Kaplan Nursing Assessment (NAT) Essay

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(ECT) Client diagnosed w/ depression scheduled to begin series of ECT treatments. It is most important for the nurse to notify HCP about what?
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Being treated for glaucoma.
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(Post OP) First day develops fever. Auscultates crackles lower lobes. Which complication?
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Atelectasis.
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(Bowel Elimination) Help facilitate bowel elimination?
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Increase dietary bulk.
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(Pain management) Without morphine?
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LOC fluctuates alert to lethargic.
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(Pain Management) Prior to admin pain medication?
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Assess location, character, intensity.
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(Preop Care) After administration of pre-op medication?
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Raise side rails of bed.
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(Growth & Development: Older Adult) What statement is normal for elderly client to make?
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Eating does not appeal to me.
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(Pain Management) Most important caring for client in pain?
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Establish a trusting relationship.
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(Heparin) Lab test to monitor Heparin?
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PTT
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(Constipation) Reason elderly adults have constipation?
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Less activity and decreased muscle tone.
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(Sleep Patterns) Security guard works nights?
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Tell me about your usual sleeping habits.
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(Informed Consent) Does not want surgery?
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Encourage client to discuss reasons for cancelling.
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(Post-op Care) Has not void since before surgery 10 hours ago?
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Palpate bladder distention.
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(Body Mechanics) Proper body mechanics
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Bend knees when lifting.
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(Spinal Anesthesia) Spinal aesthesia used?
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Protected from injury since sensation impaired.
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(Play Therapy) Why child involved in play therapy?
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Young children have difficulty verbalizing emotions.
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(Therapeutic Comm) Client sits arms folded & eyes down, which approach is best?
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Used broad openings & leads to encourage discussion.
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(Anxiety) Client pacing, talking rapidly, increased resp?
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Keep explanation simple.
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(Therapeutic Comm) “Racing Heart”
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When did you first notice you were feeling anxious.
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(Schizophrenia) Stops dncing stares at nurse?
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Point out client stopped dancing & seems upset.
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(Schizophrenia) Spouse client has not slept in 3 nights?
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Promote trust.
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(Phobic Disorder) I know my feeling of being terrified of closed spaces is dumb?
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Knowing your fears don’t make sense doesn’t always help you feel better.
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(Suicide Attempt) Overdose diazepam?
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Exactly what, how much & when.
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(Schizophrenia) Inpatient unit undressed?
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Lead client back to room & help get dressed.
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(Schizophrenia) The client diagnosed with paranoid schizophrenia tells the nurse “I have a feelings of numbness in my legs. They feel like they don’t belong to me, and I think someone on TV is controlling my walking. Which response is best?
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That must be an unpleasant experience for you. Have you had these feelings before.
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(Group Therapy) nrse cares for clients in the mental health clinic. The client with depression joins an ongoing therapy group. What is the goal of group therapy?
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To communicate acceptance to the client.
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(Therapeutic Communication) A client in the hypertension clinic expresses worry to the nurse that his wife has been unemployed for more than six months, and that he is afraid that soon they will be unable to pay the rent. Which of these responses by the nurse is most appropriate?
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You’re worried that you won’t be able to pay the rent?
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(Heroin Abuse) Which of the following signs and symptoms would the nurse observe in a patient who has recently taken heroin?
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Constricted pupils, depressed respirations.
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(Schizophrenia) The nurse admits the client with a diagnosis of schizophrenia to the unit. The client’s needs are best met by which action?
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Give the client a brief orientation and stay with the client for a while.
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(Anti Social Personality) The nurse meets with the client on the psychiatric unit when another client diagnosed with antisocial personality disorder walks into the room and sits down. which response by the nurse is best?
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Right now we are talking. please leave this room and i’ll talk to you later.
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(Anxiety) The nurse instructs a patient’s spouse about how to cope with the patient’s anxiety. The nurse determines teaching is successful if the spouse makes which of the following statements?
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Anxiety represents an unconscious conflict of needs.
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(Phobic Disorder) The nurse cares for clients in the outpatient clinic. A client relates to the nurse “I travel only by train because I am terrified of flying “the nurse understands that the phobic client is most likely to respond to which intervention.
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Systemic Desensitization.
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(Suicide Attempt) A patient is slumped on the floor with a razor blade in hand; blood pours from the wrist. A nurse finds the patient. What is most important for the nurse to do?
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Call another nurse for help; stay with the patient.
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(OCD) The nurse cares for a patient diagnosed with an obsessive-compulsive disorder. The nurse observes that the patient has difficulty getting to meals on time because of hand-washing ritual. Which of the following statement by the nurse is best?
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tomorrow, I will call you 15 minutes earlier to help you get ready.
