missed questions
what is Exophthalmos
abnormal protrusion of the eyes. These clients tend to have dry, irritated eyes. Absence of corneal irritation indicates that the client is following the plan of care, which includes eye drops or ointment to protect the exposed cornea.
Hot, dry skin is an indicator
hyperglycemia
Can an LPN change a colostomy bag?
yes
A client has been admitted voluntarily to the psychiatric unit. During the admitting interview, the client confides to the nurse that he has a lethal plan for committing suicide. At the end of the interview the client asks the nurse, "How long will I have to stay here?" What should the nurse say to this client? 1. "Let's discuss this after the health team has assessed you." 2. "Since you signed papers to be admitted, you cannot leave until the primary healthcare provider discharges you." 3. "A lawyer will have to make that decision." 4. "You can leave when you are no longer suicidal."
1. "Let's discuss this after the health team has assessed you."
A homebound client lives alone, has a history of poorly controlled diabetes, and has an open wound on the left heel. The home health nurse is concerned about the client's condition and the possible need for a referral. Which intervention should the nurse initiate for this client? 1. Ask the primary healthcare provider to prescribe a diabetes educator consult. 2. Continue to monitor the healing process of the open wound. 3. Suggest nursing home placement to the family. 4. Suggest that the client's church family take the client to church each week.
1. Ask the primary healthcare provider to prescribe a diabetes educator consult.
While performing a vaginal examination on a client in labor, the nurse feels soft, squishy tissue instead of a head. What conclusion should the nurse make based on this assessment finding? 1. Breech presentation 2. Edema of cervix 3. Closed cervix 4. Intact membranes
1. Breech presentation
A nurse notes that a client with end-stage chronic renal failure has dry, itchy skin, white crystals on the skin and uremic halitosis. Which nursing intervention would be appropriate for this client? 1. Encourage use of cotton gloves during sleep 2. Apply emollients to the skin 3. Bathe in tepid water 4. Cut fingernails short 5. Provide mouth care prior to meals
1. Encourage use of cotton gloves during sleep 2. Apply emollients to the skin 3. Bathe in tepid water 4. Cut fingernails short 5. Provide mouth care prior to meals
A client diagnosed with serotonin syndrome is admitted to the unit. The nurse is familiar with this adverse reaction to the serotonin reuptake inhibitors. Which symptoms can the nurse expect on assessment? 1. Fever and shivering 2. Agitation 3. Decreased body temperature 4. Constipation 5. Increased heart rate
1. Fever and shivering 2. Agitation 5. Increased heart rate
The medication indomethacin is used to manage which symptoms? 1. Pain 2. Inflammation 3. Fever 4. Cough 5. Urticaria
1. Pain 2. Inflammation 3. Fever
The nurse is caring for a client in the emergency department who presents with hematemesis. What information is most important for the nurse to obtain during the initial assessment? 1. Vital signs 2. History of prior bleeding episodes 3. Medications the client is taking 4. Urinary output 5. Level of consciousness
1. Vital signs 4. Urinary output 5. Level of consciousness Medication history is important, but the nurse must first determine whether or not the client is in shock.
Symptoms of lithium toxicity begin to appear at blood levels greater than
1.5 mEq/L
The nurse performs a follow-up assessment of a client who was involved in a motor vehicle crash and sustained massive head injuries. The nurse notices the client's respirations have a rhythmic crescendo and decrescendo of rate and depth of respiration and include brief periods of apnea. How would the nurse document this respiratory pattern? 1. Apneustic 2. Ataxic 3. Cheyne-Stokes 4. Cluster
3. Cheyne-Stokes
While performing wound care to a donor skin graft site, the nurse notes some scabbing around the edges and black collection of blood. What is the nurse's next action? 1. Leave the scabbing area alone and apply extra ointment. 2. Notify the primary healthcare provider. 3. Gently remove the debris and re-dress the wound. 4. Apply skin softening lotion for 3 hours and then re-dress.
