Select All That Apply Practice Exam Flashcards

The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would the appropriate nursing interventions be with this client? Select all that apply:

Answer: Use active listening skills to seek information from the client.

When a client is experiencing delusions, the most appropriate nursing intervention is to establish trust and understand their perception of reality without directly challenging or reinforcing the delusion. Using active listening and encouraging the client to describe their experience validates their feelings and helps the nurse gather more information, fostering a therapeutic relationship.

Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers? Check all that apply:

Answer: Avoid use of donut type devices.

Donut-type devices are contraindicated for pressure ulcer prevention because they can create a concentrated area of pressure around the hole, leading to tissue ischemia and actually increasing the risk of pressure ulcer development in that area. Effective interventions focus on pressure redistribution and reducing shear forces.

The nurse is evaluating a client recently diagnosed with primary open angle glaucoma (POAG). What will an important nursing action be? Select all that apply:

Answer: Review meds the client is currently on to determine whether any of them cause an increased intraocular pressure as a side effect.

Certain medications, such as corticosteroids, anticholinergics, and some antidepressants, can increase intraocular pressure (IOP) and exacerbate glaucoma. Therefore, reviewing the client's current medication list is a critical nursing action to identify and potentially modify any medications that could negatively impact their glaucoma management. This helps prevent further vision loss.

A nurse understands that a patient may experience pain during peritoneal dialysis because of which of the following? Select all that apply:

Answer: Too rapid installation

Pain during peritoneal dialysis can be caused by the rapid infusion of dialysate into the peritoneal cavity. This rapid influx can stretch the peritoneum quickly, leading to discomfort or cramping. Other causes of pain include accumulation of dialysate under the diaphragm or peritonitis.

The nurse is evaluating a client’s response to hemodialysis. Which lab results will indicate the dialysis was effective? Select all that apply:

Answer: Serum potassium level decreases from 5.4 to 4.6 mEq/L

Hemodialysis is effective in removing waste products and excess electrolytes from the blood. A decrease in serum potassium from a hyperkalemic level (5.4 mEq/L) to a normal range (4.6 mEq/L) indicates effective removal of potassium. Similarly, a decrease in creatinine and BUN levels signifies effective removal of nitrogenous waste products, indicating successful dialysis.

The nurse understands that the following clinical findings are indications for dialysis. Select all that apply:

Answer: Volume overload

Indications for dialysis include severe fluid volume overload unresponsive to diuretics, significant electrolyte imbalances (like hyperkalemia, e.g., K 5.2 mEq/L if symptomatic or rapidly rising), severe metabolic acidosis, and high levels of uremic toxins as indicated by elevated BUN and creatinine (e.g., Cr 5.0 mg/dL). These conditions signify the kidneys' inability to maintain homeostasis.

The nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment finding would cause the nurse concern regarding the development of compartment syndrome? Select all that apply:

Answer: Paresthesia distal to area of injury.

Compartment syndrome is a serious condition caused by increased pressure within a muscle compartment, leading to compromised circulation and nerve function. Paresthesia (numbness or tingling) distal to the injury is a classic 'P' sign (pain, pallor, pulselessness, paresthesia, paralysis) and an early indicator of nerve compression and ischemia, requiring immediate intervention.

The nurse is preparing discharge for a patient with GERD. What would be important for the nurse to include in this teaching plan? Select all that apply:

Answer: Elevate the HOB.

Elevating the head of the bed (HOB) by 6-8 inches helps to prevent reflux of stomach acid into the esophagus by using gravity. This is a key non-pharmacological intervention for managing GERD symptoms, especially at night. Other important teaching points include dietary modifications, weight loss, and proper medication administration.

The nurse is preparing a client for cardiac catheterization. Which nursing interventions are necessary in preparing the client for this procedure. Select all that apply:

Answer: Verify consent has been signed.

Before any invasive procedure like a cardiac catheterization, it is a critical nursing responsibility to ensure that informed consent has been properly obtained and signed by the client. This confirms that the client understands the procedure, risks, and benefits, and has agreed to it voluntarily. Other important pre-procedure steps include client education, assessing allergies, and evaluating peripheral pulses.

The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephrotic syndrome. The nurse should:

Answer: Encourage the client to drink extra fluids

Cytoxan (cyclophosphamide) is an alkylating agent that can cause hemorrhagic cystitis, a serious bladder inflammation, due to the accumulation of its toxic metabolites in the bladder. Encouraging extra fluid intake helps to dilute these metabolites and promote their excretion, thereby reducing the risk of bladder toxicity and protecting the urinary tract.

The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal?

Answer: Ativan (lorazepam)

Benzodiazepines like Ativan (lorazepam) are the first-line treatment for acute alcohol withdrawal syndrome. They help to reduce the hyperexcitability of the central nervous system caused by alcohol cessation, thereby preventing or managing symptoms such as tremors, agitation, hallucinations, and seizures. Lorazepam is particularly useful due to its intermediate half-life and availability in various forms.

A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:

Answer: 3 p.m.

NPH insulin is an intermediate-acting insulin with a peak action typically occurring 4 to 12 hours after administration. If administered at 7 a.m., the client is most likely to experience the peak effect and thus signs of hypoglycemia between 11 a.m. and 7 p.m. Therefore, 3 p.m. falls within this peak window, making it the critical time for observation.

The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?

Answer: Alteration in mobility

For a client with a detached retina, the primary goal is to prevent further retinal detachment and preserve vision. Any sudden head or eye movements, or increased intraocular pressure from physical exertion, can worsen the condition. Therefore, prioritizing 'Alteration in mobility' is crucial to enforce bed rest and activity restrictions, minimizing risk and promoting healing.

The primary purpose for using a CPM machine for the client with a total knee repair is to help:

Answer: Promote flexion of the artificial joint

A Continuous Passive Motion (CPM) machine is used after total knee repair to gently and continuously move the knee joint. Its primary purpose is to prevent stiffness and scar tissue formation, thereby promoting and maintaining the range of motion, particularly flexion, of the artificial joint. This helps in early rehabilitation and improves long-term joint function.

Which of the following statements reflects Kohlberg’s theory of the moral development of the preschool-age child?

Answer: Behavior is determined by consequences.

According to Kohlberg's theory, preschool-age children are in the preconventional stage of moral development. In this stage, behavior is primarily determined by external consequences, meaning actions are judged as right or wrong based on whether they lead to punishment or reward. They lack an understanding of abstract moral principles or societal rules.

A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:

Answer: A document that the infection has completely cleared

After completing antibiotic therapy for otitis media, a recheck appointment is essential to ensure the infection has completely cleared. This follow-up confirms the effectiveness of the treatment and helps prevent potential complications such as recurrent infections, chronic middle ear fluid, or long-term hearing impairment. It also helps to avoid antibiotic resistance if the infection persists.