Adult Health
Mental Health

The nurse is monitoring a client receiving levothyroxine sodium 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

What is 1, 2, and 5

Insomnia, weight loss, and mild heat intolerance are side effects of levothyroxine sodium. Bradycardia and constipation are not side effects associated with this medication, and rather are associated with hypothyroidism, which is the disorder that this medication is prescribed to treat.


A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?

1. Bradycardia and hyperactivity

2. Decreased respiratory rate and depth

3. Headache, restlessness, and confusion

4. Bradypnea, dizziness, and paresthesias

What is 3

When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.


The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma. What assessment findings should the nurse expect to note? Select all that apply.


1. Pathological fracture

2. Urinalysis positive for Bence Jones protein

3. Hemoglobin level of 15.5 g/dL (155 mmol/L)

4. Calcium level of 8.6 mg/dL (2.15 mmol/L)

5. Serum creatinine level of 2.0 mg/dL (176.6 mcmol/L)

What is 1, 2, and 5

Multiple myeloma is a B cell neoplastic condition characterized by abnormal malignant proliferation of plasma cells and the accumulation of mature plasma cells in the bone marrow. The client with multiple myeloma may experience pathological fractures, hypercalcemia, anemia, recurrent infections, and renal failure. In addition, Bence Jones proteinuria is a finding. A serum calcium level of 8.6 mg/dL (2.15 mmol/L) and a hemoglobin level of 15.5 g/dL (155 mmol/L) are normal values. A serum creatinine level of 2.0 mg/dL (176.6 mcmol/L) is elevated indicating a renal problem.


The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?


1. "I should stay on the diabetic diet."

2. "I should perform glucose monitoring at home."

3. "I should avoid exercise because of the negative effects on insulin production."

4. "I should be aware of any infections and report signs of infection immediately to my obstetrician."

What is 3

Exercise is safe for a client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many clients are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, it is performed at the clinic or obstetrician's office. Signs of infection need to be reported to the obstetrician.


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

What is 4

The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. The correct option pertains directly to the client's feelings and is client-focused. The remaining options do not directly focus on or address the client's feelings.


The nurse is monitoring a client receiving glipizide. The nurse knows that which finding would indicate a therapeutic outcome for this client?


1. A decrease in polyuria

2. An increase in appetite

3. A glycosylated hemoglobin of 10%

4. A fasting blood glucose of 220 mg/dL (12.6 mmol/L)

What is 1

Glipizide is an oral hypoglycemic agent given to reduce the serum glucose level and the signs and symptoms of hyperglycemia. Therefore, a decrease in polyuria (a symptom of hyperglycemia) would denote a beneficial response to glipizide. Excessive appetite (polyphagia) also is a symptom of hyperglycemia. Thus, an increase in appetite would not signify a therapeutic effect. A therapeutic fasting blood glucose should be less than 100 mg/dL, and the glycosylated hemoglobin should be less than 7%.


The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note?


1. Bradycardia

2. Elevated blood pressure

3. Changes in mental status

4. Bilateral crackles in the lungs

What is 3

A client with dehydration is likely to be lethargic or complain of a headache. The client would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins, tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral crackles in the lungs because these are signs of fluid overload and an unrelated finding of dehydration.


The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem?


1. Lack of knowledge

2. Inadequate fluid volume

3. Compromised family coping

4. Inadequate consumption of nutrients

What is 2

An increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options 1, 3, and 4 are not related specifically to the information in the question.


The nurse is performing a measurement of fundal height in a client whose pregnancy has reached 36 weeks of gestation. During the measurement, the client begins to feel lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the nurse understands that which is the cause of the lightheadedness?


1. A full bladder

2. Emotional instability

3. Insufficient iron intake

4. Compression of the vena cava

What is 4

Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome late in pregnancy. Having the woman turn onto her left side or elevating the left buttock during fundal height measurement will prevent or correct the problem. The remaining options are unrelated to this syndrome.


A client calls the nurse and reports feeling anxious. What is the appropriate initial nursing action?


1. Sit and talk with the client about the feelings.

2. Ask the assistive personnel to check on the client.

3. Administer the prescribed as-needed antianxiety medication.

4. Call the client's primary health care provider to report the client's anxiety.

What is 1

The appropriate initial nursing action is to sit and talk with the client expressing anxiety. An assistive personnel is not prepared to deal with the client's anxiety. Antianxiety medication may be necessary, but this would not be the initial appropriate nursing action. While it may become necessary, calling the health care provider is premature initially.


