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NCLEX HURST REVIEW TEST QUESTIONS ANSWERS 100% CORRECT TEST BUNDLE
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EXIT HESI EXAM 2022/2023 Questions and Correct Solutions
A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provid... [Show More] er? a. WBC count 8,000 b. platelets 150,000 c. aspartate aminotransferase 10 units d. erythrocyte sedimentation rate 75mm - ✔✔ d A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests? a. platelet count b. potassium level c. creatine clearance d. prealbumin - ✔✔ a A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first? a. place an ice pack over the cast b. palpate the pulse distal to the cast c. teach the client to keep the cast clean and dry d. position the casted extremity on a pillow - ✔✔ b A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? SATA a. keep objects in the clients room in the same place. b. ensure there is high-wattage lighting in the clients room. c. approach the client from the side d. allow extra time for the client to perform tasks e. touch the client gently to announce presence - ✔✔ a, b, d A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the nurse should identify that which of the following electronic database has the most comprehensive collection nursing articles? a. medline b. C inahl c. ProQuest d. health source - ✔✔ b A nurse in the emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a brain injury. Which of the following actions should the nurse take first? a. obtain a baseline EKG b. Obtain a blood specimen for ABG analysis c. insert an 18 gauge IV catheter d. Administer 100% humidified oxygen - ✔✔ d A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? a. Place food on the left side of the client's mouth when he is ready to eat. b. Provide total care in performing the client's ADLs. c. Maintain the client on bed rest. d. Place the client's left arm on a pillow while he is sitting. - ✔✔ d A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take? a. Confront the client about this behavior. b. Express sympathy for the client's situation. c. Speak assertively to the client. d. Stand within 30 cm (1 ft) of the client when speaking with them. - ✔✔ a A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take? a. Cleanse equipment before removal from the client's room. b. Limit the client's visitors to 30 min per day. c. Discard the client's linens in a double bag. d. Discard the radioactive source in a biohazard bag - ✔✔ b A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take? a. Position the client supine b. Prepare an IV bolus of dextrose 5% in water c. Administer methylergonovine IM d. Administer calcium gluconate IV - ✔✔ d A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? a. Experiencing delusions b. Male gender c. Pervious violent behavior d. A history of being in prison - ✔✔ c A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? a. Place the cap from the solution sterile side up on clean surface b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body's first c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm (1-inch) border around any sterile drape or wrap that is considered contaminated. d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level; should be ABOVE waist level - ✔✔ a A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? a. Eat a light snack before bedtime c. Stay in bed at least 1 hr if unable to fall asleep d. Take a 1 hr nap during the day e. Perform exercises prior to bedtime - ✔✔ a A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first? a. Educate the client about current medical diagnosis b. Refer the client to a meal delivery program c. Identify environmental hazards in the home d. Arrange for client transportation to follow-up appointments Rationale Priority: Assess first. - ✔✔ c A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client? a. "Can you tell me who visited you today?" b. "What high school did you graduate from c. "Can you list your current medications?" d. "What did you have for breakfast yesterday?" - ✔✔ b A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. > b. Blood glucose level greater than 200 mg/dL at bedtime c. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC d. HbA1c level less than 7% - ✔✔ d A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination? a. The client is experiencing an adverse reaction to rifampin b. The client's seizure disorder is no longer under control c. The client is showing evidence of phenytoin toxicity d. The client is having adverse effects due to combination antimicrobial therapy - ✔✔ c A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse? a. Increase in frequency of swallowing→ may indicate bleeding b. Moderate sanguineous drainage on the drip pad c. Bruising to the face→ side effect d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative) - ✔✔ a Rationale "Requires immediate action" choose the worst possibility that could lead to. ABC A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? a. Give scheduled doses of acetaminophen every 6 hr b. Monitor the child's cardiac status c. Administer antibiotics via intermittent IV bolus for 24 hr d. Provide stimulation with children of the same age in the playroom - ✔✔ b A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco? a. Use of tobacco might lead to alcohol and drug abuse b. Smoking in adolescence increases the risk of developing lung cancer later in life c. Use of tobacco decreases the level of athletic ability d. Smoking in adolescence increases the risk of lifelong addiction - ✔✔ c A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? a. Total bilirubin b. Urine ketones c. Serum potassium- diuretic that retains potassium= hyperkalemic risk d. Platelet count - ✔✔ c [Show Less]
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NCLEX HURST REVIEW TEST QUESTIONS ANSWERS 100% CORRECT
What three things contain a lot of Na? - ✔✔ 1. Effervescent soluble medications 2. Canned processed foods 3. IVF with Na What is aldosterone? Wh... [Show More] ere is it found? - ✔✔ Steroid or mineralocorticoids; adrenal glands When blood volume is low what happens to aldosterone secretion? - ✔✔ It increases and Na/H2O are retained in order to increase volume What are two examples of too much aldosterone? Too little? - ✔✔ Cushings & Herpaldosteronism (Conn's syndrome); Addisons What is ADH also called? - ✔✔ Vasopressin What does ADH do? - ✔✔ Makes you retain ONLY H20 If you have too much ADH what happens? - ✔✔ Retain H20 FVE urine is concentrated blood is dilute If you have too little ADH what happens? - ✔✔ Lose/diuresis H20 FVD urine is dilute blood is concentrated How does SIADH become FVE? - ✔✔ The kidney can't excrete waste so they retain water because the body is producing too much ADH Where is ADH found? - ✔✔ Pituitary What type of surgery is an example that can lead to an ADH problem? - ✔✔ Sinus surgery but really anything that leads to an increased ICP What is the pt at risk for developing after sinus surgery? How is is prevented? - ✔✔ DI or going into shock; given ADH replacement (vasopressin/desmopressin acetate) Where is CVP measured? what's normal? - ✔✔ Right atrium; 2-6mmHg How do you treat FVE? - ✔✔ 1. Diuretics 2. Bedrest 3. Low Na/fluid restrictions 4. Daily weights/I&Os 5. Physical assessment 6. Give IVFs to elderly/young and pts with a hx of heart/kidney disease slowly How do you treat FVD? - ✔✔ 1. Prevent further losses 2. Replace volume (mild deficit: PO fluids, severe deficit: IVFs) 3. High risk for falls, monitor for overload what type of pts do you not use isotonic fluids for? - ✔✔ Pts with HTN, cardiac or renal disease because they can cause FVE, HTN or hypernatremia Do hypotonic solutions cause HTN? - ✔✔ No, because they rehydrate the cell but don't stay in the vascular space What type of pts do you use hypotonic solutions for? - ✔✔ Pts with HTN, cardiac or renal disease or pts who need fluid replacement because of n/v, burns, hemorrhage or for dilution when a pt has hypernatremia and cellular dehydration What type of pts do you use hypertonic solutions for? - ✔✔ Pts with HYPOnatremia or pts who have shifted large amounts of vascular volume to a 3rd space or has severe edema, burns or ascites because a hypertonic solution will return the fluid volume to the vascular space If a pt is receiving 3% NS or 5% NS what do you monitor? - ✔✔ Vitals but especially CVP Where is