Hesi Practice ?s
The nurse is teaching a group of students about assessing for respiratory system manifestations of alkalosis as a nursing priority. Which statement made by the student nurse indicates the need for further teaching? Select all that apply.
"I should assess for low blood pressure." "I should assess for increased digitalis toxicity." "I should assess for a decreased rate of ventilation in respiratory alkalosis."
A salesman with a history of heavy drinking is on a detoxification unit. He asks the nurse's permission to skip the Alcoholics Anonymous (AA) meeting held each day. What is the nurse's initial response?
"What are your feelings about going to AA meetings?"
What is the definition of a tocolytic?
A drug that inhibits labor and maintains a pregnancy
Which statement does the nurse know is true regarding a grade 2 goiter?
A goiter is usually asymmetrical The goiter is invisible or impalpable in grade 0. The goiter mass moves up while swallowing and is palpable in grade 1. The goiter mass is invisible in grade 1 while the neck is in a normal position.
Which of the following legal defenses are the most important for a nurse to develop?
Accountability
What are the instances when an adult can give consent for medical treatment? Select all that apply.
Any guardian for the adult's ward Any parent for the adult's unemancipated minor A brother or sister of an adult's minor brother or sister
Which drug used to treat acne has a bleaching effect?
Benzoyl peroxide
A student nurse is assessing socialization skills in 3-year-old and 4-year-old children. Which similar characteristics may be seen in the children of the two different ages?
Both have fear Children of 3 years of age may engage in parallel as well as associative play, whereas 4-year-old children get engaged only in associative play. Children of 4 years of age tell family tales to others without limit, 3-year-old children do not. Children of 5 years of age are eager to do things that please others, not 3-year-old or 4-year-old children.
An 18-year-old high school student arrives at the local blood drive center to donate blood for the first time. As the site is being prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. What should the nurse instruct the student to do?
Breathe into cupped hands Breathing into cupped hands allows carbon dioxide to reenter the lungs, which will increase the serum bicarbonate level, relieving the respiratory alkalosis that is occurring as a result of hyperventilation.
When a client who has had a mastectomy returns from surgery, a dressing and a portable wound drainage system to the axillary area are in place. The nurse notes an excessive amount of serosanguineous drainage on the mastectomy dressing. What is the nurse's next action?
Checking the function of the drainage system
A client reports drinking two drinks per day every day with no negative consequences. How should this person be classified?
Daily drinker
Which hormone may cause vaginal carcinoma in a female child after birth?
Diethylstilbestrol Progesterone and androgens may cause masculinization of a female fetus. Estrogen may cause congenital defects in the female reproductive system.
Which drug may cause gynecologic malignancies in females?
Diethylstilbestrol Tamoxifen is used to treat breast cancer. Raloxifene is used to prevent postmenopausal osteoporosis. The use of thalidomide during pregnancy may cause birth defects in the newborn.
Nurses on a psychiatric unit have secluded a client who has the diagnosis of bipolar I disorder, manic episode, and who has been losing control and throwing objects while in the dayroom. What is the most important intervention for the client who is given an as-needed (PRN) medication and confined to involuntary seclusion?
Evaluate the client's progress toward self-control.
What type of healthcare does a person who is "worried well" require? Select all that apply.
Evaluation, reassurance, preventive treatment
During an interview of a client with a diagnosis of bipolar I disorder, manic episode, what does the nurse expect the client to demonstrate?
Flight of ideas Associative looseness is the pattern of speech found in clients with schizophrenia
Which immunoglobulin crosses the placenta?
IgG
What is the best room assignment for a 5-year-old child admitted with injuries that may be related to abuse?
In a room near the nurses' desk
A client with a history of methamphetamine use is admitted to the medical unit. What clinical manifestation does the nurse expect when assessing the client?
Increased HR The pupils will dilate, not constrict, because the sympathetic nervous system is activated. Clients withdrawing from opioids, not methamphetamine, experience diarrhea. The respirations will be increased, not decreased, because of the activation of the sympathetic nervous system.
A child wants to be on time for a family dinner. According to Kohlberg's theory, what stage of development is the child going through?
Instrumental relativist orientation
Which term refers to the exaggeration of the posterior curvature of the thoracic spine?
Kyphosis
A nurse determines that a client is pretending to be ill. What does this behavior usually indicate?
