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. 1. Which of the following describes a preterm neonate? A. A neonate weighing less than 2,500 g (5 lb, 8 oz). B. A low-birth-weight neonate. C. A neonate born at less than 37 weeks' gestation regardless of weight. D. A neonate diagnosed with intrauterine growth retardation. 2. A client with type 1 (insulin-dependent) diabetes mellitus has just learned she's pregnant. The nurse is teaching her about insulin requirements during pregnancy. Which guideline should the nurse provide? A. "Insulin requirements don't change during pregnancy. Continue your current regimen. " B. "Insulin requirements usually decrease during the last two trimesters. " C. "Insulin requirements usually decrease during the first trimester. " D. "Insulin requirements increase greatly during labor. " 3. A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of A. right-sided heart failure. B. acute pulmonary edema. C. pneumonia. D. cardiogenic shock. 4. What's the most appropriate nursing diagnosis for a client exhibiting obsessive-compulsive behavior? A. Ineffective coping. B. Imbalanced nutrition: Less than body requirements. C. Imbalaneed nutrition: More than body requirements. D. Interrupted family processes. 5. The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to A. restrict fluid intake to 1 qt (1,000 mL)/day. B. drink liquids only with meals. C. don't drink liquids 2 hours before meals. D. drink liquids only between meals. 6. A client seeks care for low back pain of 2 weeks' duration. Which assessment finding suggests a herniated intervertebral disk?
A. Pain that radiates down the posterior thigh. B. Back pain when the knees are flexed. C. Atrophy of the lower leg muscles. D. Positive Homans' sign. 7. A client has approached the nurse asking for advice on how to deal with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is A. psychotherapy. B. total abstinence. C. Alcoholics Anonymous (AA). D. aversion therapy. 8. A 23-month-old child is brought to the emergency department with suspected croup. Which assessment finding reflects increasing respiratory distress? A. Intercostal retractions. B. Bradycardia. C. Decreased level of consciousness. D. Flushed skin. 9. A 20-year-old mother of a premature newborn smoked cigarettes during her pregnancy. Her son is a client in a neonatal intensive care unit and has a diagnosis of acute respiratory distress syndrome. Because the mother is Roman Catholic, which nursing intervention would be most appropriate for the nurse to discuss with her? A. Baptism of the infant. B. Circumcision of the infant. C. Last rites for the infant. D. Sacraments of the sick for the mother. 10. A client with shock brought on by hemorrhage has a temperature of 97.6°F (36.4℃), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mmHg. For this client the nurse should question which physician order? A. "Monitor urine output every hour. " B. "Infuse IV fluids at 83 mL/hr" C. "Administer oxygen by nasal cannula at 3 L/min" D. "Draw samples for hemoglobin and hematocrit every 6 hours. " 11. A client is hospitalized with a diagnosis of chronic glomerulonephritis. The client mentions that she likes salty foods. The nurse should warn her to avoid foods containing sodium because A. reducing sodium promotes urea nitrogen excretion. B. reducing sodium decreases edema. C. reducing sodium improves her glomerular filtration rate. D. reducing sodium increases potassium absorption. 12. The nurse is evaluating a client who is complaining of shortness of breath. The client's respiratory rate is 26 breaths per
minute so the nurse documents that he is tachypneic. The nurse understands that tachypnea means A. frequent bowel sounds. B. heart rate greater than 100 beats/minute C. hyperventilation. D. respiratory rate greater than 20 breaths/minute 13. A client who has cervical cancer is scheduled to undergo internal radiation. In teaching the client about the procedure, the nurse would be most accurate in telling the client A. she'll be in a private room with unrestricted activities. B. a bowel-cleansing procedure will precede radioactive implantation. C. she'll be expected to use a bedpan for urination. D. the preferred positioning in bed will be semi-Fowler's. 14. Before administering a tube feeding to a toddler, which of the following methods should the nurse use to check the placement of a nasogastric (NG) tube? A. Abdominal X-rays. B. Injection of a small amount of air while listening with a stethoscope over the abdominal area. C. A check of the pH of fluid aspirated from the tube. D. Visualization of the measurement mark on the tube made at the time of insertion. 15. While assessing a 2-month-old child's airway, the nurse finds that the child isn't breathing. After two unsuccessful attempts to establish an airway, the nurse should A. attempt rescue breaths. B. attempt to reposition the airway a third time. C. administer five back blows. D. attempt to ventilate with a handheld resuscitation bag. 16. Which of the following statements summarizes the underlying principle for the development of a parenbchild relationship? A. The parents to-be had good role models in their childhood. B. The relationship is part of the adult maturational process. C. The development is directly related to the physical needs of the neonate. D. The relationship is based on the need for early and frequent parent-infant contact. 17. During the night, a 50-year-old Vietnam veteran with posttraumatic stress syndrome wakens shaking and tells you that someone is trying to smother him. What is the appropriate response for the nurse in this situation? A. "It was a bad dream. You are safe. I'll stay here with you until you go back to sleep. "
B. "We can talk about it tomorrow. Try to see if you can get back to sleep. " C. "It was only a dream. There's nothing to be frightened about. " D. "I'll call the physician and see whether I can get you medication to help you go back to sleep. " 18. Physical assessment findings in the eyes of elderly people may include A. decreased lens thickness. B. decreased visual acuity. C. lightening of the skin around the orbits. D. unequal pupillary light reflex. 19. During a morning assessment, the nurse percusses tympany. The nurse understands that tympany is a loud, high-pitched, moderately long sound with a drumlike, musical quality that's most commonly heard over the A. heart. B. liver. C. pancreas. D. stomach. 20. The nurse is caring for a client who complains of lower back pain. Which instructions should the nurse give to this client to prevent back injury? A. Bend over the object you're lifting. B. Narrow the stance when lifting. C. Push or puI1 an object using your arms. D. Stand close to the object you're lifting. 21. The physician prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? A. Heparin sodium (Hep-Lock). B. Dexamethasone (Deeadron). C. Methyldopa (Aldomet). D. Phenytoin (Dilantin). 22. The nurse is caring for a client who recently underwent a total hip replacement. The nurse should A. ease the client onto a low toilet seat. B. allow the client's legs to be crossed at the knees when out of bed. C. use soft chairs when the client is sitting out of bed. D. limit client hip flexion when sitting. 23. After assessing a newly admitted 5-year-old child, the nurse makes the nursing diagnosis of Parental role conflict related to child's hospitalization. Which defining characteristic would most suggest this diagnosis?
A client tells the nurse that she has been working hard for the last 3 months to control her type 2 (non-insulin-dependent) diabetes mellitus with diet and exercise. When planning care. foot. D. the nurse should A. urine glucose level. Chlamydia trachomatis. B. D. lower thigh. with an IQ of 65 is admitted to the hospital for evaluation. knee. 28. 24. D. Which vaginal infection doesn't require treatment for sexual partners? A. ankle.A. 27. In response. D. glycosylated hemoglobin (Hb) level. fasting blood glucose level. B. insert an oral airway. listening. Parents' active participation in child's physical or emotional care. To determine the effectiveness of the client's efforts. C. Before a transesophageal echocardiogram. D. Evidence of adaptation to parental role changes. position the client on his side. C. Upon return from the procedure. Neisseria gonorrhoeae. age 5. B. 26. moderately retarded but trainable. the nurse should keep in mind that this child is A. 25. D. serum fructosamine level. A child. C. withhold food and fluids. within the lower range of normal intelligence. the nurse observes that the client has no active gag reflex. Candida albicans. Supportive child-parent interaction (speaking. C. completely dependent on others for care. touching. a client is given an oral topical anesthetic spray. the nurse should check A. She should apply the bandage beginning at the client's A. mildly retarded but educable. . The nurse must apply an elastic bandage to a client's ankle and calf. B. and eye-to-eye contact). introduce a nasogastric (NG) tube. B. C. Parents' failure to use available support systems or agencies to assist in coping. B. C. Trichomonas vaginalis.
A client with a myocardial infarction (MI) develops pulmonary crackles and dyspnea. C. "Don't worry. Which action should the nurse include in a plan of care for a client with a fiberglass cast on the right arm? A. the change in the QRS complex that would most support her suspicion is A. The nurse suspects cardiac tamponade and prints a lead Ⅱ electrocardiograph (ECG) strip for interpretation. inferior. 30. 32. Production of maternal antibodies. 33. C. . widening complex. "Breast-feeding is possible but you must be committed to it. and waste. every baby is different. narrowing complex. D. " C. C. Assess pedal and posterior tibial pulses every 2 hours. After delivering her second child. C. gases. "I'll make sure that you're seen by the lactation consultant before you're discharged. 31. Avoid handling the cast for 24 hours or until dry. B. D. In looking at the strip. lateral. Assess movement and sensation in the fingers of the right hand. She indicates that she was unsuccessful at breast-feeding her first child and that she bottlefed after 3 days of trying to nurse. and I'm sure that you'll be successful this time. posterior. Keep the casted arm warm with a light blanket. D. " B. the client tells the nurse that she wants to breast-feed. amplitude increase. The nurse should instruct the mother to introduce her infant to solid foods at what age? A. " D. D. amplitude decrease. anterior. "It's important to room-in with your neonate so that you can respond to her nursing: cues. B. A chest X-ray shows evidence of pulmonary edema. B. Following coronary artery bypass grafting. a client begins having chest "fullness" and anxiety. 2 months. Which of the following responses would best support this client's breast-feeding efforts? A. The nurse is teaching the mother of a neonate. " 34. Detoxification of some drugs and chemicals. Which of the following functions would the nurse expect to be unrelated to the placenta? A. B.29. Exchange site for food. Production of estrogen and progesterone. The specific type of MI the client had is most probably A.
4 months. His mother. A length of time that can't be determined based on her first labor. Administer antihypertensive medications as ordered. D. C. Reduce the amount of glucose and cholesterol in the diet. the client. 38. D. B. C. 6 months. absent menstruation. C. Adrenal carcinoma. D. pneumococcal strep antigen. prostate-specific antigen. D. He lives with his male companion. About half as long as her first labor. is also present. B. The nurse anticipates that the consent form should be signed by A. An inborn error of metabolisrn. 36. A client asks the nurse what PSA is.B. the mother. two physicians. A client admitted for a hysterectomy has a secondary diagnosis of Ménière s disease. a bacteria that causes pneumonia. 39. facial hair. B. frequent bruising. B. Shorter than her first labor. C. About the same length of time as her first labor. When caring for a client who is having her second baby. C. D. 37. Encourage a weight-reduction diet. A 35-year-old female client who complains of weight gain. The nurse should reply that it stands for A. 35. A corticotropin-secreting pituitary adenoma. who lives in another state. used to screen for cervical cancer. and acne is diagnosed with Cushing's syndrome. used to screen for prostate cancer. the nurse can anticipate the client's labor will be which of the following? A. the companion. B. 8 months. Which of the following nursing interventions should the nurse include in the client's plan of care to decrease the effects of tinnitus? A. A physician schedules an invasive procedure for a client with acquired immunodeficiency syndrome-related dementia. D. used to determine protein levels. Cushing's syndrome is most likely caused by which of the following? A. An ectopic corticotropin-secreting tumor. C. . who is present. protein serum antigen. papanicolaou-specific antigen. Encourage the client to listen to the radio with earphones.
The nurse should explain to the client that the primary purpose of this test is to A. 44. D. determine fluid volume. and diaphoresis. Kinked or obstructed chest tube. Excessive water in the water-seal chamber. A client with a pneumothorax receives a chest tube attached to a Pleur-evac. induce contractions. Try to maintain the usual lifestyle to promote normal development. induce fetal heart rate accelerations. D. 42. The tubing from the client to the chamber is blocked. Which of the following activities should a 2-year-old child to be able to do? A. absent breath sounds. B. D. B. Avoid contact with small children to reduce overstimulation. The nurse is caring for a primigravida who is scheduled for a fetal acoustic stimulation test (FAST). shorten the contraction stress test. Wash and dry his hands. 41. 43. Following the test. C. B. D. The nurse is caring for a client undergoing a cystoscopy to diagnose bladder cancer. C. Pink-tinged urine and bladder spasms. B. Excessive chest tube drainage. Remove a garment. C. 45. B. After insertion of a chest tube for a pneumothorax. Which signs should alert the nurse to a potential complication? A. tracheal shift. There is a leak somewhere in the tubing system. C. Dizziness and fainting. Urinary frequency and burning on urination. What cause of tension pneumothorax should the nurse check for? A. Chills and tachycardia. D.40. . C. Point out a picture. When teaching the parents of a toddler with a congenital heart defect. a client becomes hypotensive with neck vein distention. The nurse suspects a tension pneumothorax has occurred. Relax discipline and limit setting to prevent crying. Which nursing assumption would be most invalid? A. Reduce the caloric intake to decrease cardiac demand. the client returns to his room. B. The nurse notices that the fluid of the second chamber of the Pleur-evac isn't bubbling. Build a tower of eight cubes. the nurse should explain all medical treatments and should emphasize which instruction about their child? A. Infection of the lung.
calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. B. a virus. Physical findings include bilateral crackles. The client's affected lung has reexpanded. 48. The nurse documents the severity of pitting edema as +1. 47. 46. A client with a history of heart failure is examined in the outpatient department to investigate the recent onset of peripheral edema and increased shortness of breath. the nurse should take which action? A. B. hives. D. What is the best description of this type of edema? A. The nurse is assessing a postcraniotomy client and finds the urine output from a catheter is 1.500 mL for the 1st hour and the same for the 2nd hour. Tell the client to go to the hospital. D. she may be experiencing signs of heart failure from a 45% to 50% increase in blood volume. elevated blood pressure. C. The nurse should suspect A. D. now 37 weeks pregnant. D. adrenal crisis. D. paradoxical chest wall movement with respirations. Make an appointment because the client needs to be evaluated. a tubercle. 49. A client. C. Barely detectable depression when the thumb is released from the swollen area. and pitting edema of the ankles. He complains of shortness of breath and becomes tachypneic. 50. a toxin. tracheal deviation to the unaffected side. C. diminished or absent breath sounds on the affected side. . The nurse suspects a pneumothorax has developed. normal foot and leg contours. The nurse understands that urticaria is another name for A. B. C. The nurse assesses a client with urticaria. B. After listening to her concerns. muffled or distant heart sounds. The tubing needs to be cleared of fluid. distended neck veins. diabetes insipidus. Explain that these are expected problems for the latter stages of pregnancy. a third heart sound (S3).C. Cushing's syndrome. The nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation rapidly drops. Further assessment findings supporting the presence of a pneumothorax include A. diabetes mellitus. Arrange for the client to be admitted to the birth center for delivery.
Which laboratory test results would the nurse expect to find in a client diagnosed with Hashimoto's thyroiditis? A. A client who has a potassium level of 6 mEq/L should be treated with A. Thyroxine (T4).0. Tell the client to avoid crowds and infected individuals. antacids. 200ng/dL. 54. Ask friends and relatives not to visit during the course of chemotherapy. TSH. 52. T4. 22μg/dL. B. Detectable depression of less than 5 mm when the thumb is released from the swollen area. 22μg/dL. C. the nurse must solicit which of the following input from the client? A. 51. D. Take rectal temperatures for greater accuracy. 53.5. 2μg/dL. B. A client with an indwelling urinary catheter is suspected of having a urinary tract infection. clamping the tubing for 60 minutes and inserting a sterile needle into the tubing above the clamp to aspirate urine. A 33-year-old male client is admitted with an exacerbation of ulcerative colitis.B. 35ng/dL. T3. A 5-to 10-mm depression when the thumb is released from the swollen area. D. TSH. . 55. To develop an effective teaching plan. IV fluids. B. A depression of more than 1 cm when the thumb is released from the swollen area. severe foot and leg swelling. sodium polystyrene sulfonate (Kayexalate). Instruct the client to consume plenty of raw fruits and vegetables. thyroid-stimulating hormone (TSH) undetectable. 320ng/dL. T4.45μIU/mL. B.9μIU/mL. draining urine from the drainage bag into a sterile container. wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle. which is important for the nurse to include in her plan of care? A. TSH. 200ng/dL. C. fluid restriction. 2μg/dL. During a client's chemotherapy regimen for breast cancer. D. C. foot and leg swelling. normal foot and leg contours. The nurse should collect a urine specimen for culture and sensitivity by A. The nurse is performing an admission assessment and assessing the teaching needs regarding appropriate diet and lifestyle modifications for the client. triiodothyronine (T3). D. T3. Details about his childhood phobias.1μIU/mL. C. T3. disconnecting the tubing from the urinary catheter and letting the urine flow into a sterile container. C. T4. D.
The most common early sign or symptom that this client is likely to experience is A.4 to 15. asking her if she would like to talk to the chaplain. C.6 to 16. or who are suffering from nutritional inadequacies. Information about his relationship with his wife.5. which finding requires immediate nursing action? A. 3 months. elevate the affected leg as high as possible. A client delivered a healthy full-term female neonate 2 hours ago by cesarean delivery. and a mottled. D. Tachycardia and hypotension. The period of oliguria in these clients usually lasts about t0 . D. Blood stain 2" (5 cm) in diameter on the abdominal dressing. B. paresthesia. perceptual disorders.5. 3 years. manipulating behavior. C. When caring for children who are sick. encouraging a discussion of her problems and fears. The best way for the nurse to respond to her is by A.7 to 15. 10 years. 57. keep the affected leg level or slightly dependent. A client who has discovered a breast lump is tearful and expresses concern over her situation. Inspection and palpation reveal absent pulses. While the physician determines the appropriate therapy. the nurse should know the correct hemoglobin (Hb) values for children. C. 61. 60. B. 59. C. the nurse should A. cyanotic. giving her reassurance. 56. 10. When assessing this client. A client in acute renal failure is admitted to the nephrology unit. 10. Neonates. who have sustained traumas. B. beliefs. Complaints of abdominal pain. 9. A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. D. place a heating pad around the affected calf. B. D. recommending a support group. Which of the following ranges would be inaccurate? A. C. and cadaverous left calf. 10. A 38-year-old client is admitted for alcohol withdrawal.6 to 16. suppression.5. Gush of vaginal blood when the client stands up. D. B. Information about his financial status. impending coma. His feelings. and attitudes about his chronic illness. shave the affected leg in anticipation of surgery. D.5.B. C. cold. 58.
The nurse completes an incident report based on the knowledge that identification of which of the following is not a goal of the report? A. Restrict carbohydrate intake to less than 30% of the total caloric intake. if the child always drools. a client demonstrates signs of AIDS-related dementia. C. Patterns of client care problems. C. Ineffective cerebral tissue perfusion. Initiate insulin therapy. C. if the child can walk without holding onto furniture. Which of the following assessments of kidney function would the nurse make during the oliguric phase? A. 65. After taking glipizide (Glucotrol) for 9 months. The child doesn't enunciate words well and holds onto furniture when he walks. D. A 3-year-old child with Down syndrome is admitted to the pediatric unit with asthma. D. Dysfunctional grieving. B.days. The nurse asks the client . 63. As an adolescent is receiving care. 62. During a late stage of acquired immunodeficiency syndrome (AIDS). Following a fall from a horse during rodeo practice. kidneys in a state of suppression. The wound is vigorously cleaned. Bathing or hygiene self-care deficit. Switch the client to a different oral antidiabetic agent. how long the child has been like this. Prescribe an additional oral antidiabetic agent. an 18year-old client is seen in the emergency department. D. Urine output of less than 400 to 600 mL in 24 hours. He has a large. he's inadvertently injured with a warm compress. B. Learning needs of staff to prevent recurrence of incidents. Facts surrounding each incident. 64. D. The nurse should give the highest priority to which nursing diagnosis? A. No urine output. closed. D. B. B. a client experiences secondary failure. 66. C. In the past. B. C. Staff involved so they're reprimanded for their actions. Which of the following would the nurse expect the physician to do? A. Urine output directly related to the amount of IV fluids infused. and dressed. dirty laceration on his leg. how the child's condition today differs from his normal condition. the client has received the full immunization regimen for tetanus toxoid. Risk for injury. Urine output of 30 to 60 mL/hr. The nurse should ask the mother A.
