Extra Alternative Questions
The nurse is teaching a caregiver how to effectively interact with an older adult parent who suffers from impaired memory and judgment. What is the most important information for the nurse to provide? Select all that apply. "Perform all your parent's care and activities of daily living." "Speak slowly and use understandable words and phrases." "Keep music playing to promote environmental stimulation." "Allow ample time for your parent to respond to a question." "Orient and re-orient your parent as needed throughout the day." "Approach your parent from the front when beginning a conversation."
Correct response: "Speak slowly and use understandable words and phrases." "Allow ample time for your parent to respond to a question." "Orient and re-orient your parent as needed throughout the day." "Approach your parent from the front when beginning a conversation." Explanation: When interacting with a parent who has cognitive impairment, a person should speak slowly and use simple, understandable language, allow ample time for a reply, orient and re-orient as needed, and approach the parent from an angle where the speaker can be seen. The caregiver must not provide care and activities that the parent can perform. The caregiver should provide a low-stimulus environment, so continuous music would cause agitation.
A client asks the nurse what factors affect how long it will take for a hip to heal following hip replacement surgery. What are the best responses by the nurse? Select all that apply. A. the age of the client B. the height of the client C. the gender of the client D. the client's comorbidities E. the client's marital status
Correct response: -the age of the client -the client's comorbidities Explanation: The age and comorbidities of the client are important because they can affect the blood supply to the fracture, which can affect the healing process. An older client, or one with comorbidities such as hypertension and diabetes, will have slower bone healing due to a decrease in blood supply. The height of the client does not directly delay bone healing. The client's gender and marital status have no effect on healing.
A middle-age adult has been identified as being in the stagnation stage of developmental conflict. What evidence would support this assessment? Select all that apply. A. withdrawn from family obligations B. bought a new sports car C. started classes at the community college increased nap and sleeping hours D. recently became engaged
Correct response: withdrawn from family obligations increased nap and sleeping hours Explanation: Clients in the stagnation stage of development will withdraw from activities and relationships. The remaining responses do not express stagnation.
The nurse is assessing the neonate's posterior fontanel. Where should the nurse palpate?
Explanation: The posterior fontanel is triangular in form and situated at the junction of the sagittal suture and lambdoidal suture. The lambdoidal suture is the line between the occipital and parietal skull bones.
A nurse explains the process of cane usage to a hospitalized client with left-sided weakness. Place the steps of teaching proper cane usage in the correct order. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1. hand hygiene. 2. Secure a gait belt around client's waist. 3. Place the cane in the right hand. 4. Have client advance the cane and the left leg. 5. Have client advance the right leg.
Correct response: Perform hand hygiene. Secure a gait belt around client's waist. Place the cane in the right hand. Have client advance the cane and the left leg. Have client advance the right leg. Explanation: First, perform hand hygiene. Next, secure a gait belt around client's waist. Then, place the cane in the client's right hand, because the right side is the unaffected side. Have the client advance the cane and the left leg about 4 to 8 inches (10 to 20 cm). Finally, have the client advance the right leg the same distance.
A client reports dyspnea, chills, headache, and flank pain while receiving a blood transfusion. Place the nurse's actions in order from highest to lowest priority? Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1. stop the transfusion 2. keep the I.V. line open with 0.9% sodium chloride 3. inform the primary care provider and blood bank 4. monitor the client's vital signs 5. return blood products to the blood bank 6. document the transfusion-related occurrence
1. stop the transfusion 2. keep the I.V. line open with 0.9% sodium chloride 3. inform the primary care provider and blood bank 4. monitor the client's vital signs 5. return blood products to the blood bank 6. document the transfusion-related occurrence Explanation: First, the nurse should stop the transfusion and keep the I.V. line open with 0.9% sodium chloride. Next, the nurse should inform the primary care provider and blood bank. Then, the nurse should monitor the client's vital signs and return blood products to the blood bank. Finally, the nurse should document the transfusion-related occurrence.
A client with new onset of stroke-like symptoms arrives at the emergency department and is prescribed atenolol intravenously to control blood pressure under 180/100 mmHg. The monitor currently shows a blood pressure of 181/106 mmHg. In what order (from first to last) should the implement interventions? (All options must be used.) Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. -Assess airway, breathing, and circulation. -Screen the client for the ability to swallow. -Administer oxygen to keep the pulse oximetry reading above 95%. -Insert an intravenous catheter. -Administer atenolol.
