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Critical Thinking EAQ Quiz 2 (154 Questions
and Answers).
A client is receiving Digoxin. The client calls the clinic and complains of yellow vision. Which response would the nurse provide? - Verified Answer The medication may need to be discontinued. Come to the clinic this afternoon - indicates digoxin toxicity Which sexually transmitted infection causes condylomata acuminate? - Verified Answer human papillomavirus (HPV) = genital warts Which joint helps in the gliding movement of the wrist? - Verified Answer Biaxial - pivot joints permit rotation in the radioulnar area, hinge joints allow for flexion and extension, ball and socket joints permit movement in the shoulder and hips Which would the school nurse's first action be when a child reports a sore throat? - Verified Answer examine the throat- priority to determine the extent of the inflammation, significant swelling can create the potential for airway obstruction Which condition contraindicates the use of ginseng herbal therapy? - Verified Answer pregnancy - schizophrenia, bipolar depression, and Alzheimer disease are contraindicated for St. John's Wort A beta blocker is prescribed for the client with persistent ventricular tachycardia. Which response indicates that the beta blocker is working effectively? - Verified Answer decreased heart rate - beta blockers inhibit the activity of the sympathetic nervous system and of adrenergic hormones, decreasing the heart rate, conduction velocity, and workload of the heart Which action would the nurse take for a withdrawn client who suddenly screams, bursts into tears, and runs from the room to the far end of the hallway? - Verified Answer walk to the end of the hallway where the client
is standing - lets client know that the nurse is available, demonstrates acceptance of the client Which is the middle layer of the eyeball? - Verified Answer uveal tract - consists of the iris, choroid, and ciliary body A recently hospitalized client with multiple sclerosis voices a concern about generalized weakness and fluctuating physical status. Which nursing intervention is the priority for this client? - Verified Answer space activities throughout the day - will encourage maximum functioning within the limits of strength and fatigue, bed rest and limited activity may lead to muscle atrophy and calcium depletion, stress strengths rather than weaknesses Which sign in the newborn infant would reflect and Apgar score of 1 in the category of respiration? - Verified Answer a slow, weak cry - a good cry would receive a score of 2, a grimace is a sign that is evaluated in the category of reflex irritability, not respiration Which complications would the nurse monitor in a client who sustained a transection of the spinal cord, but no other injuries? - Verified Answer autonomic hyperreflexia - uninhibited and exaggerated response of the autonomic nervous system to simulation, results in BP greater than 200 mm Hg systolic it is a medical emergency Which emergency severity index (ESI) level should be considered a high priority for the nurse caring for clients in the emergency department (ED)? - Verified Answer ESI- 1 ; 1 is client is unstable, 2 client can wait 10 mins for care, 3 can wait up to one hour because they are stable, 4 can be delayed for longer Which clinical indicator would the nurse monitor to determine if the client's simvastatin is effective? - Verified Answer triglycerides - therapeutic effects include decreased levels of serum triglycerides, low density lipoprotein (LDL), and cholesterol For which additional defect would the nurse assess an infant with exstrophy of the bladder? - Verified Answer pubic bone malformation - pubic bone and bladder form during the same period of embryonic development
possess specialty training, this practice enhances the nurse to gain an in depth knowledge about spiritual, social, and psychological needs and the pathophysiology of clients living with advanced diseases Phenytoin suspension 200mg is prescribed for a client with epilepsy. The suspension contains 125mg/5mL. How many mL will the nurse administer?
