Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0?
A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:
A client who has been diagnosed with anorexia nervosa reluctantly agrees to eat all prescribed meals. The most important intervention in monitoring her dietary compliance would be to:
A 24-hours’ postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first:
Assessment of a client reveals a 30% loss of preillness weight, lanugo, and cessation of menses for 3 months. Her vital signs are BP 90/50, P 96 bpm, respirations 30, and temperature 97 οF. She admits to the nurse that she has induced vomiting 3 times this morning, but she had to continue exercising to lose “just 5 more lb.” Her symptoms are consistent with:
The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:
A psychiatric nurse is providing an orientation to a new staff nurse. She reminds the nurse that psychiatrists often use categories of medications and that it is important that she recall that some categories of medications have synonyms. Another name used to describe minor tranquilizers is which of the following?
Degenerative disorders are attributed to many factors. As a nurse assigned to a convalescent home, one must often educate families about how such conditions occur. Which of the following statements might the nurse need to explore when a daughter tries to explain to her mother what caused her degenerative disorder?
Blood work reveals the following lab values for a client who has been diagnosed with anorexia nervosa: hemoglobin 9.6 g/dL, hemocrit 27%, potassium 2.7 mEq/L, sodium 126 mEq/L. The greatest danger to her at this time is:
In acute episodes of mania, lithium is effective in 1–2 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe?
The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophrenia. At present, he is experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her son’s condition by which of the following statements?
A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:
A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U +1 in contrast to the previous assessment of U _2. The immediate nursing response is to:
A newborn girl’s father expresses concern that the newborn does not have good control of her hands and arms. It is important for the father to realize certain neurological patterns that characterize the newborn:
The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a monoamine oxidase (MAO) inhibitor. Which of the following is she restricting from the client’s diet?
The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis:
A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?
A client has had amniocentesis. One of the tests performed on the amniotic fluid is a lecithin/sphingomyelin (L/S) ratio. The results show a ratio of 1:1. This is indicative of:
In teaching the client about proper umbilical cord care, the nurse recommends that:
When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child:
The most important reason to closely assess circumferential burns at least every hour is that they may result in:
Hematotympanum and otorrhea are associated with which of the following head injuries?
Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy?
In the client with a diagnosis of coronary artery disease, the nurse would anticipate the complication of bradycardia with occlusion of which coronary artery?
The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to:
An 8-year-old child comes to the physician’s office complaining of swelling and pain in the knees. His mother says, “The swelling occurred for no reason, and it keeps getting worse.” The initial diagnosis is Lyme disease. When talking to the mother and child, questions related to which of the following would be important to include in the initial history?
A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the parents, the nurse states that:
When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. This behavior is most indicative of:
Which of the following activities would be most appropriate during occupational therapy for a client with bipolar disorder?
Proper positioning for the child who is in Bryant’s traction is:
The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should:
A client with bipolar disorder taking lithium tells the nurse that he has ringing in his ears, blurred vision, and diarrhea. The nurse notices a slight tremor in his left hand and a slurring pattern to his speech. Which of the following actions by the nurse is appropriate?
A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expect which of the following to be present in relation to his blood sugar level?
Which of the following signs and symptoms indicates a tension pneumothorax as compared to an open pneumothorax?
During burn therapy, morphine is primarily administered IV for pain management because this route:
The physician has ordered that a daily exercise program be instituted by a client with type I diabetes following his discharge from the hospital. Discharge instructions about exercise should include which of the following?
What is the most effective method to identify early breast cancer lumps?
The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the nurse remember about fluoxetine?
The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:
The nurse provides a male client with diet teaching so that he can help prevent constipation in the future. Which food choices indicate that this teaching has been understood?
After a liver biopsy, the best position for the client is:
A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD). She is started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline level is drawn. Which of the following values represents a therapeutic level?
Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels?
The nurse is teaching a mother care of her child’s spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:
The nurse would teach a male client ways to minimize the risk of infection after eye surgery. Which of the following indicates the client needs further teaching?
A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate?
The nurse is teaching a 10-year-old insulin-dependent diabetic how to administer insulin. Which one of the following steps must be taught for insulin administration?
The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?