1. Assess airway, breathing, and circulation. 2. Administer oxygen to keep the pulse oximetry reading above 95%. 3. Insert an intravenous catheter. 4. Administer atenolol. 5. Screen the client for the ability to swallow. Explanation: First, the nurse should assess airway, breathing, and circulation. Next, the nurse will administer oxygen to maintain oxygen saturation above 95% because this prevents compensatory cerebral artery vasodilation, which can increase intracranial pressure. Because the client's blood pressure exceeds the recommended value, the nurse must insert an intravenous catheter to administer the atenolol. Finally, the nurse should screen the client for the ability to swallow. Assessing the ability to swallow is not the same as assessing patency of airway; it is simply checking for an intact gag reflex and the ability to enact voluntary swallowing. The nurse should keep the client NPO until safety of oral intake is established.
The nurse is caring for a child who has been diagnosed with a brain tumor. Which assessment findings are recognized as early signs of increased intracranial pressure? Select all that apply. A. headache B. fixed and dilated pupils C. irritability D. decerebrate posturing E. dizziness
Correct response: A. headache C. irritability E. dizziness Explanation: Headache, irritability, and dizziness are early signs; fixed and dilated pupils and decerebrate positioning are late signs.
The nurse is explaining discharge instructions to a client with a fractured right femur who lives alone. Which statements by the client lead the nurse to determine that this client understands the instructions? Select all that apply. A. "I can get the cast wet and allow it to air dry." B. "I will move the joints above and below the cast regularly." C. "I can remove the padding at the top of the cast to scratch underneath it if it is bothering me." D. "I will report any foul odor under the cast to my provider." E. "I can use a hair dryer on the cool setting for any itching." F. "I will apply ice directly over the fracture site for 20 minutes each day."
B. "I will move the joints above and below the cast regularly." D. "I will report any foul odor under the cast to my provider." E. "I can use a hair dryer on the cool setting for any itching." Explanation: Range-of-motion exercises on the uninvolved joints can be used to offset the effects of prolonged immobility. A foul odor can be a sign of potential infection or complication and should be reported to the provider for further assessment. A hair dryer can be used set on a cool setting with airflow directed under the cast for itching. The cast should be kept dry. A fiberglass cast can be dried by blotting it dry with a towel and then using a hair dryer, on a low setting, until the cast is thoroughly dry. The protective padding should not be removed from the cast in order to scratch. This could predispose the skin to breakdown and infection. Ice, in a plastic bag, should be applied during the first 24 hours postoperatively.
right occiput posterior (ROP) fetal position
Baby's back favors mother's right and the back of baby's head is towards mother's posterior. In Right Occiput Posterior (ROP), baby is head down and the back is to the side- the right side. ROP is the most common of the four posterior positions. Fetal positioning is determined by how the fetus presents in relation to the mother's pelvis, which is divided into four quadrants: right anterior, left anterior, right posterior, and left posterior. In a ROP position, the fetus' occiput points to the maternal right posterior quadrant.
LA nurse is caring for a client with anorexia nervosa. Which interventions would be appropriate for this client? Select all that apply. A. Provide small, frequent meals. B. Monitor weight gain. C. Allow the client to skip meals until the antidepressant levels are therapeutic. C. Encourage the client to keep a journal. D. Encourage the client to eat three substantial meals per day.
Correct response: A. Provide small, frequent meals. B. Monitor weight gain. Encourage the client to keep a journal. Explanation: Due to self-starvation, clients with anorexia can rarely tolerate large meals three times per day. Small, frequent meals may be tolerated better by the anorexic client, and they provide a way to gradually increase daily caloric intake. The nurse should monitor the client's weight carefully because a client with anorexia may try to hide weight loss. The client may be emotionally restrained and afraid to express feelings; therefore, keeping a journal can serve as an outlet for these feelings. An anorexic client is already underweight and should not be permitted to skip meals.
A nurse is providing teaching to an adolescent who has been prescribed phenytoin for seizures. What information should the nurse include in this teaching? Select all that apply. A. "Brush your teeth using a soft toothbrush." B. "You can stop taking this medication when your seizures stop." C. "A rash is normal while taking this medication. D. "You will need to have bloodwork done frequently." E. "You should wear an ID bracelet indicating you are taking this drug."
