NCLEX-PN 400 practice questions

The nurse is caring for an older depressed client whose son was killed in an armed robbery after murdering two people. The client says, "I don't know what I did wrong. His dad died a hero in Vietnam when he was only 2 years old, but he's had everything. When he threw the cat up against the wall to see if it landed on its feet and stole money from me and denied it, his sister covered for him." The nurse plans to make which therapeutic response to the client? 1."It seems as if you or your daughter feel regret?" 2."Oh well, we can only love our children, do our very best, and hope they reflect our upbringing." 3."Don't blame yourself. You seem to have been very caring. Some people just turn out evil despite all we do for them." 4."Do I hear you saying that you feel that your son's behavior was caused by the indulgence he received from his sister?"

1."It seems as if you or your daughter feel regret?" Rationale: The most therapeutic communication by the nurse is that which seeks to promote the client to reframe a situation. In option 2 the nurse uses trite social, nontherapeutic communication. In option 3 the nurse uses false reassurance, which is nontherapeutic. In option 4 the nurse uses an inappropriate and inaccurate dynamic interpretation, which is insensitive.

A client has the following laboratory values: a pH of 7.55, an HCO3- level of 22 mEq/L (22 mmol/L), and a Pco2 of 30 mm Hg (30 mm Hg). Which action would the nurse plan to take? 1. Perform Allen's test. 2. Prepare the client for dialysis. 3. Administer insulin as prescribed. 4. Encourage the client to slow down breathing.

4. Encourage the client to slow down breathing. Rationale:The client is experiencing respiratory alkalosis based on the laboratory results of a high pH and a low Pco2 level. Interventions for respiratory alkalosis are the voluntary holding of breath or slowed breathing and the rebreathing of exhaled CO2 by methods such as using a paper bag or a rebreathing mask as prescribed. Performing Allen's test would be incorrect, because the blood specimen has already been drawn, and the laboratory results have been completed. Dialysis and insulin administration are interventions for metabolic acidosis.

The nurse is caring for a child with human immunodeficiency virus (HIV). It is most important that the nurse use which precautions to protect herself and her other clients from infection with HIV? Select all that apply. 1. Wear an N95 respirator when in the client's room. 2. Recap all needles to prevent accidental needle sticks. 3. Perform hand hygiene before and after contact with the client. 4. Use biohazard bags for items saturated with blood and bodily fluids. 5. Wear personal protective equipment when contact with blood and other bodily fluids are anticipated.

2, 3, 4, 5

The nurse is assisting to administer acetylcysteine to a client admitted with acetaminophen overdose. Before this medication is given, the nurse ensures which factor is in place? 1. The solution is given full strength. 2.The client knows how to use a nebulizer. 3.The stomach is empty from emesis or lavage. 4.The antidote to acetaminophen is readily available.

3.The stomach is empty from emesis or lavage. Rationale: Acetylcysteine can be given orally or by nasogastric tube to treat acetaminophen overdose, or it may be given by inhalation for use as a mucolytic. Before giving the medication as an antidote to acetaminophen overdose, the nurse ensures that the client's stomach is empty through emesis or gastric lavage. The solution is diluted in cola, water, or juice to make the solution more palatable (ngon dễ uống). It then is administered orally or by nasogastric tube.

The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question would the nurse ask the family to elicit information specific to the development of RF? 1. "Has the child complained of back pain?" 2. "Has the child complained of headaches?" 3. "Has the child had any nausea or vomiting?" 4. "Has the child had a sore throat or a fever within the past 2 months?"

4. "Has the child had a sore throat or a fever within the past 2 months?" Rationale: Rheumatic fever (RF) characteristically presents 2 to 6 weeks after an untreated or partially treated group A ß-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child has had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to RF.

A mother is breast-feeding her newborn baby and experiences breast engorgement. The nurse would encourage the mother to do which to provide relief of the engorgement? 1.Breast-feed only during the daytime hours. 2. Apply cold compresses to the breast before feeding. 3.Avoid the use of a bra while the breasts are engorged. 4.Massage the breasts before feeding to stimulate let-down.

4.Massage the breasts before feeding to stimulate let-down. Rationale: Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate let-down, wearing a supportive and well-fitting bra at all times, taking a warm shower or applying warm compresses just before feeding, and alternating breasts during feeding.

A patient is admitted to the hospital with a diagnosis of diabetes insipidus (DI). The nurse should be aware of what primary characteristics of DI? a. Decreased urinary output and decreased plasma osmolality b. Excretion of large quantities of urine with a very low specific gravity and urine osmolality c. Hypertension, weight gain and bradycardia d. Irritability and mental dullness

b. Excretion of large quantities of urine with a very low

The nurse is assessing a client's arteriovenous fistula being used for hemodialysis. Which findings would prompt the nurse to notify the primary health care provider immediately? Select all that apply. 1. No thrill palpated at fistula site 2. No bruit auscultated at the fistula site 3.Dialysis treatment lasting longer than 3 hours 4.Absent pulse distal to the arteriovenous fistula 5.Fistula site transparent dressing last changed 8 days ago

1, 2, 4,

The nursing student is caring for a client scheduled for cataract surgery. The student reviews the preoperative prescriptions with the nursing instructor and notes that cyclopentolate eye drops are prescribed to be administered preoperatively. The unit nurse performed an admission health assessment on the client before surgery. Which condition contraindicates using cyclopentolate? 1. Glaucoma 2.Leukemia 3.Liver disease 4.Diabetes mellitus

1. Glaucoma Rationale: Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. It is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis to dilate the eye. Mydriatics are contraindicated in glaucoma because they can cause an increase in intraocular pressure.

Ibuprofen is prescribed for a client. Which instruction would the nurse give the client about taking this medication? 1. Take with 8 ounces of milk. 2.Take in the morning after arising. 3.Take 60 minutes before breakfast. 4. Take at bedtime on an empty stomach.

1. Take with 8 ounces of milk. Rationale: Ibuprofen is a nonsteroidal anti inflammatory drug (NSAID). NSAIDs should be given with milk or food to prevent gastrointestinal irritation. Options 2, 3, and 4 are incorrect.

The nurse is caring for a client with a diagnosis of chronic kidney disease who is receiving dialysis. Epoetin alfa has been prescribed for the client. How would the nurse prepare to administer the medication? 1. The subcutaneous route 2. Shaking the vial before drawing up the medication 3. Obtaining the medication from the medication freezer 4. Mixing the medication with 0.1 mL of heparin before administration to prevent clotting

1. The subcutaneous route Rationale:Epoetin alfa is dispensed for subcutaneous or intravenous injections. Vials should not be shaken because epoetin alfa is a protein that can be denatured by agitation. Epoetin alfa is not to be mixed with other medications. The medication should be refrigerated but should not be frozen.

