CONCEPTS EXAM 3 WEEKS COMBINED

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Although sexual activity is considered a normative process, some individuals place themselves at increased risk for negative consequences related to this process. Which nonsexual behavior is likely to increase risk-taking activities? A. Having multiple sexual partners B. Using alcohol, marijuana, or illicit substances C. Having gay, lesbian, or bisexual partners D. Refraining from safe-sex practices such as condom use

The nurse is caring for a 50-year-old man who has a body mass index (BMI) of 31 kg/m2, a normal C-reactive protein level, and low serum transferrin and albumin levels. The nurse will plan patient teaching to increase the patient's intake of foods that is high in: A. Iron B. Protein C. Calories D. Carbohydrate

B. Protein

Which laboratory result in a client who has just been admitted with anemia of unknown etiology requires the most rapid action by the nurse? a. Hematocrit 30% (0.30) b. Hemoglobin 10 g/dL (100 g/L) c. Platelet count 120,000 mm 3 (120 × 10 9/L) d. White blood cell count 950 mm 3 (950 × 10 9/L)

d. White blood cell count 950 mm 3 (950 × 10 9/L)

What is the priority nursing diagnosis for a hyperactive manic client during the acute phase of treatment? Risk for injury Ineffective role performance Risk for other-directed violence Impaired verbal communication

Based on current research, which of the following patients is most likely to develop dementia? A. Karen, who works as an office manager in a high-stress environment B. Milo, who is a former boxer and is now a trainer C. Lilly, who works in a factory where asbestos is found D. Justin, who is a bartender in a dark underground club/bar

B. Milo, who is a former boxer and is now a trainer

A patient is having the arterial blood gas (ABG) measured. What would the nurse identify as the parameters to be evaluated by this test? A. Ratio of hemoglobin and hematocrit B. Status of acid-base balance in arterial blood C. Adequacy of oxygen transport D. Presence of a pulmonary embolus

B. Status of acid-base balance in arterial blood

The client's caregiver asks many questions about sickle cell anemia. She is very concerned about the child and what will happen to her in the future. The nurse is aware there are many serious complications she could experience. Which potentially fatal complication(s) can occur? (Select all that apply. One, some, or all options may be correct.)Select all that apply Vaso-occlusive crisis Cerebral vascular accident Priapism Hypertensive crisis Heart failure

A 31-year-old patient admitted with acute mania tells the staff and the other patients that he is on a secret mission for the President of the United States. He states, "I am the only one he trusts, because I am the best!" What term will the nurse use when documenting this behavior? Unpredictability Rapid cycling Grandiosity Flight of ideas

The nurse is providing care for older adults on a subacute, geriatric medical unit. What effect does aging have on hematologic function of older adults? Thrombocytosis Decreased hemoglobin Decreased WBC count Decreased blood volume

Decreased hemoglobin Older adults often have decreased hemoglobin levels as a result of changes in erythropoiesis. Decreased blood volume, decreased WBCs, and alterations in platelet number are not considered to be normal, age-related hematologic changes.

A client who has renal failure asks the nurse why anemia keeps recurring. Which reason would the nurse explain to the client? a. Increase in blood pressure b. Decrease in erythropoietin c. Increase in serum phosphate levels d. Decrease in sodium concentration

b. Decrease in erythropoietin

How would the nurse explain physiological anemia to a pregnant client? a. Erythropoiesis decreases. b. Plasma volume increases. c. Utilization of iron decreases. d. Detoxification by the liver increases

b. Plasma volume increases.

An adolescent child with sickle cell anemia is admitted to the pediatric unit during a vaso-occlusive crisis. Which pathophysiology is correct? a. Severe depression of the circulating thrombocytes b. Diminished red blood cell (RBC) production by the bone marrow c. Pooling of blood in the spleen with splenomegaly as a consequence d. Blockage of small blood vessels as a result of clumping of RBCs

d. Blockage of small blood vessels as a result of clumping of RBCs

Which action is most important for the nurse to perform before calling the healthcare provider (HCP) to report the lab values? Initiate telemetry. Complete an SBAR form. Give PO potassium chloride. Notify the unit manager.

Which behavior would be characteristic of a client during a manic episode? A Going rapidly from one activity to another B Taking frequent rest periods and naps during the day C Being unwilling to leave home to see other people D Watching others intently and talking little

Which problem is NOT considered a causative agent in delirium? A. Elevated blood urea nitrogen levels B. Infection C. Anticholinergic drugs D. Antibiotic therapy

D. Antibiotic therapy

A symptom commonly associated with panic attacks? Obsessions Apathy Fever Fear of impending doom

Fear of impending doom

an underlying symptom of pneumonia is

Pneumonia is associated with pain and shortness of breath.

When preparing to administer an ordered blood transfusion, which IV solution does the nurse use when priming the blood tubing? Lactated Ringer's 5% dextrose in water 0.9% sodium chloride 0.45% sodium chloride

0.9% sodium chloride The blood set should be primed before the transfusion with 0.9% sodium chloride, also known as normal saline. It is also used to flush the blood tubing after the infusion is complete to ensure the patient receives blood that is left in the tubing when the bag is empty. Dextrose and lactated Ringer's solutions cannot be used with blood because they will cause RBC hemolysis.

Infection with chlamydia trachomatis is of particular concern for which of the following reasons? (Select all that apply. One, some, or all options may be correct.) Select all that apply The infection is often asymptomatic, especially among females. Chlamydia is the most prevalence sexually transmitted infection worldwide. There is no effective treatment for the infection. Untreated infection can lead to endometriosis and pelvic peritonitis.

ABD

The nurse is caring for a 25-year-old woman who is requesting information to lose weight. What information will the nurse include in a weight-loss plan? A. Weigh yourself at the same time every morning and evening. B. Stick to a 600- to 800-calorie diet for the most rapid weight loss. C. Low carbohydrate diets lead to rapid weight loss but are difficult to maintain. D. Weighing all foods on a scale is necessary to choose appropriate portion sizes.

C. Low carbohydrate diets lead to rapid weight loss but are difficult to maintain.

The nurse is working with a college student who is planning to become sexually active. She is requesting a reliable method of birth control that could be easily discontinued if necessary. Which is the best option for this college student? A Coitus interruptus B Natural family planning C Oral contraceptive pills D Intrauterine device (IUD)

C. Oral contraceptive pills

What is the usual progression of Alzheimer's disease? A. A single, short episode followed by years of normal function B. Recurring remissions and exacerbations C. Progressive deterioration D. There is no usual progression

C. Progressive deterioration

A client diagnosed with Alzheimer's disease has become more forgetful and has difficulty performing familiar tasks like bathing and dressing. The nurse would assess the client as being in the stage of Alzheimer's disease labeled A. stage 1, mild. B. stage 2, moderate. C. stage 3, moderate-severe. D. stage 4, end.

C. stage 3, moderate-severe.

The nurse is reviewing the client's electronic medical record (EMR) and is discussing with the healthcare provider (HCP) the possible need for an interprofessional conference with the client due to the increasing complexity of his medical problems. The nurse uses a problem-solving approach with the client to facilitate interprofessional communication and assists the healthcare provider (HCP) with obtaining appropriate consults to better inform the team of identified issues for promoting the changes needed for this client. To begin this process, the nurse creates a list of known problems. Which problems should the nurse include in this evaluation? (Select all that apply. One, some, or all options may be correct.) Social isolation. Chronic alcohol use. Chronic gastritis. Pernicious anemia. Electrolyte imbalances. Grief and loss.

CDEF

What is a possible outcome criterion for a client diagnosed with anxiety disorder? Client demonstrates effective coping strategies. Client reports reduced hallucinations. Client reports feelings of tension and fatigue. Client demonstrates persistent avoidance behaviors.

Client demonstrates effective coping strategies.

After performing a screening assessment on a patient, which finding should be documented as a physiological stressor? Death of friend Caregiving of parent Divorce Dementia

Schizophrenia is best characterized as presenting which personality trait? A Split B Multiple C Ambivalent D Deteriorating

Several hours have passed and all medications have been given. The healthcare provider (HCP) is thinking about discharging client. The client's latest laboratory test results have arrived in his electronic medical record (EMR), and the nurse has performed another focused assessment. Which findings satisfy the nurse that the potassium electrolyte replacement medication has been effective? The client's mood and affect have improved significantly. The client's nausea and vomiting have resolved, and appetite has returned. Lack of tremoring when inflating the blood pressure cuff on the left arm. A 12-lead electrocardiography strip confirms a normal sinus rhythm and potassium level is 4.6 mEq/L (4.6 mmol/L).

To evaluate the discharge teaching completed at the hospital, the home health nurse discusses acute exacerbations of SCD with the client and her caregiver. Which behavior indicates to the nurse the caregiver understands about acute exacerbations of sickle cell disease? She is able to take the client's radial pulse within 4 beats of the nurse. She does not allow client to go outside unless she is with her. She measures client's fluid intake to remain under 1 liter a day. She demonstrates how to accurately read an oral thermometer.

According to current theory, which statement regarding eating disorders is accurate? A. Eating disorders are psychotic disorders in which patients experience body dysmorphic disorder. B. Eating disorders are frequently misdiagnosed. C. Eating disorders are possibly influenced by sociocultural factors. D. Eating disorders are rarely comorbid with other mental health disorders.

Eating disorders are possibly influenced by sociocultural factors

Which is the medication of choice in a pregnant adolescent diagnosed with syphilis during the first trimester? a. Penicillin G b. Doxycycline c. Tetracycline d. Erythromycin

a. Penicillin G

An obsession is defined as what? Thinking of an action and immediately taking the action A recurrent, persistent thought or impulse An intense irrational fear of an object or situation A recurrent behavior performed in the same manner

A recurrent, persistent thought or impulse

The nurse is aware that there is a concern about sex education in schools. The concern is not based on scientific evidence. What is the common concern? Sex education is responsible for declining marriage rates. Sex education has contributed to increased rates of suicide. Sex education causes a decline in academic achievement. Sex education promotes sexual activity during adolescence.

Which of the following is the priority component of health program planning? Determining realistic budgets. Prioritizing the nurse's objectives. Establishing clear timelines Involving the community

Which population group has the highest rate of infection with chlamydia? Older adults. Midlife adults. Young teens. Young adults.

The nurse asks the client how he is feeling. He reports that he does not have time for this hospitalization. The nurse notes that he seems annoyed. He coughs as he tries to sit up. He turns on the television, focuses on a news station, and ignores the nurse. A focused assessment. A comprehensive assessment. An emergency assessment. A psychosocial assessment.

When a delirious client insists that a vacuum hose is a large, poisonous snake, the nurse recognizes that this client is A. hallucinating. B. experiencing an illusion. C. hypervigilant. D. demonstrating agnosia.

B. experiencing an illusion.

A new case management nurse has been hired at a nursing home to investigate several recent resident deaths at the facility. What factors should the case management nurse assess for at the facility? (Select all that apply.) Select all that apply. Documentation of prescribed physical therapy sessions Skin breakdown in residents resulting from poor hygiene Altered cognitive function of residents Unexplained bruising of residents High ratio of overweight residents

BCD

What is the first-line drug used to treat mania? Lithium carbonate Carbamazepine Lamotrigine Clonazepam

Which would be the medication of choice for a client who is diagnosed with chlamydia? a. Imiquimod b. Ceftriaxone c. Azithromycin d. Benzathine penicillin

c. Azithromycin

Which manifestation indicates tertiary syphilis? a. Chancre b. Alopecia c. Gummas d. Condylomata lata

c. Gummas

A client frantically reports to the nurse that "You have got to help me! Something terrible is happening. I can't think. My heart is pounding, and my head is throbbing." The nurse should assess the client's level of anxiety as mild. moderate. severe. panic.

severe.

When prescribed lorazepam (Ativan) 1 mg po qid for 1 week for generalized anxiety disorder, the nurse should question the physician's order because the dose is excessive. explain the long-term nature of benzodiazepine therapy. teach the client to limit caffeine intake. tell the client to expect mild insomnia.

teach the client to limit caffeine intake.

Which of the following is an outcome measure the nurse might use to evaluate the sexual education program? Class attendance for students who were enrolled in the curriculum during the last school year. Number of students who correctly answered questions about contraception after completing the class. Proportion of students who participated in large group discussions during class sessions. Classroom teachers' responses to weekly evaluation of delivery of the curriculum as designed.

The client begins to cry and she angrily asks if she will ever be cured of this disease. The client states that she has no idea where her ex-husband is or if he will ever be back. The client is angry and says this is his fault. Which therapeutic approach should the nurse use to try to immediately reduce the the client's stress? Acknowledge to the client that she has the right to feel stressed. Advisethe client that getting upset only makes matters worse. Encourage the client to not be so angry because it only hurts her. Listen attentively to the client, but set barriers to angry outbursts.

Which of the following is a process measure the nurse might use to evaluate the sexual education program? Class attendance for students who were enrolled in the curriculum during the last school year. Percentage of students who reported satisfaction with the content of the class after completion. Number of students who correctly answered questions about contraception after completing the class. Proportion of students who reported they knew where to obtain reproductive health services after completing the class.

Which recommendation about immunization should the school nurse make to the client's caregiver? The client needs her second scheduled dose of MMR #2. The client is current with her immunizations. The client needs her Hepatitis A immunizations. The client needs her influenza vaccine.

The nurse obtains a history from a 34-year-old man diagnosed with chlamydia. Which patient statement indicates additional teaching is required? "This infection can be cured by taking antibiotics." "It is important to use condoms for all sexual activity." "I will avoid sexual contact for 1 week after taking the antibiotics." "My sexual partner does not have symptoms and will not need treatment."

"My sexual partner does not have symptoms and will not need treatment."

A 22-yr-old man is being treated at a college health care clinic for gonorrhea. What should the nurse include in patient teaching? "While being treated for the infection, you will not be able to pass this infection on to your sexual partner." "While you're taking the antibiotics, you will need to abstain from participating in sexual activity and drinking alcohol." "It's important to complete your full course of antibiotics in order to ensure that you become resistant to reinfection." "The symptoms of gonorrhea will resolve on their own, but it is important for you to abstain from sexual activity while this is occurring."

"While you're taking the antibiotics, you will need to abstain from participating in sexual activity and drinking alcohol."

Which action would the nurse take when administering azithromycin to treat sexually transmitted infections (STIs). Select all that apply. One, some, or all responses may be correct. 1 Observing clients for hypertension and diaphoresis 2 For allergic clients, administering the antibiotic with diphenhydramine 3 Instructing clients to take the medication until they feel better 4 Treating sexual partners after the course of antibiotics has been completed 5 Obtaining specimens for culture before administering the first dose of the antibiotic

5 Obtaining specimens for culture before administering the first dose of the antibiotic

The nurse notices that the client has no central line and only has one peripheral intravenous catheter in the left forearm. Which intervention is the best way to give the ordered potassium? Consult with a pharmacist about giving it slowly over two hours. Administer the intravenous potassium as it was ordered. Call the healthcare provider and request a new order. Inject lidocaine into the intravenous bag and give as prescribed.

A nurse in a home setting is assessing a 79-year-old male patient's risk for malnutrition. The nurse suspects malnutrition when reviewing which laboratory results? (Select all that apply.) A. Body mass index (BMI) of 17 Correct B. Waist-to-hip ratio of 1.0 C. Weight loss of 6% since last month's visit D. Prealbumin level of 16 mg/dL E. Hematocrit level of 50% F. Hemoglobin level of 8.2 g/dL

A, C, F

The embryonic period is critical because external and internal structures in the fetus are forming. When is it most important for the pregnant patient to avoid all teratogens? 8-12 weeks 4-8 weeks 12-16 weeks 16-20 weeks

B 4-8 week

A patient has been diagnosed with acute myelogenous leukemia (AML). What should the nurse educate the patient that care will focus on? Leukapheresis Attaining remission One chemotherapy agent Waiting with active supportive care

Attaining remission Attaining remission is the initial goal of care for leukemia. The methods to do this are decided based on age and cytogenetic analysis. The treatments include leukapheresis or hydroxyurea to reduce the white blood cell count and risk of leukemia-cell-induced thrombosis. A combination of chemotherapy agents will be used for aggressive treatment to destroy leukemic cells in tissues, peripheral blood, and bone marrow and minimize drug toxicity. In nonsymptomatic patients with chronic lymphocytic leukemia, waiting may be done to attain remission, but not with AML.

A nurse is assessing a menopausal female and discussing sexuality. Which statement is accurate regarding physiological effects of menopause on sexual health? A. Decreased lubrication is frequently cited as the cause for sexual problems. B. Women who have undergone hysterectomy no longer desire to be sexually active. C. Hot flashes are often bothersome and lead to decreased sexual interest. D. Women taking hormone replacement therapy may not experience climax during sex.

The healthcare provider (HCP) writes discharge orders for the client. The nurse provides discharge instructions that includes prescriptions to be filled by his chosen pharmacy, the date and time of his follow up appointment, and other self-care information on a printed document for him to take home. Which intervention is most important for the nurse to perform after giving the client his discharge information? Advise him to attend Alcoholics Anonymous (AA). Document the teaching in his medical record. Escort him to his car to ensure his safety. Provide a list of foods high in vitamin B12.

Working to help the client view an occurrence in a more positive light is referred to by which term? Flooding Desensitization Response prevention Cognitive restructuring

Cognitive restructuring

The nurse administers a Gardasil vaccine to an 18-yr-old female patient. After the injection, which patient instruction is priority? Avoid sexual activity for 24-48 hrs Remain lying down for at least 15 minutes Return to the clinic in 6 months for a second dose Use two methods of birth control to avoid pregnancy

Remain lying down for at least 15 minutes

A primary health care provider suspects a chlamydial infection and orders a highly sensitive diagnostic test. Which diagnostic test would be ordered? a. DNA probe b. Culture test c. Enzyme immunoassay d. Nucleic acid amplification test

d. Nucleic acid amplification test

The nurse is caring for a patient with polycythemia vera. What is an important action for the nurse to initiate? Encourage deep breathing and coughing. Assist with or perform phlebotomy at the bedside. Teach the patient how to maintain a low-activity lifestyle. Perform thorough and regularly scheduled neurologic assessments.

Assist with or perform phlebotomy at the bedside. Primary polycythemia vera often requires phlebotomy in order to reduce blood volume. The increased risk of thrombus formation that accompanies the disease requires regular exercises and ambulation. Deep breathing and coughing exercises do not directly address the etiology or common sequelae of polycythemia, and neurologic manifestations are not typical.

When caring for a patient with metastatic cancer, the nurse notes a hemoglobin level of 8.7 g/dL and hematocrit of 26%. What associated clinical manifestations does the nurse anticipate observing? Thirst Fatigue Headache Abdominal pain

Fatigue The patient with a low hemoglobin and hematocrit is anemic and would likely have fatigue. Fatigue develops because of the lowered oxygen-carrying capacity that leads to reduced tissue oxygenation to carry out cellular functions. Thirst, headache, and abdominal pain are not related to anemia.

A client who is 16 years old, 5 foot, 3 inches tall, and weighs 80 pounds eats one tiny meal daily and engages in a rigorous exercise program. Which nursing diagnosis addresses this assessment data? A. Death anxiety B. Ineffective denial C. Disturbed sensory perception D. Imbalanced nutrition: less than body requirements

Imbalanced nutrition: less than body requirements

The patient is admitted with hypercalcemia, polyuria, and pain in the pelvis, spine, and ribs with movement. Which hematologic problem would most likely cause these manifestations? Multiple myeloma Thrombocytopenia Megaloblastic anemia Myelodysplastic syndrome

Multiple myeloma Multiple myeloma typically manifests with skeletal pain and osteoporosis that may cause hypercalcemia, which can result in polyuria, confusion, or cardiac problems. Serum hyperviscosity syndrome can cause renal, cerebral, or pulmonary damage. Thrombocytopenia, megaloblastic anemia, and myelodysplastic syndrome are not characterized by these manifestations.

When performing a focused assessment on a client with a possible diagnosis of iron deficiency anemia, which locations would the nurse examine? SATA 1. Sclera 2. Nail beds 3. conjunctivae 4. palms of hands 5. bony prominences

2. Nail beds 3. conjunctivae 4. palms of hands

A 30-yr-old woman reports the recent appearance of itchy, slightly painful lesions on her vulva, some of which have recently burst. Which STI should the nurse suspect first? Gonorrhea Chlamydia Genial warts Genital herpes

Genital herpes

Results of a patient's most recent blood work indicate an elevated neutrophil level. The nurse recognizes that this diagnostic finding suggests which problem? Infection Hypoxemia Acute thrombotic event Risk of hypocoagulation

Infection An increase in the neutrophil count most commonly occurs in response to infection or inflammation. Hypoxemia and coagulation do not directly affect neutrophil production.

When parents share that their 8-year-old child seems to "always try to be annoying and hateful," the nurse suspects the child is demonstrating which characteristic? a. Emotionally immature b. Anxiety c. Vindictiveness d. Depression

c. Vindictiveness Vindictiveness is defined as spiteful, malicious behavior. The person with this disorder also shows a pattern of deliberately annoying people and blaming others for his or her mistakes or misbehavior. This child may frequently be heard to say "He made me do it!" or "It's not my fault!" The description is not associated with any of the other options.

Cocaine exerts which of the following effects on a client? Stimulation after 15 to 20 minutes Stimulation and euphoria Immediate imbalance of emotions Paranoia

stimulation and euphoria

Which treatment strategies would benefit a client diagnosed with chlamydia? Select all that apply. One, some, or all responses may be correct. 1 Penicillin G 2 Ceftriaxone 3 Clotrimazole 4 Doxycycline 5 Azithromycin

4 Doxycycline 5 Azithromycin

What defense mechanisms can only be used in healthy ways? Suppression and humor Altruism and sublimation Idealization and splitting Reaction formation and denial

Altruism and sublimation

A 7-year-old, who is described as impulsive and hyperactive, tells the nurse, "I am a dummy, because I don't pay attention, and I can't read like the other kids." The nurse notes that these behaviors are most consistent with which diagnosis? Attention deficit disorder Attention deficit hyperactivity disorder Autism Conduct disorde

Attention deficit hyperactivity disorder

A family member of a patient diagnosed with bipolar disorder asks what behaviors would indicate the beginnings of a manic phase. What is the best response by the nurse? "The person may experience decreased energy and interest in activities beginning in the winter months." "The person may have excess energy, talk a lot, feel restless, and spend too much money." "The person may have sudden spikes in blood pressure and crave foods that are sweet or salty." "The person may sleep more, have trouble completing hygiene needs, and have a poor appetite."

Clear communication between professional caregivers is most important for avoiding medical errors and minimizing client safety risks. Which would be the best method for the nurse to use to report the discharge plans to the home health nurse? Subjective, Background, Application, Requirement (SBAR). Situation, Background, Assessment, Recommendation (SBAR). Simple, Object, Access, Protocol (SOAP). Subjective, Objective, Assessment, Plan (SOAP).

The client's HCP has advised her caregiver to get pneumococcal and meningococcal vaccines for her at the follow-up office visit. The caregiver asks the nurse, "Why does she need to have those other vaccines? I hate for her to get more shots. She cries, and I know it hurts." What is the best response by the nurse? "I will get the HCP to explain why the vaccines are needed." "She is susceptible to infections. These vaccinations may help prevent a crisis." "These vaccines are required for all children younger than 10 years of age." "I know you don't like to see her hurt, but she must have these vaccines."

A 12-year-old male patient diagnosed with Tourette's disorder is visiting his provider. The nurse will prepare medication teaching on which class of medication to help manage the tics associated with this disorder? Select all that apply. A Mood stabilizers B Antianxiety agents C Anticholinesterase inhibitors D First-generation antipsychotics E Second-generation antipsychotics

B, d, e

Which of the following symptoms would lead a provider to suspect that a client is experiencing PTSD? Select all that apply. A. Visiting the scene of the accident over and over B. Talking with strangers about the events of the accident C. Flashbacks of the accident D. Hypervigilance E. Irritability F. Difficulty concentrating G. Mania

C. Flashbacks of the accident D. Hypervigilance E. Irritability G. Mania All these symptoms are signs of PTSD. The other options are not associated with signs of PTSD.

Which event would a client with early stage 4 Alzheimer's disease have greatest difficulty remembering? A. His or her high school graduation B. The births of his or her children C. The story of a teenage escapade D. What he or she ate for breakfast

D. What he or she ate for breakfast

A client who is dependent on alcohol tells the nurse, "Alcohol is no problem for me. I can quit anytime I want to." The nurse can assess this statement as indicating which defense mechanism? Denial Projection Rationalization Reaction formation

Denial

Which coping mechanism is used excessively by clients diagnosed with bulimia nervosa to cope with their obsession with their body image? A. Denial B. Humor C. Altruism D. Projection

Denial

A man continues to speak of his wife as though she were still alive, 3 years after her death. This behavior suggests the use of which ego defense mechanism? Altruism Denial Undoing Suppression

Denial Correct

Which factor can reduce the vulnerability of a child to etiological influences predisposing to the development of psychopathology? Resilience Malnutrition Child abuse Having a depressed parent

Resilience

A patient with a diagnosis of hemophilia had a fall down an escalator earlier in the day and now has bleeding in the left knee joint. What should be the emergency nurse's immediate action? Immediate transfusion of platelets Resting the patient's knee to prevent hemarthroses Assistance with intracapsular injection of corticosteroids Range-of-motion exercises to prevent thrombus formation

Resting the patient's knee to prevent hemarthroses In patients with hemophilia, joint bleeding requires resting of the joint to prevent deformities from hemarthrosis. Clotting factors, not platelets or corticosteroids, are administered. Thrombus formation is not a central concern in a patient with hemophilia.