magnesium excreted? - ✔✔ Kidneys What causes hyperMg? How do you treat it? - ✔✔ Renal failure and antacids Ventilator, dialysis, calcium gluconate What causes hypoMg? How do you treat it? - ✔✔ Diarrhea, alcoholism, alcohol suppresses ADH and its hypertonic Give Mg, check kidney function, seizure precautions, eat Mg What causes hyperCa? How do you treat it? - ✔✔ Too much PTH, thiazides (retain Ca), immobilization Move, fluids prevent kidney stones, Ca has an inverse relationship with phosphorus, steroids, meds What meds decrease serum calcium? - ✔✔ Biphosphates and calcitonin What causes hypoCa? How do you treat it? - ✔✔ Hypoparathroidism, radical neck, thyroidectomy (NOT enough PTH) PO Ca, IV Ca, Vit D, phosphate binders What are two phosphate binders? - ✔✔ Sevelamer hydrochloride and calcium acetate What causes hyperNa? How do you treat it? - ✔✔ Hyperventilation, heat stroke, DI restrict Na, dilute fluids, DW, I&Os, lab work What causes hypoNa? How so you treat it? - ✔✔ Drinking H20 for fluid replacement, psychogenic poly dips is loves to drink H20, D5W, SIADH Need Na, do not need H20, if having neuro problems need hypertonic solution (3%NS or 5%NS) Where is potassium excreted by? - ✔✔ Kidneys What happens to the serum K level if the kidneys are not working? - ✔✔ It goes up What causes hyperK? How do you treat it? - ✔✔ Kidney trouble, spironolactone dialysis, calcium gluconate decreases arrhythmias, glu and insulin (insulin carries glu and K into the cell), sodium polystyrene sulfonate (kayexalate) What causes hypoK? How do you treat it? - ✔✔ Vomiting, NG suction, diuretics, not eating Give K, spironolactone, eat more K During respiratory acidosis the body must excrete and retain what? - ✔✔ Excrete hydrogen and retain bicarb What are s/s of respiratory acidosis? - ✔✔ Headache, confusion, sleepy During respiratory alkalosis the body must excrete and retain what? - ✔✔ Excrete bicarb and retain hydrogen What causes respiratory alkalosis? - ✔✔ hyperventilation What are the s/s of respiratory alkalosis? - ✔✔ lightheaded, faint, peri-oral numbness, tingling in the fingers & toes What organ is the problem with metabolic acidosis? - ✔✔ Kidneys What causes metabolic acidosis? - ✔✔ DKA/starvation because the cells are starving because glucose is not available. The body will breakdown fat for energy and as a result produce ketones OR kidney failure, severe diarrhea What organ is the problem with metabolic alkalosis? - ✔✔ Kidneys What causes metabolic alkalosis? - ✔✔ Loss of GI contents or too many antacids Is metabolic acidosis and metabolic alkalosis, hyperK or hypoK? - ✔✔ Metabolic acidosis is HYPER K Metabolic alkalosis is HYPO K When does plasma seep out of tissue the most due to a burn? What is it caused by? - ✔✔ 1st 24 hrs; increased capillary permeability What is secreted in order to vasocontrict so blood is shunted towards the vital organs? What is also secreted? - ✔✔ Epinephrine and noreprinephrine aldosterone to retain Na & H20 ADH to retain H20 If the systolic BP is less than what, when will the pt not have adequate tissue perfusion? - ✔✔ <90 What is the #1 injury in burns? - ✔✔ Inhalation injury is the #1 cause of death which is caused by inhaling carbon monoxide and hydrogen cyanide How do you get carbon monoxide poisoning? (In the body) - ✔✔ Oxygen normally binds with Hbg but now CO binds to Hgb leaving the pt hypoxia because O2 can't bind to Hgb anymore If a pt is cherry red, what is wrong with them? - ✔✔ Hydrogen cyanide poisoning What type of fluids are used in fluid replacement for a burn pt? - ✔✔ LR (crystalloids) and albumin (colloids) [Show Less]
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HURST Review: Maternity Nursing Questions and Answers| Graded A+
What is the name of the hormone that induces amenorrhea? - ✔✔ progesterone Progesterone makes your temperature - ✔✔ increase after ovulation... [Show More] Signs/Symptoms of Pregnancy: Presumptive signs include - ✔✔ -amenorrhea -N/V -urinary frequency -breast tenderness Signs/Symptoms of Pregnancy - Presumptive Signs: What can be one of the first signs of pregnancy? - ✔✔ urinary frequency amenorrhea N/V breast tenderness Signs/Symptoms of Pregnancy - Presumptive Signs: Why is breast tenderness is presumptive sign of pregnancy? - ✔✔ because of the excess hormones in the body Probable signs of pregnancy include... - ✔✔ -positive pregnancy test -Goodell's sign -Chadwick's sign -Hegar's sign -uterine enlargement -Braxton Hicks contractions -pigmentation changes of skin Signs/Symptoms of Pregnancy - Probable Signs: A positive pregnancy test is based on the presence of - ✔✔ hCG levels Signs/Symptoms of Pregnancy - Probable Signs: There are other conditions that can increase hCG levels like - ✔✔ hydatidiform (molar pregnancy) or some other medications Signs/Symptoms of Pregnancy - Probable Signs: What is hydatidiform (molar pregnancy)? - ✔✔ benign neoplasm of grape-like vesicles that can become malignant If a hydatidiform (molar pregnancy) is not malignant - ✔✔ a D & C is required with close follow-up for 6 months to 1 year Probable Signs: What is Goodell's sign? - ✔✔ softening of the cervix during the second month Probable Signs: What is Chadwick's sign? - ✔✔ bluish color of the vaginal mucosa and cervix during the 4th week d/t vasocongestion Probable Signs: What is Hegar's sign? - ✔✔ softening of the lower uterine segment during the 2nd/3rd month Probable Signs: Braxton Hicks contractions occur when and for what purpose? - ✔✔ they occur throughout pregnancy and move blood through the placenta Probable Signs: What skin pigmentation changes occur? - ✔✔ -linea nigra -facial chloasma -abdomen striae -darkening of the areola Positive signs of pregnancy include - ✔✔ -fetal hearbeat -fetal movement -ultrasound Signs/Symptoms of Pregnancy - Positive Signs: Fetal heartbeat can be heard with a doppler weeks - ✔✔ 10 to 12 Positive Signs: Fetal heartbeat can be heard with a fetoscope weeks - ✔✔ 17 to 20 Pregnancy Terms: Terms include - ✔✔ -gravidity -parity -viability -TPAL Pregnancy Terms: What is gravidity? - ✔✔ the number of times someone has been pregnant Pregnancy Terms: What is parity? - ✔✔ the number of pregnancies in which the fetus reaches 20 weeks Pregnancy Terms: What is viability? - ✔✔ when an infant has the ability to live outside the uterus Pregnancy Terms: The age of viability is - ✔✔ 24 weeks; anything less is NOT considered viable Pregnancy Terms - TPAL: What does this acronym stand for? - ✔✔ T - term P - preterm A - abortion (includes spontaneous and elective) L - living children Pregnancy Terms - TPAL: Bleeding, cramping, backache...think - ✔✔ miscarriage Pregnancy Terms - TPAL: With an imminent miscarriage, the _________________ will begin to drop - ✔✔ hCG level Pregnancy Terms - TPAL: Most miscarriages occur before - ✔✔ 20 weeks Pregnancy Terms - Naegle's Rule for the EDD: Steps to calculate - ✔✔ 1. find the first day of the LMP 2. add 7 days 3. subtract 3 months 4. add 1 year Pregnancy Terms - Naegle's Rule for the EDD: This rule is only accurate plus or minus - ✔✔ 2 weeks Trimesters of Pregnancy - First Trimester: This trimester is weeks - ✔✔ 1 through 13 First Trimester - Client Education/Teaching: During this trimester it is important to teach the client about - ✔✔ -nutrition -weight gain -prenatal vitamin supplements -exercise -danger signs and potential complication of maternity -common discomforts -medications -smoking -primary healthcare provider visits -ultrasounds First Trimester - Client Education/Teaching: Increase protein intake to - ✔✔ 60 grams per day (40-45 is normal) First Trimester - Client Education/Teaching: Regarding culture, consider nutritional influences such as - ✔✔ -hot vs cold foods -Kosher foods -fasting First Trimester - Client Education/Teaching: The client should expect to gain ___________________ pounds in the first trimester and will also be dependent on what the _______________________ is - ✔✔ 1 to 4; starting BMI First Trimester - Client Education/Teaching: What are the biggest complaints with iron? - ✔✔ constipation and GI upset First Trimester - Client Education/Teaching: Always take iron with __________ and why? - ✔✔ vitamin C because it prevents GI upset and enhances absorption First Trimester - Client Education/Teaching: Folic acid prevents - ✔✔ neural tube defects First Trimester - Client Education/Teaching: What is the daily dose of folic acid? - ✔✔ 400 mcg/day First Trimester - Client Education/Teaching: What are some iron-rich foods? - ✔✔ -liver -spinach -lentils -raisins -fortified cereal -dark chocolate -dried fruit First Trimester - Client Education/Teaching: Regarding exercise, NO _____________ - ✔✔ high impact exercise First Trimester - Client Education/Teaching: What are the best exercises to do? - ✔✔ walking and swimming First Trimester - Client Education/Teaching: NO heavy exercise program, but can - ✔✔ continue regular exercise program [Show Less]