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The nurse cares for the client diagnosed with conversion reaction. The nurse identifies that this client utilizes which defense mechanisms?
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Repression and Symbolization
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(Crisis) When intervening with the client who is in a state of crisis, which statement by the nurse most effectively helps the client cope?
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What have you done when you felt this anxious before?
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(Anti Social) The nurse plans for a patient diagnosed with antisocial personality disorder. the nurse understands that the purpose of group therapy for this patient is to.
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Set limits on the patient in a nonpunitive manner.
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(Schizophrenia) A client newly diagnosed with paranoid schizophrenia tells the nurse, “there are really strange people in the corner of my room laughing at me and saying horrible things. Which response by the nurse is most appropriate?
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I don’t hear any voices, but I know this is frightening for you.
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(Conversion Disorder) Which nursing approach is best when caring for a client diagnosed with conversion reaction paralysis?
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Minimize the sick role and secondary gains.
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(Schizophrenia) The nurse understands which as the primary problem experienced by the client diagnosed with Schizophrenia.
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Difficulty forming relationships.
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(ECT) When caring for a patient after ECT, it is most important for the nurse to take which of the following actions?
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Remind the patient that memory loss is temporary.
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(Diabetes Mellitus) The nurse instructs the client recently diagnosed with type 1 diabetes about proper meal planning. which action should the nurse take first?
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Obtain a diet history that includes the client’s favorite foods and usual meal patterns.
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(Thyroidectomy) The nurse cares for a client immediately after a thyroidectomy. it is most important for the nurse to contact HCP if which is observed?
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Change in quality of respirations.
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(Hyperglycemia) The nurse identifies the treatment of choice for severe ketoacidosis in a conscious person is which?
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Insulin
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(Diabetes Mellitus) In prep for discharge, a nurse reviews the diabetic exchange list with a client diagnosed with type 1 diabetes. The nurse informs cline that a sandwich made with two slices of whole wheat bread, one slice of turkey, 1 tsp of mayonnaise, and two lettuce is the equivalent of which exchanges?
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2 bread exchanges, 1 meat exchange, 1 fat exchange, and 1 vegetable exchange.
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(Oral Hypoglycemics) A client diagnosed with type 1 diabetes asks the nurse why a pill for diabetes can’t be taken. which best describes the action of oral hypoglycemic agents?
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They stimulate beta cells in the pancreas to release endogenous insulin.
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(DKA) the nurse recognizes which symptoms are characteristic of impending diabetic ketoacidosis?
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Hot, dry, flushed skin, excessive thirst, rapid pulse.
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(Diabetes Insipidus) The nurse cares for a client with diagnosed with Diabetes Insipidus. The HCP prescribes vasopressin. The nurse determines that the medication is effective if which observation is made?
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The clients specific gravity is 1.015.
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(transfusion Reaction) the nurse cares for a client receiving a blood transfusion. The nurse observes which symptoms if fluid overload occurs during the transfusion?
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Increased pulse rate, increased BP, Increased respirations.
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(Blood Admin) Following the transfusion of one unit of packed red blood cells, the nurse prepares to administer another unit. Which action is most appropriate for the nurse to take initially?
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Check the type and cross-match with another nurse.
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(I&O) The nurse evaluates a client’s fluid balance. Which finding most likely requires an intervention?
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Output is 800 mL less than intake.
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(Brain Tumor) A young woman receiving chemotherapy for a brain tumor suddenly becomes angry and irritable with the staff. When the nurse tries to administer the client’s medications, the client throws a tray across the room and curses. Which action by the nurse is most appropriate?
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Remain with the client and call for help.
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(Chemotherapy) The nurse cares for a client with stomatitis due to chemotherapy. Which action is most important for the nurse to include in the client’s plan of care?
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Examine the client’s mouth for blisters, sores, or drainage.
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(Brachytherapy) Prior to insertion of a cervical radioactive implant, enemas are prescribed for the client. The nurse understands enemas are prescribed for which reason?
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Decrease the chance of the implant becoming dislodged.
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(Therapeutic Comm) On the evening before a scheduled lung biopsy, a clients says to the nurse, do you think I have cancer? which response by the nurse is most appropriate?
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You sound worried about what they might find tomorrow.
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(Tele-therapy) The home care nurse visits a client undergoing external radiation for treatment of lung cancer. It is most important for the nurse to include which of the following interventions in the clients plan of care?
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Use a patting motion to dry the irradiated area.
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(Kidney Injury) The client is admitted to the hospital with a diagnosis of acute kidney injury. The nurse understands which explanation is the most accurate description of the client’s condition?
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A sudden loss of kidney function due to failure of the renal system circulation or to glomerular or tubular damage.
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(Urinary Cath) The nurse notes that a patient with a foley catheter complains of discomfort, has a moderately distended bladder, and has had 20 ml of urinary drainage in the past hour. What is the first action the nurse should take?
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Inspect the catheter tubing.
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(Peritoneal Dialysis) When preparing a patient for peritoneal dialysis, which of the following nursing actions should be taken first?
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Warm the dialysate.
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(Specimen Foley) Which of the following approaches describes the correct technique for the nurse to obtain a urine specimen from a patient who has an indwelling foley catheter?