A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and would question which intervention that is written in the plan? 1.Palpate the abdomen for a mass. 2.Check the urine for the presence of hematuria. 3.Monitor the blood pressure for the presence of hypertension. 4.Monitor the temperature for the presence of a kidney infection.

1.Palpate the abdomen for a mass. Rationale: Wilms' tumor is an intraabdominal and kidney tumor. If Wilms' tumor is suspected, the mass should not be palpated. Excessive manipulation can cause seeding of the tumor and thus cause the spread of the cancerous cells. Hematuria, hypertension, and fever are signs and symptoms that are associated with Wilms' tumor.

Which findings would cause the nurse to postpone administration of an immunization and do further data collection? Select all that apply. 1. Over 60 years of age 2. Immune deficiency disease 3. Axillary temperature of 99°F 4. Negative tuberculin skin test at 48 hours 5. Type 1 diabetes mellitus requiring insulin 6. Familial history of severe allergic response to the immunization

2, 6 Rationale:Immune deficiency disease or immunosuppressive therapy require postponement of vaccination and checking with the primary medical provider. Allergic responses to substances by the client or family members should be investigated. Being over 60 years of age is not a reason to postpone or cancel immunization. Axillary temperature of 99 is not febrile. A negative tuberculin skin test for tuberculosis is expected and normal. Having insulin-dependent diabetes mellitus places a person at risk for some conditions such as pneumonia and influenza, making immunizations more important.

The nurse reinforces instructions to a client with myxedema about the dosage, method of administration, and side effects of levothyroxine sodium. Which statement by the client indicates an understanding of the nurse's instructions? 1. "I should apply the topical patch to a non hairy area." 2. "I will report any episodes of palpitations, chest pain, or dyspnea." 3. "I can expect to have diarrhea, insomnia, and excessive sweating." 4. "If I feel nervous or have tremors, I should only take half the dose."

2. "I will report any episodes of palpitations, chest pain, or dyspnea." Rationale:A major concern when initiating thyroid hormone replacement therapy is that the dosage may be too high, which can lead to cardiovascular problems. As a result, clients need to be aware of the early signs and symptoms of toxicity and that they must report these immediately to their primary health care provider. Diarrhea, insomnia, and excessive sweating are signs and symptoms of hyperthyroidism, and although they can occur with thyroid replacement therapy, they are not expected and should be reported. Tremors and nervousness are also signs of toxicity that need to be reported. Clients should never take it on themselves to adjust hormone dosage. Levothyroxine sodium is not administered topically.

The nurse is reinforcing instructions to the mother of an 8-year-old child who had a tonsillectomy. The mother tells the nurse that the child loves tacos and asks when the child can safely eat one. The nurse would make which response to the mother? 1. "In 1 week" 2. "In 3 weeks" 3."Two days following surgery" 4."When the surgeon says it's OK"

2. "In 3 weeks" Rationale: Rough, scratchy foods or spicy foods are to be avoided for 3 weeks. Citrus juices, which irritate the throat, need to be avoided for 10 days. Red liquids are avoided because they will give the appearance of blood if the child vomits. A full-liquid diet is allowed on the second postoperative day, and soft foods are allowed as the child tolerates them.

The nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first? 1. A client in skeletal traction 2. A client who is dependent on a ventilator 3. A postoperative client preparing for discharge 4. A client admitted during the previous shift with a diagnosis of gastroenteritis

2. A client who is dependent on a ventilator Rationale: The airway is always a priority, and the nurse first checks the client on a ventilator. The clients described in options 1, 3, and 4 have needs that would be identified as intermediate priorities.

The nurse is assigned to care for a child with a compound (open) fracture of the arm that occurred as a result of a fall. The nurse plans care knowing that this type of fracture involves which specific characteristic? 1.The entire bone fractured straight across 2.A greater risk of infection than a simple fracture 3.The bone being fractured but not producing a break in the skin 4.One side of the bone being broken and the other side being bent

2. A greater risk of infection than a simple fracture Rationale: In a compound (open) fracture, a wound in the skin leads to the broken bone, and there is an added danger of infection. Option 1 describes a transverse fracture. Option 3 describes a closed or simple fracture. Option 4 describes a greenstick fracture.

An older client with rheumatoid arthritis has been instructed by the primary health care provider to take acetaminophen 3000 mg to 4000 mg daily. Which laboratory test needs to be monitored on this client? 1. A lipoprotein panel 2. Liver function test (LFTs) 3. Kidney function tests (KFTs) 4. Complete blood count (CBC)

2. Liver function test (LFTs) Rationale:LFTs need to be monitored on this client. The standard ceiling dose of acetaminophen is 4000 mg each day. However, patients may be at risk for liver damage if they take more than 3000 mg daily, have alcoholism, or have liver disease. Older adults are particularly at risk because of normal changes of aging, such as slowed excretion of drug metabolites. Remind clients to read the labels of over-the-counter (OTC) or prescription drugs that could contain acetaminophen before taking them. Clients need to know that their liver enzyme levels may be monitored while taking this drug. Kidney function tests (KFTs) include serum creatinine that if elevated could be an early sign of kidney failure. Another KFT is the glomerular filtration rate (GFR) that measures how well the kidneys are removing wastes and excess fluid from the blood. The third KFT is blood urea nitrogen (BUN). As kidney function decreases, the BUN level rises. The CBC test examines cellular elements in the blood, including red blood cells, various white blood cells, and platelets. A lipoprotein panel is a blood test that can help show whether you're at risk for coronary heart disease (CHD). A lipoprotein panel measures the levels of LDL and HDL cholesterol and triglycerides in your blood. Abnormal cholesterol and triglyceride levels may be signs of increased risk for CHD.

The nurse is reviewing the laboratory results of a client receiving chemotherapy for cancer. The nurse reports which abnormal result to the primary health care provider? 1. Hematocrit, 38% 2. Platelet count, 40,000 mm3 3. White blood cell (WBC) count, 6000 mm3 4. Red blood cell (RBC) count, 4.4 million cells/mm3

2. Platelet count, 40,000 mm3 Rationale: Hematological toxicity from chemotherapy occurs when there is a decreased production of blood components (RBCs, WBCs, and platelets) owing to the effects of antineoplastic agents. Platelet counts normally are 150,000 to 400,000 mm3. The values of the hematocrit, WBC count, and RBC count are within normal limits. The nurse reports this finding because this value places the client at risk for bleeding.

