ATI RN Concept-Based Assessment Study Guide

  The child with Down syndrome should be evaluated for which condition before participating in some sports? a. Hyperflexibility b. Cutis marmorata c. Atlantoaxial instability d. Speckling of iris (Brushfield spots) - ANSWER-C. Atlantoaxial instability - Children with Down syndrome are at risk for atlantoaxial instability. Before participating in sports that put stress on the head and neck, a radiologic examination should be done. Child with Down Syndrome delayed development - ANSWER--nurse should ensure the child is enrolled in an early stimulation program which provides PHYSICAL THERAPY to develop motor skills. manifestations of increased ICP - ANSWER--decreased LOC -vomiting (often projectile) -rising bp -increasing pulse pressure -bradycardia -papilledema -fixed and dilating pupils -posturing (decorticate and decerebrate) -HTN -Cheyne-stokes respirations -wide pulse pressure manifestations of acute glaucoma - ANSWER--headache -eye pain -rapid onset of elevated IOP -vision alterations -severe pain -photophobia manifestations of DKA - ANSWER-dehydration, eyeballs soft and sunken eyes, ab pain, anorexia, KUSSMAUL RESPIRATIONS, fruity breath What nursing interventions should take priority on a client with placenta previa at 36 weeks gestation? - ANSWER--initiate large-bore IV access Education for preventing child-hood obesity - ANSWER--avoid using foods as a reward for good behavior -have healthy foods like fruits and veggies available for snacking -limit television watching to 2hr or less each day -avoid offering juice drinks (high sugar content) positive symptoms of schizophrenia - ANSWER-Delusions of reference, delusions of persecution, delusions of grandeur, thought broadcasting, though insertion -magical thinking -auditory hallucinations -clang association disorganized thought, disorganized behavior, catatonia negative symptoms of schizophrenia - ANSWER--disturbance of affect -blunting (severe reduction in the intensity of affect expression) -flat affect -inappropriate affect (might laugh hysterically while describing someones death) -emotional ambivalence nursing priority for patient with WILMs Tumor - ANSWER--avoid palpation of abdomen to avoid tumor rupture What is Wilm's tumor? - ANSWER-Renal tumor of embryonal origin that is most commonly seen in children 2-5yrs Assoc w/ Beckwith-Wiedemann syndrome (hemihypertrophy, macroglossia, visceromegaly), NF, and WAGR syndrome (Wilms' Aniridia, Genitourinary abnormalities, mental retardation) Nursing intervention for child born at 33wks and is 2 days old - ANSWER--position newborn SIDE-LYING or Prone while in nursery. -bathe child in PLAIN WATER ONLY -initiate skin-to-skin contact regardless of age or weight of newborn -lights should be dimmed during the night and at intervals during the day intimate partner violence teaching - ANSWER--nurses priority is to provide safety and develop a safety plan. Teaching for minimizing behavioral problems with client who has Alzheimer's disease (AD) - ANSWER--briefly leave the room when client becomes agitated -use a soft, calm tone of voice -avoid crowds of people when taking client on outings. manifestations of prenatal complications - ANSWER--swelling of finders, face, and sacral area (these are hypertensive conditions like PREECLAMPSIA) PYROSIS - ANSWER-heartburn; burning sensation in upper abdomen due to reflux of gastric acid leukorrhea - ANSWER-a profuse, whitish mucus discharge from the uterus and vagina Nursing actions for client with bipolar disorder experiencing mania - ANSWER--give client short, firm direction when communicating -encourage frequent rest periods during the day -offer client high-fiber foods and extra fluids -supervise client and give step-by-step directions. risk factors for postpartum hemorrhage - ANSWER-usual suspects plus: -grand multiparitiy multiple gestation, large infant, polyhydraminos dysfunctional labor, oxytocin induction or augmentation VBAC, general anesthesia therapeutic response lab values for client with ANOREXIA NERVOSA - ANSWER--BUN 18mg/dL (norm: 10-20 mg/dL) -hematocrit 40% (norm: 42-52% males; 37-47% female) -Na 138 mEq/dL (norm: 136-145 mEq/dL -K 3.7 (norm: 3.5-5.0 mEq/dL) Nursing action for client receiving IV OXYTOCIN and FHR shows VARIABLE DECELERATIONS - ANSWER--administer O2 at 10 L/min via nonrebreather -reposition client to relieve compression to umbilical chord. A nurse is caring for a client who has lung cancer and is exhibiting manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following ndings should the nurse report to the provider? A. Behavioral changes B. Client report of headache C. Urine output 40 mL/hr D. Client report of nausea E. Increased urine specfic gravity - ANSWER-A. Behavioral changes B. Client report of headache D. Client report of nausea A nurse is teaching a female adult client about screening prevention for cancer. Which of the following statements by the client indicates an understanding of the teaching? A. "I will need to have a mammogram every 2 years beginning at age 45." B. "I should have a colonoscopy every 15 years beginning at age 60." C. "I will need to have an annual breast examination every year after 40." D. "I should have a fecal occult test done every 3 years." - ANSWER-C."I will need to have an annual breast examination every year after 40." A nurse is planning care for a client who has malnutrition due to cancer. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Have the client keep a food diary. B. Encourage tooth brushing before and after meals. C. Assess laboratory test report of ferritin. D. Monitor for changes in mental status. E. Explain that fluid intake should occur between meals. - ANSWER-A. Have the client keep a food diary. B. Encourage tooth brushing before and after meals. C. Assess laboratory test report of ferritin. E. Explain that fluid intake should occur between meals. A nurse in an oncology clinic is reviewing the health record of a client who had surgery to stage ovarian cancer. The nurse reviews the following diagnostic notation on the pathology report: T2-N3-MX. Which of the following is an expected finding that supports this diagnosis? A. The tumor is 4 cm in size involving the ovary and adjacent tissues. B. No lymph nodes contain cancer cells. C. The tumor is receptive to current medication therapy. D. The cancer has metastasized to other areas in the body - ANSWER-A. The tumor is 4 cm in size involving the ovary and adjacent tissues. A nurse in a clinic is caring for a client who has suspected uterine cancer. Which of the following assessment techniques should the nurse anticipate the provider will perform on this client? A. Bimanual pelvic examination B. Papanicolaou (Pap) test with cultures C. Digital rectal examination D. Percussion of the upper abdominal quadrants for tympany - ANSWER-A. Bimanual pelvic examination A nurse is completing preprocedure teaching for a client who will undergo nuclear imaging for suspected cancer. Which of the following is an appropriate statement by the nurse? A. "The presence of a liver enzyme will be identified." B. "You will be given an injection of a radioactive substance." C. "An endoscope will be inserted through your mouth." D. "The tumor will be aspirated." - ANSWER-B. "You will be given an injection of a radioactive substance." A nurse is reviewing preoperative teaching with a client who will undergo a shave biopsy for suspected cancer. Which of the following statements by the client indicates understanding of the procedure? A. "A