Which diagnosis from the list below would be given priority for a client diagnosed with bulimia nervosa? A. Disturbed body image B. Chronic low self-esteem C. Risk for injury: electrolyte imbalance D. Ineffective coping: impulsive responses to problems

Risk for injury: electrolyte imbalance

When a nurse assesses the style of behavior a child habitually uses to cope with the demands and expectations of the environment, he or she is assessing characteristic? Temperament Resilience Vulnerability Cultural assimilation

Temperament

A 26-year-old patient who abuses heroin states to you, "I've been using more heroin lately because I've begun to need more to feel the effect I want." What effect does this statement describe? Intoxication Tolerance Withdrawal Addiction

Tolerance

Nursing assessment of an alcohol-dependent client 6 to 8 hours after the last drink would most likely reveal the presence of which early sign of alcohol withdrawal? Tremors Seizures Blackouts Hallucinations

Tremors

A 24-yr-old patient is at the clinic with symptoms of purulent vaginal discharge, dysuria, and dyspareunia. She is sexually active and has multiple partners. What should the nurse explain as the rationale for Chlamydia screening? Chlamydia is frequently comorbid with HIV Untreated chlamydia infections can lead to sepsis Untreated chlamydia infections may cause infertility Chlamydia infections are treaatable only in the early stages

Untreated chlamydia infections may cause infertility The nurse obtains a history from a 34-year-old man diagnosed with chlamydia. Which patient statement indicates additional teaching is required?

A client who is at 33 weeks' gestation has contracted gonorrhea and is prescribed probenecid and penicillin. Which instructions would the nurse give the client regarding the reason for dual therapy? a. "Your allergy to penicillin is minimized." b. "The side effects of the disease are reduced." c. "The amount of penicillin in your blood is increased." d. "Your immune defense mechanisms are more active."

c. "The amount of penicillin in your blood is increased."

In addition to being highly infectious, which additional fact would the nurse teach the client with gonorrhea? a. Easily cured b. Occurs very rarely c. Can produce sterility d. Limited to the external genitalia

c. Can produce sterility

Which would be the medication of choice in an adolescent who is diagnosed with gonorrhea and wishes to continue breast-feeding? a. Azithromycin 1 g b. Amoxicillin 500 mg c. Ceftriaxone 250 mg d. Ceftriaxone 125 mg

c. Ceftriaxone 250 mg

The parents of a child with sickle cell anemia (SSA) tell the nurse, "We have never had any symptoms of SSA and do not understand why our child has this problem." Which information will the nurse include when teaching the parents? a. SSA is caused by a random genetic mutation with no known cause. b. People who are carriers of SSA may not have symptoms, but all of their children will have SSA. c. If both parents are carriers of SSA, there is a 25% chance that offspring will have SSA. d. When a child is born with SSA, genetic testing of both parents is needed to determine if they have sickle cell trait.

c. If both parents are carriers of SSA, there is a 25% chance that offspring will have SSA.

Which statement indicates that a client with genital herpes understands the nurse's teaching of how to limit transmission of the virus to her newborn? a. "I should avoid kissing the baby on the lips." b. "I have to wear gloves when I'm holding the baby." c. "I should wash my clothes and my baby's clothes separately." d. "I have to wash my hands with soap and water before handling the baby."

d. "I have to wash my hands with soap and water before handling the baby."

The nurse is teaching a pregnant client with sickle cell anemia about the importance of taking supplemental folic acid. Which response by the nurse explains how folic acid would help? a. "It lessens sickling of red blood cells." b. "It prevents vaso-occlusive crises." c. "It helps decrease the cellular oxygen need." d. "It will promote production of hemoglobin."

d. "It will promote production of hemoglobin."

The nurse in the clinic is obtaining the health history of a 16-year-old boy with a complaint of a thick urethral discharge. Which is the most appropriate nursing action to help confirm a tentative diagnosis of gonorrhea? a. Assessing the temperature for fever b. Collecting a urine sample for a urinalysis c. Drawing blood for a complete blood count d. Obtaining a urethral specimen for a culture

d. Obtaining a urethral specimen for a culture

A poorly developed sense of empathy is thought to be the result of having what life experience? a. A family history of mental illness b. a low serum testosterone level c. suffered head trauma at an early age d. unmet physical and emotional needs

d. unmet physical and emotional needs A history of not having one's own needs met may indicate an individual who has a less well-developed sense of empathy. Research does not support any of the other options.

Assessment of a client suspected of experiencing bulimia nervosa calls for the nurse to perform A. a range of motion assessment. B. inspection of body cavities. C. inspection of the oral cavity. D. body fat analysis.

inspection of the oral cavity

client has a 4 year history of using cocaine intranasally. When brought to the hospital in an unconscious state, what nursing measure should be included in the client's plan of care? Induction of vomiting Administration of ammonium chloride Monitoring of opiate withdrawal symptoms Observation for tachycardia and seizures

observation for tachycardia and seizures

The HCP prescribes azithromycin 1 gm orally once for chlamydia. The medication on hand is 500 mg per tablet. How many tablets will the nurse administer to the client? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Ali is a 17-year-old patient with bulimia coming to the outpatient mental health clinic for counseling. Which of the following statements by Ali indicates that an appropriate outcome for treatment has been met? A. "I purge only once a day now instead of twice." B. "I feel a lot calmer lately, just like when I used to eat four or five cheeseburgers." C. "I am a hard worker and I am very compassionate toward others." D. "I always purge when I'm alone so that I'm not a bad role model for my younger sister."

" I am a hard worker and I am very compassionate toward others"

A patient comes to the outpatient clinic for treatment of uncomplicated gonorrhea. Which patient statement requires immediate clarification by the nurse? "I should avoid alcohol use for at least 2 weeks" "I will have my sexual partner come in for treatment" "After I start the antibiotic therapy, it is safe to have sex again" "After treatment, I do not need to return to the clinic for retesting"

"After I start the antibiotic therapy, it is safe to have sex again"

The nurse is obtaining a sexual history from a woman who is a new patient in the primary care clinic. It would be most appropriate for the nurse to ask which question first? "Have you ever had a sexually transmitted infection?" "Have you ever been in a relationship with anyone who hurt you?" "Have you ever been forced into sexual acts as a child or an adult?" "Are you satisfied with your sexual relationship with your partner?"

"Are you satisfied with your sexual relationship with your partner?" When taking a sexual health history, the nurse should begin with the least sensitive area of questioning and then move to more sensitive areas.

A woman has sought care because of urinary incontinence. She states that running or jumping often precipitates leakage of urine, an event that has been occurring with increasing regularity in recent months. Which assessment question is most relevant to try to determine the cause of the patient's problem? "Do you know if your mother or sisters have had similar problems?" "Do you find that you are prone to frequent urinary tract infections?" "Did you have any muscle damage when giving birth to your children?" "Do you take part in a regular program of physical exercise and stretching?"

"Did you have any muscle damage when giving birth to your children?" Trauma to the pelvic musculature during birth is often the cause of urge and stress incontinence in female patients. UTIs, family history, and exercise are less likely to contribute to an ongoing pattern of incontinence.

A 36-yr-old patient suspected of having leukemia is scheduled for a bone marrow aspiration. What statement in the patient's health history requires immediate follow-up by the nurse? "I had a bad reaction to iodine before and almost died." "I am taking an antibiotic to treat a urinary tract infection." "I have rheumatoid arthritis and take aspirin for joint pain." "I have dialysis for chronic renal failure three times a week."

"I have rheumatoid arthritis and take aspirin for joint pain." Complications of bone marrow aspiration are minimal, but there is a possibility of damaging underlying structures, especially if the sternum site is used. Other complications include hemorrhage, particularly if the patient is thrombocytopenic, and infection if the white blood cell count is low. The risk of hemorrhage is increased if the patient takes aspirin because it promotes bleeding by inhibiting platelet aggregation. Contrast dye is not used during a bone marrow aspiration. A bone marrow aspiration is not contraindicated in patients who have chronic renal failure on dialysis or a urinary tract infection on an antibiotic.

The patient who has been told she will have blood drawn for a prolactin assay asks the nurse, "What is this test for? " What is the best response by the nurse? "It will tell you if you are pregnant." "It is used to detect a cause of amenorrhea." "It will tell us if you have a reproductive cancer." "It can indicate if you have a sexually transmitted infection."

"It is used to detect a cause of amenorrhea." A prolactin assay will detect pituitary dysfunction that can cause amenorrhea. Human chorionic gonadotropin (hCG) is used to detect pregnancy. The biologic tumor markers α-fetoprotein, hCG, and CA 125 may be used to assess for reproductive cancers and to monitor therapy. The assay does not screen for a sexually transmitted infection.

The nurse is planning health promotion teaching for a group of healthy older adults in a residential community. Which statement accurately describes expected hematologic effects of aging? "Platelet production increases with age and leads to easy bruising." "Anemia is common with aging because iron absorption is impaired." "Older adults with infections may have only a mild white blood cell count elevation." "Older adults often have poor immune function with a decreased number of lymphocytes."

"Older adults with infections may have only a mild white blood cell count elevation." During an infection, the older adult may have only a minimal elevation in the total white blood cell count and may not have a fever. Presentation of infection can initially be nonspecific with disorientation, anorexia, and weakness. Platelets are unaffected by the aging process. However, changes in vascular integrity from aging can manifest as easy bruising. Iron absorption is not impaired in the older patient, but adequate nutritional intake of iron may be decreased. The total white blood cell count and differential are generally not affected by aging. However, a decrease in humoral antibody response and decrease in T-cell function may occur.

A client with mild preeclampsia is admitted to the labor and birthing suite. Which signs or symptoms would the client be likely to display if she were developing hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome)? Select all that apply. One, some, or all responses may be correct. 1 Headache 2 Constipation 3 Right upper quadrant abdominal pain 4 Vaginal bleeding 5 Nausea and vomiting

1 Headache 3 Right upper quadrant abdominal pain 5 Nausea and vomiting Headache, right upper quadrant abdominal pain, and nausea and vomiting are all indications of increasing severity of preeclampsia and HELLP syndrome. Constipation and vaginal bleeding are not related to preeclampsia.

The parents of a child who has just been diagnosed with hemophilia A ask the nurse what symptoms of bleeding they should look for in the future. Which symptoms would the nurse list? Select all that apply. One, some, or all responses may be correct. 1 Nosebleeds 2 Blood in the urine 3 Painful and swollen joints 4 Easy bruising 5 Frequent fevers 6 Fast clotting of injuries 7 Dark-colored tarry stools

1 Nosebleeds 2 Blood in the urine 3 Painful and swollen joints 4 Easy bruising 7 Dark-colored tarry stools Epistaxis, also known as nosebleeds, is a common symptom of a lack of clotting factor. Hematuria (blood in the urine) may be grossly apparent. The child may experience joint pain and deformities from bleeding into joints. Excessive bruising will occur from bleeding into tissue with seemingly minor injuries. Dark-colored tarry consistency stools are indicative of gastrointestinal bleeding. Frequent fevers are not associated with hemophilia. Prolonged clotting times occur with this condition.

The nurse is caring for a new mother who has a chlamydial infection. For which complications would the nurse assess the client's neonate? Select all that apply. One, some, or all responses may be correct. 1 Pneumonia 2 Preterm birth 3 Microcephaly 4 Conjunctivitis 5 Congenital cataracts

1 Pneumonia 2 Preterm birth 4 Conjunctivitis

Which information would the nurse provide to a client diagnosed with chlamydia and prescribed doxycycline? Select all that apply. One, some, or all responses may be correct. 1 Report worsening symptoms. 2 Refrain from sexual relations. 3 Use barrier protection devices. 4 Contact partners to be tested. 5 Take the entire course of antibiotics.

1 Report worsening symptoms. 2 Refrain from sexual relations. 3 Use barrier protection devices. 4 Contact partners to be tested. 5 Take the entire course of antibiotics.

Which explanations would the nurse provide to the students in a sex education course regarding the etiology for an increase in gonorrhea prevalence? Select all that apply. One, some, or all responses may be correct. 1 Symptoms of the disease are vague. 2 Screening blood tests are expensive. 3 The incubation period is relatively short. 4 Causative organisms have become resistant to treatment. 5 Diagnostic tests for the causative organism are not yet available

1 Symptoms of the disease are vague. 3 The incubation period is relatively short. 4 Causative organisms have become resistant to treatment.

A transfusion of packed red blood cells is prescribed for a client with anemia. List the actions in the order in which they will be performed by the nurse. 1. Ensure that the client signed a consent for the transfusion. 2. Determine the client's vital signs. 3. Verify that the number on the blood product, laboratory record, and client arm band match. 4. Don a pair of clean gloves. 5. Initiate the transfusion slowly.

1. Ensure that the client signed a consent for the transfusion. 2. Determine the client's vital signs. 3. Verify that the number on the blood product, laboratory record, and client arm band match. 4. Don a pair of clean gloves. 5. Initiate the transfusion slowly.

In which order will the nurse take these actions when caring for a client who is having a hemolytic reaction to a transfusion of packed red blood cells? 1.Stop the transfusion. 2.Change the intravenous (IV) administration set. 3.Run 0.9% normal saline at a rapid rate. 4.Notify the primary health care provider and blood bank

1.Stop the transfusion. 2.Change the intravenous (IV) administration set. 3.Run 0.9% normal saline at a rapid rate. 4.Notify the primary health care provider and blood bank The priority is to stop the transfusion to prevent further hemolysis. The next action would be to change the IV administration set to prevent infusing any blood product remaining in the tubing. Running normal saline rapidly will help decrease shock and hypotension. Notifying the primary health care provider and blood bank would be the last step because these can be done after taking action to prevent further complications of hemolysis.

Before starting a transfusion of packed red blood cells, the nurse would arrange for a peer to monitor their other assigned patients for how many minutes when the nurse begins the transfusion? 5 15 30 60

15 As part of standard procedure, the nurse remains with the patient for the first 15 minutes after starting a blood transfusion. Patients who are likely to have a transfusion reaction will more often exhibit signs within the first 15 minutes that the blood is infusing. Monitoring during the transfusion will be every 30 to 60 minutes.

The nurse calculates the client's intake and output (I&O) for the shift. She has had 24 ounces of water, 8 ounces of apple juice, and three 4-ounce cartons of milk. She received 50 mL of IV fluids per hour for the last 12 hours and had a urinary output of 1200 mL, plus one episode of wetting the bed. What is the total intake for this shift? (Enter the numerical value only. If rounding is necessary, round to the whole number.)

1920

The mother of a toddler with hemophilia A asks the nurse, "Can I give my child ibuprofen for fever or pain?" How will the nurse respond? 1 "Ibuprofen is a good choice for fever or pain." 2 "Give your child acetaminophen. Ibuprofen may cause bleeding." 3 "No. I'll explain why your child isn't allowed pain medications." 4 "You seem concerned about giving medications to your child."

2 "Give your child acetaminophen. Ibuprofen may cause bleeding." The parent is asking a specific question that should be answered by the nurse. Ibuprofen is contraindicated because it interferes with platelet function and may cause more bleeding; therefore an analgesic such as acetaminophen should be administered because it does not interfere with coagulation. Analgesics are permitted, provided they do not have anticoagulant effects

An adolescent reports uncomfortable genital warts. Which interventions would reduce the discomfort? Select all that apply. One, some, or all responses may be correct. 1 Take imiquimod. 2 Consider cryotherapy. 3 Bathe with an oatmeal solution. 4 Wear loose-fitting cotton clothes. 5 Use less water to clean the genitals

2 Consider cryotherapy. 3 Bathe with an oatmeal solution. 4 Wear loose-fitting cotton clothes.

When a client is admitted to the emergency department with disseminated intravascular coagulation caused by sepsis, which prescribed action will the nurse take first? 1 Apply antiembolism stockings. 2 Draw blood for culture and sensitivity. 3 Administer vancomycin 1 gram intravenously. 4 Transfer the client to the intensive care unit.

2 Draw blood for culture and sensitivity. Treatment of disseminated intravascular coagulation focuses on treatment of the cause of the abnormal coagulation, so rapid initiation of antibiotic therapy is essential. However, blood cultures are drawn before antibiotic administration to ensure that appropriate antibiotics can be prescribed. Antiembolism stockings are needed to help prevent venous thrombosis, but are not the priority action. The client needs to be transferred to the intensive care unit, but the nurse would not wait for the transfer to obtain cultures and administer antibiotics.

A client who is underweight has autoimmune hemolytic anemia that has been unresponsive to corticosteroids. A splenectomy is scheduled. For which complication would the nurse assess the client in the immediate postoperative period? 1 Dehiscence 2 Hemorrhage 3 Wound infection 4 Abscess formation

2 Hemorrhage A client is at risk for hemorrhage because of the vascularity of the spleen. Dehiscence is not expected; it usually occurs in obese clients. Wound infection is a complication that will take days to develop. Abscess formation is a complication that will take days to develop.

Which education would the nurse provide to the family of a 10-year-old child diagnosed with hemophilia about the genetic inheritance of the condition? 1 It follows the Mendelian law of inherited disorders. 2 The mother is a carrier of the disorder but usually is not affected by it. 3 It is an autosomal dominant disorder in which the woman carries the trait. 4 A carrier may be male or female, but the disease occurs in the sex opposite that of the carrier.

2 The mother is a carrier of the disorder but usually is not affected by it. The hemophilia gene is carried on the X chromosome but is recessive. The female is the carrier (an unaffected XO and an affected XH). If the male receives the affected XH (XHYO), he will have the disorder. Hemophilia is carried by the female; the Mendelian laws of inheritance are not sex specific. Hemophilia is a sex-linked recessive disorder. Only females carry the trait; usually males are affected.

Which parent education would the nurse provide the pregnant mother whose son was recently diagnosed with hemophilia about the chances that her next child will also be affected? 1 There is a 5% chance that the baby will be affected. 2 There is a 25% chance that the baby will be affected. 3 There is a 50% chance that the baby will be affected. 4 There is a 75% chance that the baby will be affected.

2 There is a 25% chance that the baby will be affected. Hemophilia is an X-linked recessive disorder. The mother is usually the carrier, and the father is unaffected. Before the sex of the unborn child is known, the odds are 25%; 50% of pregnancies will result in boys, and a boy has a 50% chance of having hemophilia. The laws of Mendelian genetics do not include a 5% probability of inheritance of hemophilia. A 50% or 75% chance is too high; there is only a 25% chance that the fetus will be affected.

A 2-year-old child with previously diagnosed hemophilia is admitted to the pediatric unit for observation after a motor vehicle collision. The toddler has several bruises but no other apparent injuries. Which is the nurse's specific concern regarding this child? 1 Possibility of falls 2 Undetected injury 3 Low fluid volume 4 Development of infection

2 Undetected injury Although the child has no apparent injuries, internal bleeding may have occurred. The child should be monitored for internal bleeding in case there is an undetected injury. Although all 2-year-olds are at risk for falls, falls are not the greatest danger for this child at this time. Although all toddlers are at risk for fluid imbalances because of their larger percentage of body fluid to body mass, this is not a priority at this time. A child with hemophilia is at no greater risk for infection than any other child; the skin is intact, so this is not a priority.

Which iron-rich foods should the nurse recommend for a toddler-age client who is diagnosed with iron deficiency anemia? Select all that apply. 1. Carrots 2. Chicken 3. Broccoli 4. Lean steak 5. Whole milk

2, 3, 4 Parents should be encouraged to provide an iron-rich diet that includes heme and nonheme iron sources such as poultry (chicken), green leafy vegetables (broccoli), and red meats (lean steak). Carrots are not a source of iron in the diet. Whole milk consumption should be limited as it is a source of oxalates, which decrease the absorption of iron.

Which actions would the nurse take when admitting a client having a sickle cell crisis to the nursing unit? Select all that apply. One, some, or all responses may be correct. 1. Place on strict isolation. 2. Administer hydroxyurea. 3. Administer aspirin 325 mg daily. 4. Apply oxygen via nasal cannula. 5. Administer intravenous (IV) hydration. 6. Avoid opiate-type analgesics

2. Administer hydroxyurea. 4. Apply oxygen via nasal cannula. 5. Administer intravenous (IV) hydration.

Which foods will the nurse recommend to a client with iron deficiency anemia? Select all that apply. One, some, or all responses may be correct. 1. grapes 2. spinach 3. oranges 4. beef liver 5. cantaloupe

2. Spinach 4. beef liver

The client's prescription is for ceftriaxone 1 g in 100 mL sterile normal saline IV every 12 hrs to infuse over 30 minutes. The nurse should set the infusion pump to deliver how many mL per hour? (Enter numeric value only. If rounding is required, round to the whole number.)

200

Which medication would the nurse administer to prevent maternal transmission of infection to the newborn of a client with gonorrhea? Select all that apply. One, some, or all responses may be correct. 1 Penicillin 2 Acyclovir 3 Ceftriaxone 4 Doxycycline 5 Levofloxacin

3 Ceftriaxone

A child diagnosed with attention deficit hyperactivity disorder (ADHD) is reprimanded for taking the nurse's pen without asking first. He responds by shouting, "You don't like me! You won't let me have anything, even a pen!" The nurse is most therapeutic when responding with which statement? A "I do like you, but I don't like it when you grab my pen." B "Liking you has nothing to do with whether I will loan you my pen." C "It sounds as though you are feeling helpless and insecure." D "You must ask for permission before taking someone else's things."

A patient has come to the health clinic for an annual checkup. He reports increased stress at work and having to work a lot of mandatory overtime. He has not been able to do his usual daily exercise for several weeks. What is the best response by the nurse? "Regular exercise would be good because it helps the body deal with stress." "Have you considered a medication to help you sleep at night?" "There are other ways you can reduce your stress, such as cutting back on your work hours." "Including exercise in your schedule will just increase the stress from work."

An acute phase nursing intervention aimed at reducing hyperactivity is demonstrated by which intervention? Writing in a diary Exercising in the gym Directing unit activities Orienting a new client to the unitY

The nurse conducts a review of the literature about sex education curricula and finds information about the specific curriculum provided to the middle school students. Which of the following articles would be a priority to read? (Select all that apply. One, some, or all options may be correct.) Select all that apply The effectiveness of sex education booster sessions during high school to reduce the transmission of chlamydia trachomatis. What works in preventing bullying on social media among middle school students: A review of the literature. Sex education program to reduce sexually transmitted infections among high school youth: A report from Finland. The effectiveness of school nurse counseling of high school students to reduce the transmission of colds and flu. A peer support program to reduce unwanted pregnancy and sexually transmitted infection: A feasibility study in Chicago public high schools.

The student meets again with the nurse and confirms the HSV diagnosis. The student is angry with her boyfriend because he told her that he had only been with one other girl in the past and that he did not have any sexually transmitted diseases. The student wants to know if her boyfriend could be telling the truth when he stated he does not have HSV. How should the nurse respond? Individuals can be infected with HSV and not have any symptoms. Anyone who is infected with HSV should have noticeable symptoms. Your boyfriend has most likely had more than one sexual partner. It sounds as if your boyfriend is not trustworthy.

When a client reports that lithium causes an upset stomach, the nurse should make which suggestion associated with taking the medication? With meals With an antacid 30 minutes before meals 2 hours after meals

Which statement by the client indicates she is meeting Erikson's stage of development for her age? "Look, I finished putting the puzzle together." "I don't want any of my friends to visit me here." "I need my stuffed dog so that I can go to sleep." "When I grow up, I want to be a nurse just like you."

Which patient is most likely to develop anemia related to an increased destruction of red blood cells? A 23-yr-old black man who has sickle cell disease A 59-yr-old man whose alcohol use caused folic acid deficiency A 13-yr-old child with impaired growth and development due to thalassemia A 50-yr-old woman with a history of "heavy periods" accompanied by anemia

A 23-yr-old black man who has sickle cell disease A result of a sickling episode in sickle cell anemia involves increased hemolysis of the sickled cells. Thalassemias and folic acid deficiencies cause a decrease in erythropoiesis, whereas the anemia related to menstruation is a direct result of blood loss.

The nurse is assigned to care for several patients on a medical unit. Which patient should the nurse assess first? A 60-yr-old patient with a blood pressure of 92/64 mm Hg and hemoglobin of 9.8 g/dL A 50-yr-old patient with a respiratory rate of 26 breaths/minute and an elevated D-dimer A 40-yr-old patient with a temperature of 100.8°F (38.2°C) and a neutrophil count of 256/µL A 30-yr-old patient with a pulse of 112 beats/min and a white blood cell count of 14,000/µL

A 40-yr-old patient with a temperature of 100.8°F (38.2°C) and a neutrophil count of 256/µL A low-grade fever greater than 100.4° F (38° C) in a patient with a neutrophil count below 500/µL is a medical emergency and may indicate an infection. An infection in a neutropenic patient could lead to septic shock and possible death if not treated immediately.

The nurse anticipates that the nursing history of a client diagnosed with obsessive compulsive disorder (OCD) will reveal what common assessment data? (Select all that apply.) A history of childhood trauma Correct A sibling with the disorder Correct A history of sexual abuse Correct A previous suicide attempt An eating disorder Correct

A history of childhood trauma A sibling with the disorder A history of sexual abuse An eating disorder

The nurse caring for a client experiencing a panic attack anticipates that the psychiatrist would order a stat dose of which classification of medications? Standard antipsychotic medication. Tricyclic antidepressant medication. Anticholinergic medication. A short-acting benzodiazepine medication.

A short-acting benzodiazepine medication.

Appropriate approaches used by the long-term care nurse to provide education for a 73-year-old who has just been diagnosed with diabetes include which of the following? (Select all that apply.) A. Schedule a visit by another resident who is diabetic. B. Demonstrate food choices using food photographs. C. Avoid discussion of the patient's favorite foods. D. Remind the patient that a lot of damage has already occurred. E. Encourage the patient's family to participate in teaching sessions. F. Ask the patient about past experiences with lifestyle changes.

A, B, E, F

Which of the following describe the symptoms of the manic phase of bipolar disorder? Select all that apply. Excessive energy Fatigue and increased sleep Low self-esteem Pressured speech Purposeless movement Racing thoughts Withdrawal from environment Distractibility

A, d, e , f, h

3. A patient is experiencing periods of confusion, and the family is concerned. The patient's son asks the nurse for an explanation and recommendation. What is the nurse's best response? A. "Your father may be having mini-strokes; I will notify his physician." B. "Your father is just confused about some things since he is in the hospital." C. "The confusion will pass. Your father just has to get up and move around." D. "Talk with your father about past events, and that will help with the confusion."

