NUR 497 EAQ #5 Medical Surgical & Pharm

a client who takes rifampin tells the nurse 'my urine looks orange.' Which action would the nurse take?

explain that this is expected

warm and firm without being punitive

which consistent approach would the nurse use for a client with an antisocial personality disorder?

assuring the children that their privacy will be respected

Which is the MOST appropriate approach for the school nurse to take regarding children who are to be given meds while in school?

The good boy-good girl orientation

At which stage of Kohlberg's theory does an individual want to fulfill the expectations of one's immediate group?

Which amount is the normal value of a client's inspiratory reserve volume? A. 0.5 L B. 1.0 L C. 1.5 L D. 3.0 L

D. 3.0 L The normal value of inspiratory reserve volume is 3.0 L. The normal value of tidal volume is 0.5 L. The normal value of expiratory reserve volume is 1.0 L. The normal value of residual volume is 1.5 L.

a client with cancer experiences severe nausea and vomiting from chemotherapy. The client wants to know if it is true that smoking marijuana will help. How will the nurse respond?

"There are some tetrahydrocanacinol (THC)-based medications that contain marijuana control chemotherapy-induced nausea and vomiting in some people."

A Spanish-speaking client is being cared for by English-speaking nursing staff. Which communication technique would be correct for the nurse to use when discussing health care decisions with the client? A. Contact an interpreter provided by the hospital. B. Contact the client's family member to translate for the client. C. Communicate with the client using Spanish phrases the nurse learned in a college course. D. Communicate with the client with the use of a hospital-approved Spanish dictionary.

A. Contact an interpreter provided by the hospital.

During a home visit, the nurse finds that a healthy older adult person is actively practicing laughing therapy to maintain good health without pressure or insistence from family members. Which inference about the client would the nurse make from these findings? A. Not motivated B. Intrinsically motivated C. Extrinsically motivated with self-determination D. Extrinsically motivated without self-determination

B. Intrinsically motivated

Which nursing action would be included in the plan of care for a child with acute poststreptococcal glomerulonephritis? A. Encouraging fluids B. Monitoring for seizures C. Measuring abdominal girth D. Checking for pupillary reactions

B. Monitoring for seizures Rationale Cerebral edema from hypertension or cerebral ischemia may occur, which may result in seizures. Increasing fluid intake may lead to an increase in blood pressure and edema. Measuring abdominal girth is appropriate for children with nephrotic syndrome, in which the child has hypoalbuminemia that causes fluid to shift from plasma to the abdominal cavity. Glomerulonephritis will not alter pupillary reactions.

'But you don't understand' is a common statement associated with adolescents. Which is the nurse's best response to this statement? A. I don't understand what you mean. B. I do understand; I was a teenager once too. C. It would be helpful to understand; let's talk' D. It's you who should try to understand others.

C. It would be helpful to understand; let's talk'

An infant returns to the pediatric unit with an intravenous (IV) infusion in progress after corrective surgery. Which is the priority nursing action? A. Applying adequate restraints B. Administering a mild sedative C. Removing the nasogastric tube D. Assessing the IV site for infiltration

D. Assessing the IV site for infiltration

Hypokalaemia

When a client's telemetry monitor shows flattening T waves and peaked P waves, which electrolyte disorder would the nurse consider based on these ECG changes?

Acute confusion

which clinical manifestation indicates a need for the nurse to contact the health care provider to increase the IV fluid infusion for an older client with an infection?

Polyuria

when obtaining a health history from a client recently diagnosed with type 1 diabetes, the nurse expects the client to report which clinical manifestation?

Check on the client frequently

when planning for a client's care during the detoxification phase of early alcohol withdrawal, which action would the nurse take?

a ready source of glucose should be available

when teaching an adolescent with type 1 diabetes about dietary management, which instruction would the nurse include?

thrombosis or formation of blood clots in deep veins

which adverse effect can be seen in a female client with gonadotropin deficiency and who is undergoing hormone replacement therapy?

having suicidal ideation, exhibiting tearfulness, avoiding previously enjoyed activities and relationships

which characteristics are commonly associated with adolescent depression? quizlet

Why would organizations promote transparency in health care? A. Creates effective insurance policies B. Helps determine whether medications are being diverted C. Facilitates recruitment of competent team members D. Allows continuous feedback for improving client outcomes

D. Allows continuous feedback for improving client outcomes

What would the presence of ketones in the urine of a client indicate? A. Cystitis B. Heart failure C. Urinary calculi D. Fat metabolism

D. Fat metabolism

A client is admitted to the hospital with Laënnec cirrhosis and chronic pancreatitis. Bile salts (bile acid factor) are prescribed, and the client asks why they are needed. How would the nurse respond? A. 'They stimulate prothrombin production.' B. 'They aid in the absorption of fat-soluble vitamins! C. They promote bilirubin secretion in the urine' D. 'They help the common bile duct contract stronger.'

