# VATI Comprehensive Predictor NCLEX Questions

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Low-residue diet
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.
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A RN is caring for a patient who weighs 80 kg and is 5 ft 3 in tall. Calculate the BMI and determine if the patients BMI indicates a healthy weight, underweight, overweight, or obese.
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.
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A RN admits a female patient who weighs 246 lbs with a height of 5 ft 4 in. Calculate the BMI of the female patient.
Use the formula (lbs)/(in^2) multiply by 703 BMI 42 indicates the patient is obese
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A RN is reviewing discharge instructions regarding car seat safety to the parent of a newborn. Which of the following instructions will the nurse include in the discharge teaching (SATA) A. Position the infant rear-facing in the backseat. B. Be sure the car seat is at a 90 degree angle C. Be sure the care seat is at a 45 degree angle D. Position the car seat behind the passenger or drivers seat E. Position the care seat in the middle of the back seat F. Keep infants in rear-facing car seats until age 6 months G. Keep infants in rear-facing car seat until 2 yr old or until the child reaches the maximum ht and wt for the seat.
(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.
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A RN is caring for a patient who fell at a nursing home. The patient is oriented x 3 (person, place & time) and can follow directions. Which of the following actions should the RN take to decrease the risk of another fall? (SATA) A. Place a belt restraint on the patient when they are sitting on the bedside commode B. Keep the bed in its lowest position with all side rails up 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
(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.
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A RN is caring for a patient who has a Hx of falls. Which of the following actions is the RNs priority? A. Complete a fall-risk assessment B. Educate the patient and family about fall risks C. Eliminate safety hazards from the patients environment D. Make sure the patient uses assistive aids in their possession
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.
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A RN discovers a small paper fire in a trash in a patients bathroom. The patient has been taken to safety and the alarm has been activated. Which of the following actions should the RN take? A. Open the windows in the patients room to allow smoke to escape B. Obtain a class C fire extinguisher to extinguish the fire C. Remove all electrical equipment from the patient room D. Place wet towels along the base of the door to the patients room
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.
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A nurse manager is completing an in-service on a group of new nurses in the transition to practice program. The nurse manager asks one nurse student to define the acronym the RACE. Please indicate what each letter in the acronym means.
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)
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A RN discovers that she administered an antihypertensive medication to a patient in error. Identify the appropriate sequence of steps that the RN should take using the following actions. 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
(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.
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A RN is discussing disaster planning with the board members of a hospital. Which of the following actions should the RN take? A. Incident commander B. Medical command physician C. Triage officer D. Media liaison
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
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A RN prepares the ER to admit patients who were exposed to inhalation anthrax during a bioterrorism attack. Which antibiotic is used to treat patients who have been exposed to inhalation anthrax?
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)
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A RN at a mental health clinic is caring for four patients. The RN should recognize the following patients is using dissociation as a defense mechanism?
A patient who was abused as a child describes the abuse as if it happened to someone else
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What are the signs and symptoms of hypoglycemia? Use the mnemonic He IS TIRED!
He - Headache IS - Irritability/ Sweating T - Tachycardia I - Irritability R - Restlessness E - Excessive Hunger D - Dizziness
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The RN is working with a new MD . The RN is preparing the patient for the administration of an epidural. The RN consult the MD for the verification of which medication ordered?
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.
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A nurse is caring for a patient who is receiving chemotherapy. The patient's absolute neutrophil count (ANC) is less than 1,000/mm3. What precautions should the nurse institute?
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.
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A charge RN is teaching a group of unit nurses about the policy for patients who have a history of MRSA. Which of the following information should the nurse include? A. A patient who has a history of MRSA will need antibiotics B. A patient who has a Hx of MRSA can develop immunity to the infection C. A patient who has a Hx of MRSA requires a protective environment D. A patient who has a Hx of MRSA can still transmit the infection
D. A patient who has a Hx of MRSA can still transmit the infection
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Identify the diseases the nurse should report to the CDC
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.
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A RN is determining the attack rate following an E.coli outbreak at a restaurant. If 84 people ate contaminated lettuce, and 13 people developed an E.coli infection, what should the nurse conclude as the attack rate? Use the formula
(# of exposed people who develop infection)/(# exposed people) = attack rate multiply by 100 to get the percentage 15
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A RN is reviewing data on the rates of varicella zoster (Chicken pox) for a country. If there were 416 cases of varicella in one year among a population of 32,000 people, what should the nurse record as the incidence rate per 1,000 people? Use the formula
(#cases)/(#population) x 1,000 13
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List three actions the RN should take when caring for a patient exposed to anthrax.
Apply Oxygen Establish an IV Administer Cipro/Doxycycline ABT.
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A charge nurse is teaching the patient how to identify the difference between antisocial personality d/o and narcissistic personality disorder. Please use the mnemonic CALLOUS MAN to describe antisocial personality d/o.
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.
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List three (3) risk factors for intimate partner violence.
- 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
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A nurse is caring for a client with acute mania. Provide an example of one structured activity the nurse will incorporate into the client's daily schedule.
- 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.
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The nurse is preparing a client for a surgical procedure with regional anesthesia and is reviewing the medication list. The client reports that he took his warfarin last night. What action should the nurse take?
- 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.
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A RN in the labor and delivery unit is caring for a patient who is undergoing external fetal monitoring. The RN observes that the FHR begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which os the following actions should the RN take first?
