to congestive heart failure and must be suspected in an infant presenting with the symptoms mentioned in the question. The nurse does suspect a patent ductus arteriosus (PDA) (Choice A), due to the presence of a machine-like murmur, a hallmark sign of a PDA. The nurse also suspects congestive heart failure (CHF) due to the classic presenting symptoms in the infant: poor feeding, irritability, and vomiting. Symptoms of congestive heart failure in infants with congenital heart disease are often misdiagnosed and treated as septicemia so, one should be aware of this presentation. PDA is an acyanotic type of congenital heart disease. Ductus arteriosus is the communication between the pulmonary artery and the aorta. Soon after a term birth, functional closure of the ductus arteriosus occurs from vasoconstriction. In some cases, it remains open (patent) and is referred to as PDA. A small PDA often does not cause any problem. If the PDA is large, it results in significantly increased pulmonary blood flow. A large left to right shunt through a PDA causes left atrial and left ventricular enlargement. The left ventricular end-diastolic pressure increases and eventually the left ventricle fails to handle the increased volume overload resulting in CHF. In 80% of infants with critical acyanotic congenital heart disease, congestive heart failure is the presenting symptom. Difficulty in feeding is common. This is often associated with tachypnea, sweating, and subcostal retraction. One should suspect congenital heart disease in such an infant if the feeding takes more than 30 minutes. A history of feeding difficulty often precedes overt congestive heart failure, even if only by six to 12 hours. Signs of congestive heart failure on physical exam include an S3 gallop and pulmonary rales. Congenital heart defects (CHD) are classified into two main categories: acyanotic and cyanotic. In acyanotic defects, congestive heart failure is the most common symptom. Whereas in cyanotic heart defects, the main concern is hypoxia. Choice C is incorrect. Aortic stenosis is the narrowing of the aortic valve. Critical aortic stenosis can cause congestive heart failure in an infant, but this would result in a systolic murmur, not a machine-like murmur, so the nurse does not suspect this. Choice D is incorrect. A ventricular septal defect (VSD) is an abnormal opening between the left and right ventricles. A large VSD can cause congestive heart failure in an infant but this would result in a pan-systolic murmur, not a machine-like murmur, so the nurse does not suspect this. You may watch the video below to understand the mechanism of important fetal circulation bypass defects including a PDA: NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Physiological Adaptation

The nurse provides discharge education to the parents of a six-year-old who underwent a tonsillectomy. The nurse should recommend which dietary items to this client during their recovery? Select all that apply. A. Ice chips [35%] B. Orange slices [7%] C. Potato chips [1%] D. Applesauce [37%] E. Tomato soup

Explanation Choices A and D are correct. Food items that are soft, not hot, non-acidic, and do not have jagged edges are permitted to consume following a tonsillectomy. Items such as ice chips and applesauce are permitted. Choices B, C, and E are incorrect. Citrus fruits are acidic and not permitted. Potato chips have jagged edges and will irritate the surgical incisions. Soup that is room temperature is permitted. However, tomato soup would be disallowed because it is acidic.

The nurse is caring for a client with a sacral wound infected with Methicillin-resistant staphylococcus aureus. Which personal protective equipment (PPE) is necessary to care for this client? Select all that apply. A. Gloves [35%] B. N95 respirator [2%] C. Surgical Mask [15%] D. Goggles [15%] E. Gown [34%]

Explanation Choices A and E are correct. A gown and gloves should be used when coming into contact with an MRSA wound. This prevents secretions from the wound from infecting the nurse. Choices B, C, and D are incorrect. MRSA in the wound requires contact precautions. A mask is not necessary, nor is goggles or a respirator. Additional Info MRSA is a gram-positive bacteria that is found frequently in healthcare facilities. MRSA is spread by direct contact and affects most older adults through indwelling urinary catheters, vascular access devices, open wounds, and endotracheal tubes. It is susceptible to only a few antibiotics, such as IV vancomycin and oral linezolid. For a client on contact precautions, the door may remain open. During client transport, the wound should be covered with a dry dressing.

Implantable venous access devices can be used for: Select all that apply. A. Taking blood for laboratory testing [20%] B. Chemotherapeutic drugs [23%] C. Whole blood [14%] D. Packed red blood cells [16%] E. Arterial blood gases [8%] F. Parenteral nutrition [19%]

Explanation Choices A, B, C, D, F are correct. Implantable venous access devices can be used for: Taking blood for laboratory testing Chemotherapeutic drugs Whole blood Packed red blood cells Parenteral nutrition Choice E is incorrect. Arterial blood gases are not drawn from an implantable venous access device.