Levofloxacin is prescribed for a client. While teaching the client about the medication, what should the nurse tell the client to take the medication with?

1. Water

2. An antacid

3. A zinc preparation

4. An iron supplement

What is 1

Levofloxacin is a fluoroquinolone and should be administered with water. Antacids, zinc, and iron supplements decrease absorption and should be taken at least 4 hours before or 2 hours after the medication.


The nurse is teaching a client with acquired immunodeficiency syndrome (AIDS) how to avoid food-borne illnesses. The nurse should instruct the client that which food can cause a food-borne illness?


1. Raw oysters

2. Bottled water

3. Pasteurized milk

4. Products with sorbitol

What is 1

The client is taught to avoid raw or undercooked seafood, meat, poultry, and eggs. The client also should avoid unpasteurized milk and dairy products. Fruits that the client peels are safe, as are bottled beverages. The client may be taught to avoid sorbitol, but this is to diminish diarrhea and has nothing to do with food-borne infections.


The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence?


1. Inability to pass flatus

2. Loss of anal sphincter control

3. Severe, constant pain with rapid onset

4. Firm, nontender mass palpable at the lower right costal margin

What is 1

An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually manifests as a more constant generalized discomfort. Option 4 is the description of the physical finding of liver enlargement. The liver may be enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction.


The nurse is preparing to care for a client in labor. The primary health care provider has prescribed an intravenous (IV) infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion?


1. An IV infusion of antibiotics

2. Placing the client on complete bed rest

3. Continuous electronic fetal monitoring

4. Placing a code cart at the client's bedside

What is 3

Oxytocin is a uterine stimulant used to induce labor. Continuous electronic fetal monitoring should be implemented during an IV infusion of oxytocin. There are no data in the question to indicate the need for complete bed rest or the need for antibiotics. Placing a code cart at the bedside of a client receiving an oxytocin infusion is not necessary.


Which is the primary goal of crisis intervention therapy?


1. Introduce new, effective coping methods to the client.

2. Assess the client to identify the causative stressors.

3. Establish a sustainable therapeutic nurse-client relationship.

4. Assist the client in returning to the level of precrisis functioning.

What is 4

The primary goal of crisis intervention therapy is returning the client to a level of functioning that is equal to or better than that experienced precrisis. This goal is reached through strategies that include the introduction of new coping methods directed toward the stressors that contributed to the crisis. The establishment of a therapeutic nurse-client relationship is a general goal for all nursing relationships.


The nurse is assigned to care for a client with multiple sclerosis who is receiving an intravenous dose of methocarbamol. The nurse monitors the client knowing that which is an expected side effect?


1. Insomnia

2. Excitability

3. Hypertension

4. Dark green–colored urine

What is 4

Methocarbamol is a skeletal muscle relaxant. It may cause the urine to turn a brown, black, or dark green color, and the client needs to be told that this is a harmless effect. This medication can cause hypotension. Drowsiness and dizziness can also occur. Therefore, the remaining options are incorrect.


The nurse provides instructions to a preoperative client about the use of an incentive spirometer. The nurse determines that the client needs further instruction if the client indicates that he or she will take which action?


1. Sit upright when using the device.

2. Inhale slowly, maintaining a constant flow.

3. Place the lips completely over the mouthpiece.

4. After maximal inspiration, hold the breath for 10 seconds and then exhale.

What is 4

For optimal lung expansion with the incentive spirometer, the client should assume a semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client should hold the breath for 2 or 3 seconds and then exhale slowly.


A client has sustained a superficial skin tear to the arm. The nurse should apply which dressing as the best type of bandage for this wound?


1. Dry sterile dressing

2. Wet to dry dressing

3. Gelfoam sponge dressing

4. Semipermeable film dressing

What is 4

Semipermeable film dressings are used on superficial wounds, on ulcers, and occasionally on some deep, draining, or necrotic ulcers. These dressings have the advantage of staying in place for several days, allowing tissues to heal underneath. Dry sterile dressings would stick to the wound and are inappropriate. Wet to dry dressings are unnecessary because the tissue does not need debridement. Gelfoam sponge dressings are a type of enzyme dressing used in the treatment of necrotic tissue.


