NCSBN

A client is admitted with low T3 and T4 levels and an elevated thyroid stimulating hormone (TSH) level. On initial assessment, the nurse should anticipate which of these findings? A. Lethargy B. Diarrhea C. Heat intolerance D. Skin eruptions A In hypothyroidism the metabolic activity of all cells of the body decreases, reducing oxygen consumption, decreasing oxidation of nutrients for energy, and producing less body heat. Therefore, the nurse can expect the client to report being const...

The nurse is admitting a client who is newly diagnosed with a frontal lobe brain tumor. Which statement made by a spouse may provide important information about this diagnosis and should be communicated to the health care provider? "It seems our sex life is nonexistent over the past six months." "His breathing rate is usually below 12." "I find the mood swings and the change from being a calm person to being angry all the time hard to deal with." "In the morning and evening he...

An 18 month-old weighing 22 pounds is admitted to the pediatric unit with a diagnosis of dehydration. A replacement bolus of normal saline at 20 mL/kg is ordered to be administered intravenously over 40 minutes. In mL/hour, what will be the setting for the IV delivery system? 300 Using ratio proportion:First, convert 22 pounds to kilograms (22/2.2) = 10 kg20 mL/kg = 20 x 10 kg = 200 mL200 mL/40 minutes = x mL/60 minutes (in an hour)200 x 60 = 12000/40 = 300 mL/hrUsing dimensional analysis:2...

It is the start of the shift and the nurse has just finished listening to a report on four clients. Which client should the nurse assess first? A. A client with a diagnosis of an acute traumatic brain injury who has a blood pressure of 88/58 B. A client with a diagnosis of a concussion and who doesn't remember the motor vehicle accident C. A client diagnosed with viral meningitis and has signs of meningeal irritation D. A client diagnosed with generalized seizures who complains of a heada...

How can you identify your patient? Name Date of birth MR number NOT Room number R.A.C.E R: Remove and rescue patients A: Activate fire alarm C: Contain fire E: Extinguish Restraints If a client can easily remove the device, it does not qualify as a physical restraint. A provider order for restraints can never be written in advance for "what if" situations or "as needed" (i.e., PRN). Always attempt to use the least restrictive form of restraint and/or safety devic...

The nurse is coordinating care for a postpartum client and her newborn with the unlicensed assistive personnel (UAP). The mother is human immunodeficiency virus (HIV) positive. The nurse would recognize the need to educate the UAP, who is observed doing which of the following actions? A. Assist the mother who is attempting to breastfeed her baby B. Place the infant on his or her back in the bassinet C. Wear gloves while changing the newborn's soiled diaper D. Assist the mother to walk to ...

The nurse is providing discharge teaching for a client with a long leg cast. During instructions, the nurse should recommend which of these exercises for the affected extremity? A. Aerobic B. Range of motion C. Isometric D. Isotonic C A nurse should instruct the client on isometric exercises for the muscles of the casted extremity. This means the client should be instructed to alternately contract and relax muscles without moving the affected part. The client should also be instructed ...

A client is admitted with a diagnosis of myocardial infarction (MI) and reports having chest pain. The nurse provides care based on the knowledge that pain associated with an MI is related to which of the following findings? A. Insufficient oxygenation of the cardiac muscle B. Fluid volume excess C. Arrhythmia D. An electrolyte imbalance A Due to ischemia of the heart muscle, the client will experience pain. This happens because destroyed myocardial tissue can block or interfere with t...

A nurse is teaching a mother who will breast-feed for the first time. Which of these approaches is a priority? Give the mother privacy for the initial feeding Assist the mother to position the newborn at the breast Give the mother several illustrated pamphlets Show the mother films on the physiology of lactation Assist the mother to position the newborn at the breast All of the approaches should be helpful in teaching. However, the priority is to place the infant to the ...

A LPN complains to the charge nurse that an unlicensed assistive person (UAP) consistently leaves the work area untidy and does not restock supplies. What is the best initial response by the charge nurse? 1Write down potential solutions to the problems today by shift's end 2Add this concern to the agenda of the next unit meeting 3Assure the staff nurse that the complaint will be investigated 4Explore for further identification about the nature of the problem 4 Explore for further identif...