B. 'They aid in the absorption of fat-soluble vitamins!

A 17-year-old mother is to sign the consent for her son's myringotomy. Which statement would be most appropriate? A. This procedure may not help. B. Tell me what you know about this procedure. C. Your son will need to have this done again when he's older. D. One of your parents must also sign this because you're too young.

B. Tell me what you know about this procedure.

Which of these programs is least likely to focus on medication delivery process modification? A. Evaluation research B. Quality improvement C. Experimental research D. Performance improvement

C. Experimental research

Which activity will prepare the client who has a new above-the-knee amputation for crutch walking? A. Lifting weights B. Turning in bed C. Caring for the residual limb D. Performing phantom limb exercises

A. Lifting weights

For the client taking clopidogrel, the nurse will monitor for which adverse effect? A. Nausea B. Epistaxis C. Chest pain D. Elevated temperature

B. Epistaxis

Which interventions would the nurse include in the plan of care for a client after total hip replacement? Select all that apply. One, some, or all responses may be correct. A. Maintain the affected hip in the adduction position when moving the client. B. Pain control should include regularly scheduled analgesics and as needed medications. C. The client should sit in a chair at the height to encourage flexion of the hip joint. D. Frequent neurovascular assessment should be done and compared with the unaffected side. E. When turning, the client should be log rolled to prevent the leg from falling forward or backward.

B. Pain control should include regularly scheduled analgesics and as needed medications. D. Frequent neurovascular assessment should be done and compared with the unaffected side. E. When turning, the client should be log rolled to prevent the leg from falling forward or backward.

Which intervention would the nurse use to prevent injury to others when caring for a client with intermittent explosive disorder? Select all that apply. One, some, or all responses may be correct. A. Administer antipsychotics. B. Set limits and expectations. C. Use seclusion and time out. D. Provide structure and boundaries. E. Ignore attention-seeking behaviors.

B. Set limits and expectations. D. Provide structure and boundaries. E. Ignore attention-seeking behaviors. Rationale When caring for clients with intermittent explosive disorder, interventions to promote safety and prevent injury to others include setting limits and expectations, providing structure and boundaries, and ignoring attention-seeking behavior. Antipsychotics and seclusion are used only as last-resort measures.

A client who is receiving radiation therapy for bone cancer lives alone and works full time. Which client action would the nurse encourage? A. Begin to perform regularly scheduled aerobic activity daily. B. Take a leave of absence from work when receiving therapy. C. Include rest periods during the day while receiving radiation. D. Continue the activities usually performed before becoming ill.

C. Include rest periods during the day while receiving radiation. Rationale Radiation is fatiguing; therefore, rest periods will combat fatigue. Rest ultimately will promote performance of activities of daily living and independence. Increasing activity at this time is not advised because fatigue is a side effect of radiation. Maintaining independence is important, and a leave of absence may not be emotionally or financially feasible. Although normalizing activities is desirable, this may be unrealistic when the side effects of radiation therapy are considered.

Let's ask your mother to bring in a hat for you to wear until your hair grows back

A 5 yo girl is undergoing a course of chemotherapy. ONe day the nurse sees the child crying. The child tells the nurse ' all my hair is gone, and everyone stares at me.' Which is the best response by the nurse?

explain the incision shouldn't be immersed in water until it has healed

the nurse provides discharge teaching to a client who had a total hip replacement. The client states that the plan is to go swimming at the community pool the day after discharge. Which action would the nurse take in response to the client's comment?

sharing client's data with family members

which action by the student nurse may inhibit clients from disclosing personal information?

miconazole and clotrimazole

which over the counter meds are used to treat vulvovaginal candidiasis?

