SOC4 Final Exam

The community health nurse visits a client at home. Prednisone, 10 mg orally daily, has been prescribed for the client and the nurse teaches the client about the medication. Which statement, if made by the client, indicates that further teaching is necessary? 1. "I can take aspirin or my antihistamine if I need it." 2. "I need to take the medication every day at the same time." 3. "I need to avoid coffee, tea, cola, and chocolate in my diet." 4. "If I gain more than 5 pounds a week, I will call my health care provider (HCP)."

1. "I can take aspirin or my antihistamine if I need it."

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? 1. "I cannot discuss any client situation with you." 2. "If you want to know about Carol, you need to ask her yourself." 3. "Only because you're worried about a friend, I'll tell you that she is improving." 4. "Being her friend, you know she is having a difficult time and deserves her privacy."

1. "I cannot discuss any client situation with you."

The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? 1. "I need to stop my insulin." 2. "I need to increase my fluid intake." 3. "I need to monitor my blood glucose every 3 to 4 hours." 4. "I need to call the health care provider (HCP) because of these symptoms."

1. "I need to stop my insulin."

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instructions? 1. "I should take hot baths because they are relaxing." 2. "I should sit whenever possible to conserve my energy." 3. "I should avoid long periods of rest because it causes joint stiffness." 4. "I should do some exercises, such as walking, when I am not fatigued."

1. "I should take hot baths because they are relaxing."

The home care nurse provides instructions regarding basic infection control to the parent of an infant with human immunodeficiency virus (HIV) infection. Which statement, if made by the parent, indicates the need for further instruction? 1. "I will clean up any spills from the diaper with diluted alcohol." 2. "I will wash baby bottles, nipples, and pacifiers in the dishwasher." 3. "I will be sure to prepare foods that are high in calories and high in protein." 4. "I will be sure to wash my hands carefully before and after caring for my infant."

1. "I will clean up any spills from the diaper with diluted alcohol."

The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to describe the concept of acculturation. The nurse educator should make which most appropriate response? 1. "It is a process of learning a different culture to adapt to a new or changing environment." 2. "It is a subjective perspective of the person's heritage and a sense of belonging to a group." 3. "It is a group of individuals in a society who are culturally distinct and have a unique identity." 4. "It is a group that shares some of the characteristics of the larger population group of which it is a part."

1. "It is a process of learning a different culture to adapt to a new or changing environment."

Which clients has a high risk of obesity and diabetes mellitus? Select all that apply. 1. A 40-year-old Latino American man 2. A 45-year-old Native American man 3. A 23-year-old Asian American woman 4. A 35-year-old Hispanic American man 5. A 40-year-old African American woman

1. A 40-year-old Latino American man 2. A 45-year-old Native American man 4. A 35-year-old Hispanic American man 5. A 40-year-old African American woman

A week after kidney transplantation, a client develops a temperature of 101° F, the blood pressure is elevated, and the kidney is tender. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse suspects which complication? 1. Acute rejection 2. Kidney infection 3. Chronic rejection 4. Kidney obstruction

1. Acute rejection

A client with hyperthyroidism has been given methimazole (Tapazole). Which nursing considerations are associated with this medication? Select all that apply. 1. Administer methimazole with food. 2. Place the client on a low-calorie, low-protein diet. 3. Assess the client for unexplained bruising or bleeding. 4. Instruct the client to report side/adverse effects such as sore throat, fever, or headaches. 5. Use special radioactive precautions when handling the client's urine for the first 24 hours following initial administration.

1. Administer methimazole with food. 3. Assess the client for unexplained bruising or bleeding. 4. Instruct the client to report side/adverse effects such as sore throat, fever, or headaches.

A client develops an anaphylactic reaction after receiving morphine sulfate. The nurse should plan to institute which actions? Select all that apply. 1. Administer oxygen. 2. Quickly assess the client's respiratory status. 3. Document the event, interventions, and client's response. 4. Leave the client briefly to contact a health care provider. 5. Keep the client supine regardless of the blood pressure readings. 6. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

1. Administer oxygen. 2. Quickly assess the client's respiratory status. 3. Document the event, interventions, and client's response.

Glimepiride (Amaryl) is prescribed for a client with diabetes mellitus. The nurse instructs the client to avoid consuming which food while taking this medication? 1. Alcohol 2. Organ meats 3. Whole-grain cereals 4. Carbonated beverages

1. Alcohol

The nurse is reviewing the laboratory results for a client receiving tacrolimus (Prograf). Which laboratory result would indicate to the nurse that the client is experiencing an adverse effect of the medication? 1. Blood glucose of 200 mg/dL 2. Potassium level of 3.8 mEq/L 3. Platelet count of 300,000 cells/mm3 4. White blood cell count of 6000 cells/mm3

1. Blood glucose of 200 mg/dL

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply. 1. Check the level of the drainage bag. 2. Reposition the client to his or her side. 3. Contact the health care provider (HCP). 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system for kinks. 6. Increase the flow rate of the peritoneal dialysis solution.

1. Check the level of the drainage bag. 2. Reposition the client to his or her side. 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system for kinks.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1. Communicate expected behaviors to the client. 2. Ensure that the client knows that they are not in charge of the nursing unit. 3. Assist the client in identifying ways of setting limits on personal behaviors. 4. Follow through about the consequences of behavior in a nonpunitive manner. 5. Enforce rules by informing the client that they will not be allowed to attend therapy groups. 6. Have the client state the consequences for behaving in ways that are viewed as unacceptable.

1. Communicate expected behaviors to the client. 3. Assist the client in identifying ways of setting limits on personal behaviors. 4. Follow through about the consequences of behavior in a nonpunitive manner. 6. Have the client state the consequences for behaving in ways that are viewed as unacceptable.

A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? 1. Contact the client's health care provider (HCP). 2. Call the client's family to arrange for transportation. 3. Attempt to persuade the client to stay "for only a few more days." 4. Tell the client that leaving would likely result in an involuntary commitment

1. Contact the client's health care provider (HCP).

The nurse calls the heath care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take? 1. Contact the nursing supervisor. 2. Administer the dose prescribed. 3. Withhold the medication until the HCP can be contacted. 4. Administer the recommended dose until the HCP can be located.

1. Contact the nursing supervisor.

The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action? 1. Continue with the instructions, verifying client understanding. 2. Walk around the client so that the nurse constantly faces the client. 3. Give the client a dietary booklet and return later to continue with the instructions. 4. Tell the client about the importance of the instructions for the maintenance of health care.

1. Continue with the instructions, verifying client understanding.

A client admitted to a mental health unit for treatment of psychotic behavior spends hours at the locked exit door shouting, "Let me out. There's nothing wrong with me. I don't belong here." What defense mechanism is the client implementing? 1. Denial 2. Projection 3. Regression 4. Rationalization

1. Denial

A client being seen in the emergency department immediately after being sexually assaulted appears calm and controlled. The nurse analyzes this behavior as indicating which defense mechanism? 1. Denial 2. Projection 3. Rationalization 4. Intellectualization

1. Denial

The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide (Prandin) and metformin (Glucophage) and asks the nurse to explain these medications. The nurse should provide which instructions to the client? Select all that apply. 1. Diarrhea may occur secondary to the metformin. 2. The repaglinide is not taken if a meal is skipped. 3. The repaglinide is taken 30 minutes before eating. 4. A simple sugar food item is carried and used to treat mild hypoglycemia episodes. 5. Metformin increases hepatic glucose production to prevent hypoglycemia associated with repaglinide. 6.Muscle pain is an expected effect of metformin and may be treated with acetaminophen (Tylenol).

