Mental Health
A nurse is assisting with the care of a client who has a terminal illness. The client yells at the nurse, "Get out of my sight. You're always bothering me about something!" Which of the following responses should the nurse offer?
Correct Answer: D.
"I'll be here if you would like to talk about how you feel."
This response by the nurse acknowledges the client's feelings and provides a mechanism for further conversation, which helps create and maintain a therapeutic relationship between the nurse and the client.
A nurse in a provider’s office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications?
Correct Answer: B.
Acyclovir
The nurse should anticipate a prescription for acyclovir, an antiviral medication that inhibits replication of the virus that causes herpes zoster
A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first?
Correct Answer: B.
Place the client in a semi-Fowler’s position
The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is therefore the nurse’s priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second priority because adequate ventilatory effort is essential for oxygen exchange to occur. Circulation is the third priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. A client who is receiving PEG tube feedings should be positioned with the head of the bed elevated at least 30° during and after feedings to decrease the risk of aspiration. Therefore, this is the priority action by the nurse.
A home health nurse is contributing to the plan of care for a client who is receiving chemotherapy and has neutropenia. Which of the following foods should the nurse include in the client's plan of care?
Correct Answer: D.
Baked chicken
Well-cooked meats, including baked chicken, do not pose a threat to clients who have neutropenia and may be included in the client's dietary plan. For optimal safety, poultry should be cooked until its internal temperature is 74°C (165°F).
A nurse is caring for a client with bipolar disorder who is experiencing a manic episode. Which of the following actions should the nurse take?
Correct Answer: D.
Provide high-calorie finger-foods frequently
The nurse should offer the client frequent high-calorie snacks and meals during a manic episode to provide the calorie replacement needed due to excessive physical energy and activity. Providing finger-foods increases the client’s intake when mania makes sitting down and concentrating on a meal.
A nurse is caring for a client who has smoke inhalation and full-thickness burns covering 63% of her body. Which of the following nursing actions is the nurse's priority?
Correct Answer: C.
Monitor respiratory status
The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to monitor the client's respiratory status closely. Smoke inhalation most likely includes a thermal injury to the tracheobronchial tree. Edema from the inflammatory response to heat can obstruct the airway. Endotracheal intubation might become necessary to maintain a patent airway.
A nurse is reinforcing teaching with a client who has diverticulitis about preventing acute attacks. Which of the following foods should the nurse recommend?
Correct Answer: C.
Foods high in fiber
The result of long-term, low-fiber eating habits along with increased intracolonic pressure lead to straining during bowel movements, causing the development of diverticula. High-fiber foods help strengthen and maintain active motility of the gastrointestinal tract.
A nurse is reinforcing discharge teaching with a client who has HIV. Which of the following instructions about infection prevention should the nurse include in the teaching? (Select all that apply.)
Correct Answers: A.
Avoid large gatherings of people
B.
Clean the toothbrush by running through the dishwasher
E.
Avoid digging in the garden
A nurse is assisting with a community presentation about Alzheimer’s disease. The nurse should conclude that a member of the group requires further reinforcement of teaching when she identifies which of the following findings as a manifestation of Alzheimer’s disease?
Correct Answer: B.
Sudden confusion
The nurse should clarify that a client with Alzheimer’s disease is expected to exhibit confusion that develops slowly over a period of months. Clients who have delirium exhibit sudden confusion.
what does ABCD stand when assessing suspicious skin lesions that my indicate myeloma ?
A – Asymmetry: One half of the lesion does not mirror the other. Normal moles are usually symmetrical Registered Nurse RN+1.
B – Border: Irregular, jagged, or blurred edges. Smooth, even borders are typical of benign moles Lecturio+1.
C – Color: Multiple colors (brown, tan, black, red, blue, white) or uneven color distribution. Benign moles usually have one or two colors Lecturio+1.
D – Diameter: Larger than about 6 mm (about the size of a pencil eraser). Some melanomas can be smaller when first detected Registered Nurse RN+1.