A. "Your father may be having mini-strokes; I will notify his physician." Periods of confusion may be related to mini-strokes, or transient ischemic attacks (TIAs). Confusion during hospitalization does not occur with every patient. Talking with the patient or thinking the confusion may pass is not a viable solution. The patient should be assessed and the reason for the confusion identified. Awarded 1.0 points out of 1.0 possible points.

The nurse is administering oral glucocorticoids to a patient with asthma. What assessment finding would the nurse identify as a therapeutic response to this medication? A. No observable respiratory difficulty or shortness of breath over the last 24 hours B. A decrease in the amount of nasal drainage and sneezing C. No sputum production, and a decrease in coughing episodes D. Relief of an acute asthmatic attack

A. No observable respiratory difficulty or shortness of breath over the last 24 hours

The nurse is caring for a patient diagnosed with peptic ulcer disease (PUD). The patient was prescribed the proton pump inhibitor Prevacid (lansoprazole). Which of the following supplements may be prescribed to prevent deficiency? A. Vitamin B12 B. Vitamin C C. Vitamin D D. Omega-3 fatty acids

A. Vitamin B12

The nurse is expected to perform an assessment of a client suspected to be in the earliest stage of Alzheimer's disease. What finding would be out of character if the client truly has stage 2 Alzheimer's disease? (Select all that apply) A. Willingness to respond directly to questions posed by nurse B. Charming behavior designed to hide memory deficit C. Confabulation to compensate for forgotten information D. Avoidance of questions by subject changing

A. Willingness to respond directly to questions posed by nurse

The physician mentions to the nurse that a client who is about to be admitted has "sundowning." The nurse can expect to assess nightly A. agitation. B. lethargy. C. depression. D. mania.

A. agitation.

The family members of a client with stage 1 Alzheimer's disease have jobs and cannot provide adequate supervision for the client. A reasonable alternative for the nurse to explore with them would be A. day care. B. acute care hospitalization. C. long-term institutionalization. D. group home residency.

A. day care.

A family member reports that the client had been oriented and able to carry on a logical conversation last evening, but this morning she is confused and disoriented. The nurse can suspect that the client is displaying symptoms associated with A. delirium. B. dementia. C. amnesic disorder. D. selective inattention.

A. delirium.

An initial intervention the nurse might suggest to the family members of a client diagnosed with Alzheimer's disease who has begun incontinence would be to A. label the bathroom door with a picture. B. provide toileting on an as-needed basis. C. apply disposable diapers. D. encourage hourly toileting.

A. label the bathroom door with a picture.

A nursing diagnosis appropriate for a client with Alzheimer's disease, regardless of the stage, would be A. risk for injury. B. acute confusion. C. imbalanced nutrition. D. impaired environmental interpretation syndrome.

A. risk for injury.

A nurse is interviewing a patient and assessing the patient's readiness to change. Which statements by the patient in the motivational interview reflect this willingness? (Select all that apply.) Select all that apply. The patient states, "I now realize that the drinking has affected by family life." The patient states, "I have been attending one meeting a day." The patient states, "I am glad that I did not drag others into my drinking." The patient states, "I don't think my body will recover from the drinking." The patient states, "I will watch the game at my friend's house instead of at the bar."

ABE

The nurse is completing a care plan for a patient who is exhibiting poor coping after receiving a serious medical diagnosis. Which interventions should the nurse consider? (Select all that apply.) Select all that apply. Review pamphlets about treatment options with the patient. Compile a list of activities that are of interest to the patient. Recommend a glass of wine before dinner each night for relaxation. Reinforce the fact that the medical team can make treatment decisions, so the patient does not need to worry. Identify positive aspects of the illness, such as the chance to spend more time with family.

ABE

Data about infection with chlamydia trachomatis are obtained by the health department in order to do which of the following? (Select all that apply. One, some, or all options may be correct.) Select all that apply Report to the Centers for Disease Control and Prevention (CDC). Follow up with individuals after they have received treatment. Notify others who may have contracted the infectious disease. Identify trends in the incidence of communicable diseases. Plan and implement prevention and disease control programs.

ADE

A man with a primary infection of genital herpes was prescribed acyclovir (Zovirax) orally for 10 days. The patient returns to the clinic for a follow-up visit. Which finding indicates that treatment is effective? Negative bacterial culture Absence of genital lesions Reduction of genital warts No drainage from chancre sore

Absence of genital lesions

In working with teenagers, what should the nurse include when teaching about prevention of STIs? Spermicidal jellies reduce the risk of getting STIs. Douches for women and cleaning the penis will prevent STIs Abstinence and then latex barriers, such as condoms, are the best prevention Getting an STI is embarrassing so you will want to use preventive measures.

Abstinence and then latex barriers, such as condoms, are the best prevention

Which event discovered during pregnancy would alert the nurse that a cesarean section delivery is indicated? Contact with a person with syphillis 2 weeks ago Treatment for gonococcal pharyngitis before conception Treatment for C. trachomatis at her 20th week of gestation Active herpes simplex virus type 2 vesicles on her cervix at the time of delivery

Active herpes simplex virus type 2 vesicles on her cervix at the time of delivery

The nurse is caring for a patient who is to receive a transfusion of two units of packed red blood cells. After obtaining the first unit from the blood bank, the nurse would ask which health team member in the nurses' station to assist in checking the unit before administration? Unit secretary A physician's assistant Another registered nurse An unlicensed assistive personnel

Another registered nurse Before hanging a transfusion, the registered nurse must check the unit with another RN or with a licensed practical (vocational) nurse, depending on agency policy. The unit secretary, physician's assistant, or unlicensed assistive personnel should not be asked.

Which statement about antidepressant medications, in general, can serve as a basis for client and family teaching? A. Onset of action is from 1 to 3 weeks or longer. B. They tend to be more effective for men. C. Recent memory impairment is commonly observed. D. They often cause the client to have diurnal variation.

Answer: A A drawback of antidepressant drugs is that improvement in mood may take 1 to 3 weeks or longer. None of the other options provide correct information regarding antidepressant medications

A depressed, socially withdrawn client tells the nurse, "There is no sense in trying. I am never able to do anything right!" The nurse can best address this cognitive distortion with which response? A. "Let's look at what you just said, that you can 'never do anything right.'" B. "Tell me what things you think you are not able to do correctly." C. "Is this part of the reason you think no one likes you?" D. "That is the most unrealistic thing I have ever heard."

Answer: A Cognitive distortions can be refuted by examining them, but to examine them the nurse must gain the client's willingness to participate. None of the other options examines the underlying cause of the feeling

When the nurse remarks to a depressed client, "I see you are trying not to cry. Tell me what is happening." The nurse should be prepared to implement which intervention? A. Waiting quietly for the client to reply B. Prompting the client if the reply is slow C. Repeating the question if the client does not answer promptly D. Reviewing the client's medical record to support the client's response

Answer: A Depressed clients think slowly and take long periods to formulate answers and respond. The nurse must be prepared to wait for a reply.

A new psychiatric technician mentions to the nurse, "Depression seems to be a disease of old people. All the depressed clients on the unit are older than 60 years." How should the nurse respond to this statement? A. "That is a good observation. Depression does mostly strike people older than 50 years." B. "Depression is seen in people of all ages, from childhood to old age." C. "Depression is most often seen among the middle adult age group." D. "The age of onset for most depressive episodes is given as 18 years."

Answer: B Depression can occur at any age. Children, adolescents, adults, and the elderly may all experience depression.

What statement about the comorbidity of depression is accurate? A. Depression most often exists in an individual as a single entity. B. Depression is commonly seen in individuals with medical disorders. C. Substance abuse and depression are seldom seen as comorbid disorders. D. Depression may coexist with other disorders but is rarely seen with schizophrenia.

Answer: B Depression commonly accompanies medical disorders. The other options are false statements.

When the nurse asks whether a client is having any thoughts of suicide, the client becomes angry and defensive, shouting, "I'm sick of you people! Are you ever do is ask me the same question over and over. Get out of here!" The nurse's response is based on what fact concerning hostility? A. The client is getting better and is able to be assertive. B. The client may be at high risk for self-harm. C. The client is probably experiencing transference. D. The client may be angry at someone else and projecting that anger to staff.

Answer: B Overt hostility is highly correlated with suicide; therefore the patient may be considered high risk, and appropriate precautions should be taken. The other responses are incorrect with no evidence to support them

What is the major reason for hospitalization of the depressed patient? A. Inability to go to work B. Suicidal Ideation C. Loss of appetite D. Psychomotor agitation

Answer: B Suicidal thoughts are a major reason for hospitalization for patients with major depression. It is imperative to intervene with such patients to keep them safe from self-harm. The other options describe symptoms of major depression but aren't by themselves the major reason for hospitalization

When the clinician mentions that a client has anhedonia, the nurse can expect that the client will demonstrate what behavior? A. Poor retention of recent events B. A weight loss from anorexia C. No pleasure from previously enjoyed activities D. Difficulty with tasks requiring fine motor skills

Answer: C Anhedonia is the only term that suggests the lack of ability to experience pleasure.

Beck's cognitive theory suggests that the etiology of depression is related to what factor? A. Sleep abnormalities B. Serotonin circuit dysfunction C. Negative processing of information D. Belief that one has no control over outcomes

Answer: C Beck is a cognitive theorist who developed the theory of the cognitive triad of three automatic thoughts responsible for people becoming depressed: (1) a negative, self-deprecating view of oneself; (2) a pessimistic view of the world; and (3) the belief that negative reinforcement will continue. None of the other options are related to this theory.

Assessment of the thought processes of a client diagnosed with depression is most likely to reveal what characteristic? A. Good memory and concentration B. Delusions of persecution C. Self-deprecatory ideation D. Sexual preoccupation

Answer: C Depressed clients never feel good about themselves. They have a negative, self-deprecating view of the world. This characteristic is not associated with any of the other options.

A 38-year-old patient is admitted with major depression. Which statement made by the patient alerts the nurse to a common accompaniment to depression? A. "I still pray and read my Bible every day." B. "My mother wants to move in with me, but I want to independent." C. "I still feel bad about my sister dying of cancer. I should have done more for her!" D. "I've heard others say that depression is a sign of weakness."

Answer: C Guilt is a common accompaniment to depression. A person may ruminate over present or past failings. Praying and reading the Bible describes a coping mechanism; the other responses do not describe a common accompaniment to depression.

A depressed client tells the nurse, "There is no sense in trying. I am never able to do anything right!" The nurse should identify this cognitive distortion as what response? A. Self-blame B. Catatonia C. Learned helplessness D. Discounting positive attributes

Answer: C Learned helplessness results in depression when the client feels no control over the outcome of a situation. None of the other options demonstrate these feelings

A depressed client is noted to pace most of the time, pull at her clothes, and wring her hands. These behaviors are consistent with which term? A. Senile dementia B. Hypertensive crisis C. Psychomotor agitation D. Central serotonin syndrome

Answer: C These behaviors describe the psychomotor agitation sometimes seen in clients with the agitated type of depression. None of the other options are associated so directly with these behaviors.

A client prescribed fluoxetine demonstrates an understanding of the medication teaching when making which statement? A. "I will make sure to get plenty of sunshine and not use sunscreen to avoid a skin reaction." B. "I will not take any over-the-counter medication while on the fluoxetine." C. "I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away." D. "I will report increased thirst and urination to my provider."

Answer: C This describes symptoms of serotonin syndrome, a life-threatening complication of SRRI medication. The other options are incorrect because the patient should be wearing sunscreen to avoid sunburn, may take over-the-counter medications if sanctioned by the provider, and would not have been educated to report increased thirst and urination as a side effect of fluoxetine.

A client admitted with major depression and suicidal ideation with a plan to overdose is preparing for discharge and asks you, "Why did I get a prescription for only 7 days of amitriptyline?" The nurse's response is based on what fact? A. Amtriptyline is very expensive, so the patient may have to buy fewer at a time. B. The goal is to see how the client responds to the first week of medication to evaluate its effectiveness. C. The health care provider wants to see whether any side effects occur within the first week of administration D. Amtriptyline is lethal in overdose.

Answer: D Amitriptyline is a tricyclic antidepressant (TCA); these drugs are known to be lethal in smaller doses than other antidepressants. Because the patient had a plan of overdose, the best course of action is to give a small prescription requiring her to visit her provider's office more often for monitoring of suicidal ideation and plan. Tricyclics are not known to be expensive. Antidepressant therapy usually takes several weeks to produce full results, so the patient would not be evaluated after only 1 week. Side effects are always a consideration but not the most important consideration with TCAs.

Dysthymia cannot be diagnosed unless it has existed for what period of time? A. At least 3 months B. At least 6 months C. At least 1 year D. At least 2 years

Answer: D Dysthymia is persistent depressive disorder and is a chronic condition that by definition has to have existed for longer than 2 years in adults and 1 year in children and adolescents.

A client prescribed a selective serotonin reuptake inhibitor mentions taking the medication along with the St. John's wort daily. The nurse should provide the client with what information regarding this practice? A. Agreeing that this will help the client to remember the medications. B. Caution the client to drink several glasses of water daily. C. Suggest that the client also use a sun lamp daily. D. Explain the high possibility of an adverse reaction.

Answer: D Serotonin malignant syndrome is a possibility if St. John's wort is taken with other antidepressants. None of the other options are relevant to the situation

A 16-year-old patient being treated for anorexia, has been prescribed medication to reduce compulsive behaviors regarding food now that ideal weight has been reached. Which class of medication is prescribed for this specific issue associated with eating disorders? A. Mood stabilizers B. Antidepressants C. Anxiolytics D. Atypical antipsychotics

Antidepressants

A young male patient is seeking treatment for recurrence of genital tingling, burning, and itching. The nurse will expect a prescription for which class of medications? Antivirals Antibiotics Vaccination Contraceptives

Antivirals

A patient coming to the health clinic for a blood pressure check reports to the nurse that she just does not have the energy to go out much in winter but looks forward to gardening in summer. The nurse realizes that this patient is describing a major symptom of what condition? Antisocial personality Seasonal affective disorder Anxiety Medication side effects

Nico, a 22-year-old patient, is diagnosed with schizophrenia. Which of the following symptoms would alert a provider to a possible diagnosis of schizophrenia in a 22-year-old male client? A Excessive sleeping with disturbing dreams B Hearing voices telling him to hurt his roommate C Withdrawal from college because of failing grades D Chaotic and dysfunctional relationships with his family and peers

Once the client goes home, she will continue the antibiotics and follow up with the HCP for regular blood tests. Which is the most important instruction the nurse should give the client to maintain a positive outcome? Floss teeth every day to remove bacteria from the mouth. Monitor and record temperature daily for up to 6 weeks. Stop taking the antibiotic when you feel better and call the HCP. It is not necessary to remind the HCP or dentist of the clients endocarditis.

Self-care at homeThe client is discharged home with a home health referral. The home health nurse visits the day after she is discharged from the hospital. The client's caregiver asks the home-health nurse, "I received some information from the Sickle Cell Foundation, but I have never heard of it. What kind of group is it?" How should the nurse respond? "It is a foundation that deals primarily with research to find the cure for sickle cell anemia." "It provides information on the disease and on support groups in this area." "They didn't discuss this organization with you in the hospital?" "The foundation arranges for families with children who have sickle cell to meet each other."

The ED nurse continually assesses the client for signs and symptoms of hypoxia. The client's caregiver presses the call bell to tell the nurse there is blood in the commode after the client went to the bathroom to urinate. Which action should the nurse implement? Notify the HCP immediately. Explain that blood in the urine is expected. Request a stat hemoglobin level. Request a stat sterile urine specimen.

The client is transferred from the ED to the pediatric intensive care department (PICU). In developing the plan of care with the RN team leader, the nurses identify the nursing problem, "Acute pain related to tissue ischemia" as a priority. Which intervention should be included in the care plan? Assess pain by using a numerical pain scale. Explain how to use a patient controlled analgesic pump. Apply cold compresses periodically to painful joints. Administer acetaminophen as needed (PRN) as needed for pain.

The client says that he is feeling better and it is now time to give the scheduled medications. Because of the new medical diagnosis of pernicious anemia, the healthcare provider (HCP) has prescribed cyanocobalamin (vitamin B12) 100 mcg/day subcutaneously (SQ) for seven days with a follow up clinical visit for laboratory work on the seventh day. Before giving the medication, what should the nurse do first? Sign off the medication in the electronic medical record (EMR). Teach the client about the medication being given. Locate the ventrogluteal muscle of the left hip. Ask if the client has been NPO for the last 8 hours.

The client says that she is still unclear about the placement of the PICC line and needs further explanation. Which is the best approach for the nurse to teach an adult learner? Contact the PICC line nurse to discuss placement with the client. Provide a pamphlet or video for the client to reinforce verbal instructions. Demonstrate simulation placement on a manikin for the client. Reiterate previous instructions given to the client.

The client's caregiver goes downstairs to get something to eat from the hospital cafeteria. The unlicensed assistive personnel (UAP) informs the nurse the client urinated in the bed, is crying, and wants her caregiver. Which intervention should the nurse implement first? Change the bed linens. Help change her clothes. Find the client's caregiver in the cafeteria. Document the incident in the chart.

The following day, after all consultants have either met with the client or the attending healthcare provider (HCP), the nurse prepares for a follow up discussion about treatment options. The psychologist reports that the client has newly diagnosed alcohol misuse, and he has probably had it for quite some time. He has reported that he usually enjoys about three quarts of whiskey each week. The client agrees to the nurse's request to sit with him for a while to discuss his treatment plan. His usual disengaged and surly affect has changed significantly. Today he is pleasant and very glad to see the nurse. What question should the nurse ask the client first? Are you able to tell me about your treatment plan? Do you have any thoughts of harming yourself? Have you been drinking any alcohol at all today? How do you feel about your new diagnosis of alcohol misuse?

The mother of a 3-year-old boy just diagnosed with autism spectrum is tearful and states, "The doctor said we need to start therapy right away. I just don't understand how helpful it will be—he's only 3 years old!" What response should the nurse provide to the mother's statement? A "You are right, 3 years old is very young to start therapy, but it will make you feel better to be doing something." B "Starting him on treatment now gives Taylor a much greater chance for a productive life." C "If your child starts therapy now, he will be able to stop therapy sooner." D "If you have questions, its best to ask the doctor."

The nurse can expect a client demonstrating typical manic behavior to be attired in clothing that includes with characteristics? Dark colored and modest Colorful and outlandish Compulsively neat and clean Ill-fitted and ragged

The nurse explains that even though the student's sexual partner will be wearing a condom, it is important for the student to understand the application of a latex condom to protect herself and her partner. Which instruction should the nurse include about condom application? Put on the condom before the penis is erect. Ensure no air is trapped in the tip of the condom. Avoid the use of water-based lubricants when using a condom. Use oil-based lubricants when using a condom.

What is a desired outcome for the maintenance phase of treatment for a manic client? A Exhibit optimistic, energetic, playful behavior. B Adhere to follow-up medical appointments. C Take medication more than 50% of the time. D Use alcohol to moderate occasional mood "highs."

When a hyperactive manic client expresses the intent to strike another client, the initial nursing intervention would be to question the client's motive. set verbal limits. initiate physical confrontation. prepare the client for seclusion.

Which action should the ED nurse implement first? Request arterial blood gasses stat. Administer oxygen via nasal cannula. Send the client for an x-ray of her knees and elbows. Prepare to administer analgesics as prescribed.

The nurse is admitting a new patient to the psychiatric unit. Which factors will most likely contribute to a positive outcome of the interaction? (Select all that apply.) Select all that apply. A The patient states that he or she is in pain. B The patient is awake, alert, and oriented to person, place, and time. C The patient is in a bad mood. D There are various interactive sessions going on in the unit today. E The patient has been admitted to the facility in the past. F The unit is quiet.

B, E, F

Which statement, made by a client diagnosed with dissociative identity disorder, demonstrates effective understanding in response to the question, "What exactly are the 'alters'? your provider told you about?" illustrates that the education you provided has been effective? A. "So, alters are based in mysticism and religiosity, such as demons." B. "So, alters are separate personalities with their own characteristics that take over during stress." C. "So, alters are never aware of each other." D. "So, alters are just like me, but they have no memory of the trauma I went through."

B. "So, alters are separate personalities with their own characteristics that take over during stress." Dissociative identity disorder appears to be associated with at least two dissociative identity states: one is a state or personality that functions on a daily basis and blocks access and responses to traumatic memories, and another state (also referred to as an alter state) is fixated on traumatic memories. Each alter has its own memories, behavior patterns, and characteristics. Transition from one personality to another (switching) occurs during times of stress. The other responses are incorrect, because alters may be aware of the existence of each other to some degree, and alters are not just like the host—they have different behaviors and memories.

A client's daughter states, "My mother lives with me since my dad died 6 months ago. For the past couple of months, every time I need to leave the house for work or anything else, Mom becomes extremely anxious and cries that something terrible is going to happen to me. She seems OK except for these times, but it's affecting my ability to go to work." This information supports that the client may be experiencing which anxiety-related disorder? A. Panic disorder B. Adult separation anxiety disorder C. Agoraphobia D. Social anxiety disorder

B. Adult separation anxiety disorder.

The nurse is assessing a group of patients to determine their risk of vitamin D deficiency. Which of the following patients has the highest risk for vitamin D deficiency? A. Caucasian female who is 39 weeks gestation. B. An African-American female who is breastfeeding. C. An Asian female diagnosed with hypoglycemia. D. A Hispanic female who has a BMI of 24.1.

B. An African-American female who is breastfeeding.

Which of the following statements about dissociative disorders is true? A. Dissociative symptoms are under the person's conscious control. B. Dissociative symptoms are not under the person's conscious control. C. Dissociative symptoms are usually a cry for attention. D. Dissociative symptoms are always negative.

B. Dissociative symptoms are not under the person's conscious control. Dissociation is involuntary and results in failure of the normal control over a person's mental processes and normal integration of conscious awareness. The other responses are untrue.

When evaluating the concept of gas exchange, how would the nurse best describe the movement of oxygen and carbon dioxide? A. Oxygen and carbon dioxide are exchanged across the capillary membrane to provide oxygen to hemoglobin. B. Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane. C. The level of inspired oxygen must be sufficient to displace the carbon dioxide molecules in the alveoli. D. Gases are exchanged between the atmosphere and the blood based on the oxygen-carrying capacity of the hemoglobin.

B. Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane.

4. A patient is questioning the nurse about circulation and perfusion. What is the nurse's best response? A. Perfusion assists the body by preventing clots and increasing stamina. B. Perfusion assists the cell by delivering oxygen and removing waste products. C. Perfusion assists the heart by increasing the cardiac output. D. Perfusion assists the brain by increasing mental alertness.

B. Perfusion assists the cell by delivering oxygen and removing waste products. Perfusion delivers much needed oxygen to the cells of the body and then helps to remove waste products. Perfusion does not prevent clots, does not increase cardiac output, and does not increase mental alertness. Awarded 1.0 points out of 1.0 possible points.

A 72-year-old patient diagnosed with Parkinson's disease is demonstrating behaviors associated with anxiety and has had several falls lately and is reluctant to take medications as prescribed. When his provider orders lorazepam, 1 mg PO bid, the nurse questions the prescription based primarily on what fact? A. The client may become addicted faster than younger patients. B. The client is at risk for falls. C. The client has a history of nonadherence with medications. D. The client should be treated with cognitive therapies because of his advanced age.

B. The client is at risk for falls

The family of a client diagnosed with Alzheimer's disease mentions to the nurse that seeing his loss of function has been very difficult. A nursing diagnosis that might be considered for such a family would be A. ineffective denial. B. anticipatory grieving. C. disabled family coping. D. ineffective family therapeutic regimen management.

B. anticipatory grieving.

In collaboration with the nurse, the attending healthcare provider (HCP) has consulted several specialists for a conference to plan the client's care. The nurse is also preparing to initiate a follow up discussion about treatment options with the client after the meeting. Which consultants will be most helpful during this meeting? (Select all that apply. One, some, or all options may be correct.) Occupational therapy. Hematologist. Psychologist/Psychiatrist. Gastroenterologist. Internist. Speech therapy.

BCDE

The nurse is caring for a patient newly diagnosed with major depressive disorder. What typical signs and symptoms would the nurse expect? (Select all that apply.) Select all that apply. Increased fever Slowed speech Increased white blood cell count Appetite changes Poor eye contact

BDE

A client is diagnosed with generalized anxiety disorder (GAD). The nursing assessment supports this diagnosis when the client reports which information? Symptoms started right after being robbed at gunpoint. Being unable to work for the last 12 months. Eating in public makes the client extremely uncomfortable. Repeated verbalizing prayers results in a relaxed feeling.

Being unable to work for the last 12 months. Correct

Which social behavior is often a result of a child having been exposed to some form of abuse? Speech disorders Bullying others Eating disorders Delayed motor skills

Bulling others

A nurse is presenting a workshop on interpersonal violence prevention. Which is a common risk factor for interpersonal violence should be addressed in the workshop? Poor working conditions Hypertension medications Alcohol use Poor self-esteem

A patient has begun smoking again and drinks six alcoholic beverages per day since experiencing the loss of his job. The nurse recognizes that the patient is exhibiting symptoms of which type of stress? Psychological Physiological Behavioral Emotional

A patient who is at a health clinic reports a sore throat and is exhibiting signs of depression. The nurse administers a basic screening for depression. What level of prevention is the nurse performing? Primary prevention Tertiary prevention Secondary prevention Modified prevention

A teenaged client is being discharged from the psychiatric unit with a prescription for risperidone. The nurse providing medication teaching to the client's mother should provide which response when asked about the risk her son faces for extrapyramidal side effects (EPSs)? A All antipsychotic medications have an equal chance of producing EPSs. B Newer antipsychotic medications have a higher risk for EPSs. C Risperidone is a newer antipsychotic medication and has a lower risk of EPSs than older antipsychotics. D eAdvise the mother to ask the provider to change the medication to clozapine instead of risperidone.

