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314 Cards in this Set
- Front
- Back
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Resistance or pressure that the left ventricle has to overcome to eject blood to the systemic circulation is called
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Systemic vascular resistance (SVR)
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Automaticity refers to
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The ability to spontaneously discharge an impulse
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A client asks what coronary arteries have to do with angina. When determining the answer, the nurse should take into consideration that the coronary arteries carry
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Blood from the aorta to the myocardium
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A client reports substernal chest pain. Tests results show electrocardiographic changes and an elevated cardiac troponin level. What should be the focus of nursing care?
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Improving myocardial oxygenation and reducing cardiac workload
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A laboratory test that is a specific indicator of myocardial muscle damage is
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Troponin T
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Secondary hypertension is differentiated from primary hypertension in that secondary hypertension
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Has a specific cause, such as renal disease, that can often be corrected by medicine or surgery
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A 60-year old male client comes in to the emergency department complaining of crushing substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Immediate admission orders include oxygen by nasal cannula at 4L/minute, bloodwork, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2mg of morphine sulfate intravenously. The nurse should first
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Administer the morphine
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Aspirin is administered to the client experiencing an MI because if its
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Antiplatelet action
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A physical assessment finding that the nurse would expect to be present in acute left-sided heart failure includes
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Crackles and tachycardia
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Fibrinolytic therapy is initiated for a patient with myocardial infarction. The nurse explains to the patient that this treatment is performed to
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Dissolve the clot in the artery and prevent further cellular death
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Which of the following would be a priority nursing diagnosis for a client with heart failure and pulmonary edema?
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Activity intolerance related to pump failure
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When teaching a patient about modifying risk factors associated with peripheral vascular disease, the nurse emphasizes that
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When teaching a patient about modifying risk factors associated with peripheral vascular disease, the nurse emphasizes that
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A 2-gram sodium is prescribed for a client with severe hypertension. The client does not like the diet and the nurse hears the client request that the spouse "bring in some good home-cooked food." It would be most effective for the nurse to plan to
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Wait for the client's family and discuss the diet with the client and family
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To prevent pulmonary embolus in a client on bed rest, the nurse should
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Teach the client to move the legs when in bed
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A client has edema in the lower extremities, which disappears at night. The nurse should suspect
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Right ventricular heart failure
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The nurse should prioritize and provide treatment first for a client with
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Ventricular fibrillation
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When a 70-year-old client is transferred from the emergency department, the nurse on the nursing unit should first
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Assess the client's heart and lung sounds
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A client experiences acute myocardial ischemia. The nurse administers oxygen and sublingual nitroglycerine. When assessing the electrocardiogram (EKG) for evidence that blood flow to the myocardium has improved, the nurse should focus on
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Return of the ST segment to baseline
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A diagnostic test that is useful in assessing and monitoring the pulmonary effects of heart failure is
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A chest x-ray
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A patient with DVT asks the nurse what Virchow's triad refers to. The nurse tells the patient that Virchow's triad includes
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Stasis of blood, injury to the vessel wall, and altered blood coagulation.
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When taking a respiratory history, the nurse should assess
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All of the above
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Gas exchange between the lungs and the blood is called
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Respiration
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Acute respiratory failure occurs when oxygen tension (PaO2) falls below
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50 mm Hg
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The inspection technique used to detect hyperresonance is
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Percussion
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A chest tube is inserted in a client with a pneumothorax for which of the following reasons?
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To remove air and fluid
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When suctioning a client with a tracheostomy, the nurse must remember to
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Initiate suction as the catheter is being withdrawn
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A patient has been diagnosed with a pleural effusion and is experiencing shortness of breath and decreased oxygen saturations. The nurse should anticipate which of the following interventions?
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Thoracentesis
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The physician orders a pulmonary angiogram for a patient with dyspnea and hemoptysis. The nurse recognizes that this test is most commonly used to diagnose
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Pulmonary embolism
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During a health promotion program, a nurse teaches the participants that the best way to prevent lung cancer is to
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Stop smoking and avoid secondhand smoke
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Following a thoracotomy, the patient has a nursing diagnosis of ineffective airway clearance related to inability to cough secondary to pain and positioning. The best nursing intervention for this patient is to
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Medicate the patient with analgesics 30 minutes before assisting to cough and breathe deeply
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Pulmonary edema most commonly results from
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Left-sided heart failure
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While caring for a patient with primary pulmonary hypertension, the nurse observes that the patient has exertional dyspnea and chest pain, in addition to fatigue. The nurse knows that these symptoms are related to
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Right ventricular hypertophy and dilation
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The nurse has reported to the hospital to work for the evening shift on a respiratory unit. The nurse would see which of these patients first?
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An 85-year-old client with bacterial pneumonia, temperature of 102.2 and shortness of breath
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Pink, frothy sputum is mostly likely caused by
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Pulmonary edema
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Which of the following findings would suggest a pneumothorax in a trauma victim?
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Absent breath sounds
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A client who underwent a lobectomy and has a water seal chest drainage system is breathing with a little more effort and at a faster rate than an hour ago. The client's pulse rate is also increased. Which of the following actions should the nurse implement?
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Check the tubing to ensure the client is not lying on it or kinking it
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An early sign of cancer of the larynx in the glottic area is
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affected voice sounds
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A nurse is suctioning fluids from a client with a tracheostomy tube. When suctioning, the nurse must limit the suctioning to a maximum of
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10 seconds
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A client is suspected of having a pulmonary embolism. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolus?
