G&D
Life review by the elderly, according to Erikson is demonstrated by reminiscing about past life.
Integrity vs. Despair
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 ennvironment
D.Maintaining a consistent, structured environment
-provides support and safety for child
-involved in child's physical and
psychological well-being and
development
-is what the person says it is
What is Family?
Fetal HR baseline 140, moderate variability, presence of accels, absence of decels. What is the nurse's interpretation of this fetal tracing?
Category I - Reassuring fetal status
A nurse is teaching a client who has a new diagnosis of genital herpes. Which of the following statements by the client indicates the need for further teaching?
1. "Transmission of the disease will not occur when my lesions are gone."
2. "Abstaining from sexual activity reduces the risk of transmission of the disease."
3) "The use of condoms will reduce the risk of transmission."
4) "Antiviral medications will not cure the infection."
1) "Transmission of the disease will not occur when my lesions are gone."
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?
A client is found unresponsive, pupils constricted, grayish skin color, and respirations are 8. What medication would the nurse anticipate giving?
What is naloxone (Narcan)?
Cold intolerance, bradycardia, hypotension, & lanugo
What is 'signs of anorexia'?
A nurse assesses a client with limited eye contact, appears withdrawn, inability to feel pleasure, changes in weight, sleep disturbances, impaired concentration and indecisiveness. What is the likely diagnosis?
What is 'Major Depressive Disorder'?
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
Grief response in which the client begins the grieving process before the actual loss.
Anticipatory grief
A screening tool that helps identify development issues in young children.
Denver II
A nurse in a special education program is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?
A. Allow for adjustment of rules to correlate with the child's behavior.
B. Provide a flexible schedule that adjusts to the child's interests.
C. Allow for imaginative play with peers without supervision.
D.Establish a reward system for positive behavior.
D. Children who have autism spectrum disorder benefit from a reward system for positive behavior.
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 nurse assesses a postpartum client with a fundus 1/U, displaced to the right, boggy, and a steady trickle of blood. What is the priority concern for this client?
Postpartum Hemorrhage
The best way to educate families on the evaluation of adequate nutritional intake in an infant.
6-8 wet diapers.
This exemplar of violence may be intentional or unintentional.
Trauma
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?
Upon assessment, an alcoholic client is found to be uncontrollably shaking, restlessness, hallucinations, and an elevated BP. What critical disease process should the nurse suspect?
What is Delirium Tremens (DT's)?
A nurse is assigned to care for a client with bulimia nervosa and assists the client to order a meal. Which of the following actions is important for the nurse to take regarding mealtime?
A. Emphasizing that it is the client's responsibility to re-establish trust in the nurse-client relationship
B. Allowing the client privacy during mealtime
C. Observing the client for 1-2 hours after the meal
D. Allowing as much time as possible for the client to finish the meal
What is 'C. Observing the client for 1-2 hours after the meal'?
A client presents with an abnormally elevated mood, racing thoughts, delusions, impulsiveness, and feelings of invincibility. What disease process does the nurse suspect and what is the priority concern for this client?
What is 'Mania & Safety'?
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
When a client has a prolonged or significantly difficult time moving forward after a loss.
Complicated grief
The adolescent client behaves like a younger child.
Regression
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 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
What medication is given to simulate fetal lung development in the setting of preterm labor?
Betamethasone
A nurse is teaching a group of newly licensed nurses on effective techniques for counseling clients about sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching?
1) "Use closed-ended questions when obtaining the health history."
2) "A client's reproductive health history is not needed for counseling purposes."
3) "Ask about the client's exposure to any past or present STIs."
4) "Refer the client to genetic counseling if he has had a STI."
3) "Ask about the client's exposure to any past or present STIs."
The nurse should assess the client exposure to any past or present STIs and any treatment taken.
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.
A nurse is caring for a young adult client following the sudden death of his wife. The client feels paralyzed in his ability to cope with work and family responsibilities. Which of the following types of crises is the client experiencing?
A. Situational
B. Maturational
C. Adventitious
D. Developmental
What is A. situational?
What is the first step to recovery?
What is 'acknowledging one has a problem?'
A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?
A. Identify the client's nutritional status.
B. Request a mental health consult.
C. Plan a therapeutic diet for the client.
D. Provide a structured environment for the client.
What is 'A. Identify the client's nutritional status.'?
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.
The person incorporates the loss into life.
What is acceptance?
When caring for an 11-month-old infant, the nurse would be concerned with which finding?