1. Diarrhea may occur secondary to the metformin. 2. The repaglinide is not taken if a meal is skipped. 3. The repaglinide is taken 30 minutes before eating. 4. A simple sugar food item is carried and used to treat mild hypoglycemia episodes

The nurse is reviewing a client's record and notes that the health care provider has documented that the client has a renal function disorder. On review of the laboratory results, the nurse most likely would expect to note which finding? 1. Elevated creatinine level 2. Decreased hemoglobin level 3. Decreased red blood cell count 4. Decreased white blood cell count

1. Elevated creatinine level

A client has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder? Select all that apply. 1. Fever 2. Nausea 3. Lethargy 4. Tremors 5. Confusion 6. Bradycardia

1. Fever 2. Nausea 4. Tremors 5. Confusion

A client who is human immunodeficiency virus seropositive has been taking stavudine (d4T, Zerit). The nurse should monitor which most closely while the client is taking this medication? 1. Gait 2. Appetite 3. Level of consciousness 4. Gastrointestinal function

1. Gait

The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is at most risk for developing this type of allergy? 1. Hairdressers 2. The homeless 3. Children in day care centers 4. Individuals living in a group home

1. Hairdressers

A client with chronic kidney disease is receiving epoetin alfa (Epogen). Which laboratory result would indicate a therapeutic effect of the medication? 1. Hematocrit of 32% 2. Platelet count of 400,000 cells/mm3 3. Blood urea nitrogen level of 15 mg/dL 4. White blood cell count of 6000 cells/mm3

1. Hematocrit of 32%

A client is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide which instructions to the client? Select all that apply. 1. Hypoglycemia may be experienced before dinnertime. 2. The insulin dose should be decreased if illness occurs. 3. The insulin should be administered at room temperature. 4. The insulin vial needs to be shaken vigorously to break up the precipitates. 5. The NPH insulin should be drawn into the syringe first, then the regular insulin.

1. Hypoglycemia may be experienced before dinnertime. 3. The insulin should be administered at room temperature.

The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? 1. Information regarding shelters 2. Instructions regarding calling the police 3. Instructions regarding self-defense classes 4. Explaining the importance of leaving the violent situation

1. Information regarding shelters

A client with a urinary tract infection is receiving ciprofloxacin (Cipro) by the intravenous (IV) route. The nurse appropriately administers the medication by performing which action? 1. Infusing slowly over 60 minutes 2. Infusing in a light-protective bag 3. Infusing only through a central line 4. Infusing rapidly as a direct intravenous push medication

1. Infusing slowly over 60 minutes

The nurse has been observing a client closely who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is least helpful to this client at this time? 1. Initiate confinement measures. 2. Acknowledge the client's behavior. 3. Assist the client to an area that is quiet. 4. Maintain a safe distance from the client.

1. Initiate confinement measures.

The nurse is monitoring a client receiving levothyroxine sodium (Synthroid) for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply. 1. Insomnia 2. Weight loss 3. Bradycardia 4. Constipation 5. Mild heat intolerance

1. Insomnia 2. Weight loss 5. Mild heat intolerance

The nurse is caring for a postoperative parathyroidectomy client. Which client complaint would indicate that a life-threatening complication may be developing, requiring notification of the health care provider immediately? 1. Laryngeal stridor 2. Abdominal cramps 3. Difficulty in voiding 4. Mild to moderate incisional pain

1. Laryngeal stridor

The camp nurse prepares to instruct a group of children about Lyme disease. Which information should the nurse include in the instructions? 1. Lyme disease is caused by a tick carried by deer. 2. Lyme disease is caused by contamination from cat feces. 3. Lyme disease can be caused by the inhalation of spores from bird droppings. 4. Lyme disease can be contagious through skin contact with an infected individual.

1. Lyme disease is caused by a tick carried by deer.

When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? 1. Monitor closely for harm to self or others. 2. Assist in completing an application for admission. 3. Supply the client with written information about their mental illness. 4. Provide an opportunity for the family to discuss why they felt the admission was needed.

1. Monitor closely for harm to self or others.

Which home care instructions should the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1. Monitor the child's weight. 2. Frequent hand-washing is important. 3. The child should avoid exposure to other illnesses. 4. The child's immunization schedule will need revision. 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). 6. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention.

1. Monitor the child's weight. 2. Frequent hand-washing is important. 3. The child should avoid exposure to other illnesses. 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach).

A client is admitted to the emergency department following a fall from a horse and the health care provider (HCP) prescribes insertion of a Foley catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action? 1. Notify the HCP. 2. Use a small-sized catheter. 3. Administer pain medication before inserting the catheter. 4. Use extra povidone-iodine solution in cleansing the meatus.

1. Notify the HCP.

The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? 1. One-to-one suicide precautions 2. Suicide precautions with 30-minute checks 3. Checking the whereabouts of the client every 15 minutes 4. Asking the client to report suicidal thoughts immediately

1. One-to-one suicide precautions

The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings should the nurse expect to observe? Select all that apply. 1. Pallor 2. Edema 3. Anorexia 4. Proteinuria 5. Weight loss 6. Decreased serum lipids

1. Pallor 2. Edema 3. Anorexia 4. Proteinuria

The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent? 1. Palpation of a thrill over the fistula 2. Presence of a radial pulse in the left wrist 3. Absence of a bruit on auscultation of the fistula 4. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand

1. Palpation of a thrill over the fistula

Tacrolimus (Prograf) is prescribed for a client. Which disorder, if noted in the client's record, would indicate that the medication needs to be administered with caution? 1. Pancreatitis 2. Ulcerative colitis 3. Diabetes insipidus 4. Coronary artery disease

1. Pancreatitis

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign, if exhibited in the client, would indicate hyperglycemia? 1. Polyuria 2. Diaphoresis 3. Hypertension 4. Increased pulse rate

1. Polyuria

A client with diabetes mellitus visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide (DiaBeta) daily, but recently the fasting blood glucose level has been 180 to 200 mg/dL. Which medication, if added to the client's regimen, may have contributed to the hyperglycemia? 1. Prednisone 2. Phenelzine (Nardil) 3. Atenolol (Tenormin) 4. Allopurinol (Zyloprim)

1. Prednisone

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? 1. Protecting the client from infection 2. Providing emotional support to decrease fear 3. Encouraging discussion about lifestyle changes 4. Identifying factors that decreased the immune function

1. Protecting the client from infection

The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, what is the nurse's immediate priority of care? 1. Provide safety for the client and other clients on the unit. 2. Provide the clients on the unit with a sense of comfort and safety. 3. Assist the staff in caring for the client in a controlled environment. 4. Offer the client a less stimulating area to calm down in and gain control.

1. Provide safety for the client and other clients on the unit.

The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? 1. Reassess the client. 2. Conduct a staff meeting to describe the fall. 3. Document in the nurse's notes that an incident report was completed. 4. Contact the nursing supervisor to update information regarding the fall.

1. Reassess the client.

The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate for the nurse to perform? Select all that apply. 1. Record site, date, and time of the test. 2. Give the client a list of potential allergens if identified. 3. Estimate the size of the wheal and document the finding. 4. Tell the client to return to have the site inspected only if there is a reaction. 5. Have the client wait in the waiting room for at least 1 to 2 hours after injection.

1. Record site, date, and time of the test. 2. Give the client a list of potential allergens if identified.

The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior? 1. Reflecting a cultural value 2. An acceptance of the treatment 3. Client agreement to the required procedures 4. Client understanding of the preoperative procedures

1. Reflecting a cultural value

The nurse in the mental health unit recognizes which as being therapeutic communication techniques? Select all that apply. 1. Restating 2. Listening 3. Asking the client, "Why?" 4. Maintaining neutral responses 5. Providing acknowledgment and feedback 6. Giving advice and approval or disapproval

1. Restating 2. Listening 4. Maintaining neutral responses 5. Providing acknowledgment and feedback

The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to implement which measure? 1. Restrict fluids as prescribed. 2. Care for the arteriovenous fistula. 3. Encourage foods high in potassium. 4. Administer analgesics as prescribed.

1. Restrict fluids as prescribed.

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? 1. Setting limits on the client's behavior 2. Asking the client to leave the group session 3. Asking another nurse to escort the client out of the group session 4. Telling the client that they will not be able to attend any future group sessions

1. Setting limits on the client's behavior

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1. The adolescent gives away a DVD and a cherished autographed picture of a performer. 2. The adolescent runs out of the therapy group, swearing at the group leader, and runs to her room. 3. The adolescent becomes angry while speaking on the telephone and slams down the receiver. 4. The adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking.

