After a thyroidectomy, the nurse should monitor for signs of tetany which can be caused by trauma to the parathyroid gland. The signs of tetany include
... [Show More] which of the following?
check all answers that apply
negative Chvostek's sign
positive Trousseau's sign
photophobia
cardiac dysrhythmias - correct answer positive Trousseau's sign
photophobia
cardiac dysrhythmias
All three of these are signs of tetany. A positive Chvostek's sign would also be a sign of tetany, along with carpopedal spasm, dysphagia, muscle and abdominal cramps, numbness and tingling of the face and extremities, wheezing and dyspnea, and seizures.
Your patient has had a uterine artery embolization to treat a fibroid tumor. She is being discharged and you will be giving her instructions for home care. Which of the following would NOT be a part of your instructions?
alter diet to eliminate fiber
call the health care provider if you run a fever of 101.1 degrees F or more
do not use tampons for at least four weeks
avoid straining during bowel movements - correct answer alter diet to eliminate fiber
This patient would be told to eat a normal diet including fiber and fluids. All of the other choices are appropriate instructions. Other instructions may include: take prescribed medications as ordered; call the physician if she has bleeding, pain, swelling, hematoma at the puncture site, urinary retention or abnormal vaginal drainage; and refrain from using douches or having vaginal intercourse for at least four weeks.
Your patient has had hip replacement surgery. She is being discharged and along with other instructions you advise her not to lift her leg upward from a lying position or elevate the knee when sitting. The primary reason for this is which of the following?
This type of action may cause extreme pain.
This type of action will delay healing.
This type of action may cause venous thrombosis.
This type of action may pop the prosthesis out of the socket. - correct answer This type of action may pop the prosthesis out of the socket.
This question asks for the primary reason for this advice. The primary reason is that this type of action may pop the prosthesis out of the socket.
A young adult was told that he had a significant reaction to the Mantoux test. The nurse explains that this means he
has active tuberculosis.
had active tuberculosis
has been exposed to tuberculosis
is immunocompromised. - correct answer has been exposed to tuberculosis.
A reaction to the Mantoux test for tuberculosis means the client has been exposed to the tuberculin bacillus. Further testing needs to be done to determine whether the disease is active or dormant. A positive reaction does not mean the client is immunocompromised, but clients who are immunocompromised have a high risk of tuberculosis.
Which of the following would be considered a late sign of colorectal cancer?
check all answers that apply
blood in stool
anemia
cachexia
abdominal mass - correct answer cachexia
abdominal mass
These are late signs along with guarding or abdominal distention. Blood in the stool is the most common manifestation of this cancer.
The nursing diagnosis deals with which of the following?
check all answers that apply
disease
medical condition
human response to health problems
care plan - correct answer human response to health problems
A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with human response to actual or potential health problems and life processes.
A client in a long-term care facility refuses to take his oral medications. The nurse threatens the client and tells him that, if the medication is not taken, restraints will be applied and the medication will be given by injection. The nurse's statement constitutes which legal tort?
Assault
Battery
Negligence
Right to refuse care - correct answer Assault
sault. Assault occurs when a person puts another person in fear of harmful or threatening contact. Battery is the actual contact with one's body. If the nurse actually carried out the threat, battery would also apply. Negligence involves actions below the standard of care. The client has the legal right to refuse care. In this situation, the correct action is to try to calm the client, allow him time to talk, and then determine if he will take the medications. If the client still won't take the medications, the nurse should document his refusal, note the medications, and notify the physician and nursing supervisor. The nurse should follow the facility's policy related to client's refusing care.
You have a patient who has been diagnosed with asthma. You are teaching him the proper use of an inhaler. Which of the following would NOT be included in your instruction?
Exhale completely.
Use the bronchodilator before the steroid inhaler.
If using a spacer, keep mouth open to bring in volume of air with misted medication.