- Verified Answer 8mL A client with supraventricular tachycardia (SVT) has a heart rate of 170 beats/min. After treatment with diltiazem, which assessment indicates to the nurse that the diltiazem is effective? - Verified Answer heart rate of 98 beats/min - purpose is to slow down the heart rate A client reports left- sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area. the nurse expects to identify which finding? - Verified Answer the left lung is collapsed; therefore there are no breath sounds- no vocal fremitus , or rales with rhonchi because there is no airflow into the left lung Which sexually transmitted infection (STI) is most commonly reported? - Verified Answer chlamydia Which structure is a component of the auditory ossicles? - Verified Answer malleus- along with the incus and stapes constitutes the auditory ossicles After a cerebrovascular accident (CVA, also known as "brain attack"), a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. The nurse would conclude the CVA affected which lobe of the brain? - Verified Answer parietal - sensory impulses from temp, touch, and pain travel via the spinothalamic pathway to the thalamus and then to the postcentral gyrus of the parietal lobe, the somatosensory area, frontal area is the area of abstract thinking and muscular movements, occipital area of the brain is where nerve impulses translate into sight, the temporal area is the area where nerve impulses translate into sound
During an annual physical assessment, a client reports not being able to smell coffee and most foods. Which cranial nerve function would the nurse assess? - Verified Answer 1 - the cranial nerve 1 is the olfactory nerve that concerns the sense of smell, the inability to sense odors occurs with the presence of an intracranial lesion, cranial nerve II is optic nerve, Nerve X is the vagus nerve associated with the gag reflex, supplying parasympathetic fibers to body organs, and transmitting sensory impulses from the viscera, Nerve VII is the facial nerve Which rationale supports the nursing intervention to turn the client with paraplegia every 1 to 2 hours? - Verified Answer to prevent development of pressure injuries Which step would the nurse take when preparing to administer Rho(D) immune globulin to a postpartum client? - Verified Answer ensure that the client is Rh negative and the neonate is Rh positive - given to Rh negative mothers not previously sensitized who have Rh positive neonate, it prevents Rh incompatibility in the next pregnancy , administered IM Which structure lies inside and parallel to the sclera? - Verified Answer choroid - highly vascular structure that nourishes the ciliary body, the iris, and the outermost portion of the retina During the administration of an antibiotic, the client becomes restless and flushed, and begins to wheeze. Which action will the nurse take after stopping the antibiotic? - Verified Answer assess the client's respiratory status - reaction may progress to anaphylactic shock which can lead to respiratory distress as a result of laryngeal edema or severe bronchospasm When providing care for a client with quadriplegia, which nursing intervention assists in decreasing the potential occurrence of pressure ulcers? - Verified Answer frequently reposition the client on a scheduled basis In which settings would the nurse prepare to administer developmental assessment for pediatric clients? - Verified Answer home, school, hospital, and daycare center
Which colors are often included an organizational disaster plan for use during triage? - Verified Answer red, black, green, yellow, and blue A child has a fractured arm and multiple old injuries. Child maltreatment is suspected. Which parental characteristics supports this suspicion? - Verified Answer offering inconsistent stories about the injuries Which nursing action would be included in the plan of care for a child with acute poststreptococcal glomerulonephritis? - Verified Answer monitoring for seizures - cerebral edema from hypertension or cerebral ischemia may occur, which may result in seizures A client, transferred to the postanesthesia care unit after a transurethral resection of the prostate (TURP), have an intravenous (IV) line and a urinary retention catheter. During the immediate postoperative period, for which potentially critical complication would the nurse monitor? - Verified Answer hemorrhage - common because of venous oozing and bleeding from many small arteries in the area Which type of delusion would the nurse chart about a client who says "I've figured out how foreign agents have infiltrated the news media. Now they want to shut me up?" - Verified Answer persecution - thoughts of being pursued by powerful agents because of one's special attributes are fixed false beliefs, control- external forced controlling the client, grandeur- false beliefs of being a famous figure Which nursing objective would the nurse add to the plan of care for a child with ADHD who engages in destructive behavior? - Verified Answer Keep the child from inflicting any self- injury Which nursing action has the highest priority when preparing to transfer an unconscious client who sustained a head injury from the emergency department to a neurological trauma unit? - Verified Answer validating availability of a bag valve mask during the transfer - in case of respiratory distress, intracranial pressure compresses the brainstem, which contains the medulla, the respiratory center