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Dyspnea
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As part of the assessment information, the nurse know that the majority of pulmonary emboli originate in the
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Deep leg veins
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Which serum lab values will the nurse monitor to assess kidney function?
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Blood urea nitrogen (BUN) and creatinine
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The most accurate indicator of fluid loss or gain in an acutely ill patient is
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Weight
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The most sensitive indicator of kidney disease is the
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Creatinine clearance level
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A client with a fever and urinary urgency is asked to provide a urine specimen for culture and sensitivity. The nurse should instruct the patient to collect the specimen from the
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Middle stream of urine from the bladder
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A client with acute renal failure is being assessed to determine if the cause is prerenal, intrarenal, or postrenal. If the cause is prerenal, which condition most likely caused it?
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Heart failure
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The nurse is teaching the patient with chronic renal failure about which foods to avoid. It would be most accurate for the nurse to teach the client to avoid foods high in
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Protein
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A female has a higher risk for developing cystitis than a male does. This is because of the
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Proximity of the urethra and anus
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When caring for a patient with renal calculi, the most important nursing action is to
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Strain all urine
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Systemic infection originating in the urinary tract is known as
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Cystitis
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The purpose if peritoneal dialysis is to
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Remove toxins and metabolic wastes
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An indication for hemodialysis for a client who has chronic kidney failure is
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Hyperkalemia
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When caring for a client who has had an arteriovenous shunt inserted for hemodialysis, the nurse should
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Use the surgical aseptic technique when providing shunt care
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A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Preoperatively, the nurse reinforced the client's understanding of the surgical procedure by explaining that an ileal conduit
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Conveys urine from the ureters to a stoma opening on the abdomen
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Because a client's renal stone was found to be composed of uric acid, a low purine, alkaline ash diet was ordered. Incorporation of which of the following food items into the home diet would indicate that the client understands the necessary diet modifications?
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Milk, tomatoes, apples and corn
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The client's potassium level is elevated in acute renal failure and the nurse administers sodium polystyrene sulfonate (Kayexylate). This drug acts to
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Exchange sodium for potassium ions in the colon
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The nurse initiates the client's first hemodialysis treatment. The client develops a headache, confusion and nausea. These symptoms indicate which of the following potential complications?
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Disequilibrium syndrome
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Which of the following abnormal blood values would not be improved by dialysis treatment?
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Decreased hemoglobin
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Which of the following statements by the client would indicate that she is at high risk for a recurrence of cystitis?
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"I can usually go 8 to 10 hours without needing to empty my bladder."
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The client with pyelonephritis asks the nurse, "How will I know if the antibiotics are effectively treating my infection?" The nurse's most appropriate response would be which of the following?
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"The doctor can determine your progress through urine cultures."
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Acid-base disorders are identified using analysis of
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Arterial blood gas
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The normal pH of the blood is
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7.35 – 7.45
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The component of the body's major buffer system that is controlled by the lungs is
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Carbon dioxide (CO2)
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The body's major buffer system is the
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bicarbonate-carbonic acid buffer system
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Alkalosis can be identified by
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pH greater than 7.45
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Which condition exhibits a low pH and a high CO2?
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Respiratory acidosis
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Which condition exhibits a low pH and a low HCO3?
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Metabolic acidosis
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Anion gap is used to identify
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The balance of anions and cations
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Decreased respiratory rate and depth is a mechanism used to compensate for which acid-base disturbance?
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Metabolic alkalosis
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The kidneys regulate acid-base balance by all of the following mechanisms except
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Reabsorbing carbon dioxide (CO2) into the blood
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Hyperkalemia often results in which acid-base disturbance?
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Metabolic acidosis
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Which of the following blood gas abnormalities would the nurse anticipate in a client with advanced COPD?
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Increased PaCO2
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Nasogastric suctioning can lead to which acid-base disturbance?
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Metabolic alkalosis
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A client with COPD is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as ordered. Which of the following statements is true concerning oxygen administration to a client with COPD?
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High oxygen concentrations may inhibit the hypoxic stimulus to breathe.
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Tetany, tingling of the hands and feet, and seizures are related to regulation of which of the following electrolytes in patients with metabolic alkalosis?
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Calcium
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A client has a blood gas with the following values: pH 7.24, pCO2 54, and HCO3 25. This ABG is interpreted as
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Respiratory acidosis
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End stage renal disease may be the cause of which of the following acid-base disturbances?
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Metabolic acidosis
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client has a blood gas with the following values: pH 7.54, pCO2 44, and HCO3 35. This ABG is interpreted as
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Metabolic alkalosis
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A client has the following arterial blood gas values: pH 7.52, PaCO2 28 mm Hg, and HCO3 24. The nurse determined that the patient has these values because
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The patient is hyperventilating
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A client has a blood gas with the following values: pH 7.14, pCO2 36, and HCO3 8. This ABG is interpreted as
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Metabolic acidosis
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A patient with calculi in the gallbladder is said to have
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Cholelithiasis
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Metamucil is used as a
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bulA client with a history of hiatal hernia reports to the nurse that he has trouble sleeping because of abdominal pain. It would be most beneficial to the client if the nurse instructed the patient to sleepk forming laxative
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Abdominal pain associated with indigestion is usually
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Described as crampy or burning
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H. pylori is associated with
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Peptic ulcer disease
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Which of the following would be the most appropriate nursing diagnosis for a patient with an ileostomy?