1. The adolescent gives away a DVD and a cherished autographed picture of a performer.

Which identifies accurate nursing documentation notations? Select all that apply. 1. The client slept through the night. 2. Abdominal wound dressing is dry and intact without drainage. 3. The client seemed angry when awakened for vital sign measurement. 4. The client appears to become anxious when it is time for respiratory treatments. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

1. The client slept through the night. 2. Abdominal wound dressing is dry and intact without drainage. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

A client taking lithium carbonate reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L. This level is indicative of which finding? 1. Toxic 2. Normal 3. Slightly above normal 4. Excessively below normal

1. Toxic

The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which client complaints would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply. 1. Tremors 2. Anorexia 3. Irritability 4. Nervousness 5. Hot, dry skin 6. Muscle cramps

1. Tremors 3. Irritability 4. Nervousness

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. 1. Use nonlatex gloves. 2. Use medications from glass ampules. 3. Place the client in a private room only. 4. Keep a latex-safe supply cart available in the client's area. 5. Avoid the use of medication vials that have rubber stoppers. 6. Use a blood pressure cuff from an electronic device only to measure the blood pressure.

1. Use nonlatex gloves. 2. Use medications from glass ampules. 4. Keep a latex-safe supply cart available in the client's area. 5. Avoid the use of medication vials that have rubber stoppers.

A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? 1. Using open-ended questions and silence 2. Sharing personal preference regarding food choices 3. Documenting reasons why the client does not want to eat 4. Offering opinions about the necessity of adequate nutrition

1. Using open-ended questions and silence

The nurse is caring for a client with pheochromocytoma who is scheduled for adrenalectomy. In the preoperative period, what should the nurse monitor as the priority? 1. Vital signs 2. Intake and output 3. Blood urea nitrogen results 4. Urine for glucose and ketones

1. Vital signs

The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching? 1. Withdraws the NPH insulin first 2. Withdraws the regular insulin first 3. Injects air into NPH insulin vial first 4. Injects an amount of air equal to the desired dose of insulin into each vial

1. Withdraws the NPH insulin first

The health care provider (HCP) prescribes exenatide (Byetta) for a client with type 1 diabetes mellitus who takes insulin. The nurse should plan to take which most appropriate intervention? 1. Withhold the medication and call the HCP, questioning the prescription for the client. 2. Administer the medication within 60 minutes before the morning and evening meal. 3. Monitor the client for gastrointestinal side effects after administering the medication. 4. Withdraw the insulin from the prefilled pen into an insulin syringe to prepare for administration.

1. Withhold the medication and call the HCP, questioning the prescription for the client.

The nurse is providing care to a client admitted to the hospital with a diagnosis of acute anxiety disorder. The client says to the nurse, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Wha tis the most appropriate nursing response? 1. "No, I won't tell anyone." 2. "I cannot promise to keep a secret." 3. "It depends on what the secret is about." 4. "If you tell me the secret, I may need to document it."

2. "I cannot promise to keep a secret."

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client would indicate to the nurse the possible diagnosis of posttraumatic stress disorder? Select all that apply. 1. "I'm afraid of spiders." 2. "I keep reliving the robbery." 3. "I see his face everywhere I go." 4. "I don't want anything to eat now." 5. "I might have died over a few dollars in my pocket." 6. "I have to wash my hands over and over again many times."

2. "I keep reliving the robbery." 3. "I see his face everywhere I go." 5. "I might have died over a few dollars in my pocket."

The nurse is providing discharge instructions to a client who has Cushing's syndrome. Which client statement indicates that instructions related to dietary management are understood? 1. "I will need to limit the amount of protein in my diet." 2. "I should eat foods that have a lot of potassium in them." 3. "I am fortunate that I can eat all the salty foods I enjoy." 4. "I am fortunate that I do not need to follow any special diet."

2. "I should eat foods that have a lot of potassium in them."

A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? 1. Maintain bed rest as much as possible. 2. Administer corticosteroids as prescribed for inflammation. 3. Advise the client to remain supine for 1 to 2 hours after meals. 4. Keep the room temperature warm during the day and cool at night.

2. Administer corticosteroids as prescribed for inflammation.

A client with pemphigus is being seen in the clinic regularly. The nurse plans care based on which description of this condition? 1. The presence of tiny red vesicles 2. An autoimmune disease that causes blistering in the epidermis 3. The presence of skin vesicles found along the nerve caused by a virus 4. The presence of red, raised papules and large plaques covered by silvery scales

2. An autoimmune disease that causes blistering in the epidermis

When communicating with a client who speaks a different language, which best practice should the nurse implement? 1. Speak loudly and slowly. 2. Arrange for an interpreter to translate. 3. Speak to the client and family together. 4. Stand close to the client and speak loudly.

2. Arrange for an interpreter to translate.

A client calls the nurse in the emergency department and states that he was just stung by a bumble bee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which nursing action should the nurse take? 1. Advise the client to soak the site in hydrogen peroxide. 2. Ask the client if he ever sustained a bee sting in the past. 3. Tell the client to call an ambulance for transport to the emergency department. 4. Tell the client not to worry about the sting unless difficulty with breathing occurs.

2. Ask the client if he ever sustained a bee sting in the past.

A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, how should the nurse administer the dose? 1. On an empty stomach 2. At the same time each evening 3. Evenly spaced around the clock 4. As needed when the client complains of depression

2. At the same time each evening

The nurse is caring for a client who is experiencing disturbed thought processes as a result of paranoia. In formulating nursing interventions with the members of the health care team, what best instruction should the nurse provide to the staff? 1. Increase socialization of the client with peers. 2. Avoid laughing or whispering in front of the client. 3. Begin to educate the client about social supports in the community. 4. Have the client sign a release of information to appropriate parties for assessment purposes.

2. Avoid laughing or whispering in front of the client.

The nurse calls security and has physical restraints applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. 1. Libel 2. Battery 3. Assault 4. Slander 5. False imprisonment

2. Battery 3. Assault 5. False imprisonment

The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects to note which finding the tis associated with this diagnosis? 1. Hypotension 2. Brown-colored urine 3. Low urinary specific gravity 4. Low blood urea nitrogen level

2. Brown-colored urine

A client with diabetes mellitus demonstrates acute anxiety when first admitted to the hospital for the treatment of hyperglycemia. What is the most appropriate intervention to decrease the client's anxiety? 1. Administer a sedative. 2. Convey empathy, trust, and respect toward the client. 3. Ignore the signs and symptoms of anxiety so that they will soon disappear. 4. Make sure that the client knows all the correct medical terms to understand what is happening.

2. Convey empathy, trust, and respect toward the client.

The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention? 1. Cover the bladder with petroleum jelly gauze. 2. Cover the bladder with a nonadhering plastic wrap. 3. Apply sterile distilled water dressings over the bladder mucosa. 4. Keep the bladder tissue dry by covering it with dry sterile gauze.

2. Cover the bladder with a nonadhering plastic wrap.

A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious and the nurse suspects air embolism. What is the priority nursing action? 1. Monitor vital signs every 15 minutes for the next hour. 2. Discontinue dialysis and notify the health care provider (HCP). 3. Continue dialysis at a slower rate after checking the liens for air. 4. Bolus the client with 500 mL of normal saline to break up the air embolus.

2. Discontinue dialysis and notify the health care provider (HCP).

The nurse is performing a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine (Prozac). What information would be important for the nurse to obtain during this client visit regarding the side/adverse effects of the medication? 1. Cardiovascular symptoms 2. Gastrointestinal dysfunctions 3. Problems with mouth dryness 4. Problems with excessive sweating

2. Gastrointestinal dysfunctions

The nurse performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome? 1. Hypertension 2. Generalized edema 3. Increased urinary output 4. Frank, bright red blood in the urine

2. Generalized edema

The nurse performs an admission assessment on a client who visits a health care clinic for the first time. The client tells the nurse that propylthiouracil (PTU) is taken daily. The nurse continues to collect data from the client, suspecting that the client has a history of which condition? 1. Myxedema 2. Graves' disease 3. Addison's disease 4. Cushing's syndrome

2. Graves' disease

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication? 1. Infection 2. Hyperglycemia 3. Hypophosphatemia 4. Disequilibrium syndrome

2. Hyperglycemia

When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? 1. Suppressing feelings of anxiety 2. Identifying anxiety-producing situations 3. Continued contact with a crisis counselor 4. Eliminating all anxiety from daily situations

2. Identifying anxiety-producing situations

The nurse is teaching a client who is being started on imipramine (Tofranil) about the medication. The nurse should inform the client to expect maximum desired effects at what time period following initiation of the medication? 1. In 2 months 2. In 2 to 3 weeks 3. During the first week 4. During the sixth week of administration

2. In 2 to 3 weeks

The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places highest priority on which client problem? 1. Lack of knowledge 2. Inadequate fluid volume 3. Compromised family coping 4. Inadequate consumption of nutrients

2. Inadequate fluid volume

The nurse is describing the medication side and adverse effects to a client who is taking oxazepam (Serax). What information should the nurse incorporate in the discussion? 1. Consume a low-fiber diet. 2. Increase fluids and bulk in the diet. 3. Rest if the heart begins to beat rapidly. 4. Take antidiarrheal agents if diarrhea occurs.