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
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A RN is caring for a newborn with a small gestational age (SGA). Which of the following findings is associated with this condition?
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.
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A RN is preparing to measure the fundal height of a patient who is at 22 WOG. At which location should the RN expect to palpate the fundus?
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.
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A RN is admitting a patient who has a diagnosis of preterm labor. The nurse anticipates a order by the MD for which of the following medications (SATA)
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.
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Hydrops fetalis
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
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A patient reports awaking from sleep by contractions that are occurring every five minutes and lasting 30 - 40 seconds. Which of the following questions should the nurse ask to assess for true labor vs false labor?
"Have you noticed any bloody show or fluid coming from your vagina" (RAT) True labor has nothing to do with the start of contractions
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A patient in the early postpartum period is talkative and enjoys recounting the details of her labor and birth. The RN recognizes that the behaviors must likely indicate which the following?
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.
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A RN is caring for a neonate who exhibits abstinence syndrome (NAS) and demonstrates clinical manifestations of the condition. Which assessment finding is associated with this condition?
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
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Thirty minutes after admissions to the nursing an infant appeared jittery and exhibits a weak high pitched cry. Which of the following would be the nurses priority action?
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
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A RN is performing a fundal assessment in the patient's second postpartum day. Which of the following should the RN expect if the patient is experiencing normal involution?
The fundus will present one cm below the belly button
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The patient asks the nurses to explain the difference between true and false labor. Which of the following is an example of true labor?
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.
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A RN is caring for a patient who has been prescribed mag sulfate as tocolytic therapy. Several hours after the infusion was started, contractions ceased. Which of the following is the best analysis os this data?
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.
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A patient who is 32 weeks pregnant presents to the ER with bright red vaginal bleeding for the last 3 hours. The patient reports feeling fetal movement since the bleeding started. Which of the following is the nurses priority action?
Assess maternal VS (NOTE) Do not assess the fetal heart tones; since the mother is feeling the baby move this is not necessary.
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A patient with gestational DM gave birth to a 9 LB neonate 12 hr ago. The neonate is presenting with a high pitched cry and jitteriness. Which of the following is the nurses priority intervention?
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.
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A patient diagnosed with pregnancy induced HTN has been receiving a Mag Sulfate infusion for three days. Serum drug levels have been b/t 8-10 mg/dL. Which of the following findings should the RN expect to assess in the infant after delivery?
Lethargy & respiratory depression (RAT) Tachycardia and respiratory distress is incorrect
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A RN is caring for a newborn diagnosed with neonatal infection. Which of the following risk factors is most important to the care os this patient?
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
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A RN is assessing a patient in the immediate postpartum period. The fundus is boggy and deviated to the left of the belly button. Which of the following is the most appropriate intervention?
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.
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A RN at a family-planning clinic is developing a program about teen sexuality. Which of the following is a developmental task of teen according to Erikson's theory of psychosocial development? A. Adjusting to dramatic changes to body image B. Developing hypothetical reasoning skills C. Establishing the capacity for an intimate love relationship D. Learning to make good choices and avoid risk-taking behaviors
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.
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A RN is preparing to meet with a patient who has borderline personality d/o. Which of the following actions should the nurse plan to take during the working phase of the therapeutic relationship? A. Introduce the concept of patient confidentiality B. Establish goals with the patient C. Define the roles of the nurse and patient D. Facilitate a change in the patients behavior
D. Facilitate a change in the patients behavior (RAT) confidentiality, goals and roles are established during the orientation phase of the therapeutic relationship
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A RN is caring for an older adult patient who has difficulty following a CVA. Which of the following actions should the RN take when assisting the RN at mealtime? A. Encourage the RN to drink fluids before swallowing food B. Offer the RN tart or sour foods first C. Tilt the RN's head backward when swallowing D. Turn on the TV
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.
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A public health nurse is assisting community leaders to develop a disaster response plan in the event of an outbreak of a serious communicable disease. When teaching the community leaders about infectious disease, the RN should explain that a vector is of which of the following? A. A mode of transmission for the disease B. A microorganism that causes the infection C. An environment where the pathogen can survive D. A patient who is susceptible to the infection
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.
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A RN is caring for a patient who has osteoporosis and a new order for calcium supplements. Which of the following foods should the RN recommend to promote calcium absorption? A. Fortified milk B. Ripe bananas C. Steamed broccoli D. Green leafy vegetables
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.
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A RN is preparing a patient for cardiac catheterization Which of the following pieces of information should the RN give the patient before the procedure? (SATA) A. "You'll have to lie flat for several hours after the procedure." B. " You'll receive medication to relax you before the procedure." C. " You'll feel a cool sensation after the injection of the dye." 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."
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."
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A RN is preparing an in-service presentation about the management of a MI. Death following a MI is often a result of which of the following complications? A. Cardiogenic shock B. Dysrhythmias C. HF D. Pulmonary edema
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.
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A RN is planning care for a patient who has deep partial-thickness and full-thickness thermal burns over 40% of his total body surface and is in the acute phase f burn injury. Which of the following interventions should the RN include in the plan? A. Initiate ROM exercises B. Use clean technique to provide wound care C. Place the patient on a low-protein diet D. Maintain the patient on bed rest
A. Initiate ROM exercises (RAT) to maintain mobility and to prevent contracture
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A charge nurse is observing a newly licensed RN irrigate a patient's ear, which is impacted with cerumen. Which of the following actions requires the charge RN to intervene? A. Visualizing the eardrum before irrigating B. Instilling 50 mL of fluid with each irrigation C. Using firm, continuous pressure while irrigating D. Warming the irrigation fluid to at least 37C (98F)
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.