The nurse is caring for a 58-year-old client with chronic kidney disease who is receiving peritoneal dialysis. Which finding is considered most important by the nurse, requiring primary health care provider notification? Refer to chart. Vital Signs: Temperature: 99.2°F orally Heart rate (HR): 96 beats per minute Blood pressure (BP): 130/72 mm Hg O2 saturation % on ABG: 94% Laboratory Results White blood cell (WBC) count: 15,000 cells/mL Blood glucose: 152 mg/dL Potassium: 5.2 mEq/L Blood urea nitrogen (BUN): 40 mg/dL Diagnostic Results Chest x-ray: Mild atelectasis ECG: First-degree heart block CT scan of brain: Mild encephalopathy 1.BUN: 40 mg/dL 2.WBC 15,000 mm3 3.ECG: First-degree heart block 4.Heart rate: 96 beats per minute

2. WBC 15,000 mm3 Rationale: Peritonitis is the most common complication of peritoneal dialysis and is often caused by a contamination in the system. This infection can initially be determined by an increased WBC count. It can also include abdominal pain, cloudy peritoneal fluid, fever and chills, and nausea and vomiting.

Which observation indicates that the nurse is performing a whispered voice hearing assessment test procedure correctly? 1. Stands 10 feet away from the client 2.Asks the client to block one ear at a time 3.Conducts the test with back to the client 4.Asks the client to close both eyes during the test

2.Asks the client to block one ear at a time Rationale:In a voice test, the nurse, while facing the client, stands 1 to 2 feet away and asks the client to block one external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately. Although closing the eyes would prevent lip reading, it is not a condition of the screening.

A client diagnosed with testicular cancer is prescribed cisplatin. The nurse would monitor for which toxic effect of this medication? 1. Nausea 2.Tinnitus 3.Vomiting 4.Leukocytosis

2.Tinnitus Rationale: Cisplatin is a medication that can cause neurotoxicity, nephrotoxicity, bone marrow depression, and ototoxicity, which manifests as tinnitus and high-frequency hearing loss. Nausea and vomiting are expected adverse effects, and an elevated white blood cell count is not commonly experienced.

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding would be reported immediately to the primary health care provider (PHCP)? 1. Dry cough 2. Hematuria 3. Bronchospasm 4. Blood-tinged sputum

3. Bronchospasm Rationale: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor (an abnormal, high-pitched, musical breathing sound), bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

A client with right pleural effusion by chest x-ray is being prepared for a thoracentesis. The client experiences dizziness when sitting upright. The nurse assists the client to which position for the procedure? 1. Sims' position with the head of the bed flat 2. Prone with the head turned to the side supported by a pillow 3. Left side-lying with the head of the bed elevated at 45 degrees 4. Right side-lying with the head of the bed elevated at 45 degrees

3. Left side-lying with the head of the bed elevated at 45 degrees

The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse would take which appropriate action? 1. Document the finding. 2. Continue to monitor vital signs. 3. Report the finding to the registered nurse (RN). 4. Mark the drainage on the dressing and monitor for any increase in bleeding.

3. Report the finding to the registered nurse (RN).

The client with trigeminal neuralgia is being treated with carbamazepine. Which laboratory result indicates that the client is experiencing an adverse effect of the medication? 1. Sodium level, 140 mEq/L 2.Uric acid level, 5.0 mg/dL 3. White blood cell count, 3000 mm3 4. Blood urea nitrogen (BUN) level, 15 mg/dL

3. White blood cell count, 3000 mm3 Rationale: Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, leukopenia, cardiovascular disturbance, thrombophlebitis, dysrhythmia, and dermatological effects. Options 1, 2, and 4 identify normal laboratory values.

The nurse is caring for a client dying of cancer. During care, the client states, "If I can just live long enough to attend my daughter's graduation, I'll be ready to die." Which phase of coping is this client experiencing? 1. Anger 2. Denial 3.Bargaining 4.Depression

3.Bargaining Rationale:Denial, bargaining, anger, depression, and acceptance are recognized stages that a person experiences when facing a life-threatening illness. The client's statement is indicative of bargaining. Denial is expressed as shock and disbelief and may be the first response to hearing bad news. Depression may be manifested by hopelessness, weeping openly, or remaining quiet or withdrawn. Anger may also be a first response to upsetting news, and the predominant theme is "Why me?" or the blaming of others.

A client who is pregnant will be treated by a dermatologist for acne. Which statement if made by the client indicates a need for further teaching? 1. "I will continue to perform exfoliation treatments." 2. "I will use my antibacterial soap at least one time daily." 3. "I will apply topical erythromycin to my face as previously recommended." 4. "I will continue to take the prescribed oral tetracycline hydrochloride on a daily basis."

4. "I will continue to take the prescribed oral tetracycline hydrochloride on a daily basis." Rationale: Tetracycline is avoided during pregnancy because it may cause discoloration of the child's teeth when they erupt. Exfoliation, antibacterial soap and topical erythromycin are acceptable measures to treat acne during pregnancy.

The nurse is caring for a client who had a tracheostomy tube inserted 1 week ago. The client begins to cough vigorously, and accidental decannulation of the tracheostomy tube occurs. Which action would be the nurse's immediate response? 1. Call a code. 2. Call an anesthesiologist. 3. Call a respiratory therapist. 4. Replace the tracheostomy tube.

4. Replace the tracheostomy tube. Rationale: If decannulation of a tracheostomy tube occurs 72 hours after surgical placement of the tracheostomy, the nurse prepares to replace the tube. The nurse also calls the registered nurse for help immediately. The nurse extends the client's neck and opens the tissues of the stoma to secure an airway. With the obturator inserted into the new tracheostomy tube, the nurse quickly and gently replaces the tube and immediately removes the obturator. The nurse checks for airflow through the tube and for bilateral breath sounds. If unable to secure the airway, the nurse notifies the respiratory therapist and attempts to ventilate the client with a bag-valve mask (resuscitation bag) while waiting for help. If the client is in distress and further attempts to secure the airway fail, the nurse calls the resuscitation team, including an anesthesiologist, for assistance and calls a code if necessary.

The nurse notices a "paranoid stare" during a conversation with the client diagnosed with posttraumatic stress disorder (PTSD). The client then begins to fidget and gets up to pace around the room. Which action by the nurse would be most beneficial? 1. Allow the client to pace. 2. Escort the client to a quiet room. 3. Change the conversation to a less threatening subject. 4. Share the observation with the client and help the client recognize his or her feelings.

4. Share the observation with the client and help the client recognize his or her feelings. Rationale:The action that would be most beneficial to the client is to share the observation with the client and help the client recognize his or her feelings. This action may help the client recognize and acknowledge his or her feelings. Moving to a quiet room or changing the subject will not help the client recognize behaviors and feelings. Allowing the client to pace provides no assistance and may lead to the client's becoming "out of control."

A client who was started on anticonvulsant therapy with clonazepam tells the nurse of increasing clumsiness and unsteadiness since starting the medication. The client is visibly upset by these symptoms and asks the nurse what to do. The nurse's response is based on which understanding of these symptoms? 1. The client is experiencing a severe adverse reaction to the medication. 2. Symptoms usually occur when the client takes the medication with food. 3. Symptoms are probably the result of an interaction with another medication. 4. These are expected effects during initial therapy and decrease or disappear with long-term use.