C. D. Anticipate and support the behavior as a normal part of bonding. B. B. eat only three meals per day. D. Which pregnancy-related physiologic change would place the client with a history of cardiac disease at the greatest risk for developing severe cardiac problems? A. D. advise the client to get a tetanus vaccine within 3 years. the nurse hands the neonate to the mother. identify anxiety-causing situations. Avoid consuming aged cheese when taking antianxiety agents. Avoid taking antianxiety agents on an empty stomach. Take the neonate back to the nursery and recheck the neonate's temperature. " The nurse should A. Call the pediatrician and report the behavior. The nurse is caring for a client diagnosed with bulimia. C. Within a few minutes. B. 67. 70. control eating impulses. What is the nurse's highest priority when caring for this child? . Which of the following should the nurse do? A. Avoid taking antianxiety agents at bedtime. plan on administering a dose of tetanus vaccine. Decreased cardiac output. The nurse brings a new mother her neonate for the first time approximately 1 hour after the neonate's birth. 68.about his tetanus immunization history and he says. D. Avoid mixing antianxiety agents with alcohol or other central nervous system (CNS) depressants. After checking the identification. the nurse should incorporate which of the following instructions in her teaching plan? A. Because antianxiety agents such as chlordiazepoxide (Librium) can potentiate the effects of other drugs. C. C. 69. Increased blood pressure. Increased plasma volume. B. B. "I had my last shot when I was 11 years old. avoid shopping for large amounts of food. Encourage the mother to rewrap the neonate because the room is cold. teach the client that he has life-long immunity to tetanus. the mother begins to undress her neonate. C. Decreased heart rate. request the physician to order a serum tetanus titer. 71. The most appropriate initial goal for a client diagnosed with bulimia is to A. A preschool-age child with sickle cell anemia is admitted to the health care facility in vaso-occlusive crisis after developing a fever and joint pain. D.
In administering the medication. . "I run apple. the nurse should avoid which route? A. B. Metabolic acidosis. IV. " 73. window. A. Maintaining protective isolation. a word salad. and a platelet count of 22. echopraxia. Which point is most important for the nurse to stress? A. B. Subcutaneous (SC). Providing fluids. " This response by the client is known as A. D. Respiratory acidosis. Carbonic acid deficit. neologisms. B. 74. 72. 75. The client states. The nurse would find that the client understood the surgeon's preoperative teaching when the client states. Applying cool compresses to affected joints. He reports severe bone pain and is scheduled to receive a dose of morphine sulfate. A client with three children who is still in her childbearing years is admitted for surgical repair of a prolapsed bladder. "If I should become pregnant again. D. " B. Metabolic alkalosis. The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which acid-base imbalance could the client develop as a result of diarrhea? A. C. A nurse is caring for a client with a history of GI bleeding. the procedure may need to be repeated. " C. The nurse is interviewing a client admitted to the facility with a diagnosis of schizophrenia. D. Avoiding the use of illicit drugs and alcohol. An 82-year-old female is transferred to the hospital from a long-term care facility because of severe diarrhea. as prescribed. the child would be delivered by cesarean delivery.A. C. D. Administering antipyretics. flight of ideas.000/μL. "If I have another child. B. 76. IM. "This procedure is accomplished in two separate surgeries. C. grass. sickle cell disease. "This surgery may render me incapable of conceiving another child. Oral. The client is dehydrated and receiving dextrose 5% in half-normal saline solution at 150mL/hr. C. " D. train. She is weak and dehydrated.
265g (7 lb. Reducing daily fat intake to less than 45% of total calories. The amount of blood ejected from the left ventricle per minute. On a routine visit to the physician. B. 77. The physician noted a pulse deficit. D. C. Moderate to severe pain. The difference between systolic and diastolic blood pressures.B. Unstable blood sugars. The percentage of blood emptied from the ventricle during contraction. the nurse should closely monitor this neonate for which of the following? A. Following safer-sex practices. . A female neonate delivered by elective cesarean birth to a 25-year-old mother weighs 3. Engaging in anaerobic exercise. D. C. Taking daily walks. 80. Avoiding foods that increase levels of high-density lipoproteins (HDLs). the nurse should recommend which additional measure? A. Refraining from telling anyone about the diagnosis. a condition associated with chronic arterial occlusive disease. Telling potential sex partners about the diagnosis. a client with chronic arterial occlusive disease reports stopping smoking after 34 years. The pulse deficit measures which of the following? A. 81. as required by law. Respiratory distress due to lack of contractions. 79. Urine output of 70 mL the 1st hour. C. 78. B. Hoarseness of the voice. To relieve symptoms of intermittent claudication. D. Signs of acrocyanosis. The physician prescribes amoxicillin suspension 100 mg every 8 hours for a child who weighs 33 lb (15 kg). B. C. 2 mL. A client is admitted with atrial fibrillation. D. 2. Complaints of intense thirst. How many milliliters should the nurse administer? A. The drug is supplied in a bottle labeled 250 rag/teaspoon (1mL=50 mg). D. Temperature instability due to type of birth. The difference between apical and radial pulse rates. 3 oz).5 mL. C. The nurse places the neonate under the warmer unit. In addition to routine assessments. When assessing a client with partial thickness burns over 60% of the body. B. B. which of the following should the nurse report immediately? A.
B. 7. a chest X-ray. " D. C. D. The nurse is caring for a client with left-sided heart failure. monitoring of arterial oxygen saturation (SaO2). The client's history includes diabetes mellitus and a two-pack-a-day cigarette habit for the past 42 years. "Practice meticulous foot care. complains of leg pain brought on by walking several blocks--a symptom that first arose several weeks ago. " B. the nurse can anticipate using A. age 59. diuretics. Have the child run the heel of one foot down the shin of the other leg while standing. 5 mL.5 mL. with the trunk exposed. "Reduce your level of exercise. B. arterial blood gas (ABG) studies. " 84. D. Listen for a clicking sound as the child abducts the hips. B. 400 mg three times daily with meals. " C. 83. oxygen. " B. A client. "See the physician if complications occur. The nurse is teaching a parent how to administer antibiotics at home to a child with acute otitis media.C. Have the child shrug the shoulders as the nurse applies mild pressure to the shoulders. antiembolism stockings. C. D. To reduce fluid volume excess. the nurse routinely screens for scoliosis. Have the child stand firmly on both feet and bend forward at the hips. the nurse can anticipate that he'll require A. D. "I'll give the antibiotics until my child's ear pain is gone. The nurse should provide which instruction concerning long-term care? A. To assess a client for pneumothorax resolution. 86. " . 85. Which statement accurately summarizes how to perform this screening? A. "Consider cutting down on your smoking. C. Which statement by the parent indicates that teaching has been successful? A. anticoagulants. 82. chest auscultation. The physician diagnoses intermittent claudication and prescribes pentoxifylline (Trental). "I'll give the antibiotics for the full 10-day course of treatment. The nurse is caring for a client who required chest tube insertion for a pneumothorax. When examining school-age and adolescent children.
C. Occupational therapist. C. care of a stoma. D. Which of the following would not be an indication of placental detachment? A. Cover the cast with a blanket until the cast dries. B. Carefully titrating the oxytocin based on her pattern of labor. Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) ? A. Registered dietitian.C. Keep your right leg elevated above heart level. C. 89. Enterostomal nurse therapist. Administer 2 to 3 L of IV fluid rapidly. A client is scheduled to have a descending colostomy. Relaxation of the uterus. and lifestyle changes. " D. A client has sustained a right tibial fracture and has just had a cast applied. D. Monitoring vital signs. Administer a dextrose solution containing normal saline solution. B. there's no need to see the physician for another ear examination. D. every 15 to 30 minutes. Administer 6 L of IV fluid over the first 24 hours. 91. B. 88. Allowing the client to ambulate as tolerated. Increased vaginal bleeding. An abrupt lengthening of the cord. An increase in the number of contractions. 90. Which of the following is least likely to be included in her plan of care? A. A client with intrauterine growth retardation is admitted to the labor and delivery unit and started on an IV infusion of oxytocin (Pitocin). Social worker. C. including assessment of fetal wellbeing. D. " 87. He's very anxious and has many questions concerning the surgical procedure. "If the ear pain is gone. Helping the client use breathing exercises to manage her contractions. B. B. A foul smell from the cast is normal. C. "Whenever my child is cranky or pulls on an ear. Use a knitting needle to scratch itches inside the cast. I'll give a dose of antibiotics. It would be most appropriate for the nurse to make a referral to which member of the health care team? A. D. Which instruction should the nurse provide in his cast care? A. Administer IV fluid slowly to prevent circulatory overload and collapse. .
C. grief. B. C. Acarbose (Precose). B. Checking vital signs every 15 minutes to watch for increasing blood pressure. Identifying the neonate. manipulation. confabulation. Monitoring the client's labor carefully and preparing for a fast delivery. Touching other people without their permission. B. Increased calorie intake. and using personal possessions without asking permission are all examples of A. A 68-year-old male client has been hospitalized repeatedly for chronic obstructive pulmonary disease (COPD). Continually assessing the fetal tracing for signs of fetal distress. 93. Increased digestive enzymes. poor boundaries. 96. During discharge planning. is prescribed for a client with type 2 diabetes mellitus. an alpha-glucosidase inhibitor. C. reaction formation. Aspirating mucus from the neonate's nose and mouth. "I just want to die. The nurse is providing care to a 5-year-old client with a fractured femur whose nursing diagnosis is Imbalanced nutrition: less than body requirements related to impaired physical mobility. Reducing visual and auditory stimulation. D. Every time the nurse approaches him. the nurse would be aware that the client has understood teaching when the client states. passive-aggressive behavior. 94. 95.92. I'm no good to anyone anymore. D. Promoting parental bonding. self-actualization. D. . C. During this latest admission. he has refused to participate in his self-care. " The nurse realizes that he's experiencing A. C. B. reading someone else's mail. Which of the following should be the nurse's initial action immediately following the birth of the neonate? A. the client states. D. antisocial behavior. B. Which of the following is most likely to occur with this condition? A. When caring for a client with preeclampsia. which action is a priority? A. D. Drying the infant to stabilize the neonate's temperature. Decreased protein catabolism. 97. Increased carbohydrate need.
"I should never take insulin while I'm taking this drug. not dextrose. He's in the burn unit receiving fluid resuscitation. B. 102. " 98. "Take the infant for a ride in the car. An electrocardiogram (ECG) showing no arrhythmias. " 99.8 kg) in 24 hours. A. In an industrial accident. injury to the cranial nerves. . " B. " 101. " D.A. " C. 3 kg) sustained full-thickness burns over 40% of his body. Body temperature readings all within normal limits. Limited spontaneous movement. C. When assessing a preschooler who has sustained a head trauma. In teaching a female client who is HIV-positive about pregnancy. Remains in a deep sleep. "Not everyone who has the virus gives birth to a baby who has the virus. this indicates A. Which observation shows that the fluid resuscitation is benefiting the client? A. " C. A. "The baby can get the virus from my placenta. " B. D. "If I have hypoglycemia. intact cranial nerves. The nurse is teaching the mother of an infant with tetralogy of Fallot. the nurse notes that the child appears to be obtunded. a client who weighs 155 lb (70. A urine output consistently above 100 mL/hr. The nurse should tell the mother. When a client experiences a loss of vibratory sense on examination. D. "I'm planning on starting on birth control pills. injury to the peripheral nerves. No motor or verbal response to noxious (painful) stimuli. C. C. "Leave the infant alone until the crying stops. " B. B. "Put the infant in the knee-chest position. the nurse would know more teaching is necessary when the client says. 100. "The drug makes my pancreas release more insulin. intact peripheral nerves. A weight gain of 4 lb (1. " C. responsive only to vigorous and repeated stimulation. The mother asks what to do when her infant becomes very blue and has trouble breathing after crying. "I'll need to have a C-section if I become pregnant and have a baby. Which of the following denotes the child's level of consciousness? A. " D. "It's best if I take the drug with the first bite of a meal. D. " D. sluggish speech. I should eat some sugar. B. "Offer the infant a bottle of formula. Can be aroused with stimulation.
Place him on mechanical ventilation. Apnea. B. D. Perform a lumbar puncture. D. B. B. Metabolic acidosis. Give him a barbiturate. She gets angry when her call bell isn't answered immediately. What is the nurse's most important role in caring for a client with a mental health disorder? A. neologisms. The most appropriate response to her would be. A client is admitted to the hospital with an exacerbation of her chronic systemic lupus erythematosus (SLE). Elevate the head of his bed. C. Anginal pain. . I'll come back when you've calmed down. You know that stress will make your symptoms worse. Because of these findings. C. waxy flexibility. Respiratory alkalosis. "Would you like to talk about the problem with the nursing supervisor?" D. 104. D. To offer advice. 2 L/minute via nasal cannuta. To know how to solve the client's problems. the nurse closely monitors the oxygen flow and the client's respiratory status. 107. " 106. D. To establish trust and rapport. somatic delusions. nihilistic delusions. Would you like to talk about it?" B. a young man is admitted to the emergency department. Which complication may arise if the client receives a high oxygen concentration? A. A client with pneumonia is receiving supplemental oxygen. Which intervention would be the most dangerous for the client? A. C. The client's history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. B. C. To set limits with the client. "I can see you're angry. " C. a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. "You seem angry. 105. He's unconscious and his pupils are nonreactive. His action shows evidence of A. A. After striking his head on a tree while falling from a ladder. During the assessment stage. "Calm down.103.
Large. When caring for a client with a 3-cm stage 1 pressure ulcer on the coccyx. Applying an antibiotic cream to the area three times per day. have a hormonal receptor assay annually. Instruct the client to tighten his gluteal muscles to promote better absorption. C. C. Which of the following is the most effective way for the nurse to reduce the child's risk of infection? A. B. which of the following actions can the nurse institute independently? A. B. . Poor clotting mechanism. Using a normal saline solution and applying a protective dressing as necessary. Requiring staff and visitors to wear masks. After a client receives an IM injection.108. he complains of burning pain in the injection site. Although not a normal finding. have a physician conduct a clinical examination every 2 years. Massage the area to promote absorption of the drug. The nurse formulates a nursing diagnosis of Risk for infection. High hemoglobin (Hb) levels between 14 and 20 g/dL per 100 mL of blood. 109. 110. D. Implementing reverse isolation. D. Following the American Cancer Society (ACS) guidelines. The nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. The average age of the women in the group is 47. perform breast self-examination annually. C. The nurse is speaking to a group of women about early detection of breast cancer. the nurse should recommend that the women A. immature liver. it's an expected finding of physiologic jaundice and is caused by which of the following? A. C. D. B. B. Massaging the area with an astringent every 2 hours. B. Apply a warm compress to dilate the blood vessels. Maintaining standard precautions. D. D. C. Which nursing action would be the best to take at this time? A. have a mammogram annually. A school-age child is admitted to the hospital with a diagnosis of acute lymphoblastic leukemia. Persistent fetal circulation. Using a povidone-iodine wash on the ulceration three times per day. 111. Apply a cold compress to decrease swelling. 112. Practicing thorough hand washing.
the nurse would expect that the client's initial dose for the thyroid replacement would be which of the following? A. "Weigh yourself daily and report a loss of 1 lb in 1 day. Encouraging the child to dress without help. Keeping a night light on to allay fears. call for help. 115. " B. The nurse is teaching a client recently diagnosed with myasthenia gravis. 114. "Eat a high-sodium diet. C. D. D. suggesting he take aspirin for relief because it's probably early rheumatoid arthritis. Explaining normalcy of fears about body integrity. The nurse should respond by A. B. C. Because of the client's cardiac history. D. The nurse should teach the client that myasthenia gravis is caused by A. open the airway. asking him if he has been diagnosed or treated for carpal tunnel syndrome. "Weigh yourself daily and report a gain of 2 lb in 1 day. A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. 116. " 118. . genetic dysfunction. Initiated before thyroid surgery. The nurse is preparing to begin one-person cardiopulmonary resuscitation. establish unresponsiveness. B. A client with Hashimoto's thyroiditis and a history of two myocardial infarctions and coronary artery disease is to receive levothyroxine (Synthroid). Delayed until after thyroid surgery. The nurse should first A. validating his complaint but assuming it's an adverse effect of his vocation. D. Preventing accidents. The nurse is teaching the parents of a school-age child. 25 g/day.113. inquiring further about this problem because psoriatic arthritis can accompany psoriasis vulgaris. Which teaching topic should take priority? A. " D. 117. B. assess the client for a carotid pulse. A 45-year-old auto mechanic comes to the physician's office because an exacerbation of his psoriasis is making it difficult to work. initially. "Maintain bedrest. The nurse should provide which instructions? A. 100 g/day. B. " C. C. initially. He tells the nurse that his finger joints are stiff and sore in the morning. C.
Appearance of axillary hair. ignore the comment and talk about less threatening issues. 122. encourage verbalizations about fears and stressful life situations. Testicular enlargement. D. C. A client with thyroid cancer undergoes a thyroidectomy. The nurse is caring for a client diagnosed with body dysmorphic disorder. The nurse should expect to administer A. Avoid strenuous activity because of the cardiac effects of the drug. the nurse should A. D. D. B. 250 mg/dL 120. antispasmodics. Which of the following observations signals the onset of puberty in male adolescents? A. C. thyroid supplements. 123. Nocturnal emissions. Have blood levels screened weekly for leukopenia. . C. 120 mg/dL B. decreased conduction of impulses in an upper motor neuron lesion. IV calcium. agree with the client because she feels a specific physical feature is awful. The nurse should respond that the minimum parameter for indication of diabetes mellitus is a 2-hour blood glucose level greater than A. 150 mg/dL C. compliment the client on her appearance. Appearance of pubic hair. B. B. barbiturates. A 28-year-old woman is scheduled for a glucose tolerance test (GTT). C.B. When the client verbalizes disapproval of her physical features. 121. Don't take prescribed or over-the-counter medications without consulting the physician. a lower motor neuron lesion. the client develops peripheral numbness and tingling and muscle twitching and spasms. C. upper and lower motor neuron lesions. 200 mg/dL D. D. She asks the nurse what result indicates diabetes mellitus. After surgery. B. Which of the following statements should be included when teaching clients about monoamine oxidase (MAO) inhibitor antidepressants? A. 119.
