Saunders Pre Test and Post Test Exam Questions with Answers-Assured Success | Exams Nursing | Docsity (2024)

Download Saunders Pre Test and Post Test Exam Questions with Answers-Assured Success and more Exams Nursing in PDF only on Docsity! Saunders Pre Test and Post Test Exam Questions with Answers-Assured Success Dantrolene sodium is prescribed for the client experiencing flexor spasms. The client asks the nurse how the medication is going to help. The nurse replies that this medication acts in which way? 1.Depresses the spinal reflexes causing the spasms 2.Acts on the central nervous system to suppress spasms 3.Acts directly on the skeletal muscle to relieve the spasms 4.Acts within the spinal cord to suppress excess reflex activity - Correct Answers 3 The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. 1.Auscultating lung sounds 2.Obtaining the client's temperature 3.Assessing the strength of peripheral pulses 4.Obtaining information about the client's respirations 5.Performing a musculoskeletal and neurological examination 6.Asking the client about a family history of any illness or disease - Correct Answers 1 2 4 The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client? 1.Complaints of ringing in the ear 2.An excessive amount of crewmen in the ear canal 3.Intolerance for sound levels that do not bother other people 4.Complaints of dizziness and sensations of being "off balance" - Correct Answers 3 Hyperacusis is a change in hearing for a client and the intolerance for sound levels that do not bother other people. Ringing in the ears is known as tinnitus. An excessive amount of crewmen in the ear canal is not associated with hyperacusis. Complaints of dizziness and sensations of being "off balance" are known as vertigo. A client has chronic kidney disease (CKD) that does not yet require dialysis. Which client statement indicates the need for further teaching? 1."I will reduce the sodium in my diet, and I can use salt substitutes to spice my food." 2."The amount of fluid I can have every day depends on the amount of urine I put out." 3."I will weigh myself on my bathroom scale every morning right after I have urinated." 4."I should report a gain in weight, trouble with my breathing, or increased leg swelling." - Correct Answers 2 CKD is a condition in which the kidneys have progressive problems in their ability to clear nitrogenous waste products and control fluid and electrolyte balance within the body. Conservative treatment of CKD slows progression of the disease and includes reducing the protein, sodium, potassium, and phosphorus in the diet, and controlling the blood pressure. It is important to reduce the sodium in the diet. Salt substitutes usually are potassium-based and should not be used by a client with CKD because of the risk of hyperkalemia. The client should alter the fluid intake in relation to urine output. Obtaining a daily weight is an important measurement that indicates fluid volume. The client should also monitor for signs and symptoms of fluid overload, which could include an increase in weight, edema, and fluid collection in the lungs. The nurse caring for a client who has undergone kidney transplantation is monitoring the client for organ rejection. Which findings are consistent with acute rejection of the transplanted kidney? Select all that apply. 1.Oliguria 2.Hypotension 3.Fluid retention 4.Temperature of 99.6º F (37.6º C) 5.Serum keratinize of 3.2 mg/dL (282 memo/L) - Correct Answers 1 3 5 Acute rejection is the most common type that occurs with kidney transplants and occurs 1 week to any time postoperatively. It occurs over days to weeks. Findings consistent with acute rejection include oliguria or anuria; temperature higher than 100º F (37.8º C); increased blood pressure; enlarged, tender kidney; lethargy; elevated serum keratinize, blood urea nitrogen, and potassium levels; and fluid retention. A client with a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The nurse responds, knowing that the client's craving is a result of which factor? 1.Development of tolerance for the drug 2.Lack of naturally occurring endorphins 3.Client's psychological dependency on opiates 4.Typical abuse pattern for central nervous system depressants - Correct Answers 2 balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness. Tetracycline is prescribed for a client with severe acne. The nurse instructs the client regarding the importance of reporting which finding if it occurs? 