Sem 4 final exam

A client is scheduled for arthroscopic knee surgery and asks the nurse about the procedure. Which is the best response by the nurse? 1 "It is surgical repair of a joint under direct visualization using a device with a tiny video camera attached to it." 2 "It is a radiologic procedure in which dye is injected to help diagnose the extent of the knee injury." 3 "The procedure will determine the type of treatments the primary healthcare provider will prescribe." 4 "You will be anesthetized so that you do not remember anything about the procedure."

1 "It is surgical repair of a joint under direct visualization using a device with a tiny video camera attached to it." The response "It is surgical repair of a joint under direct visualization using a device with a tiny video camera attached to it" describes the procedure for arthroscopic surgery. Arthroscopic surgery is not a radiologic procedure and does not involve the injection of dye. This is a surgical procedure; the procedure is the treatment. Although the client will be anesthetized and will not remember anything about the procedure, this response evades the client's concern and does not describe the procedure.

How does the nurse know that a client at 40 weeks' gestation is experiencing true labor? 1 Cervical dilation 2 Membrane rupture 3 Decreased fetal heart rate 4 Intensification of contractions

1 Cervical dilation True labor is marked by cervical dilation, effacement, or both. It is not uncommon for membranes to rupture before true labor begins. A change in the fetal heart rate does not indicate true labor; the rate may be slowing because the fetus is resting or fetal compromise is occurring. The client's perception of the intensity of contractions is not an indication of true labor. Because of admission to the hospital and loss of diversionary activities, the client may perceive the contractions as becoming more intense.

A nurse finds that his or her surgical mask has become moist before going to a surgery. What should the nurse do? 1 Dispose of the mask 2 Wait until the mask gets dry and then enter the operating room 3 Do not cough or sneeze while wearing the mask 4 Talk less after wearing the mask to minimize respiratory airflow

1 Dispose of the mask The nurse should dispose of a mask if it gets moist or wet because the mask might have been contaminated. The nurse should not wait till the mask gets dry; instead, the mask should be changed. Coughing or sneezing should be avoided when the nurse is in a sterile area. The nurse should talk less after wearing a dry or sterile mask to minimize respiratory airflow.

The nurse is assessing a client with a laryngeal trauma. This client presents with hemoptysis, aphonia, hoarseness, dyspnea, and subcutaneous emphysema. Which condition of the client stands first in the priority list? 1 Dyspnea 2 Aphonia 3 Hoarseness 4 Subcutaneous emphysema

1 Dyspnea Bleeding from the airway, aphonia, hoarseness, and subcutaneous emphysema are the clinical manifestations of laryngeal trauma. Maintaining a patent airway is a priority; therefore, dyspnea should be corrected to prevent life-threatening consequences. Aphonia is of moderate priority and can be corrected by clearing the throat. Hoarseness can be cleared slowly since it does not threaten the client's life. Subcutaneous emphysema is of moderate priority since it does not affect the client's life directly.

What issues are associated with the difficulty in identification of teratogens? Select all that apply. 1 Teratogenic effects may be delayed. 2 Prolonged drug exposure may be required. 3 Animal test results may not be applicable to humans. 4 Behavioral effects can be easily documented and evaluated. 5 Controlled experiments on humans can reveal the effect of teratogens.

1 Teratogenic effects may be delayed. 2 Prolonged drug exposure may be required. 3 Animal test results may not be applicable to humans. Teratogenic effects may be delayed; some drugs may take years to show their effects. To identify a teratogenic effect, the subject should be exposed to drugs for a prolonged time. Some drugs may not be toxic to animals but may have adverse effects in humans. The easy documentation and evaluation of behavioral effects may help to easily identify teratogens. Controlled experiments cannot be done in humans; this makes the identification of teratogens difficult.

It is observed that at times a client with a personality disorder clings to the nurse and at other times he maintains a noticeable distance. From this pattern of behavior what does the nurse determine are the client's conflicting fears? 1 Shame versus rejection 2 Lost self-esteem versus hostility 3 Abandonment versus identity loss 4 Engulfment versus interdependence

3 Abandonment versus identity loss Alternating clinginess and distance reflects a reenactment of the mother-child relationship; behavior vacillates between distancing to avoid engulfment and clinging to avoid being rejected. Shame often results from a struggle but is not the focus of a conflicting fear. Self-esteem and fear of hostility are outcomes, not the focus of a conflict. Engulfment is part of the conflict, but interdependence is not a conflicting fear and may be a healthy balance of dependence and independence.

A client who had a myocardial infarction develops cardiogenic shock despite treatment in the emergency department. Which client responses are related to cardiogenic shock? Select all that apply. 1 Tachycardia 2 Restlessness 3 Warm, moist skin 4 Decreased urinary output 5 Bradypnea

1 Tachycardia 2 Restlessness 4 Decreased urinary output The heart rate increases and the respiratory rate increases in an attempt to meet the oxygen demands of the body. Restlessness occurs because of cerebral hypoxia. The urine output drops to less than 30 mL/hr because of decreased arterial perfusion to the kidneys and the compensatory mechanism of reabsorbing fluid to increase the circulating blood volume. The skin becomes cool and pale as blood shunts from the peripheral blood vessels to the vital organs.

Which medications are associated commonly with upper gastrointestinal (GI) bleeding? Select all that apply. 1 Aspirin 2 Ibuprofen 3 Ciprofloxacin 4 Acetaminophen 5 Methylprednisolone

1 Aspirin 2 Ibuprofen 5 Methylprednisolone Nonsteroidal antiinflammatory drugs (NSAIDs), including acetylsalicylic acid and ibuprofen, and corticosteroids such as methylprednisolone, are known causes of drug-induced gastrointestinal (GI) bleeding by causing irritation and erosion of the gastric mucosal barrier. Acetaminophen is a safe alternative to NSAIDs to reduce the risk of GI bleeding. Ciprofloxacin, an antibiotic, has not been associated with GI bleeding.

The nurse is reviewing the laboratory report of four clients. Which does the nurse suspect to have acquired immunodeficiency syndrome (AIDS)? 1 Client A 2 Client B 3 Client C 4 Client D

1 Client A The normal lymphocyte count is between 5000 and 10,000 cells/mm 3. A client with AIDS is leukopenic and has a lymphocyte count less than 3500 cells/mm 3. Therefore, client A has AIDS. Clients B, C, and D have normal lymphocyte counts.

What intervention is included in the nursing care plan for a 4-month-old infant with tetralogy of Fallot and heart failure? 1 Providing small, frequent feedings 2 Positioning the child flat on the back 3 Encouraging nutritional fluids often 4 Measuring the head circumference daily

1 Providing small, frequent feedings Small, frequent feedings with adequate rest periods in between may improve the infant's intake at each feeding; infants with tetralogy of Fallot become extremely fatigued while suckling. Positioning the child with the head elevated, not flat on the back, facilitates respiration; an infant cardiac seat, similar to a car seat, helps maintain the child in the semi-Fowler position. As a means of reducing the cardiac workload, excessive fluids usually are not offered, and fluids may even be restricted. The head circumference is not an important assessment for infants with congenital heart disease; daily head measurements should be taken for infants with hydrocephaly.

A nurse is teaching a breastfeeding mother about cleansing her nipples. What technique should the nurse emphasize? 1 Wash the breasts and nipples with water when bathing 2 Wipe the nipples with sterile water before each feeding 3 Swab the nipples with an alcohol sponge after each feeding 4 Rub the breasts and nipples with soapy water when showering

1 Wash the breasts and nipples with water when bathing Daily washing of the breasts and nipples with water is sufficient for cleanliness. It is unnecessary to use sterile water; the infant's gastrointestinal tract is not sterile. Alcohol is drying and may cause the nipples to crack. Scrubbing, as well as the use of soap, may irritate and dry the nipples.

