Practice Session 3
A client is receiving heparin sodium intravenously at 1500 units/hour. The concentration in the bag is 25,000 units/500 milliliters. The nurse determines that how many milliliters will infuse during the nurse's 8-hour shift? Record your answer using a whole number. ___ mL
Correct 240 mL
After several years of unprotected sex, a client is diagnosed as having acquired immunodeficiency syndrome (AIDS). The client states, "I'm not worried because they have a cure for AIDS." What is the best response by the nurse? 1 "Repeated phlebotomies may be able to rid you of the virus." 2 "You may be cured of AIDS after prolonged pharmacologic therapy." 3 "Perhaps you should have worn condoms to prevent contracting the virus." 4 "There is no cure for AIDS, but there are drugs that can slow down the virus."
Correct Ans: 4 Stating "There is no cure for AIDS, but there are drugs that can slow down the virus" is an honest response that corrects the client's misconception about the effectiveness of the current antiviral medications. Phlebotomy is not the treatment used to remove the virus from the client's body. Current pharmacologic treatment does not eliminate the virus from the body; it can slow its progress and may even effect a remission (although the medications are never discontinued), but there is no known cure. Stating "Perhaps you should have worn condoms to prevent contracting the virus" is a nontherapeutic, judgmental response that can alienate the client and precipitate feelings of guilt.
Which between-meal snack should a nurse tell the parents of a preschooler with a urinary tract infection to offer their child? 1 Skim milk 2 Fresh fruit 3 Hard candy 4 Cream soup
I put 2 Ans: 1 A high-protein, high-carbohydrate snack provides additional nutrients to combat an infection and a fever. Also, fluid helps flush the urinary tract. Fruit does not provide the protein needed for the healing process. Candy provides empty calories. A cream soup is too heavy for a between-meal snack and does not provide the needed protein.
A nurse is preparing to administer an oil-retention enema and understands that it works primarily by doing what? 1 Stimulating the urge to defecate 2 Lubricating the sigmoid colon and rectum 3 Dissolving the feces 4 Softening the feces
I put 4 Ans: 2 The primary purpose of an oil-retention enema is to lubricate the sigmoid colon and rectum. Secondary benefits of an oil-retention enema include stimulating the urge to defecate and softening feces. An oil-retention enema does not dissolve feces.
The client who has a history of allergy to bee stings is brought to the emergency department following a bee sting. What are the interventions to be followed in correct order? 1. Administer oral liquid diphenhydramine. 2. Establish an intravenous infusion with normal saline. 3. Remove the stinger gently by scraping with a needle. 4. Inject epinephrine through the intramuscular route in the mid-portion of the outer thigh.
4, 3, 1, 2 Basic emergency care for bee and wasp stings includes quick removal of the stinger by scraping with a needle. But in the clients who are allergic to bee sting the foremost care that must be given is administration of epinephrine through the intramuscular route in the mid-portion of the outer thigh. After administering epinephrine, the stinger is gently removed by scraping using a needle. Later, oral liquid diphenhydramine is given. If the client has sustained a serious reaction, intravenous infusion with normal saline is established.
Which cytokine is used to treat multiple sclerosis? 1 β-Interferon 2 Interleukin-2 3 Erythropoietin 4 Colony-stimulating factor
Correct Ans: 1 β-Interferon is a cytokine used to treat multiple sclerosis. Interleukin-2 is used to treat metastatic melanoma. Erythropoietin is a cytokine used to treat anemia related to chemotherapy. Colony-stimulating factor is a cytokine used to treat chemotherapy-induced neutropenia.
Because a severely depressed client has not responded to any of the antidepressant medications, the primary healthcare provider decides to try electroconvulsive therapy (ECT). What should the nurse do before the treatment? 1 Have the client speak with other clients undergoing ECT. 2 Give a detailed explanation of what to expect after the procedure. 3 Limit the client's intake to a light breakfast on the days of the treatment. 4 Provide emotional support while presenting a simple explanation of the ECT procedure.
Correct Ans: 4 The nurse should offer support and use clear, simple terms to allay the client's anxiety. Having the client talk to ECT recipients may be too frightening or confusing to the client, and the nurse is responsible for educating the client. Severely depressed clients cannot retain long explanations. The client generally is kept on nothing-by-mouth status before ECT to prevent aspiration during the procedure.
The nurse is teaching a client about the prescribed diet after a Whipple procedure for cancer of the pancreas. Which statement should the nurse include in the dietary teaching? 1 "There are no dietary restrictions because the tumor has been removed." 2 "Your diet should be low in calories to prevent taxing your diseased pancreas." 3 "Meals should be restricted in protein because of your compromised liver function." 4 "Low-fat meals should be eaten to prevent interference with your fat digestion mechanism."
Correct Ans: 4 Whipple procedure leads to malabsorption because of impaired delivery of bile to the intestine and interruption of glucose metabolism; interference with fat digestion occurs. Clients require small, frequent low-fat, high-protein, moderate-carbohydrate meals and supplemental feedings. The response "There are no dietary restrictions because the tumor has been removed" is false reassurance. High-calorie meals are needed to provide energy and to promote the use of protein for tissue repair. High protein is required for tissue building; there is no problem with the liver in clients with cancer of the pancreas unless metastasis occurs by direct extension.