1.Sunburn 2.Persistent diarrhea 3.Epigastric burning 4.Abdominal cramping - Correct Answers 2 Tetracycline can be used to treat severe acne. Adverse effects include gastrointestinal irritation manifested as epigastric burning, cramps, nausea, vomiting, and diarrhea. These effects do not need to be reported unless the diarrhea becomes persistent and severe. If this does occur, this could indicate another adverse effect, super infection. Clostridium difficile infection is another potential adverse effect associated with tetracycline use. In addition, photosensitivity is another potential effect, which can more easily result in sunburn. Clients should be instructed to wear sunscreen. A sunburn does not need to be reported necessarily, as this is an expected and self-limiting effect. Other adverse effects include yellowing of the teeth (which can occur in the unborn fetus), hepatotoxicity, and renal toxicity. The nurse is caring for a client in the emergency department who has sustained a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing that this sequence is compatible with which most likely condition? 1.Concussion 2.Skull fracture 3.Subdural hematoma 4.Epidural hematoma - Correct Answers 4 The changes in neurological signs from an epidural hematoma begin with loss of consciousness as arterial blood collects in the epidural space and exerts pressure. The client regains consciousness as the cerebrospinal fluid is reabsorbed rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail, even small amounts of additional blood cause the intracranial pressure to rise rapidly, and the client's neurological status deteriorates quickly. The nurse is providing instructions about treatment for hemorrhoids to a client in the second trimester of pregnancy. Which statement made by the client indicates a need for further teaching? 1."Cool sits baths will help in relieving the discomfort." 2."I should perform Keel exercises as you have instructed." 3."I should apply heat packs to the hemorrhoids to help them shrink." 4."I can apply ice packs to the hemorrhoids to assist in relieving discomfort." - Correct Answers 3 Hot packs will increase the blood flow to the area and worsen the discomfort from hemorrhoids. Remedies for the symptoms of hemorrhoids include ice packs, warm or cold sits baths, gentle cleansing, and topical ointments and anesthetic agents. Keel exercises help to strengthen the perineum. After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action? 1.Turn the child to the side. 2.Administer the prescribed antiemetic. 3.Maintain NPO (nothing by mouth) status. 4.Notify the primary health care provider (PHCP). - Correct Answers 1 After tonsillectomy, if bleeding occurs, the nurse immediately turns the child to the side to prevent aspiration and then notifies the PHCP. NPO status would be maintained, and an antiemetic may be prescribed; however, the initial nursing action would be to turn the child to the side. A client whose wife recently died of cancer says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house." What is the therapeutic nursing response? 1."It will take time to adjust to your terrible loss." 2."It must be hard to accept that she has passed away." 3."Try to focus on the fact that you and your wife loved one another for years." 4."Focus on the fact that her suffering is over and that she had a good life with you." - Correct Answers 2 The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply. 1.Administer regular insulin. 2.Encourage the child to ambulate. 3.Give the child a teaspoon of honey. 4.Provide electrolyte replacement therapy intravenously. 5.Wait 30 minutes and confirm the blood glucose reading. 6.Prepare to administer glucagon subcutaneously if unconsciousness occurs. - Correct Answers 3 6 Hypoglycemia is defined as a blood glucose level less than 70 mg/dL (4 mmol/L). Hypoglycemia occurs as a result of too much insulin, not enough food, or excessive activity. If possible, the nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; rapid-releasing glucose is followed by a complex carbohydrate and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not planned for more than 30 minutes or if activity is planned. If the child becomes unconscious, cake frosting or glucose paste is squeezed onto the gums, and the blood glucose level is retested in 15 minutes; if the reading remains low, additional glucose is administered. If the child remains unconscious, administration of glucagon may be necessary, and the nurse should be prepared for this intervention. A client has been prescribed betaxolol eye drops for the treatment of glaucoma. The ambulatory care nurse determines that the client understands proper medication use if the client states the need to return to the office for monitoring of what item(s)? 1.Hearing acuity 2.Blood pressure 3.Blood glucose level 4.Presence of calf pain - Correct Answers 2 The nurse educator is conducting an in-service education session for the nurses employed in the eye and ear surgical unit of a large trauma center. In discussing the topic of cochlear implants, the educator notes that this surgical procedure is contraindicated in which client? 