Before giving cyanocobalamin, the nurse teaches the client about his medication. The client interrupts the teaching session and asks, "What happens if I just do not take the shots?" What is the best way for the nurse to respond? Are you not going to comply with this prescription? It sounds like you do not want to take these shots. You will gradually get very ill and die in 1 to 3 years. Let me talk to the healthcare provider and get you the tablets.

Despite the importance of sexual health to overall well-being, many nurses and patients are uncomfortable discussing issues related to sexuality. It is for this reason that the nurse must include questions regarding a sexual health history as part of a comprehensive health assessment. A 15-year-old female patient has come to the office for her annual physical and first pelvic examination. In this situation, which nursing action is most important? A. Encourage the patient to ask questions about sexuality. B. Screen for possible abuse. C. Excuse the parent. D. Ensure the patient that all information will be kept confidential.

Discharge Instructions Client is scheduled for discharge the next day. The nurse is completing discharge teaching with her caregiver who says they are planning a visit to Colorado to see the caregiver's sister and her family for the Christmas holidays. The client is very excited and can't wait to meet her cousins. What is the best response by the nurse? "I know that she will enjoy meeting her family." "I think you should talk to her HCP before you go." "Your planned trip may put her at risk for a crisis." "Could your family come here for the Christmas holidays instead?"

During interviews with a select group of students, the nurse is questioned about sexual and reproductive health. One student asks the nurse if any of the sexually transmitted diseases can be transmitted through oral sex. Which of the following is the correct response? It is rare for a sexually transmitted infection to be transmitted through oral sex. Sexually transmitted infections are only transmitted through vaginal or anal sex. Sexually transmitted infections can be transmitted through oral, vaginal or anal sex. Only viral sexually transmitted infections can be transmitted through oral sex.

In order to fully understand the concept of sexuality, it is necessary to become familiar with the terms used when discussing this topic. Which term best describes how one views oneself as masculine or feminine? A. Sexual identity B. Sexual orientation C. Gender identity D. Sexual behavior

Testing for pregnancy and sexually transmitted infections at a school-based health center is an example of which level of prevention? Prodromal prevention Primary prevention Secondary prevention Tertiary prevention

The ED HCP completes the assessment and diagnoses the client with a vaso-occlusive sickle cell crisis, probably secondary to pneumonia. Which orders should the nurse anticipate? Select all that apply Provide the client with cold packs to place on her joints. Admit the client to a private room and keep her in reverse isolation. Infuse 5% Dextrose in 0.33% sodium chloride (NS) at 75 mL/hr via pump. Insert a 22 French indwelling urinary catheter with an urometer.

The client is in the ICU for 3 days and is transferred to the pediatric floor. Her caregiver has been at the hospital every day and is very concerned about her condition. The caregiver asks the nurse, "What can I do to make sure this never happens again?" Which is the best initial response by the nurse? "When your daughter gets a fever give her 1 baby aspirin." "Keep her away from anyone who has an infection." "There is no way you can make sure this never happens again." "Make sure she does not participate in any strenuous activity."

Which of the following is true of the relationship between bipolar disorder and suicide? A Patients need to be monitored only in the depressed phase because this is when suicides occur. B Suicide is a serious risk because nearly 20% of those diagnosed with bipolar disorder commit suicide. C Patients with bipolar disorder are not considered high risk for suicide. D As long as patients with bipolar disorder adhere to their medication regimen, there is little risk for suicide.

Which room placement would be best for a client experiencing a manic episode? A shared room with a client with dementia A single room near the unit activities area A single room near the nurses' station A shared room away from the unit entrance

The nurse is caring for a patient on day 1 post surgical procedure. The patient becomes visibly anxious and short of breath, and states, "I feel so anxious! Something is wrong!" What action should the nurse take initially in response to the patient's actions? A. Reassure the patient that what they are feeling is normal anxiety and do deep breathing exercises with her. B. Use the call light to inquire whether the patient has been prescribed prn anxiety medication. C. call for staff help and assess the client's vital signs D. Reassure the patient that you will stay until the anxiety subsides.

C. Call for staff help and assess the client's VS.

Which statement concerning syndromes seen in other cultures but not seen in our own, such as piblokto, Navajo frenzy witchcraft, and amok should be considered true? A. Dissociative disorders such as dissociative identify disorders B. Physical disorders, not mental disorders C. Culture-bound syndromes that are not dissociative disorders D. Myths, or rumors, because they have not been sufficiently studied to be classified as real.

C. Culture-bound syndromes that are not dissociative disorders Certain culture-bound disorders exist in which there is a high level of activity, a trancelike state, and running or fleeing, followed by exhaustion, sleep, and amnesia regarding the episode. These syndromes, if observed in individuals native to the corresponding geographical areas, should be differentiated from dissociative disorders. The other responses are incorrect.

A 4 years old is referred to the outpatient mental health clinic after being in a severe car accident during which the child mother died. The father states that the child is withdrawn, not sleeping, having nightmares, and acts out the car accident over and over again when playing. The child states, "It's my fault because I'm bad." What trauma induced disorder does this data support? A. Adjustment disorder B. Dissociative identity disorder C. Posttraumatic stress disorder (PTSD) D. Acute stress disorder (ASD)

C. Posttraumatic stress disorder (PTSD) PTSD in preschool children may manifest as repetitive play that includes aspects of the traumatic event, social withdrawal, and negative emotions such as fear, guilt, anger, horror, sadness, shame, or confusion. Children may blame themselves for the traumatic event and manifest persistent negative thoughts about themselves. Unlike PTSD, adjustment disorder may be diagnosed immediately or within 3 months of exposure. Responses to the stressful event may include combinations of depression, anxiety, and conduct disturbances. Dissociative identity disorder includes the presence of "alters" or other personalities that take over in times of stress. As compared with PTSD that occurs a month after the trauma, ASD occurs from 3 days and up to 1 month after exposure to a highly traumatic event. Individuals with ASD experience three or more dissociative symptoms either during or after the traumatic event, including the following: a sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization (a sense of unreality related to the environment); depersonalization (experience of a sense of unreality or self-estrangement); or dissociative amnesia (loss of memory).

The nurse is caring for a patient with emphysema. The patient is complaining of shortness of breath and dyspnea on minimal exertion. Which assessment finding alerts the nurse that the patient is going into respiratory failure? A. The patient has bibasilar lung crackles. B. The patient is sitting in the tripod position. C. The patient's respirations have decreased from 30 to 10 breaths/minute. D. The patient's pulse oximetry indicates an O2 saturation of 91%.

C. The patient's respirations have decreased from 30 to 10 breaths/minute.

Trudy is a 72-year-old patient hospitalized with pneumonia and experiencing delirium. She points to her IV pole and screams, "Get him out of here! He's going to hurt me!" You recognize that what Trudy is experiencing is a(n): A. hallucination. B. delusion. C. illusion. D. confabulation.

C. illusion.

A diabetic patient who is hospitalized asks the nurse what factors are associated with increased blood glucose while in the hospital. Which response(s) by the nurse are appropriate? (Select all that apply.) Select all that apply. A patient's diet is different here in the hospital than at home, and that is the most likely because of the increased glucose level. Increased blood sugar occurs because the kidneys are not able to metabolize glucose as well during stressful times. Medications such as steroids may increase glucose levels. Stressors such as illness cause the release of hormones that increase blood sugar. Blood sugar may be higher in the hospital due to decreased activity or rest.

CDE

The nurse is assessing a patient using the CAGE questionnaire. Which statement(s) by the patient should make the nurse suspect possible alcoholism? (Select all that apply.) Select all that apply. The patient states, "I go to meetings once or twice a week but continue to drink." The patient states, "I can quit whenever I want to." The patient states, "I am going to try to cut down on drinking. I have been partying too much." The patient says to the nurse, "I am ashamed of how much I have been drinking lately." The patient states, "I usually have a Bloody Mary or Mimosa with breakfast." The patient states, "My wife keeps nagging me about my drinking."

CDEF

Five students arrive at the school nurse's office and sign in to be seen by the school nurse. Each identifies the reason for their visit. The nurse can see a student during the instructional period, write a pass for the student to leave during another instructional period, or refer the student to the high school staff who can assist the student to go home. Which of the following students would the nurse prioritize visiting with during the current instructional period? (Select all that apply. One, some, or all options may be correct.) Select all that apply A student who writes 'My coach told me to sign up for the brain injury prevention training.' A student who writes 'My stomach hurts and I think I am going to vomit. My brother is home sick with the same thing. My history teacher wants me to take a test but I think I should go home.' A student who writes 'I need to talk about something confidential.' A student who writes 'I have another migraine. I already took my medicine and it's getting worse. My gym teacher says I need a pass to leave class or I'll get a failing grade. I have to go home and sleep.' A student who writes 'My girlfriend just told me she is pregnant.'

A female patient arrives at the emergency department visibly upset and tearful. She refuses to have a male caregiver, asks for a room close to an exit door, and does not make eye contact with staff. What does the nurse suspect is happening with the patient? The patient may be having an acute psychotic episode related to her mental illness. The patient may be a very demanding and particular person. The patient may be abusing street drugs and needs a drug screening test. The patient may have been the victim of an acute assault.

After attending school for 2 weeks without any problems, the client reports to the school nurse that she doesn't feel well. The nurse determines she has a temperature of 102° F (38.8o C). The school nurse calls her caregiver and advises the nurse to take the client directly to the emergency department (ED). She reported pain in her knees, in her elbows, and throughout her body. In the ED, the nurse confirms vital signs with temperature 102u00b0 F (38.8° C), pulse 104 beats per minute, respirations 24 breaths per minute, blood pressure 90/68 mmhg, and pulse oximeter reading 91%. The nurse notifies the ED physician of the child's vital signs, which are: vital signs as Temperature 102° F (38.8° C), Pulse 104 beats per minute, Respirations 24 breaths per minute, Blood Pressure 90/68 mmhg, and pulse oximeter reading 91%. The school nurse reviews immunization records from the client's previous school. The nurse notes the client had four scheduled doses of DTaP, three scheduled doses of Hib, and one dose of MMR and received her Hep B series as an infant. The nurse anticipates an order for which diagnostic test by the ED HCP? Peripheral blood smear. Hemoglobin electrophoresis. Sickle-turbidity test (Sickledex). Blood cultures.

Human sexuality is interrelated with a variety of other nursing concepts that may affect sexuality or be affected by healthy sexual functioning. Prompt diagnosis and treatment of potential concerns related to concept overlap is an important nursing function. Which other concept is most likely to overlap with sexuality? A. Stress B. Gas exchange C. Pain D. Reproduction

The following Monday, the client goes with her caregiver to the local elementary school, where she is enrolled in the third grade. The caregiver meets with the school nurse to discuss the client's needs while she attends school. The school nurse has cared for several children with SCD and is very knowledgeable about the needs of children with the disease. The school nurse discusses the client's condition with the classroom teacher. Which intervention should the nurse implement? Explain that the other children should be extra nice to the client. Instruct the teacher to have the client sit at the front of the classroom. Encourage the client to participate in all playground activities. Request the client be allowed to go to the bathroom whenever she asks.

The night nurse assesses the client and notes that her vital signs are now temperature 98.3° F (36.8o C), pulse 108 beats per minute, respirations 22 breaths per minute, blood pressure 96/60 mmhg. Which action should the nurse implement? Notify the HCP immediately. Retake and assess the vital signs in 1 hour. Encourage the client to turn, cough, and deep breathe. Document the findings on the graphic sheet.

The nurse notes that the client has had many personal losses in his life, and he recently lost his legal partner in an accident. His electronic medical record (EMR) has no one listed as a person to contact in case of emergencies. Which question is the best way for the nurse to begin assessing the client's support systems and available resources? "Can you tell me more about what happened to your professional partner?" "Which neighborhood bar do you regularly go to after work in the evenings?" "I'm sorry for your loss. Was your legal partner also your domestic partner?" "Who would you like to have listed as your emergency contact person?"

When a client experiences four or more mood episodes in a 12-month period, which term is used to describe this behavior? Dyssynchronous Incongruent Cyclothymic Rapid cycling

When the wife of a manic client asks about genetic transmission of bipolar disorder, the nurse's answer should be predicated on which information? A No research exists to suggest genetic transmission. B Much depends on the socioeconomic class of the individuals. C Highly creative people tend toward development of the disorder. D The rate of bipolar disorder is higher in relatives of people with bipolar disorder.

Which of the following is an example of prevalence of communicable disease? Individuals with chlamydia who test positive when re-tested. Sexual partners exposed to an individual infected with HIV. New diagnoses of gonorrhea in the community. Number of individuals in the county with hepatitis C.

Which side effect of antipsychotic medication is generally nonreversible? A Anticholinergic effects B Pseudoparkinsonism C Dystonic reaction D Tardive dyskinesia

Which sign or diagnostic result should the nurse expect to observe in a client due to hypokalemia? An arm tremor while taking the client's blood pressure. Hyperactive deep tendon reflexes. Elevated serum glucose level. A dampened or flattened T-wave on an electrocardiogram (ECG).

A client is brought to the hospital by her daughter, who visited this morning and found her mother to be confused and disoriented. When the client is admitted, the daughter states, "I'll take her glasses and hearing aid home, so they don't get lost." The best reply for the nurse would be A. "That will be fine. I'll have you sign our hospital release form." B. "Because we do not have a copy of durable power of attorney, we cannot release them to you." C. "Don't worry. You can leave them at her bedside. We are insured for losses of this sort." D. "I would like to have your mother wear them. It will help her to be less confused."

D. "I would like to have your mother wear them. It will help her to be less confused."

The nurse would anticipate that which of the following patients will need to be treated with insertion of a chest tube? A. A patient with asthma and severe shortness of breath B. A patient undergoing a bronchoscopy for a biopsy C. A patient with a pleural effusion requiring fluid removal D. A patient experiencing a problem with a pneumothorax

D. A patient experiencing a problem with a pneumothorax

The nurse is caring for a patient who suddenly becomes agitated and confused. Which action should the nurse takes first? A. Notify the health care provider. B. Check pupils for reaction to light. C. Attempt to calm and reorient the patient. D. Assess oxygenation using pulse oximetry.

D. Assess oxygenation using pulse oximetry.

The nurse is providing teaching to a preoperative patient just before surgery. The patient is becoming more and more anxious and begins to report dizziness and heart pounding. The patient also appears confused and is trembling noticeably. Considering the scenario, what decision should the nurse make? A. To reinforce the preoperative teaching by restating it slowly. B. Have the patient read the teaching materials instead of providing verbal instruction. C. Have a family member read the preoperative materials to the patient. D. Do not attempt any further teaching at this time.

D. Do not attempt any further teaching at this time.

What is the major distinction between fear and anxiety? A. Fear is a universal experience; anxiety is neurotic. B. Fear enables constructive action; anxiety is dysfunctional. C. Fear is a psychological experience; anxiety is a physiological experience. D. Fear is a response to a specific danger; anxiety is a response to an unknown danger.

D. Fear us a response to a specific danger, anxiety is a response to an unknown danger.

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient tells the nurse he is having a "hard time breathing." His respiratory rate is 32 breaths per minute, his pulse is 120 beats per minute, and the oxygen saturation is 90%. What would be the best nursing intervention for this patient? A. Begin oxygen via a face mask at 60% FiO2 (fraction of inspired oxygen) B. Administer a PRN (as necessary) dose of an intranasal glucocorticoid C. Encourage coughing and deep breathing to clear the airway D. Initiate oxygen via a nasal cannula, and begin at a flow rate of 3 L/min

D. Initiate oxygen via a nasal cannula, and begin at a flow rate of 3 L/min

Claire is a student nurse working with Carl, an 82-year-old patient with dementia. She finds herself frustrated at times by not knowing how best to care for or communicate with Carl. Which of the following statements she could make to Carl illustrates best care practice? A. Lighthearted banter: "Carl, you look great today in your new sweater, you handsome devil!" B. Limit setting: "Carl, you cannot yell out in your room. You are upsetting other patients." C. Firm direction: "You will take a shower this morning; there is no debating about it so don't try to argue." D. Positive regard: "Carl, I am glad to be here caring for you today. Let's talk about your plans for the day."

D. Positive regard: "Carl, I am glad to be here caring for you today. Let's talk about your plans for the day."

The nurse caring for a client with Alzheimer's disease can anticipate that the family will need information about therapy with A. antihypertensives. B. benzodiazepines. C. immunosuppressants. D. acetylcholinesterase inhibitors.

D. acetylcholinesterase inhibitors.

2. The nurse is assessing a patient for sleep patterns. The patient reports that he has trouble sleeping when lying flat. The best response from the nurse is A. open a window to let fresh air into the room. B. use nasal strips to assist with breathing. C. sleep in a side-lying position. D. use pillows to prop yourself up while sleeping.

D. use pillows to prop yourself up while sleeping. Correct Using pillows to prop himself up during sleep allows the patient to breathe more easily and comfortably. Nasal strips will help with breathing, but they do not always bring relief when one is lying flat. Sleeping in a side position or opening a window does not help one to breathe more easily when one is lying flat. Awarded 1.0 points out of 1.0 possible points.

A patient who is in pain is concerned about becoming addicted to pain medication and asks the nurse, "Can I become addicted to this medication?" What is an appropriate response by the nurse? (Select all that apply.) Select all that apply. "You will not become physically addicted, but you may develop a physiological addiction." "You will likely experience euphoria from the medication." "You will likely become dependent on this medication and require other medications to control your pain." "Before stopping the medication, you may need to taper it so you do not suffer from withdrawal." "You may develop a tolerance for the medication and need more of it in order for it to be therapeutic."

What can be said about the comorbidity of anxiety disorders? Anxiety disorders generally exist alone. Depression may occur prior to onset of anxiety. Anxiety disorders virtually never coexist with mood disorders. Substance abuse disorders rarely coexist with anxiety disorders.

Depression may occur prior to onset of anxiety. Correct

A Gulf War veteran is entering treatment for post-traumatic stress disorder. What assessment is of importance to this particular client? Ascertain how long ago the trauma occurred. Find out if the client uses acting-out behavior. Determine the use of chemical substances for anxiety relief. Establish whether the client has chronic hypertension related to high anxiety.

Determine the use of chemical substances for anxiety relief.

A patient has anemia related to inadequate intake of essential nutrients. Which intervention would be appropriate for the nurse to include in the plan of care for this patient? Plan for 30 minutes of rest before and after every meal. Encourage foods high in protein, iron, vitamin C, and folate. Teach the patient to select only soft, bland, and nonacidic foods. Give the patient a list of medications that inhibit iron absorption.

Encourage foods high in protein, iron, vitamin C, and folate. Increased intake of protein, iron, folate, and vitamin C provides nutrients needed for maximum iron absorption and hemoglobin production. The other interventions do not address the patient's identified problem of inadequate intake of essential nutrients. Selection of foods that are soft, bland, and nonacidic is appropriate if the patient has oral mucosal irritation. Scheduled rest is an appropriate intervention if the patient has fatigue related to anemia. Providing information about medications that may inhibit iron absorption (e.g., antacids, tetracycline, soft drinks, tea, coffee, calcium, phosphorus, and magnesium salts) is important but does not address the patient's problem of inadequate intake of essential nutrients.

The nurse is reviewing the objective data listed in the table below of a patient with suspected allergies. Which assessment finding indicates allergies? Tab 1 Physical examination Dry cough Pale skin Tab 2 Laboratory results Neutrophils: 60%Eosinophils: 10%Basophils: 1%Lymphocytes: 20%Monocytes: 6% Tab 3 Medications Acetaminophen 1000 mg every 12 hoursLevothyroxine (Synthroid) 125 mcg each day Dry cough Eosinophil result Lymphocyte result Acetaminophen use

Eosinophil result Eosinophils are granulocytes that phagocytize antigen-antibody complexes formed during an allergic response. The normal eosinophil count is 2% to 4% of all white blood cells. The dry cough, lymphocyte result, and acetaminophen use do not indicate allergies.

A client hospitalized with anorexia nervosa has a weight that is 65% of normal. For this client, what is a realistic short-term goal for the first week of hospitalization regarding the physical impact of his/her weight? A. Gain a maximum of 3 lb. B. Develop a pattern of normal eating behavior. C. Discuss fears and feelings about gaining weight. D. Verbalize awareness of the sensation of hunger.

Gain a maximum of 3lbs.

5. Exercise and activity are included in a cardiac rehabilitation program for which purposes? (Select all that apply.) Increase cardiac output Correct Increase serum lipids Increase blood pressure Increase blood flow to the arteries Correct Increase muscle mass Correct Increase flexibility Correct A cardiac rehabilitation program seeks to increase cardiac output, blood flow to the arteries, muscle mass, and flexibility. The rehabilitation program does not want to increase serum lipids or blood pressure. Awarded 1.0 points out of 1.0 possible points. Continue

Increase cardiac output Increase blood flow to the arteries Increase muscle mass Increase flexibility A cardiac rehabilitation program seeks to increase cardiac output, blood flow to the arteries, muscle mass, and flexibility. The rehabilitation program does not want to increase serum lipids or blood pressure. Awarded 1.0 points out of 1.0 possible points. Continue

When assessing laboratory values on a patient admitted with septicemia, what does the nurse expect to find? Increased platelets Increased red blood cells Decreased erythrocyte sedimentation rate (ESR) Increased bands in the white blood cell (WBC) differential

Increased bands in the white blood cell (WBC) differential When infections are severe, such as in septicemia, more granulocytes are released from the bone marrow as a compensatory mechanism. To meet the increased demand, many young, immature polymorphonuclear neutrophils (bands) are released into circulation. WBCs are usually reported in order of maturity (initially with the less mature forms on the left side of a written report). Hence, the term "shift to the left" is used to denote an increase in the number of bands. Thrombocytosis occurs with inflammation and some malignant disorders. Increased red blood cells or decreased ESR is not indicative of septicemia.

A patient had a splenectomy for injuries sustained in a motor vehicle accident. Which phenomena are likely to result from the absence of the patient's spleen? (Select all that apply.) Impaired fibrinolysis Increased platelet levels Increased eosinophil levels Fatigue and cold intolerance Impaired immunologic function

Increased platelet levels Impaired immunologic function Splenectomy can result in increased platelet levels and impaired immunologic function because of the loss of storage and immunologic functions of the spleen. Fibrinolysis, fatigue, and cold intolerance are less likely to result from the loss of the spleen since coagulation and oxygenation are not primary responsibilities of the spleen.

The blood bank notifies the nurse that 2 units of blood ordered for a patient is ready for pick up. Which action should the nurse take to prevent an adverse effect during this procedure? Immediately pick up both units of blood from the blood bank. Infuse the blood slowly for the first 15 minutes of the transfusion. Regulate the flowrate so that each unit takes at least 4 hours to transfuse. Set up the Y-tubing of the blood set with dextrose in water as the flush solution.

Infuse the blood slowly for the first 15 minutes of the transfusion. Because a transfusion reaction is more likely to occur at the beginning of a transfusion, the nurse should initially infuse the blood at a rate no faster than 2 mL/min and remain with the patient for the first 15 minutes after hanging 1 unit of blood. Only 1 unit of blood can be picked up at a time, it must be infused within 4 hours, and it cannot be hung with dextrose.

When evaluating a patient's nutritional-metabolic pattern related to hematologic health, what priority assessment should the nurse perform? Inspect the skin for petechiae. Ask the patient about joint pain. Assess for vitamin C deficiency. Determine if the patient can perform activities of daily living

Inspect the skin for petechiae. Any changes in the skin's texture or color should be explored when assessing the patient's nutritional-metabolic pattern related to hematologic health. The presence of petechiae or ecchymotic areas could be indicative of hematologic deficiencies related to poor nutritional intake or related causes. The other options are not specific to the nutritional-metabolic pattern related to hematologic health.

The record mentions states that the client habitually relies on rationalization. The nurse might expect the client to present with what behavior? Makes jokes to relieve tension. Misses appointments. Justifies illogical ideas and feelings. Behaves in ways that are the opposite of his or her feelings.

Justifies illogical ideas and feelings.

Which signs and symptoms are associated with opioid withdrawal? Lacrimation, rhinorrhea, dilated pupils, and muscle aches. Illusions, disorientation, tachycardia, and tremors. Fatigue, lethargy, sleepiness, and convulsions. Synesthesia, depersonalization, and hallucinations

Lacrimation, rhinorrhea, dilated pupils, and muscles aches.

elective inattention is first noted when experiencing which level of anxiety? Mild Moderate Severe Panic

Moderate

A teaching need is revealed when a client taking disulfiram (Antabuse) states: "I usually treat heartburn with antacids." "I take ibuprofen or acetaminophen for headache." "Most over-the-counter cough syrups are safe for me to use." "I have had to give up using aftershave lotion."

Most over-the-counter cough syrups are safe for me to use

Questions 1. The nurse is assessing a female patient at the neighborhood clinic. The patient is complaining of "feeling tired all the time." The nurse knows that fatigue may be an underlying symptom of which condition? A. Ischemia B. Pneumonia C. Myocardial infarction D. Peptic ulcer disease

Myocardial infarction Fatigue is an atypical symptom of myocardial infarction in women.

The nurse performs a breast examination on a female patient who has never been pregnant, 1 week after her menstrual period. Which finding, if made by the nurse, would indicate a normal breast examination? Nipples are soft without retractions. Unilateral breast dimpling is present. Milky fluid is expressed from the nipples. Axillary lymph nodes are fixed and palpable.

Nipples are soft without retractions. Normal breasts are symmetric without dimpling. Nipples are soft with no drainage, retraction, or lesions noted. No masses, tenderness, or lymphadenopathy is present.