A client is scheduled to have an indwelling urinary catheter inserted before abdominal surgery. The nurse should insert the catheter in what location in the illustration? (picture not included due to Quizlet restrictions)
Correct Ans: B Option B is the urethral orifice, which anatomically is between the clitoris and the vagina; it is the opening into the urethra, the tubular structure that drains urine from the bladder. Option A is the clitoris, which is situated beneath the anterior commissure, partially hidden between the anterior extremities of the labia minora. Option C is the opening of the vagina; it is the part of the female genitalia that forms a canal from the vaginal orifice through the vestibule to the uterine cervix. Option D is the anus; it is the terminal end of the anal canal that is connected to the rectum; the rectum is a portion of the large intestine that is between the anal canal and the descending sigmoid colon.
A depressed client is very resistive and complains about inabilities and worthlessness. Which is the best nursing approach? 1 Involve the client in activities in which success can be ensured. 2 Listen to the client while postponing a planned activity for later. 3 Encourage the client to select an activity in which there is some interest. 4 Schedule the client's activities so that they can be implemented independently.
I put 1 Ans: 3 Some success is important to increase the client's self-esteem. Listening to the client while postponing a planned activity for later will support the client's feelings of uselessness. The client, who is in a major depression, does not have the interest or energy to be involved in the decision-making process or to act independently.
A client with gastric ulcer disease asks the nurse why the health care provider has prescribed metronidazole. What purpose does the nurse provide? 1 To augment the immune response 2 To potentiate the effect of antacids 3 To treat Helicobacter pylori infection 4 To reduce hydrochloric acid secretion
Correct Ans: 3 Approximately two thirds of clients with peptic ulcer disease are found to have Helicobacter pylori infecting the mucosa and interfering with its protective function. Antibiotics do not augment the immune response, potentiate the effect of antacids, or reduce hydrochloric acid secretion.
A nurse is interviewing a client with the diagnosis of dementia of the Alzheimer type. What question should the nurse ask to assess the client's orientation to place? 1 "Where are you?" 2 "Who brought you here?" 3 "Do you know where you are?" 4 "How long have you been here?"
Correct Ans: 1 "Where are you?" is the best question with which to elicit information about the client's orientation to place, because it encourages a response that can be assessed. Asking who brought the client focuses on recent memory; it does not assess orientation to place. "Do you know where you are?" can be answered yes or no and will not objectively reveal the client's orientation. "How long have you been here?" focuses on orientation to time, not place.
An obese client with type 2 diabetes asks about the intake of alcohol or special "dietetic" food in the diet. What should the nurse include in teaching? 1 Alcohol can be consumed, with its calories counted in the diet. 2 Unlimited amounts of sugar substitutes can be used as desired. 3 Alcohol should not be used in cooking because it adds too many calories. 4 Special "dietetic" foods are needed because many regular foods cannot be used.
Correct Ans: 1 In the overweight individual with type 2 diabetes, occasional alcohol can be ingested with caloric substitution for equivalent fat exchanges in the diet because it is metabolized like fat. Moderation is vital; sugar substitutes may not be used in unlimited quantities, and they must be accounted for in the dietary calculations. Alcohol can be used as long as it is accounted for in the diet. The statement that special "dietetic" foods are needed because many regular foods cannot be used is untrue; regular foods can be used in the diet of individuals with diabetes.
A client with the diagnosis of Crohn disease tells the nurse that her boyfriend dates other women. She believes that this behavior causes an increase in her symptoms. What should the nurse do first when counseling this client? 1 Help the client explore attitudes about herself 2 Educate the client's boyfriend about her illness 3 Suggest the client should not see her boyfriend for a while 4 Schedule the client and her boyfriend for a counseling session
Correct Ans: 1 Because emotional stress can influence the progress of Crohn disease, initially the nurse should help the client to explore self-attitudes to aid in better understanding the feelings engendered by her boyfriend dating others. Initially the nurse should help the client explore the situation and the feelings it engenders rather than involve the boyfriend. The client should make the decision about seeing her boyfriend. Scheduling the client and her boyfriend for a counseling session is premature; the client is not ready for a joint counseling session.
A client with hyperthyroidism is to receive methimazole. What instructions does the nurse provide? 1 Initial improvement will take several weeks. 2 There are few side effects associated with this drug. 3 This medication may be taken at any time during the day. 4 Large doses are used to quickly correct the functions of the thyroid.
Correct Ans: 1 Methimazole blocks thyroid hormone synthesis; it takes several weeks of medication therapy before the hormones stored in the thyroid gland are released and the excessive level of thyroid hormone in the circulation is metabolized. There are many common side effects that include nausea, vomiting, diarrhea, rash, urticaria, pruritus, alopecia, hyperpigmentation, drowsiness, headache, vertigo, and fever. Methimazole should be spaced at regular intervals because blood levels are reduced in approximately 8 hours. Large doses cause toxic side effects that can be life threatening, including nephritis, hepatitis, agranulocytosis, leukopenia, thrombocytopenia, hypothrombinemia, and lymphadenopathy.
A client with gastroesophageal reflux disease reports having difficulty sleeping at night. What should the nurse instruct the client to do? 1 Drink a glass of milk before retiring. 2 Elevate the head of the bed on blocks. 3 Eliminate carbohydrates from the diet. 4 Take antacids, such as sodium bicarbonate.
Correct Ans: 2 Elevating the head of the bed on blocks raises the upper torso and minimizes reflux of gastric contents. Increasing the content of the stomach before lying down will aggravate the symptoms associated with gastroesophageal reflux. Eliminating carbohydrates from the diet will have no effect on the reflux of gastric contents. The effect of antacids is not long-lasting enough to promote a full night's sleep; sodium bicarbonate is not recommended as an antacid.