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Disturbed body image
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Clinical manifestations associated with small bowel obstruction include all of the following except
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The passage of blood-tinged stool
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As the nurse prepares to assist the patient with her newly created ileostomy, she is aware that
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Fecal drainage will be liquid
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A client with a history of hiatal hernia reports to the nurse that he has trouble sleeping because of abdominal pain. It would be most beneficial to the client if the nurse instructed the patient to sleep
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With his upper body elevated
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Abdominal pain associated with appendicitis is usually located in the
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Right lower quadrant
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A physician orders gastric decompression for a client with small bowel obstruction. The nurse should plan for the gastric suction to be
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Low pressure and intermittent
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A nurse is evaluating the effectiveness of dietary instructions in a client with diverticulitis. Regular consumption of which food would indicate that the client understood the instructions?
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fiber
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A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops sharp pain in the midepigastric region, along with a rigid, boardlike abdomen. These clinical manifestations likely indicate which of the following?
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the ulcer has perforated
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A client who has had irritable bowel syndrome for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors was most likely of greatest significance in causing the exacerbation of ulcerative colitis?
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A demanding and stressful job
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Which of the following nursing diagnoses would be most appropriate for a client with intestinal obstruction?
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Fluid volume deficit related to nausea and vomiting
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Which of the following laboratory findings would the nurse expect to find in a client with appendicitis?
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Elevated white blood count
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When providing care for a client with acute pancreatitis, the nurse would anticipate which of the following orders?
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Insert a nasogastric tube and connect to low intermittent suction.
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The client with chronic pancreatitis should be monitored closely for which of the following disorders?
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diabetes mellitus
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When developing a plan of care for a patient with viral hepatitis, the nurse should incorporate which of the following into the plan of care?
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Adequate bed rest
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Which of the following measures would prevent transmission of hepatitis C to health care personnel?
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Wear gloves when in contact with blood or blood-contaminated fluids.
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The nurse develops a teaching plan for a client about how to prevent transmission of hepatitis A. Which of the following discharge instructions is appropriate for the client?
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Tell family members to wash their hands frequently.
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Acute inflammation of the brain is called
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enceph"You will need to hold your head very still during the examination."alitis
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Positive Kernig's sign and Brudzinski's sign may indicate
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Meningitis
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An unconscious client with multiple injuries arrives in the emergency room. Which nursing intervention receives the highest priority?
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establishing an airway
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The nurse is caring for a patient with a cerebral injury that impaired his speech and hearing. Most likely, the client has experienced damage to the
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Temporal lobe
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Stimulation of the autonomic nervous system that produces a parasympathetic response would most likely cause
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Increased gastric motility
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Which of the following will the nurse observe in the client experiencing a generalized grand mal (tonic-clonic) seizure?
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Loss of consciousness, body stiffening and violent muscle contractions
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It is the night before a client is to have a computed tomographic (CT) scan of the head without contrast. Which statement by the nurse would be most appropriate?
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"You will need to hold your head very still during the examination."
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What is the expected outcome of thrombolytic therapy for CVA?
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Dissolved emboli
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A patient is admitted to the hospital with left hemiplegia. To determine the size and location and whether a stroke is ischemic or hemorrhagic the nurse anticipates that the physician will order a
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CT scan
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A patient comes to the emergency department complaining of numbness of the face and an inability to speak. While the patient awaits examination, the symptoms disappear and the patient requests discharge. The nurse stresses that it is important for the patient to be evaluated because
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The patient has probably experienced a transient ischemic attack (TIA) that is a sign of progressive cerebral vascular disease.
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Which of the following is not an initial sign of Parkinson's disease?
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Tremor
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The nurse develops a teaching plan for a patient with Parkinson's disease. Which of the following topics that the nurse plans to discuss is the most important?
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Maintaining a safe environment
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A client with Parkinson's disease is prescribed levodopa (L-dopa) therapy. Improvement in which of the following indicates effective therapy?
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Muscle rigidity
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A client had had MS for 15 years and has received various drug therapies. The primary reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used is because clients with MS
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Experience spontaneous remissions from time to time
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Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)?
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Sudden bursts of energy
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What is the intended outcome for the nursing intervention of performing passive range of motion exercises on an unconscious client?
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Maintenance of joint mobility
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In some patients with myasthenia gravis, plasmapheresis may diminish symptoms. Plasmapheresis achieves this effect by removing
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Antibodies
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Without treatment, which type of brain tumor will result in death as a result of increased growth leading to increased intracranial pressure and compression of vital brain centers?
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Malignant or benign
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Progressive destruction of motor neurons occurs as a result of
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Amytrophic lateral sclerosis
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The nurse explains to a patient who is diagnosed with ALS that diagnosis is made primarily by
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History and clinical manifestations
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The master gland of the endocrine system is the
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Pituitary
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Excessive secretion of a hormone that causes fluid retention is known as
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Syndrome of inappropriate antidiuretic hormone
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A patient who is diagnosed with type I diabetes mellitus would be expected to
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Need exogenous insulin
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The nurse is completing a health assessment of a 42-year-old client with suspected Grave's disease. The nurse should assess the client for
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Tachycardia
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A 34-year-old female is diagnosed with hypothyroidism. Which signs and symptoms would the nurse expect to assess?
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Weight gain, decreased energy, and fatigue
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The most important assessment following thyroidectomy is to detect
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Laryngeal edema
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Which of the following medications should be available at the bedside to provide emergency treatment if a client develops tetany following a subtotal thyroidectomy?
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Calcium gluconate
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Which of the following is the most significant risk factor for developing type II diabetes?
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Obesity
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(Lippincott page 358 #30) Which of the following is a potential complication of diabetes mellitus?
