HURST Readiness Exam Practice Review Test.

HURST Readiness Exam Practice Review Test. A 40 year old client reports a diminished ability to visually focus on close objects and has also noticed a need for a well lit environment to enhance vision. To what would the nurse attribute these changes? a. normal changes associated with aging b. a cataract is forming c. symptoms of a brain tumor d. precipitated by diabetic retinopathy - CORRECT ANSWER a. normal changes associated with aging Rationale: aging results in stiffening of the lens, thus lessening the ability to focus. The retina is less sensitive to light, making accurate vision in low-light situations more difficult. Pupillary response diminishes, affecting the ability to adjust to changing light levels The nurse is assessing pain after surgery in a 3 year old client with a known developmental delay. Which pain scale should the nurse use to assess this client's pain level? a. CRIES scale b. numeric scale c. FLACC scale d. FACES scale - CORRECT ANSWER c. FLACC scale Rationale: The FLACC scale can be used for pediatric clients from age 2 months to 7 years and is appropriate when clients cannot communicate their pain A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What statement made by the client indicates that teaching has been effective regarding safe needle disposal? a. "I should wrap the needle in a paper towel and place in the trash." b. "I should use a hospital issued biohazard container for all needles." c. "I may use any hard plastic container with a screw-on cap." d. "I should take my needles to the nearest hospital for disposal." - CORRECT ANSWER c. "I may use any hard plastic container with a screw-on cap." Rationale: At home, an FDA approved sharps container is not needed, however, needles, syringes, and sharps may be disposed of in a hard plastic container. Clients should follow their community guidelines for sharps container disposal. This protects the sanitation engineers from injury by the sharps. The primary healthcare provider suspects the client has tuberculosis (TB) and prescribes a Mantoux test. What precautions should the nurse take when administering the Mantoux test? a. don sterile gloves b. place the client on reverse isolation c. wear a particulate respirator d. obtain a consent form e. initiate airborne precautions - CORRECT ANSWER c. wear a particulate respirator e. initiate airborne precautions Rationale: A disposable particulate respirator that fits snugly around the face is needed. The client needs to be on acid-fast bacilli (AFB) isolation precautions, not reverse isolation. Airborne precautions include a private room with negative pressure and a minimum of 6 air exchanges per hour. Ultraviolet lamps and high efficiency particulate air filters are also needed. A hysterical college student arrives in the emergency department in bloody soiled clothing. The nursing assessment reveals facial bruising and multiple contusions consistent with the client's report of being raped. Which initial nursing intervention takes priority at this time? a. notify police of the alleged rape b. allow the client privacy to wash self c. remove clothing and bag for evidence d. encourage client to express fears and anxiety - CORRECT ANSWER d. encourage client to express fears and anxiety Rationale: Although there are specific protocols that must be followed when dealing with rape clients, it is important to remember that this client had all control taken away during the attack. The emotional effects of rape are as traumatizing as the physical injuries. Allowing the client to first express emotions, such as fear or anxiety, returns a small amount of control to a situation in which the client has little or none. The nurse is caring for an adolescent client diagnosed with depression. The client is prescribed fluoxetine. What is the best response by the nurse when the client says, "What will this medicine do to me?" a. it will increase the level of serotonin in the brain b. it will decrease the production of noradrenaline c. it will lower your level of the brain hormone norepinephrine d. it will balance blood glucose and dopamine levels in your head - CORRECT ANSWER a. it will increase the level of serotonin in the brain Rationale: The action of fluoxetine is to increase the level of serotonin in the central nervous system. There is a correlation between a low level of serotonin and depression. The action of the drug should be explained to the adolescent in a manner that will be understood.