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Chapter 1 Obtaining an Initial History MULTIPLE CHOICE 1. The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first? a. Introduce him- or herself. b. Make the family comfortable. c. Give assurance of privacy. d. Explain the purpose of the interview. ANS: A The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they speci...

1. A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take? Administer oxytocin to the client via intravenous infusion. Apply oxygen at 2 L/min via nasal cannula. Prepare for insertion of an intrauterine pressure catheter. Assist the client into the knee-chest position. 2. A nurse is assessing a newborn who is 48 hr old and is experiencing opioid withdrawals....

1. A 38-week primigravida who works as a secretary and sits at a computer for 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities? Move about every hour Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will straighten out the pelvic veins and increase venous return. 2. A 26-year-old, gra...

1. Which principle of health diet suggest selecting a wide range of foods as represented by the USDA’s MyPlate food plan? a) Variety b) Moderation c) Adequacy d) Energy density 2. A group of strategies used to increase the level of health of individuals, families, groups and communities is known as: a) Wellness b) health promotion c) tertiary prevention d) nutritional assessment 3. Food descriptions on labels assist us in better understanding the products inside o...

Chapter 1: Family centered nursing care -Dictatorial or authoritarian: -Parents try to control the child’s behaviors and attitudes through unquestioned rules and expectations -Ex: The child is never allowed to watch television on school nights -Permissive: -Parents exert little or no control over the child’s behaviors, and consult the child when making decisions -Ex: The child assists with deciding whether he will watch television -Democratic or authoritative: -Parents direct the ...

1. A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) 1) Dyspnea 2) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations INCORRECT 5) Bradycardia Answer Rationale: Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to inadequate oxygen exchange in the lungs. Barrel chest is correct. The lungs of clients who have emphysema lose their elasticity, and the diaphr...

Foods high in potassium: apricots, bananas, potatoes, tomatoes, avocado, fish, spinach, beans A nurse is reinforcing diet teaching to a client who has type 2 DM. Which of the following should the nurse include in the teaching? Select all that apply. A. Carbs should comprise 55% of daily caloric intake. B. Use hydrogenated oils for cooking. C. Table sugar may be added to cereals. D. Drink an alcoholic beverage with meals. E. Protein foods can be substituted for carb foods. Answer: A, C, D ...

1. A nurse in an alcohol treatment facility is caring for a client who states, “My job is so stressful that the only way I can cope is to drink.” The nurse should recognize that the client is displaying which of the following defense mechanisms? A. Introjection (Unconscious adoption of the ideas or attitudes of others) B. Repression C. Rationalization D. Intellectualization Repression ● Unconsciously putting unacceptable ideas, thoughts, and emotions out of awareness ● ADAPTIVE US...

1. A nurse is caring for a client who has acute angle closure glaucoma and has been receiving a continuous IV infusion of mannitol 25% for one hour which of the following adverse affects should the nurse report to the provider immediately a. Peripheral edema i. The greatest risk to the client receiving mannitol IV is development of heart failure therefore the nurse should report peripheral edema to the provider immediately 2. A nurse is providing teaching to a client with peptic ulcer disea...

A nurse is reviewing laboratory results for a client who is receiving heparin via continuous IV infusion for deep-vein thrombosis. The nurse should discontinue the medication infusion for which of the following client findings? A) Potassium mEq/L B) aPTT times the control C) Hemoglobin g/dL D) Platelets 96,000/mm^3 D) Platelets 96,000/mm^3 A nurse is preparing to administer dextrose 5% in water (D5W) 400 mL IV to infuse over 1 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The n...

1. A chest radiograph film is ordered for a child with suspected cardiac problems. The child’s parent asks the nurse, “What will the radiograph show about the heart?” What knowledge about the x-ray should the nurse include in the response to the parents? a. Bones of chest but not the heart b. Measurement of electrical potential generated from heart muscle c. Permanent record of heart size and configuration d. Computerized image of heart vessels and tissues ANS: C A chest radiograph w...

