VATI Comprehensive Predictor NCLEX Questions

Dairy products & eggs, such as custard and yogurt (Rat) A low-residue diet consists of foods that are low in fiber and are easy to digest such as eggs, custard, yogurt and ripe bananas - NOTE Legumes such as lentils and black beans are high in fiber and are not considered low in residue.

Use the formula (wt. in lbs)/(ht in in^2) multiply by 703 to get the BMI. BMI is 31 (obese) (Rat) A BMI greater than 30 indicates obesity. A BMI of 25-29.9 indicates overweight. A BMI of 18.5-24.9 is a normal/healthy BMI. A BMI <18.5 indicates underweight.

Use the formula (lbs)/(in^2) multiply by 703 BMI 42 indicates the patient is obese

(A, C, E, G) A. Position the infant rear-facing in the backseat - (RAT) the car seat should never be in the front seat of a car due to the increased risk for injury from the air bags during a MVA. C. Be sure the care seat is at a 45 degree angle - (RAT) the car seat should be at a 45 degree angle. E. Position the care seat in the middle of the back seat - (RAT) the car seat should be in the middle away from air bags and side impact. G. Keep infants in rear-facing car seat until 2 yr - (RAT) keep the child in the rear-facing car seat until the child reaches 2yo or until the child reaches the maximum ht and wt for the seat.

(C,D,E) C. Make sure that the patient's call light is within reach D. Provide the patient with nonskid footwear E. Complete a fall-risk assessment Note- You do not put all the side rails up in the bed because this is considered a restraint.

A. Complete a fall-risk assessment (Rat) this is a priority nursing question therefore the question should direct you to the nursing process. The first action the nurse should take using the nursing process is to assess or collect data from the patient.

D. Place wet towels along the base of the door to the patients room - (RAT) to contain the fire and smoke in the room. Note - do not obtain a class C fire extinguisher but instead obtain a class A fire extinguisher which is used for ordinary combustibles such as cloth and paper.

R - Rescue and protect the patients who are at or near the fire. Patients who can walk are able to do so on command to a safe location. A - Activate the alarm C - Contain/confine the fire by closing doors and windows and turn off all oxygen sources and any electrical devices. Ventilate the patient who are on life support by using a bag-valve mask E - Extinguish the fire with a general/appropriate fire extinguisher (Class A)

(A, B, C, D, E) A. Call the MD B. Check the VS C. Notify the risk manager D. Complete an incident report E. Instruct the patient to remain in bed until further notice Note - If the question was a priority question, what would the RN do first? First, I would check the VS. Next, notify the MD. Third, complete an incident report. Fourth, instruct the patient to remain in bed and lastly notify the risk manager.

Medical command physical - (RAT) oversee's the use of resources (equipment and personnel) NOTE - the incident commander manages the incident and key leaders within the facility NOTE - Expect the triage officer to prioritize the treatment of patients coming in for treatment NOTE - Expect the media liaison to communicate with members of the media and press on behalf of the facility

Ciprofloxacin (Cipro) will treat and prevent the spread of anthrax (RAT) Ciprofloxacin and doxycycline IV/PO is used following exposure. Treatment includes one or two additional antibiotic (vancomycin, penicillin and anthrax antitoxin)

A patient who was abused as a child describes the abuse as if it happened to someone else

He - Headache IS - Irritability/ Sweating T - Tachycardia I - Irritability R - Restlessness E - Excessive Hunger D - Dizziness

Heparin (RAT) Heparin can cause spinal hematoma - the risk for hematoma at the puncture site for spinal or epidural medication administration is increased while taking heparin. NOTE - Factors that further increase risk include taking other anticoagulants or antiplatelet medications, Hx of spinal problems or surgery or use of an indwelling epidural catheter. NURSING CONSIDERATIONS - In patients who have spinal or epidural anesthesia: Assess insertion site for indications of hematoma formation (redness, swelling). Monitor sensation and movement of lower extremities. Notify MD of abnormal findings.

Neutropenic Precautions (RAT) The risk of serious infection increases as the ANC falls. An ANC lass than 1,000/mm^3 indicates a weak immune system and the need to initiate neutropenic precautions.

D. A patient who has a Hx of MRSA can still transmit the infection

Staphylococcus aureus (VISA/VRSA) Viral hemorrhagic fever Vancomycin-intermediate and vancomycin-resistant Typhoid fever Toxic shock syndrome (TSS) Tetanus Syphilis Smallpox Pertussis (whooping cough) Mumps Legionnaires disease Anthrax Botulism NOTE: You do not report HPV to the CDC (RAT) HPV infection and other HPV - associated clinical conditions are not nationally reportable or required by the CDC.

(# of exposed people who develop infection)/(# exposed people) = attack rate multiply by 100 to get the percentage 15

(#cases)/(#population) x 1,000 13

Apply Oxygen Establish an IV Administer Cipro/Doxycycline ABT.

C - characterized by a disregard for others/conduct d/o before age 15yr, charming and engaging verbally A - arrests, the patient commits acts for arrest L - lies L - lacks a superego, lacks empathy for others O - obligations, not honored U - unstable, can't plan ahead S - sense of entitlement, seductive behaviors, safety of self and others are ignored M - manipulative, money problems, spouse and children are not supported; failure to accept responsibilities A - aggressive and assaultive N - not a calm person, actions are impulsive; non-adherence to traditional morals and values.

- One of the highest risks for intimate partner violence is when the partner threatens to leave. - Pregnancy is considered a risk factor of intimate partner violence due to the pregnancy being unexpected, unwanted or the financial obligations/future financial obligations involved in the care of a child. - Witnessing violence in the home or being and being a victim of violence in the home growing up - Female

- Safety is the number one priority in patients in acute mania. Assessments are continuous to ensure the patient will not harm self or others. - Provide a quiet environment - seclusion may be required - One structured activity for a patient with acute mania is walking or exercising. - ECT can be used during manic episodes/rapid cycling, when the patient is a danger to self or others.