A patient does not make eye contact with the nurse and is folding his arms at his chest. Which aspect of communication has the nurse assessed? A message filter Social skills A cultural barrier Nonverbal communication

Nonverbal communication

A client brought to the emergency department after phenylcyclohexylpiperidine (PCP) ingestion is both verbally and physically abusive. What nursing intervention should be implemented to best assure the safety of the client and the milieu? (Select all that apply.) Taking him to the gym on the psychiatric unit Obtaining an order for seclusion and close observation Assigning a psychiatric technician to "talk him down" Administering naltrexone as needed per hospital protocol Obtaining a prescription for a benzodiazepine

Obtaining an order for seclusion and close observation obtaining a prescription for a benzodiazepine

A young woman reports that although she has no memory of the event, she believes that she was raped. This raises suspicion that she unknowingly ingested what substance? (Select all that apply.) Rohypnol Gamma-hydroxybutyrate (GHB) ReVia Clonidine Ayahuasca

Rohypnol Gamma-hydroxybutyrate (GHB)

A patient with cancer is having chemotherapy treatments and has now developed neutropenia. What care should the nurse expect to provide and teach the patient about? (Select all that apply.) Strict hand washing. Daily nasal swabs for culture. Monitor temperature every hour. Daily skin care and oral hygiene. Encourage the patient to eat all foods to increase nutrients. Private room with a high-efficiency particulate air (HEPA) filter

Strict hand washing. Daily skin care and oral hygiene. Private room with a high-efficiency particulate air (HEPA) filter Strict hand washing and daily skin and oral hygiene must be done with neutropenia, because the patient is predisposed to infection from the normal body flora; other people; and uncooked meats, seafood, and eggs; unwashed fruits and vegetables; and fresh flowers or plants. The private room with HEPA filtration reduces the aerosolized pathogens in the patient's room. Blood cultures and antibiotic treatment are used when the patient has a temperature of 100.4° F or more, but temperature is not monitored every hour.

The nurse is caring for a patient with microcytic, hypochromic anemia. What teaching should the nurse provide about medication therapy? Take enteric-coated iron with each meal. Take cobalamin with green leafy vegetables. Take the iron with orange juice 1 hour before meals. Decrease the intake of the antiseizure medications to improve.

Take the iron with orange juice 1 hour before meals. With microcytic, hypochromic anemia may be caused by iron, vitamin B6, or copper deficiency; thalassemia; or lead poisoning. The iron prescribed should be taken with orange juice 1 hour before meals as it is best absorbed in an acid environment. Megaloblastic anemias occur with cobalamin (vitamin B12) and folic acid deficiencies. Vitamin B12 may help red blood cell (RBC) maturation if the patient has the intrinsic factor in the stomach. Green leafy vegetables provide folic acid for RBC maturation. Antiseizure drugs may contribute to aplastic anemia or folic acid deficiency, but the patient should not stop taking the medications. The health care provider will prescribe changes in medications.

The term tolerance, as it relates to substance abuse, refers to which situation? The use of a substance beyond acceptable societal norms The additive effects achieved by taking two drugs with similar actions The signs and symptoms that occur when an addictive substance is withheld The need to take larger amounts of a substance to achieve the same effects

The need to take larger amounts of a substance to achieve the same effects

A blood type and cross-match has been ordered for a patient who has an upper gastrointestinal bleed. The results of the blood work indicate that the patient has type A blood. Which description explains this result? The patient can be transfused with type AB blood. The patient may only receive a type A transfusion. The patient has A antigens on his red blood cells (RBCs). Antibodies are present on the surface of the patient's RBCs.

The patient has A antigens on his red blood cells (RBCs). A person with type A blood has A antigens, not A antibodies, on his RBCs. An AB transfusion would result in agglutination, but he may be transfused with either type A or type O blood.

What should general teaching for patients with a sexually transmitted infection (STI) include? (Select all that apply.) Treatment of sexual partners Douching will help to provide relief of itching Importance of retesting after treatment to confirm cure Cotton undergarments are preferred over synthetic materials Sexual abstinence is needed during the communicable phase of a disease Condoms should be used during and after treatment during sexual activity

Treatment of sexual partners Importance of retesting after treatment to confirm cure Cotton undergarments are preferred over synthetic materials Sexual abstinence is needed during the communicable phase of a disease Condoms should be used during and after treatment during sexual activity

A patient has been diagnosed with stage 1A Hodgkin's lymphoma. The nurse knows that which chemotherapy regimen is most likely to be prescribed for this patient? Brentuximab vedotin (Adcetris) Two to four cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine Four to six cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine BEACOPP: bleomycin, etoposide, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), procarbazine, and prednisone

Two to four cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine The patient with a favorable prognosis early-stage Hodgkin's lymphoma (stage 1A) will receive two to four cycles of ABVD. The unfavorable prognostic featured (stage 1B) Hodgkin's lymphoma would be treated with four to six cycles of chemotherapy. Advanced-stage Hodgkin's lymphoma is treated more aggressively with more cycles or with BEACOPP. Brentuximab vedotin (Adcetris) is a newer agent that will be used to treat patients who have relapsed or refractory disease.Note: Some of acronyms for drug protocols use the brand/trade name of drugs (Adriamycin, Oncovin). These brand/trade names have been discontinued but the drugs are still available as generic drugs.

After stabilization of symptoms, what is the primary focus of treatment for a client diagnosed with anorexia nervosa? A. Weight restoration B. Improving interpersonal skills C. Learning effective coping methods D. Changing family interaction patterns

Weight restoration

A pregnant client and her husband tell the nurse they have a 1-year-old daughter with sickle cell anemia, but that they themselves do not have the disease. Which response would correctly answer the clients' question, "Will this baby also have sickle cell anemia?" a. "The chance that another child will have sickle cell anemia is 25%." b. "Only one child in a family is affected, so the others will probably be all right." c. "The most likely conclusion is that your children will have sickle cell anemia." d. "If your partner has the sickle cell gene, 50% of your children will have sickle cell anemia."

a. "The chance that another child will have sickle cell anemia is 25%."

Which value for hemoglobin would the nurse expect in a client who is experiencing sickle cell crisis? a. 6 to 8 g/100 mL (60-80 mmol/L) b. 10 to 12 g/100 mL (100-120 mmol/L) c. 12 to 14 g/100 mL (120-140 mmol/L) d. 16 to 18 g/100 mL (160-180 mmol/L

a. 6 to 8 g/100 mL (60-80 mmol/L)

Which of the following classifications of medication may be prescribed in intermittent explosive disorder? a. Anticonvulsants b. Psychostimulants c. Antianxiety agents such as benzodiazepines d. Monoamine oxidase (MAO) inhibitors

a. Anticonvulsants Although considered off-label use, anticonvulsants may reduce outbursts and contribute to mood stabilization. The other options are incorrect for use in intermittent explosive disorder.

As an adult, a client who has been diagnosed with childhood-onset conduct disorder is at high risk for developing which comorbid disorder? a. Antipersonality disorder b. Obsessive-compulsive disorder c. Kleptomania d. Depression

a. Antipersonality disorder Individuals with childhood-onset conduct disorder are more likely to have problems that persist through adolescence, and without intensive treatment, they develop antisocial personality disorder as adults. Research does not support any of the other options.

The nurse is preparing to set goals for a 10-year-old diagnosed with an impulse control disorder. To best ensure the expected therapeutic outcomes, the nurse includes goals that focus on what client need? a. Client centered and includes the client's input b. Age appropriate and achievable in a short period of time c. Simple and easily defined d. Family centered and long term in nature

a. Client centered and includes the client's input Whenever possible, outcomes should be client centered and agreed upon by both the nurse and the client or the client's designee. While the other options may be appropriate, they are not the priority.

Thr nurse is teaching a client about medication therapy for gonorrhea. Which fact about medication therapy will the nurse emphasize? a. Cures the infection b. Prevents complications c. Controls its transmission d. Reverses pathologic changes

a. Cures the infection

Which of the following statements are true regarding childhood-onset conduct disorder? (Select all that apply.) a. It is more commonly diagnosed in males. b. It is characterized by feelings of remorse and regret. c. It is usually diagnosed in late teen years. d. It is characterized by disregard for the rights of others. e. Those with conduct disorder rationalize their aggressive behaviors. f. It is usually outgrown by early adulthood.

a. It is more commonly diagnosed in males. d. It is characterized by disregard for the rights of others. e. Those with conduct disorder rationalize their aggressive behaviors. Childhood-onset conduct disorder is more common in male patients and is seen before the age of 10 years. Hallmarks include disregard for the rights of others, physical aggression, poor peer relationships, and lack of feelings of guilt or remorse. The other options are the opposite of what is correct.

When working with a client demonstrating impulse control disorders, which nursing interventions have initial priority? (Select all that apply.) a. Providing a safe environment b. Establishing a therapeutic nurse-client relationship c. Setting and enforcing limits d. Confronting the client concerning the disruptive behavior e. Presenting appropriate expectations

a. Providing a safe environment b. Establishing a therapeutic nurse-client relationship c. Setting and enforcing limits e. Presenting appropriate expectations The most important interventions with this population are to promote a climate of safety for the patient and for others, establish rapport with the patient, and set limits and expectations. Confronting behaviors is not an initial priority.

Which assessment finding would the nurse expect when assessing an 11-month-old infant with iron-deficiency anemia whose hemoglobin is 8 g/dL (80 mmol/L)? a. pallor b. tremors c. cyanosis d. spasticity

a. pallor

Which sexually transmitted infections are caused by bacteria? Select all that apply. One, some, or all responses may be correct. a. syphilis b. hepatitis c. gonorrhea d. herpes simplex e. trichomoniasis

a. syphilis c. gonorrhea

The nurse is caring for a patient with a diagnosis of immune thrombocytopenic purpura (ITP). What is a priority nursing action in the care of this patient? Administration of packed red blood cells Administration of oral or IV corticosteroids Administration of clotting factors VIII and IX Maintenance of reverse isolation and application of standard precautions

administration of oral or IV corticosteroids Common treatment modalities for ITP include corticosteroid therapy to suppress the phagocytic response of splenic macrophages. Blood transfusions, administration of clotting factors, and reverse isolation are not interventions that are indicated in the care of patients with ITP. Standard precautions are used with all patients.

A child with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis). The nurse assesses the child, obtains the child's vital signs, and reviews the child's laboratory test results. Which is the priority nursing action? a. Providing oxygen therapy b. Administering an analgesic c. Initiating a blood transfusion d. Monitoring intravenous fluids

b. Administering an analgesic

The clinic nurse is planning care for a client with chlamydia. Which treatment would the nurse anticipate implementing? a. Administration of 250 mg of acyclovir orally in a single dose b. Administration of 1 g of azithromycin orally in a single dose c. Administration of 250 mg of ceftriaxone intramuscularly in a single dose d. Administration of 2.4 million units of benzathine penicillin G intramuscularly in a single dose

b. Administration of 1 g of azithromycin orally in a single dose

A client reports to a health clinic because a sexual partner recently was diagnosed as having gonorrhea. The health history reveals that the client has engaged in receptive anal intercourse. Which finding would the nurse assess for in this client? a. Melena b. Anal itching c. Constipation d. Ribbon-shaped stools

b. Anal itching

Which comorbid conditions are commonly associated with oppositional defiant disorder? (Select all that apply.) a. Conversion disorder b. Attention deficit hyperactivity disorder (ADHD) c. Depression d. Anxiety e. Substance abuse

b. Attention deficit hyperactivity disorder (ADHD) c. Depression d. Anxiety Oppositional defiant disorder is related to a variety of other problems, including attention deficit hyperactivity disorder, anxiety, and depression. Neither of the remaining options are closely associated with this diagnosis.

The nurse reviews the prescriptions of multiple adolescents with genital herpes simplex infections. Which client's medication regimen would require correction? a. Client A b. Client B c. Client C d. Client D

b. Client B

Which complication would the nurse suspect in a client with genital herpes disease? a. Infertility b. Cold sores c. Reactive arthritis d. Bartholin abscess

b. Cold sores

The mother of a 6-year-old child expresses concern over the child's frequent temper outbursts. He deals with any frustration by bullying and hitting and seldom shows any remorse for his actions. The nurse who gathers this data will note that the child's behaviors are most consistent with which diagnosis? a. Social phobia b. Conduct disorder c. Oppositional defiant disorder d. Attention deficit hyperactivity disorder (ADHD)

b. Conduct disorder The data are most consistent with the aggressive pattern of childhood-onset conduct disorder of the aggressive type.

Which nursing intervention is appropriate for the management of intermittent explosive disorder? a. Providing intensive family therapy b. Establishing a trusting relationship with the patient c. Setting up loose boundaries so the patient will feel relaxed d. Limiting decision-making opportunities to avoid frustration

b. Establishing a trusting relationship with the patient Establishing rapport with the patient is essential in working to set goals, boundaries, and consequences, and providing opportunities for goal achievement. Intensive family therapy would not be a basic level RN intervention. Boundaries and structure are essential. Opportunities for patients to make good decisions and reach goals should be given, not limited.

A 17-year-old patient is admitted to the psychiatric unit after threatening his mother during an argument and is diagnosed with conduct disorder. Which of the following would be an appropriate short-term outcome for this patient? a. Engages in appropriate coping skills to manage stressors b. Expresses feelings c. Maintains self-control during hospitalization d. Mother will improve communication skills to interact with Eli.

b. Expresses feelings Expressing feelings is an appropriate short-term outcome and would be a good start to working with the patient to establish rapport, develop coping skills, and set goals. Engaging in appropriate coping skills and maintaining self-control are desired outcomes. Outcomes for the patient are being discussed, not outcomes for the patient's mother.

Which action would the nurse implement regarding the public health implications of a 16-year-old adolescent diagnosed with gonorrhea? a. Interviewing the adolescent's parents b. Identifying and locating the client's sexual contacts c. Instructing the client about birth control measures d. Determining the reasons for the client's promiscuity

b. Identifying and locating the client's sexual contacts

A client with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. The current pain rating is 5 on a scale of 1 to 10 at the right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. Which action would the nurse implement? a. Turning on the television for diversion b. Placing the prescribed as-needed warm, wet compress on the elbow c. Calling the primary health care provider for another analgesic prescription d. Informing the client gently that she must wait until the pump reactivates to get more medication

b. Placing the prescribed as-needed warm, wet compress on the elbow

Which statement is true about the characteristics of the oppositional defiant child? a. The defiance is generally directed toward parents and siblings. b. These behaviors are a predictor of future mental health disorders. c. Arguing tends to be more prevalent in boys. d. Girls display more blaming than do boys.

b. These behaviors are a predictor of future mental health disorders. Oppositional defiant disorder is often predictive of emotional disorders in young adulthood. None of the other statements are necessarily correct.

A client had part of the ileum surgically removed. The nurse monitors the client closely for anemia based on which rationale? a. folic acid is absorbed in the ileum b. cobalamin is absorbed in the ileum c. Iron absorption is dependent on simultaneous bile salt absorption in the ileum. d. Copper, cobalt, and nickel are dependent on simultaneous bile salt absorption in the ileum

b. cobalamin is absorbed in the ileum

Which parent education would the nurse provide when teaching an infant's parents about the major cause of iron-deficiency anemia? a. blood disorders b. overfeeding of milk c. lack of adequate iron reserves from the mother d. introduction of solid foods too early for adequate absorption

b. overfeeding of milk

To implement primary prevention of sexually transmitted infections (STIs) the nurse is counseling an adolescent. Which would be the priority nursing action? a. Help the adolescent recognize the risk. b. Provide complete information about STIs. c. Assess the adolescent's sexual risk behaviors. d. Educate the adolescent about proper preventive measures.

c. Assess the adolescent's sexual risk behaviors.

Assessment for oppositional defiant disorder should include which interventions? a. Assessing the history, frequency, and triggers for violent outbursts b. Assessing moral development, belief system, and spirituality for the ability to understand the impact of hurtful behavior on others, to empathize with others, and to feel remorse c. Assessing issues that result in power struggles and triggers for outbursts d. Assessing sibling birth order to understand the dynamics of family interaction

c. Assessing issues that result in power struggles and triggers for outbursts Oppositional defiant disorder is characterized by defiant behavior, power struggles, outbursts, and arguing with adults, so assessment of these factors would be important. Assessing for violent outbursts refers to assessment for intermittent explosive disorder. Oppositional defiant disorder is not characterized by violent behaviors. Assessing for the ability to understand the impact of hurtful behaviors on others refers to assessment for conduct disorder. Birth order is not known to play a part in oppositional defiant disorder.

Which type of isolation precautions would the postpartum nurse plan to institute for a client who has delivered her infant by cesarean birth because of active genital herpes? a. Enteric b. Droplet c. Contact d. Airborne

c. Contact

The nurse assesses a client for the development of pernicious anemia after reviewing the client's history. Which condition did the nurse most likely find in the history? a. Acute gastritis b. Diabetes mellitus c. Partial gastrectomy d. Unhealthy dietary habits

c. Partial gastrectomy

Which intervention would the nurse implement to prevent infection of the newborn in a pregnant client with gonorrhea? a. Oral antibiotics for newborn b. Schedule a cesarean section c. Silver nitrate ophthalmic ointment d. Intravenous antibiotic before delivery

c. Silver nitrate ophthalmic ointment

The parent of a child with sickle cell anemia tells the nurse that the family is going camping by a lake in the mountains this summer. The parent inquires what activities are appropriate. Which activity would the nurse suggest? a. Swimming in the lake b. Soccer with the family c. Climbing the mountain trails d. Motorboat rides around the lake

d. Motorboat rides around the lake

A syndrome that occurs after stopping the long-term use of a drug is called amnesia. tolerance. enabling. withdrawal

withdrawal

A woman is scheduled for her first Pap test. The nurse should provide which instructions? "A full bladder is needed for more accurate results." "You should rest for 2 to 3 hours after the procedure." "Do not douche for at least 24 hours before the procedure." "A Pap test will screen for sexually transmitted infections."

"Do not douche for at least 24 hours before the procedure." The patient should be told to not douche for at least 24 hours before a Pap test. The patient should empty the bladder before a Pap test. There are no activity restrictions after a Pap test. The patient should rest for 2 to 3 days after a conization. A culture or a smear tests for sexually transmitted infections. A Pap test is a cytologic study used to detect abnormal cells.

While summarizing teaching about genital herpes, which patient statement indicates a need for further instruction? "No cure is available for my genital herpes." "I will utilize my medication when I begin to have symptoms" "Genital herpes may be caused by herpes simplex virus type 1 or 2" "I am not able to infect a sexual partner unless I have active lesions"

"I am not able to infect a sexual partner unless I have active lesions"

A client who is demonstrating a moderate level of anxiety tells the nurse, "I am so anxious, and I do not know what to do." Which response should the nurse make initially? "What things have you done in the past that helped you feel more comfortable?" "Let's try to focus on that adorable little granddaughter of yours." "Why don't you sit down over there and work on that jigsaw puzzle?" "Try not to think about the feelings and sensations you're experiencing."

"What things have you done in the past that helped you feel more comfortable?"

The nurse teaches a black man with sickle cell disease about symptom management and prevention of sickle cell crisis. The nurse determines further teaching is necessary if the patient makes which statement? "When I take a vacation, I should not go to the mountains." "I should avoid being with anyone who has a respiratory infection." "I may have severe pain during a crisis and need opioid analgesics." "When my vision is blurred, I will close my eyes and rest for an hour."

"When my vision is blurred, I will close my eyes and rest for an hour." Blurred vision should be reported immediately and may indicate a detached retina or retinopathy. Hypoxia (at high altitudes) and infection are common causes of a sickle cell crisis. Severe pain may occur during a sickle cell crisis, and narcotic analgesics are indicated for pain management.

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The mother states that the toddler is very active and is difficult, constantly saying "no". Which response would the nurse communicate that would be an appropriate response? 1 "Toddlers are curious, trying to make decisions and be independent." 2 "Saying 'no' at this stage is a signal that the child may need some therapy." 3 "You must show the child from a young age that you are the boss and in charge." 4 "Responsible parenting means you must protect the child from all future injuries."

1 "Toddlers are curious, trying to make decisions and be independent." Toddlers are curious, trying to make decisions and being independent, and learning autonomy, which is a normal developmental stage for this age group. Saying "no" is the toddler's means of developing independence rather than a need for therapy. The developmental task according to Erikson is autonomy verses shame, so caregivers need to allow some independence. No person can protect absolutely another individual from all injuries.

What is the most significant modifiable risk factor for the development of impaired gas exchange? A. Age B. Tobacco use C. Drug overdose D. Prolonged immobility

B. Tobacco use

The nurse is caring for an adolescent who is pregnant and reports a past history of gonorrhea. Which intervention will the nurse perform before delivery to decrease perinatal exposure? Select all that apply. One, some, or all responses may be correct. 1 Screen at 36 weeks' gestation 2 Plan to use standard precautions 3 Administer intramuscular ceftriaxone 4 Recommend bottle feeding after birth 5 Report any greenish-yellow purulent discharge

1 Screen at 36 weeks' gestation 3 Administer intramuscular ceftriaxone

Which information would the nurse obtain in a health history for a sexually active 16-year-old to determine the client's risk for sexually transmitted infections (STIs)? Select all that apply. One, some, or all responses may be correct. 1 Sexual practices 2 Barrier protection use 3 Gender of sexual partners 4 Number of sexual partners 5 Use of illicit drugs before sex

1 Sexual practices 2 Barrier protection use 3 Gender of sexual partners 4 Number of sexual partners 5 Use of illicit drugs before sex

Which information regarding risks that may result from an untreated chlamydia infection would the nurse include when providing education for a female client? Select all that apply. One, some, or all responses may be correct. 1 Sterility 2 Ectopic pregnancy 3 Blocked Fallopian tubes 4 Pelvic inflammatory disease 5 Increased likelihood of HIV infection

1 Sterility 2 Ectopic pregnancy 3 Blocked Fallopian tubes 4 Pelvic inflammatory disease 5 Increased likelihood of HIV infection

Which nursing intervention is the priority when the nurse notices that the client receiving a blood transfusion is having an acute hemolytic reaction? 1 Stop the blood transfusion immediately. 2 Report to the primary health care provider. 3 Recheck identifying tags and numbers on the client. 4 Maintain a patent intravenous (IV) line with saline solution.

1 Stop the blood transfusion immediately. An incompatible blood transfusion can result in an acute hemolytic reaction in the client. During acute hemolytic reactions, the nurse would stop a blood transfusion as a priority nursing intervention. After stopping the blood transfusion, the nurse would report it to the primary health care provider. The nurse can then recheck the client's identifying tags and numbers and maintain a patent IV line with saline solution.

An adolescent reports genital warts. Which suggestions would the nurse provide to reduce the discomfort? Select all that apply. One, some, or all responses may be correct. 1 Try out cryotherapy if needed. 2 Wear loose-fitted cotton clothes. 3 Take a bath with oatmeal solution. 4 Use less water for cleaning the genitals. 5 Anticipate a prescription of imiquimod.

1 Try out cryotherapy if needed. 2 Wear loose-fitted cotton clothes. 3 Take a bath with oatmeal solution.

The nurse is teaching the parents of a toddler with a recent diagnosis of hemophilia about the disease. Which area of the body would the nurse include as the most common site for bleeding? 1 Brain 2 Joints 3 Kidneys 4 Abdomen

2 Joints The joints are the most commonly involved areas because of weight bearing and constant movement. Neither the brain, kidneys, nor abdomen is the most common site; however, bleeding may occur in any of these areas.

A client diagnosed with Alzheimer's disease looks confused when the phone rings and cannot recall many common household objects by name, such as a pencil or glass. The nurse can document this loss of function as A. apraxia. B. agnosia. C. aphasia. D. anhedonia.

B. agnosia.

On the figure, which point is the site for salpingitis in a client with gonorrhea? 1. A 2. B 3. C 4. D

1. A

Which iron-rich foods would the nurse encourage the client with mild anemia in early pregnancy to eat? Select all that apply. One, some, or all responses may be correct. 1. Dark leafy green vegetables 2. Legumes 3. Dried fruits 4. Yogurt 5. Ground beef patty

1. Dark leafy green vegetables 2. Legumes 3. Dried fruits 5. Ground beef patty

When reviewing the results of a toddler's complete blood count, the nurse notes decreased hemoglobin and hematocrit levels. Which other laboratory findings would the nurse expect in iron-deficiency anemia? Select all that apply. One, some, or all responses may be correct. 1. microcytic red blood cells 2. hyperchromic red blood cells 3. low total iron-binding capacity 4. slightly reduced reticulocyte count 5. increased erythrocyte sedimentation rate (ESR)

1. microcytic red blood cells 4. slightly reduced reticulocyte count

Which dietary choices by a client with iron deficiency anemia indicate that the nurse's dietary teaching has been effective? Select all that apply. One, some, or all responses may be correct. 1. scrambled eggs 2. baked potatoe 3. steamed carrots 4. spinach salad 5. dried apricots 6. sliced oranged

1. scrambled eggs 2. baked potatoe 4. spinach salad 5. dried apricots

The HCP prescribes ceftriaxone 125 mg IM once for gonorrhea infection. The medication on hand when reconstituted with sterile water is equivalent to 250 mg/2.4 mL. How many milliliters of medication should the nurse draw up and administer intramuscularly to the client? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

1.2

Mr. Baker starts vomiting. The nurse looks in his medication administration record and notices that he has a prescription for treating nausea and vomiting. He has also not had any of it since he was admitted to the unit. The healthcare provider has prescribed ondansetron (Zofran) 8 mg iv push every 8 hours as needed.How many milliliters (mL) of ondansetron (Zofran) should the nurse should draw into a syringe in preparation for administration? (enter numerical value only. If rounding is necessary, round to the whole number.)

For which medication would the nurse monitor a client closely for hemolytic anemia? 1 Tacrolimus 2 Methyldopa 3 Azathioprine 4 Procainamide

2 Methyldopa Hemolytic anemia is an autoimmune disorder in which destruction of red blood cells occurs before the end of their normal lifespan. This disorder may result after administration of methyldopa. Tacrolimus may cause adverse effects such as nephrotoxicity, lymphoma, and leukopenia. Azathioprine, administered as an immunosuppressant, may cause bone marrow suppression. Procainamide can induce the formation of antinuclear antibodies and cause a lupus-like syndrome.