4. These are expected effects during initial therapy and decrease or disappear with long-term use. Rationale: Drowsiness, unsteadiness, and clumsiness are expected effects of the medication during early therapy. They are dose related and usually diminish or disappear altogether with continued use of the medication. It does not indicate that a severe adverse reaction is occurring. It is also unrelated to interaction with another medication. The client is encouraged to take this medication with food to minimize gastrointestinal upset.

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which situation? 1.Poor dietary choices 2.Lack of exercise and poor diet 3.Inadequate dietary intake and dehydration 4.Psychomotor retardation and side effects of medication

4.Psychomotor retardation and side effects of medication Rationale: In this situation, urinary retention is most likely caused by medications. Option 4 is the only option that addresses both constipation and urinary retention. Constipation can be related to inadequate food intake, lack of exercise, and poor diet.

Immediately following cataract repair, the client's affected conjunctiva and eyelids are edematous. Which statement by the nurse accurately characterizes these findings for the client? 1. "The edema is normal and should subside within 3 days." 2. "The edema is abnormal because only the conjunctiva should be affected." 3. "The edema is abnormal and should be reported if the swelling increases." 4. "The edema is not unusual but should be reported if not improved within 24 hours."

1. "The edema is normal and should subside within 3 days." Rationale: After surgery to remove cataracts, it is normal for edema of the conjunctiva, sclera, and eyelids to be present. This is due to the trauma of surgery and should resolve in 3 or fewer days following surgery. Options 2, 3, and 4 are incorrect.

The nurse is assisting the primary health care provider in performing a caloric test on a client. Following instillation of cool water into the ear, the nurse observes the presence of nystagmus. The nurse would document the findings of this test as indicative of which result? 1. Normal 2. Positive 3. Abnormal 4. Inconclusive

1. Normal Rationale: The caloric test is useful in testing the function of cranial nerve VIII. Water that is warmer or cooler than body temperature is infused into the ear. A normal response is demonstrated by the onset of vertigo (spinning sensation) and nystagmus (involuntary eye movements) within 20 to 30 seconds. Positive, abnormal, and inconclusive results are incorrect.

The nurse is reviewing laboratory results and notes that the client's international normalized ratio (INR) is 2.2. The nurse would realize this test is performed to monitor the effectiveness of which medication? 1. Heparin 2. Warfarin 3.Dabigatran 4. Dipyridamole

2. Warfarin Rationale:The prothrombin time and INR are names for a laboratory assay that measures the extrinsic pathway of coagulation including liver function making vitamin K. The effectiveness of warfarin is monitored by the INR. Heparin is an anticoagulant that is monitored by the partial thromboplastin time (PTT). Dabigatran is an anticoagulant used for clients with atrial fibrillation and does not require laboratory testing. Dipyridamole is a medication that will cause a decrease in platelet agglutination (stickiness) and does not require any laboratory monitoring.

The nurse is gathering data from a 16-year-old pregnant client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which client statement indicates a need for further investigation? 1. "I don't like my figure anymore. My clothes are all too tight." 2. "I don't like my breasts anymore. These silver lines are ugly." 3. "I don't like my stomach anymore. That brown line is disgusting." 4. "I don't like my face anymore. I always look like I have been crying."

4. "I don't like my face anymore. I always look like I have been crying." Rationale: Options 1, 2, and 3 are dealing with body image. Although these comments should not be ignored, the need for follow-up is not urgent. Option 4 is an implication of periorbital and facial edema, which could be indicative of gestational hypertension (GH). Because this is an adolescent who has not sought early prenatal care, she is at higher risk for the development of gestational hypertension.

A client with Bell's palsy exhibits facial asymmetry and cannot close the eye completely on one side. The client is also drooling and has loss of tearing in one eye. The nurse documents that the client displays symptoms of involvement of which cranial nerve (CN)? 1. CN I 2. CN IV 3. CN V 4. CN VII

4. CN VII Rationale:Bell's palsy is a common problem involving CN VII. In addition to the symptoms identified in the question, the client may exhibit loss of the nasolabial fold, an inability to blink automatically or to swallow secretions, and possible loss of taste on the anterior two thirds of the tongue. Other conditions that can affect CN VII function include fracture of the temporal bone and parotid lacerations or contusions.

To assess for the presence of the posterior tibialis pulse, the nurse would palpate which areas? 1. In the groove just below the inguinal ligament 2. Behind the knee and lateral to the medial tendon 3. Lateral to and parallel with the extensor tendon of the big toe 4. In the groove behind the medial malleolus and the Achilles tendon

4. In the groove behind the medial malleolus and the Achilles tendon (nằm phía dưới mắt cá) Rationale: The posterior tibialis pulse can be located in the groove behind the medial malleolus or the inside of the ankle behind the bone. The femoral pulse is palpated just below the inguinal ligament halfway between the pubis and anterior superior iliac spine. Popliteal pulses, although difficult to palpate, may be felt behind the knee in the popliteal fossa. The dorsalis pedis pulse is located on the top of the foot.

Amantadine hydrochloride 100 mg orally twice daily has been prescribed for a client with Parkinson's disease, and the nurse teaches the client about the medication. Which statement by the client indicates a need for further teaching? 1. "I should see improvement in my condition in about 7 days." 2. "I can empty the capsules into food or fluid to make swallowing easier." 3. "I can get this medication in syrup form if I have difficulty swallowing." 4."I'll take this medication early in the morning and just before I go to bed."

4."I'll take this medication early in the morning and just before I go to bed." Rationale: Amantadine hydrochloride is an antiparkinson medication administered twice a day, but the last dose should not be administered near bedtime because it may cause insomnia in some clients. Options 1, 2, and 3 are correct statements for this medication.

A licensed practical nurse (LPN) is administering medications to a client who has difficulty swallowing. A time-released film-coated medication is prescribed and the client is unable to swallow the pill. Which action by the LPN is most appropriate? 1. Skip the dose and try again at a later time. 2.Crush the tablet and mix it with applesauce. 3.Give the client a large glass of water to aid in swallowing. 4.Consult with the registered nurse (RN) about contacting the primary health care provider (PHCP) regarding a medication change.

4.Consult with the registered nurse (RN) about contacting the primary health care provider (PHCP) regarding a medication change. Rationale:Time-released medications are film-coated and designed to dissolve later in the gastrointestinal tract. The contents are not made to be dissolved in the mouth or esophagus and should not be crushed or broken open. The LPN should consult with the RN because if the client has extreme difficulty swallowing, the PHCP should be notified. Offering large volumes of water and a capsule to a client with impaired swallowing could result in aspiration.