I have to blow out as fast and hard into the machine as I can

which statement shows that the newly diagnosed asthma patient understands how to use peak expiratory flow meter (PEFM)?

culture shock

A child who has newly arrived from Latin America attend a nursery school where everyone speaks English. The mother is concerned the child is no longer outgoing and has become passive in the class. Which is the probable reason for the child's behavior?

A client who had an above-the-knee amputation (AKA) has a pressure dressing on the end of the residual limb. The client asks, 'Why do I have to have this tight dressing on my leg?' Which response would the nurse provide? A. 'It decreases the swelling of the area' B. "It decreases the formation of scar tissue. C. "It prevents the formation of blood clots!' D. "It reduces phantom limb pain.

A. 'It decreases the swelling of the area' Rationale The pressure dressing prevents fluid from shifting into the interstitial compartment; this promotes shrinkage of the residual limb to facilitate use of a prosthesis. Bandaging will not affect the formation of a scar, prevent blood clots, or reduce phantom limb pain.

Which statement by a new mother observing her preterm infant in the neonatal intensive care nursery indicates that she has not yet begun the bonding process? A. 'It's such a tiny baby' B. 'Do you think he'll make it?' C. "Why does he need to be in an incubator?' D. "My baby looks so much like my husband'

A. 'It's such a tiny baby' Rationale By failing to acknowledge the infant as a person, the client indicates that she has not released her fantasy baby and accepted the real baby. Acknowledging the infant by using the word 'he' denotes a relationship. Saying that the baby looks like her husband indicates that the mother has incorporated the infant into the family.

At which interval are humidified oxygen systems replaced to prevent infection? A. 1 day B. 3 days C. 5 days D. 7 days

A. 1 day

Which statements regarding acne are correct? Select all that apply. One, some, or all responses may be correct. A. Acne is a hormonal disease. B. Acne may be caused by stress. C. Family history could be a reason for acne. D. Propionibacterium aces causes acne. E. Acne is commonly found on the face, chest, upper back, and neck.

B. Acne may be caused by stress. C. Family history could be a reason for acne. D. Propionibacterium aces causes acne. E. Acne is commonly found on the face, chest, upper back, and neck.

An adolescent was recently diagnosed with type 2 diabetes mellitus. Which information will the nurse include when providing education to the family? A. Your teen will need insulin injections for the rest of her life. B. The most important interventions are good nutrition and portion control.' C. 'This is a condition where the body produces antibodies against its own cells. D. 'This condition causes weight loss and increased appetite, thirst, and urination.

B. The most important interventions are good nutrition and portion control.' Rationale Most children with type 2 diabetes are overweight or at risk for becoming overweight. With nutritional intervention to promote proper weight, the condition may often be managed with diet and exercise alone. A lifelong insulin regimen, the production of antibodies against the child's own cells, and weight loss with increased appetite, thirst, and urination are all typical of type 1 diabetes.

The parents of a 2-year-old child are watching the nurse administer the Denver Il Developmental Screening Test to their child. They ask, Why did you make our child draw on paper? We don't let our child draw at home. Which is the best response by the nurse? A. I should have asked you about drawing first' B. These drawings help us determine your child's intelligence. C. "It lets us test the child's ability to perform tasks requiring the hands. D. "I don't understand why drawing is forbidden in your home.

C. "It lets us test the child's ability to perform tasks requiring the hands.

1- Solitary 2- Parallel 3- Associative 4- Cooperative

Children's pattern of play change as they grow from infancy through school age. Rank the order of appearance of each type of play, starting with infant play.

The nurse is preparing a child who has undergone a myringotomy for discharge. Which would the parents be taught about their child's care at home? A. Insert earplugs whenever a bath is given. B. Keep cotton in the ears until drainage subsides. C. Keep the child out of school until the ears are healed. D. Clean the child's ears with cotton-tipped swabs after each bath.

A. Insert earplugs whenever a bath is given. Rationale Water in the ears after myringotomy supports the growth of pathogens and should be avoided. The ears should be kept open to the air and allowed to drain naturally. There is no reason to keep the child isolated. Cleaning the ears with cotton swabs is contraindicated because it may result in trauma.

How are profits used in a for-profit health care organization? A. Profits are paid out to shareholders. B. Profits are used to buy new equipment. C. Profits are used to build additional facilities. D. Profits are invested in improving health care services.