- The nurse should notify the MD - Collect labs to read the INR; an INR of 1.1 or below is normal; for a person taking warfarin an INR range of 2.0 - 3.0 is an effective therapeutic range.

Place the patient in lateral position (RAT) This is a late deceleration and is associated with fetal hypoxemia due to insufficient placental perfusion, placing the patient in the lateral position is the 1st action the RN should take (NOTE) Late decelerations are associated are also with insufficient placental perfusion. Placing the patient in the lateral positions is the 1st action the nurse should take - also administer 8-10 L of O2 but position change is 1st. Hint: Think VEAL CHOP "L" Late decelerations "P" Placental insufficiency

Wide skull sutures (RAT) Small "newbies" aka premies have wide skull sutures due to inadequate bone growth. Head circumferences smaller than the normal newborn and there is reduced brain capacity. (NOTE) SGA newborns have sunken abd not abd that protrude; they also have loose dry skin and a thin yellowish umbilical cord that looks dull and dry.

Slightly above the belly button (RAT) Anything between 20-22 WOG is approximately at the level/slightly above the belly button & anything <20 WOG is below the belly button. Monitor for supine hypotension (NOTE) 3 cm above the belly button means the fundal height indicates the gestation to be >22 WOG.

Indomethacin - relaxes & suppresses the uterus and is commonly used in preterm labor Mag Sulfate - used to prevent seizures & is a tocolytic (meaning that is stops/halts preterm labor contractions) "the baby needs a little more time to bake". (NOTE) Oxytocin is incorrect - we don't want to cause contractions we want to stop them.

caused by chronic intrauterine anemia ie. Rh isoimmunization, caused by blood incompatability. Ex. Rh neg mom with a Ph pos baby. The Rh pos blood enters mom - note: this is what hydrops fetalis is

"Have you noticed any bloody show or fluid coming from your vagina" (RAT) True labor has nothing to do with the start of contractions

The taking in phase of the maternal postpartum adjustment (RAT) Positive mom-infant bonding is incorrect - the bonding describes behaviors r/t maternal adaptation to mothering the newborn, not specifically newborn-mother interaction which would be indicative of positive bonding.

Hypothermia (RAT) NAS is the result of the neonate withdrawing from drugs as the neonate is detached from the maternal supply. (NOTE) baby's with NAS will not present with diminished/decreased DTR's but increased DTR's instead, increased muscle tone, increased hypersensitivity to sound and external stimuli

Performs a heel stick (RAT) the infant may be experiencing hypoglycemia and a heel stick will allow the nurse to test the BS to assess glucose. (NOT) A drug screen is not the priority action

The fundus will present one cm below the belly button

In true labor the uterus will dilate and efface (NOTE) It is not true that the presenting part is engaged; most of the time when the patient is in true labor the presenting part is engaged - and is not a solid indication that this is true labor.

The drug is having a therapeutic effect (RAT) It is incorrect to assess DTR's; while DTR's should be assessed with a patient receiving mag sulfate this is not required based on this data.

Assess maternal VS (NOTE) Do not assess the fetal heart tones; since the mother is feeling the baby move this is not necessary.

Offer the neonate breast milk or formula (NOTE) it is incorrect to provide the neonate with O2 via oxyhood; the neonate does not present with respiratory distress or a low muffled cry.

Lethargy & respiratory depression (RAT) Tachycardia and respiratory distress is incorrect

Maternal Hx of cytomegalovirus (NOTE) the answer is not a decrease in the number of functional alveoli; a decrease in the number of functional alveoli within the lung may lead to respiratory distress of apnea but is not necessarily a predisposing factor for a neonatal infection

Assist the patient to void (NOTE) to assess the lochia is incorrect, while it will be appropriate to assess lochia a displaced uterus indicates a full bladder.

A. Adjusting to dramatic changes to body image (RAT) the major developmental task in teens (12-18 YO) is identify vs. role confusion. Teens are preoccupied with their changing bodies and how their bodies appear to others. (NOTE) Intimacy vs isolation stage occurs in early adulthood & safety is not a major developmental task for teens. However, risk-taking behaviors are the primary reason for unintentional injury, which is the most common cause of death in teens.

D. Facilitate a change in the patients behavior (RAT) confidentiality, goals and roles are established during the orientation phase of the therapeutic relationship

B. Offer the RN tart or sour foods first (RAT) A patient who has impaired swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which aids chewing and swallowing.

A. A mode of transmission for the disease (RAT) Think of a vector as a car the vector is there the bacteria/microorganism resides to get to the host.

A. Fortified milk (RAT) Provides nearly 2.5 mcg of Vit D, which promotes calcium absorption from the GI tract. Adults up to age 70 require 600 IU of Vit D/per day and 800 IU thereafter. Therefore, fortified milk is a good source of Vit D.

A. "You'll have to lie flat for several hours after the procedure." D. " You'll have to keep your leg straight after the procedure." E. "You'll have to limit the amount of fluid you drink for the first 24 hr."

B. Dysrhythmias (RAT) F-fib is one of the most common causes of death following a MI. Therefore the nurse should monitor EKG's carefully for these alterations in the heart rhythm and report and treat them STAT. (NOTE) Cardiogenic shock, HF and pulmonary edema are complications of MI, but is not the most common cause of death following MI. Other complications include emboli and pericarditis.

A. Initiate ROM exercises (RAT) to maintain mobility and to prevent contracture

B. Instilling 50 mL of fluid with each irrigation (RAT) When irrigating a patient's ear the RN should use no more than 5 - 10 mL of irrigating fluid at a time to decrease the chance of stimulating the vestibular nerve of the inner ear, which would result in N&V or dizziness.

