ADAPTATIVE QUIZING WRONG ANSWERS 1. A client with an invasive carcinoma of the bladder is receiving radiation to the lower abdomen in an attempt to shrink the tumor before surgery. What should the nurse do considering the side effects of radiation? Observe the feces for the presence of blood. CORRECT Monitor the blood pressure for hypertension. Administer enemas to remove sloughing tissue. Provide a high-bulk diet to prevent WRONG RATIONALE Radiation may damage the bowel mucosa, causing bleeding. Blood pressure changes are not expected during radiation therapy. Enemas are contraindicated with lower abdominal radiation because of the damaged intestinal mucosa. Diarrhea, not constipation, occurs with radiation that influences the intestine.
2. What clinical indicators should a nurse assess when caring for a client with hyperthyroidism? Select all that apply Top of Form Dry skin CORRECT(S) Weight loss Tachycardia Restlessness Constipation Exophthalmos WRONG RATIONALE Bottom of Form Weight loss is associated with hyperthyroidism because of the increase in the metabolic rate. Muscle weakness and wasting also occur. Tachycardia, palpitations, increased systolic blood pressure, and dysrhythmias occur with hyperthyroidism because of the increased metabolic rate
3. Which fine motor skill should the nurse anticipate when assessing a 15-month-old client during a health maintenance visit? Kneeling without support WRONG Standing without support Creeping up stairs without assistance Holding cubes in one hand without assistance CORRECT RATIONALE Bottom of Form Holding cubes in one hand without assistance is a fine motor skill the nurse should anticipate when assessing a 15-month-old client during a health maintenance visit. Kneeling, standing, and creeping up stairs without support are all gross, not fine, motor skills.
4.A nurse who plans to care for a client with an obsessive-compulsive disorder should understand that the client’s personality can usually be characterized in what way?
Marked emotional maturity WRONG Rapid, frequent mood swings Elaborate delusional systems Doubts, fears, and indecisiveness CORRECT RATIONALE Bottom of Form This disorder is characterized by anxiety and minor distortions of reality. The anxiety results in an inability to reach a decision because all alternatives are threatening. Part of emotional maturity is the ability to relate to people, and these clients have difficulty in this area. Elaborate delusions are indicative of severe emotional illness, not an anxiety disorder. Rapid mood swings are indicative of a mood disorder.
5.What clinical findings may be expected when a nurse assesses an individual with an anxiety disorder? Select all that apply. Worrying about a variety of issues CORRECT Acting out with antisocial behavior WRONG Converting the anxiety into a physical symptom CORRECT Displacing the anxiety onto a less threatening object CORRECT Demonstrating behavior common to an earlier stage of development CORRECT RATIONALE Excessive anxiety and worry about a number of events, topics, or activities for a 6-month duration are the hallmark of generalized anxiety disorder. Converting anxiety into a physical symptom is an example of a conversion disorder, which eases anxiety. Displacing the anxiety onto a less threatening object, which eases anxiety, is typical of a phobic disorder. Regression is an attempt during periods of stress to return to behavior that has been satisfying and is appropriate at an earlier stage of development. Acting out anxiety with antisocial behavior is most commonly found in individuals with personality rather than anxiety disorders.
6.A nurse is assessing a client with the diagnosis of hemorrhoids. Which factors in the client's history most likely played a role in the development of the client's hemorrhoids? Select all that apply. Constipation CORRECT Hypertension WRONG (S) Eating spicy foods Bowel incontinence Numerous pregnancies RATIONALE Straining at stool increases intraabdominal, systemic, and portal venous pressures that promote the development of hemorrhoids. The enlarging uterus from pregnancies puts pressure on the inferior vena cava that leads to increased portal venous pressure, causing anorectal varicosities. Hypertension does not contribute to the development of hemorrhoids; however, portal hypertension can precipitate hemorrhoids.
