Kaplan – QBANK | questions and answers 100% correct
The nurse cares for a 17-year-old girl diagnosed with cancer receiving chemotherapy. Which of the
... [Show More] following statements indicates to the nurse that the client has a realistic perception of her health status?
1. "I will be cured after my therapy is complete."
2. "I have started buying scarves of different colors."
3. "I will be carrying a full load of classes this semester."
4. "I must have done something to cause this illness." Correct Answer: Strategy: Think about what the words mean.
1) may or may not happen
2) CORRECT— indicates the client is realistic about what may happen because of chemotherapy; obtains wig, scarves, or hats before losing hair
3) not realistic; weakness and fatigue are common side effects of chemotherapy
4) indicates blame and guilt
The client is brought to the emergency department by friends who state, "He has been hanging with the wrong crowd. We are worried he is using drugs." The nurse notes that the client stares blankly and has an unsteady gait, stiff muscles, and eyes that are moving rapidly side to side and up and down. The nurse plans care. Which is MOSTimportant for the nurse to anticipate?
1. Increased adventitious breath sounds.
2. Decreased blood pressure, temperature, and pulse.
3. Aggressive behaviors.
4. Nausea, vomiting, abdominal cramping. Correct Answer: Strategy: The topic of the question is unstated.
(1.) client's symptoms indicate phencyclidine piperidine (PCP) intoxication; breath sounds important to assess with any new client but not priority; respiratory arrest can occur with PCP overdose
(2.) with PCP, blood pressure, temperature, and pulse are expected to increase, not decrease; overdose could even lead to a hypertensive crisis; hyperthermia can also occur
(3.) CORRECT symptoms of blank stare, rigid muscles, ataxia, and nystagmus that is both vertical and horizontal indicate probable phencyclidine piperidine (PCP) intoxication; another name for PCP is angel dust; aggression in all forms is another symptom that manifests with PCP; can take the form of assault, belligerence, impulsiveness, and/or suicidality, and is very often bizarre in nature; often occurs in unpredictable outbursts; interventions should be planned to monitor for aggressive symptoms, to prevent them, and to manage them should they occur; decreasing stimuli, avoiding trying to "talk the person down," securing potential injurious objects in the environment, having chemical and physical restraints (along with sufficient staff) available are all measures that can be planned in advance and utilized; PCP is used by itself, but is also frequently used as an adulterant with other drugs
(4.) no particular association with PCP; these are symptoms that occur with opiate withdrawal.
The nurse assesses a client in the outpatient clinic. The client states she was diagnosed with osteoarthritis 15 years ago and takes aspirin multiple times per day. Which of the following actions by the nurse is MOST appropriate?
1. Instruct the client to take the aspirin with food.
2. Ask if the client has experienced gastric distress.
3. Suggest that the client take enteric-coated aspirin.
4. Ask if the client experiences tinnitus. Correct Answer: Strategy: "MOST appropriate" indicates priority.
1) appropriate action to minimize gastric irritation
2) side effects include dyspepsia, epigastric distress, and nausea
3) decreases gastric irritation
4) CORRECT— indicates toxicity; other indications include headache, hyperventilation, agitation, confusion, diarrhea, and sweating; withhold medication and contact the physician
The medical nurse enters the room of a confused patient diagnosed with angina pectoris in order to remove the patient's nitroglycerin patch for the night. Upon opening the patient's gown, the nurse sees that the patch is not evident where charting indicated it was placed. What is the FIRST action the nurse should take?
1. Find the patch.
2. Clean the site and secure a new patch in place for the night.
3. Ask the patient what happened to the patch.
4. Administer 1 nitroglycerin tablet sublingually. Correct Answer: Strategy: "FIRST" indicates priority.
(1.) CORRECT—patient who is confused may move a transdermal patch elsewhere on the body or remove it; if it remains in the new location and another patch is applied elsewhere, tolerance and loss of angina-relieving response could occur; also, discarded patches still have sufficient active ingredients to be of harm to persons having contact with them
(2.) the site does need to be cleaned thoroughly because nitroglycerin is irritating to the skin and also should not continue to be absorbed after the patch is removed; however, a new site should be chosen for each new patch
(3.) patient is confused and may not be able to respond accurately
(4.) no indication given that this is needed
The 35-year-old mother of five children ranging in age from 4 to 17 years tells the health service nurse, "The father of my children passed away 3 weeks ago. We had been apart for several years, but the children have taken his death really badly." When asked how she herself has handled the death, she replies, "I am doing OK. I have been focused on helping the children. I can hardly believe it happened. He was only 34 years old. I don't know if and when it will really hit and upset me that he is gone." Which of the following responses by the nurse is MOST appropriate initially?