After numerous diagnostic tests, a client with jaundice receives the diagnosis of pancreatic cancer. Which rational explains the cause of the client's jaundice? - Verified Answer obstruction of the common bile duct by the pancreatic neoplasm - the common bile duct passes through the head of the pancreas, the neoplasm often constricts or obstructs the duct causing jaundice An adult client with low- functioning Down Syndrome (trisomy 21) appears in the emergency department via ambulance after an accident. Which assessment method would be the best instrument to use when determining the client's level of pain? - Verified Answer using the Wong- Baker FACES pain rating scale - client can relate to the patients Atenolol 150mg by mouth is prescribed for a client with hypertension. Each tablet contains 50mg. How many tablets will the nurse administer? - Verified Answer 3 The health care provider prescribed a blood transfusion for a client with esophageal varices. Place the following nursing actions in the correct order? - Verified Answer check the patient's vital signs, establish intravenous IV access with IV normal saline, verify the blood product with another nurse against the client's identification (ID) bracelet, monitor the client's vital signs and status according to agency policy Which statement is true regarding antipsychotic medications? - Verified Answer clozapine is a second- generation antipsychotic medication that is more effective than other second- generation antipsychotics; most first and second generation antipsychotics are equally effective, second generation may cause metabolic side effects such as diabetes and dyslipidemia, first generation may cause extrapyramidal side effects The nurse receives an order to prepare a solution for administering a cleansing enema for an adolescent client. Which is the volume of solution that would be prepared? - Verified Answer 500-750mL ; 150-250mL of warmed solution for infants, 250-35-mL of warmed solution for toddler, in school-ages children the volume of warmed solution is 300-500mL
When obtaining a healthy history from a client recently diagnosed with type 1 diabetes, the nurse expects the client to report which clinical manifestation? - Verified Answer polyuria; associated with excessive thirst (polydipsia), excessive hunger (polyphagia), and frequent urination (polyuria) are caused by the body's inability to metabolize glucose adequately Which action would the nurse take to help a female, bipolar client in the manic episode meet personal hygiene needs? - Verified Answer guide her to dress appropriately in her own clothing - wearing personal clothing helps keep them more in touch with reality For which client illness would airborne precautions be implemented? - Verified Answer chickenpox - influenza and pneumonia are transmitted by droplet, respiratory syncytial virus transmitted by direct contact The nurse would identify which medication as the most common cause of extrapyramidal side effects (EPSs)? - Verified Answer haloperidol and fluphenazine The spouse of a client with pulmonary tuberculosis (TB) received a tuberculin skin test. The nurse examined the skin test and identified an area of induration greater than 10mm. Which response to this finding would the nurse implement? - Verified Answer additional tests are necessary to determine infection status - test does not indicate whether TB is dormant or active, need chest x-ray or sputum culture , newly infected client will receive preventative therapy with Isoniazid (INH) Which assessment finding would the nurse observe in a client with bipolar disorder, manic phase? - Verified Answer constant singing - ritualistic behavior is indicative of obsessive compulsive disorder, a flat affect and apathetic demeanor are more indicative of a schizophrenic or depressive disorder To which part of the respiratory system would the client's radiology report refer when identifying the angle of Louis? - Verified Answer carina - located at the level of the manubriosternal junction
Which clinical manifestations indicate a client who sustained head and chest injuries from a motor vehicle accident, responded to medical treatments, and is ready for transfer to a critical care unit? - Verified Answer stable vital signs and complaints of pain - major indicator predicting transfer will not jeopardize the client's condition A client with cancer experiences severe nausea and vomiting from chemotherapy. The client wants to know if it is true that smoking marijuana will help. How will the nurse respond? - Verified Answer There are some tetrahydrocannabinol (THC)- based medications that contain marijuana control chemotherapy- induced nausea and vomiting in some people - THC acts as an antiemetic in some people and can be absorbed through the GI tract or inhaled. THC based medications, dronabinol and nabilone, are available by prescription to control nausea and vomiting resulting from chemotherapy Which medication may lead to bruxism? - Verified Answer Levomilnacipran - serotonin reuptake inhibitors and serotonin/norepinephrine reuptake inhibitors may lead to bruxism An adolescent visits the allergy clinic for testing. Which laboratory finding indicates that an allergic response is in progress? - Verified Answer increased eosinophil level - they increase to inhibit the inflammatory response to histamine, which is released in allergic reactions, immunoglobulins increase in response to allergic reaction A client hospitalized for uncontrolled hypertension and chest pain was started on a daily diuretic 2 days ago upon admission, with prescriptions for a daily basic metabolic panel. The client's potassium level this morning is 2.7. Which action will the nurse take? - Verified Answer Notify the health care provider that the potassium level is above normal - normal range is 3. to 5, diuretic can lead to hypokalemia, whereas others spare potassium which can cause hyperkalemia The client reports difficulty in breathing. The nurse ausculates lung sounds and assess the respiratory rate. Which is the purpose of the nurse's action?