B. Interference with renal perfusion causes prerenal azotemia (RAT) Prerenal azotemia refers to elevations in BUN and Creat resulting from problems in the systemic circulation that decrease flow to the kidneys. The decreased renal flow stimulates salt and water retention to restore volume and pressure - Prerenal axotemia results from interference with renal perfusion, such as from HF or hypovolemic shock.

C. Post a large calendar on the bulletin board (RAT) Posting a large calendar in a central location will assist this patient with orientation

C. Sudden oliguria (RAT) The RN should identify sudden oliguria as an indication of an acute intravascular hemolytic reaction. This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. This reaction results from the patients antibodies reacting to the transfused RBC's.

B. Ability to build a tower of 6 blocks D. Slightly bowed or curved leg appearance (NOTE) A 24 MO should have 16 teeth and a vocabulary of 300 words and to be able to speak in 2-3 word phrases.

A. Identify how much cleaner was in the bottle D. Insert an IV for morphine administration E. Apply a pulse oximeter (RAT) Activated charcoal is contraindicated for the treatment of poisoning with a corrosive agent because these substances can burn tissue, which the charcoal could then infiltrate - gastric lavage is contraindicated for the treatment of poisoning with a corrosive agent because this could re-expose the upper GI system to the corrosive substance, which can result in further injury.

B. "The doctor will be able to see if I have signs of RA (RAT) An arthroscopy helps with diagnosing musculoskeletal d/o such as RA, osteoarthritis, and internal joint injuries

A. The patient rigidly extends his arms (RAT) a patient who exhibits decorticate posturing internally flexes the wrists and arms and extends and plantar-flexes the legs

D. Perform a blanch test (RAT) The blanch test is used to check capillary refill, which is an indicator of peripheral circulation and tissue perfusion (NOTE) Beau's lines are depressions in the nail from temporary disturbance of nail growth. Beau's lines are caused by systemic illness or injury and are not indicators of tissue perfision

B. Wiping the labia minora in an anteriorposterios direction (NOTE) The RN should use the nondominate hand to spread the labia and provide the optimal view of the urethral meatus

B. Absent BS with distention (RAT) Paralytic ileus is an immobile bowel. In this disorder, BS are absent and the abdomen is distended.

C. "Include 2.5 cups of veggies in your daily diet." (RAT) Instruct women to consume 2.5 cups of veggies and 2 cups of fruit in the diet. (NOTE) The recommended amount of ETOH for women is a drink per day, which is equivalent to 350 mL (12 oz) of beer, 148 mL (5 oz) of wine, or 44 mL (1.5 oz) of hard ETOH that is over 80 proof.

A pulse of 4+ is bounding and does not disappear with moderate pressure. Pulse strength ranges from absent (0) to bounding (4+).

A. Increased BP (RAT) Stress and anxiety can cause the BP to increase and the HR to increase as a result of the SNS stimulation

C. Explain the procedure to the patient

A. Auscultation

C. Have the patient demonstrates the procedure (RAT) The patient demonstrating the procedure provides the RN the ability to evaluate the patient's understanding within the psychomotor domain of learning

A. Promote the use of music to compete with the client's auditory hallucinations. (RAT) Competing reality-based stimulation such as the use of music or TV during auditory hallucinations can assist in limiting the effect the hallucinations have on the patient's stress level.

A. Feelings of hopelessness D. Anhedonia E. Flat facial expression (RAT) Anhedonia is the inability to experience pleasure as a clinical manifestation of MDD.

B. Encourage frequent rest periods throughout the day. (RAT) A client who is experiencing acute mania is at risk for sleep disturbances and might go for extended periods of time without sleep. Encouraging periods of rest throughout the day can limit the risk of exhaustion (NOTE) The nurse should direct the client to areas with minimal activity to decrease stimulation. so (A) is incorrect.

B. A client who is taking lamotrigine and has developed a rash (RAT) Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify that a rash is a potentially life-threatening adverse effect of the medication and report this finding immediately (NOTE) Lithium is a medication used for mood stabilization for clients who have bipolar disorder. The nurse should identify that the lithium toxicity can result in serious complications, including death. However, a lithium level of 1.2 mEq/L is within the therapeutic range. (Normal Ref. Range for lithium is 0.6 - 1.2 mEq/L

A. Encourage the client to drink 125 mL of fluid each hour while awake. (RAT) The nurse should encourage the client to drink 125 mL of fluid each waking hour to maintain hydration. (NOTE) Initially, the nurse should measure the client's vital signs three times each day until the client's weight increases and cardiovascular status improves - so measuring the patients VS once each day is incorrect.

C. Assess the client for evidence of a perceptual disturbance. (RAT) The nurse should assess the situation to determine if the client is hallucinating or misperceiving external stimuli, also known as experiencing illusions. (NOTE) Trying to convince the client that there is not a bomb in their room negates the client's experience - so convincing the patient that there is no bomb in their room is the incorrect action to take

D. "I feel so empty without my wife that it's hard to get up every morning." (RAT) The nurse should identify that when a client has difficulty carrying on normal activities following a loss, this is an indication that there is a risk for complicated grief. (NOTE) The nurse should identify that the client is expressing guilt, which is an expected finding of grief - so - the patient stating "I wish I had been nicer and more generous with my wife before she died" is an incorrect statement

C. Determine the client's prescribed medication regimen. (RAT) The first action the nurse should take when using the nursing process is to assess the client. By determining the client's prescribed medications, the nurse can determine the cause of the hypertension, such as the client taking an MAOI to treat depression. These medications can precipitate a hypertensive crisis if consumed with tyramine-containing foods, including wine. (NOTE) The nurse should initiate IV access because fluid therapy is essential to decrease hyperthermia. However, there is another action the nurse should take first.

