Exam Review
1130: 25-year-old female reporting to the clinic for a regularly scheduled follow-up. She is being treated for bipolar disorder with lamotrigine and valproic acid. The client indicates that she 'doesn't feel better.' Over the past few weeks, she stated that 'she feels high, but yet feels low.' During the assessment, the client was alert and oriented but had a constricted affect. She described her mood as 'whatever'. She denies suicidal ideations and hallucinations. She reports her sleep has been 'terrible' and that she 'cannot turn her mind off when she lays down.'
- Discontinue valproic acid
- Discontinue lamotrigine
- Start lithium 900 mg PO twice a day
- Follow-up visit in 3 weeks
The nurse reviews the physician's orders and educates the client on the prescribed lithium
➢ Complete the sentences below by choosing from the list of options
The nurse should instruct the client that they will need to have a consistent intake of [calcium rich / sodium rich / potassium rich] foods. The client should also [take this medication only with water. / maintain a daily fluid intake of 2 to 3 liters. / be in a upright position for 30 minutes after taking the medication.] The client should also be informed to expect this medication to cause [excessive hair growth. / a fine hand tremor. / weight loss.] The nurse should also inform the client that periodic laboratory testing will be required and will include monitoring the [thyroid panel. / liver enzymes. / creatine kinase (CK).]
Correct Answer:sodium rich; maintain a daily fluid intake of 2 to 3 liters.; a fine hand tremor.; thyroid panel.- (SATA)
The nurse is teaching a client about a vegetarian diet. Which of the following foods should the nurse recommend for this diet? Select all that apply.
A)LegumesB)Almond butterC)Grilled chickenD)ApricotsE)Baked fishF)Seafood salad - (SATA)
The emergency department (ED) charge nurse is preparing for a surge of clients diagnosed with Ebola virus disease (EVD). The nurse should plan to take which action? Select all that apply.
A)Implement visitor restrictions for affected clientsB)Log entry and exit of all healthcare workers who provide careC)Ensure that bleach disinfectant wipes are available in each roomD)Provide reusable personal protective equipmentE)Have an observer for donning and doffing of personal protective equipment - (SATA)
The nurse is teaching a client who has been prescribed a 21-day course of prednisone.
➢ Which of the following information should the nurse include? Select all that apply.
A)“This medication may make you gain weight.”B)“It is best to take this medication in the morning with food.”C)“If you have further pain, it is okay to take naproxen.”D)“Your blood pressure may decrease while taking this medication.”E)“Do not abruptly stop taking this medication.”
Exam Review
- (SATA)
The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as a risk factor for developing testicular cancer? Select all that apply.
A)CryptorchidismB)Human immunodeficiency virus (HIV)C)VasectomyD)Family historyE)Herpes simplex virus (HSV) - (SATA)
The nurse is caring for a client who has a factitious disorder. The client reports chest pain. Which of the following actions should the nurse take? Select all that apply.
A)Provide reassurance that this is part of the disorderB)Notify the primary healthcare physician (PHCP)C)Obtain a 12-lead ElectrocardiogramD)Disregard the symptom as it may be unreliableE)Assess vital signs - (SATA)
The nurse is observing infection control practices in the nursing unit. Which of the following findings require follow-up? A client with
Select all that apply.
A)H. pylori placed on standard precautions.B)rotavirus provided a disposable blood pressure cuff.C)rubella and their door is kept closed at all times.D)influenza ambulating in the hall with a surgical mask.E)Legionnaires’ disease placed on contact precautions. - (SATA)
The nurse is assessing a client three days postpartum for lower extremity thrombophlebitis. Which of the following assessment findings would support this diagnosis?
Select all that apply.
A)muscle weaknessB)ulcers between the toesC)edemaD)tendernessE)cyanosisF)patches of hair loss
Exam Review
- (SATA)
The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as an increased risk for developing primary open-angle glaucoma? Select all that apply.
A)Blue eyesB)Older ageC)African ethnicityD)Diabetes mellitusE)Use of contact lenses 0100: The client was brought to the ED by his parents because they were awakened by the child crying and because 'his throat hurt.' The parents indicated that he was sick the night before, but the symptoms were not severe, and this change was sudden. The child was drooling, hot to the touch, and their voice was muffled. On assessment, the child is alert and restless. Pain was endorsed in the throat. Voice is muffled and excessive secretions were noted in his mouth. Visualization of the throat was difficult because of the excessive secretions but the throat was significantly erythemic. The child was resistant to lying supine and maintained a tripod position. Low-pitch inspiratory stridor was heard in upper lung fields, and the client had tachypnea. Peripheral pulses were 2+. Skin was hot and dry. Vital signs: T 103.4° F (39.7° C), P 141, RR 34, pulse oximetry reading 89% on room air. No significant past medical or surgical history.