A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should the nurse anticipate returning to the expected reference range within 72 hours after treatment begins?
Correct Answer: C.
Amylase
Pancreatitis is the most common diagnosis for marked elevations in serum amylase. Serum amylase begins to increase about 3 to 6 hours following the onset of acute pancreatitis. The amylase level peaks in 20 to 30 hours and returns to the expected reference range within 2 to 3 days.
A nurse is reinforcing discharge teaching with a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: A.
"I should take ibuprofen for my joint pain."
The nurse should inform the client that SLE is an autoimmune disorder characterized by exacerbations and remissions. It affects the skin, joints, organs, and any structure in the body that contains connective tissue. NSAIDs such as ibuprofen are helpful if taken on a regular schedule in reducing the client's joint pain.
A nurse is assisting with the admission of a client to an acute-care mental health facility following a suicide attempt. Which of the following actions should the nurse take first?
Correct Answer: D.
Search the client's belongings
The greatest risk to this client is self-injury from another suicide attempt; therefore, the nurse should first search the client's belongings to ensure there are no items that the client could use to harm herself.
A nurse is observing the skin of a client who has frostbite. The client has small blisters that contain blood, and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following?
Correct Answer: C.
Third-degree frostbite
When a client has third-degree frostbite, the skin of the affected area has small blisters that are blood-filled, and the skin does not blanch.
Incorrect Answers:
A. When a client has first-degree frostbite, the skin of the affected area is reddened and looks waxy.
B. When a client has second-degree frostbite, the skin of the affected area has large, fluid-filled blisters.
D. When a client has fourth-degree frostbite, the skin of the affected area is frozen. Blisters do not appear. The client’s muscles and bones are affected.
A nurse is caring for a client who is 4 hours postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect?
Correct Answer: A.
Right shoulder pain
The client can experience pain in the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1 to 2 days. Mild analgesics and a recumbent position can help relieve the client’s pain.
A nurse is reinforcing teaching with a female client who has a new diagnosis of systemic lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client requires further teaching when she identifies which of the following as a factor that can exacerbate SLE?
Correct Answer: A.
Exercise
SLE is a chronic autoimmune disease that develops when the immune system becomes hyperactive and attacks healthy body tissue. This attack results in generalized inflammation and the manifestations associated with the specific involved tissues. Most clients who have SLE can follow an exercise program to increase the aerobic capacity of cells and improve immune function, and the client should develop such a program with the provider's assistance. This client needs additional teaching about the importance of exercise to keep her muscles and joints active.
A nurse on an inpatient mental health unit is planning care for a client who was admitted following a suicide attempt. Which of the following actions should the nurse include in the plan?
Correct Answer: C.
Observe the client swallow medications
The nurse should plan to observe when the client swallows medications to ensure that he does not save the medications to take all at once
A nurse is reinforcing discharge teaching about foot care with a client who has diabetes mellitus. Which of the following instructions should the nurse include in the teaching?
Correct Answer: D.
Test water temperature with the wrist
The nurse should instruct the client to test water temperature with the wrist or a thermometer to detect if the water is too hot or too cold. Clients who have diabetes have peripheral nerve damage, making it difficult to determine temperature and increasing the risk of burns.
A nurse is collecting data from a client who has a complete intestinal obstruction. Which of the following findings should the nurse expect?
Correct Answer: D.
Hyperactive bowel sounds above the obstruction
The nurse should expect the client to have hyperactive bowel sounds above the obstruction because the intestinal peristalsis above the obstruction attempts to push the obstruction through the intestines. With a complete intestinal obstruction, there are no bowel sounds below the obstruction.
A nurse is reinforcing teaching with a client who has genital herpes about self-management. Which of the following instructions should the nurse include in the teaching?
Correct Answer: D.
Pour running water over the lesions when urinating
The nurse should instruct the client to pour running water over the lesions when urinating to relieve discomfort.