1. "Did he use drugs? It is known that some can cause a heart attack in someone so young."
2. "It may not. But you may be in the first stage of grieving, which is shock and denial."
3. "You certainly have your hands full right now, and you're doing a wonderful job."
4. "How helpful was he to you in raising and supporting the children?" Correct Answer: Strategy: Remember therapeutic communication.
(1.) not best; accurate information, especially for cocaine; may help the mother understand what occurred; however, the question is closed-ended and the whole response is factually oriented, versus encouraging expression
(2.) CORRECT—responds directly to mother's statement and focuses on her: provides factual information and the beginning of a framework to understand what she is probably going through
(3.) does not respond directly to mother's last statement or encourage discussion; does convey recognition of extent of her current responsibilities
(4.) not best initially, elicits important factual and subjective information that could be used to assess the mother's changed current and future parenting burden and to begin planning for any needed family, community, or other assistance; does not respond to mother's last statement
The nurse in the outpatient surgery prepares a 2-year-old child for a myringotomy for placement of tympanostomy tubes. It is MOST important for the nurse to take which of the following actions?
1. Use bright objects to distract the toddler during the preoperative assessment.
2. Allow the toddler to play with a toy stethoscope before auscultation.
3. Demonstrate the use of the stethoscope before auscultation.
4. Give the toddler choices when possible during the preoperative assessment. Correct Answer: Strategy: Topic of question is unstated.
1) more appropriate for an infant than a toddler
2) CORRECT— allows the child to become familiar with equipment; decreases fear of the unfamiliar objects; explain procedures by telling toddler what she/he will see, hear, taste, and feel
3) ineffective because of developmental age; more appropriate for preschool age child
4) appropriate for a school age child
A patient diagnosed with type 2 diabetes mellitus is treated for hypertension with propanolol (Inderal). History reveals that the patient is diagnosed with glaucoma and is allergic to sulfa. The nurse is MOST concerned if an order was written for which of the following medications?
1. Glycerin (Osmoglyn).
2. Pilocarpine (Isopto-Carpine).
3. Acetazolamide (Diamox).
4. Timolol maleate (Timoptic). Correct Answer: Strategy: "Nurse is MOST concerned" indicates a complication.
(1.) should be questioned but not of most concern; osmotic agent; diuretic; increases osmolarity of the blood, extracting fluid from extracellular space into the bloodstream, including aqueous humor and vitreous humor from the anterior chamber of the eye, thus decreasing intraocular pressure; glycerin needs to be used with caution in diabetics because it can cause hyperglycemia
(2.) no need to question this order; direct-acting parasympathetic function causing miosis
(3.) CORRECT—contraindicated; cross-sensitivity can occur due to allergy to antibacterial sulfonamides and sulfonamide derivatives
(4.) should be questioned, but not priority; beta blockers given for systemic use, such as propanolol and atenolol, can enhance the therapeutic and toxic effects of beta blockers prescribed for ophthalmic use
The nurse instructs a client on a postpartum about proper perineal care. The nurse determines that further teaching is needed if the client states which of the following?
1. "I will wash my hands before and after I use the restroom."
2. "I will change my peri-pads when they are soiled."
3. "I will remember to wipe my bottom from front to back."
4. "I can soak my bottom in warm or cold water, whichever feels the best." Correct Answer: Strategy: "Further teaching is necessary" indicates incorrect information.
1) true statement; decreases contamination to the perianal area
2) CORRECT— change peri-pads every time the client uses the lavatory and when they are soiled; do not place a used peri-pad against a clean perineum
3) true statement; wiping from front to back decreases exposure of pathogens from the anus
4) true statement; personal comfort is the key to peri care; some women prefer cold and some prefer warm soaks
A woman comes to the outpatient clinic in the 16th week of her pregnancy. The client asks the nurse why she is going to receive RhoGAM (Rho [D] globulin) during her pregnancy. Which of the following is the BEST response by the nurse?
1. "It resolves the incompatibility between your blood type and your infant's blood type."
2. "It prevents your infant from developing jaundice due to blood incompatibility."
