Mosbys comprehensive exam

110問 • 1年前

問題一覧

What should the nurse do to assess the neurovascular status of an extremity casted from the ankle to the thigh?

Compress and release the client’s toenails.

A nurse is assessing a client who is experiencing postmenopausal bleeding. The tentative diagnosis is endometrial cancer. Which findings in the client’s history are risk factors associated with endometrial cancer? Select all that apply.

Obesity, Family history of endometrial cancer, Previous hormone replacement therapy

A client who has breast cancer had postlumpectomy chemotherapy and is now scheduled for radiation on an outpatient basis. What is an important nursing intervention while the client is receiving radiation?

Assess the radiated site daily for redness or irritation.

A client’s problem with ineffective control of type 1 diabetes is identified when a sudden decrease in blood glucose level is followed by rebound hyperglycemia. What should the nurse do when this event occurs?

Collaborate with the health care provider to alter the insulin prescription.

A client with the diagnosis of personality disorder with antisocial behavior is hospitalized. The client is openly dis- cussing interpersonal difficulties with family members and the boss at work from whom money has been stolen. The client presently is facing criminal charges. Which behavior indicates that the client is meeting treatment goals?

Discussion of plans for each of the possible outcomes of a trial

A client with severe preeclampsia is hospitalized. What should a nurse do first to ensure her physical safety?

Place her on seizure precautions.

Which statement by a client with type 2 diabetes indicates to the nurse that additional teaching about the diet is needed?

“I can eat as much dietetic fruit as I want.”

A child is found to be allergic to dust. The nurse is preparing a teaching plan for the parents. What should the nurse include in the plan?

Damp-dusting the house will help limit dust particles in the air.

A client who has just started on a regimen of haloperidol (Haldol) is observed pacing and shifting weight from one foot to another. What side effect does the nurse document in the client’s chart?

Akathisia

A client who has been on a psychiatric unit for several weeks continually talks about delusional material. What response by the nurse is most therapeutic?

Encourage the client to focus on reality issues.

A client has a tonic-clonic seizure. What is the priority nursing intervention during the tonic-clonic stage of the seizure?

Protect the client from injury.

A nurse admits an adolescent to the psychiatric unit with the diagnosis of anorexia nervosa. What is the primary gain a client with anorexia achieves from this disorder?

Reduction of anxiety through control over food

A nurse is caring for a newborn with a myelomeningocele. What should immediate nursing care for this infant include?

Applying sterile, moist, nonadherent dressings to the sac

Oxytocin (Pitocin) augmentation via IV piggyback (IVPB) is prescribed for a client in labor after a period of ineffective uterine contractions. What nursing interventions are most important if strong contractions that last 90 seconds or longer occur? Select all that apply.

Stop the infusion., Turn the client on her side., Notify the health care provider., Verify the length of contractions., Administer oxygen via a face mask.

The cervix of a client in labor is dilated 8 cm. She tells a nurse that she has a desire to push and is becoming increas- ingly uncomfortable. She requests pain medication. How should the nurse respond?

Help her to take panting breaths.

A nurse administers an intramuscular injection of vitamin K to a newborn. What is the purpose of the injection?

Provides protection until intestinal flora is established

A child with acute poststreptococcal glomerulonephritis requests a snack. Which is the most therapeutic selection of food the nurse can provide?

Applesauce

A client reports experiencing nausea, dyspnea, and right upper quadrant pain unrelieved by antacids. The pain occurs most often after eating in fast-food restaurants. Which diet should the nurse instruct the client to follow?

Low fat

A person sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aid station. The nurse encour- ages the client to seek medical attention, but the client refuses. The nurse advises the person to go to a health care provider if:

urinary output decreases.

A client with a history of gambling has legal difficulties for embezzling money and is required to obtain counseling. During an intake interview, the client says, “I never would have done this if I had been paid what I am worth.” What factor will create the greatest difficulty when assisting this client to develop insight?

Projection of reasons for difficulties onto others

A nurse is working with a client who has the diagnosis of borderline personality disorder with antisocial behavior. What personality traits should the nurse expect the client to exhibit? Select all that apply.

Engaging, Manipulative

A client has a urinary retention catheter in place after surgery. What should the nurse do when planning for the client’s safety needs in relation to this device?

Keep the system closed at all times.

What is the most important test the nurse should check to determine whether a transplanted kidney is functioning?

