The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial meningitis
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and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial
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pressure (ICP)? t
A. Tachycardia and tachypnea
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B. Sluggish and unequal pupillary responses
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C. Increased head circumference and bulging fontanels
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D. Blood pressure fluctuations and syncope - correct answer B. Sluggish and unequal pupillary responses
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A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum
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amylase. Which additional information is the client most likely to report to the nurse?
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A. Abdominal pain decreases when lying supine
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B. Pain lasts an hour and leaves the abdomen tender
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C. Right upper quadrant pain refers to right scapula
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D. Drinks alcohol until intoxicated at least twice weekly. - correct answer A. Abdominal pain decreases when
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lying supine t
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information
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is most important for the nurse to provide the parents prior to discharge?
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A. Instructions about how much fluid the child should drink daily.
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B. Signs of addiction to opioid pain medications
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C. Information about non-pharmaceutical pain relief measures
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D. Referral for social services for the child and family - correct answer A. Instructions about how much fluid the
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child should drink daily t t t
,To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select the location on the
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image with a red dot). - correct answer I placed the red dot on the base of the neck on the right side
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After receiving report on an inpatient acute care unit, which client should the nurse assess first?
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A. The client with an obstruction of the large intestine who is experiencing abdominal distention
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B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds
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C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid
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D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity - correct answer
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D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity
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A teenager presents to the emergency department with palpitations after vaping at a party. The client is
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anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base
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imbalance?
A. Respiratory acidosis
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B. Metabolic alkalosis
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C. Metabolic acidosis
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D. Respiratory alkalosis - correct answer D. Respiratory alkalosis
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A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the nurse
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should ensure that the client's bed is in which position?
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A. Supine t
B. supine; feet elevated higher than head
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C. supine; head elevated higher than feet
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D. Fowlers - correct answer Fowlers
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The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in
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the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading? (Select
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all the apply) t t
A. Frequent syncope
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B. Occasional nocturia
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C. Flat affect
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,D. Blurred visiont t
E. Frequent drooling - correct answer A. Frequent syncope
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C. Flat affect
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D. Blurred visiont t
While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before
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reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory
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values?
A. Serum albumin
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B. Culture for sensitive organisms
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C. Serum blood glucose level
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D. Creatinine level - correct answer B. Culture for sensitive organisms
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A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-
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drowning incident. While providing care to the child, the nurse begins talking with his preadolescent brother
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who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy
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becomes withdrawn when asked about what happened. Which action should the nurse take?
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A. Develop a water safety teaching plan for the family
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B. Ask the older brother how he felt during the incident
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C. Tell the older brother that he seems depressed
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D. Commend the older brother for his heroic actions - correct answer B. Ask the older brother how he felt
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during the incident t t
A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at
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night with no relief of his discomfort. Which action should the nurse take?
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A. Encourage the client to use cooler water and apply calamine lotion after soaking
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B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief
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C. Suggest that the client take brief showers and apply oil-based lotion after showering
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D. Explain that the symptoms are caused by liver damage and cannot be relieved - correct answer A. Encourage
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the client to use cooler water and apply calamine lotion after soaking
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, An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and heart failure (HF)
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arrives in the Emergency Department (ED) in respiratory distress. The healthcare provider prescribes
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furosemide IV. Which therapeutic response to furosemide should the nurse expected in the client with acute
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HF?
A. Increased cardiac contractility
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B. Reduced preload
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C. Relaxed vascular tone
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D. Decreased afterload - correct answer B. Reduced preload
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Which intervention should the nurse include in the plan of care for a child with tetanus?
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A. Encourage coughing and deep breathing
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B. Minimize the amount of stimuli in the room
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C. Reposition from side to side every hour
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D. Open window shades to provide natural light - correct answer B. Minimize the amount of stimuli in the room
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An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in
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diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?
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A. Ate an extra peanut butter sandwich before gym class
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B. incorrectly administered too much insulin
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C. Had a cold and ear infection for the past two days
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D. Skipped eating lunch - correct answer C. Had a cold and ear infection for the past two days
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A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After
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notifying the family of the client's status, what priority action should the nurse implement?
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A. The impending signs of death should be documented
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B. The client's status should be conveyed to the chaplain
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C. The client's need for pain medication should be determined
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D. The nurse manager should be updated on the client's status - correct answer C. The client's need for pain
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medication should be determined t t t