He has a history of nightmares.D. C. During a bolus feeding. B. A client who survived an airplane crash has a diagnosis of posttraumatic stress disorder (PTSD). Don't take with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs). "Is the pain relieved by position changes?" D. Which option offers the client the most lasting relief for his symptoms? A. 127. remove the IV catheter and call the physician. write up an incident report describing the mistake. warm. Make the client comfortable. The nurse should expect hypertonic glucose. hypokalemia. Clear the client's airway. . slow the IV flow rate and hang the appropriate solution. the client vomits and begins choking. and alcohol abuse. D. D. a nurse finds that a client is receiving the wrong IV solution. hypercalcemia. The opportunity to verbalize memories of trauma to a sympathetic listener. 125. hyperkalemia. B. "Is the pain worse with the toes pointed toward the knee?" 126. Which of the following actions is most appropriate for the nurse to take? A. D. Prescribed medications taken as ordered. wait until the next bottle is due and then change to the proper solution. 124. C. "Does the pain increase with activity and lessen with rest?" C. D. Stop the feeding and remove the NG tube. hypernatremia. and tender to touch. B. depression. and sodium bicarbonate to be used to treat A. The nurse's initial response should be to A. While performing rounds. The right calf is red. C. a client has been having calf pain and notices that the painful calf is larger than the other one. 128. Start eardiopulmonary resuscitation. For the past few days. Which of the following questions about the pain should the nurse include in the assessment? A. A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. hopelessness. C. The nurse is caring for a client in acute renal failure. insulin infusions. Alcoholics Anonymous (AA) meetings. B. Family support. achy. "Does the pain worsen in the morning upon rising?" B.
Attempt to locate the nearest family member to get an accurate history. During the admission interview. " The nurse's most supportive response would be A. Assess and stabilize the client's psychological needs. D. "Do you think I will ever get better? I don't know what is wrong with me. Two middle-aged sisters have been diagnosed with Huntington's disease. " 130. "I'm not sure what is wrong. B. " C. D. A 26-year-old male is admitted to an inpatient psychiatric hospital after having been picked up by the local police while walking around the neighborhood at night without shoes in the snow. a client reports that she frequently has nightmares and memories of a rape that occurred 3 years ago. 131. A 70-year-old client with a diagnosis of left-sided cerebrovaseular accident is admitted to the facility. Maintaining protein levels. Promoting range-of-motion (ROM) exercises. He appears confused and disoriented. but the medication will help you soon enough. Take time here to talk and allow yourself to heal. " 132. the treatment will help you. which of the following objectives is most appropriate? A. " B. Maintaining vitamin levels. "This disorder is an autosomal recessive disorder. " B. "This disorder is an autosomal dominant disorder. To prevent the development of disuse osteoporosis. "Don't feel bad. The nurse's best response would be. "It sounds like you have some unresolved pain about the trauma. so each child has a 50% chance of inheriting it. Which of the following is the most immediate nursing action? A. " D. 133. The nurse is administering neostigmine to a client with myasthenia gravis. "It's important to talk to your physician about an issue such as this. Promoting weight-bearing exercises. She feels depressed and asks the nurse. "Women are symptomatic and men are carriers of this disorder. C. "Only women become symptomatic. A. C. Arrange a transfer to the nearest medical facility. so each child has a 25% chance of inheriting it. " D. Which nursing intervention should the nurse implement? . Assess and stabilize the client's medical needs. B.129. " C. The children of these clients want to know what their chances are of developing this genetic disorder.
A child. Focusing. B. truncus arteriosus. 134. C. and feeling upset with his wife. B. "You may want to talk about your employment situation in group today. 137. Warn the client that he'll experience mouth dryness. Apply lubricating lotion to the graft site. A client reports losing his job. B. coarctation of the aorta. The nurse is providing home care instructions to a client who has recently had a skin graft. not being able to sleep at night. Which of the following would the nurse instruct the client to report to her primary caregiver? A. ultrasound study results and serum estradiol levels. . patent ductus arteriosus. Use cosmetic camouflage techniques.A. a ventricular septal defect. B. Breast tenderness. B. Protect the graft from direct sunlight. Blurred vision and headache. Breakthrough bleeding within first 3 months of use. Give the medication on an empty stomach. Restating. C. ultrasound study results and serum progesterone levels. Schedule the medication before meals. Decreased menstrual flow. D. D. Making observations. is admitted with a tentative diagnosis of congenital heart disease. D. the physician prescribes IM menotropins (Pergonal). When a client being seen in a fertility clinic doesn't respond to the clomiphene citrate. Continue physical therapy. D. the nurse suspects that the child has A. When assessment reveals a bounding radial pulse coupled with a weak femoral pulse. C. This drug increases her risk of producing multiple follicles that could mature to ovulation. Which instruction is most important for the client to remember? A. A client who has received a new prescription for oral contraceptives asks the nurse how to take them. C. C. Administer the medication for complaints of muscle weakness or difficulty swallowing. B. Exploring. 135. 136. The nurse responds to the client. D. To reduce the high risk of multifetal pregnancy and its possible adverse effects the nurse should monitor A. " The nurse is using which therapeutic technique? A. age 4. 138.
products containing caffeine. he appears to be in no distress. C. The child rates his pain at 4 out of 5. The child is in no apparent distress. B. The nurse will assist with endotracheal intubation and use an uncurled tube because the A. D. B. Reincarnation. vitamin C. vitamin A. vitamin B12. cricoid cartilage is the narrowest part of the larynx. The child rates pain at 4 out of 5. B. results of tests to detect luteinizing hormone (LH) in urine. . When assessing his nutritional status. vocal cords provide a natural seal. a 9-year-old rates his pain at 4 out of 5 on the pain scale but is playing video games and laughing with his friend. vitamin B6. C. high-protein foods. 141. Which of the following would the nurse document on the child's chart? A. Self-esteem. meat. When planning dietary teaching. trachea is shorter. whole milk and other dairy products. 139. B. D. serum levels of human chorionic gonadotropin (HCG). The nurse is caring for a toddler in respiratory arrest. B. the nurse should recommend that the client consume A. Which of the following choices is a concept on which black Muslims focus? A. raw fruits and vegetables. A 21-year-old client with a history of ulcerative colitis is hospitalized for an exacerbation. however. Prophecy. Celibacy. D. and no pain medication is needed at this time. Performed teaching to help child match his pain rating to how he appears to be feeling. Pain medication administered as prescribed. The nurse is caring for a 40-year-old woman who is a black Muslim.C. such as eggs. The child doesn't understand the pain scale. D. C. Reassess when he's visibly showing signs of pain. D. 143. C. A client is admitted to the hospital with an exacerbation of his chronic gastritis. 142. and cheese. the nurse should expect a deficiency in A. 140. larynx is anterior and cephalad. One day after an appendectomy. C. D.
He's unable to attain or retain an erection. His semen isn't potent enough to impregnate. B. . D. B. C. His ejaculate is void of sperm. and arthralgia. Performing active resistive range-of-motion exercises. 146. He's disinterested in sexual intimacy. B. Nonrebreathing mask. allow the child to handle the stethoscope before listening to his lungs. 148. The physician orders supplemental oxygen for a client with a respiratory problem. What is the most appropriate nursing diagnosis for the client with acute pancreatitis? A. Venturi mask.144. C. the nurse should A. tell the child the nurse is going to listen to his chest with the stethoscope. A client reveals to the nurse that he's sexually impotent. plan interventions at the developmental level of a 7-year-old child because that is the child's age. He complains of chest pain. To provide the highest possible oxygen concentration. C. C. Which statement best expresses what the nurse should understand her client to mean? A. B. D. 145. Excess fluid volume. Applying transcutaneous electrical nerve stimulation (TENS). severe myalgia. D. Which of the following may be effective in relieving the client's joint pain? A. An 18-month-old child is brought to the emergency department with suspected croup. the nurse expects to use which oxygen delivery device? A. 147. Applying warm compresses to the joints. Deficient fluid volume. The nurse needs to assess the child's breath sounds. Applying ice packs to the joints. When planning care for a 7-year-old boy with Down syndrome. D. expose the child's chest quickly and auscultate breath sounds as quickly and efficiently as possible. The child appears frightened and cries as the nurse approaches him. A 32-year-old black man is admitted to the hospital in vasoocclusive sickle cell crisis. D. shortness of breath. B. Decreased cardiac output. Ineffective gastrointestinal tissue perfusion. 149. The best way to approach the child is to A. C. Nasal cannula. Partial rebreathing mask. ask the mother to wait briefly outside until the assessment is over.
150. 63 mmHg. Prepare to assist with ventilation. plan interventions at the developmental level of a 5-year-old because the child will have developmental delays. A client hospitalized with a pneumothorax has the following arterial blood gas (ABG) analysis: pH. 152. Obtain urine for drug screening. Indirect questioning. improved respiratory status. Part Two You will have one hour and 50 minutes to complete Part Two. D. 22 mEq/L. A client is admitted to the hospital in the manic phase of bipolar disorder. A client is admitted to the emergency department with a suspected overdose of an unknown drug. B. Open-ended sentences. and . B.28. B. One hour after the initiation of treatment. 52 mmHg. C. The parents' indication that they want to see the neonate. 153. C. D. The parents' interactions with each other. partial pressure of arterial carbon dioxide (PaCO2). the need for intubation. Prepare to begin gastric lavage. D.19. The client's arterial blood gas values indicate respiratory acidosis. C. assess the child's current developmental level and plan care accordingly. 22 mEq/L. Monitor the client's heart rhythm. The parents' expression of interest about the size of the neonate. What should the nurse do first? A. How would the nurse confirm this assessment? A. which foods would be most appropriate? . Direct questioning. 7. Which of the following would be least likely to indicate anticipated bonding behaviors by new parents? A. respiratory alkalosis. Lead-in sentences. D. When placing a diet order for the client. direct all teaching to the parents because the child can't understand. D. impending respiratory arrest. B. 154. ABG analysis reveals: pH. C. PaCO2. This change in ABG analysis indicates A. 151.B. 7. C. and . The parents' willingness to touch and hold the neonate. The nurse is caring for a client whom she suspects is paranoid. A chest tube was inserted and oxygen administered at 4 L/min by nasal cannula.
Bring extra help so it can be done quickly. Roast chicken. D. A tuna sandwich. A cheese sandwich. Talk to the mother first and then to the toddler. C. the nurse should remember that this type of angina is triggered by A. Most insurance plans won't cover evaluation of both as separate entities. PaO2 C. Therefore. Depression is commonly characterized by pain disorders and somatic complaints. Combining evaluations will save time and allow for quicker delivery of health care. B. bradyrhythmia. C. B. an apple. Vasodilation or vasoconstriction produced by an external cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD). and a dish of ice cream. B. the nurse should . Encourage the mother to hold the child. D. D. D. 159. crackers. and peas. Given this complaint. mashed potatoes. an unpredictable amount of activity. C. B. C. postural hypotension.A. Which ABG value reflects the acid concentration in the blood? A. In caring for a client with vasovagal syncope. sudden vascular fluid shifting. B. why would the nurse simultaneously evaluate both general physical and psychosocial problems? A. Which of the following would be the best approach when trying to take a crying toddler's temperature? A. pH B. 160. 157. 158. an unknown source. The nurse is reviewing a client's arterial blood gas (ABG) report. and a dish of peaches. and cookies. The nurse is caring for a client who complains of chronic pain. Ignore the crying and screaming. 156. activities that increase oxygen demand. PaCO2 D. When developing the client's plan of care. 155. A bowl of soup. the nurse should know that the associated temporary loss of consciousness is most commonly related to A. The physician doesn't have the training to evaluate for psychosocial considerations. vestibular dysfunction. C. fresh grapes. coronary artery spasm. A client is admitted to the hospital for treatment of Prinzmetal's angina. carrot sticks. D.
C. D. Ensuring that the child has accurate intake and output and eats a high-protein diet. 164. keep the client uncovered. Milk products. A 10-year-old diagnosed with acute glomerulonephritis is admitted to the pediatric unit. C. A nurse is evaluating the effectiveness of dietary instructions in a client with diverticulitis. Adolescents. Frequent trips to the bathroom with an average output of 200 to 300 mL per void. B. B. . B. Be alert for a possible eating problem and do a further indepth assessment.A. Which of the following provides the most accurate picture of retention with overflow? A. C. keep the client warm. 162. B. It's important to assess the maturity of enzyme systems (kidney and liver) in which pediatric population before administering medications? A. Which of the following would be the nurse's best action? A. Neonates. Ask the client how she feels about gaining weight and provide instructions about expected weight gain and diet. C. Regular consumption of which food would indicate that the client hasn't understood instructions? A. The nurse should ensure that which of the following is a part of the child's care? A. Toddlers. Premature infants. When caring for a client who has recently delivered. Uterus displaced to the right with increased vaginal bleeding. a client expresses concern about gaining weight. Cucumbers. maintain room temperature at 78°F (25. D. Checking every urine specimen for protein and specific gravity. match the room temperature with the client's body temperature.6℃). the nurse assesses the client for urinary retention with overflow. D. C. A varying urge to urinate with an average output of 100 mL. B. D. Fiber. Bananas. D. B. During her first prenatal visit. Intense urge to urinate with an average output of 250 mL. Obtaining a blood sample for electrolyte analysis every morning. 161. 165. Taking vital signs every 4 hours and obtaining daily weight. 163.
The physician orders a tricyclic antidepressant for a client who has suffered an acute myocardial infarction (MI) within the past 6 months. B. B. C. Performing nasogastric (NG) tube irrigation with normal saline solution. Weighing the client daily. Report the client's concerns to her caregiver. characterized by a brief loss of consciousness and period of confusion. C. C. Question the order with the physician. 168. increase his activity level. and nausea. C. Inform the client that he should discuss the MI with the physician. tremors. The nurse's first action is to . A 49-year-old client with acute respiratory distress watches everything the staff does and demands full explanations for all procedures and medications. D. Sleeping undisturbed for 3 hours. B. An elderly client's lithium level is 1. Which of the following actions would best indicate that the client has achieved an increased level of psychological comfort? A. B. The nurse should take which of the following actions? A. Administering tap water enema until the return is clear.C. Making decreased eye contact. Discontinue the medication. the nurse should encourage the client to A. D. 167. continue leading a high-stress lifestyle. follow a regular diet. B. She complains of diarrhea. D. contusion.4 mEq/L. Ask her to come back to the clinic every 2 weeks for a weight check. The least serious form of brain trauma. Which nursing intervention would most likely lead to a hyposmolar state? A. 170. concussion. 166. 171. Encouraging the client with excessive perspiration to drink broth. To decrease the risk of atherosclerosis. The nurse is teaching a client with a history of atherosclerosis. is called A. D. D. D. Joking about the present condition. avoid focusing on his weight. contrecoup. C. 169. coup. Asking to see family members. Administer the medication as ordered.
B. A client is admitted to the emergency department with complaints of chest pain and shortness of breath. When providing care for the client. hypovolemic shock. Tympanic. hold the lithium (Lithobid) and notify the physician. A 4-year-old child with pain and itching around the rectum has just been diagnosed with a pinworm infestation. D. D. it's typically due to A. A client is admitted with a suspected diagnosis of an acute myocardial infarction. C. cerebral edema. The nurse should monitor this client's fluid intake because fluid overload may cause A. Oral. Hypercalcemia. Hypoglycemia. Otorrhea and rhinorrhea are most commonly seen with which type of skull fracture? A. 174. heart failure. the nurse should avoid which route when taking a temperature? A. Hypocortisolism. Following a transsphenoidal hypophysectomy. D. C. C. Basilar. B. 173. An otherwise healthy adolescent has meningitis and is receiving IV and oral fluids. 177. B. an electrolyte imbalance. 176. Rectal. D. the nurse should assess the client carefully for which condition? A. C. dehydration. C. Axillary. the nurse should emphasize which instruction? A. The nurse knows that when a client has jugular vein distention. reassure the client that these are normal adverse effects. 175. Temporal. B. . Hyperglycemia.A. The physician prescribes mebendazole (Vermox). fluid overload. discontinue the lithium. When teaching the child's parents about the treatment regimen. The nurse's assessment reveals jugular vein distention. B. 172. D. dehydration. B. D. Look for white patches in the child's mouth. Occipital. administer another lithium dose. Parietal. C. a neck tumor.
2 weeks postpartum. C. 178. benzodiazepine overdose. End of the 6th week postpartum. C. Limit dairy products until the pinworms are eradicated. A client is diagnosed with hyperthyroidism. C. B. C. B. D. . The nurse should instruct her to A. D. D. The neonate lacks intestinal flora to make the vitamin. For a client with a head injury whose neck has been stabilized. take her prenatal vitamins. B. A reminder of the need to schedule blood work in 1 week to check blood levels of the drug. D. Which of the following describes the rationale for administering vitamin K to every neonate? A. C. The client asks the nurse how she can best deal with her fatigue. It boosts the minimal level of vitamin K found in the neonate. 7th to 9th day postpartum. The nurse is providing care for a pregnant client. try to get more rest by going to bed earlier. The nurse should expect clinical manifestations similar to A. B. which is from 14 to 30 days. flat. Encourage the child to drink lots of apple juice. D. Teaching instructions for newly prescribed buspirone should include which of the following? A. 30-degree head elevation. tell her not to worry because the fatigue will go away soon. side-lying. 179. 180. the preferred bed position is A. take sleeping pills for a restful night's sleep. A warning about the incidence of neuroleptic malignant syndrome (NMS). A warning about the drug's delayed therapeutic effect. D. C. B. The uterus returns to the pelvic cavity in which time frame? A. When the lochia changes to alba. Trendelenburg's. B. 183. A client diagnosed with anxiety disorder is prescribed buspirone (BuSpar). adrenergic stimulation. Neonates don't receive the clotting factor in utero. C. Make sure that all family members are treated. A warning that immediate sedation can occur with a resultant drop in pulse. 181. The drug prevents the development of phenylketonuria (PKU). 182. hypovolemic shock.B. Addison's disease. D.
A client with fecal impaction typically exhibits which clinical manifestation? A. D.184. B. using a cuffed tracheostomy tube. dry and scaly with flaking skin. D. Put on a mask and gown before entering the client's room. The nurse is caring for a client who has a tracheostomy tube and is undergoing mechanical ventilation. Liquid or semiliquid stools. The nurse reinforces the physician's description of a fasciotomy for a client. A serum trough level every morning. D. keeping the tracheostomy tube plugged. Increased appetite. formed stools. B. 188. A serum trough and peak level around the third dose. A client has been diagnosed with type A hepatitis. a complication of tracheostomy tube placement. 186. Wear gloves and a gown when removing the client's bedpan. C. A serum peak level after the second dose. C. Contact dermatitis is initially suspected. Hard. D. suctioning the tracheostomy tube frequently. using the minimal air leak technique with cuff pressure less than 25 cmH2O. 190. B. which of the following monitoring schedules is best for determining the drug's effectiveness? A. C. Test results show electrocardiograph changes and an elevated cardiac troponin level. A client reports substernal chest pain. What special precautions should the nurse take when caring for this client? A. Use caution when bringing food to the client. Loss of urge to defecate. inflamed with weeping and crusting lesions. B. 189. Reducing anxiety and relieving pain. Prevent the droplet spread of the organism. erythematous with raised papules. B. excoriated with multiple fissures. brown. Eliminating stressors and providing a nondemanding environment. The diagnosis is confirmed if the rash appears A. Improving myocardial oxygenation and reducing cardiac workload. B. 185. When administering gentamicin to a preschooler. D. D. When a fasciotomy is performed to alleviate . Which of the following should be the focus of nursing care? A. The nurse can help prevent tracheal dilation. C. C. A 28-year-old nurse has complaints of itching and a rash of both hands. C. 187. Confirming a suspected diagnosis and preventing complications. Serial serum trough levels after three doses (24 hours). by A.