A client develops hemolytic anemia. Which client medication can cause this adverse effect? 1 Famotidine 2 Methyldopa 3 Levothyroxine 4 Ferrous sulfate

2 Methyldopa Methyldopa is associated with acquired hemolytic anemia and should be discontinued to prevent progression and complications. Famotidine will not cause these symptoms; it decreases gastric acid secretion, which will decrease the risk of gastrointestinal bleeding. Ferrous sulfate is an iron supplement to correct, not cause, anemia. Levothyroxine is not associated with red blood cell destruction.

A client diagnosed with bipolar disorder has a nursing care plan that includes several nursing diagnoses listed. Match the nursing diagnosis to the level of priority (1 to 4). 1. Self-care deficit, bathing, and hygiene 2. Risk for injury 3. Knowledge, deficient 4. Nonadherence

2, 1, 3, 4

Which postpartum client is at the highest risk for disseminated intravascular coagulation (DIC)? 1 Gravida III with twins 2 Gravida V with endometriosis 3 Gravida II who had a 9-lb baby 4 Gravida I who has had an intrauterine fetal death

4 Gravida I who has had an intrauterine fetal death Intrauterine fetal death is one of the risk factors for DIC; other risk factors include abruptio placentae, amniotic fluid embolism, sepsis, and liver disease. Multiple pregnancy, endometriosis, and increased birthweight are not risk factors for DIC.

Rosa, a 78-year-old patient with Alzheimer's disease, picks up her glasses from the bedside table but does not recognize what they are or their purpose. She is experiencing: A. apraxia. B. agnosia. C. aphasia. D. agraphia.

B. agnosia.

A 6-year-old child with sickle cell disease is admitted with a vasoocclusive crisis (pain episode). Which are the priority nursing concerns? Select all that apply. One, some, or all responses may be correct. 1. Nutrition 2. Hydration 3. Pain management 4. Prevention of infection 5. Oxygen supplementation

2. Hydration 3. Pain management 5. Oxygen supplementation

Which medication would the nurse expect to administer to control bleeding in a child with hemophilia A? 1 Albumin 2 Fresh frozen plasma 3 Factor VIII concentrate 4 Factors II, VII, IX, X complex

3 Factor VIII concentrate Factor VIII is the missing plasma component necessary to control bleeding in a child with hemophilia A. Factor VIII is not provided by albumin. Although fresh frozen plasma does contain factor VIII, there is an insufficient amount in a plasma transfusion; a higher volume is required. A complex of factors II, VII, IX, and X is not useful in this situation.

A client with delirium strikes out at a staff member. The nurse can most correctly hypothesize that this behavior is related to A. anger. B. fear. C. an unmet physical need. D. the need for social interaction.

B. fear.

Which assessment finding indicates that disseminated intravascular coagulation (DIC) is occurring in a postpartum client who has experienced an abruptio placentae? 1 Boggy uterus 2 Hypovolemic shock 3 Multiple vaginal clots 4 Bleeding at the venipuncture site

4 Bleeding at the venipuncture site Bleeding at the venipuncture site indicates afibrinogenemia; massive clotting in the area of the separation has resulted in a decrease in the circulating fibrinogen level. A boggy uterus indicates uterine atony. Although hypovolemic shock may occur with DIC, there are other causes of hypovolemic shock, not just DIC. Blood clots indicate an adequate fibrinogen level; however, vaginal clots may indicate a failure of the uterus to contract and should be explored further.

An adolescent is admitted with an acute hemophilia episode. For which are rest, ice, compression, and elevation most helpful? 1 Encouraging immobilization 2 Decreasing swelling and inflammation 3 Providing pain relief and reducing anxiety 4 Controlling bleeding and retaining joint function

4 Controlling bleeding and retaining joint function Rest, ice, compression, and elevation (RICE) therapy is implemented to support joints and prevent bleeding into joints during an acute hemophilia episode. Reducing inflammation is not the goal of treatment for the hemophiliac process. Total immobilization is not required. Pain may be relieved to some degree but is not assured.

Gonorrhea infection can coexist with other infections. As a result of the client testing positive for gonorrhea, the nurse should prepare her for which treatments? Antimicrobial treatment of gonorrhea and chlamydia. Antiviral treatment of human papillomavirus and syphilis. Antimicrobial treatment of gonorrhea and syphilis. Antiviral treatment of trichomonas and chlamydia.

A client diagnosed with paranoid schizophrenia tells the nurse, "I have to get away. The volmers are coming to execute me." The term "volmers" can be assessed as A a neologism. B clang association. C blocking. D a delusion.

A nurse examines records for flu vaccination among older adults attending an adult day health center. The nurse is applying which step in the nursing process? Assessment. Diagnosis. Planning. Intervention. Evaluation

After fluids have started, the client relates that her pain is an 8 on the Wong-Baker FACES pain scale. Which medication should the nurse expect to be ordered for pain control? Morphine sulfate Ibuprofen. Acetaminophen. Meperidine.

Currently what is understood to be the causation of schizophrenia? A A combination of inherited and nongenetic factors B Deficient amounts of the neurotransmitter dopamine C Excessive amounts of the neurotransmitter serotonin D Stress related and ineffective stress management skills

During interviews with a select group of students, the nurse is questioned about sexual and reproductive health. One student reports that they have several open and painful sores in their genital area. Which priority action should the nurse take? Assist the student to obtain an appointment with a reproductive healthcare provider. Ask the student if they have been having unprotected sex. Discuss the treatment of viral sexually transmitted diseases. Counsel about the risk for pregnancy/paternity.

The charge nurse is transcribing prescriptions at the nurse's station. Other responsibilities of the charge nurse include answering the phone, assisting with visitor's questions, and answering the child's call lights. Which nursing task is best for the charge nurse to delegate to the UAP? Take the hourly vital signs for a child receiving a unit of blood. Teach the child's caregiver how to apply warm soaks to her joints. Educate the child about a healthy lifestyle. Change the morphine vial on the client-controlled analgesia pump.

The client agrees to undergo the Transesophageal Echocardiogram (TEE) but inquires as to the purpose of the test. The nurse explains that the results of this procedure should provide which information? Show the presence of a heart valve infection. Identify scar tissue from a heart attack. Create detailed images of the blood vessels and the blood flow within them. Examine the electrical activity of the heart.

The client is advised that infective endocarditis can damage the heart and become life threatening if not treated properly and completely. Which finding is most indicative of a life threatening complication of infective endocarditis that the nurse should discuss with the client prior to discharge? Sudden weight gain. Pruritus and rash. Nuchal rigidity. Blurred vision.

The nurse is assessing a patient's coping abilities related to expected placement in a long-term care facility. Which risk factor is of most concern to the nurse? The patient was recently diagnosed with Alzheimer disease. The patient is a retired police officer. The patient will need assistance in moving from his home. The patient's family members all live several hours away.

The nurse is assessing the coping abilities of a patient recently diagnosed with a degenerative neuromuscular disease with no known cure. Which statement by the patient alerts the nurse that more intervention is needed? "I am sleeping much better when I have two drinks and smoke before bed." "I am scheduling a family reunion for the upcoming holiday." "I have decided to sell my house and move into an apartment with my son." "I have decided to take some art lessons at the community center."

The nurse receives shift report and proceeds to the client's room, bringing equipment to measure his vital signs. Which vital sign should concern the nurse the most? Blood pressure is 142/80 mmHg. Respiration rate of 24 breaths/minute. Heart rate of 98 beats/minute. Pulse oxygenation of 94%.

The nurse removes the old dressing carefully to avoid dislodging the catheter. After removing the dressing, which information should the nurse communicate immediately to the HCP? External catheter length has changed. A brisk blood return aspirated from the catheter lumen. Both lumens are patent when flushed with 5 mL normal saline. The external catheter length is 60 cm.

What action should the nurse take on learning that a manic client's serum lithium level is 1.8 mEq/L? A Withhold medication and notify the physician. B Continue to administer medication as ordered. C Advise the client to limit fluids for 12 hours. D Advise the client to curtail salt intake for 24 hours.

An 8-year-old patient is newly diagnosed with attention deficit hyperactivity disorder (ADHD). It is important that the parents be educated to the fact that symptoms will take which form? (Select all that apply). of, inattention, and impulsivity have to be apparent: Select all that apply. A Low frustration tolerance B Poor school performance C Impulsive behaviors D Easily intimidated E Mood swings

A, b, c, e

A 9-year-old patient has been diagnosed with an intellectual development disorder (IDD). Which assessment findings support this diagnosis? Select all that apply. A Unable to explain the phrase, "Raining cats and dogs" B Reads below age level C Is capable of providing effective oral self care D Enjoy interacting with developmentally similar peers E Physically lashes out when frustrated

A, b, e

Which interventions can the nurse implement to decrease the the client's anxiety during this examination? (Select all that apply. One, some, or all options may be correct.) Select all that apply Explain each step of the procedure in advance using models. Talk to the client directing relaxation and breathing techniques. Warm a cold speculum between the folds of a heating pad before the exam. Tell the client the procedure is painless and she will feel nothing. Instruct the client that anxiety will make the exam more difficult.

ABC

The client describes the pain in her lower abdomen as sharp and cramping. The HCP prescribes hydrocodone bitartrate 5mg with acetaminophen 325 mg, two tabs PO prior to the client's pelvic exam. Before initiating the treatment, it is most important for the nurse to implement which interventions? (Select all that apply. One, some, or all options may be correct.) Select all that apply Perform a focused assessment on the upper and lower abdomen. Implement a numeric pain assessment on a scale of 1 to 10. Document a baseline of vital signs including a pulse oximetry. Use at least two client identifiers before administering the medication. Initiate the treatment without further delay because the client is in pain.

ABCD

Which instructions are most important for the nurse to include in the healthcare teaching for a client who is diagnosed with gonorrheal infections? (Select all that apply. One, some, or all options may be correct.) Select all that apply Sexual partners should be examined, cultured, and treated with appropriate regimens. Most treatment failures result from reinfections from untreated partners. Complications are consequences of reinfection. Gonorrhea infection can be spread by using public toilets. HCPs are legally responsible for reporting to the local health department.

ABCE

The client is instructed to return for a follow-up examination if symptoms persist after treatment. The nurse explains to the client that recent research shows that strains of gonorrhea bacteria have emerged that are resistant to penicillin, tetracycline, ciprofloxacin, and cefixime. Which instructions are the most important for the nurse to provide to the client prior to discharge? (Select all that apply. One, some, or all options may be correct.) Select all that apply Direct the client to take medication to her sexual partner. Advise the client to take the antibiotic until symptoms subside. Counsel the client about reinfection from a new or untreated partner. Emphasize compliance with completion of the antibiotic regimen. Recommend abstinence from sexual intercourse until treatment completion.

ACDE

A patient is being treated for an illicit drug addiction. The nurse understands that the treatment may include which intervention(s)? (Select all that apply.) Select all that apply. Observing for stress reaction Observing for delirium tremens Converting narcotic use from an illicit to a legally controlled drug Encouraging involvement in Narcotics Anonymous A motivational interview

ADE

Which statement(s) by the nurse aim to help the patient to cope by addressing the mediators of stress? (Select all that apply.) Select all that apply. "I have found a support group for newly divorced persons in your neighborhood." "You said you used to jog; getting back to aerobic exercise could be helpful." "Slowing your breathing by counting to three between breaths will calm you." "Perhaps a short-term loan from your father will make your layoff less stressful." "Journaling gives one more awareness of how experiences have affected them." "A divorce, while stressful, can be the beginning of a new, better phase of life."

ADEF

Which statement would best show acceptance of a depressed, mute client? A. "I will be spending time with you each day to try to improve your mood." B. "I would like to sit with you for 15 minutes now and again this afternoon." C. "Each day we will spend time together to talk about things that are bothering you." D. "It is important for you to share your thoughts with someone who can help you evaluate your thinking."

Answer: B Spending time with the client without making demands is a good way to show acceptance. While not inappropriate, the other options are less accepting

The nurse and student continue to develop a trusting nurse-client relationship. The nurse schedules a follow-up visit to check in with the student. Follow-up after the diagnosis of a STD/STI is which level of prevention? Primary prevention. Secondary prevention. Tertiary prevention. Prodromal prevention.

The patient is being treated for a recurrent episode of Chlamydia. What should the nurse include in patient teaching? If you are treated, your sexual partner will not need to be treated. Abstain from sexual intercourse for seven days after finishing the treatment. You will probably get gonorrhea if you have another recurrence of chlamydia. Because you have been treated before, you do not need to take a full course of medication this time.

Abstain from sexual intercourse for seven days after finishing the treatment.

What is an appropriate long-term client-centered goal/outcome for a recovering substance abuser. Ability to discuss the addiction with significant others. State an intention to stop using illegal substances. Abstain from the use of mood-altering substances. Substitute a less addicting drug for the present drug.

Abstain from the use of mood-altering substances

The family of a child diagnosed with attention deficit hyperactivity disorder (ADHD), inattentive type, is told the evaluation of their child's care will focus on symptom patterns and severity. What is the focus of child's evaluation? Select all that apply. Academic performance Activities of daily living Physical growth Social relationships Personal perception

Academic performance Activities of daily living Social relationships Personal persecution

The nurse is caring for a 36-yr-old patient receiving phenytoin (Dilantin) to treat seizures resulting from a traumatic brain injury as a teenager. It is most important for the nurse to observe for which hematologic adverse effect of this medication? Anemia Leukemia Polycythemia Thrombocytosis

Anemia Hematologic adverse effects of phenytoin include anemia, thrombocytopenia, leukopenia, granulocytopenia, agranulocytosis, and pancytopenia.

The thrombocytopenic patient has had a bone marrow biopsy taken from the posterior iliac crest. What intervention is the priority for this patient after this procedure? Position the patient prone. Apply a pressure dressing. Administer analgesic for pain. Return metal objects to the patient.

Apply a pressure dressing. The sterile pressure dressing is applied after a bone marrow biopsy to ensure hemostasis. If bleeding is present, the patient will lie on the site and may need a rolled towel for additional pressure, thus this patient will not be in the prone position. The analgesic should have been administered preprocedure. Metal objects would be removed for an MRI, not a bone marrow biopsy.

The caregiver listens attentively to the nurse discussing the client's condition and what must be done to competently care for her. After reviewing the needed care, the nurse asks the caregiver if there are any other questions. The caregiver asks, "How did my child get this awful disease? "How should the nurse respond? "This disease is an inherited autosomal recessive disease and your daughter inherited the gene responsible for causing the disease." "Your daughter has the disease because she inherited the gene from one of her parents, who is a carrier." "She must have had a bad reaction to a transfusion as a child." "She was exposed to a virus while her caregiver was pregnant."

The client informs the nurse that he can quit drinking any time he chooses and that he is not interested in psychotherapy or attending any Alcoholics Anonymous (AA) meetings. How should the nurse respond to these statements? Ask the client if he has a better solution than going to psychotherapy. Acknowledge that it's great that the client is taking better care of himself. State that you would be glad if the client would agreed to attend an AA meeting. Have the client state why won't he at least attend an AA meeting.

The purpose of the Abnormal Involuntary Movement Scale (AIMS) assessment on a persistently mentally ill client who has been diagnosed with schizophrenia is early detection of A acute dystonia. B tardive dyskinesia. C cholestatic jaundice. D pseudoparkinsonism.

Which is an example of a nurse applying community as client? Counseling a client who is having trouble managing their asthma. Planning for a peer mentorship program for youth with serious mental illness. Assisting parents to prepare for the birth of their first child. Assessing the fall risk of an older adult couple living in subsidized housing.

Which nursing intervention is designed to help a schizophrenic client minimize the occurrence of a relapse? A Schedule the client to attend group therapy that includes those who have relapsed. B Teach the client and family about behaviors associated with relapse. C Remind the client of the need to return for periodic blood draws to minimize the risk for Relapse. D Help the client and family adapt to the stigma of chronic mental illness and periodic relapses.

An person of Northern heritage is at an increased risk for which of the following: (Select all that apply.) A. Vitamin c deficiency B. Type 1 diabetes C. Celiac disease D. Type 2 diabetes E. Hypertension F. Metabolic syndrome

B, C

The client asks the nurse why it is necessary to have additional testing when she already took the prescribed antibiotic to cure the disease. Which responses by the nurse are likely to be the most helpful in explaining the need for further testing? (Select all that apply. One, some, or all options may be correct.) Select all that apply Complications need to be identified and treated, but they cannot be cured. Delay in initial treatment increased the risk for complications. Gonorrhea symptoms can be asymptomatic in women, which delays treatment. Further testing will ensure the bacteria are not resistant to treatments. Additional diagnostic tests will identify any existing complications.

BCE

The nurse performs a focused assessment. Which systems should the nurse evaluate? (Select all that apply. One, some, or all options may be correct.) Neurological system. Cardiovascular system. Respiratory system. Integumentary system. Gastrointestinal system.

BCE

Client is starting to feel better and is requiring less pain medication. Client is sleeping as the nurse makes evening rounds. Her caregiver shares with the nurse, "I have no idea what my daughter should be allowed to do so she can have some fun?" Which statement is the best response by the nurse? "You sound like you are worried about taking your daughter home." "I recommend enrolling her in a sport with running, such as soccer." " School-aged children like being in groups like Girl Scouts or Girls' Clubs." "Your daughter should not be around a lot of children, so her activities will be limit

ManagementThe day shift is coming on duty to the pediatric department. The staff available includes two experienced RNs, one new graduate who has just finished the 3-month pediatric internship, and two unlicensed assistive personnel (UAP). Which child should the charge nurse assign to the new graduate nurse? A school-aged child newly diagnosed with Cystic Fibrosis. The adolescent, who is scheduled as a probable discharge for tomorrow. A school-aged child who had an appendectomy 2 days ago. A school-aged child being evaluated for possible physical abuse.

Once the client is cleaned up and repositioned in bed, she states she is hungry, and would like to have a snack. Which food should the nurse offer to the client who is in a sickle cell crisis? Peaches. Cottage cheese. Popsicles. Lima beans.

The ceftriaxone infusion is complete. It is most important for the nurse to implement which intervention for maintaining patency of the PICC line? Use 5 mL syringe and flush the line with 10 mL of sterile saline. Flush the line with 10 mL of sterile saline using a 10 mL syringe. Slide plastic clamp to close off line and flushing is not necessary. Keep plastic clamp open at all times and flush with a 5 mL or 10 mL syringe.

The client is 45-years-old. Which life style choice is surprising given his psychosocial developmental stage based on Erikson? His sexual preferences. He prefers to live in a city where there is a lot of action. He enjoys staying out all night at his favorite local bar. He works ten to twelve hours every day in the office.

The nurse decides to interview pediatricians, reproductive health providers, and several current students to find out what they know about chlamydia infections among the high school youth. This method of data collection is known as which of the following? Focus group interviews. Community forums. Key informant interviews. Client surveys

The nurse finds that the client has a weak, irregular, and rapid pulse and his tongue is inflamed. The nurse decides to perform a neurological assessment because of mild tremoring. His unexpected neurological findings include hyperactive deep tendon reflexes and mild burning and prickling sensations on his feet and hands. He also appears to startle easily, and he has lost about 15% of his weight compared to his last visit, which was four months ago. During the assessment, the nurse suspects that the client may have pernicious anemia. Which pathophysiological process promotes this condition? Presence of Reed-Sternberg cells. Diminished total iron-binding capacity. Destruction of gastric parietal cells. Inadequate intake of dietary folate.

The nurse is aware that socioeconomic status impacts access to resources such as health services. Which of the following would be the most effective intervention to address healthcare disparities? Counsel students about the importance of completing high school. Provide parents with information about resources in the community. Collaborate with providers to offer free school-based health services. Discuss with colleagues the differences in funding for school services.

The nurse is planning long-term goals for a 17-year-old male client recently diagnosed with schizophrenia. Which statement should serve as the basis for the goal-setting process? A If treated quickly following diagnosis, schizophrenia can be cured. B Schizophrenia can be managed by receiving treatment only at the time of acute exacerbations. C Patients with schizophrenia often do not fully respond to treatment and have residual symptoms and varying degrees of disability. D If patients with schizophrenia stay on their drug regimen, they usually lead fully productive lives with no further symptoms.

The student wonders if she should tell her boyfriend about the diagnosis. Which response by the nurse is correct? According to federal law, nurses must report HSV, so the health department will contact your boyfriend. If your boyfriend does not have any symptoms, it is not necessary for him to know about the disease. It is ultimately your decision, but telling him may prevent the spread of the disease in the future. As long as you and your boyfriend do not have sex with anyone else, there is no need for him to know.

To prepare the client for the TEE, which explanation by the nurse is accurate? No special preparation is necessary prior to this procedure. Signing a consent form is not needed for the TEE procedure. The client's throat will be anesthetized throughout this procedure. Gel is applied to the skin to ease movement of the transducer.

What term is used to identify the condition demonstrated by a person who has numerous hypomanic and dysthymic episodes over a two-year period? Bipolar II disorder. Bipolar I disorder. Cyclothymia. Seasonal affective disorder.

When a child demonstrates a temperament that prompts the mother to say, "She is just so different from me; I just can't seem to connect with her." The nurse should plan to provide which intervention? A Suggest that the child's father become her primary caregiver. B Encourage the mother to consider attending parenting classes. C Counsel the mother regarding ways to better bond with her child. D Educate the father regarding signs that the child is being physically abused.

Which behavior is most indicative of a 4-year-old child diagnosed with Tourette's syndrome? A Difficulty in social relationships B Humming while performing activities that require concentration C Frequent eye blinking D Difficulty in completing tasks on time

Which drink would the nurse instruct a client with iron deficiency anemia to choose to drink with the supplement for efficient absorption? A. Water B. Skim milk C. Orange Juice D. a strawberry milkshake

C. Orange juice Vitamin C helps aid in the absorption of iron. Therefore iron supplements should be taken with a glass or orange juice or a vitamin C tablet.

A patient comes to the clinic after being informed by a sexual partner of possible recent exposure to syphilis. The nurse will examine the patient for what characteristic finding of syphilis in the primary clinical stage? Chancre Alopecia Condylomata lata Regional adenopathy

Chancre

A patient with leukemia is admitted for severe hypovolemia after prolonged diarrhea. The platelet count is 43,000/µL. It is most important for the nurse to take which action? Insert two 18-gauge IV catheters. Administer prescribed enoxaparin. Monitor the patient's temperature every 2 hours. Check stools for presence of frank or occult blood.

Check stools for presence of frank or occult blood. A platelet count below 150,000/µL indicates thrombocytopenia. Prolonged bleeding from trauma or injury does not usually occur until the platelet counts are below 50,000/µL. Bleeding precautions (e.g., check all secretions for frank and occult blood) are indicated for patients with thrombocytopenia. Injections (including IVs) should be avoided; however, when needed for critical fluids and medications, IV access should be provided through the smallest bore devices that are feasible. Enoxaparin, an anticoagulant administered subcutaneously, is contraindicated in patients with thrombocytopenia. Monitoring temperature would be indicated in a patient with leukopenia.

19-year-old college sophomore who has been using cocaine and alcohol heavily for 5 months is admitted for observation after admitting to suicidal ideation with a plan to the college counselor. What would be an appropriate priority outcome for this client's treatment plan while in the hospital? Client will return to a predrug level of functioning within 1 week. Client will be medically stabilized while in the hospital. Client will state within 3 days that they will totally abstain from drugs and alcohol. Client will take a leave of absence from college to alleviate stress.

Client will be medically stabilized while in the hospital.

Which statement is true regarding substance addiction and medical comorbidity? Most substance abusers do not have medical comorbidities. There has been little research done regarding substance addiction disorders and medical comorbidity. Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities. Comorbid conditions are thought to positively affect those with substance addiction in that these patients seek help for symptoms earlier.

Conditions such as hep C, diabetes, and HIV infection are common comorbidities.

The client continues to be upset, and she expresses fear that she may contract other sexually transmitted diseases (STDs). Which intervention should the nurse implement first to address the client's fear of contracting other STDs? Teach the client about practicing safe sex. Determine when the client will be ready to date again. Convince the client that she will have to be more careful in the future. Establish a trusting, non-judgmental method to gather complete information.

A bipolar client tells the nurse, "I have the finest tenor voice in the world. The three tenors who do all those TV concerts are going to retire because they can't compete with me." What term should the nurse use to identify this behavior? Flight of ideas Distractibility Limit testing Grandiosity

A client diagnosed with schizophrenia states to the nurse, "My, oh my. My mother is brother. Anytime now it can happen to my mother." Your best response would be: A "You are having problems with your speech. You need to try harder to be clear." B "You are confused. I will take you to your room to rest a while." C "I will get you a prn medication for agitation." D "I'm sorry, I didn't understand that. Do you want to talk more about your mother as we did yesterday?"

A client has reached the stable plateau phase of schizophrenia. What is the appropriate clinical planning focus for this client? A Safety and crisis intervention B Acute symptom stabilization C Stress and vulnerability assessment D Social, vocational, and self-care skills

A client hospitalized for a psychotic relapse is being discharged home to family. Which topic is important to address when teaching both the patient and the family to recognize possible signs of impending mania? Increased appetite Decreased social interaction Increased attention to bodily functions Decreased sleep

A nurse has begun working on a new unit with high-acuity patients. She also has care responsibilities for her children and her aging parents. The nurse is experiencing signs of being overwhelmed. What counsel by the nurse manager would help the nurse cope with her work stress? Enlist the help of other family members in the care of her children so she can focus on work. Take some time off to decide if she really wants to be a nurse. Encourage her to catch up on her documentation responsibilities while taking her lunch break. Request that another nurse help her focus on essential aspects of care rather than optional aspects of care.

A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant. After taking the new medication, the patient states, "This medication isn't working. I don't feel any different." What is the best response by the nurse? "Your life is much better now. You will feel better soon." "Don't worry. We can try taking it at a different time of day to help it work better." "I will call your care provider. Perhaps you need a different medication." "It usually takes a few weeks for you to notice improvement from this medication."