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clamp the drainage tube below the port, using a sterile needle, aspirate a specimen of urine via the port.
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(Peritoneal Dialysis) During PD, a patient suddenly begins to breathe more rapidly. Which of the following actions should the nurse take first?
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Elevate the HOB.
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(Cystoscopy) An older male patient complains to the physician of urinary frequency, urgency, and dysuria. A cystoscopy is performed. After the cystoscopy, which of the following nursing actions has the highest priority?
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Obtain the patient’s vital signs.
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(Mid stream Urine) The home care nurse visits a client reporting symptoms of a UTI. The nurse is ordered to obtain a midstream urine specimen. On arrival to the home, the client states they collected the specimen 2 hours ago and left it sitting in the bathroom. Which action by the nurse is best?
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Discard the specimen and obtain a new one.
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(Turp) A patient has a TURP of the prostate. Twenty-four hours later, the nurse notices that the patient’s urine is bright red. which of the following nursing actions is most appropriate?
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Contact the Physician.
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(Dietary: Kidney) The nurse understands which is the goal of a diet for clients with CKD?
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Lowered intake of protein to decrease BUN.
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(IVP) A patient is schedule to have an IVP. Which of the following information is most important for the nurse to obtain prior to the procedure?
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The patients history of allergies.
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(Urinary Incontinence) The home nurse cares for a client diagnosed with Alzheimer’s and urinary incontinence. when implementing the plan for urinary habit training, which of the following actions should the nurse take first?
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Establish the client’s voiding pattern.
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(Urolithiasis) The nurse cares for a patient complaining of sudden onset of severe right flank pain. the patient is diagnosed with urinary calculi. Which of the following nursing actions has the highest priority?
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Strain all urine through several layers of gauze.
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(Urinalysis) Which of the following urine outputs best indicates to the nurse that a patients kidneys are function normally?
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1,500 ml in 24 hour.
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(DDH) The nurse cares for the newborn diagnosed with DDH. The nurse expects which method of treatment to be used for the newborn.
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Pavlik Harness.
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(G&D: Preschool aged) The 5 1/2 year old child comes to the clinic for a routine exam. the parent reports that the child likes to jump and climb, questions everything, and is often observed interacting with an imaginary best friend. the nurse should advise the parent to take which action?
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Allow the child to engage in imaginary play.
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(Myelomeningocele) The nurse plans care for the infant diagnosed with a myelomeningocele. Which principle of nursing care is most important to apply when caring for this infant?
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Asepsis.
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(G&D: Preschool aged) The nurse observes the five year old playing with several other children about the same age. The nurse identifies which pay activity as the one in which the child is most likely to engage?
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Playing with a toy telephone and imitating the doctor.
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(Immunizations) The parents brings the 6 month of baby to the clinic for a check up. the parent reports the baby had a check up at 2 months of age and received first dtap. which action is most appropriate?
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Give second Dtap.
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(G&D: 7 Year old) Which guideline is appropriate for the nurse to give a mother concerning the development age of her 7 year old.
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The child’s periods of shyness should be tolerated.
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(CF) the nurse performs a home care visits for the child diagnosed with cystic fibrosis. the nurse should intervene if which finding is observed?
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The child takes the pancreatic enzymes one hour after eating.
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(Parent-Child) To prevent parent-child disturbances the nurse should complete which action?
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Discuss with the parents any problems or fears about child bearing that they may have.
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(Heart Defect) The 6 month of baby has cyanotic congenital heart defect. the nurse knows that a CHD is associated with which symptom?
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Clubbing of the fingers.
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(Thermal Injury) The 4 year old child was crying near the fireplace when the clothing caught fire and enveloped the child in flames. the nurse was in the home which action should the nurse take first?
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Push the child to the ground and make the child roll.
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(Otitis Media) The parent of the child diagnosed with frequent acute otitis media asks the nurse why this keeps happening to the child. the nurse’s response should be based on which explanation?
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Children have shorter auditory, or Eustachian tube.
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(G&D: 5 year old) The nurse cares for clients in the pediatric clinic. the nurse should investigate which child for a possible speech impairment?
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5 year old who uses single words.
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(Myelomeningocele) The 3day old infant is born with myelomeningocele. the nurse caring for the neonate should place the infant in which position?
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Prone.
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(G&D: 9 month old) The infant is able to assume a sitting position, plays peek a boo, and is starting to say mama and dada. The nurse identifies that these behaviors are characteristics of which age?
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9 months.
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(Varicella) The nurse counsels the parent of a 12 year old diagnosed with chickenpox about when the child can return to school. the nurse determines that teaching is effective if the parent makes which statement?
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My child can return to school when the lesions are crusted.
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(separation anxiety) which action should the nurse take to minimize separation anxiety experienced by a toddler?
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Keep toys from home in the bed with the child.
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(G&D: School-Aged) The school nurse assesses the physical development of school-age children. which is the most valuable tool for this assessment?
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The weight and height compared to standard tables.