B. check the client's medical record for an order for an IM as needed dose of medication for agitation. a delusion. Diaphoresis. 195. . Tremors. D. B. The nurse is interviewing a client who is currently under the influence of a controlled substance and shows signs of becoming agitated. The nurse inspects a client's back and notices small hemorrhagic spots. the fascia is opened along the length of the muscle compartment and A. B. extravasation. B. uremia. a pressure dressing is applied. C. C. D. The nurse's first action is to A. B. Express disgust with the client's behavior. remove all other clients from the day room. What should the nurse do? A. A client with schizophrenia hears a voice telling him he is evil and must die. He begins cursing and throwing furniture. Muscle weakness.compartment syndrome. the nurse would assess for hyperkalemia shown by which of the following? A. Use confrontation. osteomalacia. 194. petechiae. D. 193. B. Constipation. ideas of reference. Communicate a scolding attitude to intimidate the client. Following a unilateral adrenalectomy. 196. aspirated blood clots rapidly. C. 191. C. This procedure would be deemed effective if A. place the client in full leather restraints. 192. the skin is sutured loosely. call the physician and report the behavior. D. The nurse documents that the client has A. C. a hallucination. D. A client refuses his evening dose of haloperidol (Haldol) then becomes extremely agitated in the day room while other clients are watching television. C. the skin is left open. The nurse understands that the client is experiencing A. flight of ideas. Pericardiocentesis is performed on a client with cardiac tamponade. Be aware of hospital security. a skin graft is placed. D.
B. blood pressure decreases. C. blood pressure increases. D. heart sounds become muffled. 197. An adolescent girl who is receiving chemotherapy for leukemia is admitted for pneumonia. The adolescent's platelet count is 50,000 μL. Which of the following would be inappropriate to include in the plan of care? A. A sign over the bed that reads "NO NEEDLE STICKS AND NOTHING PER RECTUM". B. Two peripheral IV intermittent infusion devices, one for blood draws and one for infusions. C. Administration of oxygen at a rate of 4 L/min using a nonhumidified nasal cannula. D. Use of a tympanic membrane sensor to measure the client's temperature at the bedside. 198. Conditions necessary for the development of a positive sense of self-esteem include A. consistent limits. B. critical environment. C. inconsistent boundaries. D. physical discipline. 199. When developing a plan of care for a toddler with a seizure disorder, which of the following would be inappropriate? A. Padded side rails. B. Oxygen mask and bag system at bedside. C. Arm restraints while asleep. D. Cardiopulmonary monitoring. 200. When assessing a client with chest pain, the nurse obtains a thorough history. Which statement by the client is most suggestive of angina pectoris? A. "The pain lasted for about 45 minutes. " B. "The pain resolved after I ate a sandwich. " C. "The pain worsened when I took a deep breath. " D. "The pain occurred while I was mowing the lawn. " 201. Which toy would be most appropriate for a 3-year-old? A. A bicycle. B. A puzzle with large pieces. C. A pull toy. D. A computer game. 202. A client is to be discharged from an acute care facility after treatment of right leg thrombophlebitis. The nurse notes that the client's leg is pain free, without redness or edema. The nurse's actions reflect which step in the nursing process? A. Assessment.
B. Analysis. C. Implementation. D. Evaluation. 203. When teaching the mother of a 17-month-old about toilet training, which instruction would initially be most appropriate? A. Place the toddler on the potty chair every 2 hours for t0 minutes. B. Offer a reward every time the child has a bowel movement in the potty chair. C. Remove the diaper and use training pants to begin the process. D. Be sure the child is ready before starting to toilet train. 204. A 3-month-old infant just had a cleft lip and palate repair. To prevent trauma to the operative site, the nurse should do which of the following? A. Give the baby a pacifier to help soothe him. B. Lie the baby in the prone position. C. Place the infant's arms in soft elbow restraints. D. Avoid touching the suture line, even to clean. 205. To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instructions? A. Lie down after meals to promote digestion. B. Avoid coffee and alcoholic beverages. C. Take antacids before meals. D. Limit fluids with meals. 206. Which of these signs suggests that a client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion has developed complications? A. Tetanic contractions. B. Neck vein distention. C. Weight loss. D. Polyuria. 207. A client who is breast-feeding has a temperature of 102°F (38.9℃) and complains that her breasts are engorged. Her breasts are swollen, hard, and red. Which of the following actions would be inappropriate in managing the client's breast engorgement? A. Applying frozen cabbage leaves to the breasts. B. Encouraging the client to shower with her back to the water. C. Encouraging the client to nurse her baby frequently. D. Applying a breast binder to support the breasts. 208. A client's chest X-ray reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from A. cardiogenic pulmonary edema. B. respiratory alkalosis.
C. increased pulmonary capillary permeability. D. renal failure. 209. The nurse applies a fetal monitor to a 15-year-old primagravida admitted to the hospital with possible pregnancy-induced hypertension. Which monitor pattern would the nurse expect to observe if the client is experiencing uteroplacental insufficiency? A. Late deceleration. B. Early deceleration. C. Variable deceleration. D. Fetal acceleration. 210. A boy, age , develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a girl. Which statement by the mother best indicates that she understands the implications of rubella? A. "I told my husband to give my son aspirin for his fever. " B. "I'll ask the physician about giving the baby an immunization shot. " C. "I know that I won't be able to breast-feed my baby now. " D. "I'll call my neighbor who is 2 months pregnant and tell her not to have contact with my son. 211. Lochia normally progresses in which pattern? A. Rubra, serosa, alba. B. Serosa, rubra, alba. C. Serosa, alba, rubra. D. Rubra, alba, serosa. 212. A client complains of a severe, throbbing headache following a lumbar puncture. The priority nursing intervention for this client is to A. restrict fluid intake. B. increase fluid intake. C. raise the head of the bed. D. assess vital signs. 213. A client is receiving an IV infusion of dextrose 5% in water and lactated Ringer's solution at 125 mL/hr to treat a fluid volume deficit. Which of these signs indicates a need for additional IV fluids? A. Serum sodium level of 125 mEq/L. B. Temperature of 99.6 °F(37.6℃). C. Neck vein distention. D. Dark amber urine. 214. When assessing the fetal heart rate tracing, the nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left
side and administers oxygen. These actions are likely to improve which of the following? A. Fetal hypoxia. B. The contraction pattern. C. The status of a trapped cord. D. Maternal comfort. 215. The nurse is assessing the puncture site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation? A. 15-mm induration. B. Reddened area. C. 10-mm bruise. D. Blister. 216. In a group therapy setting, one member is very demanding, repeatedly interrupting others, and taking most of the group time. The nurse's best response would be, A. "Will you briefly summarize your point because others need time also?" B. "Your behavior is obnoxious and drains the group. " C. To ignore the behavior and allow him to vent. D. "I'm so frustrated with your behavior. " 217. Which of the following describes how the nurse interprets a neonate's Apgar score of 8 at 5 minutes? A. A neonate who is in good condition. B. A neonate who is mildly depressed. C. A neonate who is moderately depressed. D. A neonate who needs additional oxygen to improve the Apgar score. 218. A 9-month-old infant is admitted with diarrhea and deficient fluid volume. The nurse plans to assess this client's vital signs frequently. What other action would provide the most important assessment information? A. Measuring the infant's body weight. B. Obtaining a stool specimen for analysis. C. Obtaining a urine specimen for analysis. D. Inspecting the infant's posterior fontanel. 219. A client is hospitalized with a diagnosis of chronic renal failure. An arteriovenous fistula was created in his left arm for hemodialysis. When preparing the client for discharge, the nurse should reinforce which dietary instruction? A. "Be sure to eat meat at every meal. " B. "Monitor your fruit intake and eat plenty of bananas. " C. "Restrict your salt intake. " D. "Drink plenty of fluids. "
D. Acromegaly. B. a client receives potassium iodide (Lugol's solution) and propylthiouracil (PTU). in 3 to 4 months. If the device is functioning properly. B. Ataxia and intention tremor. 223. C. C. The nurse would expect the client's symptoms to subside A. preoccupation with food. Unilateral hearing loss and tinnitus. Sitting without support. D. Preoccupation with exercise. which decreases when he sits up and leans forward. C. C. 222. mitral valve is closed. the nurse suspects that he has A. B. Perfectionism. B. Based on this assessment. triseupid valve is closed. C. A client with myocardial infarction and cardiogenic shock is placed in an intra-aortic balloon pump (IABP). but preoccupied with food. No similarities. Which of the following is a normal developmental task for an infant this age? A. D. Relaxed personality. 221. developed another myocardial infarction (MI). Which signs and symptoms are associated with an acoustic neuroma? A. in 1 to 2 weeks. The nurse is caring for a bulimic client and an anorectic client. C. shoulders. Before undergoing a subtotal thyroidectomy. pericarditis. and arms. pulmonic valve is open. D. back. Playing patty-cake. A client being evaluated in the emergency department complains of chest pain that radiates to his neck. D. the balloon inflates when the A. B. in a few days. immediately. . B. 225. endocarditis. The nurse is assessing an 8-month-old during a wellness checkup. Feeding himself with a spoon. D. Saying two words. Amenorrhea and obesity. 224. What cognitive characteristics would be similar for both of these clients? A.220. myocarditis. aortic valve is closed.
on protective isolation. C. Inability to speak clearly. Administer metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed. Serve small portions of bland food. the nurse should give the highest priority to which action in the plan of care? A. B. D. Which assessment finding is most typical in aphasia? A. B. C. C. D. 229. C. D. Withhold fluids for the first 4 to 6 hours after chemotherapy administration. 231. C. D. 228. Which nursing action would be most effective in helping her cope with these cramps? A. 230. D. Suggesting that she walk for 1 hour twice per day. Fundal massage. on contact isolation. Administration of oxytoxics. B. After a cerebrovascular accident (CVA) a client develops aphasia. Which action is inappropriate? A. a client develops nausea and vomiting. For this client. Encourage rhythmic breathing exercise. Rhinorrhea. on neutropenic precautions. A client who is 7 months pregnant reports severe leg cramps at night. Which clinical manifestation would be the earliest indication that the neonate may have cystic fibrosis? A. Absence of the gag reflex. Steatorrhea. B. The nurse is caring for a neonate 12 hours after birth. Teaching her to dorsiflex her foot during the cramp. Instructing her to increase milk and cheese intake to 8 to 10 servings per day. in a negative-pressure room. Meconium ileus.226. B. 227. A client is experiencing an early postpartum hemorrhage. A certified nursing assistant (CNA) is caring for a client with Clostridium difficile diarrhea and asks the charge nurse. "How can I keep from catching this from the client?" The nurse reminds the CNA to wash her hands and to ensure the client is placed A. Decreased sodium levels. C. Advising her to take over-the-counter calcium supplements twice per day. Difficulty swallowing. Arm and leg weakness. B. After cancer chemotherapy. . Inserting an indwelIing urinary catheter.
B. Placing the client in respiratory isolation. D. a client is scheduled for chemotherapy and a ileal conduit urinary diversion. 236. Inadequate protein intake. This drug would be destroyed by gastric acid and so it can't be given by mouth. Postoperative nursing care would include A. Pad count. flushing the nasogastric (NG) tube with sterile water. 233. D. The nurse should include which of the following points in the client's preoperative teaching? A. Inadequate vitamin D intake. D. For which reason would intrathecal administration be selected? A. administering pain medications every 6 hours. C. Low calcium level. C. and a fever. B. A client is admitted to the hospital with a productive cough. Which action is most important in the initial plan of care? A. B. The client's need to perform stoma self-care immediately after surgery. . withholding fluids by mouth until the return of peristalsis. D. A client with a diagnosis of a bleeding gastric ulcer goes to the operating room for a partial gastrectomy. Wearing gloves during all client contact. Monitoring the client's fluid intake and output. The procedure creates a stoma and he must wear a pouch afterward. The client's need to remain on bed rest for 3 days following surgery. 232. Which factor is most likely responsible for the failure to heal? A. B. positioning the client in high Fowler position. A child is to receive intrathecal methotrexate (Folex) for treatment of meningeal leukemia. B. adverse effects may appear more quickly. C. A client on prolonged bed rest has developed a pressure ulcer. C. The child has very poor veins and is unable to receive drugs IV. Assessing the client's temperature every 8 hours. C.D. Following a cystoscopy that confirmed a diagnosis of bladder cancer. This drug is poorly transported across the blood-brain barrier. Because the drug is rapidly absorbed if given IM. night sweats. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Inadequate massaging of the affected area. 234. 235. so it's administered intrathecally.
241. "Does your mother know about this?" B. The client will be able to control urine passage through the stoma. Impaired physical mobility related to surgery. "I hope you aren't pregnant. Which of the following would be the best response by the nurse? A. his church. you're too young. which nursing diagnosis takes highest priority for this client? A. 239. D. Deficient fluid volume related to blood and fluid loss from surgery. D. C. start using insulin. pounding heartbeat is diagnosed with mitral valve prolapse. The nurse should anticipate that the client will need to A. D. B. Which intervention isn't appropriate for this client? A. Does the baby's father know?" D. C.D. "Congratulations. C. A client with a forceful. urticaria. A common physiological response to stress and anxiety is A. Glucose tolerance test results show a blood glucose level of 160 mg/dL. This client should avoid which of the following? A. "Tell me what pregnancy would mean to you. Foods rich in protein. Inviting the client's clergyman to visit him. 240. She tells the nurse she hopes she's pregnant. D. 242. sedation. " 238. Aerobic exercise programs. diarrhea. Risk for aspiration related to anesthesia. High volumes of fluid intake. Acute pain related to surgery. B. . Encouraging the client to discuss religious beliefs and practices. vertigo. 237. B. The nurse is assessing a client suffering from stress and anxiety. C. A client who received general anesthesia returns from surgery. " C. The nurse is providing care for a pregnant client in her second trimester. Caffeine-containing products. B. Encouraging the client to discuss concerns with the clergy. A client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward God. and the clergy. Postoperatively. Acknowledging the client's spiritual distress. A 15-year-old female with a urinary tract infection is admitted to the facility.
Which statement made by the client would indicate to the nurse that the client requires further teaching? A. B. friction rubs. 245. " D. coarse crackles. establish a time limit to get ready for the procedure. C. C. The nurse is assessing a client with heart failure. monitor her urine for glucose. " B. The nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin A. " 247. The breath sounds commonly auscultated in clients with heart failure are A. prepare the child by positive self-talk. count and sing with the child. enhances oxygen transport to tissues. Episodes of nausea and vomiting. D. B.B. . B. D. B. the nurse can A. D. D. and cord studies indicate that the neonate is A-positive. hold and rock him and give him a security object. C. Which behavior would cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? A. The nurse is caring for a toddler with Down syndrome. An increased sense of rectal pressure. restores the inflammatory response. "I'll need to keep several pillows between my legs at night. enhances protein synthesis. tracheal. C. Poor feeding patterns including vomiting. " C. An increase in fetal heart rate variability. Weight loss greater than 10%. fine crackles. start taking an oral antidiabetic drug. C. be taught about diet. Which of the following would be least likely if the neonate developed neonate hemolytic disease? A. Lethargy or irritability. It's such a habit. reduces edema. D. B. A decrease in intensity of contractions. 246. "I don't know if I'll be able to get off that low toilet seat at home by myself. D. "The occupational therapist is showing me how to use a 'sock puller' to help me get dressed. A client undergoes a total hip replacement. C. 244. Signs of kernicterus. "I need to remember not to cross my legs. 243. To help the toddler cope with painful procedures. 248. A term neonate's mother is O-negative.
While assessing a client who complained of lower abdominal pressure. 12 oz). an enlarged kidney. renal calculi. He has a compound fracture of his left femur and he's comatose. a distended bladder. D. between 2. He has a large contusion on his left chest and a hematoma in the left parietal area. 6 oz and 8 lb. C. They tell the nurse. B. 250. C. 8 oz).000 and 4. By calling attention to or attempting to prevent the behavior. By discouraging the client from verbalizing anxieties. " Which intervention by the nurse has the highest priority? A. We intubated him and he's maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag. allow ventilation of the site. avoid pressure on the site. Assessing the left leg. keep the site fully covered. D. C. "He fell from a two-story building. at least 2. What would be the nurse's most appropriate response? . C. Placing the client in Trendelenburg's position. C.000 g (4 lb. The nurse is caring for a client with a new donor site that was harvested to treat a new burn. D. 251. 253. Assessing level of consciousness. make the site dependent. B. An appropriate-for-gestational-age neonate should weigh A. in the 50th percentile. 254. By designating times during which the client can focus on the behavior. How should the nurse respond to this compulsive behavior? A. D.249. B. Assessing the pupils. B. The nurse notices that a client with obsessive-compulsive disorder washes his hands for long periods each day. between the 10th and the 90th percentiles for age. D. She asks the nurse how she should respond to the situation. Emergency medical technicians transport a 28-year-old iron worker to the emergency department. a mother reveals that she has observed her 6-year-old son playing with his penis during his bath.500 g (5 lb. During a parenting group meeting. The nurse should position the client to A. the nurse notes a firm mass extending above the symphysis pubis. B. 252. By urging the client to reduce the frequency of the behavior as rapidly as possible. a urinary tract infection. The nurse suspects A.
A client who recently had a cerebrovascular accident requires a cane to ambulate. Notify the physician.A. When teaching about cane use. "Supervise his baths and encourage him to stop doing it. D. Polyps. 257. Which of the following is not a contributing factor to unstable blood sugars in the neonate? A. When assessing an infant for changes in intracranial pressure (ICP). Prematurity. the nurse notes that the client's nasogastric (NG) tube has stopped draining. the rationale for holding a cane on the uninvolved side is to A. maintain stride length. Irrigate the NG tube. Respiratory distress. Increase the suction level. " D. Postdated infant. 256. Weight gain. Several hours after surgery. it's important to palpate the fontanels. B. prevent leaning. distribute weight away from the involved side. B. Duodenal ulcers. C. 259. Hemorrhoids. Reposition the NG tube. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer? A. D. "Ignore it and hope that he outgrows it. " C. How should the nurse respond? A. " 255. The nurse is interviewing a client about his medical history. C. D. "If he does it often. prevent edema. D. 258. " B. B. "Avoid characterizing it as bad because that's normal at his age. you might consider disciplining him. B. Where the nurse should palpate to assess the anterior fontanel? . A client with cancer undergoes a total gastrectomy. C. Cesarean delivery. C.
mark A in the space provided. "Oh. The color of the ecchymotic areas ranges from blue to purple to yellow. (Select A or B. ) Document the client's statement and complete a body map indicating the size. (Select A or B. ) Assist the client in developing a safety plan for times of increased violence. shape. If a choice is not correct. ) Report suspicions of abuse to the local authorities. 262. Infants weighing less than 2. A fullterm neonate can be diagnosed with intrauterine growth retardation. The question below is followed by six choices numbered 260-265. Answers and Rationales 1. color. 264. (Select A or B. D Multiple-correct answer item Directions. " How should the nurse respond? 260. (Select A or B. I tripped. mark B. B C. When asked by the nurse how she got these bruises. ) Provide the client with telephone numbers of local shelters and safe houses. Blacken one circle on your answer sheet for each number. 263. C D. . ) Tell the client that she needs to leave the abusive situation as soon as possible. 261. While providing care to a 26-year-old married female. C A preterm infant is a neonate born at less than 37 weeks' gestation regardless of what the neonate weighs. (Select A or B. A B. 265.A. ) Call the client's husband to discuss the situation. the client responds. the nurse notes multiple ecchymotic areas on her arms and trunk. (Select A or B. location. If a choice is correct. and type of injuries.500 g are described as low-birth-weight neonate.