➢ For each assessment finding below, click to specify if the finding is consistent with the disease process of epiglottitis, laryngotracheobronchitis, or streptococcal pharyngitis. Each finding may support more than one (1) disease process
- A. throat pain
- B. inspiratory stridor
- C. sudden onset of symptoms
- D. restlessness
- E. tripod position with drooling
- F. muffled voice
1450: Client reports to the clinic with her daughter because of various concerning symptoms that started about eight months ago. The client's daughter has noticed that her mother has become increasingly clumsy and uncoordinated. She reports that she is tripping over her own feet, which has caused her to fall twice. The client's daughter also reports becoming emotionally labile for 'no apparent reason.' The client reports that she gets 'spells of double vision that lasts for a few days' that seem to worsen with the heat. The client's daughter is concerned because her mother is not the 'get up and go' type of woman she used to be. The client does endorse generalized fatigue that worsens as the day progresses. In fact, she states she goes to bed early because she gets so tired by 6 pm. The client says that two weeks ago, her vision doubled so much that she purchased an eye patch at the drugstore, which did help. Her daughter reports checking on her mother; her language was garbled and unrecognizable. She was almost ready to take her to the ED because she thought she was having a stroke. Finally, the client provided documentation from two urgent care visits in the past six months because of urinary tract infections. The client indicates she has had urinary problems dealing with urgency. She states that she has no pain, and in fact, she has difficulty determining if she has a UTI because she has decreased sensation in her pelvic region, which she cannot explain. On assessment, the client's breathing is unlabored, and breath sounds are clear bilaterally. Skin warm to touch with no tenting; bruising noted on the client's shins; pulses 2+ and regular. Capillary refill is 3 seconds. The client is alert and oriented to person, place, and situation. She currently takes no medications and has a medical history of uterine fibroids.
➢ For each client finding below, click to specify if the finding is consistent with the disease process of Parkinson's disease, myasthenia gravis, or multiple sclerosis
Each finding may support more than one (1) disease process
- A. diplopia
- B. emotional lability
- C. generalized fatigue
- D. muscle incoordination
- E. diminished response to pain
- F. heat sensitivity
- G. urinary urgency
Day 1
1100: Client transferred from the emergency department to behavioral health. The client is experiencing an acute manic episode and was found wandering the street with bizarre behavior. The client is alert, oriented to place and time only. Bright and expansive affect. Speech is slightly pressured with a normal pitch. The speech is circumstantial. The client's appearance is disheveled. The thought process is disorganized, and the client denies any hallucinations, although grandiose delusions were noted. Impaired insight and judgment. Psychomotor agitation was present as the client paced in the room during the interview. The plan is to admit involuntarily and start valproic acid to stabilize mood.
Day 3
0915: Nursing reports that the client has refused all medications and only eats 5-10% of all meals. The client is alert and oriented to place only. Expansive affect. Speech is pressured with a high pitch. The speech is nonsensical and tangential. The client is dressed in normal hospital attire. The thought process is disorganized, with significant derailments. The client denies any hallucinations, although grandiose delusions were noted—severely impaired insight and judgment. Considerable psychomotor agitation was present as the client paced relentlessly in the room during the interview.
Day 1
Oral Temperature 97.8° F (36.6° C)
Pulse 82
Respiratory rate 18
Blood pressure 133/81 mm Hg
Pulse oximetry reading 98% on room air
Day 2
Oral Temperature 98.9° F (37.2° C)
Pulse 94
Respiratory rate 16
Blood pressure 127/71 mm Hg
Pulse oximetry reading 97% on room air
Day 3
Oral Temperature 99.5°F (37.5°C)
Pulse 104
Respiratory rate 18
Blood pressure 110/74 mm Hg
Pulse oximetry reading 96% on room air
Day 3
- discontinue oral valproic acid
- valproic acid intravenous piggy-back (IVPB) 15 mg/kg every 12 hours
- obtain previous psychiatric medical records from the most recent hospitalization
- obtain a complete blood count (CBC) and complete metabolic panel (CMP)
- 0.9% sodium chloride (normal saline) 1000 mL, IV, once
The nurse reviews all of the clinical data and prepares to act based on day three's findings
➢ Complete the sentence below from the list of options
The nurse should ****prioritize**** [obtaining the laboratory testing / administering the saline infusion / initiating the valproic acid infusion / retrieving the client's previous medical records] because of the client's [vital signs. / risk for liver injury. / affect and psychomotor agitation. / inability to recall their health history.]