The parents of a client in a psychiatric hospital send an unwrapped birthday gift to the unit for their daughter but do not stay to visit with her. The client responds to this situation by crying. What is the best response by the nurse? 1 Limit her contact with the parents. 2 Discuss her parents' behavior with her. 3 Distract her by engaging her in an activity. 4 Take her to the coffee shop for a birthday treat.
Correct Ans: 2 Helping the client understand the meaning of the parents' behavior can reduce the parents' emotional control over her. Limiting her contact with the parents is a temporary measure and does not reduce the emotional conflict with the parents. Distraction is not a therapeutic way to cope with realistic feelings. Taking her to the coffee shop for a birthday treat ignores the necessity of clarifying her parents' behavior.
A mother needs to get her blood pressure (BP) checked, but her 4-year-old child is interfering in the process. What should the nurse do to gain the child's cooperation? 1 Ask the mother to restrain the child. 2 Instruct the mother to scold her child. 3 Allow the child to manipulate the instrument. 4 Scare the child by showing an injection needle
Correct Ans: 3 Preschoolers cooperate if they are allowed to help the nurse measure the blood pressure of a parent or to manipulate the nurse's equipment. Hence, the nurse should allow the child to manipulate the instrument. The nurse should not have the mother restrain or scold her child because this may induce fear in the child. At this age, preschoolers are afraid of bodily harm, and this fear interferes with the willingness to allow nursing interventions. Hence, the nurse should not scare the child with the help of an injection needle.
While awaiting the biopsy report before removal of a bone tumor, the client reports being afraid of a diagnosis of cancer. How should the nurse respond? 1 "Worrying is not going to help the situation." 2 "Let's wait until we hear what the biopsy report says." 3 "It is very upsetting to have to wait for a biopsy report." 4 "Operations are not performed unless there are no other options."
Correct Ans: 3 "It is very upsetting to have to wait for a biopsy report" addresses the fact that the client's feelings of anxiety are valid. Stating "Worrying is not going to help the situation" or "Let's wait until we hear what the biopsy report says" does not address the client's concerns and may inhibit the expression of feelings. Telling the client that operations are not performed unless there are no other options is irrelevant and does not address the client's concerns.
The nurse is choosing the gauge size for a peripheral catheter to administer saline to an infant. What size of gauge would be most appropriate for this nursing priority? 1 18 gauge 2 20 gauge 3 24 gauge 4 14 gauge
Correct Ans: 3 A 24-26 gauge size is appropriate for transfusion and administration of saline in an infant. An 18 gauge is the preferred size for surgery for an adult. A 20 gauge size is adequate for all therapies related to an adult client. A 14 gauge is the preferred size for trauma and surgical clients requiring rapid fluid resuscitation in an adult client.
While assessing a client during an ophthalmic pupillary physical examination, the primary healthcare provider observes a noticeable difference in the size of pupils in the client. Which term should the nurse use to describe this condition? 1 Mydriasis 2 Hyperopia 3 Anisocoria 4 Arcus senilis
Correct Ans: 3 A noticeable difference in the size of the pupils of the clients is known as anisocoria, a normal condition in about 5% of people. The normal diameter of the pupil is between 3 and 5 mm; clients with hyperopia have smaller pupils with a diameter of less than 3 mm. Mydriasis is the process of pupillary dilation. Arcus senilis is an opaque bluish-white ring within the outer edge of the cornea caused by the presence of fat deposits.
After a transurethral prostatectomy, a client returns to the postanesthesia care unit with a three-way indwelling catheter with continuous bladder irrigation. Which nursing action is the priority? 1 Observing the suprapubic dressing for drainage 2 Maintaining the client in the semi-Fowler position 3 Monitoring for bright red blood in the drainage bag 4 Encouraging fluids by mouth as soon as the gag reflex returns
Correct Ans: 3 Blood clots are normal 24 to 36 hours after surgery, but bright red blood can indicate hemorrhage. The surgery is performed through the urinary meatus and urethra; there is no suprapubic incision. It is unnecessary to keep the client in the semi-Fowler position. The client is initially allowed nothing by mouth and then advanced to a regular diet as tolerated. Continuous irrigation supplies enough fluid to flush the bladder.
A client who underwent chemotherapy has leukopenia. Which instruction from the nurse will be beneficial for the client? 1 "You should avoid exposure to the sun." 2 "You should eat high-fiber foods and increase fluid intake." 3 "You should avoid large crowds and people with infections." 4 "You should consume iron supplements and erythropoietin."
Correct Ans: 3 Low levels of white blood cells are called leukopenia. A leukopenic client should avoid large crowds and people with infection as the client may contract infection due to compromised immunity. The suggestion of avoiding exposure to the sun would be beneficial for a client with chemotherapy-induced skin changes. The suggestion of eating high-fiber foods and increasing fluid intake would be beneficial for a client with constipation after chemotherapy. Consuming iron supplements and erythropoietin would be required for a client who developed anemia after chemotherapy.
The nurse is teaching arm exercises to a woman who has undergone a right mastectomy. What instruction will the nurse give the client? 1 "Wear a sling between exercise periods." 2 "Exercise the right arm before the left arm." 3 "Perform exercises with both arms simultaneously whenever possible." 4 "Wait until the drain has been removed before starting the exercises."
Correct Ans: 3 Postmastectomy exercises should be bilateral, involving the use of both arms simultaneously, whenever possible, to prevent shortening of muscles and contracture of joints. A sling immobilizes the arm, resulting in joint stiffness and loss of muscle tone. Exercises are usually started within 24 hours of surgery to prevent contractures and muscle atony of the affected arm.