test of my bone marrow will be performed." B. "A lymph node will be removed." C. "A needle will be inserted into the mass." D. "A small skin sample will be obtained." - ANSWER-A. INCORRECT: A bone marrow aspiration is a type of needle biopsy. B. INCORRECT: A sentinel node biopsy involves excision of a lymph node. C. INCORRECT: A needle biopsy involves aspiration of a tumor for fluid and tissue sampling. D. CORRECT: A shave biopsy is a sampling of the outer skin layer using a scalpel or razor blade. NCLEX® Connection: Physiological Adaptations, Illness Management A nurse is planning care for a client who will undergo genetic testing for suspected cancer. Which of the following interventions should be included in the plan of care? A. Obtain a signed informed consent form. B. Withhold all medications prior to the procedure. C. Verify the prescription for a tumor marker assay. D. Ensure the client is placed in a recovery position after testing. - ANSWER-A. CORRECT: A signed informed consent form should be obtained prior to the procedure. B. INCORRECT: Medication does not affect the results of genetic testing. C. INCORRECT: A tumor marker assay is a laboratory test to identify the presence of specific body proteins in blood, body secretions and tissue and is not a component of genetic testing. D. INCORRECT: Genetic testing involves collection of blood or saliva and a recovery positioning is not required following testing. A nurse is planning care for a client who has a platelet count of 10,000/mm3. Which of the following interventions should the nurse include in the plan of care? A. Apply prolonged pressure to puncture site after blood sampling. B. Administer epoetin alfa as prescribed. C. Place the client in a private room. D. Have the client use an oral topical anesthetic before meals - ANSWER-A. CORRECT: The nurse should implement bleeding precautions for the client who has thrombocytopenia. B. Epoetin alfa is administered to the client who has anemia. C. The client who has neutropenia is placed in a private room. D. A topical oral anesthetic is used for the client who has mucositis. A nurse is caring for a client who is receiving chemotherapy and has mucositis. Which of the following actions should the nurse take? A. Use a glycerin-soaked swab to clean the client's teeth. B. Encourage increased intake of citrus fruit juices. C. Obtain a culture of the lesions. D. Provide an alcohol-based mouthwash for oral hygiene. - ANSWER-A. Glycerin-based swabs should be avoided when providing oral hygiene to a client who has mucositis. B. Acidic foods should be discouraged for a client who has oral mucositis. C. CORRECT: The nurse should obtain a culture of the oral lesions to identify pathogens and determine appropriate treatment. D. Nonalcoholic mouthwashes are recommended for a client who has mucositis. A nurse is planning care for a client who is undergoing chemotherapy and is on neutropenic precautions. Which of the following interventions should be included in the plan of care? (Select all that apply.) A. Encourage a high-fiber diet. B. Remove plants from the room. C. Have the client wear a mask when leaving the room. D. Have client-specific equipment remain in the room. E. Eliminate raw foods from the client's diet. - ANSWER-A. There is no benefit to a high-fiber diet for a client who has neutropenia. B. CORRECT: Neutropenic precautions include the client not having contact with flowers and plants due to the presence of surface infectious agents in the water and soil. C. CORRECT: Neutropenic precautions include having the client wear a mask when leaving the room to reduce the incidence of infection. D. CORRECT: Neutropenic precautions include having equipment available that is only for use in caring for the client to reduce the incidence of infection. E. CORRECT: A client who has neutropenia should avoid consuming raw foods due to the presence of surface infectious agents on peeling and rind. A nurse is caring for a client who is undergoing chemotherapy and reports severe nausea. Which of the following statements should the nurse make? A. "Your nausea will lessen with each course of chemotherapy." B. "Hot food is better tolerated due to the aroma." C."Try eating several small meals throughout the day." D."Increase your intake of red meat as tolerated." - ANSWER-A. Nausea usually occurs to the same extent with each session of chemotherapy. B. Cold foods are better tolerated than warm or hot foods because odors from heated foods can induce nausea. C. CORRECT: Several small meals a day are usually better tolerated by the client who has nausea. D. Red meat is not tolerated well by the client undergoing chemotherapy because the taste of meat is frequently altered and unpalatable. A nurse is caring for a client who has cervical cancer and is scheduled for brachytherapy. Which of the following actions should the nurse take? (Select all that apply.) A. Permit visitors to stay with the client 30 min at a time. B. Place the client on bed rest. C. Insert an indwelling urinary catheter. D. Administer fiber laxatives. E. Dispose soiled linens in hamper outside client's room. - ANSWER-A. CORRECT: The client who has cervical cancer will have a vaginal radiation implant. Visitors should remain for no more than 30 min at a time and maintain a distance of at least 6 ft. B. CORRECT: The client who has cervical cancer will have a vaginal radiation implant. Bed rest is needed to prevent displacement of the implant. C. CORRECT: The client who has cervical cancer will have a vaginal radiation implant. A catheter is needed to prevent displacement of the implant during ambulation. D. Fiber laxatives, which stimulate bowel movements, are not used to prevent displacing the vaginal radiation implant. E. The nurse should dispose all the client's linens in a metal container inside the client's room due to the exposure of radiation. A nurse is caring for a client who has leukemia and has developed thrombocytopenia. Which of the following actions should the nurse take first? A. Plan for the client to take rest periods throughout the day. B. Encourage the client to cough, turn, and deep breath every 2 hr. C. Assess temperature every 4 hr. D. Monitor platelet counts. - ANSWER-A. The nurse should offer the client rest periods throughout the day. However, another action is the priority. B. The nurse should encourage the client to cough, turn and deep breathe every 2 hr. However, another action is the priority. C. The nurse should assess the client's temperature every 4 hr. However, another action is the priority. D. CORRECT: The greatest risk to the client who has thrombocytopenia is injury due to bleeding. The priority action for the nurse to take is to initiate bleeding precautions, such monitoring platelet count. A nurse is reviewing the health record of a client who has suspected ovarian cancer. Which of the following findings supports this diagnosis? (Select all that apply.) A. Previous treatment for endometriosis B. Family history of colon cancer C. First pregnancy at age 24 D. Report of scant menses E. Use of oral contraceptives for 10 years - ANSWER-A. CORRECT: Endometriosis is a risk factor for ovarian cancer. B. CORRECT: A family history of breast, ovarian, or colon cancer is a risk factor for ovarian cancer. C. A first pregnancy after 30 years of age or nulliparity is a risk factor for ovarian cancer. D. Dysmenorrhea or heavy bleeding is a risk factor for ovarian cancer. E. Birth control pills offer protection against ovarian cancer. A nurse is caring for a