During interviews with a select group of students, the nurse is questioned about sexual and reproductive health. One student asks the nurse about the transmission of herpes. Which information regarding herpes simplex virus (HSV) transmission should the nurse present? Herpes can be cured with antiviral medications if diagnosed early. Herpes can only be transmitted through oral sex. With increased sex education, the prevalence of herpes has decreased in recent years. Herpes can cause painful sores in the mouth, anus, and genital area.

The nurse is assessing a 4-year-old child in a health clinic. Which situation should cause the nurse to explore for possible abuse? The caregiver reporting angry outbursts from the child while they were in a store Being brought to the clinic from daycare Recent scrapes and bruises on both knees Different explanations of the injury from the child's parents

The nurse meets with the client and the caregiver to discuss their health condition. The caregiver asks the nurse, "I have heard of sickle cell disease (SCD) and I know it can be very bad, but I don't know exactly what it is." Which is the best initial response by the nurse to explain SCD to the client's caregiver? "I have some written material that will explain all about the disease." "It is a disease of the blood that requires taking medication every day." "Your daughter will probably have episodes of severe joint pain and will need to be hospitalized." "Red blood cells become 'C' shaped, stiff, and sticky, which blocks the blood vessels."

The student is angry with her boyfriend and says she is breaking up with him. Which is a priority nursing intervention? Focus on the interest of the community and general public. Urge the student to think about her boyfriend's interests. Take measures to decrease incidences of HSV among the high school population. Establish trust and maintain client confidentiality.

Elaine is a 62-year-old patient who is recovering from a urinary tract infection during which she was hospitalized with delirium. She is following up with her primary care provider 4 weeks after being discharged. Based on research regarding possible post delirium complications, what are important areas for the provider to assess at this time? A. Sleeping habits B. Sexual functioning C. Symptoms of posttraumatic stress D. Depression and level of cognition

D. Depression and level of cognition

Which medication is FDA approved for treatment of anxiety in children? A. Sertraline B. Fluoxetine C. Clomipramine D. Duloxetine

D. Duloxetine

The nurse is performing an assessment on a female patient. What assessment finding should be documented and reported to the primary health care provider? Dimpling of breast Dark pink genitalia Watery cervical mucus Triangular hair distribution

Dimpling of breast Dimpling of the breast is highly suspicious for carcinoma of the breast. Dark pink genitalia, watery cervical mucus, and triangular pubic hair distribution are all normal female reproductive system assessment findings.

A client diagnosed with bulimia nervosa uses enemas and laxatives to purge to maintain weight. What is the likely physiological outcome of this practice? A. Increase in the red blood cell count B. Disruption of the fluid and electrolyte balance C. Elevated serum potassium level D. Elevated serum sodium level

Disruption of the fluid and electrolyte balance

The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic findings should the nurse expect to find? Elevated D-dimers Elevated fibrinogen Reduced prothrombin time (PT) Reduced fibrin degradation products (FDPs)

Elevated D-dimers The D-dimer is a specific marker for the degree of fibrinolysis and is elevated with DIC. FDP is elevated as the breakdown products from fibrinogen and fibrin are formed. Fibrinogen and platelets are reduced. PT, PTT, aPTT, and thrombin time are all prolonged.

A client experiencing a panic attack keeps repeating, "Im dying, I can't breathe.". What action by the nurse should be most therapeutic initially? Encouraging the client to take slow, deep breaths Verbalizing mild disapproval of the anxious behavior Asking the client what he means when he says "I am dying." Offering an explanation about why the symptoms are occurring

Encouraging the client to take slow, deep breaths

An older adult male patient with hypertension is prescribed amlodipine. The nurse should assess for which possible adverse effect? Gynecomastia Increased sex drive Erectile dysfunction Prostate gland enlargement

Erectile dysfunction Some antihypertensive medications (e.g., amlodipine) may cause erectile dysfunction (or impotence), decreased sex drive, and difficulty achieving orgasm.

Benzodiazepines are useful for treating alcohol withdrawal because they are associated with which action? Blocking cortisol secretion Increasing dopamine release Decreasing serotonin availability Exerting a calming effect

Exerting a calming effect

Panic attacks in Latin American individuals often involve demonstration of which behavior? Repetitive involuntary actions Blushing Fear of dying Offensive verbalization's

Fear of dying Correct

Which subjective symptom should the nurse would expect to note during assessment of a client diagnosed with anorexia nervosa? A. Lanugo B. Hypotension C. 25-lb weight loss D. Fear of gaining weight

Fear of gaining weight

The nurse can determine that inpatient treatment for a client diagnosed with an eating disorder would be warranted when which assessment data is observed? A. Weighs 10% below ideal body weight. B. Has serum potassium level of 3 mEq/L or greater. C. Has a heart rate less than 60 beats/min. D. Has systolic blood pressure less than 70 mm Hg.

Has a systolic bp of less than 70mm/Hg

A client reveals that she induces vomiting as often as a dozen times a day. The nurse would expect assessment findings to support which electrolyte imbalance? A. Hypernatremia B. Hypokalemia C. Hypercalcemia D. Hypolipidemia

Hypokalemia

The patient diagnosed with anemia had laboratory tests done. Which results indicate a lack of nutrients needed to produce new red blood cells (RBCs)? (Select all that apply.) Increased homocysteine Decreased reticulocyte count Decreased cobalamin (vitamin B12) Increased methylmalonic acid (MMA) Elevated erythrocyte sedimentation rate (ESR)

Increased homocysteine Decreased cobalamin (vitamin B12) Increased methylmalonic acid (MMA) Increased homocysteine and MMA along with decreased cobalamin (vitamin B12) indicate cobalamin deficiency, which is a nutrient needed for RBC production. Decreased reticulocytes indicate low bone marrow activity in producing RBCs, not available nutrients. Elevated ESR is related to an increased inflammatory process, not anemia.

When educating a client diagnosed with bulimia nervosa about the medication fluoxetine, the nurse should include what information about this medication? A. It will reduce the need for cognitive therapy. B. It will be prescribed at a higher than typical dose. C. There are a variety of medications to prescribe if fluoxetine proves to be ineffective. D. Long-term management of symptoms is best achieved with tricyclic antidepressants

It will be prescribed at a higher than typical dose

The nurse knows that hemolytic anemia can be caused by which extrinsic factors? Trauma or splenic sequestration crisis Abnormal hemoglobin or enzyme deficiency Macroangiopathic or microangiopathic factors Chronic diseases or medications and chemicals

Macroangiopathic or microangiopathic factors Macroangiopathic or microangiopathic extrinsic factors lead to acquired hemolytic anemias. Trauma or splenic sequestration crisis can lead to anemia from acute blood loss. Abnormal hemoglobin or enzyme deficiency are intrinsic factors that lead to hereditary hemolytic anemias. Chronic diseases or medications and chemicals can decrease the number of red blood cell (RBC) precursors which reduce RBC production.

A patient who has sickle cell disease has developed cellulitis above the left ankle. What is the nurse's priority for this patient? Start IV fluids. Maintain oxygenation. Maintain distal warmth. Check peripheral pulses.

Maintain oxygenation. Maintaining oxygenation is a priority as sickling episodes are frequently triggered by low oxygen tension in the blood which is commonly caused by an infection. Antibiotics to treat cellulitis, pain control, and fluids to reduce blood viscosity will also be used, but oxygenation is the priority.

The client experiencing bulimia differs from the client diagnosed with anorexia nervosa by exhibiting which characteristic? A. Maintaining a normal weight B. Holding a distorted body image C. Doing more rigorous exercising D. Purging to keep weight down

Maintaining a normal weight

The plan of care for a client who has elaborate washing rituals specifies that response prevention is to be used. Which scenario is an example of response prevention? Having the client repeatedly touch "dirty" objects Not allowing the client to seek reassurance from staff Not allowing the client to wash hands after touching a "dirty" object Telling the client that he or she must relax whenever tension mounts

Not allowing the client to wash hands after touching a "dirty" object

an underlying symptom of ischemia is

Pain Ischemia is associated with pain.

Inability to leave one's home because of avoidance of severe anxiety suggests the existence of which anxiety disorder? Panic attacks with agoraphobia Correct Obsessive-compulsive disorder Posttraumatic stress response Generalized anxiety disorder

Panic attacks with agoraphobia

Which statement is true of the eating disorder referred to as bulimia? A. Patients with bulimia often appear at a normal weight. B. Patients with bulimia binge eat but do not engage in compensatory measures. C. Patients with bulimia severely restrict their food intake. D. One sign of bulimia is lanugo.

Patients with bulimia often appear at a normal weight

an underlying symptom of Peptic ulcer disease is

Peptic ulcer disease is associated with pain and intestinal discomfort.

A child diagnosed with autism will demonstrate impaired development in which area? Adhering to routines playing with other children swallowing and chewing eye-hand coordination

Playing with other children

A patient will receive a hematopoietic stem cell transplant (HSCT). What is the nurse's priority after the patient receives combination chemotherapy before the transplant? Prevent patient infection. Avoid abnormal bleeding. Give pneumococcal vaccine. Provide companionship while isolated.

Prevent patient infection. After combination chemotherapy for HSCT, the patient's bone marrow is destroyed in preparation to receive the bone marrow graft. Thus, the patient is immunosuppressed and is at risk for a life-threatening infection. The priority is preventing infection. Bleeding is not usually a problem. Giving the pneumococcal vaccine at this time should not be done; it should have been done previously. Providing companionship is not the primary role of the nurse, although the patient will need support during the time of isolation.

The nurse is performing an admission assessment of an older adult male patient prior to bladder resection surgery. What assessment finding of the patient's genitourinary system would be unexpected? The patient's left testicle hangs lower than his right. Pubic hair is absent from the patient's genital region. The patient's intestines are not palpable through the inguinal rings. The patient's foreskin can be manually retracted to expose the meatus.

Pubic hair is absent from the patient's genital region. An absence of pubic hair is an unexpected finding in an older male patient. It is common for the left testicle to hang lower than the right, and the intestines are often not palpable through the inguinal rings. The foreskin should be easily retractable.

Which assessment finding would support the presence of a hemostasis abnormality? Purpura Pruritus Weakness Pale conjunctiva

Purpura Purpura may occur when platelets or clotting factors are decreased and bleeding into the skin occurs. Pruritus is not related to hemostasis but to hematologic cancers (e.g., lymphomas, leukemias) or increased bilirubin. Weakness and pale conjunctiva are not related to hemostasis unless a lot of bleeding leads to anemia with low hemoglobin level.

A 62-yr-old patient with disseminated intravascular coagulation (DIC) after urosepsis has a platelet count of 48,000/μL. The nurse should assess the patient for which abnormality? Pallor Purpura Pruritus Palpitation

Purpura The normal range for a platelet count is 150,000 to 400,000/μL. Purpura is caused by decreased platelets or clotting factors, resulting in small hemorrhages into the skin or mucous membranes. Pallor is decreased or absent coloration in the conjunctiva or skin. Pruritus is an intense itching sensation. Palpitation is a sensation of feeling the heart beat, flutter, or pound in the

A person who recently gave up smoking and now talks constantly about how smoking fouls the air, causes cancer, and "burns" money that could be better spent to feed the poor is demonstrating which ego defense mechanism? Projection Rationalization Reaction formation Undoing

Reaction formation

The treatment team meets to discuss a client's plan of care. Which of the following factors will be priorities when planning interventions? Readiness to change and support system Current college performance Financial ability Availability of immediate family to come to meetings

Readiness to change and support system

A 20-year-old was sexually molested at age 10, but he can no longer remember the incident. Which ego defense mechanism is in use? Projection Repression Displacement Reaction formation

Repression

A 5-year-old who consistently omits the sound for 'r' and 's' when speaking is demonstrating which type of disorder? Speech Language Social communication Specific learning

Speech

The nurse collects a nutritional history from a 22-yr-old woman who is planning to conceive a child in the next year. Which foods reported by the woman would indicate that her diet is high in folate and iron? Crab, fish, and tuna Milk, cheese, and yogurt Spinach, beans, and liver White rice, potatoes, and pasta

Spinach, beans, and liver Normal intake of iron and folic acid is necessary for the development of red blood cells, and normal levels before conception and in early pregnancy are particularly important for normal fetal development. Foods high in both folic acid and iron include liver, red meat, egg yolks, turkey or chicken giblets, beans, lentils, chickpeas, soybeans, spinach, and collard greens. In addition, enriched cereals, pasta, and breads are also high in both folic acid and iron (check the labels).

A cultural characteristic that may be observed in a teenage, female Hispanic client in times of stress would include what behavior? Suddenly tremble severely Exhibit stoic behavior Report both nausea and vomiting Laugh inappropriately

Suddenly tremble severely Correct

The nurse working with clients diagnosed with eating disorders can help families develop effective coping mechanisms by implementing which intervention? A. Teaching the family about the disorder and the client's behaviors B. Stressing the need to suppress overt conflict within the family C. Urging the family to demonstrate greater caring for the client D. Encouraging the family to use their usual social behaviors at meals

Teaching the family about the disorder and the client's behaviors

Generally, which statement regarding ego defense mechanisms is true? They often involve some degree of self-deception. They are rarely used by mentally healthy people. They seldom make the person more comfortable. They are usually effective in resolving conflicts.

They often involve some degree of self-deception

The nurse is preparing to perform an assessment for a newly admitted patient with a potential hematologic disorder and petechiae. What does the nurse anticipate finding when assessing this patient? Tiny purple spots on the skin Large ecchymotic areas on the skin Hyperkeratotic papules and plaques Small, raised red areas on the soles of the feet

Tiny purple spots on the skin Petechiae present as tiny purple spots on the skin. Large ecchymotic areas are purpura. Hyperkeratotic papules and plaques characterize actinic keratosis. Small, raised red areas on the soles of the feet signify Osler's nodes.

A 10-year-old who is frequently disruptive in the classroom begins to fidget and then moves on to disruptive behavior. What is the most appropriate initial technique for managing this sort of disruptive behavior? Therapeutic holding Seclusion Quiet room Touch control

Touch control

A patient is being treated for non-Hodgkin's lymphoma (NHL). What should the nurse first teach the patient about the treatment? Skin care that will be needed Method of obtaining the treatment Treatment type and expected side effects Gastrointestinal tract effects of treatment

Treatment type and expected side effects The patient should first be taught about the type of treatment and the expected and potential side effects. Nursing care is related to the area affected by the disease and treatment. Skin care will be affected if radiation is used. Not all patients will have gastrointestinal tract effects of NHL or treatment. The method of obtaining treatment will be included in the teaching about the type of treatment.

The history and physical of a 29-year-old female patient are indicative of human papillomavirus (HPV) infection. What treatment option should be discussed with the patient? Gardasil Antibiotic therapy Wart removal options Treatment with antiviral drugs

Wart removal options

Which child is demonstrating behaviors that support a diagnosis of adolescent onset conduct disorder? a. A 12-year-old male who steals a bicycle as a gang initiation b. A 9-year-old male who smokes half a pack of cigarettes a day c. A 12-year-old female who regularly bullies her younger siblings d. A 9-year-old female who engages in sexually provocative behaviors

a. A 12-year-old male who steals a bicycle as a gang initiation In adolescent-onset conduct disorder, no symptoms are present prior to age 10. Affected adolescents tend to act out misconduct with their peer group (e.g., early onset of sexual behavior, substance abuse, risk-taking behaviors). Males are more likely to fight, steal, vandalize, and have school discipline problems, whereas girls tend to lie, be truant, run away, abuse substances, and engage in prostitution.

A woman in active labor arrives at the birthing unit. She tells the nurse that she was told that she had a chlamydial infection the last time she visited the clinic; however, she stopped taking the antibiotic after 3 days because she "felt better." In light of this history, which would the nurse anticipate as part of the plan of care? a. Administration of antibiotics before delivery b. Oxytocin infusion to augment labor c. Epidural anesthesia to relieve difficult labor discomfort d. Magnesium sulfate infusion to prevent a precipitous birth

a. Administration of antibiotics before delivery

Which sexually transmitted infection is caused by Chlamydia trachomatis? a. Cervicitis b. Gonorrhea c. Genital warts d. Genital herpes

a. Cervicitis

What instructions should the nurse give to an adolescent to prevent sexually transmitted infections? Select all that apply. a. Remember to use condoms properly. b. Abstain from any kind of sexual activity c. Make sure you are up-to-date with your vaccinations. d. Have sexual contact only if you and your partner are monogamous. e. Remember to have regular screening from STI's

a. Remember to use condoms properly. c. Make sure you are up-to-date with your vaccinations. d. Have sexual contact only if you and your partner are monogamous.

Pyromania, a behavior associated with impulse control disorders, causes an individual to engage in what behavior? a. Starting fires b. Stealing for thrill c. Self-mutilate d. Directing anger toward others

a. Starting fires Pyromania is described as repeated, deliberate fire setting. This behavior does not include any of the other stated options.

Which is the most appropriate nursing intervention for an adolescent child with sickle cell anemia? a. Teaching the family how to limit sickling episodes b. Preparing the child for occasional blood transfusions c. Educating the family about prophylactic medications d. Explaining to the child how excess oxygen causes sickling

a. Teaching the family how to limit sickling episodes

When a client develops iron-deficiency anemia, which of the client's laboratory test results would the nurse expect to be decreased? a. ferritin level b. platelet count c. WBC count d. total iron-binding capacity

a. ferritin level

Which instruction would the nurse give to the pregnant client with anemia? a. Take an iron and calcium supplement together daily. b. Drink orange juice with an iron supplement. c. Include fresh fruit at every meal. d. Include 4 servings of calcium-rich foods daily

b. Drink orange juice with an iron supplement

A sexually active female client is upset with her diagnosis of gonorrhea and asks the nurse, "What can I do to prevent getting another infection like this?" Which practical response would the nurse provide? a. "Douche after every sexual intercourse." b. "Avoid engaging in sexual behaviors." c. "Insist that your partner uses a condom." d. "Use a spermicidal cream with sexual intercourse."

c. "Insist that your partner uses a condom."

Which statement by the female client with a diagnosis of gonorrhea indicates she has understood the teaching by the nurse on how to avoid future infection? a. "I'll douche after each time I have sex." b. "Having sex is a thing of the past for me." c. "My partner has to use a condom all the time." d. "I'll be using a spermicidal cream from now on."

c. "My partner has to use a condom all the time."

The nurse is teaching a client with chlamydia about medication compliance and preventing recurrence. Which statement by the client indicates the need for further instruction? a. "If there is more drainage or I have pain, I will call the office." b. "The full regimen of prescribed oral antibiotics needs to be taken." c. "Sexual intercourse should be avoided for 3 days after treatment." d. "I will notify all my sexual partners of the infection so they can get treated."

c. "Sexual intercourse should be avoided for 3 days after treatment."

Which length of time would the nurse teach a client regarding the incubation period of syphilis? a. 1 week b. 4 months c. 2 to 6 weeks d. 48 to 72 hours

c. 2 to 6 weeks

A primigravida in the first trimester of pregnancy is diagnosed with gonorrhea. Which dosage of ceftriaxone is recommended to prevent the transmission of gonorrhea? a. 250 mg given after delivery b. 125 mg given after delivery c. 250 mg started immediately d. 125 mg started immediately

c. 250 mg started immediately

Which cause of anemia would the nurse recognize as the most common cause of anemia in 1-year-olds? a. thalassemia b. lead poisoning c. iron deficiency d. sickle shape of blood cells

c. iron deficiency

Which statement helps the nurse determine that a woman with genital herpes (HSV-2) infection understands her self-care? a. "When I have a baby, I don't want a cesarean." b. "I can have sex as soon as the herpes sores have healed." c. "When I finish the acyclovir prescription I will be cured." d. "I must be careful when I have sex because herpes is a lifelong problem."

d. "I must be careful when I have sex because herpes is a lifelong problem."

A nurse is teaching a male client about measures to maintain sexual health and prevent transmission of sexually transmitted infections (STI). Which statement of the client indicates effective learning? a. "I will use condoms when having sex with an infected partner." b. "I will perform a genital self-examination every month before bathing." c. "I will refrain from getting the human papilloma virus vaccine (HPV) before the age of 27 years." d. "I will consult with my primary healthcare provider when there is a rash or ulcer on my genitalia."

d. "I will consult with my primary healthcare provider when there is a rash or ulcer on my genitalia."

Which response would the nurse provide to a client who has been diagnosed with genital herpes at her annual examination and asks how the health care provider knew that she had herpes? a. "There's a sore in your vagina." b. "There's a rash near your vagina." c. "You have a typical discharge from your vagina." d. "You have blisters on the skin around your vagina."

d. "You have blisters on the skin around your vagina."

A breast-feeding teenage mother is diagnosed with syphilis. Which would be the medication of choice for this client? a. Doxycycline b. Tetracycline c. Azithromycin d. Benzathine penicillin

d. Benzathine penicillin

The client asks about the risks and preventions of becoming infected again with endocarditis. It is most important for the nurse to include which instruction in the healthcare teaching of a client diagnosed with infective endocarditis? Remind HCPs and dentists of the client's history of endocarditis. Daily vigorous brushing and flossing teeth reduces risk of reinfection. Reduce risk of antibiotic resistance by not applying antibiotic ointments to open skin. Once the first dose of antibiotic is administered and completed at home, there is no need to continue to monitor your temperature.

When preparing educational materials for the family of a client diagnosed with progressive dementia, the nurse will include information related to local: (select all that apply): A. day care centers B. legal professionals C. home health services D. family support groups E. professional counseling

A. day care centers C. home health services D. family support groups E. professional counseling

Dementia in an older adult is often a misdiagnosis for A. depression. B. cerebral emboli. C. normal effects of aging. D. poor nutritional status.

A. depression.

A client being prepared for discharge tells the nurse, "Dr. Jacobson is putting me on some medication called naltrexone. How will that help me?" Which response is appropriate teaching regarding naltrexone? "It helps your mood so that you don't feel the need to do drugs." "It will keep you from experiencing flashbacks." "It is a sedative that will help you sleep at night so you are more alert and able to make good decisions." "It helps prevent relapse by reducing drug cravings."

"It helps prevent relapse by reducing drug cravings"

Which topics will the school nurse include in adolescent education on sexually transmitted infections (STIs)? Select all that apply. One, some, or all responses may be correct. 1 Condom use 2 Sexual identity 3 Types of contraception 4 Number of sexual partners 5 Alcohol and drug consumption

1 Condom use 3 Types of contraception 4 Number of sexual partners

The term "perceptual disturbance" refers to difficulty A. processing information about one's internal and external environment. B. changing one's way of thinking to accommodate new information. C. performing purposeful motor movements. D. formulating words appropriately.

A. processing information about one's internal and external environment.

The nurse is conducting discharge teaching with an adolescent with hemophilia. Which statement by the client indicates a need for further teaching? 1 "I'll use a straight razor when I start shaving." 2 "I plan on trying out for the swim team next year." 3 "If I injure a joint, I'll keep it still, elevate it, and apply ice." 4 "If I get a little scratch, I can apply gentle pressure for 10 to 15 minutes."

1 "I'll use a straight razor when I start shaving." A straight razor should not be used by the adolescent with hemophilia, so further teaching is required. The adolescent with hemophilia should be taught to use an electric razor for shaving. Contact sports should be avoided, but swimming is a recommended activity, so trying out for the swim team indicates that the adolescent understands the teaching. If a superficial injury occurs, gentle, prolonged pressure should be applied until the bleeding has stopped. If a muscle or joint injury occurs, the area should be immobilized, elevated, and iced. Both statements indicate that the adolescent has understood the teaching.

Which population would the nurse include in a community education session on sexually transmitted infections (STIs)? Select all that apply. One, some, or all responses may be correct. 1 Adolescents 2 Homosexual men 3 Transgender clients 4 Multiple sex partners 5 Intravenous drug users

1 Adolescents 2 Homosexual men 3 Transgender clients 4 Multiple sex partners 5 Intravenous drug users

Which factor that influences the spread of sexually transmitted infections (STIs) would the nurse include in a teaching session? Select all that apply. One, some, or all responses may be correct. 1 Age 2 Drug abuse 3 Lack of education 4 Multiple sex partners 5 Absent or subtle symptoms 6 Limited access to health care

1 Age 2 Drug abuse 3 Lack of education 4 Multiple sex partners 5 Absent or subtle symptoms 6 Limited access to health care

Which finding would the nurse expect when assessing the nasal passages of a client with thrombocytopenia? 1 Blood clots 2 Nasal polyps 3 Purulent discharge 4 Pale, swollen turbinates

1 Blood clots Thrombocytopenia increases risk for epistaxis and the nurse may see bleeding or clots. Nasal polyps are not associated with thrombocytopenia. Purulent discharge may occur with foreign bodies in the nose or sinus infection, but would not be expected with thrombocytopenia. Pale and swollen turbinates are caused by allergies and not associated with thrombocytopenia.

The nurse notes a provider's order written at 10:00 AM for two units of packed red blood cells to be administered to a patient who is anemic as a result of chronic blood loss. If the transfusion is picked up at 11:30 AM, the nurse should plan to hang the unit no later than what time? 11:45 AM 12:00 noon 12:30 PM 3:30 PM

12:00 noon The nurse must hang the unit of packed red blood cells within 30 minutes of signing them out from the blood bank.

The client becomes tearful as she expresses concern about how she will explain her hospitalization to her two teenage daughters. Which approach by the nurse is most helpful in reducing the client's fear? Offer professional resources to assist the client in understanding her diagnosis and treatment. Provide the family with information about the client's diagnosis and treatment. Volunteer to discuss the diagnosis and treatment with the client's daughters on her behalf. Advise the client that the HCP is responsible for informing family members.

The client is to be discharged from the hospital with a prepared antibiotic, IV pump with tubing, alcohol wipes, IV access (PICC), normal saline solution and flushes. When planning the client's discharge, it is most important for the nurse to coordinate with which member of the healthcare team? Case Manager. Home Health Nurse. Pharmacist. Registered Dietician.