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(Myelomeningocele) Prior to surgery to myelomeningocele, which action should the nurse perform to care for the area of the defect?
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Apply a moist, sterile dressing.
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(Thermal Injury: Nursing Care) The 4year old child sustains a deep partial-thickness burn. Based on an understanding of G&D, the nurse anticipates which hospital experiences will probably be the most upsetting to the child?
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Intramuscular Injections.
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(Cystic Fibrosis) The nurse instructs the parents of a 7year old child diagnosed with cystic fibrosis about required dietary modifications. which adjustment is likely to be made in a normal diet?
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Increased Protein.
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(Down Syndrome) The nurse counsels the parents of a child with Down’s syndrome. Which statement if made by the parents to the nurse, indicated further teaching is necessary?
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My Child’s development will become more rapid in time.
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(Poisoning) The neighbor of the nurse comes running to the nurse’s house saying I just found my 2 year old in the kitchen surrounded by several bottles of cleaning solutions and the bottles are all open. Which action by the nurse is best?
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Call the poison control center.
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(17 month Child) The 17 month old child sucks a thumb, especially at night when quieting for sleep. which suggestion by the nurse is best?
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Don’t intervene, it will subside. The behavior usually peaks at 24 months.
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(Croup) The 3 year old child is seen in the local clinic for croup. the childs parent asks the nurse what to do for the child at home to alleviate symptoms. Which suggestion by the nurse is most appropriate?
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(Look at Quiz let) Stand with your child in front of an open freezer.
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(G&D: Adolescence) The nurse interviews a 15 year old client. The nurse is most concerned if the adolescent makes which statement?
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I don’t perspire like other kids.
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(Pregnancy and Type 1 Diabetes) A 25 year old primigravida diagnosed with type1 diabetes mellitus reviews insulin regimen with the nurse. The nurse reinforces the importance of regular prenatal care and explains changes in insulin requirements will include which of the following?
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Insulin requirements will increase during pregnancy and decrease after delivery.
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(Exercise during pregnancy) A woman comes to the clinic pregnant with her second child. She questions the nurse about the amount of exercise that is acceptable for her to perform during her pregnancy. Which of the following is the most important response by the nurse?
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What is your usual type of exercise
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(Abdominal Hysterectomy) The nurse prepares a client for an abdominal hysterectomy. The client asks why she has to have a foley catheter. Which statement by the nurse is most appropriate?
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This will allow you to heal by keeping your bladder decompressed.
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(Postpartum) The nurse cares for the client immediately after a normal vaginal delivery. Which action should the nurse take first?
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Palpate fundus, Observe lochial flow.
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(Dietary Iron) The woman tells the nurse that she has always had a heavy menstrual flow and needs extra iron. The nurse should recommend the client eat which food?
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Chicken Livers.
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(Prenatal Nutrition) By her fifth month of pregnancy, a 32 year old multipara of average prenatal height and weight has gained 14 pounds. Which of the following actions by the nurse is most important?
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Inform the client her weight gain is appropriate and she should continue on her present diet.
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(Prenatal Nutrition) The nurse instructs a client in the prenatal clinic about nutrition during pregnancy. The nurse determines teaching is successful if the client selects which of the following foods from a menu?
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Two eggs and 8 oz of milk.
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(Rupture of membranes) A woman is in active labor when her membranes rupture. She expresses a concern to the nurse she is afraid of having a dry labor. which of the following responses by the nurse is most appropriate?
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Amniotic fluid does not function as lubrication for the labor process.
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(RH) The nurse cares for clients in the prenatal clinic. The nurse identifies which of the following pregnant women as most likely to have a problem with Rh incompatibility with her fetus?
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An Rh-negative woman who conceived with a Rh-positive man and who has Rh antibodies.
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(Brachytherapy) Which of the following measures is most effective in protecting the nursing staff from harmful exposure to radiation when caring for a patient with a radiation implant?
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Rotate the staff members assigned to the patient.
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(Choking) The school nurse attends a soccer game at the local high school. The nurse notes a pregnant woman has grabbed her throat, indicates that she is choking, and is unable to speak. Which of the following actions, if taken by the nurse is best?
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The nurse stands behind the woman and performs chest thrusts.
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(Preterm Infant) The parents of a preterm infant visit the infant in the newborn nursery. They see their infant resting comfortably in the isolette and express concern about disturbing the baby. Which of the following responses by the nurse is best?
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Preterm infants need to develop a sense of trust and security and holding the infant promotes this.
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(Palpate) The nurse observes a staff member palpate uterine contractions. The nurse determines the staff member is using the correct technique if which of the following is observed?
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Place one hand on the abdomen over the fundus and with the fingertips press gently.
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(Circumcision) After a newborn circumcision, the nurse should take which of the following actions?
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Apply petroleum gauze and observe carefully for bleeding.
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(Newborn) The nurse performs a home care visit on a mother who delivered a baby three days ago. The client expresses alarm when she hears that her baby has lost 8 oz. which of the following responses by the nurse is most appropriate?
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That is a normal weight loss. Sometimes babies lose as much as 10% of their birth weight.
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(Brachytherapy) The nurse prepares a client for placement of internal radiation. The nurse understands the client will receive an indwelling foley catheter and a tap water enema for which of the following reasons?
answer