3. Gently remove the debris and re-dress the wound.
The nurse evaluates an electrocardiogram (EKG) and notices a U-wave. The nurse suspects that this occurrence is caused by which electrolyte imbalance? 1. Hypermagnesemia 2. Hypocalcemia 3. Hypokalemia 4. Hyponatremia
3. Hypokalemia
An alert client presents to the emergency department with vomiting for 3 days, and unable to keep food or fluids down for the last 24 hours. What imbalance does the nurse suspect this client has? 1. Hypocalcemia 2. Hypermagnesemia 3. Hypokalemia 4. Metabolic alkalosis 5. Respiratory acidosis
3. Hypokalemia 4. Metabolic alkalosis
A 15 year old comes into the women's clinic with amenorrhea, breast tenderness, and urinary frequency. Which term should the nurse use to describe these signs/symptoms of pregnancy? 1. Probable 2. Positive 3. Presumptive 4. Early
3. Presumptive Presumptive signs of pregnancy can be caused by conditions other than pregnancy.
The nurse is caring for a client who is unresponsive during a postictal state. Which position is correct for this client? 1. Prone 2. Supine 3. Side lying 4. Semi-fowlers
3. Side lying
The nurse is assigned to care for a client who has developed intestinal obstruction and has had an NG tube inserted to low suction. Blood gases are pH 7.54, pCO2 52, HCO3 35. Assessment of the client by the nurse reveals that the client is weak, shaky, and reporting tingling of the fingers. The nurse determines that this client is in which acid base balance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
4. Metabolic alkalosis Metabolic alkalosis occurs from gastric losses via vomiting, NG tubes to suction, or lavage, and potent diuretics. Signs and symptoms include n/v, sensorium changes, tremors, convulsions. pH > 7.45, pCO2 > 45, HCO3 > 27
A nurse attaches a client to continuous cardiac monitoring due to a potassium level of 2.8 mEq (2.8 mmol). The nurse should monitor for which dysrhythmia? 1. Third degree heart block 2. Atrial fibrillation 3. Premature atrial contractions 4. Premature ventricular contractions
4. Premature ventricular contractions
A nurse is reviewing the laboratory results of a client receiving chemotherapy. The platelet count is 10,000/mm3. What would be the priority nursing assessment? 1. Assess level of consciousness 2. Assess temperature 3. Assess urine for blood 4. Assess skin turgor
Assess level of consciousness
Which electrolyte imbalance would be the nurse's priority concern in the burn client?
Hyperkalemia...when the cells lyse they release potassium and then the serum potassium goes up! And if the kidneys stop...we are in real trouble!
proper position for administration of an enema.
Left Sims' position is left side with knee and thigh drawn upward
symptoms of serotonin syndrome
Myoclonus, shaking chills, and mental confusion
The CRIES scale is used with
neonates and infants
is a consent necessary for a Mantoux test?
no
A client with Graves' disease and exophthalmos returns to the clinic for evaluation. Which assessment indicates to the nurse that the client is adhering to the teaching plan? 1. Moist, shiny, soft hair 2. Resting heart rate of 120 3. Adheres to the prescribed low sodium diet 4. An absence of corneal irritation
An absence of corneal irritation
What is Myasthenia Gravis
Myasthenia gravis is a disorder wherein the postsynaptic neuromuscular junction receptor sites are decreased. This decrease in receptor sites causes decreased muscular depolarization. The clinical manifestations of this disease are progressive muscle weakness and fatigue. Eventually clients may experience difficulty breathing due to weakness and fatigue of the respiratory muscles. Muscle fatigue impairs chewing and swallowing.
The nurse is caring for a client who has developed hypovolemic shock. The client is receiving albumin. What assessment findings indicate that the albumin has been effective? 1. Decrease in urine output 2. Reduction in tachycardia 3. Proteinuria 4. Absence of Kussmaul's respirations
Reduction in tachycardia Tachycardia is a compensatory mechanism of hypovolemic shock. A reduction in tachycardia in the hypovolemic shock client is indicative of an improved circulating blood volume.
What does the non-stress test tell the nurse?
The baby is doing well and the placenta is providing enough oxygen at this time
The FLACC scale can be used for
pediatric clients from age 2 months to 7 years and is appropriate when client's cannot communicate their pain
Epigastric pain relieved by vomiting is found with clients who suffer
peptic ulcers
what is the Somogyi effect.
hyperglycemia following an episode of hypoglycemia; especially : hyperglycemia that occurs after breakfast following nocturnal hypoglycemia and that may occur in type 1 diabetes especially when too much insulin has been taken the day before
what is Graves' disease
hyperthyroidism
Sweating and clamminess are symptoms of
hypoglycemia.
what is neuroleptic malignant syndrome
is a life-threatening, neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs. Symptoms include high fever, sweating, unstable blood pressure, stupor, muscular rigidity, and autonomic dysfunction.
Spider angiomas are seen in clients with
liver disease
Toxoplasmosis is transmitted through
the feces of infected cats or through ingestion of raw or rare meats.