3. "It prevents your body from manufacturing antibodies to your infant's blood type."
4. "It prevents your blood from mixing with the blood of your infant." Correct Answer: Strategy: Think about the action of RhoGAM.
1) isoimmunization occurs when an Rh-negative mother becomes pregnant with and gives birth to an Rh-positive infant; the problem is with Rh incompatibility, not blood-type incompatibility
2) if mother forms antibodies; causes hemolysis and jaundice in the infant; jaundice within the first 24 hours of life indicates hemolytic disease of the newborn; physiologic jaundice occurs after 24 hours
3) CORRECT— it prevents the mother from forming antibodies to the Rh+ blood; sensitization may occur during pregnancy, birth, abortion, or amniocentesis
4) is not the action of RhoGAM
A client in the psychiatric unit continually complains to the nurse that his stomach is missing. Which of the following responses by the nurse is MOST appropriate?
1. "Well then, you should not have any trouble losing weight."
2. "Where did your stomach go?"
3. "It sounds like you feel very empty and alone."
4. "I am here to help you." Correct Answer: Strategy: "MOST appropriate" indicates discrimination is required to answer the question.
1) nontherapeutic; closed response
2) do not argue with the client having a delusion; they will try to convince the nurse about the truth of the delusion
3) CORRECT— delusions often reflect feelings of emptiness and loneliness; help nurse to focus on feelings and not the delusion
4) nontherapeutic; focus on nurse
The nurse performs teaching for a client receiving clonidine (Catapres-TTS) transdermal patch. Which of the following statements, if made by the client to the nurse, indicates teaching is successful?
1. "I like the new heart-healthy meals that can be microwaved."
2. "I will change the patch every 7 days."
3. "I will cut the used patch into four pieces before disposing of it."
4. "I use an electric blanket to keep warm at night." Correct Answer: Strategy: "teaching is successful" indicates correct information.
1) should be cautious around microwave because leaking radiation can heat the patch's metallic backing and result in burns
2) CORRECT— Catapres is a centrally acting alpha-adrenergic used to treat hypertension; apply to nonhairy site every 7 days; side effects include drowsiness, sedation, orthostatic hypotension; heart failure
3) dispose of carefully due to retained medication
4) contraindicated due to increased absorption of medication due to heat; if heat is required, adjusting dose may be needed to avoid toxicity
A 6-year-old girl is brought to the well-child clinic for a checkup by her mother. While the child is playing in the clinic playroom, the nurse observes her behavior. Which of the following activities demonstrates to the nurse that the child has musculoskeletal development that is age-appropriate but not advanced for her age?
1. The child runs after a rolling ball.
2. The child walks up and down the stairs.
3. The child hops and skips.
4. The child neatly ties her shoelaces. Correct Answer: Strategy: Picture a 6 year old.
1) appropriate for child of 2 years
2) develops 2-4 years of age
3) CORRECT— appropriate skills for 4-6 years of age
4) advanced motor skill accomplished after age 6
The nurse cares for clients in the emergency department. The nurse assesses a client following a car wreck. Which of the following observations, if made by the nurse, warrants the nurse remaining with the client?
1. Client is disoriented to person, place, and time, and vital signs are irregular.
2. Client's vital signs are irregular and client is hostile.
3. Client is agitated with rapid respirations.
4. Client's blood pressure is elevated and client is apprehensive. Correct Answer: Strategy: Think about each answer.
1) CORRECT— poses a safety risk; nurse should remain with client
2) requires close monitoring, but answer #1 takes priority
3) respirations are increased with agitation
4) symptoms in #1 take priority
The nurse determines that a client's tracheostomy requires suctioning. Which of the following actions should the nurse take FIRST?
1. Elevate the head of the client's bed to 90°.
2. Quickly insert the suction catheter.
3. Preoxygenate the client.
4. Put on clean gloves. Correct Answer: Strategy: "FIRST" indicates priority.
1) not necessary to elevate the client's head
2) must set up sterile field and preoxygenate the client before inserting the suction catheter
3) CORRECT— prevents hypoxia associated with tracheal suctioning
4) wear sterile gloves
The school nurse is observing a high-school basketball game. Two cheerleaders are tumbling and hit each other in mid-air. One of the cheerleaders begins to cry and says, "I think my arm is broken." Which of the following actions should the school nurse take FIRST?
1. Call 911.
2. Immobilize the arm. [Show Less]