NCLEX-PN 2 Flashcards

Terms Definitions
RSV- Causes
Panic attacks
Aspirin overdose
Trendelenburg Test determines
muscle weakness
Pulmonary Valve Stenosis- Tests
Cardiac catheterization
Chest X-ray
Pesco Vegetarian
eats seafood but excludes meat, poultry, eggs, and dairy products
The rebounding of the fetus against the examiner's fingers on palpation.
A client is experiencing problems with balance and fine and gross motor function. Identify that area of the client's brain that's malfunctioning.
When performing an assessment, the nurse collects the following data: impaired coordination, decreased muscle strength, limited range of motion, and the client's reluctance to move. This data indicates which nursing diagnosis?
Impaired mobility
Polio teaching
pt will have muscle weakness, rest periods will conserve energy
Fundal Height
A. Measured to evaluate gestaional age of fetus.
B. During 2nd & 3rd trimesters (18 to 30 weeks), fundal height in centimeters approx. equals the fetus's age in weeks, + or - 2 cm.
C. 14-16 weeks, fundus can be found above symphysis pubis
D. 20-22 weeks, fundus rises to level of the umbilicus.
E. At term, fundus nearly reaches the xiphoid proces.
The nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect what complication?
During labor, meconium in the amniotic fluid is a normal finding in which of the following situations?
Breech presentation
The physician prescribes a monoamine oxidase (MAO) inhibitor for a client. Which nursing diagnosis would be most appropriate to focus on during client teaching?
Risk for injury
When performing an abdominal assessment, the nurse should follow which examination sequence?
Inspection, auscultation, percussion, and palpation
The nurse notes that a client frequently coughs while eating. Which health team member should be notified of this finding?
Speech therapist
Identity vs role confusion
adolescence, 12-20 yrs of age, develops sense of identity
Nagele's rule
For estimating date of birth: To be accurate, woman must have regular 28 day menstral cycle.
Take 1st day of last menstral period: 9-12-2009
Add 7 days: 9-19-2009
Subtract 3 months: 6-19-2009
Add 1 yr.: 6-19-2010
Estimated date of birth: June 19, 2010
A 14-year-old client diagnosed with acne vulgaris asks what causes it. Which factors should the nurse identify for this client? Select all that apply:
Growth of anaerobic bacteria
The nurse is conducting a neonatal assessment of a baby boy, born 3 hours earlier. Which assessment would make the nurse suspect a congenital hip dislocation?
Unequal gluteal folds
A nurse on the pediatric floor is caring for a toddler. The nurse should keep in mind that toddlers:
express negativism.
A pregnant client who is older than age 35 is at increased risk for which pregnancy-associated complication?
Placenta previa
The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as:
A nurse is teaching clients in an outpatient clinic about monoamine oxidase (MAO) inhibitors. The nurse would best evaluate the clients' understanding of how their medications work by noting which of the following?
Food selections
A home health nurse is visiting a home care client with advanced lung cancer. While collecting data on the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?
Positive signs of pregnancy
1. Visualization of the fetus via radiography or ultrasound.
2. Fetal heart rate detected by ultrasound examination at 6 weeks' gestation, by electronic devices at 10 to 12 weeks' gestation, and by nonelectronic device (fetoscope) at 20 weeks' gestation.
3. Fetal movements palpated.
4. Fetal movements visible
The nurse is preparing to administer 4 units of regular insulin to a client with type 1 diabetes mellitus. Which supplies does the nurse need to perform the injection? Select all that apply:
27-gauge, <font face="LWWSYM">r</font><font face="LWWSYM">"</font> needle
The nurse is planning care for a 16-year-old client in the prenatal clinic. Adolescents are prone to which complication during pregnancy?
Iron deficiency anemia
A licensed practical nurse (LPN) is delegating responsibilities to a certified nursing assistant (CNA) on a busy postpartum unit. Which task can be delegated to the CNA?
Bottle-feeding a 24-hour-old neonate
An emergency department nurse suspects neglect in a 3-year-old boy admitted for failure to thrive. Signs of neglect in the child would include:
poor hygiene and weight loss.
The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point about preventing transmission of the human immunodeficiency virus (HIV) is most important for the nurse to stress?
Following safer-sex practices
Which nutritional instructions should the nurse provide to a 32-year-old primigravida client? Select all that apply:
Intake of all minerals, especially iron, should be increased.
Apgar score of 9
cyanosis of the hands and feet; score less than 10 is likely due to cyanosis
An inpatient psychiatric client suddenly becomes loud and visibly anxious. What's the best action for the nurse to take?
