The nurse is caring for a client with body dysmorphic disorder. The client tells the nurse, "My ugly ears make everyone sick!" Which defense mechanism is
... [Show More] this client utilizing?
Select all that apply
1. Sublimation
2. Somatization
3. Symbolism
4. Projection
5. Conversion
3. Symbolism
4. Projection
Which client should the nurse recognize as being at greatest risk for the development of cancer?
1. Smoker for 30 plus years
2. Body builder taking steroids and using tanning salons
3. Newborn with multiple birth defects
4. Older individual with acquired immunodeficiency syndrome
4. Older individual with acquired immunodeficiency syndrome
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01:20
A client is seen at the clinic two weeks after starting amitriptyline. The client reports improved sleep patterns and appetite, but no change in feelings of sadness or depression. What comment by the nurse is most appropriate?
1. "Would you like me to ask the doctor to increase your dose?"
2. "You might need to be changed to a different medication."
3. "Tell me what type of situations make you feel depressed."
4. "Some medications take a little longer to improve moods."
4. "Some medications take a little longer to improve moods."
What is the primary electrolyte that the nurse should be aware to monitor for in a client who is receiving an insulin infusion?
1. Sodium
2. Potassium
3. Calcium
4. Phosphorus
2. Potassium
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A nurse is providing care to a post-operative parathyroidectomy client. Which occurrence takes highest priority?
1. Psychoses
2. Renal calculi
3. Positive Trousseau's sign
4. Laryngospasm
4. Laryngospasm
The unlicensed assistive personnel (UAP) reports to the nurse that a client who received morphine sulfate 4 mg IVP 30 minutes ago has a respiratory rate of 10 breaths/ minute. What is the nurse's priority intervention?
1. Administer naloxone 0.4 mg IVP.
2. Notify the primary healthcare provider of respiratory status.
3. Deliver breaths at 20 breaths/ minute via a bag-valve mask.
4. Instruct the UAP to ambulate the client.
1. Administer naloxone 0.4 mg IVP.
The nurse is caring for a 5 year old client who is 12 hours post tonsillectomy. The client is pain free and has advanced to a soft diet. What is the priority nursing intervention?
1. Apply warm compresses to the throat.
2. Encourage gargling to reduce discomfort.
3. Position the child supine.
4. Monitor for frequent clearing of the throat
4. Monitor for frequent clearing of the throat
A client is admitted to the Labor & Delivery Unit with severe preeclampsia. Which nursing intervention does the nurse include in the plan of care for this client?
Select all that apply
1. Monitor for headache.
2. Place client in left recumbent position.
3. Insert indwelling urinary catheter.
4. Administer propranolol for BP > 100 diastolic.
5. Initiate external fetal heart monitoring.
1. Monitor for headache.
2. Place client in left recumbent position.
3. Insert indwelling urinary catheter.
5. Initiate external fetal heart monitoring.
The nurse identifies that additional teaching about skin care is needed when an 80 year old client makes what statement?
1. "I shower 3 - 4 times per week."
2. "I apply moisturizers at least daily."
3. "I bathe in the tub at least 6 times per week."
4. "I drink 64 ounces (1.89 L) of liquid per day."
3. "I bathe in the tub at least 6 times per week."
A 35 year old client asks a clinic nurse how to find out if the client is overweight or obese. The client weighs 135 pounds and is 5 feet 2 inches tall. What should the nurse educate the client about?
1. Calculating body mass index
2. Measuring abdominal circumference
3. Determining lean body mass
4. Finding the nearest hydrostatic testing location
1. Calculating body mass index
An alert elderly client has been admitted to the hospital and placed on bedrest following a fall at home. During evening medication rounds, the nurse notes the client has become disoriented to time and place. The nurse is aware a new onset of confusion could be the result of what factors?
Select all that apply
1. Admission to the hospital.
2. Amount of physical pain.
3. Current bed confinement.
4. Advanced age.
5. Response to analgesic.
1. Admission to the hospital.
2. Amount of physical pain.
3. Current bed confinement.
5. Response to analgesic.
The family of a client recently placed on antipsychotic medications for the treatment of schizophrenia calls the nursing hot line and reports that the client's temperature is 105.1ºF (40.6ºC), and that the client's muscles are stiff. What should the nurse tell the family?
1. Continue to monitor for signs and symptoms of infection.
2. Transport the client to the emergency room.
3. The signs and symptoms will subside within a day or so.
4. They should call the primary healthcare provider tomorrow.
2. Transport the client to the emergency room.
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A client who has recurrent episodes of allergic rhinitis asks the nurse what could be done to decrease symptoms. What instruction should the nurse provide to this client?
Select all that apply
1. Remove pets from interior of home.
2. Treat a stuffy nose with warm salt water.
3. Remove carpeting.
4. Stay inside when pollen count is at its lowest.
5. Wash bed linens in hot water.
1. Remove pets from interior of home.
2. Treat a stuffy nose with warm salt water.
3. Remove carpeting.
5. Wash bed linens in hot water.
The nurse is preparing to hang an IV bag of Heparin after receiving a prescription from a client's primary healthcare provider: Heparin IV to infuse at 1000 U/h.
