NCLEX PassPoint - PN
The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When describing a healthy stoma, which statement should the nurse be sure to include? "The stoma should appear dark and have a bluish hue." "At first, the stoma may bleed slightly when touched." "A burning sensation under the stoma faceplate is normal." "The stoma should remain swollen distal to the abdomen."
"At first, the stoma may bleed slightly when touched." Explanation: For the first few days to a week after a client receives a colostomy, slight bleeding normally occurs when the stoma is touched because the surgical site is still fresh. However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation under the faceplate is abnormal and indicates skin breakdown.
Which statement made by the parent of a 16-month-old child with cystic fibrosis should alert a nurse to investigate further? "My child is not walking yet." "My child cries when I leave the room." "My child doesn't interact with other 16-month-olds." "My child is saying a few words and short phrases."
"My child is not walking yet." Explanation: A toddler should be walking by 15 months. At 10 months, an infant holds on to furniture while walking, walks with support at 11 months, and takes his first steps at 12 months. By 12 months, a child can say a few words, with more words and short phrases being added each month. A child at 16 months, the child engages in solitary play and has little interaction with other children. Separation anxiety is common in toddlers.
Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is SIDS most likely to occur? 1 to 2 years 6 months to 1 year, peaking at 10 months 1 week to 1 year, peaking at 2 to 4 months 6 to 8 weeks
1 week to 1 year, peaking at 2 to 4 months Explanation: SIDS can occur anytime between ages 1 week and 1 year. The incidence peaks at ages 2 to 4 months.
An 18-month-old is admitted with a diagnosis of meningitis. The toddler has a rectal temperature of 105 degrees F (40.5 degrees C). The nurse has inserted an intravenous catheter and started antibiotic therapy. Which of the following nursing actions are also indicated? Select all that apply. Place a tracheostomy set at bedside. Reassess the toddler's temperature hourly. Sponge the toddler with tepid water. Administer an antipyretic per health care provider orders. Bathe the toddler in a cool alcohol bath until shivering occurs.
Administer an antipyretic per health care provider orders. Sponge the toddler with tepid water. Reassess the toddler's temperature hourly. Explanation: The priority for the toddler is to assess and lower the toddler's temperature. Administering an antipyretic, sponging with tepid water, and closely reassessing the temperature are indicated. A tracheostomy is not indicated.
A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change? Bluish urine Coldness of the soles Redness of the upper part of the feet Purplish stools
Bluish urine Explanation: Lymphangiography may turn the urine blue temporarily; it doesn't alter stool color. For several months after the procedure, the upper part of the feet may appear blue, not red. Lymphangiography doesn't affect the soles.
The nurse observes that a 2-hour-old neonate has acrocyanosis. Which nursing action is a priority? Notify the health care provider of the need for genetic counseling. Activate the code blue or emergency system. Do nothing because acrocyanosis is normal in a neonate. Immediately take the neonate's temperature according to facility policy.
Do nothing because acrocyanosis is normal in a neonate. Explanation: Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn't last more than 24 hours after birth. Activating the emergency system, taking the neonate's temperature, or notifying the health care provider is inappropriate because the finding is a normal finding.
During a senior citizen health screening, the nurse observes a 75-year-old female with a severely increased thoracic curve, or "humpback". What is this condition called? Scoliosis Kyphosis Genus varum Lordosis
Kyphosis Explanation: Kyphosis refers to an increased thoracic curvature of the spine, or "humpback." Lordosis is an increase in the lumbar curve or swayback. Scoliosis is a lateral deformity of the spine. Genus varum is a bow-legged appearance of the legs.
The nurse is collecting data on a 3-year-old child who has ingested toilet bowl cleaner. What finding should the nurse expect? Reddish-colored skin Edematous lips Lower abdominal pain Hypertension
Edematous lips Explanation: The child who has ingested a caustic poison, such as lye (found in toilet bowl cleaners), may develop lip edema, ulcers of the lips and mouth, pain in the mouth and throat, excessive salivation, dysphagia, and burns of the mouth, lips, esophagus and stomach. Bleeding from burns in the GI tract can lead to pallor, hypotension, tachypnea, and tachycardia. Reddish-colored skin, hypertension, and lower abdominal pain don't commonly occur in caustic poisoning.
A 3-year-old child has a positive culture for streptococcus organisms. Which intervention is most appropriate? Give the client aspirin. Give the client antibiotics. Give the client corticosteroids. Encourage fluid intake.
Give the client antibiotics. Explanation: Infection caused by streptococcus organisms is treated with antibiotics, mainly penicillin. Antipyretics, such as acetaminophen, may be given for fever. Aspirin isn't recommended. Corticosteroids are not indicated. Fluid intake is encouraged to prevent dehydration from decreased oral intake due to a sore throat or to replace fluids lost due to possible diarrhea from the antibiotics.