Filgrastim 5 mcg/kg/day by injection is prescribed for a client who weighs 132 lb (60 kg). The vial label reads filgrastim 300 mcg/mL. How many milliliters should the nurse administer? Record your answer using a whole number. ___mL

1 mL The prescribed dose is 5mcg/kg. The patient's weight is 60 kg. The available concentration is 300 mcg/mL. Use the dimensional analysis and/or ratio and proportion methods to determine the appropriate amount of medication to be administered. 5mcg x 60kg = 300 mcg

The nurse is providing postoperative care to a client who had an abdominal cholecystectomy and choledochostomy who has a T-tube and a nasogastric tube in place. The client refuses deep breathing and coughing exercises. Which conclusion by the nurse is the most probable reason for the noncompliance? 1 T-tube movement increases. 2 Pain at the incision site increases. 3 The nasogastric tube gets irritating. 4 The bandage on the abdomen is constricting.

2 Pain at the incision site increases. The incision is just below the diaphragm; deep breathing causes tension and pain when the thorax expands, and coughing increases intraabdominal pressure, which stresses the surgical area. The T-tube will not move because it is sutured in place. Clients with nasogastric tubes generally resort to breathing through the mouth, limiting nasal irritation. Dressings do not encircle the abdomen; they should not be tight enough to restrict respirations.

Methods of relieving back pain are explained during a childbirth class. What activities identified by the client permit the nurse to conclude that the teaching has been understood? Select all that apply. 1 Tailor sitting 2 Pelvic rocking 3 Forward tilting 4 Sacral pressure 5 Kegel exercises

2 Pelvic rocking 3 Forward tilting 4 Sacral pressure Pelvic rocking eases tension in the muscles of the lumbar region. Lumbar pain during pregnancy results from the changes in posture as the uterus grows. Forward tilting eases tension in the muscles of the lumbar region. Lumbar pain during pregnancy results from the changes in posture as the uterus grows. Applying the heel of the hand to the laboring client's sacral area (counterpressure) helps relieve the back discomfort that may result when a fetus is in the occiput posterior position. Tailor sitting helps relax the muscles of the pelvic floor. Kegel exercises strengthen the muscles of the pelvic floor.

A secretary in a home health agency gossips about coworkers and then writes them notes to tell them how valuable they are to the organization and how much she likes working with them. What defense mechanism is being used by the secretary? 1 Denial 2 Undoing 3 Displacement 4 Intellectualization

2 Undoing Undoing is atonement for or an attempt to dissipate unacceptable acts or wishes. Denial is the refusal to accept or perceive unpleasantness as it actually exists. Displacement is the discharge of pent-up feelings onto something or someone that is less threatening than the original source of the feelings. Intellectualization is the use of abstract thinking to minimize painful feelings.

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care? 1 Increase fluid intake. 2 Restrict fluids. 3 Encourage early mobility. 4 Elevate the knee gatch of the bed.

3 Encourage early mobility. In the immediate postoperative period, mobility is encouraged because veins require the assistance of the surrounding muscle beds to help pump blood toward the heart. This reduces venous stasis and the risk of thrombophlebitis. Increased fluid intake, if not contraindicated, will prevent dehydration and venous stasis. Therefore restriction of fluids may promote venous stasis and increase risk. Elevating the knee gatch of the bed will impede venous blood flow and increase the risk for thrombophlebitis.

A client with osteoporosis is prescribed raloxifene. What should the nurse monitor in the client? 1 Check serum creatinine 2 Monitor urinary calcium 3 Monitor liver function tests 4 Observe for anxiety and drowsiness

3 Monitor liver function tests Raloxifene increases the risk for hepatic disease. Therefore the liver function test is monitored in a client who is prescribed this drug. Serum creatinine is checked in a client who is prescribed zoledronic acid. Urinary calcium is monitored in a client who is prescribed calcium supplements. Anxiety and drowsiness is observed in a client who is prescribed risedronate.

4.When monitoring a client 24 to 48 hours after surgery, the nurse should assess for which problem associated with anesthetic agents? 1 Colitis 2 Stomatitis 3 Paralytic ileus 4 Gastrocolic reflux

3 Paralytic ileus After surgery clients are at risk for paralytic ileus as a result of receiving an anesthetic agent. The nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery, through actions such as turning and early ambulation. Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool. Colitis, stomatitis, and gastrocolic reflux are not postoperative complications related to anesthetic agents.

What should a nurse do immediately when a client returns from the postanesthesia care unit following a subtotal thyroidectomy? 1 Inspect the incision. 2 Instruct the client not to speak. 3 Place a tracheostomy set at the bedside. 4 Place in the supine position for 24 hours.

3 Place a tracheostomy set at the bedside. Thyroid surgery sometimes results in accidental removal of the parathyroid glands. A resultant hypocalcemia may lead to contraction of the glottis, causing airway obstruction; edema around the operative site also may cause an airway obstruction. A patent airway takes priority over incision inspection. Speaking is important to determine the status of the laryngeal nerve. The semi-Fowler position is indicated to maximize respiratory excursion.

A client in labor is receiving an oxytocin infusion. Which alteration in client status does the nurse recognize as an adverse reaction resulting from prolonged administration? 1 Change in affect 2 Hyperventilation 3 Water intoxication 4 Increased temperature

3 Water intoxication Oxytocin has an antidiuretic effect, acting to reabsorb water from the glomerular filtrate. Oxytocin does not alter the client's affect. Hyperventilation is caused by an inappropriate breathing pattern, not prolonged use of oxytocin. Fever occurs with infection or dehydration, not prolonged administration of oxytocin.

A pregnant woman reports nausea and vomiting during the first trimester of pregnancy. The nurse explains that an increase in which hormone is the precipitating cause of the nausea and vomiting? 1 Estrogen 2 Progesterone 3 Luteinizing hormone 4 Chorionic gonadotropin

4 Chorionic gonadotropin Chorionic gonadotropin, secreted in large amounts by the placenta during gestation, and the metabolic changes associated with pregnancy can precipitate nausea and vomiting in early pregnancy; usually the manifestations of morning sickness disappear after the first trimester. Estrogen and progesterone are increased throughout pregnancy, but neither is the cause of the nausea and vomiting. Luteinizing hormone is present only during ovulation.

A female nurse has been caring for a depressed 75-year-old woman who reminds her of her grandmother. The nurse spends extra time with her every day and brings her home-baked cookies. What does the nurse's behavior reflect? 1 Affiliation 2 Displacement 3 Compensation 4 Countertransference

4 Countertransference With countertransference the professional provider of care exhibits an emotional reaction to a client based on a previous relationship or on unconscious needs or conflicts. Affiliation is turning to others for support and help when stressed or conflicted. Displacement is the discharge of pent-up feelings onto something or someone else that is less threatening than the original source of the feelings. Compensation is attempting to balance deficiencies in one area by excelling in another area.

16.A client visits the prenatal clinic for the first time. The client tells the nurse that her last menstrual period began June 10. The nurse uses the Nägele rule to calculate the EDB. What is the EDB? 1 April 7 2 March 7 3 April 10 4 March 17

4 March 17 The EDB is March 17. Using the Nägele rule, subtract 3 months and add 1 year and 7 days to the first day of the last menstrual period. April 7, March 7, and April 10 all represent inaccurate applications of the Nägele rule.

A client on her first prenatal clinic visit is at 6 weeks' gestation. She asks how long she may continue to work and when she should plan to quit. How should the nurse respond? 1 "What activities does your job entail?" 2 "How do you feel about continuing to work?" 3 "Most women work throughout their pregnancies." 4 "Usually women quit work at the start of their third trimester."

