G&D
An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action is most appropriate for this infant?
A. Encouraging the infant to hold a bottle
B. Keeping the infant on bed rest to conserve energy
C. Rotating caregivers to provide more stimulation
D. Maintaining a consistent, structured feeding environment
D. Maintaining a consistent, structured feeding environment
When a client has a prolonged or significantly difficult time moving forward after a loss.
Complicated grief
The nurse teaches a primigravida about lightening and that it occurs about 2 weeks before the onset of labor. Which statement reflects the client's understanding of the information?
A. "I may experience painful urination after lightening occurs."
B. "I will feel a little short of breath right after lightening occurs."
C. "I may experience constipation after lightening occurs."
D. "I will likely notice I have to pee more often after lightening occurs."
D. "I will likely notice I have to pee more often after lightening occurs."
Lightening refers to the descent of the fetal head into the pelvis and engagement. With this descent, pressure on the diaphragm decreases, easing breathing, but pressure on the bladder increases, leading to urinary frequency. Dysuria might indicate a urinary tract infection. Constipation may occur throughout pregnancy due to decreased peristalsis, but it is unrelated to lightening.
Pediatric client presents with injuries that are not consistent with the narrative. What is the nurse's priority action?
Mandatory reporting.
An external influence that threatens to disrupt the equilibrium that is needed to maintain homeostasis; relies upon how the person perceives it
What is stressor?
The optimal care for patients withdrawing from substances of abuse is facilitated by the nurse's understanding that severe morbidity and mortality are often associated with withdrawal from:
A. Alcohol and CNS depressants
B. CNS stimulants and hallucinogens.
C. Narcotic antagonists and caffeine.
D. Opiates and inhalants.
ANS: A
Which person is at the highest risk for suicide?
A. A 50-year-old married white male with depression who has a plan to overdose if circumstances at work do not improve.
B. A 45-year-old married white female who recently lost her parents, suffers from bipolar disorder, and attempted suicide once as a teenager.
C. A young, single white male who is alcohol dependent, hopeless, impulsive, has just been rejected by his girlfriend, and has ready access to a gun he has hidden.
D. An older Hispanic male who is Catholic, is living with a debilitating chronic illness, is recently widowed, and states: "I wish that God would take me too."
ANS: C
A new staff nurse is on an orientation tour with the head nurse. A client approaches her and says, “I don’t belong here. Please try to get me out.” The staff nurse’s best response would be:
A. “What would you do if you were out of the hospital?”
B. “I am a new staff member, and I’m on a tour. I’ll come back and talk with you later.”
C. “I think you should talk with the head nurse about that.”
D. “I can’t do anything about that.”
What is 'B'?
As a new staff member, the nurse should clarify who she is and why she is there. She also should acknowledge the client’s attempt to initiate interaction by offering to talk at a more appropriate time. Option A might be used in a later interaction, but is not appropriate at this tim
The school nurse is speaking with a child who is home alone after school for a few hours most days. Which statement by the child would need further investigation?
1. “I know I’m not allowed to have my friends over until my parent gets home from work.”
2. “I always check the caller ID before I answer the phone. I don’t answer it if I don’t know who the caller is.”
3. “I answered the door yesterday and the salesman wanted to come in even though my parent wasn’t home."
4. “My parent has every emergency number I could need posted next to the phone.”
3. “I answered the door yesterday and the salesman wanted to come in even though my parent wasn’t home."
When children are home alone after school they need to have an understanding of rules to promote safety. The child who answers the door when their parents are not at home has demonstrated a lapse in judgment. This needs further investigation and education. The remaining items are appropriate actions.
Today, families come in a variety of structures. Which statement best describes a blended family?
1. All the adult relatives living in the household participate in raising the children and grandchildren.
2. Both adults are custodial parents and bring their children to the family structure.
3. The parents choose to legally take into their family structure a child who is not a biological child to either parent.