A nurse is caring for a client who recently underwent a total hip replacement. The client is progressing well and expects to be discharged the following day. When returning to bed after ambulating, the client reports severe pain in the surgical wound. Which action should the nurse take? Assume the client anxious about being discharged, and administer pain medication. Suspect a wound infection, and monitor the client's temperature and vital signs. Inspect the surgical site and affected extremity. Reassure the client that pain is a direct result of increased activity.
Inspect the surgical site and affected extremity. Explanation: Worsening pain after a total hip replacement may indicate dislocation of the prosthesis. Evaluation of pain should include inspection of the wound and the affected extremity. Assuming that the client is anxious about discharge and administering pain medication does not locate the cause of the pain. Sudden severe pain is not normal after hip replacement. Wound infections are usually distinguished by purulent drainage.
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. While monitoring the client, which clinical findings that commonly accompany respiratory alkalosis would the nurse expect to assess? Hallucinations or tinnitus Abdominal pain or diarrhea Light-headedness or paresthesia Nausea or vomiting
Light-headedness or paresthesia Explanation: The client with respiratory alkalosis may report light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. While monitoring the client, which clinical findings that commonly accompany respiratory alkalosis would the nurse expect to assess? Hallucinations or tinnitus Nausea or vomiting Light-headedness or paresthesia Abdominal pain or diarrhea
Light-headedness or paresthesia Explanation: The client with respiratory alkalosis may report light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.
A nurse is reinforcing education with a parent on how to reduce the baby's risk of developing otitis media. Which instruction should the nurse be sure is included in the teaching plan? Administer antibiotics whenever the baby has a cold. Place the baby in an upright position when giving a bottle. Avoid getting the ears wet while bathing or swimming. Clean the external ear canal daily.
Place the baby in an upright position when giving a bottle. Explanation: Feeding a baby in an upright position reduces the pooling of formula in the nasopharynx. Formula provides a good medium for the growth of bacteria, which can travel easily through the short, horizontal Eustachian tubes. The other interventions do not reduce the risk of a baby developing otitis media.
An average-weight client reports of generalized steady abdominal pain. The nurse should suspect an abdominal aortic aneurysm, if the abdominal pain is accompanied by which finding? Pink, frothy sputum Elevated cardiac enzymes Pulsating mass in the periumbilical area Positive Babinski's sign
Pulsating mass in the periumbilical area Explanation: Signs of abdominal aortic aneurysm include gnawing, generalized, steady abdominal pain; lower back pain that's unaffected by movement; gastric or abdominal fullness; pulsating mass in the periumbilical area (if the client isn't obese), systolic bruit over the aorta on auscultation of the abdomen; bruit over the femoral arteries; and hypotension (with aneurysm rupture). Elevated cardiac enzymes indicate heart muscle damage. Positive Babinski's sign indicates damage to the pyramidal tract of the central nervous system. Pink, frothy sputum is a sign of pulmonary edema.
A client has a diagnosis of stroke versus transient ischemic attack (TIA). Which statement demonstrates the difference between a TIA and a stroke? TIAs may cause a permanent motor deficit. TIAs may be hemorrhagic in origin. TIAs typically resolve in 24 hours. TIAs may predispose the client to a myocardial infarction (MI).
TIAs typically resolve in 24 hours. Explanation: Symptoms of TIA result from a transient lack of oxygen to the brain and usually resolve within 24 hours. Hemorrhage into the brain has the worst neurologic outcome and isn't associated with a TIA. Permanent motor deficits don't result from TIA. Unstable angina, not a TIA, may predispose the client to a future MI.
After a motor vehicle crash, a client has a chest tube inserted that begins to drain a large amount of dark red fluid. Which explanation best describes what caused this type of drainage from the chest tube insertion? It is normal for the drainage to be dark red. An artery was nicked when the chest tube was inserted. The chest tube was inserted improperly. The client has experienced a hemothorax instead of a pneumothorax.
The client has experienced a hemothorax instead of a pneumothorax. Explanation: Because of the traumatic cause of injury, the client has a hemothorax, in which blood collection causes the collapse of the lung. The placement of the chest tube will drain the blood from the space and re-expand the lung. There's a slight chance of nicking an intercostal artery during insertion, but it's fairly unlikely if the person placing the chest tube has been trained. The initial chest x-ray would help confirm whether there was blood in the pleural space or just air.
A client has a serum calcium level of 7.2 mg/dl. During the physical examination, the nurse expects to assess: Trousseau's sign. Homans' sign. Hegar's sign. Goodell's sign
Trousseau's sign. Explanation: This client's serum calcium level indicates hypocalcemia, an electrolyte imbalance that causes Trousseau's sign (carpopedal spasm induced by inflating the blood pressure cuff above systolic pressure). Homans' sign (pain on dorsiflexion of the foot) indicates deep vein thrombosis. Hegar's sign (softening of the uterine isthmus) and Goodell's sign (cervical softening) are probable signs of pregnancy.