Say, "Let's go talk in your room."
Which of the following statements about external otitis is true?
External otitis is characterized by pain when the pinna of the ear is pulled.
A client develops a pulmonary embolism after total knee surgery and must be converted from heparin to warfarin (Coumadin) anticoagulant therapy. What should the nurse tell the client?
Prothrombin time (PT) and international normalized ratio (INR) will be periodically checked for dose adjustment.
The nurse is reviewing a postpartum client's care plan before discharge. Which factor is the most likely to interfere with this client's parental attachment?
Recent loss of a parent
A client tells the nurse that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check:
glycosylated hemoglobin level.
The human embryo grows at a very rapid rate. At what gestational age does a single-chambered heart begin to beat and pump its own blood cells through main blood vessels?
Approximately 24 days
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 rights should the nurse include in the discussion? Select all that apply:
Right to personal mail
The nurse and assistant must put a rigid, comatose client back into bed. The client is currently propped up in a reclining chair that doesn't have removable arms. What is the best way to return the client to bed?
Use a mechanical lift.
For a client with bulimia, which assessment is least important in the care plan?
Note changes in respiratory rate.
The nurse is caring for a client who's showing signs of hypoglycemia. This client will most likely have a blood glucose level:
below 70 mg/dl.
Which of the following is the most desirable position for a neonate with a congenital dislocated hip?
Prone position with hips abducted
For a client with an exacerbation of rheumatoid arthritis, the physician prescribes prednisone (Deltasone). When caring for this client, the nurse should monitor for which adverse drug reactions?
Weight gain, hypertension, and insomnia
The nurse provides care for a client receiving oxygen from a nonrebreathing mask. Which nursing intervention has the highest priority?
Assessing the client's respiratory status, orientation, and skin color
A neonate with a tracheoesophageal fistula is to undergo a repair. Postoperatively, which of the following nursing measures should be implemented first?
Change the client's position every 2 hours from the back to either side, keeping the head slightly elevated.
The nurse is teaching an elderly client about good bowel habits. Which statement by the client would indicate to the nurse that additional teaching was required?
"I need to use laxatives regularly to prevent constipation."
The client has just given birth to her first child, a healthy, full-term baby girl. The client is Rh<font face="LWWSUB">o</font>(D)-negative and her baby is Rh-positive. What intervention will be performed to reduce the risk of Rh in
Administration of Rh<font face="LWWSUB">o</font> immune globulin I.M. to the mother within 72 hours
The nurse is collecting data on a client who has been admitted to the emergency department. Which signs would suggest an overdose with an antianxiety agent?
Emotional lability, euphoria, and impaired memory
The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:
destroys the odor-proof seal.
The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:
rest in an air-conditioned room.
Which nursing diagnosis should the nurse expect to see in a care plan for a client in sickle cell crisis?
Acute pain related to sickle cell crisis
What should the nurse teach the parents of a child who's receiving methylphenidate (Ritalin)?
Monitor the child's growth closely because the drug may interfere with growth and development.
Which one of the following clients has the greatest risk for aspiration?
A stroke client with dysarthria
A client has received treatment for depression for 3 weeks. Which behavior suggests that the client is recovering from depression?
The client talks about the difficulties of returning to college after discharge.
The nurse is caring for an adolescent client who underwent surgery for a perforated appendix. When caring for this client, the nurse should keep in mind that the main life-stage task for an adolescent is to:
develop an identity and independence.
A client with cholecystitis is receiving propantheline bromide (Pro-Banthine). The client is given this medication because it:
inhibits contraction of the bile duct and gallbladder.
A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely to be evidence of ineffective coping?
Inability to make choices and decisions without advice
The nurse is administering preoperative sedation to a client going to the operating room for a aortobifemoral bypass. After administering preoperative sedation to the client, the nurse should:
place the bed in low position with the side rails up.
A client who sustained a closed head injury is deteriorating and the prognosis is poor. The client meets brain-death criteria. Which nursing intervention is most appropriate at this time?
Approach the client's family about organ donation.
The nurse is instructing a client about the use of antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:
forcing blood into the deep venous system.
When caring for a client who's being treated for hyperthyroidism, it's important to:
balance the client's periods of activity and rest.
A client in the first trimester complains of nausea every morning and asks about medicine to prevent it. What's the nurse's most helpful response?
"Let me tell you about some methods to control nausea without medication."
The nurse is caring for a client who has suffered a severe stroke. During data collection, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are:
progressively deeper breaths followed by shallower breaths with apneic periods.
