An adult who had been abused as a child is discussing the group therapy program. Which statement indicates that the client has gained insight?
Children who are abused learn to cope with the painful experiences by ignoring painful feelings and avoiding getting close to people. As adults, victims of abuse usually continue to repress feelings, avoid close interpersonal relationships, and frequently use alcohol or drugs to block painful memories. Long-term effects in adults might include criminal/violent behavior (for adult males), substance abuse, and a variety of social and emotional problems (including suicidal thoughts, anxiety, hostility, dissociation, and interpersonal difficulties).Psychosocial Integrity
How is the information documented on incident reports used?
Risk management plays a vital role as an arm of quality monitoring and improvement programs. It utilizes information obtained from incident reports, as well as audits, committee minutes, service complaints, and clientsatisfaction questionnaires to perform all of the tasks identified.Safety and Infection Control
A nurse assesses a 83 year-old female’s venous ulcer for the second time that is located near the right medial malleolus. The wound is exhibiting purulent drainage and the patient has limited mobility in her home. Which of the options is the best course of action?
A determination of arterial blood flow should be made, prior to encouraging increased activity, or notifying additional team members.
A nurse is caring for a patient in the step down unit. The patient has signs of increased intracranial pressure. Which of the following is not a sign of increased intracranial pressure?
Unilateral pupil changes indicate changes in ICP.
A 93 year-old female with a history of Alzheimer’s Disease gets admitted to an Alzheimer’s unit. The patient has exhibited signs of increased confusion and limited stability with gait. Moreover, the patient is refusing to use a w/c. Which of the following is the most appropriate course of action for the nurse?
Stimulation in the form of pictures may decrease signs of confusion.
When planning care of a client who has a been diagnosed with Amphetamine Abuse, the nurse should use the knowledge that:
Amphetamines cause the release of norepinephrine and dopamine from storage vesicles into the synapse. The increased catecholamines at the receptors causes increased stimulation. Clear patterns of tolerance and withdrawal have not been described. Prolonged or excessive use of amphetamines can lead to psychosis. People use amphetamines for the feelings of euphoria, relief from fatigue, energy, and alertness. Overdose can cause seizures, cardiac arrhythmias, hypertension, and hyperthermia. When abstaining, the client might experience fatigue, depression, and irritability lasting for several weeks. Drug cravings are common and might lead to relapse.Psychosocial Integrity
A central venous pressure reading of 11cm/H(2)0 of an IV of normal saline is determined by the nurse caring for the patient. The patient has a diagnosis of pericarditis. Which of the following is the most applicable:
>10cm/H(2)0 may indicate a condition of pericarditis
A 32-year-old female frequently comes to her primary care provider with vague complaints of headache, abdominal pain, and trouble sleeping. In the past, the physician has dutifully prescribed medication, but little else. Which of the following comments by the nurse to the physician is appropriate?
There is a correlation between vague symptoms, such as abdominal pain, and battered syndrome. The astute clinician should question any woman who presents with suspicious symptoms such as these. Rarely are women offended by a properly worded question, such as, “Do you feel safe in your present relationship?” Studies show an increase in case finding when such questions are asked. It is not mandatory that all women are assessed for violence, but it is prudent that allpersons new to a clinician be assessed by at least the one question noted previously. Castigating or shaming the physician typically does not improve client outcomes and might make for a difficult working environment for the nurse. Tactless comments, like the one in Choice 4, are not collegial and should be avoided.Psychosocial Integrity
An infection in a central venous access device is not eliminated by giving antibiotics through the catheter. How might bacterial glycocalyx contribute to this?
Glycocalyx is a viscous polysaccharide or polypeptide slime that covers microbes. It enhances adherence to surfaces, resists phagocytic engulfment by the white blood cells, and prevents antibiotics from contacting the microbe. Glycocalyx does not have the effects described in Choices 2, 3, and 4.Pharmacological Therapies
The home health nurse has made a visit to an 85-year-old female client’s home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?
