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If your patient is acutely psychotic, which of the following independent nursing interventions would not be appropriate?
A. Conveying calmness with one on one interaction
B. Recognizing and dealing with your own feelings to prevent escalation of thepatient’s anxiety level
C. Encourage client participation in group therapy
D. Listen and identify causes of their behavior
Which of the following syndromes associated with incomplete lesions of the spinal cord is a result of damage to one-half of the spinal cord?
A. Brown-Séquard syndrome
B. posterior cord syndrome
C. central cord syndrome
D. cauda equina syndrome
A client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure. The nurse tries torefocus the client. The nurse notes that the client is frequently startled by noises in the hall. Assessment reveals rapid speech, trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to feeling nervous and having trouble sleeping. Based on the assessment, the nurse documents that the client has:
A. mild anxiety.
B. moderate anxiety.
C. severe anxiety.
D. a panic attack.
A 64 year-old Alzheimer’s patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure?
A. Secure the restraints to the bed rails on all extremities.
B. Notify the physician that restraints have been placed properly.
C. Communicate with the patient and family the need for restraints.
D. Position the head of the bed at a 45 degree angle.
A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?
A. temperature of 102° F and a productive cough
B. arterial blood gases (ABGs) with a PaO2 of 92 and PaCO2 of 40 mmHg
C. trachea deviating to the right
D. barrel-chested appearance
Metformin (Glucophage) is administered to clients with type II diabetes mellitus. Metformin is an example of:
A. an antihyperglycemic agent.
B. a hypoglycemic agent.
C. an insulin analogue.
D. a pancreatic alpha cell stimulant.
An nurse is instructing a patient on the order of sensations with the application of an ice water bath for a swollen right ankle. Which of the following is the correct order of sensations experienced with an ice water bath?
A. cold, burning, aching, and numbness
B. burning, aching, cold, and numbness
C. aching, cold, burning and numbness
D. cold, aching, burning and numbness
A 20-year-old male client had a diving accident with subsequent paraplegia. He says to thenurse, “No woman will ever want to marry me now.” Which of the following responses bythe nurse is most therapeutic?
A. “Don’t worry. Maybe you’ll meet a paraplegic woman.”
B. “There is someone for everyone in this world.”
C. “You are still an attractive man, even though you can’t walk.”
D. “Tell me more about your feelings on this issue.”
A patient has recently been prescribed Zidovudine (Retrovir). The patient has AIDS. Whichof the following side effects should the patient specifically watch out for?
A. Weakness and SOB
B. Fever and anemia
C. Hypertension and SOB
D. Fever and hypertension
A client reports that someone is in the room and trying to kill him. The nurse’s best response is:
A. “No one is in your room. Let’s get you more medicine.”
B. “I do not see anyone, but you seem to be very frightened.”
C. “No one can hurt you here.”
D. “Just tell the person to go away.”
A twenty-one year old man suffered a concussion and the MD ordered a MRI. The patientasks, “Will they allow me to sit up during the MRI?” The correct response by the nurseshould be.
A. “I will have to talk to the doctor about letting you sit upright during the test.”
B. “You will be positioned in the reverse Trendelenburg position to maximizethe view of thebrain.”
C. “The radiologist will let you know.”
D. “You will have to lie down on your back during the test.”
A thirty-seven year-old female in room 307 has a diagnosis of acquired immune deficiency syndrome (AIDS). Which of the following situations requires nurse intervention?
A. A certified nursing assistant states, “The patient in 307 is not wearing glovesshaving her
legs.”
B. A nursing assistant at the nursing station states, “The patient in 307 has arespiratory
rate of 16.”
C. A nursing student in the cafeteria states, “Dr.Jones told the patient in room307 that she
was going to die.”
D. A certified nursing assistant states, “Dr. Jones hasn’t made rounds thismorning.”
A nurse is reviewing a patient’s current Lithium levels. Which of the following values isoutside the therapeutic range?
A. 1.0 mEq/L
B. 1.1 mEq/L
C. 1.2 mEq/L
D. 1.3 mEq/L
A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client’s needs at this time?
A. asking whether another individual wants to be her support person
B. assuring her that the nursing triage group will be with her at all times
C. telling her you will try to locate her family
D. reinforcing the woman’s confidence in her own abilities to cope and maintain a sense of control
A nurse is caring for a patient in the step down unit. The patient has signs of increasedintracranial pressure. Which of the following is not a sign of increased intracranialpressure?
A. Bradycardia
B. Increased pupil size bilaterally
C. Change in LOC
D. Vomiting
A nurse has been assigned a patient who has recently been diagnosed with Guillain-Barre’Syndrome. Which of the following statements is the most applicable when discussing theimpairments with Guillain-Barre’ Syndrome with the patient?
A. Guillain-Barre’ Syndrome gets better after 5 years in almost all cases.
B. Guillain-Barre’ Syndrome causes limited sensation in the abdominal region.
C. Guillain-Barre’ Syndrome causes muscle weakness in the legs.
D. Guillain-Barre’ Syndrome does not effect breathing in severe cases.
In hanging a parenteral IV fluid that is to be infused by gravity, rather than with an infusion pump, the nurse notes that the IV tubing is available in different drop factors. Which tubing is a microdrop set?