B. Set realistic limits on the client's behavior. (RAT) Clients who have antisocial personality disorder can seem to be in control of their behavior, but are manipulative and impulsive and can suddenly become aggressive and assaultive. The nurse should establish clear limits on specific aggressive and demanding behaviors. (NOTE) Clients who have antisocial personality disorder do not lack assertiveness. They tend to act in an aggressive and exploitative manner. This strategy should be used for clients who have dependent or histrionic personality disorders. - so (D) is incorrect.

C. Attention to body language (RAT) Use of active listening involves identifying verbal and nonverbal communication by the client, which includes attention to body language. (NOTE) The nurse uses this therapeutic technique to demonstrate willingness to wait for the client's response - (B) is incorrect

A. Total body fat 8.7% (RAT) The nurse should recognize that criteria for hospitalization includes having a weight less than 75% of ideal body weight, or less than 10% body fat. The nurse should report this finding to the provider. (NOTE) Criteria for hospitalization is a heart rate less than 50/min during the daytime - (D) is incorrect

D. "In the event a client threatens harm to others, medications can be administered without consent." (RAT) The charge nurse should inform the participants that their primary commitment is to the client and their priority is always to advocate for and protect their health and safety. During an emergency situation, if the client is threatening harm to self or others, medications can be administered without the client's consent and without a court order. (NOTE) Because laws vary from state to state, nurses should become familiar with the requirements as it relates to reporting neglect or maltreatment of clients. The nurse should inform the participants that in most states failure to report the suspected neglect, physical maltreatment, or exploitation of a disabled adult results in a misdemeanor charge - (B) is incorrect.

C. Experiences feelings of isolation (RAT) The nurse should expect clients who have PTSD to feel estranged and detached from others. (NOTE) The nurse should identify difficulty sleeping and hypervigilance as expected manifestations of PTSD - so (B) is incorrect

A. Increased creatine phosphokinase (CPK) (RAT) An increase in CPK, a muscle enzyme released when muscle tissue is damaged, occurs with cardiomyopathy. (NOTE) AST does not decrease when a client is experiencing alcoholic cardiomyopathy - (D) is incorrect

D. Spending adequate time with a client who is verbally abusive (RAT) By spending adequate time with a client who is verbally abusive, the nurse is demonstrating the ethical principle of justice. When the nurse spends an appropriate amount of time with each client regardless of their behavior and in keeping with their individual needs, the nurse guarantees that all clients receive equal care - the answer is not (B) because attempting alternative therapies instead of restraints for a patient who is combative is demonstrating the principle of non-maleficence.

C. Call for a team of staff members to help with the situation. (RAT) The greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to themselves or others. (NOTE) Once the nurse and other clients are safe, the nurse should assess the client who was hit for injuries to determine if medical intervention is needed. However, this is not the first action the nurse should take - (D) is incorrect

B. Early identification of changes, such as decreased social involvement, is important. (RAT) Decreased social involvement is a manifestation of depression, and early identification of findings can lead to early intervention. (NOTE) Medication is not always effective for all clients, and the nurse cannot guarantee that additional inpatient care will not be necessary - (C) is incorrect

B. "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight." (RAT) The nurse is using the therapeutic technique of summarizing to review the key points of the discussion. (NOTE) The nurse is using the therapeutic technique of focusing in this statement - (A) is incorrect

B. Establish screening programs to identify at-risk clients. (RAT) This is an example of secondary prevention. By establishing screening programs, the nurse can identify individuals who are at risk for partner violence in the community and can take the necessary steps to address individual client needs. (NOTE) This is an example of primary prevention. Positive coping mechanisms help clients and their partners cope with stress and help to prevent the incidences of partner violence in the community - (A) is incorrect.

B. Ask group members to discuss their feelings about this client's monopolizing behavior. (RAT) This intervention will validate other members' feelings toward the client who is dominating the meeting. It also should encourage group problem-solving. (NOTE) Ignoring the client does not address the behavior and is unlikely to solve the problem (D) is the incorrect answer

C. "I will not take charge of my partner's work responsibilities." (RAT) The nurse should identify that it is important for the individual who has the substance use disorder to take charge of personal responsibilities. (NOTE) The nurse should identify that avoiding social events is a codependent behavior (A) is incorrect

A. Occupational therapy B. Meal delivery services D. Physical therapy E. Home health services

A. "It appears as though you would like to open the door." (RAT) This statement is an example of the therapeutic technique of making observations. This technique encourages the client to notice the behavior so that they can describe thoughts and feelings related to that behavior. (NOTE) This statement is an example of non-therapeutic communication. It assumes an understanding of the client's feelings and offers no constructive interventions - (C) is incorrect.

C. Tachycardia (RAT) The nurse should monitor the child for tachycardia, which is an adverse effect of methylphenidate. (NOTE) Dry mouth is an adverse effect of methylphenidate (D) is incorrect

B. Rhinorrhea (RAT) The nurse should expect the client who is experiencing opioid withdrawal to have rhinorrhea and flu-like manifestations such as yawning, sneezing, and abdominal pain. (NOTE) The nurse should expect the client experiencing opioid withdrawal to have hyperthermia (D) is incorrect

B. Blood pressure 154/96 mmHg (RAT) Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3° C (101° F). It will be important for the nurse to rule out infection in the client who has a fever. (NOTE) A client who is experiencing alcohol withdrawal can experience profuse sweating and dilated pupils as a part of the autonomic nervous system's response. The autonomic nervous system is responsible for management of homeostasis. It has sympathetic and parasympathetic effects impacting the pupils of the eyes as well as the circulatory, respiratory, gastrointestinal, genitourinary, and integumentary systems (C) incorrect