7.The serum potassium level of a client who has diabetic ketoacidosis is 5.4 mEq/L (5.4 mmol/L). What would the nurse expect to see on the ECG tracing monitor? Abnormal P waves and depressed T waves Peaked T waves and widened QRS complexes CORRECT Abnormal Q waves and prolonged ST segments Peaked P waves and an increased number of T waves RATIONALE Potassium is the principal intracellular cation, and during ketoacidosis it moves out of cells into the extracellular compartment to replace potassium lost as a result of glucose-induced osmotic diuresis; overstimulation of the cardiac muscle results. The T wave is depressed in hypokalemia. Initially, the QT segment is short, and as the potassium level rises, the QRS complex widens. P waves are abnormal because the PR interval may be prolonged and the P wave may be lost; however, the T wave is peaked, not depressed. The ST segment becomes depressed. The PR interval is prolonged, and the P wave may be lost. QRS complexes and thus T waves become irregular, and the rate does not necessarily change. 8.The nurse should assess an infant with gastroesophageal reflux for what complication? Bowel obstruction WRONG Abdominal distention Increased hematocrit CORRECT Respiratory problems Bottom of Form Reflux of gastric contents to the pharynx predisposes the infant to aspiration and the development of respiratory problems. There is no risk for a bowel obstruction; the problem is an incompetent esophageal sphincter. An increased hematocrit is not expected unless there is severe dehydration. Abdominal distention does not occur, because gastric contents are forcefully vomited.
9.The registered nurse is teaching a student nurse about the disaster triage tag system. The nurse provides details of four clients along with their conditions for identification. Which statement made by the student nurse indicates effective learning? "I would issue a red tag to client A."
"I would issue a black tag to client B." CORRECT "I would issue a green tag to client C. "I would issue a yellow tag to client D." Client C with a sprain, which is a minor injury that does not require immediate treatment, should be given a green tag according to the triage tag system. Client A with open fractures that are due to a major injury should be given a yellow tag according to the triage tag system. Client B with airway obstruction has an immediate threat to life and should be given a red tag according to the triage tag system. Client D with shock has an immediate threat to life and should be given a red tag according to the triage tag system.
10.A student nurse is asking a registered nurse to suggest a database source to find information on studies related to allied health sciences. Which database would the registered nurse suggest? EMBASE CORRECT MEDLINE WRONG National Guidelines Clearinghouse WRONG Cochrane Database of Systematic Reviews WRONG RATIONALE The MEDLINE database includes studies in medicine, nursing, dentistry, psychiatry, veterinary medicine, and allied health. EMBASE includes biomedical and pharmaceutical studies. The National Guidelines Clearinghouse includes a repository for structured abstracts about clinical guidelines and their development. It also includes a condensed version of the guidelines. The Cochrane Database includes full text of regularly updated systematic reviews prepared by the Cochrane Collaboration as well as completed reviews and protocols.
11. A nurse collaborates with a depressed client to increase self-esteem. What behavior should the nurse recall as typical of this type of client? Sets unrealistic goals CORRECT Engages in criminal activity WRONG Attempts to manipulate others WRONG Overestimates current strengths WRONG RATIONALE A depressed client may formulate goals that are unrealistic and therefore unattainable because of a lack of physical or emotional energy. This may trigger further negative feelings and decrease self-esteem. Goals based on cognitive distortions will also be unrealistic and lead to further negative feelings. Depressed clients are experiencing cognitive distortions and negativity and usually do not have a desire to manipulate others. Depressed clients are usually unable to see their strengths and abilities as a result of their negative thinking. Criminal activity is typically associated with antisocial personality disorder, not depression.
12.Which individual is categorized as one who would be considered as "dependent status"? Unit secretary WRONG Nurse manager Registered nurse (RN) CORRECT Licensed practical nurse (LPN) RATIONALE Licensed practical nurses (LPNs) who work under the direction of a registered nurse (RN) or a physician have dependent status. The unit secretary does not have a legal recognition. The nurse manager is an individual who is answerable to the designated delegator. The RN as a delegator assigns the work to LPNs. 13. The registered nurse is teaching a nursing student who underwent training for disaster management on how to cope effectively after a disaster event. Which statements by the nursing student indicate a need for further teaching? Select all that apply. "I will support co-workers." "I will eat snacks for energy." "I will work for 15 hours per day." CORRECT "I will monitor stress levels of colleagues." "I will talk about my feelings with my family." CORRECT RATIONALE Without intervention during or after an emergency, healthcare professionals who have worked in a disaster event may develop post-traumatic stress disorder (PTSD). In order to prevent this, they should not work more than 12 hrs. per day. They should share their feelings with the staff and managers who worked along with them. These healthcare professionals should support their co-workers and eat healthy snacks for energy. Stress levels should also be monitored to prevent PTSD.
14.If the nurse is considering whether the right equipment and resources are available to complete a task, which delegation right is considered? Task WRONG Supervision Circumstance CORRECT Communication RATIONALE If the right equipment and resources are available to complete a task, it is considered the right circumstance. Task is the delegation right that involves asking if the task is appropriate to delegate based on institutional policies and procedures. Supervision is the delegation right involving the provision of clear feedback related to completion of an assigned task. Communication is the right that involves asking the delegator and delegate to understand a common work-related language.