Prevent displacement of the implant.
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(Therapeutic Comm) On the evening before a modified radical mastectomy a 29 year old patient tells the nurse she is afraid that her husband will not find her sexually attractive if her breast is removed. Which of the following responses by the nurse is best?
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Youre worried about how he’ll react to the change in your body.
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(Diabetes Mellitus) The home care nurse makes a home visit to a client diagnosed with type 1 diabetes at 29 weeks gestation. The client states that she has been nauseated for 24 hours. It is most important for the nurse to ask which question?
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Have you taken your insulin today?
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(Rupture of membranes) A woman comes to the hospital in labor. Her membranes rupture at 4:10 am. Which of the following actions should the nurse take first?
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Observes for a prolapsed cord or meconium-stained fluid.
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(Prophylactic Eye Drops) In the delivery room, the nurse places drops in a newborn’s eyes. The nurse explains to the mother the drops.
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Protect against infections that could lead to blindness.
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(NG Tube) The nurse cares for a client with a nasogastric tube in place. The client reports discomfort in the back of the throat. Which action by the nurse is best?
answer

Spray with viscous lidocaine solution.
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(Low protein diet) A client is scheduled for bowel surgery, and the HCP orders a low-residue diet as a part of the bowel prep. The nurse instructs the client about foods allowed on a low-residue diet. The nurse determines the teaching is effective if the client chooses which menu?
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Roast lamb, buttered rice, and sponge cake.
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(Cirrhosis) The nurse identifies which diet best meets the nutritional needs of a client diagnosed with cirrhosis?
answer