Malingering
A child would be demonstrating outwardly focused anger or aggression in an overt manner when engaging in which behavior?
Scribbling on a classmate's art assignment
A nurse is assessing a toddler and the dynamics of the child's family, in which abuse is suspected. What behaviors are expected? Select all that apply.
The child cringes when approached. The child has unexplained healed injuries. The child lies still while surveying the environment.
Which statements relate to preterm labor? Select all that apply.
The treatment for preterm labor includes bed rest and hydration. Preterm labor before the 20th week is indicative of a nonviable fetus.
The nurse is caring for a client with a diagnosis of diabetic ketoacidosis. Which arterial blood gas results are associated with this diagnosis?
pH: 7.28; PCO 2: 28; HCO 3: 18
A nurse is recalling Piaget's theory of cognitive development. Which statement is a characteristic of the concrete operations stage?
"A child is able describe a process without actually doing it."
A nurse provides smoking-cessation education to a client with chronic obstructive pulmonary disease (COPD). The nurse concludes that the client is ready to quit smoking when the client makes which statement?
"I'll cut back to a half pack a day."
What is true about psychosocial changes observed in adolescents? Select all that apply.
"They search for personal identity." "They develop their own ethical systems." An adolescent tends to search for his or her personal identity and develop his or her own ethical system during psychosocial development. During cognitive development, adolescents consider themselves invincible and consider their parents materialistic.
An infant with hypertrophic pyloric stenosis is admitted to the pediatric unit. What does the nurse expect to find when palpating the infant's abdomen?
An olive-sized mass in the right upper quadrant The olive-like mass is caused by the thickened muscle (hypertrophy) of the pyloric sphincter.
Which statement is true for attachment in the newborn?
Attachment is the interaction between parent and child. Attachment is a process that evolves over the first 24 months.
Which physical assessment maneuver is the nurse performing when instructing the client to breathe in slowly and a little more deeply than normal through the mouth?
Auscultation The nurse asks the client to breathe deeply while performing palpation. During inspection, the nurse asks the client to sit upright or to have the head of the bed upright. While performing percussion, the nurse helps the client to assume the semi-sitting or supine position.
A registered nurse is educating a nursing student on the various classifications of torts. What acts are classified as intentional torts in nursing practice? Select all that apply.
Battery Assault False imprisonment Unintentional torts: negligence and malpractice
Which part of the client's brain is primarily associated with life support and basic functions of the body?
Brain stem
A client is ambivalent about making a change in health behavior. Which stage of health behavior does the nurse suspect?
Contemplation
The nurse is caring for a client with emphysema. During assessment, the nurse expects to auscultate which type of breath sounds?
Diminished breath sounds
Which condition may lead to collapse of the walls of the bronchioles and alveolar air sacs?
Emphysema
Radium inserted in the vagina of a client now is being removed. Which safety precaution should the nurse employ when assisting with the radium removal?
Ensure that long forceps are available for removing the radium
Which sexually transmitted disease is treated with antiviral drugs?
Genital herpes
A community health nurse is educating a client who is interested in discontinuing cigarette smoking. What should the teaching plan include?
Helping the client set a date to stop smoking
A client with a long history of alcohol abuse develops cirrhosis of the liver. The client exhibits the presence of ascites. What does the nurse conclude is the most likely cause of this client's ascites?
Impaired portal venous return
A 65-year-old man is admitted to a mental health facility with a diagnosis of substance-induced persisting dementia resulting from chronic alcoholism. When conducting the admitting interview, the nurse determines that the client is using confabulation. What does the nurse recall precipitates the client's use of confabulation?
Marked memory loss
A nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response does the nurse expect?
Metabolic acidosis
A specimen for arterial blood gases is obtained from a severely dehydrated 3-month-old infant with a history of diarrhea. The pH is 7.30, Pco 2 is 35 mm Hg, and HCO 3 - is 17 mEq/L (17 mmol/L). What complication does the nurse conclude has developed?
Metabolic acidosis
A critically ill 5-year-old child exhibits Kussmaul respirations. What does the nurse suspect may be causing an increasing acid-base imbalance?