A. Profits are paid out to shareholders. Rationale Health care organizations can be classified as for-profit and not-for-profit based on how the profits are distributed. In a for-profit organization, the profits are generated for the shareholders. In a not-for-profit organization, the profits are used to buy new equipment, build additional facilities, and improve health care services.

Which is the etiological factor of nephrogenic diabetes insipidus (DI)? A. Meningitis B. Lithium therapy C. Graves disease D. Sulfonamide therapy

B. Lithium therapy Rationale Lithium therapy is the etiological factor of nephrogenic DI. Central nervous system infections such as meningitis are etiological factors of central DI. Goiter, an enlarged thyroid gland, is commonly seen in clients with Graves disease. Sulfonamide is a goitrogen that can cause goiter.

A 2-year-old toddler has hearing loss caused by recurrent otitis media. Which treatment would the nurse anticipate that the practitioner will recommend? A. Eardrops B. Myringotomy C. Mastoidectongy D. Steroid therapy

B. Myringotomy

After a cerebrovascular accident (CVA, also known as "brain attack), a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. The nurse would conclude the CVA affected which lobe of the brain? A. Frontal B. Parietal C. Occipital D. Temporal

B. Parietal

The home health nurse provides education for a client with cancer of the tongue who will begin gastrostomy feedings at home. Which client statement indicates effective teaching? A. 'Before I start the procedure, I will don sterile gloves. B. 'Before I start the procedure, I will obtain my body weight.' C. 'Before I start the procedure, I will measure the residual volume.' D. 'Before I start the procedure, I will instill 1 oz [30 mL] of a carbonated liquid.'

C. 'Before I start the procedure, I will measure the residual volume.'

A client returns from the postanesthesia care unit after a rotator cuff repair. Which action would the nurse take? A. Monitor for a pulse deficit. B. Obtain hourly blood pressure readings. C. Assess for capillary refill in the nail beds. D. Put the shoulder through range-of-motion exercises.

C. Assess for capillary refill in the nail beds.

A client sustains a back injury after falling 20 feet (6 m). In which position would the nurse place the client? A. Lateral position with a pillow between the knees B. Any position that reduces pain and is comfortable C. Supine position while not allowing the spine to flex D. Sitting position with a pillow placed in the small of the back

C. Supine position while not allowing the spine to flex

anorexia nervosa

the nurse records the client's weight and body mass index (BMI) at a healthy range, but the client states, 'I wish I were as thin as my coworkers.' Which culturally bound condition is the client at risk or?

Which is the maximum recommended length for enema tube insertion in an adolescent? Record your answer using a whole number.

10 cm

Which action would the nurse take for a newly admitted client with schizophrenia who refuses to remove dirty clothing? A. Allow the client to undress when ready to help maintain identity. B. Provide two outfits and help the client decide which one to wear. C. Explain that clean clothes will look more attractive and increase self-esteem. D. Get assistance to remove the clothing to meet the client's basic hygiene needs.

A. Allow the client to undress when ready to help maintain identity. Rationale The nurse would allow the client to undress when ready to help maintain identity. Any approach other than allowing the client to undress when ready will probably be seen as threatening, increase anxiety, and result in a physical confrontation. Providing two outfits and helping the client make a simple decision will increase anxiety, not foster decision-making. Explaining that clean clothes will look more attractive and increase self-esteem will increase anxiety, not increase self-esteem. Getting assistance and removing the clothing to meet the client's basic hygiene needs will increase the client's anxiety and will probably result in a physical confrontation.

An 8-year-old child has experienced the death of a sister. The child begins to ask many questions about what happens to the body after death. The parents wonder if this is abnormal behavior picked up from playing video games. Which is the best response by the nurse? A. "Playing video games can cause morbid behaviors. B. "Children handle the event of death more realistically than adults do.! C. 'School-aged children are inquisitive and ask a lot of questions about death.' D. "'Giggling, attracting attention, and playing are the usual ways of dealing with death.'

C. 'School-aged children are inquisitive and ask a lot of questions about death.'

Which is an example of private indemnity health insurance? A. Medicare B. Medicaid C. Blue Cross Blue Shield Association D. State Children's Health Insurance Program

C. Blue Cross Blue Shield Association

A 50-year-old client has difficulty communicating because of expressive aphasia after a cerebrovascular accident (CVA, also known as a 'brain attack'). When the nurse inquired about the client's feelings, the spouse responded. Which communication strategy would the nurse use to address this behavior? A. Ask the spouse how to know the client's feelings. B. Instruct the spouse to let the client answer. C. When the spouse leaves, return to speak with the client. D. Acknowledge the spouse, but look at the client for a response.

