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54 Cards in this Set

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1.The nurse is monitoring a client who is receiving oxytocin (Pitocin) to induce labor. The nurse should be prepared for which maternal adverse reactions?
Select all that apply:
1. Hypertension
2. Jaundice
3. Dehydration
4. Fluid overload
5. Uterine tetany
6. Bradycardia
1. 1, 4, 5
2. A client who is 29 weeks pregnant comes to the labor and delivery unit. She states that she's having contractions every 8 minutes. The client is also 3 cm dilated. Which medications can the nurse expect to administer?
Select all that apply:
1. Folic acid (Folvite)
2. Terbutaline (Brethine)
3. Betamethasone
4. Rho (D) immune globulin (Rhogam)
5. I.V. fluids
6. Meperidine (Demerol)
2. 2, 3, 5
3. The nurse is evaluating a client who is 34 weeks pregnant for premature rupture of the membranes (PROM). Which findings indicate that PROM has occurred?
Select all that apply:
1. Fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry
2. Acidic pH of fluid when tested with nitrazine paper
3. Presence of amniotic fluid in the vagina
4. Cervical dilation of 6 cm
5. Alkaline pH of fluid when tested with nitrazine paper
6. Contractions occurring every 5 minutes
3. 1, 3, 5
4. What information should the nurse include when teaching postcircumcision care to parents of a neonate before discharge from the hospital?
Select all that apply:
1. The infant must void before being discharged home.
2. Petroleum jelly should be applied to the glans of the penis with each diaper change.
3. The infant can take tub baths while the circumcision heals.
4. Any blood noted on the front of the diaper should be reported.
5. The circumcision will require care for 2 to 4 days after discharge.
4. 1, 2, 5
5. A 28-year-old client is admitted with inflammatory bowel syndrome (Crohn's disease). Which therapies should the nurse expect to be part of the care plan?
Select all that apply:
1. Lactulose therapy
2. High-fiber diet
3. High-protein milkshakes
4. Corticosteroid therapy
5. Antidiarrheal medications
5. 4, 5
6. The nurse is assisting in the discharge planning for a client with alcoholism. Which of the following should be included in the discharge plan?
Select all that apply:
1. Strongly encourage participation in Alcoholics Anonymous (AA).
2. Provide nutritional information and counseling.
3. Establish an exercise program.
4. Discuss relapse prevention.
5. Have the client introduce himself slowly to people from his former lifestyle.
6. 1, 2, 3, 4
7. The nurse receives a change-of-shift report for a 76-year-old client who had a total hip replacement. The client is not oriented to time, place, or person and is attempting to get out of bed and pull out an I.V. line that's supplying hydration and antibiotics. The client has a vest restraint and bilateral soft wrist restraints. Which action by the nurse would be appropriate?
Select all that apply:
1. Assess and document the behavior that requires continued use of restraints.
2. Tie the restraints in quick-release knots.
3. Tie the restraints to the side rails of the bed.
4. Ask the client if he needs to go to the bathroom and provide range-of-motion exercises every 2 hours.
5. Position the vest restraints so that the straps are crossed in the back.
7. 1, 2, 4
8. The nurse is performing a Denver Developmental Screening Test II on a 4 1/2-year-old child. What behaviors should the nurse expect the child to demonstrate?
Select all that apply:
1. He balances on each foot for at least 6 seconds.
2. He copies a square using straight lines and square corners.
3. He prepares his own cereal without help.
4. He copies a circle that's closed or very nearly closed.
5. He speaks clearly.
6. He draws a person with at least three body parts.
8. 3, 4, 5, 6
9. The nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client?
Select all that apply:
1. Illness in one family member can affect all members.
2. Family roles don't change because of illness.
3. A family member may have more than one role at a time in a family.
4. Children typically aren't affected by adult illness.
5. The effects of an illness on a family depend on the stage of the family's life cycle.
6. Changes in sleeping and eating patterns may be signs of stress in a family.
9. 1, 3, 5, 6
10.A client is receiving chlordiazepoxide (Librium) to control the symptoms of alcohol withdrawal. The chlordiazepoxide has been ordered as needed. Which symptom may indicate the need for an additional dose of this medication?
Select all that apply:
1. Tachycardia
2. Mood swings
3. Elevated blood pressure and temperature
4. Piloerection
5. Tremors
6. Increasing anxiety
10. 1, 3, 5, 6
11. The nurse is assisting in the discharge planning for a client with alcoholism. Which of the following should be included in the discharge plan?