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A RN is preparing an in-service program about the stages of AKI. Which of the following pieces of information should the RN include about prerenal azotemia? A. Prerenal azotemia begins prior to the onset of s/s B. Interference with renal perfusion causes prerenal azotemia C. Prerenal azotemia is irreversible, even in the early stages D. Infections and tumors cause prerenal azotemia
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.
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A RN at a LTC facility notes a patient with dementia is having problems with orientation. Which of the following actions should the RN take to improve the patients level of orientation? A. Encourage the patient to make choices about meals and activities B. Use written signs to label specific rooms C. Post a large calendar on the bulletin board D. Place an electronic wander alert bracelet on the patient's wrist
C. Post a large calendar on the bulletin board (RAT) Posting a large calendar in a central location will assist this patient with orientation
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A RN is assessing a patient who is receiving a transfusion of PRBC's. Which of the following findings should the RN identify as an indication of an acute intravascular hemolytic reaction? A. Severe hypertension B. Low body temperature C. Sudden oliguria D. Decreased respirations
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.
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A RN is conducting a health assessment for a 24-MO toddler at the local health department. The RN should expect which of the following findings? (SATA) A. 8 deciduous teeth B. Ability to build a tower of 6 blocks C. Vocabulary of 10-20 words D. Slightly bowed or curved leg appearance E. Head circumference greater than chest circumference
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.
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A RN in the ER is assisting with the care of a 4 YO who ingested toilet bowel cleaner. The child has hemoptysis, is crying, and states, "It burns." Which of the following actions should the RN perform? (SATA) A. Identify how much cleaner was in the bottle B. Administer activated charcoal C. Perform immediate gastric lavage D. Insert an IV for morphine administration E. Apply a pulse oximeter
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.
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A RN is preparing a patient who is scheduled to have an arthroscopy the following day. Which of the following statements indicates that the patient understands the pre-procedure teaching? A. "I have to keep my leg straight throughout the whole procedure." B. "The doctor will be able to see if I have signs of RA C. "I should expect to stay overnight until I can walk around." D. "Ill have a scar that will be about an inch long."
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
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A RN is caring for a patient who has a TBI and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the RN anticipate when drawing a blood sample? A. The patient rigidly extends his arms B. The patient internally flexes his wrists C. The patient curls into a fetal position D. The patient internally rotates his legs
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
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A RN is performing a physical assessment of a patient. Which of the following actions should the nurse take to assess the patients tissue perfusion? A. Perform a Romberg test B. Check nails for Beau's lines C. Palpate for respiratory excursion D. Perform a blanch test
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
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A RN is performing a straight urinary catheterization for a female patient who has urinary retention. Which of the following actions indicates the RN is maintaining sterile technique? A. Applying sterile gloves to open the catheter package B. Wiping the labia minora in an anteriorposterios direction C. Spreading the labia with the dominate hand D. Using a cotton ball to wipe right and left labia majora
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
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A RN is caring for a patient who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the RN expect? A. Frequent BS with gas B. Absent BS with distention C. Hyperactive BS with diarrhea D. Normal BS with increased peristalsis
B. Absent BS with distention (RAT) Paralytic ileus is an immobile bowel. In this disorder, BS are absent and the abdomen is distended.
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A RN is providing teaching about nutritious diets to a group of adult women. Which of the following statements should the RN include? A. "Include at least 3 g of Na in your daily diet." B. "Limit wine consumption to 239 mL daily." C. "Include 2.5 cups of veggies in your daily diet." D. "Limit water intake to 1.5 L each day."
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.
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What do you know about a Pulse ?
A pulse of 4+ is bounding and does not disappear with moderate pressure. Pulse strength ranges from absent (0) to bounding (4+).
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A RN is assessing a patient who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the RN expect ? A. Increased BP B. Decreased BS level C. Decreased O2 use D. Increased GI motility
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
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A RN is preparing to insert an NG tube for a patient who has a bowel obstruction. Which of the following actions should the RN take first ? A. Give the patient a glass of water B. Assist the patient into a sitting position C. Explain the procedure to the patient D. Measure the length of tubing to be inserted
C. Explain the procedure to the patient
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A RN is assessing a patient who is undergoing a physical examination. Following the inspection, which of the following techniques should the RN use next when assessing the RN's abdomen ? A. Auscultation B. Light palpation C. Percussion D. Deep palpation
A. Auscultation
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A RN is teaching a patient how to self-administer insulin. Which of the following actions should the RN take to evaluate the patient's understanding of the process within the psychomotor domain of learning? A. Ask the patient if he wants to self-administer B. Have the patient list the steps of the procedure C. Have the patient demonstrates the procedure D. Ask the patient if he understands the purpose of insulin
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
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A RN is planning care for a patient who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the RN include in the plan? A. Promote the use of music to compete with the client's auditory hallucinations. B. Inform the client that the auditory hallucinations are not real. C. Avoid asking the client if they are experiencing auditory hallucinations. D. Instruct the client on the use of voice recognition regarding the auditory hallucinations.
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.