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Blood pressure of 160/100
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The nurse should teach the diabetic client that a common symptom of hypoglycemia is
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Nervousness
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A client presents to the emergency room with diabetic ketoacidosis. The nurse would identify which of the following nursing diagnoses as a priority problem?
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Deficient fluid volume
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The nurse teaches the client to monitor for signs of which potential complication following hypophysectomy?
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Hypopituitarism
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Which of the following is a priority outcome for a client with diabetes insipitus?
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Maintains normal fluid and electrolyte balance
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When teaching a client newly diagnosed with Addison's disease, the nurse should explain that the disease results from
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Idiopathic atrophy of the adrenal gland
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(Lippincott page 362 #58) Which of the following is a priority for a client in Addisonian crisis?
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Preventing irreversible shock
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A 42-year-old female client reports that she has gained weight and her face and body are "rounder," while her legs and arms have become thinner. A tentative diagnosis of Cushing's disease is made. While examining the client, the nurse would expect to find
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Bruised areas on the skin
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A priority in the first 24 hours following adrenalectomy is
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Preventing adrenal crisis
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Which of the following findings would be typical of Addison's disease?
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Hypoglycemia
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Clients experiencing hypoparathyroidism exhibit which of the following lab abnormalities?
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Hypocalcemia
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A client who is taking steroids for the treatment of advanced COPD is most likely to develop which of the following complications?
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Cushing's syndrome
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A six-year-old boy has been diagnosed with conjunctivitis. What teaching should be included in the teaching of this child and his parents?
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Use a new tissue every time discharge is wiped from the eye.
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Which of the following drugs is used to treat glaucoma?
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Cholinergics
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The nurse instructs the patient who has undergone eye surgery to avoid activities that would increase intraocular pressure, such as
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Gazing upward
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Which of the following is a symptom of acute angle-closure glaucoma?
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Seeing halos around lights
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The ability of the eye to focus and refocus is called
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Accommodation
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The nurse is administering eye drops to a client with glaucoma. To achieve maximum absorption, the nurse should instill the eye drop into the
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Conjunctival sac
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The nurse is caring for a 45-year-old male client with a retinal detachment in his left eye. What symptoms would the nurse expect to find during assessment?
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Flashing lights in the visual field
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A patient with low vision and peripheral field defects may require assistance with which of the following activities?
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Mobility
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Which of the following drugs is a beta blocker?
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timolol
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Conjunctivitis may be caused by bacteria, viruses, allergens or irritants. What symptoms differentiate bacterial conjunctivitis from other types?
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Acute onset, moderate pain, and purulent discharge
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Which of the following terms refers to involuntary rhythmic eye movement?
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Nystagmus
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Of the following tests, which uses a tuning fork to detect unilateral hearing loss?
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Weber
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Of the following terms, which refers to loss of hearing related to damage of the end organ for hearing or cranial nerve VIII?
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Sensorineural hearing loss
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Which of the following patients would be at an increased risk for falls?
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A patient with vertigo
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A client has conductive hearing loss caused by otosclerosis. To facilitate communication with the client, the nurse should
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Sit or stand in front of the client when speaking
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The most important assessment following thyroidectomy is to detect
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Laryngeal edema
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Which of the following medications should be available at the bedside to provide emergency treatment if a client develops tetany following a subtotal thyroidectomy?
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Calcium gluconate
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Which of the following is the most significant risk factor for developing type II diabetes?
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Obesity
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(Lippincott page 358 #30) Which of the following is a potential complication of diabetes mellitus?
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Blood pressure of 160/100
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The nurse should teach the diabetic client that a common symptom of hypoglycemia is
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Nervousness
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A client presents to the emergency room with diabetic ketoacidosis. The nurse would identify which of the following nursing diagnoses as a priority problem?
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Deficient fluid volume
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The nurse teaches the client to monitor for signs of which potential complication following hypophysectomy?
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Hypopituitarism
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Which of the following is a priority outcome for a client with diabetes insipitus?
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Maintains normal fluid and electrolyte balance
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When teaching a client newly diagnosed with Addison's disease, the nurse should explain that the disease results from
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Idiopathic atrophy of the adrenal gland
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(Lippincott page 362 #58) Which of the following is a priority for a client in Addisonian crisis?
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Preventing irreversible shock
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A 42-year-old female client reports that she has gained weight and her face and body are "rounder," while her legs and arms have become thinner. A tentative diagnosis of Cushing's disease is made. While examining the client, the nurse would expect to find
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Bruised areas on the skin
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|
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A priority in the first 24 hours following adrenalectomy is
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Preventing adrenal crisis
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Which of the following findings would be typical of Addison's disease?
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Hypoglycemia
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Clients experiencing hypoparathyroidism exhibit which of the following lab abnormalities?
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Hypocalcemia
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A client who is taking steroids for the treatment of advanced COPD is most likely to develop which of the following complications?
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Cushing's syndrome
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The nurse is planning care for a client with Meniere's disease. Which nursing diagnosis takes highest priority?
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Risk for injury related to vertigo
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A 78-year-old client with sensorineural hearing loss is admitted to a rehabilitation center after hip replacement surgery. A risk factor for this client would be
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Altered perceptions
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A 17-year-old girl is attending a concert. The music at the concert will be 80 to 90 dB. The girl should be aware of which of the following?
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Hearing loss may occur with a decibel level in this range
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Which of the following may cause irreversible tissue damage and persistent tympanic membrane perforation?
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Chronic otitis media
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The nurse closely monitors the patient receiving which of the following categories of medications known to cause ototoxicity?