client 24 hr following a liver lobectomy for hepatocellular carcinoma. Which of the following laboratory reports should the nurse monitor? A. Urine specific gravity B. Blood glucose C. Serum amylase D. D-dimer - ANSWER-A. Alterations in urine specific gravity following a liver lobectomy are not expected. B. CORRECT: Blood glucose should be monitored during the first 24 to 48 hr following a liver lobectomy due to decreased gluconeogenesis and stress to the liver from surgery. C. Alterations in serum amylase following a liver lobectomy are not expected. D. Alterations in the D-dimer following a liver lobectomy are not expected. A nurse is providing teaching about colon cancer to a group of women 45 to 65 years of age. Which of the following statements should the nurse include in the teaching? A. "Colonoscopies for individuals with no family history of cancer should begin at age 40." B. "A sigmoidoscopy is recommended every 5 years beginning at age 60." C."Fecal occult blood tests should be done annually beginning at age 50." D."An endoscopy provides a definitive diagnosis of colon cancer." - ANSWER-A. A colonoscopy is recommended every 10 years beginning at age 50 for a client who has no family history of cancer. B. A sigmoidoscopy is recommended every 5 years beginning at age 50. C. CORRECT: Fecal occult blood tests should be done annually by clients ages 50 to 75. D. A biopsy performed during an endoscopic procedure confirms this diagnosis. A nurse is caring for a client who has multiple types of skin lesions. Which of the following skin lesions are indicative of a malignant melanoma? (Select all that apply.) A. Diffuse vesicles B. Uniformly colored papule C. Area with asymmetric borders D. Rough, scaly patch E. Irregular colored mole - ANSWER-A. Diffuse vesicles are consistent with an allergic reaction. B. A uniformly colored papule is consistent with a birthmark or skin injury. C. CORRECT: A lesion with asymmetric borders is considered suspicious for a melanoma. D. A rough, scaly patch is consistent with skin irritation due to friction. E. CORRECT: A lack of uniformity of pigmentation of a mole is considered suspicious for a melanoma. A nurse is caring for a client who has chronic cancer pain and has a permanent epidural catheter for administration of a fentanyl/bupivacaine solution. The nurse should monitor the client for which of the following findings? (Select all that apply.) A.Respiratory depression B.Hypotension C.Sedation D.Muscle spasticity E.Sensory blockage - ANSWER-A.Respiratory depression B.Hypotension C.Sedation E.Sensory blockage A nurse is caring for a client who will undergo a neurolytic ablation. The client asks the nurse the reason for this procedure. Which of the following responses should the nurse make? A."It attempts to provide permanent pain relief." B."It treats adverse effects of your pain medication." C."It treats decreases in immunity." D."It treats decreases in cells that stop bleeding." - ANSWER-A."It attempts to provide permanent pain relief." A nurse is caring for a client who has cancer and has a prescription for transcutaneous electrical nerve stimulation (TENS) for pain management. Which of the following actions should the nurse take? A.) Apply a conductive gel before applying the electrodes from the TENS unit on the client's skin. B.) Apply alcohol to the client's skin before attaching the electrodes from the TENS unit. C.) Attach the electrodes from the TENS unit over painful incisions or skin damage. D.) Avoid other pain medications when using the TENS unit. E.) Apply cold to the skin where electrodes are applied. - ANSWER-A.) Apply a conductive gel before applying the electrodes from the TENS unit on the client's skin. A nurse is planning care for a client who has cancer and will undergo cryoanalgesia. Which of the following interventions should the nurse include in the plan of care? A.) Monitor oxygen saturation during the procedure. B.) Instruct the client to apply heat to the insertion site. C.) Assess for irritation of the mucous membranes in the mouth following the procedure. D.) Evaluate bladder control after the procedure. - ANSWER-D.) Evaluate bladder control after the procedure A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? A. Fluctuations in blood pressure B. Loss of cognitive function C. Ineffective cough D. Drooping eye lids - ANSWER-B. Loss of cognitive function A nurse is teaching a group of parents of E. coli. Which of the following should be included in the teaching? (select all that apply) A. Severe abdominal cramping occurs B. Watery diarrhea is present for more than 5 days C. It can lead to hemolytic uremic syndrome D. It is a food borne pathogen E. Antibiotics are given for treatment - ANSWER-A. Severe abdominal cramping occurs C. It can lead to hemolytic uremic syndrome D. It is a food borne pathogen A nurse is beginning a physical assessment of a client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? ( Select all that apply). A. Areas of parethesia B. Involuntary eye movements C. Alopecia D. Increased salivation E. Ataxia - ANSWER-A. Areas of parethesia B. Involuntary eye movements E. Ataxia Sickle Cell Anemia teachings - ANSWER--The nurse should instruct the parent to report a severe headache to the child's provider because it can be an indication of a stroke. -The nurse should instruct the parent to encourage the child to increase fluid intake to maintain hydration. -The nurse should instruct the parent to apply warm compresses to the affected joints to prevent vasoconstriction A nurse on the medical-surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? A. Client who has an ulceration of the right heel whose blood glucose is 300 ,g/dL B. Client who reports right calf pain and shortness of breath. C. Client who has blood on a pressure dressing in the femoral area following a cardiac catherterization. D. Client who had dark red coloration of left toes and absent pedal pulse. - ANSWER-B. Client who reports right calf pain and shortness of breath. A nurse is teaching a client who has multiple sclerosis and a new prescription for BACLOFEN. Which of the following statements should the nurse include in the teaching? A. "This medication will help you with your tremors." B. "This medication will help you with your bladder function." C. "This medication may cause your skin to bruise easily." D. "This medication may cause your skin to appear yellow in color." - ANSWER-D. "This medication may cause your skin to appear yellow in color." A nurse is caring fora client who has ingested a toxic agent. Which of the following actions should the nurse plan to take? (Select all that apply.) A. Induce vomiting B. Instill activated charcoal. C. Perform a gastric lavage with aspiration. D. Administer syrup of ipecac. E. Infuse IV fluids. - ANSWER-B. Instill activated charcoal. C. Perform a gastric lavage with aspiration. E. Infuse IV fluids. LAB VALUES suggestive of HELLP Syndrome - ANSWER--Alanine Aminotransferase (ALT) (norm: 7-55 units/L) -Aspartate aminotransferase (AST) (norm: 10-40 units/L) A nurse is admitting a client who has multiple myeloma and a WBC count of 2,200/mm3. Which of the following foods should the nurse prohibit the family members from bringing to the client? A. Fried chicken from a fast food restaurant B. A case of canned nutritional supplements C. A factory-sealed box of chocolates D. A fresh fruit basket - ANSWER-D. A fresh fruit basket A nurse in the emergency department is assessing a client who is unresponsive. The client's partner states, "He