Research

The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in this discussion? Select all that apply. 1. Hemodialysis 2.Peritoneal dialysis 3.Kidney transplant 4.Bilateral nephrectomy 5.Intense immunosuppression therapy

1, 2, 4

The nurse is evaluating the respiratory outcomes for a client with Guillain-Barré syndrome. The nurse determines that which are acceptable outcomes for the client? Select all that apply. 1. Spontaneous breathing 2. Oxygen saturation of 98% 3.Adventitious breath sounds 4.Normal arterial blood gas levels 5.Vital capacity within normal range

1, 2, 4, 5

The nurse is performing an admission assessment on a child with a seizure disorder. The nurse is interviewing the child's parents to determine their adjustment to caring for their child, who has a chronic illness. Which statement, if made by the parents, would indicate a need for further teaching? 1. "Our child sleeps in our bedroom at night." 2. "We worry about injuries when our child has a seizure." 3. "Our child is involved in a swim program with neighbors and friends." 4. "Our babysitter just completed cardiopulmonary resuscitation training."

1. "Our child sleeps in our bedroom at night."

A nursing student is assisting a school nurse in performing scoliosis screening on the children in the school. The nurse assesses the student's preparation for conducting the screening. The nurse determines that the student demonstrates understanding of the disorder when the student states that scoliosis is characterized by which finding? 1. Abnormal lateral curvature of the spine 2.Abnormal anterior curvature of the lumbar spine 3. Excessive posterior curvature of the thoracic spine 4. Abnormal curvature of the spine caused by inflammation

1. Abnormal lateral curvature of the spine

A child has just returned from surgery and has a hip spica cast. What is the nurse's priority action for this client? 1. Elevate the head of the bed. 2.Assess the circulatory status. 3.Abduct the hips using pillows. 4.Turn the child onto the right side.

1. Assess the circulatory status

A client with myasthenia gravis arrives at the hospital emergency department in suspected crisis. The health care provider plans to administer edrophonium to differentiate between myasthenic and cholinergic crises. The nurse ensures that which medication is available in the event that the client is in cholinergic crisis? 1. Atropine sulfate 2. Morphine sulfate 3. Protamine sulfate 4. Pyridostigmine bromide

1. Atropine sulfate

A client who has had a prostatectomy has been instructed in perineal exercises to gain control of the urinary sphincter. The nurse determines that the client demonstrates a need for further teaching when he states that he will perform which movement as part of these exercises? 1. Bearing down as if having a bowel movement 2. Tightening the muscles as if trying to prevent urination 3.Contracting the abdominal, gluteal, and perineal muscles 4.Tightening the rectal sphincter while relaxing abdominal muscles

1. Bearing down as if having a bowel movement

The nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement by one of the parents indicates an understanding of the use of the harness? "I can remove the harness to bathe my infant." 2."I need to remove the harness to feed my infant." 3."I need to remove the harness to change the diaper." 4."My infant needs to remain in the harness at all times."

1. I can remove the harness to bathe my infant

Cerebral palsy (CP) is suspected in a child and the parents ask the nurse about the potential warning signs of CP. The nurse should provide which information? Select all that apply. 1.The infant's arms or legs are stiff or rigid. 2.A high risk factor for CP is very low birth weight. 3.By 8 months of age, the infant can sit without support. 4.The infant has strong head control but a limp body posture. 5.The infant has feeding difficulties, such as poor sucking and swallowing. 6.If the infant is able to crawl, only one side is used to propel himself or herself.

1. Infants arms or legs are stiff or rigid 2. A high risk factor for CP is very low birth weight 5. The infant has feeding difficulties, such as poor sucking and swallowing 6. If the infant is able to crawl, only one side is used propel themselves

The nurse is caring for a newborn infant with spina bifida (myelomeningocele) who is scheduled for surgical closure of the sac. In the preoperative period, which is the priority problem? 1. Infection 2. Choking 3. Inability to tolerate stimulation 4. Delayed growth and development

1. Infection

The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are characteristics of this disorder? Select all that apply. 1, Nocturia 2. .Incontinence 3.Enlarged prostate 4.Nocturnal emissions 5.Decreased desire for sexual intercourse

1. Nocturia 2. Incontinence 3. Enlarged prostate

A client with multiple sclerosis tells a home health care nurse that she is having increasing difficulty in transferring from the bed to a chair. What is the initial nursing action? 1. Observe the client demonstrating the transfer technique. 2.Start a restorative nursing program before an injury occurs. 3.Seize the opportunity to discuss potential nursing home placement. 4.Determine the number of falls that the client has had in recent weeks.