Metabolic acidosis caused by a concentration of cations in body fluids
A client is hospitalized after four days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, Pco 2 50 mm Hg, bicarbonate 58 mEq/L (58 mmol/L), chloride 55 mEq/L (55 mmol/L), sodium 132 mEq/L (132 mmol/L), and potassium 3.8 mEq/L (3.8 mmol/L). What condition does the nurse determine the results to indicate?
Metabolic alkalosis
Which drug is used to induce abortion?
Mifepristone
What drugs are used to induce abortion in an adolescent? Select all that apply.
Misoprostol Mifepristone Methotrexate
A nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation?
Pain
Which hormone promotes bone resorption in a client?
Parathyroid hormone (PTH)
When intimate partner violence (IPV) is suspected, the nurse plays an important role as an advocate for the victim. The advocate role includes what important components? Select all that apply.
Planning for future safety Validating the experiences Promoting access to community services
What is the nurse's priority responsibility when abuse of an 8-year-old child is suspected?
Protecting the child from future abuse
Which component of decision-making refers to the duties and activities an individual is employed to perform?
Responsibility
Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee?
Right communication Right task refers to delegating a task that is repetitive, requires less supervision, and has predictable results. Right person is delegating a task to the correct person who has the ability to perform said task. Right supervision refers to providing appropriate monitoring, evaluation, and feedback of the delegated task.
What childhood problem has legal as well as emotional aspects and cannot be ignored?
School phobia
Which nursing action indicates that the nurse is actively listening to the client?
The nurse interprets what the client is saying and reiterates in his or her own words.
A 6-year-old child with a leg fracture of suspicious origin is brought into the emergency department by the mother and the mother's boyfriend. It is the child's first visit to this hospital. After assessing the child, a nurse anticipates that the healthcare provider will order a skeletal survey. Why is a skeletal survey the preferred diagnostic tool?
The skeletal history of the current fracture and any previous healing or healed fractures are identified.
A registered nurse is educating a nursing student about the process of resolving an ethical dilemma. What information should the nurse provide regarding negotiation of outcomes?
"A nurse should provide a personal point of view." During the process of negotiating outcomes, the nurse is required to provide a personal point of view.
Which response by the nurse during a client interview is an example of back channeling?
"All right, go on..." Back channeling involves the use of active listening prompts such as "Go on...", "all right", and "uh-huh." Such prompts encourage the client to complete the full story.
Which client would have relatively smaller tidal volumes due to limited chest wall movement?
A client with phrenic nerve paralysis
A client comes to the emergency department reporting chest pain and difficulty breathing. A chest x-ray reveals a pneumothorax. Which finding should the nurse expect to identify when assessing the client?
Absence of breath sounds over the affected area Distended neck veins are associated with failure of the right side of the heart and can occur with a mediastinal shift, but there is no evidence of either. Paradoxical respirations occur with flail chest, not pneumothorax. Purulent sputum is a sign of infection, not pneumothorax.
A nurse is providing information about Alcoholics Anonymous (AA) meetings to a client with a history of alcohol abuse. What will be required when the client attends AA meetings?
Acknowledging an inability to control the alcoholism
Hormonal imbalance
Addison's disease, also called Addison's insufficiency, causes skin manifestations, such as vitiligo and hyperpigmentation. A client with Cushing's disease displays "moon face" and truncal obesity.
A nurse providing care in a hospital witnesses a client's spouse shaking the client vigorously because the client has had an episode of incontinence. Because of the suspicion of physical abuse, legally the nurse should discuss the concerns with which party?
Adult Protective Services
The nurse is caring for a client who is in pain following surgery. The nurse informs the primary health care provider about the client's request for pain medication. What is the role of the nurse in this situation?
Advocate
A nurse decides to use the CAGE screening questionnaire with a client admitted for substance abuse. What is the client abusing?
Alcohol CAGE is an acronym for the key words (Cut down, Annoyed, Guilty, and Eye-opener)
The nurse suspects that a client is in the chronic persistent stage of Lyme disease. Which symptoms support the nurse's suspicion? Select all that apply.
Arthritis Chronic fatigue Dyspnea and dizziness are the symptoms of the early disseminated stage. Erythema migrans is observed in the localized stage.
An 18-year-old woman is brought to the emergency department by her two roommates after being found unconscious in the bathroom. Laboratory tests are ordered. The nurse reviewing the findings notes that the urinalysis is positive for flunitrazepam. The nurse knows that flunitrazepam is often used for what?