9. but it isn't . In pneumonia. especially if they are ill and hospitalized. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. During labor.2. necessitating adjustment of the insulin dosage. and cyanosis. C Maternal insulin requirements usually decrease during the first trimester due to rapid fetal growth and maternal metabolic changes. In right-sided heart failure. weakness or paralysis of the innervated muscle group may result. after decreasing during the first trimester. B Total abstinence is the only effective treatment for alcoholism. 3. Circumcision may be performed on the infant of a Roman Catholic. A client in cardiogenic shock would show signs of hypotension and tachycardia. the client exhibits hepatomegaly. and aversion therapy are all adjunctive therapies that can support the client in his efforts to abstain. causing sciatic nerve inflammation. If nerve root compression remains untreated. Small amounts of water are allowable before meals. Slight knee flexion should relieve lower back pain. the client would have a temperature spike. A Disk herniation may compress spinal nerve roots. fluid may be driven from the pulmonary capillary beds into the alveoli. and aids in preventing rapid gastric emptying. restlessness. insulin requirements diminish due to extreme maternal energy expenditure. 8. Positive Homans' sign is more indicative of phlebothrombosis. and peripheral edema. tachycardia. A The client's coping skills are ineffective when anxiety increases. A Clinical manifestations of respiratory distress include intercostal retractions. The other diagnoses don't correspond to the observed behavior. Maternal insulin requirements fluctuate throughout pregnancy. attendance at AA meetings. causing pulmonary edema. There is no need to restrict the amount of fluids. they rise again during the second and third trimesters when fetal growth slows. Taking fluids between meals allows for adequate hydration. 6. B Because of decreased contractility and increased fluid volume and pressure in clients with heart failure. A The Roman Catholic practice is to baptize infants soon after birth. Psychotherapy. 7. jugular vein distention. just the time when the client drinks fluids. which produces pain that radiates down the leg. lower leg atrophy may occur if muscles aren't used. 4. tachypnea. dyspnea. and sputum that varies in color. 5. D A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. reduces the amount of bulk ingested with meals.
checking the pH of fluid aspirated from the tube is the most reliable technique for checking proper NG tube placement without taking X-rays before each feeding. Because auscultation of air can be heard when the tube is in the esophagus as well as in the stomach. 14. an indwelling catheter will be used. An IV infusion rate of 83 mL/hr wouldn't begin to replace the necessary fluids and reverse the problem. The next step is to clear the airway with back blows and chest thrusts. C The child's airway is blocked despite attempts to establish it. Positioning in bed shouldn't exceed a 20-degree elevation because sitting up can cause the implants to move from their intended locations. which changes blood vessel permeability and allows plasma to move into interstitial tissue. large breaths. 10. gastric. or intestines. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. 12. Fluid retention increases blood volume. Therefore. A heart rate greater than 100 beats/minute is tachycardia. Frequent bowel sounds refers to hyperactive bowel sounds. 13. lungs. 11. 15. B The client will receive an enema before the procedure because bowel motility during cervical radiation implant therapy can disrupt or dislodge the implants. B Reducing sodium intake reduces fluid retention. but it also refers to deep. the nurse can assume the . Semi-Fowler's position is 45 degrees. The other options are appropriate for this client. Urea nitrogen excretion can be increased only by improved renal function. X-rays can't be performed multiple times every day. The client will be in a private room.considered a Roman Catholic practice. To keep the bladder empty. D A respiratory rate greater than 20 breaths/minute is tachypnea. Breaths can't be administered until the airway is patent. C Intestinal. After two attempts to position the airway. it isn't affected by sodium intake. Last rites or sacraments of the sick wouldn't be appropriate for the mother of the child. Hyperventilation may increase respirations. this isn't the best test for checking placement. B Because shock signals a severe fluid volume loss (700 to 1300 mL) its treatment includes rapid IV fluid replacement to sustain homeostasis and prevent death. causing edema. and respiratory fluids have different pH values. and activities will be restricted in order to keep the implants in place. Sodium intake doesn't affect the glomerular filtration rate. Observing the insertion measurement mark isn't a good check either because the mark may remain the same even though the tube has migrated up or down into the esophagus. Potassium absorption is improved only by increasing the glomerular filtration rate.
Talking about it in the morning won't comfort the client when he's most upset. Additional assessment findings include increased lens thickness and opacity. to prevent seizures. A Administration of heparin. D Early and frequent contact promotes love and satisfaction and can support the learned parental behavior that enhances parenting abilities and reduces ambivalence and feelings of resentment. darkening of the skin around the orbits. For a client with hemorrhagic shock. A The important intervention is to assist the client to feel safe. such as the stomach and the bowel.airway is blocked. Therefore. who can form strong infant attachments. D Instruct the client to limit hip flexion to 90 degrees while sitting. instead. 16. Supply an elevated toilet seat so the client can sit without having to flex his hip more than 90 degrees. The nurse can't ventilate the child with a handheld resuscitation bag until the airway is patent. 18. 20. dexamethasone may be used to decrease cerebral edema and pressure. No one should bend over an object when lifting. prevents back strain. 17. methyldopa. D Standing close to an object being lifted moves the body's center of gravity closer to the object. When lifting. providing better balance. Staying with him until he's able to sleep again or listening to him if he wants to talk is the most appropriate action for the nurse to take in this situation. 22. and bending should be at the hips and knees. Part of the adult maturational process excludes adolescents. 19. could increase the bleeding associated with hemorrhagic stroke. Using a larger number of muscle groups distributes the workload. Having good role models in childhood may be helpful but isn't the primary principle. to decrease blood pressure. an anticoagulant. and an equal but slowed pupillary reflex. the back should be straight. 21. Calling the physician for a sleeping aide doesn't help the client cope with stress. B Decreased visual acuity is common in elderly people. Instruct the client not to cross his legs. to bear the weight. to avoid dislodging or dislocating the . rather than the arms or back. the nurse should question this order to prevent additional hemorrhage in the brain. The relationship isn't directly related to the neonate's physical needs because human contact is needed for the infant to survive. rather than the back. and phenytoin. Pushing or pulling an object using the weight of the body. D Tympany is produced by air-containing structures. Stating that it was only a dream trivializes his experience. spreading the legs apart widens the base of support and lowers the center of gravity. allowing the legs.
23. and C. or knee doesn't promote venous return. 25. In this case. The placenta produces estrogen . D Fetal immunities are transferred through the placenta. Caution the client against sitting in chairs that are too low or too soft. which the mother's body considers a foreign protein. B Following a transesophageal echocardiogram in which the client's throat has been anesthetized. There is no indication for oral airway placement. 24. One with an IQ below 36 is severely and profoundly impaired. parents' active participation in the child's care. D Because some of the glucose in the bloodstream attaches to some of the Hb and stays attached during the 120-day life span of red blood cells. This method promotes venous return. 27. the nurse should begin applying the bandage at the client's foot. and inserting an NG tube is unnecessary. T. Fasting blood glucose and urine glucose levels give information about glucose levels only at the point in time when they were obtained. but the maternal immune system is actually suppressed during pregnancy to prevent maternal rejection of the fetus. a person with an IQ between 50 and 70 is classified as mildly mentally retarded but educable. requiring custodial care. The client should be in the upright position. trachomatis are sexually transmitted diseases that require that partners be treated. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks. food and fluid should be withheld until the gag reflex returns. and evidence of adaptation to parental role changes don't suggest this diagnosis. the placenta isn't responsible for the production of maternal antibodies. 28. The other types of MI aren't usually associated with heart failure. 26. which is undesirable. One with an IQ between 36 and 50 is classified as moderately retarded but trainable. Beginning at the ankle. 29. these chairs increase flexion. B C. A An anterior MI causes left ventrieular dysfunction and can lead to manifestations of heart failure. A An elastic bandage should be applied from the distal area to the proximal area. 30. lower thigh. albicans is treated with nystatin (Mycostatin) and doesn't require treatment for sexual partners. gonorrhoeae. vaginalis. C A failure to use available support systems or agencies is one of the defining characteristics of this diagnosis. Thus. B According to the American Association on Mental Deficiency. N.prosthesis. Supportive child-parent interaction. which include pulmonary crackles and dyspnea. glycosylated Hb levels provide information about blood glucose levels during the previous 3 months.
fiberglass casts dry quickly and can be handled without damage soon after application. The other options are incorrect. 36. 32. the infant usually has been introduced to iron-fortified infant cereal and vegetables and will begin to try fruits. although a close significant other. which are found in the legs. C Solid foods are typically introduced around age 6 months. Two physicians need not sign a consent form when a relative is available. By age 8 months. Unlike plaster casts. Ectopic corticotropin-secreting tumors are more common in older men and are often associated with weight loss. B One way to help support this client's wishes to breast-feed is to instruct her to room-in with her neonate so she can respond to the neonate's cues. They aren't recommended at an earlier age because of the protrusion and sucking reflexes and the immaturity of the infant's GI tract and immune system. B Listening to the radio with earphones is one way to override the buzzing sound in the ears caused by tinnitus. The client wouldn't take antihypertensive medications for this disorder. 31. can't sign because he isn't a blood relative. 34. 38. D The nurse should assess a casted arm every 2 hours for finger movement and sensation to ensure that the cast isn't restricting circulation. To reduce the risk of skin breakdown. 39. The nurse should assess the brachial and radial pulses distal to the cast--not the pedal and posterior tibial pulses. detoxifies some drugs and chemicals.and progesterone. C A corticotropin-secreting pituitary adenoma is the most common cause of Cushing's syndrome in women ages 20 to 40. The other options don't support the client's need for guidance. Diet regulation may affect the occurrence of attacks of Ménière's but not the effects of tinnitus. B A woman having her second baby can anticipate a labor about half as long as her first labor. Sending the neonate to the nursery lessens the mother's ability to learn her neonate's breast-feeding cues. B The mother should sign the consent form because she's the closest living relative. The companion. D Fluid surrounding the heart such as in cardiac tamponade. Adrenal carcinoma isn't usually . suppresses the amplitude of the QRS complexes on an ECG. and exchanges nutrients and electrolytes. 37. the nurse should leave a casted arm uncovered to allow for air circulation through the cast pores to the skin below. The client can't sign because of his diagnosis. which is used to screen for prostate cancer. 35. Narrowing or widening complexes and amplitude increase aren't expected on the ECG of an individual with cardiac tamponade. A PSA stands for prostate-specific antigen. 33.
44. however. 45. B Kinking and blockage of the chest tube is a common cause of a tension pneumothorax. D According to the Denver Ⅱ Developmental Screening test. In this case. Absence of bubbling in the second chamber signifies a block in the system. Pinktinged urine and bladder spasms may be expected after cystoscopy. A Chilis and tachycardia may indicate bladder infection and should be reported to the physician immediately. The FAST isn't used to induce contractions. A female with an inborn error of metabolism wouldn't be menstruating. Note. It's normal for bubbling to occur during inspiration. Reducing the child's caloric intake doesn't necessarily reduce cardiac demand. which are used to maintain the client in a lithotomy position. 43. that the occurrence of bright red blood may be an indication of hemorrhage. D Parents of a child with a heart defect should treat the child normally and allow self-limited activity. This noninvasive technique induces fetal heart rate accelerations by using lowfrequency vibrations on the maternal abdomen over the fetal head. Orthostatic dizziness and fainting may occur after the legs have been removed from stirrups. the client indicates normal physiologic changes due to the growing uterus and pressure on the diaphragm. A -year-old can build a tower of eight cubes and point out a picture. Contact with peers promotes normal growth and development and therefore should be encouraged. It can shorten the length of the nonstress test. 40. Clients commonly feel burning on urination and urinary frequency after cystoscopy as a result of irritation from the cystoscope. It can also mean that the affected lung has reexpanded. Excessive water won't affect the chest tube drainage. most 2-year-olds are able to remove one garment. A 3-year-old can wash and dry his hands. Altering disciplinary patterns and deliberately preventing crying or interactions with other children can foster maladaptive behaviors. B Bubbling in the second chamber of a Pleur-evac system signifies that air is moving from the collection chamber to the water seal chamber. The client doesn't need to be seen or . or determine fluid volume. B The nurse must distinguish between normal physiologic complaints of the latter stages of pregnancy and those that need referral to the health care provider. Infection and excessive drainage won't cause a tension pneumothorax.accompanied by hirsutism. 46. but continuous bubbling signifies a leak in the closed system. shorten the length of the contraction stress test. 42. 41. B The FAST is being used more commonly.
T4 is subnormal and T3 and TSH levels are elevated (option C). T3.admitted for delivery. 53. Taking temperatures rectally increases the risk of rectal abscess due to rectal trauma. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4. 49. A toxin is a poison. 52. and polyphagia. A virus is an infectious parasite. polydipsia. and restriction of fluids won't reduce the potassium level. A Hives and urticaria are two names for the same skin lesion. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as +3. 47. and infected individuals. they aren't appropriate for the neutropenic client. C The client receiving chemotherapy is susceptible to infection from bone marrow suppression and granulocytopenia. D Sodium polystyrene sulfonate (Kayexalate) is a resin that pulls potassium into the bowel and is excreted with defecation. With Hashimoto's thyroiditis. hypovolemia. Cushing's syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. Although rectal temperatures may be more accurate. 5 to 12 μg/dL. Muffled or distant heart sounds occur in pericardial tamponade. A In the case of a pneumothorax. IV fluids.3 to 5. Clients should be instructed to avoid malls. A tubercle is a tiny round nodule produced by the tuberculosis bacillus. auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. 50. With hypothyroidism. Raw fruits and vegetables may be contaminated by pathogens and should be avoided during severe neutropenia or washed in hot soapy water. 65 to 195 μg/dL. With primary hyperthyroidism. T4 and T3 levels are typically subnormal and TSH is elevated.4μIU/mL. T4 and T3 levels are elevated and TSH is subnormal (options A and B). The client's signs aren't indicative of heart failure. movie theaters. Antacids. and hypotension. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia. A Pitting edema is documented as +1 when depression is barely detectable on release of thumb pressure and when foot and leg contours are normal. Paradoxical chest wall movements occur in flail chest conditions. A detectable depression of less than 5 mm accompanied by normal leg and foot contours warrants a +2 rating. there is no need for sterile garb . Meticulous hand washing by staff and visitors will prevent the spread of infection. D Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after brain surgery. TSH 0. 48. Tracheal deviation occurs in a tension pneumothorax. D Normal thyroid function tests are as follows: T4. 51. Diabetes mellitus is a hyperglycemic state marked by polyuria.
58. The values for a 3-month-old. altitude. Suppression is a conscious effort to conceal unacceptable thoughts. A A rising pulse rate and falling blood pressure may be signs of hemorrhage. sex. it may be appropriate to ask her if she would like to see the chaplain or attend a support group. giving false test results. or acts and serves as a coping mechanism for most alcoholics. 57. The nurse should express interest in the client and her concerns regarding her present state. beliefs. B Assessment data should include information regarding the client's feelings. and attitudes about his illness. keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. D Perceptual disorders. the nurse should maintain the client on bedrest. After allowing the client to express her needs. 55. Coma isn't an immediate consequence. feelings. When there is no urine in the tubing.and no need to avoid visiting-the client will need emotional support from family at this time. 56. and a 10-year-old are correct as stated above. Any break in the closed urine drainage system may allow the entry of microorganisms. the catheter may be clamped for no more than 30 minutes to allow urine to collect. A Discussing problems and fears is an appropriate nursing intervention to assist a client with coping with or adapting to her illness. Manipulative behaviors are part of the alcoholic client's personality but not a sign of alcohol withdrawal. 59. C While the physician makes treatment decisions. Disease as well as such nonpathologic conditions as age. Tubing shouldn't be disconnected from the urinary catheter. a 3-year-old. Lochia pools in the vagina of a postpartum client who . 60. are very common with alcohol withdrawal. Urine in urine drainage bags may not be fresh and may contain bacteria. A To sustain them until active erythropoiesis begins. 54. Elevating the leg would worsen tissue ischemia. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Shaving an ischemic leg may cause accidental trauma from cuts or nicks. and the degree of fluid retention or dehydration can affect Hb values. B Most catheters have a self-sealing port for obtaining a urine specimen. especially frightening visual hallucinations. neonates have Hb concentrations higher than those of older children. Antiseptic solution is used to reduce the risk of introducing microorganisms into the catheter. The normal value of Hb for neonates is 18 to 27g/dL. Giving the client reassurance is inappropriate at this time. Although the other options are partially correct. option B is the best answer. impulses.
Because CNS deterioration results from infection--not altered tissue perfusion--Ineffective cerebral tissue perfusion isn't an appropriate diagnosis. A 2" blood stain on a fresh surgical incision isn't a cause for immediate concern. D In a client with AIDS. and recovery. Focusing on negative aspects of the child's behavior is inappropriate. 62. Because this type of dementia impairs cognition and judgment. and the amount of output isn't related to IV fluids infused. ) Serum tetanus titer levels aren't used to determine whether tetanus toxoid should be . 63. 65. The purpose of an incident report is threefold: to identify ways to prevent recurrences of incidents. 66. C If a client has a wound contaminated with soil that may contain animal excrement and he has completed the full childhood tetanus immunization regimen. A client who has diabetes should get about 70% of his calories from carbohydrates and monounsaturated fats. (It had been 7 years since the client's last dose. it places the client at risk for injury. The kidneys aren't in a state of suppression. A The main goal of an incident report following an adventitious event isn't punishment for those involved in the incident. Asking how long the child has been like this may be interpreted poorly by the caregiver. insulin may be used in addition to the antidiabetic agent. diuresis. A client who has had a cesarean delivery usually feels pain at the incision site after her anesthesia has worn off. 64. However. C The three phases of acute renal failure are the oliguria phase (less than 400 to 600 mL of urine produced in 24 hours).has been sitting and may suddenly gush out when she stands up. deterioration of the central nervous system (CNS) can lead to AIDS-related dementia. to identify patterns of care problems. 61. the average output isn't 30 to 60 mL/hr. he should be given a dose of tetanus toxoid if it has been 5 or more years since the most recent dose. however. the area of blood should be circled and timed. B Many clients (25% to 60%) with secondary failure respond to a different oral antidiabetic agent. Although self-care deficit and dysfunctional grieving can be associated with AIDS. if a new oral antidiabetic agent is unsuccessful in keeping glucose leveis at an acceptable level. An increase in size of the blood stain and oozing of the surgical incision should be promptly reported to the physician. they don't take precedence for a client with AIDS-related dementia. Therefore. and to identify facts surrounding each incident. it wouldn't be appropriate to initiate insulin therapy at this time. C Identify the chief complaint from how the child was previously behaving at home. Focus on what the child can do--and not on what he can't do--to preserve the family's self-esteem.