2. Increase fluids and bulk in the diet.

A mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 1 mg/dL. The nurse reviews this result and makes which interpretation? 1. It is positive. 2. It is negative. 3. It is inconclusive. 4. It requires rescreening at age 6 weeks.

2. It is negative.

The nurse is providing discharge instructions to a client receiving sulfamethoxazole. Which instruction should be included in the list? 1. Restrict fluid intake. 2. Maintain a high fluid intake. 3. If the urine turns dark brown, call the health care provider (HCP) immediately. 4. Decrease the dosage when symptoms are improving to prevent an allergic response.

2. Maintain a high fluid intake.

A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action would the nurse prepare to carry out initially? 1. Warm the client. 2. Maintain a patent airway. 3. Administer thyroid hormone. 4. Administer fluid replacement.

2. Maintain a patent airway.

The nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task that is most appropriate for this phase? 1. Planning short-term goals 2. Making appropriate referrals 3. Developing realistic solutions 4. Identifying expected outcomes

2. Making appropriate referrals

Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions should the nurse include when administering this medication? Select all that apply. 1. Restrict fluid intake. 2. Monitor liver function studies. 3. Instruct the client to avoid alcohol. 4. Administer the medication with an antacid. 5. Instruct the client to avoid exposure to the sun. 6. Administer the medication on an empty stomach.

2. Monitor liver function studies. 3. Instruct the client to avoid alcohol. 5. Instruct the client to avoid exposure to the sun.

The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors? 1. Signs of depression 2. Normal reactions to a devastating event 3. Evidence that the client is a high suicide risk 4. Indicative of the need for hospital admission

2. Normal reactions to a devastating event

The nurse is caring for a client who is 2 days postoperative following an abdominal hysterectomy. The client has a history of diabetes mellitus and has been receiving regular insulin according to capillary blood glucose testing four times a day. A carbohydrate-controlled diet has been prescribed but the client has been complaining of nausea and is not eating. On entering the client's room, the nurse finds the client to be confused and diaphoretic. Which action is most appropriate at this time? 1. Call a code to obtain needed assistance immediately. 2. Obtain a capillary blood glucose level and perform a focused assessment. 3. Ask the unlicensed assistive personnel (UAP) to stay with the client while obtaining 15 to 30 g of a carbohydrate snack for the client to eat. 4. Stay with the client and ask the UAP to call the health care provider (HCP) for a prescription for intravenous 50% dextrose.

2. Obtain a capillary blood glucose level and perform a focused assessment.

The nurse caring for a client who is taking an aminoglycoside should monitor the client for which adverse effects of the medication? Select all that apply. 1. Seizures 2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias 5. Hepatotoxicity

2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias

A client with acute kidney injury has a serum potassium level of 6.0 mEq/L. The nurse should plan which action as a priority? 1. Check the sodium level. 2. Place the client on a cardiac monitor. 3. Encourage increased vegetables in the diet. 4. Allow an extra 500 mL of fluid intake to dilute the electrolyte concentration.

2. Place the client on a cardiac monitor.

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? 1. Diarrhea 2. Polyuria 3. Polyphagia 4. Weight gain

2. Polyuria

The nurse identifies low-risk therapies to a client and should include which therapies in the discussion? Select all that apply. 1. Herbs 2. Prayer 3. Touch 4. Massage 5. Relaxation 6. Acupuncture

2. Prayer 3. Touch 4. Massage 5. Relaxation

A client who has been taking buspirone (Buspar) for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred? 1. Paranoid thought process 2. Rapid heartbeat or anxiety 3. Alcohol withdrawal symptoms 4. Thought broadcasting or delusions

2. Rapid heartbeat or anxiety

The home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should tell the client to take which action? 1. Freeze the insulin. 2. Refrigerate the insulin. 3. Store the insulin in a dark, dry place. 4. Keep the insulin at room temperature.

2. Refrigerate the insulin.

A hospitalized client has begun taking bupropion (Wellbutrin) as an antidepressant agent. The nurse understands that which is an adverse effect, indicating that the client is taking an excessive amount of medication? 1. Constipation 2. Seizure activity 3. Increased weight 4. Dizziness when getting upright

2. Seizure activity

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply. 1. Polyuria 2. Shakiness 3. Palpitations 4. Blurred vision 5. Lightheadedness 6. Fruity breath odor

2. Shakiness 3. Palpitations 5. Lightheadedness

A client is admitted to the emergency department following a motor vehicle accident. The client was wearing a lap seat belt when the accident occurred and now the client has hematuria and lower abdominal pain. To assess further whether the pain is caused by bladder trauma, the nurse should ask the client if the pain is referred to which area? 1. Hip 2. Shoulder 3. Umbilicus 4. Costovertebral angle

2. Shoulder

Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the UAP violated? 1. Libel 2. Slander 3. Assault 4. Negligence

2. Slander

A client is unwilling to go out of the house for fear of "making a fool of myself in public." Because of this fear, the client remains homebound. Based on these data, which mental health disorder is the client experiencing? 1. Agoraphobia 2. Social phobia 3. Claustrophobia 4. Hypochondriasis

2. Social phobia

The nurse notes that a client with schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing which medication complication? 1. Parkinsonism 2. Tardive dyskinesia 3. Hypertensive crisis 4. Neuroleptic malignant syndrome

2. Tardive dyskinesia

A female client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which nursing actions aremost appropriate? Select all that apply. 1. Tell the client that testing is not necessary unless arthralgia develops. 2. Tell the client to avoid any woody, grassy areas that may contain ticks. 3. Instruct the client to immediately start to take the antibodies that are prescribed. 4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. 5. Tell the client if this happens again to never remove the tick but vigorously scrub the area with an antiseptic.

2. Tell the client to avoid any woody, grassy areas that may contain ticks. 3. Instruct the client to immediately start to take the antibodies that are prescribed. 4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease.

The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? 1. Lower the head of the bed. 2. Test the drainage for glucose. 3. Obtain a culture of the drainage. 4. Continue to observe the drainage.

2. Test the drainage for glucose.

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis could be caused by which event? 1. Witnessing a murder 2. The death of a loved one 3. A fire that destroyed the client's home 4. A recent rape episode experienced by the client

2. The death of a loved one

The clinic nurse is instructing the parent of a child with human immunodeficiency virus (HIV) infection regarding immunizations. The nurse should provide which instruction to the parent? 1. The hepatitis B vaccine will not be given to the child. 2. The inactivated influenza vaccine will be given yearly. 3. The varicella vaccine will be given before 6 months of age. 4. A Western blot test needs to be performed and the results evaluated before immunizations.

2. The inactivated influenza vaccine will be given yearly.

The nurse provides medication instructions to a client who is taking levothyroxine (Synthroid) and should tell the client to notify the health care provider (HCP) if which problem occurs? 1. Fatigue 2. Tremors 3. Cold intolerance 4. Excessively dry skin

2. Tremors

Bethanechol chloride (Urecholine) is prescribed for a client with urinary retention. Which disorder would be a contraindication to the administration of this medication? 1. Gastric atony 2. Urinary strictures 3. Neurogenic atony 4. Gastroesophageal reflux

2. Urinary strictures

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1. Move the client next to the nurse's station. 2. Use an indirect light source and turn off the television. 3. Keep the television and a soft light on during the night. 4. Play soft music during the night, and maintain a well-lit room.