As a date rape drug
A nurse who promotes freedom of choice for clients in decision-making best supports which principle?
Autonomy
A nurse is recalling common terms that are used in health ethics. What does beneficence in health ethics refer to?
Beneficence refers to taking positive actions to help others. Fidelity refers to the agreement to keep promises. Nonmaleficence refers to avoiding harming an individual.
A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I will not discuss any client's illness with you. Are you concerned about it?" This response is based on the nurse's knowledge that to discuss a client's condition with someone not directly involved with that client is an example of what?
Breach of confidentiality Libel occurs when a person writes false statements about another that may injure the individual's reputation. Negligence is a careless act of omission or commission that results in injury to another. Defamation of character is the publication of false statements that injure a person's reputation.
A parent of four is remanded to the psychiatric unit by the court for observation. The client was arrested and charged with abusing a 2-year-old child, who is in the pediatric intensive care unit in critical condition. The nurse approaches the client for the first time. How should the nurse anticipate that the client will likely respond? Select all that apply.
By denying beating the child By avoiding talking about the situation By exhibiting an emotional response that is inconsistent with the degree of injury
A toddler on the pediatric unit is required to have temporary dietary restrictions after colorectal surgery. What is the best way for the nurse to promote adherence to the restrictions?
By handling dietary changes in a matter-of-fact way
How does an individual overcome conflicting thoughts that arise during an Electra complex?
By identifying with the parent of the same sex
A healthcare provider prescribes disulfiram for a client who abuses alcohol. The nurse teaches the client that disulfiram will have which action?
Cause a severe adverse reaction if alcohol is consumed
Which part of the client's brain primarily regulates muscle functioning and coordinates movement?
Cerebellum The cerebrum is associated with higher brain functions, such as thought and action. The epithalamus acts as a connection between the motor pathways and regulates emotions. The hypothalamus regulates the body temperature and secretions of the endocrine gland.
While a client is attending an Alcoholics Anonymous (AA) meeting, a nurse talks with the client's spouse about the purpose of AA. What is the priority goal of this self-help group?
Changing destructive behavior
A married woman is brought to the emergency department of a local hospital. Her eyes are swollen shut, and she has a bruise on her neck. She reports that she is being beaten by her husband. How does the nurse expect the husband to behave when he arrives at the emergency department?
Charming
When planning for a client's care during the detoxification phase of acute alcohol withdrawal, what need should the nurse anticipate?
Checking on the client frequently
A male college student who is smaller than average and unable to participate in sports becomes the life of the party and a stylish dresser. What defense mechanism does the nurse determine that the client is using?
Compensation Had the student incorporated the qualities of the college athlete, that would be introjection. Sublimation is related to unacceptable impulses that may pose a threat.
A client is taking fertility drugs for the first time. Which adverse effect of the drug should the nurse inform the client about?
Constipation
A client with chronic obstructive pulmonary disease (COPD) reports a 5-pound (2.3 kg) weight gain in one week. What does the nurse recall is the complication that may have precipitated this weight gain?
Cor pulmonale A sudden weight gain is an initial sign of right ventricular failure caused by COPD.
A client's blood gases reflect diabetic ketoacidosis. Which clinical indicator should the nurse identify when monitoring this client's laboratory values?
Decreased HCO 3
The nurse understands that research demonstrates that malnutrition occurs in as many as 50% of hospitalized clients. The nurse should assess a postoperative client with anorexia for what sign of malnutrition?
Delayed wound healing Dependent edema usually occurs with severe protein deficiency and heart failure. Spoon-shaped nails usually occur with iron deficiency anemia. Loose, decayed teeth usually indicate prolonged malnutrition.
A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam; I get so annoyed when people drink too much." What does this nurse's comment reflect?
Demonstration of a personal bias
One afternoon the nurse on the unit overhears a young female client having an argument with her boyfriend. A while later the client complains to the nurse that dinner is always late and the meals are terrible. The nurse identifies the defense mechanism that the client is using as what?
Displacement
When counseling the 20-year-old parents of a 13-month-old child, the nurse considers that the defense mechanism most often used by physically abusive parents is what?
Displacement
A client who has been experiencing chest pain and vomiting for several hours is admitted to the hospital with a diagnosis of myocardial infarction. The client is transferred immediately to the cardiac intensive care unit. The client's potassium level is below the expected range. Considering this laboratory result, what should the nurse monitor the client's electrocardiogram (ECG) for?