15.Learning to be comfortable with conflict and ambiguity as they are the normal states of the human condition, rather than being uncomfortable with conflict and ambiguity is a power strategy for the nursing
leader. SELECT ALL THE APPLY Accept responsibility for one’s mistakes. CORRECT Give credit to others where credit is due. CORRECT Learn to be uncomfortable with conflict and ambiguity. Use business cards when introducing yourself to new contacts. CORRECT Develop the ability to let constructive criticism roll off your back. WRONG RATIONALE Accepting responsibility for one’s mistakes and then learning from them is a power strategy for a nursing leader. Giving credit to others where credit is due and using business cards when introducing yourself to new contacts, as well as collecting the business cards of those you meet when networking, are power strategies for a nursing leader. Developing the ability to take constructive criticism gracefully and learning to let destructive criticism "roll off your back" is a power strategy for nursing leaders.
16.A nurse is working in a health care organization that has Magnet status. What specific responsibility does the nurse have in this organization? The nurse must follow best-practices for quality improvement. WRONG The nurse must use research-based practice to provide client care. The nurse must collect data for comparison against a national level. CORRECT The nurse must refrain from taking independent actions during client care. RATIONALE The nurse in a Magnet health care organization must collect data on specific nursing-sensitive quality indicators or outcomes. This data must be compared with the national, state, or regional database to demonstrate quality care. The nurse must always follow evidence-based practice while providing client care. Best practice may not always be beneficial for the client. The nurse must use a problem-solving approach and combine research-based practice with client preferences and values. Nurses in Magnet health care organizations are encouraged to practice with a sense of empowerment and autonomy to deliver quality care.
17.A nurse manager is informed that a community disaster drill will take place. The disaster scenario will include a bombing in a shopping mall with hundreds of casualties. What location should the nurse consider for triage of casualties when planning for this exercise? In the hospital parking lot At the scene of the disaster CORRECT In the emergency department At the closest school gymnasium WRONG RATIONALE Mass casualty events have triage at the scene to prevent overwhelming the hospital with casualties, while at the same time preventing the hospital from becoming a secondary target of additional attacks. The hospital parking lot is too close to the hospital to provide safety from additional attacks. Performing triage in the emergency department will quickly overwhelm the department and will interfere with provision of care to clients who will benefit from interventions.
Quiz: Collaboration/Managing Care - Care Coordination 18.When planning a citywide national homeland security (Canada: Public Health Agency of Canada’s Centre for Emergency Preparedness) disaster preparedness drill, a nurse is assigned to the triage committee. Place the following criteria in an order that reflects the most efficient triage plan for an actual mass casualty incident (MCI). Tension pneumothorax CORRECT Compound fracture of femur CORRECT Laceration of thigh muscle WRONG Crushing head injury WRONG. Severe wrist sprain WRONG RATIONALE Critically ill clients who can survive with care are categorized as "immediate" and are treated first; they receive a code of "Red." In a major disaster, the exact opposite of what is done in a nondisaster situation occurs. The object is to get the greatest number of survivors treated fast. A tension pneumothorax involves increasing positive pressure in the pleural space, which leads to lung collapse. An inability to breathe can quickly lead to death if not treated immediately. Open fractures of the long bones are also categorized as "Red" because, if untreated, infection and bleeding are life-threatening complications. This, however, does not pose the immediate threat that a tension pneumothorax does. Those who are injured but for whom care can be postponed for a few hours are categorized as "delayed" and treated second; they receive a code of "Yellow." Treatment of vascular injuries without evidence of shock can be delayed. Those who have minor injuries are categorized as "minimal" and are treated third; they receive a code of "Green." A sprain is not life threatening; care can be delayed for an extended period. Those who are critically ill and have little or no chance of survival are categorized as "expectant" and are treated last; they receive a code of "Black." A crushing head injury causes severe brain injury; chances of survival are unlikely. QUALITY IMPROVEMENT 19. A client is placed on a stretcher and restrained with straps while being transported to the x-ray department. A strap breaks, and the client falls to the floor, sustaining a fractured arm. Later the client shows the strap to the nurse manager, stating, "See, the strap is worn just at the spot where it snapped." What is the nurse's accountability regarding this incident? Exempt from any lawsuit because of the doctrine of respond at superior WRONG Totally responsible for the obvious negligence because of failure to report defective equipment CORRECT Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client Exonerated, because only the hospital, as principal employer, is responsible for the quality and maintenance of equipment RATIONALE Using a stretcher with worn straps is negligent; this oversight does not reflect the actions of a reasonably prudent nurse. The nurse is responsible and must ascertain the adequate functioning of equipment. The hospital shares responsibility for safe, functioning equipment.