Rugs and clutter are a primary cause of falls in the home and should be eliminated if possible to decrease the risk of a fall. The elderly and those with gait issues are at an increased risk for a fall at home. The client should have a raised toilet seat and grab bars available in the bathroom to aid in movement in this potential slippery area of the home. Some clients find it difficult to rise up and down from the toilet and to get in and out of the shower. These items are all important in maintaining safety in the home. The client should not limit her movement within the home unless ordered by the physician. This decreases the ability of the client to perform activities of daily living and hinders the client’s return to a normal lifestyle after surgery. The client should notwear baggy clothing such as long robes, and the client should not wear socks on slippery floors. These items can cause the client to trip, slip, or fall.Health Promotion and Maintenance
A nurse is covering a pediatric unit and is responsible for a 15 year-old male patient on the floor. The mother of the child states, “I think my son is sexually interested in girls.” The most appropriate course of action of the nurse is to respond by stating:
Adolescents exhibiting signs of sexual development and interest are normal.
A nurse has been assigned a patient who has recently been diagnosed with Guillain-Barre’ Syndrome. Which of the following statements is the most applicable when discussing the impairments with Guillain-Barre’ Syndrome with the patient?
Muscle weakness in the lower extremities is found in acute cases of Guillain-Barre’ Syndrome.
In hanging a parenteral IV fluid that is to be infused by gravity, rather than with an infusion pump, the nurse notes that the IV tubing is available in different drop factors. Which tubing is a microdrop set?
All microdrop sets are calculated to give 60 drops for each milliliter of IV fluid. Macrodrop sets are calculated to give 10, 15, or 20 drops for each milliliter of IV fluid.Pharmacological Therapies
A 28 year-old male has a diagnosis of AIDS. The patient has had a two year history of AIDS. The most likely cognitive deficits include which of the following?
Cognitive changes may include confusion and disorientation.
A patient has experienced a severe third degree burn to the trunk in the last 36 hours. Which phase of burn management is the patient in?
The shock phase is considered the first 24-48 hours in wound management.
Why is it often necessary to draw a complete blood count and differential (CBC/differential) when a client is being treated with an antiepileptic drug (AED)?
Some AEDs cause aplastic anemia and megaloblastic anemia. Choices 1, 2, and 3 are not side effects of AEDs.
During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechaie of the palate. The nurse should:
Generally oral sex leaves little physical evidence. Injury to the soft palate (such as bruising, abrasions, and petechaie) and pharyngeal gonorrhea are the only signs. Infants are at risk for sexual abuse.Psychosocial Integrity
A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?
A mediastinal shift is indicative of a tension pneumothorax along with theother symptoms in the question.Because the individual was involved in an MVA, assessment is targeted at acute traumatic injuries to the lungs, heart, or chest wall rather than other conditions indicated in the other choices. Choice 1 is common with pneumonia. Values in Choice 2 are not alarming. Choice 4 is typical of someone with chronic obstructive pulmonary disease (COPD). A tensionpneumothorax is a dangerous complication and a medical emergency where entering air cannot escape by the same route and pressure within the pleural cavity increases, resulting in complete collapse of the lung. A mediastinal shift to the unaffected side and a downward displacement of the diaphragm can be observed.Physiological Adaptation
A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy’s mother indicates a need for further teaching by the nurse?
A client having a seizure should be turned to the side to prevent aspiration of secretions. The other statements
are correct and indicate adequate understanding of teaching.Reduction of Risk Potential
The goals of palliative care include all of the following except:
The goals of palliative care include choices 1, 2, and 4. Choice 3 is not part of palliative care. All aspects of
medical, emotional, social, and spiritual needs of the dying client should be focused on until the end of life.Basic
Care and Comfort
A teenage client is admitted to the hospital because of acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs?
Acetaminophen is extensively metabolized in the liver. Choices 1, 3, and 4 are incorrect because prolonged
use of acetaminophen might result in an increased risk of renal dysfunction, but a single overdose does not
precipitate life-threatening problems in the respiratory system, renal system, or adrenal glands.Pharmacological
Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except:
Addiction is not of primary concern when treating the pain of terminally ill clients. Clients with cancer who
are taking opioid analgesics can develop tolerance, constipation, and sedation.Basic Care and Comfort
Which of the following neurological disorders is characterized by writhing, twisting movements of the face and limbs?
Huntington’s chorea is characterized by writhing, twisting movements of the face and limbs. The remaining
options are neurological disorders that do not have such movements as part of their disease process.Reduction of
A health care worker is concerned about a new mother being overwhelmed by caring for her infant. The health care worker should:
Prevention of child abuse is centered on teaching the parents how to care for their child and cope with the
demands of infant care. Parenting classes can help build self-confidence, self-esteem, and coping skills. Parents
benefit by understanding the developmental needs of their children, while learning how to manage their home
environment more effectively. The classes also increase the parents’ social contacts and teach about community
The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine?
