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The nurse conducts a physical examination of a client suspected to have bulimia. Which of the following observations by the nurse MOST likely indicates bulimia?


The client has ulcerated mucous membaranes of the mouth.

due to frequent vomitting
 
The nurse cares for a multipara client who delivered a female infant 1hour ago. The nurse observe's the client's breast are soft; the uterus is boggy to the right of the midline and 2 cm below the umbilicus; moderate lochia rubra. It is MOST important for the nurse to take which of the following actions?  


Offer the client the bedpan.

boggy uterus deviated to the right indicates full bladder encourage the client to void
A young adult imbolized for trauma to the spinal cords has periods of diaphoresis, a draining abdominal wound, and diarrhea. On the basis of the nursing assessment, which of the following is MOST important nursing diagnosis?


Risk for impaired skin integrity related to immobilization and secretions.

skin is very susceptible to breakdown because of immobility and bodily secretions; needs numerous nuring interventions to prevent this
The nurse cares for a client one day after a thoracotomy. Nursing actions listed on the care plan include turn, cough and deep breath q 2 hours. The nurse understands that the purpose of this nursing action includes which of the following?  


Promote ventilation and respiratory acidosis

primary purpose of this nursing measure is to improve and/or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis 
A neonate weighing 7 lb and 4 oz with Apgar scores of 7 and 8 at 1 and 5 minutes, respectively is admitted to the nursery. Because the infant's mother is diagnosed with a type 1 diabetes, the nurse knows that the infant is at GREATEST risk for developing which of the following?


hypoglycemia

fetus produces incrased insulin to match mother's increased glucose level during pregnancy; infant continues to have high insulin output after birth, resulting in hypoglycemia
The nurse in outpatient clinic assits with an application the left arm of a pre-school aged child. After the cast is applied the nurse should take which following precautions?


Elevate the client's arm on two pillows

minimizes swelling, elevated for the frist 24 - 48 hours, protects from pressure and flattening of cast
The nurse cares for patients on pediatric units. The mother of a 2 y/o who is one day postoperative, tells the nurse, "My child is so restless and overactive." The nurse should take which of the following actions?


Check to see when the child last received pain medications.

young children typically become restless and overactive if in pain; grimacing, clenching teeth, rocking and aggressive behaviour may also be observed
The nurse plans a diet for a child with cystic fibrosis. Which of the following dietary requirements should be considered by the nurse?

high protein, low fat, high calories

impaired intestinal absorption due to cystic fibrosis necessitates a diet, higher in protein and calories; fat is decreased because it may interfere with absorption of other nutrients
A male client is admitted with urinary tract problems. A prostate specific antigen (PSA) and acid phosphatase test are to be done. The nurse knows that  


these tests are valuable screening test for prostatic cancer

PSA test has replaced acid phosphatase test in screening for prostatic cancer; tests must be drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSA value
A client with clear lung sounds and unlabored breathing receives aminophylline IV. Which of the following is the MOST appropriate nursing action if the client's IV infiltrates?  


Call the physician and recommend that the IV medications be changed to PO

before a new IV is started on this client, the physician should be called and PO medications  recommended
The nurse is aware that Rh immune globulin (RhoGAM) is administered to prevent complications in which of the following situations?


The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs.

RhoGAM is given to an Rh-negative mother who gives birth to an Rh-positive baby when the baby has a negative Coombs test.    
The nurse in the outpatient client instructs a client diagnosed with right-sided weakness to walk dwon stairs using a cane. What behavior if demonstrated by the client indicates to the nurse that teaching is successful?


The client leads with the cane followed by the right leg and then the left leg.

to gow down stairs, advance cane and  weak leg, then strong leg; memory trick; the good goes up; the bad goes down
The nurse makes patient assignments on the obstetrics unit. Which of the following patients should the nurse assign to the RN who has been reassigned to the obstetrics unit from outpatient surgery?
A patient at 16 weeks' gestation addmitted with hyperemesis and receiving IV fluids

monitor IV therapy, administer antiemetics and nutritional supplements 
A 2 day old infant in the newborn nursery does not appear interested in taking formula from the mother or the nurse. An appropriate diagnosis is high risk for


fluid volume defecit

may become dehydrated
The nurse cares for clients in a medical clinic. A nursing assessment of a client  with a hiatal hernia is most likely to reveal which of the following?

Complaints of awakening at night with a heartburn

classic symptoms of hiatal hernia associated with reflux
An older client with pneumonia is admitted to the medical/surgical unit. The nurse should place the client in a room with which of the following patients?  


a 50 y/o recovering alcoholic with cellulitis of the right foot

genralized nonfollicular that involves deeper connective tissue both patients have infections 
A client is admitted with irritable bowel syndrome. Then urse anticipates that the client's history will reflect which of the following?


pattern of alternating diarrhea and constipation

condition is often called spastic bowel disease; no inflammation is present
The nurse cares for a client who had an above the knee amputaion (AKA) with an immediate prosthetic fitting. It is MOST important for the nurse to take which of the following actions?   
Provide cast care on the affected extremity

cast applied to provide uniform compression, prevent pain and contractures
The school nurse observes a group of preschool children in the playroom. The nurse recognizes which of the following activities as appropriate behavior for a 5 y/o boy?