QUIZ HEALTH PLOLICY
20.A client who had previously signed a consent form for a liver biopsy reconsiders and decides not to have the procedure. What is the nurse's best initial response? "Why did you sign the consent form originally?" WRONG "I can understand why you changed your mind." "Can you tell me your reasons for refusing the procedure?" CORRECT "You must be afraid about something concerning the procedure." RATIONALE The response "Can you tell me your reasons for refusing the procedure?" attempts to explore why the client is refusing the procedure; the question promotes communication. The response "Why did you sign the consent form originally?" is accusatory; the client has the right to withdraw consent at any time. The response "I can understand why you changed your mind" is a conclusion without appropriate data; it may also increase the client's anxiety level. "You must be afraid about something concerning the procedure" is a conclusion without appropriate data; it also puts the client on the defensive. 21.A nurse is working with an unlicensed assistive personnel (UAP) in caring for a group of clients. Which statement by the UAP indicates a correct understanding of the UAP's role? "I will turn off clients' IVs that have infiltrated." WRONG "I will take clients' vital signs after their procedures are over." CORRECT "I will use unit written materials to teach clients before surgery." "I will help by giving medications to clients who are slow in taking pills." RATIONALE Monitoring vital signs after procedures is within the scope of a UAP's role. Registered professional nurses or licensed practical nurses, not UAPs, should perform turning off clients' intravenous (IV) infusions that have infiltrated. Using unit written materials to teach clients before surgery should be performed by registered professional nurses or licensed practical nurses, not UAPs. COMFORT 22. An obese client has had an abdominal cholecystectomy. How does the nurse plan to alleviate tension on the surgical wound after surgery? Limiting deep breathing Maintaining T-tube patency Maintaining nasogastric tube patency CORRECT Encouraging the right side-lying position RATIONALE Maintaining nasogastric tube patency ensures gastric decompression, thus preventing abdominal distention, which places tension on the incision. Deep breathing should be encouraged to prevent respiratory complications. Maintaining T-tube patency only ensures a portal of exit for bile drainage; the tube is not irrigated, and an obstruction will lead to jaundice rather than tension on the surgical wound. The right sidelying position after a cholecystectomy can increase, not decrease, tension in the operative area.
HEALTH POLICY/SYSTEM HEALTH CARE LAW "Was reasonable care provided?" CORRECT "Was there a breach of nursing duty?" CORRECT "Except for the nurse’s action, would the injury have occurred?" CORRECT "Did the nurse fully understand the actions would result in harm?" RATIONALE Negligence is the as the failure to do or not do what a reasonably careful nurse would do under the circumstances. The elements that must be present to determine negligence include whether the nurse fulfilled the legal duties to provide reasonable care and foresee a risk of injury under certain circumstances and whether there was a breach of duty and whether any injury resulted if there was a breach of duty.
22. A client with rheumatoid arthritis does not want the prescribed cortisone and informs the nurse. Later, when the nurse attempts to administer cortisone, the client asks what the medication is and the nurse gives an evasive answer. The client takes the medication and later discovers that it was cortisone. The client states an intent to sue. What factors in this situation must be considered in a legal action? Select all that apply. Clients have a right to refuse treatment. CORRECT Nurses are required to answer clients truthfully. CORRECT The healthcare provider should have been notified. CORRECT The client had insufficient knowledge to make such a decision. Legally prescribed medications are administered despite a client's objections. WRONG
RATIONALE Clients who are mentally competent have the right to refuse treatment; the nurse must respect this right. A client's questions must always be answered truthfully. The healthcare provider should be notified when a client refuses an intervention so that an alternative treatment plan can be formulated. This is done after the nurse explores the client's reasons for refusal. 23. Before a treatment requiring informed consent can be performed, what information must the client be given? Select all that apply. The cost of the treatment WRONG Alternative treatment options CORRECT The risks and benefits of the treatment CORRECT The risks involved in refusing the treatment CORRECT The nature of the problem requiring the treatment CORRECT
RATIONALE For consent to be legal it must be informed. The information provided to the client includes the nature of the problem or condition, the nature and purpose of the proposed treatment, and the risks and benefits of the treatment. Alternative treatment options, the probability that the proposed treatment will be successful, and the risks involved in not consenting to the treatment must also be provided. Cost of the treatment is not considered relevant to informed consent.
24.Which position is used to assess the extension of the hip joint and buttocks?