A client is admitted with a diagnosis of premature labor. The nurse discovers that the client has been using heroin throughout her pregnancy. What is the most appropriate action for the nurse to take? 1 Notify the nurse manager of the unit. 2 Inform no one because all client information is confidential. 3 Inform the client's primary healthcare provider. 4 Alert the hospital security department, because heroin is an illegal substance.
Correct Ans: 3 The fetus of a heroin-addicted mother is at risk for serious complications such as hypoxia and meconium aspiration. It is important to notify the primary healthcare provider of the client's heroin use, because this information will influence the care of the client and newborn. This information is used only in relation to the client's care. With the client's consent, it may be shared with other social service or health agencies that become involved with the client's long-term care. The nurse manager of the unit may be notified, because it relates to the care of the client and her newborn. Client information is confidential, and only necessary staff should be privileged to such information. Hospital security would only be notified if actual illicit substances were discovered on hospital premises.
Which action of the nurse leader indicates implementing Gardner's task of "explaining"? 1 Assisting clients and families in formulating their vision of future well-being 2 Providing self-care to enhance the ability to care for staff, clients, and their families 3 Teaching and interpreting the information to ensure clients' functioning and well-being 4 Assisting clients in sorting out and articulating personal values in relation to health problems
Correct Ans: 3 The nurse leader implements Gardner's task of "explaining" by teaching and interpreting the information that ensures clients' functioning and well-being. The nurse leader implements Gardner's task of "envisioning goals" by assisting clients and their families in formulating their vision of future well-being. The nurse leader implements Gardner's task of "renewing" by providing self-care to enhance the ability to care for staff, clients, and their families. The nurse leader implements Gardner's task of "affirming values" by assisting clients and their families as they sort out and articulate personal values in relation to health problems.
A nurse is teaching crutch walking to a client who had arthroscopic surgery of the knee. The nurse should instruct the client to place weight on which part of the body? 1 The upper arms 2 The axillary region 3 The palms of the hands 4 Both lower extremities
Correct Ans: 3 To prevent nerve damage in the axillary area, the palms should bear all the weight. Placing weight on the upper arms is unsafe and almost impossible to perform. Pressure in the axillary area causes nerve damage to the brachial plexus. Weight bearing on the affected lower extremity is initially contraindicated.
A nurse takes a 1-year-old child to the hospital playroom. What toy should the nurse select for this child? 1 Rocking horse 2 Stuffed animal 3 Four-piece puzzle 4 Squeaky plastic duck
Correct Ans: 4 A plastic toy that squeaks is appropriate for a 1-year-old child because it provides auditory, tactile, and visual stimulation. The potential for injury is too great for a 1-year-old child to be placed on a rocking horse. A stuffed animal should not be kept in a playroom because it cannot be washed between uses by different children. A 1-year-old is too young for a puzzle.
A client has been placed in seclusion as a result of uncontrolled physical aggression directed toward both the staff and another client. In light of the events set forth in the documentation, what should the nurse manager do initially? 1 Include the client in a discussion with staff regarding the managing of the events. 2 Compliment the staff on managing the potentially dangerous situation so therapeutically. 3 Question the use of a phenothiazine like promazine to manage aggressive behavior. 4 Ask for details regarding how the staff attempted to manage the client before seclusion was initiated.
Correct Ans: 4 Documentation must include descriptions of attempted interventions that support that the seclusion was the least restrictive management alternative. The client would benefit from a discussion regarding the events leading up to and during the seclusion, and the staff may have managed the event successfully, but there is an omission in the documentation that requires attention and so has priority. Phenothiazines are used to assist in managing such behaviors and were prescribed and administered according to a primary healthcare provider's prescription.
A client on the psychiatric unit who is receiving high-dosage risperidone is exhibiting tremors of the hands. What will be the nurse's first intervention? 1 Withholding the medication 2 Telling the client it is transitory 3 Giving the client finger exercises 4 Contacting the primary healthcare provider
Correct Ans: 4 The primary healthcare provider is responsible for prescribing medications but depends on the nurse's observations before making decisions. This is not a severe enough finding to warrant withholding the drug. It is a reaction to the risperidone, and it is not transitory. Giving the client finger exercises will have no effect on the tremors.
While speaking with a client with schizophrenia, the nurse notes that the client keeps interjecting sentences that have nothing to do with the main thoughts being expressed. The client asks whether the nurse understands. What is the best response by the nurse? 1 "You aren't making any sense; let's talk about something else." 2 "You're so confused; I can't understand what you're saying to me." 3 "Why don't you take a rest? We can talk again later this afternoon." 4 "I'd like to understand what you're saying, but I'm having difficulty following you."
Correct Ans: 4 The statement "I'd like to understand what you are saying, but I'm having difficulty following you" lets the client know the nurse is trying to understand; it increases the client's self-esteem and points out reality. Clients with schizophrenia have problems with associative links, and these same problems will occur regardless of the topic. The statement "You're so confused; I can't understand what you're saying to me" and telling the client to take a rest and promising to talk about the client's concerns again later in the day cut off communication and tell the client that the nurse will speak only if the client's communication makes sense.