Librium comes in capsule form and usually can be taken with water. especially during the second trimester. A During a vaso-occlusive crisis. cool compresses would cause vasoconstriction. Antipyretics may be administered to reduce fever but don't play a crucial role in resolving the crisis. Providing IV and oral fluids promotes hemodilution. Aged cheese is restricted with monoamine oxidase inhibitors. No available tetanus immunization confers life-long immunity. 67. These clients don't necessarily have to have a cesarean delivery if they .administered. the client should be instructed to avoid alcohol while taking Librium because it potentiates the drug's CNS depressant effect. The client must be kept away from known infection sources but doesn't require protective isolation. The nurse should anticipate and support this behavior. 70. It's highly doubtful that the neonate would become chilled during this brief time of being undressed. Controlling shopping for large amounts of food isn't a goal early in treatment. not Librium. These changes may cause cardiac stress. Blood pressure during early pregnancy may decrease. Therefore. Eating three meals per day isn't a realistic goal early in treatment. causing ischemia and tissue damage. A Potentiating effect refers to a drug's ability to increase the potency of another drug if taken together. sickle-shaped red blood cells (RBCs) clump together and obstruct blood vessels. 69. but it gradually returns to prepregnancy levels. Taken at bedtime. B The behavior demonstrated by the mother is normal during the "taking-hold" process. the bladder repair may need to be repeated. 72. which aids the free flow of RBCs through blood vessels. rewrapping the neonate and taking her back to the nursery to check her temperature isn't necessary. it doesn't need to be reported. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the plan of care after initially addressing stress and underlying issues. which exacerbates sickling. C Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxietycausing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. this drug will induce sleep. C Pregnancy increases plasma volume and expands the uterine vascular bed. 68. possibly increasing the heart rate and cardiac output. Because this is normal behavior for establishing a relationship. Therefore. 71. Warm compresses may be applied to painful joints to promote comfort. B Because the pregnant uterus exerts a lot of pressure on the urinary bladder.
This procedure is completed in one surgery. Neonates who aren't subjected to contractions are at an increased risk for developing respiratory distress. Respiratory acidosis is caused by alveolar hypoventilation. although the exact mechanism is unclear. Although avoiding the use of alcohol and illicit drugs is helpful. A Daily walks relieve symptoms of intermittent claudication. C AIDS clients must follow safer-sex practices to prevent transmission of the human immunodeficiency virus. which may cause metabolic acidosis.000/μL. Vomiting could lead to metabolic alkalosis. 77. D Hoarseness indicates injury to the respiratory system and could indicate the need for immediate intubation. B Diarrhea causes the body to lose bicarbonate. The bleeding can be difficult to stop. The client already has an IV access. B A word salad is an illogical word grouping. B The squeezing action of the contractions during labor enhances fetal lung maturity. the nurse should avoid using the IM route because the area is highly vascular and can bleed readily when penetrated by a needle. Cardiac output is the amount of blood ejected from the left ventricle per minute. A The pulse deficit measures the difference between the apical pulse rate and radial pulse rate. and this procedure doesn's render them sterile. Pain. 78. 80. either severe or moderate. and ejection fraction refers to the percentage of blood emptied from the ventricle during contraction. 75. Anaerobic exercise may exacerbate these symptoms. The client's urine output is adequate. 73. especially because IV morphine is effective almost immediately. Therefore. Clients with chronic arterial occlusive . 74. 79. The type of birth has nothing to do with temperature or glucose stability. Echopraxia is an involuntary repetition of movements. Thirst following burns is expected because of the massive fluid shifts and resultant loss leading to dehydration. Oral and SC routes are preferred over IM. is expected with a burn injury.become pregnant. Neologisms are bizarre words that have meaning only to the client. 76. C With a platelet count of 22. the client bleeds easily. Carbonic acid excess occurs with respiratory alkalosis. the most important point the nurse can make is that drug users can best avoid transmission by using clean needles and disposing of used needles. Flight of ideas is a rapid succession of unrelated ideas. so it would be the best route. Pulse pressure is the difference between systolic and diastolic blood pressures. The AIDS client has no legal obligation to tell anyone about an AIDS diagnosis. and acrocyanosis is a normal finding. but they're less effective for acute pain management than IV.
D Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. but it's difficult to determine if the chest is reexpanded sufficiently. such as furosemide. The heel-to-shin test evaluates cerebellar function. The nurse then asks the child to bend forward at the hips and inspects for a rib hump. A Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet. scapulae. HDLs have the lowest cholesterol concentration. otherwise the infection won't be eradicated. Therefore. making them susceptible to injury and poor healing. Anticoagulants prevent clot formation but don't decrease fluid volume excess. A There are 250 mg in 1 teaspoon (5 mL). x=2. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis. 81. Antiembolism stockings prevent venostasis and thromboembolism formation. this client should stop smoking. so this client should eat foods that raise HDL levels. Because nicotine is a vasoconstrictor. reduce total blood volume and circulatory congestion. Chest auscultation will determine overall lung status. 85. the nurse has the child stand firmly on both feet with the trunk exposed and examines the child from behind. However. A To screen for scoliosis. a lateral curvature of the spine. or hips. 86. ABG levels may show hypoxemia. 84. not just when complications occur. The nurse should teach the client to bathe the feet in warm water and dry them thoroughly. SaO2 values may initially decrease with a pneumothorax. meticulous foot care is essential. even if the child feels well. The child should receive 2 mL of suspension (100 mg). 83. possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. but they typically return to normal in 24 hours. checking for asymmetry of the shoulders. 1 mL=50 mg. therefore. cut the toenails straight across. a sign of scoliosis. C Diuretics. a known cause of arterial occlusive disease. Having the child shrug the shoulders against mild resistance helps evaluate the integrity of cranial nerve Ⅺ. The client must see the physician regularly to evaluate the effectiveness of the therapeutic regimen. 82. and avoid taking medications unless the physician approves. Antibiotics should be taken at prescribed intervals to . Daily walking is beneficial to clients with intermittent claudication. wear well-litting shoes. Oxygen administration increases oxygen delivery to the myocardium and other vital organs. The nurse would listen for a clicking sound while the child abducts the hips when screening for developmental dysplasia of the hip. not just consider cutting down. 250 mg/5 mL= 100 mg/x mL.disease must reduce daily fat intake to 30% or less of total calories. A Antibiotics must be given for the full course of therapy.
they're of a lesser priority. 91. A typical fluid resuscitation protocol is 6 L of fluid over the first 12 hours. . monitoring vital signs. when the client is stabilized. Profound intravascular depletion requires aggressive fluid replacement. 88. Therefore. depending on the degree of hypovolemia. A reexamination at the end of the course of antibiotics is necessary to confirm that the infection is resolved. An abrupt lengthening of the cord. and assisting with breathing exercises are appropriate actions to include. C Because the fetus is at risk for complications. isotonic normal saline solution and. with more fluid to follow over the next 24 hours. D An enterostomal nurse therapist is a registered nurse who has received advanced education in an accredited program to care for clients with stomas. C Relaxation isn't an indication for detachment of the placenta. and an increase in vaginal bleeding are all indications that the placenta has detached from the wall of the uterus. but they can't provide preoperative and postoperative teaching. frequent and close monitoring is necessary. The cast shouldn't be covered while drying because this will cause heat buildup and prevent air circulation. teach about stoma care. Commonly prescribed fluids include dextran (in cases of hypovolemic shock). D A client with preeclampsia is at risk for seizure activity because her neurologic system is overstimulated. A Regardless of the client's medical history. in addition to administering pharmacologic interventions to reduce the possibility of seizures. No foreign object should be inserted inside the cast because of the risk of cutting the skin and causing an infection. the client shouldn't be allowed to ambulate. A foul smell from a cast is never normal and may indicate an infection. B The leg should be elevated to promote venous return and prevent edema. Social workers provide counseling and emotional support. The occupational therapist can assist a client with regaining independence in activities of daily living. including fetal well-being. the nurse should lessen auditory and visual stimulation. Various fluids can be used. Although the other actions are important. hypotonic half-normal saline solution. 87. and provide emotional support. A registered dietitian can review any dietary changes and help the client with meal planning. rapid fluid resuscitation is critical for maintaining cardiovascular integrity. The enterostomal nurse therapist can assist with selection of an appropriate stoma site. 92.maintain blood levels and not as needed for pain. an increase in the number of contractions. 89. Carefully titrating the oxytocin. Therefore. 90.
If the child remains in a deep sleep and is responsive only to vigorous and repeated stimulation. he's lethargic. 97. D Carbohydrate need increases because healing and repair of tissue requires more carbohydrates. Digestive enzymes are decreased--not increased. 100. Confabulation is a behavioral reaction in which the client creates stories or invents answers to fill in memory gaps in an unconscious attempt to maintain self-esteem. he's comatose. 95. D The client with a chronic illness goes through a grieving process that is related to the loss of his previous level of function. Decreased appetite--not increased--is a problem. Poor boundaries are symptoms of antisocial and passive-aggressive behavior. This occurs when the infant's oxygen requirements are greater than what is supplied in the blood. not 30 minutes to an hour before. Promoting parental bonding and identifying the neonate are appropriate after the neonate has been dried. It's safe to be on a regimen that includes insulin and an alphaglucosidase inhibitor. the client uses behaviors that are the opposite of what he would like to do. 98. but a Cesarean section delivery isn't necessary when the mother is HIV-positive. which is the inability to differentiate between self and others. Manipulation is an attempt to control another person. 96. Aspiration of the infant's nose and mouth occurs at the time of delivery. The alpha-glucosidase inhibitors work by delaying the carbohydrate digestion and glucose absorption. If the child shows no motor or verbal response to noxious stimuli. C The child is obtunded if he can be aroused with stimulation. Selfactualization is the process of fulfilling one's potential. The use of birth control will prevent the conception of a child who might have HIV. It's true that a mother who is HIV-positive can give birth to a baby who is HIV-negative. . he's stuporous. B The infant is having a "tet" or blue spell. D Acarbose delays glucose absorption. 94. B The nurse's first action is to dry the neonate and stabilize the neonate's temperature. C The described behaviors indicate poor personal boundaries. If the child has limited spontaneous movement and sluggish speech. The client should take the drug at the start of a meal. D The human immunodeficiency virus (HIV) is transmitted from mother to child via the transplacental route. In reaction formation. Grief is commonly manifested as loss of motivation and refusal to perform functions of which the client is fully capable. so the client should take an oral form of dextrose rather than a product containing table sugar when treating hypoglycemia.93. Increased--not decreased--protein catabolism is present. 99. which is an acute spell of hypoxia and cyanosis.
A Hypoxia is the main breathing stimulus for a client with COPD. The nurse shouldn't offer advice. Leaving the infant alone until the crying stops will cause an increase in cyanosis. which causes more blood to be shunted to the pulmonary artery. not excessive oxygen administration. not alkalosis. Weight gain from fluid resuscitation isn't a goal.Treatment involves placing the infant in the knee-chest position to reduce venous return from the extremities because that blood is desaturated. however. administering oxygen at any concentration dilates blood vessels. If there's a loss of vibratory sense. high oxygen concentrations decrease the ventilatory drive. 103. but it would be inappropriate in this situation. the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. C It's extremely important that the nurse establish trust and rapport. A client with COPD may have anginal pain from generalized vasoconstriction secondary to hypoxia. Thus. an injury to the peripheral nerves is probable. 101.5 mL/(kg · hr). Respiratory alkalosis results from alveolar hyperventilation. leading to respiratory acidosis. 104. It also increases systemic vascular resistance. Offering to listen to the client express her anger can help the nurse and the client understand its cause and begin to deal with it. a 4 lb weight gain in 24 hours suggests third spacing. easing anginal pain. If the kidneys are adequately perfused. In fact. Anginal pain results from a reduced myocardial oxygen supply. . Setting limits is also important but not as important as developing trust and rapport. and a urine output consistently above 100 mL/hr is more than adequate. 105. Excessive oxygen administration may lead to apnea by removing that stimulus. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators. the expected urine output of a 155 lb client is 35 mL/hr. High oxygen concentrations don't cause metabolic acidosis. A ride in the car may quiet some infants. B Appropriate perception of vibration indicates intact dorsal column tracts and peripheral nerves. Although stress can exacerbate the symptoms of SLE. An infant who is crying and having trouble breathing shouldn't be offered a bottle because of the danger of aspiration. she should help the client develop the coping mechanisms necessary to solve his own problems. A In a client with burns. In a client with COPD. 102. they will produce an acceptable urine output of at least 0. A Verbalizing the observed behavior is a therapeutic communication technique in which the nurse acknowledges what the client is feeling. Instead.
or the world. lumbar puncture shouldn't be done because it can quickly decompress the central nervous system and. Reverse isolation doesn't significantly reduce the incidence of infection in immunosuppressed clients. cause additional damage. not to reduce the client's risk of infection. Thorough hand washing is the single most effective way to prevent infection in an immunosuppressed cIient. Cold decreases the pain but allows the medication to stay in the muscle longer. B The correct answer is waxy flexibility. Massage is a good intervention but applying a warm compress is better.telling the client to calm down doesn't acknowledge her feelings. all women should perform breast selfexamination monthly (not annually). in turn. 109. isolation may cause psychological stress. " The hormonal receptor assay is clone on a known breast tumor to determine whether the tumor is estrogen. Neologisms are invented meaningless words. Instead of relying on masks and other barrier methods. which. Offering to get the nursing supervisor also doesn't acknowledge the client's feelings. thereby. and elevating the head of the bed may be used to reduce ICP. B Applying heat increases blood flow to the area. B Washing the area with normal saline solution and applying a protective dressing are within the nurse's realm of interventions and will protect the area. After a head injury. barbiturates may be given to prevent seizures. 111. 106. C The client's history and assessment suggest that he may have increased intracranial pressure (ICP). the . Somatic delusions involve a false belief about the functioning of the body. Standard precautions are intended mainly to protect caregivers from contact with infectious matter. 110. mechanical ventilation may be required if breathing deteriorates. D Acute lymphoblastic leukemia and its treatment cause immunosuppression.or progesterone-dependent. If this is the case. 108. B According to the ACS guidelines. Using a povidone-iodine wash and an antibiotic cream require a physician's order. Nihilistic delusions are false ideas about self. Ignoring the client's feelings suggests that the nurse has no interest in what the client has said. increases the absorption of the medication. furthermore. "Women older than age 40 should have a mammogram annually and a clinical examination at least annually (not every 2 years). Staff and others need not wear masks when visiting because most infections are transmitted by direct contact. 107. Tightening the gluteal muscles may cause additional burning if the drug irritates muscular tissues. others. Massaging with an astringent can further damage the skin. which is defined as retaining any position that the body has been placed in.
A weight gain may further stress the respiratory system and worsen the client's condition. Approximately 15% to 20% of individuals with psoriasis will also develop psoriatic arthritis. A Elderly clients and clients with cardiac disease should begin with low-dose levothyroxine increased at 2. A combined upper and lower neuron lesion generally occurs as a result of spinal injuries. and should be encouraged to dress without help (with the exception of tying shoes). elevated Hb. C COPD causes pulmonary hypertension. Poor clotting mechanisms. have fears concerning body integrity. D The primary cause of neonate jaundice is the immaturity of the liver and its inability to break down red cells effectively. It would be incorrect to assume that his pain is caused by early rheumatoid arthritis or his vocation without asking more questions or performing diagnostic studies. A Anyone with psoriasis vulgaris who reports joint pain should be evaIuated for psoriatic arthritis. Preschool children are afraid of the dark. 117. 113.nurse should keep persons with known infections out of the client's room. caused by a lower neuron lesion at the myoneural junction. He should eat a low-sodium diet to avoid fluid retention and should engage in moderate exercise to avoid muscle atrophy. leading to right ventricular failure or cor pulmonale. 114. 115. Younger clients would be started on the usual maintenance dose of 100 g/d. 118. which can be painful and cause deformity. A Accidents are the major cause of death and disability during the school age years. especially in the face and throat. . 112. A lesion involving cranial nerves and their axons in the spinal cord would cause decreased conduction of impulses at an upper motor neuron. and persistent fetal circulation contribute to the jaundice but aren't causes of it. The resultant venous congestion causes dependent edema. This slow titration prevents further cardiac stress. Clients with Hashimoto's thyroiditis don't require surgical intervention. It isn't a genetic disorder. assess the client for breathing while opening the airway. Carpal tunnel syndrome causes sensory and motor changes in the fingers rather than localized pain in the joints. 116. but none of these should take priority over accident prevention. The nurse should then call for help. Therefore accident prevention should take priority when teaching parents of school-age children. and check for a carotid pulse. deliver two breaths. D Myasthenia gravis is characterized by a weakness of muscles.to 4-week intervals until 100 g/d is reached. A The correct sequence begins with establishing unresponsiveness.
Thyroid supplements will be necessary following thyroidectomy but aren't specifically related to the identified problem. Ignoring the client or complimenting the client won't be helpful. Then sexual development progresses. C Hyperkalemia. insulin. 122. Blood dyscrasias aren't a common problem with MAO inhibitors. Hypernatremia. She won't be able to accept the compliment. and muscle spasms. Pointing toes toward the knee will elicit discomfort. A Encouraging the client to discuss stressful life situations helps focus on the underlying issues. a living will doesn't apply to nonterminal events such as choking on an enteral feeding device. Aspirin and NSAIDs are safe to take with MAO inhibitors. tingling. a common complication of acute renal failure. C Testicular enlargement signifies the onset of puberty in the male adolescent. Manifestations of calcium deficiency include numbness. with sodium bicarbonate if necessary. 124. is life-threatening if immediate action isn't taken to reverse it. The administration of glucose and regular insulin. Barbiturates aren't indicated. Activity doesn't need to be limited. A client with intermittent claudication experiences pain that increases during activity and decreases with rest. 121. D Removal of the thyroid gland can cause hyposecretion of parathormone leading to calcium deficiency.119. The . Agreeing with her strengthens her problem. C A GTT indicates a diagnosis of diabetes mellitus when the 2-hour blood glucose level is greater than 200 mg/dL. 126. Treatment includes immediate administration of calcium. The time of the day doesn't influence the pain associated with DVT. hypokalemia. 120. can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. The client's preoccupation with a specific physical feature is a means of not coping with life. A MAO inhibitor antidepressants when combined with a number of drugs can cause life-threatening hypertensive crisis. There is no indication that the client is terminally ill. A dependent position will increase venous stasis and the pain associated with DVT. Furthermore. or sodium bicarbonate. A A living will states that no lifesaving measures are to be used in terminal conditions. D The client's symptoms indicate deep vein thrombosis (DVT). and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose. It's imperative that a client checks with his physician and pharmacist before taking any other medications. 125. causing the appearance of pubic hair and axillary hair and the onset of nocturnal emissions. Antispasmodics don't treat the problem's cause. 123. Confirmation occurs when at least one subsequent result is greater than 200 mg/dL.
if the client does weightbearing exercises. Adverse effects of the medication include increased salivation. Neostigmine must be given at scheduled times to ensure consistent blood levels. 133. Making the client comfortable ignores the life-threatening event. Option D could make the client feel guilty for being upset about the trauma. including AA meetings. . Maintaining protein and vitamins levels is important. Removing the catheter is unnecessary and subjects the client to unnecessary needlesticks. but neither will prevent osteoporosis. C When the mechanical stressors of weight bearing are absent. Antidepressants may help but these drugs can mask feelings and can't provide lasting relief.nurse should clear the client's airway. The nurse acknowledges the client's traumatic experience and pain as well as encourages her to talk. each child has a 50% chance of inheriting it. 127. and abdominal cramps. Waiting until the next bottle is due is inappropriate and places the client at risk for problems and the nurse in legal jeopardy. Treatment for alcohol abuse. 128. An incident report describing the specific error should be completed after the correct solution has been started. 132. Men and women are equally affected. the nurse should maintain the access and start the proper solution. and D don't address the client's immediate medical needs. C When a client is getting the wrong IV solution. it should be administered at least 45 minutes before eating to improve chewing and swallowing. Option B ignores the client's need for reassurance. disuse complications can be prevented. C. Options B. therefore. 131. must be considered when planning care but alone doesn't provide lasting relief. 130. ROM exercises will help prevent muscle atrophy and contractures. Family members are commonly frightened by the information and can't be consistently supportive. A The possibility of frostbite must be evaluated before the other interventions. C Because neostigmine's onset of action is 45 to 75 minutes. Therefore. sweating. Taking neostigmine with a small amount of food reduces GI adverse effects. clients with PTSD can obtain the most lasting relief if they verbalize memories of the trauma to a sympathetic listener. disuse osteoporosis can occur. Option C indicates that the nurse isn't capable of helping the client deal with therapeutic issues. nausea. 129. B Huntington's disease is an autosomal dominant disorder. A Option A is the most supportive statement. A Although talking about their experiences can be difficult. Cardiopulmonary resuscitation isn't indicated and removing the NG tube would exacerbate the situation. bradycardia.