4. Custodial parents live together and raise one parent's children as one family
2. Both adults are custodial parents and bring their children to the family structure.
The stepfamily consists of a custodial parent and children and a new spouse. If both partners in the marriage bring children from a previous marriage into the household, the family is usually termed a blended family. If there are adult relatives living in the household along with the parents and their children, it is termed an extended family. When parents legally take a non-biologic child into their home and raise it as their biologic child it is an adoptive family. When one or both of the adults in the household are custodial and they live together, raising their children as one family, it is termed a cohabitation family.
During the assessment of a client at 26 weeks' gestation, the nurse notes the findings listed below. What finding is priority for the nurse to notify the primary health care provider?
1. generalized hair loss
2. hyperpigmented rash over the maxillary region bilaterally
3. nosebleeds
4. generalized edema
4. generalized edema
Generalized edema, specifically of the hands, feet and face after the 24th week of gestation may indicate gestational hypertension. Gestational hypertension could greatly compromise the client and their fetus and requires quick medical intervention; this is the priority to notify the provider. Generalized hair loss, hyperpigmented maxillary rash (chloasma), and nosebleeds are typically benign findings, and each is common in pregnancy.
A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?
1) "As a nurse, I am required by law to report suspected child abuse."
2) "I am unable to discuss this, but I can contact my supervisor to speak with you."
3) "The provider will be coming to explain the situation."
4) "I reported the incident to my supervisor who decided to contact the authorities."
1) "As a nurse, I am required by law to report suspected child abuse."
A nurse is required by law to report suspected child abuse. Therefore, this is a truthful, non-accusatory response.
Which statement by the patient demonstrates an understanding of the treatment of choice for patients managing the effects of traumatic events?
a. "I attend my therapy sessions regularly."
b. "Those intrusive memories are hidden for a reason and should stay hidden."
c. "Keeping busy is the key to getting mentally healthy."
d. "I've agreed to move in with my parents, so I'll get the support I need."
What is A?
The nurse performs a nursing assessment of a client with a suspected alteration of self. Which nursing action should the nurse include in the assessment? (Select all that apply.)
A.Interview the client.
B.Establish a safe environment.
C.Assess the client's role mastery.
D.Establish a therapeutic relationship.
E.Assess the client's personal identity.
A B D E
Rationale: When performing an assessment of a client with a suspected alteration of self, the nurse should establish and maintain a safe environment, establish a therapeutic relationship, interview the client, and avoid asking personal questions that will not substantially add to the assessment data. Assessing the client's role mastery and personal identity are not important aspects of nursing assessments of clients with alterations of self.
The nurse is reviewing orders given for a patient with depression. Which order should the nurse question?
A. A low starting dose of a tricyclic antidepressant
B. An SSRI given initially with an MAOI
C. Electroconvulsive therapy to treat suicidal thoughts
D. Elavil to address the patient's agitation
ANS: B
A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication?
A. Platelet count
B. Blood glucose level
C. Liver function studies
D. White blood cell count
What is 'D'?
A client taking clozapine may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count. Treatment is interrupted if the white blood cell count decreases to less than 3000 mm3 (3 x 10⁹/L). Agranulocytosis could be fatal if undetected and untreated. The other laboratory studies are not related specifically to the use of this medication
A parent and their 4-week-old infant have arrived for a health promotion visit. Which activity will the nurse expect to perform?
1. Assess for anterior fontanelle closure.
2. Obtain a serum lead level.
3. Administer a varicella injection.
4. Plot the child's head circumference on a growth chart.
4. Plot the child's head circumference on a growth chart.
The nurse will plot the head circumference of the child as part of developmental surveillance and screening. Administering a vaccination for varicella would not occur until 12 months of age. Anterior fontanelle does not close until 12-18 months. A serum lead level is typically obtained at 12 months of age, once the child is walking.
A nurse is assessing a family as a system. Which of the following factors should the nurse include when assessing sociocultural context?