1 "What activities does your job entail?" More information is needed before the nurse can give a professional response. Although it is important to ascertain the client's feelings about continuing to work, at this time she is seeking information. Although it is true that most women work throughout their pregnancies, more information is needed before the nurse can respond. It is misinformation to state that usually women quit work at the start of the third trimester.

A nurse is assessing a newborn in the well baby nursery. What type of respirations does the nurse expect to identify in a healthy newborn? 1 Deep and retracting 2 Shallow and thoracic 3 Stertorous and regular 4 Abdominal and irregular

4 Abdominal and irregular A newborn's respirations are abdominal, diaphragmatic, and irregular; the rate varies from 30 to 60 breaths/min. Retractions are a sign of respiratory distress. A newborn's respirations are abdominal, not thoracic. Stertorous breathing may indicate respiratory distress.

A client scheduled for a transurethral prostatectomy expresses concern about the effect the surgery will have on sexual ability. Which information should the nurse share with the client? 1 May experience retrograde ejaculations 2 May have a diminished sex drive 3 Will have prolonged erections 4 Will be impotent

1 May experience retrograde ejaculations Ejection of semen into the bladder instead of the urethra is common after a transurethral prostatectomy. The surgery should not interfere with the libido and will not cause prolonged erections. Impotence is not typical with this approach; it may occur with the retroperitoneal approach.

A student is anxious about an upcoming examination but is able to study intently and does not become distracted by a roommate's talking and loud music. What level of anxiety is demonstrated by the student's ability to shut out the distractions? 1 Mild 2 Panic 3 Severe 4 Moderate

1 Mild A person with mild anxiety has a broad perceptual field and increased problem-solving abilities. Panic is characterized by a completely disruptive perceptual field. With severe anxiety, the perceptual field is reduced, as is the ability to focus on details. A moderately anxious person shuts out peripheral events and focuses on central concerns but has a decreased ability to problem solve.

A nurse is planning to teach a client about self-care. What level of anxiety will best enhance the client's learning abilities? 1 Mild 2 Panic 3 Severe 4 Moderate

1 Mild Mild anxiety motivates one to action, such as learning or making changes. Higher levels of anxiety tend to blur the individual's perceptions and interfere with functioning. Attention is severely reduced by panic. The perceptual field is greatly reduced with severe anxiety and narrowed with moderate anxiety.

The nurse is caring for a client with a somatoform disorder, conversion-type paralysis. What is the best nursing approach? 1 Discussing topics other than the paralysis 2 Explaining the reason for the physical problem 3 Asking how the client feels about being paralyzed 4 Encouraging the client to slowly walk around the room

1 Discussing topics other than the paralysis Discussion of signs and symptoms should not be initiated by the nurse; the signs and symptoms should be accepted by the nurse. Discussion should be focused on the client's feelings and current situation. Explaining the reason for the physical problem may take away the client's unconscious defense and increase anxiety. Asking how the client feels about being paralyzed focuses on the paralysis rather than feelings. Encouraging the client to slowly walk around the room denies the client's symptoms; in reality this client cannot make the legs move to walk.

A client is diagnosed with hepatitis A. The nurse takes the client's history. Which employment history is most likely linked to the development of hepatitis A? 1 Works at a plumbing business 2 Works in a hemodialysis unit at a hospital 3 Works as a dishwasher at a local restaurant 4 Works at an occupational arsenic compound business

1 Works at a plumbing business Hepatitis A primarily is spread via a fecal-oral route; sewage-polluted water may harbor the virus. Working at a hemodialysis unit is closely linked to hepatitis types B, C, and D; these types are more often spread via the blood-borne route. Using disposable equipment and proper handling of syringes decreases the risk of spreading the virus. Working as a dishwasher at a local restaurant does not increase the risk of developing the disease, but it will increase the risk of an infected individual spreading the disease to others. Exposure to arsenic or carbon tetrachloride will not cause hepatitis A.

A client with schizophrenia is admitted to a psychiatric unit. The client is talking while walking in the hall, is unkempt, and obviously has not washed in several days. What should the nurse say when trying to help this client shower? 1 "Would you like a shower?" 2 "I'll help you take your shower now." 3 "When do you want your shower, now or later?" 4 "You'll feel so much better if you have a shower."

2 "I'll help you take your shower now." The client is displaying a self-care deficit; stating the intention of helping the client shower is direct, does not require the client to make a decision, provides help, and meets the client's physiologic and psychological needs. The client may or may not be capable of making a decision; if the client says no, the nurse will be confronted with a dilemma: meeting the client's physiologic needs will contradict the client's wish not to bathe. The client may not be able to tell the nurse when the shower is desired, because the client may be incapable of making a decision. "You'll feel so much better if you have a shower" may be false reassurance; the client may not be able to process cause and effect.

A nurse in the pediatric unit is admitting an 8-year-old child with asthma after an exacerbation at home. The child is short of breath. In what position should the child be placed to facilitate breathing and to promote respiratory drainage? 1 Supine 2 Left lateral 3 High-Fowler 4 Trendelenburg

3 High-Fowler The high-Fowler position gives the lungs more room to expand, thereby promoting respiration and affording more comfort. The supine, left lateral, and Trendelenburg positions will all increase dyspnea; they do not permit chest expansion.

A rubella vaccination is ordered for a client. Which statement made by the client is cause for concern? 1 " I have been trying to conceive a baby for a few months." 2 "I have plans to have a baby by next year." 3 "I have no history of rubella in childhood." 4 "I have plans to get married by the next year."

1 " I have been trying to conceive a baby for a few months." Rubella infection is a cause for concern in women of childbearing age because it increases the risk of congenital abnormalities in a developing fetus. However, the client should not be given the rubella vaccine if already pregnant because it could affect the fetus. The client can be given the rubella vaccine if they are in child-bearing age, with the precautionary instruction to avoid conception for at least three months after vaccination. The nurse should give the rubella vaccination to the client who has not previously had rubella in childhood. This is because the client's body will not have developed antibodies against rubella and needs the vaccination. A client who is planning to get married by the next year should be encouraged to receive rubella vaccination to eliminate risk of developing the infection.

The registered nurse is teaching a student nurse about the physical examination of the integumentary system for a preoperative client. Which statement made by the student nurse indicates a need for further teaching? 1 "I should assess the neck for distended veins." 2 "I should assess the skin turgor for signs of dehydration." 3 "I should examine the skin for rashes, boils, or infections." 4 "I should question the client about any current or previous skin disorders."

1 "I should assess the neck for distended veins." When the nurse does a physical examination of a preoperative client, examining the neck for distended neck veins falls under the cardiovascular system. Instead, skin turgor is inspected for signs of dehydration and for rashes, boils, or infections, especially around the planned surgical site to prevent complications. The client is questioned about any current or previous skin disorders.

A female accountant comes to the health clinic for a preemployment physical. During the health history the new employee frequently states, "I feel so nervous about starting this job." She is able to connect with her feelings, thoughts, and actions but constantly focuses her attention on starting the new job. What does the nurse determine that the client is exhibiting? 1 A moderate level of job-related anxiety 2 A severe level of anxiety related to new situations 3 An inappropriate response to handling new situations 4 An ineffective coping mechanism in handling job-related stress

1 A moderate level of job-related anxiety The ability to connect feelings, thoughts, and actions, plus inattention to all but the anxiety-causing subject, is associated with a moderate level of anxiety. Severe anxiety is related to dissociation, selective inattention, and an inability to connect feelings, thoughts, and actions. The development of mild or moderate anxiety is common in new situations because of apprehension related to the unknown. There is insufficient information for the nurse to come to the conclusion that the client is exhibiting an ineffective coping mechanism in handling job-related stress.