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NCLEX Practice Questions HURST REVIEW (Fundamentals) Questions and Answers
C. Assessment A nurse is caring for a patient with chronic heart failure who is very ill. The patient has a "no code" order. The patient goes into ventric... [Show More] ular fibrillation and the nurse defibrillates the patient. The nurse states she was unaware of the "no code" order. What part of the nursing process did the nurse fail to perform? A. Planning B. Evaluation C. Assessment B. Implementation B. Implementation On the morning laboratory report, the patient's potassium is noted to be 2.5 mEq/L. The nurse does not want to "bother the physician this early." During the change-of-shift report, the patient develops ventricular tachycardia and has to be resuscitated. What part of the nursing process did the nurse fail to perform? A. Evaluation B. Implementation C. Assessment D. Planning AD B. Assess and analyze the level of care needed by the patient. A patient in the critical care unit has an order to be transported off the unit for a diagnostic procedure. The nurse fails to ensure that the patient is properly monitored during transport, and the patient experiences a cardiac arrest. Which of the following actions did the nurse fail to adequately perform? A. Make the proper nursing diagnosis. B. Assess and analyze the level of care needed by the patient. C. Act as a patient advocate to postpone the examination. D. Communicate findings in a timely manner. C. No. There were no damages associated with failure to document The nurse fails to record a set of vital signs on a blood transfusion report, which is against hospital policy. The patient does not sustain any damage as a result. Can the nurse be charged with malpractice in this case? A. No. Documentation is not part of the duty of nurse. B. Yes. Even though there were no damages, the nurse failed to follow hospital protocol. C. No. There were no damages associated with failure to document D. Yes. Failure to document always results in negligence. A. Beneficence B. Nonmaleficence C. Autonomy A patient with metastatic cancer tells the nurse, “I am tired and do not want to be put on a breathing machine.” The patient’s out-of-town son wants “everything done for my mother” when his mother later develops respiratory distress. Which ethical principles are involved in this dilemma? (Select all that apply.) A. Beneficence B. Nonmaleficence C. Autonomy D. Justice E. Paternalism A. The hospital ethics committee C. The nursing supervisor D. The nursing ethics committee The nurse is concerned that the physician is ignoring the wishes of the patient and family in the care of a patient. The nurse should take these concerns to: (Select all that apply.) A. The hospital ethics committee B. The ANA (American Nurses Association) C. The nursing supervisor D. The nursing ethics committee E. he policy and procedure committee C. Nonmaleficence The nurse observes a coworker diverting narcotics by administering normal saline to a patient in pain. By not reporting this observation, the nurse is in violation of what ethical principle concerning the patients under the care of the impaired nurse? A. Autonomy B. Justice C. Nonmaleficence D. Veracity A. Withdrawing treatment The family of a patient who is receiving mechanical ventilation for respiratory distress associated with an inoperable brain tumor asks that the patient be extubated to "allow natural death" to occur. This is an example of what situation? A. Withdrawing treatment B. Rationing care C. A criminal act D. Withholding treatment A. Moral distress A nurse has been having difficulty sleeping since the death of a patient who had a stressful family situation involving a DNR (do not resuscitate) order. She is arguing with her husband and coworker and is complaining about working conditions. The nurse's symptoms could be signs of what problem? A. Moral distress B. Moral confusion C. Immoral distress D. Change fatigue B. Fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area. C. Second intercostal space to the right of the sternum to hear sounds from the aortic valve area Where should a nurse place the stethoscope when auscultating heart sounds? Select all that apply A. First intercostal space left of the sternum to hear sounds from the pulmonic valve area. B. Fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area. C. Second intercostal space to the right of the sternum to hear sounds from the aortic valve area. D. Fifth intercostal space left side of sternum to hear sounds from the mitral area. E. Apex of the heart to hear the loudest 2nd heart sound (S2). 1. Stop the feeding and assess gastric residual volume in 1 hour A client receiving 50 mL/hr of enteral feedings has a gastric residual volume of 200 mL and is reporting nausea. What is the appropriate nursing intervention? 1. Stop the feeding and assess gastric residual volume in 1 hour. 2. Reduce the infusion rate to 25 mL/ hour and reevaluate residual volume in 4 hours. 3. Change the feeding schedule from continuous to intermittent delivery. 4. Discard the 200 mL and continue the feedings at the same rate. 4. You have some genuine concerns about the open heart surgery, and you feel as if your children are not addressing your concerns. A client states, "I really do not want to go through open heart surgery. I have told my children this, but they still want me to go through with the surgery. I don’t know what to do." What is the best response for the nurse as client advocate? 1. Your children are correct. The open heart surgery is the best thing for your health. 2. You feel as if your children are not addressing your concerns. You and your family will need to resolve this before you go to surgery. 3. I can contact your primary healthcare provider so that you can discuss your concerns regarding open heart surgery. 4. You have some genuine concerns about the open heart surgery, and you feel as if your children are not addressing your concerns. AD 2. Clarify the prescription with the primary healthcare provider. The nurse is caring for a client with a fibula fracture. The primary healthcare provider makes rounds and writes prescriptions. What is the nurse's best action? 1. Check the prescription prior to sending it to the pharmacy. 2. Clarify the prescription with the primary healthcare provider. 3. Notify the pharmacy that the prescription is needed immediately. 4. Gather the supplies needed for an injection. 2. Have client return to bed and utilize slide board to transfer to litter. [Show Less]
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Hurst Readiness Exam 1 Questions and 100% Verified Answers
The nurse is teaching a group of pregnant women about hormonal changes during pregnancy. The nurse recognizes that teaching was successful when the women i... [Show More] dentify which hormone as causing amenorrhea? 1. Progesterone 2. Estrogen 3. Follicle-stimulating hormone (FSH) 4. Human chorionic gonadotropin (hCG) - ✔✔ Rationale 1. Correct: Progesterone causes amenorrhea. 2. Incorrect: Estrogen renders the female genital tract suitable for fertilization. 3. Incorrect: This stimulates the growth of the graafian follicle in the ovary. 4. Incorrect: This is the hormone present in urine for pregnancy test The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest wound. The nurse notes paradoxical chest wall movement. Which problem does the nurse suspect? 1. Mediastinal shift 2. Tension pneumothorax 3. Flail chest 4. Pulmonary contusion - ✔✔ Rationale 3. Correct: Hallmark of flail chest is paradoxical chest wall movement. This is often described as a see-saw effect when observing the rise and fall of the chest. 1. Incorrect: A closed or open tension pneumothorax results from the lung collapsing and air entering into the pleural cavity. This results in pressure shifting toward the unaffected pleural cavity. 