HCC3- Exam 3 study guide

A nurse is caring for a client who is taking sucralfate. Which of the following outcomes indicates a therapeutic effect of this medication?

Relief of GI pain

A nurse on an inpatient mental health unit is admitting a client who has panic-lvl anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time?

Remain with the client for a while

A nurse is caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?

Remind the client to look for food on the left side of the tray

A public health nurse is assessing an older adult client who lives with a family member. The nurse identifies several bruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take FIRST?

Report the findings to a supervisor

A nurse is caring for a client 4h following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?

Respiratory status

A nurse is caring for a client who has a TBI. Which of the following findings should the nurse identify as an indication of ICP?

Restlessness

A nurse in the ED is assessing a client who has experienced intimate partner abuse. The nurse should monitor the client for which of the following behavioral findings?

Self-esteem disturbance.

A nurse is teaching a client who has a new rx for phenytoin. The nurse should instruct the client to monitor for which of the following effects of this medication?

Skin rash

A nurse in the ED is caring for a client who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125ml/hr. Which of the following is an appropriate nursing action by the nurse?

Slow the rate to 50 ml/hr

A nurse is teaching a client who has a new RX for lithium to tx bipolar disorder. The nurse should instruct the client to ensure an adequate intake of which of the following dietary elements?

Sodium

A nurse is teaching staff which factors to include in an abuse assessment of a client. Which of the following factors should the nurse include in the teaching? (Select all that apply?

Suicide risk, Coping patterns, Support systems, Alcohol use

A nurse is caring for a client who is in the manic phase of bipolar disorder. The client is running around the unit trying to organize competitive games with the clients. Which of the following is an appropriate intervention?

Take the client outside for a walk

A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? (Select all that apply.)

Talking in rapid, continuous speech, Interacting with others in a flirtatious way, Spending large sums of money

A nurse is assessing a client who sustained a basal skull fx and notes a thin stream of clear drainage coming from the client's rt. Nostril. Which of the following actions should the nurse take first?

Test the drainage for glucose

A nurse is caring for a client who has a new RX for risperidone. Which of the following rating scales should the nurse complete prior to administering the first dose of risperidone?

The AIMS scale (abnormal involuntary movement scale) **(Risperidone, an antipsychotic, can cause tardive dyskinesia, involuntary movements that may include the tongue, lips, and face.

A nurse in a substance abuse clinic is assessing a client who recently started taking disulfiram. The client reports having d/c'd the medication after experiencing sever nausea and vomiting. Which of the following reasons should the nurse suspect to be a likely cause of the client's distress?

The client consumed alcohol while taking the medication.

A nurse is receiving a transfer report for a client who has a head injury. The client has GCS score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on THIS data?

The client opens his eyes when spoken to

A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting dx of acute mania?

The client responds to questions with disorganized speech.

A nurse is providing D/C teaching to a client who has bipolar disorder and will be discharged with an RX for lithium. The nurse should teach the client that which of the following factors put her at risk for lithium toxicity?

The client runs four miles outdoors every afternoon

A nurse is assessing a family as a system. Which of the following factors should the nurse include when assessing sociocultural context?

The family's religious practices

A nurse reviews the laboratory report for a client who is receiving lithium po q TID. The client's current serum lithium lvl is 1.8 mEq/L. The nurse identifies that this lab value indicates which of the following?

The lithium lvl is at the toxic lvl

A client states, "I just don't know what to do about my partner's drinking. Every time I see him drinking beer, I start to feel extremely anxious." Which of the following is the most therapeutic response by the nurse?

The next time your partner starts drinking, what is something you might do to decrease your anxiety?

A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

The partner has lost 20 lb in the past 2 mos.

A nurse is caring for a client who has bipolar disorder and has been taking lithium for 1 year. Before administering the medication, the nurse should check to see that which of the following tests have been completed?

Thyroid hormone assay

A nurse is in a client's room when the client begins to have a tonic-clonic seizure. Which of the following actions should the nurse take first?

Turn the client's head to the side

A nurse administers desmopressin to a client who has diabetes insipidus. The nurse recognizes that which of the following laboratory findings indicate a therapeutic effect of the medication?

Urine specific gravity 1.015

A nurse is caring for a client who has ICP following a closed-head injury. Which of the following action should the nurse take?

Use log rolling to reposition the client

A nurse is teaching a client who has bipolar disorder and a RX for lithium to recognize manifestations of toxicity. Which of the following statements by the client indicates an understanding of the teaching?