A nurse is caring for a primigravida during labor. At 7 cm of dilation a prescribed pain medication is administered. Which medication requires monitoring of the newborn for the side effect of respiratory depression? 1 Butorphanol 2 Hydroxyzine 3 Promethazine 4 Diphenhydramine

1 Butorphanol Respiratory depression may occur in the newborn because the duration of action of butorphanol is 3 to 4 hours and the circulating blood level will be high if birth occurs during that time. Hydroxyzine, promethazine, and diphenhydramine are all antihistamines that have a sedative effect and are administered early in labor to promote sleep and decrease anxiety.

Upon assessment, the primary healthcare provider finds that the client is experiencing weight gain as well as elevated lipid and blood glucose levels. Which drugs in the client's prescription list are most likely to cause these metabolic side effects? Select all that apply. 1 Clozapine 2 Asenapine 3 Quetiapine 4 Olanzapine 5 Ziprasidone

1 Clozapine 4 Olanzapine Clozapine and olanzapine are second-generation antipsychotic (SGA) drugs that may cause metabolic side effects such as diabetes and dyslipidemia. Asenapine and ziprasidone are SGAs that may cause torsades de pointes by prolonging the QT interval. Quetiapine is an antipsychotic and used to treat bipolar disorders and may cause loss of appetite, but also increased blood glucose levels and elevated cholesterol.

During the fourth stage of labor, about 1 hour after giving birth, a client begins to shiver uncontrollably. What should the nurse's priority intervention be? 1 Cover the client with blankets to alleviate this typical postpartum sensation. 2 Check vital signs because the client may be experiencing hypovolemic shock. 3 Monitor the client's blood pressure because shivering may cause it to rise. 4 Obtain a prescription for an increase in the rate of the intravenous fluid infusion to restore the client's fluid reserves.

1 Cover the client with blankets to alleviate this typical postpartum sensation. There are several theories about why chilling occurs; one is that it is caused by vasomotor instability resulting from fetus-to-mother transfusion during placental separation; comfort measures such as warm blankets or fluids are indicated. Although the vital signs should be monitored during the fourth stage of labor, they are not being monitored because of the shivering, which is an expected response to the birth. Changes in blood pressure are unexpected. Shivering is not a sign of dehydration.

A client developed acute herpes zoster and was treated with antiviral medication within 72 hours of the appearance of the rash. The client is reporting persistent pain 1 week later. What does the nurse identify as the cause of the posttherapeutic neuralgia? 1 Damage to the nerves 2 Untreated major depression 3 Scarring in the area of the rash 4 Continued presence of the skin rash

1 Damage to the nerves After the original infection has healed, the virus either remains quiescent or it may return. Posttherapeutic neuralgia, which occurs in some individuals, results from damage to the nerves caused by the varicella-zoster virus; the neuralgia may last for months. Untreated major depression and scarring in the area of the rash are unrelated to posttherapeutic neuralgia. The rash does not cause posttherapeutic neuralgia.

A woman is being seen in the prenatal clinic at 36 weeks' gestation. The nurse is reviewing signs and symptoms that should be reported to the primary healthcare provider with the mother. Which signs and symptoms require further evaluation by the primary healthcare provider? Select all that apply. 1 Decreased urine output 2 Blurred vision with spots 3 Urinary frequency without dysuria 4 Heartburn after eating a fatty meal 5 Contractions that are regular and 5 minutes apart 6 Shortness of breath after climbing a flight of stairs

1 Decreased urine output 2 Blurred vision with spots 5 Contractions that are regular and 5 minutes apart Decreased urine output, blurred vision, and severe headache may occur with pregnancy-associated hypertension. Contractions that become regular are associated with the onset of labor. Preparatory (Braxton Hicks) contractions ease when the client walks. Urinary frequency occurs in the first trimester and again in the third trimester as the uterus settles back into the pelvis. The weight of the uterus may delay emptying of the stomach and make heartburn a more frequent problem. Shortness of breath would be expected after the client climbs a flight of stairs.

A client is using ritualistic behaviors. Why should a nurse give the client ample time in which to perform the ritual? 1 Denial of this activity may precipitate a panic level of anxiety. 2 Anger turned inward on the self should be allowed to be expressed. 3 Successful performance of independent activities enhances self-esteem. 4 Ample time provides an opportunity to point out the inappropriate behavior.

1 Denial of this activity may precipitate a panic level of anxiety. The repeated act protects the client against severe anxiety; interruption of the ritual will result in increased anxiety. The performance of a ritual is not anger turned inward on the self; the ritual reduces anxiety. Rituals are not activities that enhance self-esteem; they control anxiety. Pointing out that the behavior is inappropriate will further increase anxiety. The client does not want to perform the ritual but feels compelled to do so to keep anxiety at a controllable level.

The nurse is caring for a 4-year-old child who has been hospitalized with an acute asthma exacerbation. Which assessment finding requires action by the nurse? 1 Diminished breath sounds 2 Pulse rate of 110 beats/min 3 Pulse oximetry reading of 95% 4 Respiratory rate of 24 breaths/min

1 Diminished breath sounds At the beginning of an asthma episode, wheezing may be heard only with a stethoscope. As the severity of the episode increases, wheezing may become audible to the unaided ear. Children in severe respiratory distress may not demonstrate wheezing because of decreased air movement; diminished breath sounds in a child may signal an inability to move air, so this finding requires action. The normal pulse range for a 4-year-old is 80 to 125 beats/min; a pulse of 110 beats/min does not require action. The normal respiratory range for a 4-year-old is 20 to 30 breaths/min, so a respiratory rate of 24 breaths/min does not require action. A pulse oximetry reading of 95% is acceptable. Once the child has been hospitalized with an acute asthma attack, oxygen saturation should be kept at 95% or higher.

A client had a bypass graft because of an abdominal aortic aneurysm. Postoperative prescriptions include measurements of the client's abdominal girth. Which serious problem may be indicated by an increasing abdominal girth? 1 Graft leakage 2 Bowel puncture 3 Abdominal infection 4 Postoperative flatulence

1 Graft leakage During the first 24 hours after surgery, a sudden increase in abdominal girth most likely is graft related and needs to be investigated. Bowel puncture is a remote possibility but will present with classic signs (e.g., boardlike abdomen, abdominal pain) other than increasing abdominal girth. It is too early for an infection to manifest signs and symptoms. It is too early for postoperative flatulence to occur.

A mother whose child has been killed in a school bus accident tells the nurse that her child was just getting over the chickenpox and did not want to go to school but she insisted that the child go. The mother cries bitterly and says that her child's death is her fault. The nurse understands that perceiving a death as preventable most often will influence the grieving process in that it may do what? 1 Grow in intensity and duration 2 Progress to a psychiatric illness 3 Be easier to understand and to accept 4 Cause the mourner to experience a pathological grief reaction

1 Grow in intensity and duration Deaths that are perceived as preventable cause more guilt for the mourners and therefore increase the intensity and duration of the grieving process. Perceiving a death as preventable will not necessarily result in a pathological reaction, but it will usually make it harder to understand and accept the death.

A client is receiving warfarin. Which test result should the nurse use to determine whether the daily dose of this anticoagulant is therapeutic? 1 International normalized ratio (INR) 2 Accelerated partial thromboplastin time (APTT) 3 Bleeding time 4 Sedimentation rate

1 International normalized ratio (INR) Warfarin initially is prescribed day by day, based on INR blood test results. This test provides a standard system to interpret prothrombin times. APTT is used to evaluate the effects of heparin, which acts on the intrinsic pathway. Bleeding time is the time required for blood to cease flowing from a small wound; it is not used for warfarin dosage calculation. Sedimentation rate is a test used to determine the presence of inflammation or infection; it does not indicate clotting ability.