2. Use an indirect light source and turn off the television.

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? 1. Wearing gloves 2. Wearing a gown and gloves 3. Wearing a gown, gloves, and a mask 4. Wear a gown and gloves to change the bed linens and gloves only for the bath

2. Wearing a gown and gloves

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? 1. Chess 2. Writing 3. Ping pong 4. Basketball

2. Writing

Which statement demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected? 1. "Autonomy is the fundamental right of each and every client." 2. "A client's rights are guaranteed by both state and federal laws." 3. "Being respectful and concerned will ensure that I'm attentive to my clients' rights." 4. "Regardless of the client's condition, all nurses have the duty to respect client rights."

3. "Being respectful and concerned will ensure that I'm attentive to my clients' rights."

The nurse receives a call from a client concerned about eliminating brown-colored urine after taking nitrofurantoin (Furadantin) for a urinary tract infection. The nurse should make which appropriate response? 1. "Discontinue taking the medication and make an appointment for a urine culture." 2. "Decrease your medication to half the dose because your urine is too concentrated." 3. "Continue taking the medication because the urine is discolored from the medication." 4. "Take magnesium hydroxide (Maalox) with your medication to lighten the urine color."

3. "Continue taking the medication because the urine is discolored from the medication."

A client says to the nurse, "The federal guards were sent to kill me." What is the best nursing response to the client's concern? 1. "I don't believe this is true." 2. "The guards are not out to kill you." 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the guards were sent to hurt you?"

3. "Do you feel afraid that people are trying to hurt you?"

A 6-year-old child with human immunodeficiency virus (HIV) has been admitted to the hospital for pain management. The child asks the nurse if the pain will ever go away. The nurse should make which best response to the child? 1. "The pain will go away if you lie still and let the medicine work." 2. "Try not to think about it. The more you think it hurts, the more it will hurt." 3. "I know it must hurt, but if you tell me when it does, I will try and make it hurt a little less." 4. "Every time it hurts, press on the call button and I will give you something to make the pain go all away."

3. "I know it must hurt, but if you tell me when it does, I will try and make it hurt a little less."

The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the scouts about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further instructions? 1. "I need to bring a hat to wear during the trip." 2. "I should wear long-sleeved tops and long pants." 3. "I should not use insect repellents because it will attract the ticks." 4. "I need to wear closed shoes and socks that can be pulled up over my pants."

3. "I should not use insect repellents because it will attract the ticks."

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. What is the most appropriate nursing response? 1. "You need to try to be realistic. The rape did not just occur." 2. "It will take some time to get over these feelings about your rape." 3. "Tell me more about the incident that causes you to feel like the rape just occurred." 4. "What do you think that you can do to alleviate some of your fears about being raped again?"

3. "Tell me more about the incident that causes you to feel like the rape just occurred."

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an inadequate understanding of the peak action of NPH insulin and exercise? 1. "The best time for me to exercise is after I eat." 2. "The best time for me to exercise is after breakfast." 3. "The best time for me to exercise is mid- to late afternoon." 4. "The best time for me to exercise is after my morning snack."

3. "The best time for me to exercise is mid- to late afternoon."

The nurse is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, what is the most appropriate question? 1. "With whom do you live?" 2. "Who is available to help you?" 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?"

3. "What leads you to seek help now?"

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 1. "You need to stop that behavior now." 2. "You will need to be placed in seclusion." 3. "You seem restless; tell me what is happening." 4. "You will need to be restrained if you do not change your behavior."

3. "You seem restless; tell me what is happening."

A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? 1. "Have you shared your feelings with your family?" 2. "I think we should talk more about your anger with your family." 3. "You're feeling angry that your family continues to hope for you to be cured?" 4. "You are probably very depressed, which is understandable with such a diagnosis."

3. "You're feeling angry that your family continues to hope for you to be cured?"

When the community health nurse visits a client at home, the client says, "I haven't slept at all the last couple of nights." Which response by the nurse illustrates a therapeutic communication response to this client? 1. "I see." 2. "Really?" 3. "You're having difficulty sleeping?" 4. "Sometimes, I have trouble sleeping too."

3. "You're having difficulty sleeping?"

Prednisone is prescribed for a client with diabetes mellitus who is taking Humulin NPH insulin daily. Which prescription change does the nurse anticipate during therapy with the prednisone? 1. An additional dose of prednisone daily 2. A decreased amount of daily Humulin NPH insulin 3. An increased amount of daily Humulin NPH insulin 4. The addition of an oral hypoglycemic medication daily

3. An increased amount of daily Humulin NPH insulin

A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action? 1. Requesting that a peer remain with the client at all times 2. Removing the client's clothing and placing the client in a hospital gown 3. Assigning a staff member to the client who will remain with the client at all times 4. Admitting the client to a seclusion room where all potentially dangerous articles are removed

3. Assigning a staff member to the client who will remain with the client at all times

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note? 1. Hematuria 2. Proteinuria 3. Bacteriuria 4. Glucosuria

3. Bacteriuria

The nurse is caring for a postrenal transplantation client taking cyclosporine (Sandimmune). The nurse notes an increase in one of the client's vital signs and the client is complaining of a headache. What vital sign is most likely increased? 1. Pulse 2. Respirations 3. Blood pressure 4. Pulse oximetry

3. Blood pressure

The nurse, who is administering bethanechol chloride (Urecholine), is monitoring for cholinergic overdose associated with the medication. The nurse should check the client for which sign of overdose? 1. Dry skin 2. Dry mouth 3. Bradycardia 4. Signs of dehydration

3. Bradycardia

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate nursing action? 1. Call the police. 2. Cut up the photograph and throw it away. 3. Call the nursing supervisor and report the incident. 4. Call the laboratory and ask for the individual's name who sent the photograph.

3. Call the nursing supervisor and report the incident.

The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1. Call security. 2. Call the police. 3. Call the nursing supervisor. 4. Lock the co-worker in the medication room until help is obtained.

3. Call the nursing supervisor.

A client receiving tricyclic antidepressants arrives at the mental health clinic. Which observation would indicate that the client is following the medication plan correctly? 1. Client reports not going to work for this past week. 2. Client complains of not being able to "do anything" anymore. 3. Client arrives at the clinic neat and appropriate in appearance. 4. Client reports sleeping 12 hours per night and 3 to 4 hours during the day.

3. Client arrives at the clinic neat and appropriate in appearance.

A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 100.2° F. Which nursing action is most appropriate? 1. Encourage fluids. 2. Notify the health care provider. 3. Continue to monitor vital signs. 4. Monitor the site of the shunt for infection.

3. Continue to monitor vital signs

A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. Which condition will be the focus of this consult? 1. Psychosis 2. Repression 3. Conversion disorder 4. Dissociative disorder

3. Conversion disorder

A hospitalized client is started on phenelzine (Nardil) for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply. 1. Figs 2. Yogurt 3. Crackers 4. Aged cheese 5. Tossed salad 6. Oatmeal raisin cookies

3. Crackers 5. Tossed salad

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings would the nurse expect to note as confirming this diagnosis? Select all that apply. 1. Increase in pH 2. Comatose state 3. Deep, rapid breathing 4. Decreased urine output 5. Elevated blood glucose level 6. Low plasma bicarbonate level

3. Deep, rapid breathing 5. Elevated blood glucose level 6. Low plasma bicarbonate level

A daily dose of prednisone is prescribed for a client. The nurse provides instructions to the client regarding administration of the medication and should instruct the client that which time is best to take this medication? 1. At noon 2. At bedtime 3. Early morning 4. Any time, at the same time, each day

3. Early morning

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? 1. Hold the next dose of insulin. 2. Come to the clinic immediately. 3. Encourage the child to drink liquids. 4. Administer an additional dose of regular insulin.

3. Encourage the child to drink liquids.

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that they would like to take an herbal substance to help lower their blood pressure. The nurse should take which action? 1. Tell the client that herbal substances are not safe and should never be used. 2. Teach the client how to take their blood pressure so that it can be monitored closely. 3. Encourage the client to discuss the use of an herbal substance with the health care provider. 4. Tell the client that if they take the herbal substance they will need to have their blood pressure checked frequently.