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A RN is documenting admission assessment findings for a patient who has MDD. The RN should identify which of the following findings as clinical manifestations? (SATA) A. Feelings of hopelessness B. Pressured speech C. Grandiosity D. Anhedonia E. Flat facial expression
A. Feelings of hopelessness D. Anhedonia E. Flat facial expression (RAT) Anhedonia is the inability to experience pleasure as a clinical manifestation of MDD.
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A RN is planning care for a patient who is experiencing acute mania. Which of the following interventions should the RN include in the POC to promote sleep? A. Have the client participate in a morning aerobics group. B. Encourage frequent rest periods throughout the day. C. Provide a distraction such as television at night. D. Offer the client hot chocolate at bedtime.
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.
question
A RN is caring for a group of patients. Which of the following findings should the RN report? A. A client who is taking clozapine and has a WBC count of 7,500/mm3 B. A client who is taking lamotrigine and has developed a rash C. A client who is taking valproate and has a platelet count of 150,000/mm3 D. A client who is taking lithium and has a lithium level of 1.2 mEq/L
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
question
A RN is admitting a patient who has anorexia nervosa and is at 60% of ideal body weight. Which os the following interventions should the RN include in the POC? A. Encourage the client to drink 125 mL of fluid each hour while awake. B. Allow the client to eat independently in their room. C. Weigh the client twice weekly. D. Measure the client's vital signs once each day.
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.
question
During morning rounds a RN finds a patient who has schizophrenia trembling and tearful in their bed. The patient reports that a bomb was placed in their room by a family member during visiting hours. Which of the following actions should the RN take ? A. Ask the client to identify the bomb in the room. B. Initiate disaster protocols per facility policies and procedures. C. Assess the client for evidence of a perceptual disturbance. D. Convince the client that there is no bomb in their room.
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
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A RN in a clinic is assessing a patient whose partner died 4 months ago. Which of the following statements indicates that the patient is at risk for complicated grief? A. "I wish I had been nicer and more generous with my wife before she died." B. "I told my wife to go to the doctor, but she wouldn't listen to me." C. "I think about my wife all the time when I go on outings with my family." D. "I feel so empty without my wife that it's hard to get up every morning."
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
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A RN in an ER is admitting a patient who reports experiencing a HA and heart palpitations after having a glass of wine 1 hr ago. The patient has a Hx of depression and a BP of 210/105 mmHg and a temp of 39.9 C (103.8 F). Which of the following actions should the nurse take first? A. Administer phentolamine 5 mg IV to the client. B. Apply a hypothermic blanket to the client. C. Determine the client's prescribed medication regimen. D. Initiate IV access for the client.
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.
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A RN is establishing a therapeutic relationship with a patient who has antisocial personality d/o. Which of the following strategies should the RN use when communicating with this patient? A. Behave in a friendly manner toward the client. B. Set realistic limits on the client's behavior. C. Show respect for the client's need for isolation. D. Act as a role model for assertiveness.
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.
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A RN is communicating with a patient in an inpatient mental health facility. Which of the following actions by the RN demonstrates the use of active listening? A. Offering self B. Use of silence C. Attention to body language D. Reflection of feelings
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
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A RN is reviewing the medical record of a patient who has anorexia nervosa. Which of the following findings should the RN identify as an indication the patient requires hospitalization? A. Total body fat 8.7% B. Potassium 3.6 mEq/L C. Temperature 36.1Â° C (96.9Â° F) D. Heart rate 54/min
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
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A charge nurse is preparing an educational session for a group of new nurses to review patient rights under the law. Which of the following statements should the RN make? A. "Information regarding clients should remain confidential until after their death." B. "Failure to report suspected maltreatment or neglect of a disabled adult is a felony in all states." C. "As long as client identity is disguised, their health information can be shared between professionals on the internet." D. "In the event a client threatens harm to others, medications can be administered without consent."
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.
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A RN in a community health center is teaching families of patients who have PTSD about expected clinical manifestations. Which of the following manifestations should the RN include? A. Repeatedly talks about the traumatic incident B. Sleeps excessively C. Experiences feelings of isolation D. Uses repetitive speech
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
question
A RN is caring for a patient who has alcoholic cardiomyopathy. Which of the following lab findings should the RN expect? A. Increased creatine phosphokinase (CPK) B. Increased low-density lipoproteins (LDL) C. Decreased fasting blood glucose D. Decreased aspartate aminotransferase (AST)
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
question
A RN on a MH unit is caring for a group of patients. Which of the following actions by the RN is an example of the ethical principle of justice ? A. Allowing a client to choose which unit activities to attend B. Attempting alternative therapies instead of restraints for a client who is combative C. Providing a client with accurate information about their prognosis D. Spending adequate time with a client who is verbally abusive
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.
question
A RN on a MH unit observes a patient who has acute mania hit another patient. Which of the following actions should the nurse take first ? A. Call the provider to obtain an immediate prescription for restraint. B. Prepare to administer benzodiazepine IM. C. Call for a team of staff members to help with the situation. D. Check the client who has was hit for injuries.
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
question
A RN is planning discharge teaching with a family member of a patient who has a new diagnosis of depression. Which of the following information about relapse should the RN include ? A. Additional acute episodes of depression are unlikely following inpatient care. B. Early identification of changes, such as decreased social involvement, is important. C. Medication compliance will prevent further need for inpatient hospitalization. D. It is helpful to regularly reinforce to the client that things will get better.