A mother frantically calls the emergency room (ER) asking what to do about her 3-year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to:
Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, “Begin oxytocin induction at 1 mU/min.” The nurse should:
A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:
A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20-minute examination, the nurse notes three fetal movements accompanied by accelerations of the fetal heart rate, each 15 bpm, lasting
15 seconds. The nurse interprets this test to be:
A 26-year-old client is in a treatment center for aprazolam (Xanax) abuse and continues to manifest moderate levels of anxiety 3 weeks into the rehabilitation program, often requesting medication for “his nerves.” Included in the client’s plan of care is to identify alternate methods of coping with stress and anxiety other than use of medication. After intervening with assistance in stress reduction techniques, identifying feelings and past coping, the nurse evaluates the outcome as being met if:
A nurse should carefully monitor a client for the following side effect of MgSO4:
A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client’s weight increase is most likely due to:
A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate
(MgSO4) therapy, the nurse knows it is safe to repeat the dosage if:
A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months. The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, “I don’t know what to do, I’m afraid to go home.” The best response by the nurse to the client would be:
A client who is gravida 1 para 1 vaginally delivered a 7- lb girl. She received a midline episiotomy at delivery. When assessing the level of her uterus immediately following delivery, the nurse would expect the fundus to be located:
A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?
A client has just received an epidural block. She is laboring on her right side. The nurse notes that her blood pressure has dropped from 132/68 to 78/42 mm Hg. The nurse’s first action would be to:
For the past several months, an elderly female client with Alzheimer’s disease has experienced paranoia; hallucinations; and aggressive, disruptive behavior. The family is utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that the client demonstrates involuntary movements of the tongue and fingers. This may most likely indicate:
After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered. Which statement shows that the client will properly care for her son’s circumcision?
A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:
A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?
A 40-year-old client has lived for 8 years with an abusive spouse. She married her husband in her senior year of high school after becoming pregnant. Shortly after the baby was born, he began to physically abuse her. She has attempted to leave him several times, but she has always returned. She is unable to support herself financially, and her husband threatens to kill her if she leaves him. This time, her husband has beaten her so badly she cannot stop the bleeding from the gash above her eye. She admits her husband caused her injury. In assessing a person after experiencing spousal abuse, which need has the highest priority?
A 12-year-old girl has been diagnosed with insulindependent diabetes mellitus. Which of these principles would best guide her nutritional management?
The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by:
Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise. Which of the following long-term objectives would be unrealistic?
A male client seeks counseling after his wife of 19 years threatened to divorce him. For most of their marriage, he has physically and verbally abused her. When asked about his behavior in the process of the nursing assessment, the client states, “I was mean to my wife because she insists on cooking meals and wearing clothes that I do not like.” This defense mechanism is an example of:
A female client comes for her second prenatal visit. The nurse-midwife tells her, “Your blood tests reveal that you do not show immunity to the German measles.” Which notation will the nurse include in her plan of care for the client? “Will need . . .
The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child?
A female client was employed as a client care technician in a hemodialysis unit. She recently began to experience extreme fatigue, being able to sleep for 16–20 hours at a time. She also noted that her urine was tea colored, which she rationalized was a result of the vitamins she began taking to alleviate fatigue. She was diagnosed with hepatitis B. After a brief hospital stay, she is discharged to her parent’s home. Her mother asks the nurse if any precautions are necessary to prevent transmission to the client’s family. The nurse explains necessary precautions, which include:
The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks’ gestation. An appropriate response by the nurse would be:
A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:
A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?
A female client has just died. Her family is requesting that all nursing staff leave the room. The family’s religious leader has arrived and is ready to conduct a ceremony for the deceased in the room, requesting that only family members be present. The nurse assigned to the client should perform the appropriate nursing action, which might include:
A 5-year-old child is hospitalized for an acute illness. The nurse encourages the family to bring her favorite objects from home. What is the nurse’s rationale?
A successful executive left her job and became a housewife after her marriage to a plastic surgeon. She started doing volunteer work for a charity organization. She developed pain in her legs that advanced to the point of paralysis. Her physicians can find no organic basis for the paralysis. The client’s behavior can be described as:
A depressed client is seen at the mental health center for follow-up after an attempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that the drug must accumulate to an effective level before symptoms are totally relieved. Symptom relief is expected to occur within:
A 75-year-old client is hospitalized with pneumonia caused by gram-positive bacteria. Which one of the following best describes a gram-positive bacterial pneumonia?
A 45-year-old client has a permanent colostomy. Which of the following foods should he avoid?
Clients receiving antipsychotic drug therapy will often exhibit extrapyramidal side effects that are reversible with which of the following agents ordered by the physician?
An obstructing stone in the renal pelvis or upper ureter causes:
A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation?
A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to:
A 70-year-old homeless woman is admitted with pneumonia. She is weak, emaciated, and febrile. The physician orders enteral feedings intermittently by nasogastric tube. When inserting the nasogastric tube, once the tube passes through the oropharynx, the nurse will instruct the client to:
A client is to have a coronary artery bypass graft performed in the morning using a saphenous vein. He wants to know why the physician does not use the internal mammary artery for his bypass graft because his friend’s physician uses this artery. The nurse tells the client that the internal mammary artery:
A 29-year-old client is diagnosed with borderline personality disorder. He has aroused the nurse’s anger by using a condescending tone of voice with other clients and staff persons. Which of the following statements from the nurse would be most appropriate in acknowledging feelings regarding the client’s behavior?