2. Incorrect: Tension pneumothorax occurs when there is an accumulation of air in the pleural cavity. The client may exhibit dyspnea, tachycardia, or hypotension. 4. Incorrect: A pulmonary contusion usually results from blunt trauma. Bruising of lung would be demonstrated by pain but not paradoxical chest wall movement. Which client can a nurse manager safely transfer from the telemetry unit to the obstetrical unit in order to receive a new admit? 1. Client admitted with possible tuberculosis (TB) awaiting skin test results. 2. Client diagnosed with seizure disorder. 3. Client with a new pacemaker scheduled to be discharged in the morning. 4. Client with a history of mild heart failure prescribed one unit of packed red blood cells for anemia. - ✔✔ Rationale 2. Correct: OB nurses would have the appropriate knowledge needed to care for a client with a seizure disorders, because they care for clients who have eclampsia (seizures). 1. Incorrect: This client might have tuberculosis (TB) and is not a good choice to move to the OB floor, because of the risk for transmission of an infectious disease. 3. Incorrect: This client is not the best one to be transferred to the OB floor, because these nurses do not routinely care for clients with a new pacemaker. The client is also likely to remain on a cardiac monitor until discharge. 4. Incorrect: This client is at risk for fluid volume overload since there is a history of heart failure and would require close monitoring while receiving a blood transfusion. The nurse is teaching a group of clients who have reduced peripheral circulation how to care for their feet. What points should the nurse include? 1. Check shoes for rough spots in the lining. 2. File toenails straight across. 3. Cover feet and between toes with creams to moisten the skin. 4. Break in new shoes gradually. 5. Use pumice stones to treat calluses. - ✔✔ Rationale 1., 2., & 4. Correct: Rubbing from rough spots in the shoe can lead to corns or calluses. File the toenails rather than cutting to avoid skin injury. File nails straight across the ends of the toes. If the nails are too thick or misshapen to file, consult podiatrist. Break in new shoes gradually by increasing the wearing time 30-60 minutes each day. 3. Incorrect: Cover the feet, except between the toes, with creams or lotions to moisten the skin. Lotion will also soften calluses. A lotion that reduces dryness effectively is a mixture of lanolin and mineral oil. 5. Incorrect: Avoid self-treatment of corns or calluses. Pumice stones and some callus and corn applications are injurious to the skin. Do not cut calluses or corns. Consult a podiatrist or primary healthcare provider first. When caring for young adult clients, which developmental tasks would the nurse expect to see? 1. Satisfying and supporting the next generation. 2. Reflecting on life accomplishments. 3. Developing meaningful and intimate relationships. 4. Giving and sharing with an individual without asking what will be given or shared in return. 5. Developing sense of fulfillment by volunteering in the community. - ✔✔ Rationale 3. & 4. Correct: In young adulthood, the developmental tasks involve intimacy versus isolation. Intimacy relates more to sharing than to sex. Intimacy produces feelings of safety, closeness, and trust. 1. Incorrect: Parenting is a primary task of middle adulthood. This is the middle adulthood stage of Generativity versus Stagnation, where each adult must find some way to satisfy and support the next generation. 2. Incorrect: During late adulthood, there is refection on life accomplishments. This is the maturity stage of Ego Integrity versus Despair, where there is a reflection of one's life. 5. Incorrect: During middle age, a sense of fulfillment can be found by volunteering in the community. This is part of middle age, where the adult is finding ways to support others. What symptoms does the nurse expect to see in a client with bulimia nervosa? 1. Amenorrhea 2. Feelings of self-worth unduly influenced by weight 3. Recurrent episodes of binge eating 4. Recurrent inappropriate compensatory behavior to prevent weight gain 5. Lack of exercise - ✔✔ Rationale 2., 3. & 4. Correct: Diagnostic criteria for bulimia nervosa are recurrent episodes of binge eating: recurrent inappropriate compensatory behavior to prevent weight gain such as laxative, diuretic, or enema use, induced vomiting, fasting, and excessive exercise; and feeling of self-worth unduly influenced by weight. Amenorrhea is found in anorexia nervosa. 1. Incorrect: Amenorrhea is found in anorexia nervosa. 5. Incorrect: Excessive exercise is found in bulimia nervosa as a means to compensate for the binge eating. A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital signs, laboratory studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing cause of the pain? 1. Surgical cannulation of the bile duct is causing spasm and pain. 2. Carbon dioxide used intraperitoneally is irritating the phrenic nerve. 3. Large abdominal retractors used in the procedure compressed a nerve. 4. Side lying position in the operating room generated pressure damage. - ✔✔ Rationale 2. Correct: Phrenic nerve irritation can result in referred pain to the left shoulder. Carbon dioxide (CO2) is used to inflate the abdominal/chest wall during the procedure for better visualization of the internal organs. If the CO2 irritates the phrenic nerve, it radiates to the shoulder. 1. Incorrect: Surgical cannulation of the bile duct is not performed during a laparoscopic cholecystectomy. 3. Incorrect: Large abdominal retractors are not used during this procedure. This is done via a small incision to accommodate a scope. 4. Incorrect: The client is turned in several directions during the procedure to prevent damage to the abdominal viscera. A client is admitted to the medical unit with an acute onset of fever, chills and RUQ pain. Vital signs are: T 99.8°F (37.7°C), P 132, RR 34, B/P 142/82. ABG results are: pH-7.53, PaCO2 30, HCO3 22. The nurse determines that this client is in what acid/base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis - ✔✔ Rationale 2. Correct: This client has a severe infection. Hyperventilation due to anxiety, pain, shock, severe infection, fever, and liver failure can lead to respiratory alkalosis. pH > 7.45, PCO2 < 35, HCO3 normal. 1. Incorrect: Not acidosis with hyperventilation and pH of 7.53. 3. Incorrect: Not a metabolic related acid/base imbalance since the HCO3 is in normal range and is not acidosis. 4. Incorrect: Not a metabolic related acid/base imbalance since the HCO3 is in normal range. An unlicensed assistive personnel (UAP) has explained how to prevent the spread of infection to the charge nurse. Which statement by the UAP indicates that further teaching is needed? 1. "Soap and water should be used for hand washing when our hands are visibly soiled." 2. "Gloves do not have to be worn when taking a client's vital signs or passing out meal trays." 3. "Standard precautions should be used on all clients." 4. "When caring for a client who has a suppressed immune response, a N95 mask should be worn." - ✔✔ Rationale 4. Correct: Standard precautions are needed. If there is a risk for coming in contact with client secretions or excretions, a standard mask may be worn. Routine nursing care does not warrant the use of an N95 mask. This type mask is needed for client's who are placed on Airborne Precautions such as for tuberculosis (TB). 1. Incorrect: This is a correct statement regarding the prevention of infection. Hand washing with soap and water is part of standard precautions. 2. Incorrect: This is a correct statement. Gloves are needed when coming into contact with body fluids. 3. Incorrect: This is a correct statement. Standard precautions is part of the first line of defense against the spread of infection. The nurse is preparing to discharge a client who has been placed on tranylcypromine. The nurse teaches the client about food to avoid while taking this medication. What food choice by the client confirms appropriate understanding of the teaching? 1. Cottage cheese 2. Salami 3. Baked chicken 4. Potatoes - ✔✔ Rationale 2. Correct: The client taking a monoamine oxidase inhibitor (MAOI) such as tranylcypromine should avoid foods rich in tyramine or tryptophan. These include: cured foods, those that have been aged, pickled, fermented, or smoked. These can precipitate a hypertensive crisis. 1. Incorrect: Clients taking MAOIs can eat cottage cheese in reasonable amounts. 