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
question
A RN is counseling a teen who has anorexia and reports excessive laxative use and a fear of gaining weight. The patient states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurses use of summarizing ? A. "You've discussed several concerns about your weight. Let's go back and talk about your belief that you are fat." B. "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight." C. "You don't want to look at yourself because you think you are fat." D. "You and I can work together to overcome your fears of gaining weight."
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
question
A RN is planning prevention strategies for partner violence in the community. Which of the following strategies should the RN include as a method of secondary prevention? A. Provide teaching about the use of positive coping mechanisms. B. Establish screening programs to identify at-risk clients. C. Refer survivors of intimate partner abuse to a legal advocacy program. D. Organize rehabilitation therapy for clients who have experienced intimate partner abuse.
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.
question
A RN is facilitating a community meeting for acute care patients. One patient is constantly talking and using the majority of the group's time. Which of the following interventions should the RN implement ? A. Tell the client to talk less or risk being removed from the meeting. B. Ask group members to discuss their feelings about this client's monopolizing behavior. C. End the group meeting and take the client aside to discuss the disruptive behavior. D. Focus on other group members and ignore the client who is doing all the talking.
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
question
A RN is providing teaching to the partner of a patient who is in a rehab program for alcohol use disorder. The RN should identify that which of the following statements by the patient/s partner indicates an understanding of the teaching ? A. "I will avoid social events until my partner has completed treatment." B. "It is important for me to focus my attention on my partner's addiction." C. "I will not take charge of my partner's work responsibilities." D. "I want my partner to promise to change addictive behaviors."
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
question
A Rn is preparing to DC an older adult home who attempted suicide. The patient lives alone and has difficulty performing ADL's. Which of the following should the RN initiate ? (SATA) A. Occupational therapy B. Meal delivery services C. Speech-language pathologist D. Physical therapy E. Home health services
A. Occupational therapy B. Meal delivery services D. Physical therapy E. Home health services
question
A RN observes a patient on the MH unit pushing on the locked doors. Which os the following statements should the RN make? A. "It appears as though you would like to open the door." B. "You will feel more comfortable after you've been here for a while." C. "It is okay to not want to be here." D. "You really shouldn't be pushing on the door."
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.
question
A RN is caring for a child who is taking methylphenidate. The RN should monitor the child for which of the following findings as an adverse effect of this medication? A. Weight gain B. Tinnitus C. Tachycardia D. Increased salivation
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
question
A RN is assessing a patient who is experiencing opioid withdrawal. Which of the following manifestations should the RN expect ? A. Sedation B. Rhinorrhea C. Bradycardia D. Hypothermia
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
question
A RN on a med - surge unit is assessing a patient who sustained injuries 12 hr ago following a motor vehicle crash. The patients admission blood ETOH level was 325 mg/dL. Which of the following findings should indicate to the RN that the patient is experiencing alcohol withdrawal ? A. Somnolence B. Blood pressure 154/96 mmHg C. Pinpoint pupils D. BS 210 mg/dL
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 38.3Â° C (101Â° 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
question
A RN is educating the parent of a child who has a new diagnosis of autism spectrum d/o. Which of the following manifestations of this d/o should the RN include in the teaching? A. Fear of abandonment B. Motor and verbal tics C. Hostile behavior D. Language delay
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
question
A RN is performing a cognitive assessment to distinguish delirium from dementia in a patient whose family reports episodes of confusion. Which of the following assessment findings supports the RN's suspicion of delirum ? A. Slow onset B. Aphasia C. Confabulation D. Easily distracted
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
question
A RN is creating a POC for a patient who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the RN include in the POC? A. Document the client's behavior every 8 hr. B. Limit the client's fluid intake to 50 mL/hr. C. Renew the prescription for the client every 4 hr. D. Toilet the client every 4 hr.
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
question
A RN is assessing a family's dynamics during a counseling session. The RN should recognize which of the following findings as an indication of a boundary issue? A. An adolescent family member who questions parental authority B. A family with three generations in the same household C. Older children who are responsible for their younger siblings D. Two adults and their children from prior relationships in the same household
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
question
A RN is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the RN include in the teaching ? A. Complete documentation about the client's status every hour while they are in restraints. B. Maintain the client in restraints for a minimum of 4 hr. C. Apply restraints when other means of managing the client's behavior have failed. D. Request that the provider assess the client within 8 hr of the application of restraints.
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
question
A RN is caring for a patient who has a new diagnosis of breast cancer. The patient becomes quiet and withdrawn and says to the nurse, "What do you think people will say about me when I'm gone?" Which os the following responses should the RN make? A. "What are you worried they will say about you?" B. "The thought of having breast cancer may seem hopeless." C. "Maintaining a positive attitude can influence your recovery." D. "You will be remembered as a kind person."
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.
question
At the start of a counseling session with the RN, the patient states, "We're wasting time with these meetings. I can't trust anyone with what's really bothering me about things I've done." Which of the following responses should the RN provide? A. "What makes you think that?" B. "These sessions are for your own good. We need to continue them." C. "Is it because you feel like no one would understand what you are experiencing?" D. "Perhaps you'd rather talk about that visit you had with your sister".