A female client with a history of frequent exacerbations of asthma asks the nurse to explain to her why she is at greater risk for fractures than other women her age. What is the nurse's best response? 1. "The steroids you are taking decrease calcium in the bone by sending it to the blood." 2. "Taking steroids causes bone calcium to increase, thus causing osteoporosis." 3. "Clients who have asthma are not able to exercise enough to prevent fractures from occurring." 4. "Asthma should not put you at increased risk for fractures but you are at risk for increased blood glucose levels."
1. "The steroids you are taking decrease calcium in the bone by sending it to the blood." Long term use of steroids decreases serum calcium, so the body takes calcium from the bone and puts it in the blood in order to bring serum calcium back to normal. Every time a steroid is given, calcium is removed from the bone, thus leading to a greater risk for osteoporosis, and a risk for fractures. Drug therapy for asthma (not asthma itself) may put client at risk for osteoporosis.
Which signs and symptoms would indicate to the nurse that the client is having an anaphylactic response after receiving penicillin? 1. Complaints of a scratchy throat 2. Faint expiratory wheeze on auscultation. 3. Client statement, "I feel like something is wrong." 4. Bounding radial pulse rate of 100/min 5. BP 100/70
1. Complaints of a scratchy throat 2. Faint expiratory wheeze on auscultation. 3. Client statement, "I feel like something is wrong." The client would have a thready, weak pulse.
The nurse is providing discharge education to a client after a concussion. What should the nurse emphasize to report to the primary healthcare provider? 1. Difficulty waking up 2. Headache (3/10 on the pain scale) 3. Blurry vision 4. Achy feeling all over 5. Vomiting
1. Difficulty waking up 3. Blurry vision 5. Vomiting only report a headache if severe
The nurse is caring for a client on the cardiac unit. Which assessments are most important for the nurse to perform prior to the administration of diltiazem? 1. Note the rate and character of the apical pulse. 2. Ausculate the anterior and posterior breath sounds. 3. Check the morning results of serum calcium. 4. Review the last 24 hour urine output. 5. Monitor blood pressure. 6. Assess for chest pain.
1. Note the rate and character of the apical pulse. 5. Monitor blood pressure. 6. Assess for chest pain. Monitor blood pressure and pulse before and frequently during administration of diltiazem, as it causes systemic vasodilation and suppresses arrythmias. Diltiazem is used to treat angina so the nurse should assess for anginal pain.
A client with type II diabetes reports normal blood glucose levels at bedtime and high blood glucose levels in the morning for the past week. What instruction would the nurse give the client? 1. Take their blood sugar around 2am for several days. 2. Decrease bedtime snacking. 3. Decrease intermediate acting insulin. 4. Increase intermediate acting insulin.
1. Take their blood sugar around 2am for several days. Morning hyperglycemia may be the result of dawn's phenomenon or the Somogyi effect. The client must take their blood sugar between two and three o'clock in the morning for several days to determine the cause of morning hyperglycemia. If the client has decreased blood sugar between two and three o'clock in the morning, suspect Somogyi effect.
The nurse is administering the prescribed Mantoux tuberculin skin test to a client. The nurse does not observe the tense blister like formation at the injection site. Which action should the nurse take? 1. Chart the injection site response as the only action. 2. Administer another Mantoux tuberculin skin test at a different site. 3. Circle the area, wait 48 to 72 hours, and assess for a reaction. 4. Call the primary healthcare provider.
2. Administer another Mantoux tuberculin skin test at a different site.
The nurse is caring for a client taking enoxaparin. Which group of symptoms should be reported to the primary healthcare provider? 1. AST of 12 U/L and ALT 20 U/L 2. Hematocrit of 46% decreased to 35% and blood pressure decreases from 122/78 to 108/54 3. Ecchymosis around the abdominal subcutaneous injection site and platelet count of 200,000. 4. Hemoglobin of 14.5 g/dL (2.3 mmol/L) increased to 16 g/dL (2.5 mmol/L) and increased erythemia of oral mucus membranes.
2. Correct: These values indicate a drop in hematocrit and drop in blood pressure. Both of these could represent bleeding. These would be important to report to the primary healthcare provider. 1. Incorrect: The nurse would need to watch and report any signs of liver complications due to the drug use. The AST and ALT are two liver enzyme values that would increase with liver complications. These two values represent normal AST (8-40 U/L) values and ALT (10-30 U/L). 3. Incorrect: Bruising (ecchymosis) at the injection site is a frequent occurrence with administration of enoxaparin. This platelet count is within the normal range. 4. Incorrect: These Hgb and color of oral mucus membranes indicate an increase in Hgb. This would not indicate bleeding.