- Verified Answer data collection- the nurse is gathering objective data to support the subjective data
Which antibody forms first, after exposure to an antigen? - Verified Answer Immunoglobulin M(IgM) - first antibody formed by a newly sensitized B-lymphocyte plasma cell ; IgA has low circulating levels and responsible for preventing infection in the upper and lower respiratory tracts and the GI and genitourinary tracts. IgE variable concentrations and is associated with antibody-mediated hypersensitivity reactions. IgG heavily expressed on second and subsequent exposures to antigens to provide sustained long term immunity against invading microorganisms Which result would the nurse expect to find when reviewing the serum screening tests of a client with acquired immunodeficiency syndrome (AIDS)? - Verified Answer a decrease in the CD4T cells - HIV infects helper T- lymphocytes, 300 or fewer CD4T cells per cubic millimeter of blood of CD4 cells accounting for less than 20% of lymphocytes is suggestive of AIDS ; T-cell growth decreased, IgE associated with allergies and parasitic infections, glucose 6 phosphate dehydrogenase is associated with drug induced hemolytic anemia and hemolytic disease of the newborn Pulse oximetry is prescribed for an adolescent. Which would the nurse do to ensure accuracy of the pulse oximeter reading? - Verified Answer attach the probe to a finger or earlobe The weight of three month old infant with tetralogy of Fallot has declined from the 25th percentile to the 5th. Which mechanism would the nurse suspect is the reason for this inadequate weight gain? - Verified Answer inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse - because of quick fatigue it is difficult for the infant to consume sufficient calories to adequate weight gain Which term describes the practice of placing clients with the same infection in a semi-private room? - Verified Answer cohorting a client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. What are the priority nursing assessments? - Verified Answer quality of respirations and presence of pulses - assessing breathing and circulation are the priorities in trauma management, basic life functions must be maintained or reestablished ABCs
Which is the most important action the nurse would take in preparation for a lumbar puncture for a child with tentative diagnosis of bacterial meningitis? - Verified Answer asking the parents what they were told about the test - informed consent is required, procedure should be explained by the health care practitioner and the nurse would confirm the parent's comprehension and have them sign the consent form Which action would the nurse take for an adolescent with a long history of drug abuse, stealing, and refusal to comply with rules? - Verified Answer serve as a role model for a mature behavior while providing a structured setting - client is unable to control impulses at this time so control must be provided for the client Which site would the nurse use to administer vitamin K to a newborn? - Verified Answer vastus lateralis - because it is well developed and there is little danger of nerve injury A client had an annual tuberculin purified protein derivative (PPD) test, and the area of induration was 10mm within 48 hours after planting. Which conclusion would the nurse make about the client's response to this diagnostic? - Verified Answer client has been exposed to tubercle bacillus When checking placement of a feeding tube, the nurse is unable to hear the air injected because of noise breath sounds. Which should the nurse do? - Verified Answer try aspirating stomach contents - gastric returns indicate correct placement of the feeding tube The day after undergoing abdominal appendectomy, a school- aged child is prepared for ambulation. Which nursing action would be most effective before the start of ambulation? - Verified Answer administering the prescribed pain medication A client has a colon resection and formation of a colostomy 2 days ago. Which color indicates to the nurse that the stoma is viable? - Verified Answer brick red - indicates adequate vascular perfusion
oxygen, assessing vital signs, obtaining a 12 lead EKG, drawing blood for cardiac enzymes, auscultating heart sounds, administering nitroglycerin The nurse is preparing to assess several clients at a pediatric clinic. Which client would require a developmental screening versus developmental surveillance during a scheduled health maintenance visit? - Verified Answer a 9 month old infant Tissue plasminogen activator (t-PA) is to be administered to a client in the emergency department. Before beginning the infusion, which assessment is the nurse's priority? - Verified Answer signs of bleeding - contraindicated for administration of thrombolytic agents, administration in the presence of bleeding can cause life threatening hemorrhage A client with sickle cell anemia is experiencing a pain episode (vaso- occlusive crisis) and has a patient controlled analgesia (PCA) pump. The current pain rating is 5 on a scale of 1 to 10 at the right elbow. The nurse observes that the pump is "locked out" for another 10 mins. Which action would the nurse implement? - Verified Answer placing the prescribed as needed warm, wet compress on the elbow - vasodilation should help reduce pain from cellular clumping At which height is it no longer safe for a toddler to sleep in a crib? - Verified Answer 36 inches Clients with which tag are referred to as "walking wounded" clients while managing a disaster? - Verified Answer green, can evacuate themselves - red given to clients who have immediate threats to their life and should be treated immediately, black tags are given to clients who are not expected to live or are dead, yellow tags are given to clients who sustained major injuries and need treatment within 30mins to 2 hours Which Glasgow Coma Scale indicates that the client is in a coma? - Verified Answer score of 8 or below indicates coma - consists of three assessments; eye opening, response to auditory stimuli and motor response, rated from 3-15, the lower the score the more indicative of a coma, to achieve the rating of 9 and up the client must be exhibiting some meaningful responses