The boy talks on the telephone and immitates his father

immitative behavior seen at this stage
Which of the following statements, if made by the nurse, is accurate about the exercise program required for a patient with rhematoid arthritis?


"When inflammation is severe, decrease the number of repetitions of the exercise."

should reduce repetitions when the patient experiences more pain
The nurse assess a client with severe bilateral peripheral edema. Which of the following is the BEST way for the nurse to determine the degree of edema in a limb?


Depress the skin and rank the degree of pitting.

severity of edema is characterized by grading it +1 or (2- mm pitting) to 4+ (8-mm  pitting)
A 6-month old infant has had all of the required immunizations. The nurse knows that this would include which of the following?


Two doses of diptheria, tetanus, and pertussis vaccine

first dose of DPT may be given at 2 months of age, the second is give around 4 months 

The nurse should include which of the following in a teaching plan for a client receiving tetracycline?


Use a maximum-protection sunscreen when outdoors.

because of problems related to photosensitivity, client should wear sunscreen, wide-brim hats, long sleeve when at risk for sun exposure
A client is admitted for a series of test to verify diagnosis of Cushing syndrome. Which of the following assessment findings, if observed by the nurse, supports this diagnosis? Select all that apply.


Buffalo hump, hyperglycemia, hypernatremia

hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings and susceptiblity to infections 
The nurse cares for a patient several days after a above-knee amputation (AKA). Which of the following symptoms are characteristic of an infected residual limb wound?  


the patient complains of persistent pain at the operative site

pain is characteristic of inflammation and infection
Which of the following statements, if made by the client to the nurse, indicates that the client is using the defense mechanism of conversion?  


"I was unable to take the final exam because I was unable to write."

client has converted his anxiety over school performance into a physical symptom that interferes with his ability to perform  
Which observation indicates to the nurse that the client needs further teaching before self-administering insulin?


The client administers the insulin while it is still cold from the refrigerator.

insulin should be administered at room temperature; temperature extremes should be avoided
A client has orders for cefoxitin (Mefoxin) 2 g IV piggyback in 100 mL 5% dextrose in water. The primary IV is 5% dextrose in lactated Ringer's and is infusing by gravity. It is MOST important for the nurse to take which of the following actions?
Hang the infusion piggyback higher than the primary infusion bag.

when using a gravity drip, piggyback fluid levels need to be higher than primary infusion
An infant is admitted with vomiting and diarrhea. The infant's interior fontanelle is depressed and temperature is 103.2*F (39.5*C). Which of the following nursing actions is MOST appropriate?


Observe the infant's ability to take in fluids.

assessment; will assist in determining if hydration can be done through oral fluids alone
A client is taking propanolol (Inderal) 40 mg BID and furosemide (Lasix) 40 mg daily for several months. Two weeks ago, the physician added verapamil (Calan) 80mg TID to the client's medication regimen. The client returns to the outpatient clinice for evaluation. It is MOST important for the nurse to assess for which of the following?

Peripheral edema

Calan is Ca channel blocker, depresses myocardial contractility, decreases work of ventricles and O2 demand, dilates coronary arteries; when used with other antihypertensives can cause hypotension and heart failure
A client has a 3 way Foley-catheter following a transurethral resection. The nurse should rapidly infuse the irrigating solutions if which of the following is observed?


Bright red drainage or clots are present

3 way Foley catheter should be irrigated rapidly when bright-red drainage or clots are present; irrigation rate should be decreased to about 40 gtt/min when the drainage clears
The nurse knows that which of the following symptoms is supportive of a diagnosis of Guillian-Barre syndrome?

Respiratory failure, flaccid paralysis, urinary retention

classic symptoms include respiratory failure and flaccidity due to paralysis of the muscles and urinary retention due to loss of sensation
The nurse observes the fetal heart monitor for a client in active labor. The fetal heart tracing shows early fetal decelerations. The nurse is aware that this is


A slowing early in the contraction, and is usually a normal finding

occurs in response to compression of fetal head; uniform shape corresponds to rise in intrauterine pressure as uterus contracts, does not indicate fetal stress
   
A client is scheduled for a myelogram at the outpatient clinic. The physician's office nurse reinforces the physician's explanation of the procedure. Which of the following statements, if made by the nurse, correctly describes a myelogram?