Serum creatinine level

A pregnant adolescent at 10 weeks’ gestation visits the prenatal clinic for the first time. The nutrition interview indicates that her dietary intake consists mainly of soft drinks, candy, French fries, and potato chips. Why does the nurse consider this diet inadequate?

Nutritional composition of the diet places her at risk for a low-birth-weight infant.

A nurse in the prenatal clinic is assessing a woman at 34 weeks’ gestation. The client’s blood pressure is 166/ 100 mm Hg and her urine is +3 for protein. She states that she has a severe headache and occasional blurred vision. Her baseline blood pressure was 100/62 mm Hg. What is the priority nursing action?

Arrange transportation to the hospital.

A child has cystic fibrosis. Which statement by the parents about their plan for the child’s dietary regimen provides evidence that they understand the nurse’s instructions?

“I should provide high-calorie foods between meals.”

A nurse is caring for a client with glaucoma. What rationale associated with the need for treatment of this condition should the nurse include in a teaching program?

Lost vision cannot be restored.

A nurse is caring for a client with a below-the-knee amputation. What should the nurse encourage the client to do to prepare the residual limb for a prosthesis?

Press the end of the residual limb against a pillow periodically.

A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client?

Give prescribed drugs to promote bronchiolar dilation.

A health care provider orders daily sputum specimens to be collected from a client. When is the most appropriate time for the nurse to collect these specimens?

On awakening

Which factor is essential to consider when a nurse evaluates whether a unit environment is conducive to psychologic safety for a confused client with dementia?

Realistic limits and controls are set.

A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress?

Restlessness

What clinical findings does a nurse expect when assessing a child with acute laryngotracheobronchitis. Select all that apply.

Fever, Inspiratory stridor, Hoarseness, Barking cough

An IV infusion of magnesium sulfate is prescribed for a client with severe preeclampsia. The dose is twice the usual adult dose. When a nurse questions the dosage, the health care provider insists that it is the desired dose and directs the nurse to administer the medication. How should the nurse respond to this directive?

Withhold the dose and notify the nurse manager.

Which nursing action should be included in the plan of care for a child with acute poststreptococcal glomerulonephritis?

Monitoring for seizures

A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine the client is taking because it intensifies the most serious adverse effect of acetaminophen?

Alcohol

The parents of a child who is dying of cancer ask the nurse whether they should tell their 7-year-old son that his sister is dying. What is the most appropriate response by the nurse?

“Your son probably doesn’t understand death as we do but fears it just the same. He should be told the truth to let him prepare for his sister’s possible death.”

A nurse is caring for an underweight adolescent girl who is diagnosed with anorexia nervosa. What are common char- acteristic of girls with this disorder that the nurse should identify when obtaining a health history and performing a physical assessment? Select all that apply.

Fatigue, Secondary amenorrhea

A client with major depression is admitted to the hospital. What is the most therapeutic initial nursing intervention?

Conveying an attitude of concern that is not intrusive

During the first trimester, a client tells a nurse at the prenatal clinic that she frequently feels nauseated. What should the nurse teach her about reducing the nausea?

Eat small, frequent meals.

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). What complications are most commonly associated with COPD?

Cardiac problems

A new parent asks a nurse how to care for the baby’s umbilical cord stump. What should the nurse include in the teaching?

Provide sponge baths until the stump falls off.

After resection of a lower lobe of the lung, a client has excessive respiratory secretions. Which independent nursing action should the nurse implement?

Turning and positioning

A health care provider explains a cystectomy and an ileal conduit to a client with invasive carcinoma of the bladder. Later the client expresses concerns about the possibility of offensive odors associated with this procedure. What is the best response by the nurse?

“Tell me more about what you are thinking.”

Using Piaget’s theory of cognitive development, what should the nurse expect a 6-month-old infant to demonstrate?

Beginning of object permanence

An internal fetal monitor is applied while a client is in labor. What should the nurse explain about positioning while the monitor is in place?

The most comfortable position can be assumed.

During a newborn assessment a nurse reports a sign of respiratory distress. What clinical manifestation did the nurse identify?

Flaring nares

On the third postpartum day, a woman who is breastfeeding calls the nurse at the clinic and asks why her breasts are tight and swollen. What should the nurse consider before explaining why her breasts are engorged?

The lymphatic system in the breasts is congested.

A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first-aid measure that a nurse should instruct the person to apply before seeking health care?

Cool, moist towels

A nurse is assessing a newborn. What finding indicates the need for follow-up care?