In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to
the number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the
age of the child. In this example, the child is 18 months old, so the formula is 18 – 6 = 12. An 18-month-old child
should have approximately 12 teeth.Health Promotion and Maintenance
Which of the following lab values is associated with a decreased risk of cardiovascular disease?
High HDL cholesterol and low LDL cholesterol are associated with a decreased risk of cardiovascular
disease.Reduction of Risk Potential
For a client with suspected appendicitis, the nurse should expect to find abdominal tenderness in which quadrant?
The nurse should expect to find abdominal tenderness in the lower-right quadrant in a client with appendicitis.
A 20-year-old obese female client is preparing to have gastric bypass surgery for weight loss. She says to the nurse, “I need this surgery because nothing else I have done has helped me to lose weight.” Which response by the nurse is most appropriate?
This statement is most appropriate, as it shows respect and empathy. The other statements are both insensitive
and unprofessional.Physiological Adaptation
A client is taking hydrocodone (Vicodin) for chronic back pain. The client has required an increase in the dose and asks whether this means he is addicted to Vicodin. The nurse should base her reply on the knowledge that:
Drug tolerance is characterized by the ability to ingest a larger dose without adverse effect and decreased
sensitivity to the substance. Substance dependence is a severe condition indicating physical problems and
disruption of the person’s social, family, and work life. The psychological behaviors related to substance use are
termed addiction. Dual diagnosis is the coexistence of substance abuse and psychiatric disorders.Psychosocial
Which sign might the nurse see in a client with a high ammonia level?
Coma might be seen in a client with a high ammonia level.Reduction of Risk Potential
Which of the following terms refers to soft-tissue injury caused by blunt force?
A contusion is a soft-tissue injury caused by blunt force. It is an injury that does not break the skin, is caused
by a blow and is characterized by swelling, discoloration, and pain. The immediate application of cold might
limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress.
A sprain is caused by a wrenching or twisting motion. A dislocation is a condition in which the articular surfaces
of the bones forming a joint are no longer in anatomic contact.Physiological Adaptation
Which of the following conditions is mammography used to detect?
Mammography is used to detect tumors or cysts in the breasts, not the other conditions.Reduction of Risk
To remove a client’s gown when she has an intravenous line, the nurse should:
Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line
causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative
except in an emergency. IV gowns, which open along sleeves, are widely available.Basic Care and Comfort
Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?
A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to
death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of
ABC (airway, breathing, and circulation) prioritizes care decisions.Physiological Adaptation
The nurse teaching about preventable diseases should emphasize the importance of getting the following vaccines:
Vaccines are one of the most effective methods of preventing and controlling certain communicable diseases.
The smallpox vaccine is not currently in use because the smallpox virus has been declared eradicated from the
world’s population. Diseases such as polio, diphtheria, pertussis, and measles are mostly controlled by routine
childhood immunization. They have not, however, been eradicated, so children need to be immunized against
these diseases.Physiological Adaptation
A client has been diagnosed with Disseminated Intravascular Coagulation (DIC) and transferred to the medical intensive care unit (ICU) subsequent to an acute bleeding episode. In the ICU, continuous Heparin drip therapy is initiated. Which of the following assessment findings indicates a positive response to Heparin therapy?
Effective Heparin therapy should stop the process of intravascular coagulation and result in increased
availability of fibrinogen. Heparin administration interferes with thrombin-induced conversion of fibrinogen to
fibrin. Bleeding should cease due to the increased availability of platelets and coagulation factors.Physiological
Nonpharmacological pain management involves all of the following except:
All physical and psychosocial therapies can be used concurrently with drugs and other modalities to manage pain. These interventions can be carried out by the nurse with the client and family.Basic Care and Comfort
When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration?
Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract.Physiological Adaptation
For which condition might a client’s antidiuretic hormone (ADH) level be increased?
ADH level is increased in the client with nephrogenic diabetes insipidus.Reduction of Risk Potential
Which of the following diseases places a client at risk for developing cirrhosis?
Alcoholism places a client at risk for developing cirrhosis. None of the other choices are related to cirrhosis.Physiological Adaptation
The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?