Which of the following observations are non-reassuring when assessing a fetal heart rate strip? Select all that apply. A. Fetal bradycardia [31%] B. Variable decelerations [27%] C. Late decelerations [33%] D. Early decelerations [9%]

Explanation Choices A, B, and C are correct. A is correct. Fetal bradycardia, or a decrease in fetal heart rate below 110 bpm, is a non-reassuring sign on a fetal heart rate strip. When the nurse notes this sign, she will need to intervene by repositioning the mother on her left side, increasing IV fluids, administering oxygen, and notifying the healthcare provider quickly. Also, fetal bradycardia is often a result of uterine hyperstimulation. If the client is on the oxytocin drip, the nurse should discontinue the infusion. B is correct. Variable decelerations, or sharp and profound drops in the fetal heart rate unrelated to the time of contractions, are a non-reassuring sign on a fetal heart rate strip. Anytime that the nurse notes this sign, she will need to intervene by lying the mother on her left side, increasing IV fluids, administering oxygen, and notifying the healthcare provider quickly. Variable decelerations are often caused by cord compression, such as a prolapsed cord, and would be an emergency requiring quick nursing intervention. C is correct. Late decelerations, or dips in the fetal heart rate that occur after a contraction, are a non-reassuring sign on a fetal heart rate strip. Anytime that the nurse notes this sign, she will need to intervene by laying the mother on her left side, increasing IV fluids, administering oxygen, and notifying the healthcare provider quickly. Late decelerations are due to uteroplacental insufficiency and require intervention by the nurse. Choice D is incorrect. Early decelerations are not a non-reassuring sign on a fetal heart rate monitoring strip. Early decelerations are when the fetal heart rate decreases at the same time as a contraction. Early decelerations are due to the pressure of the head of the fetus on the pelvis or soft tissue and are characterized by a return to baseline at the end of the contraction. The nurse requires no intervention after an early deceleration. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Reduction of Risk potential; Problems with Labor and Delivery

While ambulating a patient who has an infusion running through their peripherally inserted central catheter (PICC) in the right arm, they suddenly complain of dyspnea and chest pain. You immediately sit them down in the closest chair and assess them. Their BP is 72/38 mmHg and their heart rate is 186. What is the priority nursing action? Select all that apply. A. Clamp the catheter [19%] B. Notify the health care provider [36%] C. Lay the patient flat [10%] D. Administer oxygen [34%]

Explanation Choices A, B, and D are correct. The nurse suspects that the patient has an air embolism related to their PICC line. This is a potential complication of central venous catheters and the nurse is expected to monitor for it. Signs and symptoms include tachycardia, hypotension, chest pain, dyspnea, tachypnea, and hypoxia. Since the nurse suspects an air embolism, she should clamp the catheter immediately to prevent any further air entry. This is a medical emergency, and the health care provider should be notified promptly. Hypoxia is a symptom of an air embolism; therefore the patient should immediately begin receiving oxygen to prevent tissue ischemia and further complications. Choice C is incorrect. Laying the client supine could cause air embolism to exit the right atrium of the heart and travel to the brain or lungs, causing complications such as a stroke or pulmonary embolism (PE). The patient should be positioned on their left side with their head lower than their feet. This will trap the embolism in the right atrium of the heart and prevent further complications.

The nurse has provided medication instructions to a client who has been prescribed a fentanyl transdermal patch. Which of the following statements, if made by the client, would indicate a correct understanding of the instructions? Select all that apply. A. "I may still need pain medication while this patch is applied." [32%] B. "If the patch comes loose, I may reinforce it with a piece of tape." [22%] C. "I can apply heat to the patch site to increase the pain relief." [2%] D. "I should remove this patch while I am sleeping." [7%] E. "The patch will need to be changed every 72 hours." [36%]

Explanation Choices A, B, and E are correct. Fentanyl can be delivered by a variety of routes, including transdermal patches. This patch is effective for around-the-clock pain control, but the client may still experience breakthrough pain requiring a more immediate release type of pain control. The client may reinforce the patch with tape if it starts to loosen. The fentanyl patch should be changed every 72 hours, with a new patch applied to a new site. Choices C and D are incorrect. Heat should not be applied to a fentanyl patch. This may result in the medication being rapidly discharged and could cause the client to experience opioid toxicity. The fentanyl patch is intended to provide around-the-clock pain control, and thus, it would be inappropriate for the client to remove it while they are sleeping. NCLEX Category: Pharmacological and Parenteral Therapies Related Content: Medication Administration Question Type: Knowledge/Comprehension Additional Info Fentanyl is an opioid that can be delivered in a variety of preparations (intravenous, transdermal, buccal). The transdermal patch is effective for providing a client with continuous pain control for 72 hours. This medication will take 24-hours to reach its peak effect, and the nurse should anticipate the client to experience breakthrough pain. Fentanyl patches should be applied to a clean area with minimal hair. Hair may be clipped but not shaven to ensure appropriate adhesion to the skin.