1.A client with bilateral profound hearing loss 2.A client who communicates primarily by speech 3.A client who became deaf before learning to speak 4.A client who received no benefit from conventional hearing aids - Correct Answers 3 Adults who were born deaf or became deaf before learning to speak usually are not candidates for this type of surgery. Criteria for a cochlear implant procedure are bilateral profound hearing loss, use of speech as the primary mode of communication, lack of benefit from conventional hearing aids, evidence of strong family and social support, and realistic client expectations for the outcome of the implant procedure. The client has developed atrial fibrillation, with a ventricular rate of 150 beats/minute. The nurse should assess the client for which associated signs and/or symptoms? 1.Flat neck veins 2.Nausea and vomiting 3.Hypotension and dizziness 4.Hypertension and headache - Correct Answers 3 A HEPA filter mask must be worn whenever the nurse enters the client's room because these masks can remove almost 100% of the small TB particles. This mask must fit snugly around the nose and mouth. The nurse provides instructions regarding the administration of liquid oral cyclosporine solution to a client. Which statement, if made by the client, would indicate the need for further teaching? 1."I need to mix the concentrate well and drink it immediately." 2."I will mix the concentrate with orange juice to improve the taste." 3."I will purchase a dropper from the pharmacy to calibrate the amount of medication that I need." 4."After taking the medication, I need to rinse the container with diluent and drink it to ensure that I have taken the complete dose." - Correct Answers 3 The client needs to be instructed to dispense the oral liquid into a glass container using a specially calibrated pipette. The client should not use any other type of dropper to calibrate the amount of prescribed medication. The remaining options identify correct procedure for administering this medication. The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? 1.Avoid overuse of the eyes. 2.Decrease the amount of salt in the diet. 3.Eye medications will need to be administered for life. 4.Decrease fluid intake to control the intraocular pressure. - Correct Answers 3 The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life. The nurse is performing cardiopulmonary resuscitation (CPR) on a client who has had a cardiac arrest. An automatic external defibrillator (AED) is available to treat the client. Which activity will allow the nurse to assess the client's cardiac rhythm? 1.Hold the defibrillator paddles firmly against the chest. 2.Apply adhesive patch electrodes to the chest and move away from the client. 3.Connect standard electrocardiographic electrodes to a trans telephonic monitoring device. 4.Apply standard electrocardiographic monitoring leads to the client, and observe the rhythm. - Correct Answers 2 The nurse or rescuer puts two adhesive patch electrodes on the client's chest in the usual defibrillator positions. The nurse stops CPR and requests that anyone near the client move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates whether defibrillation is necessary. The primary health care provider is preparing to administer edrophonium to the client with myasthenia gravis. In planning care, the nurse understands which about the administration of edrophonium? Select all that apply. 1.Edrophonium is a long-acting cholinesterase inhibitor. 2.Atropine is used to reverse the effects of edrophonium. 3.If symptoms worsen following administration of edrophonium, the crisis is cholinergic. 4.Edrophonium is used to distinguish between a my asthenic crisis and a cholinergic crisis. 5.An improvement in symptoms following administration of edrophonium indicates my asthenic crisis. - Correct Answers 2 3 4 5 Edrophonium is an ultra-short-acting reversible cholinesterase inhibitor that can be used to distinguish between a cholinergic and a my asthenic crisis. To distinguish between overtreatment (cholinergic crisis) and under treatment (my asthenic crisis), edrophonium is administered; this is often referred to as a Tension test. Overtreatment of myasthenia gravis with reversible cholinesterase inhibitors results in a cholinergic crisis. Under treatment can result in a my asthenic crisis. Both cholinergic and my asthenic crises result in increased muscle weakness or paralysis. If symptoms improve after the administration of edrophonium, the crisis is my asthenic; if symptoms worsen, the crisis is cholinergic. Atropine must be readily available so that edrophonium can be reversed if the symptoms worsen. The nurse is collecting data from a client who is at 32 weeks' gestation. The nurse measures the fundal height in centimeters and expects the findings to be how many centimeters (cm)? 