Correct response: -"Brush your teeth using a soft toothbrush." -"You will need to have bloodwork done frequently." -"You should wear an ID bracelet indicating you are taking this drug." Explanation: This drug can cause gingival hyperplasia, so proper dental care is important to prevent infection. This drug has a narrow therapeutic index and many drug interactions. A steady serum level is needed to maintain effectiveness without toxicity, so serum levels should be done frequently. An ID bracelet is necessary because of the numerous drug interactions. This drug should not be stopped abruptly as this may precipitate seizures. A measles-like rash may lead to Steven-Johnson syndrome. If this rash occurs, the drug should not be used. Remediation:
When reviewing a client's chart, the nurse reads the progress note below. 10/15 1130 Client, age 28, admitted to unit with diagnosis of antisocial personality disorder and suicide attempt after cutting his right wrist. Right wrist dressing appears dry and intact. Client states, "I don't want to be here and I'm not following your treatment plan or any of your rules. I'm going to tell everyone here not to follow your rules." —Barbara Jones, RN Which statement, about the client's condition, is most accurate? A. The client is refusing the required psychotropic drugs used to treat his condition. B. The client manipulates others, but not his family C. The client is not motivated to change his behavior or his lifestyle. D. The client can quickly make behavior changes if motivated
Correct response: The client is not motivated to change his behavior or his lifestyle. Explanation: Clients with antisocial personality disorder feel nothing is wrong with their behavior, and they have no desire to change. These clients don't benefit from psychotropic drug therapy. They attempt to manipulate the people around them. A quick behavior change isn't a realistic expectation for clients with this disorder.
The nurse is caring for a client on the rehabilitation unit who has hearing loss. In planning care, the nurse documents ways to minimize the obstacles to successful communication with this client. Select all that may apply. A. Stand or sit in the client's line of vision. B. Close the door to the client's room. C. Talk loudly and slowly to the client. D. Minimize the distraction from television and visitors. E. Be certain hearing aids are functioning properly. F. Get the client's attention before communicating.
Correct response: A. Stand or sit in the client's line of vision. B. Close the door to the client's room. D. Minimize the distraction from television and visitors. D. Be certain hearing aids are functioning properly. F. Get the client's attention before communicating . Explanation: It is essential to communicate appropriately with the hearing-impaired client. Face the client and get the client's attention before speaking. Eliminate distractions and background noises. Make sure the client has hearing aids in, and that the battery is working. Speaking loudly and slowly is not necessary and may interfere with comprehension, as loud sounds may reverberate.
After repeated office visits and diagnostic tests, the healthcare provider is unable to find a physical cause for the client's symptoms and recommends a psychiatric referral. The client states, "I can't imagine why I should see a psychiatrist." What statements by the nurse will help the client? Select all that apply. A. "All the diagnostic tests are negative, so we have to explore other explanations for your symptoms." B. "There is a known correlation between physical symptoms and stress, and we should explore this." C. "A psychiatrist is part of the medical team and can offer input into your overall plan of care." D."Your care is being transferred to the psychiatrist because there is nothing medically wrong with you." E. "Psychiatric treatment can best resolve your symptoms because they are psychosomatic."
Correct response: A. "All the diagnostic tests are negative, so we have to explore other explanations for your symptoms." B. "There is a known correlation between physical symptoms and stress, and we should explore this." C. "psychiatrist is part of the medical team and can offer input into your overall plan of care." Explanation: The healthcare provider is likely investigating the client for somatic symptom disorder, which involves a preoccupation with physical symptoms that do not have a physical cause. Repeated physical examinations, diagnostic tests, and reassurance from the healthcare provider won't allay the client's concerns about physiologic disease. Many clients falsely believe that there is no relationship between psychological and physiologic issues, so the nurse should explain that the relationship does exist and should be explored. The nurse should also explain the benefit of psychiatric care for medical illnesses because many clients are unaware of it. This client's symptoms may be psychosomatic, but many people misinterpret this to mean they are fabricated by the client. Therefore, making this statement without explaining that psychosomatic symptoms are real and are felt as physical manifestations may result in defensiveness.
The nurse is assessing a client with a hematoma and compartment syndrome in the same extremity. Which symptoms would the nurse anticipate? Select all that apply. A. edema B. increased venous pressure C. decreased venous circulation D. increased arterial circulation E. decreased pain on movement
Correct response: A. edema B. increased venous pressure E. decreased venous circulation Explanation: The hemorrhage in compartment syndrome would cause edema, increased venous pressure, and decreased venous and arterial circulation. Compartment syndrome would cause increased pain.