1.Most communicable diseases can be prevented with immunizations. Antibiotics and antitoxins reduce serious complications. Immunizations are a form of primary prevention. Secondary prevention includes the control of the spread of the disease to others. Conjunctivitis, which is also known as pink eye, is spread by direct contact. Incubation will depend on the infection. Pertussis, which is also known as whooping cough, is spread through direct contact, droplet, and indirect contact with freshly ...

A client has been prescribed metoclopramide. Which of the following should the nurse include in client education regarding this medication? Select one: a. Notify your provider if you experience restlessness or spasms of the face or neck. An adverse effect of Reglan is extrapyramidal symptoms. The client should stop the medication and notify the provider if these occur. b. This medication can cause urinary frequency. c. Decrease your fluid intake while taking this medication. d. This medicat...

1) A nurse is assisting a child who has multiple closed fractures of the lower extremities due to a motor- vehicle crash. The nurse should monitor the child for which of the following complications during the first 24 hr after the injury occurred? c. Volkmann ischemic contracture 2) A nurse is teaching the parent of a toddler who has phenylketonuria about meal planning. Which of the following information should the nurse include in the teaching? b. Avoid foods containing milk products 3)...

1. A nurse in an infertility clinic is providing care to a couple who has been unable to conceive for 18 months. Which of the following data should be included in the assessment? (select all that apply) A. Occupation B. Menstrual history C. Childhood infectious diseases D. History of falls E. Recent blood transfusions A. CORRECT: Occupational hazards include exposure to teratogenic substances in the workplace, such as radiation, chemicals, herbicides, and pesticides. B. CORRECT: Menstrual...

Carbs: 45-65% of daily calories function: energy, regulate fat, cardiac and cns system, protein metabolism. Glycogen: stored carb in the liver and muscle and it release between the meals to regulate the Blood glucose level. Carbs 4 calories per gram per energy * Fiber intake 25gr women, for M 38gr per day * Protein 10-35% daily calories, 0.8 gr per kg body weight, tissue building, immune function, neutral nitrogen balance. Wound healing is important. ▪ Complete protein: all 9 amino acids...

PART 1: GENERAL NOTES (Important Facts) Vitamin B12 is for pernicious anemia Ferrous sulfate for iron deficiency 18.5-24.9 bmi is healthy weight Below 18.5 BMI is underweight 25-29.9 is overweight 30 BMI or greater is obese rangea 10-20 is normal BUN level <200 is ok for blood glucose Celiac disease remove any gluten from diet, wheat rye and barley Pregnant woman increase iron to be able to promote RBC growth to fetus Stomatitis you want to avoid spicy, acidic foods and salty foods ...

A nurse us admitting a school-aged child who has pertussis. Which of the following actions should the nurse take? Initiate droplet precautions for the child A nurse is caring for a newly-admitted school-aged child who has hypopituitarism. Which of the following medications should the nurse expect the provider to recommend to the parents for treating the child’s condition? Recombinant growth hormone A nurse is interviewing the parents of an 18-month old toddler during a well-child visit. ...

LOC • Alert: responsive, answer questions appropriately, opens eyes spontaneously. • Lethargic: open their eyes, can answer questions but easily falls asleep. • Stupor: barely responds to painful stimuli (like rubbing the patients’ sternum) • Comatose: unconscious/does not respond to painful stimuli • Decorticate: flexion/ internal rotation of upper extremities, joints and legs • Decerebrate: neck/elbows extension, wrist and finger flexion Torts: unintentional torts- negli...

• Bacterial Meningitis o Couple questions on the ATI Final o Nursing Care for Meningitis (Highlights) ▪ Reportable findings: The presence of petechiae or a purpuric-type rash requires immediate medical attention ▪ Isolate the client as soon as meningitis is suspected and maintain droplet precautions per facility protocol. • Droplet precautions require a private room or a room with clients who have an infection from the same microorganism, ensuring that each client has his or h...