3. Encourage the client to discuss the use of an herbal substance with the health care provider.

A manic client begins to make sexual advance towards visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? 1. Place the client in seclusion for 30 minutes. 2. Tell the client that the behavior is inappropriate. 3. Escort the client to their room, with the assistance of other staff. 4. Tell the client that their telephone privileges are revoked for 24 hours.

3. Escort the client to their room, with the assistance of other staff.

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which symptoms are associated with this diagnosis? Select all that apply. 1. Tremors 2. Weight loss 3. Feeling cold 4. Loss of body hair 5. Persistent lethargy 6. Puffiness of the face

3. Feeling cold 4. Loss of body hair 5. Persistent lethargy 6. Puffiness of the face

The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination? 1. Fever, diarrhea, groin pain, and ecchymosis 2. Nausea, vomiting, scrotal edema, and ecchymosis 3. Fever, nausea, vomiting, and painful scrotal edema 4. Diarrhea, groin pain, testicular torsion, and scrotal edema

3. Fever, nausea, vomiting, and painful scrotal edema

An Asian American client is experiencing a fever. The nurse recognizes that the client is likely to self-treat the disorder, using which method? 1. Prayer 2. Magnetic therapy 3. Foods considered to be yin 4. Foods considered to be yang

3. Foods considered to be yin

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? Select all that apply. 1. Administer regular insulin. 2. Encourage the child to ambulate. 3. Give the child a teaspoon of honey. 4. Provide electrolyte replacement therapy intravenously. 5. Wait 30 minutes and confirm the blood glucose reading. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

3. Give the child a teaspoon of honey. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

The nurse is providing dietary instructions to a client who has been prescribed cyclosporine (Sandimmune). Which food item should the nurse instruct the client to exclude from the diet? 1. Red meats 2. Orange juice 3. Grapefruit juice 4. Green leafy vegetables

3. Grapefruit juice

Amikacin (Amikin) is prescribed for a client with a bacterial infection. The nurse instructs the client to contact the health care provider (HCP) immediately if which occurs? 1. Nausea 2. Lethargy 3. Hearing loss 4. Muscle aches

3. Hearing loss

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? 1. Suggesting a reduction of medication 2. Allowing increased "in-room" activities 3. Increasing the level of suicide precautions 4. Allowing the client off-unit privileges as needed

3. Increasing the level of suicide precautions

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level was 950 mg/dL. A continuous intravenous infusion of short-acting insulin is initiated, along with intravenous rehydration with normal saline. The serum glucose level is now 240 mg/dL. The nurse would next prepare to administer which item? 1. Ampule of 50% dextrose 2. NPH insulin subcutaneously 3. Intravenous fluids containing dextrose 4. Phenytoin (Dilantin) for the prevention of seizures

3. Intravenous fluids containing dextrose

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar state (HHS) is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? 1. Endotracheal intubation 2. 100 units of NPH insulin 3. Intravenous infusion of normal saline 4. Intravenous infusion of sodium bicarbonate

3. Intravenous infusion of normal saline

The nurse is caring for a client who has been taking a sulfonamide and should monitor for signs/symptoms of which side/adverse effects of the medication? Select all that apply. 1. Ototoxicity 2. Palpitations 3. Nephrotoxicity 4. Bone marrow depression 5. Gastrointestinal (GI) effects 6. Increased white blood cell (WBC) count

3. Nephrotoxicity 4. Bone marrow depression 5. Gastrointestinal (GI) effects

The nurse provides instructions to a client who is taking levothyroxine (Synthroid). The nurse should tell the client to take the medication at which time? 1. With food 2. At lunchtime 3. On an empty stomach 4. At bedtime with a snack

3. On an empty stomach

After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse performs an assessment on the client, knowing that which symptom is most indicative of this disorder? 1. Fatigue 2. Diarrhea 3. Polydipsia 4. Weight gain

3. Polydipsia

The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? 1. Swelling in the genital area 2. Swelling in the lower extremities 3. Positive punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions noted on the skin

3. Positive punch biopsy of the cutaneous lesions

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? 1. Hypoglycemia 2. Level of hoarseness 3. Respiratory distress 4. Edema at the surgical site

3. Respiratory distress

The nurse is instructing a client regarding intranasal desmopressin (DDAVP). The nurse should tell the client that which occurrence is a side effect of the medication? 1. Headache 2. Vulval pain 3. Runny nose 4. Flushed skin

3. Runny nose

The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine (Videx). The nurse interprets that the client may have the medication discontinued by the health care provider if which elevated result is noted? 1. Serum protein level 2. Blood glucose level 3. Serum amylase level 4. Serum creatinine level

3. Serum amylase level

The nurse is caring for a client diagnosed with catatonic stupor who is lying on the bed in a fetal position. What is the most appropriate nursing intervention? 1. Ask direct questions to encourage talking. 2. Leave the client alone so as to minimize external stimuli. 3. Sit beside the client in silence with occasional open-ended questions. 4. Take the client into the dayroom with other clients so that they can help watch him.

3. Sit beside the client in silence with occasional open-ended questions.

Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet? 1. Pork roast, rice, vegetables, mixed fruit, milk 2. Crab salad on a croissant, vegetables with dip, potato salad, milk 3. Sweet and sour chicken with rice and vegetables, mixed fruit, juice 4. Noodles and cream sauce with shrimp and vegetables, salad, mixed fruit, iced tea

3. Sweet and sour chicken with rice and vegetables, mixed fruit, juice

The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL, temperature of 101° F, pulse of 88 beats/minute, respirations of 22 breaths/minute, and blood pressure of 100/72 mm Hg. Which assessment would be of most concern to the nurse? 1. Pulse 2. Respiration 3. Temperature 4. Blood pressure

3. Temperature

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? 1. The client fell out of bed. 2. The client climbed over the side rails. 3. The client was found lying on the floor. 4. The client became restless and tried to get out of bed.

3. The client was found lying on the floor.

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1. Obtain a court order for the surgical procedure. 2. Ask the EMS team to sign the informed consent. 3. Transport the victim to the operating room for surgery. 4. Call the police to identify the client and locate the family.

3. Transport the victim to the operating room for surgery.

A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition? 1. Pyelonephritis 2. Glomerulonephritis 3. Trauma to the bladder or abdomen 4. Renal cancer in the client's family

3. Trauma to the bladder or abdomen

Sildenafil (Viagra) is prescribed to treat a client with erectile dysfunction. The nurse reviews the client's medical record and should question the prescription if which data is noted in the client's history? 1. Insomnia 2. Neuralgia 3. Use of nitroglycerin 4. Use of multivitamins

3. Use of nitroglycerin

An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? 1. "Oh, really. I will discuss this situation with your son." 2. "Let's talk about the ways you can manage your time to prevent this from happening." 3. "Do you have any friends that can help you out until you resolve these important issues with your son?" 4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan? 1. "Caution should be used when straddling the infant on a hip." 2. "Vital signs should be taken daily to check for bladder infection." 3. "Catheterization will be necessary when the infant does not void." 4. "Circumcision has been delayed to save tissue for surgical repair."

4. "Circumcision has been delayed to save tissue for surgical repair."

The nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement by the student indicates an accurate understanding of this disorder? 1. "Cushing's disease results from an oversecretion of insulin." 2. "Cushing's disease results from an undersecretion of corticotropic hormones." 3. "Cushing's disease results from an undersecretion of mineralocorticoid hormones." 4. "Cushing's disease results from an increased pituitary secretion of adrenocorticotropic hormone."

4. "Cushing's disease results from an increased pituitary secretion of adrenocorticotropic hormone."

The nurse provides home care instructions to the parent of a child with acquired immunodeficiency syndrome (AIDS). Which statement by the parent indicates the need for further teaching? 1. "I will wash my hands frequently." 2. "I will keep my child's immunizations up to date." 3. "I will avoid direct unprotected contact with my child's body fluids." 4. "I can send my child to day care if he has a fever, as long as it is a low-grade fever."

4. "I can send my child to day care if he has a fever, as long as it is a low-grade fever."

