A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expert the client to report. a. Loss of central vision b. Having a loss of peripheral vision c. Seeing bright flashes of light and floaters d. Having decreased ability to perceive colors Symptoms of cataracts include painless blurred vision and a decrease in the ability to perceive colors. A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next? a. Complete a vascular assessment b. Administer an antipyretic c. Decrease environmental stimuli d. Assess the cranial nerves The greatest risk to the client ICP which may lead to herniation of the brain and death. The nurse should perform neurological assessments including evaluation of the cranial nerves at least every 4 hours. Early neurological changes to be monitored for include a decrease in the LOC, the development of Cushing’s triad (severe hypertension, widened pulse pressure, and bradycardia), and changes in pupillary reaction. A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? a. Fatigue The nurse should identify that the client who has anemia due to blood loss following surgery will experience fatigue. This is due to the body’s decreased ability to carry oxygen to vital tissues and organs. Constipation is a manifestation of anemia due to blood loss following surgery. Tachycardia is a manifestation of anemia due to blood loss following surgery. b. Hypertension c. Bradycardia d. Diarrhea A nurse is caring for a client 3 days after admission for treatment of depression. The client leaves her current activity, approaches the nurse and states, “There’s no reason to go on living, I just want to end it all.” Which of the following actions should the nurse take? a. Ask the client if she has a plan to commit suicide. The nurse should take seriously all statements regarding suicide. Asking the client if she has a suicide plan is a specific question that the nurse should include when assessing a client who has possible suicidal ideation. b. Recognize the attempt at manipulation and escort the client back to her activity. c. Assist the client to her room and allow her to rest before resuming activity. d. Notify the client’s family and request a visitor to stay with the client until thoughts of suicide are gone. A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see? a. Decreased WBC b. Increases serum amylase. With acute pancreatitis, serum amylase rises within 24 hour of the start of the client’s symptoms. c. Decreased serum lipase. d. Increase serum calcium. A nurse is teaching a client who has a new diagnosis of atrial fibrillation. The nurse should instruct the client to monitor for which of the following complications? a. Bradycardia b. Pulmonary embolism Altered atrial contractions can cause blood pooling and thrombus formation. The client is at risk for developing a pulmonary embolism or embolic stroke. The client should monitor and report immediate manifestations, such as shortness of breath, or neurological changes. c. Peripheral vascular disease d. Hypertension A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client’s history? a. Gallstones The client’s history might reveal biliary obstruction from a gallstone causing bile to inflame the pancreas. b. Hypolipidemia c. COPD d. Diabetes melitus A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take? a. Encourage fluid intake of 1500 mL/day b. Position head of bed at 10 degrees. c. Cough and deep breath every 8 hr. d. Obtain a sputum culture. The nurse should obtain a sputum culture to determine which antibiotics needed for the organism that is causing the pneumonia. A nurse in an emergency department is caring for an adolescent following a suicide attempt. After reviewing the client’s history, the nurse should determine that which of the following is the priority risk factor for suicide complication? a. ?Active psychiatric disorder b. ?Previous suicide attempt ?A prior suicide attempt is found in as many as half of the adolescents who attempt suicide. c. ?Loss of a parent d. ?History of substance abuse A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was. a. Dysphagia b. hoarseness Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long exposure to tobacco and alcohol. Hoarseness that does not resolve for several weeks is the earliest manifestation of cancer of the larynx because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh and lower in pitch than normal. c. Dyspnea d. Weight loss A nurse is teaching a group of newly licensed nurses on effective techniques for counseling clients about sexually transmitted infections. Which of the following statements should the nurse include in the teaching? a. “Use closed-ended questions when obtaining the health history.” b. “A client’s reproductive health history is not needed for counseling purposes.” c. “Ask about the client’s exposure to any past or present STIs.” The nurse should assess the client's exposure to any past or present STIs and any treatment taken. d. “Refer the client to genetic counseling if he has had a STI. A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following actions should the nurse include in the plan of care? a. Keep the infant NPO for 6 hr prior the procedure. b. Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure. c. Place the infant in an infant seat for 2 hr following the procedure. d. Hold the infant’s chin to his chest and knees to his abdomen during the procedure. During the procedure, the infant is positioned on her side in a fetal position (knees curled to abdomen and chin tucked to chest) to open up the subarachnoid. A nurse is teaching a client about causes of biliary cirrhosis. Which of the following information should the nurse include in the teaching? a. Excessive alcohol consumption b. hepatitis C c. hepatotoxic medications d. Obstruction of the bile duct prolonged obstruction of the common bile duct is the most common cause of biliary cirrhosis A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect? a. Pruritus b. Hypertension c. Bradykinesia The nurse should expect to find bradykinesia a difficulty moving in a client who has Parkinson's disease. d. Xerostomia A nurse is admitting a client who has acute heart failure following a myocardial infarction. the nurse recognizes that which of the following prescriptions by the provider requires clarification? a. Morphine sulfate 2 mg IV bolus every 2 hours PRN pain b. Laboratory Testing of serum potassium upon admission c. 0.9% normal saline IV at 50 ml/hr continuous 0.9% sodium chloride is isotonic and will not cause the fluid shift needed in this client to reduce circulatory overload. This prescription requires clarification d. Bumetanide 1 mg IV bolus every 12 hr A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure as indicated by which of the following findings? a. nuchal rigidity b. Pupils reactive to light c. widened pulse pressure A widened pulse pressure is a manifestation of increased ICP. Other manifestations include bradycardia, vomiting, and decreased level of consciousness. d. elevated temperature A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates an understanding of teaching?(SATA) a. “I must stop smoking.” b. " I should limit my exercise. " c. "I will stop consuming alcohol." The client does not have to stop consuming alcohol. Consuming Less Than 3 oz per day can assist in decreasing the risk of coronary artery disease. However, consuming more than 3 oz per day has been associated with an increased risk of cardiac disease. d. “ I need to monitor my weight." e. "I am limiting my intake of fast food." A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client's provider, and completes the incident report, which of the following actions should the nurse take? a. Make a copy of the incident report for the provider b. submit the incident report to the risk manager The purpose of an incident report is to provide information to the risk manager who will investigate the incident and work with the other members of the healthcare team to control risk of the client injury. c. place the incident report in the client's chart d. document in the chart that an incident report has been filed A nurse is teaching a client about the intradermal purified protein derivative (PPD). which of the following information should the nurse include? a. “An indurated area of 4 mm indicates a positive result." b. "The injection site will be evaluated within 24 hours.” c. "The test is performed and previous results are negative." The nurse should assess whether the client has tested positive to Prior PPD test. For clients who have tested positive, chest x-ray is performed to determine exposure. d. "Positive results suggest active infectious disease.” A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? a. turn the clients head to the side. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to turn the clients head to the side. This action keeps the clients airway clear secretions to prevent aspiration. b. Check the clients motor strength. c. Loosen clothing around the clients waist. d. Document the time the seizure began. A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan?(SATA) a. Administer Furosemide The nurse should administer furosemide to the client to reduce fluid accumulation in the abdomen. b. administer warfarin The nurse should avoid administering warfarin to the client due to possible destruction of platelets caused by splenomegaly, which can result in spontaneous bleeding. Propranolol is prescribed instead to discourage bleeding. c. Implement a low sodium diet The nurse should Implement a low sodium diet to control fluid accumulation in the abdomen. d. measure the client's abdominal girth The nurse should measure the client's abdominal girth. Daily weights and an even more reliable indicator of fluid accumulation. e. Encourage weightlifting doing physical therapy The nurse should understand weightlifting can cause bleeding. A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care? a. Provide respite services for the parents b. Improve the client’s communication skills c. Foster self care activities d. Modify the environment A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? a. Hypotension b. Tachycardia c. Irritability The nurse should monitor the client for behavioral changes, such as confusion, restlessness, and irritability as manifestations of increased intracranial pressure. d. Tinnitus A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (SATA) a. Grooming b. Long term memory c. Support systems d. Affect e. Presence of pain A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse’s priority? a. The client's ECG tracing shows irregular heart rate without p waves. b. the client has an aptt of 80 Seconds c. the client experiences sudden weakness of one arm and leg Sudden weakness or numbness of the face and one arm or leg and can indicate that the client is at greatest risk for stroke, therefore, this is the nurse’s priority finding. In addition to these findings, the client may appear confused, have slurred speech, loss of balance, dizziness, or sudden severe headache. d. The client's urine output is cloudy and odorous. A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis about the use of antitubercular Medications. Which of the following information should the nurse include in the teaching? a. Medications will need to be taken for the rest of the client's life, even if the client feels better b. Medications will need to be taken until the mantoux test is negative. c. A typical course of treatment involves 6 to 9 months of consistent medication use. Pulmonary TB is a contagious bacterial infection caused by mycobacterium tuberculosis. Active TB is usually treated with the simultaneous administration of a combination of medications to which two organisms are susceptible. Such therapy is continued until the disease has control. A six to nine-month resume consisting of 2, and often 4, different medications is used. The client should not drink alcohol during this time. d. The client's family will also need to take medications to prevent infection A nurse is reviewing The laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect? a. Hco3 30 meq / l b. paco2 50 mm Hg c. Ph 7.45 d. potassium 3.3 meq / l A nurse is caring for a client who has asthma and developed viral pharyngitis. Which of the following findings should the nurse expect? a. Petechiae on the chest and the abdomen b. WBC 16000 mm3 c. Negative throat culture A client who has viral pharyngitis will have a negative throat culture. A client who has bacterial pharyngitis usually has a throat culture positive for beta hemolytic streptococcus. d. Severe hyperemia of pharyngeal mucosa A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? a. Troponin I Troponin I is a myocardial muscle protein that is released when there is an injury to the cardiac muscle. Levels are elevated as early as two to three hours following a myocardial infarction. b. troponin t Troponin T is a myocardial muscle protein that is released when there is an injury to the cardiac muscle. Levels are elevated as early as two to three hours following a myocardial infarction. c. plasma low density lipoprotein (LDL) elevation of plasma low-density lipoprotein indicates a client's risk for coronary artery disease. Increase and LDL levels does not diagnose myocardial infarction. d. CPK CPK or creatinine kinase is an enzyme that is elevated in the presence of muscle injury. Although CPK is not specified for myocardial damage it is used in conjunction with other diagnostic tests to support a diagnosis of myocardial infarction. A CPK isoenzyme, CK – MB, is specific to cardiac muscle and a significant elevation in this I sew ins I'm indicates a myocardial infarction has occurred e. myoglobin Elevation of myoglobin indicates myocardial injury. Myoglobin levels will significantly increase within approximately 3 hours following myocardial infarction. This test is used in conjunction with other diagnostic tests to support a diagnosis of myocardial infarction. A nurse is assessing a child who is in Sickle Cell crisis. Which of the following findings should the nurse expect? a. High fever a low-grade fever is a manifestation of sickle cell crisis b. Bradycardia tachycardia is more common with sickle cell anemia than bradycardia c. Pain a client who is in Sickle Cell crisis has severe pain resulting from tissue hypoxia and necrosis d. constipation Sickle Cell crisis generally affects the lungs and deliver, rather than the gastrointestinal tract A nurse is teaching a client who has emphysema about self management strategies. Which of the following statements by the client indicates an understanding of the teaching? a. “I will inhale slowly through pursed lips to help me breathe