D The cricoid cartilage in the toddler is the narrowest part of the larynx and provides a natural seal. the client must protect the graft from direct sunlight. and nuts to reduce bowel movements. She didn't restate the question. especially if steatorrhea is present.134. The test to detect urinary levels of LH is a hormonal assessment of ovulatory function--not an assessment of the number of maturing cells. Fat intake should be limited. but these aren't reasons to choose an uncurled tube. such as a weak femoral pulse and a bounding radial pulse. 136. B To avoid burning and sloughing. The vocal cords are narrower in an adult. the nurse can determine the number of maturing follicles. seeds. This results in reduced . The trachea is shorter and the larynx is anterior and cephalad. such as blurred vision and headaches. Serum levels of HCG indicate whether the corpus luteum is producing enough estrogen and progesterone to maintain the pregnancy until the placenta develops further. ask further questions (exploring). and didn't make an observation. Caffeine-containing and carbonated beverages should be avoided because they stimulate intestinal peristalsis. 137. whole grains. and truncus arteriosus. breakthrough bleeding. Serum progesterone levels indicate whether ovulation has occurred and correlate well with basal body temperature changes but don't indicate the number of follicles. dried fruit and beans. 139. A The objective of menotropins therapy is to produce one or two healthy follicles. D Some adverse effects of birth control pills. bran. 138. B Coarctation of the aorta causes signs of peripheral hypoperfusion. ventricular septal defect. The other three interventions are all helpful to the client and his recovery but are less important. 141. by carefully monitoring the client's ultrasound study results and serum estradiol levels. This keeps the endotracheal tube in place without requiring a cuff. and decreased menstrual flow may occur as a normal response to the use of birth control pills. A Clients with ulcerative colitis should be encouraged to consume foods high in protein and calories to promote healing. Because these two effects in particular may be precursors to cardiovascular compromise and embolus. require a report to the health care provider. 140. D The nurse is using focusing by suggesting that the client discuss a specific issue. Breast tenderness. 135. the client may need to use another form of birth control. These signs are rare in patent ductus arteriosus. C Injury to the gastric mucosa causes gastric atrophy and impaired function of the parietal cells. Clients should also be encouraged to avoid raw fruits and vegetables.
D A nonrebreathing mask provides the highest possible oxygen concentration--up to 95%. B Impotence is defined as the inability to achieve penile erection. Ice causes decreased blood flow to the affected joint. Infertility is the term used when a man's semen is incapable of impregnating a woman. Nurses frequently make judgments about pain based on behavior. comfort the child with objects with which he's familiar. D Toddlers are naturally curious about their environment and letting them handle minor equipment is distracting and helps them gain trust in the nurse. 145. 144. believe the pain rating. and the nurse must document what the child reports. A Venturi mask delivers precise concentrations of 24% to 44%. because the same amount of room air always enters the mask opening. Eventually. A nasal cannula doesn't deliver concentrations above 40%. A partial rebreathing mask delivers oxygen concentrations up to 90%. regardless of the client's respiratory pattern. which can result in children being inadequately medicated for pain. which is necessary for the absorption of vitamin B12. such as "Do you want me to listen first to the front of your chest or your back?" 146. Reincarnation is associated with Far Eastern religions. The child should be given limited choices to allow autonomy. Also. pernicious anemia will occur. The nurse should turn the client frequently to prevent skin breakdown and conserve the client's energy. increasing pain.production of intrinsic factor. and celibacy is a practice in a number of the world's religions. Prophecy is a focus of such religions as Seventh-Day Adventism and Fundamental Baptist. If a child's behavior appears to differ from the child's rating of pain. relieving pain. including celibacy and asexuality. TENS application is reserved for chronic pain. D Black Muslims stress the importance of cooperation among black business and education in the elevation of the self-esteem of its adherents. A child who uses passive coping behaviors (such as distraction and cooperation) may rate pain as more intense than children who use active coping behaviors (such as crying and kicking). C Warm compresses increase blood flow to the affected joint. Disinterest in sexual intimacy can be labeled with a number of terms. and should approach the child slowly and unhurriedly. The caregiver should be encouraged to hold and console her child. 143. 147. B Pain is what the child says it is. The nurse should only expose one area at a time during assessment. It also involves being unable to maintain an erection to the point of ejaculation. . 142.
The volume deficit may be caused by vomiting. Assessment findings are more important than ABG analysis in determining whether the client requires intubation or if respiratory arrest is imminent. Because children with Down syndrome can vary from mildly to severely mentally challenged. After chest tube insertion. A Respiratory acidosis is associated with hypoventilation. not the chronological age. Willingness to touch and hold the neonate. especially one with mild limitations. A child with Down syndrome is capable of learning. 152. the nurse can safely monitor the heart rhythm. Hypovolemic shock would cause a decrease in cardiac output. expressing interest about the neonate's size. which in this client suggests intake of a drug that suppresses the brain's respiratory center. B The client may have a difficult time sitting long enough to eat his meal. Gear teaching toward the appropriate developmental age. 155. the client's respiratory status has improved. After the client's respiratory function has been stabilized. Therefore. ABG analysis in respiratory alkalosis shows an elevated pH and a low PaCO2. hemorrhage (in hemorrhagic pancreatitis). therefore. D Parental interaction will provide the nurse with a good assessment of the stability of the family's home life but it has no indication for parental bonding. A Clients with acute pancreatitis commonly experience deficient fluid volume. D The original ABG analysis reveals respiratory acidosis commonly seen with a pneumothorax. C Nursing care should be planned at the developmental age of a child with Down syndrome. which can lead to hypovolemic shock. . B Direct questions (such as "Do you hear voices?" or "Do you feel safe right now?") are the most appropriate technique for eliciting verifiable responses from a psychotic client. The other options may not elicit helpful responses. The other foods require the client to sit and eat. and obtain a urine sample for drug screening. pH is increasing toward normal. and the PaCO2 is decreasing. the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. 154. finger foods that can be eaten easily are most appropriate. 153. and plasma leaking into the peritoneal cavity. prepare for gastric lavage. a task the client will be unable to achieve at this time. 149.148. 151. but this wouldn't be the primary nursing diagnosis. Tissue perfusion would be altered if hypovolemic shock occurred. and indicating a desire to see the neonate are behaviors indicating parental bonding. A Psychosocial factors should be suspected when pain persists beyond the normal tissue healing time and physical causes have been investigated. 150. The other choices may or may not be correct but certainly aren't credible in all cases. each child should be individually assessed.
The nurse should also keep the client warm by maintaining his room temperature between 68° and 74°F (20° and 23. C In diverticulitis. 159. An unpredictable amount of activity may trigger unstable angina. 161. Matching the room temperature with the client's body temperature is inappropriate. The valves in their arteries and veins are already insufficient and exposing them to vast changes in temperature could influence the client's response.3℃). 157. Keeping the client uncovered would lead to chilling. A varying urge to urinate with an average urine output of 100 mL is a classic picture of a client whose bladder is distended and needs to be catheterized to restore normal function. in turn. D Parasympathetic hyperactivity leading to sudden hypotension secondary to bradyrhythmia causes vasovagal syncope. 158. A Prinzmetal's or variant angina is triggered by coronary artery spasm. Extreme temperatures aren't good for clients with PVD. Because the client may be voiding and may not have an urge to void doesn't mean that bladder function has been properly restored. Ignoring the crying and screaming may be the second step. Bananas and milk products aren't contraindicated. Fiber and residue are recommended in the diet. The bicarbonate ( ) value indicates the amount of bicarbonate or base in the blood. vascular fluid shifting. the partial pressure of arterial carbon dioxide (PaCO2) value represents the amount of carbon dioxide dissolved in the blood. the best approach is to talk to the mother and ignore the toddler at first. vegetables with seeds are prohibited in the diet because the seeds can lodge in diverticula and cause flareups. A The nurse should keep the client covered and expose only the portion of the client's body that is being assessed. The last resort is to bring in assistance so the procedure can be completed quickly.156. This approach helps the toddler get used to the nurse before she attempts any procedures. Having the mother hold the toddler will help if she can do this. C When dealing with a crying toddler. Vasovagal syncope isn't caused by vestibular (inner ear) dysfunction. A room temperature of 78°F may be too warm for some clients and too cool for others. That is. leads to syncope. It also gives the toddler an opportunity to see that the mother trusts the nurse. or postural hypotension. C Retention with overflow is a commonly missed nursing assessment. . bradyrhythmia leads to cerebral ischemia which. 160. Activities that increase myocardial oxygen demand may trigger predictable stable angina. 162. The partial pressure of arterial oxygen (PaO2) value indicates the amount of oxygen dissolved in the blood. A The pH in an ABG report reflects the acid concentration in the blood.
but their frequency is determined by the child's status. to discuss questions of care with the physician. B The client should be encouraged to increase his activity level. Administering the medication would be an act of negligence. following a low-cholesterol. A weight check every 2 weeks also is unnecessary. Obtaining daily weight and monitoring intake and output also provide evidence of the child's fluid balance status. A nurse can't discontinue a medication without a physician's order. Typically. Checking urine specimens for protein and specific gravity and daily monitoring of serum electrolyte levels may be done. A Because major complications--such as hypertensive encephalopathy. These are less important nursing measures in this situation. Maintaining an ideal weight. not the client's. Reporting the client's concern about weight gain to the health care provider isn't necessary at this time. 165. Deficiencies associated with immaturity become more important with decreasing age. It's also important for the nurse to determine whether the client has any complicating problems such as an eating disorder. Coup and contrecoup are types of injuries in which the damaged area on the brain forms directly below the site of impact (coup) or at the site opposite the injury (contrecoup) due to movement of the brain within the skull. and cardiac decompensation--can occur. acute renal failure. C Factors related to growth and maturation significantly alter an individual's capacity to metabolize and excrete drugs. monitoring vital signs (including blood pressure) is an important measure for a child with acute glomerulonephritis. with most increasing to adult levels within I to 8 weeks after birth. and the nurse should question their use in a client with cardiac disease. the premature infant is at risk for problems because of immaturity. protein intake remains normal for the child's age and is only increased if the child is losing large amounts of protein in the urine. A Weight gain during pregnancy is a normal concern for most women. 166. Sodium and water restrictions may be ordered depending on the severity of the edema and the extent of impaired renal function. Enzyme systems develop quickly. Within the 1st year of life. The nurse must first teach the client about normal weight gain and diet in pregnancy. A contusion is bruising of the brain tissue with small hemorrhages in the tissue.163. Thus. B Concussions are considered minor with no structural signs of injury. all are probably as active as they will ever be. low- . 167. 168. 164. C Cardiovascular toxicity is a problem with tricyclic antidepressants. then assess the client's response to that information. It's the nurse's responsibility.
However. 171. Weighing the client is the easiest. and avoiding stress are all important factors in decreasing the risk of atherosclerosis. and trusting and is less anxious. D Sleeping undisturbed for a period of time would indicate that the client feels more relaxed. these also could be diversions. Because tap water is hypotonic.sodium diet. comfortable. 170. It would be unusual for an adolescent to develop heart failure unless the overhydration was extreme. it helps identify rather than contribute to fluid imbalance. Abrupt withdrawal of endogenous cortisol may lead to severe adrenal insufficiency. 174. most accurate method to determine fluid changes. A Because of the inflammation of the meninges. A The client has symptoms of lithium toxicity. Hypovolemic shock would occur with an extreme loss of fluid or blood. Fluid overload won't cause dehydration. Drinking broth wouldn't contribute to a hyposmolar state because it doesn't replace sodium and water lost through excessive perspiration. Therefore. Decreasing eye contact. Signs of hypocortisolism include vomiting. A nurse can't discontinue a medication without a physician's order. This increase causes the veins to distend and can be seen most obviously in the neck veins. Therefore. dehydration and hypotension. After the corticotropin-secreting tumor is removed. it would be absorbed by the body. but it doesn't directly contribute to jugular vein distention. and joking may also indicate that the client is more relaxed. causing vasodilation and bradycardia. asking to see family. The oral. 173. 175. and administering another dose would increase the toxic effects. the client is vulnerable to developing cerebral edema and increased intracranial pressure. Steroids should be given during surgery to prevent hypocortisolism from occurring. NG tube irrigation with normal saline solution wouldn't cause a shift in fluid balance. and tympanic routes are appropriate for measuring the temperature of cardiac clients. the rectal route should be avoided. increased weakness. 172. axillary. the client shouldn't be at . diluting the body fluid concentration and lowering osmolality. A The nurse should assess for hypocortisolism. These aren't normal adverse effects. Introducing a thermometer into the rectum may stimulate the vagus nerve. D Fluid overload causes the volume of blood within the vascular system to increase. B When caring for the client with a cardiac disorder. An electrolyte imbalance may result in fluid overload. C Administering a tap water enema until return is clear would most likely contribute to a hyposmolar state. her lithium should be held and the physician notified immediately. 169.
178. Drinking apple juice and limiting dairy products don't affect the outcome of treatment of pinworms. Blood level checks aren't necessary. A significant involutional complication is the failure of the uterus to return to the pelvic cavity within the prescribed time period. Trendelenburg's position is contraindicated because it can raise ICP. resulting in cerebrospinal fluid (CSF) leaking through the ears and nose. B She should listen to the body's way of telling her that she needs more rest and try going to bed earlier. . The client must be instructed to continue taking the drug as directed. 176. benzodiazepine overdose. B Because pinworms are highly contagious. all family members should be treated simultaneously. such as tachycardia. 180. 182. Side-lying isn't specifically a therapeutic treatment for increased ICP. White patches signal oral candidiasis. Vitamin K stimulates the liver to produce clotting factors. which is necessary for blood coagulation. 179.risk for hypoglycemia or hyperglycemia. This is known as subinvolution. A The normal involutional process returns the uterus to the pelvic cavity in 7 to 9 days. A Otorrhea and rhinorrhea are classic signs of a basilar skull fracture. systolic hypertension. and anxiety--all seen in adrenergic (sympathetic) stimulation. which is unrelated to pinworm infestation or treatment. Manifestations of hypovolemic shock. 181. B Neonates are at risk for bleeding disorders during the 1st week of life because their GI tracts are sterile at birth and lack the intestinal flora needed to produce vitamin K. False reassurance is inappropriate and doesn't help her deal with fatigue now. and Addison's disease are more similar to a hypometabolic state. B Hyperthyroidism is a hypermetabolic state characterized by signs. B For clients with increased intracranial pressure (ICP). Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. which is an inherited metabolic disease. 177. NMS hasn't been reported with this drug. Vitamin K doesn't prevent PKU. Injury to the dura commonly occurs with this fracture. but tachycardia is frequently reported. the head of the bed is elevated to promote venous outflow. D The client should be informed that the drug's therapeutic effect might not be reached for 14 to 30 days. Vitamins won't take away fatigue. 183. Sleeping pills shouldn't be consumed prenatally because they can harm the fetus. Calcium imbalance shouldn't occur in this situation. Any fluid suspected of being CSF should be checked for glucose or have a halo test done.
the fascia is opened along the length of the muscle compartment and the skin is left open to prevent . Excoriation is more common in skin disorders associated with a moist environment. Special precautions aren't needed when feeding the client. A The client is exhibiting clinical signs and symptoms of a myocardial infarction (MI). Suctioning is vital but won't prevent tracheal dilation. reducing anxiety and relieving pain. and providing a nondemanding environment are secondary to improving myocardial oxygenation and reducing workload. A serum peak and trough level (taken half an hour before the dose and half an hour after the dose has been administered) around the third dose (the third dose provides enough medication build up in the blood stream to be measured) is the most accurate way to determine the correct serum values. C To prevent tracheal dilation. therefore. brown. C Aminoglycosides such as gentamicin have a narrow range between therapeutic and toxic serum levels. 188. crusting lesions are also uncommon unless the reaction is quite severe or has been present for a long time. C During fasciotomy. such as cleaning products. Clients usually report the urge to defecate--although they can't pass stool-and decreased appetite. a serum peak level after the second dose. a minimal-leak technique should be used and the pressure should be kept at less than 25 cmH2O. A The passage of liquid or semiliquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. This technique is used when weaning the client from tracheal support. and urine. 185. Confirming the diagnosis of MI and preventing complications. A Contact dermatitis is caused by exposure to a physical or chemical allergen. but disposable utensils should be used. Clients with fecal impaction don't pass hard. 186. and serial serum trough levels won't provide sufficient data about the effectiveness of the antibiotic. formed stools because the stool can't move past the impaction. B The nurse should wear gloves and a gown when removing the client's bedpan because the type A hepatitis virus occurs in stools. 189. A trough level every morning. erythema. skin care products. 190. Allergic reactions tend to be red and not scaly or flaky. Type A hepatitis isn't transmitted through the air by way of droplets. Initial symptoms of itching. Stressors can't be eliminated. Use of a cuffed tube alone won't prevent tracheal dilation. only reduced. 187. and raised papules occur at the site of exposure and can begin within 1 hour of exposure. and latex gloves. nursing care should focus on improving myocardial oxygenation and reducing cardiac workload.184. It may also occur in blood. Weeping. nasotracheal secretions. The tracheostomy shouldn't be plugged to prevent tracheal dilation.
such as hearing voices or seeing objects. and constipation aren't seen in hyperkalemia. C Cardiac tamponade is associated with decreased cardiac output. If pericardiocentesis is effective. C Petechiae are small hemorrhagic spots. tongue. and usually the compartment can be closed in 3 to 5 days. When the wound is closed. D A hallucination is a sensory perception. 196. Ideas of reference refers to the mistaken belief that someone or something outside the client is controlling his ideas or behavior. 191. bradycardia. and face are findings associated with hyperkalemia. feet. A sign to remind others to avoid needle sticks and to not give anything via the rectum. 192. that only the client experiences. 193. the needle may have entered the heart. The other actions are appropriate responses after ensuring the safety of other individuals. 194. Sterile dressings are applied but without applying pressure. Flight of ideas refers to a speech pattern in which the client skips from one unrelated subject to another. Tremors. should be aware of hospital security and other assisting personnel. A skin graft may be needed to complete closure at a later date. the presence of two peripheral IVs. Uremia is an excess of urea and other nitrogen products in the blood. Clients with cardiac tamponade may have muffled heart sounds. The other options may cause a relatively docile client to become belligerent. This teen's platelet level is decreased. Removing a small amount of blood may improve cardiac output and blood pressure. A delusion is a false belief. Osteomalacia is the softening of bone tissue. D The nurse's first priority is to consider the safety of the clients in the therapeutic setting. it may be sutured or secured with tape. A Muscle weakness. and paresthesia of the hands. nausea. so she's at risk for bleeding. which is transient and occurs from transient hypoaldosteronism when the adenoma is removed. 195. If blood clots rapidly. The nose is a vascular region that can bleed easily if the mucosa is dried by the oxygen. . resulting in decreased blood pressure. 197. C The nurse. Extravasation is the leakage of fluid in the interstitial space. Pericardial blood doesn't clot rapidly because it's defibrinated by cardiac motion within the cardiac sac. diaphoresis. for her own protection.further compression from swelling. C Oxygen should be humidified to assure that irritation of the mucosa doesn't occur. The wound is watched closely. and the use of a tympanic temperature device are all aspects of care that would decrease the client's risk of bleeding. diarrhea. heart sounds become normal.