Wait at least one minute between inhaled doses (puffs). - correct answer If using a spacer, keep mouth open to bring in volume of air with misted medication.
If using a spacer, the mouthpiece should be gripped in the mouth. If not using a spacer, the mouth should be kept open to bring in volume of air with misted medication. The other choices are correct instructions.
Pulmonary edema is a life-threatening event that can result from severe heart failure. If a client develops pulmonary edema which of the following actions is appropriate?
check all answers that apply
Place the client in a low-Fowler's position.
Administer oxygen.
Ensure that an intravenous access device is in place.
Prepare for intubation if required. - correct answer Administer oxygen.
Ensure that an intravenous access device is in place.
Prepare for intubation if required.
These are all appropriate actions. You should immediately place the client in high-Fowler's position, with the legs in a dependent position, to reduce pulmonary congestion and relieve edema.
A female client's gonorrhea culture is positive for gonorrhea. Which of the following actions should the nurse take?
instruct the client to wait in the office for 25 minutes after the examination to allow the local anesthesia to wear off
instruct the client to wait 24 hours before taking prescribed medication
ask the client for the names of all of her sexual partners
instruct the client to douche 5 hours after the procedure to get rid of the solution used for the culture - correct answer ask the client for the names of all of her sexual partners
k the client for the names of all of her sexual partners. A gonorrhea culture is used to identify if an individual has gonorrhea by using a swab to obtain discharge from the cervix, throat, anus or urethra. For a positive result on the diagnostic test, the N. gonorrhea organism is present. For this test, the nurse should inform the client to not douche before the examination and douching is not recommended after the examination. The nurse should also obtain from the client a listing of all sexual partners that the client has had in order to contact them so the partners can receive treatment. This way the gonorrhea infection does not spread to other individuals.
The type of angina that may occur at rest and results from a coronary artery spasm is which of the following?
check all answers that apply
stable angina
Prinzmetal's angina
preinfarction angina
intractable angina - correct answer Prinzmetal's angina
Prinzmetal's angina is also called variant angina or vasospastic angina. It results from coronary artery spasm. Attacks may be associated with ST-segment elevation noted on the electrocardiogram.
stable angina
Prinzmetal's angina
preinfarction angina
intractable angina
Postoperative care for a woman following a mastectomy will include arm exercises to:
strengthen the affected muscles.
increase firmness in the remaining breast tissue.
decrease pain as the surgical site heals.
promote drainage after lymphatic disruption. - correct answer promote drainage after lymphatic disruption.
A mastectomy includes the removal of lymph nodes. The recommended exercises will help promote drainage and prevent swelling. The exercises will not help strength muscles, increase breast firmness, or help with pain control.
In your state, screening for neural tube defects is mandated by law. You know that this test is highly associated with
both false positives and false negatives
reliability of results
multiple gestations
infections during pregnancy - correct answer both false positives and false negatives
There are various techniques to determine fetal and maternal well-being. The screening for neural tube defects by testing either maternal serum alpha-fetoprotein (AFP) levels or amniotic fluid AFP levels is highly associated with both false positives and false negatives.
Which of the following is would indicate implied consent to a procedure?
check all answers that apply
The patient voluntarily submits to the procedure.
The patient consents in writing.
The patient orally consents.
The patient consents orally and in writing. - correct answer The patient voluntarily submits to the procedure.
When a patient voluntarily submits to the procedure, this indicates implied consent. Consenting in writing or orally is considered expressed consent.
Your patient has been prescribed a bronchodilator for her asthma along with a corticosteroid to reduce inflammation. Which of the following is NOT a corticosteroid?
check all answers that apply
Salbutamol
Beclomethasone dipropionate
Fluticasone propionate
Flunisolide
Budesonide - correct answer Salbutamol
Salbutamol is a bronchodilator. All of the other choices are corticosteroids.