1. 22 cm 2. 28 cm 3. 32 cm 4. 40 cm - Correct Answers From 22 weeks until term, the fundal height measured in centimeters is roughly plus or minus 2 cm of the gestational age of the fetus in weeks. If the fundal height exceeds weeks of gestation, additional assessment is necessary to investigate the cause for the unexpected uterine size. If an unexpected increase in uterine size is present, it may be that the estimated date of delivery is incorrect and the pregnancy is more advanced than previously thought. If the estimated date of delivery is correct, it may be possible that more than 1 fetus is present. A case manager is reviewing the records of the clients in the nursing unit. Which occurrence, if noted in a client's record, would the nurse identify as a positive variance? 1.A client is performing colostomy irrigations. 2.The client with a leg ulcer is demonstrating signs of wound healing. 3.A postoperative client is discharged home 1 day earlier than expected. 4.The client with diabetes mellitus is administering insulin injections appropriately. - Correct Answers 3 Variances are actual deviations or detours from the critical path. Variances are positive or negative, avoidable or unavoidable, and may be caused by a variety of factors. A positive variance occurs when the client achieves maximum benefits and is discharged earlier than anticipated on his or her critical path. The nurse is reviewing the medical record for a client who has been diagnosed with Hodgkin's disease. The nurse should check which diagnostic test noted in the client's record to determine the stage of the disease? 1.Blood studies 2.Bone marrow examination 3.Excisional lymph node biopsy 4.Positron emission topography (PET) scan - Correct Answers A case manager is reviewing the records of the clients in the nursing unit. Which occurrence, if noted in a client's record, would the nurse identify as a positive variance? 1.A client is performing colostomy irrigations. 2.The client with a leg ulcer is demonstrating signs of wound healing. 3.A postoperative client is discharged home 1 day earlier than expected. 4.The client with diabetes mellitus is administering insulin injections appropriately. - Correct Answers Variances are actual deviations or detours from the critical path. Variances are positive or negative, avoidable or unavoidable, and may be caused by a variety of factors. A positive variance occurs when the client achieves maximum benefits and is discharged earlier than anticipated on his or her critical path. The nurse has administered diazepam 5 mg by the intravenous route to a client. The nurse should plan to maintain the client on bed rest for at least how long? 1. 1 hour 2. 3 hours 1."I should be sure to eat at least 1 cucumber every day." 2."Beet greens, parsley, or yogurt will help to control the colostomy odor." 3."I will need to increase my egg intake and try to eat ½ to 1 egg per day." 4."Green vegetables such as spinach and broccoli will prevent odor, and I should eat these foods every day." - Correct Answers 2 The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also may reduce odor, but it is a gas- forming food and should be avoided. Cucumbers, eggs, and broccoli also are gas- forming foods and should be avoided or limited by the client. Gemfibrozil is prescribed for a client. Which laboratory finding should alert the nurse to the need to withhold the medication and contact the primary health care provider? 1.Elevated glucose 2.Elevated triglycerides 3.Elevated liver function tests 4.Elevated blood urea nitrogen (BUN) - Correct Answers 3 Gemfibrozil is used to treat hypercholesterolemia. One adverse effect is hepatotoxicity. The medication does not affect glucose. An elevated triglyceride level is not an indication to hold the medication. An elevated BUN is unrelated to this medication and would not be an indication that the medication should be held. The nurse has administered prochlorperazine to a client for relief of nausea and vomiting. The nurse should then assess the client for which frequent side or adverse effect of this medication? 1.Diarrhea 2.Drooling 3.Blurred vision 4.Excessive tearing - Correct Answers 3 Prochlorperazine is a phenothiazine-type antiemetic and antipsychotic agent. A frequent side or adverse effect is blurred vision. Other frequent side and adverse effects of this medication are constipation, dry mouth, and dry eyes. A client who has had a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse should take which actions? Select all that apply. 