D. Language delay (RAT) The nurse should identify that language delays are a manifestation of autism spectrum disorder. (NOTE) Motor and verbal tics are a manifestation of Tourette's syndrome rather than autism spectrum disorder (B) incorrect

D. Easily distracted (RAT). Extreme distractibility is a hallmark manifestation of delirium. (NOTE) Delirium has an acute onset. Dementia is a slow, progressive decline (A) incorrect

C. Renew the prescription for the client every 4 hr. (RAT) The nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hr, for a maximum of 24 hr. (NOTE) The nurse should offer toileting to the client every 15 to 30 min while the client is in seclusion (D) incorrect

C. Older children who are responsible for their younger siblings (RAT) This is an example of enmeshed boundaries in which there are no distinctions between the roles of family members. (NOTE) An adolescent who questions parental authority is demonstrating appropriate behavior for developmental age (A) incorrect

C. Apply restraints when other means of managing the client's behavior have failed. (RAT) According to the Patient Self-Determination Act, clients have a right to be free from restraints or seclusion unless the safety of the client or others is at risk. De-escalation methods for controlling behavior should be attempted prior to initiating restraints. (NOTE) The nurse should document the client's status, including behavior and vital signs, and address the client's physical and safety needs every 15 min (A) is incorrect

B. "The thought of having breast cancer may seem hopeless." (RAT) Restating what the patient said in order to focus on her feelings of hopelessness, allows the patient to share emotions related to the diagnosis.

C. "Is it because you feel like no one would understand what you are experiencing?" (RAT) The nurse is demonstrating the non-therapeutic communication technique of verbalizing the implied, which helps clarify the implicit meaning of the patient's statement and encourages further discussion. (NOTE) (A) demonstrates the non-therapeutic communication technique of assuming the existence of an external source of power. This allows the patient to blame something else for behavior rather than accepting the responsibility.

D. "I will feel the urge to urinate following this procedure." (RAT) After a TURP, the patient will feel the urge to urinate. The RN should reassure him that he will receive pain medication to help this discomfort. (NOTE) The patient might have temporary dribbling and leakage of urine following a TURP. The RN should reassure the patient that these manifestations will resolve - (C) is incorrect

A. Encourage the patient to control weight (RAT) The RN should encourage weight control to stabilize the patients BS and improve glycosylated Hgb levels. Obesity is a risk factor for type 2 DM, and moderate calorie restriction can improve control of DM. (NOTE) The RN should inspect the patient's feet daily. The patient is at risk for foot injury due to impaired circulation and reduced sensation in the lower extremities

Confusion (RAT) Brady-dysrhythmia can cause decreased perfusion, which can lead to confusion. The RN should monitor the patient's mental status (NOTE) HTN is incorrect; instead Brady-dysrhythmia can cause hypotension and sweating. THINK - slow HR, less blood is pumped to the brain.

Inquire about the presence of claudication (RAT) Arterial ulcer caused by (PAD) will present with claudication. Other s/s of PAD pain that is relieved when the legs rest; numbness and burning in the feet; hair loss to the lower calf, ankle and foot & dry, scaly, mottled skin

"You might no longer be able to feel chest pain." (RAT) Heart transplant patients usually are no longer able to feel chest pain due to the denervation of the heart.

S (swelling of the hands and fingers) W (wt gain) E (external JVD) A (abd distention) D (dependent edema) E (enlarged kidney [hydronephrosis], spleen, liver) N (neck vein distention)

S (sob when lying flat [orthopnea]) W (wheezing and lung crackles) E (edema in the lungs) E (excertion when breathing [dyspnea]) T (tachypnea) D (dry cough) O (orthopnea) E (extreme weakness)

(CK) Creatine Kinase - MB (RAT) CK-MB is the isoenzyme specific to the myocardium. Increased CK-MB = Myocardial muscle injury

Assisting with thrombolytic therapy (RAT) The RN should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy

Ask the patient to speak privately with the nurse after the meeting

NA 155 mEq/L (RAT) A child with a head injury can develop diabetes insipidus as a result of hypo-function which leads to a antidiuretic hormone. Underexcretion of antidiuretic hormone leads to polyuria and polydipsia and possibly dehydration. (NOTE) Urine specific gravity of 1.045 is incorrect - the USG above the ref range the child with a USG will have a low USG as a result of dilute urine.

Vomiting Lethargy (RAT) as a result of the obstruction that occurs when a segment of the bowel telescopes within another bowel segment. (RAT) Lethargy because the infant is in severe pain and cries inconsolably, leading to exhaustion

Potassium of 4.1 mEq/L (RAT) this medication is used to treat hyperkalemia by exchanging Na and K in the gut. The K value indicates that the medication is effective (NOTE) Reporting an onset of loose stools within 15 min of administers is incorrect, instead diarrhea is an AE of the medication.

Presence of strabismus (RAT) Crossing of the eye goes away around 3-4 MO. If not corrected early, this can lead to blindness. (NOE) presence of an open anterior frontal is incorrect because this is expected until 12 MO.

Increased temp Xerophthalmia Cervical lymphadenopathy (RAT) Kawasaki is an acute illness associated with hyperthermia (increased fever/temp) that is unresponsive to antipyretics or ABT. (RAT) Ophthalmic manifestations of Kawasaki disease include reddening of the conjunctiva and dryness of the eyes (xeropthalmia) (RAT) The child can develop enlarged lymph nodes on one side of the neck that are non-tender and are greater than 1.5 cm in size (NOTE) Kawasaki is a disease that affects the vascular system, including the heart. The child will have increased HR will not have bradycardia but tachycardia instead. The increase in the HR will present with a gallop rhythm. The long term effects of this condition is coronary artery aneurysms or MI. Other s/s associated with this disease - strawberry tongue, cracked lips and edema of the mouth and neck (oral mucosa and pharynx)

Deep respirations of 32/min (RAT) Kussmaul respirations are rapid and deep respiration. The body is trying to eliminate excess carbon to return to homeostasis. (NOTE) Paradoxic respirations of 26/min is incorrect - these respirations will present with a flail-chest and are not an expected finding of ketoacidosis.