A person's reaction to pain is subjective. It is influenced by certain factors. Which of the following are factors that may influence a patient's pain experience?
check all answers that apply
gender
culture
religion
acute hypotension - correct answer gender
culture
religion
A person's pain experience will be subjective. There are many factors that influence how a patient will feel and handle pain. Anxiety, culture, religion, and gender affect a patient's response to pain.
You are assessing a child who has been diagnosed with Duchenne muscular dystrophy. Which of the following would NOT be an indicator of this disease?
Gowers sign
increasing clumsiness
vomiting (usually in the morning)
waddling gait - correct answer vomiting (usually in the morning)
There are a number of assessments that you might make in a patient with Duchenne muscular dystrophy. Vomiting is not one of them. The child may have a waddling gait, increasing clumsiness and muscle weakness, Gower sign (difficulty rising to standing position), delayed cognitive development, elevated CPK and SGOT/AST among other signs.
In establishing a teaching plan for a client who is in the first trimester of pregnancy, the nurse identifies a long list of topics to discuss. Which is most appropriate for the first visit?
Asking the woman what questions and concerns she has about parenting
Dealing with heartburn and abdominal discomfort
Nutrition and activity during pregnancy
Preparation for labor and delivery - correct answer Nutrition and activity during pregnancy.
Nutrition and activity are important concerns from the first trimester onward. Labor and delivery is a third trimester concern, and parenting is of most concern in either the third trimester or post delivery. Heartburn and abdominal discomfort do not usually occur until the third trimester.
All of the following are appropriate guidelines in terms of nutrition and feeding for an infant EXCEPT:
check all answers that apply
Fluoride supplementation may be needed at about 6 months of age, depending on the infant's intake of fluoridated tap water.
At 12 months of age, eggs can be given.
Avoid microwaving baby bottles and baby food.
Mix any necessary medications with formula. - correct answer Mix any necessary medications with formula.
This would not be an appropriate guideline. Never mix food or medications with formula. Also avoid adding honey to formula, water, or other fluid to prevent botulism.
The nurse develops a teaching plan for a client who has a 5 cm laceration of the arm. Which of the following is an appropriate learning outcome?
the client's wound is healing and there is no infection present
the nurse provided instructions to the client
the nurse discusses with the client resources available
the identification of the signs and symptoms of a wound infection - correct answer the identification of the signs and symptoms of a wound infection.
The nurse should expect the client to be able to identify the processes involved in normal wound healing, identify the signs and symptoms of an infection of the wound, show that he or she can use wound cleansing equipment and know when, where and the time to return to the physician for a follow up appointment. Further, the client's wound is healing and there is no infection present, is an incorrect answer choice as this represents a nursing goal of wound care. Then, the nurse provide instructions to the client and the nurse discusses with the client resources available are examples of teaching methods the nurse uses to teach the client regarding wound care.
A burn that is dry, leathery, and possibly edematous is which of the following?
check all answers that apply
superficial, partial thickness
first degree burn
second degree burn
full thickness burn - correct answer full thickness burn
A full-thickness burn (third-degree burn) has a dry, leathery, and possibly edematous appearance. Its color is white to charred and there is little or no pain. The depth of the burn is to subcutaneous tissue and possible fascia, muscle, and bone.
Which of the following is typical of a fetus at week 16 of fetal development?
check all answers that apply
Fetus is 11.5 to 13.5 cm in length.
Fetus has reflex hand grasp functions.
Fetus is 100 g.
Lanugo hair begins to develop. - correct answer Fetus is 11.5 to 13.5 cm in length.
Fetus is 100 g.
Lanugo hair begins to develop.
These are all typical of a 16-week-old fetus. Reflex hand grasp functions occur at week 24.
Which of the following statements about antineoplastic medications is NOT accurate?
check all answers that apply
Antineoplastic medications kill or inhibit the reproduction of neoplastic cells.
Antineoplastic medications are only used to decrease life-threatening complications.
The effect of antineoplastic medications may not be limited to neoplastic cells.