3. Incorrect: Clients taking MAOIs can eat baked chicken. 4. Incorrect: Clients taking MAOIs can eat potatoes. Which nurse is providing cost effective care to a client? 1. Providing palliative care to a terminally ill client. 2. Beginning discharge planning on admit. 3. Counseling clients on cigarette smoking cessation. 4. Educating a group of parents on the importance of childhood immunizations. 5. Performing a postop wound dressing change using clean gloves. - ✔✔ Rationale 1., 2., 3., & 4. Correct. Palliative care is considered cost effective when caring for the terminally ill client. There was a 60% drop reported in the healthcare costs since palliative care was introduced. In comparison to conventional care, palliative care is considered as cost effective in reducing unnecessary utilization of resources. Palliative care has focused on the efficient and the effective care that is centered on the clients. The nurse who begins discharge planning on admit is providing cost effective care. The client may not be able to learn all that is needed if waiting until the day of discharge. Also, supplies and equipment may be needed. If waiting until the day of discharge to determine client needs, then discharge can be delayed. This is costly. Counseling to quit cigarette smoking, colonoscopies, giving beta-blockers to clients after heart attacks are well-established interventions that are effective and also are cost-effective. Two additional preventive interventions were found to be cost-saving: childhood immunization and counseling adults on the use of low dose aspirin. 5. Incorrect. A postop surgical wound dressing change is a sterile procedure: Sterile gloves are necessary and failure to use them could lead to infection, which would then increase the cost of care to a client. [Show Less]
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NCLEX Practice Questions HURST REVIEW (Adult Health) Questions and Answers
A male client diagnosed with primary hyperaldosteronism is receiving spironolactone. Which potential side effect should the nurse educate the client regard... [Show More] ing? Select all that apply 1. Erectile dysfunction 2. Gastrointestinal upset 3. Gynecomastia 4. Hypernatremia 5. Hypokalemia 1. Erectile dysfunction 2. Gastrointestinal upset 3. Gynecomastia The nurse is preparing discharge teaching for a client diagnosed with peripheral vascular disease (PVD). Which teaching points should the nurse include about foot and leg care? Select all that apply 1. Wear soft cotton socks 2. Avoid hot whirlpools 3. Rub feet dry 4. Wash feet every other day 5. Clear pathways in house 1. Wear soft cotton socks 2. Avoid hot whirlpools 5. Clear pathways in house AD The nurse is caring for a client diagnosed with Guillain-Barre' Syndrome. What assessment finding would the nurse expect see in this client? Select all that apply 1. Areflexia 2. Dysphagia 3. Hemiplegia 4. Orthostatic hypotension 5. Hypertonia 1. Areflexia 2. Dysphagia 4. Orthostatic hypotension A client received a severe burn to the right hand. When dressing the wound, it is important for the nurse to do what? 1. Apply a wet to dry dressing for debridement. 2. Wrap each digit individually to prevent webbing. 3. Open blisters to allow drainage prior to dressing. 4. Allow the client to do as much of the dressing change as possible. 2. Wrap each digit individually to prevent webbing. The edrophonium (Tensilon) test has been prescribed for a client. Which statement by the client would indicate to the nurse that the client understands this test? 1. "This medication will be given to me as an IM injection immediately after my muscles are tired." 2. "This test will determine if I have multiple sclerosis." 3. "The test is positive if my muscles do not get stronger after injection with this medication." 4. "I will be asked to perform a repetitive movement to test my muscles." 4. "I will be asked to perform a repetitive movement to test my muscles." A client is admitted to the emergency department after sustaining burns to the chest and legs during a house fire. Which assessment should the nurse perform immediately? 1. Respiratory 2. Cardiac 3. Airway 4. Neurological 3. Airway What is the priority nursing action for a client that was admitted with tingling of the toes and feet after having the flu for several days when the client begins to have numbness in the legs and hips? 1. Notify the primary healthcare provider 2. Monitor for paresthesia in the fingers and hands 3. Insert an indwelling urinary catheter 4. Assist the client with performing passive range of motion 1. Notify the primary healthcare provider A client reports excruciating paroxysmal facial pain occurring after feeling a cool breeze and drinking cold beverages. Based on this client's reports, what disorder does the nurse suspect? 1. Bell's palsy 2. Submucous cleft palate 3. Trigeminal neuralgia 4. Temporomandibular joint disorder (TMD) 3. Trigeminal neuralgia The nurse is reviewing sequential lab results on a newly admitted client with multiple health issues. Critical changes in which body system require the nurse to immediately notify the primary healthcare provider? 1. Renal 2. Endocrine 3. Pulmonary 4. Cardiovascular 1. Renal A client with chronic arterial occlusive disease has a bypass graft of the left femoral artery. Postoperatively, the client develops left leg pain and coolness in the left foot. What is the priority action by the nurse? 1. Elevate the leg. 2. Check distal pulses. 3. Increase the IV rate. 4. Notify the primary healthcare provider. 4. Notify the primary healthcare provider. What should be included in the discharge teaching plan for a client who has lymphedema post right mastectomy? Select all that apply 1. Use a thimble when sewing. 2. Wear a heavy duty oven mitt for removing hot objects from the oven. 3. Long sleeves should be worn to prevent insect bites. 4. Shave underarms with an electric razor. 5. Avoid wearing jewelry. 1. Use a thimble when sewing. 2. Wear a heavy duty oven mitt for removing hot objects from the oven. 3. Long sleeves should be worn to prevent insect bites. 4. Shave underarms with an electric razor What should the nurse include in the teaching plan for a client who has iron deficiency anemia? Select all that apply 1. Consume iron rich foods such as dried lentils, peas, and beans. 2. Notify primary healthcare provider of glossitis, anorexia, and paresthesia. 3. Iron is needed for white blood cell development. 4. Educate about ferrous sulfate supplement. 5. After drinking liquid iron, follow immediately by water. 1. Consume iron rich foods such as dried lentils, peas, and beans. 2. Notify primary healthcare provider of glossitis, anorexia, and paresthesia. 4. Educate about ferrous sulfate supplement. [Show Less]
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Hurst NCLEX review Test Questions and Answers| Rated A+
NCLEX hospital . . . - ✔✔ is perfect and you only care for client on screen Priority questions - ✔✔ which one is the Killer answer? *NOTE: P... [Show More] ain isn't a priority and expected problems related to conditions-like kidney stones positive for hematuria and 8/10 pain-not priority over other conditions Call physician when - ✔✔ only if not a nursing intervention available Never pick an answer - ✔✔ *that isn't the least invasive * that isn't client focused *that doesn't allow client to speak or rushes their complaint off *puts off work to someone else *if you're down to 2, pick the killer answer *has long-term consequences * don't delay care/treatment report what to next shift nurse - ✔✔ something "new" or "different" or "possible" like illnesses can be put in - ✔✔ same room if you have no baseline in question - ✔✔ assume normal limits elevate _______ and dangle _______ - ✔✔ elevate veins and dangle arteries. E goes with E and A goes with A any fluid problem, daily do what - ✔✔ I&O and weights with pacemaker always worry when - ✔✔ rate is decreased Mg or calcium problem, think what first - ✔✔ muscles restless client think what first - ✔✔ hypoxia always limit protein with kidney clients except which - ✔✔ those with nephrotic syndrome first sign of respiratory acidosis - ✔✔ hypoxia possibly remember with SIADH - ✔✔ too many letters, too much water "Soggy Sid" aldosterone, think - ✔✔ sodium and water, releases K Al likes to swim in saltwater ADH - ✔✔ H20 (three letters/three digits) remember what about traction - ✔✔ never release unless you have order from dr to do so when you see polyuria, think what first - ✔✔ shock first when you see fluid retention, think what first - ✔✔ heart problems what should you ALWAYS assume - ✔✔ the worst * you always have something to worry about if you see "assessment" or "evaluation" in stem - ✔✔ think signs and symptoms don't ever use what in a nursing diagnosis - ✔✔ a medical diagnosis less volume ____ pressure and more volume _____ pressure - ✔✔ less volume, less pressure more volume, more pressure if problem is in kidneys - ✔✔ HCO3 will be affected if problem in lungs - ✔✔ CO2 will be affected when triaging, emergent means: urgent means: non-urgent means - ✔✔ emergent is lift threatening urgent is stable on arrival but needing timely attention non-urgent is stable and not in immediate need of ER treatment when you see words like always, never, total . . . - ✔✔ don't ever choose them! They're too limiting. Look for things like might or maybe or sometimes! arrythmias are not big deal unless what - ✔✔ they affect cardiac output Remember order of Maslow's - ✔✔ Biological and physiological needs, safety, belonging and love needs, esteem needs and then self-actualization needs like personal growth and fulfillment what tasks can NAP be assigned - ✔✔ stable patients (could be complex also) and tasks that are routine, simple, repetitive, everyday activities that don't require nursing judgment such as feeding, hygiene, ambulation LVNs can be delegated tasks BUT . . . - ✔✔ R.N. still is accountable and responsible for it assignment - ✔✔ the work you must get accomplished during your shift RN to RN assignments transfer - ✔✔ responsibility and accountability with delegation, you can transfer - ✔✔ the responsibility but not the accountability. Supervision - ✔✔ guidance and direction, oversight and eval by the RN to see that delegated task is accomplished. What specific things do you have to tell the person you are delegating to? - ✔✔ You must make sure exactly which task you've assigned them, which should be done first, etc., and any other tasks you need completed and when. Give CLEAR directions indicating what ranges you want reported to you. after task is completed, check what - ✔✔ &Was task done properly?* If not, provide teaching. *Was the task done in the proper timeframe?* Will the delay affect client safety? *Were the client's needs met?* Did the task change and require higher level of education? Maybe you should do the task! don't assume someone is competent to do something just because of what - ✔✔ Their job description. It's our job to find out our staff's strength and weakness. If we identify a weakness of our NAP, what do we do to remedy that? - ✔✔ Teach, teach, teach and DOCUMENT WHAT WE TAUGHT -- it's our responsibility when we get a nurse from another unit to our floor, what do we consider them - ✔✔ a brand new nurse. Cannot handle any specialized care. Most important thing we can do before we start our new job - ✔✔ malpractice insurance If a staff member performs your assigned tasks which were not delegated to them and a problem occurs, what do you do - ✔✔ Teach, teach, teach and document what you taught. ALWAYS fill out an incident report and then go home and document the incident for yourself. The hospital will protect its interests and you need to protect yours. what can LVNs help us with - ✔✔ Stable clients only. Can handle data collection but never the actual steps in nursing process. They can implement tasks on careplan and SPECIFIC tasks for us on our unstable client. Can't start but can remove IVs RN must do what - ✔✔ Admission history. If someone else does it for you, NEVER sign off on the form until you have validated the data. [Show Less]
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HURST review Quiz Questions and 100% Verified Answers
effervescent soluble medications - ✔✔ have lots of sodium!!! Ex. Alka-Seltzer, Airborne Vit C tablets where is aldosterone found - ✔✔ adren... [Show More] al glands which are located at the top of the kidney where is ADH found - ✔✔ pituitary anytime we have a patient who has had a head injury, sinus surgery, craniotomy, or ICP that is increasing what is the first thing we want to think? - ✔✔ ADH problem??? what drugs act as ADH replacement - ✔✔ Vasopressin (Pitressin) Desmopressin Acetate (DDVAP) how does Bedrest affect diuresis - ✔✔ Bed rest causes diuresis to increase as ANP is released and the production of ADH is decreased Think: when I run I wont pee when I'm relaxing I need to pee. everytime I lay down and get comfortable, then I realize I have to go pee. ANP - ✔✔ atrial natriuretic peptide excretes Na and H2o when a client has hypertension, cardiac/renal disease but in fluid volume deficit and needs to be rehydrated with IV fluids, what fluids are best choice to prevent FVE - ✔✔ hypotonic when would it be appropriate to use hypertonic solutions - ✔✔ for the client with hyponatremia, or someone who has shifted large amounts of vascular volume to a 3rd space -severe burns -severe edema -ascites Calcium - ✔✔ 9-10.5 how is magnesium excreted - ✔✔ kidneys Administering Magnesium/Calcium IV we can expect - ✔✔ these drugs to act like a sedative everything will be relaxed what do we need to check before administering magnesium - ✔✔ Kidney function what foods are high in magnesium - ✔✔ ALL THINGS GREEN SUNFLOWER SEEDS SESAME SEEDS FLAX SEEDS how does parathyroid hormone work - ✔✔ when it senses that calcium is low in the blood it pulls calcium from the blood and pulls it into the bone what electrolyte are we concerned about with a patient who had thyroidectomy - ✔✔ calcium deficiency Phosphate binders - ✔✔ Sevelamer hydrochloride Calcium Acetate what should I do if I am administering Magnesium IV and the patients urinary output drops - ✔✔ STOP THE INFUSION they are probably retaining too much magnesium now IF WE HAVE A SODIUM PROBLEM - ✔✔ WE HAVE A FLUID PROBLEM psychogenic polydipsia - ✔✔ loves to drink water what is the major problem with oral potassium - ✔✔ GI upset foods high in potassium - ✔✔ ALL THINGS GREEN EGGPLANT CANTALOUPE TOMATOES STRAWBERRIES TUNA halibut cauliflower oranges lima beans POTATOES Albumin helps keep the fluid where - ✔✔ in the vascular space! halo sign - ✔✔ CSF leakage bradycardia after a head injury may suggest - ✔✔ Increased ICP aphasia - ✔✔ the ability to comprehend information stereognosis - ✔✔ ability to recognize objects by feeling their form, size, and weight while the eyes are closed when a mother is hemorrhaging, and I go to massage the fundus what else should I assess for - ✔✔ a distended bladder. which would prevent uterus from contracting GTPAL - ✔✔ Gravidity (G) is defined as the number of times pregnant, including the current pregnancy. Term (T) is defined as any birth after the end of the 37th week, and preterm (P) refers to any births between 20 and 37 weeks. Both term and preterm describe liveborn and stillborn infants. Abortion (A) is any fetal loss, whether spontaneous or elective, up to 20 weeks gestation. Living (L) refers to all children who are living at the time of the interview. Multiple fetuses such as twins, triplets, and beyond are treated as one pregnancy and one birth when recording the GTPAL. Risk for gestational diabetes - ✔✔ Birth of an infant weighing more than 9 lbs (4.08 kg) is a risk factor for gestational diabetes. Other risk factors include maternal age older than 25, obesity, history of unexplained stillborn, family history of Type 1 diabetes in a first-degree relative, strong family history of Type 2 diabetes, and history of gestational diabetes in a previous pregnancy. Ethnic groups at increased risk include Hispanic, Native-American, Asian, and African-American. Maternal/Fetal glucose & insulin - ✔✔ -Fetal insulin production begins at around 10 weeks' gestation, and insulin is secreted at levels that are adequate for utilization of the glucose obtained from the mother. -Increasing levels of estrogen and progesterone in the first trimester stimulate the pancreas to increase insulin production, resulting in decreased blood glucose levels. -Maternal glucose, not insulin, crosses the placenta through the process of carrier-mediated facilitated diffusion. --Increased levels of hormones increase insulin resistance because they act as insulin antagonists. This serves as a glucose-sparing mechanism to ensure an adequate glucose supply to the fetus. what fetal test is done to determine lung maturity and chromosomal abnormalities - ✔✔ amniocentesis Butorphanol tartrate is - ✔✔ an opioid agonist-antagonist. Respiratory depression, nausea, and vomiting occur less often with this group of drugs when compared with opioid agonists. However, because butorphanol tartrate also acts as an antagonist, it is not suitable for women with a history of opioid dependence because it can precipitate withdrawal symptoms (abstinence syndrome) in both the mother and the neonate. Rh immunity - ✔✔ Rh immune globulin is given to a mother who has Rh-negative blood and the infant is Rh-positive. It is given within 72 hours of delivery. where should the uterus be 24 hours after delivery - ✔✔ The uterine fundus should be midline at the umbilicus after birth for 24 hours. A fundus elevated above the umbilicus or shifted to the left or right may indicate blood in the uterus or a full bladder. [Show Less]