The vaginal discharge after birth is called lochia, and it changes from red (rubra) to serosa (clear) on the third postpartum day. If it returns to red or contains clots, it could signal impending hemorrhage or infection and the physician should be notified. It is not normal for the breasts to be tender. If the breasts become engorged, they might be tender and the mother might need to be given additional instructions on breast care. Tenderness, redness, and fatigue are clinical manifestations of mastitis and should be reported to the physician. A woman should void in normal patterns and frequency after birth. Increased frequency is a sign of a urinary tract infection and should be reported to the physician. By the time of discharge, the woman’s temperature should be normal. Elevations should be reported to the physician.Health Promotion and Maintenance
One of the major functions of the kidneys in maintaining normal fluid balance is:
Major functions of the kidneys in maintaining normal fluid balance include regulation of extracellular fluid and osmolarity by selective retention and excretion of fluids, regulation of pH of the extracellular fluid by retention of hydrogen ions, and excretion of metabolic wastes and toxic substances. ADH is manufactured by the pituitary, and the parathyroid regulates calcium and phosphate balance.Physiological Adaptation
As part of the teaching plan for a client with type I diabetes mellitus, the nurse should include that carbohydrate needs might increase when:
Active exercise increases insulin sensitivity, thus lowering blood glucose levels. Additional carbohydrates might be needed to balance the usual insulin dose. All of the other choices increase blood glucose levels.BasicCare and Comfort
When a client wishes to improve her appearance by removing excess skin from her face and neck, the nurse should provide teaching regarding which of the following procedures?
Rhytidectomy is the procedure for removing excess skin from the face and neck. It is commonly called a face-lift. Dermabrasion involves the spraying of a chemical to cause light freezing of the skin, which is then abraded with sandpaper or a revolving wire brush. It is used to remove facial scars, severe acne, and pigment from tattoos. Rhinoplasty is performed to improve the appearance of the nose and involves reshaping the nasal skeleton and overlying skin. Blepharoplasty is the procedure that removes loose and protruding fat from the upper and lower eyelids.Health Promotion and Maintenance
Neural tube defects in the fetus have been primarily associated with which deficiency in the mother?
Folic acid is essential for the development of the neural tube and might prevent the defect or failure of the tube to close (congenital anomalies).Physiological Adaptation
Increased cortisol levels might be found in a client with which condition?
Cushing’s syndrome produces elevated cortisol levels. Addison’s disease produces decreased cortisol levels. The other conditions are not associated with cortisol levels.Reduction of Risk Potential
A standard walker is used when clients:
A walker is used for clients who have balance problems, cardiac problems, or cannot use crutches or a cane. The client needs to bear partial weight and have strength in her wrists and arms. The client uses her upper body to propel the walker forward.Basic Care and Comfort
During the work phase of the nurse-client relationship, the client says to her primary nurse, “You think that I could walk if I wanted to, don’t you?” What is the best response by the nurse?
This response answers the question honestly and nonjudgmentally and helps to preserve the client’s selfesteem.
Choice 1 is an open and candid response but diminishes the client’s self-esteem. Choice 2 doesn’t answer the client’s question and is not helpful. Choice 3 increases the client’s anxiety because her inability to walk might be directly related to an unconscious psychological conflict that has not been resolved.Psychosocial Integrity
Which of the following actions should a nurse take first for a client who has just vomited 300 cc of bright red blood?
The blood pressure should be checked first for a client who has just vomited 300 cc of bright red blood, to determine whether the client is hypotensive. The other actions can be taken later.Reduction of Risk Potential
All of the following clients are in need of an emergency assessment except:
The client with an old injury does not need an emergency assessment because this is not a life-threatening or new situation or condition.Safety and Infection Control
Which of the following represents a normal serum potassium level?
Normal serum potassium levels fall in a range of 3.5–5.5mEq/L. The other choices listed fall below or above this range.Reduction of Risk Potential
A nurse is caring for a client with an elevated cortisol level. The nurse can expect the client to exhibit symptoms of:
High levels of cortisol can produce sodium and fluid retention and potassium deficit, thus creating urinary deficit.Physiological Adaptation
What does client and family communication and education concerning restraints do?
Cooperation is more likely if the client and family understand the purpose of and expected gains from restraints.