A client has been taking clomiphene citrate for 3 months to treat anovulatory cycles. Which finding should be reported to the primary healthcare provider immediately? 1 Missed period 2 Blurred vision 3 Weight gain 4 Hot flashes

1 Missed period Clomiphene is classified in pregnancy category X, and it should be discontinued if the client is pregnant. The client should notify her primary healthcare provider of the presumptive signs of pregnancy. Weight gain, blurred vision, and hot flashes are all common side effects of this ovulation inducer.

While providing nursing care for an adolescent undergoing chemotherapy for leukemia, a nurse notes blood on the child's pillowcase, as well as several bloody tissues. Which of the child's laboratory test results should the nurse review? 1 Platelet count 2 Hematocrit level 3 Prothrombin time 4 Red blood cell count

1 Platelet count The platelet count is reduced as a result of bone marrow depression associated with leukemia and the side effects of chemotherapeutic agents. A low hematocrit level might indicate anemia, but it does not establish its cause. Prothrombin time is influenced by vitamin K factors, not by lack of platelets. The red blood cell count does not affect this type of bleeding.

A client at 36 weeks' gestation arrives at the prenatal clinic for a routine examination. The nurse determines that the client's blood pressure has increased from 102/60 mm Hg to 134/88 mm Hg and becomes concerned she may be experiencing mild preeclampsia. What other sign of mild preeclampsia does the nurse anticipate? 1 Proteinuria of 1+ 2 Mild ankle edema 3 Episodes of dizziness on arising 4 Weight gain of 2 lb (907 g) in 2 weeks

1 Proteinuria of 1+ Preeclampsia is characterized by increased blood pressure and proteinuria. Mild ankle edema, known as physiologic edema, is commonly seen in the third trimester. Although no longer a diagnostic criterion for preeclampsia, edema, evidenced by excessive weight gain or edema of the hands and face, may support the diagnosis. Episodes of dizziness on arising may occur in the third trimester, because the enlarged uterus impedes venous return, causing supine hypotension. Weight gain of 2 lb in 2 weeks is expected during the third trimester.

Unsatisfied needs create anxiety that motivates an individual to action. What should the nurse identify as the purpose for this action? 1 Reducing tension 2 Denying the situation 3 Minimizing physical discomfort 4 Problem-solving and focusing on the problem

1 Reducing tension The primary purpose for action when a client is anxious is the reduction of emotional tension and prevention of escalation of the anxiety. When tension is reduced, anxiety is diminished, and the person feels more comfortable, safe, and secure. When acting to reduce anxiety, the person is extremely aware of the presence of anxiety and is not attempting to deny its existence. When anxiety becomes severe, the client is unable to focus on or solve the problem. Emotional tension, not physical discomfort, needs to be reduced. Minimizing the escalation of anxiety has an effect on psychological, rather than physical, discomfort.

A child is admitted to the hospital with pneumonia. What is the priority need that must be included in the nursing plan of care for this child? 1 Rest 2 Exercise 3 Nutrition 4 Elimination

1 Rest Rest reduces the need for oxygen and minimizes metabolic needs during the acute, febrile stage of the disease. The child requiring hospitalization for pneumonia is usually confined to bed and needs to reduce activity to conserve oxygen. Nutrition is not a priority; the child is expected to be anorectic during the febrile phase. Elimination is usually not a problem, except as a result of immobility.

5.A woman visits the prenatal clinic because an over-the-counter pregnancy test has rendered a positive result. After the initial examination verifies the pregnancy, the nurse explains some of the metabolic changes that occur during the first trimester of pregnancy. What should the nurse include? Select all that apply. 1 Sleep needs increase 2 Fluid retention increases 3 Body temperature decreases 4 Calcium requirements remain the same 5 The need for carbohydrates decreases

1 Sleep needs increase 2 Fluid retention increases 4 Calcium requirements remain the same Estrogen increases the secretion of corticosteroids, which decrease the basal metabolic rate, resulting in fatigue. Sodium is retained, and fluid retention increases to meet total needs. During the first trimester approximately 1000 mg of calcium is needed each day. There is no longer a recommendation for an increase in daily calcium intake during pregnancy and lactation. The daily recommended intake of 1000 mg for women older than 19 years and 1300 mg for women younger than 19 years is adequate for fetal bone and tooth development. Body temperature increases because of the increased metabolism related to the growth of the fetus. Carbohydrate needs increase because the secretion of insulin by the pancreas is increased; however, insulin is destroyed rapidly by the placenta. The stress of pregnancy may precipitate gestational diabetes.

The nurse has already removed a snakebite victim to a safe area. What action should the nurse take as the next priority in this situation? 1 The nurse should encourage the client to rest. 2 The nurse should remove jewelry and clothing. 3 The nurse should take photographs of the snake. 4 The nurse should call for immediate emergency assistance.

1 The nurse should encourage the client to rest. The next priority of the nurse is to encourage the client to rest to decrease the venom circulation. The next priority for the nurse is to remove jewelry and constricting clothing. The third priority for the nurse is to call immediate emergency assistance. As a final prioritizing measure, the nurse should take digital photographs of the snake for identification.

The client has arrived at the medical surgical unit after discharge from the post anesthesia care unit. Which areas should the nurse observe when making a focused assessment of the airway? 1 The nurse should monitor if the neck is in proper alignment. 2 The nurse should observe the rate and the depth of the respirations. 3 The nurse should look at the quality and the pattern of the breathing. 4 The nurse should see if the client is using accessory muscles to breathe.

1 The nurse should monitor if the neck is in proper alignment. To make a focused assessment of the airway, the nurse should observe if the neck of the client is in proper alignment with the body. The nurse should monitor the rate and the depth of the respirations while checking the breathing of the client. The quality and the pattern of breathing are also necessary to assess. The nurse should observe the client's use of accessory muscles required for breathing.

A client at 10 weeks' gestation tells the nurse in the maternity clinic that she is worried because she is voiding frequently. How should the nurse respond? 1 Recommend that she inform her healthcare provider. 2 Explain why this is expected in early pregnancy. 3 Tell the client not to worry because this is expected. 4 Collect the client's urine for a culture and sensitivity test.

2 Explain why this is expected in early pregnancy. The client should be given accurate information. Urinary frequency is caused by the pressure of the enlarging uterus on the bladder. Until 12 to 14 weeks of pregnancy the uterus is in the pelvic cavity. It then rises into the abdominal cavity, after which urinary frequency diminishes. It is unnecessary to refer the client to the healthcare provider. Urinary frequency is an expected adaptation during the first and last trimesters of pregnancy. Telling the client not to worry is demeaning because it implies that the client is not capable of understanding an explanation. It is not necessary to plan for a culture and sensitivity testing because the routine point-of-care urinalysis performed at each visit will indicate whether an infection is present and whether culture and sensitivity testing are necessary.

The nurse in the postanesthesia care unit is caring for a client who had a left-sided pneumonectomy. Which goal is priority? 1 Replace blood loss 2 Maintain ventilatory exchange 3 Maintain closed chest drainage 4 Replace supplemental oxygenation

2 Maintain ventilatory exchange Oxygen and carbon dioxide exchange is essential for life and is the priority. Blood replacement is not the priority. Closed chest drainage is unnecessary with a left-sided pneumonectomy because there is no lung to reinflate. Supplemental oxygenation is not the priority.