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Anti-inflammatory agents
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The three primary typed of blood cells in the blood are:`
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Erythrocytes, leukocytes, and thrombocytes
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Blood cell formation (hematopoiesis) occurs in the
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Bone marrow
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The most frequent symptom and complication of anemia is:
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Fatigue
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Patients with _______________ are at high risk for bleeding.
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Thrombocytopenia
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A client with thrombocytopenia secondary to leukemia develops epistaxis. The nurse should instruct the patient to
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Sit upright, leaning slightly forward
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The nurse is administering vitamin B12 to a client with pernicious anemia, secondary to gastrectomy. Which route should the nurse use to most effectively administer the vitamin?
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Intramuscular route
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During the physical assessment of a patient with thrombocytopenia, the nurse would expect to find
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Petechiae and purpura
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A patient with a hematologic disorder has a smooth, shiny red tongue. The nurse would expect the patient's laboratory results to include
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Hgb 9.6 g/dl
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Bleeding and petechiae do not occur until the platelet count falls below 50,000/mm^3. The normal value for blood platelets is:
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Between 150,000 and 400,000/mm^3
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|
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A patient is being treated with chemotherapeutic agents. The nurse revises the patient's care plan based on the CBC results of
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WBC 4000/mm^3
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In addition to the general symptoms of anemia, the patient with pernicious anemia also manifests
|
Neurologic symptoms
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|
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The common feature of leukemia is
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An unregulated accumulation of white cells in the bone marrow, which replace normal marrow elements
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The nursing diagnosis that is most appropriate for a patient with moderate to severe anemia of any etiology is
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Activity intolerance related to decreased hemoglobin and imbalance between oxygen supply and demand
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|
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The increased tendency toward coronary and cerebral thrombosis seen in individuals with polycythemia vera is attributable to the
|
Increased viscosity of the blood
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A female client has a low hemoglobin level, which is attributed to a nutritional deficiency of iron. The nurse should recommend an increase in which food in the client's diet?
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Liver
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Which of the following is contraindicated for a patient diagnosed with disseminated intravascular coagulation?
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Administering coumadin
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What factor besides the degree of neutropenia does the nurse assess in determining the client's risk for infection?
|
Length of time the neutropenia has existed
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|
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The nurse evaluates that the client correctly understands how to report signs of bleeding when the client makes which of the following statements?
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"Ecchymoses are large purple skin bruises."
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|
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Hemophilia is a hereditary bleeding disorder that
|
Is associated with all of the above
|
|
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The goal of nursing care for a client with acute myeloid leukemia is to prevent
|
Hemorrhage and infection
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A woman you care for in a clinical setting is found to have a cystocele. You would explain to her that this is
|
A pouching of the bladder into the vaginal wall
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|
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An adolescent describes her menstrual pattern to you. Which of the following observations is typical of a usual menstrual pattern?
|
Flow usually lasts 3 to 7 days.
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A teen approaches you about when to begin testicular self-exams. Testicular exams should begin
|
in adolescence
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A woman visits your family planning clinic requesting a prescription for birth control pills. Which of the following factors would indicate that an ovulation suppressant would not be the best contraceptive method for her?
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She has a family history of thromboembolism.
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A woman calls you to report that she has had some cramping since the insertion of her IUD and that her present menstrual flow is heavy. You would advise her to do which of the following?
|
Consider this normal because her IUD has been newly inserted
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|
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How can pelvic inflammatory disease (PID) affect fertility?
|
It interferes with the transport of ova due to tubal scarring.
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During her gynecological check-up, a 17-year-old woman states that recently she has been experiencing cramping and pain during her menstrual periods. The nurse would document this complaint as which of the following?
|
Dysmenorrhea
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Your client states she has noticed a small lump in her left breast. You know that most malignant tumors of the breast are found in which quadrant of the breast?
|
Upper outer quadrant
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A single, young adult woman received instructions from the nurse regarding the use of an oral contraceptive. The woman would demonstrate a need for further instruction if she
|
Stops asking her sexual partners to use condoms and spermicide
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|
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The narrowing of the preputial opening of foreskin is called
|
Phimosis
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Upon vaginal examination of a 30-year-old woman, the nurse documents the following findings: profuse, thin grayish-white vaginal discharge with a "fishy" odor; complaints of pruritus. Based on these findings, the nurse suspects that this woman has
|
Bacterial vaginosis
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|
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Fibrocystic change in the breast is
|
Lumpiness with pain and tenderness found in varying degrees in breast tissue of healthy women during menstrual cycles
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|
|
The viral sexually transmitted infection that may lead to cellular changes on the cervix is
|
Human papillomavirus (HPV)
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After a mastectomy, a woman should be instructed to do all of the following except
|
Avoid all sexual activity
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|
|
Practical suggestions to help achieve fertility would include which of the following?
|
The male-superior position for coitus is best to achieve conception by placing the sperm near the cervix.
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|
|
You are providing education about birth control methods to your client. She asks you about potential side effects of the birth control pill. You know that potential side effects of the pill include all but one of the following
|
iron deficiency anemia
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|
|
A condition in which one or both of the testes fail to descend into the scrotum is called
|
Cryptorchidism
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|
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What important immediate postoperative care practice should the nurse remember when caring for a woman who has had a mastectomy?
|
Do not apply the blood pressure cuff to the affected arm.