A. The sense of self among individual family members
B. The future goals of the family
C. The roles of family members
D. The family's religious practices
D. The family's religious practices
A client at 28 weeks' gestation has been hospitalized with moderate bleeding that is now stabilizing. The nurse performs a routine assessment and notes the client sleeping, lying on the back, and electronic fetal heart rate (FHR) monitor showing gradually increasing baseline with late decelerations. Which action will the nurse perform first?
1. Administer oxygen to the client.
2. Notify the health care provider.
3. Reposition the client to left side.
4. Increase the rate of IV fluids.
3. Reposition the client to left side.
The fetus is showing signs of fetal distress. The immediate treatment is putting the client in a side-lying position to ensure adequate perfusion to the fetus. After placing the client on the side, the nurse should re-assess the FHR and determine if oxygen, IV fluids, and calling the health care provider are needed.
A nurse is caring for a child who has been physically abused by a family member. Which of the following statements should the nurse to say to the child?
1) "I promise I won't tell anyone about this."
2) "Let's discuss what happened with your family."
3) "Your family is terrible for doing this to you."
4) "It is not your fault that this happened."
4) "It is not your fault that this happened."
The nurse should reinforce to the child that the abuse is not his fault.
Lily, a single mother of four, comes to the crisis center 24 hours after an apartment fire in which all the family’s household good and clothing were lost. Lilly has no other family in the area. Her efforts to mobilize assistance have been disorganized, and she is still without shelter. She is distraught and confused. When responding to the patient, the intervention that take priority is:
A. Reduce anxiety
B. Arrange shelter
C. Contact out-of-area family
D. Hospitalize and place the patent on suicide precautions
ANS: A
Which nursing intervention is a priority when planning nursing care for a client experiencing delirium tremens (DTs) related to alcohol withdrawal?
ANS: A
Option B – is not correct monitoring during DT’s would not be the priority as well as we do not monitor coagulations times
Option C – vital signs are taken frequently however not for shock.
Option D – is important however it is not the priority.
What is the priority assessment question for a client who states they are having suicidal ideation?
What is asking "Do you have a plan?"?
A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer’s disease. Which of the following interventions should the nurse include in the plan?
A. Rotate assignment of daily caregivers.
B. Provide an activity schedule that changes from day to day.
C. Limit time for the client to perform activities.
D. Talk the client through tasks one step at a time.
What is 'D'?
The nurse should plan to talk the client through tasks one step at a time to minimize confusion and promote independence, which will decrease the client's anxiety level.
A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply).
A. Long attention span
B. Delayed language development
C. Spinning a toy repetitively
D. Ritualistic behavior
E. Consistent limit testing
B, C, D
Delayed language development is correct. A delay in speech and language development is an expected finding of autism.
Spins a toy repetitively is correct. Interest in repetitive activities is an expected finding of autism.
Ritualistic behavior is correct. A need for routine and the presence of ritualistic behavior are expected findings of autism.
A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?
A. The partner has placed locks on the doors leading outside
B. The partner has hired a house cleaner
C. The partner has lost 20 lbs in the past 2 months
D. The partner redirects the client when the client is frustrated.
C. The partner has lost 20 lbs in the past 2 months
A pregnant client undergoing labor induction is receiving an oxytocin infusion. Which finding requires immediate intervention?
1. fetal heart rate of 150 beats/min
2. contractions every 2 minutes, lasting 45 seconds
3. early decelerations noted on the fetal tracing
4. urine output of 20 ml/hour
4. urine output of 20 ml/hour
A urine output of 20 ml/hour is below acceptable limits of 30 ml/hour and requires intervention as urinary retention can lead to numerous complications such as hemorrhaging. Fetal heart rate of 150 beats/min is within the accepted range of 110 to 160 beats/min. Contractions should occur every 2 to 3 minutes, lasting 40 to 60 seconds. Early decelerations on the fetal tracing are important to continue to monitor but are not priority.