High in protein and high in Carbs.
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(Colonoscopy Care) The nurse performs preop teaching for a patient scheduled for a colostomy. The nurse explains to the patient that 24 hours after the surgery the colonstomy drainage will be which of the following?
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A scant amount of bright bloody drainage.
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(NG Tubes) The nurse understands the most common reason for insertion of a nasogastric tube in a post op client diagnosed with a duodenal ulcer includes which reason?
answer

Decompress the stomach.
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(colostomy care) The nurse cares for a patient after the physician performed a sigmoid colostomy due to cancer. The nurse instructs the patient about how to care for the stoma. The nurse knows that teaching is successful if the patient makes which of the following statemenet?
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I will clean around the stoma with soap and water and pat dry.
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(Gastroenteritis) The nurse performs a home care visit on a client with a diagnosis of right-sided cerebrovascular accident. The clients spouse complains about having frequent loose stools, and the physician diagnosed viral gastroenteritis. The nurse is most concerned if which of the following is observed?
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The Spouse prepares lunch for the client.
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(Immunity) the spouse of a client with Hep B is given Hep B immune globulin. The nurse understands this offers which type of protection?
answer

passive acquired
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(Hep A) The school nurse is informed that a sixth grader in the school has been diagnosed with Hep A. it is most important for the nurse to teach the parents of the classmates to observe the children for what?
answer

Fatigue.
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(Cirrhosis) The nurse obtains a history from a client suspected of having cirrhosis. which statement, if made by the client to the nurse, should the nurse recognize as most directly to a client’s development of cirrhosis?
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I have been drinking a fifth of vodka a day for the last few months.
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(Colostomy Care) The nurse on the surgical unit cares for several clients with new colosotomies. Immediately after surgery, the nurse identifies which of the following stomas is expected?
answer

Beefy-red
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(Suction Trach) The nurse observes a student nurse suction the right bronchus of a patient via the tracheostomy. The nurse determines care is appropriate if the student nurse places the patient head in which position?
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The patients head turned to the left.
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(COPD) the nurse obtains a history from a man admitted with COPD. The nurse identifies which of the following factors is related to patient developing COPD
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The patient smoked for more than 30 years.
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(TB) The nurse cares for a patient diagnosed with active TB. which of the instruction should the nurse give the patient about follow-up care after discharge from the hospital?
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We would like you to come to the clinic monthly to check the effects of the medication you are taking?
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(Thermal Injury) A patient is admitted to the hospital after sustaining severe electrical burn. A trach is performed, and the patient is unable to use either hand. It is most important for the nurse to take which of the following actions?
answer