"The test involves a lumbar puncture with injection of contrast medium, allowing x-ray visualization of the vetebral canal."

contrast medium or air is injected into spinal subarachnoid space through a spinal puncture; identifies tumors, cysts, and herniated vertebral discs
The nurse caring for a client on suicide precautions makes the following observations: the client is verbalizing other options besides suicide, appears to be responding to antidepressant medications, and is sleeping and eating better, and has indicated a willingness to interact more with family members. Based on these data, which of the following nursing actions is MOST appropriate?  

Recoomend that the treatement team reevaluate the client's treatment plan.

data suggests that the client is beginning to benefit from treatment; entire treatment team should share data and make a decision about the suicide precautions so that restrictions are changed gradually on the basis of a full-data picture
The nurse obtains a history from the father of a 6 y/o boy with a history of epilepsy who was admitted with uncontrolled seizures. It is MOST for the nurse to ask which of the following questions?

"What was your son doing before the seizure?"

seizure may result from triggering mechanism (loud noise, music, flickering light, prolonged readings, drugs)
A client is diagnosed with obsessive-compulsive disorder manifested by the compulsion of hand-washing. The nurse knows that which of the following BEST describes the client's need for the repetitive acts of hand-washing?


Hand-washing helps the client avoid undesirable thoughts and maintain some control over guilt and axiety.

compulsive behaviour is an unconscious attempt to control and/or relieve the tension and axiety the client is experiencing.
The nurse cares for an elderly client who has just had a prosthetic hip implant. The nurse should position the client in which of the following positions?


Side-lying with the affected hip in a position of abducted

position of abduction should be maintained
A mother brings her 10 y/o and 3  y/o daughters to the pediatrician's office because the younger girl complains of dysuria. The physician orders a catherization to obtain a urine specimen. The nurse should take which of the following actions?

Describe the procedure to the child in short concrete terms while talking calmly.

children this age need simple explanations
The nurse cares for client after an electroconvulsive therapy (ECT) treatment. The nurse should report which observation to the client's physician?  


backache

client undergoing ECT needs to be instructed about what he/she could expect during and after ECT; expected effects include headache, disrupted memory (short term and long term), and general confused state; backache is not a usual effect; thorough description of the pain in relation to severity, duration, location, and what makes better needs to be assesses and reported to the physician 
A mother brings her 9 month old infant to the pediatrician's office with complaints of a fever of 102.2*F (39.9*C) and frequent vomitting. The nurse expects which of the following reflexes to still be present?


Babinski's reflex

stroking outer sole of foot upward causes toe to hyperextend and fan and great toe to dorsiflex; disappears after 1 y/o
The nurse cares for an adult client with multi-infarct dementia. Which of the following actions, if taken by the nurse is BEST?   


Monitoring wandering behaviors during a 7-day period.

approrpiate assessment to determine if client wanders during specific times od the day; assess before implementing
A teenager diagnosed with anorexia nervosa is admitted to the hospital. In planning to care for the client, the nurse would expect the client to
want to talk about and plan her meals

display a marked preoccupation with food
The nurse cares for a client admitted with a diagnosis of acute hypoparathyroidism. It is MOST important for the nurse to have which of the following items available?
tracheostomy set

tracheostomy set is the most important for the client's safety due to risk of laryngospasm
An adult woman has missed her menstrual period. The client's menstrual period began May 8 and ended May 12. The nurse determines that the client's EDC (estimated date of confinement) is which of the following?

FEb. 15

When using the Naegele rule, add 7 days to the first day of last menstrual period and subtract 3 months
The nurse checks the incision of a patient 48 hours after a surgery of a hernia repair. Which of the following indicates a possible complication?


the incision line is red

should be pink and not red; others signs include increased warmth, tenderness, pain, purulent or odorous drainage 
The nurse knows that which of these plans is MOST successful in caring for a client with dementia?


adjust the environment to meet the client's individual needs

client with dementia does not have cognitive abilities to learn new skills or to adapt; environment must be adapted for client with attention to safety and predictability
Alient has partial-thickness and ful thickness burns over 75% of his body. The nurse is MOST concerned if which of the following is observed?

tachypnea

body responds to early response to hypovolemic shock by adrenergic stimulation; vasoconstiction compensates for the loss in fluid resulting in cool, clammy skin, tachycardia, tachypnea, and pale color
The nurse observes a client who is taking phenelzine (Nardil) eat another client's lunch. After a few minutes, the client complains of headache, nausea, and rapid heartbeat, and begins to vomit. The nurse anticipates administering which of the following medications?


Nifedipine (Procardia)

antihypertensive; the client experienceing hypertensive crisis d/t ingestion of tyramine; side effects include dizziness, headache and nervousness
The nurse receives report from the previous shift. Which of the following clients should the nurse see FIRST?

A client is receiving ciprofloxacin (Cipro) and complains of a fine macular rash

indicates hypersensitivity reaction; should stop medication and notify the physician 
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