Well-meaning family members might release restraints if their purpose is not clear.Safety and Infection Control
Padding on a restraint helps:
Padding distributes pressure so that bony prominences do not receive the brunt of pressure when a client pulls against the restraints. Pressure, especially over bony prominences, causes tissue damage due to ischemia.Safetyand Infection Control
Health promotion activities are designed to help clients:
Health promotion activities are designed to help clients reduce the risk of illness, maintain maximum
function, and promote health habits related to health care.Health Promotion and Maintenance
A nurse observes a client sitting alone and talking. When asked, the client reports that he is “talking to the voices.” The nurse’s next action should be:
Nurses might observe behavioral cues that can indicate the presence of hallucinations. Talking about the
hallucinations is reassuring and validating to the client who has them. Focusing on the symptoms and asking
about the hallucinations helps the client gain control.Psychosocial Integrity
A client states, “I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?” The nurse should respond with which of the following statements?
All of the choices are methods of preventing cancer. Sleep is important in maintaining homeostasis, which
helps the body respond to disease. Monthly breast examination can indicate cancer or fibrocystic disease. The
body has a physiological response to stress that can decrease the immune response and increase the risk of
disease.Health Promotion and Management
A client is given an opiate drug for pain relief following general anesthesia. The client becomes extremely somnolent with respiratory depression. The physician is likely to order the administration of:
Tolerance is the capacity to ingest an increasing amount of a substance without effect and the experience of
decreased sensitivity to the substance. Tolerance can develop with long-term use of many drugs. Choice 1 is the
dose required to produce a defined magnitude of drug effect. Choice 3 binds to a receptor and causes an action.
Choice 4 is the maximal response produced by a drug.Pharmacological Therapies
The focus of a nurse case manager is:
By definition, case management is a process of providing for the comprehensive care needs of a client for
continuity of care throughout the health care experience.Coordinated Care
The family carries out its health care functions in which of the following ways?
The family provides sick care to its members. The other options are incorrect.Prevention and Early
Detection of Disease
A 65-year-old female client is experiencing postmenopausal bleeding. Which type of physician should this client be encouraged to see?
A gynecologist is the physician who treats and manages disease of the female reproductive organs. A radiologist
evaluates X-rays. A physiatrist is the physician manager of a rehabilitation team. An oncologist treats clients with
The death of a beloved spouse places the surviving partner in which type of crisis?
A situational crisis is an unexpected, unplanned event, such as the death of a spouse. Option 1 is a normal
maturational crisis; Choices 2 and 3 are not recognized crisis states.Coordinated Care
A corporate executive works 60–80 hours a week. The client is experiencing some physical signs of stress. The nurse teaches the client biofeedback techniques. This is an example of which of the following health-promotion interventions?
Biofeedback techniques can be used to quiet the mind, release tension, and counteract responses of general
adaptation syndrome or stress syndrome. Nurses teaching relaxation techniques should encourage use of these
techniques in stressful situations.Psychosocial Integrity
Ethical and moral issues concerning restraints include all of the following except:
Policies and procedures, though important, are not in the category of ethical and moral issues. The other
options are ethical and moral issues.Safety and Infection Control
Using clichés in therapeutic communication leads the client toward:
The use of clichés in therapeutic communication is commonly construed by the client as the nurse’s lack of
understanding, involvement, and caring, so the client might feel demeaned and discounted.Psychosocial Integrity
According to the ANA Code of Ethics for Nurses, professional nurses have an ethical obligation to:
All the choices are elements of the ANA Code of Ethics for Nurses.Coordinated Care
Following the change of shift report, the nurse should analyze the information and set priorities accordingly. When the plan has been formulated, at what point during the shift can or should the nurse’s plan be altered or modified?
The nurse changes the plan to respond to changes in needs.Coordinated Care
A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child?
Preschool-age children require bedtime rituals that should be followed in the hospital if possible. Choice 1
increases a child’s fear. Choices 2 and 4 do not promote sleep.Basic Care and Comfort
The greatest time savers when planning client care include all of the following except:
The greatest time-savers when planning client care are activities that facilitate focus and completion of
priority items. Time-savers include setting goals, establishing priorities, planning tasks, delegating where
appropriate, re-assessment, and ongoing evaluation of needs.Coordinated Care
The nurse is teaching a client about erythema infectiosum. Which of the following factors are not correct?
Fifth’s disease, erythema infectiosum, is uncommon in adults. All the other statements are correct.Safety and
A client recently lost a child due to poisoning. The client tells the nurse, “I don’t want to make any new friends right now.” This is an example of which of the following indicators of stress?