D. Acknowledge the spouse, but look at the client for a response.

Which characteristic of adolescence is exemplified by risk-taking behavior without fear of consequences? A. Animism B. Personal fable C. Imaginary audience D. Sense of invulnerability

D. Sense of invulnerability Rationale Adolescents have the belief that they are invulnerable. Feelings of invulnerability often lead to risk-taking behaviors, especially in early adolescence. A toddler experiences animism, in which he or she personifies objects and believes that they have feelings. The personal fable is seen in adolescents; the adolescent thinks of him- or herself as the center of attention and believes that he or she is unique. Adolescents also feel that they have an imaginary audience, enthusiastically listening to or watching him or her.

Center for Medicare and Medicaid Services (CMS)

Which organization assists in establishing policies related to Medicare and Medicaid payment for meaningful use of electronic health records (EHRs)?

self =-help group

Which type of group is AA?

A 7-year-old child sustains a fractured femur in a bicycle accident. The admission x-ray films reveal evidence of fractures of other long bones in various stages of healing. Which would the nurse suspect as the cause of the fracture? A. Child abuse B. Vitamin D deficiency C. Osteogenesis imperfecta D. Inadequate calcium intake

A. Child abuse Rationale Injuries in various stages of healing are the classic sign of child abuse. Vitamin D deficiency, osteogenesis imperfecta, and inadequate calcium intake may all be investigated after child abuse has been ruled out.

The nurse is educating new parents about circumcision. Which structure of the penis would the nurse tell the parents is removed during circumcision? A. Glans B. Prepuce C. Epididymis D. Vas deferens

B. Prepuce Rationale Circumcision is a procedure that involves removal of the prepuce, a skin fold over the glans. The glans is the tip of the penis. The epididymis is the internal structure that promotes transportation of the sperm. The vas deferens carries the sperm from the epididymis to the ejaculatory duct.

After numerous diagnostic tests, a client with jaundice receives the diagnosis of pancreatic cancer. Which rational explains the cause of the client's jaundice? A. Necrosis of the parenchyma caused by the neoplasm B. Excessive serum bilirubin caused by red blood cell destruction C. Obstruction of the common bile duct by thè pancreatic neoplasm D. Impaired liver function, resulting in incomplete bilirubin metabolism

C. Obstruction of the common bile duct by thè pancreatic neoplasm Rationale The common bile duct passes through the head of the pancreas; the neoplasm often constricts or obstructs the duct, causing jaundice. Necrosis of the pancreatic parenchyma caused by the neoplasm will not cause jaundice. Excessive serum bilirubin caused by red blood cell destruction is the prehepatic cause of jaundice. Impaired liver function, resulting in incomplete bilirubin metabolism, is a hepatic cause of jaundice.

Which medication is indicated for treating obsessive-compulsive disorder? A. Imipramine B. Lithium salts C. Amitriptyline D. Clomipramine

D. Clomipramine Rationale Clomipramine is a tricyclic antidepressant medication prescribed for treating obsessive- compulsive disorder. Childhood enuresis (bed wetting) necessitates the administration of imipramine. Lithium salt is prescribed to treat bipolar disorders: Dysthymias can be treated by the administration of antidepressant medications such as amitriptyline.

A child has a fractured arm and multiple old injuries. Child maltreatment is suspected. Which parental characteristic supports this suspicion? A. Inquiring about the time of discharge B. Displaying signs of guilt about the injuries C. Expressing concern about the child's health D. Offering inconsistent stories about the injuries

D. Offering inconsistent stories about the injuries

A client is brought to the emergency department triage by private car with bone protruding from the right lower leg. Which assessment would the triage nurse perform first? A. Vital signs B. Pain level C. Neurologic check D. Pedal pulses

D. Pedal pulses

An adolescent displaying low self-esteem complains of inflamed, red, and painful lesions on his forehead. Which condition is likely? A. Varicoceles B. Acne vulgaris C. Open comedones D. Closed comedones

B. Acne vulgaris

Which term is used to indicate an absence of menstruation? A. Gonorrhea B. Amenorrhea C. Dysmenorrhea D. Ectopic pregnancy

B. Amenorrhea

Prednisone is prescribed for a client with an exacerbation of colitis. Which explanation would the nurse provide for administering prednisone? A. The client will be protected from getting an infection. B. Symptoms associated with the colitis will decrease slowly over time. C. Although the medication causes anorexia, weight loss may not occur. D. Although the medication decreases intestinal inflammation, it will not cure the colitis.