Waite 3 days before taking a tub bath (RAT) the child should keep the site clean and dry for at least 3 days to decrease the risk of infections. Tub baths should be avoided for 3 days to avoid immersion of the incision in water. (NOTE) Follow a diet that is low in fiber for. a week is incorrect because the child can resume their regular diet after the procedure.

Provide a child with a book about adventures (RAT) to help the child expand their knowledge and imagination (NOTE) Giving the child a large piece puzzle is incorrect because this is something you would give to a preschooler.

The infant should gain 680 g (1.5 lbs) per month until age 5 MO

The radial nerve can be tapped to elicit a brachioradialis reflex.

On the un-operated side (RAT) the RN should position the patient on the un-operated side to prevent a rapid reduction of intracranial fluid and to protect the child from injuring the operative site.

Increased sleeping (RAT) After a head injury the infants LOC can decline, show signs of excessive sleeping and eventually go into a coma. (NOTE) Other s/s of increased ICP are bradycardia, slow pupil/sluggish pupil constriction/reaction, seperate cranial sutures and distended scalp veins from edema.

B. Minimize physical contact with the child initially (RAT) The nurse should initially minimize physical contact with the toddler, and then progress from the least traumatic to the most traumatic procedures. (NOTE) It is recommended to start with the least invasive interventions and proceed to the more invasive. The head to toe approach is recommended for preschool-age and older children - (A) is incorrect

A. Cow's milk (RAT) According to evidence-based practice, the nurse should instruct the parent that cow's milk is the most common food allergy in children. Some children are sensitive to the protein, called casein, found in cow's milk. They have difficulty metabolizing the casein and are, therefore, allergic to cow's milk. (NOTE) The nurse should instruct the parent that some children have an allergy to eggs because they contain albumin, which is a protein that some clients are unable to metabolize; however, evidence-based practice indicates that another food allergy is more common.

B. Babinski (RAT) The Babinski reflex, which is elicited by stroking the bottom of the foot and causing the toes to fan and the big toe to dorsiflex, should be present until the age of 1 year. Persistence of neonatal reflexes might indicate neurological deficits. (NOTE). The stepping reflex, in which the infant takes reflexive steps when placed on his or her feet in an upright position, disappears by the age of 4 weeks. (NOTE) The Moro reflex should disappear at the age of 3 to 4 months. It is an extension of the arms and flexion of the elbows in response to a sudden jarring, followed by flexion and adduction of the extremities. (NOTE) The extrusion reflex, which causes the infant to spit out food placed on the tongue rather than moving it to the back of the mouth, is absent by the age of 4 months.

C. Object permanence (RAT) Object permanence refers to the cognitive skill of knowing an object still exists even when it is out of sight. In discovering a hidden object while playing peek-a-boo, the infant experiences validation of this concept. (NOTE) Playing peek-a-boo does not serve to establish a sense of trust. Trust is developed by the consistent care given in the first year of life - (B) is incorrect

A. Wash and dry the infant's genitalia and perineum thoroughly. (RAT) This is the method used to obtain a routine urine specimen of any sort in a child who is not toilet trained. The skin should be washed and dried to promote application of the adhesive of the collection device. (NOTE) It is acceptable for the nurse to place the infant's penis and scrotum inside the collection bag in order to ensure a snug fit and prevent leaking - (C) is incorrect

A. Observe the parents' actions when feeding the child. B. Maintain a detailed record of food and fluid intake. (RAT) Inappropriate feeding techniques and meal patterns provided by parents can contribute to a child's growth failure. (RAT) A nutritional goal for the child who has suspected FTT is to correct nutritional deficiencies, which can be identified by recording all food and fluid intake. (NOTE) A consistent structured routine of feeding the child at the same time and place is used to promote weight gain. A child who has failure to thrive might not offer feeding cues - (C) is incorrect (NOTE) Caregivers should sit directly in front of the child to maintain a face-to-face position during feeding and promote eye contact. The emphasis is on encouraging feeding - (D) is incorrect

D. Adult tetanus booster (Td) (RAT) Td is recommended for wound prophylaxis in children ages 7 years and older. Td is also recommended every 10 years after 18 years of age. (NOTE) DTaP is used to provide immunity against diphtheria, tetanus, and pertussis in infants and children under the age of 7 years. DTaP is not recommended for wound prophylaxis -(A) is incorrect

D. Rock the child in long rhythmic movements. (RAT) The nurse can implement relaxation strategies by sitting with the child in a well-supported position such as against the chest, and then rocking or swaying back and forth in long, wide movements. (NOTE) This is an example of a distraction strategy (A) is incorrect

A. Presence of sparse, fine pubic hair (RAT) The development of sexual characteristics prior to the age of 9 years in boys, and 8 years in girls, is an indication of precocious puberty and requires further evaluation. (NOTE) The head circumference of a school-age child decreases when compared to full height due to skeletal lengthening -(B) is incorrect

C. Position the car seat so it is rear-facing. D. Secure a safety gate at the top and bottom of the stairs. E. Maintain the water heater temperature at 49° C (120° F). (RAT) Infants and children should remain in the rear-facing position when in a car seat until the age of 2 years or until they reach the recommended height and weight per the manufacturer's guidelines. (RAT) As the infant begins to crawl and becomes more mobile, the risk of falls increases. (RAT) To prevent a burn injury, the temperature of the water heater should not exceed 49° C (120° F).