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|
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When teaching self-care prevention of genital cadidiasis infections, the nurse should instruct the woman to
|
Limit time spent in damp exercise clothes and limit exposure to bath salts or bubble bath
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|
|
Because of the effect of cyclic ovarian changes on the breast, the best time for breast self-examination is
|
5 to 7 days after menses cease
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|
|
What is the normal range for a fetal heart rate?
|
120 to 160 beats/minute
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Which of the following nursing interventions is appropriate when preparing a woman for an amniocentesis?
|
Be certain she knows there is a slight risk for complication, such as preterm labor, from amniocentesis.
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|
|
An 18-year-old pregnant woman asks why she has to have a routine alpha- fetoprotein serum level drawn. You explain that this
|
May reveal chromosomal abnormalities
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Which of the following tasks is the most important task of the first trimester of pregnancy?
|
Accepting the pregnancy
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|
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Which of the following is a positive sign of pregnancy?
|
Fetal movement felt by examiner
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|
As a pregnant woman lies on the examining table, she grows very short of breath and dizzy. This probably happens because
|
Blood is trapped in the vena cava in a supine position
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|
|
A woman in her 24th week of pregnancy states that she has never experienced allergies but is now experiencing nasal stuffiness. She asks what medications she can take for this ailment. The best response to this inquiry would be:
|
"The nasal stuffiness may not be an allergy but may be due to increased estrogen."
This is wrong it is due to increased progesteron |
|
|
Utilize the GTPAL system to classify a woman who is currently 18 weeks pregnant. This is her fourth pregnancy. She has delivered one baby vaginally at 26 weeks who died, she has experienced a miscarriage, and she has one living child who was delivered at 38 weeks gestation.
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4,1,1,1,1
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What advice would you give to a woman who is 4 months pregnant and owns cat?
|
Ask someone else to change the cat litter
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A woman of normal weight asks you what is an ideal weight gain during pregnancy. Which of the following would be your best answer?
|
25 to 35 pounds is ideal.
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|
A pregnant woman asks you if she can take an over-the-counter vitamin during pregnancy rather than her prescription prenatal vitamin. A chief ingredient in prenatal vitamins that makes them important for pregnancy is
|
folic acid
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|
|
A pregnant woman asks you about the advantages of an alternative birthing center. You would explain to her that
|
birth is viewed as a wellness event
|
|
|
For which of the problems would the nurse be alert in a pregnant woman with gestational diabetes?
|
Hydramnios related to glucose/insulin imbalance
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|
|
A woman who is Rh negative asks you how many children she will be able to have before Rh incompatibility causes them to die in utero. Your best response is
|
As long as she receives RHIG, there is no limit
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|
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A woman is diagnosed as having pregnancy-induced hypertension. Which of the following is the most typical symptom of this?
|
Protein in urine
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A woman who is 3 months pregnant has come in for her first prenatal visit. The nurse should instruct her to do which of the following?
|
Eat foods rich in protein, iron and other nutrients to provide an additional 300 calories a day.
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|
|
A pregnant woman asks why she is scheduled to receive an ultrasound. The nurse would respond appropriately by stating
|
"An ultrasound is a routine examination to monitor how the infant is growing and moving and to check for any abnormalities."
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|
|
A woman during her first trimester of pregnancy asks you how much longer she will have urinary frequency. You advise her that
|
Urinary frequency is a common complaint during the first trimester and then again in the third trimester of pregnancy.
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|
|
Which food is not a good source of iron?
|
milk
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|
|
A woman wants to exercise during her pregnancy. Which of the following is a rule of which she should be aware?
|
She should not include pushing as an exercise.
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|
|
To assess the frequency of a woman's labor contractions, you would time
|
The beginning of one contraction to the beginning of the next
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|
|
You place an external fetal monitor on a woman in labor. Which of the following instructions would be best to give her?
|
Lie on her side so she is comfortable
|
|
|
If a fetus is not receiving enough oxygen during labor because of uteroplacental insufficiency, which of the following patterns would you anticipate seeing on the monitor?
|
Fetal heart rate declining late with contractions and remaining depressed
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|
|
If the monitor pattern of uteroplacental insufficiency is present, which of the following would you do first?
|
Turn her or ask her to turn to her side
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|
|
During labor, effacement of the cervix occurs. This is described as which of the following?
|
Thinning and shortening of the cervix
|
|
|
Although the time frame for labor differs with individual women, which time period would you find excessive for a nulliparous woman?
|
A latent phase of 24 hours
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|
|
When caring for a woman in labor, the fetal heart monitor demonstrates late decelerations. The most common cause for their occurrence is
|
Uteroplacental insufficiency
|
|
|
The injection of a local anesthetic to block specific nerve pathways is referred to as which of the following?
|
Regional block
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|
|
A woman's husband expresses concern about risk for paralysis from an epidural block being given to his wife. Which of the following would be the most appropriate response?
|
"The injection is given in the third space outside the spinal cord."
|
|
|
Immediately following an epidural block, a woman's blood pressure suddenly falls to 90/50mmHg. Your first action would be to
|
Turn her on her left side or raise her legs
|
|
|
A patient who is in transition reports her pain medication last given 3 hours ago has worn off. She asks if she can have another dose of the Demerol. How should the nurse respond to her request?
|
"Your stage of labor makes giving another dose unsafe."
|
|
|
To prevent thrombophlebitis following a cesarean birth, which of the following would be most important to implement?
|
encourage the woman to ambulate
|
|
|
When a woman in labor has reached 8cm dilation, you notice the fetal heart rate suddenly slows. On perineal inspection, you observe that the fetal cord has prolapsed. Your first action would be to
|
Place her in a knee-chest position
|
|
|
A woman's nurse-midwife tells her that the woman has developed dystocia. You would explain that this means
|
Difficult or abnormal labor
|
|
|
You assess that the fetus of a woman is in occiput posterior position. Which of the following identifies the way you would expect her labor to differ from others?