Hips are abducted at 30 degrees.

A nurse is assessing a group of older adults. Which should the nurse consider to be least likely to be affected by aging?

Strategies to handle stress

What should be the initial nursing action after the birth of a preterm infant with an Apgar score of 6?

Dry the infant and place in a warm environment.

Which is most important for the nurse to do when provid- ing care to a client who has had a transurethral resection of the prostate?

Ensure patency of the indwelling catheter.

A client is to receive 125 mL of IV fluid every hour. The drop factor of the IV tubing is 10 gtt/mL. How many drops per minute should the nurse administer? Record your answer using a whole number.

21 gtts/min

A client on a psychiatric unit who has been hearing voices is receiving a neuroleptic medication for the first time. The client takes the cup of water and the pill and stares at them. What is the most therapeutic statement the nurse can make?

“Your doctor wants you to have this medicine. Swallow it.”

After a therapy session with a health care provider in the mental health clinic, a client tells the nurse that the therapist is uncaring and impersonal. What is the nurse’s best response?

“You have strong feelings about your therapy session and your therapist.”

A client who has just had a kidney transplant is transferred from the postanesthesia care unit (PACU) to the intensive care unit (ICU). How often should the nurse in the ICU monitor the client’s urinary output?

Every hour.

A client who uses ritualistic behavior taps other clients on the shoulders three times while going through the ritual. The nurse infers that this client has a:

reduced ability to adapt to life’s stresses.

A pregnant client with severe preeclampsia is receiving IV magnesium sulfate. What should the nurse keep at the bedside to prepare for the possibility of magnesium sulfate toxicity?

Calcium gluconate

A person who is hospitalized for alcoholism becomes boisterous and belligerent and verbally threatens the nurse. What is the most appropriate response by the nurse?

Sedate and place the client in a controlled environment.

A family of a client with myasthenia gravis asks the nurse whether the client will be an invalid. What is the nurse’s best response?

“There will be periods when bed rest will be necessary and times when regular activity will be possible.”

A parent of a 2-year-old child who was just diagnosed with cystic fibrosis expresses concern about the child’s frailty and low weight. What is the nurse’s most appropriate reply?

“Digestive enzymes will be given to help your child digest food.”

During the first well-baby visit after discharge from the hospital, the parents inform the nurse that their baby has difficulty sucking and swallowing and tires easily. What should the nurse consider when assessing this infant?

Difficulty when feeding may be an early indication of a heart defect.

For which clinical indicator should the nurse monitor a child with chronic hypoxia?

Clubbing of fingers

A nurse is caring for a client with a fracture of the head of the femur. The health care provider places the client in a Buck extension. What explanation does the nurse give the client for why the traction is being used?

Reduces muscle spasms.

A client has a total hip arthroplasty. What should the nurse do when caring for this client after surgery?

Use a pillow to keep the legs abducted.

Which client in a psychiatric unit needs immediate thera- peutic intervention from the nurse?

50-year-old woman who is pacing around the dayroom and picking fights with other clients

A client in a psychiatric hospital with the diagnosis of major depression is tearful and refuses to eat dinner after a visit with a friend. What is the most therapeutic nursing action?

Offer an opportunity to discuss the visit.

A person with a history of alcoholism states, “I have been drinking since last Friday to celebrate my son’s graduation from college.” What defense mechanism does the nurse identify the client is using?

Rationalization

The parents of a child with spasmodic croup ask why their child is receiving humidified oxygen. What effect of humidified oxygen should the nurse include in the explanation?

Minimizes tissue edema

A client has a surgical creation of a colostomy. What is the most effective nursing intervention to initially help the client accept the colostomy?

Introduce equipment needed to care for the colostomy.

When planning care for a child with autism, the nurse understands that given a choice, the child with autism usually enjoys playing:

on a playground merry-go-round.

A client who is at 26 weeks gestation arrives at the clinic for her scheduled examination. Her blood pressure is 150/86. She tells the nurse that she has gained 5 pounds in the last 2 weeks. What is the priority nursing action?

Test the client’s urine for albumin.

What behavior does a nurse expect of a newborn about 1 hour after birth?

Relaxed and sleeping quietly

A client who has a phobia about dogs is about to begin systematic desensitization. The client asks what the treat- ment will involve. What is the nurse’s best response?

“Your contact with dogs will increase while using relaxation techniques.”