B. Inability to vocalize vowel sounds (RAT) The infant should begin vocalizing vowel sounds at the age of 7 months, and by the age of 10 months, be able to say at least one word. (NOTE) The infant should creep on her hands and knees at the age of 9 months, and begin to stand while holding onto furniture at the age of 10 months - (A) is incorrect

B. Frequent hospitalization (RAT) Children who experience multiple and frequent hospitalizations are at an increased risk for stress-related reactions to hospitalization. (NOTE) Children between the ages of 6 months and 5 years are more vulnerable to the stress of hospitalization than a 10-year-old child - (A) not correct

C. Birth weight is tripled (RAT) The birth weight should triple by 12 months of age. By 30 months of age, the birth weight should be quadrupled. (NOTE) The skill of hopping on one foot is not developed until around the age of 4 years -(B) incorrect

B. Instruct the child to use a soft sponge toothbrush when brushing her teeth. (RAT) The child should use a soft sponge toothbrush when brushing her teeth because a regular toothbrush might cause further irritation to the mucosal ulcers. (NOTE) Preschool-age children should not take viscous lidocaine, because it depresses the gag reflex, increasing their risk of aspiration - (A) is incorrect

B. Check for pulses in the affected leg every 4 hr. (RAT) Traction might lead to neurovascular compromise. The nurse should assess for edema, pulses, pain, color, and temperature of the extremity every 4 hr. (NOTE) Buck's traction is skin traction, which works without the use of pins (C) is incorrect

B. Inactive and thumb sucking (RAT) A child who is sucking his thumb and refusing to eat or drink is displaying manifestations of the second stage of separation anxiety, which is despair. (NOTE) The protest stage is the first stage seen in separation anxiety, which includes the child crying and screaming (A) is incorrect.

B. Check the child's blood pressure every 4 hr. (RAT) The nurse should check the child's blood pressure every 4 to 6 hr to monitor for hypertension. (NOTE) Glomerulonephritis does not require strict bed rest, because ambulation does not have an effect on the disease. However, a child might experience fatigue with glomerulonephritis and can voluntarily restrict activities when the disease is most active (A) is incorrect

D. Serum cholesterol 700 mg/dL (RAT) A serum cholesterol level of 700 mg/dL is above the expected reference range. A child who has nephrotic syndrome will have high serum cholesterol findings because of the increase in plasma lipids (D).

B. Nausea D. Urticaria E. Stridor

D. Varicella (RAT) Children who have varicella might commence with a maculopapular rash that progresses to vesicles on erythematous bases that eventually rupture and crust over. (NOTE) A child who has fifth disease usually begins with bright red cheeks producing a "slapped-cheek" appearance. Following this, a rash appears on the extremities and trunk. The rash fades centrally, giving a lacy (reticulated) appearance to the rash (B) is incorrect

A. Transposition of great arteries (RAT) An infant who has transposition of great arteries will have severe cyanosis because reversal of the anatomic position of the aorta and pulmonary artery allows venous blood to enter the systemic circulation without oxygenation. (NOTE) An infant who has a ventricular-septal defect, a hole in the septal wall between the ventricles, can have increased pulmonary vascular resistance but is unlikely to have cyanosis because oxygenation of the blood remains adequate for the systemic circulation (B) is incorrect

A. "What year did you graduate from high school?" (RAT) When assessing a client's remote memory, the nurse should ask questions that determine the client's ability to remember things from the distant past. The nurse should ask questions that can be validated to ensure that the information is correct. (NOTE) The nurse should ask the client about the current date when assessing the client's orientation (D) is incorrect

B. A 9-month-old infant who reportedly nearly drowned after climbing into the tub and turning on the water (RAT) The nurse should identify that, while a 9-month-old might have the ability to climb into the tub, it is unlikely that he could turn the water on. The nurse should suspect possible abuse because the reported cause of the accident seems inconsistent with the developmental abilities of most 9-month-old infants. (NOTE) Toddlers have recently mastered walking and experience many falls and collisions. Because the bruises are in various stages of healing and are located over bony prominences, this likely indicates falling on several occasions (A) is incorrect

B. "You must feel very frightened to think someone wants to hurt you." (RAT) The nurse should acknowledge the client's feelings about the delusion. This acknowledgement helps the client to feel safe and accepted. (NOTE) The nurse should reinforce reality rather than encourage the client to focus on the delusional belief (A)

C. "You feel better when you don't take your medication?" (RAT) The nurse should use the therapeutic communication tool of validating or clarifying the client's feelings. The client has stated a preference for not taking the medication. This open-ended paraphrasing acknowledges the client's statement and allows for further exploration of the subject. (NOTE) The nurse should avoid non therapeutic communication that minimizes the client's current feelings (A) is incorrect

C. "The next time this occurs, what might you do to ensure your safety?" (RAT) The nurse should use the therapeutic communication technique of encouraging formulation of a plan of action. With this technique, the nurse encourages the client to explore alternative actions to ensure her safety if abuse occurs in the future. The nurse should assist the client to develop a safety plan, which includes information about shelters, so that she has the information if she chooses to leave in the future. (NOTE) The nurse should avoid offering an opinion or advice, which is a non therapeutic communication technique that blocks further dialogue with the client (D) is incorrect

B. Possesses feelings of decreased self-worth (RAT) The nurse should expect the client who has anorexia nervosa to have an altered sense of self-image and self-identity. The client often bases feelings of self-worth on body weight; therefore, feelings of self-worth are often decreased because the client views herself as overweight. (NOTE) The nurse should expect the client who has anorexia nervosa to have medical complications due to decreased body weight and malnutrition. The client who has anorexia nervosa is focused on weight without regard to personal health consequences (C) is correct

C. "There's no point in living any longer." (RAT) The nurse should identify this client comment as an overt statement about the client's risk for suicide. The nurse should assess the client's suicidal ideation further and implement interventions to promote her safety. (NOTE) The nurse should identify this client comment as a covert statement (A).