While evaluating the needs of a client during the second trimester, the nurse can anticipate which of the following?
Increasing introspection but a general sense of well-being
The nurse is collecting data on a pregnant woman in the clinic. In the course of collecting data, the nurse learns that this woman smokes one pack of cigarettes a day. The first step the nurse should take to help the woman stop smoking is to:
assess the client's readiness to stop.
The nurse is caring for a 45-year-old male client admitted with a retinal detachment in his left eye. What symptoms would the nurse expect to find during assessment?
Flashing lights in the visual field
The mother of a hospitalized 3-year-old girl expresses concern because her daughter is wetting the bed. What should the nurse tell her?
It's common for a child to exhibit regressive behavior when anxious or stressed.
A client comes to the emergency department with chest pain. After an electrocardiogram shows a heart rate of 116 beats/minute with irregular beats, the client is admitted to the intensive care unit. Which nursing diagnosis is the priority?
Anxiety related to the threat of death
A client with seizure disorder is having a grand mal seizure. During the active seizure phase, the nurse should:
place the client on his side, remove dangerous objects, and protect his head.
When teaching the family of a client with schizophrenia, the nurse should provide which information?
Support is available to help family members meet their own needs.
The physician has told a client to check his pulse each morning before taking digoxin (Lanoxin). After the nurse teaches the client how to take a radial pulse, what client behavior indicates an accurate understanding of the technique?
The client uses his middle three fingertips to palpate the radial artery.
The nurse is talking with a client who recently attempted suicide. The client asks her not to tell anyone one about their conversation. How should the nurse respond?
"I'll need to share information with the rest of your health care team if it's important to your care."
Before forcing a client to take a medication, the nurse should give priority to which of the following?
The client's danger to self or others
The nurse is caring for a client undergoing I.V. antibiotic therapy with gentamicin sulfate. Which of the following interventions is most important?
Monitor blood urea nitrogen (BUN) and creatinine levels, throughout the course of therapy
A 76-year-old widowed mother of six is admitted to a long-term care facility with a diagnosis of organic mental disorder. Which of the following approaches would be most helpful for the nurse in meeting the client's needs?
Simplify the environment as much as possible.
A client is recovering from a stroke and will be discharged in a few days. When helping to develop this client's discharge plan, the nurse should include which intervention?
Discuss home care needs with the client before the day of discharge.
The nurse is collecting data on a newly admitted client. When filling out the family assessment, who should the nurse consider to be a part of the client's family? Select all that apply:
All people the client views as family
Which of the following would be most important to include when teaching home management of a child with hemophilia?
Toothbrushes should be held under warm water before use.
A nurse working in a senior center encounters a client who recently lost his spouse as well as several friends and family members. What is the best way for the nurse to assist the client?
Encourage the client to participate in grief counseling.
A client is admitted to the hospital with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn't answered immediately. The most appropriate response to her would be:
"You seem angry. Would you like to talk about it?"
Which statement about somatoform pain disorder is accurate?
The pain is real to the client, even though there may not be an organic etiology for the pain.
The nurse is teaching parents about accident prevention for a toddler. Which of the following guidelines is most appropriate?
Make sure all medications are kept in containers with childproof safety caps.
The nurse is caring for a client experiencing an anxiety attack. Appropriate nursing interventions include:
staying with the client and speaking in short sentences.
The client most at risk for sensory overload is:
an 80-year-old client in the intensive care unit (ICU).
The nurse is caring for a client with diabetes mellitus. When teaching the client about foot care, which instruction should the nurse provide?
Avoid hot water bottles and heating pads.
The nurse is caring for a client who was given pain medication before leaving the postanesthesia care unit. Upon returning to her room, the client complains of pain and requests more pain medication. Which is the best action for the nurse to take?
Notify the physician that the client is continuing to complain of pain.
Which of the following concepts about anorexia nervosa should the nurse consider in understanding a client's cry for help?
Rejection of food as a way to obtain love and care from parents
A 37-year-old man with a history of schizophrenia is having hallucinations. He shouts to the nurse, "You're stepping on spiders! Move aside. Don't you see them?" What's the nurse's best response?
"No, I don't see them, but I believe that you do see them."
The nurse is teaching a client about breast self-examinations. The client asks if she should have an annual mammogram. According to the American Cancer Society, how should the nurse respond?
All women over 40 years of age should have an annual mammogram.
As a nurse is talking to a client, the client begins choking on his lunch. He's coughing forcefully. The nurse should:
stay with him but not intervene at this time.
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