When collecting data on a child with muscular dystrophy, the nurse expects which finding? Joint swelling Pain Waddling gait Limited range of motion (ROM)
Waddling gait Explanation: A waddling, wide-based gait is a sign of muscular dystrophy. Pain, joint swelling, and limited ROM are rare with this disease.
The nurse is caring for an 18-month-old child admitted to the pediatric unit with a diagnosis of celiac disease. Which finding would the nurse expect to observe in this child? bulges in the groin area a protuberant abdomen a palpable abdominal mass a concave abdomen
a protuberant abdomen Explanation: A child with celiac disease would have a protuberant abdomen due to the presence of fat, bulky stools, undigested food, and flatus. A concave abdomen, bulges in the groin area, and a palpable abdominal mass are not associated with celiac disease.
A client comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar region, which radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. The nursing instructor asks the student where is the common formation site? How should the student reply? "The most common renal calculi formation site is the kidney." "The most common renal calculi formation site is the ureter." "The most common renal calculi formation site is the bladder." "The most common renal calculi formation site is the urethra."
"The most common renal calculi formation site is the kidney." Explanation: The most common site of renal calculi formation is the kidney. Calculi may travel down the urinary tract with or without causing damage and may lodge anywhere along the tract or may stay within the kidney. The ureter, bladder, and urethra are less common sites of renal calculi formation.
The nurse cares for a client who has experienced a stroke. During morning round, the nurse observes that the client has deeper breaths followed by shallower breaths with apneic periods. Which breathing pattern should the nurse document? Biot's respirations tachypneic rate Cheyne-Stokes Kussmaul breathing
Cheyne-Stokes Explanation: Cheyne-Stokes respirations are breaths that become progressively deeper, followed by shallower respirations with apneic periods. Biot's respiration is rapid, deep breathing with abrupt pauses between each breath and equal depth between each breath. Kussmaul respiration is rapid, deep breathing without pauses. Tachypnea is shallow breathing with increased respiratory rate.
Observation of a client reveals thin extremities, but an obese truncal area and a "buffalo hump" at the shoulder area with reports of weakness and disturbed sleep. The nurse interprets this data as indicating which disorder? Graves' disease hyperparathyroidism Addison's disease Cushing syndrome
Cushing syndrome Explanation: Clients with Cushing syndrome have truncal obesity with thin extremities and a fatty "buffalo hump" at the back of the neck. Clients with Addison's disease show signs of weakness, anorexia, and dark pigmentation of the skin. Clients with Graves' disease (hyperthyroidism) have symptoms of heat intolerance, irritability, and bulging eyes. Hyperparathyroidism is characterized by osteopenia and renal calculi.
A nurse obtaining data from a client observes jugular vein distention (JVD). Which condition does the nurse suspect this client to have? abdominal aortic aneurysm heart failure myocardial infarction (MI) deep vein thrombosis
heart failure Explanation: Elevated venous pressure, exhibited as JVD, indicates the heart's failure to pump. JVD is not a sign of abdominal aortic aneurysm or deep vein thrombosis. An MI, if severe enough, can progress to heart failure; however, in and of itself, an MI does not cause JVD.
The nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect? Heart failure Cardiac tamponade Tension pneumothorax Pulmonary embolism
Heart failure Explanation: A client with heart failure has decreased cardiac output caused by the heart's decreased pumping ability. A buildup of fluid occurs, causing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. A client with pulmonary embolism experiences acute shortness of breath, pleuritic chest pain, hemoptysis, and fever. A client with cardiac tamponade experiences muffled heart sounds, hypotension, and elevated central venous pressure. A client with tension pneumothorax has a deviated trachea and absent breath sounds on the affected side as well as dyspnea and jugular vein distention.
Which of the following complications is most common after an abdominal aortic aneurysm resection? Hemorrhage and shock Enteric fistula Renal failure Graft occlusion
Hemorrhage and shock Explanation: Hemorrhage and shock are the most common complications after abdominal aortic aneurysm resection. Renal failure can occur as a result of shock or from injury to the renal arteries during surgery. Graft occlusion and enteric fistula formation are rare complications of abdominal aortic aneurysm repair.
A 2-year-old child is brought to the emergency department with suspected croup. Which data collection finding reflects increasing respiratory distress? Fever Intercostal retractions Pallor Bradycardia
Intercostal retractions Explanation: Clinical manifestations of respiratory distress include tachypnea, tachycardia, restlessness, dyspnea, and intercostal retractions. Fever is a sign of infection. Bradycardia is a late sign of impending respiratory arrest. Cyanosis, not pallor, is a sign of increasing respiratory distress.