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HURST Review: Psychiatric Nursing Questions and Correct Answers
Depression: Signs/Symptoms - ✔✔ -loss of interest in life's activities -negative view of the world -anhedonia -usually related to loss -poor kept... [Show More] appearance Depression Signs/Symptoms: What is anhedonia? - ✔✔ loss of pleasure in usually pleasurable things Depression Signs/Symptoms: In mild depression there is _____________ while there is ______________ in severe depression - ✔✔ weight gain; weight loss Depression Signs/Symptoms: There are crying spells with ________________ and no more tears with ___________________ - ✔✔ mild to moderate depression; severe depression Depression Signs/Symptoms: It is commons for client's to experience - ✔✔ sleep disturbances Depression Signs/Symptoms: These clients have slow thoughts so we need to - ✔✔ speak slowly to them and use the therapeutic communication technique of silence (give them time to process) Depression Signs/Symptoms: Clients who are depressed can have ___________________ and _________________ - ✔✔ delusions; hallucinations Depression Treatment: They may need help with - ✔✔ their self-care Depression Treatment: Prevent _________________ because _______________________ makes the client feel better - ✔✔ isolation; interacting with others Depression Treatment: Help them experience - ✔✔ accomplishments Depression Treatment: Be careful with _______________ as they may make the client _________________ - ✔✔ compliments; feel worse Depression Treatment: If severely depressed, ________________________________ may be the best thing you can do. It's a _______________________________ - ✔✔ sitting with client and making no demands; self-esteem thing Depression Treatment: As they feel better, encourage them to _____________________. Let the client know that _________________________________________ - ✔✔ describe their feelings; you understand they are in pain and feel powerless Depression Treatment: Help them set - ✔✔ accomplishable goals Depression Treatment: If they are capable, activities such as _________________________________________ will help with depression - ✔✔ walking, running, weight lifting Depression Treatment: Assess for - ✔✔ suicide risk Depression Treatment: As depression lifts, what happens to suicide risk? - ✔✔ the risk goes up Depression Treatment: Observe clients when they start taking antidepressants because - ✔✔ their risk for suicide just went up (increase in SSRIs and energy) Depression Treatment: A sudden change in mood towards the better may indicate - ✔✔ that the client has made the decision to kill themselves Depression Treatment: Culturally, ____________________ have a higher suicide rate - ✔✔ American Indians Depression Treatment: ___________ clients are particularly at risk for suicide - ✔✔ Elderly Depression Treatment: ______________________ tend to be very successful because they generally use ______________________ - ✔✔ Elderly men; very lethal methods Depression Treatment: When assessing suicide risk, ask clients 3 very important questions - ✔✔ 1. do they have a plan? 2. what is the plan? 3. how lethal is the plan? Depression Treatment: When assessing suicide risk, determine if they ____________________ and if they have ever ____________________ - ✔✔ have access to the plan; attempted suicide before Depression Treatment: When assessing suicide risk, watch for things like - ✔✔ -isolating themselves -writing a will -collecting harmful objects -giving away their belongings Depression Treatment: Suicide interventions include - ✔✔ -direct, closed ended statements -providing a safe environment -safe-proofing the room -getting a signed contract to postpone suicide Depression Treatment: A signed contract post poning suicide is done in hope that - ✔✔ the client will develop coping mechanisms during this time Mania: One pole is __________ and the other is ________________ - ✔✔ mania; depression Mania: Signs/Symptoms - ✔✔ -continuous high -labile emotions (periods of extremes) -flight of ideas -delusions -constant motor activity -no inhibitions -altered sleep patterns -poor judgment -manipulation Mania: Delusions are just - ✔✔ a false idea Mania: Types of delusions can include - ✔✔ -delusions of grandeur (ex. client thinks they are Jesus) -delusions of persecution Mania: Constant motor activity leads to - ✔✔ exhaustion Mania: Lack of inhibition can include - ✔✔ -inappropriate dress -hyper-sexual behaviors (an attention-seeking mechanism) Mania: Manipulation makes these clients - ✔✔ feel secure and powerful Mania Treatment: Decrease - ✔✔ the stimuli Mania Treatment: Don't ___________ or __________________ - ✔✔ argue; try to reason Mania Treatment: Do you talk a lot about the delusion? - ✔✔ no Mania Treatment: Let the client know you ____________________________, but that you ___________________ - ✔✔ accept that they need the belief or delusion; do not believe it Mania Treatment: Look for the - ✔✔ underlying need in the delusion Mania Treatment: The underlying need with delusions of persecution is the - ✔✔ need to feel safe Mania Treatment: The underlying need with delusions of grandeur is the - ✔✔ need to feel good about self Mania Treatment: Set ___________ and be ______________ - ✔✔ limits; consistent Mania Treatment: They feel most secure in - ✔✔ one-on-one relationships Mania Treatment: Remove - ✔✔ hazards (no cigarettes-1 or 2 then monitor) Mania Treatment: Stay with the client as - ✔✔ anxiety increases Mania Treatment: These clients need - ✔✔ a structured schedule [Show Less]
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HURST Maternity Review Test Questions and Answers Verified to Pass
What is the name of the hormone that induces amenorrhea? - ✔✔ progesterone- makes the temperature go up after ovulation How often should you have ... [Show More] sex if you are trying to get pregnant? - ✔✔ every other day What can be one of the first signs of pregnancy? - ✔✔ urinary frequency Presumprtive signs of pregnancy - ✔✔ amenhorrhea n/v urinary frequency breast tenderness hydatidiform mole (molar pregnancy) - ✔✔ neoplasm of grape like vesicles that can become malignant goodell's sign - ✔✔ softening of the cervix- an indication of pregnancy Chadwick's sign - ✔✔ bluish color of the vaginal mucosa and cervix; occurs around the 4th week; indicates pregnancy Hegar's sign - ✔✔ softening of the lower uterine segment occurs around the 2nd or 3rd month linea nigra - ✔✔ dark line down the center of the abdomen facial chloasma - ✔✔ mask of pregnancy darkening of the areola can be a sign of - ✔✔ pregnancy When is fetal heart beat heard? - ✔✔ 10-12 weeks with doppler 17-20 weeks with fetoscope gravidity - ✔✔ the number of times someone has been pregnant parity - ✔✔ the number of times in which the fetus reaches 20 wks Viability - ✔✔ ability of the fetus to survive outside the womb 24 weeks TPAL - ✔✔ term, preterm, abortion, living spontaneous abortion - ✔✔ miscarriage most miscarriages occur by when - ✔✔ 20 wks Naegele's Rule - ✔✔ add 7 days to first day of LMP, subtract 3 months, add 1 year How accurate is naegele's rule - ✔✔ plus or minus 2 wks First trimester is weeks - ✔✔ 1-13 How much protein should a client eat during the first trimester of pregnancy? - ✔✔ 60 g weight gain in the first trimester - ✔✔ 1-4 pounds total What are the biggest complaints with iron? - ✔✔ constipation and GI upset take iron with vit - ✔✔ c folic acid prevents - ✔✔ neural tube defects (myomeningocele) Foods with iron - ✔✔ liver, spinach