A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? 1. "I will sign as a witness to your signature." 2. "You will need to find a witness on your own." 3. "Whoever is available at the time will sign as a witness for you." 4. "I will call the nursing supervisor to seek assistance regarding your request."

4. "I will call the nursing supervisor to seek assistance regarding your request."

The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? 1. "I will stop taking my insulin if I'm too sick to eat." 2. "I will decrease my insulin dose during times of illness." 3. "I will adjust my insulin dose according to the level of glucose in my urine." 4. "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL."

4. "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL."

The nurse provided discharge instructions to the parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicate that further teaching is necessary? 1. "I'll check his temperature." 2. "I'll give him medication so he'll be comfortable." 3. "I'll check his voiding to be sure there's no problem." 4. "I'll let him decide when to return to his play activities."

4. "I'll let him decide when to return to his play activities."

The mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. The health care provider has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV. The nurse should make which most appropriate response to the mother? 1. "I am so pleased also that everything has turned out fine." 2. "Because symptoms have not developed, it is unlikely that your infant will develop HIV infection." 3. "Everything looks great, but be sure that you return with your infant next month for the scheduled visit." 4. "Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old."

4. "Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old."

The nurse is interviewing a client with type 2 diabetes mellitus. Which statement by the client indicates an understanding of the treatment for this disorder? 1. "I take oral insulin instead of shots." 2. "By taking these medications, I am able to eat more." 3. "When I become ill, I need to increase the number of pills I take." 4. "The medications I'm taking help release the insulin I already make."

4. "The medications I'm taking help release the insulin I already make."

The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client understands the instructions? 1. "My medications aren't likely to make me anxious." 2. "I'll go to support group and talk so that I don't hurt anyone." 3. "It's not likely that I'll get anxious or hear things if I get enough sleep and eat well." 4. "When I begin to hallucinate, I'll call my therapist and talk about what I should do."

4. "When I begin to hallucinate, I'll call my therapist and talk about what I should do."

A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." What is the nurse's best response? 1. "Have you talked to your family about this?" 2. "Everyone feels this way when they are depressed." 3. "You will feel better once your medication begins to work." 4. "You sound very upset. Are you thinking of hurting yourself?"

4. "You sound very upset. Are you thinking of hurting yourself?"

A client with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication? 1. "You have everything to live for." 2. "Why do you see yourself as a failure?" 3. "Feeling like this is all part of being depressed." 4. "You've been feeling like a failure for a while?"

4. "You've been feeling like a failure for a while?"

The nurse is developing a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? 1. A crisis state indicates that the client has a mental illness. 2. A crisis state indicates that the client has an emotional illness. 3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis. 4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? 1. A coagulation time of 5 minutes 2. A urinary output of 50 mL/hour 3. A blood urea nitrogen level of 20 mg/dL 4. A heart rate that is 90 beats/minute and irregular

4. A heart rate that is 90 beats/minute and irregular

Phenazopyridine (Pyridium) is prescribed for a client for symptomatic relief of pain resulting from a lower urinary tract infection. The nurse should provide the client with which information regarding this medication? 1. Take the medication at bedtime. 2. Take the medication before meals. 3. Discontinue the medication if a headache occurs. 4. A reddish orange discoloration of the urine may occur.

4. A reddish orange discoloration of the urine may occur.

A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? 1. Encouraging quiet reading and writing for the first few days 2. Identification of physical activities that will provide exercise 3. No socializing activities, until the client asks to participate in milieu 4. A structured program of activities in which the client can participate

4. A structured program of activities in which the client can participate

On review of the client's record, the nurse notes that the mental health admission was voluntary. Based on this information, the nurse anticipates which client behavior? 1. Fearfulness regarding treatment measures. 2. Anger and aggressiveness directed toward others. 3. An understanding of the pathology and symptoms of the diagnosis. 4. A willingness to participate in the planning of the care and treatment plan.

4. A willingness to participate in the planning of the care and treatment plan.

The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? 1. Correct the acidosis. 2. Administer 5% dextrose intravenously. 3. Apply a monitor for an electrocardiogram. 4. Administer short-duration insulin intravenously.

4. Administer short-duration insulin intravenously.

A client is scheduled for discharge and will be taking phenobarbital sodium (Luminal) for an extended period. The nurse would place highest priority on teaching the client which point that directly relates to client safety? 1. Take the medication only with meals. 2. Take the medication at the same time each day. 3. Use a dose container to help prevent missed doses. 4. Avoid drinking alcohol while taking this medication.

4. Avoid drinking alcohol while taking this medication.

The home care nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item? 1. Eggs 2. Milk 3. Yogurt 4. Bananas

4. Bananas

The nurse is caring for a 4-year-old child with human immunodeficiency virus (HIV) infection. The nurse should plan care with the understanding that which childhood psychosocial need occurs at this age? 1. Expressing fear, withdrawal, and denial 2. Beginning to understand that something is wrong 3. Unable to grasp the concept of illness and death 4. Beginning to conceptualize the death process as involving physical harm

4. Beginning to conceptualize the death process as involving physical harm

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 related to bladder spasms 3. Urinary output of 200 mL higher than intake 4. Blood pressure, 90/50 mm Hg; pulse, 130 beats/minute

4. Blood pressure, 90/50 mm Hg; pulse, 130 beats/minute

A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted? 1. The child has no tears. 2. Urine specific gravity is 1.030. 3. Urine output is less than 1 mL/kg/hour. 4. Capillary refill is less than 2 seconds.

4. Capillary refill is less than 2 seconds.

A client is diagnosed with pheochromocytoma. The nurse understands that pheochromocytoma is a condition that has which characteristic? 1. Causes profound hypotension 2. Is manifested by severe hypoglycemia 3. Is not curable and is treated symptomatically 4. Causes the release of excessive amounts of catecholamines

4. Causes the release of excessive amounts of catecholamines

A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription? 1. Obtains a weight 2. Takes the temperature 3. Takes the blood pressure 4. Checks the amount of urine output

4. Checks the amount of urine output

A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication? 1. Diuretics 2. Antibiotics 3. Antitussives 4. Decongestants

4. Decongestants

The nurse is collecting data from a client who has a history of benign prostatic hyperplasia. To determine whether the client currently is experiencing this condition, the nurse should ask the client about the presence of which early symptom? 1. Nocturia 2. Urinary retention 3. Urge incontinence 4. Decreased force in the stream of urine

4. Decreased force in the stream of urine

The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which action to correct the error? 1. Documenting a late entry into the client's record 2. Trying to erase the error for space to write in the correct data 3. Using whiteout to delete the error to write in the correct data 4. Drawing one line through the error, initialing and dating, and then documenting the correct information

4. Drawing one line through the error, initialing and dating, and then documenting the correct information

A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder? 1. Hematuria and pyuria 2. Dysuria and proteinuria 3. Hematuria and urgency 4. Dysuria and penile discharge

4. Dysuria and penile discharge

A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do? 1. Eat twice the amount normally eaten at lunchtime. 2. Take half the amount of prescribed insulin on practice days. 3. Take the prescribed insulin at noontime rather than in the morning. 4. Eat a small box of raisins or drink a cup of orange juice before soccer practice.

4. Eat a small box of raisins or drink a cup of orange juice before soccer practice.

The role of the nurse regarding complementary and alternative medicine should include which action? 1. Advising the client about "good" versus "bad" therapies 2. Recommending herbal remedies that the client should use 3. Discouraging the client from using any alternative therapies 4. Educating the client about therapies that he or she is using or is interested in using

4. Educating the client about therapies that he or she is using or is interested in using

Following kidney transplantation, cyclosporine (Sandimmune) is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication? 1. Normal hemoglobin level 2. Decreased creatinine level 3. Decreased white blood cell count 4. Elevated blood urea nitrogen level

4. Elevated blood urea nitrogen level

The police arrive at the emergency department with a client who has lacerated both wrists. What is the initial nursing action? 1. Administer an antianxiety agent. 2. Examine and treat the wound sites. 3. Secure and record a detailed history. 4. Encourage and assist the client to ventilate feelings.