The nurse is assigned to care for a 2-year-old child who has been admitted to the hospital for surgical correction of cryptorchidism. What is the highest priority in the postoperative plan of care for this child? 1.Force oral fluids. 2.Encourage coughing. 3.Test the urine for glucose. 4.Prevent tension on the suture.

4.Prevent tension on the suture. Rationale: When a child returns from surgery, the testicle is held in position by an internal suture that passes through the testes and scrotum and is attached to the thigh. It is important not to dislodge this suture. Depending on the type of anesthesia used, option 2 may be appropriate but is not the priority in this surgery. Although adequate hydration is important to maintain, fluids should not be forced. Testing urine for glucose is not related to this type of surgery.

A primary health care provider's prescription reads atenolol, 0.025 g orally daily. The medication bottle reads atenolol, 25-mg tablets. The nurse prepares how many tablet(s) to administer the dose? Fill in the blank.

1 tab

The nurse is assessing a client with a diagnosis of bipolar affective disorder-mania. Which characteristics appropriately describe this client's diagnosis? Select all that apply. 1. Outlandish behaviors 2. Takes a shower every other day 3. Purposeless arousal and movement 4. Occasional episodes of mild depression 5. Grandiose delusions of being King Arthur 6.Incessant talking that includes sexual innuendos

1, 3, 5, 6

The nurse is caring for a client in the critical care unit. The nurse is reviewing the Critical Care Family Needs Inventory. The nurse knows that the most important issues of family members of critically ill clients include which factors? Select all that apply. 1. Receiving assurance 2. Receiving information 3. Having support available 4. Remaining near the client 5. Talking to the doctor every day 6. Being given snacks to eat at the bedside

1. Receiving assurance 2. Receiving information 3. Having support available 4. Remaining near the client Rationale: Needs of family members of critically ill clients are a very important concern for nurses working in critical care areas. Besides the basic need of comfort, family members need to receive information and assurance about the client's status. Family members also must be able to remain at the client's bedside and have support such as social service or religious ministry available, if needed. Being able to talk to the doctor every day may not be reasonable as long as the family members receive daily information. Also, having snacks at the bedside is not a basic family need.

A urinary analgesic is prescribed for a client with a urinary tract infection. When would the nurse tell the client that it is best to take the medication? 1. With meals 2. At bedtime 3. 1 hour before meals 4. In the morning before breakfast

1. With meals Rationale:A urinary antiseptic is administered with meals to decrease gastrointestinal side effects. At bedtime, 1 hour before meals, and in the morning before breakfast are incorrect.

The medication prescribed is methylprednisolone acetate 60 mg intramuscularly. The medication label states methylprednisolone acetate 40 mg/1 mL. How many milliliters will the nurse prepare to administer to the client? Fill in the blank.

1.5.ml

The nurse is collecting data from a client and is reviewing the client's health record to determine the risk for preterm labor. Which finding places the client at risk for preterm labor? 1.A urinary tract infection 2.A single-fetus pregnancy 3.A 26-year-old primigravida 4.A hemoglobin of 13.5 g/dL

1.A urinary tract infection Rationale: One risk factor for preterm labor is the presence of a genitourinary infection. Although the connection is not clearly understood, one hypothesis involves the release of prostaglandins by the pathogens, which may contribute to the initiation of contractions. Other risk factors for preterm labor include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age less than 15 years or first pregnancy older than the age of 35.

During data collection on a child for a well-child visit, a parent tells the nurse "We have a chore chart at our house. When our child does chores without prompting for 3 days in a row, the child gets an extra 30 minutes of screen time. So far, it seems to be working!" The nurse determines the child's behavior corresponds with which stage of Kohlberg's moral development? 1.Pre-conventional: Obtaining rewards 2.Pre-conventional: Avoiding punishment 3.Conventional: Obeying rules and regulations 4. Post-conventional: Making and keeping promises

1.Pre-conventional: Obtaining rewards Rationale: The child is in the pre-conventional stage, and obtaining rewards is the focus of the child's behavior. There is nothing in the question that mentions avoiding punishment. In the later stages of Kohlberg's moral development, a person obeys rules and regulations, and makes and keeps promises.

Which are the most important interventions that can help reduce the incidence of hospital-acquired urinary catheter infections? Select all that apply. 1.Empty the urinary drainage bag every 12 hours. 2.Use indwelling urinary catheters judiciously. 3.Remove indwelling catheters when no longer needed. 4.Use strict aseptic technique when inserting all urinary catheters. 5.Do not insert straight catheters into a client more than once a day. 6.Irrigate all indwelling catheters every day to prevent obstruction.

2, 3, 4 Rationale: Catheter associated urinary tract infections (CAUTI) are costly, prolong hospitalizations, and can lead to complications and even death. Strategies used to help reduce the incidence of hospital-acquired infections include judicious (medically necessary, not convenience) use of indwelling catheters, removing urinary catheters when no longer needed, and inserting all urinary catheters using strict sterile technique. Emptying the urinary drainage bag at 12-hour intervals, performing straight catheterization more than once per day, and catheter irrigation are not interventions that prevent CAUTI.

A client with heart failure who is taking furosemide and digoxin calls the nurse and complains of anorexia and nausea. The nurse would take which action? 1. Administer an antiemetic. 2. Hold the morning dose of furosemide. 3. Administer the daily dose of digoxin. 4. Check the result of the potassium level drawn 3 hours ago.

4. Check the result of the potassium level drawn 3 hours ago. Rationale: Anorexia and nausea are two of the common symptoms associated with digoxin toxicity, which is compounded by hypokalemia. The nurse should first check the results of the potassium level. This would provide additional data to report to the health care provider, which is a key follow-up nursing action. The nurse would not hold the furosemide without a prescription to do so given the information provided. The nurse would withhold the digoxin and notify the registered nurse, who would contact the health care provider because digoxin toxicity is suspected. The nurse would not administer an antiemetic without further investigating the client's problem. The digoxin blood level should also be checked.

The nurse enters a client's room to check the client who began receiving a blood transfusion 45 minutes earlier. The client is flushed and dyspneic. The nurse listens to the client's lung sounds and notes the presence of crackles in the lung bases. The nurse determines that this client is most likely experiencing which complication of blood transfusion therapy? 1. Bacteremia 2. Hypovolemic shock 3. Transfusion reaction 4. Fluid (circulatory) overload

4. Fluid (circulatory) overload Rationale: With fluid (circulatory) overload, the client has the presence of crackles in the lungs in addition to dyspnea. Hypovolemic shock (restlessness, increased pulse, decreased blood pressure) is not likely to occur in a client receiving fluids. An allergic reaction, which is one type of blood transfusion reaction, would produce symptoms such as flushing, dyspnea, itching, and a generalized rash. With bacteremia, the client would have a fever, which is not part of the clinical picture presented.

The nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. The nurse places the infant in which position? 1. In a supine, side-lying position 2.Prone, with the head of the bed elevated 15 degrees 3.With the head at a 60-degree angle with the neck slightly flexed 4.With the head and chest at a 30-degree angle, with the neck slightly extended

4.With the head and chest at a 30-degree angle, with the neck slightly extended Rationale:The nurse should position the infant with the head and the chest at a 30- to 40-degree angle with the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. Options 1, 2, and 3 do not achieve these goals.

A mother of a child brings the child to a clinic and reports that the child has a fever and has developed a rash on the neck and trunk. Roseola is diagnosed, and the mother is concerned that her other children will contract the disease. Which instruction would the nurse reinforce to the mother to prevent the transmission of the disease? 1. "Disease transmission is unknown." 2. "The disease is transmitted through the urine and feces, so the other children should use a separate bathroom." 3. "The disease is transmitted through the respiratory tract, so the child should be isolated from the other children as much as possible." 4. "The disease is transmitted by contact with body fluids, so any items contaminated with body fluids need to discarded in a separate receptacle."

1. "Disease transmission is unknown." Rationale: The method of transmission of roseola is unknown. Options 2, 3, and 4 are not correct transmission routes of roseola.

The nurse is preparing to administer an enema to an adult client. Which interventions would the nurse plan to perform for this procedure? Select all that apply. 1. Apply disposable gloves. 2. Place the client in the right Sims' position. 3. Lubricate the enema tube and insert it approximately 4 inches. 4. Clamp the tubing if the client expresses discomfort during the procedure. 5. Hang the enema solution container 24 inches above the client's anus. 6. Ensure that the temperature of the solution is between 100°F (37.8°C) and 105°F (40.5°C).

1. Apply disposable gloves. 3. Lubricate the enema tube and insert it approximately 4 inches. 4. Clamp the tubing if the client expresses discomfort during the procedure. 6. Ensure that the temperature of the solution is between 100°F (37.8°C) and 105°F (40.5°C).

The nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which assessment finding most likely indicates a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of a tearing sensation 4. Complaints of lower abdominal discomfort

1. Changes in vital signs Rationale:Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with vulvar hematoma. Options 3 and 4 are inaccurate for a client who is anesthetized. Heavy bruising may be noted, but vital sign changes are most likely to indicate the presence of a hematoma.

The nurse is reinforcing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further teaching? 1. "I should keep an extra battery available at all times." 2. "I should not wear the hearing aid during an ear infection." 3. "I should turn the hearing aid off after removing it from my ear." 4. "I should wash the ear mold frequently with mild soap and water."

3. "I should turn the hearing aid off after removing it from my ear." Rationale:Nurses should have a basic knowledge of the care of a hearing aid to assist the client in its use. The client should be instructed to turn the hearing aid off before removing it from the ear to prevent squealing feedback. The hearing aid should be turned off when not in use, and the client should keep an extra battery available at all times. The client should wash the ear mold frequently with mild soap and water using a pipe cleaner to cleanse the cannula. The client should not wear the hearing aid during an ear infection.

The nurse determines a child is in the "preoperational" phase of Piaget's cognitive developmental theory when the child makes which statement? 1. "I know all of my multiplication tables by memory". 2. "The ball is gone," when a ball disappears out of sight. 3. "I'll use a map to help me find my way in a new town". 4. "The moon follows me, and goes to bed when I go to bed".

4. "The moon follows me, and goes to bed when I go to bed". Rationale:In the preoperational stage, the child is demonstrating egocentric thinking by believing the moon's actions revolve around the child. In the sensorimotor stage, a child does not believe an object exists if it is not in sight. A child in the concrete operations stage is able to classify, order, and sort facts, such as the multiplication tables. A child in the formal operations stage is able to solve more complex problems, such as using a map to determine location and directions.

The nurse is completing a medication reconciliation form for a client. Which is a primary purpose of this process? 1. To make sure the pharmacy knows what medications the client was taking at home 2.To make sure the client is well informed about why each medication needs to be taken 3.To make sure medical insurance companies have a complete list of the client's medications 4.To compare a client's medication prescriptions to all of the medications the client is taking at home

4.To compare a client's medication prescriptions to all of the medications the client is taking at home Rationale: Medication reconciliation is a process of comparing a client's medication prescriptions to all of the medications the client is taking. It helps avoid medication errors related to omissions, duplications, dosing errors, and drug interactions and is done at every transition of care when new medications are prescribed or rewritten. This process does not directly affect the pharmacy or insurance company. It is not related to teaching clients about their medications, although nurses still must inform clients about what medications they are taking and why they need to take them.

A manic client is placed in a seclusion room after an outburst of violent behavior, including physical assault on another client. As the client is secluded, which action would the nurse perform? 1.Inform the client that she is being secluded to help regain control of herself. 2.Remain silent because verbal interaction would be too stimulating for the client. 3.Tell the client that she will be allowed to rejoin the others when she can behave. 4.Determine whether the client understands the reason that the seclusion is necessary.

1.Inform the client that she is being secluded to help regain control of herself. Rationale: The client needs to be removed to a nonstimulating environment because of the client's behavior. Remaining silent, telling the client that she will be allowed to rejoin the others when she can behave, and determining whether the client understands the reason that the seclusion is necessary are nontherapeutic. Additionally, remaining silent implies punishment. It is best to directly inform the client of the purpose of the seclusion.

A nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse must assign 4 clients and has a licensed practical nurse (LPN) and 3 assistive personnel (AP) on a nursing team. To which client would the nurse assign the LPN? 1. A client requiring frequent ambulation 2. The client requiring a 24-hour urine collection 3. An older adult client requiring assistance with a bed bath 4. A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours

4. A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours Rationale: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Collecting a 24-hour urine, assisting with frequent ambulation, and giving a bed bath can be done by an AP. The LPN is skilled in wound irrigations and dressing changes, and this client should be assigned to this staff member.

The nurse is preparing to teach a pregnant client about the warning signs in pregnancy and prepares a list of the warning signs that indicate the need to notify the primary health care provider. Which warning signs would the nurse place on the list? Select all that apply. 1. Facial edema 2. Rapid weight gain 3. Visual disturbances 4. Generalized edema 5. Nausea on arising in the morning 6. The presence of irregular painless contractions

1. Facial edema 2. Rapid weight gain 3. Visual disturbances 4. Generalized edema Rationale: Facial or generalized edema, rapid weight gain, and visual disturbances are warning signs in pregnancy. Nausea upon arising is a common discomfort of pregnancy. Braxton Hicks contractions are the normal, regular, painless contractions of the uterus that may occur throughout the pregnancy. Additional warning signs in pregnancy include vaginal bleeding, premature rupture of the membranes, preterm uterine contractions that are normal and regular, change in or absence of fetal activity, severe headache, epigastric pain, persistent vomiting, abdominal pain, and signs of infection.