The nurse is teaching the Type II diabetic about monitoring average blood glucose levels over time. The nurse evaluates teaching has been effective when the client verbalizes the need to return to the clinic for which test? 1. Glucose tolerance test 2. Glycosylated hemoglobin 3. Glucose-6-phosphate dehydrogenase 4. Fasting blood glucose
2. Glycosylated hemoglobin Glycosylated hemoglobin tests the average blood glucose over 90 days. Glucose-6-phosphate is an enzyme that assists in glucose metabolism. Deficiency in glucose-6-phosphate dehydrogenase is linked to a genetic defect
The nurse is caring for a client taking lithium. Which comment by the client indicates lack of understanding of the therapeutic regimen? 1. I must keep my sodium intake steady over time. 2. If I miss a dose of lithium, I should make it up with the next dose. 3. I must check with my primary healthcare provider before changing my diet for weight loss. 4. I must keep my exercise routine the same or discuss with my primary healthcare provider.
2. If I miss a dose of lithium, I should make it up with the next dose. If a client misses a dose of lithium, the client should take the next dose as prescribed without doubling it. If the client adds the missed dose, toxicity may occur.
After a retropubic prostatectomy for treatment of benign prostatic hyperplasia, a client enters the post-anesthesia care unit with a three way indwelling urinary catheter that has a continuous irrigation of normal saline infusing. On the initial assessment of the urine in the indwelling urinary catheter bag, the nurse observes the drainage is dark red. Which action should the nurse take first? 1. Chart the drainage color and amount. 2. Increase the flow rate of the irrigation solution until the urine is a light pink. 3. Notify the primary healthcare provider of the dark red drainage from the indwelling urinary catheter. 4. Pull traction on the indwelling tubing and tape the indwelling tubing to the client's leg.
2. Increase the flow rate of the irrigation solution until the urine is a light pink.
The nurse is caring for a client with a long history of emphysema. Which clinical signs/symptoms, if noted by the nurse, would support a history of emphysema? 1. Atelectasis 2. Increased AP diameter 3. Breathlessness 4. Use of accessory muscles with respiration. 5. Leans backwards to breathe. 6. Clubbing of fingernails
2. Increased AP diameter 3. Breathlessness 4. Use of accessory muscles with respiration. 6. Clubbing of fingernails
The nurse is attempting to maintain a patent airway on an alert but very drowsy client who is reporting chest pain with no evidence of trauma. Which nursing measure is most appropriate? 1. Oropharyngeal airway 2. Nasopharyngeal airway 3. Head tilt-chin lift 4. Jaw thrust
2. Nasopharyngeal airway
The nurse is caring for a client diagnosed with major depression post electroconvulsive therapy (ECT). What nursing interventions should be included in this post treatment period? 1. Monitor vital signs every hour for eight hours. 2. Position the client on their side. 3. Stay with the client until fully awake. 4. Provide flexibility in scheduling routine activities. 5. Encourage the client to ambulate in room and hall.
2. Position the client on their side. 3. Stay with the client until fully awake.
A client who has a history of intolerance to fatty foods is admitted to the hospital with a sudden onset of severe right upper quadrant pain radiating to the right shoulder. What should be included in the nurse's initial focused assessment of this client? 1. "Do you have pain in the middle of your stomach that is relieved by vomiting?" 2. "Have you noticed any red splotches on your skin?" 3. "Please describe your bowel habits and stool." 4. "Tell me how often you eat high fat meals."
3. "Please describe your bowel habits and stool." Clay-colored stools are a sign of biliary obstruction and are due to lack of bile in the stool. Bile adds a darker color to the stool. Asking the client to describe stool is open ended and will give the nurse more detail.
A child was diagnosed with attention-deficit/hyperactivity disorder (ADHD) in the clinic one week ago. Today the child's mother calls the clinic to tell the nurse, "Ever since my child has been on methyphenidate he has not been able to sleep." What is the best response for the nurse to make? 1. "I will discuss this with the primary healthcare provider. A different medication may be prescribed." 2. "The insomnia will get better over time. Just wait it out." 3. "To prevent insomnia, give him the last daily dose at least 6 hours before bedtime." 4. "He may have overdosed on the medication. Take him to the emergency department now."
3. "To prevent insomnia, give him the last daily dose at least 6 hours before bedtime." If the medication is sustained-released, administer the dose in the morning.