A client seeks care for low back pain of 2 weeks' duration. Which data collection finding suggests a herniated intervertebral disk? Atrophy of the lower leg muscles Back pain when the knees are flexed Homans' sign Pain radiating down the posterior thigh
Pain radiating down the posterior thigh Explanation: A herniated intervertebral disk may compress the spinal nerve roots, causing sciatic nerve inflammation that results in pain radiating down the leg. Slight knee flexion should relieve, not precipitate, low back pain. If nerve root compression remains untreated, weakness or paralysis of the innervated muscle group may result; lower leg atrophy may occur if muscles aren't used. Homans' sign is more typical of phlebothrombosis.
During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into his or her mouth. Which of the following actions would enhance latching on to the nipple? Tilt the bottle so that the nipple fills with formula. Stroke the neonate's lips gently with the nipple. Use a nipple with the largest possible opening. Squeeze the baby's lower jaw to open the mouth.
Stroke the neonate's lips gently with the nipple. Explanation: Stroking the neonate's lips gently with the nipple usually causes the mouth to open wide enough for nipple insertion. Tilting the bottle or pushing the tip of the nipple into the neonate's mouth may cause continued difficulty. Using a nipple with larger openings wouldn't help resolve the problem and may allow too much formula to enter the mouth once the neonate starts to suck. To suck effectively, the neonate needs to compress the entire nipple, not just the tip.
An agitated client with left-sided heart failure reports increasing shortness of breath and coughs up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of which disorder? cardiogenic shock pneumonia acute pulmonary edema right-sided heart failure
acute pulmonary edema Explanation: Heart failure causes decreased contractility and increased fluid volume and pressure. Fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema. The client may become short of breath and cough up pink-tinged, foamy sputum. In right-sided heart failure, hepatomegaly, jugular vein distention, and peripheral edema occur. A client with pneumonia would have a temperature spike and sputum that varies in color. Cardiogenic shock is characterized by hypotension and tachycardia.
A nurse prepares to perform postural drainage on a client. How should the nurse determine the best position to facilitate clearing the lungs? auscultation of lung sounds percussion of the chest wall palpation for tactile fremitus inspection of chest expansion
auscultation of lung sounds Explanation: The nurse should auscultate the client's lung sounds before doing postural drainage to determine the areas that need draining. Inspection, percussion, and palpation are all evaluation parameters that give good information about the respiratory system, but they are not necessary to determine lung areas requiring postural drainage.
The nurse is checking the legs of a client who's 36 weeks pregnant. Which finding should the nurse expect? absent pedal pulses sluggish capillary refill unilateral calf enlargement bilateral dependent edema
bilateral dependent edema Explanation: As the uterus grows heavier during pregnancy, femoral venous pressure rises, leading to bilateral dependent edema. Factors interfering with venous return, such as sitting or standing for long periods, contribute to edema. Absence of pedal pulses and sluggish capillary refill signal inadequate circulation to the legs; an unexpected finding during pregnancy. Unilateral calf enlargement, also an abnormal finding, may indicate thrombosis.
A nurse performs cardiopulmonary resuscitation (CPR) for 1 minute on an infant without calling for assistance. In reassessing the infant after 1 minute of CPR, the nurse finds the infant still isn't breathing and has no pulse. The nurse should then: resume CPR beginning with chest compressions. call for assistance. resume CPR beginning with breaths. declare her efforts futile.
call for assistance. Explanation: After 1 minute of CPR, the nurse should call for assistance and then resume efforts. CPR shouldn't be stopped after it has been started unless the nurse is too exhausted to continue. A cycle usually ends with breaths, so the next beginning cycle after pulse check and summoning help would begin with chest compressions.
A client exhibits signs of dementia. Which condition, that can cause a dementia similar to Alzheimer's disease (AD), is reversible? multiple sclerosis electrolyte imbalance multiple small brain infarctions human immunodeficiency virus infection (HIV)
electrolyte imbalance Explanation: Electrolyte imbalance is a correctable metabolic abnormality that may present with dementia type symptomology. Multiple sclerosis presents with neuromuscular changes, not dementia. Small brain infarctions do not present with dementia-like symptoms. HIV does not present with dementia.
When caring for a child diagnosed with a ventricular septal defect, how would the nurse describe this condition when talking with the parents? failure of a septum to develop completely between the ventricles narrowing of the aortic arch failure of a septum to develop completely between the atria narrowing of the valves at the entrance of the pulmonary artery
failure of a septum to develop completely between the ventricles Explanation: Failure of a septum to develop between the ventricles results in a left-to-right shunt, which is noted as a ventricular septal defect. When the septum fails to develop between the atria, it's considered an atrial septal defect. The narrowing of the aortic arch describes coarctation of the aorta. Narrowing of the valves at the pulmonary artery describes pulmonary stenosis.
