Select All That Apply Practice Exam Flashcards

A client has a diagnosis of primary insomnia. Before assessing this client, the nurse recalls the numerous causes of this disorder. Select all that apply:

Answer: Chronic stress

Primary insomnia is often influenced by various lifestyle and environmental factors. Chronic stress and excessive caffeine intake are known to disrupt sleep patterns, making it difficult to fall or stay asleep. Environmental noise can also directly interfere with sleep, contributing to the development of primary insomnia.

Select all that apply to the use of barbiturates in treating insomnia:

Answer: Barbiturates deprive people of REM sleep

Barbiturates are known to suppress REM sleep. When these medications are discontinued, a rebound effect occurs, leading to an increase in REM sleep, often accompanied by vivid dreams or nightmares. This rebound REM sleep and associated nightmares are common withdrawal symptoms when discontinuing barbiturates.

Select all that apply that is appropriate when there is a benzodiazepine overdose:

Answer: Gastric lavage

For a benzodiazepine overdose, interventions focus on reducing absorption and reversing the drug's effects. Gastric lavage and activated charcoal with a saline cathartic help remove unabsorbed medication from the GI tract. Flumazenil is a specific benzodiazepine receptor antagonist that can reverse the sedative effects of an overdose.

A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further instruction? Select all that apply.

Answer: "I need to limit playing football to only the weekends."

Clients with hyperparathyroidism are at increased risk for bone demineralization and fractures, so high-impact activities like football should be avoided. Additionally, exercising in the evening can stimulate the body and interfere with sleep, making it an inappropriate recommendation for encouraging good sleep patterns.

A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply.

Answer: Administering oxygen

In pulmonary edema, immediate interventions aim to improve oxygenation, reduce fluid overload, and decrease cardiac workload. Administering oxygen addresses dyspnea, furosemide (Lasix) promotes diuresis to reduce fluid, morphine sulfate reduces anxiety and venous return, and a Foley catheter allows for accurate monitoring of urine output and fluid balance.

The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply.

Answer: To avoid activities that require bending over

After cataract surgery, clients should avoid activities that increase intraocular pressure, such as bending over. An eye shield protects the surgical eye, especially during sleep, from accidental injury. A decrease in visual acuity could indicate a serious complication and warrants immediate medical attention, while acetaminophen is appropriate for managing minor discomfort.

The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply.

Answer: To avoid activities that require bending over

After cataract surgery, clients should avoid activities that increase intraocular pressure, such as bending over. An eye shield protects the surgical eye, especially during sleep, from accidental injury. A decrease in visual acuity could indicate a serious complication and warrants immediate medical attention, while acetaminophen is appropriate for managing minor discomfort.

When the nurse is collecting data from the older adult, which of the following findings would be considered normal physiological changes? Select all that apply.

Answer: Decline in visual acuity

As people age, several physiological changes are considered normal. A decline in visual acuity (presbyopia), increased susceptibility to urinary tract infections due to changes in the urinary system, and more frequent awakenings after sleep onset are common age-related findings.

Which data indicates to the nurse that a client may be experiencing ineffective coping?

Answer: Constantly neglects personal grooming

Ineffective coping is often manifested by a significant decline in self-care activities and personal hygiene. Constantly neglecting personal grooming suggests a withdrawal from self-care and a potential inability to manage daily life stressors, indicating a struggle with healthy coping mechanisms.

The mother of a child with cystic fibrosis tells the nurse that her child makes “snoring” sounds when breathing. The nurse is aware that many children with cystic fibrosis have:

Answer: Nasal polyps

Nasal polyps are common in children with cystic fibrosis due to chronic inflammation and mucus buildup in the nasal passages. These growths can obstruct airflow, leading to symptoms like 'snoring' sounds during breathing and chronic nasal congestion, which is a characteristic finding in this population.

A client is hospitalized with hepatitis A. Which of the client’s regular medications is contraindicated due to the current illness?

Answer: Lipitor (atorvastatin)

Lipitor (atorvastatin) is a statin medication primarily metabolized by the liver. In a client with hepatitis A, which causes acute liver inflammation, medications that are heavily metabolized by the liver or are potentially hepatotoxic should be avoided or used with extreme caution. Atorvastatin can cause liver damage, making it contraindicated in acute hepatitis.

The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates that the client understands his new diet?

Answer: Oatmeal, apple juice, dry toast, and coffee

A diet for hypertension emphasizes low sodium and low fat. Oatmeal, apple juice, and dry toast are generally low in sodium and fat, making this the most appropriate choice for a client managing blood pressure. Options with bacon, ham, or whole milk are high in sodium and saturated fat, which are detrimental for hypertension.

An 18-month-old is being discharged following hypospadias repair. Which instruction should be included in the nurse’s discharge teaching?

Answer: The child should not play on his rocking horse.

Following hypospadias repair, it is crucial to prevent pressure or trauma to the surgical site to promote healing and prevent complications. Activities that involve straddling or direct pressure on the perineal area, such as riding a rocking horse, should be avoided to protect the surgical repair.

An obstetrical client calls the clinic with complaints of morning sickness. The nurse should tell the client to:

Answer: Keep crackers at the bedside for eating before she arises

Eating a few dry crackers before getting out of bed helps absorb stomach acids and can reduce the nausea associated with morning sickness. This is because an empty stomach can exacerbate nausea, and consuming bland carbohydrates before rising can stabilize blood sugar and settle the stomach. It's a common and effective non-pharmacological intervention for early pregnancy discomfort.

The nurse has taken the blood pressure of a client hospitalized with methicillin-resistant staphylococcus aureus. Which action by the nurse indicates an understanding regarding the care of clients with MRSA?

Answer: The nurse leaves the stethoscope in the client’s room for future use.

For clients with highly contagious infections like MRSA, medical equipment should be dedicated to that client to prevent cross-contamination. Leaving the stethoscope in the client's room ensures it is only used for that specific individual, minimizing the risk of transmitting the bacteria to other patients or areas. This practice aligns with isolation precautions and infection control guidelines.

The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician’s teaching by telling the parents that:

Answer: The medication will be needed throughout the child’s lifetime.

Congenital hypothyroidism results from the thyroid gland's inability to produce sufficient thyroid hormones, which are crucial for normal growth and neurological development. Without lifelong hormone replacement therapy, children would experience severe developmental delays and intellectual disability. Therefore, medication must be continued indefinitely to support proper physiological function.