was pulling weeds in the yard and slumped to the ground." Which of the following techniques should the nurse use to open the client's airway? A. Heat-tilt, chin-lift B. Modified jaw thrust C. Hyperextension of the head D. Flexion of the head. - ANSWER-A. Heat-tilt, chin-lift A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the newly licensed nurse indicate understanding of the teaching? A. The newborn will have decreased muscle tone B. The newborn will have a continuous high pitched cry C. The newborn will sleep for 2-3 hours after a feeding D. The newborn wil have mild tremors when disturbed - ANSWER-B. The newborn will have a continuous high pitched cry HELLP syndrome - ANSWER-is characterized as severe preeclampsia that involves liver dysfunction. A nurse is teaching a group of parents about infants who have failure to thrive. Which of the following characteristics should be included in the teaching? A. They have been neglected. B. They come from an impoverished environment. C. They manifest colicky behaviors. D. They exhibit developmental delays. - ANSWER-D. Infants who have failure to thrive exhibit developmental delays as a result of decreased nutritional intake needed for brain development. A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multimedication regimen. Which of the following instructions should the nurse give the client related to the medication ethambutol (Myambutol)? A. "Your urine may turn a dark orange." B. "Watch for a change in the sclera of your eyes." C. "Watch for any changes in vision." D. "Take vitamin B6 daily." - ANSWER-C. "Watch for any changes in vision." A nurse in the emergency department is caring for a client who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following actions should the nurse take? (Select all that apply.) A. Remove wet clothing. B. Maintain normal room temperature. C. Apply warm blankets. D. Apply a heat lamp. E. Infuse warmed IV fluids. - ANSWER-A. Remove wet clothing. C. Apply warm blankets. D. Apply a heat lamp. E. Infuse warmed IV fluids. teachings of gastric bypass surgery for management of obesity - ANSWER--clients are at risk for dumping syndrome. The nurse should teach the client that this can be avoided by reclining for 30 min following meals. Remaining in a reclining position slows gastric emptying and minimizes the risk of dumping syndrome. - results in a loss of intrinsic factor, which is a protein secreted by the stomach that is necessary for absorption of vitamin B12, and therefore requires monthly injections of vitamin B12 and iron. - teach the client that his diet will consist of pureed foods and liquids for a minimum of 6 weeks following surgery A nurse is providing instructions to a client prior to her first mammogram which of the following information should the nurse provide prior to the procedure? A. "You should not take any aspirin products prior to mammogram" B. " Do not use apply any deodorant the day of the exam" C. " You will need to avoid sexual intercourse the day before the mammogram" D. " You should avoid exercise prior to the exam" - ANSWER-B. " Do not use apply any deodorant the day of the exam" A nurse is reviewing the common emergency management protocol for clients who have asystole. Which of the following actions should the nurse plan to take during this cardiac emergency? A. Perform defibrillation B. Prepare for transcutaneous pacing. C. Administer IV epinepherine D. Elevate the client's lower extremities - ANSWER-C. Administer IV epinepherine A nurse is caring for a client who is at 42 weeks gestation and in labor. The client asks the nurse what should she expect because her baby is postmaster. Which of the following statements should the nurse make? A. Your baby will have excess body fat B. Your baby will have flat areola without breast buds C. Your baby's heels will easily move to his ears D. Your baby's skin will have a leathery appearance - ANSWER-D. Your baby's skin will have a leathery appearance A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid (Nydrazid) 250 mg PO daily, rifampin (Rifadin) 500 mg PO daily, pyrazinamide 750 mg PO daily, and ethambutol (Myambutol) 1 mg PO daily. Which of the following client statements indicate understanding of the teaching? Select all that apply. A. "I can substitute one medication for another if I run out because they all fight infection." B. "I will wash my hands each time I cough." C. "I will wear a mask when I am in a public area." D. "I am glad I don't have to have any more sputum specimens." E. "I don't need to worry where I go once I start taking my medications." - ANSWER-B. "I will wash my hands each time I cough." C. "I will wear a mask when I am in a public area." A nurse is teaching a client who has a new prescription for sulfasalazine. Which of the following instructions should the nurse include in the teaching? A. "Take the medication 2 hr after eating." B. "Discontinue this medication if your skin turns yellow‐orange." C."Notify the provider if you experience a sore throat." D."Expect your stools to turn black." - ANSWER-A. Sulfasalazine should be taken right after meals and with a full glass of water to reduce gastric upset and prevent crystalluria. B. yellow‐orange coloring of the skin and urine is a harmless effect of sulfasalazine. C. CORRECT: Sulfasalazine can cause blood dyscrasias. The client should monitor and report any manifestations of infection, such as a sore throat. D. Sulfasalazine can cause thrombocytopenia and bleeding. Black stools are a manifestation of gastrointestinal bleeding, and the client should report this to the provider. A nurse is caring for an infant whose screening test reveals that he may have sickle cell disease. Which of the following tests should be performed to distinguish if the infant has the trait or the disease? A. Sickle solubility test (Sickledex) B. Hemoglobin electrophoresis C. Complete blood count D. Transcranial Doppler - ANSWER-A. INCORRECT: The Sickle solubility test is a screening tool that detects the presence of abnormal hemoglobin, but does not distinguish between the trait and the disease. B. CORRECT: The hemoglobin electrophoresis test should be performed to distinguish if the infant has the trait or the disease. C. INCORRECT: A complete blood count tests for anemia, and tells the average size of the red blood cells, and the amount of hemoglobin in the red blood cells. It will not distinguish between sickle cell disease and sickle cell trait. D. INCORRECT: The transcranial Doppler is performed to assess intracranial vascular flow and detect the risk for cerebrovascular accident and will not distinguish between sickle cell disease and sickle cell trait. Nurse is caring for a client following the loss of her partner due to a terminal illness. identify the sequence of engel's five stages of grief that the nurse should expect the client to experience. (select the stages of grief in order of occurrence. all steps must be used.) A. Developing awareness B. Restitution C. Shock & disbelief D. Recovery E. Resolution of the loss - ANSWER-C. Shock & disbelief A. Developing awareness B. Restitution D. Recovery E. Resolution of the loss A nurse in a clinic is teaching a client who has ulcerative colitis. Which of the following statements by the client indicates understanding of the teaching? A. "I will plan to limit fiber in my diet." B. "I will restrict fluid intake during meals." C. "I will switch to black tea instead of drinking coffee." D. "I will try to eat three moderate to large meals a day." - ANSWER-A. CORRECT: A low‐fiber diet is recommended for the client who has ulcerative colitis to reduce inflammation. B. A client who has dumping syndrome should avoid fluids with meals. C. Caffeine can increase diarrhea and cramping. The client should avoid caffeinated beverages, such as black tea. D. Small, frequent meals are recommended for the client who has ulcerative colitis. A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching? A. "You will need continue to take the multimedication regimen for 4 months." B. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication." C. "You will need to remain hospitalized for treatment." D. "You will need to wear a mask at all times." - ANSWER-B. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication." A nurse is preparing to administer iron dextran (Proferdex) IM to a school-age child who has iron deficiency anemia. Which of the following actions by the nurse is appropriate? A. Administer the dose in the deltoid muscle. B. Use the Z-track method when administering the dose. C. Avoid injecting more than 2 mL with each dose. D. Massage the injection site for 1 min after administering the dose. - ANSWER-A. INCORRECT: The nurse should administer the dose in to a large muscle mass. B. CORRECT: The nurse should use the Z-track method when administering the dose. C. INCORRECT: The nurse should avoid injecting more than 1 mL with each dose. D. INCORRECT: To reduce irritation and skin staining, the nurse should not massage the injection site after administering the dose. A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. Which of the following is an appropriate statement by the nurse about this medication? A. "You may notice yellowing of your skin." B. "You may experience pain in your joints." C. "You may notice tingling of your hands." D. "You may experience a loss of appetite." - ANSWER-C. "You may notice tingling of your hands." A nurse is discussing gout with a client who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors for this disease? (Select all that apply.) A. Diuretic use B. Obesity C. Deep sleep deprivation D. Depression E. Cardiovascular disease - ANSWER-A. Diuretic use B. Obesity E. Cardiovascular disease Varenicline - ANSWER-Trade name: (Chantix) Smoking Cessation Aid A nurse is assessing a client who has a new diagnosis of SLE. Which of the following findings should the nurse expect? A. weight gain B. Petechiae on thighs C. systolic murmur D. Alopecia - ANSWER-D. Alopecia A nurse is providing information to a group of clients at a local community center about tuberculosis. Which of the following clinical manifestations should be included in the teaching? Select all that apply. A. Persistent cough B. Weight gain C. Fatigue D. Night sweats E. Purulent sputum - ANSWER-A. Persistent cough C. Fatigue D. Night sweats E. Purulent sputum A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate? A. swelling of joints of the fingers B. Pallor of toes with cold exposure C. Feet that become reddened with ambulation D. Client report of intense feelings of heat in the fingers. - ANSWER-B. Pallor of toes with cold exposure A nurse is conducting a class for a group of newly licensed nurses on caring for clients who are at risk for suicide. Which of the following information should the nurse include in the teaching? A. A client's verbal threat of suicide is attention seeking behavior B. interventions are ineffective for clients who really want to commit suicide C. Using the term suicide increases the clients risk for a suicide attempt. D. A no-suicide contract decreases the client's risk for suicide - ANSWER-D. A no- suicide contract decreases the client's risk for suicide A nurse working in an outpatient clinic is assessing a client who has rheumatoid arthritis (RA). The client reports increased joint tenderness and swelling. Which of the following findings should the nurse expect? (Select all that apply). A. Recent influenza B. Decreased range of motion C. Hypersalivation D. Increased blood pressure E. Pain at rest - ANSWER-A. Recent influenza B. Decreased range of motion E. Pain at rest A nurse is reviewing the serum laboratory data of a client who has an acute exacerbation of Crohn's disease. Which of the following laboratory tests should the nurse expect to be elevated? (Select all that apply.) A. Hematocrit B. Erythrocyte sedimentation rate C. WBC D. Folic acid E. Albumin - ANSWER-A. Hematocrit is decreased as a result of chronic blood loss. B. CORRECT: Increased erythrocyte sedimentation rate is a finding in a client who has Crohn's disease as a result of inflammation. C. CORRECT: Increased WBC is a finding in a client who has Crohn's disease. D. A decrease in folic acid level is indicative of malabsorption due to Crohn's disease. E. A decrease in serum albumin is indicative of malabsorption due to Crohn's disease. A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching? A. "You can experience morning stiffness when you get out of bed." B. "You can experience abdominal pain." C. "You can experience weight gain." D. "You can experience low blood sugar." - ANSWER-A. "You can experience morning stiffness when you get out of bed." A nurse is teaching a group of parents about Salmonella. Which of the following should be included in the teaching (select all that apply) A. Incubation period is nonspecific B. It is a bacterial infection C. Bloody diarrhea is common D. Transmission can be from house pets E. Antibiotics are used for treatment - ANSWER-B. It is a bacterial infection C. Bloody diarrhea is common E. Antibiotics are used for treatment A nurse is caring fora client who has RA. Which of the following laboratory tests are used to diagnose this disease? (Select all that apply.) A. Urinalysis B. Erythrocte sedimentation rate (ESR) C. BUN D. Antinuclear antibody (ANA) titer E. WBC count - ANSWER-B. Erythrocte sedimentation rate (ESR) D. Antinuclear antibody (ANA) titer E. WBC count A nurse is assessing a client who has been taking prednisone following an exacerbation of inflammatory bowel disease. The nurse should recognize which of the following findings as the priority? A. Client reports difficulty sleeping. B. The client's urine is positive for glucose. C. Client reports having an elevated body temperature. D. Client reports gaining 4 lb in the last 6 months. - ANSWER-A. The client is at risk for sleep deprivation because prednisone can cause anxiety and insomnia. However, another finding is the priority. B. The client is at risk for hyperglycemia because prednisone can cause glucose intolerance. However, another finding is the priority. C. CORRECT: The greatest risk to the client is infection because prednisone can cause immunosuppression. Therefore, the nurse should identify indications of an infection, such as an elevated body temperature, as the priority finding. D. The client is at risk for weight gain because prednisone can cause fluid retention. However, another finding is the priority. A nurse is reviewing the medical record of a client who has cystocele. Which of the following findings should the nurse identify as a risk factor for the development of this disorder? A. BMI of 18 B. Nulliparity C. Chronic Constipation D. Postmenopausal - ANSWER-D. Postmenopausal A nurse is caring for a client who had no prenatal care, is Rh-negative, and will undergo an external version at 37 weeks of gestation. Which of the following medication should the nurse plan to administer prior to the version? A. Prostaglandin gel B. Magnesium sulfate C. Rho(d) immune globulin D. Oxytocin - ANSWER-C. Rho(d) immune globulin -Rho(d) immune globulin is administered to an rh-negative client at 28 weeks of gestation. because this client had no prenatal care, it should be given prior to the version to prevent isoimmunization. A nurse is planning care for a client who has meningitis and is at risk for increased ICP. Which of the following actions should the nurse plan to take? (select all that apply) A. Implement seizure precautions B. Perform neurological checks four times a day C. Administer morphine for pain D. Turn off room lights and television E. Monitor for impaired extra-ocular movements F. Encourage the client to cough frequently - ANSWER-A. Implement seizure precautions D. Turn off room lights and television E. Monitor for impaired extra-ocular movements A nurse is completing discharge teaching with a client who has Crohn's disease. Which of the following instructions should the nurse include in the teaching? A. Decrease intake of calorie‐dense foods. B. Drink canned protein supplements. C. Increase intake of high fiber foods. D. Take a bulk‐forming laxative daily. - ANSWER-A. A high‐protein diet is recommended for the client who has Crohn's disease. B. CORRECT: A high‐protein diet is recommended for the client who has Crohn's disease. Canned protein supplements are encouraged. C. A low‐fiber diet is recommended for the client who has Crohn's disease to reduce inflammation. D. Bulk‐forming laxatives are recommended for the client who has diverticulitis. Myelomeningocele (spina bifida) - ANSWER-most severe form of spina bifida in which the spinal cord and meninges protrude through the spine A nurse is reviewing the use of the meningococcal vaccine (MCV4) for the prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include? A. The vaccine is indicated to reduce risk of respiratory infection. B. The vaccine is administered in a series of four doses. C. The vaccine is recommended for adolescents before starting college. D. The vaccine is initially given at 2 months of age. - ANSWER-C. The vaccine is recommended for adolescents before starting college. A nurse is providing instruction to the teacher of a child who has attention- deficit/hyperactivity disorder (ADHD). Which of the following classroom strategies should be included in the teaching? (Select all that apply.) A. Eliminate testing. B. Allow for regular breaks. C. Combine verbal instruction with visual cues. D. Establish consistent classroom rules. E. Decrease stimuli in the environment. - ANSWER-B. Allowing for regular breaks will assist the client who has ADHD to focus on the required tasks. C. Combining verbal instruction with visual cues will assist the client who has ADHD with learning information. D. Providing consistent classroom rules will assist the client who has ADHD to become successful. E. Stimuli in the environment distract the client who has ADHD, so they should be decreased. A nurse is reviewing the plan of care for a client who has systemic lupus erythematosus (SLE). The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse anticipate? (Select all that apply.) A. Positive ANA titer B. Increased hemoglobin C. 2+ urine protein D. Increased serum C3 and C4 E. Elevated BUN - ANSWER-A. Positive ANA titer C. 2+ urine protein E. Elevated BUN A nurse in a provider's office is reviewing a client's laboratory results, which shows a positive rapid plasma regain (RPR). Which of the following tests will be administered to the client to confirm the diagnosis of syphilis? A. Veneral Diseased research laboratory (VDRL) B. D-Dimer C. Fluorescent treponemal antibody absorbed (FTA-ABS) D. Sickledex - ANSWER-C. Fluorescent treponemal antibody absorbed (FTA-ABS) A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? A. Keep the client in a side-lying position. B. Monitor the client's vital signs. C. Reorient the client to the environment. D. Check the client for injuries. - ANSWER-A. CORRECT: The greatest risk to the client is aspiration during the postictal phase. Therefore, the priority intervention is to keep the client in a side-lying position so secretions can drain from the mouth. B. INCORRECT: Monitoring vital signs to determine the stability of the client is important, but it is not the priority nursing action. C. INCORRECT: Reorienting the client to the environment because the client may feel confused after a seizure is important, but it is not the priority nursing action. D. INCORRECT: Checking the client for injuries that may of occurred from involuntary movement during the seizure is important, but it is not the priority nursing action. A nurse is teaching a client who has SLE about self-care. Which of the following statements by the client indicates an understanding of the teaching? A. "I should limit my time to 10 min in the tanning bed." B. " I will apply powder to any skin rash." C. "I should use a mild hair shampoo." D. "I will inspect my skin once a month for rashes." - ANSWER-C. "I should use a mild hair shampoo." A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (Select all that apply.) A. Overwhelming fatigue should be avoided. B. Caffeinated products should be removed from the diet. C. Looking at flashing lights should be limited. D. Aerobic exercise may be performed. E. Episodes of hypoventilation should be limited. F. Use of aerosol hairspray is recommended. - ANSWER-A. CORRECT: The nurse should instruct the client to avoid overwhelming fatigue, which may trigger a seizure by stimulating abnormal electrical neuron activity. B. CORRECT: The nurse should instruct the client to remove caffeinated products from the diet, which may trigger a seizure by stimulating abnormal electrical neuron activity. C. CORRECT: The nurse should instruct the client to refrain from looking at flashing lights, which may trigger a seizure by stimulating abnormal electrical neuron activity. D. INCORRECT: The nurse should instruct the client to decrease physical activity, which may help to avoid triggering a seizure. E. INCORRECT: The nurse should instruct the client to limit excess hyperventilation, which may trigger a seizure by stimulating abnormal electrical neuron activity. F. INCORRECT: The nurse should instruct the client to avoid using aerosol hairspray, which may trigger a seizure by stimulating abnormal electrical neuron activity. A nurse is interviewing a 25-year-old client who has a new diagnosis of dysthymia. Which of the following findings should the nurse expect? A. There are wide fluctuations in mood. B. The report of a minimum of five clinical findings of depression. C. The presence of manifestations for at least 2 years. D. There is an inflated sense of self-esteem. - ANSWER-C. The presence of manifestations for at least 2 years. Nurse is caring for a client who lost his mother to cancer last month. the client states, "i'd still have my mother if the doctor would have diagnosed her sooner." Which of the following responses should the nurse make? A. "You sound angry. anger is a normal feeling associated with loss." B. "I think you would feel better if you talked about your feelings with a support group." C. "I understand just how you feel. i felt the same when my mother died." D. "Do other members of your family also feel this way?" - ANSWER-A. This response acknowledges the client's emotion & provides education on the normal grief response A nurse is providing teaching about epistaxis to the parent of a school-age child. Which of the following should the nurse include as an appropriate action to take when managing an episode of epistaxis? (Select