An infant who has undergone surgical correction of a myelomeningocele is to be discharged. What information should the nurse include when preparing the parents to care for their infant at home? 1 The need to limit the infant's fluid intake to formula 2 The need to provide a quiet environment to limit external stimuli 3 The positions to be avoided to help prevent the infant from turning 4 How to perform range-of-motion exercises for the lower extremities
Correct Ans: 4 Passive range of motion, positioning, and stretching may help decrease the risk of muscle contractures in the lower extremities. Fluid intake should be unrestricted to provide adequate kidney function and prevent constipation. The infant needs stimulation to develop mentally and socially. Development of mobility should be encouraged; the infant's movements should not be restricted.
A nurse caring for a pregnant client prioritizes nursing actions on the basis of Maslow's hierarchy of needs. Which statement of the client does the nurse consider to be a self-esteem need? 1 "I cannot contact my family as I eloped from home in order to get married." 2 "If I don't comply with my husband's demands, I might not have anywhere to live." 3 "My husband hurts me sometimes when I'm not able to live up to his expectations." 4 "I deserve ill treatment from my husband as I'm incapable of doing even simple things perfectly."
Correct Ans: 4 The client feels that she is incapable of performing simple tasks perfectly. This shows a lack of self-esteem. The nurse will consider this statement to be a self-esteem need. The client conveys to the nurse that she is not in touch with her family members. The nurse will consider this statement to be a love and belonging need as the client displays impaired social interaction. The client informs the nurse that she is in danger of losing her shelter. The nurse understands this statement to be an indication of a physiological need. The nurse notes that the client is in physical and psychological danger due to the husband's actions. The client displays the lack of safety and security need.
What should the nurse should explain to the newly pregnant primigravida about how and when the fetal heartbeat will first be heard? 1 A fetoscope around 8 weeks 2 A fetoscope at 12 to 14 weeks 3 Electronic Doppler ultrasonography after 17 weeks 4 Electronic Doppler ultrasonography at 10 to 12 weeks
Correct Ans: 4 The fetal heartbeat can be heard on electronic Doppler ultrasound between 10 and 12 weeks' gestation. Around 8 weeks is too early for the heartbeat to be heard with a fetoscope; a fetoscope can pick up the fetal heartbeat accurately around the twentieth week. The fetal heartbeat can be heard at least 5 weeks earlier with the use of electronic Doppler ultrasound.
A client is admitted to the emergency department at 34 weeks' gestation with trauma and significant bleeding from the leg. What is the priority intervention after determining fetal well-being? 1 Obtaining the client's vital signs 2 Offering the client emotional support 3 Placing the client in a left lateral position 4 Drawing the client's blood for laboratory screening
I put 1 Ans: 3 The left lateral position will increase placental perfusion, which may be compromised because of the significant bleeding. Obtaining the client's vital signs is not the priority. Although providing emotional support and drawing the client's blood for laboratory screening are both important, preventing fetal and maternal compromise is the priority.
A nurse in a long-term care facility is caring for a bedridden client with multiple chronic illnesses. Although usually continent, the client expresses anger through urinary incontinence. What should the nurse do to best address this situation? 1 Offer the client a bedpan every 2 hours. 2 Encourage the client to watch more television. 3 Decrease the client's fluid intake in the evening. 4 Assist the client in setting realistic short-term goals.
I put 1 Ans: 4 People with chronic illnesses often feel helpless and powerless. This can turn into anger and acting-out behaviors against those providing care. Helping the client set and achieve realistic short-term goals fosters client independence and hope. Because the client is able to control elimination, frequent toileting is not the problem. Although distraction is important, it should be varied and the client's preferences taken into consideration. Radio and television do not promote interaction. As a means of preventing urinary stasis and dehydration, fluid intake should be encouraged. Also, restricting fluid intake will not prevent intentional incontinence.
A nurse is teaching a client and family about the characteristics of dementia of the Alzheimer type. What physiologic characteristic should the nurse include? 1 Periodic exacerbations 2 Aggressive acting-out behavior 3 Hypoxia of selected areas of brain tissue 4 Areas of brain destruction called senile plaques
I put 1 Ans: 4 When an older person's brain atrophies, some unusual deposits of iron are scattered on nerve cells. Throughout the brain, areas of deeply staining amyloid, called senile plaques, can be found; these plaques represent the end stage of destruction of brain tissue. Periodic exacerbations are associated with chronic deterioration, not with remissions and exacerbations. Aggressive acting-out behavior may or may not be part of the disorder. Hypoxia of selected areas of brain tissue is typical of vascular dementia, not dementia of the Alzheimer type.
A client newly diagnosed with cancer of the pancreas is scheduled for surgery. The client says to the nurse, "Wouldn't I be better off with some other treatment instead of surgery?" What response by the nurse is the best? 1 "It's a good idea to explore other acceptable treatments for your cancer. There is information available for you." 2 "Surgery is the recommended approach. Why don't you discuss this further with the healthcare provider?" 3 "Maybe you will be more confident with a second opinion. I think you need a referral to another healthcare provider." 4 "With your disease your prognosis will improve if you follow the suggestion to have the recommended surgery."
I put 1 Correct: 2 The response "Surgery is the recommended approach. Why don't you discuss this further with the healthcare provider?" provides needed information and establishes an opportunity for further discussion of surgery. The response "It's a good idea to explore other acceptable treatments for your cancer. There is information available for you" implies the other approaches are as effective as surgery; this places doubt in the client's mind that surgery is the most effective option. The response "Maybe you will be more confident with a second opinion" is an inappropriate response; the competence of the healthcare provider was not questioned, but there exists a need for further discussion of the treatment. Making this type of referral is not the nurse's role. The response "With your disease your prognosis will improve" is false reassurance; it cuts off communication and does not address the need for further discussion.