Obtain a blow-touch call bell.
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(Asthma) The nurse performs teaching for a client diagnosed with asthma. The nurse determines further teaching is necessary if the client makes which statement?
answer

Im going to have to establish a regular bedtime routine.
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(TB) A patient is started on rifampin and isoniazid. Which of the following explanations concerning these meds is most appropriate for the nurse to give?
answer

You will have to take this medicine about a year.
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(Choking) An adult is eating lunch and suddenly starts to choke, gasp for breath, and grab the throat. which of the following actions should the nurse take first?
answer

Ask the patient to speak.
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(Acute laryngo) The ped nurse cares for a 3 year old child diagnosed with acute laryngotracheobronchitis in a coupette. The nurse is most concerned is which of the following is observed?
answer

The grandmother gives the child a teddy bear.
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(Trach) A patient requires an emergency trach. When caring for the trach the nurse should take which of the following actions?
answer

clean the siteevery four hours.
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(Parkinson’s Disease) the nurse instructs the family of a patient diagnosed with Parkinsons. Which of the following statements by the family reflects a need for further education?
answer

We will buy lots of soup for dad.
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(Head Injury) The nurse in the ED admits patients from a multicar accident. which of the following patients should nurse see first?
answer

Clear fluid draining from the right ear.
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(Meniere’s Disease) The nurse finds a client diagnosed with Meniere’s disease leaning over the sink in the room and clutching it with both hands. After determining that the client is having an acute attack, which action should nurse take first?
answer

Help the clinet back to bed and place pillow on either side of clients head.
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(Coma) The nurse cares for a client with a GSC of 7. The nurse identifies it is most important to give eye care to this patient for which reason?
answer

To prevent corneal irritation.
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(Meniere’s Disease) The nurse cares for a patient diagnosed with MD. The nurse expects the patient to exhibit what?
answer

Vertigo, hearing loss, tinnitus.
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(Sensory Dep) The nurse plans care for an elderly patient recently admitted for acute pulmonary edema. The nurse understands which of the following nursing assessments is most important to prevent the patient from experiencing sensory dep?
answer

Assess support system for the family.
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(Parkinson) Which of the following nursing goals is most realistic and appropriate in planning care for a patient with Parkinson.
answer

Maintain optimal function within the patients limitations.
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(Bell’s Palsy) The nurse instructs a clinet diagnosed with bell’s palsy. it is most important for the nurse to make which statement about nighttime care?
answer

Apply an eye shield over the affected eye.
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(Thrombophlebitis) Which of the following nursing measures is most effective for preventing thrombophlebitis for a patient while on bedrest?
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Instruct the patient to flex and point his toes every two hours.
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(Cirrhosis) The client with alcoholic cirrhosis is at great risk to develop which complication?
answer

Epistaxis.
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(Eye Infection) A patient is treated for an infection involving the left eye. The prescribed meds include eye drops and antibiotic ointment. When apply ointment it is most important for nurse to take which action?
answer

Avoid touching the eyeball with the tip of the tube.
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(Eye Medication) The nurse identifies that which of the following approaches is the proper technique for eye drop instruction?
answer

Instruct patient to look up, retract lower eyelid, and instill drops.
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(Blindness) The nurse identifies which environmental factor is most helpful to maintain independence for a client who is blind?
answer

The furniture in the room consistently arranged.
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(Eye Trauma) The nurse cares for clinets in outpatient clinic. I think I have a piece of glass in my eye.
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Cover the eye with a protective shield.
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(Eye Infection) Protect vision from further injury?
answer

Prevent cross contamination between the eyes.
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(Otitis Media) A client is seen in clinic for otitis media. Directly related to development?
answer

Cold two weeks ago.
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(Snellen Chart) Purpose?
answer

Assess visual acuity.
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(Detached Retina) Take which action?
answer

