practice exam

The nurse is caring for a client who is malnourished. What instruction should be provided to the client when the meal tray arrives? Select all that apply.

"Be sure to eat the baked chicken." "It's important for you to eat the broccoli." "Try to drink all of the milk on your tray." The client with malnourishment is at risk for skin breakdown and needs protein and vitamin C to help the most with prevention of skin breakdown. Protein is included in the chicken and milk. Vitamin C is in the broccoli. The roll, while providing carbohydrates, is not as important. The client should not be forced to eat the entire meal to get the dessert but should make choices based on what is important to eat for good health.

The nurse is teaching a client about using topical gentamicin sulfate. Which comment by the client indicates the need for additional teaching?

"I should apply it to large open areas." The aminoglycoside antibiotic gentamicin sulfate should not be applied to large denuded areas because toxicity and systemic absorption are possible. The nurse should instruct the client to avoid excessive sun exposure because gentamicin sulfate can cause photosensitivity. The client should be instructed to apply the cream or ointment for only the length of time prescribed because a superinfection can occur from overuse. The client should contact the HCP if the condition worsens after use.

The client with acute mania states to the nurse, "I am the prince of peace and can save the world. Those against me will find me and take me to another world. They will come. I know it." The client is beginning to scan the room and starts to repeat his delusion. Which response by the nurse is most therapeutic?

"Let us walk around the unit for a while." The nurse suggests an activity such as walking around the unit to distract the client from the paranoid grandiose delusion that could result in loss of control. This action interrupts the client's anxious state and helps to redirect energy and focus on an activity based in reality. The focus must be on the underlying need or feeling of the delusion and not on the content. Asking the client to describe the people who will come challenges the client and forces the client to cling to the delusion. Stating that the nurse and staff will protect the client conveys agreement with the client's belief system, reinforcing the client's delusion. Telling the client that he is not the prince of peace and repeating his name challenges the client and his present belief system. Doing so may lead to decreased trust in the nurse and an aggressive response, or it may force the client to defend his beliefs.

A nurse is caring for a client with Raynaud's phenomenon secondary to systemic lupus erythematosus (SLE). Which of the client statements demonstrates an understanding of the nurse's teaching about this disorder? Select all that apply.

"My hands get pale and bluish, and feel numb and painful when I'm really stressed." "I probably got this disorder because I am also diagnosed with lupus." "This problem is caused by a temporary lack of circulation in my hands." "I will have to discuss medication that might treat this problem with my health care provider." Raynaud's phenomenon causes blanching, cyanosis, coldness, numbness, and throbbing pain in the hands when the client is exposed to cold or stress. It is caused by episodic vasospasm in the small peripheral arteries and arterioles and can affect the feet as well as the hands. The phenomenon is commonly associated with connective tissue diseases such as lupus and may be alleviated by calcium channel blockers or adrenergic blockers. It does not limit the client's ability to function, although the symptoms are bothersome. Keeping the hands warm and learning to manage stressful situations effectively reduces the frequency of episodes. The disorder can progress to skin ulcerations and even gangrene in some clients, so all skin changes should be reported to the health care provider promptly.

After the nurse teaches the parents of a child with febrile seizures about methods to lower temperature other than using medication, which statement by the parents indicates successful teaching?

"We will wrap him in a blanket if he starts shivering." Shivering, the body's defense against rapid temperature decrease, results in an increase in body temperature. Therefore, the parents need to take measures to stop the shivering (and the resulting increase in body temperature) by increasing the room temperature or the temperature of the child's immediate environment (such as with blankets) until the shivering stops. Then, attempts are made to lower the temperature more slowly. Shivering does not necessarily correlate with being cold. Alcohol, a toxic substance, can be absorbed through the skin. Its use is to be avoided.

During a unit meeting attended by clients and staff, several clients are criticizing their primary nurses. These clients have also been intimidating two other clients who have recently been admitted to the unit, and now the new clients have stopped sharing their opinions during the meeting. What is the first action for the nurse to take?

Ask the clients criticizing their nurses to suggest some possible solutions for the practices they are criticizing. Recognizing that the clients are part of the solution to the issues they are presenting demonstrates a client-centered approach to care. Having the new clients challenge the behaviors of other clients does not facilitate the development of a therapeutic milieu. Warning clients that behaviors are unacceptable reinforces a sense of client powerlessness and does not build a therapeutic relationship. Discussing respect and collaboration would happen after the criticisms have been acknowledged and the clients have been asked for their opinions.

A primigravid client at 39 weeks' gestation is admitted to the hospital for induction of labor. The health care provider (HCP) has prescribed prostaglandin E2 gel for the client. Before administering prostaglandin E2 gel to the client, the nurse should perform which action first?

Assess the frequency of uterine contractions. Before administering prostaglandin E2 gel, the nurse would assess the frequency and duration of any uterine contractions first because prostaglandin E2 gel is contraindicated if the client is having contractions. If there are no contractions, the client should be placed in a semi-Fowler's position to allow for vaginal insertion of the gel. Although determining whether the client's membranes have ruptured is part of the assessment of any client in labor, it is not specifically related to the administration of prostaglandin E2 gel. If the membranes remain intact, an amniotomy may be performed once the client begins to dilate and the fetal head is engaged. However, it is not necessary for the nurse to prepare the client for this procedure at this time.

A parent asks the nurse if a child's iron deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which principle?

