NursGuru

    Exam Review

    1. A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?
      A)
      Acetone odor to breath
      B)
      Malignant hypertension
      C)
      Blood glucose level below 40 mg/dL
      D)
      Cheyne-Stokes breathing
    2. A nurse in a mental health facility is caring for a young adult client. Which of the following findings in the client’s medical record are consistent with antisocial personality disorder?
      (SATA)
      A)
      Experience with legal system since teenage years
      B)
      Adhering to financial responsibilities
      C)
      Employment status
      D)
      Relationship with family
      E)
      Acceptance of responsibility
      F)
      Substance use
      G)
      Compassion toward others
      H)
      Rechanneling anger with physical activity
    3. A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?
      A)
      Allow the client to pace alone until physically tired
      B)
      Instruct the client to sit down and stop pacing
      C)
      Have a staff member escort the client to her room
      D)
      Walk with the client at a gradually slower pace
    4. A nurse is caring for a client who reports frequent social use of alcohol. The client tells the nurse that they have been reprimanded at work for being late several times after they had been out late drinking. Which of the following statements by the client might indicate that the client has developed a substance use disorder?
      A)
      "I am taking art lessons to relieve stress."
      B)
      "I have been hanging out with friends who are my support system."
      C)
      "I am so focused right now. I have a lot of goals."
      D)
      "I have lost 15 pounds! I just don't want to eat lately."

    Exam Review

    1. A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer’s disease. Which of the following interventions should the nurse include in the plan?
      A)
      Provide an activity schedule that changes from day to day.
      B)
      Rotate assignment of daily caregivers.
      C)
      Talk the client through tasks one step at a time.
      D)
      Limit time for the client to perform activities.
    2. A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?
      A)
      Check the client’s medication record to assess whether the client has been refusing her lithium.
      B)
      Administer the morning dose of lithium.
      C)
      Prepare for gastric lavage due to an extremely elevated lithium level.
      D)
      Hold the medication and assess for early manifestations of toxicity.
    3. A nurse is providing education to a client who needs a cholecystectomy due to a build-up of calculi or gallstones. Which of the following is the best response from the nurse to explain what caused this problem?
      A)
      The gallbladder has become blocked by a tumor and is no longer working.
      B)
      The gallbladder became infected by a virus and needs to be removed.
      C)
      The gallbladder has become inflamed due to a build-up of gallstones that are blocking the common bile duct.
      D)
      The gallbladder has become inflamed due to the cholesterol in the gallstones.
    4. A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?
      A)
      Bleeding
      B)
      Pancreatitis
      C)
      Cataracts
      D)
      Dysrhythmias

    Exam Review

    1. A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client?
      A)
      Insulin detemir
      B)
      NPH insulin
      C)
      Insulin glargine
      D)
      Regular insulin
    2. A nurse is planning care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse include in the plan?
      A)
      Encourage frequent ambulation.
      B)
      Administer antibiotics.
      C)
      Encourage increased fluid intake.
      D)
      Obtain weight weekly.
    3. A nurse is providing discharge teaching for a client who is to perform peritoneal dialysis at home. Which of the following information should the nurse include?
      A)
      "You should anticipate pain the first week during the inflow of dialysate."
      B)
      "You should expect redness at the catheter exit site."
      C)
      "You should avoid foods high in fiber."
      D)
      "You should warm the dialysate in a microwave oven before instillation."
    4. A nurse is caring for a client who has Cushing’s syndrome. The nurse should recognize that which of the following are manifestations of Cushing’s syndrome? (Select all that apply.)
      A)
      Hypertension
      B)
      Purple striations
      C)
      Moon face
      D)
      Buffalo hump
      E)
      Tremors