The nurse is encouraging a client to participate in recreational therapy. The client states that it is best to stay alone and not bother others. Which statement is an appropriate response from the nurse? 1."Can you tell me more about your feelings?" 2."I understand you are feeling negative, tell me more." 3."Your primary health care provider (PHCP) has prescribed this so please go." 4."I can't make you go, but you need to think of getting better and this is one way."

1."Can you tell me more about your feelings?" Rationale: Clients who are possibly depressed may refuse to participate in prescribed treatments including recreational therapy. A neutral statement that focuses on the client is the best response to the client. This statement offers an opportunity for the client to detail concerns, and there is no judgment on the part of the nurse. Option 2 encourages the client to verbalize but is judgmental. Option 3 cuts off the communication with falling back on prescribed activities. Option 4 involves giving advice and cuts off communication.

A client who was hospitalized for depression is being prepared by the nurse for discharge. In evaluating the coping strategies learned during hospitalization, the nurse should recognize which statement by the client is an indication that further teaching is needed? 1."I know that I won't become depressed again." 2"I know that I can't be all things to all people." 3."I need to take my medications just as prescribed." 4."I have learned ways to deal with the stresses in my life."

1."I know that I won't become depressed again." Rationale: Further teaching is needed when the client says, "I know that I won't become depressed again." Depression may be a recurring illness for some people. The client needs to understand the symptoms and recognize when or if treatment needs to begin again. The other statements identify that the client has learned some coping skills, such as setting limits and taking medications.

A child seen in the clinic is found to have rubeola (measles), and the mother asks the nurse how to care for the child. Which instruction would the nurse provide to the mother? 1. Keep the child in a room with dim lights. 2. Give the child warm baths to help prevent itching. 3. Allow the child to play outdoors because sunlight will help the rash. 4. Take the child's temperature every 4 hours and administer 1 baby aspirin for fever.

1. Keep the child in a room with dim lights. Rationale:A nursing consideration in rubeola is eye care. The child usually has photophobia, so the nurse should suggest that the parent keep the child out of brightly lit areas. Children with viral infections are not to be given aspirin because of the risk of Reye's syndrome. Warm baths and the sun will aggravate itching. In addition, the child needs to rest.

The nurse reinforces instructions to a client at risk for thrombophlebitis regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information? 1."I need to avoid pregnancy by taking oral contraceptives." 2."I should avoid sitting in one position for long periods of time." 3."I can finally stop wearing these support stockings that you gave me." 4."I will be sure to maintain my fluid intake to at least four glasses daily."

2."I should avoid sitting in one position for long periods of time." Rationale: Avoidance of sitting or standing for a prolonged period of time is one of the measures for the prevention of venous stasis and thrombophlebitis. Taking oral contraceptives causes hypercoagulability that could result in thrombophlebitis. Support stockings are used to promote venous return, to maintain normal coagulability, and to prevent injury to the endothelial wall. Adequate hydration is maintained to prevent hypercoagulability, and four glasses daily are an inadequate amount of fluid.

The nurse is caring for a client with depression in the mental health unit who is refusing to take the prescribed oral antidepressant. Which are the nurse's best actions in response to this client's medication refusal? Select all that apply. 1. Document the refusal of medication. 2. Notify the registered nurse. 3. Ask the client why he is refusing the medication. 4. Crush the pill and sprinkle it on the client's meal. 5. Administer the medication as an intramuscular injection.

1. Document the refusal of medication. 2. Notify the registered nurse. 3. Ask the client why he is refusing the medication. Rationale: The nurse's best action to a client's refusal to take a prescribed oral antidepressant include notifying the registered nurse, documenting the client's refusal, and discussing the reasons why the client is refusing the medication. It would be inappropriate for the nurse to administer the medication as an injection or crush and sprinkle it over the client's food because the client has the right to refuse medication.

The nurse is reinforcing home care instructions to a client following a gastric resection. The nurse would include which instruction to the client? 1. Avoid iron supplementation. 2. Eat a diet high in vitamin B12. 3. Take actions to prevent dumping syndrome. 4. Self-monitor for signs and symptoms of lower gastrointestinal hemorrhage.

3. Take actions to prevent dumping syndrome. Rationale: Dumping syndrome can occur in clients after gastric surgery and may occur as an early or late complication. Upper rather than lower gastrointestinal hemorrhage may also occur. A diet high in vitamin B12 will not prevent pernicious anemia because the client lacks intrinsic factor needed for absorption of the vitamin. Instead the client requires injections to supplement this vitamin. Iron supplements are necessary to help the absorption of parenteral vitamin B12.

When assisting in the identification process required before a blood transfusion, which action will the nurse take when it is noted that all of the necessary information is correct, except for the client's name? 1. Call the blood bank about the discrepancy. 2. Relabel the transfusion with the correct name. 3. Hang the unit of blood because the blood information matches. 4. Notify the primary health care provider that the client will not receive any blood.

1. Call the blood bank about the discrepancy. Rationale: The nurse would notify the registered nurse of the discrepancy. Then should call the blood bank and notify the personnel about the discrepancy per the registered nurse's guidance. The unit should not be hung, and information on the requisition or bag should not be altered in any way. The nurse assigned to the client may choose to call the primary health care provider, but the nature of that communication would be to report a delay in the transfusion because of the problem, not to report that there would be no transfusion.

The nurse has provided instructions to a client scheduled for a mammography regarding the procedure. Which statement by the client indicates an understanding of the procedure? 1. "I cannot eat on the day of the test." 2. "The test takes about 1 hour and is painless." 3. "I will need to wear a sports bra for the procedure." 4. "I should not wear deodorant on the day of the test."

4. "I should not wear deodorant on the day of the test." Rationale: Mammography takes about 15 to 30 minutes to complete. Some discomfort may be experienced because of the breast compression required to obtain a clear image. Maintaining a nothing-by-mouth (NPO) status before the procedure is not necessary. A sports bra is not required; the test is performed without clothing. Deodorants, powders, and lotions should not be worn on the day of the test because it will affect the testing process and affect the imaging of the breasts.

A client in the prenatal clinic presents with a blood pressure reading of 140/90 mm Hg, which is an elevation from last month's reading of 114/66 mm Hg. Which additional sign or symptom suggests to the nurse that the client has mild preeclampsia? 1.Headaches 2.Generalized edema 3.Weight gain of 10 pounds 4.Trace amount of protein

4.Trace amount of protein Rationale: Preeclampsia is considered mild when the diastolic blood pressure does not exceed 100 mm Hg and proteinuria is no more than 500 mg/day (trace to 1+). Symptoms such as headache, visual disturbances, or abdominal pain are typically absent with mild preeclampsia. Therefore, the only sign of mild preeclampsia from the options given is a trace amount of protein. A rapid weight gain and generalized edema may occur. Headaches are present in severe preeclampsia.

