nursing

A nurse in an emergency department completes an assessment on an adolescent client that has conduct disorder. The client threatened suicide to a teacher at school. Which of the following statements should the nurse include in the assessment? a)Tell me about your siblings? B)Tell me what kind of music you like? c) Tell me how often do you drink alcohol? d) Tell me about your school schedule? - Tell me how often do you drink alcohol A nurse is observing bonding to the client her newborn. Which of the following actions by the client requires the nurse to intervene? A- Holding the new born in an en face position b- asking the father to change the newborns diaper c- requesting the nurse to take the newborn nursery so she can rest d- Viewing the newborns actions to be uncooperative - Viewing the newborns actions to be uncooperative A nurse is caring for a client who is taking levothyroxine. Which of the following findings should indicate that the medication is effective? A- Weight loss b- Asking the father to change the newborns diaper c- absence of seizures d- Decrease inflammation - Weightloss this drug acts as T4 and will normalize the effects of hypothyroidism A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching? A- contact the provider if the cord still turns black b- clean the base of the cord with hydrogen peroxide daily c- Keep the cord dry unitl it falls off d- The cord stump will fall off in five days - Keep the cord dry until it falls off (cord should be kept clean and dry to prevent infection, it will turn black, clean with neutral ph cleanser, cord falls off in 10-14 days) A nurse is assessing a client in PACU. Which of the following findings indicates decreased cardiac output? A- Shivering b- oliguria c- Bradypnea d- Constricted pupils - Oliguria A nurse is assisting with mass casualty triage, explosion at a local factory. Which of the following client should the nurse identify as the priority? A- A client that has massive head trauma B- A client has full thickness burns to face and trunk C- A client with indications of hypovolemic shock D- A client with open fracture of the lower extremity - A client with indications of hypovolemic shock A nurse is receiving report on four clients. Which of the following clients should the nurse asses first? A- a client who has illegal conduit and mucus in the pouch b- Client pleasant arteriovenous additional vibration palpated c- Client whose chronic kidney disease with cloudy diasylate outflow D- A client was transurethral resection of the prostate with red tinged urine in the bag - A client whose chronic kidney disease with cloudy diasylate outflow A nurse is caring for a client just received the first dose of lisinopril. The following is an appropriate nursing intervention? a- place's cardiac monitoring b- monitor the clients oxygen saturation level c- provide standby assist with the client from bed d- encourage foods high in potassium - Provide standby assist with the client from bed A nurse is caring for a client who is in labor and his seat is recieving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse expect? a-Feta hypoxia b- abrupto placentae c- post maturity d- head compressions - head compressions A nurse is caring for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as an indication for hemodialysis? a- Glomerular filtration rate of 14 ml/minute b- BUN 16 ml/dl c- serum magnesium 1.8 mg mg/dl d- serum phosphorus 4.0 m mg/dl - glomerular filtraion rate of 14 ml/minute A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The following is an appropriate action for the nurse to take? a- placed infant under radiant warmer b- move the probe site every 3 hrs c- heat the skin one minute prior to placing the program d- placed a sensor on the index finger - Heat the skin one minute prior to placing the program. A nurse in a mental health facility receives a change to shift report on for clients. Which of the following clients should the nurse plan to asses first? a- A client placed in restraints to the aggressive behavior b- a new limited client pleasures history 4.5 kg weight loss in the past two months c- client is receiving prn dose of health heard all two hours ago for increased anxiety d- Applied he'll be receiving his first ect treatment today - Cliet placed in restraints to the aggressive behavior A nurse is working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management. Which of the following statements by the nurse is an appropriate description of the use of hypnosis during labor? a- Hypnosis focuses on biofeedback as a relaxation technique b- hypnosis promoted increased control of her pain perception during contractions c- hypnosis uses therpeutic touch to reduce anxiety during labor d- hynosis provides instructions to minimize pain - Hypnosis promotes increased control of her pain perception during contractions. A nurse is a county jail health clinic is leading group therapy sessions. A client who has incarcerated for theft is addressing the group. Which of the following is an example of reaction formation? (reaction formation is when using opposite feelings, being super nice to someone you dislike) a- I steal things because it is the only way i can keep my mind off my bad marriage b- i can't believe i was accused of something i didn't do c- i don't want to talk about my feelings right now, we will talk more next time d- i think that people are just lazy and should earn extra money - I think that your people are just lazy and should earn money honestly A nurse is obtaining medical history of a client who has a new prescription for isosorbide mononitrate. Which of the following should the nurse identify as a contraindication to medication? a- Glaucoma b- hypertension c- polycythemia d- migraine headaches - Glaucoma NA - n/a The nurse is caring for a client recovering from an acute myocardial infarction. Which of the following intervention should the nurse include in the point of care? a- Draw a troponin level every four hours b- performance EKG every 12 hrs c- plant oxygen tent fell over minutes via rebreather mask d- obtain a cardiac rehabilitation consult - Obtain cardiac rehabilitation consult A nurse is caring for a client who has breast cancer and has been covering receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider ? a- WBC 3,000 /mm3 b- Hemoglobin 12 g/dl c- Platelet 250,000/mm3 d- aPTT 30 seconds - WBC 3,000/mm3 Home health nurse is carefully planned for alzheimer's disease. To the following actions should the nurse include in the plan of care? a- Place a daily calendar in the kitchen b- replace the button clothing with zippered items c- replace the carpet with hardwood floors d- create variation in daily routine - Place a daily calendar in the kitchen Nurse is performing change of shift assessment on 4 clients. Which of the following findings should the nurse report to the providers first? a- The client was cystic fibrosis and has a thick productive clock and report thirst b- client who has gastroenteritis and is lethargic and confused c- the client has diabetes mellitus has morning fasting legal cost of 185 over deal d- the client was sick of signing and reports pain 15 minutes after receiving oral analgesic - Client who has gastroenteritis and is lethargic and confused A nurse is caring for a client who was in second trimester of preganancy and asks how to treat constipation. Which of the following statements by the nurse is appropriate? a- Decrease taking vitamins and supplements to every other day b- Eat 15 g of fiber per day c- consume 48 ounces of water each day d- drink hot water with lemon juice each morning when you wake up - Drink hot water with leon juice every morning when you wake up. n/a - n/a A nurse is caring for a client who is preparing his advance directives. Which is the following statements by the client indicates an understanding of advanced directives? (select all that apply) a- I can't change my instructions once a minute b- my doctor will need to approve my advance directives c- i need an attorney to witness my signature on the advance directives d- I have the right to refuse treatment e- my health care proxy can make medical decisions for me - I have the right to refuse treatment My healthcare proxy can make medical decisions for me A nurse is caring for a client who has 32 weeks gestation and has history of cardiac disease. Which of the following positions should the nurse place the client to best promote optimal cardiac output? a- the chest b- standing c- supine d- left lateral - Left lateral A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an AP? a- client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry b- client who has awoken following a bronchoscopy and requests a drink c- client who had a myocardial infarction 3 days ago and reports chest comfort d- client who had a cerebrovascular accident two days ago and needs help toileting - Client who had a cerebrovascular accident two days ago and needs help toileting Nurse providing discharge teaching to the client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider? a- constipation b- blurred vision c- fever d- dry mouth - Fever A nurse observes an AP providng care to a child who is in skeletal traction. W