Senior Seminar Quiz 6 | Questions with 100% Correct Answers

Senior Seminar Quiz 6 | Questions with 100% Correct Answers The ED nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 1. Adhering to the mandatory abuse-reporting laws 2. Notifying the caseworker of the family situation 3. Removing the client from any immediate danger 4. Obtaining treatment for the abusing family member The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? 1. Incessant talking and sexual innuendoes 2. Grandiose delusions and poor concentration 3. Outlandish behaviors and inappropriate dress 4. Nonstop physical activity and poor nutritional intake The nurse is caring for a client who was involuntarily hospitalized to a mental health unit and is scheduled for ECT. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination in planning care? 1. The informed consent does not need to be obtained 2. The informed consent should be obtained from the family 3. The informed consent needs to be obtained from the client 4. The HCP will provide the informed consent A client newly diagnosed with DM is instructed by the HCP to obtain glucagon for emergency home use. The client asks a home care nurse about the purpose of the medication. What is the nurse's best response to the client's question? 1. "It will boost the cells in your pancreas if you have insufficient insulin." 2. "It will help to promote insulin absorption when your glucose levels are high." 3. "It is for the times when your blood glucose is too low from too much insulin." 4. "It will help to prevent lipoatrophy from the multiple insulin injections over the years.: The nurse is providing care to a Puerto Rican-American client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is the most appropriate nursing action for this client? 1. Restrict the number of family members visiting at one time 2. Inform the family that emotional outbursts are to be avoided 3. Make the necessary arrangements so that family members can visit 4. Contact the HCP to speak to the family regarding their behaviors A client presents to the ED with upper GI bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? 1. Assessment of vital signs 2. Completion of abdominal exam 3. Insertion of prescribed NG tube 4. Thorough investigation of precipitating events The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia? 1. Use of confabulation 2. Improvement in sleeping 3. Absence of sundown syndrome 4. Presence of personal hygienic care The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? 1. Engaging in immoral acts 2. Always reinforcing self-approval 3. Observing rigid rules and regulations 4. Having the need always to make the right decision The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions? 1. "Iron supplements will give me diarrhea." 2. "Meat does not provide iron and should be avoided." 3. "The iron is best absorbed if taken on an empty stomach." 4. "On the days that I eat green leafy veggies or calf liver, I can omit taking the iron supplement." Levothyroxine is prescribed for a client diagnosed with hypothyroidism. Upon review of the client's record, the nurse notes that the client is taking warfarin. Which modification to the plan of care should the nurse review with the client's HCP? 1. A decreased dosage of levothyroxine 2. An increased dosage of levothyroxine 3. A decreased dosage of warfarin sodium 4. An increased dosage of warfarin sodium A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure? 1. Side-lying with a pillow under the hip 2. Prone with a pillow under the abdomen 3. Prone in slight Trendelenburg position 4. Side-lying with the legs pulled up and the head bent down onto the chest A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan to respond to the client's statement? 1. Reassure the client that things will get better 2. Tell the client that this is not true and that we all have a purpose in life 3. Identify recent behaviors or accomplishments that demonstrate the client's skills 4. Remain with the client and sit in silence; this will encourage the client to verbalize feelings The nurse reviews the arterial blood gas results of an assigned client and notes that the lab report indicates a pH of 7.30, PaCO2 of 58 mm Hg, PaO2 of 80 mm Hg, and HCO3 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis The nurse has admitted a client to the clinical nursing unit after undergoing a right mastectomy. The nurse should plan to place the right arm in which position? 1. Elevated on a pillow 2. Level with the right atrium 3. Dependent to the right atrium 4. Elevated above shoulder level On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction? 1. "I need to urinate frequently throughout the day." 2. "The prescribed medication must be taken until it is finished." 3. "My fluid intake should be increased to at least 3000 mL daily." 4. "Foods and fluids that will increase urine alkalinity should be consumed." A client received 20 units of Humulin N insulin subQ at 8:00. At what time should the nurse plan to assess the client for a hypoglycemic reaction? 