Elevated U and flattened T waves
A nurse is implementing interventions to assist an aggressive client in deescalating the agitated behavior. Select all that apply.
Encouraging the client to express perceived needs Avoiding verbal struggles in an attempt to demonstrate authority Providing the client with clear options to the unacceptable behavior Explaining the expected outcomes if the client is unable to control the unacceptable behavior
What are the elements of discovery of a lawsuit? Select all that apply.
Experts Medical records The depositions of witnesses Proof of negligence is a part of a trial. Petition and elements of the claim are a part of the pleadings phase.
The following data are recorded during the assessment of a client being treated in the emergency department for minor injuries resulting from a mugging and robbery. In light of this information, the nurse should initially do what?
Explain that feeling anxious is a common response to such an experience
The nurse is caring for a client with Alzheimer disease who exhibits behaviors associated with hyperorality. To meet the client's need for a safe milieu, what instructions will the nurse give the staff to monitor the client?
For attempts at eating inedible objects
Which period of Piaget's theory marks the end of cognitive development?
Formal operations The sensorimotor period is the first period when a newborn develops a schema or pattern for dealing with the environment. The second period is the preoperational period when a child develops egocentrism and animism. During the concrete operations period, children are able to perform mental operations.
A young pregnant adolescent reports bleeding and abdominal pain and is diagnosed with an ectopic pregnancy. Which risk factors should the nurse look for in the client? Select all that apply.
Habit of smoking Damage to the fallopian tubes History of pelvic inflammatory disease
What will the nurse expect diagnostic studies of a client with Cushing syndrome to indicate?
High levels of 17-ketosteroids in a 24-hour urine test
What are the manifestations of hypoestrogenism? Select all that apply.
Hot flashes Amenorrhea Reduced bone density
A client is receiving haloperidol for agitation, and the nurse is monitoring the client for side effects. Which response identified by the nurse is unrelated to an extrapyramidal tract effect?
Hypertensive crisis Akathisia, characterized by restlessness and twitching or crawling sensations in the muscles, is an extrapyramidal side effect. Opisthotonos, characterized by hyperextension and arching of the back, is an extrapyramidal side effect. Oculogyric crisis, characterized by the uncontrolled upward movement of the eyes, is an extrapyramidal side effect.
A client appears anxious, exhibiting 40 shallow respirations per minute. The client complains of feeling dizzy and lightheaded and of having tingling sensations of the fingertips and around the lips. What does the nurse conclude that the client's complaints probably are related to?
Hyperventilation
A nurse is caring for a toddler with severe dehydration and its associated acid-base imbalance. What compensatory mechanism within the body is activated to counteract the effects of the child's acid-base imbalance?
Increased respiratory rate The child has metabolic acidosis; the lungs compensate by blowing off excess carbonic acid in the form of carbon dioxide.
Which of these refers to the accountability element of the decision making process?
Individuals being answerable for their actions Autonomy refers to the freedom of choice and responsibility of choices. Responsibility refers to the duties and activities that an individual is employed to perform. Authority refers to legitimate power to give commands and make final decisions specific to a given position.
To provide appropriate psychosocial support to clients, a nurse must understand development across the life span. What theory is the nurse using in considering relationships and resulting behaviors as the central factors that influence development?
Interpersonal theory Cognitive theory is associated with Jean Piaget; cognitive theory explains how thought processes develop, are structured, and influence behavior. Psychosocial theory is associated with Erik Erikson; psychosocial theory identifies social interaction as the source that influences human development. Erikson identified eight stages of human life, with each stage built on the previous stages and influenced by past experiences. Psychosexual theory is associated with Sigmund Freud; psychosexual theory views child development as a biologically driven series of conflicts and gratifying internal needs.
A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis. What is the initial intervention the nurse should expect the primary healthcare provider to prescribe for this client?
Intravenous (IV) fluids IV fluids are given to combat dehydration in ketoacidosis and to keep an IV line open for administration of medications.
Which of these features are exhibited by an adolescent? Select all that apply.
Invulnerability Personal fable Toddlers get to know their abilities to control situations and seem pleased with it. Preschoolers refine the mastery of their bodies and eagerly await the beginning of formal education.