Which diagnostic test results indicates if a client will develop acquired immunodeficiency syndrome (AIDS) from the human immunodeficiency virus (HIV)? - Verified Answer dependent on the number of CD4+ T cells Which method of contraception may provide adolescents with the longest duration of protection? - Verified Answer levonorgestrel intrauterine system is a T shaped intrauterine system that releases levonorgestrel, must be plaved within 7 days of menses and provides protection up to 5 years During which stage of development would the nurse anticipate sibling relationships that fluctuate between open bickering and supportive relationships? - Verified Answer middle school age Which outcome would indicate a client who was hospitalized with severe anxiety is ready to be discharged? - Verified Answer maintains anxiety at a manageable level Which medication is unsafe to administer as an IV bolus? - Verified Answer potassium chloride - this can cause cardiac arrest, must be diluted and infused slowly through and IV infusion pump Which intervention would the nurse include in the plan of care for a client admitted with herpes zoster? - Verified Answer acyclovir, silvadene, gabapentin, wet compresses, contact isolation ; antiviral medications such as acyclovir, silvadene can be applied to open vesicles, gabapentin can be used to treat the nerve pain associated, wet compresses can be applied to vesicles to relieve discomfort, herpes zoster is highly contagious and must be placed on isolation precautions Which action is the priority when the nurse is establishing a therapeutic environment for a client? - Verified Answer ensuring the client's safety A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. Which percentage of total body surface area (TBSA) would the nurse calculate? - Verified Answer 36% -
Which effect of povidone-iodine would the nurse consider when using it on the client's skin before obtaining a specimen for a blood culture? - Verified Answer eliminates surface bacteria that will contaminate culture results Which method of delivering client care works well in disaster situations? - Verified Answer functional method - each care provider knows the expectations of the assigned role and completes the tasks quickly and efficiently A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, which would the nurse expect to find? - Verified Answer brown or black mole with red, white, or blue areas - have irregular shape and lack uniformity in color ; petechiae are pinpoint red dots that indicate areas of bleeding under the skin ; a red birth mark is a vascular birthmark and often fades with time, a patchy loss of skin pigmentation indicated vitiligo Which assessment finding is associated with chronic eczema? - Verified Answer rough, thick skin The nurse assesses the integumentary system of four clients. Which client has the least chance of a false- positive result while undergoing assessment of capillary refill time? - Verified Answer client with epilepsy - a client with epilepsy does not have any circulatory inadequacy A child is administered a rotavirus vaccine. Which adverse medication effect would the nurse monitor for? - Verified Answer intussusception - a life threatening form of bowel obstruction that occurs due to the bowel folding in on itself ; DTaP causes encephalopathy, MMR induce thrombocytopenia, meningococcal conjugate vaccines cause Guillain- Barre syndrome in some children Which gross motor skill is found in children between 2 to 4 months of age?
- Verified Answer the child can bear weight on the forearms when prone ; 8-10 can creep on hands and knees, birth and 1 month has predominant inborn reflexes, 6-8 months can sit alone without support
Which health care team member is a first responder when an emergency or mass casualty incident (MCI) occurs? - Verified Answer critical care nurse Which color tag would the nurse use to triage a victim of a train derailment who is able to walk independently to the first aid station? - Verified Answer green While performing a physical assessmnet, the nurse notices a minute, nonpalpable change in the skin color of a client. Which would be the type of skin lesion involved? - Verified Answer macule - a flat, nonpalpable change in skin color that is less than 1cm ; wheal is localized edema caused by a mosquito bite ; papuled are palpable, circumscribed solid elevations in the skin that are smaller than 1cm ; vesicles are small, circumscribed skin elevations that are filled with serous fluid The nurse understands which group of the pediatric population is at higher risk of developing respiratory complications upon administration of general anesthesia? - Verified Answer neonates - physical characteristics of the larynx and small airway diameter, the structure of the respiratory system, and the high metabolic rate of neonates place them at higher risk Which variable is an example of an external variable? - Verified Answer socioeconomic factors Which hormones are secreted by the posterior pituitary gland? - Verified Answer oxytocin and antidiuretic (vasopressin) hormone - prolactin, corticotropin, and melanocyte-stimulating hormones are secreted by the anterior pituitary gland Which action will the nurse take to determine a client's pulse pressure? - Verified Answer subtracting the diastolic from the systolic reading ; multiplying heart rate by the stroke volume is cardiac output, calculating the difference between the apical and radial rate is the pulse deficit Which clinical finding would the nurse associate with hypokalemia? - Verified Answer muscle weakness - serum hypokalemia diminishes the magnitude of the neuronal and muscle cell resting potential, edema is associated with electrolyte imbalances, including sodium excess
