H&I quiz questions

While teaching a wellness class on the warning signs of stroke, a participant asks the nurse, "What's the most important thing for me to remember?" What is an appropriate response by the nurse? a. "Keep a list of your medications" b. "Know your family history" c. "Be alert for sudden weakness or numbness" d. "Call 911 if you notice a gradual onset of paralysis or confusion"

"Be alert for sudden weakness or numbness"

A client admitted to the inpatient unit is being considered for electroconvulsive therapy (ECT). The client is calm, but the client's daughter is hypervigilant and anxious. The daughter says to the nurse, "My mother's brain will be shocked with electricity. How can the doctor even think about doing this to her?" Which of the following responses by the nurse would be therapeutic? "Maybe you'll feel better if you see the ECT room and speak to the staff." "I think you need to speak directly to the psychiatrist." "Your mother has decided to have this treatment. You should support her." "It sounds as though you are very concerned about the procedure. Let's discuss the procedure."

"It sounds as though you are very concerned about the procedure. Let's discuss the procedure."

Which comment most clearly shows an individual views mental illness with stigma? "Severe environmental stress sometimes causes mental illness." "Some mental illnesses are brain disorders resulting from changes in how impulses are transmitted." "Most people with mental illness are unmotivated." "Some mental illnesses are inherited."

"Most people with mental illness are unmotivated."

Which statement is most concerning regarding a depressed client's state of mind? "Shooting myself with dad's gun will end it all quickly." "When I get out of here I'm going to kill myself." "I just want to go to sleep and not wake up." "I'm so tired of living like this; I want it to be over."

"Shooting myself with dad's gun will end it all quickly."

A patient cries as the nurse explores the patient's relationship with a deceased parent. The patient says, "I shouldn't be crying like this. It happened a long time ago." The following responses by the nurse will facilitate communication EXCEPT? "The loss of your parent is very painful for you." "I can see that you feel sad about this situation." "Why do you think you are so upset?" "Crying is a way of expressing the hurt you're experiencing."

"Why do you think you are so upset?"

Which goal for treatment of alcohol withdrawal should be addressed first? Learn about dependence and recovery. Develop alternate coping strategies. Achieve physiologic stability. Develop a peer support system.

Achieve physiologic stability. The individual must have completed withdrawal and achieved physiologic stability before he or she is able to address any of the other treatment goals.

A client says to the nurse, "Life doesn't have any joy in it anymore. Things I once did for pleasure aren't fun." How would the nurse document this complaint: Anhedonia Dysthymia Euphoria Psychomotor retardation

Anhedonia

The mental health nurse has been meeting with a client on a weekly basis and, over the past several weeks, the client has been consistently 15 minutes late. Which of the following nursing actions is appropriate regarding the client's lateness for the scheduled meetings? Tell the client that the meetings will be terminated. Ask the client if something is going on that the client may have difficulty handling. Ignore the behavior. Because the client is consistently late, begin to arrive 15 minutes later than the scheduled time also.

Ask the client if something is going on that the client may have difficulty handling.

A client who attempted suicide by hanging is brought to the emergency department by emergency medical services. The immediate nursing action is which of the following? Perform a focused assessment, paying particular attention to the client's neurological status. Assess the client's respiratory status and for the presence of neck injuries. Call the mental health crisis team and notify them that a client who attempted suicide is being admitted to the hospital. Take the client's vital signs.

Assess the client's respiratory status and for the presence of neck injuries.

A client in the manic phase of bipolar disorder is unable to sleep during the night. Which interventions could be helpful to this client? Encourage the client to watch television. Engage in conversation. Extend daytime naps. Assist the client with a warm bath and provide a light snack.

Assist the client with a warm bath and provide a light snack.

An acutely depressed client is receiving cognitive-behavioral therapy (CBT). The nurse is developing a plan of care for the client and includes interventions that focus on this type of therapy. The following interventions would the nurse include in the CBT except? Assisting the client to rehearse new cognitive and behavioral responses. Assisting the client to identify and test negative cognition. Assisting the client with the administration of antidepressant medications. Assisting the client to develop alternative thinking patterns.