The nurse determines the apical heart rate of a 2-day-old newborn to be 140 beats/minute. Which intervention is most appropriate related to this finding?


1. Reassess the heart rate in 15 minutes.

2. Contact the primary health care provider (PHCP).

3. Document the finding in the electronic health record.

4. Attach the newborn to a cardiac monitor to obtain additional data.

What is 3

The normal heart rate in a newborn is 110 to 160 beats/minute. Therefore, a heart rate of 140 beats/minute is normal and the nurse would document the finding. The other options are incorrect.


The client diagnosed with depression says to the nurse, "I haven't had an appetite at all for the last few weeks." Which response by the nurse best assesses the client's nutritional issue?


1. "The last few weeks?"

2. "You haven't had an appetite at all?"

3. "Have patience; it will take time for your appetite to improve."

4. "When the medication begins to work, your appetite will return."

What is 2

The therapeutic communication technique is restatement. Although it is a technique that has a prompting component to it, it repeats the client's major theme, which helps the nurse obtain a more specific perception of the problem from the client. The length of time is not as relevant as defining what the nutritional issue actually involves. The other options minimize the client's concerns about eating. Eliminate options that fail to focus on the nutritional issue or block the communication process by minimizing the client's concern.


A female client with a diagnosis of breast cancer is taking cyclophosphamide. The client calls the health care clinic and tells the nurse that the medication is upsetting her stomach. Which instruction should the nurse provide to the client?


1. Take the medication with food.

2. Avoid drinking fluids while taking the medication.

3. Try to take the medication with a small amount of orange juice.

4. Continue to take the medication on an empty stomach, and lie down after taking the medication.

What is 1

Hemorrhagic cystitis is a toxic effect that can occur with the use of this medication. The medication should be taken on an empty stomach, but if the client complains of gastrointestinal (GI) upset, it can be taken with food. The client who is taking cyclophosphamide needs to be instructed to drink copious amounts of fluids during the administration of this medication. Orange juice probably would cause and increase the GI upset. Option 4 will not assist in relieving the discomfort experienced by the client.


The nurse has admitted a client to the clinical nursing unit following a right-sided mastectomy. The nurse should plan to place the right-sided arm in which position?


1. Elevated above shoulder level

2. Elevated on 1 or 2 pillows

3. Level with the right-sided atrium

4. Dependent to the right-sided atrium

What is 2

The client's operative arm should be positioned so that it is elevated on 1 or 2 pillows and does not exceed shoulder elevation. This promotes optimal drainage from the limb without impairing the circulation to the arm. If the arm is positioned flat (option 3) or dependent (option 4), this could increase the edema in the arm, which is contraindicated because of lymphatic disruption caused by surgery.


The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)?


1. Updating the home safety sheet

2. Leaving the client in an unchilled area of the room

3. Noting a bowel movement on the client progress note

4. Recording the amount of urine obtained with catheterization

What is 2

The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly pressure and overchilling. For this reason, the nurse ensures that the client is positioned with no pinching or pressure on paralyzed body parts and that the client will be sufficiently warm.


The nurse is monitoring a postpartum client who is bleeding for signs of shock. Which indicates an early sign of shock?


1. Complaints of abdominal cramping

2. An increased pulse rate of 80 to 120 beats/min

3. Complaints of feeling tired yet is feeling hungry

4. An increase in the respiratory rate from 18 to 22 breaths/min

What is 2

During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure is not the earliest sign of shock. An increase in the respiratory rate from 18 to 120 breaths/min is not a concern and is within normal range. Complaints of abdominal cramping, feeling tired, and feeling hungry is normal in the postpartum period.


A client states that she was raped a few weeks ago but still feels "as if it just happened to me." Which response should the nurse make to the client?


1. "It is very, very hard to get over these types of feelings after being raped."

2. "What do you think you should do to reduce the likelihood that you will be raped again?"

3. "Tell me more about what happened and what causes you to feel like the rape just occurred."

4. "It's hard, but try to keep a sense of perspective. After all, it's been a while since the rape occurred."

What is 3

The correct option explores the client's thoughts and feelings directly and fully. At the same time, it conveys an unhurried, nonjudgmental, and supportive attitude that is therapeutic. The client needs reassurance that these feelings are normal and may be expressed in this safe care environment. Avoid any option that places the client's feelings on hold, blocks further communication, or is likely to increase the client's fear.

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