The nurse is caring for a client with a Mantoux tuberculin skin test to be read. Which assessment finding would best indicate a positive test? 1. Formation of a vesicle that is at least 6 mm in diameter 2. A sharply demarcated region of erythema 3. A central area of induration surrounded by erythema 4. A circle of blanched skin surrounding the injection site
3. A central area of induration surrounded by erythema
The nurse is caring for a newly admitted diabetic client. The initial assessment reveals that the client is unresponsive, BP is 98/64, Resp 38, HR 100, T 97.2ºF/36.2ºC. The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
3. Metabolic acidosis Kussmaul respirations occur due to excess ketones in the body causing metabolic acidosis. A diabetic client who is unresponsive with fruity ketone breath is assumed to be in acidosis. The respiratory rate indicates that the lungs are trying to fix the metabolic acidosis with Kussmaul breathing.
The nurse is providing post-operative care to the craniotomy client. Hourly urinary output increases from 100 mL last hour to 500 mL this hour. What action by the nurse takes priority? 1. Elevate HOB 90 degrees 2. Auscultate apical pulse 3. Obtain a blood pressure 4. Assess Glasgow Coma Score
3. Obtain a blood pressure
The nurse is teaching crutch walking to a client with a fractured lower leg with a non weight bearing cast. Which crutch gait would be most appropriate for the nurse to teach? 1. Swing through 2. Two point 3. Three point 4. Four point alternating
3. Three point All of the weight bearing is done by the unaffected leg and the crutches. The injured leg does not touch the ground during the performance of this gait. This is most appropriate for the client with a lower leg cast.
A client taking phenelzine is admitted to the hospital. Which order should the nurse question? 1. Take Blood pressure lying, sitting, and standing once per shift. 2. Order a complete blood count and liver profile studies. 3. Eliminate foods containing tyramine from diet. 4. Discontinue phenelzine. Begin fluoxetine 20 mg by mouth at bedtime.
4. Discontinue phenelzine. Begin fluoxetine 20 mg by mouth at bedtime. There should be at least five weeks between giving phenelzine and fluoxetine
A charge nurse receives a report of back discomfort after work every day from a surgical nurse. Which action by the surgical nurse should be addressed by the charge nurse? 1. Frequently shifting weight from one foot to the other. 2. Standing straight with knees slightly bent while assisting. 3. Raising work station to waist level. 4. Twisting at the waist to reach for an object during cleanup.
4. Twisting at the waist to reach for an object during cleanup.
A client with a head injury manifests symptoms of increasing intracranial pressure. The primary healthcare provider prescribes mannitol IV. How would the nurse plan to evaluate the effectiveness of this medication? 1. Monitor urine output hourly 2. Take vital signs every 15 minutes 3. Measure head circumference every 8 hours 4. Assess the level of consciousness every hour
Assess the level of consciousness every hour
what is atelectasis and what causes it
Atelectasis is collapse of alveolar lung tissue, and findings reflect presence of a small, airless lung. This condition is caused by complete obstruction of a draining bronchus by a tumor, thick secretions, or an aspirated foreign body, or by compression of lung.
Clients taking MAOIs cannot consume foods containing large amounts of
Clients taking MAOIs cannot consume foods containing large amounts of tyramine. Bananas and avocados are high in tyramine.
A client diagnosed with arachnophobia is prescribed alprazolam 0.5 mg orally three times daily. The nurse knows that teaching about this medication is successful when the client makes what statement? 1. Alprazolam will take up to two weeks to start working. 2. The drug does not cause drowsiness, so my daily activities will not suffer. 3. This medication cannot be taken with food. 4. I should not stop taking alprazolam suddenly.
I should not stop taking alprazolam suddenly.
The nurse is caring for a client starting on vancomycin for MRSA infection. What nursing interventions are appropriate? 1. Provide the client food or a snack to take with the medication 2. Verify that the client's BUN and cretinine are within normal range 3. Check the chart for a perscription for an antiemetic. 4. Request the placement of a PICC line for IV administration
Provide the client food or a snack to take with the medication
What kind of comments should the nurse expect from a client exhibiting clang associations?
Use of rhyming words when talking
Abdominal rigidity indicates
either perforation or internal bleeding. Both of these symptoms are considered an "acute abdomen" and are emergencies.
The FACES scale is indicated for
for children ages 3 years and up. When using the FACES scale, the child must be able to understand the difference between pain and being sad.
Protamine sulfate is given for
heparin overdose... Overdose is seen with a aPTT of 110 seconds. Depending on therapeutic intent, a client's aPTT levels should be between 60-80 seconds. (Normal aPTT for a client not on an anticoagulant is 25-35 seconds).