1.Giving the client thin liquids 2.Thickening liquids to the consistency of oatmeal 3.Placing food on the unaffected side of the mouth 4.Allowing plenty of time for chewing and swallowing 5.Leave the client alone so that the client will gain independence by feeding self - Correct Answers 2 3 4 The client with dysphagia is started on a diet only after the gag and swallow reflexes have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration. The client is not left alone because of the risk of aspiration. The home care nurse is performing an assessment on a client with a diagnosis of Bell's palsy. Which assessment question will elicit specific information regarding this client's disorder? 1."Do your eyes feel dry?" 2."Do you have any spasms in your throat?" 3."Are you having any difficulty chewing food?" 4."Do you have any tingling sensations around your mouth?" - Correct Answers 4 Bell's palsy is a one-sided facial paralysis caused by compression of the facial nerve. Manifestations include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulties. The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply. 1.Allergy to pollen 2.History of headaches 3.Previous back injury 4.History of hypertension 5.History of diabetes mellitus - Correct Answers 2 3 4 5 Previous neurological problems such as headache or back injury place the client at greater risk for development of a neurological disorder. Chronic diseases such as hypertension and diabetes mellitus also place the client at greater risk. Assessment for allergies is a routine part of the health history, regardless of the nature of the client's problem. A client with acquired immunodeficiency syndrome (AIDS) is receiving ganciclovir. The nurse should take which priority action in caring for this client? 1.Monitor for signs of hyperglycemia. 2.Administer the medication without food. 3.Administer the medication with an antacid. 4.Ensure that the client uses an electric razor for shaving. - Correct Answers 4 Because ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects, the nurse monitors for signs and symptoms of bleeding and implements the same precautions as for a client receiving anticoagulant therapy. The medication may cause hypoglycemia, but not hyperglycemia. The medication does not have to be taken on an empty stomach or without food and should not be taken with an antacid. The nurse is teaching a woman in her first trimester measures to alleviate nausea and vomiting. Which statement by the woman indicates that further teaching is required? 1."I will avoid fried foods." 2."I will eat 5 or 6 small meals a day." 3."I will eat dry crackers for breakfast after I get up." 4."I will contact the clinic if the vomiting does not subside." - Correct Answers 3 Dry crackers should be eaten before getting out of bed rather than after arising. A pediatrician prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription? 1.Obtains a weight 2.Takes the temperature 3.Takes the blood pressure 4.Checks the amount of urine output - Correct Answers 4 In hypotonic dehydration, electrolyte loss exceeds water loss. The priority assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine output is less than 1 to 2 mL/kg/hr, potassium chloride should not be administered. Although options 1, 2, and 3 are appropriate assessments for a child with dehydration, these assessments are not related specifically to the IV administration of potassium chloride. The nurse is evaluating the condition of a client after pericardialcentesis performed to treat cardiac tamponed. Which observation would indicate that the procedure was effective? 1.Peritonitis 2.Appendicitis 3.Intussusception 4.Hirschsprung's disease - Correct Answers 2 The most common symptom of appendicitis is a colicky, per umbilical, or lower abdominal pain located in the right quadrant. Peritonitis is a complication that can follow organ perforation or intestinal obstruction. The classic signs and symptoms of intussusception are acute, colicky abdominal pain and currant jelly-like stools. Clinical manifestations of Hirschsprung's disease include constipation, abdominal distension, and ribbon-like, foul-smelling stools. A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal. The nurse should alert the primary health care provider because the vital sign changes and client assessment are most consistent with which complication? The client has a decreasing BP, increasing RR and HR 1.Cardiogenic shock 2.Cardiac tamponed 3.Pulmonary embolism 4.Dissecting thoracic aortic aneurysm - Correct Answers 1 Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension; a rapid pulse that becomes weaker; decreased urine output; and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock. The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. 