The healthcare provider (HCP) has also prescribed a single dose of intravenous (IV) magnesium sulfate 2 mg in 100 mL of 5% dextrose in water over one hour to be given now. The nurse is preparing to give the prescribed intravenous (IV) magnesium. Which laboratory values should the nurse monitor cautiously before starting the medication? Blood urea nitrogen (BUN) and serum creatinine levels. White blood cell (WBC) and red blood cell counts (RBC). Activated partial thromboplastin time (aPTT). Hemoglobin (Hb), hematocrit (Hct), and platelet count.

The most common course of schizophrenia is an initial episode followed by what course of events? A Recurrent acute exacerbations and deterioration B Recurrent acute exacerbations C Continuous deterioration C Complete recovery

The nurse calculates incidence proportions for student pregnancies for the last three years. The calculation is based on the following information. There were 5,550 high school students enrolled each year. In year one, 6 of 2,900 10th, 11th, and 12th grade females were pregnant and 2 12th grade students were parents. In year two, 3 of 3,005 9thand 10th grade females were pregnant and 5 11th and 12th grade students were parents. In year three, 3 of 2,777 9th, 10th, and 12th grade females were pregnant and 2 11th grade students were parents. What was the incidence of pregnancy in year two? 1/1,000. 2/1,000. 3/1,000. 6/1,000.

Which of the following is an example of incidence of communicable disease? New diagnoses of gonorrhea in the community. Number of individuals in the county with hepatitis C. Sexual partners exposed to an individual infected with HIV. Individuals with chlamydia who test positive when re-tested.

Which of the following would be assessed as a negative symptom of schizophrenia? A Anhedonia B Hostility C Agitation D Hallucinations

Which side effects of lithium can be expected at therapeutic levels? A Fine hand tremor and polyuria B Nausea and thirst C Coarse hand tremor and gastrointestinal upset D Ataxia and hypotension

Which male patient does the nurse identify is most susceptible to experiencing erectile dysfunction as a consequence of his drug regimen? A patient who takes a biguanide for type 2 diabetes. A patient who takes a β-adrenergic blocker for hypertension. A patient who uses a proton pump inhibitor to control acid reflux. A patient who is taking a cephalosporin antibiotic in order to treat cellulitis.

A patient who takes a β-adrenergic blocker for hypertension. Antihypertensives are commonly implicated in cases of erectile dysfunction. Antibiotics, PPIs, and biguanides are less likely to negatively impact men's sexual function.

The nurse is having a therapeutic conversation with a patient newly diagnosed with hypertension. Which communication techniques will most likely prove effective for this patient? (Select all that apply.) Select all that apply. A The nurse waits until the patient has been awake for a few hours before beginning the teaching plan. B The nurse helps the patient identify weight loss goals that are reasonable. C The nurse gives the patient a sheet full of information and asks the patient to read the information and let the nurse know if they have any questions. D The nurse and patient engage in a humorous conversation about the top ten "what not to eat when you are being treated for hypertension." E The nurse presents a laminated poster to the patient that depicts pictures of foods that would be on the low sodium diet. F The nurse states the risk factors and statistics of patients who do not take their medications as prescribed.

A, b, d, e

The client asks if she can continue her daily exercise routine with the PICC line in place when she returns home. Which activities should the nurse instruct the client to continue upon discharge? (Select all that apply. One, some, or all options may be correct.) Select all that apply Perform usual activities of daily living. Keep dressing clean, dry, and intact. Lift light weights as tolerated. Avoid excessive physical activity. Cover with plastic when swimming.

ABD

Which of the following are components of a comprehensive sexual education program?(Select all that apply. One, some, or all options may be correct.) Select all that apply Abstinence. Sexually transmitted diseases/infections. Religious views about sexuality. Pregnancy prevention. Healthy communication and healthy relationships.

ABDE

The nurse has received new orders by electronic medical record (EMR) in response to the recent laboratory results. One of the orders is for intravenous potassium chloride 20 mEq/100 mL over one hour. Which drug implications are important for the nurse to consider before giving it? (Select all that apply. One, some, or all options may be correct.) A. The intravenous site should be monitored closely for infiltration. B. Giving the infusion too rapidly can cause fatal hyperkalemia. C. It should be injected directly and slowly by intravenous push. D. The intravenous infusion is best given through a central line. E. The intravenous potassium can be given by gravity infusion. F. Administering the intravenous medication can burn a peripheral vein.

ABDF

What are some primary prevention activities a nurse can perform related to substance abuse? (Select all that apply.) Select all that apply. Education to prevent substance abuse Focusing on relapse prevention Identification of risk factors for abuse Referral to a self-help group for stress relief and meditation Medical detoxification

ACD

Which response by a 15-year-old boy demonstrates a common symptom observed in patients diagnosed with major depressive disorder? A. "I'm so restless. I can't seem to sit still." B. "I spend most of my time studying. I have to get into a good college." C. "I'm not trying to diet, but I've lost about 5 pounds in the past 5 months." D. "I go to sleep around 11 pm but I'm always up by 3 am."

Answer: D

The nurse explains to the client that medications will be administered to obtain which expected outcome? The first treatment is one in a series of treatments that will cure the infection. Uncomplicated gonorrhea is cured with a single dose of antibiotic therapy. The infection cannot be cured completely, but medication will reduce the pain. Antiviral medication will cure the infection faster and minimize pain in one dose.

During the follow up meeting, the student asks the nurse, "Is it possible to transmit the infection when I do not have any symptoms?" How should the nurse respond? "The greatest risk for transmitting infection is when there are no visible lesions or symptoms." "It is possible to transmit the virus when no visible lesions or symptoms are present." "If you don't have a recurrence after the first year, you decrease the chance of transmitting the virus to others." "You do not need to worry about transmitting the virus if you use condoms during vaginal sex."

Morning laboratory results have begun appearing in the client's electronic medical record (EMR). Which electrolyte deficiency would make the nurse suspect that this client may be suffering from chronic alcohol use? Potassium. Magnesium. Phosphate. Sodium.

The nurse finishes documenting the client interview and notices that new laboratory results have been posted in the electronic medical record (EMR). The nurse notes that the serum magnesium level is 1.22 mg/dL (0.50 mmol/L), and the normal range is 1.58 to 2.55 mg/dL (0.65 to 1.05 mmol/L). Which other result will need intervention? Chloride of 99 mEq/L (99 mmol/L). Potassium of 2.9 mEq/L (2.9 mmol/L). Glucose of 105 mg/dL (5.83 mmol/L). Sodium of 137 mEq/L (137 mmol/L).

The nurse reviews the PICC line x-ray report for placement confirmation and prepares to administer the ceftriaxone per the HCP's prescription. To detect any untoward effects of ceftriaxone, it is most important for the nurse to assess the client for which symptoms throughout the duration of the infusion? Discoloration of bilateral extremities. Snoring sounds or stridor. Painful urination. Weak bilateral hand grasp.

A cardiothoracic surgeon is consulted and recommends deferring surgery for the client until after antibiotic treatment is complete. The client asks why she should wait if the valve is already damaged. Which response is best for the nurse to provide? The damaged valve can be removed after the infection is treated with antibiotic. Antibiotics completely inhibit embolization from valvular vegetations. Surgery is used in the event antibiotic is ineffective in treating the disease. The client can choose either surgery or antibiotics to treat infective endocarditis.

A client diagnosed with disorganized schizophrenia would have greatest difficulty with the nursing intervention? A Interacting with a neutral attitude B Using concrete language C Giving multistep directions D Providing nutritional supplements

A client diagnosed with paranoid schizophrenia refuses food, stating the voices are saying the food is contaminated and deadly. Which response should the nurse provide to this client statement? A "You are safe here in the hospital; nothing bad will happen to you." B "The voices are wrong about the hospital food. It is not contaminated." C "I understand that the voices are very real to you, but I do not hear them." D "Other people are eating the food, and nothing is happening to them."

A client, who has been prescribed clozapine 6 weeks ago, reports flulike symptoms including a fever and a very sore throat, the nurse should initiate which nursing intervention? A Suggest that the client take something for the fever and get extra rest. B Advise the physician that the client should be admitted to the hospital. C Arrange for the client to have blood drawn for a white blood cell count. D Consider recommending a change of antipsychotic medication.

A manic client tells a nurse "Bud. Crud. Dud. I'm a real stud! You'd like what I have to offer. Let's go to my room." What is the best initial approach to managing this behavior? A Reprimand the client by stating, "What an offensive thing to suggest!" B Clarifying the nurse-client relationship by stating, "I don't have sex with clients." C Distracting the client by suggesting, "It's time to work on your art project." D Enforcing consequences by responding, "Let's walk down to the seclusion room."

The client says she has taken penicillin in the past and experienced no allergies to the medication. Which statement indicates that the nurse understands the importance of confirming this information prior to administering penicillin or cephalosporin? Based on the client's history, she will never experience an allergic reaction to penicillin or cephalosporin. A penicillin sensitivity reaction that occurs once inoculates the client from future allergic responses. Despite the client's history, she could experience an allergic reaction to penicillin or cephalosporin. Based on the client's history, she is not likely to react to penicillin but could definitely experience an allergic reaction to cephalosporin.

The client thanks the nurse for the concern and states that he does not have a desire to attempt suicide. He states that since he has had some rest, good food, and medical treatment, he is feeling much better. He tells her what he knows about his treatment plan: He will start attending grief support meetings and taking better care of himself in general, but he will not be going to psychotherapy or attending any Alcoholics Anonymous meetings. The client has not mentioned what he will do about his chronic alcohol use while describing his treatment plan. Which term would the nurse use to summarize where he is in his alcohol misuse treatment plan? Depression. Bargaining. Denial. Acceptance.

The nurse provides the student with instructions about ways to reduce the risk of HSV transmission. The nurse explains that a condom should always be worn between HSV outbreaks, and sexual activity should be avoided during the prodromal phase and when lesions are present. The nurse teaches the student how to recognize the prodromal stage of HSV. Which symptoms are indicative of the prodromal stage of genital HSV? Vesicular lesions on the genitals. Shallow moist ulcerations around the genitals. Tingling, burning, or itching at the site the lesions will eventually appear. Crusting and epithelialization of the erosions.

The nurse visits with the student who wanted to discuss a confidential concern. The student reports that she decided to have sex with her boyfriend of 9 months. The student reports that they had sex without a condom and now she has painful sores on her inner labia. The nurse suspects that the student has contracted herpes simplex virus (HSV). The nurse suspects that the student has contracted herpes simplex virus (HSV). What is the priority nursing action? Inform the student's parent/guardian. Consult with the student's healthcare provider. Refer the student for sexually transmitted disease testing and treatment Counsel the student about the importance of using condoms during sex.

The pelvic examination allows for the inspection and palpation of external and internal reproduction structures in order to identify deviations, inform medical diagnoses, and collect specimens for laboratory analysis. Which is the best approach for the nurse to position the client for the pelvic examination? Head flush with top of examination table, hips and knees flexed, feet in stirrups. Genupectoral position with weight of body supported by knees and chest. Buttocks at the edge of the examination table, hips and knees flexed, feet in stirrups. Sim's position on one side with knee and thigh drawn upward to chest.

A married couple present to the preconceptual clinic with questions about how a fetus's chromosomal sex is established. What is the best response by the nurse? A At climax, chromosomal sex is established. B At ejaculation, chromosomal sex is established. C At fertilization, chromosomal sex is established. D At ovulation, chromosomal sex is established.

C At fertilization, chromosomal sex is established.

A female patient comes to the clinic at 8 weeks' gestation. She lives in a house beneath electrical power lines, which is located near an oil field. She drinks two caffeinated beverages a day, is a daily beer drinker, and has not stopped eating sweets. She takes a multivitamin and exercises daily. She denies drug use. Which finding in the history has the greatest implication for this patient's plan of care? A Drinking alcohol should be avoided during pregnancy because of its teratogenic effects. B Living near an oil field may mean the water supply is polluted. C Eating sweets may cause gestational diabetes or miscarriage. D Electrical power lines are a potential hazard to the woman and her fetus.

C Eating sweets may cause gestational diabetes or miscarriage.

A 20-year-old woman comes for preconceptual counseling. She wants to get pregnant soon. Which health-promoting habit would have the highest priority at this time? A Getting daily exercise B Avoidance of sweets C Immediate tobacco cessation D Stopping all caffeine

C Immediate tobacco cessation

What are the foundational concerns regarding the use of restraint and seclusion when providing care to children? Select all that apply. A Parents may initiate a lawsuit if injury occurs. B Staff have conflicted feelings leading to ineffectiveness. C Research suggests both are psychologically and physically harmful. D Staff tends to be undertrained in use of restraints in children. E The principle of least restrictive intervention is a primary concern.

C, e

Which of the following tools is the best measure to determine a patient's gas exchange and respiratory function? A. Chest x-ray B. Oxygen saturation C. Arterial blood gas (ABG) analysis D. Central venous pressure monitoring

C. Arterial blood gas (ABG) analysis

Before beginning a transfusion of packed red blood cells (PRBCs), which action by the nurse would be of highest priority to avoid an error during this procedure? Add the blood transfusion as a secondary line to the existing IV. Stay with the patient for 60 minutes after starting the transfusion. Check the identifying information on the unit of blood against the patient's ID bracelet. Prime new primary IV tubing with lactated Ringer's solution to use for the transfusion.

Check the identifying information on the unit of blood against the patient's ID bracelet. The patient's identifying information (name, date of birth, medical record number) on the ID bracelet should exactly match the information on the blood bank tag that has been placed on the unit of blood. If any information does not match, the transfusions should not be hung because of possible error and risk to the patient. The transfusion is hung on blood transfusion tubing, not a secondary line, and cannot be hung with lactated Ringer's solution because it will cause RBC hemolysis. Usually, the patient will need continuous monitoring for 15 minutes after the transfusion is started, as this is the time most transfusion reactions occur. Then the patient should be monitored every 30 to 60 minutes during the administration.

Tara and Aaron are twins who are both diagnosed with schizophrenia. Aaron was diagnosed at 23 years old and Tara at 31 years old. Based on your knowledge of early and late onset of schizophrenia, which of the following is true? A Tara and Aaron have the same expectation of a poor long-term prognosis. B Tara will experience more positive signs of schizophrenia such as hallucinations. C Aaron will be more likely to hold a job and live a productive life. D Tara has a better chance for positive outcomes because of later onset.

The PICC nurse completes the placement procedure and records a length of 60 cm double-lumen peripherally inserted central catheter in the basilic vein of the left inner arm. After insertion of a PICC line, which action is the most important for the nurse to implement first? Use 10 mL of sterile saline to flush before and after medication administration. Flush with 5 mL of heparin (10 units/mL) in a 5 mL syringe daily. Begin infusion of ceftriaxone 1 g IV every 24 hrs. Contact the radiologist for a chest x-ray indicating placement.

The client asks where on her arm the PICC line will be inserted. Which explanation by the nurse is most helpful? The catheter will be inserted through a vein of the antecubital fossa. The tip of the catheter will reside in the superior vena cava (SVC). Catheters are ideally placed at the caval-atrial junction. The catheter will be inserted at the inner side of the bend of the arm.

The nurse assesses the client's lifestyle choices to explore what resources he has for health promotion. Which lifestyle choice could concern the nurse about a client with possible chronic alcohol use? Sexual preferences. He works ten to twelve hours every day in the office. He prefers to live in a city where there is a lot of action. He enjoys staying out all night at his favorite local bar.

When a client diagnosed with paranoid schizophrenia tells the nurse, "I have to get away. The volmers are coming to execute me," an appropriate response for the nurse would be: A "You are safe here. This is a locked unit, and no one can get in." B "I do not believe I understand the word volmers. Tell me more about them." C "Why do you think someone or something is going to harm you?" D "It must be frightening to think something is going to harm you."

Which type of dementia has a clear genetic link? A. Alcohol-induced dementia B. Multi-infarct dementia C. Creutzfeldt-Jakob disease D. Alzheimer's disease

D. Alzheimer's disease

A male patient with a history of transient ischemic attacks (TIAs) is undergoing rehabilitation following an ischemic stroke. The patient's medical history is likely to be related to what health problems? Inguinal hernia Erectile dysfunction Testosterone deficiency Benign prostatic hyperplasia (BPH)

Erectile dysfunction Stroke is a common cause of erectile dysfunction. A stroke and underlying cardiovascular disease is unlikely to be related to an inguinal hernia, testosterone deficiency, or BPH.

The nurse receives a provider's order to transfuse fresh frozen plasma to a patient with acute blood loss. Which procedure is most appropriate for infusing this blood product? Hang the fresh frozen plasma with lactated Ringer's solution. Fresh frozen plasma must be given within 24 hours after thawing. Infuse the fresh frozen plasma at a rate of 50 mL/hr for the duration. Hang the fresh frozen plasma as a piggyback to a primary IV solution without KCl.

Fresh frozen plasma must be given within 24 hours after thawing. The fresh frozen plasma should be administered as rapidly as possible and should be used within 24 hours of thawing to avoid a decrease in factors V and VIII. Fresh frozen plasma is infused using any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infused, unless a second IV line has been started for the transfusion.

Which nursing diagnosis should be considered for a child with attention deficit hyperactivity disorder ADHD? Anxiety risk for injury defensive coping impaired verbal communication

Risk for injury

The nurse is asked to teach an adolescent female patient about menstruation. What is important for the nurse to include when teaching the adolescent? The length of the menstrual cycle should be 28 days. Menstrual cycles are often irregular for the first 1 to 2 years. The female loses around 1 cup of blood with each menstrual period. Follicle-stimulating hormone (FSH) causes maturity of the follicle for ovulation.

Menstrual cycles are often irregular for the first 1 to 2 years.

Which communication term can be applied to this statement: How messages are received and interpreted would include personal states such as mood disturbance, environmental stimuli related to the setting of the communication, and contextual variables? Internal noise Metacommunication Vigor communication Therapeutic communication

Metacommunication

A patient with an acute peptic ulcer and major blood loss requires an immediate transfusion with packed red blood cells. Which task is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? Confirm the IV solution is 0.9% saline. Obtain the vital signs before the transfusion is initiated. Monitor the patient for shortness of breath and back pain. Double-check the patient identity and verify the blood product.

Obtain the vital signs before the transfusion is initiated. The RN may delegate tasks such as taking vital signs to UAP. Assessments (e.g., monitoring for signs of a blood transfusion reaction [shortness of breath and back pain]) are within the scope of practice of the RN and may not be delegated to UAP. The RN must also assume responsibility for ensuring the correct IV fluid is used with blood products. A licensed nurse must complete verification of the patient's identity and the blood product data.

When teaching nursing students about the male sexual response, what should the nurse call the phase that includes ejaculation? Plateau phase Orgasmic phase Resolution phase Excitement phase

Orgasmic phase The orgasmic phase is when ejaculation occurs from contraction of the penile and urethral musculature propelling the sperm outward through the meatus. The excitement phase is manifested by penile erection in response to sexual stimulation. The plateau phase is when the erection is maintained. There is a slight increase in vasocongestion and testicle size, and the glans penis may be more reddish-purple. The resolution phase is after ejaculation when the penis gradually returns to its unstimulated, flaccid state.

Delusionary thinking is a characteristic of which form of anxiety? Chronic anxiety Acute anxiety Severe anxiety Panic level anxiety

Panic level anxiety

Biological theorists suggest that the cause of eating disorders may be related to which factor? A. Normal weight phobia B. Body image disturbance C. Serotonin imbalance D. Dopamine excess

Serotonin imbalance

An older adult female patient reports hair growing on her chin. How should the nurse explain this occurrence to this patient? There is too much estrogen in your body. There is not enough testosterone in your body. The estrogen in your body is decreased since menopause. The negative feedback system for your hormones is working.

The estrogen in your body is decreased since menopause. Many of the reproductive changes associated with aging for women occur related to the decrease in estrogen associated with menopause. After menopause there may be increased androgens. Estrogen stimulation is related to negative feedback, and GnRH would stimulate greater follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which results in a higher level of estrogen production by the ovaries. The negative feedback mechanism is not active because this system occurs when there is decreased level of circulating estrogen, which increases the level of GnRH production by the hypothalamus, leading to increased FSH and LH from the pituitary, which results in higher estrogen production.

The nurse is caring for a patient with a diagnosis of disseminated intravascular coagulation (DIC). What is the first priority of care? Administer heparin. Administer whole blood. Treat the causative problem. Administer fresh frozen plasma.

Treat the causative problem. Treating the underlying cause of DIC will interrupt the abnormal response of the clotting cascade and reverse the DIC. Blood product administration occurs based on the specific component deficiencies and is reserved for patients with life-threatening hemorrhage. Heparin will be administered if the manifestations of thrombosis are present and the benefit of reducing clotting outweighs the risk of further bleeding.

The nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement? a. "I'll start to have symptoms when I drink less fluid." b. "I'll start to have symptoms when I have fewer platelets." c. "I'll start to have symptoms when I decrease the iron in my diet." d. "I'll start to have symptoms when I have fewer white blood cells.

a. "I'll start to have symptoms when I drink less fluid."

At 6 weeks' gestation a client is found to have gonorrhea. For which medication would the nurse anticipate preparing a teaching plan? a. Ceftriaxone b. Levofloxacin c. Sulfasalazine d. Trimethoprim/sulfamethoxazole

a. Ceftriaxone

A client diagnosed with conduct disorder craves what experience? a. Excitement without concern for possible negative outcomes b. Control of situations and constantly strategizes for such power c. Friendship but from those older than themselves d. Material possessions but lacks focus and direction

a. Excitement without concern for possible negative outcomes People with conduct disorder crave excitement and do not worry as much about consequences as other people do. None of the other options demonstrates a need associated with conduct disorder.

Which education is appropriate to give a client at 16 weeks' gestation whose partner has just informed her that he has genital herpes? a. Latex or polyurethane condoms must be used when the couple is having intercourse. b. Mutual monogamy must be practiced. c. It will be necessary to refrain from sexual contact during pregnancy. d. Meticulous cleaning of the vaginal area after intercourse is essential

a. Latex or polyurethane condoms must be used when the couple is having intercourse.

After the nurse has finished teaching a client about sickle cell anemia, which statement indicates that the client has a correct understanding of the condition? a. "I have abnormal platelets." b. "I have abnormal hemoglobin." c. "I have abnormal hematocrit." d. "I have abnormal white blood cells.

b. "I have abnormal hemoglobin."

Which statement by an adolescent indicates the need for additional teaching regarding sexually transmitted infections (STIs)? a. "We use condoms with nonoxynol-9." b. "I use spermicide as contraception." c. "My partner uses a female condom." d. "I have never used drugs or alcohol."

b. "I use spermicide as contraception."

When treating impulse control disorders, psychodynamic psychotherapy is directed toward which goal? a. Mastering relaxation techniques b. Identifying the triggers of the rage c. Teaching the client self-distracting techniques d. Helping the client replace the rage with acceptable alternative feelings

b. Identifying the triggers of the rage Psychodynamic psychotherapy focuses on underlying feelings and motivations and explores conscious and unconscious thought processes. In working with impulse control problems, the therapist may help the patient to uncover underlying feelings and reasons behind rage or anger. This may help them to develop better ways to think about and control their behavior. None of the other options are considered goals of this form of therapy.

The nurse is helping an adolescent with iron-deficiency anemia make breakfast meal choices. Which food would the nurse suggest? a. apple fruit cup b. bowl of raisin bran c. cup of blueberry yogurt d. slice of wheat bread toast with butter

b. bowl of raisin bran

A 4-year-old child diagnosed with sickle cell anemia is at a high risk of acquiring pneumococcal diseases. The child has previously received two doses of the pneumococcal conjugate vaccine (PCV). Based on the immunization protocol, which dose of PCV should the nurse administer? a. Administer four more doses of PCV. b. Administer three more doses of PCV. c. Administer two more doses of PCV. d. Administer one more dose of PCV

c. Administer two more doses of PCV.

Which information about genital herpes would the nurse teach the students in the high school sex education class? a. A healthy lifestyle will prevent exacerbations. b. Once the infection is effectively treated, exacerbations are rare. c. Although exacerbations occur, they are not as severe as the initial episode. d. The most effective way to prevent exacerbations is to abstain from sexual activity.

c. Although exacerbations occur, they are not as severe as the initial episode.

The parents of a 3-month old infant who is breast-fed ask the nurse how to prevent nutritional anemia. Which is the best response by the nurse? a. Supplemental iron will not be needed for the first year. b. Solid foods need not be introduced until 7 or 8 months of age. c. Anemia will not develop as long as the infant is gaining weight. d. Baby cereal or an iron supplement should be given around 4 months of age

d. Baby cereal or an iron supplement should be given around 4 months of age

Which behavior consistently demonstrated by a child is a predictor of future antisocial personality disorder in adults? a. Sadness b. Remorse c. Guilt d. Callousness

d. Callousness Callousness may be a predictor of future antisocial personality disorder in adults. The remaining options would indicate a degree of empathy not observed in a client who is demonstrating antisocial tendencies.

Which is the nurse's priority when evaluating a child with sickle cell anemia whose spleen autoinfarcted 2 years prior? a. Monitoring for signs of jaundice b. Assessing the abdomen frequently c. Monitoring serial hematocrit readings d. Determining parental knowledge about infection

d. Determining parental knowledge about infection

A patient with thrombocytopenia secondary to sepsis has small, pinpoint deposits of blood visible through the skin on the anterior and posterior chest. The nurse will document this skin abnormality as: petechiae. erythema. ecchymosis. telangiectasia.

petechia Petechiae are pinpoint, discrete deposits of blood less than 1 to 2 mm in the extravascular tissues and visible through the skin or mucous membranes. Erythema is redness occurring in patches of variable size and shape. Telangiectasia is visibly dilated, superficial, cutaneous small blood vessels. Ecchymosis is a large, bruise-like lesion caused by a collection of extravascular blood in the dermis and subcutaneous tissue.

Which intervention would be least useful for accurate assessment of the weight of a client diagnosed with anorexia nervosa? A. Weigh 2 times daily first week, then three times weekly. B. Weigh fully clothed before breakfast. C. Do not reweigh client when client requests. D. Permit no oral intake before weighing.

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