Vomiting is an indication of toxicity.

A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?

Walking with the nurse in the courtyard.

A nurse suspects that a family caregiver is neglecting an older adult client. Which of the following statements by the caregiver should the nurse identify as the priority to address?

We buy the RX we can afford

A nurse is teaching a client who has bipolar disorder about lithium. Which of the following stmts should the nurse include in the teaching?

We will monitor your lithium lvls closely while you are taking this medication.

A nurse is reviewing the medical record of a client who has schizophrenia and is receiving olanzapine. Which of the following findings should the nurse identify as an adverse effect of olanzapine?

Weight gain of 3 lb in 2 weeks

A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instruction should the nurse include?

When walking, move your left foot forward first

A nurse is caring for a client who has bipolar disorder and is taking lithium. The client reports blurred vision and ataxia. Which of the following actions should the nurse take?

Withhold the medication.

A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse calls the provider immediately. Which of the following responses by the nurse is appropriate?

You must be very upset about something

A nurse is caring for a client who has HTN an dis afraid to take his BP medication. Which of the following nursing statements is an example or the therapeutic communication response of reflection?

You seem upset about taking your BP medication

A nurse is caring for a client who has sustained a TBI. The nurse should monitor the client for which of the following manifestations of increased ICP?

Decreased LOC

A nurse is caring for a group of clients on a mental health unit. Which of the following actions should the nurse implement to establish therapeutic relationships with the clients?

Demonstrate genuineness when communicating.

A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find?

Dilated scalp veins

A nurse in an ED is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take FIRST?

Document the client's verbatim stmts

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse take?

Encourage the client to take small bites

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

Experiencing diarrhea

A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital AMA. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands that restraining this client would be considered which type of civil action by the nurse?

False imprisonment

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in ICP? (Select all that apply.)

HA, Slurred speech, Pupillary changes, Disorientation

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's POC?

Have consistent unit routines.

A male nurse is assigned to care for a female client who was admitted to the hospital for tx of injuries following a domestic abuse incident. The client tells the nurse manager she does not want a male nurse as her caregiver. Which of the following nurse responses should the nurse manager make?

I can review the assignments and arrange for a female nurse to care for you.

A home health nurse is speaking to a group of acute care nurses about domestic violence. Which of the following statements by one of the acute care nurses indicates need for clarification?

I have heard that abusers think of themselves as important and have high self-esteem.

A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following stmts indicates an understanding by the newly licensed nurse?

If suspicion of abuse exists, then reporting is mandatory.

A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings?

Impaired sense of humor

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

Inability to recognize his family members

A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?

Incorporate nonverbal cues in the conversation

A nurse is caring for a client following a suicide attempt. The client has a hx of depression, substance abuse, and anorexia nervosa. Which of the following actions by the nurse is priority?

Initiating suicide precautions.

A nurse is developing a therapeutic relationship with a client. The nurse should perform which of the following actions during the working phase of a therapeutic relationship?

Instruct the client about methods to achieve goals

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse ID as a manifestation of IICP?

Irritability

A nurse is caring for a child who has been physically abused by a family member. Which of the following statements should the nurse say to the child?

It is not your fault that this has happened to you.

A nurse is providing teaching to a client who has a new dx of Parkinson's dz. On which of the following medications should the nurse prepare to instruct the client?

Levodopa/carbidopa

A nurse is assessing a client who was involved in a MVA. Which of the following techniques should the nurse use to test corneal reflexes?

Lightly touch the eyes with a wisp of cotton

A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication?

Liver function tests must be monitored

A nurse is planning care for a client who has a cerebral aneurysm. Which of the following actions should the nurse plan to take?

Maintain the client on absolute bed rest

A nurse is caring for an adolescent client who has conduct disorder. The client reports that she has received five speeding tickets in the past 6 mos. Which of the following interventions should the nurse take?

Make a contract with the client not to drive over the speed limit.

A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take?

Minimize environmental stimuli

A nurse is reviewing the d/c instructions with a client who has bipolar disorder and is taking lithium. Which of the following manifestations should the nurse include as an indication of mild toxicity?

Muscle weakness

A nurse is providing care to a client who is on strict bed rest following sx. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse committed?

Negligence

A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Notify EMS

A nurse is providing d/c teaching to a client who has a new RX for lithium. Which of the following info should the nurse include in the teaching?

