Exam (elaborations)

Concordia University TexasForm A 1. A nurse is caring for a client who states, “My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out.” The nurse should recognize the client is demonstrating which of the following defen

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NUR MISC

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Concordia University ( )

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Form A

1. A nurse is caring for a client who states, “My boss accused me of stealing yesterday. I was so
angry I went to the gym and worked out.” The nurse should recognize the client is demonstrating
which of the following defense mechanisms?
The client is exhibiting behaviors consistent with sublimation, which is displayed when a client substitutes
socially unacceptable behavior for acceptable behavior.

2. A nurse is caring for a client who has generalized anxiety disorder and is to begin taking
alprazolam. Which of the following actions should the nurse take?
The nurse should initiate fall precautions for a client who has a new prescription for alprazolam because
common adverse effects associated with this medication are orthostatic hypotension, dizziness, confusion,
and lethargy.

3. A nurse on a med-surg unit is caring for a client prior to a surgical procedure. Which of the
following findings should indicate to the nurse that the client has the ability to sign the informed
consent?
The ability of the client to accurately describe the upcoming procedure indicates that the provider
adequately informed the client and that the client is able to sign the informed consent form.

4. An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the
following actions by the AP requires the nurse to intervene?

The AP should place a pillow under the client's left arm to prevent internal rotation of the left shoulder.

5. The nurse should implement contact precautions for a client who has an infection spread by direct
contact, such as MRSA.

6. Using the evidence-based practice approach to client care, the nurse should identify that the priority
action is massaging the client's uterus. Uterine massage will expel clots and increase uterine firmness,
resulting in decreased bleeding.

7. The nurse should instruct the parent to secure the retainer clip at the level of the newborn's axillae.
The bones of the rib cage and sternum provide protection to underlying organs in the event of a
collision. Placing the clip on the abdomen increases the risk for injury to internal organs.

The nurse should instruct the parent to place a blanket over the newborn once secure in the car seat.
Blankets, coats, or heavy clothing can make it difficult to secure the shoulder harnesses tightly, leading
to injury in the event of a collision.

The nurse should instruct the parent that the newborn should remain rear-facing in the back seat of the
vehicle until the age of 2 or until reaching the age and weight the car seat manufacturer recommends.
In a collision, this position decreases the force on the newborn's head and neck.

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, The nurse should instruct the parent to place the newborn's car seat at a 45° angle. Newborns' heads
are large in proportion to their body and they do not have the muscle strength to hold their heads
upright.
8. When conducting a root cause analysis, the nurse should look at the factors that could possibly lead to
the clients' falls. This can include environmental factors that might be causing the problem.
9. The nurse's responsibility is to provide the client with information about specific instructions for
addressing medical treatment in a living will. The nurse should assist the client while they are able to
make decisions for themself by providing information about what end-of-life preferences to document.
10. Clients who have delirium exhibit rapid, inappropriate, incoherent, and rambling speech patterns.
Clients who have schizotypal personality disorder exhibit social awkwardness.
Clients who have dependent personality disorder demonstrate excessively clinging behavior.
Clients who have paranoid personality disorder project blame.
11. The greatest risk to this client is injury due to a fall. Therefore, the priority information for the nurse to
communicate is that the client requires assistance during transfers.
12. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the
priority finding is a boggy uterus, which can indicate uterine hemorrhage. The nurse should
immediately intervene to stimulate uterine contractions and prevent blood loss. If the uterus becomes
relaxed during the postpartum period, the client will rapidly lose blood because no permanent thrombi
have formed at the placenta.
13. The greatest risk to this client is injury from violence. Therefore, the first action the nurse should take is
to develop a safety plan with the client.
14. The nurse should anticipate administering flumazenil, a competitive benzodiazepine receptor
antagonist, to reverse the sedative effects of lorazepam. In addition, the nurse should continue to
support the client's respirations with a bag-valve mask.
15. Marking the edges of stairs with paint or colored tape for contrast can help older adult clients who have
impaired vision prevent injury by decreasing the risk of falls
16. The first stage of the change process is the unfreezing stage, when the nurse should inform the staff
about the current staffing issues. This can increase their understanding of why changes are necessary.
17. To prevent sunburns, guardians should apply sunscreen, dress their child in protective clothing, and
avoid sun exposure between 1000 and 1400.
18. The nurse should delegate the insertion of a nasogastric tube to the LPN because this task is within
the LPN's scope of practice.
19. The expected reference range for the axillary temperature of a newborn is between 36.5° C to 37.5° C
(97.7° F to 99.5° F). An axillary temperature of 36.2° C (97.2° F) or below in a newborn who is 2 hr old
indicates cold stress and should be reported to the provider.
20. The nurse should explain to the parent that newborns are deficient in vitamin K and should receive it
following birth because this deficiency can lead to bleeding.
21. The nurse should involve the client in the referral process, including selection of the physical therapist
and the location.
22. Diaphoresis is an expected finding of MDMA use. Additionally, the client might experience increased
tactile sensitivity, lowered inhibition, chills, muscle cramping, teeth clenching, and mild hallucinogenic
effects.
23. The nurse should place the BP cuff in a labeled bag before removing it from the client's room and
sending it to the proper facility location for decontamination.
24. Clozapine can cause agranulocytosis, which can be life-threatening. Therefore, a WBC count of less
than 3,000/mm3 is a contraindication for the client to receive clozapine. The nurse should withhold the
medication and notify the provider of the client's WBC count.
25. The adolescent should keep the catheter clamped to prevent blood backflow. Not all tunneled
catheters have a pressure-sensitive valve that prevents blood reflux.
26. The nurse should instruct the child to keep both eyes open during visual acuity testing.

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Exam (elaborations)

Concordia University TexasForm A 1. A nurse is caring for a client who states, “My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out.” The nurse should recognize the client is demonstrating which of the following defen

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