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.
question
A RN is providing teaching to a patient who is preoperative prior to a transurethral resection of the prostate (TURP). Which of the following patient statements indicates an understanding of the information ? A. "I will not need to have a urinary catheter following this procedure." B. "I will expect my urine to be cloudy after having this procedure." C. "At least I won't have leakage of urine after having this procedure." D. "I will feel the urge to urinate following this procedure."
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
question
A RN is planning care for a patient who has type 2 DM. Which of the following interventions should the RN include in the plan? A. Encourage the patient to control weight B. Inspect the patient's feet once each week C. Restrict the patients activity D. Apply moisturizer between the patient's toes
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
question
A RN in the ER is assessing a patient who has a Brady-dysrhythmia. Which of the following findings should the nurse monitor for?
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.
question
A RN is admitting a patient who has a leg ulcer and a Hx of DM. The RN should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer?
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
question
A RN is providing teaching for a patient who is 2 days post-op following a heart transplant. Which of the following statements should the RN include in the teaching?
"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.
question
What is the acroymn "SWEADEN" for Rt Sided HF?
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)
question
What is the acroymn "SWEET DOE"
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)
question
A RN is caring for a patient who had an onset of chest pain 24 hours ago. The RN should recognize that an increase in which of the following is a diagnosis of a MI ?
(CK) Creatine Kinase - MB (RAT) CK-MB is the isoenzyme specific to the myocardium. Increased CK-MB = Myocardial muscle injury
question
A RN in the ER is caring for a patient who had a MI. The patient's Hx reveals she is 1 week post-op following an open cholecystectomy. The RN should recognize that which of the following interventions is contraindicated?
Assisting with thrombolytic therapy (RAT) The RN should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy
question
During a group session on a osych unit, the nurse leader observes that one of the patients frequently interrupts the session. Which of the following nursing actions is the most appropriate for this situation?
Ask the patient to speak privately with the nurse after the meeting
question
A RN is caring for a 10 YO child following a head injury. Which of the following findings should the RN identify as an indication that the child is developing diabetes insipidus?
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.
question
A RN is admitting an infant who has intussusception. Which of the following findings should the RN expect? (SATA)
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
question
A RN is assessing a teen who received a sodium polystyrene sulfonate enema. Which of the following indicates effectiveness of the medication?
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.
question
A RN is assessing a 6 MO infant during a well child visit. Which of the following should the nurse report to the provider?
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.
question
A RN in an ER is assessing a toddler who has Kawasaki disease. Which of the following findings should the RN expect? (SATA)
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)
question
A RN is caring for a school-age child who has DM and was admitted with a diagnosis of DKA. When performing the respiratory assessment, which of the following findings should the nurse expect?
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.
question
A RN is teaching a school age child and their parent about post-op care following a cardiac catheterization. Which of the following instructions should the RN include?
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.
question
A RN is planning developmental activities for a newly admitted 10 YO child who has neutropenia. Which of the following actions should the nurse plan to take?
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.
question
A weight of 5.9 kg (13 lb) is the expected ref range for a 4 MO who weighed 3.2 kg (7 lbs) at birth
The infant should gain 680 g (1.5 lbs) per month until age 5 MO
question
A RN is assessing a school ge child who has an acute spinal cord injury following sports injury x 1 week ago. The RN will tap the brachieal nerve to elicit the biceps reflex.
question
A nurse is caring for a child who is post op following ventriculoperitoneal (VP) shunt placement. In which of the following positions should the RN place the patient?
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.
question
A RN is assessing an infant following a motor vehicle accident (MVA). Which of the following findings should the nurse monitor to identify increased ICP?
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.
question
A RN in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the RN take? A. Perform the assessment in a head to toe sequence B. Minimize physical contact with the child initially C. Explain procedures using medical terminology D. Stop the assessment if the child becomes uncooperative
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
question
A RN is teaching the parent of an infant about food allergies. Which of the following foods should the RN include as being the most common food allergy in children? A. Cow's milk B. Wheat bread C. Corn syrup D. Eggs
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.
question
A RN is performing a physical assessment on a 6 MO infant. Which of the following highlight reflexes should the RN expect to find? A. Stepping B. Babinski C. Extrusion D. Moro
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.
question
A RN is observing a mother who is playing peek-a-boo with her 8 MO. The mother asks if this game has any developmental significance. The RN should inform the mother that peek-a-boo helps develop which of the following concepts in the child? A. Hand-eye coordination B. Sense of trust C. Object permanence D. Egocentrism
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
question
A RN is planning to collect a speciman from a male infant using a urine collection bag. Which of the following actions should the RN take? A. Wash and dry the infant's genitalia and perineum thoroughly. B. Apply a small coating of water-soluble lubricant to the skin of the infant's perineal area. C. Avoid placing the scrotum inside the collection bag. D. Wait several hours after positioning the device before checking it.
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
question
A RN is planning care for a 10MO infant who is suspected failure to thrive (FTT). Which of the following interventions should the RN include in the POC? (SATA) A. Observe the parents' actions when feeding the child. B. Maintain a detailed record of food and fluid intake. C. Follow the child's cues as to when food and fluids are provided. D. Sit beside the child's high chair when feeding the child. E. Play music videos during scheduled meal times.