The nurse is teaching a group of students about drug toxicity. The nurse is correct in stating which of the following? Select all that apply. A. "Naloxone is the treatment for opioid toxicity." [33%] B. "Magnesium is the treatment for lead toxicity." [5%] C. "N-acetylcysteine is the treatment for naproxen toxicity." [8%] D. "Calcium gluconate is the treatment for magnesium toxicity." [25%] E. "Flumazenil is the treatment for benzodiazepine toxicity." [29%]

Explanation Choices A, D, and E are correct. The antidote for opioid toxicity is naloxone which may be given IV, IM, Intranasal, or SubQ. Magnesium toxicity is treated with calcium gluconate. Flumazenil is indicated for benzodiazepine toxicity. Choices B and C are incorrect. High lead levels would be treated with succimer, which is indicated for heavy metals and lead. N-acetylcysteine is utilized in the treatment of acetaminophen toxicity - not naproxen which is an NSAID.

Which of the following educational points regarding fevers in children is essential for the LPN to review with a family being discharged home today? Select all that apply. A. Go to the emergency department for a temperature greater than 100.4 degrees F. [20%] B. Call the primary care office for a fever lasting longer than 3 days. [33%] C. Call the primary care office if the patient is not having any wet diapers. [31%] D. Go to the emergency department if the patient is eating less than usual and has a fever. [17%]

Explanation Choices B and C are correct. The parents should be educated to call the primary care office for fever lasting longer than three days. At that point, the child needs to be evaluated to determine the cause of the illness and appropriate action to decrease body temperature (Choice B). If the child is not having any wet diapers, they are severely dehydrated. The parents should be educated to monitor for this and call the primary care office for instructions. Likely, the child needs to be evaluated for the cause of the fever and subsequent dehydration determined then treated (Choice C). Choice A is incorrect. It is not necessary to go to the emergency room immediately for a temperature higher than 100.4 F. While this is our threshold for a fever, it does not require an emergency room visit. Instead, you should advise the parents to notify the primary care physician if the fever lasts longer than three days so that the child can be treated appropriately. Choice D is incorrect. If a child has a fever, it is very reasonable for their fluid/food intake to decrease. They likely do not feel well and do not have an appetite. If this persists for three days or longer, there are signs of dehydration, or the temperature surpasses 105 F, then the child needs to be seen by the healthcare provider. NCSBN Client Need: Topic: Health promotion and maintenance, Subtopic: Pediatrics

Which of the following signs and symptoms would be expected in a client with Cushing's disease? Select all that apply. A. Hypotension [8%] B. Acne [20%] C. Hirsutism [35%] D. Buffalo hump [38%]

Explanation Choices B, C, and D are correct. B is correct. Acne is an expected symptom of Cushing's disease. This is due to increased sex hormones, such as testosterone, estrogen, and progesterone. Excessive levels of these hormones cause oily skin to build up, which often leads to acne. C is correct. Hirsutism is defined as an excessive body in either men or women in places where the hair usually is absent, such as the chin or cheeks of the face. Hirsutism is caused by an increased amount of androgens, or male sex hormones such as testosterone, in the body. In Cushing's disease, there are increased levels of sex hormones, therefore hirsutism is often seen in these clients. D is correct. A buffalo hump is the classic sign of Cushing's disease. This refers to a lump of fat that develops between the shoulder blades on the top of the back. It is due to the excessive amount of glucocorticoids that clients with Cushing's disease have. Glucocorticoids cause the breakdown of fats and when there are too many, they can cause fat redistribution. This often leads to fat in odd places, such as a buffalo hump. Other signs of Cushing's disease due to fat redistribution are truncal obesity, moon face, and lipolysis. Choice A is incorrect. Hyper, not hypotension would be expected in a client with Cushing's. This is due to too many mineralocorticoids, specifically aldosterone. With increased levels of aldosterone, the body retains too much sodium and water. With increased fluid in the vasculature, the blood pressure rises, and the patient is hypertensive. Hypotension would be expected in a patient with Addison's disease, where the body has a decreased amount of steroids. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Basic care, comfort; Endocrine

The nurse is teaching a group of students on incident reports. Which of the following situations would require an incident report? Select all that apply. A. A patient requesting to view their medical record. [1%] B. A patient complaining about poor care from a nurse. [27%] C. A patient leaving against medical advice (AMA). [28%] D. A patient requesting an increase in pain medication. [1%] E. A patient threatening a nurse with bodily harm. [42%]

Explanation Choices B, C, and E are correct. Incident (sometimes termed occurrence or event) reporting is required when any activity deviates from the norm. Events such as complaints from the patient regarding their care, leaving against medical advice (AMA), and threatening a nurse with bodily harm are all examples of incidents requiring factual reporting. Choices A and D are incorrect. Incident reporting would be inappropriate for a patient requesting to view their medical record. This is a right afforded to them. A request for an increase in pain medication or even a request for pain medication does not require reporting. Additional information: Incident (sometimes termed occurrence or event) reporting is a tool to mitigate future risks. Elements of a report should include - A factual account of the incident. Do not assume or make opinions. The date and time of the incident and the duration (if applicable). Patient or visitor statements in quotation marks. Key interventions took after the incident. This includes if contact was made with the primary healthcare provider. Witness quotes and witnesses pertinent to the event. The incident should not solely be logged in the medical record or nursing notes but a separate incident report must be filled out.