The client has been scheduled for electroconvulsive therapy (ECT). The health care provider has discussed the procedure with the client. The client says to the nurse, "My health care provider has discussed ECT with me, but could you remind me of some of the side effects I may experience?" Select all that apply. headache confusion dementia muscle pain short-term memory loss
headache confusion muscle pain short-term memory loss Explanation: A client may temporarily experience headache, confusion, muscle pain, and short-term memory loss. Dementia is not a side effect of ECT; dementia would signal a long-term irreversible condition.
The nurse is collecting data on a client. She notes clubbed fingers. This finding indicates: malnutrition. hypoxia. hyperthyroidism. Raynaud's disease.
hypoxia. Explanation: Clubbing is a sign of prolonged hypoxia. Causes of clubbing include emphysema, chronic bronchitis, lung cancer, and heart failure. Beau's lines (transverse depressions in the nail that extend beyond the nail bed) occur with acute illness, malnutrition, and anemia. Koilonychia (thin, spoon-shaped nails with lateral edges that tilt upward) is associated with Raynaud's disease, malnutrition, chronic infections, and hypochromic anemia. Onycholysis (loosening of the nail plate with separation from the nail bed) is associated with hyperthyroidism, psoriasis, contact dermatitis, and Pseudomonas infections.
A client has been treated with antibiotic therapy for right lower-lobe pneumonia for 10 days and will be discharged today. Which physical finding would lead the nurse to believe it's appropriate to discharge this client? respiratory rate of 32 breaths/minute fever of 102º F (38.9º C) continued dyspnea normal vesicular breath sounds in right base
normal vesicular breath sounds in right base Explanation: If the client still has pneumonia, the breath sounds in the right base will be bronchial, not the normal vesicular breath sounds. If the client still has dyspnea, fever, and increased respiratory rate, the client should be re-examined by the health care provider before discharge because he may have another source of infection or still have pneumonia.
A nurse is assisting with the education for the family of a client with dementia. Which response by the nurse would be the most accurate definition of dementia? personal neglect in self-care memory loss occurring as a natural consequence of aging loss of intellectual abilities that impairs the ability to perform basic care poor judgment, especially in social situations
loss of intellectual abilities that impairs the ability to perform basic care Explanation: The ability to perform basic self-care is an important measure of the progression of dementia. Personal neglect and poor judgment typically occur in dementia but aren't considered defining characteristics. Memory loss reflects underlying physical, metabolic, and pathologic processes.
The nurse is monitoring an infant with bronchiolitis for dehydration. What intervention is the highest priority? checking blood levels every 4 hours collecting a urinalysis every 8 hours weighing each diaper measuring intake and output
measuring intake and output Explanation: Accurate measurement of intake and output is essential to assess for dehydration. Blood levels may be obtained daily or every other day. A urinalysis every 8 hours is not necessary. Urine-specific gravities are recommended, but can be obtained with diaper changes. Weighing diapers is a way of measuring output only.
An infant's parent gives a history of poor feeding for a few days. The nurse observes white plaques in the infant's mouth with an erythematous base. The plaques stick to the mucous membranes tightly and bleed when scraped. The nurse would suspect which condition? herpes lesions chickenpox oral candidiasis measles
oral candidiasis Explanation: Oral candidiasis, or thrush, is a painful inflammation that can affect the tongue, soft and hard palates, and buccal mucosa. Chickenpox, or varicella, causes open ulcerations of the mucous membranes. Herpes lesions are usually vesicular ulcerations of the oral mucosa around the lips. Measles that form Koplik spots can be identified as pinpoint, white, elevated lesions.
A nurse is collecting data from a client with a history of cocaine use. Which condition might typically be found with this client? perforated nasal septum glossitis bilateral ear infections pharyngitis
perforated nasal septum Explanation: The client who snorts cocaine frequently commonly develops a perforated nasal septum. Glossitis, bilateral ear infections, and pharyngitis aren't common physical findings for a client with a history of cocaine use.
The nurse caring for an infant with pyloric stenosis should be alert for which classic sign or symptom? chronic diarrhea excessive drooling loss of appetite projectile vomiting
projectile vomiting Explanation: The obstruction seen in pyloric stenosis doesn't allow food to pass through to the duodenum. The classic sign of projectile vomiting occurs when the stomach becomes full, and the infant vomits for relief. Drooling would not be a finding in a child with pyloric stenosis but rather in a child with tracheoesophageal fistula. Chronic hunger is commonly seen. There's no diarrhea because food doesn't pass the stomach.
Which therapeutic strategy is used to reduce anxiety in a client diagnosed with illness anxiety disorder? suicide precautions relaxation exercises electroconvulsive therapy pharmacological intervention
relaxation exercises Explanation: A nurse can initiate relaxation exercises to decrease anxiety without an order from the physician. In illness anxiety disorder, there is a very low risk of suicide. Medical intervention would include electroconvulsive therapy and pharmacological intervention.