Usually only one medication is used in order to increase the therapeutic response.
Chemotherapy dosing is usually based on total body surface area and type of cancer. - correct answer Antineoplastic medications are only used to decrease life-threatening complication.
Usually only one medication is used in order to increase the therapeutic response.
These statements are not accurate. Antineoplastic medications are used to cure, increase survival time, and decrease life-threatening complication. Usually several medications are used in order to increase the therapeutic response.
A patient's ability to implement his own decisions is the right to which of the following?
check all answers that apply
informed consent
self-determination
professionalism
accountability - correct answer self-determination
Self-determination is often used synonymously with autonomy. It means having a form of personal liberty to choose and implement one's own decisions, free from deceit, duress, constraint, or coercion.
You are assigned to instill eye medication in a patient's eye. All of the following are appropriate for this task EXCEPT:
check all answers that apply
instructing the patient to tilt the head backward, open the eyes, and look up
pulling the upper lid upward before instilling the medication
squeezing the bottle gently to allow the drop to fall into the conjunctival sac
instructing the client to squeeze the eyes shut after instilling the medication - correct answer pulling the upper lid upward before instilling the medication
instructing the client to squeeze the eyes shut after instilling the medication
These are not appropriate measures. Pull the lower lid down against the cheekbone and instruct the client to close the eyes gently; not squeeze the eyes shut.
The RN is providing discharge instructions to a mother of a 3-year-old child who has undergone an orchiopexy to correct cryptorchidism. Which of the following statements made by the mother would indicate further teaching is necessary?
"I'll give him medication so he'll be comfortable."
"I'll check his voiding to be sure there is no problem."
"I will let him decide when he wants to return to his play activities."
"I will check his temperature." - correct answer "I will let him decide when he wants to return to his play activities."
Vigorous activities should be restricted for 2 weeks following this type of surgery to allow for healing and prevent injury. Normal 3- year-olds want to be active, therefore, to prevent dislodging of the internal sutures, activity should be restricted. Monitoring the urine output, providing analgesics, and monitoring temperature are all important for the mother to be instructed upon.
A nurse is caring for a patient who is in labor. The nurse has assessed a nonreassuring fetal heart rate manifesting as tachycardia unrelated to maternal variables. A pH blood sample is ordered. Which of the following fetal scalp pH values would indicate true acidosis?
7.25
7.15
7.30
7.35 - correct answer 7.15
Normal fetal scalp pH in labor is 7.25 to 7.35. If the value is below 7.2 this would indicate true acidosis. Therefore the 7.15 value would indicate true acidosis.
The nurse is caring for an African-American female patient who is 75 years old. The patient complains of a gradual loss of her peripheral vision. Examination has indicated increased IOP. Which of the following is the most likely cause of her symptoms?
check all answers that apply
subconjunctival hemorrhage
primary closed-angle glaucoma
primary open-angle glaucoma
macular degeneration
cataracts - correct answer primary open-angle glaucoma
Primary open-angle glaucoma has a gradual onset of increased IOP due to blockage of drainage of the aqueous humor. The optic nerve undergoes ischemic damage resulting in permanent visual loss. It is the most common type of glaucoma and is most commonly seen in elderly patients, especially those of African background or diabetics.
You are teaching a class to encourage smokers to quit. You ask each person to write down how many packs they smoke per day and for how many years. The first person has smoked 2 packs per day for 12 years. How many pack-years would that amount to?
6
4
24
12 - correct answer 24
Smoking history is quantified in pack-years. To find this value, you would multiply the number of packs smoked per day by the number of years. In this woman's case she smoked 2 packs per day for 12 years. Her pack-years value is 24.
When performing an assessment on a client with dementia, the RN must gather certain information. Which data gathered during the assessment indicates a manifestation associated with dementia?
Absence of sundown syndrome.
Presence of personal hygienic care.
Confabulation.