1.Nausea 2.Confusion 3.Bradypnea 4.Tachycardia 5.Hyperkalemia 6.Lightheadedness - Correct Answers 1 2 4 6 Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis. During a mental status examination, the client states, "Glass breaks if you throw stones or shoot at it with a gun. My cousin shoots guns at the police all the time at target practice. People who live in glass houses shouldn't throw stones." How will the nurse appropriately document the client's speech? 1.Speech is incoherent and tangential. 2.Speech is illogical and loosely associated. 3.Speech is distractible and contains flight of ideas. 4.Speech is pressured and contains clang associations. - Correct Answers 2 Loose associations are speech patterns in which there is a lack of a logical relationship between thoughts and ideas; this causes speech and thought to seem inexact, vague, unfocused, and diffuse The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs? 1.Suctioning is required frequently. 2.The client's skin and mucous membranes are light pink. 3.Aspiration of gastric contents occurs during suctioning. 4.Excessive secretions are suctioned from the tube and stoma. - Correct Answers 3 Necrosis of the tracheal wall can lead to formation of an abnormal opening between the posterior trachea and the esophagus. The opening, called a tracheoesophageal fistula, allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents. Options 1, 2, and 4 are not signs of this complication. The community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, which is the immediate action? 1.Cooling the injury with water 2.Removing all clothing immediately 3.Removing the tar from the burn injury 4.Leaving any clothing that is saturated with tar in place - Correct Answers 1 Scald burns and tar or asphalt burns are treated by immediate cooling with saline solution or water, if available, or immediate removal of the saturated clothing. Clothing that is burned into the skin is not removed because increased tissue damage and bleeding may result. No attempt is made to remove tar from the skin at the scene. The nurse is admitting a 10-month-old infant who is being hospitalized for a respiratory infection. The nurse develops a plan of care for the infant and includes which most appropriate intervention? 1.Keeping the infant as quiet as possible 2.Restraining the infant to prevent dislodging of tubes 3.Placing small toys in the crib to provide stimulation for the infant 4.Providing a consistent routine with touching, rocking, and cuddling throughout hospitalization - Correct Answers 4 A 10-month-old is in the Trust versus Mistrust stage of psychosocial development according to Erikson. The infant is developing a sense of self, and the nurse should appropriately provide a consistent routine for the child. Hospitalization may have an adverse effect, and the nurse should touch, rock, and cuddle the infant to promote a sense of trust and provide sensory stimulation. A rubella titer is performed on a client who has just been told that she is pregnant. The results of the titer indicate that the client is not immune to rubella. Which should the nurse anticipate to be prescribed for this client? 1.Immunization with rubella 2.Retesting rubella titer during pregnancy 3.Antibiotics to be taken throughout the pregnancy 4.Counseling the mother regarding therapeutic abortion - Correct Answers 2 A rubella titer is performed to determine immunity to rubella. If the client's titer is less than 1:8, the mother is not immune. A retest during pregnancy is prescribed, and the mother is immunized postpartum if she is not immune. A client returning to the nursing unit after a cardiac catheterization procedure has a stat prescription to receive a dose of intravenous procainamide. Which piece of equipment would be most appropriate for the nurse to use in determining the client's response to this medication? 1.Glucometer 2.Pulse oximetry 3.Cardiac monitor 4.Noninvasive blood pressure cuff - Correct Answers 3 1."I'll come back later to see if you have changed your mind." 2."You don't have to take the medication if you don't want to." 3."This medication is going to help you get better, so why don't you go ahead and take it?" 4."Do you want me to call your primary health care provider (PHCP) and tell him you won't take your medication?" - Correct Answers 2 The client has the right to refuse medications or any other aspect of therapy. Therefore, the correct option is the therapeutic response. The nurse is collecting data from a client and notes that the client is taking carbamazepine. The nurse determines that this medication has been prescribed to treat which condition? 