The nurse is caring for a 19-year-old client recently diagnosed with multiple sclerosis (MS). What interventions would be important for the nurse to include when teaching this client ways to prevent the exacerbation of symptoms? Select all that apply. A. suggesting a support group or meditation to decrease stress B. providing a hot bath or shower to promote relaxation C. decreasing fluid intake D. planning activities to avoid fatigue E. promoting regular physical activity
Correct response: A. suggesting a support group or meditation to decrease stress planning activities to avoid fatigue promoting regular physical activity Explanation: Heat, stress, and fatigue may exacerbate MS. Support groups and meditation can help decrease stress. A cool shower may help reduce heat symptoms. Daily physical activity is important, within the limits of the client's pain or fatigue. Decreasing fluids may predispose the client to dehydration, stress, and infection and can increase symptoms.
A client is started on steroid therapy after an adrenalectomy. Which information is most important to share with this client? Select all that apply. A. take the prescribed dose daily, and do not miss a dose B. notify your healthcare provider if you experience increased urination C. discontinue steroid therapy after two weeks D. take this medication for the rest of your life E. take two doses if you miss a dose
Correct response: A. take the prescribed dose daily, and do not miss a dose B. notify your healthcare provider if you experience increased urination D. take this medication for the rest of your life Explanation: Steroid therapy following an adrenalectomy will continue for the rest of the client's life. It is important to take the dose daily, and not miss a dose. The client should be instructed about potential side effects such as hyperglycemia, which could manifest as symptoms such as increased urination. Clients should take the medication as soon as they remember the missed dose, but should not double the dose the next day.
A four-year-old child has recently been diagnosed with acute lymphocytic leukemia (ALL). What information about ALL should the nurse provide when educating the child's parents? Select all that apply. A. Leukemia is a rare form of childhood cancer. B. ALL affects all blood-forming organs and systems throughout the body. C. The child shouldn't brush their teeth because of the increased risk of bleeding. D. Adverse effects of treatment include sleepiness, alopecia, and stomatitis. E. There's a 95 percent chance of remission with treatment. D. The child shouldn't be disciplined during this difficult time.
Correct response: B. ALL affects all blood-forming organs and systems throughout the body. D. Adverse effects of treatment include sleepiness, alopecia, and stomatitis. E. There's a 95 percent chance of remission with treatment. Explanation: In ALL, abnormal white blood cells proliferate, but they don't mature past the blast stage. These blast cells crowd out the healthy white blood cells, red blood cells, and platelets in the bone marrow, leading to bone marrow depression. The blast cells also infiltrate the liver, spleen, kidneys, and lymph tissue. Common adverse effects of chemotherapy and radiation include nausea, vomiting, diarrhea, sleepiness, alopecia, anemia, stomatitis, mucositis, pain, reddened skin, and increased susceptibility to infection. There's a 95 percent chance of obtaining remission with treatment. Leukemia is the most common form of childhood cancer. The child still needs appropriate discipline and limits. A lack of consistent parenting may lead to negative behaviors and fear.
The nurse is planning to discharge a 16-year-old adolescent with a diagnosis of autoerotic asphyxiation. The admission diagnosis was possible suicide attempt. What are concerns for this client? Select all that apply. A. the risk of contracting an STI B. lack of knowledge related to diagnosis C. risk of accidental death D. risk of harming a sexual partner E. the need for sexual celibacy
Correct response: B. lack of knowledge related to diagnosis D. risk of accidental death Explanation: A person with autoerotic asphyxiation typically is a young person who acts alone. Masturbation with, and without, sexual toys and pornography is concluded with the act of deliberately hanging by the neck to increase sexual arousal. The nurse must emphasize, during discharge teaching, the need to avoid this risky behavior because it can end in accidental death. It is an opportunity to reinforce all disease, medication, and treatment planning. There little concern for contracting an STD or harming a sexual partner during this sexual act. Recommending celibacy is not an appropriate intervention.