how much folic acid a day during pregnancy - ✔✔ 400 mcg best exercises during the first trimester - ✔✔ walking and swimming During pregnancy dont let heart rate get above - ✔✔ 140 What should a pregnant person avoid to prevent overheating? why? - ✔✔ hot tubs and heating blankets- overheating can cause birth deffects What are you going to tell a pregnant person about taking meds? - ✔✔ dont take anything without asking your doctor first what is smoking during pregnancy associated with? - ✔✔ small for gestational age, decreased birth weight, cleft lip or palate, and a doubled risk of placental abruption How often should a pregnant client visit the primary health care provider? first 28 wks 28-36 wks after 36 wks - ✔✔ once a month every 2 wks weekly until delivery Before an ultrasound, what will you ask the client to do? - ✔✔ drink water to distend the bladder pushes the uterus up closer to the and surface to get a good picture of baby What do you have a client do before an ultra sound normally, other that pregnancy? - ✔✔ void Second trimester is weeks - ✔✔ 14-26 Recommended calorie increase for the 2nd trimester? - ✔✔ 300 calories a day, or 500 if an adolescent Expected weight gain in second trimester? - ✔✔ 1 pound a week Should the client be experiencing n/v breast tenderness urinary frequency during the 2nd trimester - ✔✔ no, yes, no quickening - ✔✔ the first movement of the fetus in the uterus that can be felt by the mother. Happens around 16-20 wks, and happens sooner the more babies the client has fetal heart rate during second trimester? - ✔✔ 110-160 kegel exercises help to keep what from doing what - ✔✔ keep your uterus from falling out Third trimester is weeks - ✔✔ 27-40 weight gain in 3rd trimester - ✔✔ 1 pound a week s/s of pre eclampsia - ✔✔ increased blood pressure proteinuria edema Two or more pounds of weight gain in a week after the 2nd trimester, think - ✔✔ pre eclampsia bp definition for pre eclampsia - ✔✔ 160/110 or greater that is documented 6 hours apart How is fetla position/presentation determined? - ✔✔ Leopold maneuvers Leopold maneuvers - ✔✔ have the client void first do between contractions Where do you put the doppler on a fetus in utero? - ✔✔ back lightening - ✔✔ usually occurs 2 weeks before term when the presenting part of the fetus descends into the pelvis the client will notice that she is able to breath more easily bc the pressure on the diaphragm decreases causes the client the pee more often again [Show Less]
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Hurst Quiz Review Questions and Answers 2023
Which assessment findings would be of concern to the nurse who is caring for a client who has an arterial line to the radial artery? Capillary refill: Lef... [Show More] t hand-2 seconds; Right hand- 4 seconds. Blue tinged color to finger tips of the right hand Left radial pulse-88/min; Right radial pulse-82/min Blanching to right hand While making evening rounds, the nurse discovers an elderly, confused client standing next to the bed with the IV pulled out, gown wet with urine and the side rails still in the up position. The client’s arm band is on the floor. To ensure client safety, what is the most important intervention for the nurse to include in the plan of care? Provide for scheduled toileting intervals. The nurse has been caring for a client who is confused. Upon entering the room, the nurse finds the client on the floor. The side rails are up, there is urine on the floor, and an abrasion is noted on the client's forehead. Which information should the nurse include in the incident report? Abrasion on the clients forehead Clients confused state Presence of urine on the floor Side rails were up The emergency department nurse is assigned to care for four pediatric clients with varying symptoms. Which client should the nurse examine first? 6 month old with respiratory rate of 68/min while sleeping A client, post laparoscopic cholecystectomy, develops pain in their right shoulder. Vital signs, laboratory studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing cause of the pain? Carbon dioxide used intraperitoneally is irritating the phrenic nerve. A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which nursing intervention would promote trust in this individual? Attend an activity with the client who is reluctant to go alone. Consider client preferences when possible in decisions concerning care. Provide a blanket when the client is cold. Provide food when the client is hungry. A 65 year old client is admitted for management of dehydration with an IV infusion of LR @ 125 mL/hr. What assessment findings would be of concern to the nurse? Anxiety Crackles noted right posterior lung field S3 heart sound A client comes to the clinic reporting palpitations, as well as nausea and vomiting while taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this information, what is the most important question for the nurse to ask the client? "Are you using any products that contain alcohol?" A client who has chronic renal failure has been prescribed synthetic erythropoietin for the prevention of anemia. Which assessment finding should be reported to the primary healthcare provider? Swelling of feet and ankles Parents of school-aged children are working toward a goal of healthy family TV viewing. Which parental statement indicates adequate understanding of appropriate use of TV in the family? I don't allow my kids to watch violent TV shows. The nurse initiates cardiac monitoring on a 6 year old immediately after the child has a seizure. How should the nurse document the rhythm? Sinus arrhythmia The emergency department called the labor and delivery unit to give report on a 24 year old primigravida at term, having contractions every 5-8 minutes. The unit is very busy, and all the RNs are with other clients. What action by the charge nurse would be most appropriate? Instruct the LPN/VN to obtain initial vital signs and connect the client to a fetal monitor, then report this data to the charge nurse. What action should the nurse take first for the 5 year old client brought to the urgent care clinic with a blistering sunburn? Apply cool water soaks. The charge nurse on the Labor and Delivery unit is making morning assignments. What client would be most appropriate for a newly hired licensed practical nurse (LPN)? Completing perineal care for post-delivery clients. The nurse is teaching a community health class for cancer prevention and screening. Which individual does the nurse recognize as having the highest risk for colon cancer? Has a family history of colon polyps A client with a history of cardiac disease has safely delivered a full-term infant. When discussing discharge instructions, the nurse knows the teaching was successful when the client makes what statement? I must include lots of fiber to prevent constipation A client with a history of cardiac disease has safely delivered a full-term infant. When discussing discharge instructions, the nurse knows the teaching was successful when the client makes what statement? I should return to my previous dose of cardiac medication The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider? Weight gain of 5 pounds in one week Angioedema Serum potassium of 5.8 Which action by a nurse would require the charge nurse to intervene? Walking in the hallway outside the operating room without a hair covering. The nurse is planning daily activities for a client who has a diagnosis of schizophrenia. The client tends to spend most of the time in bed and is very uncomfortable when other clients are in the day area of the unit. What activity would be most therapeutic for this client? Spending time in brief one on one interactions with the nurse A client with Graves' disease and exophthalmos returns to the clinic for evaluation. Which assessment indicates to the nurse that the client is adhering to the teaching plan? An absence of corneal irritation 0245 Called to room by client’s mother. Reports, “My son has been coughing and wheezing for the past 15 minutes”. Client anxious, sitting on side of bed. Skin pale, lips cyanotic. Nonproductive cough noted every 1-2 minutes. Diffuse, audible expiratory wheezes with coarse rhonchi in upper and lower bilateral lung fields. Mild retractions. Peak flow is 90 L/min (Expected peak flow 240 L/min). Difficulty speaking. Top 4 Findings [Show Less]
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