Stress can alter a person’s relationships with others.Psychosocial Integrity
When teaching a client about anti-retroviral therapy for human immunodeficiency virus (HIV), the PN should emphasize:
HIV mutates very rapidly, and any interruption of therapy can allow viral resistance to emerge—even taking
a dose late. Choice 2 is incorrect because, when the virus is kept in check with anti-retrovirals, the client’s own
immune system is able to keep opportunistic infections at bay. Choices 3 and 4 are incorrect because therapy
should not be interrupted for any reason. If the client develops toxicity, another anti-retroviral drug might be
Incidences of child abuse apperar to be higher in the African-American community and might be explained by:
Child abuse is higher in households with lower socioeconomic status and single parents. The increased incidence might be due to increased stress and fewer support systems.Psychosocial Integrity
A client who is newly diagnosed with Parkinson’s disease and beginning medication therapy asks the nurse, “How soon will I see improvement ?” The nurse’s best response is:
It might take several weeks of therapy for the client with Parkinson’s disease to see improvement in symptoms.
Choice 1 is also true but is not the best response to the question. Choice 2 might be indicated but is not the best
response to the question. Choice 3 is incorrect.Physiological Adaptation
Which of the following is the most appropriate diet for a client who is unable to swallow?
Nasogastric feedings are most appropriate for a client who is unable to swallow. Nothing by mouth leads to
nutritional deficiencies. The client might aspirate a clear liquid diet. TPN is not necessary as long as the gut is
still functioning.Reduction of Risk Potential
Pulling is easier than pushing. So pulling a client rather than pushing him or her has which of the following advantages?
Pulling an object works with gravitational force not opposing it, lowering risk of muscle strain.Basic Care
The best lab test to diagnose disseminated intravascular coagulation (DIC) is:
In DIC, many small clots form throughout the body and are immediately broken down. D-dimer measures a
specific fibrin split (or degradation) product and is the most specific test for DIC. Choice 1 is incorrect because
platelets are consumed in DIC, but this is not specific. Choices 3 and 4 are both elevated (because clotting factors
have been used up) but, again, are not specific.Physiological Adaptation
Which of the following allergies might be a contraindication for a client to receive contrast enhancement for intracranial computed tomography?
Iodine allergy might be a contraindication for contrast media, not the other allergies.Reduction of Risk Potential
When discussing the patterns of use of alcohol and other drugs, the nurse should include which piece of information?
Recent research reveals that 83% of all persons in the United States, age 12 or older, report using alcohol sometime in their lives. Use of alcohol and illicit drugs appears to increase into the mid-20s, and then levels off and decreases with age. Both lifetime prevalence and intensity of alcohol use are greater in males. Caucasians report higher levels of alcohol use than African Americans or Hispanics. Those with more education are more likely to use alcohol, but heavy use is more common among the less educated and the unemployed.Psychosocial Integrity
The nurse is caring for a postpartum woman who has relinquished her baby for adoption. The care plan for the client should include which of the following priority strategies?
Most women who relinquish their infants at birth have come to that decision with a great deal of love and
pain. They have made plans in advance. The nurse needs to first provide them with opportunities to express their
feelings that might include grief, loneliness, and guilt. A referral for grief counseling might be appropriate if no
other support system exists or the mother indicates that she wants assistance working through her grief. If the
nurse assesses that the grief process is abnormal, a referral is also appropriate. The mother has probably already
made a decision about whether or not she wants to see her baby. The nurse should ask her and make arrangements
for that to happen if the mother requests it. Seeing the baby might aid in the grief process. Until relinquishment
occurs, this is the mother’s baby and she should be allowed to see it as often as she wants. The mother does have
the right to change her mind until final legal arrangements are made. But suggesting this option might lead her to
think that the nurse believes she shouldn’t relinquish her baby.Health Promotion and Maintenance
In managing nausea related to Morphine epidural analgesia, the nurse should administer:
Compazine is the drug that should be administered.Basic Care and Comfort
A client with sickle cell disease is worried about passing the disease on to children. Which of the following statements by the PN is most appropriate for this client?
A client with sickle cell disease passes on the least sickle cell trait and possibly sickle cell disease, depending
on the sickle status of the other parent. Choice 1 is not helpful to the client. Choices 3 and 4 are not true.
Which of the following isoenzymes is elevated in a client who has had a myocardial infarction?
CPK-MB is elevated in clients who have had a myocardial infarction. CPK-BB is elevated in clients who
have brain damage, and CPK-MM is elevated in clients who have skeletal muscle damage. CPK-MI does not
exist.Reduction of Risk Potential
Which of the following should not be included in the teaching for clients who take oral iron preparations?