4. Encourage and assist the client to ventilate feelings.

A client newly diagnosed with chronic kidney disease has just been started on peritoneal dialysis. During the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse is most appropriate? 1. Stop the dialysis. 2. Slow the infusion. 3. Decrease the amount to be infused. 4. Explain that the pain will subside after the first few exchanges.

4. Explain that the pain will subside after the first few exchanges.

A client gives the home health nurse a bottle of clomipramine (Anafranil). The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication? 1. Complaints of insomnia 2. Complaints of hunger and fatigue 3. A pulse rate less than 60 beats/minute 4. Frequent hand-washing with hot soapy water

4. Frequent hand-washing with hot soapy water

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note? 1. Sweating and tremors 2. Hunger and hypertension 3. Cold, clammy skin and irritability 4. Fruity breath odor and decreasing level of consciousness

4. Fruity breath odor and decreasing level of consciousness

The nurse is administering risperidone (Risperdal) to a client who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client? 1. Get adequate sunlight. 2. Continue driving as usual. 3. Avoid foods rich in potassium. 4. Get up slowly when changing positions.

4. Get up slowly when changing positions.

An external insulin pump is prescribed for a client with diabetes mellitus and the client asks the nurse about the functioning of the pump. The nurse bases the response on which information about the pump? 1. Is timed to release programmed doses of short-duration or NPH insulin into the bloodstream at specific intervals 2. Continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels 3. Is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream 4. Gives a small continuous dose of short-duration insulin subcutaneously, and the client can self-administer a bolus with an additional dose from the pump before each meal

4. Gives a small continuous dose of short-duration insulin subcutaneously, and the client can self-administer a bolus with an additional dose from the pump before each meal

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? 1. Hypertension, tachycardia, and fever 2. Hypotension, bradycardia, and hypothermia 3. Restlessness, irritability, and generalized weakness 4. Headache, deteriorating level of consciousness, and twitching

4. Headache, deteriorating level of consciousness, and twitching

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which action first? 1. Call the hospital lawyer. 2. Refuse to float to the ICU. 3. Call the nursing supervisor. 4. Identify tasks that can be performed safely in the ICU.

4. Identify tasks that can be performed safely in the ICU.

The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function 2. Exploring the client's potential for self-harm 3. Inquiring about the client's perception or appraisal of why the rescue was unsuccessful 4. Inquiring about and examining the client's feelings for any that may block adaptive coping

4. Inquiring about and examining the client's feelings for any that may block adaptive coping

A 7-year-old child is seen in a clinic, and the primary health care provider documents a diagnosis of primary nocturnal enuresis. The nurse should provide which information to the parents? 1. Primary nocturnal enuresis does not respond to treatment. 2. Primary nocturnal enuresis is caused by a psychiatric problem. 3. Primary nocturnal enuresis requires surgical intervention to improve the problem. 4. Most children outgrow the bed-wetting problem without therapeutic intervention.

4. Most children outgrow the bed-wetting problem without therapeutic intervention.

A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion? 1. Potassium infusion 2. NPH insulin infusion 3. 5% dextrose infusion 4. Normal saline infusion

4. Normal saline infusion

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the most appropriate nursing action? 1. Monitor the client. 2. Elevate the head of the bed. 3. Medicate the client for nausea. 4. Notify the health care provider (HCP).

4. Notify the health care provider (HCP).

A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1. Performing a procedure without consent 2. Threatening to give a client a medication 3. Telling the client that he or she cannot leave the hospital 4. Observing care provided to the client without the client's permission

4. Observing care provided to the client without the client's permission

A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess the client for which manifestations of this complication? 1. Warmth, redness, and pain in the left hand 2. Aching pain, pallor, and edema of the left arm 3. Edema and reddish discoloration of the left arm 4. Pallor, diminished pulse, and pain in the left hand

4. Pallor, diminished pulse, and pain in the left hand

An infant of a mother infected with HIV is seen in the clinic each month and is being monitored for symptoms indicative of human immunodeficiency virus (HIV) infection. The nurse assesses the infant, knowing that which infection is the most common opportunistic infection of children infected with HIV? 1. Meningitis 2. Gastroenteritis 3. Cytomegalovirus infection 4. Pneumocystis jiroveci pneumonia

4. Pneumocystis jiroveci pneumonia

The nurse has just administered ibuprofen (Motrin) to a child with a temperature of 38.8° C (102° F). The nurse should also take which action? 1. Withhold oral fluids for 8 hours. 2. Sponge the child with cold water. 3. Plan to administer salicylate (aspirin) in 4 hours. 4. Remove excess clothing and blankets from the child

4. Remove excess clothing and blankets from the child

Oxybutynin chloride (Ditropan XL) is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication? 1. Pallor 2. Drowsiness 3. Bradycardia 4. Restlessness

4. Restlessness

The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome who is receiving foscarnet, an antiviral medication. The nurse should monitor the results of which laboratory study while the client is taking this medication? 1. CD4 cell count 2. Lymphocyte count 3. Serum albumin level 4. Serum creatinine level

4. Serum creatinine level

Trimethoprim-sulfamethoxazole (TMP-SMZ; Bactrim) is prescribed for a client. The nurse should instruct the client to report which symptom if it develops during the course of this medication therapy? 1. Nausea 2. Diarrhea 3. Headache 4. Sore throat

4. Sore throat

The nurse understands that which information collected during the assessment of a child recently diagnosed with glomerulonephritis is most often associated with the diagnosis? 1. Child fell off a bike onto the handlebars 2. Nausea and vomiting for the last 24 hours 3. Urticaria and itching for 1 week before diagnosis 4. Streptococcal throat infection 2 weeks before diagnosis

4. Streptococcal throat infection 2 weeks before diagnosis

A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder? 1. Soft and swollen prostate gland 2. Reddened, swollen, and boggy prostate gland 3. Tender and edematous prostate gland with ecchymosis 4. Tender, indurated prostate gland that is warm to the touch

4. Tender, indurated prostate gland that is warm to the touch

A client's unresolved feelings related to loss would be most likely observed during which phase of the therapeutic nurse-client relationship? 1. Trusting 2. Working 3. Orientation 4. Termination

4. Termination

The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine (Pentam 300). The client develops a temperature of 101° F. The nurse continues to assess the client, knowing that this sign most likely indicates which condition? 1. That the dose of the medication is too low 2. That the client is experiencing toxic effects of the medication 3. That the client has developed inadequacy of thermoregulation 4. That the client has developed another infection caused by leukopenic effects of the medication

4. That the client has developed another infection caused by leukopenic effects of the medication

The nurse is preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that surgery is necessary. The nurse considers the client's religious preferences in developing the plan of care and should document which information? 1. The client believes the soul lives on after death. 2. Medication administration is not allowed. 3. Surgery is prohibited in this religious group. 4. The administration of blood and blood products is not allowed.

4. The administration of blood and blood products is not allowed.

Nitrofurantoin (Macrodantin) is prescribed for a client with a urinary tract infection. The client contacts the nurse and reports a cough, chills, fever, and difficulty breathing. The nurse should make which interpretation about the client's complaints? 1. The client may have contracted the flu. 2. The client is experiencing anaphylaxis. 3. The client is experiencing expected effects of the medication. 4. The client is experiencing a pulmonary reaction requiring cessation of the medication.

4. The client is experiencing a pulmonary reaction requiring cessation of the medication.

A client with schizophrenia has been started on medication therapy with clozapine (Clozaril). The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? 1. Platelet count 2. Blood glucose level 3. Liver function studies 4. White blood cell count

4. White blood cell count

The nurse educator asks a student to list the five categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, would indicate an understanding of the five categories of CAM? 1. Herbology, hydrotherapy, acupuncture, nutrition, and chiropractic care 2. Mind-body medicine, traditional Chinese medicine, homeopathy, naturopathy, and healing touch 3. Biologically based practices, body-based practices, magnetic therapy, massage therapy, and aromatherapy 4. Whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine

4. Whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine

A health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV) to determine the presence of HIV antigen in the infant. The nurse anticipates that which laboratory study will be prescribed for the infant? 1. Chest x-ray 2. Western blot 3. CD4+ cell count 4. p24 antigen assay

4. p24 antigen assay