|
Experience of additional back pain
|
|
|
When caring for a newborn several hours after birth, you assess his respiratory rate. In a normal newborn, this would be
|
30 to 60 breaths/minute
|
|
|
On inspection, you note that a newborn has a normal head-to-body proportion. This proportion for the head is
|
One fourth his total length
|
|
|
On Apgar evaluation, reflex irritability is tested by which of the following?
|
Slapping the soles of the feet and observing the response
|
|
|
A newborn is noticeably jaundiced on the third day of life. Which of the following responses would be most appropriate?
|
"This is from a normal breakdown of red blood cells."
|
|
|
Vitamin K is routinely given to newborns because
|
Lack of vitamin K leads to faulty blood clotting
|
|
|
The terms "growth" and "development" are often used interchangeably. To which of the following does "development" refer?
|
He learns to throw a ball overhand.
|
|
|
During their school-age years, children understand concepts best if they can see the concept illustrated. This type of thinking is termed
|
Concrete thought
|
|
|
The mother of a 3-month-old is concerned because her daughter does not yet sit by herself. Which of the following statements best reflects average sitting ability?
|
Most babies do not sit steadily until 8 months; she is normal.
|
|
|
Which developmental task, according to Erikson, should an infant accomplish during the infant year?
|
Trust
|
|
|
A 2-year-old holds his breath until he passes out when he wants something his mother does not want him to have. You would base your evaluation of whether these temper tantrums are a form of seizure on the basis that
|
Seizures are not provoked; temper tantrums are
|
|
|
A 4-year-old is hospitalized with a urinary tract infection. Based on what you know of her cognitive development, which approach would be best to prepare her for an x-ray?
|
Help her pretend the x-ray machine is a camera.
|
|
|
Which of the following immunizations would you plan to administer at a preschool health maintenance visit?
|
DTaP
|
|
|
The developmental task of the school-age period, according to Erikson, is gaining a sense of
|
Industry versus inferiority
|
|
|
A 10-year-old spends 2 hours by herself every afternoon before her parents arrive home. Which of the following would be the most appropriate safety measure to suggest that the parents teach the child?
|
Preparing a no-cook snack for herself
|
|
|
An adolescent is concerned that he is going to be unusually short. You would advise him that the epiphyseal lines of long bones in boys that govern growth usually close between ages
|
18 and 20 years
|
|
|
All infants should have their head circumference measured at health assessment visits. This measurement is made from
|
Just above the eyebrows through the prominent part of the occiput
|
|
|
You administer a Denver Developmental Screening Test to a preschooler. Which of the following statements is the best introduction to this test for her mother?
|
"This test will identify different developmental skills your child can perform."
|
|
|
What physical finding would best suggest that an infant is dehydrated?
|
A depressed fontanelle
|
|
|
Children differ from adults in body composition. The difference that makes diarrhea so devastating in an infant is that an infant has
|
A high proportion of extracellular fluid
|
|
|
Tetralogy of Fallot is the most frequently occurring type of congenital heart disease in children. The four anomalies associated with this defect are
|
Ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, overriding aorta
|
|
|
To assess for cyanosis in an infant with cardiovascular disease, it would be best to assess
|
The child's tongue and buccal membrane
|
|
|
You see a school-age child in an ambulatory setting because of rheumatic fever. Which of the following would you expect to find revealed by the health history?
|
Knee pain, abdominal rash, subcutaneous nodules
|
|
|
Which assessment below would increase your suspicion that iron-deficiency anemia may be present in a child?
|
A 15-year-old girl constantly sucks ice cubes.
|
|
|
A school-age child is admitted to the hospital with a vaso-occlusive sickle cell crisis. Which measure in his care should be given priority?
|
Maintaining a fluid intravenous line
|
|
|
A 3-year-old boy is diagnosed with intussusception. Which symptom reported by the parents would have led the nurse to suspect this diagnosis?
|
Bloody-mucus stool
|
|
|
A 2-year-old boy is seen for acute laryngotracheobronchitis. Which of the following observations would lead you to suspect that airway occlusion is occurring?
|
His respiratory rate is gradually increasing.
|
|
|
A 6-year-old is diagnosed as having streptococcal pharyngitis. When planning care, you should be aware that the chief danger of such an infection is that
|
A small proportion of children develop rheumatic fever
|
|
|
To relieve a child's feeling of thirst immediately after tonsillectomy, the best thing to offer would be
|
Ice chips
|
|
|
Which of the following nursing diagnoses would be most appropriate for a child with pneumonia during the acute phase of illness?
|
Activity intolerance related to poor oxygen-carbon dioxide exchange
|
|
|
You would plan activity periods for a child with pneumonia to include
|
Frequent position changes to prevent pooling of secretions
|
|
|
To gain a preschooler's cooperation to swallow an oral medication, your best approach would be to
|
Ask if he would like to take his medicine in a cup or through an oral syringe
|
|
|
You notice that a child who has pneumonia has blood gas values of PaO2, 80; PaCO2, 60; pH, 7.31. Based on this, the child is experiencing
|
Respiratory acidosis
|
|
|
When assessing a child for cyanosis, the nurse should keep in mind that
|
The degree of cyanosis is not an accurate indicator of the degree of hypoxia
|
|
|
When you momentarily turn your back while caring for an infant, she aspirates a small toy. She begins coughing, turns cyanotic, and is unable to make a sound. Which of the following nursing actions would be most important?