Iron should not be mixed with antacids.Physiological Adaptation
The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response?
Single-grain infant cereals are recommended first because they are easily digestible and have added iron content. Choice 3 is incorrect because yogurt is a milk product and introduction should be delayed until the child is 12 months of age because of the risk of milk allergy. Choices 1 and 2 are incorrect because fruits and vegetables are usually given following the introduction of cereals.Basic Care and Comfort
Which of the following statements is correct regarding rape?
The definition ofrapeis sexual intercourse against someone’s will. It is a degrading, brutal crime of violence and can occur between any two persons regardless of their marital status.Psychosocial Integrity
The method of splinting is always dictated by:
The method of splinting is always dictated by the severity of the client’s condition and the priority decision.
Basic Care and Comfort
A client with Parkinson’s disease has difficulty performing voluntary movements. This is known as:
Dyskinesia is an impairment of the ability to execute voluntary muscles.Physiological Adaptation
Which of the following client groups should the nurse recognize as the fastest-growing segment of the homeless population?
Single mothers with two or three children are the fastest-growing segment of the homeless population. The majority of the children are under the age of five, and the total number of children who are homeless account for more than one-third of the homeless population in the United States. In the past, single adults were the largest group in the homeless population, with more men than women being homeless. Runaway adolescents account for another group of homeless children. Many are victims of abuse or long-term family or school problems.HealthPromotion and Maintenance
Acute hyphema is associated with what type of injury?
An acute hyphema occurs as a result of a blunt injury to the eye and is manifested by a half-moon appearance or a horizontal line across the globe when the client is upright (due to blood collected in the anterior chamber).Safety and Infection Control
One day postoperative, the client complains of dyspnea, and his respiratory rate (RR) is 35, slightly labored, and there are no breath sounds in the lower-right base. The nurse should suspect:
The first three symptoms could be indicative of any of the conditions. The distinguishing symptom is the lack of breath sounds in the lower-right base, which is assessed when a portion of the lung has collapsed.Physiological Adaptation
American families are having difficulty adequately performing their vital health care function. What are the basic reasons for this difficulty?
Scholars suggest that the reasons families are having difficulty providing health care for their members lies with both the structure of the health care system and the family structure. Major factors explaining differences in utilization patterns of medical services include the lack of healthcare insurance coverage, lack of services for special populations (that is, teenage males), perception by families of the health care system and the health care provider, and lack of partnership between health care providers and families in mutually addressing health care issues.Health Promotion and Maintenance
Local anesthetics block the conduction of pain impulses to the spinal cord. Their duration of action:
Diffusion and absorption depend on the chemical properties of the anesthetic and other factors such as local pH and blood flow. Duration might or might not be longer than general anesthesia. Duration can be short if the type of local anesthetic is a short-acting agent. Client weight is not a factor.Pharmacological Therapies
A client asks the nurse what risk factors increase the changes of getting skin cancer. The risk factors include all except:
Conditions that increase risks for skin cancer are: light or fair complexion, history of having bad sunburns or scars from previous burns, personal or family history of skin cancer, frequently working or playing outdoors with exposure to the sun, exposure to X-rays or radiation, exposure to certain chemicals through work or hobbies (coal, pitch, asphalt, petroleum), repeated trauma or injury to an area resulting in scars, older than age 50, male gender, and living in a geographic location near the equator or at high altitudes. Ways to prevent skin cancer are avoiding exposure to the sun, wearing a hat to protect the face, avoiding all sun lamps, and using a sunscreen with a minimum of 15 sun protection factor (SPF) if exposure to the sun is unavoidable. Teaching clients how to recognize a potential problem involves inspecting the skin frequently; noting all birthmarks, freckles, and moles; and seeking medical assistance if any of the following are noted: change in color, change in shape, change in surface texture, change in size, change in the surrounding skin, or a new mole or a sore that does not heal.HealthPromotion and Maintenance
Who should receive the hepatitis A vaccine?
Hepatitis A is for individuals who travel or persons with chronic liver disease. Infants receive the hepatitis B vaccine at birth. DTaP is administered at 18 months of age. Individuals who come into contact with blood should be immunized against hepatitis B.Health Promotion and Maintenance
A female having her first child is experiencing which type of crisis event?