1. 10:00 2. 11:00 3. 17:00 4. 24:00 The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? 1. A pregnant woman who exclaims, "My baby is not moving." 2. A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" 3. A young child standing next to an adult family member who is screaming, "I want my mommy!" 4. An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead." A client with DM is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my HCP's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation? 1. An expected coping mechanism 2. An ineffective defense mechanism 3. A need to notify the hospital lawyer 4. An expression of guilt on the part of the client A client with terminal cancer arrives at the ED DOA. After an autopsy is prescribed, the client's family requests that no autopsy be performed. Which response to the family is most appropriate? 1. "The decision is made by the ME." 2. "An autopsy is mandatory for any client who is DOA." 3. "I will contact the ME regarding your request." 4. "It is required by federal law. Tell me why you don't want the autopsy done." A client who is positive for HIV delivers a newborn infant. The nurse provides instructions to help the client with care of her infant. Which client statement indicates the need for further instruction? 1. "I will be sure to wash my hands before and after bathroom use." 2. "I need to breast-feed, especially for the first 6 weeks postpartum." 3. "Support groups are available to assist me with understanding my diagnosis of HIV." 4. "My newborn infant should be on antiviral medications for the first 6 weeks after delivery." An adolescent client is diagnosed with conjunctivitis, and the nurse provides information to the client about the use of contact lenses. Which client statement indicates the need for further information? 1. "I should obtain new contact lenses." 2. "I should not wear my contact lenses." 3. "My old contact lenses should be discarded." 4. "My contact lenses can be worn if they are cleaned as directed." The nurse teaches a client newly diagnosed with type 1 DM about storing Humulin N insulin. Which statement indicates to the nurse that the client understood the discharge teaching? 1. "I should keep the insulin in the cabinet during the day only." 2. "I know I have to keep my insulin in the refrigerator at all times." 3. "I can store the open insulin bottle in the kitchen cabinet for 1 month." 4. "The best place for my insulin is on the window sill, but in the cupboard is just as good." The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preop teaching instructions should include which statement? 1. "Your hair will need to be shaved." 2. "You will receive spinal anesthesia." 3. "You will need to ambulate after surgery." 4. "Brushing your teeth needs to be avoided for at least 2 weeks after surgery." During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem? 1. "I will drink 8 oz of water with each meal." 2. "I will eat 3 servings of cracked wheat bread each day." 3. "I will eat 2 saltine crackers before I get up each morning." 4. "I will eat fresh fruits and veggies for snacks and dessert each day." A 6-year-old child has just been diagnosed with localized Hodgkin's disease, and chemo is planned to begin immediately. The mother of the child asks the nurse why radiation therapy was not prescribed as a part of the treatment. What is the nurse's best response? 1. "It's very costly and chemo works just as well." 2. "I'm not sure. I'll discuss it with the HCP." 3. "Sometimes age has to do with the decision for radiation therapy." 4. "The HCP would prefer that you discuss treatment options with the oncologist." An infant born with an imperforate anus returns from surgery after requiring a colostomy. The nurse assesses the stoma and notes that it is red and edematous. Based on this finding, which action should the nurse take? 1. Elevate the buttocks 2. Document the findings 3. Apply ice immediately 4. Call the HCP The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? 1. Document the findings 2. Arrange for hearing testing 3. Notify the HCP 4. Cover the ears with gauze pads The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice? 1. The nail beds 2. The skin in the sacral area 3. The skin in the abdominal area 4. The membranes in the ear canal The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan? 1. Ensure that the knots are at the pulleys 2. Check the weights to ensure that they are off of the floor 3. Ensure that the head of the bed is kept at a 45- to 90-degree angle 4. Monitor the weights to ensure that they are resting on a firm surface The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information? 1. Apply restraints to the client 2. Ask the family to stay with the client 3. Place a clock and calendar in the client's room 4. Ask the lab to perform electrolyte studies The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client?