1. Observe the client demonstrating the transfer technique

The nurse is monitoring a client who has just returned from surgery after a transurethral resection of the prostate (TURP). The client has a 3-way Foley catheter in place for ongoing bladder irrigation. The nurse is observing the color of the client's urine and should expect which urine color during the immediate postoperative period? 1. Pale pink urine 2. Dark pink urine 3. Tea-colored urine 4. Bright red blood with small clots in the urine

1. Pale, pink urine

A girl who is playing in the playroom experiences a tonic-clonic seizure. During the seizure, the nurse should take which actions? Select all that apply. 1. Remain calm. 2. Time the seizure. 3. Ease the child to the floor. 4. Loosen restrictive clothing. 5.Keep the child on her back.

1. Remain calm 2. Time the seizure 3. Ease the child to the floor 4. Loosen restrictive clothing

A client with recent-onset Bell's palsy is upset and crying about the change in facial appearance. The nurse plans to support the client emotionally by making which statement to the client? 1."This is not a stroke, and many clients recover in 3 to 5 weeks." 2."This is caused by a small tumor, which can be removed easily." 3."This is similar to a stroke, but all symptoms will reverse without treatment." 4."This is a temporary problem, with treatment similar to that for migraine headaches."

1. This is not a stroke, and many clients recover in 3-5 weeks

The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Place the child in a prone position. 5. Move furniture away from the child. 6. Insert a padded tongue blade in the child's mouth.

1. Time the seizure 3. Stay with the child 5. Move furniture away from the child

The nurse is providing home care instructions to the parents of a child with a seizure disorder. Which statement indicates to the nurse that the teaching regarding seizure disorders has been effective? 1. "We're glad we only have to give our child the medication for 30 days." 2. "We will make appointments for follow-up blood work and care as directed." 3."We're glad there are no side effects from taking the antiseizure medications." 4."After our child has been seizure free for 1 month, we can discontinue the medication."

2. "We will make appointments for follow-up blood work and care as directed."

A child with developmental dysplasia of the hip is placed in a Pavlik harness. The nurse should demonstrate to the parents how to place the child in this harness by placing the child's legs in which position? 1.Prone 2.Abduction 3.Adduction 4.Extension

2. Abduction

A child must wear a brace for correction of scoliosis. The nurse creates a plan of care knowing the child is at risk for which problem? 1. Inability to ambulate 2. Breaks in skin integrity 3. Decreased oxygenation 4. Delayed growth and development

2. Breaks in skin integrity

A client is diagnosed with Bell's palsy. The nurse assessing the client expects to note which symptom? 1.A symmetrical smile 2.Difficulty closing the eyelid on the affected side 3.Narrowing of the palpebral fissure on the affected side 4.Paroxysms of excruciating pain in the lips and cheek on the affected side

2. Difficulty closing the eyelid on the affected side

The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse should monitor for which sign of a serious complication associated with this type of traction? 1. Lack of appetite 2.Elevated temperature 3.Decrease in the urinary output 4.Increase in the blood pressure

2. Elevated temperature

The nursing student is caring for a client with benign prostatic hyperplasia (BPH). The nursing instructor asks the student to identify the clinical manifestations associated with this condition. The student needs further teaching if the student states that which finding is an early symptom of BPH? 1.Nocturia 2.Hematuria 3.Decreased force of urine stream 4.Difficulty initiating urine stream

2. Hematuria

The nurse has given the client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs further teaching if the client makes which statements? 1. "I will perform facial exercises." 2."I will expose my face to cold to decrease the pain." 3."I will massage my face with a gentle upward motion." 4."I will wrinkle my forehead, blow out my cheeks, and whistle frequently."

2. I will expose my face to cold to derease the pain

The home care nurse is visiting a client with a diagnosis of Parkinson's disease. The client is taking benztropine mesylate orally daily. The nurse provides information to the spouse regarding the side effects of this medication and should tell the spouse to report which side effect if it occurs? 1. Shuffling gait 2. Inability to urinate 3. Decreased appetite 4. Irregular bowel movements

2. Inability to urinate

A client is admitted with an exacerbation of multiple sclerosis. The nurse is assessing the client for possible precipitating risk factors. Which factor, if reported by the client, should the nurse identify as being unrelated to the exacerbation? 1.Annual influenza vaccination 2.Ingestion of increased fruits and vegetables 3.An established routine of walking 2 miles each evening 4.A recent period of extreme outside ambient temperatures

2. Ingestion of increased fruits in vegetables

The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure? 1. Body stiffening 2.Spasms of the entire body 3.Sudden loss of consciousness 4.Brief flexion of the extremities