The nurse is prioritizing care of a client in the immediate postpartum period. What is the nurse's priority assessment? Select all that apply. A. blood glucose level B. electrocardiogram (ECG) C. height of fundus D. blood pressure E. urinary output
Correct response: C. height of fundus D. blood pressure E. urinary output Explanation: A focused physical assessment should be performed every 15 minutes for the first 1 to 2 hours postpartum, including an assessment of the fundus, lochia, perineum, blood pressure, pulse, and bladder function. A blood glucose level needs to be obtained only if the client has risk factors for an unstable blood glucose level, or if she has symptoms of an altered blood glucose level. An ECG would be necessary only if the client is at risk for cardiac difficulty.
The nurse is caring for an infant newly admitted with a diagnosis of exstrophy of the bladder. Which interventions are most appropriate? Select all that apply. A. Gather supplies in anticipation of Foley catheter insertion. B. Implement a latex-free environment for the infant. C. Maintain the infant in a prone position. D. Cover the defect with a non-adherent dressing. E: . Place the infant in a thermo-controlled environment. F. Place a diaper snugly over the genitalia to ensure accurate output monitoring.
Correct response: Implement a latex-free environment for the infant. Cover the defect with a non-adherent dressing. Place the infant in a thermo-controlled environment. Explanation: Exstrophy of the bladder is a congenital defect in which the bladder is externalized on the abdomen. Treatment requires specialized care, including a latex-free environment, supine positioning, covering the defect with a non-adherent dressing, and maintaining a thermoneutral environment. Catheterization is not performed for these clients, and the bladder defect is never covered with a diaper.
A nurse receives an order to start an infusion of blood for a client who is hemorrhaging due to a placenta previa. What priority action(s) will the nurse take to initiate the infusion? Select all that apply. Inserting a 18-gauge catheter Confirming consent Obtaining baseline vital signs Assessing intake and output Beginning NPO status
Correct response: Inserting a 18-gauge catheter Confirming consent Obtaining baseline vital signs Explanation: The nurse will need to use a larger gauge catheter (typically 16G or 18G for placenta previa), confirm consent, and obtain baseline vital signs before beginning the infusion. This is standard practice with blood transfusions. The intake and output is important but does not change the infusion. Clients receiving blood do not need to be NPO.
The nurse reads the chart entry for a client who attends group therapy and uses cannabis daily: 2/10 1700 The client is congested, with a dry hacking cough. The client could not verbalize treatment goals when asked in the group session. The client laughed when the therapist gave each participant a worksheet to fill out and bring back to the next group, and stated, "I'm not doing that." What health problem is this client experiencing because of extended cannabis use? A. amotivational syndrome B. delirium tremens C. vascular dementia D. cognitive distortions
Correct response: amotivational syndrome Explanation: Long-term use of cannabis is associated with amotivational syndrome. Amotivational syndrome is a psychological health condition that is characterized by losing interest in cognitive and social activities. The client will display a sense of apathy. Delirium tremens is associated with alcohol withdrawal. Vascular dementia is associated with an alteration in a person's thought processes caused by disrupted blood flow to the brain. Cognitive distortions are inaccurate thoughts used to reinforce negative thoughts or feelings, and are common in clients with depression.
The nurse is teaching a client about the risk factors for developing osteoporosis. What is the most important information for the nurse to include? Select all that apply. A. inadequate dietary intake of calcium B. blood pressure medications C. family history D. smoking E. oral hypoglycemics
Correct response: inadequate dietary intake of calcium family history smoking Explanation: Inadequate dietary intake of calcium, family history, and smoking are risk factors of osteoporosis. There is no evidence that blood pressure medications or oral hypoglycemics are risk factors.
2/10/2017 0800 A client was admitted for intracranial hemorrhage four days ago. Morning laboratory results demonstrate a low serum sodium of 121 mEq/L, a low serum osmolality of 256 mOsm/kg, a high urine osmolality of 588 mOsm/kg, and a high urine sodium of 89 mmol/L. Vital signs are stable. Urine output is high, averaging greater than 100 cc/hr. Which nursing interventions should the nurse include when planning care for a client with cerebral salt wasting (CSW) syndrome? A. fluid restriction B. sodium and fluid replacement C. sodium restriction D. synthetic vasopressin replacement
Correct response: sodium and fluid replacement Explanation: Cerebral salt wasting syndrome is a volume-depleted and sodium-wasting state, requiring fluid replacement with isotonic solutions to prevent further deterioration. Its presentation is similarly to the syndrome of inappropriate antidiuretic hormone secretion (SIADH), which is treated with free water restriction. Synthetic vasopressin replacement is used to treat central diabetes insipidus.