Health Assessment
A patient states, “I see two of everything.” The nurse should document this as:
A. Photophobia
B. Diplopia
C. Presbyopia
D. Myopia
B. Diplopia
A nurse is teaching a patient with diabetes about the purpose of the Hemoglobin A1C (HgbA1C) test. Which statement by the patient indicates the need for further teaching?
A. "This test shows my average blood sugar levels over the past 2 to 3 months."
B. "The higher my A1C, the better I am controlling my blood sugar."
C. "A result below 5.7% is considered normal."
D. "An A1C level of 6.5% or higher indicates diabetes."
B. "The higher my A1C, the better I am controlling my blood sugar."
A nurse at an acute mental health facility is caring for a client who has acute mania due to bipolar disorder. At 0300, the client runs to the nurse’s station and demands to see the provider immediately. Which of the following responses should the nurse offer?
A. “Your request is unreasonable. We cannot call your provider at 3:00 in the morning.:
B. “If you calm down for 5 minutes, then I will call your provider for you.”
C. “Calm down, go back to your room, and come back in 15 minutes so we can talk about how you’re feeling.”
D. “You must be very upset about something to want to see your provider in the middle of the night.”
D. “You must be very upset about something to want to see your provider in the middle of the night.”
What is a late sign of arterial blood occlusion in compartment syndrome?
A. Paresthesia
B. Paralysis
C. Pulselessness
D. Pallor
C. Pulselessness
A patient is ordered to receive bethanechol chloride (Urecholine) for urinary retention. Which health condition would serve as a contraindication for this medication?
A. Asthma
B. Hypertension
C. Diabetes mellitus
D. Chronic allergies
A. Asthma
The nurse notices lichenification on a patient’s elbows. What is the likely cause?
A. Prolonged scratching
B. Drug allergy
C. Poor hygiene
D. Exposure to moisture
A. Prolonged scratching
The nurse is caring for a patient receiving oxygen therapy through a non-rebreather mask. Which of the following is the most important for the nurse to monitor during the use of this mask?
A. Ensure the bag never deflates completely during inspiration.
B. Ensure the oxygen flow rate is less than 10L/min.
C. Assess for nasal breakdown at the cannula site.
D. Assess for wheezing or rhonchi on auscultation.
A. Ensure the bag never deflates completely during inspiration.
A nurse is admitting a client who states he is hearing voices telling him what to do. Which of the following actions should the nurse take?
A. Instruct the client to sit in a quiet place when he hears voices
B. Ask the client to repeat what the voices are saying
C. Tell the client that the voices do not exist
D. Provide therapeutic touch when the client seems anxious
B. Ask the client to repeat what the voices are saying
Which of the following best describes metaplasia?
a. Increase in cell number
b. Increase in cell size
c. Change from one cell type to another
d. Programmed cell death
c. Change from one cell type to another
A patient who is taking levothyroxine (Synthroid) begins to develop weight loss, diarrhea, and stress intolerance. The nurse should be aware that this might be an indication of what hormonal condition?
A. Addison’s disease
B. Hyperthyroidism
C. Cushing’s syndrome
D. Development of acromegaly
B. Hyperthyroidism
A nurse asks a patient to puff out their cheeks and smile. Which cranial nerve is being tested?
A. CN V
B. CN IX
C. CN XII
D. CN VII
D. CN VII
Which of the following would be an example of a "fomite" in the chain of infection?
A. A nurse’s gloved hands.
B. The air in a hospital room.
C. A contaminated doorknob.
D. A patient’s skin.
C. A contaminated doorknob.
A nurse is teaching a client who has agoraphobia about systematic desensitization. Which of the following comments should the nurse include in the teaching?