A maturational crisis occurs when an individual arrives at a new stage of development and must develop new coping strategies. Choice 1 arises from sources external to individuals. Choice 3 occurs when some event external to a person (floods, hurricanes) disrupts his or her coping behaviors. Choice 4 is not a crisis intervention.Psychosocial Integrity
A client with a diagnosis of Schizophrenia has been released from an acute care setting. The client had a prolonged recovery from relapse. One of the parents says to the discharge nurse, “I do not understand what is going on. The hospital said she was better, but all she does is sit around all day and smoke. We cannot get her to go to the vocational training you arranged.” The nurse recognizes that more teaching is needed about:
The nurse conducting discharge teaching must stress the lengthy recuperation process with emphasis on the sedative qualities of the medication used to prevent relapse. Support groups are useful for caregivers. The emphasis during recuperation is on maintaining nutrition and hygiene.Psychosocial Integrity
The three major sequential maturational crises for females include:
The three major sequential maturational crises affecting females are puberty, pregnancy, and menopause. These are life events that have been studied by many researchers and are considered the major events in a woman’s life. Puberty is the onset menarche. Pregnancy is a turning point in one’s life from which there is no return. Menopause is the cessation of menses. The nurse has the responsibility to assess, plan, implement appropriate concepts to facilitate effective functioning, and enhance growth and development. Choices 2, 3, and 4 are not sequential maturational crises.Psychosocial Integrity
A serious complication of a total hip replacement is displacement of the prosthesis. What is the primary sign of displacement?
Pain on movement and weight bearing indicates pressure on the nerves or muscles caused by the dislocation. Other symptoms of dislocation include an inability to bear weight and a shortening of the affected leg. Edema is not a primary sign of displacement.Physiological Adaptation
The nurse can best communicate to a client that he or she has been listening by:
Restating allows the client to validate the nurse’s understanding of what has been communicated. It’s an active listening technique. Regarding Choice 2, judgments should be suspended in a nurse-client relationship. Choice 3 is incorrect because leading questions ask for more information rather than showing understanding. Choice 4 communicates understanding, but the client has no way of measuring the understanding.PsychosocialIntegrity
When caring for a Native-American family, the nurse needs to consider which of the following?
Symbols of health or traditions might include certain ritualistic items that are used to maintain, protect, or restore physical, mental, or spiritual health.Psychosocial Integrity
When questioning an elder about suspected abuse, the nurse should keep the questions:
Questions about suspected should be direct and nonconfrontational. Indirect questions encourage denial.
A visitor accidentally knocks over a plastic pleural drainage system connected to a client, and it cracks. What should the nurse do first?
If a crack is seen in a pleural drainage system, it should be changed immediately. The remaining choices can be performed later.Reduction of Risk Potential
A client has just returned from surgery where a femoral-popliteal bypass was performed. The nurse has assessed the client and is unable to feel a pulse at either the dorsalis pedis or the posterior tibial sites of the left foot. The foot feels warm and the color is pink. What action should the nurse perform next to prevent ischemia?
The nurse should immediately obtain a Doppler device and recheck the pulses. The dorsalis pedis and posterior tibial can be difficult to assess and might need to be verified with a Doppler. Because the client just had a surgery in which a complication is arterial insufficiency, the client must be monitored carefully. If the pulses are not found, the nurse should recognize that this is an emergent situation, and the physician must be notified immediately. If the nurse waits 30 minutes before determining if the pulses can be felt, this could compromise the viability of the client’s foot due to ischemia. Documenting the findings is important but must be performed after the nurse locates the dorsalis pedis and posterior tibial pulses or any necessary interventions are made.Health Promotion and Maintenance
A community health nurse is asked to organize a health promotion project that plans to provide glucose screening. This activity is most beneficial within what realm?
Public glucose screening has been found to be an ineffective way to screen for diabetes unless based on health risk screening for those persons identified to be at risk or displaying symptoms.Safety and InfectionControl
There are many types of torts that can be committed against clients. They include all of the following except:
Felonies are serious crimes punishable by time in prison. Types of torts are assault, battery, and negligence in addition to slander, invasion of privacy, false imprisonment, and fraud.Coordinated Care
The nurse is teaching a client about sleep and gives background information on normal sleep patterns. Which of the following substances promotes sleep?
Serotonin is a substance that is in the body and promotes sleep. Serotonin might play a role in synthesis of a hypnogenic factor that directly causes sleep. Drugs and alcohol can disrupt REM sleep, although they might accelerate the onset of sleep.Basic Care and Comfort