A. 15 drops per milliliter
B. 60 drops per milliliter
C. 20 drops per milliliter
D. 10 drops per milliliter
Medical records indicate a patient has developed a condition of respiratory alkalosis. Which of the following clinical signs would not apply to a condition of respiratory alkalosis?
A. Muscle tetany
B. Syncope
C. Numbness
D. Anxiety
The nurse sustains a needle puncture that requires HIV prophylaxis. Which of the followingmedication regimens should be used?
A. an antibiotic such as Metronidazole and a protease inhibitor (Saquinivir)
B. two non-nucleoside reverse transcriptase inhibitors
C. one protease inhibitor such as Nelfinavir
D. two protease inhibitors
How does the ANA define the psychiatric nursing role?
A. a specialized area of nursing practice that employs theories of human behavior as its
science and the powerful use of self as its art
B. assisting the therapist to relieve the symptoms of clients
C. to solve clients’ problems and give them the answers
D. having a client committed to long-term therapy with the nurse
Signs of internal bleeding include all of the following except:
A. painful or swollen extremities.s
B. a tender, rigid abdomen.
C. vomiting bile.
D. bruising.
A patient asks a nurse the following question. Exposure to TB can be identified best with which of the following procedures? Which of the following tests is the most definitive of TB?
A. Chest x-ray
B. Mantoux test
C. Breath sounds examination
D. Sputum culture for gram-negative bacteria
A 64 year-old male who has been diagnosed with COPD, and CHF exhibits an increase intotal body weight of 10 lbs. over the last few days. The nurse should:
A. Contact the patient’s physician immediately.
B. Check the intake and output on the patient’s flow sheet.
C. Encourage the patient to ambulate to reduce lower extremity edema.
D. Check the patient’s vitals every 2 hours.
Which type of dressing is recommended to place over a site when a chest tube is removed by the physician?
A. transparent dressing
B. colloidal dressing
C. petrolatum gauze
D. nonadherent dressing
The physician wants to know if a client is tolerating his total parenteral nutrition. Which of the following laboratory tests is likely to be ordered?
A. triglyceride level
B. liver function tests
C. a glucose tolerance test
D. a complete blood count
A gastroenterologist should be consulted for clients suffering from:
A. digestive system diseases.
B. urinary system diseases.
C. female reproductive system diseases.
D. nervous system diseases.
A 24 year-old man has been admitted to the hospital due to work-related back injury. Thepatient’s wife would like to see the patient’s chart. The nurse should:
A. Provide the chart to the patient’s wife following verbal approval by the patient.
B. Provide the chart to the patient’s wife after consulting with the patient’s physician.
C. Get written approval from the patient prior to providing the wife with chart informationand call the MD about the patient’s request.
D. Tell the patient’ wife, a copy of the patient’s medical record is on-file with medicalrecords.
A 62 year-old female is being seen on a home visit by a nurse. The patient reports she has been taking Premarin for years. Which of the following would indicate an over-dosage?
A. Lower extremity edema
B. Sensory changes in the upper extremities
C. Increased occurrence of fractures
D. Decreased peripheral blood flow
A patient has been diagnosed with diabetes mellitus. Which of the following is not a clinical sign of diabetes mellitus?
A. Polyphagia
B. Polyuria
C. Metabolic acidosis
D. Lower extremity edema
A woman seeks assistance because she recently remembered childhood sexual abuse.The nurse should include which of the following goals for this client?
A. prosecuting the perpetrator
B. managing symptoms of anxiety and fear
C. determining if the memories are real
D. collaborating the client’s story
A paraplegic client is in the hospital to be treated for an electrolyte imbalance. Which level of care is the client currently receiving?
A. primary prevention
B. secondary prevention
C. tertiary prevention
D. health promotion
After the client discusses her relationship with her father, the nurse says, “Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?” This is an example of:
A. verbalizing the implied.
B. seeking consensual validation.
C. encouraging evaluation.
D. suggesting collaboration.
A 14 year-old boy has been admitted to a mental health unit for observation and treatment. The boy becomes agitated and starts yelling at nursing staff members. What should the nurse first response be?
A. Create an atmosphere of seclusion for the boy according to procedures.
B. Remove other patients from the area via wheelchairs for added speed.
C. Ask the patient, “What is making you mad?”
D. Ask the patient, “Why are you doing this, have you thought about what yourparents might say?”
The nurse working with elderly clients should keep in mind that falls are most likely tohappen to elderly who are:
A. in their 80s.
B. living at home.
C. hospitalized.
D. living on only Social Security income.
A 32-year-old female frequently comes to her primary care provider with vague complaints of headache, abdominal pain, and trouble sleeping. In the past, the physician has dutifully prescribed medication, but little else. Which of the following comments by the nurse to the physician is appropriate?
A. “Often women who are victims of domestic violence suffer vague symptoms such as
abdominal pain.”
B. “Often women become offended if asked about their safety in relationships.”
C. “It is mandatory that all women be questioned about domestic violence.”
D. “How would you feel to know that her partner is beating her and you didn’t ask?”
A nurse working a surgical unit, notices a patient is experiencing SOB, calf pain, and warmth over the posterior calf. All of these may indicate which of the following medical conditions?
A. Patient may have a DVT.
B. Patient may be exhibiting signs of dermatitis.
C. Patient may be in the late phases of CHF.
D. Patient may be experiencing anxiety after surgery.