Select all that apply:
1. Strongly encourage participation in Alcoholics Anonymous (AA).
2. Provide nutritional information and counseling.
3. Establish an exercise program.
4. Discuss relapse prevention.
5. Have the client introduce himself slowly to people from his former lifestyle.
11. 1, 2, 3, 4
12. The nurse is caring for a client with anorexia nervosa who has a nursing diagnosis of Imbalanced nutrition: Less than body requirements related to dysfunctional eating patterns. Which of the following interventions would be supportive for this client?

Select all that apply:
1. Provide small, frequent meals.
2. Monitor weight gain.
3. Allow the client to skip meals until the antidepressant levels are therapeutic.
4. Encourage the client to keep a journal.
5. Monitor the client during meals and for 1 hour after meals.
6. Encourage the client to eat three substantial meals per day.
12.. 1, 2, 4, 5
13. When assessing a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior. Which assessment is the nurse also likely to find?

Select all that apply:
1. The client functions well in other areas of his life.
2. The degree of aggressiveness is out of proportion to the stressor.
3. The violent behavior is most often justified by a stressor.
4. The client has a history of parental alcoholism and chaotic abusive family life.
5. The client has no remorse about the inability to control his behavior.
13. 1, 2, 4
14 .A 28-year-old client is admitted with inflammatory bowel syndrome (Crohn's disease). Which therapies should the nurse expect to be part of the care plan?

Select all that apply:
1. Lactulose therapy
2. High-fiber diet
3. High-protein milkshakes
4. Corticosteroid therapy
5. Antidiarrheal medications
14. 4, 5
15. Which findings are common in neonates born with esophageal atresia?

Select all that apply:
1. Decreased production of saliva
2. Cyanosis
3. Coughing
4. Inadequate swallow
5. Choking
6. Inability to cough
15. 2, 3, 5
16. While preparing a client for an upper GI endoscopy (esophagogastroduodenoscopy), the nurse should implement which interventions?

Select all that apply:
1. Administer a preparation to cleanse the GI tract, such as Golytely or Fleets Phospha-Soda.
2. Tell the client he shouldn't eat or drink for 6 to 12 hours before the procedure.
3. Tell the client he must be on a clear liquid diet for 24 hours before the procedure.
4. Inform the client that he'll receive a sedative before the procedure.
5. Tell the client that he may eat and drink immediately after the procedure.
16. 2, 4
17. A client with a retroperitoneal abscess is receiving gentamicin (Garamycin). Which signs should the nurse monitor?

Select all that apply:
1. Hearing
2. Urine output
3. Hematocrit (HCT)
4. Blood urea nitrogen (BUN) and creatinine levels
5. Serum calcium level
17. 1, 2, 4
18.The nurse is explaining the Bill of Rights for psychiatric patients to a client who has voluntarily sought admission to an inpatient psychiatric facility. Which of the following rights should the nurse include in the discussion?

Select all that apply:
1. Right to select health care team members
2. Right to refuse treatment
3. Right to a written treatment plan
4. Right to obtain disability
5. Right to confidentiality
6. Right to personal mail
18. 2, 3, 5, 6
19. In the emergency department, a client reveals to the nurse a lethal plan for committing suicide and agrees to a voluntary admission to the psychiatric unit. Which information will the nurse discuss with the client to answer the question, "How long do I have to stay here?"

Select all that apply:
1. "You may leave the hospital at any time unless you are suicidal."
2. "Let's talk more after the health team has assessed you."
3. "Once you've signed the papers, you have no say."
4. "Because you could hurt yourself, you must be safe before being discharged."
5. "You need a lawyer to help you make that decision."
6. "There must be a court hearing before you leave the hospital."
19. 1, 2, 4
20. The nurse has developed a relationship with a client who has an addiction problem. Which information would indicate that the therapeutic interaction is in the working stage?