Obtain a daily weight **Clients who are taking lithium should monitor their daily weight due to the risk of fluid imbalance.

A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take?

Obtain a detailed history.

A nurse is caring for a child who is postoperative following ventriculoperitoneal VP shunt placement. In which of the following position should the nurse place the client?

On the unoperated side

A nurse in the ED is caring for a client who has an epidural hematoma following an MVA. Which of the following is an expected finding for this client?

Alternating periods of alertness and unconsciousness

A nurse is providing care to children on a general pedi unit. Which of the following children should the nurse ID as a potential victim of abuse?

A child whose parents answer questions for the child

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?

A lucid period followed by an immediate loss of consciousness

A nurse on the ICU is caring for a client who has severe TBI and a CPP of 59 mmHg. Which of the following actions should the nurse take?

Adjust the client's HOB

A nurse is preparing to administer phenytoin IV to a client who has a seizure disorder. Which of the following actions should the nurse plan to take?

Administer a saline solution after injection

A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for two weeks and has a current lithium lvl of 1.0 mEq/L. Which of the following actions should the nurse take?

Administer the morning dose of lithium

A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?

Adopt a neutral attitude when providing care

A nurse is providing teaching to a client who has seizures and a new rx for phenytoin. Which of the following information should the nurse provide?

Alcohol increases the chance of phenytoin toxicity

A nurse in the ED is caring for a client following an MVA in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining form the client's nose. Which of the following interventions should the nurse take?

Allow the drainage to drip onto a sterile gauze pad

A nurse is caring for a client who has right-sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop?

Apply a protective boot to the right ankle

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

As a nurse, I am required by law to report suspected child abuse.

A nurse in an ED is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?

Ask the client to describe the situation.

A nurse is bathing a toddler and notices that she has several bruises. Which of the following actions should the nurse take first?

Ask the parents what caused the bruises.

A nurse is caring for a client who has a mental health disorder. The client asks about his medications and their effects. The nurse asks the client why he needs to know this. Which of the following NONTHERAPEUTIC communication techniques is the nurse using?

Asking for an explanation

A nurse is caring for a client who was admitted for suspected abuse. The client is quiet and withdrawn. Which of the following actions should the nurse take to promote client communication?

Be direct and honest when speaking with the client

A nurse is assessing an 11 mo old infant. Which of the following manifestations is associated with a CNS infection?

Bulging fontanel

A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Call emergency services

A nurse is leading a family therapy session for a mother, father, and two adolescent siblings. Which of the following stmts should the nurse recognize as an example of effective communication among family members?

Can you tell me the reason you get upset each time I go to the mall?

A nurse is reviewing medications for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following client prescriptions should the nurse realize is expected to reduce the client's mania?

Carbamazepine

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess CN III?

Checking the pupillary response to light

A nurse in the emergency department is caring for a client who was sexually assaulted. Which of the following resources will provide the most effective support immediately following the incident?

Close friend

A nurse is caring for a client who has an ICP reading of 40 mmHg. Which assessment should the nurse recognize as a late sign of ICP? (Select all that apply.)

Confusion, Nonreactive dilated pupils, Slurred speech

A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have bipolar disorder? (Select all that apply.)

Paroxetine, Lithium, Valproate, Carbamazepine

An acute care nurse receives shift report for a client who has ICP. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

Plantar flexion of the legs

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

Poor impulse control

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

Position the child laterally

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

Position the child side-lying

A nurse is planning care for a group of clients on a mental health unit. Which of the following actions should the nurse plan to take to create a therapeutic environment?

Provide continuity of care by assigning the same staff.

A nurse is assessing a client who has a traumatic head injury to determine motor fx response. Which of the following client responses to painful stimulus is expected?

Pushes the painful stimulus away

A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because of my boss. It was part of my job to go to parties and drink with clients." The client's statement is an example of which of the following defense mechanisms?

Rationalization

A nurse is preparing to administer an osmotic diuretic IV to a client w/ increased ICP. Which of the following should the nurse identify as the purpose of the medication?

Reduce edema of the brain

A nurse is caring for a client who is discussing his PTSD and states: Everyone thinks you should be able to put it out of your mind. It happened so long ago - just get over it! The nurse responds: IT must be very frustrating to encounter this kind of attitude. The nurse is using which of the following therapeutic communication techniques?

Reflection

A nurse is preparing to teach a client about his prescription of lithium for the tx of bipolar disorder. Which of the following statements should the nurse include in the teaching?

diarrhea