A nurse is teaching staff which factors to include in an abuse assessment of a client. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
1. Suicide risk
2. Socioeconomic status
3. Coping patterns
4. Support Systems
5. Alcohol Use
1., 3., 4., 5.
Suicide risk is correct. The person may feel desperate and trapped and view suicide as the only option. Any risk of harm to the client or to other people should be included in the assessment.
Coping patterns is correct. Coping patterns should be included in an abuse assessment to assess family strengths and stressors.
Support systems is correct. Support systems should be included in an abuse assessment, as the person may be in a dependent and isolated situation and unaware of available support.
Alcohol use is correct. Alcohol and drug use should be included in an abuse assessment, as the person may self-medicate to escape the situation.
Which treatment should a nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder (GAD)?
A. Long-term treatment with diazepam (Valium)
B. Acute symptom control with citalopram (Celexa)
C. Long-term treatment with buspirone (Buspar)
D. Acute symptom control with ziprasidone (Geodon)
What is C. buspirone (Buspar)?
A client is admitted with Wernicke’s encephalopathy. The nurse anticipates that the first physician’s orders will include:
A. A magnetic resonance image (MRI)
B. A steroid medication, such as Decadron (dexamethasone)
C. The vitamin thiamine 100 mg IM STAT
D. An EEG
What is C. - The vitamin thiamine 100 mg IM STAT?
With Wernicke’s encephalopathy, the critical and often life-saving intervention is to give vitamin B (thiamine) STAT. This acute condition occurs in relation to chronic alcoholism (Korsakoff’s syndrome) with an inadequate intake of basic nutrients. The syndrome improves with an adequate diet, but only 25% fully recover. Korsakoff’s condition remains after Wernicke’s encephalopathy is treated. The other answers would not be implemente
A reduction in sodium intake can increase the level of this medication in the blood producing toxic/dangerous results
What is 'Lithium carbonate'?
A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?
A. A client wants to know the current time while there is a clock on the wall.
B. A client attempts to climb out of bed and repeatedly states she must get home.
C. A client requests extra blankets when the thermostat in the room indicates 25.6° C (78° F).
D. A client refuses to get out of bed and has no motivation to attend to daily hygiene.
What is 'B'?
Delirium is characterized by a change in cognition that occurs over a short period of time. It results from a secondary physiological condition (e.g., infection, surgery, prolonged hospitalization, hypoxia, fever, medications) and is a transient disorder. Although delirium can occur with any age, it is more common in older adults. It frequently progresses in the evening hours and is sometimes called "sundown syndrome." Delirium is characterized by alterations in memory, agitation, restlessness, illusions, or hallucinations. A client who becomes acutely confused and agitated may be showing manifestations of delirium.
A nurse on a pediatric unit is caring for a toddler. Which of the following behaviors is an effect of hospitalization? Select all that apply.
1. Believes the hospital is a punishment
2. Experiences separation anxiety
3. Displays intense emotions
4. Exhibits regressive behaviors
5. Manifests disturbance in body image
2, 3, 4.
2. Experiences separation anxiety
3. Displays intense emotions
4. Exhibits regressive behaviors
Preschool age believe hospitalization is a form of punishment. Body image disturbances are seen in adolescents.
A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients?
1) A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eyesight
2) A client who has terminal cancer and needs assistance with pain management
3) A client who is recovering from a stroke and needs someone to provide care while his spouse is at work
4) A client who has dementia and needs help with activities of daily living
2) A client who has terminal cancer and needs assistance with pain management
A client who has a terminal disease and who is deemed to have less than 6 months to live is eligible for hospice services. Hospice care provides the client with physical and psychological support, which includes management of symptoms, such as pain and dyspnea.
A nurse is caring for multiple newborns. Which newborn should the nurse see first?