2. Spasms of the entire body

The clinic nurse is assessing a child suspected of having juvenile rheumatoid arthritis (JRA). Which assessment findings should the nurse expect to note in a child who has been diagnosed with JRA? Select all that apply. 1. Hematuria 2. Morning stiffness 3. Painful, stiff, and swollen joints 4. Limited range of motion of the joints 5. Stiffness that develops later in the day 6. History of late-afternoon temperature

2. morning stiffness 3. painful, stiff, and swollen joints 4. limited range of motion in the joints 6. history of late-afternoon temperature

The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the child can perform range-of-motion exercises at this time. The nurse should make which response? 1. "Avoid all exercise during painful periods." 2. "Range-of-motion exercises must be performed every day." 3."Have the child perform simple isometric exercises during this time." 4. "Administer additional pain medication before performing range-of-motion exercises."

3. "Have the child perform simple isometric exercises during this time."

The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction? 1."I will encourage my child to perform prescribed exercises." 2."I will have my child wear soft fabric clothing under the brace." 3."I should apply lotion under the brace to prevent skin breakdown." 4."I should avoid the use of powder because it will cake under the brace."

3. "I should apply lotion under the brace to prevent skin breakdown

The nurse is giving a client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed touch-down of the affected leg. The nurse should tell the client to perform which action? 1. Advance the crutches along with both legs simultaneously. 2.Advance the crutches along with the right leg, and then advance the left leg. 3.Advance the crutches along with the left leg, and then advance the right leg. 4.Advance the left leg along with right crutch, and then the right leg and left crutch.

3. Advance the crutches along with the left leg, and then advance the right leg.

The nurse has provided instructions to a client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further teaching? 1. "I will rest each afternoon after my walk." 2 ."I should cough and deep breathe many times during the day." 3."I can change the time of my medication on the mornings when I feel strong." 4."If I get abdominal cramps and diarrhea, I should call my health care provider."

3. I can change the time of my medication on the mornings when I feels strong

Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder? 1. "Treatment needs to be started as soon as possible." 2. "I realize my infant will require follow-up care until fully grown." 3."I need to bring my infant back to the clinic in 1 month for a new cast." 4."I need to come to the clinic every week with my infant for the casting."

3. I need to bring my infant back to the clinic every in 1 month for a new cast

A client with multiple sclerosis is experiencing muscle weakness, spasticity, and an ataxic gait. On the basis of this information, the nurse should include which client problem in the plan of care? 1. Inability to care for self 2. Interruption in skin integrity 3.Interruption in physical mobility 4. Inability to perform daily activities

3. Interruption of physical mobility

The nurse is assisting a health care provider (HCP) examining a 3-week-old infant with developmental dysplasia of the hip. What test or sign should the nurse expect the HCP to assess? 1.Babinski's sign 2.The Moro reflex 3.Ortolani's maneuver 4.The palmar-plantar grasp

3. Ortolani's maneuver

The nurse is planning measures to increase bed mobility for a client in skeletal leg traction. Which item should the nurse consider to be most helpful for this client? 1. Television 2. Fracture bedpan 3. Overhead trapeze 4. Reading materials

3. Overhead trapeze

The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client? 1. Walking on the toes 2. Unsteady and staggering 3. Shuffling and propulsive 4.Broad-based and waddling

3. Shuffling and propulsive

The nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia? 1. Nocturia 2.Scrotal edema 3.Occasional constipation 4.Decreased force in the stream of urine

4 decreased force in the steam of urine

The nurse is assisting a health care provider (HCP) during the examination of an infant with developmental hip dysplasia. The HCP performs the Ortolani maneuver. The nurse determines that the infant exhibits a positive response to this maneuver if which finding is noted? 1. A shrill cry from the infant 2.Asymmetry of the affected hip 3. Reduced range of motion in the right and left hip 4. A palpable click during abduction of the affected hip

4. A palpable click during abduction of the affected hip

The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which assessment finding should the nurse expect to note documented in the infant's record regarding this condition? 1. Full range of motion in the affected hip 2. An apparent short femur on the unaffected side 3. Asymmetrical adduction of the affected hip when placed supine, with the knees and hips flexed 4. Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table

4. Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table

A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which assessment finding indicates the need to notify the health care provider (HCP)? 1.Red, bloody urine 2. Pain rated as 2 on a 0-10 pain scale 3. Urinary output of 200 mL higher than intake 4. Blood pressure, 100/50 mm Hg; pulse, 130 beats/minute

4. Blood pressure, 100/50; pulse 130

The nurse is performing an assessment of a 7-year-old child who is suspected of having episodes of absence seizures. Which assessment question to the mother will assist in providing information that will identify the symptoms associated with this type of seizure? 1. "Does twitching occur in the face and neck?" 2. "Does the muscle twitching occur on one side of the body?" 3. "Does the muscle twitching occur on both sides of the body?" 4. "Does the child have a blank expression during these episodes?"