The client has been scheduled for electroconvulsive therapy (ECT). The health care provider has discussed the procedure with the client. The client says to the nurse, "My health care provider has discussed ECT with me, but could you remind me of some of the side effects I may experience?" Select all that apply. confusion headache muscle pain short-term memory loss dementia
tissue necrosis through most of the dermis Explanation: A client with a deep partial-thickness burn will have tissue necrosis to the epidermis and dermis layers. Necrosis through all skin layers is seen with full-thickness injuries. Erythema and pain are characteristic of superficial injury. With deep burns, the nerve fibers are destroyed and the client will not feel pain in the affected area. Superficial burns present with slight epidermal damage.
The nurse is collecting data on a 6-year old child. The child reports dysuria and urgency. The parent reports that the child has recently had some enuresis. The nurse recognizes these as signs and symptoms of which condition? nephrotic syndrome urinary tract infection acute glomerulonephritis obstructive uropathy
urinary tract infection Explanation: Frequency and urgency can lead to enuresis. All are symptoms of urinary tract infection.
A 2-year-old child has been diagnosed with asthma. The parents ask about the most common asthma triggers. What is the nurse's response? weather the cat next door one parent with asthma peanut butter
weather Explanation: Excessively cold air, wet or humid changes in weather and seasons, and air pollution are some of the most common asthma triggers. Food allergens are rarely responsible for airway reactions in children. Household pets are a trigger. Evidence suggests that asthma is partly hereditary in nature, but heredity isn't an allergen.
A nurse is assessing a client who has a rash on the chest and upper arms. Which questions should the nurse ask in order to gain further information about the client's rash? Select all that apply. "Have you recently traveled outside the country?" "Do you smoke cigarettes or drink alcohol?" "Are you allergic to any medications, foods, or pollen?" "How old are you?" "What have you been using to treat the rash?" "When did the rash start?"
"When did the rash start?" "Are you allergic to any medications, foods, or pollen?" "What have you been using to treat the rash?" "Have you recently traveled outside the country?" Explanation: The nurse should first find out when the rash began; this can assist with the correct diagnosis. The nurse should also ask about allergies; rashes can occur when a person changes medications, eats new foods, or contacts pollen. It is also important to find out how the client has been treating the rash; some topical ointments or oral medications may worsen it. The nurse should ask about recent travel; exposure to foreign foods and environments can cause a rash. The client's age and smoking and drinking habits would not provide further insight into the rash or its cause.
The nurse is caring for a child with a diagnosis of croup. What advice should the nurse give to the parent when concern is expressed about the child waking at night due to the cough? Hold child in the bathroom with a hot shower running, allowing steam to fill room. Call 911 for assistance. Administer another dose of medication. Immediately take the child to an ambulatory care center.
Hold child in the bathroom with a hot shower running, allowing steam to fill room. Explanation: Steam from the shower will decrease laryngeal spasms, so taking the child to the bathroom and turning on a hot shower should help. It is not necessary to call 911 each time a child has a coughing episode with croup. Driving the child to a patient care center would be dangerous if something more serious happened on the way. If the child is coughing he would not be able to do a breathing treatment successfully.
A child comes to the emergency department (ER) with symptoms of asthma and the health care provider begins treatment. The nurse is requested to obtain a sputum culture. What is the best explanation for the test in this situation? It will identify the causative agent of the asthma attack. It will identify any risk factors associated with asthma. It will complete the protocol for asthma treatment. It will rule out a respiratory infection.
It will rule out a respiratory infection. Explanation: When a patient has asthma, it is appropriate to do a sputum analysis to rule out a respiratory infection. It is not part of the protocol for asthma treatment, and it will not identify risk factors or agents that precipitated an asthma attack.
A nurse is reinforce educating the parents of a 5-year-old child admitted to the pediatric unit with cystic fibrosis. Which statement concerning steatorrheaic stools is most accurate? They're frothy, foul-smelling, and fatty. They're clay-colored. They're orange or green. They're black and tarry.
They're frothy, foul-smelling, and fatty. Explanation: Children with cystic fibrosis have an abnormal electrolyte transport system in the cells that eventually blocks the pancreas, preventing the secretion of enzymes that digest certain foods such as protein and fats. This results in foul-smelling, fatty stool. Black, tarry stool is observed in clients who have upper GI bleeding, are on iron medications, or who consume diets high in red meat and dark-green vegetables. Clay-colored stool indicates possible bile obstruction. Orange or green stool may indicate intestinal infection.
A client admitted with a diagnosis of pneumonia is known to be a "blue bloater." What would be the nurse's best explanation to the client for using this term? coughing more frequently retaining more carbon dioxide exhaling more carbon dioxide producing more sputum
retaining more carbon dioxide Explanation: Clients with chronic obstructive bronchitis appear bloated; they have large barrel chests, peripheral edema, cyanotic nail beds, and, at times, circumoral cyanosis. Retaining more carbon dioxide, not exhaling more, is the reason for the blue color. Producing more sputum and coughing more frequently does not contribute to the overall color of the client. Clients with emphysema appear pink and cachectic.