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
question
A RN in an emergency dept is caring for an 8 YO who is up-to-date with current immunization recommendations and has a deep puncture injury. Which of the following should the RN anticipate to administer? A. Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine B. A single injection of tetanus immune globulin (TIG) mixed with the pediatric tetanus booster (DT) C. Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine D. Adult tetanus booster (Td)
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
question
A RN is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the RN take? A. Ask the child to hold his breath and then blow it out slowly. B. Ask the child to describe a pleasurable event. C. Bounce the child gently while holding him upright. D. Rock the child in long rhythmic movements.
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
question
A RN is assessing a 6 YO child at a well child visit. Which of the following findings requires further assessment by the nurse? A. Presence of sparse, fine pubic hair B. Decreased head circumference compared to full height C. Increased leg length related to height D. Presence of a loose, central incisor
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
question
A RN is teaching the parent of an infant about home safety. Which of the following information should the RN include? (SATA) A. Use a wheeled infant walker. B. Place soft pillows around the edge of the infant's crib. 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 49Â° C (120Â° F).
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 49Â° C (120Â° 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 49Â° C (120Â° F).
question
A RN is assessing a 9 MO during a well-child visit. Which of the following findings indicates that the infant has a developmental delay ? A. Creeps on hands and knees B. Inability to vocalize vowel sounds C. Uses crude pincer grasp D. Stands by holding onto support
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
question
A RN on a peds unit is reviewing the health record of a child who is demonstrating increasing levels of stress after admission. The RN should identify which of the following findings as a risk factor for stress-related reaction to hospitalization? A. Age 10 B. Frequent hospitalization C. Parent bonding with child D. Calm, quiet demeanor
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
question
A RN is assessing a 30 MO toddler during a well-child visit. Which of the following findings requires further assessment by the nurse? A. Primary dentition is complete B. Unable to hop on one foot C. Birth weight is tripled D. Able to state first and last name
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
question
A RN is caring for a preschool child who has mucosal ulceration after receiving chemo. Which of the following actions should the nurse take? A. Place viscous lidocaine on the child's oral lesions. B. Instruct the child to use a soft sponge toothbrush when brushing her teeth. C. Encourage the child to mouth rinse with hydrogen peroxide every 2 to 4 hr. D. Give the child lemon glycerin swabs to use after each meal.
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
question
A RN is caring for a child who has been in Buck's traction for 2 days. Which of the following actions should the nurse take to prevent complications? A. Manually move the weights to the floor when the child is experiencing pain. B. Check for pulses in the affected leg every 4 hr. C. Cleanse the pins every 12 hr. D. Inform parents to discourage visitors for the child.
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
question
A RN is caring for a 4 YO child who has pneumonia. The child's mother left 2 hours ago and he is currently experiencing the seperation anxiety stage of despair. Which of the following findings should the nurse expect? A. Crying and screaming B. Inactive and thumb sucking C. Shows interest in toys around him D. Attempts to escape and find parent
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.
question
A RN is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take? A. Maintain the child on strict bed rest. B. Check the child's blood pressure every 4 hr. C. Check the child's blood pressure every 4 hr. D. Provide the child with a low-carbohydrate diet.
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
question
A RN is caring for a child who has suspected nephrotic syndrome. Which of the following lab values should the nurse expect? A. Platelet count 120,000/mm3 B. Serum sodium 160 mEq/L C. Hgb 9 g/dL D. Serum cholesterol 700 mg/dL
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).
question
A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling and the nurse notes that the child has allergies to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (SATA) A. Bradycardia B. Nausea C. Hypertension D. Urticaria E. Stridor
B. Nausea D. Urticaria E. Stridor
question
A nurse is caring for a child who has vesicular rash. The parents of the child asks the nurse what illness can cause this rash for 6 days. The nurse should expect that the child has which of the following conditions? A Measles B. Fifth disease C. Tetanus D. Varicella
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
question
A nurse is caring for a group of infants who have congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis? A. Transposition of great arteries B. Ventricular-septal defect C. Coarctation of the aorta D. Patent-ductus arteriosus
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
question
A nurse is performing a mental status assessment on an older adult patient who has dementia. Which of the following questions should the nurse as to assess the patient's remote memory? A. "What year did you graduate from high school?" B. "What is your favorite childhood memory?" C. "What did you have for supper yesterday?" D. "What is today's date?"
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
question
A nurse in a pediatric emergency dept is caring for four patients. The nurse should suspect possible abuse with which of the following patients? A. A 14-month-old toddler who has recently learned to walk and has many bruises on bony prominences in various stages of healing B. A 9-month-old infant who reportedly nearly drowned after climbing into the tub and turning on the water C. A 6-year-old toddler who has a fracture of the tibia and fibula, which reportedly occurred while riding a bicycle D. A 3-year-old toddler who has burns in a splash pattern over the face and chest, reportedly sustained when a tablecloth was pulled, spilling a teapot
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
question
A RN is caring for a patient who has dementia. The patient states to the nurse, "Everyone wants to kill me." Which of the following responses should the nurse make? A. "Tell me how everyone wants to hurt you." B. "You must feel very frightened to think someone wants to hurt you." C. "No one here wants to kill you." D. "Who in particular do you think wants to kill you?"
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)
question
A RN in a MH clinic is caring for a patient who has bipolar DO and states, "I no longer take my medication becasue I like the feeling of being manic." Which of the following responses by the nurse is an example of therapeutic communication? A. "You might feel good now, but what about when you get depressed?" B. "Why do you think you like feeling manic?" C. "You feel better when you don't take your medication?" D. "What do you think your provider will say about you going off your medication?"