Assisting the client with the administration of antidepressant medications.

A client with peripheral vascular disease (PVD) has symptoms of intermittent claudication. The nurse caring for this client understands that intermittent claudication: a. Causes pain that occurs when inactive b. Is often described as a burning sensation c. Causes cramping or aching pain in lower extremities that occurs with predictable level of activity d. Causes pain at all times

Causes cramping or aching pain in lower extremities that occurs

The nurse in the emergency department is reviewing the blood alcohol level (BAL) of a client brought in by ambulance from home. The client's BAL is 0.10%. Which symptom supports the client's current BAL? Clumsy and slurred speech Inability to remain upright Seizures and hallucinosis Vomiting and blackout

Clumsy and slurred speech

A client is admitted to the psychiatric unit with a diagnosis of bipolar disorder and mania. The nurse would prioritize that which of the following symptoms or behaviors requires immediate intervention? Constant, incessant talking, with sexual innuendoes Outlandish behaviors and wearing odd and eccentric clothing Grandiose delusions of being a czar of Russia Constant physical activity and poor oral intake

Constant physical activity and poor oral intake

Which assessment demonstrates the nurse's understanding of the relationship between substance abuse and the development of symptoms characteristic of withdrawal? Determining the patient's age and gender Evaluating the patient's food and fluid intake over the last 48 hours Observing the patient for fine tremors of the hands, especially the fingers Determining the amount of alcohol the patient ingested in the last 24 hours

Determining the amount of alcohol the patient ingested in the last 24 hours

Which behaviors would demonstrate a strong possibility for successful rehabilitation for a patient with a substance abuse-related diagnosis? States that, "I promise I'll never use drugs again." Has shown ability to use effective coping mechanisms Control over emotions resulting in aggressive behavior Plans to associate with old friends "only when they aren't drinking"

Has shown ability to use effective coping mechanisms

Which assessment findings would prompt the nurse to suspect a disulfiram (Antabuse) reaction? Skin rash, itching, and urticaria Pallor, hypotension, and muscle cramping Dry skin, bradycardia, fatigue, and headache Headache, dyspnea, nausea, vomiting, and flushing

Headache, dyspnea, nausea, vomiting, and flushing

The nurse caring for the new mother of African-American descent should implement which intervention regarding sudden infant death syndrome (SIDS)? a. Instruct on face-up position when in the crib b. Encourage good hand washing c. Ensure adequate nutritional intake for the mother and newborn d. Instruct on side-lying and face-down positions when in the crib

Instruct on face-up position when in the crib

The nurse is providing care to a client who is exhibiting clinical manifestations of bipolar disorder. Which assessment findings support that the client is at an increased risk for this disorder? Works out at the gym every week Currently employed Blood pressure 120/80 mmHg Mother diagnosed with bipolar disorder

Mother diagnosed with bipolar disorder

Documentation in a patient's chart shows, "Throughout a 5-minute interaction, patient fidgeted and tapped left foot, periodically covered face with hands, and looked under chair while stating, 'I enjoy spending time with you.'" Which analysis is most accurate? Nurse is viewing the patient's behavior through a cultural filter. Patient is demonstrating psychotic behaviors. Patient is giving positive feedback about the nurse's communication techniques. Patient's verbal and nonverbal messages are incongruent.

Patient's verbal and nonverbal messages are incongruent.

A nurse is conducting an admission assessment on a client with alcohol abuse. The assessment findings include a recent fall at home, decreased appetite, complaints of blurred vision, and a denial that alcohol has negative effects on the body. When developing the plan of care for this client, the nurse should indicate which nursing diagnosis as the priority? Potential for injury Knowledge deficit Alteration in sensory perception Nutritional imbalance

Potential for injury

Which intervention has priority when a nurse suspects a staff member of providing patient care while being impaired by alcohol or drugs? Asking the staff member to explain their suspicious behavior Adjust the staff member's assignment to minimize patient contact Providing the staff member with material regarding alcohol abuse and treatment Reporting the staff member's suspicious behavior to the nursing supervisor on duty

Reporting the staff member's suspicious behavior to the nursing supervisor on duty