Maintain bedrest.
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(Mastoidectomy) The patient has difficulty drinking without drooling. Take which action?
answer

Check the patients ability to whistle
question

(Anemia) the nurse learns the client lives in a two story house, and the bedrooms are on second floor. most important to ask what?
answer

Where do you plan to sleep?
question

(Iron Deficiency Anemia) Teaching is effective if the client selects which menu?
answer

Flank steak, green leafy vegetables, and prunes.
question

(Hemophilia) Diagnosed with hemophilia bumps his knee and develops painful swelling of the knee. In caring for the client which action is best?
answer

Apply ice to the knee and elevate the leg.
question

(Hemophilia) Parent crying child will bleed to death. Tell what information.
answer

Availability of replacement therapy of clotting factors.
question

(Schilling Test) Know before starting the test?
answer

How to collect a 24 hour urine.
question

(Cast Care) Three hours after arriving, client complains about a hot feeling under cast. Which action is best?
answer

Check the circulation and change the patient’s position.
question

(RA) Which finding for RA highest priority?
answer

Slight contracture of the right wrist.
question

(Amputation) Care for limb at home.
answer

Expose the residual limb to air.
question

(Total Hip Arthroplasty) Intervene if what is observed?
answer

Heels are lying on bed with toes pointed upward.
question

(RA) Most appropriate with RA?
answer

Assist with heat application and ROM
question

(Cast Care) Muscles strong during time the cast is on?
answer

Ill teach you how to do isometric exercises.
question

(Aspirin) Adminsiter with what?
answer

A glass of milk.
question

(Total Hip Arthroplasty) Place left leg in what position?
answer

Abducted with toes pointing upward.
question

(Cast Care) Newly applied plaster cast to le.
answer

elevate the leg on pillows and leave cast open to air.
question

(Amputation) Immediate prosthetic fitting. Plan of care?
answer

Provide cast care of affected extremity
question

(RA) Difference RA and OA?
answer

RA is systemic and OA is not.
question

(Amputation) Type 1 diabetes right BKA so extensive?
answer

A BKA results in better circulation and healing.
question

(OA) Spouse makes what statement?
answer

I can tell my husband has been worrying because he is wringing his hands.
question

(Nasogastric Tube Insertion) – To ensure correct placement of the endotracheal tube
answer

Verify placement by evaluating gastric aspirate. Aspirate should have a pH of 4 or less
question

Signs of gout
answer

Joint pain, swelling, limitation of movement, contractures deformities and nodules over bony prominences
question

(Hearing Impaired Patient) To enhance the patients ability to understand you, it is most important to….
answer

position self directly in front of client then converse in a well-lit, quiet room, speaking clearly and slowly, do not shout.
question

(Measles Incubation) Incubation period before someone exposed to measles will start exhibiting signs…..
answer

10-20 days
question

(Intravenous Pyelogram) Client education: pre-procedure
answer

NPO after midnight
question

Thyroidectomy: Nursing responsibilities
answer

Administer humidified air to promote easier respirations and promote secretions
question

(Croup) Treatment
answer

A warm, moist environment for the child created by running the shower until the bathroom fills with steam
question

(Injection) Intramuscular – IM technique
answer

Insert needle, aspirate, if no blood showing inject med slowly
question

(Angina Pectoris): What to do first
answer

Take an EKG before administering nitroglycerin or other nitrates
question

(Breast Examination) Technique
answer

Looking in mirror, first with arms at side, then with arms above head and finally with arms on hips look for dimpling or retractions, changes or discharge. Lying down palpate breasts to detect unusual growths
question

(Immunization) Tetanus
answer

If patient steps on a rusty nail 6-1/2 years after getting a tetanus immunization the patient would get the tetanus toxoid booster because the rusty nail is considered a “dirty” wound
question

(Tracheostomy) Care
answer

Rinse with sterile water and dry. Care should be performed Q8hrs and PRN.
question

(Laryngectomy) Results in…
answer

With a partial laryngectomy the patient retains the ability to speak. With a total laryngectomy the patient loses the ability to speak and smell

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