all that apply.) A. Press the nares together at least 10 min. B. Breathe through the nose until bleeding stops. C. Pack cotton or tissue into the naris that is bleeding. D. Apply a warm cloth across the bridge of the nose. E. Insert petroleum into the naris after the bleeding stops - ANSWER-A. CORRECT: Pressing the nares together for at least 10 min is an appropriate action to take when managing an episode of epistaxis. B. INCORRECT: The child should breathe through the mouth until the bleeding stops. C. CORRECT: Packing cotton or tissue into the naris that is bleeding is an appropriate action when managing an episode of epistaxis. D. INCORRECT: Applying an ice pack across the bridge of the nose is an appropriate action when managing an episode of epistaxis. E. CORRECT: Inserting petroleum into the naris after the bleeding stops is an appropriate action when managing an episode of epistaxis A nurse is developing a plan of care for the nutritional needs of a client who has stage 4 PD. Which actions should the nurse include in the plan of care? SATA A. Provide large balanced meals B. Record diet and fluid intake C. Document weight every other week D. Place the client in Fowler's position to eat. E. Offer nutritional supplements between meals - ANSWER-B. Record diet and fluid intake E. Offer nutritional supplements between meals rationale: weight should be recorded weekly A nurse is providing education to a client prior to her first (pap) test. Which of the following statements should the nurse make? A. " You should urinate immediately after the procedure is over" B. " You will not feel any discomfort" C. " You may experience some bleeding after the procedure" D. " You will need to hold your breath during the procedure" - ANSWER-C. " You may experience some bleeding after the procedure" A nurse is reinforcing teaching with a client who has PD and has received a prescription for bromocriptine (Parlodel). Which of the following instructions should the nurse include in the teaching? A. Rise slowly when standing B. Increase carbohydrate intake C. Limit exposure to heat D. Report any skin discolorations - ANSWER-A. Rise slowly when standing rationale: An adverse effect of Parlodel is orthostatic hypotension A school nurse is providing an education session about menstruation with a group of adolescent female students. Which of the following statements should the nurse include? Select all that apply A. "The average age of onset of menstruation is 10" B. "The range for a typical menstrual cycle begins with the last day of the menstrual period C. " The first day of the menstrual cycle begins with the last day of the menstrual period" D. " Ovulation typically occurs around the 14th day of the menstrual cycle" E. " A menstrual period can last as long as 9 days. - ANSWER-B. "The range for a typical menstrual cycle begins with the last day of the menstrual period D. " Ovulation typically occurs around the 14th day of the menstrual cycle" E. " A menstrual period can last as long as 9 days. Nurse is working with a client who has recently lost his mother. the nurse recognizes that which of the following factors influence a client's grief and coping ability? (select all that apply.) A. Interpersonal relationships B. Culture C. Birth order D. Religious beliefs E. Prior experience with loss - ANSWER-A. Interpersonal relationships B. Culture D. Religious beliefs E. Prior experience with loss dissociative amnesia - ANSWER--loss of memory for personal information, either partial or complete -common in clients with PTSD A nurse is assessing a client who reports severe HA and a stiff neck. The nurse's assessment reveals positive Kernig's sign. Which of the following actions should the nurse perform first? A. Administer antibiotics B. Implement droplet precautions C. Initiate IV access D. Decrease bright lights - ANSWER-B. Implement droplet precautions A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family? A. Allowing the client to function independently will strengthen her muscles and promote healing. B. The client needs to be given privacy at times for self-reflecting and organizing her life. C. The client's sense of loss can be lessened through retaining control of certain areas of her life. D. Performing ADLs is required prior to discharge from an acute care facility. - ANSWER-C. The client's sense of loss can be lessened through retaining control of certain areas of her life. A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? (select all that apply) A. Place client in a supine position B. Flex client's hip and knee C. Place hands behind the client's neck D. Bend client's head toward chest E. Straighten the client's flexed leg at the knee - ANSWER-A. Place client in supine position C. Place hand's behind client's neck D. Bend client's head toward chest A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding? A. "ECT is the recommended initial treatment for bipolar disorder." B. "ECT is contraindicated for clients who have suicidal ideation." C. "ECT is effective for clients who are experiencing severe mania." D. "ECT is prescribed to prevent relapse of bipolar disorder." - ANSWER-C. ECT is appropriate for the treatment of severe mania associated with bipolar disorder A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if he can expect this same type of tumor to occur in other areas of his body. Which of the following is an appropriate response by the nurse? A. "It can spread to breasts and kidneys." B. "It can develop in your gastrointestinal tract." C. "It is limited to brain tissue." D. "It probably started in another area of your body and spread to you brain." - ANSWER-C. "It is limited to brain tissue." A nurse is caring for a child who has depression. Which of the following findings are associated with this diagnosis? (Select all that apply.) A. Prefers being with peers B. Weight loss C. Report of low self-esteem D. Sleeping more than usual E. Hyperactivity - ANSWER-B. Weight loss or gain are findings associated with depression. C. Low self-esteem is a finding associated with depression. D. Sleeping more than usual is a finding associated with depression. A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take for this sign? A. Stroke the lateral aspect of the sole of the foot. B. Ask the client to blink his eyes. C. Observe for facial drooping. D. Have the client stand erect with eyes closed. - ANSWER-D. Have the client stand erect with eyes closed. A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (select all that apply) A. Monitor for bradycardia B. Provide an emesis basin at the bedside C. Administer antipyretic medication D. Perform a skin assessment E. Keep the head of the bed flat - ANSWER-B. Provide an emesis basin at bedside C. Administer antipyretic medication D. Perform a skin assessment A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching? A. "Rape is a crime of passion." B. "Acquaintance rape often involves alcohol." C. "Young adults are the typical victims of sexual assault." D. "The majority of rapists are unknown to the victims." - ANSWER-A. Rape is a crime of violence, aggression, anger, and power. B. CORRECT: Alcohol and other substances are often associated with date or acquaintance rape. C. Individuals of all ages are affected by sexual assault and can be male or female. D. The majority of perpetrators are known to the vulnerable persons. A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? SELECT ALL THAT APPLY A. provide flexible client behavior expectations B. offer concise explanations