Improvement of sleeping. - correct answer confabulation
Dementia has variant findings, from the development of mild cognitive defects to severe, life-threatening alterations in neurological functioning. The client who uses confabulation is providing the fabrication of events or experiences to fill in memory gaps. As dementia progresses, the client will have episodes of wandering or sundowning.
A menopausal woman tells her nurse that she experiences discomfort from vaginal dryness during sexual intercourse, and asks, "What should I use as a lubricant?" The nurse should recommend:
petroleum jelly.
a water-soluble lubricant.
body cream or body lotion.
less-frequent intercourse. - correct answer a water-soluble lubricant.
water-soluble lubricant. A Water-soluble jelly should be used. Petroleum jelly, body creams, and body lotions are not water soluble. Less-frequent intercourse is an inappropriate response.
You have a patient with cardiomyopathy who presents with tachycardia, hypotension and a narrowed pulse pressure. The patient also has tachypnea and pulmonary congestion evidenced by crackles. This patient is most likely experiencing which of the following?
check all answers that apply
cardiogenic shock
hypovolemic shock
obstructive shock
distributive shock - correct answer cardiogenic shock
Cardiogenic shock occurs when either systolic or diastolic dysfunction of the pumping action of the heart results in reduced cardiac output. This patient shows typical signs of cardiogenic shock. Other signs of peripheral hypoperfusion include: cyanosis, pallor, diaphoresis, and diminished pulses.
Part of the RN role involves delegation of client assignments. Which of the following is an appropriate delegation for a nursing assistant?
Care for a client requiring colostomy irrigation.
Care for a client who requires a urine specimen collected.
Care for a client with difficulty swallowing food and fluids.
Care for a client receiving continuous tube feeding. - correct answer Care for a client who requires a urine specimen collected.
The nurse must delegate tasks by determining the assignment based on the skill level of subordinate staff. The most appropriate in this situation would be to collect the urine specimen. Colostomy irrigation and tube feedings are not permitted skills for unlicensed staff. The client with difficulty swallowing is at risk for aspiration.
The ethical principle that is most closely related to the concept of free will is which of the following?
check all answers that apply
beneficence
autonomy
justice
fidelity - correct answer autonomy
Autonomy is a state of being self-regulating, self-defining, and self-reliant. A person, therefore, has the free will to dictate his own thoughts and actions.
You have a patient with Alzheimer's disease whose symptoms become more pronounced in the evening. You understand that this is known as which of the following?
check all answers that apply
sundowning
secondary dementia
confabulation
hyperorality - correct answer sundowning
Sundowning (also known as sundown syndrome) is the situation in which symptoms and problem behaviors of those with cognitive disorders become more pronounced in the evening. This may occur in both delirium and dementia.
Which of the following should be the nurse's initial action immediately following the birth of the baby?
Aspirating mucus from the infant's nose and mouth
Drying the infant to stabilize the infant's temperature
Promoting parental bonding
Identifying the newborn - correct answer Drying the infant to stabilize the infant's temperature
The nurse's first action should be to dry the baby and stabilize the infant's temperature. Aspiration of the infant's nose and mouth occurs at the time of delivery. Prompting parental bonding and identifying the neonate are appropriate after the baby has been dried.
The gray-blue discoloration of the flanks seen in hemorrhagic pancreatitis is which of the following?
check all answers that apply
Turner's sign
Murphy's sign
Cullen's sign
Trousseau's sign - correct answer Turner's sign
Turner's sign is a gray-blue discoloration of the flanks seen in acute hemorrhagic pancreatitis. Cullen's sign is a bluish discoloration of the abdomen and periumbilical area also seen in acute hemorrhagic pancreatitis.
The nurse is obtaining an infant's chest circumference. The nurse should align the tape measure
with the lower section of the chest
with the center of the chest in line with the nipples
directly above the abdomen and transverse to the chest
against the center of the chest in line with the child's arm - correct answer with the center of the chest in line with the nipples [Show Less]