1. newborn with respirations of 48 breaths/min making intermittent grunting sounds
2. newborn with a temperature of 36.2°C without a hat
3. newborn with jaundice who needs a STAT bilirubin draw
4. newborn with a heart murmur
1. newborn with respirations of 48 breaths/min making intermittent grunting sounds
Signs of respiratory distress to observe for include cyanosis, tachypnea, expiratory grunting, sternal retractions, and nasal flaring. Although a respiratory rate of 48 breaths/min is normal, the intermittent grunting suggests an effort to keep alveoli open to allow for ease of breathing. This needs to be closely monitored. Transient functional cardiac murmurs may be heard during the neonatal period as a result of the changing dynamics of the cardiovascular system at birth. Usually, they are benign. A temperature of 97.1°F (36.2°C) is low and needs follow-up, but it is not the priority over the airway. A newborn with jaundice (yellowing of the skin) needing a STAT draw is important but is not the priority over a newborn with a possibly compromised airway.
A nurse is screening a client who has presented to the health care visit with their spouse. Which finding(s) leads the nurse to suspect that the client may be experiencing intimate partner violence? Select all that apply.
•1. reference to a friend who is being abused
• 2. evasive answers to questions asked
• 3. spouse display of anger toward health care providers
• 4. overprotectiveness of spouse
• 5. reported injury consistent with current findings
•1. reference to a friend who is being abused
• 2. evasive answers to questions asked
• 3. spouse display of anger toward health care providers
• 4. overprotectiveness of spouse
•Clues to possible intimate partner violence include: referring to abuse of a "friend"; answering questions evasively; reporting injuries that are inconsistent with the findings; displaying anger toward health care providers; and the partner being overprotective at a visit.
A 22-year-old hospitalized client with a recent diagnosis of acquired immunodeficiency syndrome (AIDS) says to the nurse, “The food on this breakfast tray is terrible. Why can’t you people do even simple things well?” What is the nurse’s best response?
A. “I know you are angry, but I cannot let you make me the object of you anger. I will send up the dietitian.”
B. “This is not about breakfast. Tell me what you are really angry about.”
C. “I understand you are angry. I’ll shut the door and let you calm down and then we can talk again.”
D. “I hear a lot of anger in your voice that is expected and healthy. Do you want a new breakfast, or would you like something else?”
ANS: D
It is important to acknowledge the client’s anger, help him or her identify the source of the anger, and offer choices or control when possible. Taking the anger personally and deferring to the dietitian is not therapeutic. Being confrontational about the client’s source of anger is not therapeutic. Leaving the room and closing the door ignores the client’s issue and connotes a sense of punishment.
Which intervention should the nurse include in the plan of care for a client experiencing opiate withdrawal?
A. Administer diazepam (Valium)
B. Administer naloxone (Narcan)
C. Administer clonidine (Catapres)
D. Administer bromocriptine (Parlodel)
What is C. clonidine (Catapres)?
A nurse in a mental health clinic is caring for a client who has bipolar disorder and a prescription for an antipsychotic medication. The provider and nursing staff suspect the client is not adhering to his medication therapy. Which of the following interventions should the staff use to encourage the client's adherence? (Select all that apply.)
A. Perform mouth checks following the administration of the medication.
B. Provide for once-daily dosing.
C. Use sustained-release forms.
D. Engage the client in conversation following medication administration
E. Rotate staff that administer the medication
What is 'B, C, & D'?
Provide for once-daily dosing is correct. Once-daily dosing of medications simplifies the therapy, making it easier for the client to comply. Use sustained-release forms is correct. Sustained-release forms remain in the client's system longer, requiring less frequent dosing. Engage the client in conversation following medication administration is correct. If the client is speaking,he will be less likely able to hide the medication in his mouth.
A nurse is caring for a client who is cognitively impaired. Which of the following rooms will provide a therapeutic environment for this client?
A. A room adjacent to the nursing station
B. A room without a window
C. A room with dim lighting
D. A room containing personal belongings
What is 'D'?