A nurse cares for a patient with an opioid overdose. Which focused assessment has the highest priority? Cardiovascular Respiratory Neurologic Hepatic

Respiratory

The mother of a 5-month-old baby is concerned because the child has developed a runny nose, cough, and low-grade fever over the last few days. What do these signs suggest to the nurse? a. Respiratory syncytial virus (RSV) bronchiolitis b. Bronchitis c. Pneumonia d. Meningitis

Respiratory syncytial virus (RSV) bronchiolitis

A client who has attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. Which of the following is the priority nursing action at this time? Request that a friend of the client remain with the client at all times. Suggest placing the client in a seclusion room where all potentially dangerous articles have been removed. Stay with the client at all times. Have the client put on a hospital gown, and remove the client's clothing from the room.

Stay with the client at all times.

The nurse observes a young child, admitted with possible respiratory syncytial virus (RSV) bronchiolitis, grunting with expiration. What should the nurse do to assist this child? a. Limit fluids b. Suction the airway to relieve the obstruction c. Lay the child on his back d. Assist the child to clear the nasal passages

Suction the airway to relieve the obstruction

A client admitted with chronic venous insufficiency has an infected wound of the left lower extremity. What will the nurse find when assessing this wound? a. Ulceration that is pale in color b. Surrounding skin brown in color c. Skin surrounding the ulcer is cool to touch d. Pulses absent in the extremity with the wound

Surrounding skin brown in color

A nurse caring for a client with a pulmonary embolism expects to find which diagnostic result? a. Elevated CO2 level found on end-tidal carbon dioxide monitor b. Tachycardia and nonspecific EKG changes c. Patchy infiltrates on chest x-ray d. Metabolic alkalosis on ABGs

Tachycardia and nonspecific EKG changes

The nurse is helping to conduct a group therapy session. During the session, a male client threatens to act out physically and states that he will punch another member of the group. Which of the following is the appropriate initial nursing action? Call security to come to the session immediately. Tell the client that he must leave immediately. Tell the client that he can talk about his anger but cannot act on it in during the group session. Tell the client that if he hits another client, he will be restrained and placed in seclusion.

Tell the client that he can talk about his anger but cannot act on it in during the group sess

A new mother asks what needs to be done to prevent the baby from sudden infant death syndrome. What should the nurse do to assist the mother? a. Instruct the mother to keep the baby with her at all times to assess for periods of apnea b. Encourage the mother to place the child in a face-down position for sleep c. There is no one cause for the syndrome; the best thing is to keep baby healthy d. Suggest the mother to avoid immunizing the child

There is no one cause for the syndrome; the best thing is to keep baby healthy

The clinic nurse is educating a group of new moms on the risk factors and prevention of respiratory syncytial virus (RSV). The nurse is aware that which action is the best way to prevent RSV? a. Offer small, frequent meals b. Encourage oral intake c. Wash hands frequently d. Expose baby to as many people and situations as possible to strengthen immunity

Wash hands frequently

The nurse is preparing to discharge a client recovering from a pulmonary embolism. How should the nurse instruct this client? Select all that apply. a. Anticoagulation administration schedule b. Diet to include green leafy vegetables c. Remain on bed rest for 7 days d. Symptom recurrence

a. Anticoagulation administration schedule d. Symptom recurrence

The nurse is planning care for a client admitted with a stroke. Which intervention would support the client's sensorimotor needs? a. Speak in normal conversational pattern and tones b. Talk loudly and distinctly c. Provide complete care d. Encourage use of non-affected arm to feed self, bathe, and dress

a. Encourage use of non-affected arm to feed self, bathe, and dress

An older client is diagnosed with a left middle cerebral artery hemorrhagic stroke. To meet the needs of the client and family, the nurse will provide teaching in which areas? Select all that apply. a. How to use a sign board b. Risks and benefits of tPA (or other fibrinolytic therapy) c. Time adjustment to complete activities d. Transfer techniques e. Information on impulse control

a. How to use a sign board c. Time adjustment to complete activities d. Transfer techniques