What flow rate should the nurse set the IV infusion pump rate at? Round to the nearest whole number.
Heparin 25,000 units (100usp units/mL) added to 0.45% NS 250mL
10
25000 / 250 NS = 1,000 units
250,000 / 25,000 = 10
A client buzzes the nurses' station to report chest pain. The nurse looks at the client's cardiac rhythm strip, then hurries into the client's room to find the client unresponsive and without a pulse. What initial action should the nurse take?
Exhibit - Ventricular Tachycardia demonstrated on EKG
1. Administer Epinephrine 1mg IV push.
2. Begin cardiopulmonary resuscitation (CPR) for 2 minutes.
3. Defibrillate at 120 joules.
4. Insert supraglottic airway device.
3. Defibrillate at 120 joules
The head nurse on a busy surgical unit is evaluating several fresh post-operative clients. Which observation should the nurse report immediately to the primary healthcare provider?
1. A post transurethral resection client with cherry colored urine
2. A post mastectomy client drains 40 mL of bloody drainage within 3 hours of the surgery
3. A post ileostomy client with a beefy red stoma and mucus drainage
4. A post thyroidectomy client reporting tingling in toes and fingers
4. A post thyroidectomy client reporting tingling in toes and fingers
A client is undergoing outpatient psychiatric treatment for somatization disorder. Prior to the beginning of group therapy, the client tells the nurse, "I keep having headaches that are killing me! This has never happened to me before." What is the nurse's best response to this client?
1. You need to sit down, because we need to start the group session now.
2. I will notify the primary healthcare provider about your headaches, after the group session.
3. I guess we can discuss your pain now. Group therapy will have to start later.
4. Your headaches are not real, so ignore them. Go on into therapy so we can start.
2. I will notify the primary healthcare provider about your headaches, after the group session.
A client diagnosed with an embolic stroke has been admitted to the medical unit. Which nursing assessment would the nurse include to identify an early sign of increased intracranial pressure (ICP)?
1. Bradypnea
2. Bradycardia
3. Restlessness
4. Elevated systolic pressure
3. Restlessness
A client who has been taking phenytoin for several years arrives to the clinic for follow-up care. During the nurse's history and physical of the client, which findings indicate a possible side effect to the phenytoin?
Select all that apply
1. Skin rash
2. Reports fatigue
3. Dyspnea on exertion
4. Pale conjunctiva
5. Heart rate 60/min
1. Skin rash
2. Reports fatigue
3. Dyspnea on exertion
4. Pale conjunctiva
What signs and symptoms would a nurse assess for in a client who is receiving hospice care and is close to death?
Select all that apply
1. Cool extremities
2. Mottling
3. Cheyne-Stokes respirations
4. Loss of appetite
5. Increased blood pressure
1. Cool extremities
2. Mottling
3. Cheyne-Stokes respirations
4. Loss of appetite
A client is being cared for on the orthopedic unit following a football game injury which resulted in a fracture of the left tibia and fibula. An open reduction of the fracture has been performed and a leg cast was applied. The client is receiving Morphine via a Patient Controlled Analgesia (PCA) pump at 2 mg/hr. The client begins reporting an increase in the pain level (9/10) that is not being relieved by the current Morphine dosing, and is experiencing a sensation that "pins are sticking" in the left foot. What action by the nurse is needed?
Select all that apply
1. Increase the PCA dosing of Morphine.
2. Elevate the foot of the bed.
3. Perform neurovascular checks.
4. Apply ice around sides of cast.
5. Prepare for possible bivalving of the cast.
6. Notify primary healthcare provider.
3. Perform neurovascular checks.
5. Prepare for possible bivalving of the cast.
6. Notify primary healthcare provider.
An elderly client with a recent diagnosis of atrial fibrillation (AF) caused by valvular heart disease, tells the nurse, "My daughter has AF and she only has to take one dabigatran pill a day. I have to take warfarin daily and have my blood checked every month. Why do I have to do all of this?" What education would the nurse provide to the client?
1. Your daughter's atrial fibrillation must not be caused by a heart valve problem so she can take a medication that does not require routine clotting studies.
2. Each primary healthcare provider may treat this dysrhythmia differently based on what the provider is used to prescribing.
3. When your daughter gets older, her primary healthcare provider will switch her to warfarin for the treatment of atrial fibrillation.
4. Your atrial fibrillation is caused by a heart valve problem which is treated best by warfarin, but clotting studies have to be done routinely.
4. Your atrial fibrillation is caused by a heart valve problem which is treated best by warfarin, but clotting studies have to be done routinely.
The primary healthcare provider prescribed phenytoin for a client with grand mal seizures. What intervention would the nurse plan for the client's care?