Exam Review
The nurse is assessing a client taking prescribed risperidone.
➢ Which of the following findings would indicate the client is having an adverse effect?
A)ptosisB)gingival hyperplasiaC)polycythemiaD)gynecomastia0855: Client was brought to the clinic by her husband, who reports that she has been falling frequently, having difficulty remembering things, and numbness and tingling in the lower extremities. Onset was 2 weeks ago, with the falling and memory impairment worsening over the past week. The client's husband reports that he is worried about his wife's drinking because it has increased from three beers a day to five or six. She reports that her last drink was four days ago. The client's medical history includes atrial fibrillation, and current medications include apixaban and metoprolol.
On assessment, the client is alert and oriented to person, place, and time, speech is delayed. Her gait is unsteady and requires assistance with ambulation. Pupils are equal, round, and reactive to light with nystagmus. Skin is warm to touch and a normal color for ethnicity. Breathing is unlabored, and lung sounds are clear bilaterally. Peripheral pulses 2+ and irregular. Vital signs: T 97°F (36°C), P 72, RR 14, BP 136/78, pulse oximetry reading 97% on room air. Denies any pain, but reports tingling in her lower extremities.
➢ Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress
Actions to Take: perform a FAST (Face, Arm, Speech Time) assessment | start a peripheral vascular access device | obtain a prescription for thiamine | obtain a prescription for lorazepam
Potential Conditions: alcohol intoxication | Wernicke encephalopathy | transient ischemic attack | alcohol withdrawal
Parameters to Monitor: peripheral pulses | gait | level of conciousness | lower extremity paresthesias
Actions to Take: perform a FAST (Face, Arm, Speech Time) assessment | start a peripheral vascular access device | obtain a prescription for thiamine | obtain a prescription for lorazepam
Parameters to Monitor: peripheral pulses | gait | level of conciousness | lower extremity paresthesias
The nurse is caring for a client who has ulcerative colitis (UC). The nurse should teach the client to Select all that apply.
A)eat consistent amounts of carbohydrates at mealtimes.B)avoid drinking fluids with meals.C)obtain recommended colon cancer screenings.D)avoid taking anti-diarrheal medication.E)increase the intake of non-caffeinated fluids during exacerbations.A nurse is caring for a client who is admitted to the emergency department with suspected rhabdomyolysis.
➢ Which of the following interventions should the nurse anticipate implementing initially for this client?
A)Administering intravenous fluidsB)Monitoring the client's liver enzymesC)Administering corticosteroidsD)Initiating prophylactic antibiotic therapy
Exam Review
1040: 16-year-old gravida 1 para 0, at 34 weeks gestation, reports a frontal headache and edema in the hands and face that started three days ago. Despite taking acetaminophen, she reports that the headache has not subsided. She rates her headache pain as 7 on a scale of 0 (no pain) to 10 (severe pain). The headache is getting so bad that she reports photophobia. She denies any abdominal (epigastric) pain, nausea, or vomiting. She reports missing her last two antepartum checkups because of the lack of transportation. Vital signs: T 97.7° F (36.5° C), P 95, RR 19, BP 141/92 mm Hg. Pulse oximetry 95% on room air. Dipstick urine analysis obtained showed proteinuria.
1140: Dipstick urine analysis obtained showed proteinuria. Fetal heart rate obtained via doppler ultrasound 134 beats-per-minute. Vital signs: T 97.7° F (36.5° C), P 92, RR 16, BP 144/94 mm Hg. Pulse oximetry 96% on room air.
1415: Bedside ultrasound completed. Vital signs: T 97.7° F (36.5° C), P 89, RR 15, BP 143/91 mm Hg. Pulse oximetry 95% on room air.