1.Glaucoma 2.Diabetes mellitus 3.Parkinson's disease 4.Trigeminal neuralgia - Correct Answers 4 Carbamazepine is classified as an iminostilbene derivative and is used as an anticonvulsant, ant neuralgic, antimony, and antipsychotic. It is not used to treat any of the conditions noted in the remaining options. The nurse is reviewing the postoperative prescriptions for a client who had a transsphenoidal hypophysectomy. Which prescription, if noted on the record, would indicate the need for clarification? 1.Assess vital signs and neurological status. 2.Instruct the client to avoid blowing his nose. 3.Apply a loose dressing if any clear drainage is noted . 4.Instruct the client about the need for a Medic Alert bracelet. - Correct Answers 3 The nurse should observe for clear nasal drainage; constant swallowing; and a severe, persistent, generalized, or frontal headache. These signs and symptoms indicate cerebrospinal fluid leak into the sinuses. If clear drainage is noted after this procedure, the surgeon needs to be notified. Therefore, clarification is needed regarding application of a loose dressing. The remaining options indicate appropriate postoperative interventions. A client begins to experience extrapyramidal side effects from an antipsychotic medication. The nurse anticipates that the primary health care provider will prescribe which medication to treat this condition? 1.Haloperidol 2.Benztropine 3.Chlorpromazine 4.Prochlorperazine - Correct Answers 2 Benztropine is an anticholinergic medication used to treat drug-induced extrapyramidal reactions (except tardive dyskinesia). The remaining options are antipsychotic medications. Antipsychotic medications can cause extrapyramidal reactions. The mother of an 18-month-old child tells the clinic nurse that the child has been having some mild diarrhea and describes the child's stools as "mushy." The mother tells the nurse that the child is tolerating fluids and solid foods. The most appropriate suggestion regarding the child's diet would be to give the child which items? 1.Applesauce, bananas, wheat toast 2.Mashed potatoes with baked chicken 3.Gelatin, strained cabbage, and custard 4.Fluids only until the "mushy" stools stop - Correct Answers 2 The continued feeding of a normal diet can prevent dehydration, reduce stool frequency and volume, and hasten recovery. Common foods that are especially well tolerated during diarrhea are bland but nutritional foods, including complex carbohydrates (rice, wheat, potatoes, cereals), yogurt containing live cultures, cooked vegetables, and lean meats. The foods in options 1 and 3 may worsen the diarrhea. Fluids only will affect nutritional status. A client admitted 72 hours ago with a diagnosis of depression presents for breakfast today appropriately dressed and well groomed, and appears to be calm and relaxed, yet more energetic than before. Which initial action should the nurse take after noting this client's behavior? 1.Institute the unit's suicide precaution protocol. 2.Alert the client's psychiatrist of these changes immediately. 3.Notify the staff of these observations at today's team meeting. 4.Ask the client directly about the presence of any suicide-related thoughts. - Correct Answers 4 A sudden improvement in a depressed client's mood may indicate that the client has decided to commit suicide. The most direct way to validate the nurse's impression is to ask the client directly about suicidal ideation or plans. The other options are not the most appropriate initial nursing intervention. A client with coronary artery disease is scheduled to have a diagnostic exercise stress test. Which instruction should the nurse plan to provide to the client about this procedure? 1.Eat breakfast just before the procedure. 2.Wear firm, rigid shoes, such as work boots. 3.Wear loose clothing with a shirt that buttons in front. 4.Avoid cigarettes for 30 minutes before the procedure. - Correct Answers 3 The client should wear loose, comfortable clothing for the procedure. Electrocardiogram (ECG) lead placement is enhanced if the client wears a shirt that buttons in the front. The client should receive nothing by mouth after bedtime or for a minimum of 2 hours before the test. The client should wear rubber-soled, supportive shoes, such as athletic training shoes. The client should avoid smoking, alcohol, and caffeine on the day of the test. Inadequate or incorrect preparation can interfere with the test, with the potential for a false-positive result. The nurse is creating a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. What is the priority nursing intervention? 1.Promoting bed rest 2.Restricting oral fluids 3.Allowing the child to play 4.Encouraging visits from friends - Correct Answers 1 Bed rest is required during the acute phase, and activity is gradually increased as the condition improves. Fluids should not be forced or restricted. Providing for quiet play according to the developmental stage of the child is important. Visitors should be limited to allow for adequate rest.