    Exam Review

    1. A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times?
      A)
      0745
      B)
      0815
      C)
      0720
      D)
      0730
    2. A nurse is caring for a client following his first hemodialysis treatment. The client reports a headache, nausea, and restlessness. The nurse should identify these findings as manifestations of which of the following complications?
      A)
      Septicemia
      B)
      Peritonitis
      C)
      Dialysis disequilibrium
      D)
      Air embolism
    3. A nurse is caring for a client who has borderline personality disorder (BPD). As part of the client’s plan of care, the nurse reviews the day’s schedule with the client each morning. As the nurse begins to review the schedule, the client says, "Why don’t you shut up already? I can read it myself, you know!" Which of the following responses should the nurse give the client?
      A)
      "We do this every day. Why are you so angry with me this morning?"
      B)
      "Fine. Here is the schedule, and I will expect you to be on time to your therapies."
      C)
      "I don’t like it when you address me with that tone of voice."
      D)
      "I know you can, but are you going to read it or not?"
    4. A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client?
      A)
      A semi-private room with a roommate who has a similar diagnosis
      B)
      A private room in a quiet location on the unit
      C)
      A seclusion room until the client’s activity level becomes more subdued
      D)
      A private room close to the nursing station

    Exam Review

    1. A nurse is performing an assessment of a female client in the clinic. The client reports foul-smelling urine and pain with urination. The client states, "I bet I have a UTI. Why do I tend to get urinary tract infections?" Which of the following statements should the nurse include in the explanation?
      A)
      "As a female, you have more E. coli in your gastrointestinal system that can enter the bladder through your urethra."
      B)
      "If you take too many showers you are more susceptible to getting a UTI because you are washing off the protective bacteria."
      C)
      "As a female, you have a shorter urethra creating an easier way for bacteria to invade your bladder."
      D)
      "At your age, you have more sexual intercourse than older females making you more likely to get a UTI."
    2. A nurse is teaching about disease management for a client who has type 1 diabetes mellitus. Which statement made by the client indicates an understanding of the teaching?
      A)
      I am to take my blood sugar reading after meals.
      B)
      Insulin allows me to eat ice cream at bedtime.
      C)
      I give the insulin injections in my abdominal area.
      D)
      A weight reduction program will make me hypoglycemic.
    3. A nurse is assessing a client who is admitted with hyperthyroidism. The client reports a weight loss of 5.4 kg (12 lb) in the last 2 months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. Which of the following actions should the nurse take to prevent a thyroid crisis?
      A)
      Keep the client NPO.
      B)
      Administer aspirin as prescribed for any sign of hyperthermia.
      C)
      Provide a quiet low-stimulus environment.
      D)
      Observe the client carefully for signs of hypocalcemia.
    4. A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity?
      A)
      The client eats 2 to 3 gm of sodium-containing foods daily.
      B)
      The client avoids NSAIDS.
      C)
      The client drinks 2 liters of liquids daily.
      D)
      The client runs 4 miles outdoors every afternoon.

    Exam Review

    1. A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse’s station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?
      A)
      "I can’t call a doctor in the middle of the night unless it’s an emergency."
      B)
      "Go back to your room, and I’ll try to get in touch with your doctor."
      C)
      "You are being unreasonable, and I will not call your doctor at this hour."
      D)
      "You must be very upset about something."
    2. A nurse is caring for a client who is 8 hr postoperative following a subtotal thyroidectomy. In which of the following positions should the nurse keep the client?
      A)
      High Fowler's with neck in a neutral position.
      B)
      Semi-Fowler's with neck extended.
      C)
      High Fowler's with neck extended.
      D)
      Semi-Fowler's with neck in a neutral position.
    3. A nurse is caring for a client who has acute pancreatitis. After treating the client’s pain, which of the following should the nurse address as the priority intervention?
      A)
      Auscultate the client's lungs.
      B)
      Provide oral hygiene.
      C)
      Withhold oral fluids and food.
      D)
      Assist the client to a side-lying position.
    4. A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time and they are trying to poison my food." Which of the following statements should the nurse make?
      A)
      "You seem to be having very frightening thoughts."
      B)
      "Why do you think you are being lied about and poisoned?"
      C)
      "You are mistaken. Nobody is lying about you or trying to poison you."
      D)
      "Who is lying about you and trying to poison you?"