7.Which medications will prevent the binding of human immunodeficiency virus (HIV) to a client's cells? Select all that apply. 1 Rilpivirine 2 Maraviroc 3 Saquinavir 4 Raltegravir 5 Enfuvirtide

2 Maraviroc 5 Enfuvirtide Maraviroc and enfuvirtide are entry inhibitors that prevent the binding of HIV. Rilpivirine is one of the nonnucleoside reverse transcriptase inhibitors that inhibit the action of reverse transcriptase. Saquinavir is one of the protease inhibitors that prevent the protease enzyme from cutting HIV proteins into proper lengths. Raltegravir is one of the integrase inhibitors; it binds with integrase enzymesand prevents HIV from incorporating its genetic material into the host cell.

Which personal protective equipment will the nurse wear when providing central venous access device site care? 1 Double sterile gloves 2 Mask and sterile gloves 3 Hair cap and sterile gloves 4 Mask, gown, and double gloves

2 Mask and sterile gloves A mask will protect the catheter insertion site from droplet and airborne microorganisms emanating from the nurse, and sterile gloves will protect the insertion site from contact with microorganisms on the nurse's hands. Double gloves and a hair cap are not needed. Gown use is based upon facility protocol.

A recovering alcoholic joins Alcoholics Anonymous (AA) to help maintain sobriety. What type of group is AA? 1 Social group 2 Self-help group 3 Resocialization group 4 Psychotherapeutic group

2 Self-help group Alcoholics Anonymous is a self-help group of people who meet to attain and maintain sobriety. A social group centers on building interpersonal relationships through participation in mutual activities. A resocialization group centers on increasing social skills that may be diminished or lacking. A psychotherapeutic group treats mental and emotional disorders with the use of psychological techniques and always has a member of the healthcare profession as its leader.

A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing? 1 Atrial fibrillation 2 Sinus tachycardia 3 Ventricular fibrillation 4 First-degree atrioventricular block

2 Sinus tachycardia The presence of a P wave before each QRS complex indicates a sinus rhythm. A heart rate greater than 100 beats per minute indicates tachycardia. Atrial fibrillation causes an irregular rhythm, and P waves are not identifiable. Ventricular fibrillation is irregular and shows no PQRST configurations. A first-degree atrioventricular block pattern has a prolonged PR interval and is regular.

At mealtime a client with schizophrenia moves to the counter to choose food but is unable to decide what to do next. How can the nurse best assist the client? 1 Providing nonverbal communication 2 Speaking in simple declarative statements 3 Asking basic questions requiring simple choices 4 Rewarding the client for each of the food items chosen

2 Speaking in simple declarative statements Ambivalence makes decision-making difficult, if not impossible; simple, easy-to-follow declarative statements limit the choices available for the indecisive client. The client will be unable to interpret nonverbal communication and will experience increased confusion and indecision. Asking basic questions to elicit simple choices or giving a reward for each item chosen is inappropriate, because the pressure to make choices may increase the client's ambivalence and discomfort.

A nurse is assessing a newly admitted client with the pressure ulcer indicated in the picture. Which pressure ulcer stage should the nurse document on the admission history and physical? 1 Stage I 2 Stage II 3 Stage III 4 Stage IV

2 Stage II A stage II pressure ulcer is a partial-thickness ulceration of epidermis or dermis; it presents as an abrasion, blister, or shallow crater; has a red/pink wound bed, has no tissue sloughing, and may have an intact/open serum-filled blister. A stage I ulcer has tissue injury with intact skin with nonblanchable redness of a localized area; the ulcer may appear with persistent red, blue, or purple hues. A stage III pressure ulcer has full-thickness ulceration involving the epidermis, dermis, and subcutaneous tissue; sloughing may be present. It presents as a deep crater with or without undermining, and bone, tendon, and muscle are not exposed. A stage IV pressure ulcer involves full-thickness skin loss and damage to muscle, bone, or tendon; sloughing or eschar may be present on parts of the wound bed, and it often includes undermining and tunneling.

A nurse is managing the care of a client with recently diagnosed schizophrenia. Effective therapeutic communication will directly affect which client-focused outcomes? Select all that apply. 1 The client will become capable of part-time employment. 2 The client will effectively express emotional and physical needs. 3 The client will demonstrate wellness reflective of physical potential. 4 The client will demonstrate an understanding of the mental health disorder. 5 The client will recognize the issues most important to managing this disorder.

2 The client will effectively express emotional and physical needs. 4 The client will demonstrate an understanding of the mental health disorder. 5 The client will recognize the issues most important to managing this disorder. Therapeutic communication facilitates the exchange of information between the nurse and the client that focuses on the client attaining health and wellness. This information can be directed toward the client's health needs, such as the effective expression of the client's physical and emotional needs, the understanding of the cause and prognosis of the current mental health problem, and the recognition of issues important to the management of the client's health issues. The client's ability to maintain part-time employment and the client's physical health potential are minimally affected by therapeutic communication.

The nurse teaches a high school sex education class that herpes genitalis infection cannot be cured, but the disease is marked by remissions and exacerbations. What else should the students be taught about this infection? 1 A healthy lifestyle will prevent exacerbations. 2 Once the infection is effectively treated, exacerbations are rare. 3 Although exacerbations occur, they are not as severe as the initial episode. 4 The most effective way to prevent exacerbations is to abstain from sexual activity.

3 Although exacerbations occur, they are not as severe as the initial episode. The initial infection is both local and systemic; exacerbations are milder and localized. Although optimum health habits may limit exacerbations, they will not prevent them. There is no treatment that will limit the number of exacerbations. Exacerbations are precipitated by physical and emotional stress, not by sexual activity.

A nurse is caring for a client whose mobility is restricted to a wheelchair following a motor vehicle accident. The client has been prescribed physiotherapy as a part of rehabilitation care. What interventions should the nurse consider when the client is discharged from the healthcare facility? Select all that apply. 1 Focus firmly on the challenges faced by the client 2 Refrain from including children in the support system 3 Assist the family in identifying community support systems 4 Encourage the primary caregiver to set a routine time for respite 5 Consider the primary caregiver's experience in the discharge plan

3 Assist the family in identifying community support systems 4 Encourage the primary caregiver to set a routine time for respite 5 Consider the primary caregiver's experience in the discharge plan The nurse should assist the family in identifying support within the community. The family may need assistance with meals, physiotherapy exercises, and care for younger children. The nurse should encourage the primary caregiver to set a routine time for respite. The nurse should consider the primary caregiver's experience and abilities with nursing care while planning client discharge. The nurse should not only focus on the weaknesses and challenges faced by the client, but also the client's strengths. Children should be included in the support system, and the client and family should spend time sharing their stories with each other.

What antenatal precautions should be taken to minimize the risk of drug-induced teratogenesis? Select all that apply. 1 Preventing conception 2 Discontinuing teratogenic drugs during pregnancy 3 Avoiding the use of nonessential drugs during pregnancy 4 Terminating the pregnancy if the drug that causes teratogenicity cannot be withheld 5 Educating the client about the risks associated with teratogenic medication

3 Avoiding the use of nonessential drugs during pregnancy 4 Terminating the pregnancy if the drug that causes teratogenicity cannot be withheld 5 Educating the client about the risks associated with teratogenic medication Precautions should be taken while administering drugs during pregnancy to prevent teratogenesis. Nonessential drugs should be avoided. In conditions such as cancer where the treatment is highly toxic to the developing fetus but cannot be ethically withheld, terminating of pregnancy is recommended. Educating the client about risks associated with teratogenic medication is important because most pregnancies are unplanned. Preventing conception and discontinuing teratogenic drugs are not appropriate because the woman is already pregnant.

During a physical examination in the prenatal clinic the client's vaginal mucosa is noted to have a purplish discoloration. Which sign should the nurse document in the client's clinical record? 1 Hegar 2 Goodell 3 Chadwick 4 Braxton Hicks

3 Chadwick A purplish coloration, called the Chadwick sign, results from the increased vascularity and blood vessel engorgement of the vagina. The Hegar sign is softening of the lower uterine segment. The Goodell sign is softening of the cervix. After the fourth month of pregnancy, irregular, painless uterine contractions, called Braxton Hicks contractions, can be felt through the abdominal wall.