Select all that apply:
1. The client addresses how the addiction has contributed to family distress.
2. The client reluctantly shares the family history of addiction.
3. The client verbalizes difficulty identifying personal strengths.
4. The client discusses the financial problems related to the addiction.
5. The client expresses uncertainty about meeting with the nurse.
6. The client acknowledges the addiction's effects on the children.
20. 1, 3, 6
21.The nurse is assessing a client's extraocular eye movements as part of the neurologic examination. Which cranial nerves are the nurse assessing?

Select all that apply: Nclex SATA
1. Cranial nerve II
2. Cranial nerve III
3. Cranial nerve IV
4. Cranial nerve V
5. Cranial nerve VI
6. Cranial nerve VIII
21. 2, 3, 5
22. The nurse is assessing a 2-year-old client diagnosed with bacterial meningitis. Which of the following signs and symptoms of meningeal irritation is the nurse likely to observe?

Select all that apply: Nclex SATA
1. Generalized seizures
2. Nuchal rigidity
3. Positive Brudzinski's sign
4. Positive Kernig's sign
5. Babinski reflex
6. Photophobia
22. 2, 3, 4, 6
23. The nurse is assessing the level of consciousness of a client who suffered a head injury. She uses the Glasgow Coma Scale and determines that the client's score is 15. Which responses did the nurse assess in this client?

Select all that apply: Nclex SATA
1. Spontaneous eye opening
2. Tachypnea, bradycardia, and hypotension
3. Unequal pupil size
4. Orientation to person, place, and time
5. Motor response to pain localized
6. Incomprehensible sounds
23. 1, 4
24. The nurse is caring for a client with a complete T5 spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and a blood pressure of 162/96 mm Hg. The client reports a severe, pounding headache. Which nursing interventions would be appropriate for this client?

Select all that apply: Nclex SATA
1. Elevating the head of the bed 90 degrees
2. Loosening constrictive clothing
3. Using a fan to reduce diaphoresis
4. Assessing for bladder distention and bowel impaction
5. Administering antihypertensive medication
6. Placing the client in a supine position with legs elevated
24. 1, 2, 4, 5
25. The nurse is preparing a female client with tonic-clonic seizure disorder for discharge. Which instructions should the nurse include about phenytoin (Dilantin)?