Fludrocortisone is prescribed for a client with adrenal insufficiency. Which responses to the medication should the nurse teach the client to report? Select all that apply. 1 Edema 2 Rapid weight gain 3 Fatigue in the afternoon 4 Unpredictable changes in mood 5 Increased frequency of urination
I put 1, 2, 3 Ans: 1, 2 Fludrocortisone has a strong effect on sodium retention by the kidneys, which leads to fluid retention, causing edema and weight gain. Fatigue may occur with adrenal insufficiency and is not related to cortisone therapy. Unpredictable changes in mood commonly occur, but are not as serious a threat as fluid retention. Fluid retention, and thus decreased urination, may occur.
What are the roles and responsibilities of a senior nurse leader while implementing strategies for improving the quality of the organization? Select all that apply. 1 Participating actively in the quality improvement activities 2 Setting priorities for staff effectiveness and client health outcomes 3 Providing support systems for staff who have been involved in a sentinel event 4 Building infrastructure, providing resources, and removing barriers for improvement 5 Meeting regularly with staff to monitor their progress and help them improve their work
I put 1, 2, 3, 4, 5 Ans: 2, 3, 4 Setting priorities for staff effectiveness and client health outcomes are the responsibilities of senior leaders. This also includes providing a support system for staff who have been involved in a sentinel event. While preparing the quality improvement plan, the senior leader should build infrastructure, provide resources, and remove barriers for improvement. Participating actively in the quality improvement activities is the responsibility of a follower. The nurse manger has the responsibility of meeting with the staff regularly to monitor their progress and help them improve their work.
A parent expresses concern that the adolescent child is not ingesting enough calcium because of an allergy to milk. What alternative foods or liquids should the nurse suggest? Select all that apply. 1 Cottage cheese 2 Green leafy vegetables 3 Black or baked beans 4 Yogurt 5 Oranges 6 Salmon and sardines
I put 1, 2, 4 Ans: 2, 3, 5, 6 Green leafy vegetables, black and baked beans, oranges, and salmon and sardines are all good sources of calcium even though they do not contain milk or milk products. Cottage cheese and yogurt both contain milk and therefore must be eliminated.
An epidural anesthetic is planned for the adolescent who is in labor. What nursing interventions are essential before epidural anesthesia is administered? Select all that apply. 1 Performing a baseline vaginal examination 2 Telling the adolescent what to expect with each procedure 3 Identifying risk factors that contraindicate epidural anesthesia 4 Having the parents sign a consent form for the epidural anesthesia 5 Explaining the need to stay in one position while the epidural catheter is in place
I put 1, 2, 5 Ans: 1, 2, 3 A baseline vaginal examination is needed to determine the extent of cervical dilation and effacement. Before any procedure is implemented, the nurse should explain the procedure and answer any questions. Risk factors that contraindicate epidural anesthesia include antepartum hemorrhage, bleeding disorders, and allergy to the medication. None of these conditions is indicated in the client's history. Although a signed informed consent is legally required for this invasive procedure, the adolescent, not the parents, should sign the consent; a pregnant woman is considered an emancipated minor and is legally empowered to sign the consent. The client should change position from side to side every hour to promote distribution of the anesthetic and to maintain circulation to the uterus and placenta.
What steps should the nurse take for managing an adolescent that sustained drug poisoning? Select all that apply. 1 Induce gastric lavage. 2 Give ipecac syrup to the client. 3 Turn the head of the client to the side. 4 Empty the mouth to clean the residue of the drug. 5 Call local poison control center before any intervention.
I put 1, 3, 4 Ans: 3, 4, 5 The nurse should turn the head of the client to the side to avoid aspiration. The nurse should empty the mouth if there is any remaining drug. If the victim is conscious and alert, the nurse should call the local poison control center or the national toll-free poison control center number before attempting any intervention. The nurse should refrain from inducing vomiting in the client as there is a risk of aspiration. Ipecac syrup causes vomiting so it is no longer recommended for routine treatment of poisoning.
Which characteristic does the nurse associate with a punch biopsy? 1 It is usually indicated for superficial or raised lesions. 2 It is more uncomfortable than other biopsies while healing. 3 It is performed using a circular cutting instrument 2 to 6 mm in diameter. 4 It removes only the portion of the skin that rises above the surrounding tissue.
I put 2 Ans: 3 Punch biopsy is a common technique that involves the use of a small circular cutting instrument with a diameter of 2 to 6 mm. Shave biopsies are usually recommended for superficial or raised lesions. Excisional biopsies are comparatively more uncomfortable than punch or shave biopsies. Shave biopsies remove the skin portion that rises above surrounding tissues.
A 6-week-old infant and his mother arrive in the emergency department in an ambulance. The father arrives several minutes later with two children, 7 and 9 years old. The infant is not breathing, and the eventual diagnosis is sudden infant death syndrome (SIDS). The parents take turns holding the infant in another room. The nurse remains present and provides emotional support to the parents. What is an important short-term goal for this family? 1 Identifying the problems that they will be facing as a result of the loss of the infant 2 Accepting that there was nothing that they could have done to prevent the infant's death 3 Including the infant's siblings in the events and grieving in the wake of the infant's death 4 Seeking out other families who have lost infants to SIDS and obtaining support from them
I put 2 Ans: 3 The other children need to be involved with the grieving process and to work through their own feelings. Identifying the problems that the family will be facing in regard to the loss of the infant is a long-term goal. It is too early to seek out other families who have lost infants to SIDS and receive support from them. It is premature to accept that there was nothing that the family could have done to prevent the infant's death; in fact, they may never achieve this goal.