The nurse is reviewing laboratory results for a client with peritonitis. Which results would the nurse expect to observe? partial thromboplastin time (PTT) longer than 100 seconds potassium level above 5.5 mEq/L hemoglobin (Hb) level below 10 mg/dl white blood cell (WBC) count above 15,000/μL
white blood cell (WBC) count above 15,000/μL Explanation: Because of infection, the client's WBC count will be elevated. A PTT longer than 100 seconds may suggest disseminated intravascular coagulation (DIC), a serious complication of septic shock. A hemoglobin level below 10 mg/dl may occur from hemorrhage. A potassium level above 5.5 mEq/L may suggest renal failure.
The nurse is assessing a client whose membranes ruptured prematurely 12 hours ago. Which is the nurse's highest priority to evaluate when collecting data on this client? White blood cell (WBC) count Frequency and duration of contractions Cervical effacement and dilation Maternal vital signs and fetal heart rate (FHR)
Maternal vital signs and fetal heart rate (FHR) Explanation: After premature rupture of the membranes (PROM), monitoring maternal vital signs and FHR takes priority. Maternal vital signs, especially temperature and pulse, may suggest maternal infection caused by PROM. FHR is the most accurate indicator of fetal status after PROM and may suggest sepsis caused by ascending pathogens. Assessing cervical effacement and dilation should be avoided in this client because it requires a pelvic examination, which may introduce pathogens into the birth canal. Evaluating the frequency and duration of contractions doesn't provide insight into fetal status. The WBC count may suggest maternal infection; however, it can't be measured as often as maternal vital signs and FHR can and therefore provides less current information.
Which finding will the nurse most likely observe when performing a health screening of an older adult female client who has loss of bone density? increased thoracic curvature of the spine excessive lateral curvature of the spine bowing of the lower leg in relation to the thigh inward curvature of the lumbar and cervical spine
increased thoracic curvature of the spine Explanation: Kyphosis refers to an increased thoracic curvature of the spine that occurs with osteoporosis. Lordosis is an increase in the lumbar curve, or swayback, which can be caused by achondroplasia (abnormal bone growth that results in short stature), spondylolisthesis (vertebrae in the lower back slips forward), or obesity. Scoliosis is a lateral deformity of the spine that results from disease of the vertebral column, trauma or imbalance of the neuromuscular system, or congenital abnormality. Genu varum is a bowed appearance of the legs that is most commonly caused by rickets or any condition that prevents bones from forming properly, skeletal problems, infection, and tumors.
A client has a long leg cast applied for a tibia fracture. Which statement made by the client would indicate to the nurse that compartment syndrome may be developing? "I am having a decrease in sensation of my toes." "My leg really itches." "My toenails are pink." "I have some discomfort when I try and move my foot around."
"I am having a decrease in sensation of my toes." Explanation: Compartment syndrome can occur from internal (bleeding) and external pressure (cast or dressing) and can cause a feeling similar to the foot "falling asleep" (related to a lack of sensation). Blood flow is impaired. The toenails should be pink and capillary refill less than 3 seconds. The leg will itch underneath the cast and it is important to reinforce that no objects should be placed under the cast to scratch the skin. This can damage skin integrity and predispose the client to infection.
The nurse is collecting data from a client with a rash on the chest and upper arms. Which questions should the nurse ask to obtain more information about the client's rash? Select all that apply. "Are you allergic to any medications, foods, or pollen?" "Do you smoke cigarettes or drink alcohol?" "What have you been using to treat the rash?" "Have you traveled outside the country?" "When did the rash start?" "How old are you?"
"When did the rash start?" "Are you allergic to any medications, foods, or pollen?" "What have you been using to treat the rash?" "Have you traveled outside the country?" Explanation: Finding out when the rash first appeared helps the health care provider make a diagnosis and determine the stage of the disease process. Obtaining an allergy history is necessary, because rashes related to allergies can occur when a client changes medications, eats new foods, or has contact with allergens in the air (such as pollen). How the client has been treating the rash is important, because topical ointments and oral medications may worsen the rash. Travel outside the country exposes the client to foreign foods and environments that can contribute to the onset of a rash. The client's age and smoking or drinking habits have no real value in determining the cause of the rash.