A nurse is caring for a client admitted to a mental health unit because of suicidal ideation. Which intervention provides the greatest safety for this client? 1 Seclusion room 2 Four-point restraints 3 Constant one-on-one supervision 4 Removal of unsafe objects from the environment

3 Constant one-on-one supervision A member of the health team provides a continuous presence to ensure the safety of a client who is at high risk for suicide. Although removing unsafe objects from the environment is important, clients who are intent on self-harm will find ways even if such objects are removed. Seclusion and four-point restraints are overly restrictive.

The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client's pain exhibits which characteristic? 1 Causes mild perspiration 2 Occurs after moderate exercise 3 Continues after rest and nitroglycerin 4 Precipitates discomfort in the arms and jaw

3 Continues after rest and nitroglycerin When neither rest nor nitroglycerin relieves the pain, the client may be experiencing an acute myocardial infarction. Angina may cause mild diaphoresis; acute myocardial infarction causes profuse diaphoresis, which should be reported. Chest pain after exercise is expected; activity increases cardiac output, which can cause angina. Anginal pain can, and often does, radiate.

One morning a client tells the nurse, "My legs are turning to rubber because I have an incurable disease called schizophrenia." What is this statement an example of? 1 Hallucinations 2 Paranoid thinking 3 Depersonalization 4 Autistic verbalization

3 Depersonalization The state in which the client feels unreal or believes that parts of the body are distorted is known as depersonalization or loss of personal identity. This is not an example of a hallucination; a hallucination is a sensory experience for which there is no external stimulus. The client's statement does not indicate any feelings that others are out to do harm, are responsible for what is happening, or are in control of the situation. The statement is not an example of autistic verbalization.

A nurse is assessing a client and finds the following (see image). Which abnormal finding can be identified from the given figure?

3 Hordeolum The condition depicted in the figure is a hordeolum; it is an infection of the sebaceous glands in the eyelid margin. A chalazion is a chronic inflammatory granuloma of the Meibomian (sebaceous) glands in the eyelid. Blepharitis is a chronic bacterial inflammation of the lid margins. Conjunctivitis is an infection and inflammation of the conjunctiva.

A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients? 1 Inept 2 Eccentric 3 Impulsive 4 Dependent

3 Impulsive Impulsive, potentially self-damaging behaviors are typical of clients with this personality disorder. Inept behavior, by itself, is not typical of clients with any specific personality disorder. Eccentric behavior is more typical of the client with a schizotypal personality disorder. Dependent behavior is more typical of the client with a dependent personality disorder.

A nurse gave a client naloxone. To evaluate the effectiveness of the medication, what should the nurse assess for? 1 Change in level of consciousness 2 Increased pain 3 Increased respiration 4 Decreased heart rate

3 Increased respiration Naloxone is given for decreased respirations caused by opioid overdose. The amount given is determined by the respiratory status, not the level of consciousness. Undesirable side effects of naloxone are pain and rapid heart rate with dysrhythmias.

A nurse is caring for a toddler with severe dehydration and its associated acid-base imbalance. What compensatory mechanism within the body is activated to counteract the effects of the child's acid-base imbalance? 1 Profuse diaphoresis 2 Increased temperature 3 Increased respiratory rate 4 Renal retention of hydrogen ions

3 Increased respiratory rate The child has metabolic acidosis; the lungs compensate by blowing off excess carbonic acid in the form of carbon dioxide. Diaphoresis is a compensatory mechanism to reduce fever by evaporation, not to compensate for metabolic acidosis. Fever is not a compensatory mechanism to counter metabolic acidosis; fever with dehydration results from inadequate fluid for perspiring and cooling. The kidneys excrete hydrogen and ammonium ions to compensate for metabolic acidosis.

When planning interventions to help a client with bipolar I disorder, manic episode, meet rest and sleep needs, what must the nurse remember about the manic client? 1 Experiences few sleep pattern disturbances 2 Requires less sleep than the average person 3 Is easily stimulated, and this interferes with sleep 4 Needs to expend energy to be tired enough to sleep

3 Is easily stimulated, and this interferes with sleep Manic individuals readily respond to environmental cues. Increased stimulation increases activity; decreased stimulation decreases activity. Sleep pattern disturbances characteristically occur because of psychomotor activity. All individuals require adequate rest and sleep; hyperactive clients may become exhausted because of their high activity level. Expending energy only increases the tendency to remain awake.

When attempting to assess the behavior of an older adult with a diagnosis of vascular dementia, what does the nurse know is probable about the client's use of defense mechanisms? 1 Incapable of using any defense mechanisms 2 Using one method of defense for every situation 3 Making exaggerated use of old, familiar mechanisms 4 Attempting to develop new defense mechanisms to meet the current situation

3 Making exaggerated use of old, familiar mechanisms Clients with dementia try to use defense mechanisms that have worked in the past but use them in an exaggerated manner. The client can use defense mechanisms but is not capable of focusing on one defense mechanism. Because of brain cell destruction clients are unable to develop new defense mechanisms.

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant enterococcus (VRE). After notifying the primary healthcare provider, which action should the nurse take to decrease the risk of transmission to others? 1 Insert a Foley catheter. 2 Initiate droplet precautions. 3 Move the client to a private room. 4 Use a high-efficiency particulate air (HEPA) respirator when entering the room.

3 Move the client to a private room. Clients with VRE should be moved to a private room to decrease transmission to others. VRE has been identified in the urine, not respiratory secretions. Contact isolation should be implemented. A Foley catheter should not be inserted because it will predispose the client to develop an additional infection. A HEPA respirator is not required when entering the room.

Which factor is essential to consider when the nurse determines whether a unit's environment is conducive to psychologic safety for a confused client with dementia? 1 Nursing care is flexible. 2 The client's needs are met entirely. 3 Realistic limits and controls are set. 4 The physical surroundings are clean and orderly.

3 Realistic limits and controls are set. Confused clients find comfort and security in an environment that provides realistic limits and controls, because this reduces the need for self-regulation. Flexible nursing care may be confusing and may precipitate anxiety. No environment can meet all of a client's needs. Cleanliness and orderliness are components of physical, not psychological, safety.

Nursing actions for an older adult should include health education and promotion of self-care. Which is most important when working with an older adult client? 1 Encouraging frequent naps 2 Strengthening the concept of ageism 3 Reinforcing the client's strengths and promoting reminiscing 4 Teaching the client to increase calories and focusing on a high-carbohydrate diet

3 Reinforcing the client's strengths and promoting reminiscing Reinforcing strengths promotes self-esteem; reminiscing is a therapeutic tool that provides a life review that assists adaptation and helps achieve the task of integrity associated with older adulthood. Frequent naps may interfere with adequate sleep at night. Reinforcing ageism may enhance devaluation of the older adult. A well-balanced diet that includes protein and fiber should be encouraged; increasing calories may cause obesity.

A client with the diagnosis of bipolar disorder, depressive episode, has been hospitalized on a psychiatric unit for 1 week. What is the most appropriate activity for this client? 1 Completing a jigsaw puzzle alone 2 Playing cards with several other clients 3 Talking with the nurse several times during the day 4 Engaging in a game of table tennis with another client

3 Talking with the nurse several times during the day Involving the client in a one-on-one conversation provides individualized, low-anxiety-producing attention and gives the message that the client is important, which supports self-esteem. Completing a jigsaw puzzle alone may require too much concentration for a depressed client. Playing a game of cards with several other clients may require too much concentration for a depressed client; also, it involves competition, which is not therapeutic at this time. A depressed client does not have the energy to engage in a game of table tennis; also, this is a competitive game, which is not therapeutic at this time.