C. establish consistent limits D. disregard client complaints E. use a firm approach with communication - ANSWER-B. offer concise explanations C. establish consistent limits E. use a firm approach with communication A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply.) A. Have suction equipment available for use. B. Feed the client thickened liquids. C. Place food on the unaffected side of the client's mouth. D. Assign an assistive personnel to feed the client slowly. E. Teach the client to swallow with her neck flexed. - ANSWER-A. Have suction equipment available for use. B. Feed the client thickened liquids. C. Place food on the unaffected side of the client's mouth. E. Teach the client to swallow with her neck flexed. A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? (Select all that apply.) A. Provide privacy. B. Ease the client to the floor if standing. C. Move furniture away from the client. D. Loosen the client's clothing. E. Protect the client's head with padding. F. Restrain the client. - ANSWER-A. CORRECT: The nurse should implement privacy to minimize the client's embarrassment. B. CORRECT: The nurse should ease the client to the floor to prevent falling. C. CORRECT: The nurse should move the furniture away from the client to prevent injury. D. CORRECT: The nurse should loosen the client's clothing to minimize restriction of movement. E. CORRECT: The nurse should protect the client's head from injury by placing the client's head in her lap or using a pillow or blanket under the head during a seizure. F. INCORRECT: The nurse should not restrain the client, which may cause an injury or more seizure activity. A nurse is caring for a client who was recently raped. The client states, "I never should have been out on the street alone at night." Which of the following responses should the nurse make? A. "Your actions had nothing to do with what happened." B. "You should focus on recovery rather than blaming yourself for what happened." C."You believe this wouldn't have happened if you hadn't been out alone?" D."Why do feel that you should not have been alone on the street at night?" - ANSWER-A. This response offers the nurse's opinion, which is a nontherapeutic communication technique. B. This responses indicates disapproval, which is a nontherapeutic communication technique. C. CORRECT: This response uses the therapeutic communication technique of restating, which promotes reflection and verbalization of feelings. D. This responses asks a "why" question, which is a nontherapeutic communication technique. A nurse is providing discharge instructions to a female client who has a prescription for phenytoin (Dilantin). Which of the following information should the nurse include? A. Consider taking oral contraceptives when on this medication. B. Watch for receding gums when taking the medication. C. Take the medication at the same time every day. D. Provide a urine sample to determine therapeutic levels of the medication. - ANSWER-A. INCORRECT: The nurse should not instruct the client to take oral contraceptives, because contraceptive effectiveness is decreased when taking phenytoin. B. INCORRECT: The nurse should instruct the client that phenytoin causes overgrowth of the gums. C. CORRECT: The nurse should instruct the client to take phenytoin at the same time every day to enhance effectiveness. D. INCORRECT: The nurse should instruct the client to have period blood tests to determine the therapeutic level of phenytoin. A nurse is assessing with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? Select all that apply A. Conducting a suicide risk screening on all new clients B. Creating a support group for family members of clients who completed suicide C. Educating high school teens about suicide prevention D. Initiate one on one observation for a client who has current suicidal ideation E. Teaching middle school educators about warning indicators of suicide - ANSWER-A. Conducting a suicide risk screening on all new clients C. Educating high school teens about suicide prevention E. Teaching middle school educators about warning indicators of suicide A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following client findings pose an immediate concern? (Select all that apply.) A. Trace of bloody drainage on dressing B. Capillary refill of affected limb of 6 seconds C. Mottled appearance of the limb D. Throbbing pain of affected limb that is decreased following IV bolus analgesic E. Pulse of 2+ in the affected limb - ANSWER-B. Capillary refill of affected limb of 6 seconds C. Mottled appearance of the limb A nurse is performing a preoperative assessment for a client who is scheduled for an anterior colporrhaphy. Which of the following clients statements should the nurse expect? A. "I have to push the feces out of a pouch in my vagina with my fingers" B. "I have pain and bleeding when I have a bowel movement" C. " I have had frequent urinary tract infections" D. " I am embarrassed by uncontrollable flatus" - ANSWER-C " I have had frequent urinary tract infections" A nurse educator is reviewing the use of cardiopulmonary bypass during surgery for coronary artery bypass grafting with a group of nurses. Which of the following should be included in the discussion? (Select all that apply.) A. The client's demand for oxygen is lowered. B. Motion of the heart ceases. C. Rewarming of the client takes place. D. The client's metabolic rate is increased. E. Blood flow to the heart is stopped. - ANSWER-B. Motion of the heart ceases. C. Rewarming of the client takes place. Purpose of palliative care - ANSWER-Palliative care: provides relief from pain and other distressing symptoms; affirms life and regards dying as a normal process; intends neither to hasten or postpone death; integrates the psychological and spiritual aspects of patient care; offers a support system to help patients live as actively as possible until death; A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client's lower back. The nurse should suspect? A. retroperitoneal bleeding. B. cardiac tamponade. C. bleeding from the incisional site. D. heart failure. - ANSWER-C. bleeding from the incisional site. A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following information should the nurse include in the teaching? A. The use of a microwave to heat food is permitted. B. Inform a provider to order only a MRI when a scan is needed. C. Place a magnet over the implantable device when an aura occurs. D. The use of ultrasound diathermy for pain management is recommended. - ANSWER- A. INCORRECT: The client should be instructed to avoid using a microwave, which may affect the stimulator. B. INCORRECT: The client should be instructed to inform his providers about the stimulator, which would be affected if an MRI were performed. C. CORRECT: The client should be instructed to hold a magnet over the implantable device when an aura occurs so as to decrease seizure activity. D. INCORRECT: The client should be instructed to avoid the use of ultrasound diathermy for pain management because of its effect on the simulator. A nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following is an expected finding? A. Rubor of the affected leg when elevated B. 3+ dorsal pedal pulse in left foot C. Thin, peeling toenails of left foot D. Report of intermittent claudication in the affected leg. - ANSWER-D. Report of intermittent claudication in the affected leg. A nurse is caring for a client who states, "I plan to commit suicide." Which of the following assessments shou