Waiting a few more months until the child is closer to age 2 years allows the child to develop more control. C Restraints should never be used on a child with a seizure disorder because they could harm him if a seizure occurs. for a school-age child. which increases the heart's need for oxygen and can precipitate angina. D The nursing actions described constitute evaluation of expected outcomes.198. and put together puzzles. 203. 200. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. 204. Because they could damage the operative site. A critical environment erodes a person's esteem. 199. 201. and laboratory studies. The bag and mask system should be present in case the child needs oxygen during a seizure. but knowing whether the child is ready to toilet train is initially most appropriate. A A structured lifestyle demonstrates acceptance and caring and provides a sense of security. for a toddler. Anginal pain typically is self-limiting and lasts 5 to 15 minutes. Lawn mowing increases the cardiac workload. Padded side rails will prevent the child from injuring himself during a seizure. 202.or 6-year-old child. The suture line should be cleaned gently to prevent infection. D All of the instructions are appropriate. Many 17-month-olds don't have the neuromuscular control to be able to be trained. which could interfere with healing and damage the cosmetic appearance of the repair. suction catheters. . Implementation is the phase of the nursing process where the nurse puts the plan of care into actiorn. Inconsistent boundaries lead to feelings of insecurity and lack of concern. a pull toy. C Soft restraints from the upper arm to the wrist prevent the infant from touching his lip but allow him to hold a favorite item such as a blanket. Physical discipline can decrease self-esteem. B At age 3. such objects as pacifiers. Food consumption doesn't reduce this pain. physical examination. and a computer game. Assessment consists of the client's history. but may ease pain caused by a GI ulcer. Dried blood collecting on the suture line can widen the scar. D Angina pectoris is chest pain caused by a decreased oxygen supply to the myocardium. Cardiopulmonary monitoring should be readily available for checking vital signs during a seizure. A bicycle is appropriate for a 5. children like to color. The mother should be taught the signs of readiness for toilet training. Deep breathing has no effect on anginal pain. draw. The findings show that the expected outcomes have been achieved. A baby in a prone position may rub her face on the sheets and traumatize the operative site. and small spoons shouldn't be placed in a baby's mouth after cleft palate repair.
however. Exposure to rubella doesn't affect a woman's ability to breast-feed. C ARDS results from increased pulmonary capillary permeability. Rubella immunization isn't recommended for children until age 12 to 15 months. 212. B The nurse should encourage the client to increase her fluid intake to approximately 3 qt (3 L)/day for 24 to 48 hours. D Fetal defects can occur during the first trimester of pregnancy if the pregnant woman gets rubella. A Late deceleration is caused by uteroplacental insufficiency. lochia changes from bright red (rubra). The client doesn't need to limit fluids with meals as long as the fluids aren't gastric irritants. 208. which leads to noncardiogenic pulmonary edema. Aspirin shouldn't be given to young children because it has been implicated in the development of Reye's syndrome. such as coffee and alcohol. Early deceleration is caused by head compression. it doesn't cause ARDS. and variable deceleration is caused by umbilical cord compression. Tylenol should be used instead. the nurse should advise the client to avoid foods and beverages that tend to increase stomach acid. to clear white (alba). 209. and to take antacids after eating. The headache is most likely due to decreased cerebrospinal fluid (CSF) . A As the uterus involutes and the placental attachment area heals. The nurse also should teach the client to avoid lying down after meals. Severe SIADH can cause such complications as vascular fluid overload. In the initial stage of ARDS. which can aggravate reflux. Tetanic contractions aren't associated with this disorder. to pinkish (serosa).205. Facing the shower head can stimulate the breasts and intensify the problem. Renal failure also doesn't cause ARDS. Frequent feedings will permit the breasts to empty fully and establish the supply-demand cycle that is appropriate for the infant. which is signaled by neck vein distention. respiratory alkalosis may arise secondary to hyperventilation. The other options are incorrect. Fetal acceleration is a sign of fetal well-being. pulmonary congestion occurs secondary to heart failure. In cardiogenic pulmonary edema. B SIADH causes antidiuretic hormone overproduction and leads to fluid retention. B To prevent reflux of stomach acid into the esophagus. 211. 207. 206. Binding the breasts isn't appropriate because the constriction will diminish the milk supply. 210. D Engorgement in a breast-feeding woman requires careful management to preserve the milk supply while managing the increased blood flow to the breasts. but weight gain and fluid retention from oliguria are. Frozen cabbage leaves work well to reduce the pain and swelling and should be applied every 4 hours.
and raising the head of the bed may worsen the headache. A A 10-mm induration strongly suggests a positive response in this tuberculosis screening test--so. 218. PTU blocks the conversion . Option B is judgmental. Results of stool or urine analyses may provide information. Option D focuses more on the nurse than on the client's need. or improve maternal comfort. C In a client with chronic renal failure. free a trapped cord. 217. 216. potassium. causing pain. A temperature of 99. Lying flat may decrease pain. meat (high in protein). The serum sodium level normally ranges from 135 to 145 mEq/L. bananas (high in potassium). such as amino acids and ammonia. 213. A score of 4 to 6 would indicate moderate distress. 220. A These actions. protein. 214. dark amber urine is concentrated and. increase the amount of maternal circulating oxygen by taking pressure created by the uterus off the aorta and improving blood flow. Therefore. The movement causes tension on the meninges and venous sinuses. Potassium iodide reaches its maximum effect in 1 to 2 weeks.6°F is only slightly elevated and doesn't indicate fluid volume deficit. The posterior fontanel usually closes between ages 6 and 8 weeks and therefore doesn't reflect fluid balance in a 9-month-old infant. The remaining options aren't positive reactions to the test and require no further evaluation. and fluid because the kidneys can't secrete adequate urine. This fluid loss allows the brain to move abnormally within the skull. and fluids may lead to a dangerous accumulation of electrolytes and protein metabolic products. D Normally. the client must limit his intake of sodium. 215. a 15-mm induration clearly requires further evaluation. D Potassium iodide reduces the vascularity of the thyroid gland and is used to prepare the gland for surgery. A Option A redirects the client to focus his comments and allows him to make his point. which will improve fetal hypoxia.circulating around the cranium. Neck vein distention is a sign of fluid volume overload. and option C doesn't help facilitate communication. unrestricted intake of sodium. suggests continued fluid volume deficit. A An Apgar score of 8 indicates that the neonate has macte a good transition to extrauterine life. urine appears light yellow. a score of 0 to 3 would indicate severe distress. 219. These actions won't improve the contraction pattern. A Frequent assessment of weight provides important information about fluid balance and the infant's response to fluid replacement. but they're typically not available for at least 24 hours. in this client. Extra oral fluid intake will increase CSF production.
obesity. Although moderate exercise promotes circulation. A 15month-old child should be able to say two words. Ataxia and intention tremors are seen with a cerebellar brain tumor. 224. leg cramps cause shortening of the gastrocnemius muscle in the calf. 223. Excessive calcium intake may cause hypercalcemia. Dorsiflexing or standing on the affected leg extends that muscle and relieves the cramp. and rhinorrhea isn't usually present. PTU effects are also seen in 1 to 2 weeks. 221. which . A Cognitive distortions are similar in both disorders. C Common during late pregnancy. A According to the Denver II Developmental Screening test. 227. 226. the nurse should practice contact isolation. promoting leg cramps. A 10. therefore. clients are usually given a beta-adrenergic blocker such as propranolol. the toddler should be able to feed himself with a spoon. the small intestine becomes blocked with thick meconium. difficile can be transmitted from person to person by hands or waste containers such as a bedpan. walking 2 hours per day during the third trimester is excessive. pericardial pain is commonly pleuritie and eases when the heart is pulled away from the diaphragmatic pleurae of the lungs. calcium supplements or additional servings of high-calcium foods may be unnecessary. D Unilateral hearing loss that occurs over an extended time and tinnitus are classic signs and symptoms of an acoustic neuroma. most infants should be able to sit unsupported by age 7 months. To relieve symptoms of hyperthyroidism in the interim. Myocarditis has nonspecific symptoms that reflect the accompanying systemic infection. meconium ileus is the earliest indication that a neonate has the disorder. When in direct contact with the client. DC. 228. The hallmark indication of endocarditis is intermittent fever and malaise resulting from infection of the endocardium. C An IABP inflates during diastole when the tricuspid and mitral valves are open and the aortic and pulmonic valves are closed. C Pericarditis is an inflammation of the fibroserous sac that envelops the heart. Steatorrhea may be present later and may be used as a guideline for administration of pancreatic enzymes. Infants and children with this disorder have increased sodium levels.month-old should be able to play patty-cake. B In cystic fibrosis. Amenorrhea. The anorectic client is more likely than the bulimic client to overexercise for weight control. the more biologically active thyroid hormone. 222. If the client eats a balanced diet. By 17 months. 225. and acromegaly are signs of a pituitary tumor. Unlike the pain of an MI. Rarely do people with eating disorders have relaxed personalities.of thyroxine to triiodothyronine. the physician must evaluate the client's need for calcium supplements.
230. B Postoperatively. Therefore. but the client should be placed in isolation first. D By the time the client is hemorrhaging. The remaining options are unlikely to be as successful' in achieving this outcome. such as metoclopramide. helps prevent dehydration. such as dexamethasone. broken skin. this medication is administered intrathecally to ensure the entire body receives . C Administration of an antiemetic. Monitoring fluid intake and output may be required. D Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. to decrease the risk of abdominal distention and obstruction. A negative-pressure room is used when the organism is spread by the airborne route. The NG tube isn't flushed. 231. Fundal massage is appropriate to ensure that the uterus is well contracted. and body fluids and substances. a common complication of chemotherapy. this isn't evident in this case. The client will probably require pain medication more often then every 6 hours. The client may have arm and leg weakness or an absent gag reflex after a CVA. Inadequate vitamin D intake and low calcium levels aren't factors in poor healing for this client. but these findings aren't related to aphasia. inadequate protein intake impairs wound healing. blood. C Because the IV route doesn't allow chemotherapeutic agents to reach all areas invaded by leukemic cells. 232.includes wearing gloves and a gown. The client should be positioned for comfort (not necessarily the high Fowler position). Assessing the temperature every 8 hours isn't frequent enough for a client with a fever. can reduce the severity of chemotherapy-induced nausea and vomiting. a pad count is no longer appropriate. Neutropenic precautions are for clients with an absolute neutrophil count of 1. which isn't evident in this case. Protective isolation is used to protect a client who is immunocompromised. Difficulty swallowing is called dysphagia. 233. Inserting an indwelling urinary catheter eliminates the possibility that a full bladder may be contributing to the hemorrhage. A pressure ulcer should never be massaged. the client should have nothing by mouth until peristaltic activity returns. and an anti-inflammatory. B Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis).000/μL or less. to avoid disturbing the suture line. respiratory isolation is indicated. 229. This in turn. difficile diarrhea. and oxytoxics may be ordered to promote sustained uterine contraction. The nurse should only wear gloves for contact with mucous membranes. 235. B A client on bed rest suffers from a lack of movement and a negative nitrogen balance. 234. which isn't true of C.
rather than insulin. Aerobic exercise helps increase cardiac output and decrease heart rate. Although this medication may be given by mouth. 241. Oral antidiabetic drugs aren't used in pregnant females. D The client's blood glucose level should be controlled initially by diet and exercise. Encouraging the client to discuss his concerns with the clergy is also appropriate. 236. 242. D Risk for aspiration related to anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes. Making a statement about her being too young to be pregnant is a value judgment and inappropriate. which can exacerbate palpitations and should be avoided by a client with symptomatic mitral valve prolapse. although important. or IV. B When talking with adolescents. The client will be encouraged to get out of bed the first day after surgery to prevent complications of immobility. 239. Contractions don't decrease in intensity. The other choices could also be related to stress and anxiety but they don't occur as commonly as diarrhea. B The nurse shouldn't invite his clergyman to visit the client. 237. are secondary.treatment. 238. The nurse should be able to discern that information by the client's behavior. High-fluid intake helps maintain adequate preload and cardiac output. C The nurse should ensure that the client understands that a stoma will be formed and that he'll need to wear a pouch. Acknowledging the client's spiritual distress may help the nurse build a therapeutic relationship with the client. possibly leading to aspiration. unless the client specifically asks to see that member of the clergy. The nurse will care for the stoma immediately after surgery. it's best to get their viewpoints and thoughts first. self-care will begin when the client is physically able. A An increased sense of rectal pressure indicates that the client is moving into the second stage of labor. Urine sugars aren't an accurate indication of blood glucose levels. Doing so promotes therapeutic communication. B Diarrhea is a common physiological response to stress and anxiety. 243. 240. Encouraging the client to discuss religious beliefs and practices is a first step in developing a plan for the client. these routes would be inappropriate in this situation. C Caffeine is a stimulant. Protein-rich foods aren't restricted but highcalorie foods are. Asking whether the mother knows or about the baby's father focuses the attention away from the adolescent. The client will need to watch her overall diet intake to control her blood glucose level. there isn't a change in . IM. The other options. Urine flow can't be controlled through a stoma.
With a compound . Neonates who develop severe jaundice as a result of Rh and ABO incompatibility will exhibit lethargy or irritability and poor feeding patterns. 244. If bilirubin levels are high enough to cross the blood brain barrier (usually 20 mg and higher). Ventilation of the site and keeping the site fully covered are practices in some institutions but aren't hallmarks of donor site care. Tracheal breath sounds are auscultated over the trachea. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Likewise. should be used to prevent severe hip flexion. Friction rubs occur with pleural inflammation. and nausea and vomiting don't usually occur. Hemoglobin is responsible for oxygen transport. an important part of wound healing. B Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. 246. D The client should be encouraged to consume foods high in vitamin C because it's essential for protein synthesis. such as a raised toilet seat. Placing the site in a position of dependence isn't a justified aspect of donor site care. and diversionary tactics. 249. 250. 245. time limits. A In the scenario. the most important assessments must include those addressing the problem of a rising bilirubin. airway and breathing are established so the nurse's next priority should be circulation. Coarse crackles are caused by secretion accumulation in the airways. rocking. A sock puller helps a client get dressed without flexing the hips beyond 90 degrees. teaching the client to avoid crossing the legs also reduces the risk of hip dislocation. An older child or a child without Down syndrome may benefit from positive self-talk. C A universal concern in the care of donor sites for burn care is to keep the site away from sources of pressure. D To prevent hip dislocation after a total hip replacement. 247. the neonate is at serious risk for neurologic impairment due to permanent cell damage (kernieterus). the client must avoid bending the hips beyond 90 degrees. C The child with Down syndrome may have difficulty coping with painful procedures and may regress during his illness.fetal heart rate variability. such as counting and singing. C Although weight loss may be greater than 10%. Hemostasis is responsible for the inflammatory response and reducing edema. and giving the child a security object may be comforting to the child. Assistive devices. but the success of these tactics depends on the child. 248. Holding.
Large-forgestational-age weight is above the 90th percentile. Duodenal ulcers and hemorrhoids aren't a preexisting condition of colorectal cancer. D Colorectal polyps are common with colon cancer. A urinary tract infection and renal calculi aren't palpable. Frequency of the compulsive behavior should be reduced gradually.fracture of the femur. " Disciplining the child for the behavior may have an adverse affect on his psychosocial development. and this behavior shouldn't be characterized as "bad. The feeling of pressure is usually relieved with urination. D The bladder isn't usually palpable unless it's distended. Neonates who have respiratory distress or are postdated will use up their stores of brown fat as a result of these complications. Neurologic assessment is a secondary concern to airway. The nurse shouldn't call attention to or prevent the behavior. Encouraging the client to verbalize anxieties may help distract his attention from the compulsive behavior. Weight loss--not gain--is an indication of colorectal cancer. the nurse should assess the site. doing so may cause pain and terror in the client. 254. and small-forgestational-age is below the 10th percentile for age. D Neonates delivered by cesarean birth without any other contributing factors should have adequate stores of brown fat to control blood glucose levels. therefore. Holding the cane close to the body prevents leaning. 253. 255. A Appropriate-for gestational-age neonate weights fall between the 10th and the 90th percentiles for age. A The nurse should designate times during which the client can focus on compulsive behavior or obsessive thoughts. The nurse doesn't have enough data to warrant putting the client in Trendelenburg's position. Supervising a 6-yearold's bath won't foster the child's initiative. A Exploring genitalia is normal for a school-age child. Instructing the parent to "ignore it and hope that he outgrows it" is subtly implying that the child's behavior should be of concern if it doesn't stop by a certain age. Reduced bladder tone due to general anesthesia is a common postoperative complication that causes difficulty in voiding. 257. Use of a cane won't maintain stride length or prevent edema. 251. Stores of brown fat aren't deposited until 36 weeks. B Holding a cane on the uninvolved side distributes weight away from the involved side. so infants born at less than 36 weeks won't have the necessary stores to maintain a normal blood glucose level. not rapidly. The kidneys aren't palpable above the symphysis pubis. which is the developmental milestone for school-age children. there is a high risk of profuse bleeding. 252. breathing. 256. . and circulation.
Nurses do. B 262. A widened. A 261. B 265. frontal. A detailed description of physical findings of abuse in the medical record is essential if legal action is pursued. . 259. It's shaped like a diamond and normally measures 4 to 5 cm as its widest point. A An NG tube that fails to drain during the postoperative period after gastrectomy should be reported to the physician immediately.bulging fontanel is a sign of increased ICP. which could increase pressure on the suture line because fluid isn't draining adequately. Contacting the client's husband without her consent violates confidentiality. have a duty to report cases of actual or suspected abuse in children or elderly clients. Repositioning or irrigating the tube in a client who has bad gastric surgery can disrupt the anastamosis. All women suspected to be victims of abuse should be counseled on a safety plan. The nurse should not report this suspicion of abuse because the client is a competent adult who has the right to self-determination. 260. D The anterior fontanel is formed by the junction of the sagittal. which consists of recognizing escalating violence within the family and formulating a plan to exit quickly. The nurse should respond to the client in a nonthreatening manner that promotes trust. Increasing the level of suction may cause trauma to GI mucosa or the suture line. and coronal sutures. The tube may be occluded. A The nurse should objectively document her assessment findings.258. rather than ordering her to break off her relationship. B 264. however. A 263.
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