better.” The client should first inhale slowly through the nose, then exhale slowly through pursed lips. b. "I will avoid getting a flu shot." The client is at risk for respiratory infections. Therefore, the client should avoid crowds and she'll get the annual vaccinations against influenza. c. "I will follow a daily diet high in calories and protein." Clients who have emphysema have greater than usual nutritional requirements for calories and protein off and need nutritional supplements between meals. d. "I will lie on my stomach to practice abdominal breathing everyday." The client should practice abdominal diaphragmatic breathing exercises daily lying on the back with his knees Flex. A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? a. "Without treatment glaucoma can cause blindness." The nurse should explain that without treatment glaucoma can result in blindness due to irreversible damage to the retina and optic nerve b. "Double vision is a common symptom of glaucoma." The nurse should explain that visual manifestations of glaucoma include a gradual loss of visual field, blurred vision, and seeing Halos around lights. c. "Glaucoma is caused by inadequate production of fluid within the eye." The nurse should explain that glaucoma is the result of increased intraocular pressure caused by A disruption in the drainage and reabsorption of the aqueous. d. “Use of eye drops will improve Vision over time.” A group of nurses are discussing risk factors for transmission of human immunodeficiency virus (HIV) from clients. Which of the following individuals should the nurse identify as being at the greatest risk for Contracting HIV? a. An occupational therapist who works with a client who has HIV b. a personal trainer who works with a client who has HIV c. a phlebotomist who collects blood from clients who have HIV d. a nurse who works with an insurance company and collect urine samples from clients who have HIV A nurse is caring for a client who has heart failure in a new prescription for furosemide. For which of the following adverse effects should the nurse monitor? a. Hypervolemia b. Hypertension c. Hypokalemia d. hypoglycemia A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include? a. Encourage breathing exercise before meals to promote appetite b. Place food in the affected side of the mouth c. encourage the client to take small bites d. place the client with the head recline back to facilitate swallowing A nurse is caring for an older adult client who has left sided heart failure. Which of the following assessment findings should the nurse expect? a. Frothy sputum Left sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestation include hacking cough, frothy sputum, wheezing, fatigue, and weakness. b. Dependent edema right sided heart failure has greatest systemic effects based on increased venous pressure and congestion. Manifestations include dependent edema to the extremities and sacrum, enlarged liver and spleen, and ascites. c. nocturnal polyuria nocturnal polyuria indicates right sided heart failure d. jugular vein distention jugular vein distention is right sided heart failure A nurse in the emergency department is caring for a client who has myasthenia gravis and is in crisis. Which factor should the nurse identify as a possible cause of myasthenic crisis? a. Developing a respiratory infection The most common triggers of myasthenic Crisis are respiratory infection, not taking, or taking too little, of prescribed medication, surgery, and high environmental temperatures. b. Taking too much prescribed medication c. diet high in protein d. not exercising enough A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan of care? a. Provided a cognitively stimulating environment. b. Rotate staff to prevent caregiver role strain. c. Limit the client's choices for daily activities. d. Use confirmation to manage negative behavior A nurse is setting goals for a client who has AIDS and is at the end of life. Which of the following are realistic goals? a. the client will verbalize is understanding of the mode of disease transmission b. the client will experience a weight gain of 1to 2 pounds per week c. the client will increase attendance at Community social activity d. the client will receive medication to minimize episodes of breakthrough pain A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? a. Gradual onset of several hours a client who has a thrombotic ischemic stroke still has a gradual onset of manifestation occurring over several minutes 2 hours. A client who has had a hemorrhagic stroke tends to have an acute onset. b. manifestations preceded by a severe headache A hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid space. It can be caused by hypertension, and aneurysm, or an arteriovenous malformation. A sudden severe headache is an expected initial manifestation of a hemorrhagic stroke. c. maintain consciousness a client who