Select all that apply: Nclex SATA
1. "Monitor for skin rash."
2. "Maintain adequate amounts of fluid and fiber in the diet."
3. "Perform good oral hygiene, including daily brushing and flossing."
4. "Receive necessary periodic blood work."
5. "Report to the physician any problems with walking, coordination, slurred speech, or nausea."
6. "Feel safe about taking this drug, even during pregnancy."
25. 1, 3, 4, 5
Signs and symptoms of Tuberculosis
• Waking up sweating at night
• Low grade fever
• Dull aching chest pain
• Cough streaked with blood
• Weight loss
• Anorexia
• Fatigue
Signs and symptomsof Bacterial Meningitis
• N & V
• Seizures
• Stiff Neck
• Photophobia
• Positive Brudinzki sign
Signs and symptoms of DKA
• Fruity breath Odor
• Oliguria
• Kausmall Breathing (deep & nonlabored)
Ovarian Cancer
Risk factors:
• Ovarian dysfunction
• Vaginal use of talcum powder
• Alcohol
• Race - White women & family history
• Infertility
• Age - Peak=5th decade of life
• Nulliparity
• Genetic predisposition
Site For IM Injection Adult
• Deltoid
• Ventrogluteal
• Vastus Lateralis
• Gluteus Maximus
Signs and symptoms of Liver Cirrhosis
• Nausea & Vomiting
• Edema
• Ascites
Bladder Ca
Risk Factors:
• Hx of smoking
• Exposure to radiation
• Working in industrial Factory
What to avoid when taking Dilantin
• do not floss throughout the day
• do not use hard bristled toothbrush
Gingivitis
Signs and symptoms of Hydrocephalus
• Anterior fontanel bulges & nonpulsating
• Bones of head separated (cracked pot sound)
• Check for sun-setting eyes
• Increase ICP
• Evidence of Frontal Bossing
• Failure to thrive
• Irritability
• High-pitched cry
Diabetic Mellitus Foot Care
• Meticulous care to feet
• Wash feet with warm water not hot & dry
• Can use lotion but No lotion in between toes
• Wear socks to keep feet warm
• Avoid thermal baths, heating pads
• Do not soak feet
• Inspect feet daily
• Do not treat corns, blisters
• Wear loose socks and no barefoot
• Change into clean cotton socks daily
• Break in new shoes gradually
• Use emery board
• Do not smoke
• Do not wear same pair of shoes 2 days in a row
Normal In 8 Months Old Child
• can sit without support
• can roll from front to back
• can hold a bottle
• closure of ant. fontanel
• can say mama and dada
• 2 teeth present
Signs and symptoms of Acute Pancreatitis
• Abdominal Pain severe –acute sx
• Complication : Shock,Hypovolemia
• Limited fat & protein intake
ESRD DIET
• Restricted protein intake
• Increase CHO
• Low K, P
• Restrict Na
Signs and symptoms of HYPERTHYROIDISM
• Soft smooth skin & hair
• Mood swings
• HPN
• Diaphoresis
• Intolerance to heat
• PTU drug to block thyroid synthesis
Management of ANAPHYLACTIC REACTION
• Stop medication
• Maintain airway
• Notify MD
• Maintain IV access of 0.9 NSS
• Place in supine position with legs elevated
• Monitor VS
• Administer prescribed emergency drugs
Signs and symptoms of ULCERATIVE COLITIS
• Severe diarrhea with blood & mucus
• Abdominal tenderness & cramping
• Anorexia
• Wt. Loss
• Vit. K deficiency
• Anemia
• Dehydration
• Electrolyte imbalance
• Low residue & high protein diet
Signs and symptoms of SUPERIOR VENA CAVA OCCLUSION
• Sx occur in the morning
• Edema of face, eyes & tightness of
shirt/ (Stoke’s sign)
• Late sx: edema of arms, hands,
dyspnea, erythema, epistaxis
CERVICAL CANCER
Risk Factors:
• African- American/ Native women
• Behavior (Sexual promiscuity)
• Chronic instrumentation of cervix
• Disease –STD
• Early age of Sex
• High Parity
• Poor Hygiene
• Low economic status
• Multiple sexual partners
• Partner with Prostate CA
Signs and symptoms of PARKINSONS
• Tremors, akinesia, rigidity
• Weakness, “motorized propulsive gait
• Slurred speech, dysphagia, drooling
• Monotonous speech
• Mask like expression
• Teach ambulation modification: goose stepping walk (marching), ROM exercises
• Activities should be scheduled for late morning when energy level is highest
• Encourage finger exercises.
• Promote family understanding of disease intellect/sight/ hearing not impaired,
1. The nurse is planning care for a client with hyperthyroidism. Which nursing interventions are appropriate?
Select all that apply:
1. Instill isotonic eye drops, as necessary.
2. Provide several small, well-balanced meals.
3. Provide rest periods.
4. Keep the environment warm.
5. Encourage frequent visitors and conversation.
6. Weigh the client daily.
1. Answer: 1, 2, 3, 6
2. The nurse is caring for a client with emphysema. Which nursing interventions are appropriate?
Select all that apply: Nclex SATA
1. Reduce fluid intake to less than 2,500 ml/day.
2. Teach diaphragmatic, pursed-lip breathing.
3. Administer low-flow oxygen.
4. Keep the client in a supine position as much as possible.
5. Encourage alternating activity with rest periods.
6. Teach use of postural drainage and chest physiotherapy.
2. Answer: 2, 3, 5, 6
3. The nurse is caring for a client who underwent surgical repair of a detached retina of the right eye. Which interventions should the nurse perform?
Select all that apply: Nclex SATA
1. Place the client in a prone position.
2. Approach the client from the left side.
3. Encourage deep breathing and coughing.
4. Discourage bending down.
5. Orient the client to his environment.
6. Administer a stool softener.
3. Answer: 2, 4, 5, 6
4. The client has a tumor of the posterior pituitary gland. The nurse planning his care should include which interventions?
Select all that apply: Nclex SATA
1. Take daily weight.
2. Restrict fluids.
3. Assess urine specific gravity.
4. Encourage intake of coffee or tea.
5. Monitor intake and output.
4. Answer: 1, 3, 5
5. The nurse is developing a care plan for a client with injury to the frontal lobe of the brain. Which interventions should be part of the care plan?
Select all that apply: Nclex SATA
1. Keep instructions simple and brief because the client will have difficulty concentrating.
2. Speak clearly and slowly because the client will have difficulty hearing.
3. Assist the client with bathing because he will have vision disturbances.
4. Orient the client to person, place, and time as needed because of memory problems.
5. Assess vital signs frequently because vital bodily functions are affected.
5. Answer: 1, 4
6. The nurse is caring for a client whose cultural background is different from her own. Which actions are appropriate?
Select all that apply: Nclex SATA
1. Consider that nonverbal cues, such as eye contact, may have a different meaning in different cultures.
2. Respect the client's cultural beliefs.
3. Ask the client if he has cultural or religious requirements that should be considered in his care.
4. Explain the nurse's beliefs so that the client will understand the differences.
5. Understand that all cultures experience pain in the same way.
6. Answer: 1, 2, 3
7. A 62-year-old client has just been diagnosed with terminal cancer and is being transferred to home hospice care. The client's daughter tells the nurse, "I don't know what to say to my mother if she asks me if she's going to die." Which of the following responses by the nurse would be appropriate?
Select all that apply: Nclex SATA
1. "Don't worry, your mother still has some time left."
2. "Let's talk about your mother's illness and how it will progress."
3. "You sound like you have some questions about your mother dying. Let's talk about that."
4. "Don't worry, hospice will take care of your mother."
5. "Tell me how you're feeling about your mother dying."
7. Answer: 2, 3, 5
8. A 62-year-old client has just been diagnosed with terminal cancer and is being transferred to home hospice care. The client's daughter tells the nurse, "I don't know what to say to my mother if she asks me if she's going to die." Which of the following responses by the nurse would be appropriate?