A client diagnosed with peripheral vascular disease is obese, has a 30-year history of cigarette smoking, and works as a contractor. What should the nurse instruct the client about the diagnosis? a. Nicotine is a vasoconstrictor b. Obesity is a factor in cardiovascular disease, but not peripheral vascular disease c. The client's occupation is a major risk factor d. Nicotine primarily affects coronary arteries and the lungs

a. Nicotine is a vasoconstrictor

The nurse is assessing a client being treated for congestive heart failure. What physical findings would indicate that the client's condition is not improving? Select all that apply. a. Worsening bilateral extremity edema b. Pulse oximetry reading of 96% c. Moderate amount of yellow/green mucus d. Crackle breath sounds in all lobes e. Urine output 160ml over an 8 hour shift

a. Worsening bilateral extremity edema d. Crackle breath sounds in all lobes e. Urine output 160ml over an 8 hour shift

The nurse working in the emergency department provides care to an infant who arrived in cardiac and respiratory arrest. Resuscitative efforts failed and the infants cause of death is sudden infant death syndrome (SIDS). The parents are grieving and will need collaborative interventions. Which interventions does the nurse plan for when providing care to these parents? Select all that apply. a. Psychosocial assessment b. Grief counselor referral c. Social services consult d. Visit from the chaplain, per parents wishes e. Psychotherapist referral

a.Psychosocial assessment b. Grief counselor referral c. Social services consult d. Visit from the chaplain, per parents wishes

A nurse working in the Emergency Department is aware that there are various cultural and ethnic risk factors for stroke. The nurse understands that which of the following is an example of this? a. The prevalence of hypertension among Hispanics is the highest in the world b. African-American are more likely to die following a stroke than whites c. Hispanics have almost twice the number of first-ever strokes compared with whites d. African-American have an increased incidence of intracerebral hemorrhage

b. African-American are more likely to die following a stroke than whites

A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the priority? a. Provide oxygen via mask b. Encourage us of incentive spirometry c. Administer heparin IV infusion d. Initiate continuous cardiac monitoring

c. Administer heparin IV infusion Rationale: Using the ABCs approach to client care the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention. The other 3 options would be important but not of greatest priority. In addition patient may not require use of oxygen via mask.

The nurse is positioning a client with heart failure in bed. Which sleeping position would be most appropriate for the patient? a. Laying in the prone position b. Lying on either side c. Seated in a recliner with 2-3 pillows under feet d. Seated in a recliner with no pillows

c. Seated in a recliner with 2-3 pillows under feet

The nurse is planning care for several clients. Which client has the greatest risk of developing heart failure? b. 52 year old Caucasian female with acid reflux c. 29 year old Hispanic male who is overweight a. 50 year old Asian female with asthma d. 68 year old African American male with hypertension

d. 68 year old African American male with hypertension

A client diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. The nurse would identify which diagnosis as a priority for this client? a. Impaired physical mobility b. Anxiety c. Ineffective tissue perfusion d. Impaired gas exchange

d. Impaired gas exchange

The nurse is planning care for a new mother of African-American descent who smoked during the pregnancy and whose sister lost a child to sudden infant death syndrome (SIDS). What should be included in this client's plan of care? Select all that apply. a. Information on bottle feeding the infant b. Ages at which the child should receive immunizations c. Reasons why the child should sleep with others d. Using bedding that is firm e. Smoking cessation information

d. Using bedding that is firm e. Smoking cessation information

The nurse is evaluating teaching provided to a client with peripheral vascular disease. Which client observation indicates teaching has been effective? a. Sitting in a chair with a pillow behind knees b. Smoking a pipe instead of cigarettes c. Sitting in a chair d. Washing the lower extremities with mild soap and water, drying the legs, and apply light moisturizer

d. Washing the lower extremities with mild soap and water, drying the legs, and apply light moisturizer

A patient asks the nurse, "I read an article online about psychosocial factors that influence depression. What are psychosocial factors?" The following are examples a nurse could cite to support the premise that a patient's depression may be influenced by psychosocial factors except: feeling strong guilt over having an abortion when one's religion forbids it. having two first-degree relatives with bipolar disorder. experiencing the death of a parent a month before the onset of depression. having a hostile and over-involved family.

having two first-degree relatives with bipolar disorder.