A nurse is providing dietary teaching for a client who is receiving a high-protein diet while recovering from an acute episode of colitis. What should the nurse include is the rationale for this diet?

Repairs tissues

A nurse is caring for a client experiencing an acute episode of bronchial asthma. What outcome should be achieved?

Raising mucous secretions from the chest

When a developmental appraisal is performed on a 6-month- old infant, which observation is most important to the nurse in light of a diagnosis of hydrocephalus?

Head lag

A new mother refuses to look at her newborn who has a severe birth defect. What is the nurse’s most therapeutic approach?

Reinforce the explanation of the handicap and allow time for her to discuss her fears.

When teaching a class about parenting, the nurse asks the participants what they do when their toddlers have a temper tantrum. Which statement demonstrates one parent’s understanding of the origin of temper tantrums?

“I try to prevent a temper tantrum by allowing my child to choose between two reasonable alternatives.”

A nursing assistant interrupts the performance of a ritual by a client with obsessive-compulsive disorder. What is the most likely client reaction?

Anxiety

When a nurse is working with a client with psychiatric problems, a primary goal is the establishment of a therapeu- tic nurse-client relationship. What is the major purpose of this relationship?

Assist the client in acquiring more effective behavior

A health care provider prescribes a diuretic for a client with hypertension. What should the nurse include in the teaching when explaining how diuretics reduce blood pressure?

Reduces the circulating blood volume

A nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selected by the client indicates to the nurse that dietary teaching about thiazide diuretics was effective?

Broccoli

A 20-year-old college student comes to the college health clinic reporting increasing anxiety, loss of appetite, and an inability to concentrate. What is the most appropriate response by the nurse?

“It has been difficult for you. How long has this been going on?”

A nurse is caring for a client who attempted suicide. What is the most desirable short-term client outcome during this crisis situation?

Establishing a no-suicide contract

A 3 12-year-old child is admitted to the hospital for an appendectomy. What should the nurse use to best prepare the child for the hospital experience?

Therapeutic play

A client with adrenal insufficiency reports feeling weak and dizzy, especially in the morning. What should the nurse determine is the most probable cause of these symptoms?

A hypoglycemic reaction

A client is admitted to the hospital with a diagnosis of chronic kidney failure. For signs of what electrolyte imbal- ance should the nurse monitor the client?

Hypocalcemia

During her sixth month of pregnancy, a woman visits the prenatal clinic for the first time. As part of the initial assess- ment, a CBC and a urinalysis are performed. Which labora- tory finding should alert the nurse that further assessment is required?

Hemoglobin level of 10 g/dL

Two hours after an uneventful labor and birth, a client’s uterus is four fingerbreadths above the umbilicus. After urinary catheterization, the fundus remains firm and four fingerbreadths above the umbilicus. What is the priority nursing action?

Notify the health care provider.

A client receives spinal anesthesia during labor and birth. Twenty-four hours later, she tells a nurse that she has a headache. Which statements indicate to the nurse that the headache is a reaction to the anesthesia? Select all that apply.

“I have ringing in my ears.”, “It improves when I lie down.”, “Bright lights really bother my eyes.”, “My head hurts more when I am sitting watching TV.”

A client has a history of hypothyroidism. Which skin condi- tion should the nurse expect when performing a physical assessment?

Dry

A nurse is caring for a client who has had an open reduction internal fixation of a fractured hip. Which nursing assess- ment of the affected leg is most important after this surgery?

Toes for mobility

A nurse is caring for a client with myxedema who has under- gone abdominal surgery. What should the nurse consider when administering opioids to this client?

One third to one half the usual dose should be prescribed.

A nurse is caring for a child with spasmodic croup. Which clinical finding alerts the nurse that immediate nursing intervention is required?

Rapid respirations

Which position would most help to decrease a client's discomfort when the client's spouse injects Vitamin B12, using the ventrogluteal site?

Lying on the abdomen with toes pointed inward.

Which of the following manifestations does the nurse most likely observe in a client with Hodgkin's disease?

Painless, enlarged cervical lymph nodes.

The client had been diagnosed to have aplastic anemia. Which of the following statements of the client indicates the need for further teaching?

"I am allowed to go and watch basketball games."

100

The client with chronic myelocytic leukemia will receive blood transfusion. Which of the following is inappropriate nursing action?

Administer lactated ringers in dextrose 5 % as "piggy back".

Astignars random QS

Kyla Angelique Son · 19問 · 1年前

Astignars random QS