A. Says Mama and Dada
B. Waves Bye-Bye
C. Pulls self to stand
D.Sits with assistance
D. Sits with assistance
A nurse in an urgent care clinic is studying the developmental stages of various clients. In which of the following clients should the nurse first expect to see manifestations of autism?
A. Neonate
B. Toddler
C. Middle Age
D. Geriatric
B. Toddler
A nurse is leading a family therapy session for a mother, father, and two adolescent siblings. Which of the following statements should the nurse recognize as an example of effective communication among family members?
A. "If you keep saying that, I will tell everyone what you did last night."
B. She is always bossing me around. Should she do that?
C. Can you tell me the reason get upset each time I go to the mall?
D. Please do not raise your voice at the children. I am the one who left dishes in the sink.
C. Can you tell me reason you get upset each time I go to the mall?
A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during this test. Which of the following should the nurse include? (Select all that apply.)
A. Fetal breathing
B. Fetal motion
C. Fetal neck translucency
D. Amniotic fluid volume
E. Fetal Gender
A. Fetal breathing
B. Fetal motion
C. Amniotic fluid volume
Bonus: tone (fine motor movements)
Education, Abstinence, Condom use
What are ways to reduce risk and/or prevent the transmission of STDs?
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 client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client with be assigned to this client’s room. Which client would be the best choice as a roommate for the client with anorexia nervosa?
A. A client with pneumonia
B. A client undergoing diagnostic tests
C. A client who thrives on managing others
D. A client who could benefit from the client’s assistance at mealtime
What is 'B. A client undergoing diagnostic tests'?
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.
The person cannot accept the fact of the loss. It is a form of physiological protection from a loss that the person cannot bear.
What is denial?
Cristina, a mother of a 4-year-old child tells the nurse that her child is a very poor eater. What’s the nurse’s best recommendation for helping the mother increase her child’s nutritional intake?
A. Allow the child to feed herself
B. Use specially designed dishes for children – for example, a plate with the child’s favorite cartoon character
C. Only serve the child’s favorite foods
D. Allow the child to eat at a small table and chair by herself
A. Allow the child to feed herself
The best recommendation is to allow the child to feed herself because the child’s stage of development is the preschool period of initiative. Special dishes would enhance the primary recommendation. The child should be offered new foods and choices, not just served her favorite foods. Using a small table and chair would also enhance the primary recommendation.
The nurse recognizes that further teaching is required when the student makes the following statement regarding client with Cerebral Palsy?
1. They will always present with severe cognitive delays.
2. They may have issues with their speech due to poor muscle tone.
3. Some clients will have visual problems like strabismus.
4. There are often problems such as contractures.
1
A nurse is leading a therapeutic group for clients at an outpatient mental health clinic. Which of the following client statements indicates a problem with role transition?
1. "If my husband had gone to the doctor like I told him to, he'd be alive today."
2. "I am so angry with my husband's attitude. He thinks he knows everything!"
3) "I want to have an intimate relationship, but I end up breaking off relationships as soon as they begin."
4) "I just can't seem to find any energy to take care of my children since my husband divorced me."
4) "I just can't seem to find any energy to take care of my children since my husband divorced me."
This statement indicates that the client is experiencing a problem with role transition, which can result from a change in personal, occupational, or social status.
A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?
1) Saturated perineal pad in 30 min
2) Deep tendon reflexes 4+
3) Fundus at level of umbilicus
4) Approximated edges of episiotomy
2. Deep tendon reflexes
Deep tendon reflexes 4+ are hyperactive and indicate that the client is at greatest risk for preeclampsia and seizures. The nurse should identify this as the priority finding. The nurse should also monitor for headaches, visual disturbances and epigastric pain. The provider will likely prescribe magnesium sulfate IV infusion.
Which of the following are expected reflexes in the newborn? (select all that apply)
1. Rooting
2. Moro
3. Babinski
4. Step
5. Tonic-neck
All
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 bad 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.
Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? Select all that apply.
A. “Tell me what happened.”
B. “What coping methods have you used, and did they work?”
C. “Describe to me what your life was like before this happened.”
D. “Let’s focus on the current problem.”
E. “I’ll assist you in selecting functional coping strategies.”
What is A. “Tell me what happened.” B. “What coping methods have you used, and did they work?” & C. “Describe to me what your life was like before this happened.”?
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 is assessing a client who has malnutrition. Which of the following findings should the nurse expect?
A. Increased vital capacity
B. Moist skin
C. Heat intolerance
D. Decreased mental status
What is 'D. Decreased mental status'?
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'?
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.