- Vital signs every two to four hours
- Obtain fetal heart rate
- Transabdominal ultrasound
- Obtain medical records from previous visits
The nurse reviews the nurse's note and discusses it with the physician
➢ For each assessment finding below, click to specify if the finding is consistent with the disease process of preeclampsia, severe preeclampsia, or eclampsia.
Each finding may support more than 1 disease process.
Note: Each column must have at least 1 response option selected
- A. blood pressure 143/91 mm Hg
- B. proteinuria
- C. no abdominal pain
- D. facial edema
- E. frontal headache
- F. photophobia
- 0.9% sodium chloride (normal saline) via continuous infusion at 100 ml/hr
- check blood glucose hourly
- npo (nothing by mouth)
- ondansetron 4 mg intravenous push q 4 hours PRN nausea and vomiting
- complete metabolic panel q 4 hours
- glucagon 1 mg intramuscular (IM) for symptoms of hypoglycemia
- regular insulin via continuous infusion via protocol (below)
The nurse reviews the flow sheet and orders.
➢ Based on all of the clinical data, what actions should the nurse take at 1200? Select all that apply.
A)Notify the primary health care provider.B)Complete an incident report.C)Reduce the insulin infusion to 6 units/hr.D)Administer the prescribed glucagon.E)Request an order for a serum sodium level.F)Request an order for a serum potassium level.The nurse is caring for a client who has soft-limb wrist restraints applied.
➢ The highest priority for the nurse is to
A)provide the client with opportunities to discuss their feelings.B)document the neurovascular assessments.C)assess the client's mood and affect.D)offer nutrition and hydration.The nurse knows that the concept of management is most closely associated with:
A)Decision-making, problem-solving, and priority setting.B)Inspirational abilities and coaching.C)Visionary abilities and supervision.D)Motivational and visionary abilities.
Exam Review
The nurse has attended a staff education program about incident reporting.
➢ It would indicate effective understanding if the nurse states that the primary purpose of incident reporting is to
A)implement corrective measures needed to prevent recurrence.B)collect data about errors and compare it to different time periods.C)communicate the error(s) to other departments within the facility.D)notify the individual involved of the deviation from the standard of care.0800: Upon assessment, the client is visibly anxious and struggling to breathe, with pink frothy sputum noted during coughing.The client is experiencing sudden shortness of breath and chest tightness. Physical examination reveals bilateral crackles in all lung fields, jugular venous distension (JVD), and peripheral cyanosis. An ECG shows sinus tachycardia with no ischemic changes, and a chest X-ray reveals pulmonary vascular congestion. The client reports a history of chronic heart failure.
Vital Signs
Heart Rate (HR) 118 bpm
Blood Pressure (BP) 182/98 mmHg
Respiratory Rate (RR) 32 breaths/min
Oxygen Saturation (SpO₂) 82%
Temperature 37.9°C (100.2F)
➢ Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
Action to take: Administer high-flow oxygen via a non-rebreather mask. | Initiate a fluid bolus of 0.9% normal saline | Administer sublingual nitroglycerin as prescribed. | Administer IV morphine sulfate as prescribed. | Position the client in the Trendelenburg position
Most likely experiencing: Chronic obstructive pulmonary disease (COPD) exacerbation | Acute respiratory distress syndrome (ARDS) | Cardiac tamponade | pulmonary edema
Parameter to Monitor: Blood pressure | Oxygen saturation | Respiratory rate | Urine output | Temperature
Action to take: Administer high-flow oxygen via a non-rebreather mask. | Initiate a fluid bolus of 0.9% normal saline | Administer sublingual nitroglycerin as prescribed. | Administer IV morphine sulfate as prescribed. | Position the client in the Trendelenburg position
Parameter to Monitor: Blood pressure | Oxygen saturation | Respiratory rate | Urine output | Temperature
A client with benign prostatic hyperplasia (BPH) is post-operative following transurethral resection of the prostate (TURP) and is now receiving continuous bladder irrigation. Upon assessment, the nurse notes that the output from the urinary catheter has stopped.
➢ Which nursing intervention is most appropriate?
A)Reinsert a new catheterB)Increase the infusion rate of the irrigationC)Attempt to dislodge a clotD)Contact the health care provider (HCP)The nurse in the emergency department (ED) is caring for a client diagnosed with acute pancreatitis.
➢ The nurse should prioritize obtaining a prescription for
A)intravenous fluids.B)ondansetronC)the insertion of a nasogastric tube (NGT).D)fentanyl via patient-controlled analgesia.