A client with severe preeclampsia who was admitted to the high-risk unit anxiously asks the nurse, "Will my baby be all right?" How should the nurse respond? 1 "There's no way of telling at this time what the outcome will be." 2 "If you do what the primary healthcare provider tells you to do, everything will progress normally." 3 "The baby will probably be alright. Did you know that the amniotic fluid provides protection?" 4 "We'll be monitoring your baby's condition continuously. Would you like to listen to the baby's heartbeat?"

4 "We'll be monitoring your baby's condition continuously. Would you like to listen to the baby's heartbeat?" Explaining to the client that the fetus will be closely monitored and asking whether she would like to hear the heartbeat serves to reassure the client of the fetus's well-being. Stating that there is no way of telling at this time what the outcome will be does not provide the mother with reassurance regarding the fetus's status or whether anything is being done to monitor the fetus. Stating that if the client does what the primary healthcare provider tells her to do everything will progress normally provides false reassurance; following instructions does not guarantee a healthy newborn. Stating that the baby will be all right provides false reassurance, and amniotic fluid makes the umbilical cord less vulnerable but does not protect against other causes of fetal compromise.

A nurse is caring for a client who was admitted with the diagnosis of severe preeclampsia and is now receiving an intravenous infusion of magnesium sulfate. What is the classification of this medication? 1 Diuretic 2 Oxytocic 3 Antihypertensive agent 4 Central nervous system depressant

4 Central nervous system depressant Magnesium sulfate is a central nervous system depressant; it eases cerebral irritability, thus preventing seizures. Magnesium sulfate is not a diuretic; however, adequate kidney function is necessary to promote its excretion, otherwise toxicity will result. Magnesium sulfate is not an oxytocic; oxytocin is used to promote uterine contractions and can cause an increased blood pressure. Magnesium sulfate is not an antihypertensive; however, it may cause a transient decrease in blood pressure because of its peripheral dilating effect.

A client states, "I get down on myself when I make a mistake." In a cognitive therapy approach, which nursing interventions are most appropriate? Select all that apply. 1 Teaching the client relaxation exercises to diminish stress 2 Exploring with the client past experiences that have caused distress 3 Providing the client with mastery experiences designed to boost self-esteem 4 Encouraging the client to replace these negative thoughts with positive thoughts 5 Helping the client modify the belief that anything less than perfection is unacceptable

4 Encouraging the client to replace these negative thoughts with positive thoughts 5 Helping the client modify the belief that anything less than perfection is unacceptable Cognitive therapy seeks to find underlying self-defeating beliefs and replace them with more reality-based positive beliefs. It encourages the use of cognitive restructuring (cognitive reframing) through positive self-talk and a rational mindset. Teaching the client relaxation exercises to diminish stress reflects a behavioral approach. Exploring with the client past experiences that have caused distress is a psychoanalytical approach. Providing the client with mastery experiences to boost self-esteem is a behavioral approach.

While receiving an adrenergic beta 2 agonist drug for asthma, the client complains of palpitations, chest pain, and a throbbing headache. What is the most appropriate nursing action? 1 Withhold the drug and notify the healthcare provider. 2 Tell the client not to worry; these are expected side effects from the medicine. 3 Give instructions to breathe slowly and deeply for several minutes. 4 Explain that the effects are temporary and will subside as the body becomes accustomed to the drug.

4 Explain that the effects are temporary and will subside as the body becomes accustomed to the drug.

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The parents ask how this could happen in addition to many other questions. Hemophilia A is linked to a deficiency in what? 1 Factor II 2 Factor III 3 Factor IX 4 Factor VIII

4 Factor VIII Hemophilia type A, which is the most common type of hemophilia, is from a deficiency of Factor VIII. Factors II and III are distractors. Factor IX is associated with hemophilia type B.

Nursing assessment of a client in labor reveals that she is entering the transition phase of the first stage of labor. Which clinical manifestations support this conclusion? 1 Facial redness and an urge to push 2 Bulging perineum, crowning, and caput 3 Less intense, less frequent contractions 4 Increased bloody show, irritability, and shaking

4 Increased bloody show, irritability, and shaking Increased bloody show, irritability, and shaking are some of the classic signs of the transition phase of the first stage of labor. The increase in bloody show is related to the complete dilation of the cervix, the irritability is related to the intensity of contractions, and the shaking is believed to be a vasomotor response. Facial redness and an urge to push are associated with the start of the second stage of labor. A bulging perineum, crowning, and caput signal that birth is imminent. Less intense, less frequent contractions may signal uterine hypotonicity, which may occur throughout the first stage of labor.

A client reports pain during urination and a profuse, yellowish-green penile discharge. After an assessment, the primary healthcare provider schedules the client for a nucleic acid amplification test (NAAT). Which organism may be the cause of the client's condition? 1 Escherichia coli 2 Treponema pallidum 3 Mycoplasma hominis 4 Neisseria gonorrhoeae

4 Neisseria gonorrhoeae A client with pain during urination and a profuse, yellowish-green penile discharge may have gonorrhea caused by Neisseria gonorrhoeae. The NAAT is highly sensitive and specific to gonorrhea. Organisms such as Escherichia coli may cause pelvic inflammatory disease. Signs include lower abdominal and pelvic pain. Treponema pallidum, which causes syphilis, is manifested by chancres and rashes. Mycoplasma hominis is a bacterium that produces bacterial vaginosis, which is manifested by upper genital tract infections.

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? 1 Primary 2 Secondary 3 Superinfection 4 Nosocomial

4 Nosocomial A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.

The nurse is taking the health history of a client who has been admitted for repair of a cystocele and rectocele. Which signs or symptoms would the nurse expect the client to report? 1 White vaginal discharge and itching 2 Sporadic bleeding and abdominal pain 3 Increased temperature and intractable diarrhea 4 Stress incontinence and low abdominal pressure

4 Stress incontinence and low abdominal pressure As the uterus drops, the vaginal wall relaxes. When the bladder herniates into the vagina (cystocele) and the rectal wall herniates into the vagina (rectocele), the individual feels pressure or pain in the lower back and/or pelvis. When there is an increase in intraabdominal pressure in the presence of a cystocele, incontinence results. A white vaginal discharge (leukorrhea) and vaginal itching (pruritus) do not indicate cystocele and rectocele; they are common with a vaginal infection. Sporadic bleeding is not expected with cystocele and rectocele. Increased temperature and intractable diarrhea are not expected with cystocele and rectocele; a fever would indicate an infection; constipation, not diarrhea, is more likely to occur.

While assessing the hair of a client with a complaint of hair loss, the nurse notices straightening combs on the scalp. Which condition does the nurse suspect in the client? 1 Vitiligo 2 Nevus of Ota 3 Pseudofolliculitis 4 Traction alopecia

4 Traction alopecia Traction alopecia is hair loss resulting from straightening combs. Vitiligo is an abnormal skin condition that may be due to loss of pigment in the affected area. Nevus of Ota is an abnormal skin condition that appears as a slate-gray or bluish-gray birthmark located on the forehead and face around the eye area. Pseudofolliculitis is an inflammatory response to ingrown hairs that occurs after shaving too closely in the beard area.

A man who has 40% of the body surface area burned is admitted to the hospital. Fluid replacement of 7200 mL during the first 24 hours has been prescribed. What does the nurse calculate the hourly intravenous (IV) fluid to be? Record your answer using a whole number. ___ mL/hr

The total volume to be infused is 7200 mL. The total time of infusion is 24 hours. 7200 mL/24 hr = 300 mL/hr