1.Correct
3. Incorrect
4.Incorrect
RATIONALE To assess the extension of hip joint and buttocks, the client should be positioned in prone position (as seen in the second figure). The dorsal recumbent position (as seen in the first figure) is used for an abdominal assessment. The lateral recumbent position (as seen in the third figure) is used to assess murmurs. The supine position (as seen in the fourth figure) is used to assess the heart, abdomen, extremities, and pulses.
24. What birth weight in a neonate indicates that the infant is a very low birth weight (VLBW) infant? 900 g 1300 g CORRECT 1700 g 2000 g RATIONALE Infants whose birth weight is less than 1500 g are known as very low birth weight infants. Infants whose birth weight is less than 1000 g are known as extremely low birth weight infants. Infants whose birth weight is less than 2500 g are known as low birth weight infants. SAFETY 25.Which nursing action is the priority when administering chelation therapy for a preschool-age client? Assessing vital signs Monitoring urine output CORRECT Conducting a behavioral assessment Providing education to reduce lead exposure RATIONALE Adequate urinary output must be ensured with administration of calcium EDTA, the medication used for chelation therapy. Clients receiving the drug intramuscularly must be able to maintain adequate oral intake of fluids. Monitoring vital signs, conducting a behavioral assessment, and providing education to reduce lead exposure are not priority nursing actions when administering chelation therapy.
HEALTH AND PHYSICAL ASSESSMENT 26.A client with severe bleeding due to a motor vehicle accident was admitted to the emergency department. The nurse assessed that the client was unconscious and the healthcare provider diagnosed the client with a hand fracture. The client is receiving oxygen therapy as well as intravenous fluids through the antecubital fossa. Which sites should be used to obtain the client’s pulse rate? Select all that apply. Apical INCORRECT Carotid CORRECT Brachial Femoral CORRECT Popliteal RATIONALE Clients with severe bleeding may develop hypovolemic shock. The carotid and femoral pulses are easily accessible sites to measure pulses in clients with hypovolemic shock. The apical pulse may not be palpable in a client with hypovolemic shock. Because the client is diagnosed with a hand fracture and is receiving intravenous fluids through the antecubital fossa, the brachial artery cannot be accessed to measure the pulse rate. The popliteal site is used to assess the status of the circulation in the lower leg.
CLINICAL JUDMENT 27. What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. Tetany Seizures Diarrhea CORRECT Weakness CORRECT Dysrhythmias CORRECT RATIONALE Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia meaning cause diarrhea, weakness, and cardiac dysrhythmias. 28. A client's problem with ineffective control of type 1 diabetes is pinpointed as a sudden decrease in blood glucose level followed by rebound hyperglycemia. What should the nurse do when this event occurs? Give the client 8 oz (240 mL) of orange juice. Seek a prescription to increase the insulin dose at bedtime. Encourage the client to eat smaller, more frequent meals. Collaborate with the primary healthcare provider to alter the insulin prescription. CORRECT Bottom of Form The client is experiencing the Somogyi effect. It is a paradoxical situation in which sudden decreases in blood glucose are followed by rebound hyperglycemia. The body responds to the hypoglycemia by secreting glucagon, epinephrine, growth hormone, and cortisol to counteract the low blood sugar; this results in an excessive increase in the blood glucose level. It most often occurs in response to hypoglycemia when asleep. Top of Form toddler who has undergone cleft palate repair is now able to tolerate fluids. What should the nurse use to offer the toddler fluids? Small cup CORRECT Soft nipple Bulb syringe Teflon-coated spoon Bottom of Form RATIONALE Feeding with a small cup is best because liquids can be given slowly, without stress on the suture line; also, a cup is age appropriate for a toddler. Sucking on a nipple may exert pressure on the suture line; also, a cup is more age appropriate BASIC CARE AND COMFORT Top of Form The nurse observes that a school-age child does not have proper oral hygiene and therefore is at an increased risk for oral problems. The parents tell the nurse that the child brushes the teeth independently. What does the nurse suggest to the parents?
"Help the child with brushing and flossing." CORRECT "Ask the child to use a brush with hard bristles." "Ask the child to brush every hour for a few days." "Avoid fruit juice and sugary beverages in the child’s diet." RATIONALE Brushing and flossing conscientiously helps prevent oral problems. In this case, the child may not be able to brush the teeth effectively without parental assistance, which may have caused the oral problems. Therefore, the nurse should instruct the parents to help the child with brushing and flossing. Hard bristles may hurt the gums, so the nurse should advise the parents to use a brush with soft nylon bristles.