A. “You will watch from a secure location as your therapist goes to public spaces.”
B. “You will start your therapy by staying in a public space until your anxiety decreases.”
C. “You will be instructed to say ‘stop!’ out loud when you become anxious in public spaces.”
D. “You will be exposed to increasing levels of public spaces.”
D. “You will be exposed to increasing levels of public spaces.”
A 70-year-old patient with a history of atrial fibrillation is diagnosed with a cardiogenic embolic ischemic stroke. What is the most likely cause of this patient's stroke?
A. Blockage of a small artery in the brain
B. A clot formed in the heart due to irregular contractions
C. Spontaneous rupture of a blood vessel
D. Hypertension causing damage to blood vessels in the brain
B. A clot formed in the heart due to irregular contractions
The nurse recognizes that drugs from which of the following classes cause increased risk for peptic ulcers, decreased wound healing, and increased capillary fragility?
A. Glucocorticoids
B. Antidiuretic hormones
C. Growth hormones
D. Antithyroid hormones
A. Glucocorticoids
Which temperature reading method is typically 1°F higher than oral readings?
A. Axillary
B. Temporal
C. Rectal
D. Tympanic
C. Rectal
Which of the following is the most accurate description of the "prodromal" stage of infection?
A. The period when the body is starting to exhibit specific signs and symptoms of disease.
B. The period when the patient feels better, and recovery begins.
C. The time when the person is most infectious, but the signs are vague and nonspecific.
D. The stage in which organisms are actively growing and multiplying, but no symptoms are present.
C. The time when the person is most infectious, but the signs are vague and nonspecific.
A charge nurse is conducting a class on therapeutic communication to a group of newly licensed nurses. Which of the following responses by the newly licensed nurse requires additional teaching regarding nonverbal communication?
A. Personal space
B. Posture
C. Eye contact
D. Intonation
D. Intonation
A nurse is caring for a patient with cirrhosis who is experiencing pruritus. What is the most likely cause of this symptom?
A nurse is caring for a patient with cirrhosis who is experiencing pruritus (itching). What is the most likely cause of this symptom?
A. Accumulation of bile salts in the skin
B. Inadequate glucose production by the liver
C. High ammonia levels in the bloodstream
D. Fluid overload in the peritoneal cavity
A. Accumulation of bile salts in the skin
A client has a new prescription for imipenem to treat a severe infection. What findings should the nurse report while collecting this client’s medical history?
A. The home medication list includes valproic acid for seizure disorder
B. The home medication list includes insulin injections for diabetes
C. The home medication list includes oral contraceptives
D. The home medication list includes ferrous sulfate for anemia
E. A recent history of UTI
A. The home medication list includes valproic acid for seizure disorder
The nurse documents a positive Babinski reflex in an adult patient. What does this indicate?
A. Normal finding in adults
B. Lower motor neuron dysfunction
C. Upper motor neuron lesion
D. No clinical significance
C. Upper motor neuron lesion
A nurse is caring for a patient who is at risk of falling. The nurse leaves the patient unattended in the bathroom, and the patient falls. Which element of negligence is most likely to be proven in this case?
A. Duty
B. Breach of duty
C. Causation
D. Damages
B. Breach of duty
A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription for lithium. Which of the following medications may be administered safely while the client is taking lithium?
A. Ibuprofen
B. Haloperidol
C. Valproic acid
D. Hydrochlorothiazide
C. Valproic acid
A nurse is teaching a patient with sickle cell anemia about avoiding triggers of a vaso-occlusive crisis. Which of the following should be included in the teaching?
A. "Avoid exposure to cold weather and dehydration."
B. "Engage in vigorous exercise to improve circulation."
C. "It is safe to travel by airplane without precautions."
D. "Ensure adequate iron intake to prevent anemia."
A. "Avoid exposure to cold weather and dehydration."
A client with history of CHF is being treated for constipation. The nurse must avoid what laxatives?
A. Psyllium
B. Sodium phosphate enema (Saline Enema)
C. bisacodyl (Dulcolax)
D. senna (Senokot)
E. docusate sodium
F. mineral oil enema (Fleet enema)
B. Sodium phosphate enema (Saline Enema)