D. Although the medication decreases intestinal inflammation, it will not cure the colitis.

selegiline Phenelzine, Isocarboxazid & Tranylcypromine are MAO-As.

Which antidepressant medication is a selective monoamine oxidase-B inhibitor (MAO-B)?

Chlamydia

Which is the most common cause of ophthalmia neonatorum in infants born to adolescent mothers?

monitoring radial pulses

Which is the priority nursing action for a child with severe burns on the arms and who is scheduled for therapeutic escharotomy?

preparing the budget, staffing, strategic planning of programs and services, employee evaluations and employee development

Which is the role of the nurse administrator in a health care setting?

knee joint

Which joint would be palpated by the nurse to identify genu valgum (knock-knees)?

ovaries and adrenal glands

Which part of the female reproductive system produces testosterone?

Carina

To which part of the respiratory system would the client's radiology report refer when identifying the angle of Louis?

Which foods would the nurse recommend for a client who is at risk for developing osteoporosis? Select all that apply. One, some, or all responses may be correct. A. Canned tuna B. Scrambled eggs C. Chicken breast D. Broiled beef steak E. Baked sweet potato

C. Chicken breast D. Broiled beef steak Rationale One serving of white meat chicken or one serving of beef contains more than 200 mg of calcium. A serving of canned tuna, two eggs, and sweet potatoes contain each less than 200 mg of calcium.

Which refers to the professional obligation of the nurse to assume responsibility for actions? A. Accountability B. Individuality C. Responsibility D. Bioethics

A. Accountability

The CAGE questionnaire is used to screen the client's use of which substance? A. Alcohol B. Barbiturates C. Hallucinogens D. Multiple drugs

A. Alcohol

Which diagnostic test is used for the direct visualization of ligaments, menisci, and articular surfaces of joints? A. Arthroscopy B. Muscle biopsy C. Ultrasonography D. Electromyography

A. Arthroscopy

When a client has a superficial tumor involving only 1 vocal cord, which surgery would the nurse anticipate? A. Cordectomy B. Tracheotomy C. Total laryngectomy D. Oropharyngeal resections

A. Cordectomy Rationale A cordectomy is a surgical procedure performed in dients with laryngeal cancer; this surgery involves the removal of a vocal cord.A tracheotomy is a surgical incision in the trachea for the purpose of establishing an airway. A total laryngectomy is a surgical procedure in which the Entire larynx, hyoid bone, strap muscles, and I or 2 tracheal rings are removed. A nodal neck dissection is also done in a total laryngectomy if the nodes are involved. An oropharyngeal resection is a surgical procedure performed to treat cancer of the oropharynx.

A client is admitted to the hospital for an adrenalectamy. Before the client's replacement steroid therapy is regulated fully, the nurse will monitor the client for which complication? A. Hypotension B. Hypokalemia C. Hypernatremia D. Hyperglycemia

A. Hypotension Rationale Because of instability of the vascular system and the lability of circulating adrenal hormones after an adrenalectomy, hypotension frequently occurs until the hormonal level is controlled by replacement therapy. Hyperglycemia is a sign of excessive adrenal hormones; after an adrenalectomy, adrenal hormones are not secreted. Sodium retention is a sign of hyperadrenalism; it does not occur after the adrenals are removed. Potassium excretion is a response to excessive adrenal hormones; after an adrenalectomy, adrenal hormones are decreased until replacement therapy is regulated.

Which information indicates a nursing student's accurate understanding about skeletal muscles? A. Skeletal muscle accounts for about half of a human being's body weight. B. Skeletal muscle contraction propels blood through the circulatory system. C. Skeletal muscle contraction is modulated by neuronal and hormonal influences. D. Skeletal muscle occurs in the walls of hollow structures such as airways and arteries.

A. Skeletal muscle accounts for about half of a human being's body weight. Rationale Skeletal muscle is a type of striated voluntary muscle that accounts for about half of a human being's body weight. Cardiac muscle contraction propels blood through the circulatory system. Skeletal muscle contraction requires neuronal stimulation only. Smooth muscle, not skeletal, is found in the walls of hollow structures such as airways and arteries.