An adolescent with a BMI of 30 reports fatigue, frequent urination, and a tingling sensation on the feet. The adolescent is then diagnosed with type 2 diabetes mellitus. Which nursing interventions would be appropriate? Select all that apply. 1 Bariatric surgery 2 Physical activities 3 Dietary restrictions 4 Dietary counseling 5 Behavior modification
I put 2, 3, 4 Ans: 2, 4, 5 An adolescent with type 2 diabetes mellitus should engage in regular physical activity to reduce his or her weight and glucose levels. Dietary counseling helps to improve nutritional intake and decrease saturated fats and sugars. Behavior modification weight programs help adolescents identify and eliminate inappropriate eating behavior habits. Bariatric surgery is recommended for clients with morbid obesity (characterized by a BMI greater than 40). Dietary restriction should not be recommended because this action may cause a lot of nutrients.
Which drugs used for the treatment of plaque psoriasis will the nurse administer subcutaneously? Select all that apply. 1 Alefacept 2 Infliximab 3 Etanercept 4 Adalimumab 5 Ustekinumab
I put 2, 4, 5 Ans: 3, 4, 5 Etanercept, adalimumab, and ustekinumab are administered subcutaneously. Alefacept is given via the intramuscular route. Infliximab is administered via the intravenous route.
The primary nurse calls the pediatric nurse practitioner to examine the genital area of a 5-year-old girl in whom sexual abuse by her father is suspected. How can the primary nurse be most supportive to the child? 1 By describing the procedure and staying with the child during the examination 2 By explaining that the nurse wants to see if there is "anything wrong down there" 3 By asking whether she prefers the nurse or the mother to stay with her during the examination 4 By helping the mother explain the examination and the findings in terms that the child will understand
I put 3 Ans: 1 Describing the procedure and staying with the child during the examination provides reassurance and support for the child. Using the phrase "anything wrong down there" could cause the child to have negative feelings about herself. Asking the child to decide whether she prefers the nurse or the mother is not therapeutic and may be threatening. Depending on the mother's involvement, explaining the examination and the findings may threaten rather than support the child.
A 15-month-old child with the diagnosis of hydrocephalus is to undergo computed tomography (CT). What action should the nurse include when preparing the toddler for the CT scan? 1 Shaving the head 2 Administering the prescribed sedative 3 Starting the prescribed intravenous infusion 4 Giving the child a simple explanation of the procedure
I put 3 Ans: 2 A 15-month-old toddler will have difficulty complying with directions to remain still and may be extremely frightened by the equipment, so sedatives are usually prescribed. Shaving the head is not necessary; the head must remain still but need not be shaved. Starting the prescribed infusion is not necessary unless a contrast medium is being used. The child is too young to understand even a simple explanation of the procedure.
A nurse is explaining the myringotomy procedure to an infant's parents. What should the nurse explain about the incision? 1 It takes several days to heal, leaving some scar tissue. 2 It provides immediate relief of pressure in the middle ear. 3 It widens the perforation in the eardrum, allowing drainage. 4 It may result in permanent perforation of the tympanic membrane.
I put 3 Ans: 2 The incision for drainage produces relief of pressure and results in immediate relief of pain. This incision does not leave a scar, because healing by primary intention occurs within 24 hours. A myringotomy is performed to prevent the trauma of perforation. The incision is small and heals spontaneously within 24 hours.
A client with a diagnosis of schizophrenia, undifferentiated type, was admitted to the mental health hospital 3 days ago. The client stays in the bedroom except to eat and has no verbal interaction with other clients. When the nurse approaches, the client walks away and says, "Just leave me alone." What is the best response by the nurse? 1 "We need to talk." 2 "I'll talk to you later." 3 "What are you angry about?" 4 "Is there a reason to be so upset?"
I put 3 Ans: 2 The response "I'll talk to you later" allows the client to have the choice of communicating and leaves channels of communication open. The response "We need to talk" does not provide for any choice by the client. The response "What are you angry about?" assumes that the nurse knows the client's feelings; the nurse should not make this assumption. "Is there a reason to be so upset?" is a judgmental response; the nurse should not make the assumption that the client is upset.
Rehabilitation of a client with chronic obstructive pulmonary disease (COPD) involves strategies to decrease hospital admissions and to live a more active life. What should the nurse teach the client to do? 1 Initiate activities to eliminate infection. 2 Inhale during movements that require energy. 3 Implement breathing that uses the thoracic muscles. 4 Incorporate humidification into the home environment.
I put 3 Ans: 4 Humidification of the environment helps to prevent thickened secretions. Liquefied secretions are easier to expectorate. Measures to prevent infection are essential; however, infections are impossible to eliminate. Exhaling requires less energy than inhaling; therefore, movements that use energy should be done during exhalation. The use of abdominal muscles rather than thoracic muscles improves the client's breathing.
A mother with newly diagnosed ovarian cancer knows that she must tell her 8-year-old child about the diagnosis and how her upcoming treatment will affect their family life. She asks the nurse how she should answer if her child asks, "Are you going to die?" What should the nurse advise the mother to answer? 1 "No, but why do you ask that?" 2 "I might, but can we talk about this later?" 3 "Everyone dies, but I'll be around for a long time." 4 "I don't know, but I'm going to try very hard to stay alive."