Propylthiouracil is prescribed for a client diagnosed with hyperthyroidism. The client asks the nurse, "Why do I have to take this medication if I am going to get radiation therapy?" What explanation does the nurse provide?
It decreases production of thyroid hormones.
Which description describes a coalesced type of skin lesion configuration?
Lesions merge together and appear confluent Circumscribed skin lesions are well defined with sharp borders. Annular skin lesions are ringlike with raised borders around flat centers of the normal skin. Lesions with wavy borders that resemble a snake are described as serpiginous.
A nurse administers intravenous (IV) therapy to the wrong client. What possible legal complications might the nurse face in such situation?
Malpractice
The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco 2 of 50 mm Hg, HCO 3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L). The nurse concludes that the findings support what diagnosis?
Metabolic alkalosis
Which organism infestation is diagnosed with the help of the mineral oil test?
Mites
Which feature in the client indicates hypersecretion of adrenocorticotrophic hormone?
Moon face Protrusion of the lower jaw is a feature of acromegaly, caused by excess secretion of growth hormone. Heat intolerance is seen in clients with excess secretion of thyrotropin. In acromegaly, the client presents with "barrel-shaped" chest appearance.
A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias. Which reason for increased incidence of dysrhythmias in this client should the nurse monitor?
Myocardial hypoxia
After surgical implantation of radon seeds for oral cancer, what side effects of the radiation does the nurse observe in the client?
Nausea or vomiting
A nurse is counseling clients who are attending an alcohol rehabilitation program. Which substance poses the greatest risk of addiction for these clients?
Nicotine
What are the important points to be considered when imparting practical knowledge to nursing students about preventing complications in the hospital? Select all that apply.
Nursing students should never be assigned any tasks they are unprepared for. Nursing students can work as nursing assistants or nurse's aides when not attending classes. Nursing students should notify the nursing supervisor in case they are delegated tasks they are not prepared for.
Which part of the female reproductive system produces testosterone in females?
Ovary
A breastfeeding mother requires treatment for depression. Which drug would be safe to use if the mother wishes to continue breastfeeding the newborn?
Paroxetine
Which side effects are associated with systemic antibiotic therapy for acne in adolescents? Select all that apply.
Photosensitivity Vaginal candidiasis Arthralgia, nasal irritation, and decreased night vision are side effects of isotretinoin.
Which is the most common opportunistic infection in a client infected with human immunodeficiency virus (HIV)?
Pneumocystis jiroveci pneumonia It causes tachypnea and persistent dry cough. Candidiasis presents in a client infected with AIDS because the immune system can no longer control Candida fungal growth. Cryptosporidiosis, an intestinal infection caused by Cryptosporidium organisms, presents in clients with AIDS as does toxoplasmosis encephalitis, which is caused by Toxoplasma gondii and is acquired through contact with contaminated cat feces or by ingesting infected undercooked meat.
The parents of a preschooler tell the nurse that they try to inculcate good eating habits by asking the child to be at the table until the "plate is clean." What condition is the child at risk for?
Poor eating habits
Two weeks after sustaining a spinal cord injury, a client begins vomiting thick coffee-ground material and appears restless and apprehensive. What is the most important initial nursing action?
Prepare for insertion of a nasogastric tube
The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what?
Prevent an adult client from getting up at night when there is insufficient staffing on the unit.
The nurse teaches the client about endocrine functioning of Part A. Which information from the client indicates successful learning? (temple region, pituitary gland)
Promotes growth
A client is admitted to the emergency department with a stab wound of the chest. What is the priority when the nurse performs a focused assessment of the client's response to this injury?
Quality and depth of respirations
Which physical assessment of the skin indicates that a client is addicted to phencyclidine?
Red and dry skin A client with alcohol abuse will have burns on the skin. Vasculitis is associated with cocaine abuse. Diaphoresis is associated with chronic abuse of sedative hypnotics.
Surgery to correct hypertrophic pyloric stenosis is performed on a 3-week-old infant who has been fed formula. Which postoperative feeding regimen is most appropriate?
Regular formula feeding within 24 hours of the surgery An initial feeding of glucose and electrolytes in water or breast milk is given 4 to 6 hours after surgery. Once clear fluids are being retained, formula feedings are begun within 24 hours.