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
question
A RN in the ER is caring for a female patient who has bruises on the trunk and face. The patient reports her partner did it. When offered information about shelters for intimate partner violence, the patient declines, stating, "I could never leave my husband because of my kids." Which of the following responses should the nurse make? A. "Aren't you worried about the safety of your children?" B. "Can you identify your behaviors that provoke your partner?" C. "The next time this occurs, what might you do to ensure your safety?" D. "You need to remove yourself and your children from the abusive situation."
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
question
A RN is assessing a patient who has anorexia nervosa. The RN should expect the patient to display which of the following characterstics? A. Refuses to participate in physical exercise activities B. Possesses feelings of decreased self-worth C. Preoccupied with concerns about personal health D. Avoids discussion of food
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
question
A RN receives a call on a crisis intervention hotline from a patient. Which of the following statements should the nurse identify as an OVERt statement indicating the patients risk for suicide? A. "Everything will be better soon." B. "Soon no one will have to worry about me." C. "There's no point in living any longer." D. "I want to donate my organs to help others."
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).
question
A RN in an emergency dept is caring for an 18 MO toddler who has a fractures left femur. Which of the following statements by the toddler's parents should cause the nurse to suspect child abuse? A. "My child fell down the stairs." B. "My child was riding a bicycle and fell off." C. "My child slipped out of the high chair." D. "My child climbed up on a chair and it tipped over."
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
question
A RN is caring for a patient who reminds her of a negative person in her past. These memories cause the nurse to unconsciously displace negative feelings towards the patient. The nurse should recognize that she is demonstrating which of the following behaviors? A. Suppression B. Countertransference C. Transference D. Assertiveness
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
question
A nurse is providing support for the parents of a cild who has a new diagnosis of terminal brain tumor. The nurse should expect the parents to experience which of the following stages of grief first? A. Denial B. Bargaining C. Anger D. Depression
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
question
A RN is caring for a patient who has a new diagnosis of colon cancer. Shortly after the patient receives the diagnosis, the nurse enters the patient's room and the patient begins yelling, "I have received terrible care here and no one cares about me. " The nurse should recognize that the patient is demonstrating which of the following defense mechanisms? A. Denial B. Displacement C. Reaction formation D. Projection
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
question
An ER nurse is assessing a patient who has an anxiety d/o. The patient is flushed, perspiring profusely, and is experiencing palpitations. The patient begins to scream, "I am going to die! This is it! I am having a heart attack!" The RN should determine the patients level of anxiety to be which of the following? A. Moderate B. Panic C. Severe D. Mild
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
question
A RN is performing an admission assessment for a patient who has schizophrenia. The RN notices that the a patient's appearance is unkempt and he appears to be actively hallucinating. Which of the following should be the nurses priority assessment ? A. Perception of reality B. Ability to follow directions C. Physical needs D. Mental status
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
question
A RN is assessing a newly admitted patient who has generalized anxiety d/o and states, "I drink alcohol to forget the pain." The patient is exhibiting a maladaptive response to which of the following defense mechanisms? A. Rationalization B. Conversion C. Projection D. Suppression
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.
question
A RN is providing teaching to a patient who has schizophrenia and is taking quetiapine fumarate. The nurse should instruct the patient that which of the following blood tests should be performed periodically? A. Potassium B. Uric acid C. Glucose D. Calcium
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
question
A nurse is assessing a patient who has a psychotic d/o and a new script for haloperidol. The patient is pacing in the hallway and states, " I can't seem to sit still." Which of the following extrapyramidal side effects is the patient likely experiencing? A. Dystonia B. Parkinsonism C. Tardive dyskinesia D. Akathisia
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
question
A RN is assessing a patient who has been taking an antipsychotic medication for 6 years and the provider has started tapering off the dosage. The RN should monitor the patient for which of the following manifestations of tardive dyskinesia? A. Muscular weakness B. Muscle spasms C. Involuntary tongue protrusion D. Uncontrolled rolling of the eyes
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
question
A RN in a MH facility is caring for a patient who has generalized anxiety d/o. Which of the following statements should the RN make? A. "We'll assist you with making decisions." B. "Someone will work with you when you have flashbacks." C. "You'll be going through aversion therapy to help you cope." D. "The therapy will help you control your impulses."
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
question
A RN is caring for a patient who has dementia. Which of the following findings should the RN expect? A. Altered level of consciousness B. Impaired judgment C. Rapid change in personality D. Disturbances in perception
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
question
A RN in the emergency dept is assessing a patient who has cocaine intoxication. Which of the following findings should the nurse expect? A. Pinpoint pupils B. Drowsiness C. Nystagmus D. Hypervigilance
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
question
A RN is assessing a patient who has an anxiety d/o and is taking benzodiazepine. For which of the following AE should the RN monitor the patient? A. Seizures B. Dizziness C. Polyuria D. Insomnia
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
question
A RN is caring for a newly admitted patient who is experiencing ETOH withdrawal. Which of the following findings should the RN expect? A. Bradycardia B. Increased somnolence C. Slurred speech D. HA
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
question
A RN is reviewing the health Hx of a young adult patient who has a depressive d/o. Which of the following factors should the RN identify as increasing the patients risk for depression? A. The client is an only child. B. The client lives in an urban setting. C. The client is married. D. The client is female.