Which action would be appropriate to implement when collecting a 24-hour urine test? A. Start the time of the test after discarding the first voiding. B. Discard the last voiding in the 24-hour period for the test. C. Insert a urinary retention catheter to promote the collection of urine. D. Strain the urine after each voiding before adding the urine to the container.

A. Start the time of the test after discarding the first voiding.

The nurse is assessing a client with a cast to the extremity. Which assessment finding would the nurse document in the electronic health record without any follow-up intervention required? A. Warmth B. Numbness C. Skin desquamation D. Generalized discomfort

A. Warmth

When making rounds, the nurse observes a client who is experiencing a seizure. Which action would the nurse take? A. Hyperextend the client's neck B. Move obstacles away from the client C. Restrain the client's body movements D. Attempt to place an airway in the client's mouth

B. Move obstacles away from the client Rationale Moving obstacles away from the client helps the client avoid hitting objects and thus prevents trauma during the tonic-clonic phase of the seizure. Hyperextending the neck is contraindicated; it may injure the client. Restraining the client's body movements is contraindicated; it may injure the client. Attempting to place an airway in the client's mouth during the tonic-clonic phase of the seizure can cause injury.

Which type of treatment is the Buck extension? A. Skeletal traction B. Cutaneous traction C. Halter transfixation D. Balanced suspension

B. Cutaneous traction Rationale Buck extension is an example of traction applied directly to the skin (cutaneous) by tape or by a foam boot. Skeletal traction is applied directly to the bony skeleton. There is no such intervention as halter transfixation. A halter (strap) may be used with cervical or pelvic traction. Balanced suspension traction keeps the affected extremity elevated off the bed.

Which statement accurately describes a health care policy as it relates to health care economics? A. It relates to maintaining standards of health care and achieving outcomes related to the goals of health care, B. It provides overarching goals and helps in setting priorities and values for the distribution of health resources, C. It governs the insurance industry and plays a very important role in the application of health care funding and reform. D. It involves the collaboration of health care workers and other resources required to perform all required client care activities.

B. It provides overarching goals and helps in setting priorities and values for the distribution of health resources, Rationale A health care policy provides overarching goals and helps in setting priorities and values for the distribution of health resources. Health care quality relates to issues surrounding standards of care and health care outcomes. Health care coordination involves the collaboration between health care professionals and other resources, which are required to deliver client care. Health care law is a governing factor in health care economics and plays a vital role in the application of health care funding and reform.

The nurse in the emergency department notes large welts and scars on the back of a toddler who has been admitted for an asthma attack. Which additional information must be included in the nurse's assessment? A. History of an injury B. Signs of child abuse C. Presence of food allergies D. Recent recovery from chickenpox

B. Signs of child abuse Rationale When unexplained injuries are found, further assessment is required because it is the nurse's legal responsibility to report suspected child abuse. History of an injury is just one aspect of the assessment for child abuse. The presence of food allergies is not related to scars on the child's back. Although chickenpox may leave scars, it does not cause welts.

Which diagnostic study is used to determine bone density? A. Diskogram B. Standard x-ray C. Computed tomography (CT) scan D. Magnetic resonance imaging (MRI)

B. Standard x-ray Rationale A standard x-ray is used to determine bone density. A diskogram is used to visualize abnormalities of the intervertebral disc. A CT scan is used to identify soft tissues, bony abnormalities, and various types of musculoskeletal trauma. MRI is used to diagnose avascular necrosis, disc disease, tumors, osteomyelitis, ligament tears, and cartilage tears.

Which is true about the effect of grief and loss in toddlers? A. They show resilience after a loss. B. They express a sense of change in sleeping. C. They understand the concepts of permanence. D. They get disrupted in developing an autonomous sense of self.