B. "My child was riding a bicycle and fell off." (RAT) The nurse should suspect possible child abuse in response to this statement because an 18-month-old toddler is not expected to have the developmental ability to ride a bicycle. (NOTE) The nurse should identify that 18-month-old toddlers are at a high risk for accidental injury due to falls because of increased mobility and curiosity; therefore, this report by the parent does not indicate child abuse (A) is incorrect

B. Countertransference (RAT) The nurse demonstrates countertransference by unconsciously attributing feelings, positive or negative, about another towards the client. (NOTE) The client demonstrates transference through the unconscious displacement of feelings towards the nurse (C) is incorrect

A. Denial (RAT) Evidenced-based practice indicates the nurse should first expect the parents to experience denial. Denial is the first stage of grief and is followed by anger, bargaining, depression, and finally acceptance. (NOTE) The nurse should expect the parents to eventually experience the bargaining stage of grief; however, there is another stage of grief that the nurse should expect first (B) is incorrect

B. Displacement (RAT) The nurse should identify displacement as the redirection of thoughts, feelings, and impulses from an object that causes to anxiety to a safer, more acceptable one. In this scenario, the client is redirecting his anxiety about the diagnosis to the staff that is providing care. (NOTE) The nurse should identify projection when the client attributes undesired impulses to another (D) is incorrect

B. Panic (RAT) This client's manifestations indicate the panic level of anxiety and indicate manifestations of a panic disorder. (NOTE) In severe anxiety, the perceptual field is scattered and the client is not able to focus on anything except relieving the anxiety. This client's manifestations indicate a high level of anxiety (C) is incorrect

C. Physical needs (RAT) The nurse should consider Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs priority-setting framework, the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchal levels. It is important, however, for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The fourth level of Maslow's Hierarchy of Needs includes usefulness, self-worth, and self-confidence in fulfilling self-esteem needs. (NOTE) The client's perception of reality is important to assess in order to set realistic goals and determine safety needs; however, it is not the nurse's priority assessment (C) is incorrect

A. Rationalization (RAT) Rationalization is a defense mechanism by which a person covers up a real or perceived problem or weakness. This client is attempting to justify alcohol use by explaining that it helps to relieve pain. This is done to protect the client's ego and to satisfy the nurse. (NOTE) Suppression is the conscious blocking of disturbing feelings by putting things out of conscious thoughts to avoid worrying about a stressor (D) is incorrect.

C. Glucose (RAT) Clients taking quetiapine are at risk for abnormal glucose metabolism, which can result in diabetes mellitus. Therefore, the client should have glucose testing periodically. (NOTE) Clients who have gout should have uric acid testing periodically (B) is incorrect

D. Akathisia (RAT) Akathisia is an extrapyramidal adverse effect characterized by the client's report of a sense of inner restlessness and by observable behaviors such as pacing, rocking forward and backward in a chair, and constant foot tapping. (NOTE) Tardive dyskinesia is an irreversible finding characterized by involuntary movements of extremities (C) is incorrect

C. Involuntary tongue protrusion (RAT) Tardive dyskinesia begins with mouth and facial movements and then progresses to involve other muscle groups. All clients receiving antipsychotic therapy for months to years are at risk. This adverse effect is potentially irreversible and discontinuing the drug rarely relieves these manifestations. (NOTE) Dystonia is a condition in which the client experiences involuntary muscular movements of the face, arms, legs, and neck. This adverse effect occurs most often in men and clients 25 years of age and younger. The nurse should assess for dystonia in the first days of antipsychotic medication therapy (B) is incorrect

A. "We'll assist you with making decisions." (RAT) Clients who have generalized anxiety disorder are often indecisive and dread making decisions. Therefore, the nurse should reassure the client that they will receive help with making decisions. (NOTE) Clients who have behaviors that might not be successfully treated by other methods, such as alcohol use disorder or aggression, can benefit from aversion therapy. Aversion therapy is not a treatment method for clients who have generalized anxiety disorder ( C) is incorrect

B. Impaired judgment (RAT) Impaired judgment occurs in clients who have dementia because they lose their ability to reason, think abstractly, and have rational thoughts. (NOTE) Disturbance in perception is an expected finding in a client who has psychosis (D) is in correct

Hypervigilance (RAT) Paranoid behavior is an expected finding for a client who has cocaine intoxication. (NOTE) Dilated pupils are a common finding associated with cocaine intoxication (A) is incorrect

B. Dizziness (RAT) Dizziness is a common adverse effect the nurse would expect in a client who has a prescription for a benzodiazepine. Other common adverse effects are drowsiness and sedation. (NOTE) Benzodiazepines are often prescribed for the treatment of seizure disorder. However, sudden withdrawal of benzodiazepines can be associated with the development of seizures (A) is incorrect

D. HA (RAT) Headache is an expected finding in a client who is experiencing alcohol withdrawal. This can occur 4 to 12 hr following cessation of alcohol use. Other findings include hand tremors, nausea, vomiting, sweating, depression, or irritability. (NOTE) Slurred speech is an expected finding in a client who is experiencing alcohol intoxication (C) is incorrect

D. The client is female. (RAT) The nurse should identify female gender as a primary risk factor for depression. The incidence of depressive disorders is greater in women than in men by almost 2 to 1. (NOTE) The client's status as an only child is not a risk factor for depression (A) is incorrect