I put 3 Ans: 4 In the first discussion the mother should convey some facts, but not overload the child with details, and offer hope; honest answers are important for the child's sense of security and well-being. An 8-year-old child may not be able to respond to the "Why?" question and become anxious, overwhelmed, and defensive. Avoiding an answer may close off communication and increase feelings of uncertainty and anxiety. Promising to stay alive constitutes false reassurance because the mother's prognosis is uncertain at this time.
A client is admitted to an emergency unit after a factory explosion. The nurse is obtaining the client's family history and checking for a medical alert bracelet. Which safety consideration is the nurse following? 1 Client identification 2 Injury prevention for staff 3 Injury prevention for clients 4 Risk for errors and adverse events
I put 3 Ans: 4 Risk for errors and an adverse event is a safety consideration applied by nurses to identify any possible risks to a client's health. It involves obtaining the client's family history and checking the client for a medical alert bracelet. Client identification involves providing an identification (ID) bracelet for each client and using two unique identifiers. Injury prevention for staff is a safety consideration that involves use of standard precautions at all times to prevent any violence involving clients. Injury prevention for clients is a safety consideration that involves keeping rails on the stretcher or placing it in a lower position.
A registered nurse is educating a nursing student about abortion-related issues. Which statement provided by the nursing student post-teaching needs correction? 1 "If a woman is in her first trimester, she may end her pregnancy according to state regulations." 2 "In the third trimester when the fetus becomes viable, the state's interest is to protect the fetus." 3 "If the fetus is over 28 weeks old, the state requires viability tests before conducting abortions." 4 "In the second trimester, the state enforces regulation regarding the person performing the abortion and the abortion facility."
I put 4 Ans: 1 A woman may end her pregnancy in the first trimester without state regulation because the risk of natural mortality from abortion is less than regular childbirth. In the third trimester when the fetus becomes viable, the state's interest is to protect the fetus. Thus, the state forbids abortion unless it is required to save the mother. If the fetus is over 28 weeks of gestational age, then some states require viability tests before conducting abortions. In the second trimester, the state enforces regulations for the person performing the abortion because it has an interest in protecting maternal health.
The nurse is performing bedside sonography for a female client who underwent a hysterectomy. Which nursing intervention needs correction? 1 Using the female icon on the bladder scanner 2 Placing an ultrasound gel pad right above the pubic bone 3 Pointing the scan head so the ultrasound is projected towards the client's coccyx 4 Placing the midline of the probe over the abdomen about 1.5 inches (3.8 cm) above the pubic bone
I put 4 Ans: 1 Before performing a bedside sonography, the male or female icon on the scanner should be selected. The male icon should be selected for men and for women who have undergone a hysterectomy. An ultrasound gel pad should be placed right above the pubic bone. The scan head should be pointed in such a way that the ultrasound is projected towards the client's coccyx. The midline of the probe should be placed over the abdomen about 1.5 inches (3.8 cm) above the pubic bone.
A male client with the dual diagnosis of major depression and polysubstance abuse has been attending group therapy. One day the client tells the nurse, "The things they talk about in group don't really pertain to me." What is the most therapeutic response by the nurse? 1 Confronting the client with realistic feedback 2 Identifying the client's stress-coping tolerance 3 Informing the client that he needs to get more involved 4 Asking the client what therapy he thinks would be more helpful
I put 4 Ans: 1 The client is using denial to separate from group members and needs realistic feedback to prevent withdrawal. Identifying the client's stress-coping tolerance will not help the client become involved with the group. Informing the client that he needs to get more involved is inadequate; the client first needs to recognize that the problems being discussed are applicable. The client is avoiding treatment. Asking about therapy preferences is not helpful.
A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation? 1 Procedures used to implement client care 2 Sequence of steps used to meet the client's needs 3 Activities employed to identify a client's problem 4 Mechanisms applied to determine nursing goals for the client
I put 4 Ans: 2 The nursing process is a step-by-step method that scientifically provides for a client's nursing needs. Procedures used to implement client care, activities employed to identify a client's problem, and mechanisms applied to determine nursing goals for the client are only steps in the nursing process.
A client is admitted to a rehabilitation unit after a brain attack (cerebrovascular accident, CVA) with residual hemiparesis. To help achieve the goal of safe walking with a cane, what should the nurse teach the client to do? 1 Shorten the stride of the unaffected extremity. 2 Advance the cane and the affected extremity simultaneously. 3 Lean the body toward the side with the cane when ambulating. 4 Hold the cane on the same side as the affected extremity and increase the base of support.
I put 4 Ans: 2 Advancing the cane and the affected extremity simultaneously supports stability. The body is supported partially on the affected limb and partially on the cane as the unaffected limb moves forward. Shortening the stride of the unaffected extremity will produce an awkward gait and instability; normal ambulation should be approximated. Leaning the body toward the cane when ambulating will change the center of gravity and cause instability. The cane is held on the unaffected, not the affected, side and advanced at the same time as the affected extremity to increase the base of support and provide stability.
A client is admitted to an alcohol rehabilitation center. On the fourth day after admission, the nurse detects a strong odor of alcohol on the client's breath. What is the nurse's first action? 1 Asking where the client got the alcohol 2 Locating and removing the alcoholic substance 3 Conveying the staff's disappointment in this behavior 4 Documenting and notifying the practitioner of the client's drinking
I put 4 Ans: 2 The nurse should remove the substance before the client or other clients have an opportunity to consume more alcohol. The primary concern is not where the alcohol was obtained but instead protecting the client from consuming more. Making the client feel guilty could increase the desire for more alcohol. The client may drink the remaining alcohol while the nurse documents the information and notifies the practitioner.