The nurse is assisting in developing a postoperative plan of care for a client following a right mastectomy. Which interventions will be included in the plan of care? Select all that apply. 1. Place the right arm on a pillow. 2. Monitor the right arm for edema. 3. Check the incision for approximation. 4. Place a warm compress on the affected arm. 5. Monitor and measure drainage in the Jackson-Pratt drain. 6.Place a notation: "No intravenous (IVs), blood draws, or blood pressure readings in right arm."

1, 2, 3, 5, 6 Rationale: Following mastectomy, the arm should be elevated above the level of the heart. Specific arm exercises should be encouraged. No blood pressure readings, injections, IV lines, or blood draws should be performed on the affected arm, and a sign above the bed will alert all health care personnel. The nurse would also assess the incision for approximation (incision is pulled together or intact) during dressing changes and monitor and measure drainage in the Jackson-Pratt drain. Warm compresses are not used in the postoperative period because this will promote edema in the arm.

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition? 1. An infectious disease of the central nervous system 2. An inflammation of the brain as a result of a viral illness 3. A congenital condition that results in moderate to severe retardation 4. A chronic disability characterized by impaired muscle movement and posture

4. A chronic disability characterized by impaired muscle movement and posture Rationale:Cerebral palsy is a chronic disability characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply. 1. Scarring is less severe in a child than in an adult. 2. A delay in growth may occur after a burn injury. 3. An immature immune system presents an increased risk of infection for infants and young children. 4. Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total body surface area. 5. The lower proportion of body fluid to body mass in a child increases the risk of cardiovascular problems. 6. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

2,3,6 Rationale: Pediatric considerations in the care of a burn victim include the following: Scarring is more severe in a child than in an adult. A delay in growth may occur after a burn injury. An immature immune system presents an increased risk of infection for infants and young children. The higher proportion of body fluid to body mass in a child increases the risk of cardiovascular problems. Burns involving more than 10% of total body surface area require some form of fluid resuscitation. Infants and young children are at increased risk for protein and calorie deficiencies because they have smaller muscle mass and less body fat than adults.

Thrombolytic therapy was administered to a client following an acute inferior myocardial infarction. The nurse giving discharge instructions to the client evaluates a need for further teaching when the client makes which statement? 1. "I will avoid venipunctures if possible." 2. "I will treat fever with acetaminophen." 3. "I will report temperature over 104° F (40° C)." 4. "I will apply pressure for 10 minutes for minor bleeding."

4. "I will apply pressure for 10 minutes for minor bleeding." Rationale:Thrombolytic medication causes lysis of blood clots. Client teaching includes reporting a temperature over 104° F (40° C), which can be an indicator of internal bleeding. Other instructions include avoiding venous or arterial punctures and rectal temperatures. Fevers can be treated with acetaminophen or aspirin. Pressure should be applied for 30 seconds to a minor bleeding site. Inform the primary health care provider if this does not attain hemostasis.

During an initial prenatal visit, the nurse notes that the primary health care provider documents that the client is experiencing iron deficiency anemia. Which client data support this finding? Select all that apply. 1. Reports of fatigue 2. Pink mucous membranes 3. Increased vaginal secretions 4. Hemoglobin level of 10.2 g/dL 5. Increased frequency of voiding

1 , 2 Rationale:Anemia is a common problem in pregnancy and is characterized by a hemoglobin level of less than between 10.5 and 11 g/dL. Iron deficiency anemia and folic acid deficiency are two common types of anemia that present a concern during pregnancy. Although fatigue may be seen in some pregnant women, its presence may reflect complications caused by decreased oxygen supply to vital organs, thus supporting the laboratory findings. The other options are normal observations during pregnancy.

A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which diagnosis? 1.Psychosis 2.Repression 3. Conversion disorder 4. Dissociative disorder

3. Conversion disorder Rationale:A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. It is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person's capacity to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness.

The nurse, a Cub Scout leader, is preparing a group of Cub Scouts for an overnight camping trip and instructs them about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further teaching? 1."I need to bring a hat to wear during the trip." 2."I should wear long-sleeved tops and long pants." 3."I should not use insect repellent because it will attract the ticks." 4."I need to wear closed shoes and socks that can be pulled up over my pants."

3."I should not use insect repellent because it will attract the ticks. Rationale: In the prevention of Lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, one should avoid heavily wooded areas or areas with thick underbrush. Socks can be pulled up and over the pant legs to prevent ticks from entering under clothing.

The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement? 1. "My medications won't make me anxious." 2."I'll go to a support group and talk so that I won't hurt anyone." 3. "I won't get anxious or hear things if I get enough sleep and eat well." 4. "I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone."

4. "I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone." Rationale: There may be an increased risk for impulsive and/or aggressive behavior if a client is receiving command hallucinations to harm self or others. Talking about the auditory hallucinations can interfere with the subvocal muscular activity associated with a hallucination. Option 4 is a specific agreement to seek help and evidences self-responsible commitment and control over his or her own behavior.

The nurse educates a mother about her newborn's diagnosis of fetal alcohol syndrome (FAS). Which statement by the mother provides the nurse with assurance that the mother understands this syndrome? 1. "Cognitive impairment is unlikely to happen." 2. "Withdrawal symptoms will occur in about 3 days." 3. "The reason my baby is so large is because of this metabolic problem." 4. "Withdrawal symptoms include tremors, abnormal reflexes, and uncontrollable crying."

4. "Withdrawal symptoms include tremors, abnormal reflexes, and uncontrollable crying." Rationale: The long-term prognosis for newborns with FAS is poor. Signs/symptoms of withdrawal include tremors, abnormal reflexes, sleeplessness, seizures, abdominal distention, hyperactivity, and uncontrollable crying. Central nervous system (CNS) disorders are the most common problems associated with FAS. As a result of the CNS disorders, children born with FAS are often hyperactive and have a high incidence of speech and language disorders. Symptoms of withdrawal often occur within 6 to 12 hours after life or at the latest, within the first 3 days of life. Most newborns with FAS are mildly to severely cognitively impaired. The newborn is usually growth deficient at birth.

A client is admitted to the emergency department with a diagnosis of drug-induced anxiety related to over ingestion of his prescribed antipsychotic medication. Which important piece of information would the nurse obtain initially? 1.Name and phone number of the nearest relative 2.Name of the ingested medication and the amount ingested 3.Reason for the suicide attempt and whether he will attempt it again 4.Length of time on the medication and symptom control information

2.Name of the ingested medication and the amount ingested Rationale: The name and the amount of medication ingested are of utmost importance in treating this potentially life-threatening situation. The relatives and the reason for the suicide attempt are not the most important initial data. The length of time on the medication and symptom control are also not priorities in this situation. In an emergency, lifesaving facts are obtained first.