has had an ischemic stroke maintains a level of Consciousness. A client who has a hemorrhagic stroke has a decreased level of Consciousness extending from stupor to coma. d. History of neurological effects lasting less than 1 hour A nurse is presenting discharge instructions to a client who has multiple sclerosis. The client reports symptoms of hypoxia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? a. Wear an eyepatch on the right eye. All times b. plan to relax in the hot Spa each day c. engage in vigorous exercise program d. Implement a schedule to include periods of rest A nurse is teaching a client who has angina pectoris about starting therapy with SL nitroglycerin tablets. The nurse should include which of the following instructions regarding having to take this medication? a. "take this medication after each meal and at bedtime.” b. “take one tablet every 15 minutes during the acute attack." c. "take 1 tablet at the first indication of chest pain." d. "take this medication with 8 oz of water.” A nurse is caring for a child who has Otitis media with effusion. the nurse should identify which of the following manifestations indicates a tympanic membrane rupture? a. Green blue discharge in the ear canal b. increase temperature c. sudden pain relief accumulation of exudate caused by a otitis media with effusion increases pressure behind the tympanic membrane. The pressure release is with the tympanic membrane rupture, which results in sudden pain relief. d. Popping sensation when swallowing A nurse is teaching a client who is postpartum and has been diagnosed with iron deficiency anemia. Which of the following dietary recommendations should the nurse include in the teaching playing? a. Yogurt and mozzarella b. spinach and beef c. Milk and turkey slices d. fish and cottage cheese A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan? a. Include foods high in starch and proteins b. include foods high in fiber c. avoid foods high in fat The nurse should instruct the client to follow a low-fat diet to decrease episodes of biliary colic. A client who has chronic cholecystitis is has intolerance to fatty foods d. Avoid foods high in sodium A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asked what this blood test will show. Which of the following explanations should the nurse provide for the client? a. Troponin is an enzyme that indicates damage to the brain, heart, and skeletal muscle tissue. Creatinine kinase is the enzyme that indicates damage to the brain, heart, and skeletal muscle tissue. b. troponin is a lipid who's levels reflect the risk for coronary artery disease. Cholesterol is a lipid whose levels reflect the risk for coronary artery disease. c. Troponin is a heart muscle protein that appears to be in the bloodstream when there's damage to the heart. Troponin is a myocardial muscle protein that releases into the bloodstream when there is an injury to the myocardial muscle. Troponin levels are a specific point of care testing for clients who are having a myocardial infarction. d. troponin is a protein that helps transport oxygen throughout the body. A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect? a. Fatty stools b. straw colored urine c. tenderness in the left upper abdomen d. ecchymosis of the extremities A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching? a. Avoid eating at fast-food restaurants b. avoid serving raw foods c. practice effective hand hygiene d. Wear barrier protection during vaginal intercourse A nurse is caring for a child who has a tracheostomy. After such a tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective? a. Increase respiratory rate b. stable oxygen saturation c. clear breath sounds d. brisk capillary refill A nurse is teaching a Community Education course about the physical complications related to substance use disorder. Which of the following findings should the nurse identify as the primary cause of liver cirrhosis? a. Alcohol b. Caffeine c. Cocaine d. inhalants A client who has a history of myocardial infarction is prescribed aspirin 325 mg. The nurse recognizes the aspirants given due to which of the following actions of the medication? a. Analgesic b. Anti-inflammatory c. antiplatelet aggregate d. Antipyretic A nurse is preparing to administer a transfusion of RBC’'s to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? Select all that apply a. Dyspnea Dyspnea is a clinical manifestation of fluid volume overload b. gastrointestinal bloating Gastrointestinal bleeding is not a clinical manifestation of fluid volume overload. c. jugular vein distention Jugular vein distention is a clinical manifestation of fluid volume overload d. Confusion Confusion is a clinical manifestation of fluid volume overload e. hypotension Hypertension, not hypotension, is a clinical manifestation of fluid volume overload. Hypotension is a manifestation of hemolytic transfusion reaction.