A client is diagnosed with diabetic ketoacidosis. Which insulin should the nurse expect the health care provider to prescribe?
Regular insulin Regular insulin is rapid acting and should be used for diabetic coma. Insulin glargine is long-acting insulin, which is not indicated in an emergency. NPH insulin is intermediate-acting insulin; it is not indicated for use in an emergency. Inhaled insulin has not been approved for management of diabetic ketoacidosis.
After an automobile collision involving a fatality and a subsequent arrest for speeding, a client has amnesia regarding the events surrounding the accident. Which defense mechanism is being used by the client?
Repression Projection is attributing one's own unacceptable feelings and thoughts to others. Suppression is consciously keeping unacceptable feelings and thoughts out of awareness.
A nurse is caring for a client after abdominal surgery and encourages the client to turn from side to side and to engage in deep-breathing exercises. What complication is the nurse trying to prevent?
Respiratory acidosis Shallow respirations, bronchial tree obstruction, and atelectasis compromise gas exchange in the lungs; an increased carbon dioxide level leads to respiratory acidosis. Metabolic acidosis occurs with diarrhea; alkaline fluid is lost from the lower gastrointestinal tract. Metabolic alkalosis is caused by excessive loss of hydrogen ions through gastric decompression or excessive vomiting. Respiratory alkalosis is caused by increased expiration of carbon dioxide, a component of carbonic acid.
A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority?
Respiratory exchange The ascending paralysis can reach the diaphragm, leading to death from respiratory failure
A nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). What is most important for the nurse to assess?
Signs of dehydration HPS causes partial and then complete obstruction. Nonprojectile vomiting progresses to projectile vomiting, which rapidly leads to dehydration.
What are the side effects of oral psoralen in phototherapy? Select all that apply.
Sunburn Persistent pruritus
What sexually transmitted diseases are caused by bacteria? Select all that apply.
Syphilis Gonorrhea Hepatitis A and herpes simplex are caused by viruses. Trichomoniasis is caused by a protozoan.
Two 14-year-old girls are best friends and always eat lunch together at school. One of the girls eats rapidly and then immediately leaves to go to the girls' restroom. After a week or so the other girl begins to suspect that her friend is using self-induced vomiting to keep her weight down. Because the friend is not sure what to do, she speaks with a relative who is a nurse. What should the nurse encourage her to do?
Talk to the school nurse about her concerns
A client with end-stage renal disease needs a kidney transplant. Which statements regarding the National Organ Transplant Act are true? Select all that apply.
The National Organ Transplant Act of 1984 prohibits the purchase or sale of organs. The act provides civil and criminal immunity to the hospital and the healthcare provider. The act protects the donor's estate from liability for injuries or damage that results from the use of the gift.
What should a nurse understand regarding the Uniform Anatomical Gift Act?
The Uniform Anatomical Gift Act gives individuals who have reached 18 years of age the right to make an organ donation The National Organ Transplant Act of 1984 prohibits the purchase or sale of organs. The Americans with Disabilities Act (1990) protects the rights of people with physical or mental disabilities. The National Organ Transplant Act of 1984 provides civil and criminal immunity to hospitals and healthcare providers.
Which of these characteristics are found in an adolescent according to Erikson's theory of psychosocial development? Select all that apply.
The adolescent is concerned about his or her appearance and body image. The adolescent acquires a sense of identity by participating in decision-making. A toddler develops his or her autonomy by making choices. A child between three and six years old develops a superego or conscience. According to Erikson's theory of psychosocial development, ages 3-5 years old concentrates on work and play, not adolescents.
The nurse observes that a child fails to make eye contact and has poor impulse control. Upon further assessment, the nurse finds that the parent is an alcoholic and often neglects the child. What can be said about the child?
The child has developed reactive attachment disorder (RAD).
he nurse is assessing an 8-month-old child's gross motor development. Which action by the child indicates late development?
The child is unable to stand by holding onto furniture When a child is 10 months old, the child can change from a prone to a sitting position. When a child is 12 months old, the child is able to sit down from a standing position without any help. When a child is at least 9 months old, the child can sit steadily on the floor for a prolonged period of time.
What characteristics develop in an adolescent according to Piaget's theory of cognitive development? Select all that apply.