Children with iron deficiency anemia are more susceptible to infection than are other children. Children with iron deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis.

While providing care to a 26-year-old married client, the nurse notes multiple areas of ecchymosis on the torso. The bruises were in various stages of healing. When asked about the cause of the bruises, the client replied, "Oh, I tripped." How should the nurse respond? Select all that apply.

Document the client's statement. Assess the extremities, and document areas of injury and ecchymosis. Ask about current antiplatelet medications the client may be taking. The nurse should objectively document the assessment findings. A detailed description of physical abuse is essential in the medical records if legal action is pursued. Potential causes of the ecchymosis should be noted before a determination of abuse is made. Contacting the client's spouse without consent violates confidentiality. Notifying local authorities is not appropriate if domestic abuse is not certain.

Which scenario below complies with the HIPAA (Canadian Privacy Act and Personal Information Protection and Electronic Documents Act) regulations?

The healthcare team is discussing a client's care during a formal care conference.

A nurse is caring for four clients who gave birth 12 hours ago. Which client is at greatest risk for complications?

gravida 2 para 2002, cesarean birth, incision site intact, hemoglobin level 9.8 g/dl Women who have anemia during pregnancy (defined as a hemoglobin less than 10 g/dl) may experience more complications such as poor wound healing and inability to tolerate activity. An intact incision site and a pulse of 84 beats/minute after a cesarean birth and a temperature of 99.8° F (37.7° C) after a vaginal delivery with episiotomy are findings within normal limits. Dehydration can cause a slightly elevated temperature. Although women whose membranes are ruptured more than 24 hours before birth are more prone to developing chorioamnionitis, the client with anemia is at greater risk for complications.

An adolescent client is admitted to the facility for behavior management after multiple arrests and expulsion from high school. The suspected diagnosis is conduct disorder. What primary contributors for developing conduct disorder will the nurse assess for?

history of child abuse and a complicated birth Conduct disorder is defined by a repetitive pattern of behavior of aggression and infraction of age-appropriate norms that persists for at least one year. Risk factors include complications at birth that lead to specific types of damage to neural pathways, child abuse, or repetitive traumas as a child. While an unstable home is a risk factor, one should not assume a single parent home is unstable. Being from a large family with many siblings is more closely associated with conduct disorder than is being an only child. Poor school performance is a symptom of conduct disorder but not a cause for it, and overly strict parenting rather, than passive parenting, increases the risk. The desire to participate in violent video games may be a symptom of conduct disorder but is not a cause; additionally, there is no proven link given the number of youths who participate in such games without developing mental health issues.

A client is transferred from the coronary care unit to the step-down unit. Which information should be included in the transfer report? Select all that apply. The client:

needs oxygen at 2 L/minute. has a "do not resuscitate" prescription. uses the bedpan. has been in normal sinus rhythm for 6 hours. The nurse should report that the client is using oxygen, has a "do not resuscitate" prescription, can use the bedpan, and is in normal sinus rhythm. Information about having four grandchildren is not needed to help with the client's continuity of care.

The client with a terminal illness states to the nurse, "I am at the point where the treatment seems as bad to me as the illness." What topic of conversation would the nurse view as most important as they discuss the client's concerns?

perceptions of illness burden When the client equates the treatment as being as difficult as the illness, the need to discuss the perceived benefits of treatment verses the burden of treatment becomes the essential conversation topic. The other topics related to prognosis, illness progression, and symptom management are secondary issues to address with the client.

A nurse is completing a health assessment with an adult client in a healthcare provider's office. What assessment data will the nurse report to the healthcare provider as indications of fluid volume excess? Select all that apply.

pitting extremity edema feelings of fatigue bounding pulses The nurse will report bounding pulses, pitting edema, and feelings of fatigue as indications of fluid volume excess due to the stress of fluid on the circulatory system. A The blood pressure and heart rate will be elevated with fluid volume excess.

A 6-year-old child was admitted to the pediatric unit after sustaining a broken leg in a motor vehicle accident. Which specialist would be most important to involve in this child's care during hospitalization?

social worker The nurse should collaborate with the social worker to provide care for the child involved in a motor vehicle accident. After such a traumatic life event, care will involve dealing with the child's emotional health as well as physical recovery. Home health care isn't usually needed for this type of injury, and nutrition isn't a top priority problem for this child. There's nothing to suggest that the infectious disease nurse is required to care for this child.

During a rectal examination, which finding is evidence of a urethral injury?

the presence of a boggy mass When the urethra is ruptured, a hematoma or collection of blood separates the two sections of the urethra. This condition may feel like a boggy mass on rectal examination. Because of the rupture and hematoma, the prostate becomes high riding. A palpable prostate gland usually indicates a nonurethral injury. Absent sphincter tone would refer to a spinal cord injury. The presence of blood (a positive Hemoccult) would probably correlate with GI bleeding or a colon injury.

Several high-school seniors are referred to the school nurse because of suspected alcohol misuse. When the nurse assesses the situation, what would be most important to determine?

the reasons they choose to use alcohol Information about why adolescents choose to use alcohol or other drugs can be used to determine whether they are becoming responsible users or problem users. The senior students likely know the legal implications of drinking, and the nurse will establish a more effective relationship with the students by understanding motivations for use. The type of alcohol and when and with whom they are using it are not the first data to obtain when assessing the situation.