A 2-day-old infant boy has been diagnosed with an atrial septal defect due to a persistent patent foramen ovale.
When explaining the diagnosis to the mother, the nurse includes in the discussion the function of the foramen ovale. In fetal circulation, the foramen ovale allows a portion of the blood to bypass the:
Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:
A client has a history of alcoholism. He is currently diagnosed with cirrhosis of the liver. The nurse would expect him to be on which type of diet?
One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The client’s level is 1.3 mEq/L. The nurse recognizes that this level is considered to be:
A 30-year-old client is exhibiting auditory hallucinations. In working with this client, the nurse would be most effective if the nurse:
A client has received digoxin 0.25 mg po daily for 2 weeks. Which of the following digoxin levels indicates toxicity?
At her first prenatal visit, a 21-year-old woman who is gravida 2, para 0, ab 1, is currently at 32 weeks’ gestation and has a history of drug abuse, smoking, and occasional ethyl alcohol use. Fetal ultrasound tests indicate poor fetal growth. The most likely reason for the infant’s intrauterine growth retardation is:
A 13-year-old hemophiliac is hospitalized for hemarthrosis of his right knee. To relieve the pain, the nurse should:
A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:
An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?
A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in duration. The fetus is at 0 station, cervix is dilated 8 cm and effaced 90%. The physician orders an oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that the RN discontinue the infusion if which one of the following occur?
A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?
A schizophrenic client who is experiencing thoughts of having special powers states that “I am a messenger from another planet and can rule the earth.” The nurse assesses this behavior as:
A physician’s order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant?
A 55-year-old man has recently been diagnosed with hypertension. His physician orders a low-sodium diet for him. When he asks, “What does salt have to do with high blood pressure?’’ the nurse’s initial response would be:
The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine contractions. Her physician assesses her cervix as 95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2F at this time. The physician orders that she be prepared for a cesarean delivery. In preparing the client for the cesarean delivery, which one of the following physician’s orders should the RN question?
Nursing care of the infant prior to surgical closure of a meningomyelocele would include:
A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?
When planning care for the passive-aggressive client, the nurse includes the following goal:
A client had a myocardial infarction 5 days ago. His physician has ordered an echocardiogram to determine how his myocardial infarction has affected his ventricular wall motion. When the client asks if this test is painful, an appropriate response is:
A client calls the prenatal clinic to schedule an appointment. She states she has missed three menstrual periods and thinks she might be pregnant. During her first visit to the prenatal clinic, it is confirmed that she is pregnant. The registered nurse (RN) learns that her last menstrual period began on June 10. According to Nägele’s rule, the estimated date of confinement is:
An elective saline abortion has been performed on a 3- week primigravida. Following the procedure, the nurse should be alert for which early side effect?
At 16 weeks’ gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to:
At 32 weeks’ gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, “How do I prepare for the test I am scheduled for?” The RN will most likely inform her of the following instructions to help prepare her for the test:
A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician’s office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as:
A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?
The nurse is teaching a client how to perform monthly testicular self-examination (TSE) and states that it is best to perform the procedure right after showering. This statement is made by the nurse based on the knowledge that:
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?
Goal setting for a client with Meniere’s disease should include which of the following?
The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
The nurse is teaching a child’s parents how to protect the child from lead poisoning. The nurse knows that a common source of lead poisoning in children is:
The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client’s chief complaint?
Which of the following nursing care goals has the highest priority for a child with epiglottitis?
The nurse is in the hallway and one of the visitors faints. The nurse should:
The mother of a client is apprehensive about taking home her 2 year old who was diagnosed with asthma after being admitted to the emergency room with difficulty breathing and cyanosis. She asks the nurse what symptoms she should look for so that this problem will not happen again. The nurse instructs her to watch for the following early symptoms:
The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the client?
A 16-year-old diabetic girl has been selected as a cheerleader at her school. She asks the nurse whether she should increase her insulin when she is planning to attend cheerleading practice sessions lasting from 8 to 11 AM. The most appropriate answer would be:
During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule out Laennec’s cirrhosis of the liver. The nurse knows the pruritus is directly related to:
The physician decides to prescribe both a short-acting insulin and an intermediate-acting insulin for a newly diagnosed 8-year-old diabetic client. An example of a short-acting insulin is:
A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?
Discharge teaching for the client who has a total gastrectomy should include which of the following?