B. They express a sense of change in sleeping.

A client has been given a prescription for acetylsalicylic acid. The nurse recalls that this medication has which property? A. Sedative B. Hypnotic C. Analgesic D. Antibiotic

C. Analgesic

An adolescent who has had a leg amputated because of bone cancer begins to experience phantom limb sensations. How would the nurse respond to complaints of pain? A. By withholding the medication to help prevent addiction B. By stating that the limb has been removed and that the pain is psychological C. By acknowledging that the pain is real and administering medication to relieve it D. By explaining that the phantom limb sensation will subside within a few more days

C. By acknowledging that the pain is real and administering medication to relieve it

Which instruction would the nurse give a client returning to work as a carpenter after surgery for carpal tunnel syndrome of the right hand? A. Avoid carrying tools with the arms. B. Learn to hammer with the left hand. C. Do stretching exercises during breaks. D. Avoid power tools such as drills or screwdrivers.

C. Do stretching exercises during breaks.

Which action would the nurse take when administering a transfusion of 2 units of packed red blood cells (PRBCs) to a client? A. Infuse lactated Ringer's solution with the PRBCs. B. Warm the blood to 98°F (36.7°C) to prevent chills. C. Infuse the blood at a slow rate during the first 15 minutes. D. Draw blood samples from the client after each unit is transfused.

C. Infuse the blood at a slow rate during the first 15 minutes. Rationale A slow rate provides time to recognize a reaction that is developing before too much blood is administered. Normal saline may be infused with blood, but lactated Ringer's solution will cause red blood cell hemolysis. Blood is not warmed to 98°F (36.7°C) to prevent chills; this could cause clotting and hemolysis. Drawing blood samples from the client after each unit is transfused is not necessary.

Which part of the kidney senses changes in blood pressure? A. Calices B. Glomerulus C. Macula densa D. Juxtaglomerular cells

C. Macula densa Rationale The macula densa, a part of the distal convoluted tubule, consists of cells that sense changes in the volume and pressure of blood. Calices are cuplike structures, present at the end of each papilla, that collect urine. The glomerulus is the initial part of the nephron, which filters blood to make urine. Juxtaglomerular cells secrete renin. Renin is produced when sensing cells in the macula densa sense changes in blood volume and pressure.

During a home visit to a client, the nurse identifies tremors of the client's hands. When discussing this assessment, the client reports being nervous, having difficulty sleeping, and feeling as if the collars of shirts are getting tight. Which additional assessment would the nurse report immediately to the health care provider? A. Increased appetite B. Recent weight loss C. Feelings of warmth D. Fluttering in the chest

D. Fluttering in the chest Rationale Many of these problems are associated with hyperthyroidism; palpitations may indicate cardiovascular changes requiring prompt intervention. The increased metabolism associated with hyperthyroidism can lead to heart failure. Although an increased appetite becomes a compensatory mechanism for the increased metabolism associated with hyperthyroidism, it is not life threatening. Although unexplained weight loss can result from catabolism associated with hyperthyroidism, it is not life threatening. Although a feeling of warmth caused by the increased metabolism associated with hyperthyroidism is uncomfortable, it is not life threatening.

Which condition would the nurse suspect in the client who reports a burning sensation and sharp pain on the sole of a foot? A. Torticollis B. Pes planus C. Crepitation D. Plantar fasciïtis

D. Plantar fasciïtis Rationale Plantar fasciitis is a burning sensation and sharp pain on the sole of the foot. It is caused by chronic degeneration and inflammation. Torticollis is the twisting of the neck to one side to an unusual position. Pes plans is the abnormal flatness of the sole and arch of the foot. Crepitation is a frequent, audible crackling sound with a palpable grating that accompanies movement.

The nurse provides education to a group of student nurses about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise? A. Decreases chest pain B. Conserves energy C. Increases oxygen saturation D. Promotes elimination of CO2

D. Promotes elimination of CO2 Rationale Pursed-lip breathing increases positive pressure within the alveoli and makes it easier for clients to expel air from the lungs. This in turn promotes elimination of CO 2. It also helps clients slow their breathing pattern and depth with respirations. It does not decrease chest pain, conserve energy, or increase oxygen saturation.

Which accurately describes hospice care? A. A resident's temporary or permanent home, where the surroundings have been made as homelike as possible B. Offers an attractive long-term care setting with an environment akin to the client's home, which offers the client greater autonomy C. Service that provides short-term relief for people providing home care to an ill, disabled, or frail older adult D. System of family-centered care that allows clients to remain at home in comfort while easing the pains of terminal illness

D. System of family-centered care that allows clients to remain at home in comfort while easing the pains of terminal illness

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When teaching a client about digoxin, which symptom will the nurse include as a reason to withhold the digoxin?