Select all that apply: Nclex SATA
1. "Don't worry, your mother still has some time left."
2. "Let's talk about your mother's illness and how it will progress."
3. "You sound like you have some questions about your mother dying. Let's talk about that."
4. "Don't worry, hospice will take care of your mother."
5. "Tell me how you're feeling about your mother dying."
8. Answer: 1, 2, 4
9. While providing care to a 26-year-old married female, the nurse notes multiple ecchymotic areas on her arms and trunk. The color of the ecchymotic areas ranges from blue to purple to yellow. When asked by the nurse how she got these bruises, the client responds, "Oh, I tripped." How should the nurse respond?
Select all that apply: Nclex SATA
1. Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries.
2. Report suspicions of abuse to the local authorities.
3. Assist the client in developing a safety plan for times of increased violence.
4. Call the client's husband to discuss the situation.
5. Tell the client that she needs to leave the abusive situation as soon as possible.
6. Provide the client with telephone numbers of local shelters and safe houses.
9. Answer: 1, 3, 6
10. A nurse is working with the family of a client who has Alzheimer's disease. The nurse notes that the client's spouse is too exhausted to continue providing care all alone. The adult children live too far away to provide relief on a weekly basis. Which nursing interventions would be most helpful?
Select all that apply: Nclex SATA
1. Calling a family meeting to tell the absent children that they must participate in helping the client.
2. Suggesting the spouse seek psychological counseling to help cope with exhaustion
3. Recommending community resources for adult day care and respite care
4. Encouraging the spouse to talk about the difficulties involved in caring for a loved one with Alzheimer's disease.
5. Asking whether friends or church members can help with errands or provide short periods of relief.
6. Recommending that the client be placed in a long-term care facility.
10. Answer: 3, 4, 5