4. Does the child have a blank expression during these episodes?

The pediatric nurse educator provides a teaching session to the nursing staff regarding juvenile idiopathic arthritis (JIA). Which action by a nursing staff member in the care of a child with JIA indicates a need for further education? 1. Assesses for joint stiffness in the child 2.Encourages performance of isometric exercises 3.Administers nonsteroidal antiinflammatory medication 4.Emphasizes the importance of rising quickly in the mornings

4. Emphasizes the importance of rising quickly in the mornings

The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? 1. "I need to be sure not to go barefoot around the house." 2. "If I cut my toenails, I need to be sure that I cut them straight across." 3. "It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." 4. "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day."

4. I need to be sure that I elevate my leg above the level of my heart for at least an hour every day

The nurse is implementing a teaching plan for a 4-month-old child who has been diagnosed with developmental dysplasia of the hip. The child will be placed in the Pavlik harness. Which statement by the family indicates that they understand the care of their child while placed in the Pavlik harness? 1. "I know that the harness must be worn continuously." 2. "I will bring my child back to the orthopedic office in a month or two so the straps can be checked." 3. "I realize that I will also need to put two diapers on my child so that the harness will stay dry and does not get soiled." 4."I will watch for any redness or skin irritation where the straps are applied and call the health care provider for red areas."

4. I will watch for any redness or skin irritation where the straps are applied and call the health care provider for red areas

A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action? 1. Administer an antiemetic. 2. Increase the intravenous fluids. 3. Place the child in a Sims' position. 4. Notify the health care provider (HCP).

4. Notify the health care provider (HCP)

A client who has experienced nonunion of a fracture is scheduled for bone grafting using cadaver bone. The client appears restless and anxious about the procedure. After determining that the client understands the surgical procedure, the nurse should explore which item next? 1. Concern about the level of postoperative pain 2. The availability of assistance for the client after discharge 3. Whether the client needs a PRN prescription for an antianxiety agent 4.Potential worry about contracting hepatitis or possibly human immunodeficiency virus infection

4. Potential worry about contracting hepatitis or possibly HIV

The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? 1. Emergency cart 2. Tracheotomy set 3. Padded tongue blade 4. Suctioning equipment and oxygen

4. Suctioning equipment and oxygen

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process? 1.An infectious disease of the central nervous system 2.An inflammation of the brain as a result of a viral illness 3.A chronic disability characterized by impaired muscle movement and posture 4.A congenital condition that results in moderate to severe intellectual disabilities

A chronic disability characterized by impaired muscle movement and posture

You're explaining to a group of outpatients about the signs and symptoms that may present with osteoarthritis. Select all the signs and symptoms that may present with this condition: A. Herberden's Node B. Morning stiffness for less than 30 minutes C. Soft, tender, warm joints D. Fever E. Anemia F. Hard and bony joints G. Crepitus H. Bouchard's Node

A, B, F, G, E

The nurse is creating a plan of care for a newborn infant with spina bifida (myelomeningocele type). The nurse includes assessment measures in the plan to monitor for increased intracranial pressure. Which assessment technique should be performed that will best detect the presence of an increase in intracranial pressure? 1. Check urine for specific gravity. 2.Monitor for signs of dehydration. 3.Assess anterior fontanel for bulging. 4.Assess blood pressure for signs of hypotension.

Assess anterior fontanel for bulging

A patient is newly diagnosed with osteoarthritis. Which medication below is NOT ordered to treat this condition? A. NSAIDs B. Intra-articular corticosteroids C. DMARDs D. Glucosamine

C

A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding should be noted in this condition? 1.Limited range of motion in the affected hip 2.An apparent lengthened femur on the affected side 3.Asymmetrical adduction of the affected hip when the infant is placed supine with the knees and hips flexed 4.Symmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table

Limited range of motion on the affected hip

A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse should anticipate that which type of wound care to the fasciotomy site will be prescribed? 1. Dry sterile dressings 2. Hydrocolloid dressings 3. Moist sterile saline dressings 4 .One-half strength povidone-iodine dressings

Moist sterile saline dressings

The nurse is performing an assessment on a client with Guillain-Barré syndrome. The nurse determines that which finding would be of most concern? 1. Difficulty articulating words 2. Lung vital capacity of 10 mL/kg 3. Paralysis progressing from the toes to the waist 4.A blood pressure (BP) decrease from 110/78 mm Hg to 102/70 mm Hg

Vital capacity to 10 mL / kg