1. Offer the client frequent high calorie snacks.
2. Check the apical pulse before each dose.
3. Perform or assist with oral hygiene every shift.
4. Give the medication 30 minutes prior to meal.
3. Perform or assist with oral hygiene every shift.
A client is suspected of having a pheochromocytoma. The nurse is explaining the process of a VMA (Vanillylmandelic acid) urine test to be complete at home. What statement made by the client indicates the need for further teaching?
Select all that apply
1. "I need to keep the urine in the fridge during the 24 hours."
2. "I will have to stay well-hydrated to get enough urine to test."
3. "It does not matter what I eat or drink during this process."
4. "I need to throw away my first voiding when I start this test."
5. "I should void at the end of the 24 hours and keep that urine."
1. "I need to keep the urine in the fridge during the 24 hours."
2. "I will have to stay well-hydrated to get enough urine to test."
3. "It does not matter what I eat or drink during this process."
A child with acute lymphocytic leukemia (ALL) is receiving chemotherapy through a single lumen Groshong catheter. During the infusion, the child reports nausea and has vomited. The primary healthcare provider has prescribed ondansetron IV. What action should the nurse take?
1. Ask primary healthcare provider for an oral antiemetic.
2. Give ondansetron IVPB with the chemotherapy.
3. Wait until chemotherapy is complete to infuse ondansetron.
4. Stop chemotherapy temporarily and flush line to give ondansetron.
4. Stop chemotherapy temporarily and flush line to give ondansetron.
The nurse's assessment of a client post-op abdominoplasty reveals tachycardia, restlessness and shallow slow breaths. The client was medicated with morphine 2 mg IVP one hour ago. The primary healthcare provider prescribes arterial blood gases (ABG). Which ABG report is consistent with this clinical picture?
1. pH 7.30, PaCO2 40, HCO3 29
2. pH 7.33, PaCO2 48, HCO3 25
3. pH 7.47, PaCO2 35, HCO3 29
4. pH 7.50, PaCO2 33, HCO3 22
2. pH 7.33, PaCO2 48, HCO3 25
Which prevention measure should the nurse include when instructing a client on avoidance of otitis externa?
1. Gently cleaning the ear canal with a cotton tipped applicator daily.
2. Use of astringent drops after bathing.
3. Taking preventative antibiotics prior to swimming in lakes or ponds
4. Routine use of nasal saline to clear the sinuses and eustachian tubes.
2. Use of astringent drops after bathing.
A hiker that was lost in the mountains for 3 days experienced exposure to below freezing temperatures. Upon arrival to the emergency department (ED), the nursing assessment reveals hard, mottled, bluish-white toes bilaterally, and the client reports being unable to feel the toes. Which actions should the nurse initially take?
Select all that apply
1. Remove any wet or constricting clothing.
2. Initiate a controlled and rapid rewarming process with warm water.
3. Wrap each toe individually with sterile gauze.
4. Encourage the client to walk.
5. Apply a heating pad to the feet.
6. Massage the frozen digits.
1. Remove any wet or constricting clothing.
2. Initiate a controlled and rapid rewarming process with warm water.
3. Wrap each toe individually with sterile gauze.
In what order should the home health nurse see assigned clients? Place in priority order.
a. Client diagnosed with multiple sclerosis who called the office to say life is not worth living anymore.
b. Client diagnosed with rheumatoid arthritis who requires an occupational consult.
c. Client diagnosed with acquired immune deficiency syndrome (AIDS) dementia, whose family is requesting hospice information.
d. Client diagnosed with systemic lupus erythematosus discharged home from the hospital this AM with a prescription for home healthcare.
a. Client diagnosed with multiple sclerosis who called the office to say life is not worth living anymore.
d. Client diagnosed with systemic lupus erythematosus discharged home from the hospital this AM with a prescription for home healthcare.
c. Client diagnosed with acquired immune deficiency syndrome (AIDS) dementia, whose family is requesting hospice information.
b. Client diagnosed with rheumatoid arthritis who requires an occupational consult.
A client is admitted to the hospital reporting chills, fatigue and left lower leg pain for nearly a week. During initial assessment, the nurse notes wide-spread swelling and redness of left ankle in addition to a fever of 103.5° F (39.72° C). Which admission order should the nurse implement first?
1. Perform sterile wound care to lower leg.
2. Start I.V. for administration of antibiotics.
3. Place client on bedrest with left leg elevated.
4. Draw blood for serial cultures and lab work.
3. Place client on bedrest with left leg elevated.
Which assigned postpartum client should the nurse identify as being at highest risk for hemorrhage?
1. C-section delivery
2. Vaginal delivery of twins
3. Vaginal delivery of premature baby
4. Precipitous delivery of gravida 5
1. C-section delivery
Which finding by the nurse would need to be reported to the primary healthcare provider immediately when caring for an infant who was born with a myelomeningocele?
Select all that apply
1. High pitched cry
2. Eyes fixed downward
3. Increasing head circumference
4. Decrease in a feeding by 30 mL
5. Projectile vomiting
1. High pitched cry
2. Eyes fixed downward
3. Increasing head circumference
5. Projectile vomiting [Show Less]