|
Turn the infant prone and administer back blows.
|
|
|
When planning to teach a 5-year-old who is cognitively challenged how to wash his hands, which would be the most effective method?
|
Demonstrating how to wash hands
|
|
|
You care for a 6-year-old boy with acute glomerulonephritis. When planning care for him, you should be aware that glomerulonephritis usually follows an infection of what organism?
|
A beta-hemolytic streptococcus
|
|
|
You obtain a history from the mother of a child with glomerulonephritis about how he became ill. Which of the following would you expect her to tell you she noticed?
|
Dark brown urine
|
|
|
A child in renal failure is prescribed aluminum hydroxide gel, but does not like the taste of it. You would explain to him that the purpose of this is to
|
Reduce absorption of phosphorus from the GI tract
|
|
|
Which assessment finding at the insertion site of a hemodialysis catheter would suggest infection?
|
Erythema
|
|
|
You care for a 10-year-old boy with growth hormone deficiency. Which therapy would you anticipate will be prescribed for him?
|
Intramuscular injections of growth hormone
|
|
|
When discussing care of an infant with congenital hypothyroidism, you would stress that the infant will need
|
Administration of levothyroxine for a lifetime
|
|
|
A 7-year-old is diagnosed as having type 1 diabetes. One of the first symptoms usually noticed by parents when this illness develops is
|
Loss of weight
|
|
|
After hospital discharge, the mother of a child newly diagnosed with type 1 diabetes mellitus telephones you because her daughter is acting confused and very sleepy. Which emergency measure would you suggest the mother carry out before she brings the child to see her doctor?
|
Give her a glass of orange juice.
|
|
|
A 1-year-old girl has experienced a febrile convulsion. You would teach her parents that to prevent a second convulsion, they should
|
Prevent her temperature from going above 101°F by administering acetaminophen
|
|
|
A 9-year-old has suffered a concussion after a fall from a tree. When assessing the child for signs of increased intracranial pressure, you would be alert for which of the following?
|
Increased temperature, decreased respiratory rate
|
|
|
When assessing children using a Snellen eye chart, you should be aware that the first number of the vision report (20/20) represents
|
The distance the child stands from the chart
|
|
|
To assess for abnormal eye alignment, you would observe a child while you
|
Cover one eye and then remove the cover
|
|
|
School-age children run a high incidence of pediculosis. Of the following, which best suggests pediculosis?
|
Small white particles on the hair strands
|
|
|
To straighten an infant's ear canal to examine it, you would pull the pinna
|
Down and back
|
|
|
To alleviate discomfort in a child following an immunization, you would advise the parents to
|
Administer acetaminophen (80 mg per year of age)
|
|
|
A 7-year-old is admitted to the hospital for a fractured femur. He has skeletal traction applied and will be in bed for several weeks. You want to incorporate play into his care. What type of activity would be most effective in preventing muscle atrophy in his unaffected leg?
|
Kicking a balloon at the foot of the bed
|
|
|
As you prepare to administer a medication to a preschooler, you realize that she is extremely underweight for her age. What action would you take?
|
Measure her height and weight, and check whether the dose is correct for her.
|
|
|
To give an intramuscular injection to an 8-month-old, which of the following sites would you use?
|
The muscle of the anterior thigh
|
|
|
A neighbor of a child with muscular dystrophy is concerned that she may contract his illness. You would explain to her that
|
Muscular dystrophy is inherited, so it is not contagious
|
|
|
You are caring for a child with a broken wrist that has just been placed in a cast. You would elevate the arm to
|
Prevent edema
|
|
|
The physician of a child with juvenile arthritis asks you to telephone the school to arrange a new activity program for her. A change you would anticipate arranging for her is to
|
Modify her physical program
|
|
|
A 9-year-old boy who is blind is admitted to the hospital. When serving him a meal in bed, which of the following statements would be most appropriate to increase his self-esteem?
|
"You have a sandwich on your plate, a glass of milk to your right, and an apple to your left."
|
|
|
The mother of a child having myringotomy tubes placed asks, "Will my son lose his hearing while the tubes are in place?" What is your best answer?
|
"The tubes are inserted into a section of eardrum in which the hearing is not affected."
|
|
|
A 5-year-old is diagnosed with acute otitis media. Which nursing intervention below would be a primary one?
|
Relief of pain
|
|
|
A 10-year-old boy develops bacterial conjunctivitis of the right eye. The eye is inflamed and drains a thick yellow discharge. An important measure you would want to teach him is
|
To clean the discharge away from the inner to the outer canthus
|
|
|
A child is diagnosed with erythema infectiosum. Which report by the mother assisted with the diagnosing of this illness?
|
Red cheeks and rash
|
|
|
Infants or children receiving antibiotics may develop thrush (oral candidiasis). Which of the following findings suggests that an infant has thrush?
|
Presence of a white membrane on tongue
|
|
|
You teach a child to use a FACES pain rating scale before surgery. At that time, she points to the smiling face. Following surgery, when you suspect she has pain, she points again to the smiling face. You would interpret this as
|
She is using the scale to predict what she would like, not what she has
|
|
|
Conscious sedation is a pain management technique that is used with children. During conscious sedation for a preschooler, which of the following actions would be most important?
|
Assessing vital signs frequently because they can become depressed
|
|
|
Which of the following would you expect to observe about the rash associated with chickenpox (varicella)?
|
Various stages of lesions present at the same time
|