A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms? Coma, anxiety, confusion, headache, and cool, moist skin Kussmaul's respirations, dry skin, hypotension, and bradycardia Polyuria, polydipsia, polyphagia, and weight loss Polyuria, polydipsia, hypotension, and hypernatremia
Coma, anxiety, confusion, headache, and cool, moist skin Explanation: Signs and symptoms of hypoglycemia include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin, tremors, coma, and seizures. Kussmaul's respirations, dry skin, hypotension, and bradycardia are signs of diabetic ketoacidosis. Excessive thirst, hunger, hypotension, and hypernatremia are symptoms of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight loss are classic signs and symptoms of diabetes mellitus.
A nurse is monitoring a client who has just returned from a cardiac catheterization. Which is an appropriate nursing intervention? Assess for bowel sounds. Remove the dressing over the puncture site. Palpate the peripheral pulses. Assist the client to ambulate.
Palpate the peripheral pulses. Explanation: Cardiac catheterizations are invasive procedures in which a catheter is threaded through an artery. Postprocedure care requires bed rest and monitoring vital signs, puncture sites, and peripheral pulses. The dressing over the puncture site should not be removed. Assessing bowel sounds is not the priority. Assist the client to ambulate is not appropriate.
A nurse is reviewing data on a client suspected of having a pneumothorax. Which intervention would best confirm the diagnosis? client can't use incentive spirometer client experiencing dyspnea auscultation of breath sounds chest x-ray results
chest x-ray results Explanation: A chest x-ray will show the area of collapsed lung if pneumothorax is present, as well as the volume of air in the pleural space. Listening to breath sounds won't confirm a diagnosis. The client wouldn't do well with an incentive spirometer at this time. A client may experience dyspnea for many reasons besides a pneumothorax.
A client experiences polydipsia and voiding large amounts of waterlike urine with a specific gravity of 1.003. What do these clinical manifestations indicate to the nurse? diabetic ketoacidosis syndrome of inappropriate antidiuretic hormone (SIADH) secretion diabetes insipidus diabetes
diabetes insipidus Explanation: Diabetes insipidus is characterized by a great thirst (polydipsia) and large amounts of waterlike urine, which has a specific gravity of 1.001 to 1.005. Diabetes involves polydipsia, polyuria, and polyphagia, but the client also has hyperglycemia. Diabetic ketoacidosis involves weight loss, polyuria, and polydipsia, and the client has severe acidosis. A client with SIADH secretion can't excrete a dilute urine; he retains fluid and develops a sodium deficiency.
The nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. Which condition should the nurse suspect? cardiac tamponade heart failure tension pneumothorax pulmonary embolism
heart failure Explanation: A client with heart failure has decreased cardiac output caused by the heart's decreased pumping ability. A buildup of fluid occurs, causing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. A client with pulmonary embolism experiences acute shortness of breath, pleuritic chest pain, hemoptysis, and fever. A client with cardiac tamponade experiences muffled heart sounds, hypotension, and elevated central venous pressure. A client with tension pneumothorax has a deviated trachea and absent breath sounds on the affected side as well as dyspnea and jugular vein distention.
After an infant with a cleft lip has surgical repair and heals, the parents can expect to see which result? malaligned teeth distortion of the jaw a larger upper lip minimal scarring
minimal scarring Explanation: If there is no trauma or infection to the site, healing occurs with little scar formation. There may be some inflammation right after surgery, but after healing, the lip is a normal size. No jaw malformation occurs with cleft lip repair
An anxious client is brought to the walk in clinic with difficulty breathing following a bee sting. Which of the following is the nurse's priority action? assist the client to lie down monitor the client's airway administer 100% oxygen via mask assess the site to remove the stinger
monitor the client's airway Explanation: The initial priority action with any client having difficulty breathing is to assess and maintain the airway. All other actions may be completed following the assessment of the airway.
A client is diagnosed with disseminated intravascular coagulation (DIC) postpartum. The nurse recognizes that DIC may be related to which antepartum complication? severe pre-eclampsia urinary retention fetal decelerations Rhogam administration
severe pre-eclampsia Explanation: DIC is a life-threatening defect in coagulation that may occur in several complications of pregnancy (abruption placenta, pre-eclampsia, HELLP syndrome, sepsis). While anticoagulation is occurring, inappropriate coagulation also is occurring in the microcirculation. DIC can result in time clot formation in small blood vessels which block blood flow to organs and cause ischemia. Urinary retention, Rhogam administration, or fetal decelerations do not increase the risk of DIC.
A nurse is evaluating a client with hyperthyroidism. Which findings should the nurse anticipate that correlate with the diagnosis? diaphoresis, fever, and decreased sweating exophthalmos, diarrhea, and cold intolerance appetite loss, constipation, and lethargy weight loss, nervousness, and tachycardia
weight loss, nervousness, and tachycardia Explanation: Weight loss, nervousness, and tachycardia are signs of hyperthyroidism. Other signs of hyperthyroidism include exophthalmos, diaphoresis, fever, and diarrhea. Weight gain, constipation, lethargy, decreased sweating, and cold intolerance are signs of hypothyroidism.