The individual develops the ability to reason with respect to possibilities The individual demonstrates feelings and behaviors characterized by self-consciousness During the preoperational stage, a child between the ages of 2 and 7 demonstrates animism, in which they personify objects. According to Piaget's theory, reversibility is one of the primary characteristics that develop in a child between 7 and 11 years old. Infants develop a schema or action pattern for dealing with the environment.
A client who has had a subtotal thyroidectomy does not understand how hypothyroidism can develop when the problem was initially hyperthyroidism. On what fact should the nurse base her response?
There may not be enough thyroid tissue to supply adequate thyroid hormone.
Which cartilage is also known as the Adam's apple?
Thyroid
Which hormone increases the rate of protein synthesis in a client?
Thyroxine
The nurse is reviewing the joint fluid examination of four clients. Which client's report indicates a normal finding?
Transparent, straw-colored fluid
A client is transferred to the postanesthesia care unit after abdominal surgery. The client begins vomiting. What nursing action is most important when caring for this client?
Turning the client onto the side
After reviewing the client's laboratory reports, the physician concludes that the client has primary hypofunction of the adrenal gland. Which clinical manifestation is likely to be observed in that client?
Uneven patches of pigment loss
Which stage of Kohlberg's theory is an individual in if he or she wants to modify a law if it is not fair to a particular group?
Universal ethical principle orientation According to the social contract orientation stage, a person tends to follow a law even if it is not fair. During the society-maintaining stage, an individual shows concerns for his or her society and makes decisions in accordance to his or her society. During the instrument relativist orientation stage, a child recognizes that there is more than one correct view.
A client with a history of drug abuse begins group therapy. After attending the first meeting the client says to the nurse, "It helps to know that I'm not the only one with this type of problem." What concept does this statement reflect?
Universality Universality is the sense that one is not alone in any situation. Altruism in group therapy is giving support, insight, and reassurance to others. Catharsis involves group members relating to one another through the verbal expression of negative and positive feelings. Transference occurs when a client unconsciously assigns to the therapist feelings and attitudes originally associated with another important person in the client's life.
A client with type 1 diabetes who has been adhering to a prescribed insulin regimen is admitted to the hospital in ketoacidosis. Which factor may have precipitated the ketoacidosis?
Upper respiratory infection
A 9-year-old child with type 1 diabetes is admitted to the hospital with deep, rapid respirations; flushed, dry cheeks; abdominal pain with nausea; and increased thirst. What laboratory findings is the nurse most likely to observe?
pH 7.25; glucose 460 mg/dL (25.5 mmol/L) The clinical manifestations indicate ketoacidosis
A nurse is caring for an infant with severe dehydration. Which blood gas report most likely reflects the acid-base balance of this infant?
pH of 7.20 and HCO 3 - of 20 mEq/L (20 mmol/L) Low blood pH and bicarbonate levels indicate metabolic acidosis, which occurs with severe dehydration because the reduced urine output causes retention of hydrogen ions
A woman who is frequently physically abused tells the nurse in the emergency department that it is her fault that her husband beats her. What is the most therapeutic response by the nurse?
"You say that it was your fault—help me understand that."
Which of these statements about language development in children ages 12 to 36 months are true? Select all that apply.
24-month-old children use pronouns 36-month-old children learn to use five or six new words each day. Children 18-months-old use approximately 10 words. Children 24-months-old speak in two-word sentences drawn from a vocabulary of up to 300 words.
A nursing student is recalling the definitions of acts that are classified as torts in nursing practice. Which tort involves intentional touching without the client's consent?
Battery
According to the Piaget's theory, which behavior does a nine-year-old child show?
Concrete thinking
Addicted clients commonly expect discrimination and lack of empathy from others. How can the nurse best overcome these expectations?
Demonstrating a nonjudgmental attitude
Which period of Piaget's theory covers the prevalence of egocentrism in adolescents?
Formal operations
How would the student nurse describe a quasi-intentional tort occurring during the practice of nursing?
It is an act that lacks intent but involves volitional action.
A client on diuretic therapy developed metabolic alkalosis. What does the nurse consider to be the priority nursing care while correcting alkalosis?
Preventing falls A client with alkalosis has hypotension and muscle weakness.
A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results?
Sodium and chloride levels
What stage of Kohlberg's theory of moral development defines "right" by the decision of the conscience?
Universal ethical principle orientation
